Friday, 1 May 2015

ClinicSpeak: needle size and type reduces headache from LPs

What needle was used when you had your LP? #ClinicSpeak #MSBlog #MSResearch

"The study below confirms our own findings that using a smaller, atrauamtic or non-cutting, needle to perform lumbar punctures (LP or spinal tap) reduces the incidence of post-LP headache substantially. In this study the incidence of post-LP headache dropped from 36% to 1.6%. This is why we are using the thinner atraumatic/non-cutting/Sprotte needle in the PROXIMUS study. So next time you are asked to have a LP by your neurologist as part of routine care or a study please ask them what needle they are using."
"Way back in the late 1990's I tried to get my previous hospital to adopt atraumatic needles; my business case was turned down because at that time the cutting needle cost £0.25 and the non-cutting needle ~£7. The latter price was because of limited suppliers and has subsequently come down a little. I would hate to guess how many patients had to be readmitted for the management of post-LP needles as a result of this policy. False economy? The problem is that at the time the people who paid for lumbar puncture needles (the hospital) were not the same people who paid for the readmitting patients for the complications of LPs (at that time the so called primary care trusts). The sad thing is that at that time the hospitals stood to make money from re-admissions. Thankfully, the NHS payers have gotten wise to the problem and now Trusts are penalised for readmissions and it is now counted as a sign of poor quality care. This may explain why we have not had problem getting our business case for atraumatic needles through management; anything that prevents re-admissions is now considered a good thing."




Epub: Bertolotto et al. The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice. Cephalalgia. 2015 Apr. pii: 0333102415583983.

OBJECTIVES: The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles.


METHODS: In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH.

RESULTS: PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant (p < 0.001 and p = 0.008, respectively) and it approached significance when comparing the 25S and 25W (p = 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles.

CONCLUSION: The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH.

7 comments:

  1. I certainly hope this works. I dread the mention of LP. Two Lumber punctures, total stay in hospital 20 days. No brainer(excuse the pun).

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  2. My son's hospital told him to take paracetemol and see his GP when he phoned up and told them of the splitting headaches and sickness he got when he was upright post LP. It took him 10 days to get over it

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  3. My LP (using a 20Q needle) was hands down the worst thing I've experienced since I was diagnosed with MS (including relapses, drug side effects, etc.). The procedure itself was mildly uncomfortable, but the after effects were horrific. I got head-splitting headaches if I did anything except lay on my back, and the paracetemol/caffeine allowed me just enough time to sit up and eat. The doctors kept telling me to wait it out and everything would get better, but it didn't. I eventually drove myself to the ER and got a blood patch, which finally resolved it a couple days later.

    Basically, the 20Q should be illegal to use, and neurologists should only require these when absolutely necessary.

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    1. I had exactly the same experience. Chief resident had difficult time performing the LP, even commented that he really was a MD ( ha ha). Joke was on me had to go back for a blood patch.

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    2. It doesn't help that the nursing staff have no idea what the pain is like. Drugs and food left out of reach. The slightest move and you end up vomiting. Noise coming from other patients and visitors unbelievable.

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  4. Had an LP yesterday
    Done with me say up leaning over a table, done with a Whitaker needle and no lying down after at all, was in and out, no headaches so far but you never know I guess

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    Replies
    1. If you haven't had a headache yet, it's unlikely you will now.

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