[Postdural puncture headache: diagnosis, prevention and therapy]

The effects of needle deformation during lumbar puncture

Objective:

The aim of this study is to assess deformation of the tip and deflection from the axis of 22-gauge Quincke needles when they are used for diagnostic lumbar puncture (LP). Thus, it can be determined whether constructional alterations of needles are important for predicting clinical problems after diagnostic LP.

Materials and Methods:

The 22-gauge Quincke needles used for diagnostic LP were evaluated. A specially designed protractor was used for measurement and evaluation. Waist circumference was measured in each patient. Patients were questioned about headaches occurring after LP.

Results:

A total of 115 Quincke-type spinal needles used in 113 patients were evaluated. No deflection was detected in 38 (33.1%) of the needles. Deflection between 0.1° and 5° occurred in 43 (37.3%) of the needles and deflection ≥ 5.1° occurred in 34 patients (29.6%). Forty-seven (41.5%) patients experienced post lumbar puncture headache (PLPH) and 13 (11.5%) patients experienced intracranial hypotension (IH). No statistically significant correlation between the degree of deflection and headache was found (P > 0.05). Epidural blood patch was performed for three patients. Deformity in the form of bending like a hook occurred in seven needles and IH occurred in six patients using these needles. Two of the needles used in three patients requiring blood patch were found to be bent.

Conclusion:

Deformation of needles may increase complications after LP. Needle deformation may lead to IH. In case of deterioration in the structure of the needle, termination of the puncture procedure and the use of a new needle could reduce undesirable clinical consequences, especially IH.

Continuous spinal anesthesia for lower limb surgery: a retrospective analysis of 1212 cases

Background

Continuous spinal anesthesia is a very reliable and versatile technique for providing effective anesthesia and analgesia. However, the incidence of possible complications, including postdural puncture headache or neurological impairment, remains controversial. Therefore, the aim of the present retrospective study was to analyze a large number of patients for the incidence of adverse events after continuous spinal anesthesia with a microcatheter.

Methods

This retrospective study was conducted on 1212 patients who underwent surgery of the lower extremities with continuous spinal anesthesia, which was administered with 22-gauge Quincke spinal needles and 28-gauge microcatheters. Sociodemographic and clinical data were available from the patient records, and data on headaches and patient satisfaction were drawn from a brief postoperative patient questionnaire.

Results

The patient population included 825 females (68%) and 387 males; the median age was 61 (56–76). The types of operations performed were 843 hip prostheses, 264 knee prostheses, and 105 other leg operations. No major complications were observed in any of these patients. Tension headaches were experienced by 190 (15.7%) patients, but postdural puncture headaches were reported by only 18 (1.5%) patients. Nearly all patients (98.4%) were satisfied with continuous spinal anesthesia and confirmed that they would choose this kind of anesthesia again.

Conclusion

Based on the findings of this large data analysis, continuous spinal anesthesia using a 28-gauge microcatheter appears to be a safe and appropriate anesthetic technique in lower leg surgery for aged patients.

[Current aspects of anesthetic management in urological patients]

Patients with coronary stents should take clopidogrel and acetylsalicylic acid for 4 weeks or 12 months after stenting. Stopping this medication early, e.g., for surgery, results in a 90-fold increase in the patient's risk for myocardial infarction from stent thrombosis. The mortality due to perioperative acute coronary syndrome clearly exceeds that due to perioperative bleeding complications. If oral medication resulting in platelet inhibition has to be paused "bridging" with short-acting, intravenous GPIIb/IIIa antagonists is possible. In recent years perioperative beta-blockade has been recommended for patients with high coronary vascular risk, and recently also for those with medium or low risk. Current studies, however, indicate that patients on beta-blockers have increased perioperative mortality because of bradycardia, hypotension, and anemia. Therefore, anemia and hypotension should be rigorously avoided.Anesthetic management may have an influence on the postoperative course of cancer. Combined epidural-general anesthesia provides a benefit by minimizing the use of systemic opioids and volatile anesthetics. Presumably, this and a decreased response to surgical stress increase the ability of the patient's immune system to deal with cancer dissemination and micrometastasis.

[Postpartum cerebral venous sinus thrombosis after epidural anaesthesia]

Cerebral venous sinus thrombosis during pregnancy or puerperium is not a rarity. Nevertheless, it is often misdiagnosed. With the increasing use of regional anaesthesia in obstetrics the differential diagnosis of postdural puncture headache is often difficult. The case of a patient is reported who suffered from both intracranial hypotension and cerebral venous sinus thrombosis in the postpartum period.