Spinal Needles for Lumbar Puncture

30 November 2014

We read with dismay the report ‘Feasibility of Lumbar Puncture in the Study of Cerebrospinal Fluid Biomarkers for Alzheimer’s Disease: A Multicenter Study in Spain’ [1]. In 2005, the Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology recommended the use of atraumatic needles for lumbar puncture [2]. This was based on only one study in the neurology literature, but overwhelming evidence in the anesthesiology literature [3]. We find it astounding that in 2014, cutting edge-tipped spinal needles are still being used for this purpose.

Furthermore, when there is no need to measure CSF pressure, which is generally the case when CSF samples are taken for the purpose of diagnosing Alzheimer’s disease, there is clear evidence that the smallest caliber needle is associated with the lowest incidence of headache. The use of a 27-gauge pencil point needle was associated with a zero incidence of headache when used for lumbar puncture in patients aged 18-45 [4].

Anesthesiologists consistently perform lumbar punctures on a daily basis including spinal anesthesia for caesarean section, which is routine and often performed in young women who are at high risk for headaches. We urge the Neurology community to adopt some of the techniques routinely used in anesthesia [5]. This not only includes the use of the smallest caliber pencil-point spinal needle but complete aseptic technique consisting of masks, gowns, gloves, and full skin preparation.

We advocate the use of a 27-gauge pencil point needle and to improve cerebrospinal fluid flow, there are hybrid needles with a 22-gauge shaft. These have the advantage of minimal leak from the dura because of the small puncture hole, while having the flow characteristics of a 22-gauge needle [6].

Safe patient care is critical. Adoption of these practices is essential if cerebrospinal fluid screening and diagnosis is to become an essential part of Alzheimer’s disease management.

Brendan Silbert, David Scott, Lisbeth Evered
Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia and Acute Pain Medicine, St Vincent’s Hospital, Melbourne, Victoria, Australia

References
[1] Alcolea D, Martinez-Lage P, Izagirre A, Clerigue M, Carmona-Iragui M, Alvarez RM, Fortea J, Balasa M, Morenas-Rodriguez E, Llado A, Grau O, Blennow K, Lleo A, Molinuevo JL (2014) Feasibility of lumbar puncture in the study of cerebrospinal fluid biomarkers for Alzheimer's disease: a multicenter study in Spain. J Alzheimers Dis 39, 719-726.
[2] Armon C, Evans RW, Therapeutics, Technology Assessment Subcommittee of the American Academy of Neurology (2005) Addendum to assessment: Prevention of post-lumbar puncture headaches: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 65, 510-512.
[3] Lambert DH, Hurley RJ, Hertwig L, Datta S (1997) Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth 22, 66-72.
[4] Corbey MP, Bach AB, Lech K, Frorup AM (1997) Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anaesthesiol Scand 41, 779-784.
[5] Silbert B, Scott D, Evered L, Maruff P (2011) The needle has been blunt for 20 years. Int Psychogeriatr 23, 330-331.
[6] Ginosar Y, Smith Y, Ben-Hur T, Lovett JM, Clements T, Ginosar YD, Davidson EM (2012) Novel pulsatile cerebrospinal fluid model to assess pressure manometry and fluid sampling through spinal needles of different gauge: support for the use of a 22 G spinal needle with a tapered 27 G pencil-point tip. Br J Anaesth 108, 308-315.

Comments

We thank Dr. Silbert et al. for their comments on our manuscript about the feasibility of lumbar puncture in the study of cerebrospinal fluid (CSF) biomarkers for Alzheimer’s disease (AD). We agree with several of the points raised in their letter but would like to clarify some of the comments in view of the different research settings.

First of all, we of course agree with Silbert et al. that lumbar puncture should be performed by experienced physicians following international guidelines and that patient safety is a critical issue. It is undeniable that the long experience in lumbar puncture in the field of anesthesiology is of great value for the medical community in general and for the field of neurology in particular. However, it is important to emphasize here that the setting of clinical practice or research studies in neurodegenerative diseases differs substantially from that of spinal anesthesia. For example, the subject characteristics, the purpose of the procedure, and the volume of CSF required for the diagnosis of AD are substantially different. Silbert at al. cite a study by Corbey et al. [1] to argue that the atraumatic 27-gauge Whitacre needle is the needle of choice because of its association with a zero incidence of headache. However, this study was performed in young subjects (<45) following spinal anesthesia before surgery. The extrapolation of these data to a group of aged subjects (usually >60) in whom large volumes of CSF (5-12 ml) are intentionally obtained, as in our setting, is unclear, stressing the need for multicenter studies in subjects undergoing lumbar puncture for diagnostic or research purposes in the context of neurodegenerative diseases. In our study [2], we found that atraumatic needles were associated with a lower incidence of headache, but also with a trend toward a higher frequency of blood-tinged CSF. Blood contamination is known to confound the analyses of several CSF biomarkers, and this could be an important limitation for the diagnosis of neurodegenerative diseases and for clinical trials [3]. In addition, atraumatic needles are associated with higher failure rates in several studies [4].

Our data are in agreement with a recent large multicenter study [5] that enrolled more than 3,000 subjects and showed that lumbar puncture can be safely performed in a memory clinic. Although most centers (>80%) used cutting edge-tipped spinal needles, the occurrence of headache was below 10%. Despite these findings, however, a recent consensus guideline paper recommended the use of atraumatic needles (25-gauge) in the study of neurodegenerative diseases [6] and a new guideline based on the experience in neurological subjects will be published soon.

It is clear that the fields of anesthesiology and neurology should work together to define guidelines for lumbar puncture in the setting of neurodegenerative diseases. Such guidelines should take into account the need for a simple procedure, high volumes of CSF, lack of blood contamination, and minimal complications for the patient. These are essential points because the use of lumbar puncture for the diagnosis of AD and other neurodegenerative diseases is expected to become more widespread in coming years.

Alberto Lleó, Daniel Alcolea, Pablo Martínez-Lage, José Luís Molinuevo

References
[1] Corbey MP, Bach AB, Lech K, Frorup AM (1997) Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anaesthesiol Scand 41, 779-784.
[2] Alcolea D, Martinez-Lage P, Izagirre A, Clerigue M, Carmona-Iragui M, Alvarez RM, Fortea J, Balasa M, Morenas-Rodriguez E, Llado A, Grau O, Blennow K, Lleo A, Molinuevo JL (2014) Feasibility of lumbar puncture in the study of cerebrospinal fluid biomarkers for Alzheimer's disease: a multicenter study in Spain. J Alzheimers Dis 39, 719-726.
[3] Lleó A, Cavedo E, Parnetti L, Vanderstichele H, Herukka SK, Andreasen N, Ghidoni R, Lewczuk P, Jeromin A, Winblad B, Tsolaki M, Mroczko B, Visser PJ, Santana I, Svenningsson P, Blennow K, Aarsland D, Molinuevo JL, Zetterberg H, Mollenhauer B (2015) Cerebrospinal fluid biomarkers in trials for Alzheimer and Parkinson diseasess. Nat Rev Neurol 11, 41-55.
[4] Thomas SR, Jamieson DR, Muir KW (2000) Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ 321, 986-990.
[5] Duits FH, Martinez-Lage P, Paquet C, Engelborghs S, Lleó A, Hausner L, Molinuevo JL, Stomrud E, Farotti L, Ramakers IH, Tsolaki M, Skarsgård C, Åstrand R, Wallin A, Vyhnalek M, Holmber-Clausen M, Forlenza OV, Ghezzi L, Ingelsson M, Hoff EI, Roks G, Mendonça A, Papma JM, Izagirre A, Taga M, Struyfs H, Alcolea D, Frölich L, Balasa M, Minthon L, Twisk JW, Persson S, Zetterberg H, van der Flier WM, Teunissen CE, Scheltens P, Blennow K. Performance and complications of lumbar puncture in memory clinics: results of a multicenter study. Submitted.
[6] Del Campo M, Mollenhauer B, Bertolotto A, Engelborghs, S, Hampel H, Simonsen AH, Kapaki E, Kruse N, Le Bastard, N, Lehmann S, Molinuevo JL, Parnetti L, Perret-Liaudet, A, Saez-Valero J, Saka E, Urbani A, Vanmechelen E, Verbeek M, Visser PJ, Teunissen C (2012) Recommendations to standardize preanalytical confounding factors in Alzheimer's and Parkinson's disease cerebrospinal fluid biomarkers: an update. Biomark Med 6, 419-430.