Article Text
Abstract
There may be a direct relationship between size of the dural puncture hole and resulting cerebrospinal fluid (CSF) leak and between external diameter of needle and incidence of PDPH. a larger size dura-arachnoid puncture produces more CSF leakage so that incidence of hypotension and postdural puncture headache (PDPH) is probably higher. Our findings oppose the classical notion that dura mater1 composed of longitudinal fibers running parallel to each other and oriented in the same axis as the spinal cord. the concept is that several needle tips allow separation rather than cutting of dural fibers and a smaller dural lesions.
We, under transmission and scanning electron microscopy, studied the human spinal dura mater, arachnoid layer and the lesion caused by 25G and 27G Whitacre needles and 22G, 25G, and 29G Quincke needles with the bevel oriented vertically and horizontally in relation to the spinal axis, performing standard punctures on the fresh cadavers.2–9
The results of dural and arachnoid lesions are shown in table 1. the lesion in the arachnoid layer was found partially open in some instances, while in others the edges were better approximated and appear almost closed. In samples with the arachnoid lesion partially open, we would often observe through the opening of the arachnoid layer, the dural laminae to be partially or fully closed. the lesions always consisted of a dural structural lesion underpinning the arachnoid lesion. In this context, ‘closed’ applies to lesion edge approximation rather than physical sealing of the hole flaps.
Quincke spinal needles caused a precise and controlled cut, while Pencil (Whitacre) point tips caused greater tearing of tissue margins and folding at the edges of the lesion. the edges of dural and arachnoid lesions caused by pencil point needles were ragged and irregular. There were no significant differences between parallel and perpendicular bevel approach using the same needle type.
For the arachnoid injury, which may contribute primarily to PDPH, pencil-point needle injury wounds are ‘avulsion’ lesions not ‘splitting’ lesions.
The etiology and pathogenesis of PDPH cannot be solely explained by the type and size of needle used, the effect of cerebral vasodilatation also should be considered.10
References
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