Article Text

Download PDFPDF
ESRA19-0617 Spinal anaesthesia still alive! Microanatomy of dural puncture lesions. Factors that affect its repair
  1. MA Reina1,
  2. LT Le-Wendling2,
  3. A Oviedo-Baena2,
  4. Y Zasimovich2,
  5. OC Nin2 and
  6. A Boezaart2,3
  1. 1CEU San Pablo University School of Medicine, Department of Anesthesiology, Madrid, Montepríncipe University Hospital, Madrid, Spain
  2. 2Division of Acute and Perioperative Pain Medicine, Department of Anesthesiology and the Department of Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
  3. 3Alon P. Winnie Research Institute, Gainesville, Florida, and Still Bay, South Africa, Madrid, Spain


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


  1. Franksson C, Gordh T. Headache after spinal anesthesia and a technique for lessoning its frequency. Acta Chirurgica Scand 1946;94:443–445.

  2. Reina MA, López A, Dittmann M, De Andrés JA. Structural analysis of the thickness of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:135–137.

  3. Reina MA, López A, Dittmann M, De Andrés JA. Analysis of the external and internal surface of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:130–134.

  4. Reina MA, Dittmann M, López A, van Zundert A. New perspectives in the microscopic structure of human dura mater in the dorso lumbar region. Reg Anesth 1997;22:161–166.

  5. Reina MA, Prats-Galino A, Sola RG, Puigdellívol-Sánchez A, Arriazu Navarro R, De Andrés JÁ. Structure of the arachnoid layer of the human spinal meninges: a barrier that regulates dural sac permeability. Rev Esp Anestesiol Reanim 2010;57:486–492.

  6. Reina MA, López A, Dittmann M, De Andrés JA. Ultrastructure of spinal dura mater. In: Reina MA, Ed. Atlas of Functional Anatomy of Regional Anesthesia and Pain Medicine. New York: Springer; 2015, pp.411–434.

  7. Reina MA, Pulido P, García De Sola R. Ultrastructure of spinal arachnoid layer. In: Reina MA, Ed. Atlas of Functional Anatomy of Regional Anesthesia and Pain Medicine. New York: Springer; 2015, pp. 435–454.

  8. Reina MA, De León Casasola OA, López A, De Andrés JA, Martín S, Mora M. An in vitro study of dural lesions produced by 25 Gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med. 2000;25:393–402.

  9. Reina MA, López A, Badorrey V, De Andrés JA, Martín S. Dura-arachnoids lesions produced by 22G Quincke spinal needles during a lumbar puncture. J Neurol Neurosurg Psychiatry 2004;75:893–897.

  10. revised May 19, 2019.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.