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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.54 no.6 Campinas Nov./Dec. 2004
Needle fracture during spinal puncture. Case report*
Fractura de aguja durante punción subaracnóidea. Relato de caso
Marcos G C Cruvinel, TSA, M.D.I; André V C Andrade, M.D.II
dos Hospitais Vera Cruz e Life Center
IIAnestesiologista do Hospital Vera Cruz
OBJECTIVES: After fine spinal needles (26G, 27G and 29G) introduction and
consequent decrease in post dural puncture headache, spinal anesthesia is being
increasingly used. Its complications are uncommon however recently we have observed
a seemingly unusual complication: needle fracture during spinal puncture. This
report aimed at describing the fact and at pointing its possible causes in addition
to its prevention.
CASE REPORT: Male patient, 53 years old, 90 kg, 175 cm, with chronic systemic hypertension and renal failure presented for emergency renal transplantation. Spinal morphine was proposed for postoperative analgesia. Puncture at L3-L4 with 27G needle was attempted without success, and was followed by attempt at L2-L3 when needle deformation was observed. Needle has broken at removal, leaving behind a 43 mm fragment in the L2-L3 interspinous ligament, which was confirmed by fluoroscopy. General anesthesia was induced and fragment was removed by fluoroscopic surgical exploration. Renal transplantation was then performed uneventfully.
CONCLUSIONS: Decreased needle gauge has decreased post dural puncture headache but has also made needles fragiles. When ligaments are more resistant and puncture is attempted more than once there may be material stress leading to needle fracture. In conclusion, when there is increased resistance to needle introduction and puncture difficulty, the risk of deformation and potential fracture should be balanced against fine needle advantages.
Key Words: ANESTHETIC TECHNIQUES, Regional: spinal block; COMPLICATIONS
Y OBJETIVOS: Después de la introducción de las agujas de calibre
fino (26G, 27G y 29G) y la consecuente disminución de la incidencia de
cefalea pos-punción de dura-máter, la raquianestesia viene siendo
cada día más empleada. Sus complicaciones son poco frecuentes.
Recientemente, sin embargo, fue observada una complicación aparentemente
rara, de fractura de la aguja durante punción subaracnóidea. El
objetivo de este relato es registrar el hecho y exponer las posibles causas
y su prevención.
RELATO DEL CASO: Paciente del sexo masculino, 53 años, 90 kg, 175 cm, portador de hipertensión arterial sistémica crónica e insuficiencia renal crónica se presentó, en carácter de urgencia, para trasplante renal. Fue propuesta la administración de morfina subaracnóidea con la finalidad de analgesia pós-operatoria. Inicialmente se intentó, sin éxito, punción en L3-L4 con aguja 27G, se siguió una tentativa de punción en L2-L3, cuando se percibió deformación de la aguja. Al ser retirada la aguja se partió, permaneciendo un fragmento de 43 mm en el ligamento interespinoso de L2-L3, confirmado por fluoroscopia. Fue inducida anestesia general y se procedió a una exploración quirúrgica guiada por fluoroscopia con retirada del fragmento de la aguja. A continuación, el trasplante renal fue realizado sin intercurrencias.
CONCLUSIONES: La disminución del calibre de las agujas, que trajo la ventaja de la reducción de la incidencia de cefalea después de punción de la dura-máter, hizo también con que ellas se volviesen más débiles. En casos donde los ligamentos son más fuertes y la punción intentada más de una vez, puede haber deformación del material que se pone quisquilloso a la quiebra. Se concluye que en situaciones en las que hay resistencia aumentada por el pasaje de la aguja o dificultad de punción, el riesgo de su deformación y la posibilidad de fractura deben ser afrontados con las ventajas del uso de agujas de fino calibre.
Spinal anesthesia is simple and effective. In addition to virtually no systemic toxicity risk, it has fast onset, promotes total analgesia with excellent muscle relaxation and is widely used in our country. After the introduction of fine needles (26G, 27G and 29G) and consequent decrease in post dural puncture headache it has become the most widely used regional technique 1-3. It is the procedure of choice in many situations, being routinely used with low incidence of complications. Most common complication in the literature is post dural puncture headache. Other less frequent complications include failure, low back pain, bradycardia, upper blockade, neurological complications such as cauda equina syndrome, transient neurological symptoms and permanent neurological injuries including paraplegia, cardiac arrest and death 3-13.
However, an uncommon complication seldom described in the literature has been recently observed, namely needle fracture during spinal puncture 14,15. This report aimed at describing the fact and at pointing its possible causes in addition to its prevention.
Male patient, 53 years old, 90 kg, 175 cm, with chronic systemic hypertension and renal failure following hypertensive nephropathy, presented for emergency renal transplantation. Patient was under hemodialysis with preoperative tests without significant changes, except for increased serum creatinine and urea, compensated metabolic acidosis, mild anemia and diastolic dysfunction at echocardiogram. Spinal morphine (200 µg) was proposed aiming at postoperative analgesia. After monitoring with ECG, pulse oximetry and continuous mean blood pressure, patient was sedated with 3 mg midazolam and placed in the sitting position. Spaces between spinous processes L2-L3 and L3-L4 were easily located. Puncture at L3-L4 with 27G Quincke needle (B Braun®) was unsuccessful and was followed by attempt at L2-L3 when needle deformation was observed. Resistance to mandrel removal was increased and it was mildly deformed (Figure 1). Since there was no CSF reflux we confirmed the suspicion that possible needle progression was due to its deformation and not to its advance toward spinal space. Needle has broken at removal leaving behind a 43 mm fragment (Figure 2) in L2-L3 interspinous ligament, which was confirmed by fluoroscopy.
Figure 3 shows possible deformation and rupture mechanism. General anesthesia was induced and fragment was removed by fluoroscopic surgical exploration. Renal transplantation was then performed uneventfully.
Although uncommon and initially surprising, a more careful thought has shown that this complication is not totally unexpected. Benham 16 has examined 222 needles and has found deformation in 36 (16.2%). Among different needle types and gauges, 25G needles were significantly less damaged as compared to finer needles. Decreased needle size, with the advantage of decreasing post dural puncture headache, has also made them fragile, leading to higher puncture difficulties and possibility of failures 3-9. When ligaments are more resistant and puncture is attempted more than once, there may be material stress which may lead to fracture. Oliveira Filho et al. 17 have found 7.29% more than four neuraxial blockade attempts. Our patient presented three out of the four predicting factors for difficult puncture studied by this author: age above 40 years, body mass index above 25 kg.m2 and low height. Patient did not seem to have anatomic vertebral column changes.
Chaney 18 calls the attention to the possibility of major deformities in fine needles, in spite of the external appearance of routine puncture. Imbelloni et al. 19 has reported 29G needle deformity highlighting that this has never happened with 27G needles, differently from our case. Although uncommon, there may be marked needle deformation in cases of difficult puncture. Its prompt replacement is recommended for all cases.
The indication of fine needle puncture for our patient is arguable since surgery would be major, he was not a young patient and had predicting factors for difficult puncture. Maybe a thicker 25G needle would not represent increased risk for headache with less chance for deformation. Another point to consider was the insistence in puncturing with 27G needle. Even without visible signs of needle wear, maybe the best decision would be to replace it after the first unsuccessful attempt.
In conclusion, our case suggests that when there is increased resistance to needle progression or puncture difficulty, the risk for deformation and consequent possibility of fracture should be balanced against fine needle advantages.
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Submitted for publication
April 8, 2004
Accepted for publication August 12, 2004
* Received from Departamento de Anestesiologia do Hospital Vera Cruz, Belo Horizonte, MG