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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.3 Campinas May/June 2005
LETTER TO THE EDITOR
Needle fracture during spinal puncture. Case report
I was surprised by the report on needle fracture during spinal anesthesia 1. This complication should be a warning for median subarachnoid punctures throughout the whole interspinous ligament.
I consider the interspinous ligament a substitute for the introducer coming with fine needles. To the four difficult puncture predicting factors (patients above 40 years of age, slim, with Body Mass Index (BMI)2 25 and lumbar skeletal changes) I would like to add one more: professional activity.
Activities requiring long periods in the sitting position, especially truck/bus drivers, tend to present disk flattening followed by permanent paraspinal contracture, which impairs not only palpation of superficial anatomic references (spinous apophyses, when palpable) but also median puncture pathway through very thick ("hard") interspinous ligaments with chronic inflammation, thus impairing tactile sensitivity during needle progression.
Face to this, I always puncture the spinal space via paramedian route, in the sitting (preferable), lateral or prone position 2 (sensitive or posterior spinal anesthesia) without abdominal pad, smoothly advancing the fine needle (preferable 27G or 29G) in 1 to 2 cm stages.
If Cruvinel et al. 1 approached the spinal space through the paraspinal muscle, they would be able to better monitor any obstacles to needle advance, as opposed to what has happened through the interspinous ligament (probably too thick). The possible reason for needle fracture might have been several puncture attempts in an exceptionally too thick ligament with the same needle, thus weakening its metal alloy as suggested by the authors. Replacing needles used in previous failed attempts is not a demerit.
Karl Otto Geier, M.D.
We thank Dr. Geier's interest in our report and we have the following comments:
1. We share the surprise with the fact. We agree with the statement that it should be a warning. This was exactly the objective of our report: warning about the possibility of needle fracture when fine needles are used (27G or 29G). Fine needles imply brittleness. In cases where interspinous ligament is too thick and spinal puncture is difficult, needle fracture is a real possibility after several attempts, as shown by our report.
2. Enriching was the association of professional activity and difficult puncture. Dr. Geier used drivers as example. After reading his comments we have reviewed patient's records and noticed that he is a bus driver. It seems to us that this association should be scientifically investigated. One more lesson taught by this case: social history, which is often undervalued, could supply relevant information for the anesthetic strategy.
3. It is hard to say that if the paramedian route had been used needle fracture would be prevented. We agree that with this route we prevent interspinous ligament transposition, thus having fewer obstacles for needle progression.
4. Agreeing with Dr. Geier, we believe that there is no demerit in replacing excessively used or deformed needles by new ones. The report of this potential complication may supply substrate, especially for paying sources, to justify the use of more than one needle.
5. Last but not least, we highlight that difficulties and complications happen even with experienced professionals. If it is important to prevent them, it is even more important to be prepared to deal with them.
Marcos Guilherme Cunha Cruvinel, TSA
André V C Andrade
01. Cruvinel MGC, Andrade AVC - Fratura de agulha durante punção subaracnóidea. Relato de caso. Rev Bras Anestesiol, 2004;54:794-798.
02. Imbelloni LE, Vieira EM, Gouveia MA et al - Raquianestesia posterior para cirurgias anorretais em regime ambulatorial. Estudo piloto. Rev Bras Anestesiol, 2004;54:774-780.