title: Dural tissue trauma and cerebrospinal fluid leak after epidural needle puncture: effect of needle design, angle, and bevel orientation.
abstract: BACKGROUND
  The effects of epidural needle design, angle, and bevel orientation on cerebrospinal fluid leak after puncture have not been reported. The impact of these factors on leak rate was examined using a dural sac model. Dural trauma was examined using scanning electron microscopy.
  
  
  METHODS
  Human cadaveric dura, mounted on a cylindrical model, was punctured with epidural needles using a micromanipulator. Tissue was punctured at 15 cm H2O (left lateral decubitus) system pressure, and leak was measured at 25 cm H2O (semisitting) pressure. Leak rates and trauma were compared for the following: (1) six different epidural needles at 90 degrees, bevel parallel to the dural long axis; (2) 18-gauge Tuohy and 18-gauge Special Sprotte epidural needles, 30 degrees versus 90 degrees; (3) 18-gauge Tuohy, bevel perpendicular versus parallel to the dural long axis.
  
  
  RESULTS
  With the 90 degrees puncture, bevel parallel, the greatest leak occurred with a 17-gauge Hustead (516 +/- 319 ml/15 min), and the smallest leak occurred with a 20-gauge Tuohy (100 +/- 112 ml/15 min; P = 0.0018). A 20-gauge Tuohy puncture led to statistically significant reductions in leak (P value range, 0.0001-0.0024) compared with all needles except the Special Sprotte. With the 30 degrees versus 90 degrees angle, 30 degrees punctures with an 18-gauge Tuohy produced nonstatistically significant leak reductions compared with the 18-gauge Tuohy at 90 degrees. The puncture angle made no difference for the Special Sprotte. Nonsignificant reductions were found for the Special Sprotte compared with the Tuohy. With the 18-gauge Tuohy bevel orientation, perpendicular orientation produced nonstatistically significant reductions in leak compared with parallel orientation.
  
  
  CONCLUSIONS
  Cerebrospinal fluid leak after puncture was influenced most by epidural needle gauge. Leak rate was significantly less for the 20-gauge Tuohy needle.
authors.affiliation: Department of Anesthesia, Women's College Hospital Campus, Sunnybrook and Women's College Hospital, University of Toronto, Ontario, Canada. pamela.angle@swchsc.on.ca
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: Angle
authors.forename: Jean E
authors.initials: JE
authors.lastname: Kronberg
authors.forename: Dorothy E
authors.initials: DE
authors.lastname: Thompson
authors.forename: Cameron
authors.initials: C
authors.lastname: Ackerley
authors.forename: John Paul
authors.initials: JP
authors.lastname: Szalai
authors.forename: James
authors.initials: J
authors.lastname: Duffin
authors.forename: Peter
authors.initials: P
authors.lastname: Faure
mesh_terms: D000775:Anesthesia, Spinal / Q000009:adverse effects / Q000295:instrumentation*; D002555:Cerebrospinal Fluid; D004388:Dura Mater / Q000293:injuries*; D004867:Equipment Design; D006261:Headache / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D009339:Needles; D013129:Spinal Puncture / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods