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Regarding “Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index”

Regarding “Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus... LETTERS Regarding “Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index” e read with interest the article by Philip et al on postpro- prefer them while the more experienced attending radiologists Wcedural complications after fluoroscopically-guided dural prefer Whitacre needles? Needles were chosen by the operators in puncture (fLP) because their results were dissimilar to those in this retrospective study, so operator preference, experience, and our own research. In our study of 2141 patients who underwent expertise are important confounding variables that were not fLP with Quincke needles, 0.8% (18/2141) required an epidural included. blood patch (EBP) for postprocedural headache. In contrast, of The advantages of atraumatic needles in unguided (blind) the 2258 patients who underwent fLP with Quincke needles in dural punctures have been established in the neurology litera- the study by Philip et al, 4.3% (97/2258) required EBP. Of the ture. It remains controversial, however, whether these advan- patients who underwent fLP with Whitacre spinal needles in their tages are present when image guidance is used. The rate of EBP study, 1.4% (30/2177) required EBP. We have several questions in fLP is markedly lower than that for unguided punctures, for Philip et al that might help us to understand the higher rates which may obviate any advantage of needle choice. of EBP in their patients and may call into question their conclu- It is unclear to us why our rate of postprocedural EBP is sub- sion that atraumatic needles result in lower rates of EBP from fLP stantially lower than that recorded by Philip et al. This rate may in overweight and obese patients. reflect differences in technique, patient population, or operator Young age and female sex are predisposing factors for posi- expertise. The work by Philip et al is interesting, but firm conclu- tional headaches following lumbar puncture, as confirmed in our sions regarding the relative advantages of needle type in fLP 2 1 study. No data were provided in the article by Philip et al should be based on literature that controls for patient characteris- regarding the age and sex of patients. There might be a higher tics such as age and sex as well as operator characteristics such as percentage of young women among the patients treated with experience. Quincke needles or among their patient population overall com- pared with our cohort. Disclosure forms provided by the authors are available with the full text and PDF of this article at www.ajnr.org. We note in Table 3 of the article by Philip et al that the P value for needle caliber was ,.001 in patients with a body mass REFERENCES index of .30, yet the 95% confidence interval of the odds ratio 1. Philip JT, Flores MA, Beegle RD, et al. Rates of epidural blood patch encompasses unity. These statistics appear to be internally dis- following lumbar puncture comparing atraumatic versus bevel-tip crepant. We note this particularly because in our study, we did needles stratified for body mass index. AJNR Am J Neuroradiol 2022;43:315–18 CrossRef Medline not find the needle caliber to be a predictive variable. 2. Rodriguez D, Branstetter BF, Agarwal V, et al. JOURNAL CLUB: inci- All procedures in our study were performed by a single expe- dence of complications following fluoroscopically guided lumbar rienced operator. Philip et al indicated that procedures in their punctures and myelograms. AJR Am J Roentgenol 2016;206:20–25 study were performed by radiologists, but they provided no infor- CrossRef Medline mation about years in practice or number of cases performed by each practitioner in a typical year. It is unclear whether trainees B. Branstetter were the primary operators in these procedures. Given that V. Agarwal M. Hughes Quincke needles are more steerable, might radiology residents Department of Radiology University of Pittsburgh Medical Center http://dx.doi.org/10.3174/ajnr.A7562 Pittsburgh, Pennsylvania AJNR Am J Neuroradiol 43:E11 Feb 2023 www.ajnr.org E11 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

Regarding “Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index”

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Publisher
American Journal of Neuroradiology
Copyright
© 2022 by American Journal of Neuroradiology
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.a7562
Publisher site
See Article on Publisher Site

Abstract

LETTERS Regarding “Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index” e read with interest the article by Philip et al on postpro- prefer them while the more experienced attending radiologists Wcedural complications after fluoroscopically-guided dural prefer Whitacre needles? Needles were chosen by the operators in puncture (fLP) because their results were dissimilar to those in this retrospective study, so operator preference, experience, and our own research. In our study of 2141 patients who underwent expertise are important confounding variables that were not fLP with Quincke needles, 0.8% (18/2141) required an epidural included. blood patch (EBP) for postprocedural headache. In contrast, of The advantages of atraumatic needles in unguided (blind) the 2258 patients who underwent fLP with Quincke needles in dural punctures have been established in the neurology litera- the study by Philip et al, 4.3% (97/2258) required EBP. Of the ture. It remains controversial, however, whether these advan- patients who underwent fLP with Whitacre spinal needles in their tages are present when image guidance is used. The rate of EBP study, 1.4% (30/2177) required EBP. We have several questions in fLP is markedly lower than that for unguided punctures, for Philip et al that might help us to understand the higher rates which may obviate any advantage of needle choice. of EBP in their patients and may call into question their conclu- It is unclear to us why our rate of postprocedural EBP is sub- sion that atraumatic needles result in lower rates of EBP from fLP stantially lower than that recorded by Philip et al. This rate may in overweight and obese patients. reflect differences in technique, patient population, or operator Young age and female sex are predisposing factors for posi- expertise. The work by Philip et al is interesting, but firm conclu- tional headaches following lumbar puncture, as confirmed in our sions regarding the relative advantages of needle type in fLP 2 1 study. No data were provided in the article by Philip et al should be based on literature that controls for patient characteris- regarding the age and sex of patients. There might be a higher tics such as age and sex as well as operator characteristics such as percentage of young women among the patients treated with experience. Quincke needles or among their patient population overall com- pared with our cohort. Disclosure forms provided by the authors are available with the full text and PDF of this article at www.ajnr.org. We note in Table 3 of the article by Philip et al that the P value for needle caliber was ,.001 in patients with a body mass REFERENCES index of .30, yet the 95% confidence interval of the odds ratio 1. Philip JT, Flores MA, Beegle RD, et al. Rates of epidural blood patch encompasses unity. These statistics appear to be internally dis- following lumbar puncture comparing atraumatic versus bevel-tip crepant. We note this particularly because in our study, we did needles stratified for body mass index. AJNR Am J Neuroradiol 2022;43:315–18 CrossRef Medline not find the needle caliber to be a predictive variable. 2. Rodriguez D, Branstetter BF, Agarwal V, et al. JOURNAL CLUB: inci- All procedures in our study were performed by a single expe- dence of complications following fluoroscopically guided lumbar rienced operator. Philip et al indicated that procedures in their punctures and myelograms. AJR Am J Roentgenol 2016;206:20–25 study were performed by radiologists, but they provided no infor- CrossRef Medline mation about years in practice or number of cases performed by each practitioner in a typical year. It is unclear whether trainees B. Branstetter were the primary operators in these procedures. Given that V. Agarwal M. Hughes Quincke needles are more steerable, might radiology residents Department of Radiology University of Pittsburgh Medical Center http://dx.doi.org/10.3174/ajnr.A7562 Pittsburgh, Pennsylvania AJNR Am J Neuroradiol 43:E11 Feb 2023 www.ajnr.org E11

Journal

American Journal of NeuroradiologyAmerican Journal of Neuroradiology

Published: Feb 1, 2023

References