Transcript The Evolution of the Spinal Needles Joseph Eldor, MD An Inguinal Hernia operation in 1382…Without Spinal needles Valsalva, in 1682, was the first to remark.

The Evolution of the Spinal
Needles
Joseph Eldor, MD
An Inguinal Hernia operation in
1382…Without Spinal needles
Valsalva, in 1682, was the first to remark on
the CSF when he cut open the spine of a
dog and noticed the liquid "which in all its
aspects resembles that which is found in
the joints".
In 1764, Cotugno described the presence of
a collection of water around the brain and
inside the spinal column.
In 1825, Magendie was credited with
appreciating that this fluid circulated
around the brain and the spinal column.
By 1841, Zophar Jayne of Illinois had
designed a syringe attached to a small,
sharp, hollow beak with an opening on the
side near the tip.
Subsequently, in 1853, Daniel Ferguson
developed a syringe and hollow platinum
trochar with an oblique opening on one
side encased in an outer tubing, also with
an oblique opening.
Ferguson is credited by some as being the
first to use a hollow needle with a
sharpened extremity, allowing skin
penetration and attachment to a syringe.
Alexander Wood of Edinburgh is credited
with developing the first hollow
hypodermic needle in 1853.
The birthdate of regional anesthesia was
September 15, 1884, the date on which
Carl Koller , an intern at the Allgemeines
Krankenhaus in Vienna, conclusively
demonstrated the topical anesthetic
properties of cocaine applied to the
conjunctiva of the eye.
The first application of the principle of nerve
blocking for surgical anesthesia was
carried out early in November 1884, when
Halsted removed a supraorbital lipoma
following cocainization of the supraorbital
nerve at the supraorbital notch.
The first spinal anesthetic was administered
accidentally by J. Leonard Corning, a
Neurologist from New York in 1885.
Corning was experimenting with the action
of cocaine on the spinal nerves of a dog
when he accidentally breached the dura
between two lumbar vertebra, causing
paralysis of the hindquarters, and hence
inadvertently performed the first spinal
anesthesia.
Corning developed his own spinal needle
and introducer. The needle was made of
gold or platina. The needle tip was based
on the hypodermic needle developed by
Wood in 1853. It was sharp,with a short
cutting bevel.
Corning Needle (1900)
In 1891, Quincke published a paper
describing a standardised technique of
lumbar puncture for the release of CSF for
diseases associated with increased
intracranial pressure. He used a needle of
which it is difficult to find a description,
except that it was a sharp, bevelled,
hollow needle.
August Bier, on August 24, 1898, asked his assistant, Dr.
Hilderbrandt, "to perform a lumbar puncture on me", 8
days after he first performed it on a 34-year-old patient
for excision of a tuberculous capsule at the ankle joint.
Bier wrote that he did not feel any discomfort "except for
a quick flash of pain in one leg at the moment that the
needle penetrated the meninges". Unfortunately, the
experiment was not successful because of an error (the
syringe did not fit the needle tightly... and consequently
some CSF ran out and most of the cocaine was lost). No
sensory loss ensued.
Dr. Hilderbrandt immediately offered to
submit himself to the experiment, which
was successful.
Both of them "went to eat after the experiments
were performed on our bodies. We had no
physical discomfort, we ate, drank wine, and
smoked several cigars". However, next morning,
after a one hour morning stroll Bier felt slight
headache which increased in intensity during the
course of the day. Nine days after the puncture,
all the symptoms disappeared. After 3 more
days, "I was able to go on a train trip without
discomfort and was fit enough to participate in a
strenuous 8 day hunting trip in the mountains".
In 1899, Bier published six case reports of
surgery to the lower limbs under spinal
anesthesia with cocaine. The needle used
was described as a Quincke needle.
Bier also designed a larger bore needle that
needed no introducer. The Bier spinal
needle was 15G or 17G, with a long,
cutting bevel and a sharp point.
Bier Needle (1899)
Dr. Augustus Karl Gustav Bier
(1861-1949)
Amputation in 1890
Bainbridge described a needle in 1900 that
was attached to a metal syringe. It had a
small circular hub, a short, sharp cutting
bevel and a stylet with a matching bevel.
Bainbridge Needle (1900)
Barker designed in 1907 a needle which
had a sharp, medium-length bevel and a
stylet with a matching bevel. Barker
advised that needles be made of hard
nickel.
Barker Needle (1907)
ALL SPINAL NEEDLES ARE NOT
CREATED EQUAL…
As early as 1898 Sicard realised that the
cause of PDPH (Post Dural Puncture
Headache) was the loss of CSF through
the dural tears.
In 1914, Ravaut advised the use of finer
needles to limit the size of the dural tear.
In 1914, Babcock described a needle that
was closer in design to the original
Corning needle but with a finer cannula to
limit the incidence of PDPH. It had a
sharp, medium-length bevel with a
matching stylet. It was made of iridised
platinum or gold and was 20G in diameter.
Referred to as the Quincke-Babcock
needle.
Quincke-Babcock Needle (1914)
Gaston Labat designed a spinal needle that
was made of unbreakable nickel. It was a
medium-gauge cannula with a short, sharp
bevel and matching stylet, with the tip
ground to match the bevel of the cannula.
Labat Needle (1921)
In 1922, Hoyt published his theory that the
large bore needles were, because of their
rigidity, resulting in large holes in the dura
and an increased loss of CSF. He
proposed the use of a two-needle
technique with a larger bore outer needle
being used for penetration of the outer
tissues and a finer inner needle for
penetration of the dura and arachnoid.
Hoyt Needle (1922)
In the 1920s, heat-tempered stainless steel
was developed in England. Towards the
end of World War I, Germany was
manufacturing a hard steel alloy that was
rustproof, very resistant to breaking and
could be worked to a sharp point that was
resistant to deformation. The rustproof
products became the mainstay of needle
production.
The Greene needle was sized between 20G
and 26G. The point was a rounded, noncutting bevel of medium length with a
matching, bevelled, fitted stylet.
There is some disagreement as to the actual
date of the introduction of the Greene
needle: Herbert Morton Greene presented
his work in 1923 and 1926.
However, the design should perhaps be
attributed to Barnett A Greene who, in
1950, published on the use of a 26G
needle passed through a 21g introducer.
Greene Needle (1926 or 1950)
George Praha Pitkin devised in 1927 a 20G
or 22G needle made of relatively flexible
rustproof steel with a collar to mark the
depth of insertion. The tip of the needle
had a short, sharp bevel ground off to a
taper of 45º, resulting in a rounded,
blunted bevel heel.
Pitkin Needle (1927)
Kirschner,in 1931, described a needle for
spinal anesthesia with an opening in the
shaft just proximal to the beveled closed
end. He claimed that the lateral orifice
allowed unilateral, cephalad or caudal
anesthesia to be administered.
Rovenstine took up the design idea of the
closed-end needle and in 1944 published
a paper describing his spinal needle.
Rovenstine’s needle was 19G or 20G. It
had a closed, short-bevelled point with a
lateral orifice 2 mm from the distal end of
the needle.
Rovenstine Needle (1944)
Haraldson, a Swedish doctor, published a
paper in 1951 (several months before Hart
and Whitacre) that described a needle with
a solid non-cutting tapering point and an
orifice on the conical surface 2 mm from
the actual tip of the needle.
He quoted a PDPH rate of 9% for the noncutting needle (none severe) as opposed
to 32% (18% severe) for a cutting needle.
Hart and Whitacre published their paper
entitled: “Pencil point needle in prevention
of post spinal headache” in October 1951.
Whitacre Needle (1951)
In 1955, Brace produced a needle with a
medium length, sharp, cutting bevel.
Brace Needle (1955)
Continuous spinal anesthesia
needles
Dean had described a technique of
continuous spinal anesthesia in 1907 in
which he left the spinal needle in situ
during surgery and injected more local
anesthetic solution as and when
necessary…
Lemmon published a paper in 1940
describing a 17G or 18G nickel/silver alloy
malleable needle and introducer with a
sharp, medium-length, cutting bevel and a
small opening in the long side of the bevel
to enable free flow of CSF. The patient lay
on a mattress and table that had a hole
placed so as to accommodate the
protruding needle…
Lemmon Needle (1940)
In 1943, Hingson presented his modification
of the Lemmon needle.
Hingson-Ferguson Needle (1943)
In 1944, Tuohy used a 15G directional spinal
needle through which he passed a nylon
ureteric catheter into the subarachnoid
space to allow continuous spinal
anesthesia.
Edward Boyce Tuohy (1908-1959)
Tuohy Needle (1944)
A year later, Tuohy published an article
describing an adaptation of his needle to
incorporate a “Huber tip”, which allowed
directional control of the catheter to point
cephalad or caudal as required.
One of the modifications of the Tuohy
needle was the Tuohy-Flowers needle,
with a shorter and blunter bevel and the
stylet protruding beyond the bevel of the
needle to ease insertion of the point
through tough ligaments.
Tuohy-Flowers Needle (1956)
Another needle for continuous spinal
anesthesia was that of Cappe and
Deutsch who described in 1953 a
malleable cone-tipped spinal needle. It
was 20G in diameter and had a Whitacre
tip and an 18G introducer.
Cappe and Deutsch Needle (1953)
On October 13, 1947, two incidents occurred which
resulted in one of the most famous of all medicolegal
actions as far as the speciality of anesthesia was
concerned. Two patients, Cecil Roe and Albert Woolley
who were on the same operative list for relatively minor
surgical procedures, developed permanent, painful,
spastic paraparesis following spinal anesthesia with
hypobaric 1:1500 cinchocaine (nupercaine; dibucaine)
administered by the same anesthetist. Both patients
sued the hospital and the anesthetist and the case came
to court in October 1953 and lasted 11 days.
This case had a profound effect on the
practice of spinal anesthesia, as
anesthetists were fearful of producing
permanent neurological damage and the
technique, in the UK, was probably
retarded by 20-25 years.
However, Noble and Murray in a review
published in 1971 of 78,746 spinal
anesthetics in Canada, found no
permanent neurological sequelae.
Similarly, Moore and Bridenbaugh in 1968
surveyed 12,386 and Dripps and Vandam
in 1954 - 10,098 spinal anesthetics, and
did not find evidence of permanent
neurological deficits.
In an editorial published in 1975 on spinal
anesthesia Scott and Thorburn wrote that "it has
been virtually ignored in the last 20 years for
several reasons, including the introduction of
muscle relaxants. Since the Woolley and Roe
cases, reported in 1954, in which two patients
developed painful and permanent paraplegia
following spinal anaesthesia, the use of the
technique in the United Kingdom has been
confined to a few enthusiasts".
Levy described his stylet-point needle in
1957, 29 years after Sise first described a
needle where the stylet formed the tip of
the advancing needle. Levy needle was a
20G needle with a sharp pencil-point tip
that included the stylet, and which
protruded 2-3 mm beyond the bevelled
end of the cannula, with a smooth junction
between the two.
Levy Needle (1957)
Tapered needles were one way of providing
needle rigidity while having the finer tip.
The cannula was 20g at the hub, tapering
to 24g at the tip. The tapers available were
either a gradual taper or a distal taper.
Gradual Taper Needle
Distal Taper Needle
The 1960s saw the introduction of
disposable spinal needles.
The 1970s saw an increasing use of
epidural anesthesia for surgical
procedures.
However, by the late 1980s, spinal
anesthesia was once more becoming a
popular technique.
Thirty seven years after Whitacre’s
development of the pencil-point needle,
Sprotte published in 1987 his paper on a
modification of the Whitacre needle.
Jürgen Sprotte (born:1945)
Sprotte Needle (1987)
A study describing the Atraucan needle was
published in 1993. It has a double bevel
with the sharp point making an initial
incision. The second part of the bevel then
dilates this incision rather than cutting a
larger hole.
Atraucan Needle (1993)
Eldor decribed in 1996 a pencil point tip with
two lateral holes opposite each other.
Eldor Needle (DHPP) (1996)
Eldor Needle: Advantages
- The area of the two holes is almost the same as of the
single hole Sprotte needle`s area, which enables more
rapid CSF reflux.
- The anesthetic solution injection spreads through both
holes.
- There is a possible advantage of a more diffuse
anesthetic dispersion and less anesthetic solution
dosage.
- The Eldor spinal needle allows anesthetic solution
injection when one of the holes is obstructed by a tissue
fragment, through the opposite hole.
- It reduces the incidence of the Transient Neurologic
Symptoms (TNS).
Eldor needle dispersion
In 2000, an article was published that
described a “new design concept” – a
modification of a Quincke needle to make
a “tip holed spinal needle”. It is marketed
as the “Ballpen” without mentioning its true
inventor from 1957 – Dr. Levy.
Ballpen Needle (2000)
In a meta-analysis of a total of 29 studies with a 2,813
patients ALMOST ALL THE CASES OF TNS
(TRANSIENT NEUROLOGIC SYMPTOMS) WERE
DONE BY THE WHITACRE, SPROTTE, PENCIL POINT,
or the SMALL BORE QUINCKE.
(Eberhart LH, Morin AM, Kranke P, Geldner G, Wulf H.
Transient neurologic symptoms after spinal anesthesia. A
quantitative systematic overview (meta-analysis) of
randomized controlled studies. Anaesthesist 2002
Jul;51(7):539-46).
Single hole dispersion
“The most likely explanation is
maldistribution of the drug in the CSF
causing high local concentrations around
certain nerve roots.” (Gisvold SE. Editorial.
Acta Anaesthesiol Scand 1999; 43: 369–
370).
A dural hole made by a 22G spinal
needle
A dural hole made by a 28G Pencil
point spinal needle
"Evolution is not a force but a process. Not a
cause but a law."
John Morley (1838-1923)
THANK YOU