So much of what we do is based upon either what we’ve been taught or what the sales person shows us that our department is willing to purchase. Lumbosacral epidural injections are an accepted way to manage chronic low back pain, particularly if there’s a radicular component. Research has demonstrated the need for fluoroscopy, what should be injected, and the appropriate injection technique. Dr. Jae Hun Kim, Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Hwayangdong, Kwangjin-gu, Seoul, Korea, and colleagues randomized 616 patients who underwent 1376 transforaminal epidural steroid injections (TFESIs) to determine whether intravascular injection was more likely with a Whitacre or a Quincke needle. Their findings are discussed in the article “A Comparison of Quincke and Whitacre Needles with Respect to Risk of Intravascular Uptake in S1 Transforaminal Epidural Steroid Injections: A Randomized Trial of 1376 Cases” that was published in this month’s issue of Anesthesia & Analgesia.
This was a prospective and randomized trial. Both needles were 25G and 9 cm in length. Patients were randomized to receive either of the two needles. The procedure was performed in the prone position, guided by fluoroscopy. One-sided injections were performed in 242 cases and bilateral injections in 1134 cases.
Intravascular injection was greater if a Quincke needle was used (24% intravascular injection when a Quincke needle was used compared to 17% intravascular injection when the Whitacre needle was used). Two of the twelve physicians had higher intravascular injection rates relative to the others. Intravascular injection was also correlated with positive blood aspiration and intrasacral bone contact.
This is not the first study to show the advantage of a Whitacre needle compared to a Quincke needle. Specifically, postdural puncture headaches are less likely with a Whitacre needle. Some would argue that it is unethical to use a Quincke needle because of the higher incidence of postdural puncture headache, particularly in obstetric patients. Might that also be true for lumbosacral epidural injections?
Risk factors for postdural puncture headache are discussed in OpenAnesthesia.