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J.T. Philip, M.A. Flores, R.D. Beegle, S.C. Dodson, S.A. Messina and J.V. Murray
American Journal of Neuroradiology February 2023, 44 (2) E12; DOI: https://doi.org/10.3174/ajnr.A7770
J.T. Philip
aUniversity of Texas Southwestern Medical CenterDallas, Texas
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M.A. Flores
bAdventHealth Medical Group Radiology at Central FloridaOrlando, Florida
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R.D. Beegle
bAdventHealth Medical Group Radiology at Central FloridaOrlando, Florida
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S.C. Dodson
bAdventHealth Medical Group Radiology at Central FloridaOrlando, Florida
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S.A. Messina
cMayo Clinic RochesterRochester, Minnesota
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J.V. Murray Jr.
dMayo ClinicJacksonville, Florida
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We appreciate the feedback from Branstetter et al. As with any retrospective study, our study has limitations. One of the main limitations of our study is that the lumbar punctures (LPs) were performed by a variety of radiologists with variable levels of experience, including trainees.1 While this feature introduces potential confounding variables, we believe it is more indicative of how LPs are performed in most radiology departments; thus, it is a more accurate estimation of post–dural puncture headaches (PDPHs) necessitating an epidural blood patch (EBP). The number of LPs performed in radiology has been increasing.2 They are performed by a variety of practitioners with a variety of experience levels, including increasingly by nonphysician providers such as in the study of Rodriguez et al.3 We believe our study is a “real-world” estimation of EBP rates in a heterogeneous patient population with a heterogeneous group of operators. Our study was designed to examine whether there were differences in EBP rates when comparing traumatic with atraumatic needles stratified to the body mass index, not to determine whether there were different EBP rates based on sex or age.

We do not know why our rates of EBP in the Quincke group were higher than those found in the study of Rodriguez et al.3 A different patient cohort certainly could be contributory. At the institution where the data were collected, there was a relatively low threshold to perform an EBP in patients with post-LP headaches, and there was a streamlined process for clinicians to refer patients for EBP. Perhaps the threshold for performing an EBP was different at the two institutions. The rate of post-LP “any headache” was higher than the “severe headache” rate at 2.2% in the study of Rodriguez et al.3 Our rate of EBP in the Quincke group was well below that reported in the study from Hatfield et al4 for fluoroscopically guided LPs with a 22-ga Quincke needle, which was 15.2%.

We acknowledge an error in Table 3 of our article. As stated in our results section, we found no statistically significant difference in rates of EBP when comparing the 22-ga Quincke with the 20-ga Quincke needle. The confidence interval in Table 3 is correct. The corrected P value is .411.

We believe that our study and other studies involving both fluoroscopically guided and non-fluoroscopically guided LPs are compelling in demonstrating an increased rate of PDPHs necessitating an EBP when comparing traumatic-versus-atraumatic spinal needles. However, these studies suffer from the inherent limitations of retrospective studies. We believe a well-designed prospective randomized study would likely end any remaining debate.

References

  1. 1.↵
    1. Philip JT,
    2. Flores MA,
    3. Beegle RD, et al
    . Rates of epidural blood patch following lumbar puncture comparing atraumatic versus bevel-tip needles stratified for body mass index. AJNR Am J Neuroradiol 2022;43:315–18 doi:10.3174/ajnr.A7397 pmid:35027350
    Abstract/FREE Full Text
  2. 2.↵
    1. Johnson DR,
    2. Waid MD,
    3. Rula EY, et al
    . Comparison of radiologists and other specialists in the performance of lumbar puncture procedures over time. AJNR Am J Neuroradiol 2021;42:1174–81 doi:10.3174/ajnr.A7049 pmid:33664117
    Abstract/FREE Full Text
  3. 3.↵
    1. Rodriguez D,
    2. Branstetter BF,
    3. Agarwal V, et al
    . JOURNAL CLUB: incidence of complications following fluoroscopically guided lumbar punctures and myelograms. AJR Am J Roentgenol 2016;206:20–25 doi:10.2214/AJR.15.14664 pmid:26700333
    CrossRefPubMed
  4. 4.↵
    1. Hatfield MK,
    2. Handrich SJ,
    3. Willis JA, et al
    . Blood patch rates after lumbar puncture with Whitacre versus Quincke 22- and 20-gauge spinal needles. AJR Am J Roentgenol 2008;190:1686–89 pmid:18492925
    CrossRefPubMed
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American Journal of Neuroradiology: 44 (2)
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J.T. Philip, M.A. Flores, R.D. Beegle, S.C. Dodson, S.A. Messina, J.V. Murray
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American Journal of Neuroradiology Feb 2023, 44 (2) E12; DOI: 10.3174/ajnr.A7770

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J.T. Philip, M.A. Flores, R.D. Beegle, S.C. Dodson, S.A. Messina, J.V. Murray
American Journal of Neuroradiology Feb 2023, 44 (2) E12; DOI: 10.3174/ajnr.A7770
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