Rationale and Objectives
To assess technical compliance among neuroradiology attendings and fellows to standard guidelines for lumbar puncture and myelography to minimize procedural complications such as iatrogenic meningitis and spinal headache.
Materials and Methods
We surveyed academic neuroradiology attendings and fellows in the e-mail directory of the Association of Program Directors in Radiology. We queried use of face masks, use of noncutting needles, and dural puncture practices. All data were collected anonymously.
Results
A total of 110 survey responses were received: 75 from neuroradiology attendings and 34 from fellows, which represents a 14% response rate from a total of 239 fellows. Forty-seven out of 101 (47%) neuroradiologists do not always wear a face mask during myelograms, and 50 out of 105(48%) neuroradiologists do not always wear a face mask during lumbar punctures, placing patients at risk for iatrogenic meningitis. Ninety-six out of 106 neuroradiologists (91%) use the Quincke cutting needle by default, compared to only 17 out of 109 neuroradiologists (16%) who have ever used noncutting needles proven to reduce spinal headache. Duration of postprocedure bed rest does not influence incidence of spinal headache and may subject patients to unnecessary monitoring. Only 15 out of 109 (14%) neuroradiologists in our study do not prescribe bed rest. There was no statistically significant difference in practice between attendings and fellows.
Conclusions
Iatrogenic meningitis and spinal headache are preventable complications of dural puncture that neuroradiologists can minimize by conforming to procedural guidelines. Wearing face masks and using noncutting spinal needles will reduce patient morbidity and lower hospitalization costs associated with procedural complications.
Lumbar punctures and myelograms may lead to rare but potentially fatal complications such as bacterial meningitis attributable to noncompliance with face mask use among health care personnel (HCP) . Aerosolized oral commensals and skin bacteria from HCPs, such as Streptococcus , Staphylococcus , Enterococcus , and Actinobacter , have been implicated as causative organisms . To reduce the risk of bacterial meningitis, the Centers for Disease Control (CDC) recommend that HCPs wear face masks when performing myelograms and lumbar punctures with injection . After the publication of these recommendations, there have been continued reports of bacterial meningitis outbreaks resulting from inadequate face mask use , calling into question the degree of compliance to the CDC recommendations.
The potentially grave risk of developing iatrogenic meningitis, as well as the excess morbidity associated with other procedural complications such as spinal headache, prompted our investigation into the current practices of neuroradiology fellows and attendings. We performed a survey on the use of face masks, the use of noncutting Sprotte and Whitacre spinal needles, and the length of postprocedure bed rest. A concerted effort to perform lumbar punctures and myelograms according to evidence-based medicine would help reduce the incidence of iatrogenic meningitis and spinal headache and decrease excess hospitalization costs associated with these complications.
Materials and methods
Literature Review of Procedural Guidelines
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Survey of Neuroradiologists
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Table 1
Survey of Neuroradiology Attendings and Fellows
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Cost Estimates of Procedural Complications
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Results
Standard Guidelines for Lumbar Punctures and Myelograms
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Survey Responses
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Table 2
Lumbar Puncture and Myelogram Practices among Neuroradiologists
Item Number of Attendings (%) Number of Fellows (%)P Value ∗ Number of LPs or myelograms over 6 months .799 0–20 29 (39) 10 (29) 21–40 19 (25) 9 (26) 41–60 11 (15) 10 (29) 61–80 5 (7) 3 (9) 81–100 5 (7) 1 (3) >100 6 (8) 1 (3) Use of face mask in lumbar puncture .098 Always 32 (43) 23 (68) At times 19 (25) 4 (12) Frequently 11 (15) 2 (6) Never 10 (13) 4 (12) No response 3 (4) 2 (6) Use of face mask in myelogram .262 Always 34 (45) 20 (59) At times 18 (24) 3 (9) Frequently 7 (9) 2 (6) Never 12 (16) 5 (15) No response 4 (5) 4 (12) Frequency of Quincke needle use .841 1–10 12 (16) 2 (6) 11–20 15 (20) 7 (21) >20 40 (53) 20 (59) Do not use 6 (8) 4 (12) No response 2 (3) 1 (3) Frequency of Whitacre needle use .416 1–10 6 (8) 1 (3) 11–20 0 (0) 0 (0) >20 1 (1) 0 (0) Do not use 43 (57) 18 (53) No response 25 (33) 15 (44) Frequency of Sprotte needle use .940 1–10 5 (7) 2 (6) 11–20 3 (4) 0 (0) >20 0 (0) 0 (0) Do not use 41 (55) 18 (53) No response 26 (35) 14 (41) Default needle size .703 18G 1 (1) 1 (3) 20G 24 (32) 8 (24) 21G 4 (5) 2 (6) 22G 42 (56) 23 (68) 23G 2 (3) 0 (0) 25G 2 (3) 0 (0) Postprocedure bed rest .385 None 11 (15) 4 (12) 1–3 hours 38 (51) 25 (74) 3–6 hours 21 (28) 4 (12) >6 hours 5 (7) 1 (3)
LP, Lumbar puncture.
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Cost Estimates of Procedural Complications
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Discussion
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Acknowledgments
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