Journal of Clinical Anesthesia (2014) xx, xxx–xxx
Case Report
Broken spinal needle: case report and review of the literature☆ Caroline Martinello MD (Obstetric Anesthesiology Fellow)⁎, Ruby Rubio MD (Staff Anesthesiologist), Erin Hurwitz MD (Assistant Professor of Anesthesiology), Michelle Simon MD (Assistant Professor), Rakesh B. Vadhera MD, FRCA, FFARCSI (Professor; Director of Obstetric Anesthesia) Department of Anesthesiology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555, USA Received 17 May 2013; revised 11 January 2014; accepted 19 January 2014
Keywords: Epidural needle; Neuraxial anesthesia; Obstetrical anesthesia; Spinal anesthesia; Spinal needle breakage
Abstract The occurrence of broken spinal and epidural needles has been reported. However, most case reports have focused primarily on prevention rather than on management. A broken spinal needle fragment was left in a patient before it was removed one month later due to back pain. © 2014 Elsevier Inc. All rights reserved.
1. Introduction The use of neuraxial techniques for labor analgesia and Cesarean delivery has consistently increased [1,2]. The introduction of smaller-diameter, non-cutting bevel spinal needles, while beneficial to reduce the incidence of postdural puncture headache in the obstetrical population, may have led to an increase in the incidence of other complications such as deformation and breakage of spinal needles [3]. The incidence of neuraxial needle breakage is unknown. Only one estimated incidence was reported, by Abou-Shameh et al [2], who stated that the incidence was 1:5,000 spinals performed. Three cases of ☆ Supported by departmental funding only. ⁎ Corresponding author. Caroline Martinello, MD, Department of Anesthesiology, The University of Texas Medical Branch, 301 University Blvd. Galveston, TX 77555, USA. E-mail addresses: [email protected] (C. Martinello), [email protected] (R.B. Vadhera).
http://dx.doi.org/10.1016/j.jclinane.2014.01.008 0952-8180/© 2014 Elsevier Inc. All rights reserved.
broken spinal needles in the past 20 years occurred at our hospital, giving an approximate incidence of 1:11,000 spinal anesthetics. Several previous case reports have reported broken needles during attempted neuraxial anesthesia, with most of the papers focusing on risk factors associated with this complication and how to prevent it. However, we found that little has been written about how to proceed once this adverse event has already occurred. A case of a broken spinal needle after an attempt to perform spinal anesthesia for a Cesarean delivery is presented. At our institution, institutional review board approval is not required for case reports. Review of the literature in the following medical databases: Medline, Cochrane Library, and UptoDate, using the terms "spinal needle" or “epidural needle” plus the words "broken," "fractured", and "breakage" was conducted. Of the 37 English language articles identified, 15 were considered relevant to the case [1-15]. After careful review of the articles’ reference lists, 5 additional articles were added to the analysis [16-20].
2
C. Martinello et al.
2. Case report A 26 year old, 155 cm, 116 kg (body mass index [BMI] 48.2 kg/m2), G3P2 Hispanic parturient at 40 weeks’ gestation presented for elective repeat Cesarean section. There was no significant past medical or prenatal history. The anesthetic plan for this case was subarachnoid block. After instituting routine monitoring, cleaning the skin with povidone-iodine topical solution, and draping, a skin wheal was raised using 1% lidocaine at the L3-L4 level. A 20gauge (G), 1.25-inch introducer needle was placed and a 25G, 3.5-inch Whitacre needle was advanced through the introducer needle. After meeting bony resistance, the Whitacre needle was withdrawn from within the introducer needle and advanced twice, making a slight cephalad angulation. On the third attempt, the spinal needle was advanced to the hub of the introducer needle with no perceived increased resistance, and no cerebrospinal fluid (CSF) was found. It was decided to use a longer spinal needle to reach the intrathecal space. The spinal needle was being withdrawn through the introducer so as to not lose the angulation being used. However, withdrawal of the Whitacre needle was met with resistance, necessitating removal of both needles together. Once both needles were withdrawn, the Whitacre needle was noted to be broken and the distal 4 cm portion was missing. It was decided to continue with subarachnoid block at one vertebral level cephalad, which was successful on the first attempt using a 25-G 4.65-inch Whitacre needle at a depth of approximately 8 cm. On visual inspection of the broken Whitacre needle, no structural defect was identified. After confirmation of adequate anesthesia to the T4 dermatome level, the surgery proceeded and the fetus was delivered uneventfully. During uterine closure, the patient was persistently hypotensive with an urticarial rash, consistent with latex anaphylaxis. Adequate treatment was offered and hemodynamic stability was achieved with an epinephrine infusion of 0.03 μg/kg/min. During the case, a neurosurgery consult was placed for the management and possible removal of the retained spinal needle, as the patient still had adequate anesthesia. At completion of the Cesarean section, fluoroscopy was used to determine that the needle was not near the spinal canal (Fig. 1). The recommendation from neurosurgery was that given the patient’s intraoperative complication of anaphylaxis, the inability to perform a 3-dimensional fluoroscopy due to the radiopaque operating table, and since the spinal needle fragment was sterile, it should be left in place at that time. The plan was to evaluate for the presence of neuropathy after resolution of the subarachnoid block, and again at two weeks. The patient failed to follow up at the neurosurgery clinic; however, contact with the patient via telephone disclosed her reported discomfort at the site of needle insertion. The needle was subsequently removed at another facility approximately
Fig. 1 Plain radiograph showing the needle fragment in the patient’s back.
one month postpartum. She did not experience any neurological deficits after the removal of the needle fragment.
3. Discussion In an attempt to decrease one of the most common complications of spinal anesthesia, the postdural puncture headache, routine practice is to use pencil-point needles and smaller diameter needles. However, another complication may occur with greater frequency when using these higher gauge needles: breakage of the needle [3,5,6]. Previous reports have described how spinal needles of various types may deform without the use of excessive force and in the absence of palpable resistance [5-8]. However, when resistance is met during insertion of a needle for spinal or epidural anesthesia, applying excessive force to overcome it should be avoided [9]. Long narrow-gauge needles are more prone to bending and fracture because they are metallically weaker [10]. Other common practices that are likely associated with increased risk of this complication include redirection of the needle without withdrawing it to shallow subcutaneous space, and withdrawal and redirection of the spinal needle passed inside an introducer while the introducer is kept in place [5,7,8,10]. Gentili et al [7] suggested that deformations may weaken the needle trunk, which breaks on the lip of the introducer when it is removed through it. This point apparently was the key factor in our case. We believe the spinal needle was probably deformed by the previous unsuccessful attempts and was sheared off during withdrawal while the introducer was kept in place. Possible patient-related risk factors for difficult spinal puncture and therefore for bending or breaking of spinal needles are: high BMI (Table 1), age N 40 years old, short stature, and anatomical vertebral column changes [2]. It
Broken spinal needle Table 1
3
Fifteen relevant case reports of broken needles
Ref Weight (kg) or Type of needle BMI (kg/m2)
Surgery
Time until removal
Anesthetic technique Symptoms after incident
[2] [3] [4]
110 kg 29.38 kg/m2 115 kg
27-G 4.5-in Whitacre 27-G Quincke 27-G Whitacre
Elective C-section Renal transplant Elective C-section
Spinal GA Spinal
None at 4 wks None reported None reported
[5] [6]
32.74 kg/m2 N/A
25-G 4.5-in Whitacre 24-G Sprotte
Spinal Spinal
None reported None reported
[7]
N/A
25-G Whitacre
[8] [9]
86 kg 24.83 kg/m2
25-G Whitacre Epidural needle tip
Elective C-section Femoral-popliteal bypass Peripheral vascular graft Knee arthroscopy Foreign body removal from lumbar spine Removal of intramedullary nail Labor analgesia Urgent C-section
4 days Immediately Not removed N/A N/A
[11] N/A [12] 39.44 kg/m2 [13] 50 kg/m2
[14] 22.98 kg/m2
[15] 37.42 kg/m2 [17] 180 kg [18] N/A
20-G 1.25-in Becton Dickinson introducer 18-G Tuohy 0.6-in micro-tip 22-G shaft/27-G tip spinal needle Xiaozendao (small-needle- Foreign body removal knife) acupuncture needle from cervical spine 27-G 4.5-in Whitacre 17-G 4.5-in Tuohy 23-G Quincke
Elective C-section Elective C-section Release of knee contracture
Immediately GA
None at 3 days
Immediately GA 3 yrs GA
None at 3 mos Right leg & back pain
Immediately Spinal
None reported
Same day 1 day
None Spinal
None reported None reported
3 yrs
GA
Bilateral shoulder & neck pain, paresthesia on left arm None reported None reported None reported
N/A GA Immediately GA Immediately Spinal
BMI=body mass index, G=gauge, C-section=Cesarean section, wks=weeks, GA=general anesthesia, spinal=spinal anesthesia, N/A=not available, yrs=years.
seems clear that a difficult puncture is directly correlated with the risk of needle deformation and breakage. On evaluation of predictors of successful block, de Oliveira Filho et al [16] concluded that poor spinal anatomy and increasing number of attempts were independent predictors of complications occurring during neuraxial block placement. A summary of management of a broken needle is shown in Table 1. The majority of case reports successfully removed the spinal needle immediately after it broke, and mostly during the same case and anesthetic without any reported sequelae [3,7,8,11,17,18]. Two case reports allowed a broken spinal needle to remain in place for one and 4 days prior to their removal, with good outcomes [2,13]. In another case report, a broken acupuncture needle during acupuncture therapy was left in situ. The needle gradually migrated; after three years, the patient developed neurologic symptoms [14]. Similarly, a broken epidural needle fragment left in situ also ultimately resulted in neurologic symptoms and had to be removed three years after an epidural nerve block for chronic pain [9]. In one reported case [4], the needle fragment was not removed and the patient remained asymptomatic; however, it was unclear how long the patient was followed. In our case, the spinal needle remained in place for approximately one month with development of local discomfort. As opposed to broken epidural catheters, broken needle pieces, which are
stiff and sharp, tend to migrate–potentially to the spinal cord. This situation indicates that perhaps early removal of a broken needle should be recommended, especially when the development of symptoms with the possibility of neurotrauma may occur over time [9,11,14,19,20]. Recommendations include: 1) in all case reports the operative procedure was completed and therefore cancellation of the surgery is unnecessary. 2) Immediate planning for needle fragment removal should be done either during or at the end of the surgical procedure. A radiograph or intraoperative fluoroscopy should be used to locate the needle. Depending on the surgical procedure and location of the needle, a neurosurgical or general surgery consultation also may be warranted. 3) If immediate removal is not possible, removal should be planned as soon as it is safe to do so. Finally, after its removal, the patient should be reassured that immediate removal of the spinal needle fragment is unlikely to be associated with any long-term neurological sequelae.
References [1] Grant GJ. Anesthesia for cesarean section. In: UpToDate, Hepner DL (Ed), UpToDate, Waltham, MA.
4 [2] Abou-Shameh MA, Lyons G, Roa A, Mushtaque S. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2006;15:178-9. [3] Cruvinel MG, Andrade AV. Needle fracture during spinal puncture: case report. Rev Bras Anestesiol 2004;54:794-8. [4] Teh J. Breakage of Whitacre 27 gauge needle during performance of spinal anaesthesia for cesarean section. Anaesth Intensive Care 1997;25:96. [5] Kwan WF, Lee C, Chen BJ. Severe deformation of a 25-gauge Whitacre spinal needle. Reg Anesth 1994;19:293-4. [6] Chaney MA, Brey SJ. Severe deformation of a small-gauge spinal needle. Anesth Analg 1993;77:401-2. [7] Gentili ME, Nicol JB, Enel D, Marret E. Recovery of a broken spinal needle. Reg Anesth Pain Med 2006;31:186. [8] Thomsen AF, Nilsson CG. Broken small-gauge spinal needle. Anesth Analg 1997;85:230-1. [9] You JW, Cho YH. Foraminal stenosis complicating retained broken epidural needle tip: a case report. Korean J Anesthesiol 2010;59(Suppl): S69-72. [10] Mehta M. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2007;16:94-5. [11] Eng M, Zorotovich RA. Broken-needle complication with a disposable spinal introducer. Anesthesiology 1977;46:147-8.
C. Martinello et al. [12] Dunn SM, Steinberg RB, O’Sullivan PS, Goolishian WT, Villa EA. A fractured epidural needle: case report and study. Anesth Analg 1992;75:1050-2. [13] Greenway MW, Vickers R. Broken micro-tip spinal needle. Int J Obstet Anesth 2009;18:295-6. [14] Liou JT, Liu FC, Hsin ST, Sum DC, Lui PW. Broken needle in the cervical spine: a previously unreported complication of Xiaozendao acupuncture therapy. J Altern Complement Med 2007;13:129-32. [15] Wendling AL, Wendling MT, Gravenstein D, Euliano TY. Fractured small gauge needle during attempted combined spinal-epidural anesthesia for cesarean delivery. Anesth Analg 2010;111:245. [16] de Filho GR, Gomes HP, da Fonseca MH, Hoffman JC, Pederneiras SG, Garcia JH. Predictors of successful neuraxial block: a prospective study. Eur J Anaesthesiol 2002;19:447-51. [17] Hershan DB, Rosner HL. An unusual complication of epidural analgesia in a morbidly obese parturient. Anesth Analg 1996;82: 217-8. [18] Sharma P, Singh B, Manocha A. Stylet stuck in the back: an unusual complication of spinal needle. Anesth Analg 2005;101:296-7. [19] Mayorga-Buiza MJ, Gabella F, Marquez-Rivas J, Rivero M. Broken epidural catheter. Anaesthesia 2012;67:1407. [20] Drake M. Broken epidural catheter. Anaesthesia 2012;67:803-4.
Case Report
Broken spinal needle: case report and review of the literature☆ Caroline Martinello MD (Obstetric Anesthesiology Fellow)⁎, Ruby Rubio MD (Staff Anesthesiologist), Erin Hurwitz MD (Assistant Professor of Anesthesiology), Michelle Simon MD (Assistant Professor), Rakesh B. Vadhera MD, FRCA, FFARCSI (Professor; Director of Obstetric Anesthesia) Department of Anesthesiology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555, USA Received 17 May 2013; revised 11 January 2014; accepted 19 January 2014
Keywords: Epidural needle; Neuraxial anesthesia; Obstetrical anesthesia; Spinal anesthesia; Spinal needle breakage
Abstract The occurrence of broken spinal and epidural needles has been reported. However, most case reports have focused primarily on prevention rather than on management. A broken spinal needle fragment was left in a patient before it was removed one month later due to back pain. © 2014 Elsevier Inc. All rights reserved.
1. Introduction The use of neuraxial techniques for labor analgesia and Cesarean delivery has consistently increased [1,2]. The introduction of smaller-diameter, non-cutting bevel spinal needles, while beneficial to reduce the incidence of postdural puncture headache in the obstetrical population, may have led to an increase in the incidence of other complications such as deformation and breakage of spinal needles [3]. The incidence of neuraxial needle breakage is unknown. Only one estimated incidence was reported, by Abou-Shameh et al [2], who stated that the incidence was 1:5,000 spinals performed. Three cases of ☆ Supported by departmental funding only. ⁎ Corresponding author. Caroline Martinello, MD, Department of Anesthesiology, The University of Texas Medical Branch, 301 University Blvd. Galveston, TX 77555, USA. E-mail addresses: [email protected] (C. Martinello), [email protected] (R.B. Vadhera).
http://dx.doi.org/10.1016/j.jclinane.2014.01.008 0952-8180/© 2014 Elsevier Inc. All rights reserved.
broken spinal needles in the past 20 years occurred at our hospital, giving an approximate incidence of 1:11,000 spinal anesthetics. Several previous case reports have reported broken needles during attempted neuraxial anesthesia, with most of the papers focusing on risk factors associated with this complication and how to prevent it. However, we found that little has been written about how to proceed once this adverse event has already occurred. A case of a broken spinal needle after an attempt to perform spinal anesthesia for a Cesarean delivery is presented. At our institution, institutional review board approval is not required for case reports. Review of the literature in the following medical databases: Medline, Cochrane Library, and UptoDate, using the terms "spinal needle" or “epidural needle” plus the words "broken," "fractured", and "breakage" was conducted. Of the 37 English language articles identified, 15 were considered relevant to the case [1-15]. After careful review of the articles’ reference lists, 5 additional articles were added to the analysis [16-20].
2
C. Martinello et al.
2. Case report A 26 year old, 155 cm, 116 kg (body mass index [BMI] 48.2 kg/m2), G3P2 Hispanic parturient at 40 weeks’ gestation presented for elective repeat Cesarean section. There was no significant past medical or prenatal history. The anesthetic plan for this case was subarachnoid block. After instituting routine monitoring, cleaning the skin with povidone-iodine topical solution, and draping, a skin wheal was raised using 1% lidocaine at the L3-L4 level. A 20gauge (G), 1.25-inch introducer needle was placed and a 25G, 3.5-inch Whitacre needle was advanced through the introducer needle. After meeting bony resistance, the Whitacre needle was withdrawn from within the introducer needle and advanced twice, making a slight cephalad angulation. On the third attempt, the spinal needle was advanced to the hub of the introducer needle with no perceived increased resistance, and no cerebrospinal fluid (CSF) was found. It was decided to use a longer spinal needle to reach the intrathecal space. The spinal needle was being withdrawn through the introducer so as to not lose the angulation being used. However, withdrawal of the Whitacre needle was met with resistance, necessitating removal of both needles together. Once both needles were withdrawn, the Whitacre needle was noted to be broken and the distal 4 cm portion was missing. It was decided to continue with subarachnoid block at one vertebral level cephalad, which was successful on the first attempt using a 25-G 4.65-inch Whitacre needle at a depth of approximately 8 cm. On visual inspection of the broken Whitacre needle, no structural defect was identified. After confirmation of adequate anesthesia to the T4 dermatome level, the surgery proceeded and the fetus was delivered uneventfully. During uterine closure, the patient was persistently hypotensive with an urticarial rash, consistent with latex anaphylaxis. Adequate treatment was offered and hemodynamic stability was achieved with an epinephrine infusion of 0.03 μg/kg/min. During the case, a neurosurgery consult was placed for the management and possible removal of the retained spinal needle, as the patient still had adequate anesthesia. At completion of the Cesarean section, fluoroscopy was used to determine that the needle was not near the spinal canal (Fig. 1). The recommendation from neurosurgery was that given the patient’s intraoperative complication of anaphylaxis, the inability to perform a 3-dimensional fluoroscopy due to the radiopaque operating table, and since the spinal needle fragment was sterile, it should be left in place at that time. The plan was to evaluate for the presence of neuropathy after resolution of the subarachnoid block, and again at two weeks. The patient failed to follow up at the neurosurgery clinic; however, contact with the patient via telephone disclosed her reported discomfort at the site of needle insertion. The needle was subsequently removed at another facility approximately
Fig. 1 Plain radiograph showing the needle fragment in the patient’s back.
one month postpartum. She did not experience any neurological deficits after the removal of the needle fragment.
3. Discussion In an attempt to decrease one of the most common complications of spinal anesthesia, the postdural puncture headache, routine practice is to use pencil-point needles and smaller diameter needles. However, another complication may occur with greater frequency when using these higher gauge needles: breakage of the needle [3,5,6]. Previous reports have described how spinal needles of various types may deform without the use of excessive force and in the absence of palpable resistance [5-8]. However, when resistance is met during insertion of a needle for spinal or epidural anesthesia, applying excessive force to overcome it should be avoided [9]. Long narrow-gauge needles are more prone to bending and fracture because they are metallically weaker [10]. Other common practices that are likely associated with increased risk of this complication include redirection of the needle without withdrawing it to shallow subcutaneous space, and withdrawal and redirection of the spinal needle passed inside an introducer while the introducer is kept in place [5,7,8,10]. Gentili et al [7] suggested that deformations may weaken the needle trunk, which breaks on the lip of the introducer when it is removed through it. This point apparently was the key factor in our case. We believe the spinal needle was probably deformed by the previous unsuccessful attempts and was sheared off during withdrawal while the introducer was kept in place. Possible patient-related risk factors for difficult spinal puncture and therefore for bending or breaking of spinal needles are: high BMI (Table 1), age N 40 years old, short stature, and anatomical vertebral column changes [2]. It
Broken spinal needle Table 1
3
Fifteen relevant case reports of broken needles
Ref Weight (kg) or Type of needle BMI (kg/m2)
Surgery
Time until removal
Anesthetic technique Symptoms after incident
[2] [3] [4]
110 kg 29.38 kg/m2 115 kg
27-G 4.5-in Whitacre 27-G Quincke 27-G Whitacre
Elective C-section Renal transplant Elective C-section
Spinal GA Spinal
None at 4 wks None reported None reported
[5] [6]
32.74 kg/m2 N/A
25-G 4.5-in Whitacre 24-G Sprotte
Spinal Spinal
None reported None reported
[7]
N/A
25-G Whitacre
[8] [9]
86 kg 24.83 kg/m2
25-G Whitacre Epidural needle tip
Elective C-section Femoral-popliteal bypass Peripheral vascular graft Knee arthroscopy Foreign body removal from lumbar spine Removal of intramedullary nail Labor analgesia Urgent C-section
4 days Immediately Not removed N/A N/A
[11] N/A [12] 39.44 kg/m2 [13] 50 kg/m2
[14] 22.98 kg/m2
[15] 37.42 kg/m2 [17] 180 kg [18] N/A
20-G 1.25-in Becton Dickinson introducer 18-G Tuohy 0.6-in micro-tip 22-G shaft/27-G tip spinal needle Xiaozendao (small-needle- Foreign body removal knife) acupuncture needle from cervical spine 27-G 4.5-in Whitacre 17-G 4.5-in Tuohy 23-G Quincke
Elective C-section Elective C-section Release of knee contracture
Immediately GA
None at 3 days
Immediately GA 3 yrs GA
None at 3 mos Right leg & back pain
Immediately Spinal
None reported
Same day 1 day
None Spinal
None reported None reported
3 yrs
GA
Bilateral shoulder & neck pain, paresthesia on left arm None reported None reported None reported
N/A GA Immediately GA Immediately Spinal
BMI=body mass index, G=gauge, C-section=Cesarean section, wks=weeks, GA=general anesthesia, spinal=spinal anesthesia, N/A=not available, yrs=years.
seems clear that a difficult puncture is directly correlated with the risk of needle deformation and breakage. On evaluation of predictors of successful block, de Oliveira Filho et al [16] concluded that poor spinal anatomy and increasing number of attempts were independent predictors of complications occurring during neuraxial block placement. A summary of management of a broken needle is shown in Table 1. The majority of case reports successfully removed the spinal needle immediately after it broke, and mostly during the same case and anesthetic without any reported sequelae [3,7,8,11,17,18]. Two case reports allowed a broken spinal needle to remain in place for one and 4 days prior to their removal, with good outcomes [2,13]. In another case report, a broken acupuncture needle during acupuncture therapy was left in situ. The needle gradually migrated; after three years, the patient developed neurologic symptoms [14]. Similarly, a broken epidural needle fragment left in situ also ultimately resulted in neurologic symptoms and had to be removed three years after an epidural nerve block for chronic pain [9]. In one reported case [4], the needle fragment was not removed and the patient remained asymptomatic; however, it was unclear how long the patient was followed. In our case, the spinal needle remained in place for approximately one month with development of local discomfort. As opposed to broken epidural catheters, broken needle pieces, which are
stiff and sharp, tend to migrate–potentially to the spinal cord. This situation indicates that perhaps early removal of a broken needle should be recommended, especially when the development of symptoms with the possibility of neurotrauma may occur over time [9,11,14,19,20]. Recommendations include: 1) in all case reports the operative procedure was completed and therefore cancellation of the surgery is unnecessary. 2) Immediate planning for needle fragment removal should be done either during or at the end of the surgical procedure. A radiograph or intraoperative fluoroscopy should be used to locate the needle. Depending on the surgical procedure and location of the needle, a neurosurgical or general surgery consultation also may be warranted. 3) If immediate removal is not possible, removal should be planned as soon as it is safe to do so. Finally, after its removal, the patient should be reassured that immediate removal of the spinal needle fragment is unlikely to be associated with any long-term neurological sequelae.
References [1] Grant GJ. Anesthesia for cesarean section. In: UpToDate, Hepner DL (Ed), UpToDate, Waltham, MA.
4 [2] Abou-Shameh MA, Lyons G, Roa A, Mushtaque S. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2006;15:178-9. [3] Cruvinel MG, Andrade AV. Needle fracture during spinal puncture: case report. Rev Bras Anestesiol 2004;54:794-8. [4] Teh J. Breakage of Whitacre 27 gauge needle during performance of spinal anaesthesia for cesarean section. Anaesth Intensive Care 1997;25:96. [5] Kwan WF, Lee C, Chen BJ. Severe deformation of a 25-gauge Whitacre spinal needle. Reg Anesth 1994;19:293-4. [6] Chaney MA, Brey SJ. Severe deformation of a small-gauge spinal needle. Anesth Analg 1993;77:401-2. [7] Gentili ME, Nicol JB, Enel D, Marret E. Recovery of a broken spinal needle. Reg Anesth Pain Med 2006;31:186. [8] Thomsen AF, Nilsson CG. Broken small-gauge spinal needle. Anesth Analg 1997;85:230-1. [9] You JW, Cho YH. Foraminal stenosis complicating retained broken epidural needle tip: a case report. Korean J Anesthesiol 2010;59(Suppl): S69-72. [10] Mehta M. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2007;16:94-5. [11] Eng M, Zorotovich RA. Broken-needle complication with a disposable spinal introducer. Anesthesiology 1977;46:147-8.
C. Martinello et al. [12] Dunn SM, Steinberg RB, O’Sullivan PS, Goolishian WT, Villa EA. A fractured epidural needle: case report and study. Anesth Analg 1992;75:1050-2. [13] Greenway MW, Vickers R. Broken micro-tip spinal needle. Int J Obstet Anesth 2009;18:295-6. [14] Liou JT, Liu FC, Hsin ST, Sum DC, Lui PW. Broken needle in the cervical spine: a previously unreported complication of Xiaozendao acupuncture therapy. J Altern Complement Med 2007;13:129-32. [15] Wendling AL, Wendling MT, Gravenstein D, Euliano TY. Fractured small gauge needle during attempted combined spinal-epidural anesthesia for cesarean delivery. Anesth Analg 2010;111:245. [16] de Filho GR, Gomes HP, da Fonseca MH, Hoffman JC, Pederneiras SG, Garcia JH. Predictors of successful neuraxial block: a prospective study. Eur J Anaesthesiol 2002;19:447-51. [17] Hershan DB, Rosner HL. An unusual complication of epidural analgesia in a morbidly obese parturient. Anesth Analg 1996;82: 217-8. [18] Sharma P, Singh B, Manocha A. Stylet stuck in the back: an unusual complication of spinal needle. Anesth Analg 2005;101:296-7. [19] Mayorga-Buiza MJ, Gabella F, Marquez-Rivas J, Rivero M. Broken epidural catheter. Anaesthesia 2012;67:1407. [20] Drake M. Broken epidural catheter. Anaesthesia 2012;67:803-4.
