柳叶刀:非创伤性腰穿针显著降低腰穿后头痛发生




首先,小编带着大家一起直观的认识下非创伤腰穿针和传统腰穿针外在区别......





Source: Lancet

左图:非创伤腰穿针;右图:传统腰穿针

腰穿对中枢神经系统等疾病的诊断具有重要作用。但是,头痛是腰穿后最常见的并发症,比例最多可达到35%,其他严重并发症包括出血、感染等等。传统腰穿针开口在针尖顶端,而非创伤性腰穿针开口在针头侧端。今年刚发表在《柳叶刀》杂志上的系统综述比较了这种新型的针头是否可以降低腰穿后并发症。


研究背景:非创伤性针头的发明有助于降低腰穿后的并发症。然而,许多研究表明,这些针头的临床应用不广。我们进行了一项系统综述,比较了接受非创伤腰穿针和传统腰穿针的患者的预后结局情况。


研究方法:在这项系统综述中,我们独立地检索了截止2017年8月15日的13个数据库,不限制语言种类,查找了比较所有具有腰穿指征的非创伤性和传统针头比较的随机对照研究。未进行腰穿或无传统针头比较的研究不被纳入。我们独立地筛选了这些研究,并从发表的报告中提取数据。主要结局为腰穿后头痛发生率,安全性和有效性结局用随机效应和固定效应评价。


研究结果:我们共检索到了20,241篇文献,经过剔除后本研究共纳入了1989年至2017年之间,横跨29个国家的110项研究,共涉及31412名受试者。腰穿后头痛的发生率从传统针头11%(95%CI 9.1-13.3)下降到非创伤针头4.2%(3.3-5.2)(相对风险比0.4,95%CI0.34-0.47,P<0.0001,I2=45·4%)。非创伤针头腰穿需要静脉输液或麻醉的比例(0.44,95% CI 0·29–0·64; P<0.0001),需要硬膜外血补片(0·50, 0·33–0·75; p=0·001)的比例更低,发生所有程度头痛(0·50, 0·43–0·57; p<0·0001),轻度头痛(0·52, 0·38–0·70; p<0·0001),严重头痛(0·41, 0·28–0·59; p<0·0001),神经根刺激(0·71, 0·54–0·92; p=0·011),听力下降均更低(0·25, 0·11–0·60; p=0·002)。在两组间,首次穿刺成功率、失败率、平均穿刺次数,创伤性后背痛的发生率无显著相关性。关于腰穿后头痛亚组分析显示,针头类型与患者年龄、性别、预防性静脉输液、针头规格、患者体位、腰穿指针、腰穿后卧床休息或医师专业之间无相关关联。这些结果用建议评分来检验,因此证据质量高。


研究解读:在需要腰穿的患者中,非创伤性腰穿针可以显著降低腰穿后头痛发生率,许多需要返回病房接受进一步治疗的患者需要这样的针头,并且与传统腰穿针疗效类似。这些研究结果给临床医师和利益相关人员提供了非创伤针头安全性和疗效的全面评价和高质量的证据支持,证明了它对需要腰穿的患者是一种更好的选择。

摘要原文:


Background

Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles.


Methods

In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546.


Findings

We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1–13·3) in the conventional needle group to 4·2% (3·3–5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34–0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29–0·64; p<0·0001), need for epidural blood patch (0·50, 0·33–0·75; p=0·001), any headache (0·50, 0·43–0·57; p<0·0001), mild headache (0·52, 0·38–0·70; p<0·0001), severe headache (0·41, 0·28–0·59; p<0·0001), nerve root irritation (0·71, 0·54–0·92; p=0·011), and hearing disturbance (0·25, 0·11–0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation.


Interpretation

Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.

 

End

 

Reference: Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis


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