Risk factors for post lumbar puncture headache

Lumbar Puncture Complications: A Review of Current Literature

PURPOSE OF REVIEW

This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment.

RECENT FINDINGS

Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Lumbar punctures are safe in patients with ALS and have a risk profile similar to that in the non-ALS population

INTRODUCTION/AIMS

Analysis of biofluids, especially cerebrospinal fluid (CSF), is critically important for amyotrophic lateral sclerosis (ALS) research. Collection of CSF is typically performed by lumbar puncture (LP). Previous studies have demonstrated the safety of LPs in patients with other neurodegenerative diseases, such as Alzheimer's disease, although there are no published studies of the safety of LPs in patients with ALS. We performed a retrospective analysis of complications resulting from LPs.

METHODS

This is a retrospective study of LPs performed between 2015 and 2021 on a total of 233 participants (healthy controls [n = 63], ALS [n = 154], and disease controls [n = 16]) as part of clinical research studies at the Washington University ALS Center. We used bivariate logistical analyses looking for associations between participant characteristics and adverse events (AEs), and likelihood ratio tests were used for significance testing.

RESULTS

We found an overall AE rate of 21.03%. AEs included headache, back pain, vasovagal syncope, and severe headache requiring epidural blood patch. Participants with ALS were not more likely to experience post-LP AEs compared to controls (odds ratio [OR] 0.61 [0.32-1.18]). Post-LP headaches were significantly less likely in participants with ALS (OR 0.36 [0.15-0.83]).

DISCUSSION

Our findings demonstrate that LP is a safe procedure for participants with ALS, with a similar or lower rate of AEs than in participants without ALS.

Recent Advances in Smart Epidural Spinal Needles

Lumbar puncture is a minimally invasive procedure that utilizes a spinal needle to puncture the lumbar epidural space to take a sample from the cerebrospinal fluid or inject drugs for diagnostic and therapeutic purposes. Physicians rely on their expertise to localize epidural space. Due to its critical procedure, the failure rate can reach up to 28%. Hence, a high level of experience and caution is required to correctly insert the needle without puncturing the dura mater, which is a fibrous layer protecting the spinal cord. Failure of spinal anesthesia is, in some cases, related to faulty needle placement techniques since it is blindly inserted. Therefore, advanced techniques for localization of the epidural space are essential to avoid any possible side effects. As for epidural space localization, various ideas were carried out over recent years to provide accurate identification of the epidural space. Subsequently, several methodologies based on mechanical and optical schemes have been proposed. Several research groups worked from different aspects of the problem, namely, the clinical and engineering sides. Hence, the main goal of this paper is to review this research with the aim of remedying the gap between the clinical side of the problem and the engineering side by examining the main techniques in building sensors for such purposes. This manuscript provides an understanding of the clinical needs of spinal needles from an anatomical point of view. Most importantly, it discusses the mechanical and optical approaches in designing and building sensors to guide spinal needles. Finally, the standards that must be followed in building smart spinal needles for approval procedures are also presented, along with some insight into future directions.

Awareness of Postdural Puncture Headache Among Specialists who Perform Lumbar Punctures and/or Monitor Patients Following the Procedure

Objective

Lumbar puncture (LP) is performed by specialists in different branches of medicine, complications may be encountered in various settings. In our study, we evaluated the awareness and knowledge of the diagnosis and treatment of post-dural puncture headache (PDPH) among specialists who performed LP and/or encountered complications.

Methods

This was a prospective questionnaire/scale study of 253 physicians: LP performers (anaesthesiologists, Group A; others, Group B) and those who worked in departments that did not perform LP but frequently encountered complications following LP (Group C). The questionnaire assessed specialization, frequency of LPs utilization, needle types used, positions employed, awareness of LP complications, diagnosis, management, and risk factors for PDPH.

Results

Group A had the highest percentage of physicians who stated they had knowledge about PDPH (Group A: 96.4%, Group B: 77.3%, Group C: 39.4%; P=0.000). Group C was found to be statistically less informed than the other two groups (P=0.000). It was determined that only one (1%) physician from Group C correctly answered the question about the diagnostic criteria for PDPH.

Conclusion

To our knowledge this is the first study in which the awareness of PDPH has been compared according to physicians' fields of specialisation. We believe that post-specialty training programs should be organized for physicians who will either perform LP or monitor patients who have undergone LP, and the curriculum content in relevant specialties should be reviewed.

Risk factors for post-dural puncture headache

INTRODUCTION

Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified.

OBJECTIVES

The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance.

METHOD

Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache.

RESULTS

The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted.

CONCLUSIONS

We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.

Safety and tolerability of lumbar puncture for the evaluation of Alzheimer's disease

Introduction

Lumbar puncture (LP) to collect and examine cerebrospinal fluid (CSF) is an important option for the evaluation of Alzheimer's disease (AD) biomarkers but it is not routinely performed due to its invasiveness and link to adverse effects (AE).

Methods

We include all participants who received at least one LP in the Alzheimer's Disease Neuroimaging Initiative (ADNI) Study. For comparison between groups, two-sample t-tests for continuous, and Pearson's chi-square test for categorical variables were performed.

Results

Two hundred twenty-seven LP-related AEs were reported by 172 participants after 1702 LPs (13.3%). The mean age of participants who reported at least one AE was 69.79 (standard deviation (SD) 6.3) versus none 72.44 (7.17) years (p < 0.001) with female predominance (115/172 = 67.4% vs 435/913 = 48%), and had greater entorhinal cortical thickness and hippocampal volume (3.903 (0.782) vs 3.684 (0.775) mm, p = 0.002; 7.38 (1.06) vs 7.05 (1.15) mm3, p < 0.001), respectively.

Discussion

We found that younger age, female sex, and greater thickness of the entorhinal cortex were associated with a higher rate of LP-related AE reports.

Paravertebral Cerebrospinal Fluid Exudation in Young Women with Postdural Puncture Headache: A Hypothetical Interpretation based on Anatomical Study on Intervertebral Foramen

Background Postdural puncture headache (PDPH) is defined as a prolonged orthostatic headache secondary to a lumbar puncture. The mechanism underlying this unpleasant complication and the reasons explaining its higher incidence in the young are not well understood. Here, we speculate on the mechanisms underlying PDPH based on spinal magnetic resonance imaging (MRI) in patients with PDPH and an anatomical study on the size of the intervertebral foramen.

Methods Brain and spinal MRI findings were examined in two young women with PDPH. The relationship between age and size of the intervertebral foramen on computed tomography was assessed in 25 female volunteers (22–89 years old) without spinal disease.

Results The causative interventions leading to PDPH were epidural anesthesia for painless delivery in a 28-year-old woman and lumbar puncture for examination of the cerebrospinal fluid (CSF) in a 17-year-old woman. These two patients developed severe orthostatic hypotension following the procedure. Brain MRI showed signs of intracranial hypotension, including subdural effusion, in one patient, but no abnormality in the other. Spinal MRI revealed an anterior shift of the spinal cord at the thoracic level and CSF exudation into the paravertebral space at the lumbar level. Treatment involving an epidural blood patch in one patient and strict bed rest with sufficient hydration in the second led to improvement of symptoms and reduction of paravertebral CSF exudation. The size of the intervertebral foramen at the L2–3 level in the 25 volunteers showed a decrease in an age-dependent manner (Spearman's rho −0.8751, p < 0.001).

Conclusion We suggest that CSF exudation from the epidural space of the vertebral canal to the paravertebral space through the intervertebral foramen, which is generally larger in the younger population, is the causative mechanism of PDPH.

Post-dural puncture headache: a prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures

Background

Lumbar puncture (LP) is a common and relatively safe neurological procedure. It can be complicated by post-dural puncture headache (PDPH) after both diagnostic and therapeutic procedures. The aim of this study is to identify the incidence, risk factors and clinical characterization of PDPH in the inpatient setting of the main tertiary neurology hospital in Kuwait.

Methods

We conducted a prospective observational cohort study that included patients who were admitted to neurology department at Ibn Sina hospital, Kuwait, from January 1, 2019 to December 31, 2020, on whom, LP was performed for diagnostic and/or therapeutic reasons. Multivariate logistic regression analysis was performed to evaluate the association between PDPH and different clinical parameters.

Results

A total of 285 patients were included; 225 females (78.9%), mean age of 32.9 ± 11.7 years. PDPH was reported by 84 patients (29.5%), with mean headache onset of 1.7 ± 0.8 days, and mean duration of 2.4 ± 2.1 days. The commonest headache type was dull aching in 49 patients (58.3%). Headache severity was mild to moderate in 64 patients (76.2%), with mean NRS of 4.1 ± 0.9. Most PDPH (99.3%) resolved with conservative medical management, with only 2 patients (0.7%) requiring epidural blood patch. In multivariate logistic regression model, there was a statistically significant correlation between development of PDPH and young age (p = 0.001), female gender (p = 0 .001), low BMI (p < 0 .001), pre-LP headache (p = 0.001), history of previous PDPH (p = 0.001), and number of LP attempts (p < 0.001). PDPH was statistically significantly higher in patients with optic neuritis (p = 0.009), and cerebral venous thrombosis (p = 0.007), and lower in patients with peripheral neuropathy (p = 0.011) and spinal muscular atrophy (p = 0.042).

Conclusions

Findings from clinical practice in the main tertiary neurology hospital in Kuwait were in line with literature findings. Younger age, female gender, lower BMI, pre-procedural headache, previous history of PDPH, and number of LP attempts were found to be independent risk factors for developing PDPH. To our knowledge, this study represents the first comprehensive description of PDPH in a population from the Arabian Gulf Region.

Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3

PURPOSE

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

TARGET POPULATION

Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

The causal-effect of bed rest and post-dural puncture headache in patients receiving diagnostic lumbar puncture: A prospective cohort study

BACKGROUND

Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture. Patients who received lumbar puncture were previously suggested to remain in bed for a certain time to prevent PDPH; however, this concept was challenged by recent studies. We aimed to investigate whether ambulation instead of resting supine following lumbar puncture could increase the risk of PDPH.

METHODS

The study used a prospective cohort design, applying convenience sampling among patients who received diagnostic lumbar puncture between January and September 2018 in the neurology ward of a tertiary medical center. The patients who fulfilled the inclusion criteria were informed that the current practice suggests lying supine for 6 to 8 hours after lumbar puncture, but they were allowed to either follow the suggestion or ambulate by their wills. The timing of bed rest was recorded, in addition to other possible risk factors of PDPH. The study endpoint is the presence or absence of PDPH within 48 hours of lumbar puncture.

RESULTS

A total of 137 patients who received lumbar puncture were enrolled, including 103 with bed rest following lumbar puncture and 34 without. There was no difference in demographics between the two groups. PDPH was found in 21 patients, with a total follow-up period of 5959 person-hours and an incidence density of 0.35%. There was no significant difference between the incidence of PDPH between the two groups (non-bed rest group 5.9% vs bed rest group 18.4%; p = 0.078), nor was incidence density (non-bed rest group 0.13% vs bed rest group 0.43%, p = 0.113). The results remained the same after adjusting for age.

CONCLUSION

Bed rest following lumbar puncture does not prevent PDPH, and even leads to a marginally increased risk of PDPH. Amendment to the current practice guideline post-lumbar puncture care might be needed to improve patient care.

Risk Factors for Developing Postlumbar Puncture Headache: A Case-Control Study

BACKGROUND

Postlumbar puncture headache (PLPH) is a common adverse event after lumbar puncture. The specific cause for headache remains uncertain but is assumed to be cerebrospinal fluid leakage. The headache affects the patient, family, and workplace as well as society in general. The aim of this study was to identify risk factors associated with the development of PLPH.

METHODS

This quantitative case-control study included 285 patients having undergone diagnostic lumbar puncture at a department of infectious diseases during 2015 to 2016. We examined blood glucose and blood albumin levels as well as systolic, diastolic, and mean arterial blood pressure. Statistical analysis included Student t test, χ, and logistic regression.

RESULTS

Compared with the control group, patients with PLPH tended to have a lower glucose level (5.7 vs 6.4 mmol/L), lower systolic pressure (126 vs 137 mm Hg), and lower mean arterial blood pressure (90 vs 96 mm Hg). Logistic regression analysis showed that lower systolic blood pressure (≤126 mm Hg) significantly increased the risk of PLPH (odds ratio, 0.977 [95% confidence interval, 0.957-0.998]) along with age younger than 40 years (odds ratio, 0.954 [95% confidence interval, 0.935-0.973]).

CONCLUSION

Patients with a lower systolic blood pressure had a statistically significantly increased risk of PLPH. Furthermore, younger age was also associated with an increased risk of PLPH.

The effects of preoperative reactions of emotional distress on headache and acute low back pain after spinal anesthesia: A prospective study

OBJECTIVES

To address the effect of preoperative symptoms of depression and anxiety on headache and low back pain after spinal anesthesia.

METHODS

This prospective observational cohort study included 370 patients who underwent spinal anesthesia before elective surgeries at a university hospital. The patients were evaluated in terms of symptoms of depression (Beck Depression Inventory) and anxiety (Beck Anxiety Scale) while in their wards. The patients were evaluated via telephone calls for headache and low back pain after the operation.

RESULTS

Eighty-two (82/362) (23%) patients were determined as having headache and 28 (28/362) (7.8%) were determined as having low back pain. There was a significant association between preoperative depression scores and anxiety scores and VAS scores of headache (respectively, eta-squared = 0.19, p < .001; eta-squared = 0.14, p < .001). There was a significant association between preoperative depression scores and anxiety scores and VAS scores of low back pain (respectively, eta-squared = 0.02, p = .08; eta-squared = 0.03, p = .01).

CONCLUSIONS

Preoperative symptoms of anxiety and symptoms of depression affect headache after spinal anesthesia. Preoperative symptoms of depression affect acute low back pain after spinal anesthesia. This trial was also registered at http://www.ClinicalTrials.gov. (Protocol Registration Receipt NCT03427372).

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

A vascular subtraction method for improving the variability of evoked tympanic membrane displacement measurements

OBJECTIVE

Evoked tympanic membrane displacement (TMD) measurements show a correlation with intracranial pressure (ICP). Attempts to use these measurements for non-invasive monitoring of ICP in patients have been limited by high measurement variability. Pulsing of the tympanic membrane at the cardiac frequency has been shown to be a significant source of the variability. In this study we describe a post processing method to remove the cardiac pulse waveform and assess the impact of this on the measurement and its repeatability.

APPROACH

Three-hundred and sixteen healthy volunteers were recruited for evoked TMD measurements. The measurements were quantified by V _m, defined as the mean displacement between the point of maximum inward displacement and the end of the stimulus. A sample of spontaneously pulsing TMDs was measured immediately before the evoked measurements. Simultaneous recording of the ECG allowed a heartbeat template to be extracted from the spontaneous data and subtracted from the evoked data. Intra-subject repeatability of V _m was assessed from 20 repeats of the evoked measurement. Results with and without subtraction of the heartbeat template were compared. The difference was tested for significance using the Wilcoxon sign rank test.

MAIN RESULTS

In left and right ears, both sitting and supine, application of the pulse correction significantly reduced the intra-subject variability of V _m (p value range 4.0 × 10^-27 to 2.0 × 10^-31). The average improvement was from 98 ± 6 nl to 56 ± 4 nl.

SIGNIFICANCE

The pulse subtraction technique substantially improves the repeatability of evoked TMD measurements. This justifies further investigations to assess the use of TMD measurements in clinical applications where non-invasive tracking of changes in ICP would be useful.

Incidence of postural headache after lumbar puncture requiring epidural blood patch: Effects of needle caliber; 2-year experience

PURPOSE

A common complication of lumbar puncture (LP) is postural headaches. Epidural blood patches are recommended if patients fail conservative management. Owing to a perceived increase in the number of post-lumbar puncture headaches (PLPHs) requiring epidural blood patches at a regional hospital in our network, the decision was made to switch from 20 to 22 gauge needles for routine diagnostic LPs.

MATERIALS AND METHODS

Patients presenting for LP and myelography at one network regional hospital were included in the study. The patients were contacted by nursing staff 3 days post-procedure; those patients who still had postural headaches after conservative management and received epidural blood patches were considered positive cases. In total, 292 patients were included; 134 underwent LP with 20-gauge needles (53 male, 81 female, average age 57.7) and 158 underwent LP with 22-gauge needles (79 male, 79 female, average age 54.6).

RESULTS

Of 134 patients undergoing LP with 20-gauge needles, 15 (11%) had PLPH requiring epidural blood patch (11 female, 3 male, average age 38). Of 158 patients undergoing LP with 22-gauge needles, only 5 (3%) required epidural blood patches (all female, average age 43). The difference was statistically significant (p < 0.01). Risk factors for PLPH included female gender, younger age, lower body mass index, history of prior PLPH and history of headaches.

CONCLUSION

Switching from 20-gauge to 22-gauge needles significantly decreased the incidence of PLPH requiring epidural blood patch. Narrower gauge or non-cutting needles should be considered in patients with risk factors for PLPH, allowing for CSF requirements.

Occurrence of postdural puncture headache-A randomized controlled trial comparing 22G Sprotte and Quincke

OBJECTIVE

To assess the incidence of postdural puncture headache (PDPH) using 22-gauge atraumatic needle (Sprotte, 22GS) compared with 22-gauge traumatic needle (Quincke, 22GQ).

BACKGROUND

Diagnostic lumbar puncture (dLP) is commonly complicated by PDPH. Despite evidence to support the use of 22GS, European neurologists seem to keep using 22GQ.

METHODS

This was a randomized, double-blind study. Adults (age: 18-60 years) scheduled for dLP were included. dLP and CSF acquisition were performed in accordance with highly standardized procedures. Patients were followed up on days 2 and 7.

RESULTS

In total, 172 patients were randomized and lumbar punctured, and 21 were excluded due to wrong inclusion (n = 11), needle switch (n = 7), failed dLP (n = 1), withdrawal (n = 1), and missed follow-up (n = 1). Among the remaining 151 patients (mean age: 40.7 ± 12.4 years), 77 had dLP using 22GQ and 74 using 22GS. Incidence of PDPH among patients punctured with 22GS (18%) was significantly lower (p = .004) than among patients punctured with 22GQ (39%). Relative risk was 0.45, 95% CI 0.26-0.80. Patients with PDPH had significantly lower weight (p = .035), and there was no significant difference related to age (p = .064), sex (p = .239), height (p = .857), premorbid episodic migraine (p = .829), opening pressure (p = .117), operators (p = .148), amount of CSF removed (p = .205), or number of attempts (p = .623).

CONCLUSIONS

The use of 22GS halves the risk of PDPH compared with 22GQ. This study provides strong support to make a change in practice where traumatic needles are still in regular use.

Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial

Background and Aims:

Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH.

Methods:

This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25.

Results:

Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively (P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group (P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group.

Conclusion:

Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

Does post dural puncture headache exist in idiopathic intracranial hypertension? A pilot study

BACKGROUND/OBJECTIVE

Occurrence of post-dural puncture headache (PDPH) after diagnostic lumbar puncture (LP) for idiopathic intracranial hypertension (IIH) may seem very unlikely in clinical practice. Nevertheless, it has been suggested by several studies, mainly in sub-group analyses. We aimed to evaluate the prevalence of PDPH in an IIH population and determine any eventual predictive factors of PDPH occurrence.

METHODS

We conducted a retrospective multiple-center observational study. All newly diagnosed IIH patients who met the International Classification of Headache Disorders (ICHD-3) or the Dandy modified criteria were included from three different French hospitals. They all underwent LP following the same process with the same type of needle. We recorded PDPH occurring within five days after LP, as defined by ICHD-3 criteria.

RESULTS

Seventy-four IIH patients were recruited, of whom 23 (31%) presented with PDPH. Neither classical risk factors for PDPH such as body mass index, age or gender, nor cerebrospinal fluid opening pressure, or specific IIH features were associated with occurrence of PDPH.

CONCLUSION

PDPH can occur after LP in IIH patients. Clinicians should be aware of this possible event during the IIH diagnosis assessment and should not automatically reconsider IIH diagnosis. PDPH prevention using an atraumatic needle and dedicated PDPH treatment seem relevant in IIH patients.

Postdural puncture headache as a complication of lumbar puncture: clinical manifestations, pathophysiology, and treatment

OBJECTIVE

This manuscript is a narrative review of peer-reviewed studies of postdural puncture headache (PDPH) as the most common complication of a diagnostic and therapeutic lumbar puncture (LP) and LP due to the damage of the dura mater in epidural anesthesia.

METHODS

Author searched articles related to the PDPH and its risk factors, pathophysiology diagnosis, differential diagnosis, and therapy. All studies according to the analyzed parameters and their relevance to the clinical practice, as well as quality of the study methods, were selected for further analysis.

RESULTS

The review presents the clinical and paraclinical prediction criteria for the onset, clinical features, course, and efficiency of specific therapeutic interventions which are of a particular clinical benefit for the prevention, pathogenetic treatment, and differential diagnosis of PDPH. The analysis of prediction parameters for the onset, clinical course, and associated symptoms and signs of PDPH is a contribution to the understanding of pathophysiology of intracranial hypotension, since PDPH can be considered a clinical model of intracranial hypotension.

CONCLUSIONS

Given that LP is a common procedure in clinical practice, it is necessary to have a comprehensive knowledge of the risk factors, pathophysiological, diagnostic, differentially diagnostic, and therapeutic aspects of PDPH.

Education and Message Framing Increase Willingness to Undergo Research Lumbar Puncture: A Randomized Controlled Trial

Reluctance to undergo lumbar puncture (LP) is a barrier to neurological disease biomarker research. We assessed whether an educational intervention increased willingness to consider research LP and whether message framing modified intervention effectiveness. We randomly assigned 851 recruitment registry enrollees who had previously indicated they were unwilling to be contacted about studies requiring LP to gain or loss framed video educational interventions describing the procedure and the probability of experiencing adverse events. The gain framed intervention emphasized the proportion of individuals free of adverse events; the loss frame emphasized the proportion experiencing adverse events. The primary outcome for the study was the participant's post-intervention agreement to be contacted about studies requiring LP. Participants were mean (SD) age 60.1 years (15.7), 69% female (n = 591), and mostly college educated and white. Among the 699 participants who completed the study, 43% (95% CI: 0.39, 0.47; n = 301) changed their response to agree to be contacted about studies requiring LP. We estimated that participants randomized to the gain framed intervention had 67% higher odds of changing their response compared to those randomized to the loss frame (Odds Ratio = 1.67; 95% CI: 1.24, 2.26; p < 0.001). A classification and regression tree model identified participants' pre-intervention willingness as the strongest predictor of changing response. Education, in particular education that alerts participants to the probability of not experiencing adverse events, may be an effective tool to increase participation rates in research requiring LP.

Lower Glucose Level Associated With Increased Risk for Post-Dural Puncture Headache

OBJECTIVE AND BACKGROUND

Post-dural puncture headache is the most common significant adverse event following lumbar puncture. In this study, we investigated the possible systemic factors associated with risk for post-dural puncture headache (PDPH).

METHODS

We performed a retrospective cohort study in 969 patients who underwent diagnostic lumbar puncture following a standardized protocol. We compared the clinical and laboratory profiles of the post-dural puncture headache group and non-headache group. We also identified independent factors associated with the incidence of post-dural puncture headache.

RESULTS

A total of 48 patients (5%) reported headache; 12 of these patients (25%) received a therapeutic epidural blood patch and the remaining 36 patients improved with conservative treatment. After adjusting for other variables that could be related to PDPH, we found that the development of post lumbar puncture headache was independently associated with age (OR: 0.97, 95% CI: 0.95-0.99, P = .001) and serum glucose levels (OR: 0.98, 95% CI: 0.97-0.99, P = .008).When the patients were classified by age, serum glucose levels were persistently lower in patients with PDPH vs those patients without PDPH in all age groups, with more clearly significant differences observed in the elderly (age <30 years, 103.4 mg/dL vs 106.3 mg/dL, P = .716; >60 years, 111.8 mg/dL vs 137.3 mg/dL, P = .023).

CONCLUSIONS

Low glucose levels were inversely associated with risk for post-dural puncture headache. Patients with low serum glucose should be carefully monitored for headache after lumbar puncture.

Our experience regarding patients with headache, vomiting, and urinary retention following endothermal ablation of the greater saphenous vein under spinal anesthesia: Gender type, age interval, and procedural risk factors are important

OBJECTIVES

The endovenous thermal ablation of the greater saphenous vein under spinal anesthesia is still a popular technique. Although this procedure is considered to be fast and simple, side effects such as headaches, vomiting, and urinary retention could occur. These side effects make the recovery period difficult for the patient. The patient's age, gender, and procedural risk factors such as needle sizes and types are important parameters that affect the occurrence and rate of undesirable outcomes. This retrospective study aims to evaluate the endovenous thermal ablation method for the management of incompetent great saphenous veins under spinal anesthesia.

METHODS

A total of 128 patients with incompetent varicose veins who were treated with an endovenous thermal ablation method under spinal anesthesia were retrospectively investigated between January 2016 and January 2019. The pre-, intra-, post-procedural, and follow-up data of the patients were collected and retrospectively compared.

RESULTS

A total of 128 patients (69 males, 59 females; mean age 45.8 ± 11.8 years; range 21-71 years) were included in the study. The average preprocedural great saphenous vein diameters were 7.41 ± 18.8 mm (range: 5.5-13.0). The average ablated vein length was 25.3 ± 3.4 (range: 15-35) cm. The average tumescent anesthesia use was 300.9 ± 52.6 (range: 150-500) mL. The average procedure time was 18.2 ± 1.8 (range: 11-25) min. The venous clinical severity scores and the chronic venous insufficiency quality of life questionnaire scores declined significantly (p for venous clinical severity scores: 0.001, p for chronic venous insufficiency quality of life questionnaire scores: 0.001). There was no postoperative paresis or paresthesia. There was one case of deep venous thrombosis and three cases of bruising. The total of three months' occlusion rates was 96.9% (124/128).The overall post-dural puncture headache ratio was 18%. Women significantly suffered from more headaches than men (27% vs. 10%, p = 0.013). The extreme age intervals (pertaining to ages between 18 and 30 or 50⁺) were almost significantly less affected by headaches in comparison to the group with the age interval between 31 and 50 (11.3%, 24.2%, p: 0.056). A percentage of 12.5 patients suffered from vomiting. It was recorded that female patients suffered from vomiting more so than the males (20.3%, 5.8%, p: 0.013). Pertaining to vomiting, there was no significant difference between the two age interval groups (p: 0.14). Urinary retention was observed in 6.3% of the patients. The female gender had a higher ratio of urinary retention, but the difference was insignificant. (8.5%, 4.3%, p: 0.46). There was no significant difference between the age interval groups in terms of urinary retention.

CONCLUSIONS

The endovenous thermal ablation of the greater saphenous vein under spinal anesthesia is a fast and effective treatment option for the management of incompetent saphenous veins. However, side effects such as headaches, vomiting, and urinary retention that are affected by gender types, age-intervals, and procedural characteristics should be kept in mind.

Postdural puncture headache leads to clinical worsening of pre-existing chronic headache

The incidence of postdural puncture headache (PDPH) in relation to pre-existing chronic headache (CH) was assessed, as was the clinical course of CH, at one, three, and six months after PDPH. The study was conducted as a single center cohort prospective study that included 252 patients (105 men and 147 women), average age of 47.3 ± 15.0 years, on whom lumbar puncture (LP) was performed. PDPH was reported in 133 (52.8%) patients; CH was reported in 82 (32.5%) patients. Patients with CH were more likely to have PDPH (p = 0.003). The individual clinical type of CH did not have an effect on the incidence of PDPH (p = 0.128). Patients with PDPH had a clinical deterioration of CH three and six months after LP (p = 0.047, p = 0.027, respectively) in terms of increased headache days per month and/or incomplete efficacy of performed therapy in relation to baseline values. Six months after LP, the worsening of CH was more common in women with PDPH (OR 5,687 [95% CI: 1526-21,200], p = 0.010) and patients with a longer history of CH (OR 1064 [95% CI: 1007-1124], p = 0.027). Multivariate analysis confirmed the direct association of female sex and duration of CH and its worsening six months after PDPH (OR 4478 [95% CI: 1149-17,452], p = 0.031; OR 1448 [95% CI: 1292-1808], p = 0.022). The presented results could be significant for the prediction/differential diagnosis of PDPH in patients with CH and for the prediction/prevention of CH clinical worsening after PDPH.

Factors Influencing Successful Lumbar Puncture in Alzheimer Research

OBJECTIVE

Lumbar puncture (LP) is increasingly common in Alzheimer disease research; however, agreement to undergo LP varies. We sought to determine factors influencing LP consent at Alzheimer's Disease Centers (ADCs) in the United States.

METHODS

A 3-part survey was distributed to each ADC: (1) ADC LP Experience; (2) LP Requestor Experience; and (3) Patient LP Experience (both Initial and Follow-up). In all, 64 LP Requestor, 579 Patient/Initial, and 404 Patient/Follow-up surveys were collected. Logistic regression analyses with generalized estimating equations were used to assess factors associated with LP agreement and post-LP complications.

RESULTS

Asians and those viewing LP negatively were less likely to agree to LP. Three hundred fifty-two participants had an LP; LP headache occurred in 11.9% (blood patch required in 1.4%) and 9.9% reported other complications. Younger individuals, women, those diagnosed with mild cognitive impairment, use of a Quincke needle, ≤20 mL cerebrospinal fluid drawn, and hemorrhage during LP were associated with LP headache. Use of gravity flow during LP was associated with fewer other complications (nausea, dizziness, vasovagal response, back pain, neck stiffness, and/or nerve root pain).

CONCLUSIONS

LP in Alzheimer disease research is generally safe and well tolerated. Factors influencing LP agreement potentially could be studied to advance participant acceptance of the procedure.

A new method of subarachnoid puncture for clinical diagnosis and treatment: lateral atlanto-occipital space puncture

OBJECTIVE

Lumbar puncture may not be suitable for some patients needing subarachnoid puncture, while lateral C1–2 puncture and cisterna magna puncture have safety concerns. This study investigated lateral atlanto-occipital space puncture (also called lateral cisterna magna puncture) in patients who needed subarachnoid puncture for clinical diagnosis or treatment. The purpose of the study was to provide information on the complications and feasibility of this technique and its potential advantages over traditional subarachnoid puncture techniques.

METHODS

In total, 1008 lateral atlanto-occipital space puncture procedures performed in 667 patients were retrospectively analyzed. The success rate and complications were also analyzed. All patients were followed up for 1 week after puncture.

RESULTS

Of 1008 lateral atlanto-occipital space punctures, 991 succeeded and 17 failed (1.7%). Fifteen patients (2.25%) reported pain in the ipsilateral external auditory canal or deep soft tissue, 32 patients (4.80%) had a transient increase in blood pressure, and 1 patient (0.15%) had intracranial hypotension after the puncture. These complications resolved fully in all cases. There were no serious complications.

CONCLUSIONS

Lateral atlanto-occipital space puncture is a feasible technique of subarachnoid puncture for clinical diagnosis and treatment. It is associated with a lower rate of complications than lateral C1–2 puncture or traditional (suboccipital) cisterna magna puncture. It may have potential in the neurological diagnostic and treatment fields.

Investigation of the optimal duration of bed rest in the supine position to reduce complications after lumbar puncture combined with intrathecal chemotherapy: a multicenter prospective randomized controlled trial

Purpose

This randomized, open-label trial was conducted to investigate the optimal duration of bed rest after intrathecal chemotherapy to reduce the incidence of complications without increasing patients’ tolerance to long-term bed rest.

Methods

A total of 390 patients receiving intrathecal chemotherapy were randomly assigned 1:1:1 to undergo bed rest for 6, 8, or 10 h after intrathecal chemotherapy. The primary outcome was the rate of complications after intrathecal chemotherapy. The analysis was per protocol.

Results

A total of 359 patients among the 390 patients in our study completed follow-up with 120 patients in the 6-h group, 120 in the 8-h group, and 119 in the 10-h group. The complications among the three groups differed significantly (P = 0.005). The 6-h group had significantly more complications than the 8- (50, 41.7% vs 29, 24.2%, P = 0.004) and 10-h groups (50, 41.7% vs 31, 26.1%, P = 0.011), whereas the difference between the 8- and 10-h groups was not significant (29, 24.2% vs 31, 26.1%, P = 0.737).

Conclusions

The overall results support that the optimal time interval for bed rest in the supine position after intrathecal chemotherapy is 8 h. This trial is registered with the Chinese Clinical Trial Registry (number ChiCTR-IOR-17011671).