Needle type and the risk of post-lumbar puncture headache in the outpatient neurology clinic

Preferences of Patients with Amyotrophic Lateral Sclerosis for Intrathecal Drug Delivery: Choosing between an Implanted Drug-Delivery Device and Therapeutic Lumbar Puncture

BACKGROUND

Novel intrathecal treatments for amyotrophic lateral sclerosis (ALS) may require delivery using lumbar puncture (LP). Implanted drug-delivery devices (IDDDs) could be an alternative but little is known about patients' preferences for intrathecal drug-delivery methods.

OBJECTIVE

We aimed to elicit preferences of patients with ALS for routine LP and IDDD use.

METHODS

A discrete choice experiment (DCE) and a threshold technique (TT) exercise were conducted online among patients with ALS in the US and Europe. In the DCE, patients made trade-offs between administration attributes. Attributes were identified from qualitative interviews. The TT elicited maximum acceptable risks (MARs) of complications from device implantation surgery. DCE data were analyzed using mixed logit to quantify relative attribute importance (RAI) as the maximum contribution of each attribute to a preference, and to estimate MARs of device failure. TT data were analyzed using interval regression. Four scenarios of LP and IDDD were compared.

RESULTS

Participants (N = 295) had a mean age of 57.7 years; most (74.2%) were diagnosed < 3 years ago. Preferences were affected by device failure risk (RAI 28.6%), administration frequency (26.4%), administration risk (19.7%), overall duration (17.8%), and appointment location (7.5%). Patients accepted a 5.6% device failure risk to reduce overall duration from 2 h to 30 min and a 3.6% risk for administration in a local clinic instead of a hospital. The average MAR of complications from implantation surgery was 29%. Patients preferred IDDD over LP in three of four scenarios.

CONCLUSION

Patients considered an IDDD as a valuable alternative to LP in multiple clinical settings.

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.

Preventing Post-Lumbar Puncture Headache

Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Epidural Contrast Volume on Post-Myelogram Lumbar CT Predicts the Rate of Subsequent Blood Patch Treatment

BACKGROUND AND PURPOSE

Headaches due to cerebrospinal fluid (CSF) leakage are a well-known complication of dural puncture. The purpose of this study was to determine whether the presence and volume of epidural contrast on postmyelogram CTs of the lumbar spine were associated with post-dural puncture headaches (PDPHs) requiring epidural blood patch (EBP) treatment.

METHODS

A retrospective case control study of all fluoroscopically guided lumbar myelograms performed over a 5-year period by a single radiology practitioner assistant was performed. Ten patients who underwent EBP treatment after their myelograms were identified. Forty-six patients with similar demographics who did not receive blood patches were then selected. CT-lumbar myelogram images of patients and controls were reviewed. The volume of epidural contrast was then quantified as "severe" or "mild." Severe epidural contrast was defined as contrast detected in the ventral epidural space, the extra-foraminal space, or extending greater than or equal to the length of two vertebral bodies from the level of dural puncture.

RESULTS

Some amount of epidural contrast was seen in all patients. However, a severe volume of epidural contrast was associated with increased risk for PDPH requiring an EBP (odds ratio = 37.00; 95% CI = 4.1-330.8, p = 0.0012).

CONCLUSION

Severe epidural contrast on postmyelogram CTs of the lumbar spine was associated with an increased risk of PDPH requiring EBP treatment. When present, this finding can alert the proceduralist that the patient may require closer observation and follow up with earlier intervention.

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.

Post-dural puncture headache incidence after cerebrospinal fluid aspiration. A prospective observational study

Abstract Background: Post-dural puncture headache (PDPH) is an iatrogenic condition following lumbar puncture (LP). Incidence is variable and often associated with young females. Technical features of the procedure (i.e. needle gauge) have been investigated; however there is no investigation on the method of cerebrospinal fluid (CSF) collection. Objective: To investigate whether mild CSF aspiration is associated with increased PDPH in selected patients. Methods: 336 subjects were eligible to the study. Data on 237 patients from a tertiary neurology hospital who underwent diagnostic LP from February 2010 to December 2012 were analysed. Patient demographics, lumbar puncture method, CSF biochemical characteristics, opening pressures, and a follow-up inquire on PDPH occurrence were collected. CSF was collected either by allowing free flow or by mild aspiration. Results: The aspiration arm (n=163) was comprised of 55.8% females with mean age of 52(35‒69) years. Sex distribution was not different between the two arms (p=0.191). A significant larger amount of CSF was obtained in the aspiration arm (p=0.011). The incidence of PDPH in the aspiration arm was 16.5% versus 20.2% in the free flow arm, not statistically significant (p=0.489). No relevant associations emerged from the analyses in the subgroup aged <65 years. Conclusions: Aspiration of the CSF during LP was not associated with increased rates of PDPH compared to the standard method, particularly when larger amounts of CSF are required and ideal conditions are met. This is the first study looking into this matter, aiming to add safety to the procedure. Further randomized trials are required.

Effects of running on adiponectin, insulin and cytokines in cerebrospinal fluid in healthy young individuals

Exercise can prevent the sedentary lifestyle-related risk of metabolic and cognitive decline, but mechanisms and mediators of exercise effects on human brain are relatively unexplored. We measured acute exercise-induced changes in adiponectin, insulin and other bioactive molecules in cerebrospinal fluid (CSF) and serum from young lean individuals. Samples of serum and CSF were obtained before and 1-h after the 90-min run (75–80% HRmax; maximal heart rate), additional serum was taken at finish-line. Body composition, physical fitness, metabolic rate, cognitive functions, food preference, glucose, insulin and albumin were measured. The spectrum of 174 cytokines was assessed by protein arrays, adiponectin was also determined by ELISA and immunoblotting. CSF adiponectin decreased post-exercise by 21.3% (arrays) and 25.8% (ELISA) (p < 0.009). Immunoblotting revealed reduction in a low-molecular-weight-adiponectin (p < 0.005). CSF adiponectin positively correlated with CSF/serum albumin ratio (p < 0.022), an indicator of blood-brain-barrier permeability. CSF and serum adiponectin were positively associated with memory and running-induced changes in insulinemia and CSF insulin. Additionally, running modulated CSF levels of 16 other cytokines. Acute running reduced CSF adiponectin and modulated insulin and albumin in CSF and serum. Associations of adiponectin with memory and metabolism indicate the potential role of this bioactive molecule in mediating exercise-induced adaptive response in human brain.

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.

Predictors and incidence of orthostatic headache associated with lumbar drain placement following endoscopic endonasal skull base surgery

BACKGROUND

Orthostatic headache (OH) is a potential complication of lumbar drainage (LD) usage. The incidence and risk factors for OH with the use of lumbar drainage during endoscopic endonasal procedures have not been documented.

OBJECTIVE

To investigate the incidence of post-procedure OHs associated with placement of LD in patients undergoing endoscopic endonasal procedures.

METHODS

We prospectively noted the placement of LDs in a consecutive series of endoscopic endonasal skull base surgeries. Charts were retrospectively reviewed, and patients were divided into two groups: those with OH and those without. The patient demographics, drain durations, imaging findings of intracranial hypotension, pathologies and need for a blood patch were compared between the two groups.

RESULTS

Two hundred forty-nine patients were included in the study. Seven patients (2.8%) suffered post-dural puncture OH, which was mild to moderate and disappeared 2-8 days (median 3 days) after treatment. Blood patches were used in four patients. Significant predisposing factors were age (33.0 vs. 53.5, P = 0.014) and a strong trend for female gender (85.7% vs. 47.9%, P = 0.062). BMI and drain duration were not significant. Postoperative intracranial hypotension was diagnosed radiographically in 43% of OH patients and in 5.4% of those without OH (P = 0.003). Four (1.6%) patients required treatment with an epidural blood patch.

CONCLUSION

OH associated with intracranial hypotension in patients undergoing endoscopic endonasal procedures with LDs is an infrequent complication seen more commonly in young female patients. Radiographic signs of intracranial hypotension are a specific but not sensitive test for OH.

Consensus guidelines for lumbar puncture in patients with neurological diseases

Introduction

Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.

Methods

We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III).

Results

Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications.

Discussion

When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.

Cerebrospinal Fluid Biomarkers of Cognitive Decline in Parkinson's Disease

Among the nonmotor symptoms in Parkinson's disease (PD), cognitive impairment is one of the most common and devastating. Over recent years, mild cognitive impairment (MCI) has become a recognized feature of PD (PD-MCI). The underlying mechanisms which influence onset, rate of decline, and conversion to dementia (PDD) are largely unknown. Adding to this uncertainty is the heterogeneity of cognitive domains affected. Currently there are no disease-modifying treatments that can slow or reverse this process. Identification of biomarkers that can predict rate and risk of cognitive decline is therefore an unmet need. Cerebrospinal fluid (CSF) is an ideal biomarker candidate as its constituents reflect the metabolic processes underlying the functioning of brain parenchyma. The pathological hallmark of PD is the presence of aggregated α-synuclein (α-Syn) in intracellular Lewy inclusions. In addition, there is concomitant Alzheimer's disease (AD) pathology. In AD, decreased CSF β-amyloid 1-42 (Aβ42) and increased CSF tau levels are predictive of future cognitive decline, setting a precedent for such studies to be carried out in PD. CSF studies in PD have focused on the classical AD biomarkers and α-Syn. Longitudinal studies indicate that low levels of CSF Aβ42 are predictive of cognitive decline; however, results for tau and α-Syn were not consistent. This chapter summarizes recent findings of CSF biomarker studies and cognitive dysfunction in PD.

JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms

OBJECTIVE

Headaches due to CSF leak are a well-described complication of dural puncture. It is uncertain how long patients should be observed after dural puncture to reduce the risk of headache. Most of the literature has focused on dural punctures performed without fluoroscopic guidance. The purpose of this study was to determine the incidence of complications from fluoroscopically guided dural punctures, with attention to predictive factors such as the length of bed rest after the procedure.

MATERIALS AND METHODS

We retrospectively reviewed 2141 fluoroscopically guided dural punctures performed over a 5-year period by a single radiology practitioner assistant. All patients were contacted 48-72 hours after the procedure to assess for complications. Complications were categorized according to whether the patient reported having severe headache (requiring epidural blood patch for treatment), any headache, or any complaint. Using a multivariate logistic regression model, we assessed several possible predictors of complication: patient age, patient sex, needle caliber, puncture site, distance driven after recovery, length of postprocedural bed rest, contrast concentration, and contrast volume.

RESULTS

In all, 0.8% of patients reported having a severe headache, 2.2% reported having any headache, and 2.6% reported having any complaint. In the multivariate analysis, age and sex were predictive of complication rates (with younger women having higher rates), but the other variables were not predictive. In particular, length of postprocedural bed rest showed statistical equivalence.

CONCLUSION

Fluoroscopically guided dural punctures result in few complications compared with lumbar punctures performed without fluoroscopic guidance. Postprocedural bed rest greater than 2 hours does not reduce complication rates for fluoroscopically guided lumbar punctures.

Postdural puncture headache: impact of needle type, a randomized trial

BACKGROUND CONTEXT

The most common adverse event after a lumbar puncture (LP) is a headache: In anaesthesiology, well studied is the protective effect of atraumatic spinal needles, and they are routinely used. However, this is less well known in diagnostic LP, and neurologists use atraumatic needles in less than 2% of times.

PURPOSE

The purpose of this study was to define the impact of needle type, atraumatic (Sprotte [S]) versus traumatic (Quincke [Q]) on postdural puncture headache (PDPH) incidence.

STUDY DESIGN

The study is based on a prospective, randomized, and simple-blinded clinical trial.

PATIENT SAMPLE

Patients older than 14 years were scheduled for a diagnostic or therapeutic LP.

OUTCOME MEASURES

The outcome measure included the development of PDPH according to the International Headache Association criteria.

METHODS

Patients fulfilling eligibility criteria were randomly allocated to one of two kinds of spinal needle: atraumatic or S-type or traumatic or Q-type. They were interviewed on days 2 and 7 about the development of PDPH.

RESULTS

The incidence of PDPH was 22.43% with Q-type needle and 8.51% with S-type needle, p=.04. The duration of PDPH in patients in the S-type was 1 day or less, compared with a median of 4.14 days in the Q-type (p=.00). In the logistic regression model, the S-type needle together with the age of the patient were the only two statistically significant factors in the development of postlumbar puncture headache (PLPH), both of them being protective.

CONCLUSIONS

We found a lower incidence of PDPH with atraumatic needles, and it was statistically significant compared with the traumatic needles. Our study confirms the effectiveness of the atraumatic needles to prevent PDPH.

[Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch]

BACKGROUND

In most cases cerebrospinal fluid (CSF) leaks are iatrogenic and caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine, However, spontaneous cerebral hypotension is currently detected more frequently due to improvements in diagnostic possibilities but often the cause cannot be clarified with certainty.

METHODS

There are various diagnostic tools for confirming the diagnosis and searching for the site of CSF leakage, such as postmyelography computed tomography (postmyelo-CT), indium(111) radioisotope cisternography and (myelo) magnetic resonance imaging (MRI), which show different sensitivities. In accordance with own experience native MRI with fat-saturated T2-weighted sequences is often sufficient for diagnosing CSF leakage and the site. For the remaining cases an additional postmyelo-CT or alternatively myelo-MRI is recommended. In some patients with spontaneous cranial hypotension multiple CSF leaks are found at different spinal levels. The main symptom in most cases is an orthostatic headache. While post-puncture syndrome is self-limiting in many cases, spontaneous CSF leakage usually requires blood patch therapy. A lumbar blood patch can be safely carried out under guidance by fluoroscopy. In the case of a cervical or dorsal blood patch, CT guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Despite a high success rate at the first attempt with a blood patch of up to 85%, some cases require repeating the blood patch. A targeted blood patch of a CSF leak should generally be favoured over a blindly placed blood patch; nevertheless, if a CSF leak cannot be localized by CT or MRI a therapeutic attempt with a lumbar blood patch can be carried out. After a successful blood patch intracranial hygromas and pachymeningeal enhancement in the head show fast regression; however, epidural hygromas of the spine can persist for a period of several months, even though patients are already free of symptoms.

CONCLUSION

In total, blood patch therapy is a safe and technically relative simple method with a high success rate. Therefore, it represents the therapy of choice in patients with spontaneous cerebrospinal fluid leakage as well as in cases of post-lumbar puncture syndrome refractory to conservative therapy.

Factors associated with the onset and persistence of post-lumbar puncture headache

IMPORTANCE

This study assesses factors associated with the most common adverse event following lumbar puncture.

OBJECTIVE

To identify factors associated with the risk, onset, and persistence of post-dural puncture headache (PDPH).

DESIGN, SETTING, AND PARTICIPANTS

We performed univariate and multivariable analyses of 338 lumbar punctures in the Dominantly Inherited Alzheimer Network observational study using linear mixed models, adjusting for participant-level and family-level random effects.

MAIN OUTCOMES AND MEASURES

We directly evaluated associations of 3 post-lumbar puncture outcomes (immediate postprocedural headache, PDPH at 24-hour follow-up, and PDPH receiving a therapeutic blood patch) with participant age and sex, positioning, collection method, needle size, needle insertion site, and cerebrospinal fluid (CSF) volume collected.

RESULTS

The incidence of adverse events included 73 immediate postprocedural headaches (21.6%), 59 PDPHs at 24-hour follow-up (17.5%), and 15 PDPHs receiving a therapeutic blood patch (4.4%). Greater volume of CSF collected was associated with increased risk of immediate postprocedural headache, largely owing to a nonlinear increase in risk on collection of volumes above 30 mL (odds ratio, 3.73 for >30 mL and 0.98 for <17 mL). In contrast, collection of higher volumes showed a protective effect in decreasing rates of PDPH at 24-hour follow-up and rates of PDPH receiving a therapeutic blood patch (odds ratio, 0.35 per 10 mL). Although differences in needle size did not reach statistical significance, no participant in the 24G needle group received a therapeutic blood patch compared to 8 of 253 for the larger 22G needles.

CONCLUSIONS AND RELEVANCE

Factors that acutely lower CSF pressure (eg, seated positioning or extracting very high volumes of CSF) may be associated with transient post-lumbar puncture headache, without increasing rates of persistent PDPH or therapeutic blood patch. Collection of up to 30 mL of CSF appears to be well tolerated and safe.

The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice

Objectives

The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles.

Methods

In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH.

Results

PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant ( p < 0.001 and p = 0.008, respectively) and it approached significance when comparing the 25S and 25W ( p = 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles.

Conclusion

The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH.

Does lumbar puncture at night prevent post-dural puncture headache?

OBJECTIVES

The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures.

MATERIALS AND METHODS

The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was post-dural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables.

RESULTS

Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache.

CONCLUSIONS

We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.

Are atraumatic spinal needles as efficient as traumatic needles for lumbar puncture?

The most frequent complication of lumbar puncture is post lumbar puncture headache (PLPH). Recent studies confirmed that the use of atraumatic spinal needles significantly reduces the risk of PLPH. However, the majority of neurologists still use traumatic needles, possibly caused by misconceptions and beliefs about practical performance of atraumatic spinal needles. Therefore, we investigated the practical characteristics of atraumatic and traumatic spinal needles. An experimental setup with a fluid column was used with (1) a physiological NaCl 0.9 % solution and (2) a high protein content solution. Flow rates and duration of pressure measurements were measured using a traumatic needle and an atraumatic needle. The average flow rate differed less than 10 % between the two needle types with NaCl solution, and for the high protein solution the difference was even smaller. Time taken to perform accurate pressure measurements did not differ between the two needle types using NaCl 0.9 %, and was even slightly shorter for the atraumatic needle when using the high protein solution. Average flow rates and duration of pressure measurements are comparable between atraumatic spinal needles and traumatic needles. Therefore, these performance characteristics are no reason to favor traumatic needles over atraumatic needles.

Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy

Post-lumbar puncture headaches (PLPHs) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures, placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPHs in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty-four articles were deemed appropriate for use and were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions used to treat PLPHs once they occur. There is a need for additional, pediatric-specific studies to further examine the issue of PLPH prevention and treatment.

Reducing post-lumbar puncture headaches with small bore atraumatic needles

Lumbar puncture for testing of Alzheimer's disease pathophysiology for diagnostic confirmation is likely to become more common in the coming years. Minimizing adverse effects from this testing will be essential for clinical practice. Small bore, atraumatic needles reduce the occurrence of post-lumbar puncture headache (PLPH). Our goal was to extend this recommendation specifically to a well-characterized aging population. We assessed PLPH in the Alzheimer's Disease Neuroimaging Initiative cohort and found that PLPH occurrence was reduced only when using a 24 gauge atraumatic needle. We recommend that lumbar punctures for clinical and research purposes in Alzheimer's disease be conducted with 24 gauge atraumatic needles.

A case of prolonged delayed postdural puncture headache in a patient with multiple sclerosis exacerbated by air travel

The developments of new spinal needles and needle tip designs have reduced the incidence of postdural puncture headache (PDPH). Although it is clear that reducing the loss of CSF leak from dural puncture reduces the headache, there are areas regarding the pathogenesis, treatment, and prevention of PDPH that remain controversial. Air travel by itself may impose physiological alteration in central nervous system that may be detrimental to patients with PDPH. This case report highlights a case of a young female patient who suffered from a severe incapacitating PDPH headache during high-altitude flight with a commercial jet.

Cerebrospinal fluid volume–depletion headaches in patients with traumatic brachial plexus injury

Object

Patients with brachial plexus injury (BPI) present with a combination of motor weakness/paralysis, sensory deficits, and pain. Brachial plexus injury is generally not believed to be associated with headaches. However, CSF leaks may be associated with CSF volume–depletion (low-pressure) headaches and can occur in BPI secondary to nerve root avulsion. Only a few cases of headaches associated with BPI have been reported. It is unknown if headaches in patients with BPI occur so rarely, or if they are just unrecognized by physicians and/or patients in which the focus of attention is the affected limb. The aim of this study was to determine the prevalence of CSF volume–depletion headaches in patients with BPI.

Methods

All adult patients presenting at the Mayo brachial plexus clinic with traumatic BPI were asked to complete a questionnaire addressing the presence and quality of headaches following their injury. The patients' clinical, injury, and imaging characteristics were subsequently reviewed.

Results

Between December 2008 and July 2010, 145 patients completed the questionnaire. Twenty-two patients reported new onset headaches occurring after their BPI. Eight of these patients experienced positional headaches, suggestive of CSF volume depletion. One of the patients with orthostatic headaches was excluded because the headaches immediately followed a lumbar puncture for a myelogram. Six of the other 7 patients with positional headaches had a clear preganglionic BPI. The available imaging studies in these 6 patients revealed evidence of CSF leaks: pseudomeningoceles (n = 5), CSF tracking into soft tissues (n = 3), CSF tracking into the intraspinal compartment (n = 3), CSF tracking into the pleural space (n = 2), and low-positioned cerebellar tonsils (n = 2).

Conclusions

In this retrospective study, 15.2% of patients (22 of 145 patients) with traumatic BPI suffered from a new-onset headache. Seven of these patients (4.8%) experienced postural headaches clearly suggestive of CSF volume depletion likely secondary to a CSF leak associated with the BPI, whereas the other 15 patients (10.3%) suffered headaches that may have represented a variant of CSF depletion headaches without a postural characteristic or a headache from another cause. These data suggest that CSF volume–depletion headaches occur in a significant proportion of patients with BPI and have been underrecognized and underreported.

Post-lumbar puncture headache

BACKGROUND

Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache.

METHOD

The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications.

RESULTS

Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered.

INTERPRETATION

Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.