Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

Postdural Puncture Headache Related to Procedure: Incidence and Risk Factors After Neuraxial Anesthesia and Spinal Procedures

OBJECTIVE

Postdural puncture headache (PDPH) is a potential complication of certain neuraxial anesthesia and spinal procedures, and some risk factors for PDPH have been identified. However, there have been no detailed analyses of rates and risk factors of PDPH after various spinal and neuraxial anesthesia procedures.

METHODS

Patient data from January 1, 2015, to December 31, 2017, were retrospectively analyzed. The patients underwent dural puncture procedures (spinal anesthesia, lumbar puncture [spinal tap], lumbar cerebrospinal fluid [CSF] drainage) or nondural puncture procedures (transforaminal epidural injection, interlaminar epidural injection, epidural catheterization with patient-controlled analgesia for delivery). PDPH incidence and risk factors were evaluated.

RESULTS

For dural puncture procedures, PDPH incidence was 2.96%, and risk factors were younger age, female sex, and lumbar puncture. Larger needle gauge was a risk factor according to Student t-test but not during logistic regression analysis. PDPH incidence was higher after lumbar puncture using a 22 G Tuohy needle (4.63%) than after lumbar CSF drainage using an 18 G Tuohy needle (3.05%). For nondural puncture procedures, PDPH incidence was 0.53% and did not differ between procedure types; no risk factors were identified.

CONCLUSIONS

PDPH incidence and risk factors depended on the type of neuraxial anesthesia and spinal procedures. PDPH incidence after lumbar puncture using a 22 G Tuohy needle was higher than that after lumbar CSF drainage using an 18 G Tuohy needle, suggesting that catheter insertion may reduce PDPH risk. In non-dural puncture procedures, PDPH risk did not differ according to type of procedure, and no risk factors were found.

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.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I² = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I² = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Outpatient Myelography: A Prospective Trial Comparing Complications after Myelography between Outpatients and Inpatients in Japan

STUDY DESIGN

Prospective comparative study.

PURPOSE

To compare the incidence and severity of adverse reactions associated with myelography performed in outpatients vs. in inpatients and report the safety and usefulness of outpatient myelography in Japanese patients.

OVERVIEW OF LITERATURE

Myelography is normally performed as an inpatient procedure in most hospitals in Japan. No studies have reported the usefulness and adverse effects of outpatient myelography in Japanese patients.

METHODS

We performed 221 myelography procedures. Eighty-five of the 221 patients underwent outpatient myelography using our new protocol. The incidence and severity of adverse reactions were compared with the other 136 patients, who underwent conventional inpatient myelography. We further compared the cost of outpatient and inpatient myelography.

RESULTS

The overall rate of adverse effects was 9.4% in outpatients, as compared with 7.4% in inpatients. Overall, 1.2% of outpatients and 0.74% inpatients experienced "severe" adverse effects (requiring hospitalization). There were no significant differences between the 2 groups in either the overall rate of adverse effects or the rate of "severe" adverse effects. Moreover, the average outpatient procedure cost was only one-third to one-half that of the inpatient procedure.

CONCLUSIONS

This was the first study to address the safety and usefulness of outpatient myelography in Japanese patients. If selected according to proper inclusion criteria for outpatient procedure, no significant differences were observed in the adverse effects between inpatients and outpatients. The outpatient procedure is more economical and has the added benefit of being more convenient and time-efficient for the patient.

Cerebrospinal fluid findings in geriatric patients from 2008 to 2011

BACKGROUND

The chemical composition of the cerebrospinal fluid (CSF) is age-dependent.

METHODS

Routine CSF parameters, the indications for lumbar puncture (LP), and the most frequent complications were retrospectively studied in patients older (n = 167) and younger (n = 36) than 65 years.

RESULTS

In the absence of meningeal inflammation, the mean CSF lactate level of patients older than 65 years was slightly but significantly higher than the mean CSF lactate level of younger patients. The lactate level of patients with otherwise normal CSF findings correlated significantly with the age of the patients. In the absence of meningeal inflammation, the CSF-to-serum albumin ratio (QAlbumin) was significantly higher in older patients than in younger ones. The most frequent indication for LP, suspected infection of the central nervous system (CNS) (n = 110), was confirmed in 12.7% of patients. The only LP complication documented was headache in two patients.

CONCLUSIONS

Elevations of QAlbumin and CSF lactate levels appear to be nonspecific findings in elderly patients. Suspected infections, the most frequent indication for LP, were confirmed by CSF analysis in more than 10% of patients. The very low complication rate of LP makes it a very valuable tool in the diagnostic routine for older patients with CNS diseases.

Ultrasound-guided lumbar puncture as a diagnostic aid to reduce number of attempts and complication rates

Ultrasound-guided lumbar puncture (LP) could be beneficial in situations where anatomical landmarks are difficult to identify. There is some evidence that it is associated with increased success rates and procedural ease. Its effect on complication rates has not been explored. This mixed retrospective-prospective case-control study over 6 months compares unguided (retrospective data, n = 28) and ultrasound-guided LPs (prospective data, n = 23) in non-emergency patients. Presence of factors making LPs difficult (DF) i.e. BMI ≥30 kg/m2, scoliosis and previous lumbar spinal surgery were recorded. There was a significant difference in attempt rates between unguided and ultrasound-guided LPs (median 2 vs. 1; p = 0.01) with complication rates of 50% and 26.1%, respectively ( p = 0.15). In a subgroup analysis, complication rates were significantly different in those with DF (76.9%, unguided LPs (n = 13) vs. 33.3%, ultrasound-guided LPs (n = 12); p = 0.03), with an absolute risk reduction of complications of 43.6% (NNT of 2.3) in ultrasound-guided vs. unguided LPs. In those with DF, the back pain rates were significantly reduced (53.8% unguided LPs vs. 8.3% ultrasound-guided LPs; p = 0.02). In the ultrasound-guided LP group, there was no blood contaminated cerebrospinal fluid samples, whereas this occurred in 14% of unguided LPs.

Ultrasound-guidance significantly reduced the number of LP attempts. In those with DF, the use of ultrasound significantly reduced post-procedural complication, particularly back pain. Ultrasound-guidance during LP procedures can reduce patient discomfort and encourage patient safety, thereby improving clinical practice.

Lumbar puncture and post-dural puncture headaches: implications for the emergency physician

Lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Post-dural puncture headaches occur frequently after this procedure and can be associated with significant morbidity and, occasionally, even death. There is also a lot of variation in how post-dural puncture headaches are treated once they occur. This article seeks to examine the science behind post-dural puncture headaches, their prevention and treatment.

Bevel direction and postdural puncture headache: a meta-analysis

BACKGROUND

The effect of lumbar puncture needle bevel direction on the incidence of postdural puncture headache (PDPH) is somewhat controversial. We performed a meta-analysis of available trials to determine if bevel direction during lumbar puncture would influence the incidence of PDPH.

REVIEW SUMMARY

Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to November 29, 2004) and abstracts from several national meetings (American Society of Anesthesiology, International Anesthesia Research Society, American Society of Regional Anesthesia, Society of Obstetric Anesthesia and Perinatology) for terms related to needle and bevel direction. Inclusion criteria were assessment of the incidence of PDPH after lumbar puncture with a cutting needle (eg, Quincke, Tuohy), comparison of a "parallel" (bevel oriented in a longitudinal or cephalad to caudad direction) to "perpendicular" (bevel oriented in a transverse direction) orientation during needle insertion, randomized trials, and trials primarily in adult populations. Data on study characteristics and incidence of PDPH were abstracted from qualified studies and subsequently analyzed. The search resulted in 52 abstracts from which the original articles were obtained and data abstracted, with ultimately a total of 5 articles meeting all inclusion criteria. Insertion of a non-pencil-point/cutting needle with the bevel oriented in a parallel/longitudinal fashion resulted in a significantly lower incidence of PDPH compared with that oriented in a perpendicular/transverse fashion (unadjusted rates of 10.9% versus 25.8%; odds ratio = 0.29 [95% CI = 0.17-0.50]).

CONCLUSIONS

Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.

Patient care after discharge from the ambulatory surgical center

An important and often forgotten aspect of postoperative care occurs after the patient is discharged from the ambulatory surgical center. With more than 60% of all surgeries and procedures occurring on an ambulatory basis, what happens after the patient is no longer in continuous professional care is of concern to the ambulatory nurse. Numerous physical postoperative complaints are common and expected sequelae of anesthesia and surgery in the ambulatory patient. In this article, important postdischarge complications are reviewed and contemporary management options discussed. The information contained in this review article is valuable to the provider in educating patients regarding their anticipated course of postoperative recovery.

OBJECTIVES

-Based on the content of this article, the reader should be able to (1) identify important postdischarge complications to provide patients with comprehensive discharge instructions regarding their continued recovery at home; (2) discuss contemporary management options available to treat postdischarge complications; (3) realize the incidence of specific postdischarge complications and how that relates to patient satisfaction with the surgical experience; (4) recognize signs and symptoms of postdischarge complications; and (5) identify risk factors of patients for developing specific complications in the postoperative phase.

Complications after LP related to needle type: pencil-point versus Quincke

OBJECTIVES

We studied the incidence of complications after diagnostic lumbar puncture (LP) related to needle type.

MATERIAL AND METHODS

A 5 months' observational study of routine diagnostic LP in 83 patients was conducted.

RESULTS

Significantly more headache was observed after LP using thicker cutting needles (20G Quincke) compared with thinner cutting or non-cutting needles (22G Quincke or pencil-point). No significant difference in complications after LP was found between the 22G Quincke and pencil-point needles.

CONCLUSION

The size of the needle and not the needle shape seems to be the main determinant for post-dural puncture headache (PDPH).

Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture

OBJECTIVE

To compare the ease of use of atraumatic needles with standard needles for diagnostic lumbar puncture and the incidence of headache after their use.

DESIGN

Double blind, randomised controlled trial.

SETTING

Investigation ward of a neurology unit in a university hospital.

PARTICIPANTS

116 patients requiring elective diagnostic lumbar puncture.

INTERVENTIONS

Standardised protocol for lumbar puncture with 20 gauge atraumatic or standard needles.

OUTCOME MEASURES

The primary end point was intention to treat analysis of incidence of moderate to severe headache, assessed at one week by telephone interview. Secondary end points were incidence of headache at one week analysed by needle type, ease of use by operator according to a visual analogue scale, incidence of backache, and failure rate of puncture.

RESULTS

Valid outcome data were available for 97 of 101 patients randomised. Baseline characteristics were matched except for higher body mass index in the standard needle group. By an intention to treat analysis the absolute risk of moderate to severe headache with atraumatic needles was reduced by 26% (95% confidence interval 6% to 45%) compared with standard needles, but there was a non-significantly greater absolute risk of multiple attempts at lumbar puncture (14%, -4% to 32%). Higher body mass index was associated with an increased failure rate with atraumatic needles, but the reduced incidence of headache was maintained. The need for medical interventions was reduced by 20% (1% to 40%).

CONCLUSIONS

Atraumatic needles significantly reduced the incidence of moderate to severe headache and the need for medical interventions after diagnostic lumbar punctures, but they were associated with a higher failure rate than standard needles.