Assessment: Prevention of post–lumbar puncture headaches
Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology
Randolph W. Evans, MD,
Carmel Armon, MD, MHS,
Elliot M. Frohman, MD, PhD and
Douglas S. Goodin, MD
From the American Academy of Neurology, St. Paul, MN; the University of Texas at Houston Medical School and Baylor College of Medicine (Dr. Evans); Clinical Research Center, Department of Neurology (Dr. Armon), Loma Linda University, CA; Department of Neurology (Dr. Frohman), University of Texas Southwestern Medical Center, Dallas; and the Department of Neurology (Dr. Goodin), University of California at San Francisco.
Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116
Headache (HA) is a common sequel to lumbar puncture (LP), whetherperformed for diagnosis or anesthesia.1-6 In their monographsummarizing the world literature through 1960, Tourtellotteet al.1 considered separately three principal patient populations:1) patients undergoing diagnostic LPs (excluding myelography,pneumoencephalography, and cisternal puncture), excluding alsopatients whose condition might reduce the reliability to reportHA; 2) patients undergoing nonobstetric spinal anesthesia; and3) patients undergoing obstetric spinal anesthesia. They reportedseveral observations.
The average frequency of post-LP HAs (PLPHA) in patients afterdiagnostic LP (excluding myelography, pneumoencephalography,and cisternal puncture), excluding also patients whose conditionmight reduce the reliability to report HA, was 32%. For nonobstetricspinal anesthesia, the average frequency was 13%. For obstetricspinal anesthesia, the average frequency was 18%.
In reportsin which patients received special measures to preventPLPHA,the average frequencies were 6% for diagnostic LPs, 5.5%fornonobstetric spinal anesthesia, and 6.2% for obstetric spinalanesthesia. The actual frequencies in individual series rangedfrom 0 to 18%.
The frequency of PLPHA was 36% in their ownseries of 105 normalindividuals, 30% in 317 patients with diagnosticLPs, and 2%definite and 2% probable in 100 patients undergoingspinal anesthesia(but 30 patients with HAs of other types wereexcluded fromthe latter count).
In analyzing risk factors for PLPHA, they concluded that theevidence, including their own prospective series, was convincingto consider younger age and female gender as definite risk factors.They attributed the difference of PLPHAs in obstetric and nonobstetricpatients undergoing spinal anesthesia at least in part to thesefactors. They further considered the data fairly convincingthat the smaller the needle size, the lower the frequency ofPLPHA, but were unable to show this in their prospective series.They commented that the great variability of HA frequency forthe same needle size between authors may reduce the reliabilityof this observation. With regard to all other risk factors,they concluded that the evidence was inconclusive. With regardto all preventive or therapeutic measures, they commented thatproponents of a particular treatment, in general, found it tobe beneficial; however, some of the reports were uncontrolledand some results could not be replicated by others. Today, wewould consider the latter findings a result of publication bias—ifone first tried a new approach to reducing the incidence ofPLPHA, one would be less likely to publish a failure than asuccess.
They commented on the different frequency of PLPHA in patientsundergoing diagnostic LP compared with those undergoing spinalanesthesia, and considered the following factors in their series:age, gender, needle size, fasting, hydration, premedicationand postoperative medication, minimal amount of trauma to themeninges, duration of recumbency, and the amount of CSF removed.Even after controlling for age and gender, the frequency ofPLPHA in the spinal anesthesia group was low. They speculatedthat "if patients undergoing an LP for diagnostic purposes weretreated like patients undergoing spinal anesthesia the incidence[‘frequency’] of PLPHAs could be markedly reduced."1
The work of Tourtellotte et al.1 demonstrated the large variabilityin the frequency of PLPHA in different settings and in differentseries, and the apparent ability to reduce this frequency, basedon uncontrolled reports. The average frequency that they reportedin their monograph has been replicated or even exceeded in morerecent experience (e.g., 37% in the series by Kuntz et al.7),and thus is not a problem of the past. The reason for this reviewis to identify risk factors that could be modified to reducethe frequency of PLPHAs in patients undergoing diagnostic LPs.
The large variability in reported frequencies of PLPHA is significantand should be considered at the outset. When Fishman2 commentedthat the frequency of PLPHA in many of the published reportsis greater than in his personal experience, he may have beenechoing the thoughts of many readers, although this perceptionmay be due in part to underascertainment in an uncontrolledsetting. Furthermore, in testing an intervention to reduce thefrequency of PLPHA, if the baseline rate were low (e.g., 5 to10%), a fairly large sample size would be needed for any interventionto show significant reduction in frequency. Not surprisingly,the baseline rate in most studies with significant findingshas been closer to the 20 to 30% range.
Treatments for PLPHA that have shown efficacy in the managementof PLPHA once it has occurred include oral or IV caffeine, epiduralsaline, and epidural blood patches.6 These and other possibletreatments are not considered further, as the management ofPLPHA was not the focus of this review.
PLPHA has been defined in different ways. Definitions rangefrom any HA after LP to HA after LP with definite characteristics—inparticular, a constant HA appearing or worsening significantlyupon assuming the upright position and resolving or improvingsignificantly upon lying down. Some of the definitions useddo not permit excluding possible overlap between the PLPHA describedand migraine without aura, at least in some of the patients.We elected to accept all definitions of PLPHA uncritically,but recommend that future studies of PLPHA adhere to rigorousdefinitions that will permit excluding other etiologies of HAs.Similarly, there is no uniform definition of "severe" PLPHA.Future studies should use established and well-defined criteriafor PLPHA and its severity.8,9
A literature search conducted by one of the authors (R.W.E.)served as the basis for this report. Appropriate literaturewas identified by MEDLINE searches back to 1966 using the followingkey words and phrases: post–lumbar puncture headache,prevention of post–lumbar puncture headache, complicationsof lumbar puncture, atraumatic and pencil point lumbar punctureneedles, and Whitacre and Sprotte lumbar puncture needles. Additionalarticles were found through bibliographies of these articlesand by checking pertinent textbooks. Articles deemed pivotalfor making recommendations were reviewed by members of the Therapeuticsand Technology Assessment (TTA) Subcommittee (C.A., D.G., E.F.)for the purpose of classification of the evidence as it pertainedto the recommendations at hand. Some of the background literaturewas also reviewed independently by TTA Subcommittee members.
Frequency of PLPHA continues to vary among contemporary seriesand between diagnostic and spinal anesthesia cases.
The following definite demographic risk factors were identified,based on Class II evidence: younger age, female gender, andHA before or at the time of the LP. Less certain risk factorsincluded lower body mass index (a significant factor in someseries, but of small magnitude), and prior PLPHA (not a consistentobservation).
PLPHA occurs twice as often in women as in men.7,10,11 The increasedfrequency of PLPHA in female patients is based upon a comparisonof equally sized groups of females and males and also basedupon diagnostic LP studies.7,11 Most of the increased frequencyin women is during the child-bearing years.11 The highest frequencyis in the 18- to 30-year-old age group.12,13 The frequency isless in children younger than 13 years14 and in both men andwomen older than 60 years.11 One study reports that the incidenceis greater in patients with small body mass index (weight/height2).7Younger female patients with a small body mass index may havethe highest risk of developing PLPHA.7
Patients with HAs before the LP are at greater risk for PLPHA.7,15,16The HAs are more severe and last longer than in those withouta previous or current HA.7,16 Patients with a history of PLPHAare also at increased risk.17
The following technical factors were identified:
Needle size: Convincing Class I evidence in anesthesiology seriesand either Class I or Class II evidence in neurology seriesindicate that smaller needle size is associated with lesserrisk of HA.3,4,11,17-19 When using the Quincke (conventional)needle, the incidence of PLPHA decreases with a smaller needlediameter, which is consistent with the CSF leakage theory ofPLPHA. A smaller needle diameter produces a smaller tear inthe dura, and thus there is less potential for leakage.18 Theincidence of PLPHA decreases with higher gauge Quincke needlesas follows: 16 to 19 G, about 70%; 20 to 22 G, 20 to 40%; and24 to 27 G, 5 to 12%.4 Thinner needles are technically harderto use. For diagnostic LP, use of needles with a diameter smallerthan the 20 G may not be practical unless only a small volumeof fluid is needed, because the time for the transduction ofthe opening pressure using the manometer may be too long andthe flow rate too slow.19 However, smaller diameter needlesare satisfactory for spinal and epidural anesthesia and myelography.
Direction of bevel: There is Class I evidence in anesthesiologyliterature that less incidence of PLPHA results if the bevelof the Quincke is inserted parallel to the dural fibers, ratherthan perpendicular.17,20-23 Parallel insertion means that aplane passing through the flat part of the bevel, going throughboth edges of the bevel, is parallel to the long or verticalaxis of the spine. The dural fibers run parallel to the longaxis of the spine.24 When the dura is punctured with the bevelperpendicular to the fibers, more fibers are severed than whenthe bevel is parallel to the fibers.21 Five studies of patientsreceiving spinal anesthesia have demonstrated a reduction inthe incidence of PLPHA by 50% or greater when the bevel is parallelrather than perpendicular.17,20-23
Replacement of the styletbefore withdrawing the needle: Replacementof the stylet beforewithdrawing the needle results in lessincidence of PLPHA whenusing a noncutting needle.25 Struppet al.25 randomly assigned600 patients undergoing LPs withSprotte (noncutting) 21-G needlesto one of two groups. In onegroup, the stylet was reinsertedbefore withdrawal. In the othergroup, the stylet was not reinserted.PLPHA was reported in16% of the patients in the group withoutreinsertion and in5% of the patients in the group with reinsertionof the stylet(p < 0.005). Their explanation is that a strandof arachnoidmay enter the needle with the CSF and, when theneedle is removed,the strand may be threaded back through thedural defect andproduce prolonged CSF leakage. Whether reinsertingthe styletfollowing an LP with a Quincke needle would reducethe incidenceof PLPHA is not known, although there is no reasonto believethe experience would be different than with a Sprotteneedle(Class III). There are reports of rare complicationswith bothtechniques. Rarely, a nerve root can herniate throughthe duradue to aspiration by the needle during rapid withdrawal.26,27There is a single case report of transection and withdrawalof a nerve filament due to replacement of the stylet (into ahollow needle with an end-hole-side-hole needle) following alumbar myelogram.28 Bacterial meningitis, a rare complicationof diagnostic LP,29 might theoretically be caused by reintroducinga stylet contaminated with respiratory droplets. The styletshould always be used on insertion through the skin and thesubcutaneous tissue whether using a Quincke or atraumatic needle.Rarely, a needle without a stylet may implant a plug of skinwhich can grow into an intraspinal epidermoid tumor.30,31
Needledesign: The "pencil point," noncutting, or atraumaticneedlessuch as the Whitacre32 or Sprotte33 (a modificationof the Whitacreneedle with a longer lateral opening) have aduller tip andan oval opening just proximal to the tip in contrastto theQuincke needle (figure). Although atraumatic needlesare commonlyused by anesthesiologists, most neurologists havenever heardof these needles and only 2% use them.34 There isconflictingevidence as to whether their use reduces PLPHA.There is convincingClass I evidence in the anesthesiology literaturefor less incidenceof PLPHA with a noncutting needle comparedwith a cutting needlewith the bevel parallel to dural fibers.3However, one reportusing thin needles showed a similar incidenceof PLPHA (4%)for a cutting and a noncutting needle in womenundergoing postpartumtubal ligation under spinal anesthesia.35There is limited evidencein diagnostic LPs. In particular,the two studies that reportbenefit for a noncutting needlecompared with a cutting needle36,37did not state that beveldirection was parallel to the duralfibers in patients in whoma cutting needle was used. The secondof the two reports wasmainly a myelography series. Thus, neitherwould be acceptedas evidence regarding diagnostic LPs accordingto the Halpernand Preston criteria.3 Moreover, one articleshowed less PLPHAincidence with the cutting needle than withthe noncutting needle.38In summary, there is convincing evidencein the anesthesia literaturethat PLPHA is reduced using noncutting(atraumatic) needles.The data are conflicting in the diagnosticLP literature, butthe studies have, in general, been inadequateto assess thequestion.
Figure. Three types of spinal needle tips: the Quincke, Whitacre, and Sprotte. From: Peterman SB. Postmyelography headache rates with Whitacre versus Quincke 22-gauge spinal needles. Radiology 1996;200:771–778. Reprinted with permission.
Potential problems and hazards of noncutting needles.
A few LPs with the Sprotte needle are usually necessary fora physician to feel comfortable with its use. Because the tipof the needle is relatively dull, a sharp, short introduceris provided with the Sprotte needle. The introducer should beinserted to 2/3 of its length before inserting the Sprotte needle.Unlike the Quincke needle, in which the direction can be easilychanged, the direction of the introducer has to be changed ifthe needle is not in the proper location. The procedure canbe performed without the introducer by using the anestheticneedle to make a skin entry first, but use of the introduceris simpler for most physicians and may result in less damageto the needle tip. The feel of the noncutting needle is differentthan that of the Quincke needle and the physician has to pushharder with the introduction of the needle. Occasionally, theLP cannot be performed with the Sprotte needle and the physicianwill have to change to the Quincke.39 Sprotte needles can bedamaged during LP.40-42 Based upon the large number of reportedprocedures using the Sprotte needle, the risk of significantneedle damage appears to be extremely low. Sprotte needles havea cost of about $12 per needle compared with about $4 per Quinckeneedle. LP trays including the Sprotte needle are availableat about the same price as a tray with the Quincke needle.
5. Volume of spinal fluid removed: The amount of spinal fluidremoved is not a risk factor for PLPHA.7
6. Duration of recumbencyafter the LP: There is no evidencethat the duration of recumbencyafter the LP has a role in preventingPLPHA. In 1899, followinghis experiments with spinal anesthesia,Bier43 reported thePLPHA of himself and his associate. Hisrecommendation for prevention,strict bed rest, is still advisedby many physicians today.Class I evidence shows no benefitfor prevention of PLPHA bybed rest for up to 24 hours in thesupine, prone, or head downposition.44-50 Two studies showeda mildly increased frequencyof PLPHA in recumbent patientsas compared with patients immediatelymobilized.7,51 Althoughthe reports available show no effectfor the duration of recumbencyafter diagnostic LPs, the failureto demonstrate an effect isnot the same as showing that thereis no effect. Because thereare serious methodologic concernsregarding the existing studies,it is not possible to make sucha strong conclusion. Thus, thereare important differences intechnique, study methodology, anddefinition of PLPHA and itsseverity, as well as questions regardingthe representativenessof the study populations. For example,the available studieshave not reported what patients do afterthey get up for thefirst time after an LP (for example, dothey stay up, or dothey lie down again?). Indeed, in the onlystudy in which patientcompliance is reported, only about halfof the patients (60.5%)actually followed the instructions regardingmobilization orrecumbency.50
7. Increased hydration following the LP: Thereis no evidencefor the use of increased fluids in the preventionof PLPHA.Some physicians recommend fluid intake post-LP, eventhoughthe single prospective study of this practice found thatincreasedintake of oral fluids after the LP had no impact onthe occurrenceof PLPHA.52
Class I and Class II data in the anesthesiology literature andeither Class I or Class II data in the neurology series showthat smaller needle size is associated with reduced frequencyof PLPHA (Type A). The actual choice of needle size will beinfluenced by balancing other considerations, such as ease ofuse, the need to measure pressures, and the flow rate, withthe desire to prevent PLPHA.
Class I data in the anesthesiologyliterature show that, whenusing a cutting needle, ensuringthat the bevel direction isparallel to the dural fibers reducesthe frequency of PLPHA.(Type A)
Class I data using a noncuttingneedle show that replacementof the stylet before the needleis withdrawn is associated withlower frequency of PLPHA. (TypeA)
For spinal anesthesia, Class I data show that noncuttingneedlesreduce the frequency of PLPHA (Type A). However, fordiagnosticLPs, the data are inconclusive.
Class I and ClassII data have not demonstrated that the durationof recumbencyfollowing a diagnostic LP influences the occurrenceof PLPHA.
There is no evidence that the use of increased fluids preventsPLPHA.
Future studies of PLPHA should use the International HeadacheSociety (IHS) criteria for PLPHA8 and published criteria forseverity of PLPHA,9 and should report the amount and depth ofplacement of local anesthetic. A description of PLPHA conformingto the IHS criteria6,8 is as follows: Bilateral HA that developswithin 7 days after an LP and disappears within 14 days afterthe LP. HA occurs or worsens within 15 minutes of assuming theupright position and disappears or improves within 30 minutesof resuming the recumbent position.
To identify candidatesfor a prospective study of the magnitudeof the PLPHA problemwhile overcoming publication and recallbiases, survey a randomsample of neurologists to identify thoseperforming at leasttwo LPs per month.
To determine the magnitude of the PLPHAproblem while overcomingpublication and recall biases, requestthat a sample of neurologistsperforming two or more LPs permonth (identified within thefirst survey) to participate ina 12-month prospective study.All LPs performed would be recorded,including the followinginformation: pertinent patient demographicdata, the indicationfor LP, the presence of past or concurrentHA, history of migraine(to identify patients prone to PLPHA),caffeine consumptionfor 48 hours before and after the LP, needletype and needlesize, and the amount and depth of local anesthesia.The frequencyof PLPHA would be determined by contacting allpatients 8 and15 days after the LP in order to monitor thefrequency of occurrenceof PLPHAs and severe PLPHAs, using standardizeddefinitionsfor PLPHA6,8 and severity of PLPHA.9 These neurologistswouldagree to practice taking into consideration recommendations1 through 3 above. If differences were encountered that couldnot be accounted for by the known risk factors, further surveysmay help determine their causes.
To evaluate the role of thenoncutting needle in diagnosticLPs, select two high-volumepractices using the cutting needlethat are already complyingwith recommendations 1 through 3and documenting a greater than10% frequency of severe PLPHA,to perform independent, double-blinded,prospective, studiesof same-gauge cutting versus noncuttingneedles, using standardizedmethods and controlling for age,gender, HA at the time of theLP, amount and depth of localanesthesia, history of previousHA or migraine, and caffeineconsumption for 48 hours beforeand after the LP. If two similarpractices can be identifiedthat currently use a noncuttingneedle, perform the same studyin those practices.
More definitivestudies of the role of recumbency using contemporarytechniques,current definitions of PLPHA, and broadly representedpatientpopulations are required.
Repeat surveys 2 and 3 after 3 yearsto see if there have beenany changes in the frequencies ofPLPHAs and in neurologists’practices.
If the resultsof survey 6 support that severe PLPHAs occurfrequently (>10%of LPs), even in the hands of neurologistscomplying with recommendations1 through 4, develop a collaborationwith anesthesiologiststo determine which additional technical,patient-specific, orperioperative (or peripartum) factors maycontribute to thelower frequency of PLPHA reported in spinalanesthesia and obstetricseries.
This statement is provided as an educational service of theAmerican Academy of Neurology. It is based on an assessmentof current scientific and clinical information. It is not intendedto include all possible proper methods of care for a particularneurologic problem or all legitimate criteria for choosing touse a specific procedure. Neither is it intended to excludeany reasonable alternative methodologies. The AAN recognizesthat specific patient care decisions are the prerogative ofthe patient and the physician caring for the patient, basedon all of the circumstances involved.
American Academy of Neurology Therapeutics and Technology AssessmentSubcommittee Members: Douglas Goodin, MD (Chair); Elliot MarkFrohman, MD, PhD; Robert Goldman, MD; John Ferguson, MD (Facilitator);Philip B. Gorelick, MD, MPH; Chung Hsu, MD, PhD; Andres Kanner,MD; Ann Marini, MD; Carmel Armon, MD; David Hammond, MD; DavidLefkowitz, MD; and Edward Westbrook, MD.
Quality of evidence ratings for therapeutic modalities
Class I. Evidence provided by one or more well-designed randomizedcontrolled clinical trials.
Class II. Evidence provided byone or more well-designed clinicalstudies, such as case-control,cohort studies, etc.
Class III. Evidence provided by expertopinion, nonrandomizedhistorical controls, or reports of oneor more.
Strength of recommendations
Type A. Strong positive recommendation based on Class I evidence,or based on overwhelming Class II evidence when circumstancespreclude randomized clinical trials.
Type B. Positive recommendationbased on Class II evidence.
Type C. Positive recommendationbased on strong consensus ofClass III evidence.
Type D. Negativerecommendation based on inconclusive or conflictingClass IIevidence.
Type E. Negative recommendation based on Class IIor Class Ievidence of ineffectiveness or lack of efficacy.
Acknowledgments
The suggestions of Robert A. Fishman, MD, and Stephen D. Silberstein,MD, are appreciated.
Footnotes
Approved by the AAN Therapeutics and Technology Assessment SubcommitteeMay 2, 2000; approved by the Practice Committee May 3, 2000;approved by the AAN Board of Directors June 9, 2000.
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Received December 8, 1999.
Accepted in final form June 14, 2000.
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2008 - 2009.
[Full Text][PDF]
K. V. Toyka, B. Muller, H. Reichmann, M. Strupp, O. Schuler, and T. Brandt "Atraumatic" Sprotte needle reduces the incidence of post-lumbar puncture headaches
Neurology,
October 8, 2002;
59(7):
1120 - 1121.
[Full Text][PDF]
J. McArthur Review: longer bed rest does not prevent more postpuncture headaches than immediate mobilisation or short bed rest
Evid. Based Nurs.,
July 1, 2002;
5(3):
87 - 87.
[Full Text][PDF]
M. Strupp, O. Schueler, A. Straube, S. Von Stuckrad-Barre, and T. Brandt ""Atraumatic"" Sprotte needle reduces the incidence of post-lumbar puncture headaches
Neurology,
December 26, 2001;
57(12):
2310 - 2312.
[Abstract][Full Text][PDF]
J. Thoennissen, H. Herkner, W. Lang, H. Domanovits, A. N. Laggner, and M. Mullner Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis
Can. Med. Assoc. J.,
November 1, 2001;
165(10):
1311 - 1316.
[Abstract][Full Text][PDF]
J. S Smeltzer, J. R Davies, D. Turnbull, F. McKevitt, K. W Muir, and S. Baron Headache after diagnostic lumbar puncture
BMJ,
April 21, 2001;
322(7292):
993b - 993.
[Full Text]
Recommendations for Preventing Post-Lumbar Puncture Headache Syndrome
Journal Watch Neurology,
December 20, 2000;
2000(1220):
1 - 1.
[Full Text]
Top.
Introduction
Case definition.
