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Lumbar Puncture and Post-Dural Puncture Headaches: Implications for the Emergency Physician
The Journal of Emergency Medicine, Vol. 35, No. 2, pp. 149 –157, 2008 Copyright © 2008 Published by Elsevier Inc. Printed in the USA 0736-4679/08 $–see front matter
doi:10.1016/j.jemermed.2007.03.024
Original Contributions
LUMBAR PUNCTURE AND POST-DURAL PUNCTURE HEADACHES: IMPLICATIONS FOR THE EMERGENCY PHYSICIAN Robert L. Frank,
MD, FAAEM
Department of Emergency Medicine, Mercy Hospital of Pittsburgh, University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, Pennsylvania Reprint Address: Robert L. Frank, MD, FAAEM, Department of Emergency Medicine, Mercy Hospital of Pittsburgh, University of Pittsburgh Affiliated Residency in Emergency Medicine, 1400 Locust Street, Pittsburgh, PA 15219
e Abstract—Lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Postdural 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. © 2008 Published by Elsevier Inc.
PDPH. Because emergency physicians are often faced with treating PDPHs, it is imperative that they are able to accurately diagnose them and are familiar with the available therapies and their effectiveness and risks. Additionally, are there techniques that emergency physicians should utilize in the performance of lumbar punctures to minimize the incidence of PDPHs? This article seeks to examine the science behind these issues.
e Keywords—post-dural puncture headache; spinal headache; lumbar puncture; intracranial hypotension; epidural blood patch
ANATOMY AND PHYSIOLOGY The spinal cord is bathed in cerebrospinal fluid (CSF). The CSF is contained within the dura mater, which extends from the foramen magnum to the second sacral spinal segment. The dura mater is a tubular structure made of dense collagen and elastic fibers. It was originally thought that the fibers were oriented in a direction parallel to the spine, but more recent studies using electron microscopy have shown no particular or consistent pattern of the dural fibers (3,4). The thickness of the posterior dura is also variable and unpredictable, which may have implications in the occurrence of PDPHs (3). The normal volume of CSF in the adult is 150 mL, and several times this amount is secreted and reabsorbed by the choroid plexus daily (5). The arachnoid mater is a thin layer of tissue that is loosely adherent to the under surface of the dura.
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura is penetrated, such as diagnostic lumbar punctures, spinal anesthetics, myelograms, and inadvertent dural punctures during epidural injections (1). PDPH was first described in 1898 by August Bier, who experienced this condition first hand after experimentation with spinal anesthesia with co-pioneer August Hildebrandt (2). Patients with PDPHs often present to the Emergency Department to seek care for this condition. Additionally, emergency physicians frequently perform diagnostic lumbar punctures, thus putting these patients at risk for
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SYMPTOMS
Pathophysiology The headache that ensues after dural puncture is theorized to be primarily due to loss of CSF from a defect made in the dura with resultant intracranial hypotension (6). A large defect allows for greater loss of CSF and increases the likelihood of intracranial hypotension and PDPH (7). When the patient then assumes an upright position there is downward traction on pain-sensitive intracranial veins, meninges, and cranial nerves caused by gravity and loss of buoyancy from the reduced CSF pressure (8 –10). This “sagging” of intracranial structures has been demonstrated on magnetic resonance imaging (11). CSF leak after dural puncture has been well documented (12). Manometric studies have demonstrated that adult subarachnoid pressure is reduced from the normal 5–15 cm H2O to ⬍ 4 cm H2O, and the rate of CSF leak is generally greater than CSF production (12). Support for this theory of PDPH also lies in the fact that intrathecal or epidural injections of saline restore the CSF volume, increase epidural and subarachnoid pressure, and alleviate the headache (13,14). Other proposed mechanisms for the pain of PDPH include a resultant dilatation of the cerebral blood vessels as a compensatory mechanism to restore intracranial volume, which may further exacerbate the symptoms (6). Clark also found that patients with low CSF levels of the neurotransmitter substance P, which is released with dural puncture, were three times more likely to have PDPHs than those with higher levels (15). Hypersensitivity to substance P with upregulation of receptors is thought to be a causative factor in post-dural puncture as well as other types of headache.
INCIDENCE PDPHs occur with a wide range of reported frequency, from ⬍1% in some studies to as much as 70% in others (16,17). This wide range is due to the fact that certain patient populations and dural puncture procedures carry quite variable degrees of risk for PDPH. Patients who receive dural punctures with large-bore needles (diagnostic myelography and inadvertent dural puncture during labor epidural anesthesia) are very likely to sustain PDPHs. Patients who receive spinal anesthesia with small (24 –30-gauge) non-cutting needles generally have significantly reduced risk of PDPH, with rates as low as 2% or less (7). PDPH after diagnostic lumbar puncture (excluding myelography, pneumoencephalography, and cisternal puncture) has an incidence of 6 – 40% (9,18 – 21). This number is reduced to about 5% when special measures are taken to reduce PDPH (22,23).
Although PDPHs can occur from immediately to months after dural puncture, 90% occur within the first 72 h and most within 48 h (24,25). Headaches that occur beyond this time frame should raise suspicion for other causes. PDPH is typically frontal or occipital, “burning,” and radiates into the neck and shoulders (5). Pain, though, may be in any location in the head or neck (26,27). Isolated back pain may infrequently be the presenting complaint (28). The most important diagnostic feature is that the headache is minimal or absent in the supine position and is exacerbated with upright posture (5). If this component is not present, diagnosis of PDPH should be reconsidered. PDPH is often associated with nausea and vomiting, photophobia, diplopia, low back pain, neck stiffness, dizziness, tinnitus, hearing changes, and cranial nerve palsies (27–30). PDPHs can be quite variable in their severity and duration. Seventy-two percent of PDPHs will resolve spontaneously in 7 days (31). Case reports have documented a PDPH lasting as long as 8 years (32). The headache may be mild and resolve spontaneously in a few days, or severe, lasting a week or longer and causing significant disability. A study by Tohmo et al. found that 39% of patients with PDPH had 1 week of impaired ability to perform activities of daily living (33). Additionally, PDPHs that persist untreated can predispose to subdural hematoma, herniation, and death (34 –36).
DIAGNOSIS Diagnosis of PDPH is usually a clinical diagnosis, generally aided by the history that there has been some recent procedure with actual or potential risk of dural puncture. This may include diagnostic lumbar puncture, myelogram, spinal anesthetic, epidural anesthetic or steroid injection, and spine surgery. A characteristic positional headache is also essential. Various imaging techniques to aid diagnosis have been described but are rarely needed except to rule out other causes of headache (37,38). In the postpartum period, other causes of headache such as preeclampsia, posterior leukoencephalopathy, caffeine withdrawal, migraine, and cocaine abuse should be considered. A procedure described by Gutsche also may be helpful in patients in whom the diagnosis of PDPH is uncertain (39). Firm continuous abdominal pressure is applied with the examiner’s hand while the headache is present. A PDPH will usually be significantly relieved within 30 s and return when pressure is released. This is thought to be due to an increase in pressure relieving CSF hypotension.
Post-Dural Puncture Headache in the ED
RISK FACTORS FOR PDPH Demographic and Other Risk Factors There are certain demographic factors that seem to be associated with risk of PDPH for reasons that are not well understood. Patient age is a risk factor, with ages between 18 and 40 years the highest risk range (26,32,40 – 42). The risk of PDPH at age 25 years is 3– 4 times that at age 65 years (31,42,43). Children younger than 13 years rarely get PDPH (44,45). This is thought to be due to lower CSF pressure in children (46,47). PDPHs do occur with increasing frequency in adolescents and are similar to those seen in adults (48,49). There is also significantly decreased frequency after age 60 years, which also may be related to reduced CSF pressure (50). Female sex, regardless of age, is also a risk factor for PDPH for unknown reasons. Women have approximately twice the likelihood compared to men (18,31,51). Race does not seem to be a factor in development of PDPH (25). A history of chronic or recurrent headache has been found in nearly 60% of those with PDPH (15). Previous history of PDPH is also a risk factor for development of future headaches (43). Although there is a high incidence of pregnancy-related PDPHs, a metaanalysis by Morewood did not show that pregnancy in and of itself was likely to be the cause (9). The increased frequency may be more likely related to patient age and sex. Inadvertent dural puncture during the performance of labor epidural anesthesia significantly increases the risk of PDPH, but even in pregnant women who receive only spinal anesthesia, the risk of PDPH is considerably elevated. Volume of CSF removed and its role in causing PDPH is unclear. Removal of 15–20 mL of CSF reliably caused headaches in one study (26). Volume of CSF removed did not seem to be a factor in a study by Kuntz et al. (18). The small volume usually removed during diagnostic lumbar punctures performed by emergency physicians is not likely to be a significant factor. Experience of the practitioner performing the dural puncture does not seem to be a factor in development of PDPH, nor does multiple attempts at lumbar puncture (52). Low body mass index is another a risk factor for PDPH (18). Thus, young, thin women seem to be at highest risk for PDPH. These results are summarized in Table 1.
SPINAL NEEDLES AND THEIR RELATIONSHIP TO PDPH Size of Spinal Needle There are several characteristics related to the spinal needle used that are critical determinants in development of PDPH. Although these issues have long been part of
151 Table 1. Risk Factors for Development of PDPH Factors that increase risk: Age 18–40 years Female sex Low BMI History of chronic headaches or previous PDPH Factors that do not increase risk: Race of patient Position of patient during lumbar puncture Number of attempts at lumbar puncture Experience of practitioner performing lumbar puncture Pregnancy Volume of CSF removed (for typical emergency diagnostic lumbar puncture) PDPH ⫽ post-dural puncture headache; BMI ⫽ body mass index; CSF ⫽ cerebrospinal fluid.
anesthesia practice, they are rarely considered by other specialists who perform dural puncture procedures (53– 55). Thoughtful consideration of these issues is one area in which emergency physicians can have a significant impact on reducing the occurrence of PDPHs. The first issue relates to size of the needle. Larger needles leave larger holes, allow for greater CSF leak and, thus, cause more PDPHs (7,43,50,53,56,57). The incidence of PDPH with the standard 20- or 22-gauge Quincke cutting beveled needle commonly used by non-anesthetists for diagnostic lumbar puncture is as high as 40% (9,18 –21). This could be reduced to as low as 5% using a similar 24 –27-gauge needle (58). It has been a long-held belief that the small needles used for performance of spinal anesthetics allow for too-slow fluid collection and unacceptable difficulty for use in the performance of diagnostic lumbar punctures (7). Carson and Serpell found that use of needles smaller than 22-gauge required ⬎6 min to collect 2 mL of CSF and measurement of opening pressure was similarly slow and potentially inaccurate (7). Thus, it is felt by some that needles smaller than 22gauge are inadequate for diagnostic lumbar punctures (59). Strachan et al., however, showed that 2 mL of CSF could be obtained by gentle aspiration through a 24gauge needle in ⬍1 min (60). In addition to using a smaller-gauge needle, using a needle with an atraumatic tip can further reduce the incidence of PDPH, as will be discussed below.
Needle Shape An additional factor important in reducing PDPH is the shape of the tip of the spinal needle. Green, in 1926, showed that blunt-tipped spinal needles that separate dural fibers and allow recoil with minimal tearing significantly reduce CSF leak and PDPH (61). Holst et al. showed with electron microscopy that atraumatic needles
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Figure 1. Drawing showing three types of spinal needle tips: the Quincke, the Whitacre, and the Sprotte. Reproduced with permission from (8): Peterman SB, Postmyelography headache rates with Whitacre versus Quincke 22gauge spinal needles. Radiology 1996;200:771– 8.
leave smaller holes in the dura that tend not to remain open and have three times less CSF leakage than Quincke (BD, Franklin Lakes, NJ) needles (62). In recent years, several atraumatic (also known as pencil point or non-cutting) spinal needles have been introduced, with the Sprotte (B. Braun Medical Inc., Bethlehem, PA) and Whitacre (BD, Franklin Lakes, NJ) brands being most commonly used (Figure 1). The anesthesia literature has shown conclusively that atraumatic needles significantly reduce incidence of PDPH compared to cutting Quincketype needles typically used by non-anesthesia practitioners (53). Although less studied in diagnostic lumbar puncture, there is evidence to support the use of atraumatic needles for PDPH reduction. Thomas et al. showed that PDPH incidence could be reduced from 54% to 29% if a 20-gauge atraumatic needle was used rather than a Quincke cutting beveled needle (63). The incidence could be further reduced to 4% when 22-gauge atrau-
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matic spinal needles are used (23). Strupp et al. found that patients who received a diagnostic lumbar puncture with a 22-gauge atraumatic needle had a PDPH rate of 12.2% vs. 24.4% in those who received lumbar puncture with a 22-gauge Quincke needle (19). Other investigators have shown similar reductions in PDPH with the use of 22-gauge atraumatic needles (54,64,65). Other studies have not shown a reduction in PDPH when atraumatic needles were compared to similar-gauge cutting beveled needles. Lenaerts et al. found no benefit when the 20gauge atraumatic Sprotte needle was compared to the 20-gauge cutting Yale needle (BD Madrid, Spain) (66). These findings are likely related to the fact that even though an atraumatic needle was used, it was a largebore needle that would cause a sizeable dural rent despite its non-cutting tip. Other investigators also have found no reduction in PDPH after diagnostic lumbar puncture when atraumatic 22-gauge needles were compared with cutting Quincke needles (67,68). Disadvantages of the atraumatic needles includes increased cost, different “feel” and lack of “pop” that is often felt upon piercing the dura, occasional failure to obtain CSF, and difficulty penetrating the skin due to the dull tip. This last issue can be overcome by insertion of the atraumatic spinal needle through a traditional cutting 18-gauge needle acting as an introducer placed beyond the epidermis. Taking into consideration the desirable characteristics of a spinal needle for use in diagnostic lumbar puncture and the goal of reducing the risk of PDPH, a 24-gauge atraumatic needle may be the needle of choice, especially for those at high risk for PDPH. Atraumatic needles are slightly more expensive than similar Quincke needles (approximately $12 versus $4, respectively), although this cost could be easily offset by the reduced numbers of spinal headaches (20).
Bevel Orientation Another factor that significantly reduces likelihood of PDPH when using a cutting beveled Quincke needle is the orientation of the needle tip to the dura. Although the dural fibers in general have no consistent orientation, branching elastic fibers do tend to lie in an orientation that minimizes the size of the opening when the cutting bevel of the needle is inserted parallel to the long axis of the spine (3,4). This causes fewer fibers to be cut than if the bevel were inserted in a perpendicular orientation. Thus, a smaller hole in the dura is created, less CSF leakage occurs, and there is reduced likelihood of PDPH (43,52,55,69 –71). Therefore, insertion of the needle with the cutting bevel parallel to the long axis of the spine is indicated. Tearing of the dura may also occur upon removal of the needle if it is rotated to a perpendicular
Post-Dural Puncture Headache in the ED Table 2. Things the Emergency Physician Can Do To Reduce PDPH ● Use small atraumatic spinal needles (22–24-gauge Sprotte, Whitacre) ● Insert cutting bevel parallel to long axis of spine if using Quincke-type needle ● Replace stylet before removing spinal needle ● Bed rest, hydration, prophylactic caffeine not helpful in preventing PDPH
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by increasing the rate of production of CSF to replace the fluid lost from leakage. This was not found to be beneficial in the only study that has examined this issue (75). Thus, it would seem that intake of additional fluids after a lumbar puncture does not assist in PDPH prevention (76).
PDPH ⫽ post-dural puncture headache.
Patient Positioning During Lumbar Puncture
orientation after insertion (72). Bevel orientation is not an issue with atraumatic needles, as they tend to separate dura fibers rather than cutting them, allowing them to return to their original position with decreased CSF leakage (61).
The position that the patient is placed in during LP has been postulated to play a role in the development of PDPH (77). A controlled study did not show the position used during performance of LP to have a relationship to development of PDPH (78). Strategies the emergency physician can employ to reduce the risk of PDPH are summarized in Table 2.
Stylet Replacement Replacement of the spinal needle stylet before removal of the needle also has been shown to reduce the incidence of PDPH. Strupp et al. found that stylet reinsertion reduced PDPH from 16% to 5% with 21-gauge Sprotte atraumatic needles (19). It was postulated that a strand of arachnoid mater may be pulled by the open needle on its removal and enter the dural rent, maintaining an opening that allows greater CSF leakage (19). A similar study has not been performed using cutting Quincke needles. A similar effect may occur if the spinal needle strikes bone upon insertion. This has been reported to cause a burr to develop at the needle tip that will drag the arachnoid mater out as it is withdrawn, thus creating a CSF leak (73). This concept has not been formally studied.
Bed Rest Use of bed rest to prevent PDPH was first advocated by Bier in 1899 (20). It is still advocated by many that a patient must have some period of bed rest after a lumbar puncture to prevent PDPH. A meta-analysis by Thoennisen et al. and a Cochrane review by Sudlow and Warlow evaluated all studies on this topic and found no difference in incidence of PDPH for those with immediate mobilization vs. bed rest for up to 24 h (29,74). Thus, bed rest after lumbar puncture has no role in PDPH prevention.
Hydration It is advocated by some that increased hydration after dural puncture will minimize PDPH occurrence, possibly
TREATMENT OF PDPH Treatment options for dural puncture headache depend on many factors such as severity of headache, degree of interference with activities of daily living, associated symptoms, response to conservative care, and presence of potential contraindications to more definitive therapies. Multiple treatment regimens have been advocated with varying degrees of success and risk, including medications and epidural blood patches (Table 3).
Methylxanthine Derivatives Methylxanthine derivatives such as caffeine and aminophylline have been recommended for the treatment of PDPH. It has been postulated that at least part of the pain
Table 3. Treatment for PDPH ● Supine position relieves headache but does not hasten resolution ● NSAIDs, narcotics useful for mild headache; generally not helpful if severe ● Triptans generally not effective ● Methylxanthine derivatives (caffeine) helpful if mild; effects usually temporary - Use cautiously in elderly or those who cannot tolerate potential cardiac/CNS stimulation ● Epidural blood patch generally allows rapid resolution of headache, safe - Requires anesthesia practitioner for performance - Invasive - Contraindicated if bleeding diathesis, cellulitis at puncture site, fever PDPH ⫽ post-dural puncture headache; NSAID ⫽ non-steroidal anti-inflammatory drug; CNS ⫽ central nervous system.
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from PDPH is due to cerebral vasodilatation as a compensatory attempt to restore intracranial volume (6). It is thought that methylxanthine medications cause vasoconstriction of these vessels, thus decreasing pain. It has also been theorized that these drugs antagonize purine receptors and relieve headache by this mechanism (25). Caffeine is usually given as 500-mg caffeine sodium benzoate in 1 L of intravenous fluid over 1 h, although some have given it as a rapid intravenous bolus (79,80). A second dose usually can be repeated in 1–2 h if needed. If aminophylline is used, it is given 5– 6 mg/kg over 20 min or given orally as theophylline 300 mg every 6 – 8 h (25). Side effects include central nervous system stimulation, seizures, gastric irritation, and provocation of cardiac dysrhythmias (80). Methylxanthine medications have been reported to be effective in alleviating PDPH in up to 90% of patients (79 – 86). Unfortunately, the data used to support the efficacy of caffeine are limited to one oft-cited small, methodologically flawed study and several case reports (73,76,77,80,82,84,86 – 89). The effects of caffeine seem to be temporary at best, with headache recurrence rates of up to 60% (9,83,86,89). It has no effect on CSF leakage nor does it restore normal CSF dynamics, which are thought to be the primary causes of PDPH (5). Camann et al. found oral caffeine to provide significantly better pain relief than placebo for PDPH initially, but there was no significant difference in pain scores at 24 h or in the number of epidural blood patches performed between the two groups (89). A recent North American hospital survey reports that most practitioners have abandoned the use of caffeine for treatment of PDPH due to its perceived ineffectiveness. Additionally, although it is sometimes recommended that patients consume caffeine after a lumbar puncture to prevent PDPH, it seems that this strategy, too, is ineffective (90). Further quality investigation is needed to determine the effectiveness of caffeine and theophylline in the prevention and treatment of PDPH.
Sumatriptan Sumatriptan is a serotonin agonist occasionally used in the treatment of migraines. It has been reported successful for the treatment of PDPH (43,91,92). Others have found it to be ineffective (93). A controlled trial found no evidence of benefit when using sumatriptan in the treatment of PDPH (94).
Epidural Blood Patch Despite a recent Cochrane review that was unable to draw unequivocal conclusions about its efficacy, the
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epidural blood patch (EBP) is generally considered the definitive treatment for PDPH, especially for those that are severe or debilitating (5,16,29,43,44,81,95–99). It was first described in 1960 by Gormley after it was noted that “bloody taps” were associated with decreased incidence of PDPH (100). EBP is performed by injecting 15–30 mL of the patient’s blood into the epidural space through a Tuohy epidural needle (16). This is ideally done at the site of the previous dural puncture. The injected blood spreads in both a cranial and caudal direction. The thecal sac is compressed and displaced and is thought to elevate and thus restore the subarachnoid pressure (5). It is also thought that the blood clot that forms seals off the rent in the dura and prevents further leakage of CSF. Success rates have generally been reported in 72–98% of patients, although less favorable results have been noted (1,16,39,81,97,98,101–105). Usually, there is immediate relief of the headache. EBP is most effective when performed at least 24 h after the initial puncture (25). Complications are rare but include radicular pain from nerve root irritation or displacement, cranial nerve palsies, meningeal irritation, elevated intracranial pressure, paraparesis, cauda equina syndrome, infection, and subdural hematoma (5,106 –108). Complications are usually either rare or self-limited. Contraindications to EBP include patient refusal, fever or suspected bacteremia and anticoagulation (5,108). EBP has been successfully used in adolescents (48). Patients who get no or incomplete relief after a first EBP have equivalent or higher rates of success on a second attempt (25,102). Failure of EBP is seen most often in patients with dural puncture from large bore needles, such as with inadvertent dural puncture with 16-gauge Tuohy needles during performance of labor epidural anesthesia (1,102). Prophylactic Epidural Blood Patch Some practitioners advocate use of a “prophylactic” EBP to prevent PDPH, especially in those at high risk (partiuent with inadvertent dural puncture with a large bore epidural needle). The data supporting this practice are contradictory. Several studies have shown benefit, others have not (109 –112). A recent Cochrane review found there were insufficient quality data to reach a definitive conclusion on the effectiveness of this practice (29). This practice is not likely to have much impact on the prevention of PDPH from diagnostic lumbar punctures performed by emergency physicians. CONCLUSIONS Dural puncture procedures are commonly performed by various medical practitioners, including emergency phy-
Post-Dural Puncture Headache in the ED
sicians, for many reasons. PDPH is a relatively common complication. The degree of pain and disability caused by PDPHs is considerable. Appropriate use of smallergauge, atraumatic needles is likely the single most important factor in reducing PDPH. Hydration and bed rest do little to prevent PDPH. Treatment of mild, nondebilitating headaches usually can be accomplished with limited activity, analgesics, and methylxanthine therapy until they resolve spontaneously. For more severe headaches, methylxanthine derivatives may be tried with EBP as a first-line alternative or to be used if methylxanthines fail. It is helpful to use 24-gauge Sprotte spinal needles in all patients at risk for PDPH. For patients who have moderate to severe pain, cannot or do not want to remain on bed rest, and those in whom narcotic pain medication is not a practical treatment option, EBP is an appropriate first-line therapy. In general, EBP is safe, well tolerated and effective. Though the technique for epidural blood patch is not significantly more difficult than lumbar puncture, it is a procedure most commonly performed by anesthesiologists. REFERENCES 1. Vercauteren MP, Hoffman VH, Mertens E, Sermeus L, Adriaensen HA. Seven-year review of requests for epidural blood patches for headache after dural puncture: referral patterns and the effectiveness of blood patches. Eur J Anaesthesiol 1999;16: 298 –303. 2. Calverley RK. Anesthesia as a specialty: past, present, and future. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia. Philadelphia, PA: Lippincott; 1989:35– 42. 3. Reina MA, de Leon-Casasola OA, Lopez A, De Andres J, Martin S, Mora M. An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 2000;25:393– 402. 4. Fink BR, Walker S. Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture. Anesth Analg 1989; 69:768 –72. 5. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003;91: 718 –29. 6. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry 1991;54:440 –2. 7. Carson D, Serpell M. Choosing the best needle for diagnostic lumbar puncture. Neurology 1996;47:33–7. 8. Peterman SB. Postmyelography headache: a review. Radiology 1996;200:765–70. 9. Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J 1993;149:1087–93. 10. Hilton-Jones D. Post lumbar puncture headache. Springfield IL: Charles C. Thomas; 1964. 11. Hannerz J, Ericson K, Bro Skejø HP. MR imaging with gadolinium in patients with and without post-lumbar puncture headache. Acta Radiol 1999;40:135– 41. 12. Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 1992;42:481–7. 13. Charsley MM, Abram SE. The injection of normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med 2001;26:301–5.
155 14. Usubiaga JE, Usubiaga LE, Brea LM, et al. Effect of saline injection on epidural and subarachnoid space pressures and relation to postspinal anesthesia headache. Anesth Analg 1967;46: 293– 6. 15. Clark JW. Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. J Neurol Neurosurg Psychiatry 1996;60:681–3. 16. Crawford J. Experiences with epidural blood-patch. Anaesthesia 1980;35:513–5. 17. Fishman RA. CSF in diseases of the nervous system. Philadelphia, PA: WB Saunders; 1992. 18. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology 1992;42:1884 –7. 19. Strupp M, Schueler O, Straube A, et al. “Atraumatic” Sprotte needle reduces the incidence of post-lumbar puncture headaches. Neurology 2001;57:2310 –12. 20. Evans RW, Armon C, Frohman E, et al. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:909 –14. 21. Seupaul RA, Somerville GG, Viscusi C, et al. Prevalence of postdural puncture headache after ED performed lumbar puncture. Am J Emerg Med 2005;23:913–5. 22. Candido KD, Stevens RA. Post-dural puncture headache: pathophysiology, prevention and treatment. Best Pract Res Clin Anes 2003;17:45– 69. 23. Braune HJ, Huffmann G. A prospective double-blind clinical trial, comparing the sharp Quincke needle (22G) with an “atraumatic” needle (22G) in the induction of post-lumbar puncture headache. Acta Neurol Scand 1992;86:50 – 4. 24. Weir EC. The sharp end of the dural puncture. Br Med J 2000; 320:127– 8. 25. Leibold RA, Yealy DM, Coppola M, et al. Post-dural-puncture headache: characteristics, management and prevention. Ann Emerg Med 1993;22:1863–70. 26. Davignon KR, Dennehy KC. Update on postdural puncture headache. Int Anesthesiol Clin 2002;40:89 –102. 27. Cooper G. Epidural blood patch. Eur J Anaesthesiol 1999;16: 211–5. 28. Dunbar SA, Katz NP. Post-dural puncture thoracic pain without headache: relief with epidural blood patch. Can J Anaesth 1995; 42:221–3. 29. Sudlow C, Warlow C. Epidural blood patching for preventing and treating post-lumbar puncture headache. Cochrane Database Syst Rev 2002;2:CD001791. 30. Weeks SK. Postpartum headache. In: Chestnut DH, ed. Obstetric anesthesia: principles and practice, 2nd edn. St. Louis, MO: Mosby; 1999:621–38. 31. Vandam LD, Dripps RD. Long-term follow up of patients who received 10,098 spinal anesthetics. JAMA 1956;161:586 –91. 32. MacArthur C, Lewis M, Knox EG. Accidental dural puncture in obstetric patients and long term symptoms. Br Med J 1992;304: 1279 – 82. 33. Tohmo H, Vuorienen E, Muuronen A. Prolonged impairment in activities of daily living due to postdural puncture headache after diagnostic lumbar puncture. Anaesthesia 1998;53:299 –302. 34. Edelman JD, Wingard DW. Subdural haemoatomas after lumbar dural puncture. Anesthesiology 1980;52:166 –7. 35. Lance JW, Branch GB. Persistent headache after lumbar puncture. Lancet 1994;343:414. 36. Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion following spinal anesthesia. Acta Anesthesiol Scand 1981;25:115– 6. 37. Mokri B, Parisi JE, Scheithauer BW, et al. Meningeal biopsy in intracranial hypotension: meningeal enhancement on MRI. Neurology 1995;45:1801–7. 38. Denny N, Masters R, Pearson D, et al. Postdural puncture headache after continuous spinal anesthesia. Anesth Analg 1987;66:791– 4. 39. Gutsche BB. Lumbar epidural analgesia in obstetrics: taps and patches. In: Reynolds F, ed. Epidural and spinal blockade in obstetrics. Oxford, UK: Bailliere Tindall; 1984:95–106.
156 40. Vilming ST, Schrader H, Monstad I. The significance of age, sex and cerebrospinal fluid pressure in post-lumbar puncture headache. Cephalgia 1989;9:99 –106. 41. Solomon GD, Clark JW, deSenanayake P, et al. Hypersensitivity to substance P in the etiology of postlumbar puncture headache. Headache 1995;35:25– 8. 42. Flaatten H, Rodt S, Rosland J, et al. Postoperative headache in young patients after spinal anesthesia. Anaesthesia 1987;42:202–5. 43. Lybecker H, Møller JT, May O, Nielsen HK. Incidence and prediction of postdural puncture headache. A prospective study of 1021 spinal anesthesias. Anesth Analg 1990;70:389 –94. 44. Bolder PM. Postlumbar puncture headache in pediatric oncology patients. Anesthesiology 1986;65:696 – 8. 45. Wee LH, Lam F, Cranston AJ. The incidence of post dural puncture headache in children. Anaesthesia 1996;51:1164 – 6. 46. Purtock RV, Buhl JL, Abram SE. Epidural blood patch in a nine-year old boy. Reg Anesth 1984;9:154 –5. 47. Tobias JD. Postdural puncture headache in children— etiology and treatment. Clin Pediatr 1990;33:110 –3. 48. Ylonen P, Kokki H. Epidural blood patch for management of postdural puncture headache in adolescents. Acta Anaesthesiol Scand 2002;46:794 – 8. 49. Aldrete JA. Persistent post-dural-puncture headache treated with epidural infusion of dextran. Headache 1994;34:265–7. 50. Tourtellotte WW, Henderson WG, Tucker RP, et al. A randomized, double-blind clinical trial comparing the 22 versus 26 gauge needle in production of the post-lumbar puncture syndrome in normal individuals. Headache 1972;12:73– 8. 51. Kovanen J, Sulkava R. Duration of postdural headache after lumbar puncture; effect of needle size. Headache 1986;26: 224 – 6. 52. Flaatten H, Krakenes J, Vedeler C. Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anesthesia. Acta Neurol Scand 1998;98:445–51. 53. Halpern S, Preston R. Postdural puncture headache and spinal needle design. Anesthesiology 1994;81:1376 – 83. 54. Birnbach DJ, Kuroda MM, Sternman D, et al. Use of atraumatic spinal needles among neurologists in the United States. Headache 2001;41:385–90. 55. Birnbach DJ, Khin N, Sternman D, et al. Differences in the practice of lumbar puncture between anesthesiologists and neurologists. Anesthesiology 1997;87:A988 (Abstract). 56. Ready LB, Cuplin S, Haschke RH, et al. Spinal needle determinants of rate of transdural fluid leak. Anesth Analg 1989; 69:457– 60. 57. Dittmann M, Schafer HG, Ulrich J, et al. Anatomic re-evaluation of lumbar dura mater with regard to postspinal headache. Effect of dural puncture. Anaesthesia 1988;43:635–7. 58. Ball CG, D’Alessandro FT, Rosenthal J, et al. Case history number 86: an unusual complication of lumbar puncture: a CSF cutaneous fistula. Anesth Analg 1975;54:691–2. 59. Broadley SA, Fuller GN. Lumbar puncture needn’t be a headache: use blunt needles and no bed rest. Br Med J 1997;315: 1324 –5. 60. Strachan A, Train J. Aspirating cerebrospinal fluid speeds up procedure. Br Med J 1998;316:1018 –9. 61. Green HM. Lumbar puncture and the prevention of post puncture headache. JAMA 1926;86:391. 62. Holst D, Mollmann M, Ebel C, et al. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg 1998;87:1331–5. 63. Thomas SR, Jamieson DRS, Muir KW. Randomized controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. Br Med J 2000;321:986 –90. 64. Muller B, Adelt K, Reichmann H, et al. Atraumatic needle reduces the incidence of post-lumbar puncture syndrome. J Neurol 1994;241:376 – 80. 65. Pedersen ON. Use of a 22-gauge Whitacre needle to reduce the incidence of side effects after lumbar myelography: a prospective randomised study comparing Whitacre and Quincke spinal needles. Eur Radiol 1996;6:184 –7.
R. L. Frank 66. Lenaerts M, Pepin J-L, Tombu S, et al. No significant effect of an “atraumatic” needle on incidence of post-lumbar puncture headache or traumatic tap. Cephalgia 1993;13:296 –7. 67. Luostarinen L, Heinonen T, Luostarinen M, et al. Diagnostic lumbar puncture. Comparative study between 22-gauge pencil point and sharp bevel needle. J Headache Pain 2005;6:400 – 4. 68. Aamodt A, Vedeler C. Complications after LP related to needle type: pencil-point versus Quincke. Acta Neurol Scand 2001;103: 396 – 8. 69. Mihic DN. Postspinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anesth 1985;10:76 – 81. 70. Norris MC, Leighton BL, DeSimone CA. Needle bevel direction and headache after inadvertent dural puncture. Anesthesiology 1989;70:729 –31. 71. Cruickshank RH, Hopkinson JM. Fluid flow through dural puncture sites: an in vitro comparison of needle point types. Anaesthesia 1989;44:415– 8. 72. Corbey MP, Bach AB, Lech K, et al. Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anesthesiol Scand 1997;41:779 – 84. 73. Crosby E. Postdural puncture headache. Can Med Assoc J 1994; 150:821–3. 74. Thoennissen J, Herkner H, Lang W, et al. Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. Can Med Assoc J 2001;165:1311– 6. 75. Dieterich M, Brandt T. Incidence of post-lumbar puncture headaches is independent of daily fluid intake. Eur Arch Psychiatry Neurol Sci 1988;237:194 – 6. 76. Lin W, Geiderman J. Medical myth: fluids, bed rest, and caffeine are effective in preventing and treating patients with post-lumbar puncture headache. West J Med 2002;176:69 –70. 77. Brocker RJ. Technique to avoid spinal-tap headache. JAMA 1958;168:261–3. 78. Vilming ST, Schrader H, Monstad I. Post-lumbar puncture headache: the significance of body posture. A controlled study of 300 patients. Cephalgia 1988;8:75– 8. 79. Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesth Analg 1986;65:316 –7. 80. Ford CD, Ford DC, Koenigsberg MD. A simple treatment of post-lumbar-puncture headache. J Emerg Med 1989;7:29 –31. 81. Neal JM. Management of post-dural-puncture headache. Anesthesiol Clin North Am 1992;10:163–78. 82. Sechzer PH, Abel L. Post-spinal anesthesia headache and treatment with caffeine. Evaluation with demand method. Part I. Curr Ther Res 1976;24:307–12. 83. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Part II: intracranial vascular distension. Curr Ther Res 1979;26:440 – 8. 84. Harrington TM. An alternative treatment for spinal headache. J Fam Pract 1982;15:172–7. 85. Hess JH. Postdural puncture headache: a literature review. AANA J 1991;59:549 –55. 86. Abboud TK, Zhu J, Reyes A, et al. Efficacy of intravenous caffeine for post dural puncture headache. Anesthesiology 1990; 73:A936 (Abstract). 87. Choi, A, Laurito CE, Cunningham FE. Pharmacologic management of postdural puncture headache. Ann Pharmacother 1996; 30:831–9. 88. Baumgarten RK. Should caffeine become the first line treatment for postdural puncture headache? Anesth Analg 1987;66:913– 4. 89. Camann WR, Murray RS, Mushlin PS, et al. Effects of oral caffeine on postdural puncture headache: a double-blind, placebocontrolled trial. Anesth Analg 1990;70:181– 4. 90. Esmaoglu A, Akpinar H, Ugur F. Oral multidose caffeineparacetamol combination is not effective for the prophylaxis of postdural puncture headache. J Clin Anesth 2005;17:58 – 61. 91. Carp H, Singh PJ, Vadhera R, et al. Effects of the serotoninreceptor agonist sumatriptan on postdural puncture headache: report of six cases. Anesth Analg 1994;79:180 –2. 92. Stallard N, Barry P. Another complication of combined extraduralsubarachnoid technique. Br J Anaesth 1995;75:370 –1.
Post-Dural Puncture Headache in the ED 93. Lhuissier C, Mercier FJ, Dounas M, et al. Sumatriptan: an alternative to epidural blood patch? Anaesthesia 1996;52:1078 –9. 94. Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000;40:316–9. 95. Digivovanni AJ, Dunbar BS. Epidural injections of autologous blood for post-lumbar puncture headache. Anesth Analg 1970; 49:268 –71. 96. Olsen KS. Epidural blood patch in the treatment of post-lumbar puncture headache. Pain 1987;30:293–303. 97. McGruder JM, Cooke JE, Conroy JM, et al. Headache after lumbar puncture: review of the epidural blood patch. South Med J 1988;81:1249 –52. 98. Heide W, Diener HC. Epidural blood patch reduces the incidence of post lumbar puncture headache. Headache 1990;30:280 –1. 99. Sandesc D, Lupei MI, Sirbu C, Plavat C, Bedreag O, Vernic C. Conventional treatment or epidural blood patch for the treatment of different etiologies of post dural puncture headache. Acta Anaesthesiol Belg 2005;56:265–9. 100. Gormley JB. Treatment of post-spinal headache. Anesthesiology 1960;21:565– 6. 101. Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labor epidural analgesia. Can J Anaesth 1998;45:110 – 4. 102. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headaches. Anesthesiology 2001;95:334 –9.
157 103. Abouleish E, Vega S, Blendinger I, et al. Long-term follow-up of epidural blood patch. Anesth Analg 1975;54:459 – 63. 104. Taivainen T, Pitkanen M, Tuominen M, et al. Efficacy of epidural blood patch for post dural puncture headache. Acta Anaesthesiol Scand 1993;37:702–5. 105. Williams E, Fawcett W, Jenkins G. Preventing headache after lumbar puncture: optimism generally quoted for epidural blood patching is unwarranted. Br Med J 1998;317:1588 –9. 106. Oh J, Camann W. Severe acute meningeal irritative reaction after epidural blood patch. Anesth Analg 1998;87:1139 – 40. 107. Sperry RJ, Gartrell A, Johnson JO. Epidural blood patch can cause acute neurologic deterioration. Anesthesiology 1995;82:303–5. 108. Diaz J. Permanent paraparesis and cauda equine syndrome after epidural blood patch for postdural puncture headache. Anesthesiology 2002;96:1515–7. 109. Gutterman P, Bezier HS. Prophylaxis of post myelogram headaches. J Neurosurg 1978;49:869 –71. 110. Colonna-Romano P, Shapiro BE. Unintentional dural puncture and prophylactic epidural blood patch in obstetrics. Anesth Analg 1989;69:522–3. 111. Loeser EA, Hill GE, Bennett GM, et al. Time versus success rate for epidural blood patch. Anesthesiology 1978;49:147– 8. 112. Palahnuik RJ, Cumming M. Prophylactic blood patch does not prevent post-lumbar puncture headache. Can Anaesth Soc J 1979; 26:132–3.
doi:10.1016/j.jemermed.2007.03.024
Original Contributions
LUMBAR PUNCTURE AND POST-DURAL PUNCTURE HEADACHES: IMPLICATIONS FOR THE EMERGENCY PHYSICIAN Robert L. Frank,
MD, FAAEM
Department of Emergency Medicine, Mercy Hospital of Pittsburgh, University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, Pennsylvania Reprint Address: Robert L. Frank, MD, FAAEM, Department of Emergency Medicine, Mercy Hospital of Pittsburgh, University of Pittsburgh Affiliated Residency in Emergency Medicine, 1400 Locust Street, Pittsburgh, PA 15219
e Abstract—Lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Postdural 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. © 2008 Published by Elsevier Inc.
PDPH. Because emergency physicians are often faced with treating PDPHs, it is imperative that they are able to accurately diagnose them and are familiar with the available therapies and their effectiveness and risks. Additionally, are there techniques that emergency physicians should utilize in the performance of lumbar punctures to minimize the incidence of PDPHs? This article seeks to examine the science behind these issues.
e Keywords—post-dural puncture headache; spinal headache; lumbar puncture; intracranial hypotension; epidural blood patch
ANATOMY AND PHYSIOLOGY The spinal cord is bathed in cerebrospinal fluid (CSF). The CSF is contained within the dura mater, which extends from the foramen magnum to the second sacral spinal segment. The dura mater is a tubular structure made of dense collagen and elastic fibers. It was originally thought that the fibers were oriented in a direction parallel to the spine, but more recent studies using electron microscopy have shown no particular or consistent pattern of the dural fibers (3,4). The thickness of the posterior dura is also variable and unpredictable, which may have implications in the occurrence of PDPHs (3). The normal volume of CSF in the adult is 150 mL, and several times this amount is secreted and reabsorbed by the choroid plexus daily (5). The arachnoid mater is a thin layer of tissue that is loosely adherent to the under surface of the dura.
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura is penetrated, such as diagnostic lumbar punctures, spinal anesthetics, myelograms, and inadvertent dural punctures during epidural injections (1). PDPH was first described in 1898 by August Bier, who experienced this condition first hand after experimentation with spinal anesthesia with co-pioneer August Hildebrandt (2). Patients with PDPHs often present to the Emergency Department to seek care for this condition. Additionally, emergency physicians frequently perform diagnostic lumbar punctures, thus putting these patients at risk for
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SYMPTOMS
Pathophysiology The headache that ensues after dural puncture is theorized to be primarily due to loss of CSF from a defect made in the dura with resultant intracranial hypotension (6). A large defect allows for greater loss of CSF and increases the likelihood of intracranial hypotension and PDPH (7). When the patient then assumes an upright position there is downward traction on pain-sensitive intracranial veins, meninges, and cranial nerves caused by gravity and loss of buoyancy from the reduced CSF pressure (8 –10). This “sagging” of intracranial structures has been demonstrated on magnetic resonance imaging (11). CSF leak after dural puncture has been well documented (12). Manometric studies have demonstrated that adult subarachnoid pressure is reduced from the normal 5–15 cm H2O to ⬍ 4 cm H2O, and the rate of CSF leak is generally greater than CSF production (12). Support for this theory of PDPH also lies in the fact that intrathecal or epidural injections of saline restore the CSF volume, increase epidural and subarachnoid pressure, and alleviate the headache (13,14). Other proposed mechanisms for the pain of PDPH include a resultant dilatation of the cerebral blood vessels as a compensatory mechanism to restore intracranial volume, which may further exacerbate the symptoms (6). Clark also found that patients with low CSF levels of the neurotransmitter substance P, which is released with dural puncture, were three times more likely to have PDPHs than those with higher levels (15). Hypersensitivity to substance P with upregulation of receptors is thought to be a causative factor in post-dural puncture as well as other types of headache.
INCIDENCE PDPHs occur with a wide range of reported frequency, from ⬍1% in some studies to as much as 70% in others (16,17). This wide range is due to the fact that certain patient populations and dural puncture procedures carry quite variable degrees of risk for PDPH. Patients who receive dural punctures with large-bore needles (diagnostic myelography and inadvertent dural puncture during labor epidural anesthesia) are very likely to sustain PDPHs. Patients who receive spinal anesthesia with small (24 –30-gauge) non-cutting needles generally have significantly reduced risk of PDPH, with rates as low as 2% or less (7). PDPH after diagnostic lumbar puncture (excluding myelography, pneumoencephalography, and cisternal puncture) has an incidence of 6 – 40% (9,18 – 21). This number is reduced to about 5% when special measures are taken to reduce PDPH (22,23).
Although PDPHs can occur from immediately to months after dural puncture, 90% occur within the first 72 h and most within 48 h (24,25). Headaches that occur beyond this time frame should raise suspicion for other causes. PDPH is typically frontal or occipital, “burning,” and radiates into the neck and shoulders (5). Pain, though, may be in any location in the head or neck (26,27). Isolated back pain may infrequently be the presenting complaint (28). The most important diagnostic feature is that the headache is minimal or absent in the supine position and is exacerbated with upright posture (5). If this component is not present, diagnosis of PDPH should be reconsidered. PDPH is often associated with nausea and vomiting, photophobia, diplopia, low back pain, neck stiffness, dizziness, tinnitus, hearing changes, and cranial nerve palsies (27–30). PDPHs can be quite variable in their severity and duration. Seventy-two percent of PDPHs will resolve spontaneously in 7 days (31). Case reports have documented a PDPH lasting as long as 8 years (32). The headache may be mild and resolve spontaneously in a few days, or severe, lasting a week or longer and causing significant disability. A study by Tohmo et al. found that 39% of patients with PDPH had 1 week of impaired ability to perform activities of daily living (33). Additionally, PDPHs that persist untreated can predispose to subdural hematoma, herniation, and death (34 –36).
DIAGNOSIS Diagnosis of PDPH is usually a clinical diagnosis, generally aided by the history that there has been some recent procedure with actual or potential risk of dural puncture. This may include diagnostic lumbar puncture, myelogram, spinal anesthetic, epidural anesthetic or steroid injection, and spine surgery. A characteristic positional headache is also essential. Various imaging techniques to aid diagnosis have been described but are rarely needed except to rule out other causes of headache (37,38). In the postpartum period, other causes of headache such as preeclampsia, posterior leukoencephalopathy, caffeine withdrawal, migraine, and cocaine abuse should be considered. A procedure described by Gutsche also may be helpful in patients in whom the diagnosis of PDPH is uncertain (39). Firm continuous abdominal pressure is applied with the examiner’s hand while the headache is present. A PDPH will usually be significantly relieved within 30 s and return when pressure is released. This is thought to be due to an increase in pressure relieving CSF hypotension.
Post-Dural Puncture Headache in the ED
RISK FACTORS FOR PDPH Demographic and Other Risk Factors There are certain demographic factors that seem to be associated with risk of PDPH for reasons that are not well understood. Patient age is a risk factor, with ages between 18 and 40 years the highest risk range (26,32,40 – 42). The risk of PDPH at age 25 years is 3– 4 times that at age 65 years (31,42,43). Children younger than 13 years rarely get PDPH (44,45). This is thought to be due to lower CSF pressure in children (46,47). PDPHs do occur with increasing frequency in adolescents and are similar to those seen in adults (48,49). There is also significantly decreased frequency after age 60 years, which also may be related to reduced CSF pressure (50). Female sex, regardless of age, is also a risk factor for PDPH for unknown reasons. Women have approximately twice the likelihood compared to men (18,31,51). Race does not seem to be a factor in development of PDPH (25). A history of chronic or recurrent headache has been found in nearly 60% of those with PDPH (15). Previous history of PDPH is also a risk factor for development of future headaches (43). Although there is a high incidence of pregnancy-related PDPHs, a metaanalysis by Morewood did not show that pregnancy in and of itself was likely to be the cause (9). The increased frequency may be more likely related to patient age and sex. Inadvertent dural puncture during the performance of labor epidural anesthesia significantly increases the risk of PDPH, but even in pregnant women who receive only spinal anesthesia, the risk of PDPH is considerably elevated. Volume of CSF removed and its role in causing PDPH is unclear. Removal of 15–20 mL of CSF reliably caused headaches in one study (26). Volume of CSF removed did not seem to be a factor in a study by Kuntz et al. (18). The small volume usually removed during diagnostic lumbar punctures performed by emergency physicians is not likely to be a significant factor. Experience of the practitioner performing the dural puncture does not seem to be a factor in development of PDPH, nor does multiple attempts at lumbar puncture (52). Low body mass index is another a risk factor for PDPH (18). Thus, young, thin women seem to be at highest risk for PDPH. These results are summarized in Table 1.
SPINAL NEEDLES AND THEIR RELATIONSHIP TO PDPH Size of Spinal Needle There are several characteristics related to the spinal needle used that are critical determinants in development of PDPH. Although these issues have long been part of
151 Table 1. Risk Factors for Development of PDPH Factors that increase risk: Age 18–40 years Female sex Low BMI History of chronic headaches or previous PDPH Factors that do not increase risk: Race of patient Position of patient during lumbar puncture Number of attempts at lumbar puncture Experience of practitioner performing lumbar puncture Pregnancy Volume of CSF removed (for typical emergency diagnostic lumbar puncture) PDPH ⫽ post-dural puncture headache; BMI ⫽ body mass index; CSF ⫽ cerebrospinal fluid.
anesthesia practice, they are rarely considered by other specialists who perform dural puncture procedures (53– 55). Thoughtful consideration of these issues is one area in which emergency physicians can have a significant impact on reducing the occurrence of PDPHs. The first issue relates to size of the needle. Larger needles leave larger holes, allow for greater CSF leak and, thus, cause more PDPHs (7,43,50,53,56,57). The incidence of PDPH with the standard 20- or 22-gauge Quincke cutting beveled needle commonly used by non-anesthetists for diagnostic lumbar puncture is as high as 40% (9,18 –21). This could be reduced to as low as 5% using a similar 24 –27-gauge needle (58). It has been a long-held belief that the small needles used for performance of spinal anesthetics allow for too-slow fluid collection and unacceptable difficulty for use in the performance of diagnostic lumbar punctures (7). Carson and Serpell found that use of needles smaller than 22-gauge required ⬎6 min to collect 2 mL of CSF and measurement of opening pressure was similarly slow and potentially inaccurate (7). Thus, it is felt by some that needles smaller than 22gauge are inadequate for diagnostic lumbar punctures (59). Strachan et al., however, showed that 2 mL of CSF could be obtained by gentle aspiration through a 24gauge needle in ⬍1 min (60). In addition to using a smaller-gauge needle, using a needle with an atraumatic tip can further reduce the incidence of PDPH, as will be discussed below.
Needle Shape An additional factor important in reducing PDPH is the shape of the tip of the spinal needle. Green, in 1926, showed that blunt-tipped spinal needles that separate dural fibers and allow recoil with minimal tearing significantly reduce CSF leak and PDPH (61). Holst et al. showed with electron microscopy that atraumatic needles
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Figure 1. Drawing showing three types of spinal needle tips: the Quincke, the Whitacre, and the Sprotte. Reproduced with permission from (8): Peterman SB, Postmyelography headache rates with Whitacre versus Quincke 22gauge spinal needles. Radiology 1996;200:771– 8.
leave smaller holes in the dura that tend not to remain open and have three times less CSF leakage than Quincke (BD, Franklin Lakes, NJ) needles (62). In recent years, several atraumatic (also known as pencil point or non-cutting) spinal needles have been introduced, with the Sprotte (B. Braun Medical Inc., Bethlehem, PA) and Whitacre (BD, Franklin Lakes, NJ) brands being most commonly used (Figure 1). The anesthesia literature has shown conclusively that atraumatic needles significantly reduce incidence of PDPH compared to cutting Quincketype needles typically used by non-anesthesia practitioners (53). Although less studied in diagnostic lumbar puncture, there is evidence to support the use of atraumatic needles for PDPH reduction. Thomas et al. showed that PDPH incidence could be reduced from 54% to 29% if a 20-gauge atraumatic needle was used rather than a Quincke cutting beveled needle (63). The incidence could be further reduced to 4% when 22-gauge atrau-
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matic spinal needles are used (23). Strupp et al. found that patients who received a diagnostic lumbar puncture with a 22-gauge atraumatic needle had a PDPH rate of 12.2% vs. 24.4% in those who received lumbar puncture with a 22-gauge Quincke needle (19). Other investigators have shown similar reductions in PDPH with the use of 22-gauge atraumatic needles (54,64,65). Other studies have not shown a reduction in PDPH when atraumatic needles were compared to similar-gauge cutting beveled needles. Lenaerts et al. found no benefit when the 20gauge atraumatic Sprotte needle was compared to the 20-gauge cutting Yale needle (BD Madrid, Spain) (66). These findings are likely related to the fact that even though an atraumatic needle was used, it was a largebore needle that would cause a sizeable dural rent despite its non-cutting tip. Other investigators also have found no reduction in PDPH after diagnostic lumbar puncture when atraumatic 22-gauge needles were compared with cutting Quincke needles (67,68). Disadvantages of the atraumatic needles includes increased cost, different “feel” and lack of “pop” that is often felt upon piercing the dura, occasional failure to obtain CSF, and difficulty penetrating the skin due to the dull tip. This last issue can be overcome by insertion of the atraumatic spinal needle through a traditional cutting 18-gauge needle acting as an introducer placed beyond the epidermis. Taking into consideration the desirable characteristics of a spinal needle for use in diagnostic lumbar puncture and the goal of reducing the risk of PDPH, a 24-gauge atraumatic needle may be the needle of choice, especially for those at high risk for PDPH. Atraumatic needles are slightly more expensive than similar Quincke needles (approximately $12 versus $4, respectively), although this cost could be easily offset by the reduced numbers of spinal headaches (20).
Bevel Orientation Another factor that significantly reduces likelihood of PDPH when using a cutting beveled Quincke needle is the orientation of the needle tip to the dura. Although the dural fibers in general have no consistent orientation, branching elastic fibers do tend to lie in an orientation that minimizes the size of the opening when the cutting bevel of the needle is inserted parallel to the long axis of the spine (3,4). This causes fewer fibers to be cut than if the bevel were inserted in a perpendicular orientation. Thus, a smaller hole in the dura is created, less CSF leakage occurs, and there is reduced likelihood of PDPH (43,52,55,69 –71). Therefore, insertion of the needle with the cutting bevel parallel to the long axis of the spine is indicated. Tearing of the dura may also occur upon removal of the needle if it is rotated to a perpendicular
Post-Dural Puncture Headache in the ED Table 2. Things the Emergency Physician Can Do To Reduce PDPH ● Use small atraumatic spinal needles (22–24-gauge Sprotte, Whitacre) ● Insert cutting bevel parallel to long axis of spine if using Quincke-type needle ● Replace stylet before removing spinal needle ● Bed rest, hydration, prophylactic caffeine not helpful in preventing PDPH
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by increasing the rate of production of CSF to replace the fluid lost from leakage. This was not found to be beneficial in the only study that has examined this issue (75). Thus, it would seem that intake of additional fluids after a lumbar puncture does not assist in PDPH prevention (76).
PDPH ⫽ post-dural puncture headache.
Patient Positioning During Lumbar Puncture
orientation after insertion (72). Bevel orientation is not an issue with atraumatic needles, as they tend to separate dura fibers rather than cutting them, allowing them to return to their original position with decreased CSF leakage (61).
The position that the patient is placed in during LP has been postulated to play a role in the development of PDPH (77). A controlled study did not show the position used during performance of LP to have a relationship to development of PDPH (78). Strategies the emergency physician can employ to reduce the risk of PDPH are summarized in Table 2.
Stylet Replacement Replacement of the spinal needle stylet before removal of the needle also has been shown to reduce the incidence of PDPH. Strupp et al. found that stylet reinsertion reduced PDPH from 16% to 5% with 21-gauge Sprotte atraumatic needles (19). It was postulated that a strand of arachnoid mater may be pulled by the open needle on its removal and enter the dural rent, maintaining an opening that allows greater CSF leakage (19). A similar study has not been performed using cutting Quincke needles. A similar effect may occur if the spinal needle strikes bone upon insertion. This has been reported to cause a burr to develop at the needle tip that will drag the arachnoid mater out as it is withdrawn, thus creating a CSF leak (73). This concept has not been formally studied.
Bed Rest Use of bed rest to prevent PDPH was first advocated by Bier in 1899 (20). It is still advocated by many that a patient must have some period of bed rest after a lumbar puncture to prevent PDPH. A meta-analysis by Thoennisen et al. and a Cochrane review by Sudlow and Warlow evaluated all studies on this topic and found no difference in incidence of PDPH for those with immediate mobilization vs. bed rest for up to 24 h (29,74). Thus, bed rest after lumbar puncture has no role in PDPH prevention.
Hydration It is advocated by some that increased hydration after dural puncture will minimize PDPH occurrence, possibly
TREATMENT OF PDPH Treatment options for dural puncture headache depend on many factors such as severity of headache, degree of interference with activities of daily living, associated symptoms, response to conservative care, and presence of potential contraindications to more definitive therapies. Multiple treatment regimens have been advocated with varying degrees of success and risk, including medications and epidural blood patches (Table 3).
Methylxanthine Derivatives Methylxanthine derivatives such as caffeine and aminophylline have been recommended for the treatment of PDPH. It has been postulated that at least part of the pain
Table 3. Treatment for PDPH ● Supine position relieves headache but does not hasten resolution ● NSAIDs, narcotics useful for mild headache; generally not helpful if severe ● Triptans generally not effective ● Methylxanthine derivatives (caffeine) helpful if mild; effects usually temporary - Use cautiously in elderly or those who cannot tolerate potential cardiac/CNS stimulation ● Epidural blood patch generally allows rapid resolution of headache, safe - Requires anesthesia practitioner for performance - Invasive - Contraindicated if bleeding diathesis, cellulitis at puncture site, fever PDPH ⫽ post-dural puncture headache; NSAID ⫽ non-steroidal anti-inflammatory drug; CNS ⫽ central nervous system.
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from PDPH is due to cerebral vasodilatation as a compensatory attempt to restore intracranial volume (6). It is thought that methylxanthine medications cause vasoconstriction of these vessels, thus decreasing pain. It has also been theorized that these drugs antagonize purine receptors and relieve headache by this mechanism (25). Caffeine is usually given as 500-mg caffeine sodium benzoate in 1 L of intravenous fluid over 1 h, although some have given it as a rapid intravenous bolus (79,80). A second dose usually can be repeated in 1–2 h if needed. If aminophylline is used, it is given 5– 6 mg/kg over 20 min or given orally as theophylline 300 mg every 6 – 8 h (25). Side effects include central nervous system stimulation, seizures, gastric irritation, and provocation of cardiac dysrhythmias (80). Methylxanthine medications have been reported to be effective in alleviating PDPH in up to 90% of patients (79 – 86). Unfortunately, the data used to support the efficacy of caffeine are limited to one oft-cited small, methodologically flawed study and several case reports (73,76,77,80,82,84,86 – 89). The effects of caffeine seem to be temporary at best, with headache recurrence rates of up to 60% (9,83,86,89). It has no effect on CSF leakage nor does it restore normal CSF dynamics, which are thought to be the primary causes of PDPH (5). Camann et al. found oral caffeine to provide significantly better pain relief than placebo for PDPH initially, but there was no significant difference in pain scores at 24 h or in the number of epidural blood patches performed between the two groups (89). A recent North American hospital survey reports that most practitioners have abandoned the use of caffeine for treatment of PDPH due to its perceived ineffectiveness. Additionally, although it is sometimes recommended that patients consume caffeine after a lumbar puncture to prevent PDPH, it seems that this strategy, too, is ineffective (90). Further quality investigation is needed to determine the effectiveness of caffeine and theophylline in the prevention and treatment of PDPH.
Sumatriptan Sumatriptan is a serotonin agonist occasionally used in the treatment of migraines. It has been reported successful for the treatment of PDPH (43,91,92). Others have found it to be ineffective (93). A controlled trial found no evidence of benefit when using sumatriptan in the treatment of PDPH (94).
Epidural Blood Patch Despite a recent Cochrane review that was unable to draw unequivocal conclusions about its efficacy, the
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epidural blood patch (EBP) is generally considered the definitive treatment for PDPH, especially for those that are severe or debilitating (5,16,29,43,44,81,95–99). It was first described in 1960 by Gormley after it was noted that “bloody taps” were associated with decreased incidence of PDPH (100). EBP is performed by injecting 15–30 mL of the patient’s blood into the epidural space through a Tuohy epidural needle (16). This is ideally done at the site of the previous dural puncture. The injected blood spreads in both a cranial and caudal direction. The thecal sac is compressed and displaced and is thought to elevate and thus restore the subarachnoid pressure (5). It is also thought that the blood clot that forms seals off the rent in the dura and prevents further leakage of CSF. Success rates have generally been reported in 72–98% of patients, although less favorable results have been noted (1,16,39,81,97,98,101–105). Usually, there is immediate relief of the headache. EBP is most effective when performed at least 24 h after the initial puncture (25). Complications are rare but include radicular pain from nerve root irritation or displacement, cranial nerve palsies, meningeal irritation, elevated intracranial pressure, paraparesis, cauda equina syndrome, infection, and subdural hematoma (5,106 –108). Complications are usually either rare or self-limited. Contraindications to EBP include patient refusal, fever or suspected bacteremia and anticoagulation (5,108). EBP has been successfully used in adolescents (48). Patients who get no or incomplete relief after a first EBP have equivalent or higher rates of success on a second attempt (25,102). Failure of EBP is seen most often in patients with dural puncture from large bore needles, such as with inadvertent dural puncture with 16-gauge Tuohy needles during performance of labor epidural anesthesia (1,102). Prophylactic Epidural Blood Patch Some practitioners advocate use of a “prophylactic” EBP to prevent PDPH, especially in those at high risk (partiuent with inadvertent dural puncture with a large bore epidural needle). The data supporting this practice are contradictory. Several studies have shown benefit, others have not (109 –112). A recent Cochrane review found there were insufficient quality data to reach a definitive conclusion on the effectiveness of this practice (29). This practice is not likely to have much impact on the prevention of PDPH from diagnostic lumbar punctures performed by emergency physicians. CONCLUSIONS Dural puncture procedures are commonly performed by various medical practitioners, including emergency phy-
Post-Dural Puncture Headache in the ED
sicians, for many reasons. PDPH is a relatively common complication. The degree of pain and disability caused by PDPHs is considerable. Appropriate use of smallergauge, atraumatic needles is likely the single most important factor in reducing PDPH. Hydration and bed rest do little to prevent PDPH. Treatment of mild, nondebilitating headaches usually can be accomplished with limited activity, analgesics, and methylxanthine therapy until they resolve spontaneously. For more severe headaches, methylxanthine derivatives may be tried with EBP as a first-line alternative or to be used if methylxanthines fail. It is helpful to use 24-gauge Sprotte spinal needles in all patients at risk for PDPH. For patients who have moderate to severe pain, cannot or do not want to remain on bed rest, and those in whom narcotic pain medication is not a practical treatment option, EBP is an appropriate first-line therapy. In general, EBP is safe, well tolerated and effective. Though the technique for epidural blood patch is not significantly more difficult than lumbar puncture, it is a procedure most commonly performed by anesthesiologists. REFERENCES 1. Vercauteren MP, Hoffman VH, Mertens E, Sermeus L, Adriaensen HA. Seven-year review of requests for epidural blood patches for headache after dural puncture: referral patterns and the effectiveness of blood patches. Eur J Anaesthesiol 1999;16: 298 –303. 2. Calverley RK. Anesthesia as a specialty: past, present, and future. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia. Philadelphia, PA: Lippincott; 1989:35– 42. 3. Reina MA, de Leon-Casasola OA, Lopez A, De Andres J, Martin S, Mora M. An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 2000;25:393– 402. 4. Fink BR, Walker S. Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture. Anesth Analg 1989; 69:768 –72. 5. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003;91: 718 –29. 6. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry 1991;54:440 –2. 7. Carson D, Serpell M. Choosing the best needle for diagnostic lumbar puncture. Neurology 1996;47:33–7. 8. Peterman SB. Postmyelography headache: a review. Radiology 1996;200:765–70. 9. Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J 1993;149:1087–93. 10. Hilton-Jones D. Post lumbar puncture headache. Springfield IL: Charles C. Thomas; 1964. 11. Hannerz J, Ericson K, Bro Skejø HP. MR imaging with gadolinium in patients with and without post-lumbar puncture headache. Acta Radiol 1999;40:135– 41. 12. Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 1992;42:481–7. 13. Charsley MM, Abram SE. The injection of normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med 2001;26:301–5.
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