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. 1998 Dec 5;317(7172):1588. doi: 10.1136/bmj.317.7172.1588a

Preventing headache after lumbar puncture

Most doctors are unaware of features of headache after lumbar puncture

Arun Sharma 1
PMCID: PMC1114398  PMID: 9836673

Editor—Serpell et al’s survey of lumbar puncture practice in the United Kingdom reminds us that small (22-26 gauge), atraumatic needles, which reduce the incidence of headache after lumbar puncture, are not being routinely used.1 The incidence of headache after lumbar puncture is roughly 35% with 20 gauge standard needles, 5% with 22 gauge atraumatic needles, and 1% with 25 gauge atraumatic needles.2 Adequate cerebrospinal fluid can be obtained by aspirating with smaller needles. The cost of an atraumatic (Whitacre or Sprotte) needle is about £4, compared with £1 for the standard (Quincke) needle. Using 22 gauge atraumatic needles would therefore cost £10 per headache prevented. A third of headaches after lumbar puncture are described as severe, prolonged, or debilitating and unresponsive to simple measures.3 Prolonged headache after lumbar puncture can lead to subdural haematoma.4

The authors mention that epidural blood patching is a successful way of treating persistent headache after lumbar puncture. Epidural blood patching is widely used by anaesthetists for the more severe headache after lumbar puncture caused accidentally by large 16 gauge or 18 gauge epidural needles.5

I conducted an audit at a district general hospital that performs about 150 lumbar punctures annually. Only three out of 26 doctors were aware of the option of epidural blood patching for headache after lumbar puncture (eight junior house officers, 10 middle grade doctors, and eight consultant or staff grade doctors were surveyed). In addition, less than half (of all grades) were able to state correctly the characteristic features of headache after lumbar puncture—fronto-occipital distribution, relief when the patient lies down, onset up to several days after dural puncture, and duration up to several weeks. Clearly, these points still need to be disseminated to all those who perform and teach how to perform lumbar puncture. This is an important message that is equally relevant to surgeons, obstetricians, and general practitioners who encounter headache after lumbar puncture or spinal or epidural anaesthesia.

References

  • 1.Serpell MG, Haldane GJ, Jamieson DRS, Carson D. Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in the United Kingdom. BMJ. 1998;316:1709–1710. doi: 10.1136/bmj.316.7146.1709. . (6 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Broadley SA, Fuller GN. Lumbar puncture needn’t be a headache. BMJ. 1997;315:1324–1325. doi: 10.1136/bmj.315.7119.1324. [DOI] [PMC free article] [PubMed] [Google Scholar]
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  • 4.Nel MR, Robinson N. Epidural blood patching can be used to treat headache. BMJ. 1998;316:1019. . (28 March.) [PubMed] [Google Scholar]
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BMJ. 1998 Dec 5;317(7172):1588.

Optimism generally quoted for epidural blood patching is unwarranted

Elisabeth Williams 1, William Fawcett 1, Gareth Jenkins 1

Editor—Serpell et al stated that epidural blood patching has a success rate of 90% with only minor short term sequelae.1-1 Although epidural blood patches are regarded by many as the preferred treatment for persistent headache after lumbar puncture and success rates of 97.5% have been quoted,1-2 others have found a much lower success rate (61-68%).1-3 A recent North American survey of the management of dural puncture during epidural analgesia given during labour concluded that the expressed optimism about the efficacy of epidural blood patching was not supported by the evidence available; 44% of centres reported cases of persistent headache after lumbar puncture after two or more epidural blood patches.1-4

We have performed a retrospective audit of obstetric epidurals at the Royal Surrey County Hospital over five years. The aim was to determine the efficacy of epidural blood patching in the management of headache after inadvertent lumbar puncture with a 16 gauge Tuohy needle in the obstetric population. During that time 55 lumbar punctures occurred and epidural blood patching was performed on 62 occasions in 48 patients. Our results showed that only a third of patients (16) obtained complete and permanent relief after treatment with one epidural blood patch; a further 24 obtained partial relief. Fourteen patients required a second epidural blood patch, which was completely successful in only seven.

Although in our experience failure backache was the only complication seen, other complications reported include neck pain, leg pain, paraesthesia, cranial nerve palsies, raised temperature, bradycardia, meningism, haematoma, and pneumocephalus.1-2,1-5 The optimism generally quoted for epidural blood patching in the treatment of headache after lumbar puncture is unwarranted, and not all sequelae are minor.

References

  • 1-1.Serpell MG, Haldane GJ, Jamieson DRS, Carson D. Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in the United Kingdom. BMJ. 1998;316:1709–1710. doi: 10.1136/bmj.316.7146.1709. . (6 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Abouleish E, De La Vega S, Blendinger I, Tio T-O. Long-term follow-up of epidural blood patch. Anesth Analg. 1975;54:459–463. doi: 10.1213/00000539-197554040-00012. [DOI] [PubMed] [Google Scholar]
  • 1-3.Taivainen T, Pitkanen M, Tuominen M, Rosenberg PH. Efficacy of epidural blood patch for post dural puncture headache. Acta Anaesth Scand. 1993;37:702–705. doi: 10.1111/j.1399-6576.1993.tb03793.x. [DOI] [PubMed] [Google Scholar]
  • 1-4.Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth. 1998;45:110–114. doi: 10.1007/BF03013247. [DOI] [PubMed] [Google Scholar]
  • 1-5.Hardman JG, Gajraj NM. Epidural blood patch. Br J Hosp Med. 1996;56:268–269. [PubMed] [Google Scholar]
BMJ. 1998 Dec 5;317(7172):1588.

Evidence must come from randomised trials put together systematically

Cathie Sudlow 1

Editor—Serpell et al report their survey of methods used to prevent headaches after lumbar puncture.2-1 Others have shown a similar diversity of practice with respect to needle types and techniques, the use of prophylactic bed rest and fluids, and the treatment of established headaches after lumbar puncture with various drugs or epidural blood patching.2-2,2-3 Such variation in practice usually implies a lack of reliable evidence for particular interventions, and this is certainly the case for lumbar puncture. Serpell et al, however, have relied on a non-systematic review of atraumatic versus bevelled needles; the results of a single trial of smaller versus larger needles when many other trials also address this issue; a non-randomised comparison of bed rest versus early mobilisation; a non-randomised observational study of different orientations of bevelled needles; and their own assertion that positioning the patient upright makes lumbar puncture easier.2-1

Randomised trials are the least biased way of assessing the effectiveness of interventions and provide the best evidence on which to base practice. There are many trials assessing various methods to reduce headache after lumbar puncture. Several of these trials are methodologically flawed, with potentially biased results. Others are fairly small and so provide inaccurate or inconclusive results.

The best way to sort out which interventions are clearly effective, which are clearly ineffective, and which have uncertain effects is to perform systematic reviews of all the available evidence from properly randomised trials. This evidence needs to be gathered from trials among patients undergoing lumbar puncture for diagnostic purposes, for spinal anaesthesia, and for myelography. An overview of randomised trials of different types of needles in the prevention of headache after lumbar puncture showed that smaller gauge needles were better than larger gauge needles and that atraumatic needles were better than bevelled needles.2-4 The strategy for identifying trials was, however, limited, and only patients undergoing spinal anaesthesia were included. There are no systematic reviews of prophylactic bed rest or fluid supplements after lumbar puncture, or of the various drug treatments and interventions such as epidural blood patching used to treat established headache after lumbar puncture.

Until the evidence from randomised trials has been put together systematically and made widely available, there will no doubt continue to be selective quoting of individual trial results and of unreliable non-randomised observational studies, with resulting diversity in the practice of lumbar puncture.

References

  • 2-1.Serpell MG, Haldane GJ, Jamieson DRS, Carson D. Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom. BMJ. 1998;316:1709–1710. doi: 10.1136/bmj.316.7146.1709. . (6 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Gibb WRG, Wen P. Current practice of diagnostic lumbar puncture. BMJ. 1984;289:530. doi: 10.1136/bmj.289.6444.530. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-3.Broadley SA, Fuller GN. Audit of lumbar puncture practice in United Kingdom neurology centres. J Neurol Neurosurg Psychiatry. 1997;63:266. [Google Scholar]
  • 2-4.Halpern S, Preston R. Postdural puncture headache and spinal needle design: meta-analyses. Anaesthesiology. 1994;81:1376–1383. doi: 10.1097/00000542-199412000-00012. [DOI] [PubMed] [Google Scholar]
BMJ. 1998 Dec 5;317(7172):1588.

Authors’ reply

M G Serpell 1,2,3, G J Haldane 1,2,3, D R S Jamieson 1,2,3, D Carson 1,2,3

Editor—Sharma highlights the fact that headache after lumbar puncture may go unrecognised, never mind untreated. This is an important point to rectify; all clinicians who perform lumbar puncture should be fully aware of and able to manage the possible resultant sequelae.

Williams et al suggest that epidural blood patching may not be as effective as commonly perceived. But the other treatments of established headache after lumbar puncture are not renowned for their effectiveness either, and the consequences of not treating it can be catastrophic.3-1,3-2 Comparative studies of the various treatments need to be done.

Sudlow is critical of our references. As there are no systematic reviews on any of the various aspects that may affect the incidence of headache after lumbar puncture (except for that by Halpern and Preston, which she says is flawed), we must rely on the evidence available. The number of good quality trials that conclude that atraumatic needles are better than bevelled needles is compelling. Anaesthetists as a group probably do more lumbar punctures in their role of performing spinal anaesthesia than any other specialty. The effects of lumbar puncture on morbidity are usually closely monitored. Atraumatic needles have largely replaced bevelled needles in most practices; for these personal observations to induce such a widespread change in practice must surely speak for itself.3-3 We are confident that these conclusions will be borne out when such a review is done. We acknowledge that patients undergoing myelography or diagnostic lumbar puncture are a different population from those undergoing spinal anaesthesia, but it would be reasonable to assume that the same mechanisms for headache are involved, particularly if the results of the investigations are normal.

We accept the limitations of our other references, but they are the best currently available. Our assertion that positioning the patient upright makes lumbar puncture easier is based on our analysis of a randomised study (not cited in our paper owing to the limit of five references) which showed that spinal anaesthesia was quicker to perform in the upright than in the lateral position (115 v 240 seconds, P<0.001).3-4

References

  • 3-1.Weeks SK. Spinal headache—prevention and treatment. Can J Anaesth 1990;37(suppl):liii-lviii. [DOI] [PubMed]
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  • 3-4.Serpell MG, Carson DF. Maternal position during induction of spinal anaesthesia for caesarian section. Anaesthesia. 1995;50:921–922. doi: 10.1111/j.1365-2044.1995.tb05889.x. [DOI] [PubMed] [Google Scholar]

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