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. 2001 Apr 21;322(7292):993.

Headache after diagnostic lumbar puncture

Using 20 gauge needle is blunderbuss technique

James S Smeltzer 1
PMCID: PMC1120149  PMID: 11312241

Editor—The results of Thomas et al's trial of atraumatic versus standard needles for diagnostic lumbar puncture1 confirm those of others on this topic,2–5 as well as my own personal experience. As both gauge and needle type matter,5 I am curious as to why they did not use a finer needle, consistent with most previous efforts to reduce spinal headache.

Use of a 20 gauge needle improved the study's power by increasing the overall rate of spinal headaches versus rates in other studies,2–5 but it can hardly be recommended as standard technique. The fact that one can kill houseflies with a shotgun does not mean that it is better to do so.

References

  • 1.Thomas SR, Jamieson DRS, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ. 2000;321:986–990. doi: 10.1136/bmj.321.7267.986. . (21 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Eriksson AL, Hallen B, Lagerkranser M, Persson E, Skoldefors E. Whitacre or Quincke needles—does it really matter? Acta Anaesthesiol Scand Suppl. 1998;113:17–20. doi: 10.1111/j.1399-6576.1998.tb04981.x. [DOI] [PubMed] [Google Scholar]
  • 3.Holst D, Mollmann M, Ebel C, Hausman R, Wendt M. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg. 1998;87:1331–1335. doi: 10.1097/00000539-199812000-00022. [DOI] [PubMed] [Google Scholar]
  • 4.Corbey MP, Bach AB, Lech K, Frorup AM. Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anaesthesiol Scand. 1997;41:779–784. doi: 10.1111/j.1399-6576.1997.tb04783.x. [DOI] [PubMed] [Google Scholar]
  • 5.Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J. 1993;149:1087–1093. [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Apr 21;322(7292):993.

Smaller is better where needles are concerned

John R Davies 1

Editor—It is unfortunate that Thomas et al devoted so much effort towards reducing the risk of headache after lumbar puncture from 50% to 28% by using an atraumatic needle1-1 when a smaller needle would have had a much more beneficial effect. In a line or two they dismissed anaesthetic and radiological practice, where atraumatic needles as small as 24 gauge are routine and an incidence of headache of <10% after lumbar puncture is expected.

Table.

Odds ratios and confidence intervals in meta-analysis looking at design of spinal needles and headache after lumbar puncture2

Pooled odds ratio 95% CI
Headache after lumbar puncture:
 Non-cutting v cutting needle 0.26 0.11 to 0.62
 Small v large needle 0.18 0.09 to 0.36
Failure:
 Non-cutting v cutting needle 0.52 0.27 to 1.01*
 Small v large needle NA 0.67 to 2.42*
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NA=Not applicable. *Not significant. 

A large meta-analysis, which included 12 studies from 1966 to 1993, found that the incidence of headache after lumbar puncture was significantly reduced by both the use of smaller needles and the use of an atraumatic point (table).1-2 The combined odds ratios favoured the smaller needle. As a measure of ease of use, there was no significant difference in the failure rate with type of point or needle size.

Anaesthetic trainees rapidly acquire a facility with small, atraumatic spinal needles. Cerebrospinal fluid may flow more slowly, but what other reason is there not to do diagnostic taps with a small atraumatic spinal needle?

References

  • 1-1.Thomas SR, Jamieson DRS, Muir WM. Randomised controlled trial of atraumatic versus standard needles for lumbar puncture. BMJ. 2000;321:986–990. doi: 10.1136/bmj.321.7267.986. . (21 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses. Anesthesiology. 1994;81:1376–1383. doi: 10.1097/00000542-199412000-00012. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Apr 21;322(7292):993.

Authors should have used smaller gauge needles

David Turnbull 1,2, Fiona McKevitt 1,2

Editor—We wish to raise some issues about Thomas et al's trial of atraumatic versus standard needles for diagnostic lumbar puncture.2-1

Firstly, the principal objective of the study was to see if use of 20 gauge atraumatic spinal needles rather than 20 gauge standard needles reduced the incidence of headache after lumbar puncture. The authors stated that there had been only two previous studies of this type that were methodologically adequate; these were not referenced.

Secondly, the authors stated that the incidence of headache after spinal anaesthesia is typically half that after diagnostic lumbar puncture. There is no evidence that that is the case when needles of the same calibre are used and when follow up is adequate. The articles they referenced here do not make that claim.

Thirdly, the authors chose to use 20 gauge needles; this needle size is associated with a rate of headache after dural puncture of up to 36.5%.2-2 The headache rate falls with decreasing needle gauge. An article in 1956 described the use of 22 gauge needles,2-3 and an editorial in the BMJ in 1997 recommended the use of 22 gauge atraumatic needles for diagnostic lumbar puncture.2-4 One of the authors' references showed that the flow rate of cerebral spinal fluid through a 22 gauge atraumatic needle was adequate. So why are they still using large gauge needles when this can lead to appreciable morbidity?

The outcome of this study was predictable. Greene first recommended the use of atraumatic needles in 1926, and Whitacre developed the needle in 1951. Many units are now using 22 gauge atraumatic needles for diagnostic lumbar puncture. Our unit recently changed to using 22 gauge Whitacre needles; this change has seen a reduction in headache after lumbar puncture from 27% to 17% and has not been associated with an increase in the average number of attempts (1.6 with the standard needle versus 1.4 with the Whitacre needle).

If the authors wish to put together a systematic randomised trial that shows a reduction in headache after diagnostic lumbar puncture2-5 perhaps they should have considered using smaller gauge needles.

References

  • 2-1.Thomas SR, Jamieson DRS, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ. 2000;321:986–990. doi: 10.1136/bmj.321.7267.986. . (21 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Kuntz KM, Kokemon E, Stevens JC, Muller P, Offord KP, Ho MM. Post lumbar puncture headache: experience in 501 consecutive procedures. Neurology. 1992;42:1884–1887. doi: 10.1212/wnl.42.10.1884. [DOI] [PubMed] [Google Scholar]
  • 2-3.Vandam LD, Dripps RD. Long term follow up of patients who received 10 098 spinal anesthetics. JAMA. 1956;161:586–591. doi: 10.1001/jama.1956.02970070018005. [DOI] [PubMed] [Google Scholar]
  • 2-4.Broadley SA, Fuller G. 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]
  • 2-5.Sudlow C. Preventing headache after lumbar puncture: Evidence must come from randomised trials put together systematically. BMJ. 1998;317:1589. [PubMed] [Google Scholar]
BMJ. 2001 Apr 21;322(7292):993.

Author's reply

Keith W Muir 1

Editor—These correspondents identify a reduced incidence of headache after dural puncture with smaller gauge needles. Their citations in support of this testify to the origins of such data, which are almost exclusively in anaesthesia. In neurological practice, use of needles smaller than 20-22 gauge is rare since smaller needles prolong the time taken to obtain the moderately large volumes of cerebrospinal fluid and for pressure measurement by manometry.

We certainly did not choose 20 gauge needles to increase the power of our study; we chose them because this represents routine practice. Reduction of headache after dural puncture must be balanced against the technical difficulty of the procedure, and use of very small gauge needles may be subject to the same increase in difficulty that we showed for atraumatic needles. A recent assessment under the auspices of the American Academy of Neurology emphasises the limited evidence for adoption of anaesthetic innovations for diagnostic lumbar puncture.3-1

Critics of neurologists and others performing diagnostic lumbar punctures should bear in mind that diagnostic lumbar puncture is not identical with spinal anaesthesia; extrapolation of anaesthetic data without proper appraisal may not be justified.

References

  • 3-1.Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: Prevention of post-lumbar puncture headaches. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000;55:909–914. doi: 10.1212/wnl.55.7.909. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Apr 21;322(7292):993.

Doctor given intrathecal methotrexate had headache when 20 gauge standard needle was used

Susannah Baron 1

Editor—In their editorial Serpell and Rawal remind us that use of small atraumatic needles can greatly reduce the incidence of spinal headache after lumbar puncture.4-1,4-2 This is well known to anaesthetists; why not to others?

Doctors' “see one, do one, teach one” mentality is largely to blame. As a medical house officer I was taught to use 20 gauge standard (Quincke) needles for lumbar punctures, but as an anaesthetics senior house officer I soon learnt that using 25 gauge atraumatic (Whitacre) needles makes dural puncture and spinal anaesthesia simple, quick, and effective.

Two years ago I had to receive regular intrathecal methotrexate for non-Hodgkin's lymphoma. After my first session of chemotherapy, when a 20 gauge standard needle was used for the intrathecal dose, I was bedbound for a week with backache and the classic signs of a spinal headache. At my next visit I tried in vain to explain to the consultant that I had had a severe spinal headache, and I asked for smaller atraumatic needles to be used. I was told that this time I would be given intrathecal steroid to counteract my “arachnoiditis.” I was sceptical but, as a disempowered patient, had to submit.

This time I was bedbound for two weeks. Thereafter I refused intrathecal methotrexate unless an anaesthetist performed the procedure. As I expected, the anaesthetics senior house officer or registrar was happy to do this. Dismayed at the routine use of large traumatic needles on the oncology day unit, the anaesthetist also taught the oncology senior house officer how to use 25 gauge Whitacre needles routinely.

As a patient with cancer, you accept that some unpleasant side effects of treatment are unavoidable. But spinal headaches often arise from a simple lack of interest in and understanding of prevention and treatment.4-3,4-4 Incidentally, patients receiving chemotherapy cannot receive blood patching because of the risk of infection and thrombocytopenia. Many patients having chemotherapy are young and therefore at greatest risk of spinal headache. When patients are having chemotherapy every three weeks there is a small window between recovery from treatment and the onset of neutropenia when it is possible to feel well and live a relatively normal life. This precious time is lost when it is spent lying in a dark room.

The use of small atraumatic needles should become routine for all medical specialties.

References

  • 4-1.Serpell MG, Rawal N. Headaches after diagnostic dural punctures. BMJ. 2000;321:973–974. doi: 10.1136/bmj.321.7267.973. . (21 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Thomas SR, Jamieson DRS, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ. 2000;321:986–990. doi: 10.1136/bmj.321.7267.986. . (21 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-3.Serpell MG, Haldane GJ, Jamieson SR, 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. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-4.Sharma A. Preventing headache after lumbar puncture: most doctors are unaware of features of headache after lumbar puncture. BMJ. 1998;317:1588. doi: 10.1136/bmj.317.7172.1588a. [DOI] [PMC free article] [PubMed] [Google Scholar]

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