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Recommendations for Preventing Post-Lumbar Puncture Headache Syndrome

Based on a review of literature identified by MEDLINE searching back to 1966, the American Academy of Neurology (AAN) has provided consensus recommendations for the prevention of post-lumbar puncture headache (PLPHA) and recommendations for future studies. PLPHA is a bilateral headache that develops within 7 days after a lumbar puncture (LP) and disappears within 14 days. The headache occurs or worsens within 15 minutes of assuming an upright position and disappears or improves within 30 minutes of resuming a recumbent position.

The report describes demographic and risk factors for PLPHA. Evidence-based recommendations cover needle size (the smaller the better), how to use the Quincke cutting needle (bevel up), and noncutting needles (recommended for spinal anesthetic). Recumbency after diagnostic LP and hydration prior to LP are of no value. Interestingly, PLPHA is not reported after cisternal puncture; and there is controversy about downward movement of brain when patient is upright (See J Neurol Neurosurg Psychiatry 1991; 54:440).

Comment: Post-lumbar puncture headache should be called PLPHA syndrome because there is more to its clinical manifestation than pounding headache on assuming an upright position and quick relief on lying down. Older patients are much less likely than younger patients to have the syndrome, irrespective of Quincke needle size. Young females are more likely to have PLPHA than are males. Accordingly, spinal anesthesia in older patients is well accepted, but in young individuals, its use in obstetrics and appendectomies is avoided (see Tourtellotte WW et al. Post-Lumbar Puncture Headache. CC Thomas; 1964).

The report did not mention prolonged PLPHA syndrome, a rare condition caused by leakage from the lumbar subarachnoid space to the epidural space. We demonstrated by radioisotope myelography that CSF leaked through the puncture site in the subarachnoid membrane into the epidural space, a known negative pressure compartment, with each inspiration. Treatment is either prolonged recumbency or a surgical procedure to obliterate the fistula (see Headache 1972; 2:73). In future clinical trials evaluating needles used for diagnostic taps (Quincke vs. Whitacre vs. Sprotte), the design must include matched age groups.

We concur with the AAN recommendations, but we want to emphasize that a 26-gauge needle reduces both the incidence of PLPHA syndrome (to 12 percent) and the severity of the syndrome. However, we use a 25-gauge needle because passing a 26-gauge needle requires a three-quarter-inch 20-gauge Quincke guide needle, and this is not operator friendly. We measure pressure by filling the manometer to 200 mm. If the meniscus falls, the ICP pressure is normal. If it rises, we recommend filling the manometer to 300 mm, and if the meniscus rises, the pressure is elevated. A more precise value can be obtained by means of smaller fillings of the manometer. We have shown, using a pressure transducer, that pressure through a 26-gauge needle is reliable and valid (see J Neurosurg 1974; 40:587). We remove CSF at the rate of 1 ml per minute by aspiration using a 10 ml syringe. We recommend learning to place a 25-gauge Quincke needle.

— WW Tourtellotte and P Pick

Wallace W. Tourtellotte, MD, PhD, is Staff Neurologist and Neuroscientist, Neurology Service; Emeritus Chief of Neurology, VA West Los Angeles Healthcare Center; and Professor of Neurology, Emeritus Vice-Chairman of Neurology, UCLA School of Medicine, Los Angeles, CA. Peter Pick, MD, PhD, is a neurologist in Crossville, TN.

Published in Journal Watch Neurology December 20, 2000

Citation(s):

Evans RW et al. Assessment: Prevention of post-lumbar puncture headaches. Report of the Therapeutic and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2000 Oct 55 909-914.

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