Post lumbar puncture headache: diagnosis and management. This article has been cited by other articles in PMC. Abstract. Lumbar puncture is a frequently performed procedure in medical emergencies and anaesthesia.
Headache after lumbar puncture is a common occurrence (3. If untreated, it can result in serious complications such as subdural haematoma and seizures, which could be fatal. Certain factors contribute to the development of headache after lumbar puncture. If these factors are taken into consideration, the incidence of headache could be markedly reduced. It is therefore important that the doctors are aware of the methods available for reducing the incidence of headaches after lumbar puncture. On the other hand, there are several misconceptions that are thought to decrease the incidence of headaches with no scientific basis.
This article reviews the scientific literature and highlights the practical issues involved in the diagnosis and management of headaches after lumbar puncture, including the epidural blood patch treatment. Keywords: lumbar puncture, headache, lumbar puncture needle, position during lumbar puncture, epidural blood patch. Lumbar puncture is a common procedure for diagnosis and anaesthesia. Headache is a common sequela of this procedure irrespective of the indication, although the frequency is less with spinal and epidural anaesthesia where fluid is injected and not removed. About one third of patients develop headaches after lumbar puncture,1 although the incidence may be higher, as minor symptoms may not be reported. Headache after lumbar puncture occurs more often in young adults, especially in the 1. The headache worsens within 1.
This definition helps to avoid confusion with migraine or simple headache after lumbar puncture. Characteristics of headache after lumbar puncture. The onset of headache after lumbar puncture is usually within 2. Although the headache may rarely present immediately after dural puncture,7 its occurrence should alert the doctor to an alternate cause such as rise in intracranial pressure, with associated displacement of intracranial structures. The postural nature of the headache is very characteristic and the symptoms are usually self.
Patient HelpBook Blood Patch (Return to Table of Contents for Patient HelpBook) Blood patches are performed by an anesthesiologist at a hospital for treatment of a persistent headache (spinal headache) and nausea that.
Headache after lumbar puncture is usually dull or throbbing in nature, and can start in the frontal or occipital region,8 which can later become generalised. It is possible for the pain to radiate to the neck and shoulder area, and could be associated with neck stiffness. Head movements exacerbate the pain and any manoeuvres that increase intracerebral pressure, such as coughing, sneezing, straining or ocular compression, may also worsen the symptoms. Other associated symptoms include lower back pain, nausea, vomiting, vertigo and tinnitus and, rarely, diplopia due to cranial nerve palsy and even cortical blindness.
Headache usually resolves within a few days, but the longest reported headache after lumbar puncture lasted for 1. Diagnosis. This is essentially a clinical diagnosis and the history of a dural puncture and the postural nature of the headache with associated symptoms usually confirms the diagnosis. If a diagnostic lumbar puncture is performed, it may show a low cerebrospinal fluid (CSF) opening pressure, a slightly raised CSF protein and a rise in CSF lymphocyte count. Magnetic resonance imaging of the brain may show diffuse dural enhancement with evidence of sagging, descent of the brain and brain stem, obliteration of the basilar cisterns and enlargement of the pituitary gland. Pathophysiology. The exact pathophysiology of headache after lumbar puncture is unclear. However, it is most probably related to the “hole” in the left dura after the needle has been withdrawn,1.
- Spinal or Epidural Headaches - Childbirth Resources at StorkNet's Childbirth Cubby.
- Ganglion Block Beats Blood Patch for Dural Puncture Headache.
- The epidural space is the space inside the bony spinal canal but just outside the dura mater ('dura'). In contact with the inner surface of the dura is another membrane called the arachnoid mater ('arachnoid').
- We have produced this leaflet to give you general information about the headache that may develop after your spinal or epidural injection and what treatment may be offered to you. This leaflet should answer most of the.
- A spinal headache may occur up to five days after the procedure is performed. What Are the Symptoms of a Spinal Headache? The spinal headache often is described as 'a headache like no other.' Spinal headaches are much more.
- Blood Patch Print> What is it? An epidural blood patch is a procedure that is performed when a spinal fluid leak is present and causing significant symptoms. The symptoms are typically a headache and nausea with possible.
A blood patch treats spinal headaches caused by a leak of spinal fluid decreasing the spinal pressure.
CSF from the subarachnoid space. This leakage results in a fall in intracranial CSF volume and CSF pressure. Although the loss of CSF and lowering of CSF pressure is not disputed, the actual mechanism producing the headache after lumbar puncture is not clear. There are two possible explanations. Firstly, the low CSF volume depletes the cushion of fluid supporting the brain and its sensitive meningeal vascular coverings, resulting in gravitational traction on the pain.
As a smaller needle diameter produces a smaller tear in the dura, there is less potential for leakage and incidence of headache after lumbar puncture. The incidence of headache is 7.
G, 4. 0% if the needle size is between 2. G and 1. 2% if the needle size is between 2. G. 1. 5 Although smaller needles are satisfactory for spinal and epidural anaesthesia and for myelography, for diagnostic lumbar puncture, the use of a needle with a diameter < 2. G may not be practical (unless only a small volume of fluid is needed), as the time for transduction of the opening pressure using the manometer may be too long and the flow rate may be too slow. Needles < 2. 2G take > 6 min to collect 2 ml of fluid and a similar period is required for measuring pressure and even then the measurement may be inaccurate.
In practice, therefore, a 2. G needle is the smallest size that should be used for diagnostic lumbar puncture.
Direction of bevel: As the collagen fibres in the dura matter run in a longitudinal direction, parallel to the long or vertical axis of the spine, the incidence of headache after lumbar puncture is less if the needle is inserted with the bevel parallel to the dural fibres, rather than perpendicular. This “separates” the fibres rather than cutting them, thus facilitating closure of the hole on needle withdrawal. If the needle is at right angles to the collagen fibres, the cut in the dural fibres, previously under tension, would then tend to retract, resulting in a bigger dural tear, thus increasing the likelihood of CSF leakage and the incidence of headache after lumbar puncture.
Needle design: There is convincing evidence in the anaesthesia literature that headache after lumbar puncture is reduced using non. As these needles cause temporary separation rather than cutting the elastic fibres, which then recoil after removal of the needle, the damage to the dura is less with atraumatic needles. This considerably reduces the incidence of headache and the need for medical intervention.
The literature on diagnostic lumbar puncture has been conflicting until recently. Three randomised, double.
As the tip has to be passed at least 0. Replacement of the stylet: The standard procedure is to replace the stylet before withdrawing the needle when a non. In a study of 6. 00 patients,2. It is thought that the higher incidence in the second group is due to a strand of arachnoid that may enter the needle with the CSF and when the needle is removed the strand could be threaded back through the dural defect and produce prolonged CSF leakage. Theoretically, reintroducing a stylet that may have been contaminated with respiratory droplets could result in a rare complication such as bacterial meningitis after a diagnostic lumbar puncture. Number of lumbar puncture attempts: As the number of dural punctures directly relates to the size of the dural damage, making fewer attempts at dural puncture could be associated with lesser incidence of headache after lumbar puncture. However, no studies have been conducted.
Factors not influencing the incidence of headache after lumbar puncture. The following factors do not influence the incidence of headache after lumbar puncture: The volume of the spinal fluid removed is not a risk factor for headache after lumbar puncture. There is no evidence that any duration of bed rest after lumbar puncture has a role in preventing headache. Improving hydration by increased fluids (either oral or intravenous) has not been shown to prevent headache after lumbar puncture. Mostly, lumbar punctures are performed with patients lying on their side,2.
So far, there is no convincing evidence to suggest any particular position to reduce the incidence of headache after lumbar puncture, and it depends mainly on the choice of the doctor unless it is to measure the CSF pressure, where the patient should be in the supine position. The incidence of headache after lumbar puncture does not depend on the CSF opening pressure, CSF analysis or the volume of CSF removed. Management. As headache after lumbar puncture is relatively common and is a significant cause of morbidity, it should always be explicitly discussed when a patient consents for lumbar puncture, especially those who are in a high. Supporting treatment such as rehydration, simple analgesics, opioids and anti. Generally, > 8. However, if conservative measures fail to resolve headaches after lumbar puncture, then specific treatment is indicated 7. In one survey, 4 of 1.
The aim of specific management of headache after lumbar puncture is to replace the lost CSF, seal the puncture site and control the cerebral vasodilatation. Several therapeutic measures have been suggested to treat headache after lumbar puncture based on these strategies. Blood patch: The concept of the epidural blood patch was developed after the observation made on patients who had “bloody tap”, in whom the incidence of headache was low.
Once blood is introduced into the epidural space, it will form a clot and seal the perforation, thus preventing further leak of CSF. The presence of fever, local infection in the back and bleeding disorders are the main contraindications for this procedure. Lumbar puncture is usually carried out by a trained anaesthetist. The patient is asked to lie down in a curled. About 2. 0–3. 0 ml of blood is then taken from a large vein, usually from the patient's arm, and injected immediately but slowly into the epidural space through the epidural needle. As blood will distribute into the epidural space through few spinal segments superiorly and inferiorly, it is not essential to introduce it into the exact place at which the dural puncture was performed. After the procedure, the patient is asked to lie still for 1–2 h in a supine position and is then mobilised.
This procedure has a success rate of about 7.