PDF icon Download PDF
Open Access
CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(04): 187-192
DOI: 10.1590/0004-282X20190197
Article

Post-dural puncture headache incidence after cerebrospinal fluid aspiration. A prospective observational study

Incidência de cefaleia pós-punção dural após aspiração do líquido cefalorraquidiano. Um estudo observacional prospectivo
Rodrigo Tomazini MARTINS 
1   Instituto de Neurologia de Curitiba (INC), Departamento de Neurologia, Curitiba PR, Brazil.
2   Gosford Hospital, Neurology Department, NSW, Australia.
,
Barbara TOSON 
3   Neuroscience Research Australia (NeuRA), NSW, Australia.
,
Ricardo Krause Martinez de SOUZA 
1   Instituto de Neurologia de Curitiba (INC), Departamento de Neurologia, Curitiba PR, Brazil.
4   Centro de Memória de Curitiba (CMC), Curitiba PR, Brazil.
,
Pedro Andre KOWACS 
1   Instituto de Neurologia de Curitiba (INC), Departamento de Neurologia, Curitiba PR, Brazil.
› Author Affiliations
› Further Information
Also available ateRef
  Permissions and Reprints
Preview

Abstract

Background: Post-dural puncture headache (PDPH) is an iatrogenic condition following lumbar puncture (LP). Incidence is variable and often associated with young females. Technical features of the procedure (i.e. needle gauge) have been investigated; however there is no investigation on the method of cerebrospinal fluid (CSF) collection. Objective: To investigate whether mild CSF aspiration is associated with increased PDPH in selected patients. Methods: 336 subjects were eligible to the study. Data on 237 patients from a tertiary neurology hospital who underwent diagnostic LP from February 2010 to December 2012 were analysed. Patient demographics, lumbar puncture method, CSF biochemical characteristics, opening pressures, and a follow-up inquire on PDPH occurrence were collected. CSF was collected either by allowing free flow or by mild aspiration. Results: The aspiration arm (n=163) was comprised of 55.8% females with mean age of 52(35–69) years. Sex distribution was not different between the two arms (p=0.191). A significant larger amount of CSF was obtained in the aspiration arm (p=0.011). The incidence of PDPH in the aspiration arm was 16.5% versus 20.2% in the free flow arm, not statistically significant (p=0.489). No relevant associations emerged from the analyses in the subgroup aged <65 years. Conclusions: Aspiration of the CSF during LP was not associated with increased rates of PDPH compared to the standard method, particularly when larger amounts of CSF are required and ideal conditions are met. This is the first study looking into this matter, aiming to add safety to the procedure. Further randomized trials are required.

Resumo

Introdução: Cefaleia pós-punção dural (CPPD) é uma condição iatrogênica após punção lombar (LP). Incidência é variável; frequentemente associada a mulheres jovens. Características técnicas do procedimento (ex: calibre da agulha) foram investigadas; no entanto, não há investigação sobre o método de coleta do líquido cefalorraquidiano (LCR). Objetivo: Avaliar se aspiração leve do LCR está associada ao aumento da CPPD em pacientes selecionados. Métodos: 336 indivíduos foram elegíveis para o estudo. Dados de 237 pacientes em um hospital neurológico terciário que foram submetidos à PL diagnóstica de fevereiro de 2010 a dezembro de 2012 foram analisados. Coletamos dados demográficos dos pacientes, método da PL, características bioquímicas do LCR, pressões de abertura e ocorrência da CPPD. Todos as PLs ocorreram em decúbito lateral. O LCR foi coletado permitindo livre fluxo ou aspiração leve. Resultados: O grupo aspiração (n=163) apresentava 55,8% de mulheres, idade média de 52(35–69) anos. A distribuição por sexo não foi diferente entre os dois grupos (p=0,191). Uma quantidade maior de LCR foi obtida no grupo aspiração (p=0,011). A incidência de CPPD no grupo de aspiração foi de 16,5% versus 20,2% no fluxo livre, não estatisticamente significante (p=0,489). Nenhuma associação emergiu das análises no subgrupo com idades <65 anos. Conclusões: A aspiração do LCR durante PL não está associada ao aumento da CPPD em comparação com a método padrão, particularmente quando quantidades maiores de LCR são necessárias e condições ideais são satisfeitas. Este é o primeiro estudo a investigar o topico, visando aumentar a segurança do procedimento. Necessita-se futuros estudos randomizados.

Keywords:

cerebrospinal fluid - headache - post-dural puncture headache - spinal puncture

Palavras-chave:

líquido cefalorraquidiano - cefaleia - cefaleia pós-punção dural - punção espinal


Publication History

Received: 10 October 2019

Accepted: 28 November 2019

Article published online:
13 June 2023

© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Raymond JR, Raymond PA. Post-lumbar puncture headache. Etiology and management. West J Med. 1988 May;148(5):551-54.
  • 2 Amorim JA, Maciel CM, Damázio Filho O, Aragão MFV, Barros MVG, Silva WF, et al. Cefaléia Pós-Punção Dural: Fisiopatologia, Diagnóstico E Fatores De Risco. Rev Dor. 2007 Abr/Mai/Jun;8(2):1014-27.
  • 3 Lavi R, Rowe JM, Avivi I. Lumbar puncture: it is time to change the needle. Eur Neurol. 2010;64(2):108-13. https://doi.org/10.1159/000316774
  • 4 Ghaleb A, Khorasani A, Mangar D. Post-dural puncture headache. Int J Gen Med. 2012;5:45-51. https://doi.org/10.2147/IJGM.S17834
  • 5 Frederiks JA, Koehler PJ. The first lumbar puncture. J Hist Neurosci. 1997 Aug;6(2):147-53. https://doi.org/10.1080/09647049709525699
  • 6 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91(5):718-729. https://doi.org/10.1093/bja/aeg231
  • 7 Kim SR, Chae HS, Yoon MJ, Han JH, Cho KJ, Chung SJ. No effect of recumbency duration on the occurrence of post-lumbar puncture headache with a 22G cutting needle. BMC Neurol. 2012;12:1. https://doi.org/10.1186/1471-2377-12-1
  • 8 Alstadhaug KB, Odeh F, Baloch FK, Berg DH, Salvesen R. Post-lumbar puncture headache. Tidsskr Nor Laegeforen. 2012;132(7):818-21. https://doi.org/10.4045/tidsskr.11.0832
  • 9 Dakka Y, Warra N, Albadareen RJ, Jankowski M, Silver B. Headache rate and cost of care following lumbar puncture at a single tertiary care hospital. Neurology. 2011 Jul;77(1):71-4. https://doi.org/10.1212/WNL.0b013e318220abc0
  • 10 Lin W, Geiderman J. Myth: fluids, bed rest, and caffeine are effective in preventing and treating patients with post-lumbar puncture headache. West J Med. 2002;176(1):69-70. https://doi.org/10.1136/ewjm.176.1.69
  • 11 Spielman FJ. Post-lumbar puncture headache. Headache. 1982;22(6):280-3. https://doi.org/10.1111/j.1526-4610.1982.hed2206280.x
  • 12 Hammond ER, Wang Z, Bhulani N, McArthur JC, Levy M. Needle type and the risk of post-lumbar puncture headache in the outpatient neurology clinic. J Neurol Sci. 2011 Jul;306(1-2):24-8. https://doi.org/10.1016/j.jns.2011.04.004
  • 13 Ghaleb A. Postdural puncture headache. Anesthesiol Res Pract. 2010;2010:pii: 102967. https://doi.org/10.1155/2010/102967
  • 14 Bier A. Versuche uber Cocainisirung des Ruckenmarkes. Deutsche Zeitschrift fur Chirurgie. 1899;51:361-9. https://doi.org/10.1007/BF02792160
  • 15 Frank RL. Lumbar puncture and post-dural puncture headaches: implications for the emergency physician. J Emerg Med. 2008 Aug;35(2):149-57. https://doi.org/10.1016/j.jemermed.2007.03.024
  • 16 Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006 Nov;82(973):713-6. https://doi.org/10.1136/pgmj.2006.044792
  • 17 Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010 Jul;50(7):1144-52. https://doi.org/10.1111/j.1526-4610.2010.01699.x
  • 18 Chohan U, Hamdani GA. Post dural puncture headache. JPMA. 2003;53(8):359-67.
  • 19 Wright BL, Lai JT, Sinclair AJ. Cerebrospinal fluid and lumbar puncture: a practical review. J Neurol. 2012;259(8):1530-45. https://doi.org/10.1007/s00415-012-6413-x
  • 20 Usmani S, Azmat J, Jameel S, Sirajuddin PG. Post dural puncture headache after spinal anaesthesia and chance of spinal failure: a comparative study using 23G Quincke, 25G Quincke, and 25G Whitacre needle. IOSR. 2016 Jun;15(7):67-71. https://doi.org/10.9790/0853-150736771
  • 21 Chaudry WI, Saleem S, Naaman K, Waseen H, Javaid A, Waseem MB. Comparison of 22, 23 and 25 Gauge Quincke Needles for post dural puncture headache and identification of other significant factors for PDPH in a tertiary care hospital. Proceeding SZPGMI. 2009;23(2):55-60.
  • 22 Malm J, Kristensen B, Karlsson T, Fagerlund M, Elfverson J, Ekstedt J. The predictive value of cerebrospinal fluid dynamic tests in patients with th idiopathic adult hydrocephalus syndrome. Arch Neurol. 1995 Aug;52(8):783-9. https://doi.org/10.1001/archneur.1995.00540320059013
  • 23 Zetterberg H, Tullhog K, Hansson O, Minthon L, Londos E, Blennow K. Low incidence of post-lumbar puncture headache in 1,089 consecutive memory clinic patients. Eur Neurol. 2010 Jul;63(6):326-30. https://doi.org/10.1001/archneur.1995.00540320059013
  • 24 Souza RKM, Rocha S, Martins RT, Kowacs PA, Ramina R. Gait in normal pressure hydrocephalus: characteristics and effects of the CSF tap test. Arq Neuropsiquiatr. 2018;76(5):324-31. http://dx.doi.org/10.1590/0004-282x20180037
  • 25 Seupaul RA, Somerville GG, Viscusi C, Shepard AJ, Hauter WE. Prevalence of postdural puncture headache after ED performed lumbar puncture. Am J Emerg Med. 2005 Nov;23(7):913-5. https://doi.org/10.1016/j.ajem.2005.06.003
  • 26 Carson D, Serpell M. Choosing the best needle for diagnostic lumbar puncture. Neurology. 1996 Jul;47(1):33-7. https://doi.org/10.1212/wnl.47.1.33
  • 27 Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System. 2nd edition. Philadelphia: Saunders; 1992.
  • 28 Pulec JL. Post lumbar puncture headache. J R Soc Med. 1983;76(1):84.
  • 29 Strachan A, Train J. Lumbar puncture and headache. Aspirating cerebrospinal fluid speeds up procedure. BMJ. 1998 Mar;316(7136):1018-9.
  • 30 Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160. https://doi.org/10.1111/j.1468-2982.2003.00824.x
  • 31 Strupp M, Brandt T, Müller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. Journal of neurology. 1998 Sep;245(9):589-92. https://doi.org/10.1007/s004150050250
  • 32 Mosaffa F, Karimi K, Madadi F, Khoshnevis SH, Daftari Besheli L, Eajazi A. Post-dural puncture headache: a comparison between median and paramedian approaches in orthopedic patients. Anesth Pain Med. 2011 Fall;1(2):66-9. https://doi.org/10.5812/kowsar.22287523.2159
  • 33 Park S, Kim K, Park M, Lee U, Sim HS, Shin IS, et al. Effect of 24-Hour bed rest versus early ambulation on headache after spinal anesthesia: systematic review and meta-analysis. Pain Manag Nurs. 2018 Jun;19(3):267-76. https://doi.org/10.1016/j.pmn.2017.10.012
  • 34 Valenca MM, Amorim JA, Moura TP. Why don't all individuals who undergo dura mater/arachnoid puncture develop postdural puncture headache? Anesth Pain Med. 2012;1(3):207-09. https://doi.org/10.5812/kowsar.22287523.3616
  • 35 Kwak KH. Postdural puncture headache. Korean J Anesthesiol. 2017 Apr;70(2):136-43. https://doi.org/10.4097/kjae.2017.70.2.136
  • 36 Wu CL, Rowlingson AJ, Cohen SR, Michaels RK, Courpas GE, Joe EM, et al. Gender and post-dural puncture headache. Anesthesiology. 2006 Sep;105(3):613-8. https://doi.org/10.1097/00000542-200609000-00027
  • 37 González-Martínez F, de León-Belmar J, Navarro-Gutiérrez S, et al. Disminución en la incidencia de la cefalea pospunción lumbar tras la aplicación de la segunda edición de la Sociedad Internacional de Cefaleas. Rev Neurol. 2005;41(10):582-6. https://doi.org/10.33588/rn.4110.2005161
  • 38 Monserrate AE, Ryman DC, Ma S, Xiong C, Noble JM, Ringman JM, et al. Factors associated with the onset and persistence of post-lumbar puncture headache. JAMA Neurol. 2015 Mar;72(3):325-32. https://doi.org/10.1001/jamaneurol.2014.3974
  • 39 Chow G, Schmidley JW. Lysis of erythrocytes and leukocytes in traumatic lumbar punctures. Arch Neurol. 1984 Oct;41(10):1084-85. https://doi.org/10.1001/archneur.1984.04050210082020