Lumbar Puncture Complications: A Review of Current Literature.

PURPOSE OF REVIEW: This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS: Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Rachianesthésie en ambulatoire au Centre Hospitalier Universitaire Andrainjato Fianarantsoa, Madagascar: tolérance et efficacité / Ambulatory spinal anaesthesia at the Andrainjato University Hospital of Fianarantsoa, Madagascar: tolerance and effectiveness

La rachianesthésie ambulatoire est une des méthodes d'anesthésies loco- régionales de plus en plus utilisées car permet une réhabilitation précoce. L'objectif de l'étude est d'évaluer la tolérance et l'efficacité de la rachianesthésie réalisée en ambulatoire. Méthodes : Il s'agit d'une étude rétrospective, analytique réalisée au Centre Hospitalier Universitaire Andrainjato Fianarantsoa pendant cinq ans (du mois de janvier 2016 au mois de décembre 2020). La tolérance de la rachianesthésie était évaluée par la fréquence et la gravité des incidents peropératoires et complications postopératoires. Son efficacité était estimée par le taux de sortie le jour de l'intervention et la ré-hospitalisation. Résultats : Soixante-quatre patients âgés de 44 [14-85] ans ont bénéficié d'une chirurgie viscérale, gynécologique, traumatologique ou vasculaire sous rachianesthésie. L'hypotension artérielle (n=04) et les nausées et vomissements peropératoires (n = 01) étaient les incidents retrouvés. Les complications postopératoires étaient la céphalée (n = 13), la douleur postopératoire d'intensité modérée à intense (n = 05) et les nausées et vomissements (n = 02). L'âge supérieur à 50 ans (p = 0,012) et une dose supérieure à 12 mg de bupivacaïne (p = 0,011) étaient corrélés à l'hypotension artérielle peropératoire. Le genre féminin (p = 0,004) et l'utilisation de la bupivacaïne hyperbare (p = 0,027) étaient associés aux complications postopératoires. Tous ces patients étaient sortis le jour même de l'intervention sans ré-hospitalisation. Conclusion : La rachianesthésie ambulatoire connaît actuellement un grand essor dans la pratique anesthésique. La prévention de certaines complications devrait être systématique afin d'optimiser sa tolérance et son efficacité

Post-Lumbar Puncture Headache-Does Hydration before Puncture Prevent Headache and Affect Cerebral Blood Flow?

Headache is a common complication after diagnostic lumbar puncture (DLP). We aimed to check whether hydration before puncture influences the incidence of post-lumbar puncture headache (PLPH) and affects cerebral blood flow. Ninety-nine patients enrolled for puncture were assigned to a group with (n = 40) or without hydration (n = 59). In the hydration group, 1000 mL 0.9% NaCl was infused and a minimum of 1500 mL oral fluids was recommended within the 24 h before puncture. A Transcranial Doppler (TCD) was performed before and after DLP. Mean velocity (Vm) and pulsatility index (PI) were measured in the middle cerebral arteries (MCAs). PLPH occurred in 28 patients (28.2%): six (15.4%) from the hydrated and 22 (37.3%) from the non-hydrated group (p < 0.023). Patients with PLPH were younger (p < 0.014) and with headaches in their histories (p < 0.036) compared with the non-headache group. Vm values in both MCAs after puncture were significantly lower than before puncture in all patients. In the PLPH group, Vm in MCAs before puncture were significantly higher and the PI was lower than in the non-headache group. Our findings suggest that hydration of patients within 24 h before puncture prevented PLPH. Twenty-four hours after puncture, significant decreases in Vm were observed in the MCAs of all patients. Low baseline values of PI and high Vm predisposed patients to PLPH.

Clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the BMJ Rapid Recommendation clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture. This includes the strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age or indication.

Therapeutic lumbar puncture for headache in idiopathic intracranial hypertension: Minimal gain, is it worth the pain?

BACKGROUND: Headache is disabling and prevalent in idiopathic intracranial hypertension. Therapeutic lumbar punctures may be considered to manage headache. This study evaluated the acute effect of lumbar punctures on headache severity. Additionally, the effect of lumbar puncture pressure on post-lumbar puncture headache was evaluated. METHODS: Active idiopathic intracranial hypertension patients were prospectively recruited to a cohort study, lumbar puncture pressure and papilloedema grade were noted. Headache severity was recorded using a numeric rating scale (NRS) 0-10, pre-lumbar puncture and following lumbar puncture at 1, 4 and 6 hours and daily for 7 days. RESULTS: Fifty two patients were recruited (mean lumbar puncture opening pressure 32 (28-37 cmCSF). At any point in the week post-lumbar puncture, headache severity improved in 71% (but a small reduction of -1.1 ± 2.6 numeric rating scale) and exacerbated in 64%, with 30% experiencing a severe exacerbation ≥ 4 numeric rating scale. Therapeutic lumbar punctures are typically considered in idiopathic intracranial hypertension patients with severe headaches (numeric rating scale ≥ 7). In this cohort, the likelihood of improvement was 92% (a modest reduction of headache pain by -3.0 ± 2.8 numeric rating scale, p = 0.012, day 7), while 33% deteriorated. Idiopathic intracranial hypertension patients with mild (numeric rating scale 1-3) or no headache (on the day of lumbar puncture, prior to lumbar puncture) had a high risk of post- lumbar puncture headache exacerbation (81% and 67% respectively). Importantly, there was no relationship between lumbar puncture opening pressure and headache response after lumbar puncture. CONCLUSION: Following lumbar puncture, the majority of idiopathic intracranial hypertension patients experience some improvement, but the benefit is small and post-lumbar puncture headache exacerbation is common, and in some prolonged and severe. Lumbar puncture pressure does not influence the post-lumbar puncture headache.

A dedicated lumbar puncture clinic: performance and short-term patient outcomes.

The purpose of the study was to evaluate patient outcomes, including success rates, factors associated with unsuccessful procedures and frequency of post-lumbar puncture headaches (PLPH), at a dedicated academic outpatient lumbar puncture (LP) clinic. All patients referred to our LP clinic between June 1, 2014 and May 31, 2015 were included in this consecutive observational series. We collected information about patient characteristics, operational parameters of the procedure, and complications. We also recorded rates of participation in biomedical research involving use of cerebrospinal fluid. Univariate analysis used Student's t test and Fisher's exact test. Logistic regression was used to determine independent risk factors associated with unsuccessful LP and PLPH. The mean age of patients referred to our LP clinic was 46 ± 17 years. Of the 307 referrals, 281 patients (92%) started the procedure, with successful acquisition of CSF in 267 (95%). Factors contributing to unsuccessful procedures included higher body mass index [odds ratio (OR) 1.8], older age (OR 1.9), and female sex (OR 10.3). The rate of PLPH was 5.7%. Younger age (OR 0.5), female sex (OR 6.9), high mean arterial pressure (OR 2.2), and a traumatic LP (OR 10.0) were identified as risk factors for PLPH. Notably, 202 patients (72%) consented to biomedical research. A standardized approach to outpatient LP demonstrates high procedural success rate, low PLPH rate, and high participation in biomedical research. Awareness of a group of patients at higher risk for complications including procedure failure or PLPH provides guidance for decision-making regarding referral to the outpatient LP clinic.

Post lumbar puncture headache: Case report of a serious adverse event in first-in-human study.

A lumbar puncture can be used to measure the concentrations of drugs and/or pharmacodynamic biomarkers during clinical trials of central nervous system drugs. We report a case of a post lumbar puncture headache (PLPH) in a first-in-human study, which was reported as a serious adverse event. A 20-year-old man received 200 mg of the investigational product (IP) for 7 days and underwent a lumbar puncture for cerebrospinal fluid sampling before IP administration (Day 1, pre-dose) and after 7 days and multiple IP administrations (Day 7, 1 hour post-dose). After discharge on Day 8, the subject complained of headache, nausea, vomiting, neck stiffness, and numbness of the extremities. The symptoms occurred when he got up and disappeared after he remained in the supine position for several minutes. Five days later, he visited the neurology clinic of the main hospital. The neurologist recommended hospitalization for further evaluation and symptom management, and the subject was then admitted to the hospital. There were no abnormal findings in vital signs, laboratory results, or brain-computed tomography. His symptoms disappeared during the hospitalization period. It was important to distinguish whether the headache was IP-related or lumbar puncture-related. Therefore, knowledge of clinical characteristics and differential diagnosis of PLPH is paramount. Furthermore, if severe PLPH occurs, a consultation with a neurologist and imaging studies should be considered for a differential diagnosis of PLPH.

Post lumbar puncture headache: Case report of a serious adverse event in first-in-human study

A lumbar puncture can be used to measure the concentrations of drugs and/or pharmacodynamic biomarkers during clinical trials of central nervous system drugs. We report a case of a post lumbar puncture headache (PLPH) in a first-in-human study, which was reported as a serious adverse event. A 20-year-old man received 200 mg of the investigational product (IP) for 7 days and underwent a lumbar puncture for cerebrospinal fluid sampling before IP administration (Day 1, pre-dose) and after 7 days and multiple IP administrations (Day 7, 1 hour post-dose). After discharge on Day 8, the subject complained of headache, nausea, vomiting, neck stiffness, and numbness of the extremities. The symptoms occurred when he got up and disappeared after he remained in the supine position for several minutes. Five days later, he visited the neurology clinic of the main hospital. The neurologist recommended hospitalization for further evaluation and symptom management, and the subject was then admitted to the hospital. There were no abnormal findings in vital signs, laboratory results, or brain-computed tomography. His symptoms disappeared during the hospitalization period. It was important to distinguish whether the headache was IP-related or lumbar puncture-related. Therefore, knowledge of clinical characteristics and differential diagnosis of PLPH is paramount. Furthermore, if severe PLPH occurs, a consultation with a neurologist and imaging studies should be considered for a differential diagnosis of PLPH.

Intravenous theophylline rapidly decreases post-lumbar puncture headaches.

When managing therapy for the post-lumbar puncture headaches (PLPHs), an efficacious, fast-acting, practical and safe method is preferred. Invasive methods have known complications and oral medications might be problematic when nausea and vomiting occurs with severe headaches. The aim of this study was to highlight the brief initial time for a remarkable decrease of PLPH pain levels after the administration of IV theophylline infusion. We observed that IV theophylline infusion has a rapid and marked effect on decreasing pain in PLPHs. At 30 min of theophylline infusion, mean VAS levels were decreased by 47.1 % and at 60 min of infusion, the decrease of pain was 61.9 %. We conclude that IV theophylline infusion is a rapidly effective, noninvasive, practical and low-cost way to treat PLPHs. To the best of our knowledge, this is the first study to highlight both the efficacy and the speed of the effect of pain relief in PLPHs.

How to minimize the risk for headache? A lumbar puncture practice questionnaire study.

Background - To lower the risk for post lumbar puncture (LP) headache the American Academy of Neurology (AAN) recommended using small bore atraumatic needles together with stylet reinsertion in a report from 2005. It is unclear whether these recommendations are followed or not. Objectives - To investigate the diagnostic LP preferences with respect to the AAN guidelines among neurologists by use of a short online questionnaire, and to review previously published literature on the subject. Results - A total of 284 respondents who performed diagnostic LPs completed the questionnaire. Almost half (41%) answered that they always use atraumatic needles. The most common reason (73%) for not using atraumatic needles was that these were not available. Less than half of the respondents who performed LPs had knowledge about the AAN guidelines for diagnostic LPs, and 48-76% agreed with the different recommendations therein. Five previously (1998-2015) published studies investigating LP practice among neurologists were identified. The reported frequency of atraumatic needle use (always/routinely) varied between 2 and 16%. Discussion - Atraumatic needle use was more common in this study compared with previous publications. There is still skepticism regarding some of the AAN recommendations, and needle availability appears to be the most important factor preventing atraumatic needle use. To increase the use of atraumatic needles we may perform additional studies investigating their potential benefits, and arrange training sessions for neurologists to increase their awareness and level of comfort with the atraumatic LP technique.

Risk factors for post lumbar puncture headache.

BACKGROUND: Lumbar puncture (LP) is complicated by headache in about one-third of patients. The aim of the study was to evaluate potential risk factors for post-LP headache. METHODS: 144 Patients undergoing diagnostic LP at a tertiary medical center completed questionnaires on fear of the procedure, pre-existing headache, and post-LP headache. Data on patient demographics, operator experience, and other procedure-related parameters were collected from hospital files. RESULTS: The post-LP headache group (n=37, 27.6%) was characterized by a significantly younger age and higher proportion of women relative to the no-headache group (n=97); body mass index was similar. Both groups had similar levels of fear of the procedure and there was no correlation between intensity of patients' anxiety to the procedure and its occurrence. Patients with high opening pressure had higher levels of post-LP headache (28.6% vs. 18% p=0.078) and a history of headaches was significantly more prevalent in the post-LP-headache group (66.6% vs. 38.1%, p=0.003). CONCLUSIONS: Fear of the procedure does not predispose to occurrence of post-LP headache while a history of headache and elevated intracranial pressure does. These findings may be related to the possible pathophysiology of the condition, namely a change in compliance and pressure gradients with resultant venous distention.

Subdural hemorrhage - a serious complication post-intrathecal chemotherapy. A case report and review of literature.

We need to have a high index of suspicion for subdural hemorrhage (SDH) post-lumbar puncture in hematological patients given their increased risk and the significant morbidity and mortality associated with SDHs.

Lumbar puncture preferences among Swedish neurologists.

Lumbar puncture (LP) with cerebrospinal fluid analysis is a common diagnostic tool in neurology, and may be complicated by post-LP headache (PLPHA). The American Academy of Neurology (AAN) has published guidelines for performing diagnostic LPs with the aim to reduce PLPHA risk, but our clinical hands-on experience suggests that these are not followed. We performed a questionnaire study among Swedish neurologists to investigate the acceptance and implementation of the AAN guidelines. Only one-eighth (22/174) of the respondents performed their LPs according to the AAN guidelines. The poor adherence to the AAN guidelines among Swedish neurologists may be due to perceived low credibility, as the current guidelines cite only one study to support the recommendation to use atraumatic needles, and only one study to support the recommendation to replace the stylet before needle withdrawal. An international survey has been posted ( https://www.surveymonkey.com/s/lumbarpuncturesurvey ) to investigate whether the results of this Swedish questionnaire are representative of neurologists worldwide.

Risk Factors for Post-Lumbar Puncture Headache in a Study of Alzheimer's Disease Biomarkers

BACKGROUND AND PURPOSE: In memory clinics, the lumbar puncture (LP) is increasingly being used to evaluate cerebrospinal fluid for biomarkers of Alzheimer's disease (AD). Post-lumbar puncture headache (PLPH) is the most frequent complication of LP, and can prove to be a barrier for the performance of LP. METHODS: We retrospectively collected data from 59 subjects (patients with AD and cognitively healthy controls) who were enrolled in a study aimed to identify AD biomarkers via LP. In order to determine whether subjects experienced PLPH, we assessed recorded follow-up telephone interviews. To analyze the association between the occurrence of PLPH and several demographic- and procedure-related factors, a multiple logistic regression analysis with backward stepwise method was performed. RESULTS: The overall frequency of PLPH was 49.15%. PLPH was more frequent in younger subjects and clinical diagnosis was associated with PLPH. The use of cutting-edge needles was also suggested as a statistically significant factor in the development of PLPH, and was determined to be the only factor that could be modified in order to lower the frequency of PLPH. CONCLUSIONS: Age, clinical diagnosis, and needle type were all determined to be predictive factors of PLPH.

Feasibility of lumbar puncture in the study of cerebrospinal fluid biomarkers for Alzheimer's disease: a multicenter study in Spain.

BACKGROUND: Lumbar puncture (LP) is increasingly performed in memory units due to the usefulness of cerebrospinal fluid (CSF) biomarkers in the diagnosis of Alzheimer's disease. The feasibility of this procedure in this context, however, is controversial. OBJECTIVE: Our aim was to analyze the incidence of complications and their associated factors so as to determine the impact of LP in the study of CSF biomarkers of Alzheimer's disease. METHODS: In the context of a larger international initiative, we prospectively collected data from 689 participants who underwent LP in three memory units in Spain. Data included demographic factors, headache history, subjective attitude toward the procedure, patient positioning, needle characteristics, volume of CSF extracted, attempts needed, and resting time after CSF acquisition. Five to seven days after the procedure, we asked participants about complications through a semi-structured telephone interview. RESULTS: No adverse events were reported in 441 (64.0%) participants. The most frequent complication was headache, reported by 171 (24.8%) subjects. It was severe in only 17 (2.5%). Headache was more frequent in younger participants and when a cutting-edge needle was used. Back pain was present in 111 (16.1%) cases, and it was associated with female gender, cutting-edge needles, increased number of attempts, and longer resting time after LP. No major complications were reported. The use of pen-point needles showed a trend toward a higher frequency of hematic CSF. CONCLUSION: LP can be safely performed to study CSF biomarkers. The main complication is headache, associated with younger age and use of cutting-edge needles.

Change practice now! Using atraumatic needles to prevent post lumbar puncture headache.

BACKGROUND AND PURPOSE: Lumbar puncture (LP) is a key diagnostic procedure in medicine. Post lumbar puncture headache (PLPHA) is a well recognized complication of LP. Evidence suggests that using atraumatic needles for diagnostic LP (ATNLP) reduces risk of PLPHA. However, clinicians in Europe and the USA routinely use traumatic needles for diagnostic LP (TNLP). The occurrence of PLPHA following ATNLP and TNLP was compared in a clinical setting. Further, a survey was performed exploring use of ATNLP amongst UK neurologists. METHODS: Service development study. Patients were followed up 2 and 7 days after LP using blinded telephone assessment. A questionnaire was developed to assess use of ATNLP amongst UK neurologists. Frequency, onset, duration and severity of PLPHA were recorded as were use of analgesia, general practitioner consultations, hospital readmissions, days off work due to PLPHA and cost. Neurologists were asked about their familiarity with, and use of, ATNLP. RESULTS: One hundred and nine participants attending the Royal London Hospital were included, and 74 attendees of the Association of British Neurologists 2012 conference completed an on-site questionnaire. ATNLP reduced the rate of PLPHA (27.1% vs. 60.4%; P < 0.01). In those participants who developed PLPHA symptoms were short lived (mean 50 h vs. 94 h, P = 0.02) and less severe after ATNLP. Use of ATNLP led to significant cost savings. Only one in five UK neurologists regularly use ATNLP stating lack of training and availability of atraumatic needles as main reasons. CONCLUSIONS: ATNLP significantly reduces the risk of PLPHA. Training is required 3 to facilitate a change from TNLP to ATNLP amongst clinicians.

Cefalea post-punción lumbar / Post-lumbar puncture headache

La punción lumbar es un procedimiento que se realiza con fines diagnósticos, terapéuticos, o para anestesia regional. Después de una punción lumbar se puede presentar cefalea por disminución de la presión intracraneana del líquido cefalorraquídeo, que aparece dentro de los cinco días siguientes al procedimiento y mejora en una semana. El tipo de aguja que se utiliza y la orientación del bisel pueden influir en su desarrollo. En el presente artículo se analizan los aspectos fisiopatológicos y clínicos, así como el tratamiento de la cefalea post-punción lumbar.

Lumbar puncture is a procedure used in regional anestesia, or for diagnostic and therapeutic purposes. After a lumbar puncture it can appear a headache caused by a decrease in intracranial pressure of the cerebrospinal fluid. This headache appears within five days after the procedure and improves in one week. The type of the needle and the direction of the bevel can influence the developement of this complication. This article analyzes the pathophysiological and clinical aspects, as well as the treatment of post-lumbar puncture headache.