Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom:

Abstract

The aetiology of headache after lumbar puncture is related to the hole left in the dura after the needle has been withdrawn, which allows the cerebrospinal fluid to leak out of the subarachnoid space. The headache can persist for prolonged periods and predispose to subdural haematomas, which are associated with a high mortality. Tourtellotte showed that this headache could be significantly reduced by using smaller needles.1 Also, among needles of the same size, those with atraumatic blunt tips are associated with a lower incidence of headache. They produce a smaller hole in the dura by separating rather than cutting the elastic fibres, as occurs with the Quincke tipped needles. 2We carried out a questionnaire survey of departments of neurology and neurosurgery to see if these needles were used in the practice of diagnostic lumbar puncture and to assess how else departments may be trying to prevent headaches after lumbar puncture. Methods and resultsIn September 1996 we sent a questionnaire addressed to the "senior registrar" of all (n = 105) departments of neurology and neurosurgery in the United Kingdom, as listed by the Association of British Neurologists and the Society of British Neurological Surgeons. We asked specific questions about the practice in their department of diagnostic lumbar puncture. We sent a repeat questionnaire to non-respondents two months later.The table shows the results of the survey. Seventy one departments (68%) replied. Most departments performed lumbar puncture with the patients lying on their side. Equal proportions of neurology and neurosurgery departments used the 20 gauge spinal needles (the most commonly used needle in both groups). The Quincke tipped spinal needle was used by over 70% of departments in each specialty, and only about a third of departments in each specialty oriented the bevel of the needle tip to be parallel to the longitudinal axis of the spinal cord. Over 80% of the departments clinicians used bed rest as a prophylactic measure. Neurology departments were more likely than neurosurgery departments to use systemic steroids and epidural blood patch for the treatment of headache after lumbar puncture.

Changing the needle for lumbar punctures

“…Despite the overwhelming evidence in support of the use of smaller, non-cutting needles for diagnostic lumbar punctures, the use of larger cutting needles is still widespread in neurological departments [3,4,21]. In our outpatient clinic, where a cutting 22 G needle had previously been the needle of choice, we performed a prospective, interventional study, in order to test the feasibility, drawbacks, and potential benefits of changing the needle to a 25 G non-cutting needle.…”

“…Although proven to reduce the occurrence of PDPH, the usage of small, non-cutting needles is still not widespread in neurology departments [2]. In a UK survey, a cutting needle was used in over 70% of neurology units, and only two of 48 units reported using a gauge smaller than 22 G [3]. In a US survey, the use of non-cutting needles was even lower, as only 2% of the responding neurologists reported that they routinely used this type of needle [4].…”

How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis?

“…A 1996 survey of senior registrars in all departments of neurology and neurosurgery in the United Kingdom found that 15% of respondents reported using atraumatic needles and that 73% recommended bed rest for up to 6 hours after completion of the LP. 70 A similar survey of 2287 practicing neurologists in the United States found that 2% used atraumatic needles. 70 Neurologists did not use atraumatic needles due to lack of knowledge of them or because the needles were not available for use in their institution.…”

“…70 A similar survey of 2287 practicing neurologists in the United States found that 2% used atraumatic needles. 70 Neurologists did not use atraumatic needles due to lack of knowledge of them or because the needles were not available for use in their institution. 71 The American Board of Internal Medicine recommends 3 to 5 LPs as a minimum standard for ensuring competence in completing LPs.…”

Meningeal (Postdural) Puncture Headache, Unintentional Dural Puncture, and the Epidural Blood Patch

“…[ 7 A 1996 survey of UK neurological departments found that only 8% would consider the EBP before 72 hrs had passed after lumbar puncture. 34 Safa-Tisseront et al, 35 in a prospective, uncontrolled, observational study, found a delay of less than 4 days from dural puncture before performing an EBP to be an independent risk factor for failure of the procedure. Yet, Safa-Tisseront et al were careful to state that failure of the EBP may be primarily related to the severity of the CSF leak and that their study should not be grounds for delaying the EBP.…”