Post-dural puncture headache: pathogenesis, prevention and treatment
2003; Elsevier BV; Volume: 91; Issue: 5 Linguagem: Inglês
10.1093/bja/aeg231
ISSN1471-6771
Autores Tópico(s)Head and Neck Surgical Oncology
ResumoSpinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache. Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache. Spinal anaesthesia developed in the late 1800s. In 1891, Wynter and Quincke95Pearce JM Walter Essex Wynter, Quincke, and lumbar puncture.J Neurol Neurosurg Psychiatry. 1994; 57: 179Crossref PubMed Google Scholar aspirated cerebrospinal fluid (CSF) from the subarachnoid space for the treatment of raised intracranial hypertension associated with tuberculous meningitis. The catheters and trochars used were probably about 1 mm in diameter and would certainly have led to a post-dural puncture headache. However, all Quincke and Wynters’ subjects died soon after. In 1895, John Corning, a New York physician specializing in diseases of the mind and nervous system, proposed that local anaesthesia of the spinal cord with cocaine may have therapeutic properties.50Gorelick PB Zych D James Leonard Corning and the early history of spinal puncture.Neurology. 1987; 37: 672-674Crossref PubMed Google Scholar Corning injected cocaine 110 mg at the level of the T11/12 interspace in a man to treat habitual masturbation. Despite being accredited with the first spinal anaesthetic, it is unlikely from his description and the dose of cocaine that his needle entered the subarachnoid space.82Marx GF The first spinal anesthesia. Who deserves the laurels?.Reg Anesth. 1994; 19: 429-430PubMed Google Scholar In August 1898, Karl August Bier,137Wulf HF The centennial of spinal anesthesia.Anesthesiology. 1998; 89: 500-506Crossref PubMed Scopus (0) Google Scholar a German surgeon, injected cocaine 10–15 mg into the subarachnoid space of seven patients, himself and his assistant, Hildebrandt. Bier, Hildebrandt and four of the subjects all described the symptoms associated with post-dural puncture headache. Bier surmised that the headache was attributable to loss of CSF. By the early 1900s, there were numerous reports in the medical literature of the application of spinal anaesthesia using large spinal needles.75Lee JA Arthur Edward James Barker 1850–1916. British pioneer of regional analgesia.Anaesthesia. 1979; 34: 885-891Crossref PubMed Scopus (8) Google Scholar Headache was reported to be a complication in 50% of subjects. At that time, the headache was said to resolve within 24 h. Ether anaesthesia was introduced into obstetric practice in 1847, shortly after Morton’s public demonstration. Despite the obvious advantages of regional anaesthesia for the relief of labour pain, it was not until a Swiss obstetrician in 1901 used intrathecal cocaine for the relief of pain in the second stage of labour that regional anaesthesia for obstetrics was popularized.49Gogarten W Van Aken H A century of regional analgesia in obstetrics.Anesth Analg. 2000; 91: 773-775Crossref PubMed Google Scholar Though both vomiting and a high incidence of post-dural puncture headache were noted, it was the high mortality rate in Caesarean deliveries performed under spinal anaesthesia (1 in 139) that led to the abandonment of this technique in the 1930s. The period from 1930 to 1950 has often been referred to as the ‘dark ages of obstetric anaesthesia’, when natural childbirth and psychoprophylaxis were encouraged. In 1951, Whitacre and Hart59Hart JR Whitacre RG Pencil point needle in the prevention of post-spinal headache.JAMA. 1951; 147: 657-658Crossref PubMed Google Scholar developed the pencil-point needle, based on the observations of Greene53Greene HM Lumbar puncture and the prevention of post puncture headache.JAMA. 1926; 86: 391-392Crossref Google Scholar in 1926. Developments in needle design since that time have led to a significant reduction in the incidence of post-dural puncture headache. However, dural puncture headache remains a disabling complication of needle insertion into the subarachnoid space. The spinal dura mater is a tube extending from the foramen magnum to the second segment of the sacrum. It contains the spinal cord and nerve roots that pierce it. The dura mater is a dense, connective tissue layer made up of collagen and elastic fibres. The classical description of the spinal dura mater is of collagen fibres running in a longitudinal direction.53Greene HM Lumbar puncture and the prevention of post puncture headache.JAMA. 1926; 86: 391-392Crossref Google Scholar This had been supported by histological studies of the dura mater.93Patin DJ Eckstein EC Harum K Pallares VS Anatomic and biomechanical properties of human lumbar dura mater.Anesth Analg. 1993; 76: 535-540Crossref PubMed Google Scholar Clinical teaching based upon this view of the dura recommends that a cutting spinal needle be orientated parallel rather than at right angles to these longitudinal dural fibres. Orientating the needle at right angles to the parallel fibres, it was said would cut more fibres. The cut dural fibres, previously under tension, would then tend to retract and increase the longitudinal dimensions of the dural perforation, increasing the likelihood of a post-spinal headache. Clinical studies had confirmed that post-dural puncture headache was more likely when the cutting spinal needle was orientated perpendicular to the direction of the dural fibres. However, recent light and electron microscopic studies of human dura mater have contested this classical description of the anatomy of the dura mater.102Reina MA de Leon-Casasola OA Lopez A De Andres J Martin S Mora M An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy.Reg Anesth Pain Med. 2000; 25: 393-402Crossref PubMed Google Scholar These studies describe the dura mater as consisting of collagen fibres arranged in several layers parallel to the surface. Each layer or lamellae consists of both collagen and elastic fibres that do not demonstrate specific orientation.43Fink BR Walker S Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture.Anesth Analg. 1989; 69: 768-772Crossref PubMed Google Scholar The outer or epidural surface may indeed have dural fibres arranged in a longitudinal direction, but this pattern is not repeated through successive dural layers. Recent measurements of dural thickness have also demonstrated that the posterior dura varies in thickness, and that the thickness of the dura at a particular spinal level is not predictable within an individual or between individuals.102Reina MA de Leon-Casasola OA Lopez A De Andres J Martin S Mora M An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy.Reg Anesth Pain Med. 2000; 25: 393-402Crossref PubMed Google Scholar Dural perforation in a thick area of dura may be less likely to lead to a CSF leak than a perforation in a thin area, and may explain the unpredictable consequences of a dural perforation. CSF production occurs mainly in the choroid plexus, but there is some evidence of extrachoroidal production. About 500 ml of CSF is produced daily (0.35 ml min−1). The CSF volume in the adult is approximately 150 ml, of which half is within the cranial cavity. The CSF pressure in the lumbar region in the horizontal position is between 5 and 15 cm H2O. On assuming the erect posture, this increases to over 40 cm H2O. The pressure of the CSF in children rises with age, and may be little more than a few cm H2O in early life. The consequences of perforation of the spinal or cranial dura are that there will be leakage of CSF. Neurosurgical experience of dural perforation is that even minor perforations need to be closed, either directly or through the application of synthetic or biological dural graft material. Failure to close the dural perforation may lead to adhesions, continuing CSF leak, and the risk of infection. There are few experimental studies of the response of the dura to perforation.70Keener EB An experimental study of reactions of the dura mater to wounding and loss of substance.J Neurosurg. 1959; 16: 424-447Crossref PubMed Google Scholar In 1923, it was noted that deliberate dural defects in the cranial dura of dogs took approximately one week to close. The closure was facilitated through fibroblastic proliferation from the cut edge of the dura. Work published in 195970Keener EB An experimental study of reactions of the dura mater to wounding and loss of substance.J Neurosurg. 1959; 16: 424-447Crossref PubMed Google Scholar dismissed the notion that the fibroblastic proliferation arose from the cut edge of the dura. This study maintained that the dural repair was facilitated by fibroblastic proliferation from surrounding tissue and blood clot. The study also noted that dural repair was promoted by damage to the pia arachnoid, the underlying brain and the presence of blood clot. It is therefore possible that a spinal needle carefully placed in the subarachnoid space does not promote dural healing, as trauma to adjacent tissue is minimal. Indeed, the observation that blood promotes dural healing agrees with Gormley’s original observation that bloody taps were less likely to lead to a post-dural puncture headache as a consequence of a persistence CSF leak.51Gormley JB Treatment of post-spinal headache.Anesthesiology. 1960; 21: 565-566Google Scholar It has been proposed that contact with bone during insertion may lead to spinal needle tip deformation.67Jokinen MJ Pitkanen MT Lehtonen E Rosenberg PH Deformed spinal needle tips and associated dural perforations examined by scanning electron microscopy.Acta Anaesthesiol Scand. 1996; 40: 687-690Crossref PubMed Google Scholar 90Parker RK White PF A microscopic analysis of cut-bevel versus pencil-point spinal needles.Anesth Analg. 1997; 85: 1101-1104Crossref PubMed Google Scholar Damaged needle tips could lead to an increase in the size of the subsequent dural perforation. Recent in vivo studies have demonstrated that the cutting type spinal needle is more likely to be deformed after bony contact than comparable sized pencil-point needles.90Parker RK White PF A microscopic analysis of cut-bevel versus pencil-point spinal needles.Anesth Analg. 1997; 85: 1101-1104Crossref PubMed Google Scholar However, no in vivo67Jokinen MJ Pitkanen MT Lehtonen E Rosenberg PH Deformed spinal needle tips and associated dural perforations examined by scanning electron microscopy.Acta Anaesthesiol Scand. 1996; 40: 687-690Crossref PubMed Google Scholar or in vitro work has yet demonstrated an increase in the size of dural perforation where damaged needles are used. Puncture of the dura has the potential to allow the development of excessive leakage of CSF. Excess loss of CSF leads to intracranial hypotension and a demonstrable reduction in CSF volume.52Grant R Condon B Hart I Teasdale GM Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache.J Neurol Neurosurg Psychiatry. 1991; 54: 440-442Crossref PubMed Scopus (0) Google Scholar After the development of post-dural puncture headache, the presence of a CSF leak has been confirmed with radionuclide cisternography,100Rando TA Fishman RA Spontaneous intracranial hypotension: report of two cases and review of the literature.Neurology. 1992; 42: 481-487Crossref PubMed Google Scholar radionuclide myelography, manometric studies, epiduroscopy and direct visualization at laminectomy. The adult subarachnoid pressure of 5–15 cm H20 is reduced to 4.0 cm H20 or less.100Rando TA Fishman RA Spontaneous intracranial hypotension: report of two cases and review of the literature.Neurology. 1992; 42: 481-487Crossref PubMed Google Scholar The rate of CSF loss through the dural perforation29Cruickshank RH Hopkinson JM Fluid flow through dural puncture sites. An in vitro comparison of needle point types.Anaesthesia. 1989; 44: 415-418Crossref PubMed Google Scholar (0.084–4.5 ml s−1) is generally greater than the rate of CSF production (0.35 ml min−1), particularly with needle sizes larger than 25G.29Cruickshank RH Hopkinson JM Fluid flow through dural puncture sites. An in vitro comparison of needle point types.Anaesthesia. 1989; 44: 415-418Crossref PubMed Google Scholar 101Ready LB Cuplin S Haschke RH Nessly M Spinal needle determinants of rate of transdural fluid leak.Anesth Analg. 1989; 69: 457-460Crossref PubMed Google Scholar Gadolinium-enhanced MRI, in the presence of a post-dural puncture headache, frequently demonstrates ‘sagging’ of the intracranial structures. The MRI may or may not demonstrate meningeal enhancement.56Hannerz J Ericson K Bro Skejo HP MR imaging with gadolinium in patients with and without post-lumbar puncture headache.Acta Radiol. 1999; 40: 135-141Crossref PubMed Google Scholar The meningeal enhancement is attributable to vasodilatation of thin-walled vessels in response to the intracranial hypotension. Histological studies have confirmed that the vasodilation of meningeal vessels is unrelated to an inflammatory response.56Hannerz J Ericson K Bro Skejo HP MR imaging with gadolinium in patients with and without post-lumbar puncture headache.Acta Radiol. 1999; 40: 135-141Crossref PubMed Google Scholar Although the loss of CSF and lowering of CSF pressure is not disputed, the actual mechanism producing the headache is unclear. There are two possible explanations. First, the lowering of CSF pressure causes traction on the intracranial structures in the upright position. These structures are pain sensitive, leading to the characteristic headache. Secondly, the loss of CSF produces a compensatory venodilatation vis-à-vis the Monro–Kellie doctrine.52Grant R Condon B Hart I Teasdale GM Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache.J Neurol Neurosurg Psychiatry. 1991; 54: 440-442Crossref PubMed Scopus (0) Google Scholar The Monro–Kellie doctrine, or hypothesis, states that the sum of volumes of the brain, CSF, and intracranial blood is constant. The consequence of a decrease in CSF volume is a compensatory increase in blood volume. The venodilatation is then responsible for the headache. The incidence of post-dural puncture headache was 66% in 1898.137Wulf HF The centennial of spinal anesthesia.Anesthesiology. 1998; 89: 500-506Crossref PubMed Scopus (0) Google Scholar This alarmingly high incidence of post-spinal headache was likely attributable to the use of large gauge, medium bevel, cutting spinal needles (needles 5, 6 and 7, Fig. 1). In 1956, with the introduction of 22G and 24G needles, the incidence was estimated to be 11%.132Vandam LD Dripps RD Long-term follow up of patients who received 10 098 spinal anesthetics.JAMA. 1956; 161: 586-591Crossref PubMed Google Scholar Today the use of fine gauge pencil-point needles, such as the Whitacre and Sprotte® has produced a greater reduction in the incidence of post-dural puncture headache, which varies with the type of procedure and patients involved. It is related to the size and design of the spinal needle used (Fig. 1; Table 1),36Dittmann M Schafer HG Ulrich J Bond-Taylor W Anatomical re-evaluation of lumbar dura mater with regard to postspinal headache. Effect of dural puncture.Anaesthesia. 1988; 43: 635-637Crossref PubMed Google Scholar the experience of the personnel performing the dural puncture,35Dittmann M Schaefer HG Renkl F Greve I Spinal anaesthesia with 29 gauge Quincke point needles and post-dural puncture headache in 2378 patients.Acta Anaesthesiol Scand. 1994; 38: 691-693Crossref PubMed Google Scholar and the age and sex of the patient.Table 1Relationship between needle size and incidence of post-dural puncture headacheNeedle tip designNeedle gaugeIncidence of post-dural puncture headache (%)Quincke2236128Tourtellotte WW Henderson WG Tucker RP Gilland O Walker JE Kokman E A randomized, double-blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals.Headache. 1972; 12: 73-78Crossref PubMed Google ScholarQuincke253–2547Geurts JW Haanschoten MC van Wijk RM Kraak H Besse TC Post-dural puncture headache in young patients. A comparative study between the use of 0.52 mm (25-gauge) and 0.33 mm (29-gauge) spinal needles.Acta Anaesthesiol Scand. 1990; 34: 350-353Crossref PubMed Google ScholarQuincke260.3–2045Flaatten H Rodt SA Vamnes J Rosland J Wisborg T Koller ME Postdural puncture headache. A comparison between 26- and 29-gauge needles in young patients.Anaesthesia. 1989; 44: 147-149Crossref PubMed Google Scholar 107Ross AW Greenhalgh C McGlade DP et al.The Sprotte needle and post-dural puncture headache following caesarean section.Anaesth Intens Care. 1993; 21: 280-283PubMed Google ScholarQuincke271.5–5.625Corbey MP Bach AB Lech K Frorup AM Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles.Acta Anaesthesiol Scand. 1997; 41: 779-784Crossref PubMed Google Scholar 69Kang SB Goodnough DE Lee YK et al.Comparison of 26- and 27-G needles for spinal anesthesia for ambulatory surgery patients.Anesthesiology. 1992; 76: 734-738Crossref PubMed Google ScholarQuincke290–245Flaatten H Rodt SA Vamnes J Rosland J Wisborg T Koller ME Postdural puncture headache. A comparison between 26- and 29-gauge needles in young patients.Anaesthesia. 1989; 44: 147-149Crossref PubMed Google Scholar 47Geurts JW Haanschoten MC van Wijk RM Kraak H Besse TC Post-dural puncture headache in young patients. A comparative study between the use of 0.52 mm (25-gauge) and 0.33 mm (29-gauge) spinal needles.Acta Anaesthesiol Scand. 1990; 34: 350-353Crossref PubMed Google Scholar 69Kang SB Goodnough DE Lee YK et al.Comparison of 26- and 27-G needles for spinal anesthesia for ambulatory surgery patients.Anesthesiology. 1992; 76: 734-738Crossref PubMed Google ScholarQuincke320.446Frumin MJ Spinal anaesthesia using a 32-gauge needle.Anesthesiology. 1969; 30: 560-599Crossref Google ScholarSprotte240–9.613Campbell DC Douglas MJ Pavy TJ Merrick P Flanagan ML McMorland GH Comparison of the 25-gauge Whitacre with the 24-gauge Sprotte spinal needle for elective Caesarean section: cost implications.Can J Anaesth. 1993; 40: 1131-1135Crossref PubMed Scopus (0) Google Scholar 107Ross AW Greenhalgh C McGlade DP et al.The Sprotte needle and post-dural puncture headache following caesarean section.Anaesth Intens Care. 1993; 21: 280-283PubMed Google ScholarWhitacre202–517Carrie LE Whitacre and pencil-point needles: some points to consider.Anaesthesia. 1990; 45: 1097-1098Crossref PubMed Scopus (0) Google ScholarWhitacre220.63–417Carrie LE Whitacre and pencil-point needles: some points to consider.Anaesthesia. 1990; 45: 1097-1098Crossref PubMed Scopus (0) Google Scholar 112Sears DH Leeman MI Jassy LJ O’Donnell LA Allen SG Reisner LS The frequency of postdural puncture headache in obstetric patients: a prospective study comparing the 24-gauge versus the 22-gauge Sprotte needle.J Clin Anesth. 1994; 6: 42-46Abstract Full Text PDF PubMed Scopus (0) Google ScholarWhitacre250–14.513Campbell DC Douglas MJ Pavy TJ Merrick P Flanagan ML McMorland GH Comparison of the 25-gauge Whitacre with the 24-gauge Sprotte spinal needle for elective Caesarean section: cost implications.Can J Anaesth. 1993; 40: 1131-1135Crossref PubMed Scopus (0) Google Scholar 98Quaynor H Tronstad A Heldaas O Frequency and severity of headache after lumbar myelography using a 25-gauge pencil-point (Whitacre) spinal needle.Neuroradiology. 1995; 37: 553-556Crossref PubMed Google ScholarWhitacre27025Corbey MP Bach AB Lech K Frorup AM Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles.Acta Anaesthesiol Scand. 1997; 41: 779-784Crossref PubMed Google ScholarAtraucan262.5–4115Sharma SK Gambling DR Joshi GP Sidawi JE Herrera ER Comparison of 26-gauge Atraucan and 25-gauge Whitacre needles: insertion characteristics and complications.Can J Anaesth. 1995; 42: 706-710Crossref PubMed Scopus (0) Google Scholar 131Vallejo MC Mandell GL Sabo DP Ramanathan S Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients.Anesth Analg. 2000; 91: 916-920Crossref PubMed Google ScholarTuohy167026Costigan SN Sprigge JS Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983–1993.Acta Anaesthesiol Scand. 1996; 40: 710-714Crossref PubMed Google Scholar Open table in a new tab Anaesthetists have been active in attempting to reduce the incidence of post-spinal headache. Reducing the size of the spinal needle has made a significant impact on the incidence of post-spinal headache. The incidence is ∼40% with a 22G needle; 25% with a 25G needle;4Barker P Headache after dural puncture.Anaesthesia. 1989; 44: 696-697Crossref PubMed Scopus (11) Google Scholar 44Flaatten H Rodt S Rosland J Vamnes J Postoperative headache in young patients after spinal anaesthesia.Anaesthesia. 1987; 42: 202-205Crossref PubMed Google Scholar 2%–12% with a 26G Quincke needle;4Barker P Headache after dural puncture.Anaesthesia. 1989; 44: 696-697Crossref PubMed Scopus (11) Google Scholar 45Flaatten H Rodt SA Vamnes J Rosland J Wisborg T Koller ME Postdural puncture headache. A comparison between 26- and 29-gauge needles in young patients.Anaesthesia. 1989; 44: 147-149Crossref PubMed Google Scholar and <2% with a 29G needle.47Geurts JW Haanschoten MC van Wijk RM Kraak H Besse TC Post-dural puncture headache in young patients. A comparative study between the use of 0.52 mm (25-gauge) and 0.33 mm (29-gauge) spinal needles.Acta Anaesthesiol Scand. 1990; 34: 350-353Crossref PubMed Google Scholar However, technical difficulties leading to failure of the spinal anaesthetic are common with needles of 29G or smaller.47Geurts JW Haanschoten MC van Wijk RM Kraak H Besse TC Post-dural puncture headache in young patients. A comparative study between the use of 0.52 mm (25-gauge) and 0.33 mm (29-gauge) spinal needles.Acta Anaesthesiol Scand. 1990; 34: 350-353Crossref PubMed Google Scholar In 1951, Whitacre and Hart59Hart JR Whitacre RG Pencil point needle in the prevention of post-spinal headache.JAMA. 1951; 147: 657-658Crossref PubMed Google Scholar introduced the ‘atraumatic’ spinal needle (needle 3, Fig. 1). This design offered the handling characteristics of larger needles with a low incidence of post-spinal headache (Table 1). Needle modifications since that time, such as the Sprotte®119Sprotte G Schedel R Pajunk H An ‘atraumatic’ universal needle for single-shot regional anesthesia: clinical results and a 6 year trial in over 30 000 regional anesthesias.Reg Anaesth. 1987; 10: 104-108PubMed Google Scholar and Atraucan®63Holst D Mollmann M Ebel C Hausman R Wendt M In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles.Anesth Analg. 1998; 87: 1331-1335PubMed Google Scholar needles, promise further reductions in post-spinal headache. The acceptance of small gauge needles for diagnostic lumbar puncture has been slow to develop. Until recently, diagnostic lumbar puncture was commonly performed with a 20G or even 18G medium bevel cutting needle with a high incidence of post-spinal headache. A recent publication promoted the virtues of a 20G needle for reducing the incidence of dural puncture headache!125Thomas SR Jamieson DR Muir KW Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture.Br Med J. 2000; 321: 986-990Crossref PubMed Google Scholar Though anaesthetists are in general critical of the use of large gauge needles for lumbar puncture,105Reynolds F O’Sullivan G Lumbar puncture and headache. ‘Atraumatic needle’ is a better term than ‘blunt needle’.Br Med J. 1998; 316: 1018Crossref PubMed Scopus (0) Google Scholar neurologists maintain that adequate flow of CSF can only be achieved with spinal needles of 22G or greater.18Carson D Serpell M Choosing the best needle for diagnostic lumbar puncture.Neurology. 1996; 47: 33-37Crossref PubMed Google Scholar The parturient is at particular risk of dural puncture and the subsequent headache because of their sex, young age, and the widespread application of epidural anaesthesia.44Flaatten H Rodt S Rosland J Vamnes J Postoperative headache in young patients after spinal anaesthesia.Anaesthesia. 1987; 42: 202-205Crossref PubMed Google Scholar In parturients receiving epidural anaesthesia, the incidence of dural puncture is between 0 and 2.6%.104Reynolds F Dural puncture and headache.Br Med J. 1993; 306: 874-876Crossref PubMed Google Scholar The incidence is inversely related to the experience of the anaesthetist,80MacArthur C Lewis M Knox EG Accidental dural puncture in obstetric patients and long term symptoms.Br Med J. 1992; 304: 1279-1282Crossref PubMed Google Scholar and is said to be reduced by orientation of the needle bevel parallel to the dural fibres.87Norris MC Leighton BL DeSimone CA Needle bevel direction and headache after inadvertent dural puncture.Anesthesiology. 1989; 70: 729-731Crossref PubMed Google Scholar Loss of resistance to air confers a higher risk of dural puncture than loss of resistance to fluid.105Reynolds F O’Sullivan G Lumbar puncture and headache. ‘Atraumatic needle’ is a better term than ‘blunt needle’.Br Med J. 1998; 316: 1018Crossref PubMed Scopus (0) Google Scholar After a dural puncture with a 16G Tuohy needle, up to 70% of subjects will report symptoms related to low CSF pressure.26Costigan SN Sprigge JS Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983–1993.Acta Anaesthesiol Scand. 1996; 40: 710-714Crossref PubMed Google Scholar Despite the high incidence of headache consequent upon dural puncture with a Tuohy needle, the anaesthetist needs to consider a differential diagnosis, as intracranial haematoma,65Jack TM Post-partum intracranial subdural haematoma: a possible complication of epidural analgesia.Anaesthesia. 1979; 34: 176-180Crossref PubMed Scopus (0) Google Scholar or tumour38Dutton DA A ‘postspinal headache’ associated with incidental intracranial pathology.Anaesthesia. 1991; 46: 1044-1046Crossref PubMed Google Scholar presenting with similar symptoms to, or in association with, a post-dural puncture headache have been described. In the presence of a known dural puncture, it is often recommended that pushing in the second stage should be avoided.88Okell RW Sprigge JS Unintentional dural puncture. A survey of recognition and management.Anaesthesia. 1987; 42: 1110-1113Crossref PubMed Google Scholar The evidence to support this assertion is far from conclusive, and anger from the parturient about the medicalization of her labour is best avoided.26Costigan SN Sprigge JS Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983–1993.Acta Anaesthesiol Scand. 1996; 40: 710-714Crossref PubMed Google Scholar 133Weir EC The sharp end of the dural puncture.Br Med J. 2000; 320: 127-128Crossref PubMed Google Scholar Post-dural puncture headache is reported as uncommon in children.14Carbajal R Simon N Olivier-Martin M Post-lumbar puncture headache in children. Treatment with epidural autologous blood (blood patch).Arch Pediatr. 1998; 5: 149-152Crossref PubMed Scopus (5) Google Scholar Although low CSF pressure or other physiological differences have been proffered as reasons t
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