Authors: Monserrate AE et al., JAMA Neurol 2015 Mar 72:325
Factors that acutely lower cerebrospinal fluid pressure may produce early post–lumbar puncture headache, but other factors affect headache persistence.
Diagnostic lumbar punctures aid in the diagnosis of infections and diseases of the central nervous system. Life-threatening events from lumbar punctures are rare, but post–lumbar (dural) puncture headaches (PDPH) occur in 1% to 36% of patients, depending on the needle type and factors that may lower cerebrospinal fluid (CSF) pressure. To assess factors associated with common adverse events following a lumbar puncture — immediate postprocedural headache, PDPH at 24-hour follow-up, and PDPH receiving a therapeutic blood patch — researchers retrospectively assessed lumbar punctures performed in 338 patients from the Dominantly Inherited Alzheimer Network.
The incidence of adverse events included 73 immediate postprocedural headaches (21.6%), 59 PDPHs at 24-hour follow-up (17.5%), and 15 patients with PDPH receiving therapeutic blood patch (4.4%). Greater volume of CSF collected (above 30 mL) was associated with increased risk for immediate postprocedural headache. By contrast, low CSF collection volume (below 17 mL) increased the risk for headache at follow-up and need for blood patch compared with 17 to 30 mL (odds ratios, 3.07 and 5.59, respectively). Patients’ being in a seated position during the procedure showed a trend to increased frequency of headaches both immediately and 24 hours after puncture.
In this well-conducted study, the authors conclude that factors that acutely lower CSF pressure such as seating position or extracting high volumes of CSF were associated with transient post–lumbar puncture headache, without increasing the rate of PDPH or therapeutic blood patch. Collection of 17 to 30 mL of CSF appears to be safe and well tolerated. Nontraumatic needles also reduce PDPH incidence (from 31%–36% to 3%–6%; J Neurol Sci 2011; 306:24). The pathophysiology of PDPH is unclear, but CSF volume loss, intracranial blood vessel vasodilatation, and low CSF levels of substance P may play roles. There is no evidence that routine bed rest after dural puncture prevents PDPH, and the role of fluid supplementation remains unclear (Cochrane Database Syst Rev 2013; 7:CD009199).