Shawn Dowling, PGY-2Resident Oral Rounds

Case

27F. Worse HA of her life. Reached maximal intensity with 2 minutes. Previously healthy. No Meds. No Family Hx of medical problems. You want to r/o SAH.CT head N. LP results are normal.Two days later, pt returns with a severe bilateral frontal HA, worse with standing, relieved with lying.Afebrile, no neck Sx, no other neuro Sx.What is your most likely diagnosis?

Post-Lumbar Puncture HA’s

EpidemiologyPathophysiology/AnatomyPrevention StrategiesManagement StrategiesApproach to the Difficult LP

Likely will not have time to cover

History

First spinal anesthesia was in 1875 Accidental injection of cocaine into dural space

In 1891, Quincke aspirated CSF from subarachnoid space to Tx ICPIn 1895, Corning gave the first spinal anesthesia to Tx habitual masturbation PLPHA were described from the first LP and 1st published case series was in 1899

The Lumbar Puncture

Wide number of indications in MedicineLP’s are a frequently performed procedure in the ED Primary indication in the ED is to look

for evidence of CSF infection Subarachnoid hemorrhage

LP Complications

IMMEDIATETraumatic tapCerebral herniationBack Pain

DELAYEDEpidermoid tumors – historical InfectionPLPHASubdural hematomaSpinal Epidural Hematoma

How often do they occur?

IR of PLPHA variable 1- 70% (Evans) 32% for Dx LP’s w/o precautions (20G Q) 6.1% in those who received special

precautions

ED setting(Seupal 2003) 37% with 20G Cutting 6% with 22G Cutting

Why should we be concerned about PLPHA?

Of those pts that developed PLPHA most were severe 60% were severe and 40% were moderate (Strupp) 25% persist over 1 wk without Tx Resulting in significant numbers of hospital re-

admissions, sick days and overall morbidity

The procedures can carry potential for significant morbidity In ED setting 33% of those w/PLPHA required

EBP(Seupaul 2005) Low but present risk of SDH (Samdani)

Patient Risk Factors

Young age (20-40 yrs)Female (2x of males)Pre-LP headache*?Pregnancy

*Many of the studies excluded pts with pre-LP HA’s

What is a PLPHA?

Postural HA - worsened w/i minutes of standing and relieved by lying down- in the setting of a dural punctureCharacteristic location

Frontal/occiptal

Typical onset w/i 1-3 days(90%) and usually resolve by 2 wks w/o interventions

Associated Sx: N,V, anorexia,

photophobia, tinnitus

Neck/upper shoulders

Severe cases can have Diplopia Cranial nerve dysfx

Pathophysiology

PLPHA are thought to arise from a persistent CSF leak leading to a relative intra-thecal hypovolemiaTwo theories as to what causes the pain both related to brain sagging & downward shift

1. Causes stretch of pain sensitive structures2. Cerebral vessels vasodilate to compensate

for the relative hypovolemia and thus cause Sx

Schematic of PLPHA Pathophysiology

Not all PLPHA are created equal

LP’s are done for a number of indications Diagnostic (i.e. us, neurology, radiology) Therapeutic (i.e. spinal anesthesia, chemo, etc)

Therefore populations are very heterogenous and IR, severity & duration are VERY DIFFERENTThus in reviewing the literature it is crucial to know the baseline patient data and clinical scenario/indication Unless otherwise stated these articles will be

diagnostic tests (usually by neurology)

Prevention of PLPHA

PROVENNeedle sizeNeedle type Re-inserting styletBevel orientation

UNPROVEN*Bed rest (Thoennissen)Hydration (Dieterich)Paramedian approach (Janik)Volume of CSF removed (Kuntz)

*Unproven studies – some are equivocal and further research may illicit some benefit

PLPHA & Needle Size

Numerous studies (meta-analysis - Halpern) have clearly demonstrated that the smaller the needle, the lower the IR of PLPHA

(Cutting Needles)

ED study (Seupaul)

Prospective, observational, multicentre study 20G Quincke vs 22G Quincke (EP’s choice)PLPHA was determined by f/u call in 7 daysMean age 39 yoa

Of those 12 pts with PLPHA in the 20G group 4(33%) required hospitalization for

EBP

Not a great study (non-consecutive enrolment, 25% lost to f/u, published as letter to the editor), but ONLY ED data we have

What Size is best?

The smaller the needle, the lower the risk of PLPHA – But… also more time is required to get the CSF(Carson)No statistically significant difference in success rates between large and small spinal needles (Halpern)

CSF Flow Rates & LP Needles

Assuming 6mL

17 minutes

5 minutes

3 minutes

Can we aspirate CSF to speed up process?

Prospective study, 100 consecutive pts Mean age 60 yrs, Alzheimer's patients 20G W PLPHA rate only 4%

They concluded that aspirating CSF is safe

Poorly designed study – cannot

Poorly designed study – cannot

glean any useful info from this

glean any useful info from this

See, smaller is better!!!

22G provides an optimal balance between minimizing PLPHA rates and adequate CSF flow rates. If someone is at particularly high risk of

PLPHA I.e. young, female, prior PLPHA

Could consider trying 25G (available in the ED)

Needle Type

Non-Cutting(aka pencil-point, atraumatic, blunt)

Whitacre, Sprotte, Gertie-Marx

Whitacre 22G $10.70

Cutting Quincke, Atraucan Quincke 22G $2.84

Italicized needles are the brands available for us in the ED/CHR

What’s the rationale for atraumatic needles?

1. Separate the dural fibers rather than cutting them allowing the hole to seal better

2. “tear” the dural membrane creating a ragged edge that promotes an inflammatory response, resulting in a more rapid seal of the CSF membrane

Cutting

Atraumatic

Cutting vs Atraumatic(Strupp)

RCT, double blind(?) of 22G Quincke vs SprotteN=230 pts, Diagnostic LP’s by Neurology Excluded those with recent HA,IR of post-LP HA Cutting = 24.4% Atraumatic = 12.2%

ARR = 12.2% NNT 8

Note IR is different than ED study -no cannot compare baseline pt data-no mention of how PLPHA was Dx

Are they harder to use?

RCT of 20G atraumatic vs cutting (Thomas) PLPHA w/ ARR of 26% Residents performed all LP’s and they found

1. Non-cutting more difficult to use (p <0.05)2. No-cutting required attempts/increase failure (not s.s.) 3. A significant RF for failure was increasing BMI

Neurologists/Anesthetists Experience Small learning curve, but then no difference Dr. Tang (Anesthesia) feels there is no difference

Summary of Studies

No ED studiesBut we can extrapolate from Neuro studiesATRAUMATIC needles are clearly betterWorth the marginal increase in cost

Our LP trays

Current trays in ED have 22G quincke (some have both 20G and 22G)20G, 22G, 25G Whitacres available in trauma bay (std 3.5”)Longer atraumatic needles available from central supply/radiology suite

Tips for the Atraumatic needle

Need to use introducer (18-19G needle adequate for 22G W)Insert introducer 2/3 of length initially (more if needed)Slightly different feel since you are “spreading tissue” rather than cutting throughMay not feel “pop”If unsuccessful – consider switching to Quincke

Re-Insertion of Stylet

Theory is that withdrawal of needle without the stylet would result in arachnoid fibers being withdrawn leading to a persistent dural leak because of a hole that is no as easily healedOne case report of nerve transection with replacement of stylet

RCT of re-inserting stylet or not600 pts – 300 in each arm, atraumatic needle used (21G Sprotte)IR of PLPHA Re-inserted stylet – 16.3% Not Re-inserted stylet – 5%

Severity of HA was worse in those who did not have stylet re-insertedNo studies on cutting needles but felt to be beneficial

Bevel Orientation

Theorized that needle insertion parallel to longitudinal fibers result in less leakage because bevel pushes fibers away rather than transecting themPractically bevel up (notch on hub up) when pt in LLD

Evidence for Bevel Orientation

In vitro studies with human dura Significantly decreased rate and

amount of CSF leakage if bevel oriented parallel to dural fibers (Ready et al.)

In vivo study (Flaaten et al.) RCT in spinal anasthesia pts, 27G Q IR of PLPHA

Bevel Parallel = 3.8% Bevel Perpendicular = 22.6%

Summary

Difficult to extrapolate to our patient population, needle size, diagnostic LP’sBevel orientation likely only significant if using cutting needleBut in considering evidence, recommend orienting bevel appropriately if using cutting needle –When seated bevel orientation is different!

Management of PLPHA

CaffeineEBPTriptansSaline into Epidural spaceProphylactic EBPACTHAminophylline

Will not discuss these.

Not appropriate therapeutic

options in the ED

Caffeine

Theory is that caffeine (oral or IV) leads to cerebral vasoconstriction Paucity of evidence (Camann, Sechzer) Worth a trial if patient only has mild Sx, presents early, contra-indication to EBP or unwilling to have EBPDose: 300mg PO TID until ASx Can give initial IV dose of 500mg caffeine

benzoate given over 4H

EBP

EBP

First introduced in the 1960’s after it was noted that bloody taps had less PLPHATheory is that clotted blood seals the CSF leakProcedure involves injecting 10-20mL of autologous blood into the epidural spaceContra-indications: 1)Coagulopathy, 2)IC mass lesion, 3) Fever>38.0, 4)overlying skin infection/bacteremia

Definitive evidence that EBP is effective How effective is dependent on patient population,

pre-morbid factors, etc? Likely somewhere in the neighbourhood of 75-

80% Most data is from spinal anesthesia literature

Timing of EBP is very debatable. Some evidence that one should wait at least 24H

after LP before doing EBP- success rate (Loeser, Vilming)

Tx medically in the mean time If severe speak to anesthesia even if w/i 24H.

Complications of EBP

Failure - 5-40%Back pain (typically minor) - 35%Neck pain – 1%Fever (usu < 48H) – 5%Bleeding, infection (meningitis), arachnoiditis, CN palsies and repeat dural puncture have been reported infrequently

Triptans & PLPHA

Most evidence for triptans and PLPHA are case reports/seriesSmall study by Connelly et al. of 10 pts Randomized to SC sumatriptan or salineNo difference in VAS scores but grossly underpowered

Approach to the Difficult LP

Fan-technique for anesthesiaIf excess soft tissue is your obstacle – get longer needle from interventional radiologyIf elderly – consider paramedian approachConsider changing position Some u/s evidence that seated with feet

supported provides widest interspinous space

Fluoroscopy

5-7.5MHz linear probe

Transverse plane @ level of iliac crest

Identifies midline by shadow cast by spinous process -> mark midline

Rotate the probe into a longitudinal axisIdentify the interspinous spaceProceed as normal trying to enter as close to inferior S.P. as possible

InterspinousSpace

SpinousProcess

Summary – Preventing PLPHA

Atraumatic needles (Whitacre) – Class I EvidenceSmaller needles – Class INNT =5 to prevent 1 PLPHA for 22G Whitacre vs 20G Quincke

Re-insert stylet prior to removal – Class I,IIIIf unsuccessful with atraumatic needle try cutting needle & orient bevel appropriately – Class I

Summary - Managing PLPHA

Best strategy is to try & avoid PLPHAIf patient develops PLPHA Moderate-severe speak to anesthesia

about EBP

Consider medical Tx (analgesics/caffeine) ?Within 24H CI to EBP Mild Sx Refuses EBP

Questions???

ReferencesArmon C. Addendum to Assessment: Prevention of post-lumbar puncture headaches. American Academy of Neurology. Neurology 2005; 65:510-2.Camann WR. Effects of oral caffeine ton postdural puncture headche. A double-blind placebo controlled trial. Anesthesia & Analgesia 1990;70:181-4.Carson D. et al. Choosing the best needle for diagnostic lumbar puncture. Neurology 1996; 47:33-37.Connelly NR. et al. Sumatriptan in patients with postdural puncture headaches. Headache 2000; 40:316-18Dieterich M. et al. Incidence of PLPHA is independent of daily fluid intake. Eur Arch Psychiatry Neuro Sc 1988; 237:194-6.Evans RW. et al. Assessment: Prevention of PLPHA. Neurology 2000; 55(7):909-14.Halpern S. et al. Postdural Puncture Headache and Spinal Needle Design: Metaanalyses. Anesthesiology 1994; 81: 1376-1383.Holdgate A. et al. Perils and pitfalls of lumbar puncture in the ED. Emergency Medicine 2001;13:351-358.Kuntz KM. Et al. PLPHA: Experience in 501 consecutive procedures. Neurology 1992; 42: 1884-87.

ReferencesFlaaten H. et al. Puncture technique and postural postdural puncture headache. A randomised, double-blind study comparing transverse and parallel puncture. Acta Anasthesiology Scandanavia 1998 Nov;42(10):1209-14.Janik R. Post spinal headache. Its incidence following the median and paramedian techniques Anaesthesist. 1992 Mar;41(3):137-41.Loeser, E.A., Hill, G.E., Bennet, G.M. and Sederberg, J.H., Time vs. success rate for epidural blood patch, Anesthesiology, 2 (1978) 147-148.Peterson M. et al. Bedside u/s for difficult lumbar puncture. J of Emerg Med 2005; 28:197-200.Ready et al. Spinal needle determinants of rate of transdural fluid leak. Anasthesia and Analgesia 1989 Oct;69(4):457-60.Samdani A. et al. Subdural hematoma after diagnostic lumbar puncture. Amer J Emerg Med July 2004;316-7.Sechzer PH, et al. Post-spinal anesthesia headache treated withcaffeine: evaluation with demand method—part I. Curr Ther Res1978;24:307-312.

References

Seupaul RA et al. Prevalence of Post Dural Puncture HA after ED performed LP. Acad Emerg Med; May 2003.Seupaul RA. et al. Prevalance of postdural HA after ED lumbar puncture. American Journal of Emergency Medicine 2005;23:913-14.Strupp M. et al. “Atraumatic” Sprotte needle reduces the incidence of PLPHA. Neurology, 2001; 57:2310-12.Strupp M. et al. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomzed prospective study of 600 patients. J Neurology 1998; 254:589-92.Thoennissen J. et al. Does bed rest after cervical or lumbar puncture prevent HA. CMAJ 2001; 165: 1311-1315.Vilming S. et al. When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients. Cephalalgia July 2005; 25(7):523-7.

Thanks to Denise Watt, Ian Rigby and Tim Tang for providing some clinical experience.