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Review of Post Lumbar Puncture Headaches 2012

General Spine

Rajan, P., Patel, M.D.
Mina, F., Hanna, M.D., Non ASSR Member
David, H., Uhrbrock, M.D., Non ASSR Member

Poster

Purpose

The purpose of this exhibit is to describe and illustrate pathogenesis, prevention and management of the post-lumbar puncture headaches (PLPHA).

Methods & Materials

1. Discuss diagnosis and pathogenesis of the PLPHA. 2. Review technical factors contributing to the PLPHA. 3. Review pertinent anatomy and technique of lumbar puncture (LP) to minimize risk of the post-lumbar puncture headaches. 4. Discuss management of the PLPHA.

Results

PLPHA has been defined as a constant bilateral headache starting within 7 days of LP, appearing or worsening within 15 minutes of upright position and resolving or improving within 30 minutes of resuming recumbent position. The risk factors of PLPHA include: female sex, young age (18-30 years), small body mass index and headache before and at the time of LP. Pathophysiology of PLPHA remains unclear but likely results from persistent leakage of cerebrospinal fluid (CSF) through the dural puncture site causing low CSF pressure and volume. PLPHA is a clinical diagnosis. Patients with a postural headache after a LP usually confirms the diagnosis. Several studies have shown technical factors which contribute to PLPHA. These include: needle size, direction of the bevel, needle design, replacement of the stylet before withdrawing the needle and the number of LP attempts. There are several factors not proven to contribute to the PLPHA including: volume of the CSF removed, duration of post-procedure bed rest and increased hydration following the LP. Conservative management of the PLPHA includes lying in a comfortable position and simple analgesics. If conservative management fails, therapeutic management may be indicated including: epidural blood patch, epidural saline infusion, intravenous caffeine, etc. Persistent CSF leak not responding to these measures may require surgical closure of the dural perforation.

Conclusion

PLPHA is the most common complication associated with LP. In attempting to prevent or treat this phenomenon, physicians should be aware that there are many technical factors which decrease the risk of PLPHA and also a few effective therapies which may treat PLPHA once it occurs. In the majority of cases, PLPHA will resolve spontaneously or with conservative management. A minor percentage of PLPHA cases require therapeutic intervention.

References/Financial Disclosures

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