Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

Objectives – This study was conducted to investigate complications after dural puncture. Material and methods – A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20–19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27–25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week. Results – Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5). Conclusion – Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.     

Dura-arachnoid lesions produced by 22 gauge Quincke spinal needles during a lumbar puncture

AIMS: The dural and arachnoid hole caused by lumbar puncture needles is a determining factor in triggering headaches. The aim of this study is to assess the dimensions and morphological features of the dura mater and arachnoids when they are punctured by a 22 gauge Quincke needle having its bevel either in the parallel or in the transverse position. METHODS: Fifty punctures were made with 22 gauge Quincke needles in the dural sac of four fresh cadavers using an "in vitro" model especially designed for this purpose. The punctures were performed by needles with bevels parallel or perpendicular to the spinal axis and studied under scanning electron microscopy. RESULTS: Thirty five of the 50 punctures done by Quincke needles (19 in the external surface and 16 in the internal) were used for evaluation. When the needle was inserted with its bevel parallel to the axis of the dural sac (17 of 35), the size of the dura-arachnoid lesion was 0.032 mm(2) in the epidural surface and 0.037 mm(2) in the subarachnoid surface of the dural sac. When the needle's bevel was perpendicular to the axis (18 of 35) the measurement of the lesion size was 0.042 mm(2) for the external surface and 0.033 mm(2) for the internal. There were no statistical significant differences between these results. CONCLUSIONS: It is believed that the reported lower frequency of postdural puncture headache when the needle is inserted parallel to the cord axis should be explained by some other factors besides the size of the dura-arachnoid injury.     

"Atraumatic" Sprotte needle reduces the incidence of post-lumbar puncture headaches.

Post-lumbar puncture headache (PLPH) is best explained by spinal fluid leakage due to delayed closure of a dural defect. In a prospective, randomized, double-blind study, taking into consideration all known methodological problems, the authors compared the incidence of PLPH using the "atraumatic" Sprotte needle vs the "traumatic" Quincke needle. Of the 230 patients included in the final analysis, 24.4% of patients in the "traumatic" group developed PLPH, whereas only 12.2% of patients in the "atraumatic" group did (p < 0.05). Therefore, use of the "atraumatic" Sprotte needle for lumbar puncture is recommended.     

Complications after LP related to needle type: pencil-point versus Quincke

OBJECTIVES: We studied the incidence of complications after diagnostic lumbar puncture (LP) related to needle type. MATERIAL AND METHODS: A 5 months' observational study of routine diagnostic LP in 83 patients was conducted. RESULTS: Significantly more headache was observed after LP using thicker cutting needles (20G Quincke) compared with thinner cutting or non-cutting needles (22G Quincke or pencil-point). No significant difference in complications after LP was found between the 22G Quincke and pencil-point needles. CONCLUSION: The size of the needle and not the needle shape seems to be the main determinant for post-dural puncture headache (PDPH).     

Abducens palsy after lumbar puncture.

OBJECTIVE: We report the case of a 43-year-old patient with neuralgic shoulder amyotrophy who developed abducens palsy on the left 4 days after diagnostic lumbar puncture (LP), which recovered completely within 4 months. RESULTS: Side effects after spinal tap are due to prolonged spinal fluid leakage and delayed closure of a dural defect causing intracranial hypotension. Downward 'sagging' of the brain and traction on cranial nerves may lead to abducens palsy. This case and a review of the literature illustrate the higher risk with the use of large-size traumatic needles in LP for cranial sixth nerve palsies. CONCLUSION: The presented case emphasizes the use of atraumatic small-size needles for lumbar puncture.     

Addendum to assessment: Prevention of post-lumbar puncture headaches: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

Review of the literature on prevention of post-lumbar puncture headaches (PLPHAs) since the publication of the original assessment in 2000 yielded one study comparing use of cutting to atraumatic needles in diagnostic lumbar punctures, providing Class I evidence in favor of the atraumatic needle. Taken in conjunction with data from most studies in the anesthesiology literature, the Therapeutics and Technology Assessment Subcommittee concluded that use of an atraumatic spinal needle in adult patient populations reduces the frequency of PLPHA (Level A recommendation). It affirmed a previous conclusion that smaller needle size is associated with reduced frequency of PLPHA (Level A recommendation).     

Safety and acceptability of the research lumbar puncture

Three hundred forty-two subjects underwent 428 research lumbar punctures for studies of cerebrospinal fluid (CSF) biomarkers. Subjects were 67 Alzheimer disease or mild cognitive impairment (AD/MCI) patients and 275 cognitively normal adults aged 21 to 88. Lumbar puncture was performed in the lateral decubitus or sitting position using the Sprotte 24 g atraumatic spinal needle. Up to 34 ml of cerebrospinal fluid were collected. Anxiety and pain experienced during lumbar puncture were rated on a visual analog scale. The frequency of any adverse event (11.7%), clinically significant adverse events (3.97%), and typical post-lumbar puncture headache (PLPHA) (0.93%) was low. Risk of post-lumbar puncture headache was unrelated to age, gender, position during lumbar puncture, ml of cerebrospinal fluid collected, or minutes of recumbent rest following lumbar puncture. The frequency of post-lumbar puncture headache was lower in AD/MCI (P = 0.03) than any other subject group. Anxiety and pain ratings were low. Younger subjects reported more anxiety than old (P = 0.001) and AD/MCI subjects (P = 0.008) and more pain than older normal subjects (P = 0.013). Pain ratings for women were higher than those for men (P = 0.006). Using the Sprotte 24 g spinal needle, research lumbar puncture can be performed with a very low rate of clinically significant adverse events and with good acceptability in cognitively impaired persons and cognitively normal adults of all ages.     

Incidence and Effect of Traumatic Lumbar Puncture in the Neonate

The incidence of non-traumatic, traumatic and unsuccessful lumbar punctures in 181 neonates was similar whether a needle with a stylet, a butterfly needle without stylet, or a standard venipuncture needle without stylet was used. Comparison of 20 lumbar puncture pairs in 17 patients showed that traumatic lumbar puncture does not result in a cerebrospinal fluid pleocytosis between two and 13 days after initial traumatic lumbar puncture.     

Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial

In order to define the impact of needle type on post-lumbar puncture headache (PLPH), we performed a prospective, randomized trial comparing the incidence of PLPH in patients undergoing lumbar punctures (LPs) with traumatic vs atraumatic 22-gauge needles. Fifty-eight patients underwent 85 LPs. The incidence of PLPH was 36% in the traumatic vs 3% in the atraumatic group (p = 0.002).     

Pseudocyst of the neck after traumatic avulsion of spinal C6-T2 nerve roots--case report

A case is presented of an avulsion injury of the left brachial plexus in a woman who--after surgical reconstruction of the plexus--developed a liquid fistula from a giant pseudocyst localized in this area. A prolonged persistence of the pseudocyst resulted in a severe pain syndrome and symptoms of vascular disorders in the upper limb. Since results of local treatment (punctures, pressure dressings) were unsatisfactory, the authors decided to close the liquid fistula by suturing the damaged dural sac by means of laminectomy. The necessity of particular caution when operating in the area of intervertebral foramina is emphasized. The authors also point out that in case of any of cerebrospinal fluid leakage, special attention should be paid to stopping the escape of CSF.     

Burr Hole Drainage : Could Be Another Treatment Option for Cerebrospinal Fluid Leakage after Unidentified Dural Tear during Spinal Surgery?

Authors report a rare case of acute intracranial subdural and intraventricular hemorrhage that were caused by intracranial hypotension resulted from cerebrospinal fluid leakage through an unidentified dural tear site during spinal surgery. The initial brain computed tomography image showed acute hemorrhages combined with preexisting asymptomatic chronic subdural hemorrhage. One burr hole was made over the right parietal skull to drain intracranial hemorrhages and subsequent drainage of cerebrospinal fluid induced by closure of the durotomy site. Among various methods to treat cerebrospinal fluid leakage through unidentified dural injury site, primary repair and spinal subarachnoid drainage are well known treatment options. The brain imaging study to diagnose intracranial hemorrhage should be taken before selecting the treatment method, especially for spinal subarachnoid drainage. Similar mechanism to its spinal counterpart, cranial cerebrospinal fluid drainage has not been mentioned in previous article and could be another treatment option to seal off an unidentified dural tear in particular case of drainage of intracranial hemorrhage is needed.     

CSF RBC count in successful first-attempt lumbar puncture: the interest of atraumatic needle use

The objective of this study is to analyze CSF red blood cell (RBC) count from first-attempt lumbar punctures and to analyze parameters associated with first-attempt lumbar punctures and hemorrhagic lumbar puncture. This is a prospective analysis of consecutive patients who underwent lumbar puncture for any reason other than suspected acute subarachnoid hemorrhage. Analyzed parameters were the following: age, indication for lumbar puncture, aPTT ratio, PTT, platelet count, patient’s position, needle type (atraumatic/standard), needle diameter, person performing lumbar puncture (medical student/resident/attending physician), number of lumbar levels punctured, necessity of needle repositioning, CSF RBC and white blood cell count, and protein level. Lumbar puncture resulting in RBC count > 5 RBC/mm² was classified as hemorrhagic lumbar puncture (different cut-offs were studied: > 5/> 10/> 100/> 500/> 1000 RBC). In total, 169 elective lumbar punctures in 165 different patients were included. First-attempt lumbar puncture occurred in 22% > 5 RBC, in 19.5% > 10 RBC, in 4.5% > 100 RBC, in 3% > 500 RBC, and 1.5% > 1000 RBC count. First-attempt lumbar puncture was associated with non-hemorrhagic lumbar puncture for each of the RBC count cut-offs (OR for non-hemorrhagic lumbar puncture in first-attempt lumbar puncture 2.8, 95% CI 1.4–5.7). The presence of a hemorrhagic disorder (concerning cerebral amyloid angiopathy in all patients) and higher aPTT ratio were associated with hemorrhagic lumbar puncture. Atraumatic needle use was associated with non-hemorrhagic lumbar puncture for RBC count cut-offs ≤ 5 and ≤ 10 RBC (OR for non-hemorrhagic lumbar puncture in atraumatic needle use 2.5 [95% CI 1.3–4.8] and 2.2 [95% CI 1.1–4.4], respectively). First-attempt lumbar puncture and hemorrhagic lumbar puncture were not associated with other parameters. Slightly elevated CSF RBC count after first-attempt lumbar puncture occurs relatively frequently, but is even more frequent in non-first-attempt lumbar puncture. Atraumatic needle use is associated with non-hemorrhagic lumbar puncture.     

Remote cerebral and cerebellar hemorrhage after massive cerebrospinal fluid leakage

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.     

Epidural adhesiolysis complicated by cefazolin-induced status epilepticus: two cases

Cefazolin is a strong epileptogenic agent. We describe two patients presenting with status epilepticus, apparently caused by intrathecal leakage of cefazolin via incidental dural puncture during spinal epidural adhesiolysis. Our cases suggest that the local use of antibiotics, particularly cefazolin, in the form of a mixture with contrast medium during a spinal procedure is not advisable, because of the possible incidental intrathecal leakage and the high convulsive potential of the antibiotics.     

Spinal subarachnoid hematomas: clue to a source of bleeding in traumatic lumbar puncture

Although damage to the veins of Batson's epidural plexus is usually considered the origin of bleeding in traumatic lumbar puncture, a lesion of these veins would not explain the cases in which postmortem examination shows blood confined to the subdural and subarachnoid spaces. In two patients who had lumbar punctures a few days before death, there was subarachnoid hematoma of the cauda equina at autopsy. In one of these cases, the radicular vessels were shown to be the source of bleeding. Spinal subarachnoid and subdural hemorrhages after lumbar puncture may be due to laceration of radicular vessels by the spinal needle.     

Subarachnoid Hemorrhage Presenting with Seizure due to Cerebrospinal Fluid Leakage after Spinal Surgery

Cerebrospinal fluid leakage may commonly occur during spinal surgeries and it may cause dural tears. These tears may result in hemorrhage in the entire compartments of the brain. Most common site of such hemorrhages are the veins in the cerebellar region. We report a case of hemorrhage, mimicking aneurysmal subarachnoid hemorrhage due to a cerebrospinal fluid leakage following lumbar spinal surgery and discuss the possible mechanisms of action.     

Incidence of post-lumbar puncture headache is independent of daily fluid intake

Summary The clinical practice of advising patients to increase their daily fluid intake after lumbar puncture in order to increase CSF production by re-hydration and thus try to prevent post-lumbar puncture headache (PLPH) has not yet been shown to be effective. In 100 patients the different effects of re-hydration on the incidence of PLPH (1.51 compared with 3.01 oral fluid per day over a period of 5 days) were tested prospectively. The incidence of PLPH was independent of the amount of fluid intake in both groups (18, 36%), as was the duration of PLPH. The physiology of CSF production and resorption suggests that PLPH is not a problem of CSF dynamics but a simple mechanical problem of how to close the dural rent and thereby stop the continuous leakage. It is no longer justifiable to advise patients to drink more than usual since there is no physiological or empirical basis for this and it does not seem to have even a placebo effect.     

Tc99m macroaggregated albumin cisternography for the detection of persistent cerebrospinal fluid (CSF) leak in an animal model

The present study describes a new in vivo animal model that enables the detection of cerebrospinal fluid (CSF) leakage after dural injury. A polyethylene catheter (PE 10) was inserted into the subarachnoid space in the lumbar area by a simple surgical procedure and a radioactive isotope Tc99m Macroaggregated Albumin (Tc99m MAA) was injected into the CSF. In the experimental group, a standardised dural puncture was performed in the cervical area. The accumulation of the isotope in the gauze placed over the dural puncture and viewed by a gamma camera as a spot of concentrated radioactivity, was indicative of CSF leakage. In a second group of animals with intact cervical dura the absence of leakage was presented as a picture of sporadic background radioactivity. To demonstrate the effectiveness of the model in detection of invisible leakage, blood was applied over the cervical dural defect in another group of animals and CSF leakage was assessed by the above mentioned isotope detection method. This in vivo model may be used for evaluation of the sealing properties of various materials under physiological and metabolic processes in living tissue.     

Postpuncture headache

The present study recorded prospectively subjective complaints after lumbar puncture as diagnostic procedure (n = 59), spinal - (n = 41) and peridural anaesthesia (n = 45) over a time interval of 28 days. Posture dependent headaches were never observed following peridural anaesthesis. This result disproves the hypothesis of a purely psychogenic origin of postpunctional headache. The frequency of occurrence of the postpunctional syndrome was 39% after lumbar puncture, but only 4.9% after spinal anaesthesis. The observed difference is due to the fact that needles with a smaller diameter are applied in spinal anaesthesia.     

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip

BackgroundThe classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought.ObjectiveThe purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI).MethodsWe performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018.ResultsThe mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks.ConclusionsWe describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.