Acta Neurol Scand 2014: 130: 204–209 DOI: 10.1111/ane.12267
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Does lumbar puncture at night prevent post-dural puncture headache? Park KM, Shin KJ, Ha SY, Park J, Kim SE. Does lumbar puncture at night prevent post-dural puncture headache?. Acta Neurol Scand 2014: 130: 204–209. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Objectives – The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures. Materials and methods – The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was postdural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables. Results – Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache. Conclusions – We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.
Introduction
Lumbar puncture is an essential medical procedure and usually performed for diagnostic or therapeutic purposes. Although lumbar puncture is relatively safe, several adverse events have been reported, such as headache, hemorrhage, local pain, and infections (1). Among these adverse events, post-dural puncture headache (PDPH) is one of the most common adverse events, and PDPH could have serious morbidities, such as cranial nerve palsy, seizure, and subdural hematoma (2–4). PDPH is usually diagnosed on the basis of clinical features. History of lumbar puncture and 204
K. M. Park, K. J. Shin, S. Y. Ha, J. Park, S. E. Kim Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
Key words: headache; risk factors; spinal puncture S. E. Kim, Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, 612-896 Haeundae-gu, Busan, Korea Tel.: +82 51 797 1195 Fax: +82 51 797 1196 e-mail: [email protected] Accepted for publication April 25, 2014
orthostatic headache is invariably present (5, 6). The accompanying symptoms of PDPH could be neck stiffness, tinnitus, hypoacusia, photophobia, or nausea (5, 6). PDPH is resolved either spontaneously within 1 week or within 48 h after effective treatment of the spinal fluid leak, such as epidural blood patch (5, 6). The incidence of PDPH ranges from 10 to 40%, and it depends on patient-related and technique-related risk factors (5–7). The patient-related risk factors are usually non-modifiable risk factors, such as young age, female gender, low body mass index (BMI), history of prior PDPH, and chronic headache (5, 6). The technique-related risk factors are modifiable
Risk factors for post-dural puncture headache risk factors, including large size of the spinal needle, and traumatic needle like Quincke needle and low operator experiences (5, 6). The mechanism of PDPH is uncertain, but there are two proposed hypothesis. First, low cerebrospinal fluid (CSF) pressure leads to downward pull on pain sensitive structures when patient assumes an upright position. Second, low CSF pressure leads to painful dilatation of intracranial vessels in an attempt to maintain the intracranial volume by the Monro–Kellie doctrine (5, 6). Among them, we do not know exactly what the real mechanism for PDPH is, but low CSF pressure resulting from persistent leakage of CSF at the site of lumbar puncture is important. Physiological CSF pressure is dynamic. It has been demonstrated that human CSF production exhibits a circadian pattern. The CSF production at nighttime is two to three times than that at daytime (8, 9). In addition, there have been some reports that CSF pressure at nighttime is higher than that at daytime (10–12). These diurnal rhythms may have their origin in the suprachiasmatic nucleus of the hypothalamus in the brain (10). This center controls the biological functions according to various circadian clocks and would dictate the rules of fluctuation of CSF pressure (13). There have been several studies to identify the risk factors for PDPH, but all of the studies were published prior to the development of International Classification of Headache Disorders 3rd Edition (ICHD-III beta) criteria (1, 14–17). In addition, previous studies did not control the technique-related risk factors; lumbar puncture was performed by multiple operators with varying degrees of experience, as well as varied use of needle size, type, and bevel direction (7, 18–20). Furthermore, the association between puncture time and occurrence of PDPH has been not studied yet. The aim of this study was to identify the patient-related risk factors for PDPH with same standardized procedures. In addition, we evaluated the occurrence rate of PDPH between patients who underwent lumbar puncture at daytime and nighttime, and assessed the significance of puncture time for the development of PDPH. Materials and methods
This study was conducted with an approval of the institutional review board at our institution. This study was performed retrospectively in a single tertiary hospital, serving a population of
approximately 400,000 individuals. From our hospital database, we recruited 928 patients who underwent lumbar puncture at Haeundae Paik Hospital over a period from March 2010 to December 2012, and reviewed the medical records of these patients. The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The exclusion criteria were patients (i) who underwent lumbar puncture for therapeutic purposes, such as intrathecal chemotherapy, (ii) with normal pressure hydrocephalus, (iii) with deterioration of consciousness at puncture time, or (iv) who were followed up less than 5 days. Most of the lumbar punctures were performed by one physician. All of the patients underwent lumbar puncture in a standardized way. Patients underwent lumbar puncture lying on their left or right side. The lumbar punctures were performed under aseptic condition, using a 22-gauge Quincke needle, and the opening lumbar CSF pressure was measured. The bevel direction of the cutting needle was parallel to the long axis of the spine, and reinserted stylet prior to removal of the needle. All patients had bed rest in supine position for at least four hours after lumbar puncture. We collected demographic and laboratory profiles of patients, such as age, sex, weight, height, BMI, smoking, diabetes, hypertension, CSF pressure, CSF profiles including counts of white blood cell (WBC) and protein, and glucose ratio (CSF/blood), and puncture time. We divided the patients into two groups: those with and without PDPH. PDPH was diagnosed in accordance with the ICHD-III beta criteria: (i) dural puncture has been performed, (ii) headache has developed within 5 days of the dural puncture, (iii) not better accounted for by another ICHD-III beta diagnosis (17). The primary endpoint for this study was the occurrence of PDPH as a dependent variable. The timing of recording about occurrence of PDHD was variable among patients, but we recorded it at least 5 days after lumbar puncture. The differences were analyzed with age, sex, weight, height, BMI, smoking, diabetes, hypertension, CSF pressure, CSF profile including counts of WBC and protein, and glucose ratio (CSF/ blood), and puncture time as independent variables. The lumbar puncture performed between 8:00 AM and 8:00 PM was considered as puncture at daytime, and any other time was considered as nighttime. We analyzed the variables 205
Park et al.
Of the 928 patients who underwent lumbar puncture, 413 patients met the inclusion criteria for this study. Two hundred and forty-three patients were men and 170 patients were women. The median age was 45 years (95% CI 42–48 years, range 11–91 years). The median height was 167 cm (95% CI 165–168 cm, range 102– 189 cm), and the median weight was 63 kg (95% CI 61–65 kg, range 39–184 kg). The median BMI was 23 kg/m2 (95% CI 23–23 kg/m2, range 14–37 kg/m2). Eighty-eight patients had hypertension, 42 patients had diabetes, and 90 patients were current smokers. The CSF study revealed that the median counts of WBC were 3/mm3 (95% CI 2–5/mm3, range 0–19,000/mm3), the median counts of protein were 34 mg/dl (95% CI 32–37 mg/dl, range 2–1652 mg/dl), the median ratios of glucose (CSF/blood) were 0.57 (95% CI 0.56–0.59, range 0–1), and the median CSF pressure was 10 cmH20 (95% CI 10–11 cmH20, range 1–38 cmH20). Two hundred and ninety-six patients underwent lumbar punctures at daytime, and 117 patients underwent at nighttime. Thirty-six of the 413 patients developed PDPH. Table 1 shows a comparison of demographic and
laboratory profiles between patients with and without PDPH. Age (34 vs 47 years, P = 0.0006 by Mann–Whitney U-test), BMI (22 vs 23 kg/m2, P = 0.0063 by Mann–Whitney U-test), hypertension (2/36 vs 86/377, P = 0.0172 by Fisher’s exact test), diabetes (0/36 vs 42/377, P = 0.0006 by Fisher’s exact test), CSF pressure (100 vs 100 cmH20, P = 0.0092 by Mann–Whitney U-test), WBC (2 vs 3/mm3, P = 0.015 by Mann–Whitney U-test), protein (30 vs 35 mg/dl, P = 0.0355 by Mann–Whitney U-test), glucose ratio (0.70 vs 0.56, P < 0.0001 by Mann–Whitney U-test), and puncture at daytime (33/36 vs 263/377, P = 0.0035 by Fisher’s exact test) were significantly different between the two groups. Patients with PDPH were younger, had a lower BMI, and had less diabetes and hypertension than those without PDPH. The counts of WBC and protein, as well as CSF pressure were lower in patients with PDPH than those without PDPH, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime more developed PDPH than those who were performed puncture at nighttime (OR = 4.8, 95% CI 1.4–15.9), especially, when patients visited our hospital at daytime. Among the 413 patients, 315 patients visited our hospital at daytime. Of the 315 patients, 27 of 226 (12%) patients who underwent lumbar puncture at daytime developed PDPH, whereas 2 of 89 (2%) patients who underwent lumbar puncture at nighttime occurred PDPH (P = 0.0049 by Fisher’s exact test). After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower CSF pressure, and puncture at daytime were independently significant variables for predicting PDPH (Table 2). In addition, there were no significantly different demographic and laboratory profiles between patients who performed lumbar puncture at daytime and nighttime (Table 3).
Table 1 A comparison of demographic and laboratory profiles between patients with and without post-dural puncture headache
Discussion
using Fisher’s exact test for categorical variables, and Student’s t-test or Mann–Whitney U-test for numerical variables. We performed multiple logistic regression analyses using dependent variables. In addition, we analyzed the differences of demographic and laboratory profiles between patients who performed lumbar puncture at daytime and nighttime. All statistical tests were performed using MedCalcâ. For all calculations, a P-value of less than 0.05 was considered statistically significant. Results
Parameter Men, n (%) Age, years (range) Body mass index, kg/m2 (range) Smokers, n (%) Hypertension, n (%) Diabetes, n (%) CSF pressure, cmH20 (range) WBC/mm3 (range) Protein, mg/dl (range) Glucose ratio (range) Puncture at daytime, n (%)
With PDPH (n = 36) 17 34 22 7 2 0 10 2 30 0.7 33
(47) (16–84) (17–33) (19) (6) (0) (1–19) (0–560) (11–154) (0.42–0.87) (92)
Without PDPH (n = 377)
P-value
226 47 23 83 86 42 10 3 35 0.56 263
0.2 0.001 0.006 0.884 0.017 0.038 0.009 0.015 0.036
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Does lumbar puncture at night prevent post-dural puncture headache? Park KM, Shin KJ, Ha SY, Park J, Kim SE. Does lumbar puncture at night prevent post-dural puncture headache?. Acta Neurol Scand 2014: 130: 204–209. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Objectives – The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures. Materials and methods – The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was postdural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables. Results – Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache. Conclusions – We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.
Introduction
Lumbar puncture is an essential medical procedure and usually performed for diagnostic or therapeutic purposes. Although lumbar puncture is relatively safe, several adverse events have been reported, such as headache, hemorrhage, local pain, and infections (1). Among these adverse events, post-dural puncture headache (PDPH) is one of the most common adverse events, and PDPH could have serious morbidities, such as cranial nerve palsy, seizure, and subdural hematoma (2–4). PDPH is usually diagnosed on the basis of clinical features. History of lumbar puncture and 204
K. M. Park, K. J. Shin, S. Y. Ha, J. Park, S. E. Kim Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
Key words: headache; risk factors; spinal puncture S. E. Kim, Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, 612-896 Haeundae-gu, Busan, Korea Tel.: +82 51 797 1195 Fax: +82 51 797 1196 e-mail: [email protected] Accepted for publication April 25, 2014
orthostatic headache is invariably present (5, 6). The accompanying symptoms of PDPH could be neck stiffness, tinnitus, hypoacusia, photophobia, or nausea (5, 6). PDPH is resolved either spontaneously within 1 week or within 48 h after effective treatment of the spinal fluid leak, such as epidural blood patch (5, 6). The incidence of PDPH ranges from 10 to 40%, and it depends on patient-related and technique-related risk factors (5–7). The patient-related risk factors are usually non-modifiable risk factors, such as young age, female gender, low body mass index (BMI), history of prior PDPH, and chronic headache (5, 6). The technique-related risk factors are modifiable
Risk factors for post-dural puncture headache risk factors, including large size of the spinal needle, and traumatic needle like Quincke needle and low operator experiences (5, 6). The mechanism of PDPH is uncertain, but there are two proposed hypothesis. First, low cerebrospinal fluid (CSF) pressure leads to downward pull on pain sensitive structures when patient assumes an upright position. Second, low CSF pressure leads to painful dilatation of intracranial vessels in an attempt to maintain the intracranial volume by the Monro–Kellie doctrine (5, 6). Among them, we do not know exactly what the real mechanism for PDPH is, but low CSF pressure resulting from persistent leakage of CSF at the site of lumbar puncture is important. Physiological CSF pressure is dynamic. It has been demonstrated that human CSF production exhibits a circadian pattern. The CSF production at nighttime is two to three times than that at daytime (8, 9). In addition, there have been some reports that CSF pressure at nighttime is higher than that at daytime (10–12). These diurnal rhythms may have their origin in the suprachiasmatic nucleus of the hypothalamus in the brain (10). This center controls the biological functions according to various circadian clocks and would dictate the rules of fluctuation of CSF pressure (13). There have been several studies to identify the risk factors for PDPH, but all of the studies were published prior to the development of International Classification of Headache Disorders 3rd Edition (ICHD-III beta) criteria (1, 14–17). In addition, previous studies did not control the technique-related risk factors; lumbar puncture was performed by multiple operators with varying degrees of experience, as well as varied use of needle size, type, and bevel direction (7, 18–20). Furthermore, the association between puncture time and occurrence of PDPH has been not studied yet. The aim of this study was to identify the patient-related risk factors for PDPH with same standardized procedures. In addition, we evaluated the occurrence rate of PDPH between patients who underwent lumbar puncture at daytime and nighttime, and assessed the significance of puncture time for the development of PDPH. Materials and methods
This study was conducted with an approval of the institutional review board at our institution. This study was performed retrospectively in a single tertiary hospital, serving a population of
approximately 400,000 individuals. From our hospital database, we recruited 928 patients who underwent lumbar puncture at Haeundae Paik Hospital over a period from March 2010 to December 2012, and reviewed the medical records of these patients. The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The exclusion criteria were patients (i) who underwent lumbar puncture for therapeutic purposes, such as intrathecal chemotherapy, (ii) with normal pressure hydrocephalus, (iii) with deterioration of consciousness at puncture time, or (iv) who were followed up less than 5 days. Most of the lumbar punctures were performed by one physician. All of the patients underwent lumbar puncture in a standardized way. Patients underwent lumbar puncture lying on their left or right side. The lumbar punctures were performed under aseptic condition, using a 22-gauge Quincke needle, and the opening lumbar CSF pressure was measured. The bevel direction of the cutting needle was parallel to the long axis of the spine, and reinserted stylet prior to removal of the needle. All patients had bed rest in supine position for at least four hours after lumbar puncture. We collected demographic and laboratory profiles of patients, such as age, sex, weight, height, BMI, smoking, diabetes, hypertension, CSF pressure, CSF profiles including counts of white blood cell (WBC) and protein, and glucose ratio (CSF/blood), and puncture time. We divided the patients into two groups: those with and without PDPH. PDPH was diagnosed in accordance with the ICHD-III beta criteria: (i) dural puncture has been performed, (ii) headache has developed within 5 days of the dural puncture, (iii) not better accounted for by another ICHD-III beta diagnosis (17). The primary endpoint for this study was the occurrence of PDPH as a dependent variable. The timing of recording about occurrence of PDHD was variable among patients, but we recorded it at least 5 days after lumbar puncture. The differences were analyzed with age, sex, weight, height, BMI, smoking, diabetes, hypertension, CSF pressure, CSF profile including counts of WBC and protein, and glucose ratio (CSF/ blood), and puncture time as independent variables. The lumbar puncture performed between 8:00 AM and 8:00 PM was considered as puncture at daytime, and any other time was considered as nighttime. We analyzed the variables 205
Park et al.
Of the 928 patients who underwent lumbar puncture, 413 patients met the inclusion criteria for this study. Two hundred and forty-three patients were men and 170 patients were women. The median age was 45 years (95% CI 42–48 years, range 11–91 years). The median height was 167 cm (95% CI 165–168 cm, range 102– 189 cm), and the median weight was 63 kg (95% CI 61–65 kg, range 39–184 kg). The median BMI was 23 kg/m2 (95% CI 23–23 kg/m2, range 14–37 kg/m2). Eighty-eight patients had hypertension, 42 patients had diabetes, and 90 patients were current smokers. The CSF study revealed that the median counts of WBC were 3/mm3 (95% CI 2–5/mm3, range 0–19,000/mm3), the median counts of protein were 34 mg/dl (95% CI 32–37 mg/dl, range 2–1652 mg/dl), the median ratios of glucose (CSF/blood) were 0.57 (95% CI 0.56–0.59, range 0–1), and the median CSF pressure was 10 cmH20 (95% CI 10–11 cmH20, range 1–38 cmH20). Two hundred and ninety-six patients underwent lumbar punctures at daytime, and 117 patients underwent at nighttime. Thirty-six of the 413 patients developed PDPH. Table 1 shows a comparison of demographic and
laboratory profiles between patients with and without PDPH. Age (34 vs 47 years, P = 0.0006 by Mann–Whitney U-test), BMI (22 vs 23 kg/m2, P = 0.0063 by Mann–Whitney U-test), hypertension (2/36 vs 86/377, P = 0.0172 by Fisher’s exact test), diabetes (0/36 vs 42/377, P = 0.0006 by Fisher’s exact test), CSF pressure (100 vs 100 cmH20, P = 0.0092 by Mann–Whitney U-test), WBC (2 vs 3/mm3, P = 0.015 by Mann–Whitney U-test), protein (30 vs 35 mg/dl, P = 0.0355 by Mann–Whitney U-test), glucose ratio (0.70 vs 0.56, P < 0.0001 by Mann–Whitney U-test), and puncture at daytime (33/36 vs 263/377, P = 0.0035 by Fisher’s exact test) were significantly different between the two groups. Patients with PDPH were younger, had a lower BMI, and had less diabetes and hypertension than those without PDPH. The counts of WBC and protein, as well as CSF pressure were lower in patients with PDPH than those without PDPH, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime more developed PDPH than those who were performed puncture at nighttime (OR = 4.8, 95% CI 1.4–15.9), especially, when patients visited our hospital at daytime. Among the 413 patients, 315 patients visited our hospital at daytime. Of the 315 patients, 27 of 226 (12%) patients who underwent lumbar puncture at daytime developed PDPH, whereas 2 of 89 (2%) patients who underwent lumbar puncture at nighttime occurred PDPH (P = 0.0049 by Fisher’s exact test). After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower CSF pressure, and puncture at daytime were independently significant variables for predicting PDPH (Table 2). In addition, there were no significantly different demographic and laboratory profiles between patients who performed lumbar puncture at daytime and nighttime (Table 3).
Table 1 A comparison of demographic and laboratory profiles between patients with and without post-dural puncture headache
Discussion
using Fisher’s exact test for categorical variables, and Student’s t-test or Mann–Whitney U-test for numerical variables. We performed multiple logistic regression analyses using dependent variables. In addition, we analyzed the differences of demographic and laboratory profiles between patients who performed lumbar puncture at daytime and nighttime. All statistical tests were performed using MedCalcâ. For all calculations, a P-value of less than 0.05 was considered statistically significant. Results
Parameter Men, n (%) Age, years (range) Body mass index, kg/m2 (range) Smokers, n (%) Hypertension, n (%) Diabetes, n (%) CSF pressure, cmH20 (range) WBC/mm3 (range) Protein, mg/dl (range) Glucose ratio (range) Puncture at daytime, n (%)
With PDPH (n = 36) 17 34 22 7 2 0 10 2 30 0.7 33
(47) (16–84) (17–33) (19) (6) (0) (1–19) (0–560) (11–154) (0.42–0.87) (92)
Without PDPH (n = 377)
P-value
226 47 23 83 86 42 10 3 35 0.56 263
0.2 0.001 0.006 0.884 0.017 0.038 0.009 0.015 0.036
