Technical Note
Post-lumbar puncture headache: experiences with Sprotte's atraumatic needle
A Engelhardt, S Oheim, B Neundörfer
Neurological Clinic, University of Erlangen, Nürnberg, Germany Lumbar puncture (LP) remains a necessary diagnostic technique. Nevertheless, the method is not without side effects since post-lumbar puncture headache (PLPH) can occur in up to 40% of cases (1). The PLPH presumably is caused by cerebrospinal fluid (CSF) leakage secondary to dural injury by the sharp tip of the Quincke needle. An option which may avoid PLPH is to use an atraumatic needle. A modified version of Whitacre's needle was developed by Sprotte for the purpose of regional anaesthesia (2). The tip of the needle is shaped as a closed circular cone with rounded profile. In spite of the small diameter of the needle, the CSF flow is sufficient due to a long, oval sideward aperture which is larger than the inner diameter of the needle (Fig. 1). Additionally, the wall of the atraumatic needle is thinner than the needles of Quincke and Whitacre. Since 1986, we have used this needle with good result (3, 4). Two hundred and thirty patients were randomly divided into two groups. One group was punctured with a 21 gauge atraumatic needle designed after Sprotte, the other with a 22 gauge needle of the same type (distributor in the US: Havel's Inc. 3726 Lonsdale Ave. Cincinnati, Ohio 45227). (Previous experiences and ethical considerations prevented us from comparing our outcomes with a control group punctured with conventional traumatic needles.) Patients were questioned regarding headache and other complaints before, two days after LP and between five and seven days post LP. After every puncture, users were asked about their acceptance of the technique. The handling of the needle is marginally different from the traumatic needle due to the higher flexibility and the relatively blunt top. Because of the high flexibility of the needle we use sterile gloves and hold the needle close to the top. It is introduced either in the manner of a catheter or with a sharp short introducer. Postpuncture procedures are not necessary: the patients can stand up immediately. PLPH was seen in only 5 of 230 patients; two were punctured with the 21 G needle, three with the
22 G needle. Eight patients developed postpuncture non-postural headache. The intensity of headache was mild to moderate in all but one case. Patients with PLPH more often had an increased number of RBC's in the CSF. Users rated their acceptability of the atraumatic needle as good in 87%, satisfactory in 12% and unsatisfactory in 1% of punctures. These results indicate that the frequency of post-spinal headache is reduced to between 2.5 and 6.5% when using the atraumatic Sprotte needle. Since the principle of this needle is to avoid any injury of the dural fibers and so to reduce CSF loss to a minimum, our study supports MacRobert's theory (5) of a CSF dural leak as the main cause of postspinal headache. References
1.
Sand T, Stovner LJ, Dale L, Salvesen R. Side effects after diagnostic lumbar puncture and lumbar iohexol myelography. Neuroradiology 1987;29:385-8
2.
Sprotte G, Schedel R, Pajunk H, Pajunk H. Eine "atraumatische" Universalkanüle für einzeitige Regionalanaesthesien. Regional-Anaesthesie 1987;10:104-8
3.
Engelhardt A, Oheim S, Neundörfer B. Lumbar puncture with a new atraumatic needle. J Neurol 1990;237:S54
4.
Engelhardt A, Oheim S, Neundörfer B. Post lumbar puncture headache: experiences with an "atraumatic" needle. Cephalalgia 1991;11(Suppl 11):356-7
5.
MacRobert RG. The cause of lumbar-puncture headache. JAMA 1918;70:1350-3
Received 8 February 1992, accepted 1 May 1992
Post-lumbar puncture headache: experiences with Sprotte's atraumatic needle
A Engelhardt, S Oheim, B Neundörfer
Neurological Clinic, University of Erlangen, Nürnberg, Germany Lumbar puncture (LP) remains a necessary diagnostic technique. Nevertheless, the method is not without side effects since post-lumbar puncture headache (PLPH) can occur in up to 40% of cases (1). The PLPH presumably is caused by cerebrospinal fluid (CSF) leakage secondary to dural injury by the sharp tip of the Quincke needle. An option which may avoid PLPH is to use an atraumatic needle. A modified version of Whitacre's needle was developed by Sprotte for the purpose of regional anaesthesia (2). The tip of the needle is shaped as a closed circular cone with rounded profile. In spite of the small diameter of the needle, the CSF flow is sufficient due to a long, oval sideward aperture which is larger than the inner diameter of the needle (Fig. 1). Additionally, the wall of the atraumatic needle is thinner than the needles of Quincke and Whitacre. Since 1986, we have used this needle with good result (3, 4). Two hundred and thirty patients were randomly divided into two groups. One group was punctured with a 21 gauge atraumatic needle designed after Sprotte, the other with a 22 gauge needle of the same type (distributor in the US: Havel's Inc. 3726 Lonsdale Ave. Cincinnati, Ohio 45227). (Previous experiences and ethical considerations prevented us from comparing our outcomes with a control group punctured with conventional traumatic needles.) Patients were questioned regarding headache and other complaints before, two days after LP and between five and seven days post LP. After every puncture, users were asked about their acceptance of the technique. The handling of the needle is marginally different from the traumatic needle due to the higher flexibility and the relatively blunt top. Because of the high flexibility of the needle we use sterile gloves and hold the needle close to the top. It is introduced either in the manner of a catheter or with a sharp short introducer. Postpuncture procedures are not necessary: the patients can stand up immediately. PLPH was seen in only 5 of 230 patients; two were punctured with the 21 G needle, three with the
22 G needle. Eight patients developed postpuncture non-postural headache. The intensity of headache was mild to moderate in all but one case. Patients with PLPH more often had an increased number of RBC's in the CSF. Users rated their acceptability of the atraumatic needle as good in 87%, satisfactory in 12% and unsatisfactory in 1% of punctures. These results indicate that the frequency of post-spinal headache is reduced to between 2.5 and 6.5% when using the atraumatic Sprotte needle. Since the principle of this needle is to avoid any injury of the dural fibers and so to reduce CSF loss to a minimum, our study supports MacRobert's theory (5) of a CSF dural leak as the main cause of postspinal headache. References
1.
Sand T, Stovner LJ, Dale L, Salvesen R. Side effects after diagnostic lumbar puncture and lumbar iohexol myelography. Neuroradiology 1987;29:385-8
2.
Sprotte G, Schedel R, Pajunk H, Pajunk H. Eine "atraumatische" Universalkanüle für einzeitige Regionalanaesthesien. Regional-Anaesthesie 1987;10:104-8
3.
Engelhardt A, Oheim S, Neundörfer B. Lumbar puncture with a new atraumatic needle. J Neurol 1990;237:S54
4.
Engelhardt A, Oheim S, Neundörfer B. Post lumbar puncture headache: experiences with an "atraumatic" needle. Cephalalgia 1991;11(Suppl 11):356-7
5.
MacRobert RG. The cause of lumbar-puncture headache. JAMA 1918;70:1350-3
Received 8 February 1992, accepted 1 May 1992
