Carson, D.

Haldane, G.J.

Jamieson, D.R.S.

Serpell, M.G.

English

PubMed

M G Serpell

G J Haldane

D R S Jamieson

D Carson

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Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom:

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Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom

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       Serpell, M.G. and Haldane, G.J. and Jamieson, D.R.S. and Carson, D. (1998) Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom. British Medical Journal, 316 . pp. 1709-1710. ISSN 0959-535X  http://eprints.gla.ac.uk/25502/  Deposited on: 19 March 2010   Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk Prevention of headache after lumbar puncture:questionnaire survey of neurologists and neurosurgeonsin United Kingdom:M G Serpell, G J Haldane, D R S Jamieson, D CarsonThe aetiology of headache after lumbar puncture isrelated to the hole left in the dura after the needle hasbeen withdrawn, which allows the cerebrospinal fluidto leak out of the subarachnoid space. The headachecan persist for prolonged periods and predispose tosubdural haematomas, which are associated with ahigh mortality. Tourtellotte showed that this headachecould be significantly reduced by using smallerneedles.1 Also, among needles of the same size, thosewith atraumatic blunt tips are associated with a lowerincidence of headache. They produce a smaller hole inthe dura by separating rather than cutting the elasticfibres, as occurs with the Quincke tipped needles.2We carried out a questionnaire survey of depart›ments of neurology and neurosurgery to see if theseneedles were used in the practice of diagnostic lumbarpuncture and to assess how else departments may betrying to prevent headaches after lumbar puncture.Methods and resultsIn September 1996 we sent a questionnaire addressedto the “senior registrar” of all (n = 105) departments ofneurology and neurosurgery in the United Kingdom,as listed by the Association of British Neurologists andthe Society of British Neurological Surgeons. We askedspecific questions about the practice in their depart›ment of diagnostic lumbar puncture. We sent a repeatquestionnaire to non›respondents two months later.The table shows the results of the survey. Seventyone departments (68%) replied. Most departmentsperformed lumbar puncture with the patients lying ontheir side. Equal proportions of neurology and neuro›surgery departments used the 20 gauge spinal needles(the most commonly used needle in both groups). TheQuincke tipped spinal needle was used by over 70% ofdepartments in each specialty, and only about a thirdof departments in each specialty oriented the bevel ofthe needle tip to be parallel to the longitudinal axis ofthe spinal cord. Over 80% of the departmentsclinicians used bed rest as a prophylactic measure.Neurology departments were more likely thanneurosurgery departments to use systemic steroidsand epidural blood patch for the treatment ofheadache after lumbar puncture.CommentAlthough the response relies on one person’s impres›sions of the practice of a whole department, we chose asenior trainee who would probably be exposed to mostother members.Most departments performed lumbar punctureswith patients lying on their side, but it is quicker andtechnically easier with the patient sitting upright. Onlyabout a third of departments used the correct orienta›tion of the bevel of a Quincke tipped needle to thedura. Mihic proved that the incidence of headachewhen a Quincke tipped needle was used was reduced ifthe bevel of the cutting edge was parallel to the longi›tudinal dural fibres.3The frequency of headache after diagnostic lumbarpuncture with 20 and 22 gauge Quincke needles inambulatory patients is 36%.4 In our survey both groupsthought that an acceptable rate would be less than halfthis rate, even though they used a similar needle.Atraumatic needles of this gauge can be used just aseffectively to obtain fluid samples and manometryreadings and would also reduce the incidence of head›Results of questionnaires from 71 departments of neurology andneurosurgery. Values are numbers (percentages) of departmentsunless stated otherwiseItemNeurologicalunits (n=48)Neurosurgicalunits (n=23) P valueResponse rate 48/64 (75) 23/41 (56) 0.04*Patient position:Sitting 1 (2) 0Lying on side 44 (92) 22 (96) NSEither position 3 (6) 1 (4)Smallest needle size used:18 gauge 6 (12) 4 (17)20 gauge 23 (48) 12 (52)22 gauge 13 (27) 6 (26) NS24 gauge 2 (4) 0Don’t know 4 (8) 1 (4)Needle type:Quincke tip 34 (71) 17 (74)Atraumatic tip 7 (15) 3 (13) 0.9Respondent did not answerquestion or used both types7 (15) 3 (13)Position of needle tip relative to longitudinal axis of spinal cord:Parallel 15 (31) 9 (39)Perpendicular 17 (35) 6 (26) 0.7Not considered 16 (33) 8 (35)Mean (range) volume (ml) ofcerebrospinal fluid collected8 (2 to 30) 8 (1 to 20) 0.9Mean acceptable incidence(%) of headache afterlumbar puncture (range)13 (0 to 100) 17 (5 to 100) 0.97Prophylactic bed rest after lumbar puncture:Not practised 8 (17) 5 (22)For 1›6 hours 35 (73) 15 (65) 0.8For 6›24 hours 5 (10) 3 (13)Treatment of headache after lumbar punctureRespondent suggestedsystemic steroids22 (46) 2 (9)0.002*Respondent did not suggestsystemic steroids26 (54) 21 (91)Epidural blood patch:Considered before 72 hours 4 (8) 3 (13)0.055Considered after 72 hours 27 (56) 5 (22)No response 11 (23) 9 (39)Don’t know 6 (12) 6 (26)NS=not significant as determined by Fisher’s exact probability test.*With ÷2 test.PapersDepartment ofAnaesthesia,Western Infirmary,Glasgow G11 6NTM G Serpell,consultantanaesthetistG J Haldane,specialist registrarInstitute ofNeurologicalSciences, SouthernGeneral HospitalNHS Trust,Glasgow G51 4TFD R S Jamieson,clinical lecturerDepartment ofAnaesthesia, UlsterHospital,Dundonald, BelfastBT16 0RHD Carson,consultantanaesthetistCorrespondence to:Dr Serpellmgserpell@altavista.netBMJ 1998;316:1709–101709BMJ VOLUME 316 6 JUNE 1998 www.bmj.comache.2 Bed rest was commonly practised despite havingno value in the prevention of headache.5Treatment of established headache after lumbarpuncture includes hydration, analgesics, vasopressin,and caffeine. More invasive techniques include theinstallation of saline or autologous blood into theepidural space. The latter procedure (epidural bloodpatching) has a success rate of 90% with only minorshort term sequelae. Very few of the departments in ourstudy said that they would consider this option withinthe first 72 hours, although early use is stronglyadvocated in anaesthetic circles. This may be becauseother causes of the headache are more likely or becausethe patient has a fever, which precludes blood patching.However, epidural blood patching would be consideredby a good proportion of neurologists after 72 hours.We thank all those who took the time and effort to respond toour questionnaire.Contributors: MGS and DC initiated the research. MGS par›ticipated in the study design, data collection, analysis,interpretation, and writing of the paper and will act asguarantor. GJH participated in data collection, analysis,interpretation, and writing of the paper. DRSJ participated inthe study design and the interpretation and, together with DC,edited the paper.Funding: None.Conflict of interest: None.1 Tourtellotte WW, Henderson WG, Tucker RP, Gilland O, Walker JE, Kok›man E. A randomised, double blind clinical trial comparing the 22 versus26 gauge needle in the production of the post›lumbar puncturesyndrome in normal individuals. Headache 1972;12:73›8.2 Carson D, Serpell M. Choosing the best needle for diagnostic lumbarpuncture. Neurology 1996;47:33›7.3 Mihic DN. Postspinal headache, needle surface and longitudinal orienta›tion of the dural fibres. Results of a survey. Reg Anesth 1986;9:54›6.4 Kuntz KM, Kohmen E, Stevens JC, Miller P, Offord KP, Ho MM.Post›lumbar puncture headaches: experience in 501 consecutiveprocedures. Neurology 1992;42:1884›7.5 Carbaat PAT, VanCrevel H. Lumbar puncture headache. Controlledstudy in the preventive effect of 24 hours bed rest. Lancet 1981;ii:1133›5.(Accepted 3 December 1997)Problems in retrieving national data on births:questionnaire surveyLesley SmithAlthough more data on maternal and child health arebeing collected locally, the amount of data availablenationally has fallen over the past decade.1 Centralsources of data exist in England and Wales, but clinicaldata are limited (Office for National Statistics registra›tions) or of poor quality (maternity hospital episodesystem, patient episode data Wales).2 Only NorthernIreland (child health record system) and Scotland(Scottish Morbidity Record—SMR2) provide goodquality data on maternal and child health.3If national data were available, trends in health careas well as morbidity and mortality for rare conditionscould be analysed. National data would also be usefulto the confidential inquiry into stillbirths and deaths ininfancy (CESDI)—the survey that covers fetal andinfant deaths between 20 weeks’ gestation and 1 year inEngland, Wales, and Northern Ireland. The numeratordata collected through the survey’s rapid reportingprocess cannot be interpreted without nationaldenominator data. In recognition of this need, a studywas carried out to determine whether populationbased data for 1993 and 1995 could be obtained fromregional sources.Methods and resultsIn 1993, as part of a study managed by the NationalPerinatal Epidemiology Unit, all district and regionalpublic health departments were asked for informationon sources of maternity and child health data. Systemsfor collecting either maternity or child health data werein place in almost every district. Six regions in England,Wales, and Northern Ireland operated uniformsystems across former regional health authorities; fivehad a procedure or independent survey; and three hadso many different systems that it would have beenimpossible to retrieve regional data.In September 1994, all 16 regional coordinatorsfor the confidential inquiry into stillbirths and deathsin infancy were sent a list of 22 data items and asked toidentify those available from NHS sources for all babiesdelivered in 1993 to residents in their region. Fifteenlists were returned, and four common variables ofgestation, time of delivery, parity, and onset of labourwere chosen.In January 1995, a form requesting populationbased aggregated 1993 data for the chosen variables(with clear definitions) was sent to nine regional coor›dinators. All were confident of producing results sincesimilar data had been generated for their own reports.Four of the nine regions produced all the datarequested. One region supplied half the data, whichwere hospital based and therefore unusable, and threeregions could not generate any data.In June 1996, 16 regional coordinators were sent afollow up questionnaire on 1995 data. Three did notrespond—two did not wish to and one had not partici›Difficulties met by regional coordinators in generating regional data for 1993 and 1995.Values are numbers of difficulties mentioned by coordinatorsDifficulties1993 data(n=15)1995 data(n=13)No central point covering region 7 9*Data were hospital based 4 4†Quality of data in doubt 4 3*Data aggregated or defined differently from confidential inquiry data 3 3Low priority given to providing regional data 0 3Lack of staff 2 3Data not totalled 2 2*Incompatible, non›uniform information systems 1 2*Technical problems 1 1Fee requested 1 ?Data no longer available or available too late 1 1Data not available for research 0 1*In one case, other sources indicate that difficulty still exists, but was not specifically mentioned by thecoordinator in the 1996 survey.†In all cases the difficulty still exists but was not specifically mentioned.PapersKing’s Fund,London W1M 0ANLesley Smith,researcher for CESDIcolls@kehf.org.ukBMJ 1998;316:1710–11710 BMJ VOLUME 316 6 JUNE 1998 www.bmj.com

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Prevention of headache after lumbar puncture: questionnaire survey of neurologists and neurosurgeons in United Kingdom

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