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Original Research |
1 Milwaukee Radiologists, Ltd., 2901 W Kinnickinnic River Pkwy. LL9, Milwaukee,
WI 53215.
2 Department of Radiology, Aurora St. Luke's Medical Center, Milwaukee,
WI.
3 Department of Radiology, Wheaton Franciscan Healthcare Racine, St. Mary's
Medical Center, Racine, WI.
Received October 26, 2007;
accepted after revision December 1, 2007.
Address correspondence to M. K. Hatfield
(hatfield{at}pol.net).
Abstract
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MATERIALS AND METHODS. The records of 724 consecutive patients who were referred to St. Mary's Medical Center department of radiology for fluoroscopic lumbar puncture from January 2003 through April 2007 were retrospectively reviewed. Emergency requests (191) were discarded along with those for patients with clinical signs of pseudotumor cerebri (21), normal pressure hydrocephalus (3), and failed attempts (4). The collective total was 505 elective lumbar punctures.
RESULTS. The blood patch rate for the 22-gauge Whitacre needle was 4.2%. The result for the 22-gauge Quincke point needle was 15.1% whereas that for the 20-gauge Quincke point needle was 29.6%. In addition, the level of puncture showed a blood patch rate that increased as the level of lumbar puncture lowered. The highest level of lumbar puncture was L1-L2 with the lowest recorded level being L5-S1.
CONCLUSION. The Whitacre needle is associated with a significantly lower incidence of blood patch rate after lumbar puncture. The highest level of puncture (L1-L2) also provides the lowest level of blood patch rate.
Keywords: complications • CSF leak • headache after dural puncture • lumbar puncture • Whitacre needle
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CSF production occurs mainly in the choroid plexus. About 500 mL of CSF is produced daily. The total CSF volume in the adult is approximately 150 mL, of which half is within the cranial cavity. The CSF pressure in the lumbar region in the horizontal position is between 5 and 15 cm of water. On assuming the erect posture, this increases to more than 40 cm of water [8]. Puncture of the dura has the potential to allow the development of excessive leakage of CSF. Excess loss of CSF leads to intracranial hypotension and a demonstrable reduction in CSF volume [9]. After the development of postdural puncture headache, the presence of a CSF leak has been confirmed with manometric studies. The adult subarachnoid pressure is reduced to 4 cm of water or less [10]. The higher the level of lumbar puncture, the less the hydrostatic pressure at the dural puncture site. This explains why postdural puncture headaches are not associated with cervical punctures. The rate of CSF loss through the dural perforation is generally greater than the rate of CSF production, particularly with needle sizes larger than 25 gauge [11, 12].
The actual mechanism producing the postdural puncture headache is unclear. There are two possible explanations. First, the lowering of CSF pressure causes traction on the intracranial structures in the upright position. These structures are pain-sensitive, leading to the characteristic headache. Second, the loss of CSF produces a compensatory vasodilatation. The con sequence of a decrease in CSF volume is a compensatory increase in blood volume. The vasodilatation is then responsible for the headache [9]. The primary treatment is bed rest, which limits the patient's daily activities for several days. The onset is typically within the first 48 hours after the dural puncture; it is usually noticed the following morning on arising from sleep. Rarely, the headache develops between 5 and 14 days after the procedure or immediately after the procedure. The headache is described as severe.
The common distribution is over the frontal and occipital areas radiating to the neck and shoulders. The pain is exacerbated by head movement and adoption of the upright posture and is relieved by lying down. An increase in severity of the headache on standing is the primary attribute of postdural puncture headache. Other symptoms associated with dural puncture headache include nausea, vomiting, hearing loss, tinnitus, vertigo, dizziness, paresthesia of the scalp, and upper and lower limb pain. Visual disturbances such as diplopia or cortical blindness have been reported. Most headaches resolve within 7 days, but in rare cases they can persist for several months [13].
Other than bed rest, caffeine has been shown to be an effective therapy for postdural puncture headache [14]. Caffeine is a CNS stimulant that among other properties produces cerebral vasoconstriction. When severe enough, the epidural blood patch has been shown to have a high success rate with a low incidence of complications. The theory is that the blood, once introduced into the epidural space, will clot and occlude the perforation, preventing further CSF leak [15]. Fever, infection on the back, coagulopathy, or patient refusal are contraindications to the performance of an epidural blood patch. The procedure consists of placing a needle within the epidural space near the site of the dural defect and then slowly injecting up to 30 mL of homologous blood. Success rates have been reported as high as 98%. Repeating the blood patch for refractory headaches also has a similarly high success rate [16].
The use of fine-gauge pencil-point needles such as the Whitacre needle (BD Medical) has produced a great reduction in the incidence of postdural puncture headache, which varies with the type of procedure and patient involved. It is related to the size and design of the spinal needle used, the experience of the personnel performing the dural puncture, and the age and sex of the patient [13]. This article describes our experience with elective lumbar punctures and compares the incidence of blood patch with the size and type of needle used and the level of puncture. Note should be made that lumbar punctures for myelography were not included in this study because in our experience using needles smaller than 22 gauge did not allow a fast enough flow rate of CSF to be clinically practical.
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All patients were discharged within 2 hours after lumbar puncture. They were given our department's telephone number to call if they felt they had problems relating to the procedure. They were told to get as much bed rest as possible over the next 24 hours and to drink a lot of fluids, especially caffeinated fluids. Laboratory testing for bleeding disorders was not routinely performed unless patients stated they had been told in the past that they had a bleeding disorder or if they were currently taking warfarin (Coumadin, Bristol-Myers Squibb) or enoxaparin (Lovenox, Aventis). Aspirin and antiplatelet medications were not withheld. Allergy histories were noted but rarely mattered. Latex allergies were the one exception. Our department nurse attempted to contact the patient on the next business day to determine what if any complications had developed.
Patients with headaches that developed but were not severe enough to require a blood patch were reassured by telephone and no further treatment was rendered. Rarely, patients were given a prescription for pain medication, typ i cally hydrocodone 5/500 (Vicodin, Abbott Laboratories). Those patients who had a severe persistent headache after 48 hours were always given the option of undergoing a blood patch procedure, either in our department by a trained neuroradiologist or interventionalist or in the operative suite by an anesthesiologist pain specialist. These were the only two options for blood patches in our community.
To perform a blood patch, we use sterile technique and fluoroscopic guidance to place a 22-gauge Whitaker needle within the lumbar epidural space via a translaminar approach. We choose one level above or below the dural puncture site. Confirmation of proper tip placement is made by hand injection of 2-3 mL of iohexol (Omnipaque 180, GE Healthcare) and spot views in orthogonal projections. After this, 20-25 mL of autologous blood is injected and the needle removed. The blood is obtained from an 18-gauge intracatheter IV within the antecubital fossa. The blood is injected immediately before clotting. We do this without sedation and allow the patient to recover for 10 minutes before discharge.
All medical and hospital records were reviewed, and the level of puncture was noted along with the size and type of needle used. One of three needles was always used, a 22-gauge Whitacre needle, a 22-gauge Quincke needle, or a 20-gauge Quincke needle. The size and type of needle used and the level of puncture were always recorded, as well as how many attempts were made, in all but 15 patients. In addition, to accurately quantify the incidence and severity of postdural puncture headaches, the incidence of blood patch was noted. The data were stratified according to an ascending level of puncture along with the size and type of needle and incidence of blood patch.
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This also explains why cervical punctures are not associated with postdural puncture headaches. The highest percentage of blood patch was in the multiple-level group (57.1%). This small group of patients underwent punctures at several levels. The reasons for several punctures were typically anatomic and inability to obtain a sufficient CSF sample.
Of the 505 patients included in the study group, there were a total of 49 patients who fulfilled the criteria and elected to undergo a blood patch. The incidence was higher for female patients (40) versus male patients (9). The overall female-to-male ratio for all lumbar punctures performed was equal. The average age of patients undergoing a blood patch was 38 years. The typical blood patch patient was a female between the ages of 15 and 60 years (39 patients). All blood patches were successful in relieving the dural puncture headache. One patient had to undergo two blood patch procedures to achieve satisfactory relief.
There were no additional complications that required additional treatment or imaging. As shown in Table 2, the overall incidence of blood patch was slightly lower for our experienced physician's assistant (7.4%) than with board-certified radiologists (9.7%). The lowest incidence of blood patch was accomplished by our physician's assistant using a 22-gauge Whitaker needle (2%). This com pared with the overall blood patch rate of 4.2% for the Whitaker needle. There was no correlation between the volume of CSF withdrawn and the rate of spinal headache.
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If one punctures at the L1-L2 level, the actual point of puncture is approximately the mid L2 level. The location of the conus medullaris according to age and sex was retrospectively evaluated with MRI [18]. A total of 639 adult subjects without any conspicuous spinal canal abnormality on the lumbar MRI examination were selected. The level of the conus medullaris was most commonly located at the T12-L1 intervertebral disk level. No significant difference in the conus level was found with increasing age. In our experience with 97 punctures per formed at the L1-L2 level, there was no report of complication from puncturing the conus medullaris. Operators did typically puncture off the midline to avoid this complication.
One drawback to using a 22-gauge needle compared with a 20-gauge needle is the time it takes to obtain CSF. In addition to other laboratory tests, a multiple sclerosis panel will usually be ordered for a typical patient referred for an elective lumbar puncture. This frequently requires up to 13 mL of spinal fluid. In our experience, this can be accomplished in less than 5 minutes by tipping the patient to a 45° position with the feet on the footboard for support. Coughing and Valsalva maneuvers were also used. Patients who experienced a minor vasovagal reaction were treated by lowering the table and placing a pillow under the feet until they felt they were able to proceed. No cases were canceled due to vasovagal reactions. Four cases were canceled due to inability to obtain fluid. These involved patients with extensive degenerative disk disease and an extensive operative history. For these rare cases, a C1-C2 puncture was used to obtain CSF.
In our experience in performing a lumbar myelogram, if no fluid is requested we typically use either a 25- or 27-gauge Whitaker needle. Our incidence of blood patch after lumbar myelography with either of these needles is zero. Most patients were small enough for 3.5-inch (8.9-cm) needles; however, when necessary 5-inch (12.7-cm) Whitaker and Quincke needles were used.
CSF sampling is being requested more and more for drug treatment protocols and diagnosis, clinical correlation, and follow-up after treatment. This procedure can be per formed on an outpatient basis with little morbidity and inconvenience to the patient. Postdural puncture headache is a complication that should not be treated lightly because of the potential for considerable morbidity. In the majority of cases, the problem will resolve spontaneously. In some patients, the headache lasts for months or even years. The use of a pencil-point needle, such as the Whitacre needle, significantly decreases the incidence of blood patch and postdural puncture headache. In addition, puncturing as high as possible, especially the L1-L2 level, also significantly decreases morbidity. Physician's assistants may also be trained to perform this procedure.
Acknowledgments
We thank Madonna Bahr, Lexi Antonchorgy, and Gina Weiser for their help in
the preparation of this article.
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