Addendum to assessment: Prevention of post–lumbar puncture headaches
Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology
Carmel Armon, MD, MHS and
Randolph W. Evans, MD
From the Division of Neurology (Dr. Armon), Baystate Medical Center, Springfield and Department of Neurology, Tufts University School of Medicine, Boston, MA; and Department of Neurology (Dr. Evans), University of Texas at Houston Medical School and Baylor College of Medicine.
Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116.
Review of the literature on prevention of post–lumbarpuncture headaches (PLPHAs) since the publication of the originalassessment in 2000 yielded one study comparing use of cuttingto atraumatic needles in diagnostic lumbar punctures, providingClass I evidence in favor of the atraumatic needle. Taken inconjunction with data from most studies in the anesthesiologyliterature, the Therapeutics and Technology Assessment Subcommitteeconcluded that use of an atraumatic spinal needle in adult patientpopulations reduces the frequency of PLPHA (Level A recommendation).It affirmed a previous conclusion that smaller needle size isassociated with reduced frequency of PLPHA (Level A recommendation).
Since publication of the original assessment on prevention ofpost–lumbar puncture headaches (PLPHAs) in 2000,1 additionalliterature has appeared on the subject. The purpose of thisupdate is to classify the new literature and to affirm or modifythe recommendations of the original assessment, as appropriate.A particular focus of this update was to identify any new evidenceto support the use of the atraumatic or pencil-point needleover use of the conventional "cutting" needle in performanceof diagnostic lumbar punctures (LPs) to reduce PLPHA. This hadbeen one of the directions for future research identified bythe original article because data for diagnostic LPs were lessadequate than for LPs in anesthesiology practice.
A MEDLINE search was conducted by one of the authors in June2004, using the terms "post lumbar puncture headache" and "postduralpuncture headache." Articles linked electronically to the originalassessment1 were also considered. Abstracts of articles comparingneedle types were reviewed. Full texts only of articles pertainingto diagnostic LPs were retrieved for detailed analysis. Accompanyingeditorials and related letters to the editors were reviewedfor relevant critique. Articles were classified for the qualityof the evidence that they contained, based on the American Academyof Neurology classification system (Appendix), as modified below.
In comparing atraumatic to cutting needle design, articles hadto meet the following criteria, specified in the original assessment,1to be considered class I evidence:
Prospective study design.
Randomization.
Double masking:neither patient nor evaluator of PLPHA awareof needle designused.
Equal needle diameter.
When using cutting needle,needle bevel parallel to dural fibersstated explicitly.
Styletreplaced before needle withdrawn documented explicitly.
Activeascertainment of occurrence of PLPHA by the investigators.
For the purposes of this update, any article failing in oneof these areas was automatically classified as Class IV. Theclassification of the articles and the underlying justificationare summarized in the annotated reference list and expandedselectively in the results section.
Five articles were identified initially, reporting on diagnosticLPs.2–6 Three2,3,6of these were classified as Class IVevidence. One article5 was a prospective study/case series thatdid not compare atraumatic to cutting needle types but affirmedthe importance of known demographic factors and needle size(Class II). (See annotated references.)
One Class I article4 reported 12.2% frequency of PLPHA in 115patients who had a diagnostic LP using an "atraumatic" 22G Sprotteneedle compared to 24.4% of 115 patients in whom a 22G "cutting"Quincke needle was used (p < 0.05). The mean value of theintensity of the complaint was not significantly different betweenthe two groups. The authors note that the frequencies of PLPHAin both their groups are higher than reported in other seriesdue to the relatively young age of their study population (mean40 years). While blinding of the neurologist performing theLP to needle type was part of the protocol, this may have beendifficult to maintain; however, outcome was assessed by individualsmasked to needle type, retaining the quality of the study.
One additional case series7 confirmed the importance of havingthe bevel parallel to the dural fibers, and another8 reporteda 4% frequency of PLPHA when a thin, 25-gauge atraumatic needleand a syringe were used to withdraw CSF under negative pressurefor research purposes.
The current update relies primarily on data from one Class Istudy4 in patients undergoing diagnostic LPs. It compared twospecific 22-gauge needle brands. It cannot be construed as endorsementof those brands, and the results may not be generalized to othercutting or atraumatic needle brands. The specific results maybe expressed in terms of eight patients needed to treat to preventoccurrence of PLPHA in one patient. The number of patients neededto treat to prevent one instance of PLPHA will be greater inpopulations less likely to develop PLPHA (older, male, no headacheat the time of the tap), or if smaller bore needles are compared.The reported case series8 suggests that use of small-bore, noncuttingneedles provides the lowest frequency of PLPHA. When expressedin terms of number needed to treat to prevent occurrence ofPLPHA in one patient, even the seemingly large reduction from24.4% frequency of PLPHA with a 22-gauge Quincke needle to 4%frequency with a 25-gauge atraumatic needle translates intofive patients needed to treat to prevent occurrence of PLPHAin one patient. These measures of the efficacy of atraumaticneedles in preventing PLPHAs need to be considered in lightof the greater technical expertise needed to use them, implyinga learning curve. Initially, there may be a higher failure ratewith their use. An extreme example of the learning curve isreflected in the study in which house staff beginning the neurologyrotation were taught to perform spinal taps with both needletypes.3 The procedure was abandoned in two of 99 patients, onefailing after multiple attempts with both needle types and onefailing after prolonged attempts with the cutting needle. Ofthe remaining patients, 49 patients were allocated to atraumaticneedles and 48 allocated to standard needles. More than oneattempt was required in 11 of 48 patients tapped using the standardneedle and in 18 of 49 patients using the atraumatic needle(difference not significant). LP was unsuccessful after fourattempts with the atraumatic needle in eight patients. All patientssubsequently underwent successful LP after one attempt withthe standard needle. For comparison, the LP was unsuccessfulafter four attempts in one of the 48 patients assigned to thestandard needle type. The increased risk of failure, as reflectedin need for multiple attempts with the atraumatic needle, wasrelated to body mass index (greater if >25). In contrast,there was no comment regarding failure with either needle typewhen experienced neurologists compared the two needles.4 Specialconsideration may be given to using an atraumatic needle inindividuals at greatest risk of PLPHA (e.g., younger, female,headache at the time of the tap), particularly in nonemergentsituations. Technical difficulties due to a thick ligamentumflavum may be less likely in this population. Comparisons ofopening pressures obtained with traumatic and atraumatic needlesand flow rates have been reported previously (see table 3 inCarson and Serpell9) and are comparable or favor the atraumaticbrand tested, when comparing equal-caliber needles.
New conclusion: Most studies in the anesthesiology literature,across several needle sizes, and now also one study providingClass I evidence in a patient population undergoing diagnosticLPs with a 22-gauge needle support the use of an atraumaticspinal needle to reduce the frequency of PLPHA (Type A recommendation).
Reaffirmation of a previous conclusion: Class I and ClassIIdata in the anesthesiology and the neurology literature showthat smaller needle size is associated with reduced frequencyof PLPHA (Type A recommendation).
This statement is provided as an educational service of theAmerican Academy of Neurology. It is based on an assessmentof current scientific and clinical information. It is not intendedto include all possible proper methods of care for a particularneurologic problem or all legitimate criteria for choosing touse a specific procedure. Neither is it intended to excludeany reasonable alternative methodologies. The AAN recognizesthat specific patient care decisions are the prerogative ofthe patient and the physician caring for the patient, basedon all the circumstances involved.
Class I: Prospective, randomized, controlled clinical trialwith masked outcome assessment in a representative population.The following are required:
Primary outcome(s) is(are) clearly defined.
Exclusion/inclusioncriteria are clearly defined.
Adequate accounting for dropoutsand crossovers with numberssufficiently low to have minimalpotential for bias.
Relevant baseline characteristics arepresented and substantiallyequivalent among treatment groupsor there is appropriate statisticaladjustment for differences.
Class II: Prospective matched group cohort study in a representativepopulation with masked outcome assessment that meets A throughD above OR a randomized, controlled trial in a representativepopulation that lacks one criterion A through D.
Class III: All other controlled trials including well-definednatural history controls or patients serving as own controlsin a representative population in which outcome assessment isindependently assessed or independently derived by objectiveoutcome measurement (objective outcome measurement is an outcomemeasure that is unlikely to be affected by an observer’s(patient, treating physician, investigator) expectation or bias[e.g., blood tests, administrative outcome data]).
Class IV: Evidence from uncontrolled studies, case series, casereports, or expert opinion.
Classification of recommendations
A = Established as effective, ineffective, or harmful for thegiven condition in the specified population. (Level A ratingrequires at least two consistent Class I studies.)
B = Probably effective, ineffective, or harmful for the givencondition in the specified population. (Level B rating requiresat least one Class I study or at least two consistent ClassII studies.)
C = Possibly effective, ineffective, or harmful for the givencondition in the specified population. (Level C rating requiresat least one Class II study or two consistent Class III studies.)
U = Data inadequate or conflicting given current knowledge;treatment is unproven.
Therapeutics and Technology Assessment Subcommittee members:Douglas S. Goodin, MD (Chair); Yuen T. So, MD, PhD (Vice-Chair);Carmel Armon, MD, MHS; Richard M. Dubinsky, MD, MPH: Mark Hallett,MD; David Hammond, MD; Cynthia Harden, MD; Chung Hsu, MD, PhD(ex officio); Andres M. Kanner, MD (ex officio); David S. Lefkowitz,MD; Janis Miyasaki, MD; Michael A. Sloan, MD, MS; James C. Stevens,MD.
Disclosure: The authors report no conflicts of interest.
Approved by the Therapeutics and Technology Assessment Subcommitteeon November 19, 2004; by the Practice Committee on April 13,2005; and by the AAN Board of Directors on June 26, 2005.
Received December 30, 2004. Accepted in final form May 23, 2005.
Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:909–914.[Free Full Text]
Kleyweg RP, Hertzberger LI, Carbaat PA. Significant reduction in post-lumbar puncture headache using an atraumatic needle. A double-blind, controlled clinical trial. Cephalalgia 1998;18:635–637. (Class IV evidence: unequal needle diameters [larger in the cutting needle]; direction of bevel for cutting needle not stated; LP was for caudography in the majority of patients.)
Thomas SR, Jamieson DRS, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ 2000;321:986–990. (Class IV evidence: direction of bevel for cutting needle not stated; unequal training protocols for use of the two needle types. Secondary criticism, in letters to the editor, regarding use of 20-gauge [rather than thinner] needle, with 26 of 48 patients reporting PLPHA in the "cutting" needle group and 14 of 49 in the "atraumatic" group [ITT analysis].)[Free Full Text]
Strupp M, Schueler O, Straube A, Von Stuckrad-Barre S, Brandt T. ''Atraumatic'' Sprotte needle reduces the incidence of post-lumbar puncture headaches. Neurology 2001;57:2310–2312. (Also Reply to Letter to the Editor Michael Strupp, O. Schuler, and T. Brandt [Neurology online May 3, 2002] (Class I evidence; see text.)
Vilming ST, Kloster R, Sandvik L. The importance of sex, age, needle size, height and body mass index in post-lumbar puncture headache. Cephalalgia 2001;21:738–743. (Class II: prospective study/case series: no comparison of traumatic to cutting needle types. Findings are consistent with previous reports regarding demographic and physical risk factors, and needle size.)
Aamodt A, Vedeler C. Complications after LP related to needle type: pencil-point versus Quincke. Acta Neurol Scand 2001;103:396–398. (Class IV evidence: no randomization; direction of bevel type in cutting needle not specified; nonrigorous PLPHA ascertainment protocol: equal frequency of PLPHA (23 to 24%) reported in both 22-gauge groups; severity worse in pencil-point group [small numbers, statistical significance not provided; probably NS].)
Kochanowicz J, Drozdowski W, Baniukiewicz E. Post lumbar puncture syndrome and the manner of needle insertion [in Polish]. Neurol Neurochir Pol 1999;32(suppl 6):179–182. (Abstract only reviewed. Case series analysis confirming postlumbar puncture syndrome in 7.9% in patients with bevel parallel and 19.3% of those with bevel perpendicular to dural fiber.)
Linker G, Mirza N, Manetti G, Meyer M, Putnam KT, Sunderland T. Fine-needle, negative-pressure lumbar puncture: a safe technique for collecting CSF. Neurology 2002;59:2008–2009. (Case series [N = 100]: use of a thin, 25-gauge atraumatic needle and a syringe to withdraw CSF under negative pressure for research purposes; PLPHA frequency was 4%.)
Carson D, Serpell M. Choosing the best needle for diagnostic lumbar puncture. Neurology 1996;47:33–37.[Abstract/Free Full Text]
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