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Post–Lumbar Puncture Headache and Backache in Pediatrics: A Case Series and Demonstration of Magnetic Resonance Imaging Findings

Post–Lumbar Puncture Headache and Backache in Pediatrics: A Case Series and Demonstration of... Lumbar puncture (LP) is one of the most frequently performed procedures in the pediatric emergency department (ED). Although post-LP complications have been described extensively in the adult medical literature, the exact incidence of such complications in pediatrics is unknown but is believed to be rare. In addition, there is little information pertaining to these complications in children.1 One of the first post-LP complications was reported in 1898 when August Bier, a founding father of modern anesthesia, developed a headache after undergoing spinal anesthesia.2 He postulated that this complication was due to cerebral spinal fluid (CSF) leakage at the puncture site. Other authors have suggested that post-LP headaches and backaches may be caused by epidural fluid collections.3 Complications of LPs are rare but may be life-threatening. Post-LP headache and backache are the most common complications and probably occur with greater frequency than reported because infants and many young children cannot verbalize their complaints. The following is a retrospective review of a series of children who presented to our ED with post-LP headache, backache, extremity pain, and numbness. We describe their clinical presentations, magnetic resonance imaging (MRI) studies, and treatments and discuss possible mechanisms of these complications. Patient Reports Patient 1 A 10-year-old boy presented to the ED with a 1-day history of fever, bilateral temporal and frontal headache, and an episode of emesis. Physical examination revealed an alert and oriented boy with normal neurological examination results and a supple neck. An LP was performed using a 22-gauge 212-inch needle inserted into the space between the third and fourth lumbar vertebrae (L3-4 space). Three milliliters of CSF was collected on the first attempt, and revealed 8 × 109/L white blood cells (0.69 segmented neutrophils, 0.30 lymphocytes, and 0.01 monocytes), 34 × 1012/L red blood cells, 3.3 mmol/L (60 mg/dL) glucose, 33 g/L protein, and negative Gram stain. A presumptive diagnosis of viral meningitis was made and he was discharged with instructions to return for follow-up the next day. The next day he complained of increased severity of headache, which interfered with his sleep. On physical examination he was afebrile with slight photophobia and a stiff neck. The patient received intravenous meperidine and was discharged home with instructions for bed rest and a prescription for ketorolac. He returned to the ED for a third time approximately 24 hours later with an inability to stand or sit upright due to severe back pain. He also complained of numbness in the thighs and feet when he attempted to stand upright. He had normal neurological examination results, his headache had improved, and the vomiting had resolved. Magnetic resonance imaging of the spine and head was performed. The MRI revealed an abnormal fluid collection surrounding and compressing the thecal sac in the lumbar spine (Figure 1). At follow-up 18 days later, the patient complained of numbness on the anteromedial aspect of the left calf, and had otherwise normal neurological examination results. Figure 1. View LargeDownload Sagittal (left) and axial (right) T1-weighted images (patient 1). The cauda equina roots (arrows) are compressed within the thecal sac by an abnormal fluid collection, which surrounds the sac. Patient 2 A 6-year-old boy was referred to our ED by his pediatrician for a 2-day history of headache and vomiting. He had a temperature of 38°C. An LP was performed with a 22-gauge 112-inch spinal needle placed into the L3-4 space. After 2 attempts 4.5 mL of CSF was collected revealing 39 × 109/L white blood cells (0.17 segmented neutrophils, 0.71 lymphocytes, and 0.12 monocytes), 15 × 1012/L red blood cells, 3.3 mmol/L (60 mg/dL) glucose, 27 g/L protein, and a negative Gram stain. The patient was discharged home with a diagnosis of aseptic meningitis. However, he returned to the ED the following day with complaints of back and bilateral leg pain, as well as difficulty walking because of this pain. On physical examination he had a supple neck, bilateral shin tenderness, and back pain on attempting to stand upright, but otherwise normal neurological examination results. He was discharged home receiving oral ibuprofen, only to return to the ED 1 day later with worsening back pain and inability to stand erect. Magnetic resonance imaging of the spine revealed an epidural CSF collection beginning at the L3 level and extending to the thoracic region (T11 and T12), with anterior displacement of the spinal cord (Figure 2). The patient was discharged with instructions to lie flat for 2 days. On subsequent telephone contact with the patient's family we found that his symptoms lasted another 3 days, and he returned to school 5 days after discharge from the ED. Figure 2. View LargeDownload Axial fat-suppressed T2-weighted image at the L2 level (patient 2). Abnormal bright fluid surrounds the thecal sac (arrows). Patient 3 A 15-year-old boy presented with bilateral Bell palsy, headache, backache, and a positive Lyme titer. He was referred to our ED, where an LP was performed with an 18-gauge needle. Examination of CSF revealed pleocytosis with 180 × 109/L white blood cells (0.87 lymphocytes and 0.13 monocytes). He was admitted with a diagnosis of Lyme disease with central nervous system involvement. The symptoms improved with therapy, and the patient was sent home 4 days later. The patient returned to the ED 5 days after the LP with complaints of a bifrontal headache, worse in the morning, that intensified on sitting up, accompanied by lower back pain involving the legs and hips. He had no fever or vomiting and denied neck pain or visual changes. The patient was discharged home with a diagnosis of post-LP headache. He returned to the ED 4 days later with persistence of headaches. These were relieved by lying down and were exacerbated by standing upright. A neurological consult recommended an epidural blood patch for treatment of post-LP headache. On consultation, the anesthetist believed that a blood patch was contraindicated because of the risk of introducing Lyme spirochetes into the CSF. The patient was sent home receiving naproxen sodium, with further instructions for bed rest and fluids. An MRI of the brain and spine was obtained 1 month after the LP because of persistent headaches and inability to attend school. The examination revealed thickening of the dura, attenuated basilar cisternal spaces and inferior displacement of the brainstem and cerebellum (Figure 3, left). These findings were believed to be secondary to cerebral hypovolemia due to a persistent CSF fistula at the LP site. There was also an epidural fluid collection that extended anteriorly from L3 to L4 and L5, and posteriorly from T12 through L1 and L2 (Figure 3, right). At last follow-up, 1 week later, he was still noted to have intermittent headaches, and was unable to sit upright for more than 3 hours owing to recurrence of headaches. Figure 3. View LargeDownload Left, Sagittal T1-weighted image through the midline of the cranium. The optic chiasm is displaced inferiorly (double arrows), the brainstem foreshortened, the fourth ventricle is small (short arrow), and the intracranial dura is thickened (long arrows). Right, Axial T1-weighted images at the upper lumbar level reveal compression of the cauda equina within the thecal sac (arrows) by abnormal epidural fluid. Comment Although this series is small, it is, to our knowledge, the only series of pediatric patients whose symptoms are correlated with MRI studies. The MRIs of these patients confirm that LPs can be complicated by large epidural fluid collections extending anywhere from the cauda equina to the lower thoracic region (T11 in 1 case). Furthermore, these epidural collections are capable of causing pressure on nerve roots. This compression is the most likely mechanism for the peripheral pain and numbness experienced by our patients. In 1 case (patient 1), the epidural collection was present anterior and posterior to the thecal sac. This is an expected finding as the epidural space is continuous. Gadolinium was not administered in these cases and therefore pachymeningeal enhancement, seen in other studies, is not demonstrated here.4 Headache and backache are well-recognized complications of LP.5 Headaches are thought to occur following 0.5% to 37% of LPs, and the incidence of headache is lower in those younger than 13 years.1,5-7 We cannot provide data on the incidence of post-LP headaches at our institution, although these are the only 3 patients who came to medical attention of all LPs performed during a 3-year period in our ED. The cause of these symptoms is still an area of some debate, but they are probably due to a combination of factors. One theory is that post-LP headaches may be caused by CSF leakage through a dural tear, resulting in CSF hypovolemia and downward shifting of the brain causing pressure on the pain-sensitive dural sinuses, which is amplified in the upright posture and relieved with recumbence.8 Others have postulated that post-LP headaches are due to shifts in the pressure differential within the cerebral veins and venous dilatation, which result from CSF hypovolemia caused by CSF leakage.9,10 A case series in the adult literature that demonstrated epidural CSF leaks with isotope cisternography concluded that these leaks were secondary to arachnodural rents.11 Magnetic resonance imaging findings in patient 3 were most likely due to fistula formation between the thecal sac and the epidural space with associated hypovolemic brain syndrome. This study illustrates the fact that symptoms following LP can be severe and limiting. Patient 3 required 6 days of hospitalization and persistent headaches kept him at home for weeks after the LP, although some of his symptoms were most likely due to Lyme disease. The other 2 patients were treated as outpatients with questionable success. The symptoms were self-limited, lasting from a few days to months. The effects of various drugs such as narcotics and nonsteroidal anti-inflammatory agents could not be compared owing to the small number of patients in our series. Nor could we evaluate the efficacy of invasive procedures, such as blood patching, that have been recommended in the past, since these were not attempted in any of our patients. With the use of smaller-diameter needles (eg, 22-gauge needles), the incidence of post-LP headache and backache in adults has decreased to between 5% and 25%.12,13 From the case histories of the first 2 patients in our series it is evident that serious symptoms can occur even with the use of 22-gauge needles during atraumatic LPs. The effect of the size of the needle used for the LP on the severity of the headache is unclear in our study, although the worst symptoms followed puncture by the largest needle (18 gauge). Tourtellotte et al13 and Kunkle et al9 have suggested that it is the size of the dural tear and amount of subsequent CSF leakage that determines the presence and severity of post-LP headache. A further decrease in post-LP complications has been demonstrated with the use of a 26-gauge needle13,14; however, 26-gauge needles have several potential limitations including difficulty manipulating a flexible needle in an active child, lysis of cells, and difficulty obtaining an opening pressure. The incidence of post-LP headache may also be reduced by the use of new atraumatic needles15,16 and by reinsertion of the stylet prior to removal of the LP needle at the end of the procedure.17 Also unknown are the effects of patient positioning after the LP is completed. Kunkle et al9 have suggested that CSF leakage at rates higher than 10 mL/h in an upright individual is the cause of post-LP headache. Many practitioners recommend that patients remain either in the prone or supine recumbent position for anywhere from 1 to 24 hours after LP. However, no studies to date have conclusively shown recumbency to be beneficial in the prevention of post-LP headache.6,18 None of our patients were asked to remain recumbent immediately after the performance of the LP, and it is not known whether recumbence could have prevented their symptoms. It is possible that supine positioning after LP could actually extend the caudal migration of epidural CSF fluid. Various other therapies have been attempted to provide some benefit to patients with post-LP headache; these have included epidural blood patches and infusions of saline.19,20 Some more recent controlled trials have shown intravenous caffeine to be effective in prevention of post-LP headache.21 It is postulated that the cerebral vasoconstriction caused by caffeine produces this effect. In the pediatric population, the possibility of post-LP headache and backache is not usually discussed with families when obtaining consent for LP, even though these symptoms can be debilitating. We believe that headache, backache, and peripheral nerve symptoms can be caused by CSF leaks and epidural fluid collections as demonstrated on the MRI examinations of our 3 patients. Physicians should be aware of these rare complications. References 1. Vandam LDDripps RD Long-term follow-up of patients who received 10,098 spinal anesthetics. JAMA. 1956;161586- 591Google ScholarCrossref 2. Ostheimer GW Headache in the postpartum period. Marx GFed. Clinical Management of Mother and Newborn. New York, NY Springer-Verlag NY Inc1979;27- 41Google Scholar 3. Pool JL Myeloscopy: intraspinal endoscopy. Surgery. 1942;11169- 182Google Scholar 4. Mokri BHunter SFAtkinson JLDPiepgras DG Orthostatic headaches caused by CSF leak but with normal CSF pressures. Neurology. 1998;51786- 790Google ScholarCrossref 5. Raskin NH Lumbar puncture headache: a review. Headache. 1990;30197- 200Google ScholarCrossref 6. Kuntz KMKokmen EStevens JCMiller POfford RNHo MM Post–lumbar puncture headaches: experience in 501 consecutive procedures. Neurology. 1992;421884- 1887Google ScholarCrossref 7. Orrison WWWard E Dynamic anatomy and mechanics of lumbar puncture. Int J Neuroradiol. 1995;1211- 222Google Scholar 8. Raymond JRRaymond PA Post lumbar puncture headache: etiology and management. West J Med. 1988;148551- 554Google Scholar 9. Kunkle ECRay BSWolff HG Experimental studies on headache: analysis of the headache associated with changes in intracranial pressure. Arch Neurol Psychiatry. 1935;34533- 547Google ScholarCrossref 10. Fishman RADillon WP Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology. 1993;43609- 611Google ScholarCrossref 11. Lieberman LMTourtellotte WWNewkirk TA Prolonged post-lumbar puncture cerebrospinal fluid leakage from lumbar subarachnoid space demonstrated by radioisotope myelography. Neurology. 1971;21925- 929Google ScholarCrossref 12. Spielman FJ Post lumbar puncture headache. Headache. 1982;22280- 283Google ScholarCrossref 13. Tourtellotte WWHenderson WGTucker RP et al. A randomized double-blind clinical trial comparing the 22- versus 26-gauge needle in the production of post–lumbar puncture syndrome in normal individuals. Headache. 1972;1273- 78Google ScholarCrossref 14. Wilkinson AGSellar RJMcDermott VG Comparison of side effects of myelography performed with 26-gauge and 22-gauge needles. Neuroradiology. 1991;33486- 487Google Scholar 15. Carson DSerpell M Choosing the best needle for diagnostic lumbar puncture. Neurology. 1996;4733- 37Google ScholarCrossref 16. Müller BAdelt KReichmann HTokya K Atraumatic needle reduces the incidence of post-lumbar puncture syndrome. J Neurol. 1994;241376- 380Google ScholarCrossref 17. Strupp MBrandt TMüller A Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomised prospective study of 600 patients. J Neurol. 1998;245589- 592Google ScholarCrossref 18. Hilton-Jones DHarrad RAGill MW et al. Failure of postural maneuvers to prevent lumbar puncture headache. J Neurol Neurosurg Psychiatry. 1982;45743- 746Google ScholarCrossref 19. Robbins KBPrentiss JE Prolonged headache after lumbar puncture: successful treatment with an epidural blood patch in a 12-year-old boy. Clin Pediatr. 1990;29350- 352Google ScholarCrossref 20. Heide WDiener HC Epidural blood patch reduces the incidence of post lumbar puncture headache. Headache. 1990;30280- 281Google ScholarCrossref 21. Sechzer PHAbel L Post-spinal anesthesia headache treated with caffeine, evaluation with demand method: part I. Curr Ther Res. 1978;24307- 312Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Post–Lumbar Puncture Headache and Backache in Pediatrics: A Case Series and Demonstration of Magnetic Resonance Imaging Findings

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References (25)

Publisher
American Medical Association
Copyright
Copyright © 1999 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.153.7.770
Publisher site
See Article on Publisher Site

Abstract

Lumbar puncture (LP) is one of the most frequently performed procedures in the pediatric emergency department (ED). Although post-LP complications have been described extensively in the adult medical literature, the exact incidence of such complications in pediatrics is unknown but is believed to be rare. In addition, there is little information pertaining to these complications in children.1 One of the first post-LP complications was reported in 1898 when August Bier, a founding father of modern anesthesia, developed a headache after undergoing spinal anesthesia.2 He postulated that this complication was due to cerebral spinal fluid (CSF) leakage at the puncture site. Other authors have suggested that post-LP headaches and backaches may be caused by epidural fluid collections.3 Complications of LPs are rare but may be life-threatening. Post-LP headache and backache are the most common complications and probably occur with greater frequency than reported because infants and many young children cannot verbalize their complaints. The following is a retrospective review of a series of children who presented to our ED with post-LP headache, backache, extremity pain, and numbness. We describe their clinical presentations, magnetic resonance imaging (MRI) studies, and treatments and discuss possible mechanisms of these complications. Patient Reports Patient 1 A 10-year-old boy presented to the ED with a 1-day history of fever, bilateral temporal and frontal headache, and an episode of emesis. Physical examination revealed an alert and oriented boy with normal neurological examination results and a supple neck. An LP was performed using a 22-gauge 212-inch needle inserted into the space between the third and fourth lumbar vertebrae (L3-4 space). Three milliliters of CSF was collected on the first attempt, and revealed 8 × 109/L white blood cells (0.69 segmented neutrophils, 0.30 lymphocytes, and 0.01 monocytes), 34 × 1012/L red blood cells, 3.3 mmol/L (60 mg/dL) glucose, 33 g/L protein, and negative Gram stain. A presumptive diagnosis of viral meningitis was made and he was discharged with instructions to return for follow-up the next day. The next day he complained of increased severity of headache, which interfered with his sleep. On physical examination he was afebrile with slight photophobia and a stiff neck. The patient received intravenous meperidine and was discharged home with instructions for bed rest and a prescription for ketorolac. He returned to the ED for a third time approximately 24 hours later with an inability to stand or sit upright due to severe back pain. He also complained of numbness in the thighs and feet when he attempted to stand upright. He had normal neurological examination results, his headache had improved, and the vomiting had resolved. Magnetic resonance imaging of the spine and head was performed. The MRI revealed an abnormal fluid collection surrounding and compressing the thecal sac in the lumbar spine (Figure 1). At follow-up 18 days later, the patient complained of numbness on the anteromedial aspect of the left calf, and had otherwise normal neurological examination results. Figure 1. View LargeDownload Sagittal (left) and axial (right) T1-weighted images (patient 1). The cauda equina roots (arrows) are compressed within the thecal sac by an abnormal fluid collection, which surrounds the sac. Patient 2 A 6-year-old boy was referred to our ED by his pediatrician for a 2-day history of headache and vomiting. He had a temperature of 38°C. An LP was performed with a 22-gauge 112-inch spinal needle placed into the L3-4 space. After 2 attempts 4.5 mL of CSF was collected revealing 39 × 109/L white blood cells (0.17 segmented neutrophils, 0.71 lymphocytes, and 0.12 monocytes), 15 × 1012/L red blood cells, 3.3 mmol/L (60 mg/dL) glucose, 27 g/L protein, and a negative Gram stain. The patient was discharged home with a diagnosis of aseptic meningitis. However, he returned to the ED the following day with complaints of back and bilateral leg pain, as well as difficulty walking because of this pain. On physical examination he had a supple neck, bilateral shin tenderness, and back pain on attempting to stand upright, but otherwise normal neurological examination results. He was discharged home receiving oral ibuprofen, only to return to the ED 1 day later with worsening back pain and inability to stand erect. Magnetic resonance imaging of the spine revealed an epidural CSF collection beginning at the L3 level and extending to the thoracic region (T11 and T12), with anterior displacement of the spinal cord (Figure 2). The patient was discharged with instructions to lie flat for 2 days. On subsequent telephone contact with the patient's family we found that his symptoms lasted another 3 days, and he returned to school 5 days after discharge from the ED. Figure 2. View LargeDownload Axial fat-suppressed T2-weighted image at the L2 level (patient 2). Abnormal bright fluid surrounds the thecal sac (arrows). Patient 3 A 15-year-old boy presented with bilateral Bell palsy, headache, backache, and a positive Lyme titer. He was referred to our ED, where an LP was performed with an 18-gauge needle. Examination of CSF revealed pleocytosis with 180 × 109/L white blood cells (0.87 lymphocytes and 0.13 monocytes). He was admitted with a diagnosis of Lyme disease with central nervous system involvement. The symptoms improved with therapy, and the patient was sent home 4 days later. The patient returned to the ED 5 days after the LP with complaints of a bifrontal headache, worse in the morning, that intensified on sitting up, accompanied by lower back pain involving the legs and hips. He had no fever or vomiting and denied neck pain or visual changes. The patient was discharged home with a diagnosis of post-LP headache. He returned to the ED 4 days later with persistence of headaches. These were relieved by lying down and were exacerbated by standing upright. A neurological consult recommended an epidural blood patch for treatment of post-LP headache. On consultation, the anesthetist believed that a blood patch was contraindicated because of the risk of introducing Lyme spirochetes into the CSF. The patient was sent home receiving naproxen sodium, with further instructions for bed rest and fluids. An MRI of the brain and spine was obtained 1 month after the LP because of persistent headaches and inability to attend school. The examination revealed thickening of the dura, attenuated basilar cisternal spaces and inferior displacement of the brainstem and cerebellum (Figure 3, left). These findings were believed to be secondary to cerebral hypovolemia due to a persistent CSF fistula at the LP site. There was also an epidural fluid collection that extended anteriorly from L3 to L4 and L5, and posteriorly from T12 through L1 and L2 (Figure 3, right). At last follow-up, 1 week later, he was still noted to have intermittent headaches, and was unable to sit upright for more than 3 hours owing to recurrence of headaches. Figure 3. View LargeDownload Left, Sagittal T1-weighted image through the midline of the cranium. The optic chiasm is displaced inferiorly (double arrows), the brainstem foreshortened, the fourth ventricle is small (short arrow), and the intracranial dura is thickened (long arrows). Right, Axial T1-weighted images at the upper lumbar level reveal compression of the cauda equina within the thecal sac (arrows) by abnormal epidural fluid. Comment Although this series is small, it is, to our knowledge, the only series of pediatric patients whose symptoms are correlated with MRI studies. The MRIs of these patients confirm that LPs can be complicated by large epidural fluid collections extending anywhere from the cauda equina to the lower thoracic region (T11 in 1 case). Furthermore, these epidural collections are capable of causing pressure on nerve roots. This compression is the most likely mechanism for the peripheral pain and numbness experienced by our patients. In 1 case (patient 1), the epidural collection was present anterior and posterior to the thecal sac. This is an expected finding as the epidural space is continuous. Gadolinium was not administered in these cases and therefore pachymeningeal enhancement, seen in other studies, is not demonstrated here.4 Headache and backache are well-recognized complications of LP.5 Headaches are thought to occur following 0.5% to 37% of LPs, and the incidence of headache is lower in those younger than 13 years.1,5-7 We cannot provide data on the incidence of post-LP headaches at our institution, although these are the only 3 patients who came to medical attention of all LPs performed during a 3-year period in our ED. The cause of these symptoms is still an area of some debate, but they are probably due to a combination of factors. One theory is that post-LP headaches may be caused by CSF leakage through a dural tear, resulting in CSF hypovolemia and downward shifting of the brain causing pressure on the pain-sensitive dural sinuses, which is amplified in the upright posture and relieved with recumbence.8 Others have postulated that post-LP headaches are due to shifts in the pressure differential within the cerebral veins and venous dilatation, which result from CSF hypovolemia caused by CSF leakage.9,10 A case series in the adult literature that demonstrated epidural CSF leaks with isotope cisternography concluded that these leaks were secondary to arachnodural rents.11 Magnetic resonance imaging findings in patient 3 were most likely due to fistula formation between the thecal sac and the epidural space with associated hypovolemic brain syndrome. This study illustrates the fact that symptoms following LP can be severe and limiting. Patient 3 required 6 days of hospitalization and persistent headaches kept him at home for weeks after the LP, although some of his symptoms were most likely due to Lyme disease. The other 2 patients were treated as outpatients with questionable success. The symptoms were self-limited, lasting from a few days to months. The effects of various drugs such as narcotics and nonsteroidal anti-inflammatory agents could not be compared owing to the small number of patients in our series. Nor could we evaluate the efficacy of invasive procedures, such as blood patching, that have been recommended in the past, since these were not attempted in any of our patients. With the use of smaller-diameter needles (eg, 22-gauge needles), the incidence of post-LP headache and backache in adults has decreased to between 5% and 25%.12,13 From the case histories of the first 2 patients in our series it is evident that serious symptoms can occur even with the use of 22-gauge needles during atraumatic LPs. The effect of the size of the needle used for the LP on the severity of the headache is unclear in our study, although the worst symptoms followed puncture by the largest needle (18 gauge). Tourtellotte et al13 and Kunkle et al9 have suggested that it is the size of the dural tear and amount of subsequent CSF leakage that determines the presence and severity of post-LP headache. A further decrease in post-LP complications has been demonstrated with the use of a 26-gauge needle13,14; however, 26-gauge needles have several potential limitations including difficulty manipulating a flexible needle in an active child, lysis of cells, and difficulty obtaining an opening pressure. The incidence of post-LP headache may also be reduced by the use of new atraumatic needles15,16 and by reinsertion of the stylet prior to removal of the LP needle at the end of the procedure.17 Also unknown are the effects of patient positioning after the LP is completed. Kunkle et al9 have suggested that CSF leakage at rates higher than 10 mL/h in an upright individual is the cause of post-LP headache. Many practitioners recommend that patients remain either in the prone or supine recumbent position for anywhere from 1 to 24 hours after LP. However, no studies to date have conclusively shown recumbency to be beneficial in the prevention of post-LP headache.6,18 None of our patients were asked to remain recumbent immediately after the performance of the LP, and it is not known whether recumbence could have prevented their symptoms. It is possible that supine positioning after LP could actually extend the caudal migration of epidural CSF fluid. Various other therapies have been attempted to provide some benefit to patients with post-LP headache; these have included epidural blood patches and infusions of saline.19,20 Some more recent controlled trials have shown intravenous caffeine to be effective in prevention of post-LP headache.21 It is postulated that the cerebral vasoconstriction caused by caffeine produces this effect. In the pediatric population, the possibility of post-LP headache and backache is not usually discussed with families when obtaining consent for LP, even though these symptoms can be debilitating. We believe that headache, backache, and peripheral nerve symptoms can be caused by CSF leaks and epidural fluid collections as demonstrated on the MRI examinations of our 3 patients. Physicians should be aware of these rare complications. References 1. Vandam LDDripps RD Long-term follow-up of patients who received 10,098 spinal anesthetics. JAMA. 1956;161586- 591Google ScholarCrossref 2. Ostheimer GW Headache in the postpartum period. Marx GFed. Clinical Management of Mother and Newborn. New York, NY Springer-Verlag NY Inc1979;27- 41Google Scholar 3. Pool JL Myeloscopy: intraspinal endoscopy. Surgery. 1942;11169- 182Google Scholar 4. Mokri BHunter SFAtkinson JLDPiepgras DG Orthostatic headaches caused by CSF leak but with normal CSF pressures. Neurology. 1998;51786- 790Google ScholarCrossref 5. Raskin NH Lumbar puncture headache: a review. Headache. 1990;30197- 200Google ScholarCrossref 6. Kuntz KMKokmen EStevens JCMiller POfford RNHo MM Post–lumbar puncture headaches: experience in 501 consecutive procedures. Neurology. 1992;421884- 1887Google ScholarCrossref 7. Orrison WWWard E Dynamic anatomy and mechanics of lumbar puncture. Int J Neuroradiol. 1995;1211- 222Google Scholar 8. Raymond JRRaymond PA Post lumbar puncture headache: etiology and management. West J Med. 1988;148551- 554Google Scholar 9. Kunkle ECRay BSWolff HG Experimental studies on headache: analysis of the headache associated with changes in intracranial pressure. Arch Neurol Psychiatry. 1935;34533- 547Google ScholarCrossref 10. Fishman RADillon WP Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology. 1993;43609- 611Google ScholarCrossref 11. Lieberman LMTourtellotte WWNewkirk TA Prolonged post-lumbar puncture cerebrospinal fluid leakage from lumbar subarachnoid space demonstrated by radioisotope myelography. Neurology. 1971;21925- 929Google ScholarCrossref 12. Spielman FJ Post lumbar puncture headache. Headache. 1982;22280- 283Google ScholarCrossref 13. Tourtellotte WWHenderson WGTucker RP et al. A randomized double-blind clinical trial comparing the 22- versus 26-gauge needle in the production of post–lumbar puncture syndrome in normal individuals. Headache. 1972;1273- 78Google ScholarCrossref 14. Wilkinson AGSellar RJMcDermott VG Comparison of side effects of myelography performed with 26-gauge and 22-gauge needles. Neuroradiology. 1991;33486- 487Google Scholar 15. Carson DSerpell M Choosing the best needle for diagnostic lumbar puncture. Neurology. 1996;4733- 37Google ScholarCrossref 16. Müller BAdelt KReichmann HTokya K Atraumatic needle reduces the incidence of post-lumbar puncture syndrome. J Neurol. 1994;241376- 380Google ScholarCrossref 17. Strupp MBrandt TMüller A Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomised prospective study of 600 patients. J Neurol. 1998;245589- 592Google ScholarCrossref 18. Hilton-Jones DHarrad RAGill MW et al. Failure of postural maneuvers to prevent lumbar puncture headache. J Neurol Neurosurg Psychiatry. 1982;45743- 746Google ScholarCrossref 19. Robbins KBPrentiss JE Prolonged headache after lumbar puncture: successful treatment with an epidural blood patch in a 12-year-old boy. Clin Pediatr. 1990;29350- 352Google ScholarCrossref 20. Heide WDiener HC Epidural blood patch reduces the incidence of post lumbar puncture headache. Headache. 1990;30280- 281Google ScholarCrossref 21. Sechzer PHAbel L Post-spinal anesthesia headache treated with caffeine, evaluation with demand method: part I. Curr Ther Res. 1978;24307- 312Google Scholar

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Jul 1, 1999

Keywords: magnetic resonance imaging,back pain,headache,pediatrics,diagnostic spinal puncture

There are no references for this article.