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PubMed2003

Post-dural puncture headache: pathogenesis, prevention and treatment.

Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.

Anesthesia, Spinal↗

PubMed2001

Anterior stromal puncture in the treatment of bullous keratopathy: six-month follow-up.

PURPOSE: This study was designed to evaluate the effect of anterior stromal puncture to treat patients with symptomatic bullous keratopathy. METHODS: Fourteen patients with bullous keratopathy who had decreased vision and were or were not awaiting penetrating keratoplasty were evaluated before and 1, 4, 12, and 24 weeks after anterior stromal punctures with a 25-gauge needle. The patients were questioned about pain intensity, foreign-body sensation, and photophobia. Biomicroscopy, esthesiometry, and pachymetry results were evaluated. The results before and after the punctures were compared using the McNemar test, Friedman test, and multiple comparison tests. RESULTS: The comparisons among before and 1, 4, and 12 weeks after the anterior stromal puncture of pain (p = 0.00000556), photophobia (p = 0.0252), foreign-body sensation (p = 0.0000743), and esthesiometry (p = 0.0243) showed significant statistical differences in terms of decreasing symptoms and corneal sensitivity. The average pachymetry did not show statistical difference among before and 1, 4, 12, and 24 weeks after the procedure (p = 0.956). We did not find important differences in terms of corneal neovascularization. CONCLUSION: Anterior stromal puncture is an effective, simple, and low-cost alternative for treating patients with symptomatic bullous keratopathy.

Adult↗

PubMed1990

Complications of lateral C1-2 puncture myelography.

This study reviewed the technical complication of 112 cases of lateral C1-2 puncture myelography for cervical spinal cord disorders. Spinal cord puncture and contrast injection, puncture between the occiput and C1, and blood vessel puncture were the main complications. These principally depended on the positioning of the patient's neck (hyperextension) and misdirection of the x-ray beam. For preventing major arterial puncture, the authors also reviewed 164 vertebral angiograms and determined the pathway of the vertebral arteries and the incidence of anomaly.

Female↗

PubMed1999

Nerve root herniation secondary to lumbar puncture in the patient with lumbar canal stenosis. A case report.

STUDY DESIGN: A very rare case of nerve root herniation secondary to lumbar puncture is reported. OBJECTIVE: To describe the characteristic clinical features of this case and to discuss a mechanism of the nerve root herniation. SUMMARY OF BACKGROUND DATA: There has been no previous report of nerve root herniation secondary to lumbar puncture. METHODS: A 66-year-old woman who experienced intermittent claudication as a result of sciatic pain on her right side was evaluated by radiography and magnetic resonance imaging, the results of which demonstrated central-type canal stenosis at L4-L5. The right sciatic pain was exacerbated after lumbar puncture. Myelography and subsequent computed tomography showed marked stenosis of the thecal sac that was eccentric to the left, unlike the previous magnetic resonance imaging finding. RESULTS: At surgery, a herniated nerve root was found through a small rent of the dorsocentral portion of the thecal sac at L4-L5, presenting a loop with epineural bleeding. The herniated nerve root was put back into the intrathecal space, and the dural tear was repaired. CONCLUSION: Lumbar puncture can be a cause of nerve root herniation in cases of lumbar canal stenosis. The puncture should not be carried out at an area of stenosis.

Aged↗

PubMed2005

Does prenatal diagnosis influence the morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety after endoscopic puncture of ureterocele?

PURPOSE: We compared long-term morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety of a duplex system in children with prenatal vs postnatal diagnosis of ureterocele who underwent endoscopic puncture. MATERIALS AND METHODS: A total of 48 children underwent primary endoscopic puncture of duplex system ureterocele. Of the cases 35 (73%) were diagnosed prenatally (group 1) and 13 (27%) postnatally (group 2). Median age at time of puncture was 4 months in group 1 and 3.5 years in group 2. A total of 20 patients in group 1 (57%) and 8 in group 2 (62%) presented with intravesical ureterocele, while 15 in group 1 (43%) and 5 in group 2 (38%) had ectopic ureterocele. A total of 20 children in group 1 (57%) and 7 in group 2 (54%) had a nonfunctioning renal moiety, and 15 in group 1 (43%) and 6 in group 2 (46%) had a poorly functioning ureterocele moiety. Vesicoureteral reflux (VUR) was present in 23 children in group 1 (66%) comprising 30 renal refluxing units (RRUs), and in 12 in group 2 (92%) comprising 14 RRUs. Median followup was 9 years (range 1 to 15) for both groups. RESULTS: Preoperative urinary tract infection (UTI) was common in group 2 (92%) vs group 1 (20%). No patient in group 1 had development of UTI after puncture, while 23% of the children in group 2 presented with UTI. Four children (2 from each group) with ectopic ureterocele required secondary puncture resulting in satisfactory drainage. A total of 14 RRUs (47%) showed spontaneous resolution of VUR in group 1 compared to 3 (21%) in group 2. Four RRUs (13%) required endoscopic correction due to high grade VUR in group 1. Two RRUs (17%) were treated with endoscopic correction and 2 (17%) with ureteral reimplantation due to UTI in group 2. Only 1 patient in group 1 underwent nephrectomy due to nonfunctioning kidney, while 2 patients in group 2 required partial nephrectomy due to UTI. CONCLUSIONS: Our data reveal that prenatal diagnosis of duplex system ureterocele is associated with fewer UTIs, and early endoscopic management may decrease UTI and the need for additional surgery. Nonfunctioning or poorly functioning renal moieties left in situ following successful endoscopic decompression of ureterocele are not associated with additional morbidity and do not require partial nephrectomy in the majority of the cases.

Age Factors↗

PubMed2005

Patterns of innervation of the anterior maxilla: a cadaver study with relevance to canine fossa puncture of the maxillary sinus.

OBJECTIVES/HYPOTHESIS: Complications from canine fossa puncture of the maxillary sinus are caused by damage to the anterior superior alveolar nerve (ASAN) and the middle superior alveolar nerve (MSAN). The aim of this study was to elucidate the pattern of ASAN and MSAN within the anterior maxilla and to secondly determine suitable surgical landmarks to aid in accurately localizing the area of the canine fossa least likely to produce complications when a trocar is passed into the maxillary sinus. METHODS: Anatomic dissection of the anterior face of the maxilla from 20 cadaver heads was performed. The pattern and presence of the ASAN and MSAN was identified on each side and tabulated. Landmarks for the safest entry point for canine fossa puncture were determined, and each side had a puncture placed using these landmarks. Any disruption of nerves was noted. RESULTS: Multiple differing patterns of ASAN were identified. The ASAN emerged from its foramen as a single trunk in 30 (75%) sides and in a double trunk in 10 (25%). In 24 (60%), single or multiple branches from the ASAN trunks were identified. A MSAN was identified in 9 (23%) maxillae. The safest entry point for a canine fossa puncture was where a vertical line drawn through the mid-pupillary line was bisected by a horizontal line drawn through the floor of the pyriform aperture. CONCLUSIONS: There is significant variation in the pattern of ASAN and MSAN within the anterior face of the maxilla. By using the newly described landmarks when performing a canine fossa puncture, there is reduced risk of damage to these nerves and provides a reliable point to enter the maxillary sinus.

Cadaver↗

PubMed1994

Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia.

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post-dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n = 17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n = 13) patients had an immediate conversion to spinal anaesthesia and received post-caesarean section continuous intrathecal patient-controlled analgesia consisting of fentanyl 5 micrograms.ml-1 with bupivacaine 0.25 mg.ml-1 and epinephrine 2 micrograms.ml-1 with catheterization lasting > 24 h. No parturient in group III developed a PDPH. This was substantially lower (P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.

Adult↗

PubMed2005

Effects on intracranial pressure of dural puncture in supine and head-elevated positions. A study on the cat.

BACKGROUND: Lumbar dural puncture may reduce intracranial pressure (ICP) due to a hydrostatic pressure gradient created by distal opening of the spinal fluid column towards the atmosphere. The magnitude of the reduction in hydrostatic force on the brain should depend on the vertical distance between the brain and the dural opening, and thus will increase by head elevation. No studies have analyzed ICP after dural puncture in supine and upright positions. METHODS: This study on the cat records ICP, mean arterial pressure, and central venous pressure before and after dural puncture in supine and head-elevated positions. The dural puncture was performed at a level corresponding to the lumbar region. RESULTS: Initially ICP was 10.9 +/- 1.9 mmHg (mean +/- SD), which decreased to 5.1 +/- 2.0 mmHg after 24.5 cm (18 mmHg) of head elevation (n = 7). Intracranial pressure decreased to 5.2 +/-3.5 mmHg following dural puncture in the supine position and to -11.3 +/- 4.2 mmHg after the head elevation (n = 7). Active drainage of CSF fluid in the supine position in a volume similar to that spontaneously drained after head elevation reduced ICP by 2.0 +/- 0.5 mmHg (n = 3). CONCLUSIONS: The results show that a significant ICP reduction may occur following opening of the spinal canal. The reduction can be explained more by hydrostatic forces than by loss of CSF; also explaining why it is more significant when upright than supine. The decrease in ICP increases transvascular pressure, which may induce the disappearance of the normally present subdural venous collapse with an increase in venous blood volume.

Animals↗

PubMed1995

Role of routine lumbar puncture in neonatal sepsis.

OBJECTIVE: To evaluate the utility of lumbar puncture done routinely as part of complete workup in neonatal sepsis. METHODOLOGY: Two hundred and nine consecutive lumbar punctures performed in 169 neonates were prospectively evaluated for the diagnosis of meningitis over a 6 month period in a tertiary care referral neonatal unit. RESULTS: Among babies with 'suspected clinical sepsis', five (3.3%) were diagnosed to have meningitis. None of the clinically normal babies with high risk obstetric factors alone had meningitis. The lumbar puncture was traumatic in 22.9%, and in 26.3% the fluid obtained was inadequate for complete analysis. The results were inconclusive in 37% of the cases. CONCLUSION: Based on this study, routine lumbar puncture may not be required in clinically normal newborns with adverse obstetric factors. In babies with clinical sepsis, though the yield is not very high; there are no reliable clinical or laboratory markers to predict which babies will have meningitis and hence these babies would warrant a lumbar puncture.

Birth Weight↗

PubMed1996

Comparison of 25 G and 29 G Quincke spinal needles in paediatric day case surgery. A prospective randomized study of the puncture characteristics, success rate and postoperative complaints.

A comparison of a 25 G with a 29 G Quincke needle was performed in paediatric day case surgery. Sixty healthy children aged 1 year to 13 years were randomly allocated to have spinal anaesthesia with either 25 G or 29 G Quincke needle without an introducer needle. There was a failure rate of 10% with the 29 G spinal needle compared with 0% with the 25 G needle. The time needed to perform dural puncture was shorter using 25 G than 29 G needle, 22 (+/- 31)(SD) vs 59 (+/- 63) s. The time taken for cerebrospinal fluid to appear at the needle hub was also longer, 4 (+/- 3) vs 8 (+/- 5) s. The number of puncture attempts was similar, 1.2 (+/- 0.6) vs 1.4 (+/- 0.8), with 25 G and 29 G needle. Low back pain, 5 vs1, and nonpositional headache, 2 vs 4, after 25 G and 29 G needles, respectively, were the most frequent postoperative complaints. Mild postdural puncture headache occurred in one eight year old male patient in the 25 G group. In conclusion, lumbar puncture without introducer needle was possible with both needles. The puncture characteristics favoured the 25 G needle. A shorter needle could partly alleviate the difficulties with the 29 G needle.

Adolescent↗

PubMed2004

Audio-Doppler guidance using a small-caliber Doppler probe for internal jugular venous puncture for central venous catheterization in infants and children.

BACKGROUND: We evaluated an audio-Doppler with a small-caliber probe as a guide for central venous cannulation (CVC) via the internal jugular vein (IJV) in infants and children. METHODS: The right IJV was located with a small-caliber (2.0 mm in diameter) audio-Doppler probe using 10 MHz ultrasound. The probe was placed on the neck about the level of sixth cervical vertebra and was moved until the crisp pulsatile sound of the carotid artery was identified. Then the probe was moved laterally to identify the low-pitched venous hum of the right IJV. After marking the puncture site on the skin, a sterile cannulation procedure was performed. Ultimate success rate, cannulation time < 10 min, successful cannulation within three punctures, and complications were recorded. RESULTS: Ultimate success rate was 65.6% (42/64) in infants (< 12 m), and 94.7% (72/76) in children (12 m or older). Cannulation time < 10 min was 48.4% in infants, and 85.5% in children. Successful cannulation within three punctures was 45.3% in infants and 82.8% in children. Three carotid arterial punctures occurred. CONCLUSIONS: We were not able to demonstrate absolute superiority of the results utilizing this device over the reported results of traditional landmark techniques for CVC via the right IJV. However, this device may contribute to reducing complications and be of value in teaching residents where to insert a needle for an internal jugular puncture.

Anesthesia, General↗

PubMed1992

Percutaneous introduction of left atrial cannula for left heart bypass: utility of biplane transesophageal echocardiographic guidance for transseptal puncture.

For introduction of a left atrial (LA) cannula by the transseptal puncture technique, we examined the feasibility of using biplane transesophageal echocardiography (B-TEE). A transseptal puncture was performed on 15 patients (3 male; 12 female; mean age, 48.9 +/- 11.2 years) by B-TEE guide during percutaneous transvenous mitral comissurotomy (PTMC). The entire Brocken-brough needle and the position of its tip were clearly observed in the right atrium by a longitudinal image of B-TEE in all patients (100%), and in 2 (13%) of them also by the transverse image of B-TEE. The puncture was about 1 cm caudal from the center of the fossa ovalis to avoid any large residual atrial septal defect. After transseptal puncture, a Mullin's sheath (7 Fr) and a dilator (14 Fr) were inserted into the left atrium in order, and then an Inoue's balloon catheter (12 Fr) was introduced without difficulty into the left atrium in all patients. With contrast injection, the position of the sheaths's tip was clearly confirmed by B-TEE. Left heart bypass support (left atrial-femoral artery bypass or AAB) was performed on 2 patients after percutaneous introduction of the LA cannula using this technique, and both were successfully supported and survived. With B-TEE guidance, the Brockenbrough atrial septal puncture and introduction of the LA cannula into left atrium can be performed easily. Thus, percutaneous left heart bypass can be set up quickly and safely even in an intensive care unit or outpatient emergency room without radiographic guidance.

Adult↗

PubMed2006

Novel robotic catheter remote control system: feasibility and safety of transseptal puncture and endocardial catheter navigation.

OBJECTIVES: The aims of this study were to demonstrate the safety and the feasibility of the robotic catheter remote control system (CCS) in endocardial navigation in all cardiac chambers, as well as facilitation of the transseptal puncture. BACKGROUND: CCS has been developed to facilitate control and precise positioning of catheters within the cardiovascular system. METHODS: CCS consists of a remote catheter manipulator, a set up joint, a physician workstation, and a steerable guide catheter (SGC) and sheath. A conventional 4-mm tip catheter was inserted through the SGC to perform mapping of five predefined targets in each cardiac chamber. Seven mongrel dogs were used in this study. Intracardiac echocardiography and three-dimensional (3-D) electroanatomical mapping were integrated with CCS to facilitate catheter manipulation and to guide transseptal puncture. The time to complete the transseptal puncture and the time to complete access to the predefined targets in each cardiac chamber were measured. Gross and microscopic examinations of the accessed and ablation sites were performed to evaluate safety. RESULTS: Transseptal puncture was performed successfully in all animals with a mean time of 7 +/- 3 minutes. Procedure times to access the five targets in the right atrium, right ventricle, left atrium, and left ventricle were 5.6 +/- 1.7, 4.6 +/- 1.5, 13.5 +/- 11.0, 7.0 +/- 2.9 minutes, respectively. There were no intracardiac damages associated with catheter manipulation noted in the excised hearts. CONCLUSIONS: Endocardial catheter navigation and mapping using the robotic catheter remote control is safe and feasible. Moreover, the CCS could be used to perform transseptal puncture and left atrial instrumentation.

Animals↗

PubMed2006

Post lumbar puncture headache: diagnosis and management.

Lumbar puncture is a frequently performed procedure in medical emergencies and anaesthesia. Headache after lumbar puncture is a common occurrence (32%) and carries a considerable morbidity, with symptoms lasting for several days, at times severe enough to immobilize the patient. If untreated, it can result in serious complications such as subdural haematoma and seizures, which could be fatal. Certain factors contribute to the development of headache after lumbar puncture. If these factors are taken into consideration, the incidence of headache could be markedly reduced. It is therefore important that the doctors are aware of the methods available for reducing the incidence of headaches after lumbar puncture. On the other hand, there are several misconceptions that are thought to decrease the incidence of headaches with no scientific basis. This article reviews the scientific literature and highlights the practical issues involved in the diagnosis and management of headaches after lumbar puncture, including the epidural blood patch treatment.

Blood Patch, Epidural↗

PubMed1991

Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar puncture.

Computed tomography demonstrated acute hydrocephalus less than or equal to 72 hours after subarachnoid hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. With the exception of three patients, all 104 patients received antifibrinolytic treatment. Delayed clinical deterioration from acute hydrocephalus occurred in seven (29%) of the 24 patients with acute hydrocephalus on admission and in six (8%) of the remaining 80 patients. Serial lumbar puncture was performed in 17 patients. Twelve (71%) of the 17 patients treated with serial lumbar puncture, including 10 (77%) of the 13 patients with delayed deterioration from acute hydrocephalus after admission, achieved improvement in the level of consciousness. Four of these 17 patients (4% of all 104 patients) required an internal shunt. No patient deteriorated from coning following serial lumbar puncture. The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic patients with serial lumbar puncture was not higher than the rate in those without hydrocephalus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage.

Acute Disease↗

PubMed1979

The effects of unanesthetized arterial puncture on PCO2 and pH.

Painful unanesthetized arterial puncture may produce transient hyperventilation, and this hyperventilation might alter resting values of arterial pH and PCO2. We investigated this possibility by comparing pH and PCO2 values of blood samples obtained by arterial puncture with values of arterialized venous blood obtained by a painless method. In 19 consecutive subjects, virtually no difference in pH or PCO2 resulted from an arterial puncture that could not be attributed to the inherent precision of the measuring instrument. Mean +/- SEM pH was identical (7.45 +/- 0.05) both before and during an arterial puncture, as was PCO2 (34.4 +/- 1.2 mm Hg). The variation (SD) in PCO2 within an individual subject was +/- 1.7 mm Hg, which was almost identical to the inherent precision of the Radiometer ABL-2 acid base laboratory (SD, +/- 1.32). We conclude that an unanesthetized arterial puncture provides an accurate measurement of resting pH and PCO2.

Anxiety↗

PubMed1990

Prolonged headache after lumbar puncture. Successful treatment with an epidural blood patch in a 12-year-old boy.

A case is presented of a 12-year-old boy with a post-lumbar puncture headache of 6 weeks duration that was treated successfully with an epidural blood patch. Post-lumbar puncture headache in children is an uncommon event. The incidence can be reduced by using a spinal needle no larger than 22 gauge to minimize the size of the dural puncture and subsequent leak of CSF. When a post-lumbar puncture headache occurs, conservative treatment with bedrest, hydration, analgesics, and psychologic support is usually all that is required. When a post-lumbar puncture headache lasts more than 1 week and other diagnoses have been excluded, an epidural blood patch performed by an experienced physician usually provides prompt and complete relief of symptoms with minimal risk.

Blood↗

PubMed1983

The management of headache following accidental dural puncture in obstetric patients.

The progress and management of fifty-eight obstetric patients who received an accidental dural puncture is described. Headache attributable to dural puncture occurred in 85% of patients managed conservatively. Epidural infusion or repeat epidural bolus injections of saline after delivery reduced the incidence to 65%. A therapeutic autologous blood patch using 8-10 ml of blood was performed in 28 patients at least 24 hours after the accidental puncture. Dramatic and permanent relief occurred in 75% following this procedure. A repeat blood patch was effective in four patients and ineffective in the remaining two. Mild and temporary back stiffness and one case of moderately severe radicular pain for three days were the only complications noted after the procedure. The pathophysiology and treatment of dural puncture headache is reviewed. Reduction of pressure differential across the dural puncture site is most useful in the first 24-48 hours. Persistent and severe headache occurring after this should be treated with blood patch.

Anesthesia, Epidural↗