Thursday, 29 September 2011

How common do post-LP headaches occur in research subjects?


Objective: To determine the frequency and risk factors of post-LP headache (PLPH) in research volunteers. 

Background: Despite increasing interest in measuring cerebrospinal fluid (CSF) biomarkers to investigate disease pathogenesis and diagnosis, previous case series have evaluated lumbar puncture (LP) safety only in clinical care. PLPH is a common complication after LP. 

Methods: We determined the frequency of PLPH in adults volunteering for research, as well as the variables associated with the development of PLPH. Variables studied were body mass index (BMI), HIV serostatus, volume of CSF removed, number of previous LPs, use of pre-medication, LP position, lumbar space, number of needle passes, whether or not aspiration was used and several CSF variables.  

Results: Of 675 LPs performed over 1 year, headache developed in 38 subjects (5.6%). Most PLPH (92%) resolved spontaneously or with conservative medical management; 3 required epidural blood patch. Greater headache risk was associated with lower BMI (BMI ≤25) and less prior LP experience (previous LPs). PLPH was not related to CSF volume removed or gender. 

Conclusion: In this study, where tolerance to risk was low because LPs were done for research rather than clinical purposes and healthy controls were included, adverse effects were mild and self-limited.

"This study is reassuring in that the incidence of post-LP headache is lower than the figure we normally quote subjects, i.e. 10%. In addition, the majority resolved spontaneously."

"An epidural blood patch is when we inject fresh blood taken from your arm into the space around the lower spine. The blood then clots and seals off the hole through witch the spinal fluid leaks. This is a very simple procedure."
Epidural blood patch

14 comments:

  1. My slim son had 2 LP's done, the first at a regional neurological centre, the second at a London hospital. After the first he had an LP headache. When he rang the neuro centre he was told to take paracetemols and go to see his GP if it persisted. This was 4 years ago. It resolved itself after 10 days of staying horizontal most of the time, otherwise he had headaches and was sick. He was really put off having a further LP- but did, and it was no problem. Also I thought the use of an atraumatic needle was important- unless everyone uses one now?

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  2. Re: "Also I thought the use of an atraumatic needle was important- unless everyone uses one now?"

    No not at all; we still use traumatic needles if we need to measure the spinal fluid pressure and most NHS hospitals still use traumatic needles as they are cheap. The latter is false economy as the treatment of complications from traumatic needles costs a fortune. Believe it or not we are currently doing an audit at our hospital to prove that atraumatic needles are cost-effective. Talk about reinventing the wheel.

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  3. I had my only LP done over three years ago. It was done privately and I was told at the time that having it done privately meant that the new needle could be used. I didn't really realise the significance of it until much later down the line, after I'd spoken with other MS'ers post-diagnosis who have had some awful experiences.

    The most I got was a backache, which was manageable with painkillers (I used strong cocodamol). However, I know people like the poster above who were literally flat on their backs for 5-10 days because the pain from the headache (which, I've been told paracetmol hardly begins to touch!) was so bad they felt they were going to pass out or be sick.

    I'd propose that those powers that make the decision that atraumatic needles are too expensive should be given an LP with the traumatic needle and see how they like being in the amount of pain the post-LP headache can bring!

    PS. I completely agree, Prof G, about your comment about false economy. I know people who had to be readmitted after their LP because of complications, taking up often scarce hospital resources that could be avoided.

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  4. Thirty years have passed since the two LPs performed at the start of my MS journey. Yet, I retain a vivid, vivid memory of the most horrific, disabling headache I have ever experienced in my life. Ironically, neither produced the markers the medical professionals were seeking.

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  5. Excuse me, but I don't understand the point of LPs.
    2 or more relapses + MRI activity is enough to indicate MS (Mcdonald criteria)....so what is the point of an invasive LP?

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  6. Can I just ask, why is it that someone who has a lower BMI is more likely to get a PLPH when usually, the slimmer you are, the easier it is to get the LP right first time? I am very slim and the neuroradiologist doing my LP said it was so easy doing the procedure because of my slim build, but I still got a massive PLPH which required me being re-admitted into hospital.

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  7. Re: "Excuse me, but I don't understand the point of LPs. 2 or more relapses + MRI activity is enough to indicate MS (Mcdonald criteria)....so what is the point of an invasive LP?"

    Making the diagnosis of MS can be very difficult. As you may be aware the mis-diagnosis rate, from is about 2-5%, i.e. 1 in 20 to 1 in 50 MS'ers don't have MS. Examining the CSF helps exclude other diagnoses and also helps in not making a diagnosis of MS. Believe it or not there are people in the world who don't have MS who want to have MS. The commonest cause of the latter is a condition called somatisation disorder. In summary LPs are very useful in the diagnostic phase of MS. However, we are discussing it here as an outcome measure for progressive MS trials, not for diagnosis.

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  8. The statistics for how many people got post LP headaches is shockingly low in my opinion. I cna't believe it is only 5%. I must be in the low percentage of patients as I've had 2 LPs, one done by flouroscopy and the other sitting up, and both times I had that horrible headache. I had to get a blood patch with the second LP after more than 5 days and the need to get back to work.

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  9. No way am I having another lumber puncture. It was an absolute disaster last time around and I'm not risking it again. I want an effective treatment for my PPMS but you need a better way of doing things Team G.

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  10. Re: "The statistics for how many people got post LP headaches is shockingly low in my opinion. I cna't believe it is only 5%."

    Sorry to hear about your bad experience with LPs. I assume you had an LP with a traumatic or cutting needle. The new figures may relate to the use of atraumatic needles; however we still need to use these when we want to measure the spinal fluid pressure.

    The figures are what they are and in my experience they are about right. The vast majority of LPs are uncomplicated.

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  11. Re: "Can I just ask, why is it that someone who has a lower BMI is more likely to get a PLPH ..."

    I assume the thinner you are the less fat you have in the epidural space. The fat acts to plug the hole. Do you recall what kind of needle they used for the LP? An atraumatic needle require an introducer (a larger needle to puncture the skin and ligaments) the atraumatic needle is then inserted down the introducer. In comparison a traumatic or cutting needles goes straight in.

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  12. Re: "Thirty years have passed since the two LPs performed at the start of my MS journey."

    Thirty years ago you will certainly have had the LP with a large bore traumatic or cutting needle.

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  13. Re: "I want an effective treatment for my PPMS but you need a better way of doing things."

    It is horses for courses. All we are proposing is a way for screening drugs for progressive MS more quickly. At the moment the process is too slow. We know that not everyone will volunteer for such trials, but we need a sufficient number to know that this strategy is worth pursuing.

    It is frustrating for us when you the MS'ers complain that we are not doing enough for progressive disease and when we come up with a possible solution for the road block in drug development we can't get the field to try something new.

    I am not promising that this trial design will necessarily work, but if we don't try it we won't get an answer.

    Thanks you for taking the time to do the survey. Your help is much appreciated, even if you said no.

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