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The number of definite indications for LP has decreased with the advent of better neuroimaging procedures including computed tomography (CT) scans and magnetic resonance imaging (MRI), but urgent LP is still indicated to diagnose two serious conditions [1,2]:

● Suspected CNS infection (with the exception of brain abscess or a parameningeal process).

● Suspected SAH in a patient with a negative CT scan [3]. The use of cerebrospinal fluid (CSF) examination in the evaluation of a patient with suspected SAH is discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Lumbar puncture'.)

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ous system (CNS) infections and, in certain settings, for help in the diagnosis of subarachnoid hemorrhage (SAH), CNS malignancies, demyelinating diseases, and Guillain-Barré syndrome. Urgent — <span>The number of definite indications for LP has decreased with the advent of better neuroimaging procedures including computed tomography (CT) scans and magnetic resonance imaging (MRI), but urgent LP is still indicated to diagnose two serious conditions [1,2]: ●Suspected CNS infection (with the exception of brain abscess or a parameningeal process). ●Suspected SAH in a patient with a negative CT scan [3]. The use of cerebrospinal fluid (CSF) examination in the evaluation of a patient with suspected SAH is discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Lumbar puncture'.) The most common use of the LP is to diagnose or exclude meningitis in patients presenting with some combination of fever, altered mental status, headache, or meningeal signs. Examinatio




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A nonurgent LP is indicated in the diagnosis of many other conditions. The findings are discussed in the appropriate topic reviews:

● Idiopathic intracranial hypertension (pseudotumor cerebri)

● Carcinomatous meningitis

● Normal pressure hydrocephalus

● CNS syphilis

● CNS lymphoma

● Autoimmune encephalitis

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bacterial meningitis from viral infections of the CNS. However, there is often substantial overlap. (See "Viral encephalitis in adults", section on 'Cerebrospinal fluid findings'.) Nonurgent — <span>A nonurgent LP is indicated in the diagnosis of many other conditions. The findings are discussed in the appropriate topic reviews: ●Idiopathic intracranial hypertension (pseudotumor cerebri) ●Carcinomatous meningitis ●Normal pressure hydrocephalus ●CNS syphilis ●CNS lymphoma ●Autoimmune encephalitis Conditions in which LP is rarely diagnostic but still useful include: ●Multiple sclerosis ●Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy ●Paraneoplastic




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Conditions in which LP is rarely diagnostic but still useful include:

● Multiple sclerosis

● Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy

● Paraneoplastic syndromes

● Neurosarcoidosis

● CNS vasculitis

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ropriate topic reviews: ●Idiopathic intracranial hypertension (pseudotumor cerebri) ●Carcinomatous meningitis ●Normal pressure hydrocephalus ●CNS syphilis ●CNS lymphoma ●Autoimmune encephalitis <span>Conditions in which LP is rarely diagnostic but still useful include: ●Multiple sclerosis ●Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy ●Paraneoplastic syndromes ●Neurosarcoidosis ●CNS vasculitis LP is also required as a therapeutic or diagnostic maneuver in the following situations [1,2,4,5]: ●Spinal anesthesia ●Intrathecal administration of chemotherapy ●Intrathecal administra




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In many situations, high-risk patients can be identified and risks can be mitigated. These are discussed in detail in relation to the complications with which they are associated. (See 'Complications' below.)
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to obstructive hydrocephalus, cerebral edema, or space-occupying lesion ●Thrombocytopenia or other bleeding diathesis, including ongoing anticoagulant therapy ●Suspected spinal epidural abscess <span>In many situations, high-risk patients can be identified and risks can be mitigated. These are discussed in detail in relation to the complications with which they are associated. (See 'Complications' below.) When the LP is delayed or deferred in the setting of suspected bacterial meningitis, it is important to obtain blood cultures (which reveal the pathogen in more than half of patients) a




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The choice of needle type (cutting versus atraumatic) and bore size can influence the risk of a post-LP headache, but also may increase the technical difficulty of the procedure. This is discussed in detail separately. (See "Post dural puncture headache", section on 'Prevention of PDPH after dural puncture'.)
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mptly when this is suspected. Specific treatments are discussed separately. (See "Initial therapy and prognosis of bacterial meningitis in adults", section on 'Avoidance of delay'.) TECHNIQUE — <span>The choice of needle type (cutting versus atraumatic) and bore size can influence the risk of a post-LP headache, but also may increase the technical difficulty of the procedure. This is discussed in detail separately. (See "Post dural puncture headache", section on 'Prevention of PDPH after dural puncture'.) Positioning — An LP can be performed with the patient in the lateral recumbent or prone positions or sitting upright. The lateral recumbent or prone positions are preferred over the upr




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The correct level of entry of the spinal needle is most easily determined with the patient sitting upright or standing. The highest points of the iliac crests should be identified visually and confirmed by palpation; a direct line joining these is a guide to the fourth lumbar vertebral body. However, this line may intersect the spine at points ranging from L1-L2 to L4-L5 [6], and tends to point to a higher spinal level in females and in patients with obesity [7].
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osition because they allow more accurate measurement of the opening pressure. The prone position is generally used for LPs performed under fluoroscopic guidance. (See 'Imaging guidance' below.) <span>The correct level of entry of the spinal needle is most easily determined with the patient sitting upright or standing. The highest points of the iliac crests should be identified visually and confirmed by palpation; a direct line joining these is a guide to the fourth lumbar vertebral body. However, this line may intersect the spine at points ranging from L1-L2 to L4-L5 [6], and tends to point to a higher spinal level in females and in patients with obesity [7]. The lumbar spinous processes of L3, L4, and L5, and the interspaces between, can usually be directly identified by palpation. The spinal needle can be safely inserted into the subarachn




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
The lumbar spinous processes of L3, L4, and L5, and the interspaces between, can usually be directly identified by palpation. The spinal needle can be safely inserted into the subarachnoid space at the L3-4 or L4-5 interspace, since this is well below the termination of the spinal cord in most patients.
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ar vertebral body. However, this line may intersect the spine at points ranging from L1-L2 to L4-L5 [6], and tends to point to a higher spinal level in females and in patients with obesity [7]. <span>The lumbar spinous processes of L3, L4, and L5, and the interspaces between, can usually be directly identified by palpation. The spinal needle can be safely inserted into the subarachnoid space at the L3-4 or L4-5 interspace, since this is well below the termination of the spinal cord in most patients. Spinal cord imaging is not considered necessary prior to LP, but, if performed, images should be reviewed to confirm the position of the conus prior to LP. An alternate approach to obta




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
An alternate approach to obtaining cerebrospinal fluid (CSF) with a paramedian needle insertion through the L5-S1 space (Taylor approach) (figure 1) has been successfully used in a patient with advanced ankylosing spondylitis [8]
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of the spinal cord in most patients. Spinal cord imaging is not considered necessary prior to LP, but, if performed, images should be reviewed to confirm the position of the conus prior to LP. <span>An alternate approach to obtaining cerebrospinal fluid (CSF) with a paramedian needle insertion through the L5-S1 space (Taylor approach) (figure 1) has been successfully used in a patient with advanced ankylosing spondylitis [8]. Correct patient positioning is an important determinant of success in obtaining CSF. The patient is instructed to remain in the fetal position with the neck, back, and limbs held in fl




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
Correct patient positioning is an important determinant of success in obtaining CSF. The patient is instructed to remain in the fetal position with the neck, back, and limbs held in flexion. The lower lumbar spine should be flexed with the back perfectly perpendicular to the edge of a bed or examining table. The hips and legs should be parallel to each other and perpendicular to the table. Pillows placed under the head and between the knees may improve patient comfort
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rebrospinal fluid (CSF) with a paramedian needle insertion through the L5-S1 space (Taylor approach) (figure 1) has been successfully used in a patient with advanced ankylosing spondylitis [8]. <span>Correct patient positioning is an important determinant of success in obtaining CSF. The patient is instructed to remain in the fetal position with the neck, back, and limbs held in flexion. The lower lumbar spine should be flexed with the back perfectly perpendicular to the edge of a bed or examining table. The hips and legs should be parallel to each other and perpendicular to the table. Pillows placed under the head and between the knees may improve patient comfort. Aseptic technique — The overlying skin should be cleaned with alcohol and a disinfectant such as povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent); the antiseptic sh




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
The overlying skin should be cleaned with alcohol and a disinfectant such as povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent); the antiseptic should be allowed to dry before the procedure is begun.
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ng table. The hips and legs should be parallel to each other and perpendicular to the table. Pillows placed under the head and between the knees may improve patient comfort. Aseptic technique — <span>The overlying skin should be cleaned with alcohol and a disinfectant such as povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent); the antiseptic should be allowed to dry before the procedure is begun. Many product inserts of chlorhexidine-containing solutions warn against use of chlorhexidine prior to LP because of a concern that it can cause arachnoiditis. The evidence that it does




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Many product inserts of chlorhexidine-containing solutions warn against use of chlorhexidine prior to LP because of a concern that it can cause arachnoiditis. The evidence that it does so is very limited, and many experts believe that chlorhexidine has an advantage over povidone-iodine because of its onset, efficacy, and potency [ 9-13].
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d be cleaned with alcohol and a disinfectant such as povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent); the antiseptic should be allowed to dry before the procedure is begun. <span>Many product inserts of chlorhexidine-containing solutions warn against use of chlorhexidine prior to LP because of a concern that it can cause arachnoiditis. The evidence that it does so is very limited, and many experts believe that chlorhexidine has an advantage over povidone-iodine because of its onset, efficacy, and potency [9-13]. Due to specific labeling prohibiting use, a formal institutional policy to support such use may be indicated. After the skin is cleaned and allowed to dry, a sterile drape with an openi




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After the skin is cleaned and allowed to dry, a sterile drape with an opening over the lumbar spine is placed on the patient
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advantage over povidone-iodine because of its onset, efficacy, and potency [9-13]. Due to specific labeling prohibiting use, a formal institutional policy to support such use may be indicated. <span>After the skin is cleaned and allowed to dry, a sterile drape with an opening over the lumbar spine is placed on the patient. Face masks should be used by individuals who place a catheter or inject material into the spinal canal as recommended by the Healthcare Infection Control Practices Advisory Committee a




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
Face masks should be used by individuals who place a catheter or inject material into the spinal canal as recommended by the Healthcare Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention (CDC) [14]. While routine use of face masks during diagnostic LP and neuroradiologic imaging procedures involving LP has been recommended by some [15-17], others question the practicality and necessity of the use of face masks since infections are rare and there is no proof that face masks prevent such infections [18,19]
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a formal institutional policy to support such use may be indicated. After the skin is cleaned and allowed to dry, a sterile drape with an opening over the lumbar spine is placed on the patient. <span>Face masks should be used by individuals who place a catheter or inject material into the spinal canal as recommended by the Healthcare Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention (CDC) [14]. While routine use of face masks during diagnostic LP and neuroradiologic imaging procedures involving LP has been recommended by some [15-17], others question the practicality and necessity of the use of face masks since infections are rare and there is no proof that face masks prevent such infections [18,19]. However, we believe a face mask should be used for diagnostic procedures if the procedure is likely to be prolonged or difficult, or if the person carrying out the procedure has an upp




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
Local anesthesia (eg, lidocaine) is infiltrated into the previously identified lumbar intervertebral space and a 20- or 22-gauge spinal needle containing a stylet is inserted into the lumbar intervertebral space
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, or if the person carrying out the procedure has an upper respiratory tract infection. (See "Infection prevention: Precautions for preventing transmission of infection".) Procedure technique — <span>Local anesthesia (eg, lidocaine) is infiltrated into the previously identified lumbar intervertebral space and a 20- or 22-gauge spinal needle containing a stylet is inserted into the lumbar intervertebral space. The spinal needle may be advanced slowly, angling slightly toward the head, as if aiming towards the umbilicus. The flat surface of the bevel of the needle should be positioned to face




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
The spinal needle may be advanced slowly, angling slightly toward the head, as if aiming towards the umbilicus. The flat surface of the bevel of the needle should be positioned to face the patient's flanks to allow the needle to spread rather than cut the dural sac (the fibers of which run parallel to the spinal axis). The approximate distance of the epidural space from the skin is 45 to 55 mm on average but is variable and may be longer in patients with obesity [7,20,21]
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g, lidocaine) is infiltrated into the previously identified lumbar intervertebral space and a 20- or 22-gauge spinal needle containing a stylet is inserted into the lumbar intervertebral space. <span>The spinal needle may be advanced slowly, angling slightly toward the head, as if aiming towards the umbilicus. The flat surface of the bevel of the needle should be positioned to face the patient's flanks to allow the needle to spread rather than cut the dural sac (the fibers of which run parallel to the spinal axis). The approximate distance of the epidural space from the skin is 45 to 55 mm on average but is variable and may be longer in patients with obesity [7,20,21]. Many clinicians choose to advance the needle incrementally, removing the stylet periodically to check for CSF flow, then reinserting the stylet until the subarachnoid space is entered




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
Many clinicians choose to advance the needle incrementally, removing the stylet periodically to check for CSF flow, then reinserting the stylet until the subarachnoid space is entered [ 22]. Some report a higher rate of successful LP when the stylet is removed, just after the skin is punctured and before it is passed into the subarachnoid space in order to better observe the flow of CSF upon entry of the subarachnoid space [23,24]; however, this technique may be associated with a risk of epidermoid tumor, possibly infection, or failure to get flow of CSF. (See 'Epidermoid tumor' below.)
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ch run parallel to the spinal axis). The approximate distance of the epidural space from the skin is 45 to 55 mm on average but is variable and may be longer in patients with obesity [7,20,21]. <span>Many clinicians choose to advance the needle incrementally, removing the stylet periodically to check for CSF flow, then reinserting the stylet until the subarachnoid space is entered [22]. Some report a higher rate of successful LP when the stylet is removed, just after the skin is punctured and before it is passed into the subarachnoid space in order to better observe the flow of CSF upon entry of the subarachnoid space [23,24]; however, this technique may be associated with a risk of epidermoid tumor, possibly infection, or failure to get flow of CSF. (See 'Epidermoid tumor' below.) Once CSF appears and begins to flow through the needle, a manometer should be placed over the hub of the needle (figure 2). The patient should be instructed to slowly straighten or exte




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Once CSF appears and begins to flow through the needle, a manometer should be placed over the hub of the needle (figure 2). The patient should be instructed to slowly straighten or extend the legs to allow free flow of CSF within the subarachnoid space and the opening pressure should be measured
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of the subarachnoid space [23,24]; however, this technique may be associated with a risk of epidermoid tumor, possibly infection, or failure to get flow of CSF. (See 'Epidermoid tumor' below.) <span>Once CSF appears and begins to flow through the needle, a manometer should be placed over the hub of the needle (figure 2). The patient should be instructed to slowly straighten or extend the legs to allow free flow of CSF within the subarachnoid space and the opening pressure should be measured. While the pressure measurement is affected by the position of the legs, the available evidence suggests that the effect is likely to be small. In one review, pressures were elevated by




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
While the pressure measurement is affected by the position of the legs, the available evidence suggests that the effect is likely to be small. In one review, pressures were elevated by only 1 to 2 cm H 2O in four of five studies studying this effect; however, in one study, changing position from a straight to a fully flexed position resulted in an increase in pressure of 6.4 mmHg (approximately 8.7 cm H2O) [25]
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needle (figure 2). The patient should be instructed to slowly straighten or extend the legs to allow free flow of CSF within the subarachnoid space and the opening pressure should be measured. <span>While the pressure measurement is affected by the position of the legs, the available evidence suggests that the effect is likely to be small. In one review, pressures were elevated by only 1 to 2 cm H2O in four of five studies studying this effect; however, in one study, changing position from a straight to a fully flexed position resulted in an increase in pressure of 6.4 mmHg (approximately 8.7 cm H2O) [25]. Opening pressure does not appear to be significantly different if measured in the prone or lateral recumbent position [26]. Fluid is then serially collected in sterile plastic tubes. A




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
A total of 8 to 15 mL of CSF is typically removed during routine LP. However, when special studies are required, such as cytology or cultures for organisms that grow less readily (eg, fungi or mycobacteria), 40 mL of fluid can safely be removed
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H2O) [25]. Opening pressure does not appear to be significantly different if measured in the prone or lateral recumbent position [26]. Fluid is then serially collected in sterile plastic tubes. <span>A total of 8 to 15 mL of CSF is typically removed during routine LP. However, when special studies are required, such as cytology or cultures for organisms that grow less readily (eg, fungi or mycobacteria), 40 mL of fluid can safely be removed. Aspiration of CSF should not be attempted, as it may increase the risk of bleeding [22]. The stylet should be replaced before the spinal needle is removed, as this can reduce the risk




#Geste #Lombaire #Lumbar #Meningite #Meningitis #Ponction #Procedure #Puncture
Aspiration of CSF should not be attempted, as it may increase the risk of bleeding [ 22].
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ring routine LP. However, when special studies are required, such as cytology or cultures for organisms that grow less readily (eg, fungi or mycobacteria), 40 mL of fluid can safely be removed. <span>Aspiration of CSF should not be attempted, as it may increase the risk of bleeding [22]. The stylet should be replaced before the spinal needle is removed, as this can reduce the risk of post-LP headache. (See "Post dural puncture headache", section on 'Procedural risk fact




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The stylet should be replaced before the spinal needle is removed, as this can reduce the risk of post-LP headache.
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for organisms that grow less readily (eg, fungi or mycobacteria), 40 mL of fluid can safely be removed. Aspiration of CSF should not be attempted, as it may increase the risk of bleeding [22]. <span>The stylet should be replaced before the spinal needle is removed, as this can reduce the risk of post-LP headache. (See "Post dural puncture headache", section on 'Procedural risk factors'.) No trials have shown that bed rest following LP significantly decreases the risk of post-LP headache compared




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No trials have shown that bed rest following LP significantly decreases the risk of post-LP headache compared with immediate mobilization [27,28].
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. The stylet should be replaced before the spinal needle is removed, as this can reduce the risk of post-LP headache. (See "Post dural puncture headache", section on 'Procedural risk factors'.) <span>No trials have shown that bed rest following LP significantly decreases the risk of post-LP headache compared with immediate mobilization [27,28]. (See "Post dural puncture headache", section on 'Prevention of PDPH after dural puncture'.) The Queckenstedt maneuver can be used to demonstrate that there is free flow of fluid from th




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The Queckenstedt maneuver can be used to demonstrate that there is free flow of fluid from the ventricles to the lumbar space. This maneuver is performed by measuring the CSF pressure and then observing the change in pressure after manual compression of both jugular veins. However, this test is rarely useful in modern practice, since newer techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) readily identify most obstructing spinal or basilar lesions
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LP significantly decreases the risk of post-LP headache compared with immediate mobilization [27,28]. (See "Post dural puncture headache", section on 'Prevention of PDPH after dural puncture'.) <span>The Queckenstedt maneuver can be used to demonstrate that there is free flow of fluid from the ventricles to the lumbar space. This maneuver is performed by measuring the CSF pressure and then observing the change in pressure after manual compression of both jugular veins. However, this test is rarely useful in modern practice, since newer techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) readily identify most obstructing spinal or basilar lesions. Imaging guidance — Imaging guidance is typically reserved for patients with difficult anatomy and/or unsuccessful LP attempts. Fluoroscopy — Fluoroscopic guidance for LP may be require




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A subsequently published randomized trial involving 100 adult patients undergoing LP in the emergency department found no significant difference in outcomes with ultrasound guidance [34].
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d that ultrasound guidance reduced the risk of failed and traumatic procedures (risk ratio [RR] = 0.21 and 0.27, respectively), as well as the number of needle insertions and redirections [33]. <span>A subsequently published randomized trial involving 100 adult patients undergoing LP in the emergency department found no significant difference in outcomes with ultrasound guidance [34]. The use of ultrasound in spinal anesthesia is discussed separately. (See "Spinal anesthesia: Technique", section on 'Preprocedure ultrasonography'.) COMPLICATIONS — LP is a relatively s




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LP is a relatively safe procedure, but minor and major complications can occur even when standard infection control measures and good technique are used. These complications include:

● Post-LP headache

● Infection

● Bleeding

● Cerebral herniation

● Minor neurologic symptoms such as radicular pain or numbness

● Late onset of epidermoid tumors of the thecal sac

● Back pain

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th ultrasound guidance [34]. The use of ultrasound in spinal anesthesia is discussed separately. (See "Spinal anesthesia: Technique", section on 'Preprocedure ultrasonography'.) COMPLICATIONS — <span>LP is a relatively safe procedure, but minor and major complications can occur even when standard infection control measures and good technique are used. These complications include: ●Post-LP headache ●Infection ●Bleeding ●Cerebral herniation ●Minor neurologic symptoms such as radicular pain or numbness ●Late onset of epidermoid tumors of the thecal sac ●Back pain The risk of complications was studied in a cohort of 376 patients who underwent LP for evaluation of acute cerebrovascular disease [35]. The following frequency of complications was not




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The risk of complications was studied in a cohort of 376 patients who underwent LP for evaluation of acute cerebrovascular disease [35]. The following frequency of complications was noted: backache (25 percent), headache (22 percent), headache and backache (12 percent), severe radicular pain (15 percent), and paraparesis (1.5 percent). Severe pain or paraparesis occurred in 6.7 percent of patients receiving anticoagulants following the procedure and in none of the 34 patients who did not receive anticoagulants.
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include: ●Post-LP headache ●Infection ●Bleeding ●Cerebral herniation ●Minor neurologic symptoms such as radicular pain or numbness ●Late onset of epidermoid tumors of the thecal sac ●Back pain <span>The risk of complications was studied in a cohort of 376 patients who underwent LP for evaluation of acute cerebrovascular disease [35]. The following frequency of complications was noted: backache (25 percent), headache (22 percent), headache and backache (12 percent), severe radicular pain (15 percent), and paraparesis (1.5 percent). Severe pain or paraparesis occurred in 6.7 percent of patients receiving anticoagulants following the procedure and in none of the 34 patients who did not receive anticoagulants. Post-LP headache — Headache, which occurs in 10 to 30 percent of patients, is one of the most common complications following LP. Post-LP headache is caused by leakage of cerebrospinal f




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Headache, which occurs in 10 to 30 percent of patients, is one of the most common complications following LP. Post-LP headache is caused by leakage of cerebrospinal fluid (CSF) from the dura and traction on pain-sensitive structures. Patients characteristically present with frontal or occipital headache within 24 to 48 hours of the procedure, which is exacerbated in an upright position and improved in the supine position. Associated symptoms may include nausea, vomiting, dizziness, tinnitus, and visual changes.
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re pain or paraparesis occurred in 6.7 percent of patients receiving anticoagulants following the procedure and in none of the 34 patients who did not receive anticoagulants. Post-LP headache — <span>Headache, which occurs in 10 to 30 percent of patients, is one of the most common complications following LP. Post-LP headache is caused by leakage of cerebrospinal fluid (CSF) from the dura and traction on pain-sensitive structures. Patients characteristically present with frontal or occipital headache within 24 to 48 hours of the procedure, which is exacerbated in an upright position and improved in the supine position. Associated symptoms may include nausea, vomiting, dizziness, tinnitus, and visual changes. This risk factors, prevention, and treatment of post-LP headache are discussed separately. (See "Post dural puncture headache".) Infection — Infections are rare after LP; in typical pat




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Meningitis is an uncommon complication of LP. In a review of 179 cases of post-LP meningitis reported in the medical literature between 1952 and 2005, half of all cases occurred after spinal anesthesia; only 9 percent occurred after diagnostic LP. The most commonly isolated causative organisms were Streptococcus salivarius (30 percent), Streptococcus viridans (29 percent), alpha-hemolytic strep (11 percent), Staphylococcus aureus (9 percent), and Pseudomonas aeruginosa (8 percent) [36].
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. (See "Post dural puncture headache".) Infection — Infections are rare after LP; in typical patients no techniques beyond usual aseptic technique are required. (See 'Aseptic technique' above.) <span>Meningitis is an uncommon complication of LP. In a review of 179 cases of post-LP meningitis reported in the medical literature between 1952 and 2005, half of all cases occurred after spinal anesthesia; only 9 percent occurred after diagnostic LP. The most commonly isolated causative organisms were Streptococcus salivarius (30 percent), Streptococcus viridans (29 percent), alpha-hemolytic strep (11 percent), Staphylococcus aureus (9 percent), and Pseudomonas aeruginosa (8 percent) [36]. An LP through a spinal epidural abscess can result in the spread of bacteria into the subarachnoid space. Because an LP is not needed for diagnosis, the procedure should not be performe




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An LP through a spinal epidural abscess can result in the spread of bacteria into the subarachnoid space. Because an LP is not needed for diagnosis, the procedure should not be performed in most patients with suspected epidural abscess in the lumbar region [37].
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e Streptococcus salivarius (30 percent), Streptococcus viridans (29 percent), alpha-hemolytic strep (11 percent), Staphylococcus aureus (9 percent), and Pseudomonas aeruginosa (8 percent) [36]. <span>An LP through a spinal epidural abscess can result in the spread of bacteria into the subarachnoid space. Because an LP is not needed for diagnosis, the procedure should not be performed in most patients with suspected epidural abscess in the lumbar region [37]. (See "Spinal epidural abscess".) While some cases of post-LP meningitis due to staphylococci, pseudomonas, and other gram-negative bacilli have been attributed to contaminated instrumen




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We and other authors believe that theoretical concerns about inducing meningitis in patients with bacteremia should not be used as the basis to forego LP if meningitis is suspected [19]
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nce of spontaneous meningitis in children who underwent LP and subsequently developed meningitis was not statistically different from those who did not undergo LP (2.1 versus 0.8 percent) [44]. <span>We and other authors believe that theoretical concerns about inducing meningitis in patients with bacteremia should not be used as the basis to forego LP if meningitis is suspected [19]. There are rare case reports of discitis and vertebral osteomyelitis following LP. Most cases were due to normal skin flora such as Cutibacterium species and coagulase negative staphylo




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There are rare case reports of discitis and vertebral osteomyelitis following LP. Most cases were due to normal skin flora such as Cutibacterium species and coagulase negative staphylococci [45-47]. These complications presumably result from direct inoculation of bacteria into the vertebral bone.
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[44]. We and other authors believe that theoretical concerns about inducing meningitis in patients with bacteremia should not be used as the basis to forego LP if meningitis is suspected [19]. <span>There are rare case reports of discitis and vertebral osteomyelitis following LP. Most cases were due to normal skin flora such as Cutibacterium species and coagulase negative staphylococci [45-47]. These complications presumably result from direct inoculation of bacteria into the vertebral bone. Bleeding — The CSF is normally acellular, although up to five red blood cells (RBCs) are considered normal after LP due to incidental trauma to a capillary or venule. A higher number of




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The CSF is normally acellular, although up to five red blood cells (RBCs) are considered normal after LP due to incidental trauma to a capillary or venule. A higher number of RBCs is seen in some patients in whom calculation of the white blood cell (WBC)-to-RBC ratio and the presence or absence of xanthochromia may differentiate LP-induced from true central nervous system (CNS) bleeding.
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n flora such as Cutibacterium species and coagulase negative staphylococci [45-47]. These complications presumably result from direct inoculation of bacteria into the vertebral bone. Bleeding — <span>The CSF is normally acellular, although up to five red blood cells (RBCs) are considered normal after LP due to incidental trauma to a capillary or venule. A higher number of RBCs is seen in some patients in whom calculation of the white blood cell (WBC)-to-RBC ratio and the presence or absence of xanthochromia may differentiate LP-induced from true central nervous system (CNS) bleeding. (See "Cerebrospinal fluid: Physiology and utility of an examination in disease states", section on 'Cells'.) Incidence — Serious bleeding that results in spinal cord compromise is rare




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Serious bleeding that results in spinal cord compromise is rare in the absence of bleeding risk [48]. Patients who have thrombocytopenia or other bleeding disorders or those who received anticoagulant therapy prior to or immediately after undergoing LP have an increased risk of bleeding
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ifferentiate LP-induced from true central nervous system (CNS) bleeding. (See "Cerebrospinal fluid: Physiology and utility of an examination in disease states", section on 'Cells'.) Incidence — <span>Serious bleeding that results in spinal cord compromise is rare in the absence of bleeding risk [48]. Patients who have thrombocytopenia or other bleeding disorders or those who received anticoagulant therapy prior to or immediately after undergoing LP have an increased risk of bleeding. This risk may be further increased with other factors that increase bleeding risk, such as traumatic or repeated taps. In one series, spinal hematoma developed in 7 of 342 patients (2




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In one series, spinal hematoma developed in 7 of 342 patients (2 percent) who received anticoagulant therapy after undergoing LP; five of these patients developed paraparesis [35]. In one literature review, 47 percent of 21 published cases of spinal hematoma following LP occurred in patients with a coagulopathy [49]. Thus, a high index of suspicion of spinal hematoma should be maintained in all patients who develop neurologic symptoms after an LP, including those with no known coagulopathy. In rare cases, intraventricular, intracerebral, and subarachnoid hemorrhage (SAH) have also been reported as complications of LP [50,51]
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to or immediately after undergoing LP have an increased risk of bleeding. This risk may be further increased with other factors that increase bleeding risk, such as traumatic or repeated taps. <span>In one series, spinal hematoma developed in 7 of 342 patients (2 percent) who received anticoagulant therapy after undergoing LP; five of these patients developed paraparesis [35]. In one literature review, 47 percent of 21 published cases of spinal hematoma following LP occurred in patients with a coagulopathy [49]. Thus, a high index of suspicion of spinal hematoma should be maintained in all patients who develop neurologic symptoms after an LP, including those with no known coagulopathy. In rare cases, intraventricular, intracerebral, and subarachnoid hemorrhage (SAH) have also been reported as complications of LP [50,51]. Reducing risk — We are unaware of any study that has systematically examined interventions to reduce the risk of bleeding following LP based upon the degree of thrombocytopenia or clot




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We are unaware of any study that has systematically examined interventions to reduce the risk of bleeding following LP based upon the degree of thrombocytopenia or clotting study abnormalities. Thus, at present the only guidepost is "clinical judgment."

We generally advise not performing an LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet counts <50,000 to 80,000/microL), or an international normalized ratio (INR) >1.4, without correcting the underlying abnormalities [52,53]

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uding those with no known coagulopathy. In rare cases, intraventricular, intracerebral, and subarachnoid hemorrhage (SAH) have also been reported as complications of LP [50,51]. Reducing risk — <span>We are unaware of any study that has systematically examined interventions to reduce the risk of bleeding following LP based upon the degree of thrombocytopenia or clotting study abnormalities. Thus, at present the only guidepost is "clinical judgment." We generally advise not performing an LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet counts <50,000 to 80,000/microL), or an international normalized ratio (INR) >1.4, without correcting the underlying abnormalities [52,53]. When an LP is considered urgent and essential in a patient with an abnormal INR or platelet count in whom the cause is not obvious, consultation with a hematologist may provide the bes




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For elective procedures in a patient receiving systemic anticoagulation, observational studies and expert opinion have suggested stopping the agents for a specified time period prior to spinal anesthesia or LP (table 1) [55-57]:

● Unfractionated intravenous heparin drips – Two to four hours.

● Low-molecular-weight heparin – 12 to 24 hours.

Warfarin – Five to seven days.

● Newer oral anticoagulants (NOACs), apixaban, edoxaban, and rivaroxaban – 72 hours. Dabigatran should be held 48 to 96 hours based on renal function.

● Subcutaneous heparin – <10,000 units per day is not believed to pose a substantial risk for bleeding.

None of these approaches have been carefully assessed for efficacy or risk, and all presume that the underlying indications for anticoagulation therapy allow a temporary suspension of treatment

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ained thrombocytopenia", section on 'General management principles' and "Platelet transfusion: Indications, ordering, and associated risks", section on 'Preparation for an invasive procedure'.) <span>For elective procedures in a patient receiving systemic anticoagulation, observational studies and expert opinion have suggested stopping the agents for a specified time period prior to spinal anesthesia or LP (table 1) [55-57]: ●Unfractionated intravenous heparin drips – Two to four hours. ●Low-molecular-weight heparin – 12 to 24 hours. ●Warfarin – Five to seven days. ●Newer oral anticoagulants (NOACs), apixaban, edoxaban, and rivaroxaban – 72 hours. Dabigatran should be held 48 to 96 hours based on renal function. ●Subcutaneous heparin – <10,000 units per day is not believed to pose a substantial risk for bleeding. None of these approaches have been carefully assessed for efficacy or risk, and all presume that the underlying indications for anticoagulation therapy allow a temporary suspension of treatment. While the optimal timing of restarting anticoagulation after LP is not known, the incidence of spinal hematoma in one series was much lower when anticoagulation was started at least on




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While the optimal timing of restarting anticoagulation after LP is not known, the incidence of spinal hematoma in one series was much lower when anticoagulation was started at least one hour after the LP [35]. NOACs can be restarted six to eight hours after an atraumatic spinal or epidural anesthesia or clean LP; however, in traumatic procedures with increased risk of bleeding, the guidelines recommend restarting NOACs 48 to 72 hours after complete hemostasis [57]
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one of these approaches have been carefully assessed for efficacy or risk, and all presume that the underlying indications for anticoagulation therapy allow a temporary suspension of treatment. <span>While the optimal timing of restarting anticoagulation after LP is not known, the incidence of spinal hematoma in one series was much lower when anticoagulation was started at least one hour after the LP [35]. NOACs can be restarted six to eight hours after an atraumatic spinal or epidural anesthesia or clean LP; however, in traumatic procedures with increased risk of bleeding, the guidelines recommend restarting NOACs 48 to 72 hours after complete hemostasis [57]. Antiplatelet therapy with aspirin and nonsteroidal antiinflammatory agents has not been shown to increase the risk of serious bleeding following LP. In a prospective study of 924 patie




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Antiplatelet therapy with aspirin and nonsteroidal antiinflammatory agents has not been shown to increase the risk of serious bleeding following LP. In a prospective study of 924 patients who underwent orthopedic procedures with spinal or epidural anesthesia, 386 patients were taking antiplatelet therapy prior to surgery; 193 were taking aspirin [58]. Neither aspirin nor any other antiplatelet agents were associated with an increased risk of bleeding. However, none of these patients were taking clopidogrel, ticlopidine, or a GP IIb/IIIa receptor antagonist.
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al or epidural anesthesia or clean LP; however, in traumatic procedures with increased risk of bleeding, the guidelines recommend restarting NOACs 48 to 72 hours after complete hemostasis [57]. <span>Antiplatelet therapy with aspirin and nonsteroidal antiinflammatory agents has not been shown to increase the risk of serious bleeding following LP. In a prospective study of 924 patients who underwent orthopedic procedures with spinal or epidural anesthesia, 386 patients were taking antiplatelet therapy prior to surgery; 193 were taking aspirin [58]. Neither aspirin nor any other antiplatelet agents were associated with an increased risk of bleeding. However, none of these patients were taking clopidogrel, ticlopidine, or a GP IIb/IIIa receptor antagonist. Female sex, increased age, a history of excessive bruising/bleeding, hip surgery, continuous catheter anesthetic technique, large needle gauge, multiple needle passes, and moderate or d




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Given the unknown risk of bleeding with thienopyridine derivatives (clopidogrel, ticlopidine, prasugrel, ticagrelor), it may be reasonable to suspend treatment with these agents, when possible, for one to two weeks prior to an elective LP, while pharmacologic data suggest that for GP IIb/IIIa receptor antagonists, a shorter period of treatment cessation (8 hours for tirofiban and eptifibatide and 24 to 48 hours for abciximab) may be indicated [56]
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ic technique, large needle gauge, multiple needle passes, and moderate or difficult needle placement were all significant risk factors for minor bleeding at the site of catheter placement [58]. <span>Given the unknown risk of bleeding with thienopyridine derivatives (clopidogrel, ticlopidine, prasugrel, ticagrelor), it may be reasonable to suspend treatment with these agents, when possible, for one to two weeks prior to an elective LP, while pharmacologic data suggest that for GP IIb/IIIa receptor antagonists, a shorter period of treatment cessation (8 hours for tirofiban and eptifibatide and 24 to 48 hours for abciximab) may be indicated [56]. In all cases, the relative risk of performing an LP has to be weighed against the potential benefit (eg, diagnosing meningitis due to an unusual or difficult to treat pathogen). In cas




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Patients who have persistent back pain or neurologic findings (eg, weakness, decreased sensation, or incontinence) after undergoing LP require urgent evaluation (usually spinal magnetic resonance imaging [MRI]) for possible spinal hematoma [59]
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atelet medication".) Management of spinal hematoma — The diagnosis of spinal hematoma is complicated by the concealed nature of the bleeding; thus, a high index of suspicion must be maintained. <span>Patients who have persistent back pain or neurologic findings (eg, weakness, decreased sensation, or incontinence) after undergoing LP require urgent evaluation (usually spinal magnetic resonance imaging [MRI]) for possible spinal hematoma [59]. The appropriate treatment for patients with significant or progressing neurologic deficits is prompt surgical intervention, usually a laminectomy, and evacuation of the blood. Timely d




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The appropriate treatment for patients with significant or progressing neurologic deficits is prompt surgical intervention, usually a laminectomy, and evacuation of the blood. Timely decompression of the hematoma is essential to avoid permanent loss of neurologic function [60,61]. Patients with mild symptoms or early signs of recovery may be managed conservatively with vigilant monitoring; dexamethasone may be administered to mitigate neurologic injury [49,50].
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findings (eg, weakness, decreased sensation, or incontinence) after undergoing LP require urgent evaluation (usually spinal magnetic resonance imaging [MRI]) for possible spinal hematoma [59]. <span>The appropriate treatment for patients with significant or progressing neurologic deficits is prompt surgical intervention, usually a laminectomy, and evacuation of the blood. Timely decompression of the hematoma is essential to avoid permanent loss of neurologic function [60,61]. Patients with mild symptoms or early signs of recovery may be managed conservatively with vigilant monitoring; dexamethasone may be administered to mitigate neurologic injury [49,50]. (See "Disorders affecting the spinal cord", section on 'Spinal epidural hematoma'.) Cerebral herniation — The most serious complication of LP is cerebral herniation. Suspected increased




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The most serious complication of LP is cerebral herniation. Suspected increased intracranial pressure (ICP) due to an intracranial mass lesion, cerebral edema, or obstructive hydrocephalus is a relative contraindication to performance of an LP and also requires independent assessment and treatment
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nt monitoring; dexamethasone may be administered to mitigate neurologic injury [49,50]. (See "Disorders affecting the spinal cord", section on 'Spinal epidural hematoma'.) Cerebral herniation — <span>The most serious complication of LP is cerebral herniation. Suspected increased intracranial pressure (ICP) due to an intracranial mass lesion, cerebral edema, or obstructive hydrocephalus is a relative contraindication to performance of an LP and also requires independent assessment and treatment. Incidence — The magnitude of the risk was evaluated in a report of 129 patients with increased ICP: 15 patients (12 percent) had an unfavorable outcome within 48 hours of LP [62]. Simi




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In another series of 1533 patients with bacterial meningitis, 47 (3 percent) had a clinical deterioration after LP [64]. Cardiorespiratory collapse, loss of consciousness, and death may follow. (See "Evaluation and management of elevated intracranial pressure in adults".)
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re noted in a series of 55 patients with SAH: seven patients (13 percent) experienced neurologic deterioration during or soon after an LP, six of whom had evidence of cerebral dislocation [63]. <span>In another series of 1533 patients with bacterial meningitis, 47 (3 percent) had a clinical deterioration after LP [64]. Cardiorespiratory collapse, loss of consciousness, and death may follow. (See "Evaluation and management of elevated intracranial pressure in adults".) A 1969 study of 30 patients with increased ICP who deteriorated after LP attempted to identify the clinical features of patients who were at greatest risk for this complication [65]. Th




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A 1969 study of 30 patients with increased ICP who deteriorated after LP attempted to identify the clinical features of patients who were at greatest risk for this complication [65]. The following findings were noted: 73 percent had focal findings on neurologic examination (including dysphagia, hemiparesis, and cranial nerve palsies), 30 percent had documented papilledema prior to the LP, and 30 percent had evidence of increased ICP on plain skull films (erosion of the posterior clinoid processes). Deterioration occurred immediately in one-half of the patients, with the remainder declining within 12 hours
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d a clinical deterioration after LP [64]. Cardiorespiratory collapse, loss of consciousness, and death may follow. (See "Evaluation and management of elevated intracranial pressure in adults".) <span>A 1969 study of 30 patients with increased ICP who deteriorated after LP attempted to identify the clinical features of patients who were at greatest risk for this complication [65]. The following findings were noted: 73 percent had focal findings on neurologic examination (including dysphagia, hemiparesis, and cranial nerve palsies), 30 percent had documented papilledema prior to the LP, and 30 percent had evidence of increased ICP on plain skull films (erosion of the posterior clinoid processes). Deterioration occurred immediately in one-half of the patients, with the remainder declining within 12 hours. A more recent series compared patients who did and did not deteriorate after LP and found that interrater reliability regarding the presence of a contraindication on computed tomograph




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A more recent series compared patients who did and did not deteriorate after LP and found that interrater reliability regarding the presence of a contraindication on computed tomography (CT) was only moderate (kappa = 0.47) and that a similar proportion of patients in both groups had such a contraindication (14 versus 11 percent) [ 64].
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of increased ICP on plain skull films (erosion of the posterior clinoid processes). Deterioration occurred immediately in one-half of the patients, with the remainder declining within 12 hours. <span>A more recent series compared patients who did and did not deteriorate after LP and found that interrater reliability regarding the presence of a contraindication on computed tomography (CT) was only moderate (kappa = 0.47) and that a similar proportion of patients in both groups had such a contraindication (14 versus 11 percent) [64]. Indications for CT scan — The concern about this serious complication has resulted in routine CT scanning prior to LP being the standard of care in many emergency departments. At one in




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Moreover, CT scanning is not necessary in all patients prior to LP and may not be adequate to exclude elevated ICP in others [67,68].
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ith suspected bacterial meningitis, delays the performance of LP, which in turn may delay treatment or limit the diagnostic power of CSF analysis when performed after antibiotic administration. <span>Moreover, CT scanning is not necessary in all patients prior to LP and may not be adequate to exclude elevated ICP in others [67,68]. Some studies suggest that high-risk patients can be identified, allowing the majority of patients to safely undergo LP without screening CT [66,69]. This was best illustrated in a prosp




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This was best illustrated in a prospective study of 301 adults with suspected meningitis [66]. The following findings were noted:

● Among the 235 (78 percent) who underwent CT scan before LP, 24 percent had an abnormal finding but only 5 percent (11 patients) had a mass effect

● The risk of an abnormal CT scan was associated with specific clinical features (presence of impaired cellular immunity, history of previous CNS disease, or a seizure within the previous week), as well as certain findings on neurologic examination (reduced level of consciousness, and focal motor or cranial abnormalities)

● Among 96 patients with none of these abnormalities, only three had an abnormal CT scan; one of the three misclassified patients had a mild mass effect, but all three underwent LP without herniation

● Compared with patients who did not undergo CT scan before LP, those who underwent CT scan before LP had an average of a two-hour delay in diagnosis and a one-hour delay in therapy

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e to exclude elevated ICP in others [67,68]. Some studies suggest that high-risk patients can be identified, allowing the majority of patients to safely undergo LP without screening CT [66,69]. <span>This was best illustrated in a prospective study of 301 adults with suspected meningitis [66]. The following findings were noted: ●Among the 235 (78 percent) who underwent CT scan before LP, 24 percent had an abnormal finding but only 5 percent (11 patients) had a mass effect ●The risk of an abnormal CT scan was associated with specific clinical features (presence of impaired cellular immunity, history of previous CNS disease, or a seizure within the previous week), as well as certain findings on neurologic examination (reduced level of consciousness, and focal motor or cranial abnormalities) ●Among 96 patients with none of these abnormalities, only three had an abnormal CT scan; one of the three misclassified patients had a mild mass effect, but all three underwent LP without herniation ●Compared with patients who did not undergo CT scan before LP, those who underwent CT scan before LP had an average of a two-hour delay in diagnosis and a one-hour delay in therapy Based upon these observations, we do not perform a CT scan before an LP in patients with suspected bacterial meningitis unless one or more risk factors is present: ●Altered mentation ●F




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Based upon these observations, we do not perform a CT scan before an LP in patients with suspected bacterial meningitis unless one or more risk factors is present:

● Altered mentation

● Focal neurologic signs

● Papilledema

● Seizure within the previous week

● Impaired cellular immunity

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t herniation ●Compared with patients who did not undergo CT scan before LP, those who underwent CT scan before LP had an average of a two-hour delay in diagnosis and a one-hour delay in therapy <span>Based upon these observations, we do not perform a CT scan before an LP in patients with suspected bacterial meningitis unless one or more risk factors is present: ●Altered mentation ●Focal neurologic signs ●Papilledema ●Seizure within the previous week ●Impaired cellular immunity Patients with these clinical risk factors should have a CT scan to identify possible mass lesion and other causes of increased ICP. Mass lesions causing elevated ICP are usually easily




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However, the CT scan should also be scrutinized for more subtle signs including diffuse brain swelling as manifest by loss of differentiation between gray and white matter and effacement of sulci, as well as ventricular enlargement and effacement of the basal cisterns [70]
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these clinical risk factors should have a CT scan to identify possible mass lesion and other causes of increased ICP. Mass lesions causing elevated ICP are usually easily identified on CT scan. <span>However, the CT scan should also be scrutinized for more subtle signs including diffuse brain swelling as manifest by loss of differentiation between gray and white matter and effacement of sulci, as well as ventricular enlargement and effacement of the basal cisterns [70]. Management of elevated intracranial pressure — Independent of the decision to perform LP, patients with possible elevated ICP based upon the above clinical features may require urgent




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Management of elevated intracranial pressure — Independent of the decision to perform LP, patients with possible elevated ICP based upon the above clinical features may require urgent life-saving interventions to lower ICP that may include head elevation, hyperventilation to a partial pressure of carbon dioxide (PCO2) of 26 to 30 mmHg, and intravenous mannitol (1 to 1.5 g/kg). When indicated, these should not await CT scan. These same measures should be instituted if a patient develops signs of herniation after LP. The evaluation and management of patients with elevated ICP is discussed in detail separately. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'Urgent situations'.)
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iffuse brain swelling as manifest by loss of differentiation between gray and white matter and effacement of sulci, as well as ventricular enlargement and effacement of the basal cisterns [70]. <span>Management of elevated intracranial pressure — Independent of the decision to perform LP, patients with possible elevated ICP based upon the above clinical features may require urgent life-saving interventions to lower ICP that may include head elevation, hyperventilation to a partial pressure of carbon dioxide (PCO2) of 26 to 30 mmHg, and intravenous mannitol (1 to 1.5 g/kg). When indicated, these should not await CT scan. These same measures should be instituted if a patient develops signs of herniation after LP. The evaluation and management of patients with elevated ICP is discussed in detail separately. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'Urgent situations'.) Other complications Epidermoid tumor — The formation of an epidermoid spinal cord tumor is a rare complication of LP that may become evident years after the procedure is performed [71-7




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Epidermoid tumor — The formation of an epidermoid spinal cord tumor is a rare complication of LP that may become evident years after the procedure is performed [71-73]. Most reported cases are children ages 5 to 12 years who had an LP in infancy; however, this has also been described in adults [74-76]. It may be caused by epidermoid tissue that is transplanted into the spinal canal during LP without a stylet, or with one that is poorly fitting. This complication probably can be avoided by using spinal needles with tight-fitting stylets during LP [77,78]
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patients with elevated ICP is discussed in detail separately. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'Urgent situations'.) Other complications <span>Epidermoid tumor — The formation of an epidermoid spinal cord tumor is a rare complication of LP that may become evident years after the procedure is performed [71-73]. Most reported cases are children ages 5 to 12 years who had an LP in infancy; however, this has also been described in adults [74-76]. It may be caused by epidermoid tissue that is transplanted into the spinal canal during LP without a stylet, or with one that is poorly fitting. This complication probably can be avoided by using spinal needles with tight-fitting stylets during LP [77,78]. Abducens palsy — Both unilateral and bilateral abducens palsy are reported complications of LP [79-81]. This is believed to result from intracranial hypotension and is generally accomp




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Abducens palsy — Both unilateral and bilateral abducens palsy are reported complications of LP [79-81]. This is believed to result from intracranial hypotension and is generally accompanied by other clinical features of post-LP headache. Most patients recover completely within days to weeks. Other cranial nerve palsies are rarely reported [82]
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the spinal canal during LP without a stylet, or with one that is poorly fitting. This complication probably can be avoided by using spinal needles with tight-fitting stylets during LP [77,78]. <span>Abducens palsy — Both unilateral and bilateral abducens palsy are reported complications of LP [79-81]. This is believed to result from intracranial hypotension and is generally accompanied by other clinical features of post-LP headache. Most patients recover completely within days to weeks. Other cranial nerve palsies are rarely reported [82]. Radicular symptoms and low back pain — It is not uncommon (13 percent in one series) for patients to experience transient electrical-type pain in one leg during the procedure [83]. How




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Radicular symptoms and low back pain — It is not uncommon (13 percent in one series) for patients to experience transient electrical-type pain in one leg during the procedure [83]. However, more sustained radicular symptoms or radicular injury appear to be rare [84].

Up to one-third of patients complain of localized back pain after LP; this may persist for several days, but rarely beyond [83]

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tension and is generally accompanied by other clinical features of post-LP headache. Most patients recover completely within days to weeks. Other cranial nerve palsies are rarely reported [82]. <span>Radicular symptoms and low back pain — It is not uncommon (13 percent in one series) for patients to experience transient electrical-type pain in one leg during the procedure [83]. However, more sustained radicular symptoms or radicular injury appear to be rare [84]. Up to one-third of patients complain of localized back pain after LP; this may persist for several days, but rarely beyond [83]. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline lin




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Post dural puncture headache (PDPH), also known as post lumbar puncture (LP) headache, is a common complication of diagnostic LP. It also can occur following spinal anesthesia or, more commonly, inadvertent dural puncture during attempted epidural catheter placement. The headache is usually positional (worse when upright, better when lying flat) and is often accompanied by neck stiffness, photophobia, nausea, or subjective hearing symptoms
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opics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2022. | This topic last updated: Jul 27, 2021. INTRODUCTION — <span>Post dural puncture headache (PDPH), also known as post lumbar puncture (LP) headache, is a common complication of diagnostic LP. It also can occur following spinal anesthesia or, more commonly, inadvertent dural puncture during attempted epidural catheter placement. The headache is usually positional (worse when upright, better when lying flat) and is often accompanied by neck stiffness, photophobia, nausea, or subjective hearing symptoms. This topic will review PDPH. Techniques for LP, spinal, epidural, and combined spinal-epidural (CSE) anesthesia are discussed separately. (See "Lumbar puncture: Technique, indications,




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The precise etiology of headache after dural puncture is unclear, but is thought to relate to leakage of cerebrospinal fluid (CSF) through the dural hole created by the needle.
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Technique, indications, contraindications, and complications in adults" and "Spinal anesthesia: Technique" and "Epidural and combined spinal-epidural anesthesia: Techniques".) PATHOPHYSIOLOGY — <span>The precise etiology of headache after dural puncture is unclear, but is thought to relate to leakage of cerebrospinal fluid (CSF) through the dural hole created by the needle. If CSF leaks at a rate greater than the rate of CSF production, low CSF pressure can result, accentuated at the level of the brain in the upright position. However, not all patients wit




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However, not all patients with PDPH have low CSF pressure, and not all patients with significant CSF leak develop a headache.
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the dural hole created by the needle. If CSF leaks at a rate greater than the rate of CSF production, low CSF pressure can result, accentuated at the level of the brain in the upright position. <span>However, not all patients with PDPH have low CSF pressure, and not all patients with significant CSF leak develop a headache. Three pathophysiologic mechanisms have been proposed: ●CSF hypotension results in compensatory meningeal venodilation and blood volume expansion, with headache caused by acute venous di




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hree pathophysiologic mechanisms have been proposed:

● CSF hypotension results in compensatory meningeal venodilation and blood volume expansion, with headache caused by acute venous distention. This mechanism is consistent with magnetic resonance imaging (MRI) in several reported cases of PDPH [1,2].

● Intracranial hypotension related to CSF leak may cause sagging of intracranial structures and stretch of sensory intracranial nerves, causing pain and cranial nerve palsies. In one study of seven patients with intracranial hypotension, MRI findings of downward displacement of the brain were associated with headache, and resolved along with the headache symptoms [3]. Traction of the upper cervical nerves may cause PDPH associated neck, back and shoulder pain [4].

● Altered craniospinal elasticity after lumbar puncture (LP) results in increased caudal compliance relative to intracranial compliance and acute intracranial venodilation in the upright position [5].

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lt, accentuated at the level of the brain in the upright position. However, not all patients with PDPH have low CSF pressure, and not all patients with significant CSF leak develop a headache. T<span>hree pathophysiologic mechanisms have been proposed: ●CSF hypotension results in compensatory meningeal venodilation and blood volume expansion, with headache caused by acute venous distention. This mechanism is consistent with magnetic resonance imaging (MRI) in several reported cases of PDPH [1,2]. ●Intracranial hypotension related to CSF leak may cause sagging of intracranial structures and stretch of sensory intracranial nerves, causing pain and cranial nerve palsies. In one study of seven patients with intracranial hypotension, MRI findings of downward displacement of the brain were associated with headache, and resolved along with the headache symptoms [3]. Traction of the upper cervical nerves may cause PDPH associated neck, back and shoulder pain [4]. ●Altered craniospinal elasticity after lumbar puncture (LP) results in increased caudal compliance relative to intracranial compliance and acute intracranial venodilation in the upright position [5]. INCIDENCE — The incidence of PDPH varies widely, depending on patient (eg, age, gender, pregnancy, body mass index [BMI]) and procedural (eg, needle size and type, bevel orientation for




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The incidence of PDPH varies widely, depending on patient (eg, age, gender, pregnancy, body mass index [BMI]) and procedural (eg, needle size and type, bevel orientation for cutting needles) risk factors.
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nal elasticity after lumbar puncture (LP) results in increased caudal compliance relative to intracranial compliance and acute intracranial venodilation in the upright position [5]. INCIDENCE — <span>The incidence of PDPH varies widely, depending on patient (eg, age, gender, pregnancy, body mass index [BMI]) and procedural (eg, needle size and type, bevel orientation for cutting needles) risk factors. The incidence of PDPH after spinal anesthesia is generally <3 percent, but may occur in up to 9 percent of cases, depending on the type and size of needle used [6-8]. PDPH after lumb




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PDPH after lumbar puncture (LP) occurs in approximately 11 percent of cases when a standard, traumatic needle is used [9].
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needles) risk factors. The incidence of PDPH after spinal anesthesia is generally <3 percent, but may occur in up to 9 percent of cases, depending on the type and size of needle used [6-8]. <span>PDPH after lumbar puncture (LP) occurs in approximately 11 percent of cases when a standard, traumatic needle is used [9]. PDPH related to neuraxial anesthesia is most common in obstetric patients. The reported incidence of PDPH after unintentional dural puncture (UDP) with an epidural needle (which is larg




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Patient risk factors — In various studies, common patient risk factors for PDPH have included female gender, pregnancy, age 18 to 50 years compared with older or younger ages, and a prior history of headache
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]. UDP occurs in <1 to as high as 6 percent of epidural placements [7,12-19], with 11 to 33 percent of UDP going unrecognized until the patient presents with PDPH [13,14,19-22]. RISK FACTORS <span>Patient risk factors — In various studies, common patient risk factors for PDPH have included female gender, pregnancy, age 18 to 50 years compared with older or younger ages, and a prior history of headache: ●Female gender – Several studies have found that women have a two to three times increased risk for PDPH compared with men [23-25]. ●Pregnancy – Pregnancy confers an additional risk fo




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Age – In most studies, extremes of age are associated with lower incidence of PDPH, with young adults (18 to 50 years of age) having the highest risk [23,24,31,37-39]. As an example, in one prospective study of patients who had spinal anesthesia with 25 or 27 gauge Quincke (ie, traumatic) needles, PDPH occurred in 11 percent of patients aged 31 to 50 years, compared with 4 percent of others [24].
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29,30]. ●Prior headaches – History of prior headaches (both PDPH and chronic headaches) may be a risk factor for PDPH [4,23,31-33]; although, this has not been observed in all studies [34-36]. ●<span>Age – In most studies, extremes of age are associated with lower incidence of PDPH, with young adults (18 to 50 years of age) having the highest risk [23,24,31,37-39]. As an example, in one prospective study of patients who had spinal anesthesia with 25 or 27 gauge Quincke (ie, traumatic) needles, PDPH occurred in 11 percent of patients aged 31 to 50 years, compared with 4 percent of others [24]. The incidence in very young children may be under-reported due to their inability to report headache and lack of behavioral documentation by parents and clinicians [40,41]. ●Low opening




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Prior headaches – History of prior headaches (both PDPH and chronic headaches) may be a risk factor for PDPH [4,23,31-33]; although, this has not been observed in all studies [34-36]
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; however, definitive evidence is lacking [27,28]. Second stage pushing in labor [28,29] and multiparity [16] have been associated with an increased PDPH risk in the postpartum period [29,30]. ●<span>Prior headaches – History of prior headaches (both PDPH and chronic headaches) may be a risk factor for PDPH [4,23,31-33]; although, this has not been observed in all studies [34-36]. ●Age – In most studies, extremes of age are associated with lower incidence of PDPH, with young adults (18 to 50 years of age) having the highest risk [23,24,31,37-39]. As an example,




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Pregnancy – Pregnancy confers an additional risk for PDPH, possibly due to increased cerebral vasodilation in response to cerebrospinal fluid (CSF) hypotension, related to high levels of circulating estrogen [24,26].
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with older or younger ages, and a prior history of headache: ●Female gender – Several studies have found that women have a two to three times increased risk for PDPH compared with men [23-25]. ●<span>Pregnancy – Pregnancy confers an additional risk for PDPH, possibly due to increased cerebral vasodilation in response to cerebrospinal fluid (CSF) hypotension, related to high levels of circulating estrogen [24,26]. It is also thought that increased CSF pressure during labor leads to a larger CSF leak and higher risk of PDPH; however, definitive evidence is lacking [27,28]. Second stage pushing in




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Female gender – Several studies have found that women have a two to three times increased risk for PDPH compared with men [23-25]
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tors — In various studies, common patient risk factors for PDPH have included female gender, pregnancy, age 18 to 50 years compared with older or younger ages, and a prior history of headache: ●<span>Female gender – Several studies have found that women have a two to three times increased risk for PDPH compared with men [23-25]. ●Pregnancy – Pregnancy confers an additional risk for PDPH, possibly due to increased cerebral vasodilation in response to cerebrospinal fluid (CSF) hypotension, related to high levels




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Low opening pressure – Low opening pressure during lumbar puncture (LP) may also predict an increased risk of PDPH [42]. However, a 2019 case-control retrospective study and systematic literature review found no association between either opening pressure or closing pressure and PDPH risk [43]
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ent of others [24]. The incidence in very young children may be under-reported due to their inability to report headache and lack of behavioral documentation by parents and clinicians [40,41]. ●<span>Low opening pressure – Low opening pressure during lumbar puncture (LP) may also predict an increased risk of PDPH [42]. However, a 2019 case-control retrospective study and systematic literature review found no association between either opening pressure or closing pressure and PDPH risk [43]. ●Volume of CSF removed – PDPH may have distinct temporal and prognostic profiles depending on the volume of CSF removed, particularly for high volume CSF removal. A systematic literatu




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Volume of CSF removed – PDPH may have distinct temporal and prognostic profiles depending on the volume of CSF removed, particularly for high volume CSF removal. A systematic literature review found that high volume CSF removal (ie, 20 to 30 mL) may be associated with increased risk of immediate PDPH, but decreased risk of PDPH at 24 hours, compared with lower volume CSF removal [43].
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isk of PDPH [42]. However, a 2019 case-control retrospective study and systematic literature review found no association between either opening pressure or closing pressure and PDPH risk [43]. ●<span>Volume of CSF removed – PDPH may have distinct temporal and prognostic profiles depending on the volume of CSF removed, particularly for high volume CSF removal. A systematic literature review found that high volume CSF removal (ie, 20 to 30 mL) may be associated with increased risk of immediate PDPH, but decreased risk of PDPH at 24 hours, compared with lower volume CSF removal [43]. In one retrospective study of over 300 LPs performed as part of an Alzheimer disease research trial, patients who had >30 mL CSF removed were more likely to have an immediate onset P




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High volume CSF removal with lowered closing pressure may help reduce further CSF leakage to heal the dural hole
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of an Alzheimer disease research trial, patients who had >30 mL CSF removed were more likely to have an immediate onset PDPH, but were less likely to need an epidural blood patch (EBP) [44]. <span>High volume CSF removal with lowered closing pressure may help reduce further CSF leakage to heal the dural hole. ●Low body mass index (BMI) – The literature on the effect of BMI on the risk of PDPH is inconclusive. Some studies have reported a higher risk of PDPH in patients with low BMI (≤25 kg/




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Low body mass index (BMI) – The literature on the effect of BMI on the risk of PDPH is inconclusive
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e onset PDPH, but were less likely to need an epidural blood patch (EBP) [44]. High volume CSF removal with lowered closing pressure may help reduce further CSF leakage to heal the dural hole. ●<span>Low body mass index (BMI) – The literature on the effect of BMI on the risk of PDPH is inconclusive. Some studies have reported a higher risk of PDPH in patients with low BMI (≤25 kg/m2) after diagnostic LP [45] and lower risk of PDPH after unintentional dural puncture (UDP) in obese




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Procedural risk factors — The choice of spinal needle and procedural factors can affect the risk of PDPH. We suggest the use of pencil point (atraumatic) needles for spinal anesthesia and diagnostic LP.
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k of PDPH after unintentional dural puncture (UDP) in obese parturients (BMI ≥31.5 kg/m2) [30,46]. In contrast, other studies have reported no effect of BMI on the incidence of PDPH [23,47-51]. <span>Procedural risk factors — The choice of spinal needle and procedural factors can affect the risk of PDPH. We suggest the use of pencil point (atraumatic) needles for spinal anesthesia and diagnostic LP. ●Needle tip – For both diagnostic LP and spinal anesthesia, we recommend the use of spinal needles with a pencil point tip, rather than needles with a sharp cutting tip. The use of penc




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Needle tip – For both diagnostic LP and spinal anesthesia, we recommend the use of spinal needles with a pencil point tip, rather than needles with a sharp cutting tip. The use of pencil point spinal needles reduces the risk of PDPH compared with cutting needles of the same size [8,52-54]
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risk factors — The choice of spinal needle and procedural factors can affect the risk of PDPH. We suggest the use of pencil point (atraumatic) needles for spinal anesthesia and diagnostic LP. ●<span>Needle tip – For both diagnostic LP and spinal anesthesia, we recommend the use of spinal needles with a pencil point tip, rather than needles with a sharp cutting tip. The use of pencil point spinal needles reduces the risk of PDPH compared with cutting needles of the same size [8,52-54]. Whitacre and Sprotte needles, which are the most commonly used pencil point needles, have a closed tip shaped like that of a pencil, with the hole on the side of the needle near the ti




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The incidence of PDPH was significantly lower in the atraumatic group compared with the conventional group (4.2 versus 11 percent, relative risk [RR] 0.40, 95% CI 0.34-0.47, absolute risk reduction 6.8 percent, number needed to treat to avoid one headache 15)
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-analysis of randomized controlled trials that compared pencil point and conventional (cutting) needles for LP [9]. The review identified 110 trials from 29 countries with over 31,000 subjects. <span>The incidence of PDPH was significantly lower in the atraumatic group compared with the conventional group (4.2 versus 11 percent, relative risk [RR] 0.40, 95% CI 0.34-0.47, absolute risk reduction 6.8 percent, number needed to treat to avoid one headache 15). In addition, use of atraumatic needles was associated with a significant reduction in the need for EBP (RR 0.5, 95% CI 0.33-0.75). There was no significant difference between groups fo




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In addition, use of atraumatic needles was associated with a significant reduction in the need for EBP (RR 0.5, 95% CI 0.33-0.75). There was no significant difference between groups for the success rate of LP on first attempt, LP failure rate, incidence of traumatic tap, or backache.
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up compared with the conventional group (4.2 versus 11 percent, relative risk [RR] 0.40, 95% CI 0.34-0.47, absolute risk reduction 6.8 percent, number needed to treat to avoid one headache 15). <span>In addition, use of atraumatic needles was associated with a significant reduction in the need for EBP (RR 0.5, 95% CI 0.33-0.75). There was no significant difference between groups for the success rate of LP on first attempt, LP failure rate, incidence of traumatic tap, or backache. ●Needle size – Larger conventional needle size (ie, lower needle gauge) is correlated with an increased incidence of PDPH, as demonstrated in a 2016 meta-analysis that included 12 studi




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Needle size – Larger conventional needle size (ie, lower needle gauge) is correlated with an increased incidence of PDPH, as demonstrated in a 2016 meta-analysis that included 12 studies with over 3100 patients who had neuraxial anesthesia with cutting needles [55]. As examples from the meta-analysis, the incidence of PDPH with a 22 or 23 gauge Quincke needle ranged from 8 to 25 percent, whereas the incidence of PDPH with a 27 gauge Quincke needle ranged from 0 to 14 percent
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ed for EBP (RR 0.5, 95% CI 0.33-0.75). There was no significant difference between groups for the success rate of LP on first attempt, LP failure rate, incidence of traumatic tap, or backache. ●<span>Needle size – Larger conventional needle size (ie, lower needle gauge) is correlated with an increased incidence of PDPH, as demonstrated in a 2016 meta-analysis that included 12 studies with over 3100 patients who had neuraxial anesthesia with cutting needles [55]. As examples from the meta-analysis, the incidence of PDPH with a 22 or 23 gauge Quincke needle ranged from 8 to 25 percent, whereas the incidence of PDPH with a 27 gauge Quincke needle ranged from 0 to 14 percent. In obstetric patients who undergo spinal anesthesia, there is little difference in the rate of PDPH or the need for EBP with the commonly used sizes of pencil point needles. The 2016 m




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Smaller spinal needles may be technically more difficult to use, as they tend to bend during insertion. Thus they are typically used with an introducer needle, which is inserted through the skin and along the desired needle path. Flow rate is slower than with larger bore needles; confirmatory CSF appears more slowly in the needle hub, and collection of CSF is slower. In our practice, spinal anesthesia is performed using a small gauge noncutting needle (ie, 25 gauge Whitacre).
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e of PDPH and pencil point needle size [55]. For patients who undergo diagnostic LP, the relationship between pencil point needle size and the risk of PDPH is less clear, as there are few data. <span>Smaller spinal needles may be technically more difficult to use, as they tend to bend during insertion. Thus they are typically used with an introducer needle, which is inserted through the skin and along the desired needle path. Flow rate is slower than with larger bore needles; confirmatory CSF appears more slowly in the needle hub, and collection of CSF is slower. In our practice, spinal anesthesia is performed using a small gauge noncutting needle (ie, 25 gauge Whitacre). (See "Spinal anesthesia: Technique", section on 'Choice of spinal needle'.) The optimal size of spinal needle may be different for spinal anesthesia versus diagnostic LP in which openin




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The optimal size of spinal needle may be different for spinal anesthesia versus diagnostic LP in which opening pressure and/or CSF sampling is required. In one laboratory study that compared flow rates and the rate of accurate pressure transduction for various cutting and pencil point spinal needles, the 20 gauge Sprotte needles provided rapid pressure transduction (>90 percent of true pressure within one minute) and an optimal flow rate, defined as 2 mL per minute. [56].
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lower. In our practice, spinal anesthesia is performed using a small gauge noncutting needle (ie, 25 gauge Whitacre). (See "Spinal anesthesia: Technique", section on 'Choice of spinal needle'.) <span>The optimal size of spinal needle may be different for spinal anesthesia versus diagnostic LP in which opening pressure and/or CSF sampling is required. In one laboratory study that compared flow rates and the rate of accurate pressure transduction for various cutting and pencil point spinal needles, the 20 gauge Sprotte needles provided rapid pressure transduction (>90 percent of true pressure within one minute) and an optimal flow rate, defined as 2 mL per minute. [56]. The technique of diagnostic LP is discussed in detail elsewhere. (See "Lumbar puncture: Technique, indications, contraindications, and complications in adults".) ●Needle orientation – P




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Needle orientation – PDPH is more than twice as likely if a cutting spinal or epidural needle is inserted with the bevel perpendicular, rather than parallel, to the long axis of the spine [31,57-59]. As an example, in one study, 218 patients who underwent nonobstetric surgery with spinal anesthesia using a 27 gauge Quincke needle were randomly assigned to have the needle inserted parallel or transverse to the long axis of the spine [59]. PDPH occurred in 4 percent of patients in the parallel group, and 23 percent of patients in the transverse group
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ined as 2 mL per minute. [56]. The technique of diagnostic LP is discussed in detail elsewhere. (See "Lumbar puncture: Technique, indications, contraindications, and complications in adults".) ●<span>Needle orientation – PDPH is more than twice as likely if a cutting spinal or epidural needle is inserted with the bevel perpendicular, rather than parallel, to the long axis of the spine [31,57-59]. As an example, in one study, 218 patients who underwent nonobstetric surgery with spinal anesthesia using a 27 gauge Quincke needle were randomly assigned to have the needle inserted parallel or transverse to the long axis of the spine [59]. PDPH occurred in 4 percent of patients in the parallel group, and 23 percent of patients in the transverse group. Since pencil point needles have no bevels, needle orientation is not a relevant issue when they are used. ●Reinsertion of stylet – Whether reinserting the stylet before removing the sp




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Reinsertion of stylet – Whether reinserting the stylet before removing the spinal needle reduces the risk of PDPH is unclear. Available data suggest that reinsertion does not reduce PDPH when a cutting needle is used, and the data regarding the use of pencil point needles is equivocal. Authors to this topic do not routinely reinsert the stylet before removing a spinal needle
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of patients in the parallel group, and 23 percent of patients in the transverse group. Since pencil point needles have no bevels, needle orientation is not a relevant issue when they are used. ●<span>Reinsertion of stylet – Whether reinserting the stylet before removing the spinal needle reduces the risk of PDPH is unclear. Available data suggest that reinsertion does not reduce PDPH when a cutting needle is used, and the data regarding the use of pencil point needles is equivocal. Authors to this topic do not routinely reinsert the stylet before removing a spinal needle. •Pencil point needles – Evidence of benefit for stylet reinsertion comes from a randomized trial of 600 patients undergoing diagnostic LP using a 21 gauge Sprotte needle, which found t




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Placement of spinal needle in the sitting as opposed to lateral position [66] and a higher number of needle passes may be associated with increased risk for PDPH in spinal anesthetics, but the evidence is conflicting [31,67].
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sthesia/analgesia are similar to the incidences after an epidural technique [63-65]. CSE is discussed separately. (See "Epidural and combined spinal-epidural anesthesia: Techniques".) ●Others – <span>Placement of spinal needle in the sitting as opposed to lateral position [66] and a higher number of needle passes may be associated with increased risk for PDPH in spinal anesthetics, but the evidence is conflicting [31,67]. Paramedian approach to the spinal space and decreased operator experience [68,69] may confer additional increased risk for PDPH, but results are limited and conflicting between the orth




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Paramedian approach to the spinal space and decreased operator experience [68,69] may confer additional increased risk for PDPH, but results are limited and conflicting between the orthopedic and obstetric populations [70,71].
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e sitting as opposed to lateral position [66] and a higher number of needle passes may be associated with increased risk for PDPH in spinal anesthetics, but the evidence is conflicting [31,67]. <span>Paramedian approach to the spinal space and decreased operator experience [68,69] may confer additional increased risk for PDPH, but results are limited and conflicting between the orthopedic and obstetric populations [70,71]. In epidural placements, studies have failed to show a difference in PDPH risk with the use of air versus saline for the loss of resistance technique to identify the epidural space acros




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In epidural placements, studies have failed to show a difference in PDPH risk with the use of air versus saline for the loss of resistance technique to identify the epidural space across all patient populations [72,73]. The onset of headache may be sooner in obstetric patients when air is used for loss of resistance, likely related to pneumocephalus rather than low pressure headache [20]
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space and decreased operator experience [68,69] may confer additional increased risk for PDPH, but results are limited and conflicting between the orthopedic and obstetric populations [70,71]. <span>In epidural placements, studies have failed to show a difference in PDPH risk with the use of air versus saline for the loss of resistance technique to identify the epidural space across all patient populations [72,73]. The onset of headache may be sooner in obstetric patients when air is used for loss of resistance, likely related to pneumocephalus rather than low pressure headache [20]. PREVENTION OF PDPH AFTER DURAL PUNCTURE — In addition to procedure modification, a number of strategies have been used to attempt to prevent PDPH after dural puncture. ●Bed rest – Desp




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Bed rest – Despite common recommendations for bed rest following dural puncture, this remedy has not been shown to significantly decrease the risk of PDPH [4,74-77].
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pressure headache [20]. PREVENTION OF PDPH AFTER DURAL PUNCTURE — In addition to procedure modification, a number of strategies have been used to attempt to prevent PDPH after dural puncture. ●<span>Bed rest – Despite common recommendations for bed rest following dural puncture, this remedy has not been shown to significantly decrease the risk of PDPH [4,74-77]. A meta-analysis of 16 randomized controlled trials of LP performed for anesthesia, myelography, or diagnostic purposes found no evidence in any trial that longer bed rest was superior t




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While of no use for prevention of PDPH, bed rest does decrease the intensity of the headache. (See 'Treatment' below.)
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ter bed rest [76]. The relative risk (RR) of headache among patients undergoing a diagnostic LP was 0.97 with longer bed rest. A similar lack of benefit was noted in a later meta-analysis [74]. <span>While of no use for prevention of PDPH, bed rest does decrease the intensity of the headache. (See 'Treatment' below.) ●Abdominal binder – Given the low risk of this intervention, some of the authors of this topic routinely offer abdominal binders to patients who have unintentional dural puncture (UDP)




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There is a theoretical role for abdominal compression with a tight abdominal binder for prevention and/or treatment of PDPH. The rationale for such treatment is that increased intra-abdominal pressure may be transmitted to the epidural space, may help to seal the dural puncture and decrease cerebrospinal fluid (CSF) leak, and may improve an existing headache
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erience, some patients enjoy wearing the binder in the immediate postpartum period. However, abdominal binders are not widely recommended [78], and there is little literature on their use [79]. <span>There is a theoretical role for abdominal compression with a tight abdominal binder for prevention and/or treatment of PDPH. The rationale for such treatment is that increased intra-abdominal pressure may be transmitted to the epidural space, may help to seal the dural puncture and decrease cerebrospinal fluid (CSF) leak, and may improve an existing headache. ●Prophylactic drug therapy – Based on the limited evidence available, we do not recommend administration of prophylactic medications after UDP or LP to prevent PDPH. Small trials have




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Prophylactic drug therapy – Based on the limited evidence available, we do not recommend administration of prophylactic medications after UDP or LP to prevent PDPH.
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reased intra-abdominal pressure may be transmitted to the epidural space, may help to seal the dural puncture and decrease cerebrospinal fluid (CSF) leak, and may improve an existing headache. ●<span>Prophylactic drug therapy – Based on the limited evidence available, we do not recommend administration of prophylactic medications after UDP or LP to prevent PDPH. Small trials have reported that prophylactic administration of epidural morphine [80] and intravenous (IV) cosyntropin [81] may reduce the incidence of PDPH after UDP during obstetric a




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In addition, ondansetron may reduce the risk of PDPH. In one randomized trial, 210 women were randomly assigned to receive ondansetron 0.15 mg/kg IV or saline during spinal anesthesia with a 25 gauge Quincke needle for cesarean delivery [84]. PDPH occurred in 5 percent of patients who received ondansetron, compared with 21 percent of patients who did not. Ondansetron may trigger migraine headache in susceptible patients [85]. Further research is needed to elucidate the role of these drugs in PDPH prevention.
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cosyntropin and epidural morphine was associated with decreased incidence of PDPH and need for epidural blood patch, compared with other prophylactic treatment or conservative management [83]. <span>In addition, ondansetron may reduce the risk of PDPH. In one randomized trial, 210 women were randomly assigned to receive ondansetron 0.15 mg/kg IV or saline during spinal anesthesia with a 25 gauge Quincke needle for cesarean delivery [84]. PDPH occurred in 5 percent of patients who received ondansetron, compared with 21 percent of patients who did not. Ondansetron may trigger migraine headache in susceptible patients [85]. Further research is needed to elucidate the role of these drugs in PDPH prevention. In obstetric and general surgical populations, oral caffeine has not been shown to prevent PDPH after dural puncture [86,87]. ●Prophylactic epidural blood patch – Epidural blood patch (




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In obstetric and general surgical populations, oral caffeine has not been shown to prevent PDPH after dural puncture [86,87].
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h 21 percent of patients who did not. Ondansetron may trigger migraine headache in susceptible patients [85]. Further research is needed to elucidate the role of these drugs in PDPH prevention. <span>In obstetric and general surgical populations, oral caffeine has not been shown to prevent PDPH after dural puncture [86,87]. ●Prophylactic epidural blood patch – Epidural blood patch (EBP) is an effective treatment for PDPH, and may also be performed prophylactically before a headache occurs for patients in w




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Epidural blood patch (EBP) is an effective treatment for PDPH, and may also be performed prophylactically before a headache occurs for patients in whom an epidural catheter is placed after an inadvertent dural puncture.
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hese drugs in PDPH prevention. In obstetric and general surgical populations, oral caffeine has not been shown to prevent PDPH after dural puncture [86,87]. ●Prophylactic epidural blood patch – <span>Epidural blood patch (EBP) is an effective treatment for PDPH, and may also be performed prophylactically before a headache occurs for patients in whom an epidural catheter is placed after an inadvertent dural puncture. For prophylactic EBP, blood is injected into the epidural catheter prior to its removal after anesthesia. (See 'Epidural blood patch' below.) We do not routinely perform prophylactic EB




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We do not routinely perform prophylactic EBP, since the efficacy is unclear [88-93].
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eter is placed after an inadvertent dural puncture. For prophylactic EBP, blood is injected into the epidural catheter prior to its removal after anesthesia. (See 'Epidural blood patch' below.) <span>We do not routinely perform prophylactic EBP, since the efficacy is unclear [88-93]. A review of the literature of prophylactic EBP in obstetric patients found that it does not appear to decrease the incidence of PDPH, but may decrease the intensity and/or duration of s




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Patients with PDPH typically present with frontal or occipital headache that is worse with sitting or standing, and relieved by lying flat. The headache tends to be worse if it occurs in the first 24 hours, and associated symptoms are more common with severe headaches. In some patients, the symptoms of PDPH are similar to their previously experienced migraine headaches, except that there is an added postural component
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anaged with either placement of an intrathecal catheter or replacement of an epidural catheter [94]. There was no difference in the incidence of PDPH between the two groups. CLINICAL FEATURES — <span>Patients with PDPH typically present with frontal or occipital headache that is worse with sitting or standing, and relieved by lying flat. The headache tends to be worse if it occurs in the first 24 hours, and associated symptoms are more common with severe headaches. In some patients, the symptoms of PDPH are similar to their previously experienced migraine headaches, except that there is an added postural component. Associated symptoms occur in up to 70 percent of patients [24], and may include nausea, neck stiffness, low back pain, vertigo, vision changes (diplopia, blurred vision, or photophobia




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Associated symptoms occur in up to 70 percent of patients [24], and may include nausea, neck stiffness, low back pain, vertigo, vision changes (diplopia, blurred vision, or photophobia), dizziness, or auditory disturbances (tinnitus, hearing loss) [42]. In one study of 133 patients who developed PDPH after diagnostic lumbar puncture (LP), neck stiffness was reported in 55.6 percent, shoulder stiffness in 46.6 percent, nausea and vomiting in 33 percent, tinnitus in 22 percent, and photophobia in 23 percent. [4].
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s are more common with severe headaches. In some patients, the symptoms of PDPH are similar to their previously experienced migraine headaches, except that there is an added postural component. <span>Associated symptoms occur in up to 70 percent of patients [24], and may include nausea, neck stiffness, low back pain, vertigo, vision changes (diplopia, blurred vision, or photophobia), dizziness, or auditory disturbances (tinnitus, hearing loss) [42]. In one study of 133 patients who developed PDPH after diagnostic lumbar puncture (LP), neck stiffness was reported in 55.6 percent, shoulder stiffness in 46.6 percent, nausea and vomiting in 33 percent, tinnitus in 22 percent, and photophobia in 23 percent. [4]. Approximately 90 percent of PDPHs occur within 72 hours after a dural puncture, though onset has rarely been reported up to two weeks later [42,98]. Without treatment, most headaches re




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Approximately 90 percent of PDPHs occur within 72 hours after a dural puncture, though onset has rarely been reported up to two weeks later [42,98].
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ar puncture (LP), neck stiffness was reported in 55.6 percent, shoulder stiffness in 46.6 percent, nausea and vomiting in 33 percent, tinnitus in 22 percent, and photophobia in 23 percent. [4]. <span>Approximately 90 percent of PDPHs occur within 72 hours after a dural puncture, though onset has rarely been reported up to two weeks later [42,98]. Without treatment, most headaches resolve within one week, and one-half resolve by four to five days after dural puncture [24,31,99]. Longer duration of PDPH has been associated with th




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Without treatment, most headaches resolve within one week, and one-half resolve by four to five days after dural puncture [ 24,31,99].
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percent, and photophobia in 23 percent. [4]. Approximately 90 percent of PDPHs occur within 72 hours after a dural puncture, though onset has rarely been reported up to two weeks later [42,98]. <span>Without treatment, most headaches resolve within one week, and one-half resolve by four to five days after dural puncture [24,31,99]. Longer duration of PDPH has been associated with the use of a cutting needle for dural puncture compared with a pencil point needle [100], dural puncture with the patient in the sitting




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Longer duration of PDPH has been associated with the use of a cutting needle for dural puncture compared with a pencil point needle [ 100], dural puncture with the patient in the sitting position compared with lateral decubitus, multiple attempts at dural puncture, and patient history of depression [36].
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set has rarely been reported up to two weeks later [42,98]. Without treatment, most headaches resolve within one week, and one-half resolve by four to five days after dural puncture [24,31,99]. <span>Longer duration of PDPH has been associated with the use of a cutting needle for dural puncture compared with a pencil point needle [100], dural puncture with the patient in the sitting position compared with lateral decubitus, multiple attempts at dural puncture, and patient history of depression [36]. DIAGNOSIS OF PDPH — The diagnosis of PDPH is made clinically by identifying the typical positional headache within 72 hours after a dural puncture. Other causes may need to be excluded




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The diagnosis of PDPH is made clinically by identifying the typical positional headache within 72 hours after a dural puncture. Other causes may need to be excluded if symptoms are atypical
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[100], dural puncture with the patient in the sitting position compared with lateral decubitus, multiple attempts at dural puncture, and patient history of depression [36]. DIAGNOSIS OF PDPH — <span>The diagnosis of PDPH is made clinically by identifying the typical positional headache within 72 hours after a dural puncture. Other causes may need to be excluded if symptoms are atypical. Neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is not indicated unless required to exclude alternative diagnoses. If imaging is performed, findings cons




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If imaging is performed, findings consistent with PDPH include small ventricles, downward displacement (sagging) of the brain, engorged cerebral venous sinuses, subdural fluid collections, pituitary enlargement, and diffuse meningeal enhancement [2,101,102]. These findings are analogous to those reported in patients with spontaneous intracranial hypotension. (See "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis".)
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y need to be excluded if symptoms are atypical. Neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is not indicated unless required to exclude alternative diagnoses. <span>If imaging is performed, findings consistent with PDPH include small ventricles, downward displacement (sagging) of the brain, engorged cerebral venous sinuses, subdural fluid collections, pituitary enlargement, and diffuse meningeal enhancement [2,101,102]. These findings are analogous to those reported in patients with spontaneous intracranial hypotension. (See "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis".) Diagnostic lumbar puncture (LP) should be avoided if possible, due to the risk of worsening an existing PDPH. If performed, however, a low cerebrospinal fluid (CSF) opening pressure or




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Diagnostic lumbar puncture (LP) should be avoided if possible, due to the risk of worsening an existing PDPH. If performed, however, a low cerebrospinal fluid (CSF) opening pressure or dry tap (indicative of intracranial hypotension) with increased CSF protein and lymphocyte count may be present [103].
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findings are analogous to those reported in patients with spontaneous intracranial hypotension. (See "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis".) <span>Diagnostic lumbar puncture (LP) should be avoided if possible, due to the risk of worsening an existing PDPH. If performed, however, a low cerebrospinal fluid (CSF) opening pressure or dry tap (indicative of intracranial hypotension) with increased CSF protein and lymphocyte count may be present [103]. DIFFERENTIAL DIAGNOSIS — The differential diagnosis of headache after dural puncture is broad, as outlined in the table (table 1), but a postural headache in this setting is most likely




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The differential diagnosis of headache after dural puncture is broad, as outlined in the table (table 1), but a postural headache in this setting is most likely related to the procedure.
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low cerebrospinal fluid (CSF) opening pressure or dry tap (indicative of intracranial hypotension) with increased CSF protein and lymphocyte count may be present [103]. DIFFERENTIAL DIAGNOSIS — <span>The differential diagnosis of headache after dural puncture is broad, as outlined in the table (table 1), but a postural headache in this setting is most likely related to the procedure. Serious and/or life-threatening etiologies (eg, hemorrhage, thrombosis, vasculopathy, meningitis), which may or may not be related to the dural puncture, must be ruled out in the presen




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Serious and/or life-threatening etiologies (eg, hemorrhage, thrombosis, vasculopathy, meningitis), which may or may not be related to the dural puncture, must be ruled out in the presence of focal or worsening neurologic deficits. Findings that should prompt further investigation are shown in a table ( table 2).
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OSIS — The differential diagnosis of headache after dural puncture is broad, as outlined in the table (table 1), but a postural headache in this setting is most likely related to the procedure. <span>Serious and/or life-threatening etiologies (eg, hemorrhage, thrombosis, vasculopathy, meningitis), which may or may not be related to the dural puncture, must be ruled out in the presence of focal or worsening neurologic deficits. Findings that should prompt further investigation are shown in a table (table 2). Subdural hematoma and other forms of intracranial hemorrhage are rare but potentially lethal complications of dural puncture. Intracranial hemorrhage should be suspected in patients wit




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Subdural hematoma and other forms of intracranial hemorrhage are rare but potentially lethal complications of dural puncture. Intracranial hemorrhage should be suspected in patients with prolonged headache (ie, beyond five to seven days), whose headaches become non-positional, who do not improve or worsen after an epidural blood patch (EBP), or who develop focal neurologic symptoms [104,105]
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be related to the dural puncture, must be ruled out in the presence of focal or worsening neurologic deficits. Findings that should prompt further investigation are shown in a table (table 2). <span>Subdural hematoma and other forms of intracranial hemorrhage are rare but potentially lethal complications of dural puncture. Intracranial hemorrhage should be suspected in patients with prolonged headache (ie, beyond five to seven days), whose headaches become non-positional, who do not improve or worsen after an epidural blood patch (EBP), or who develop focal neurologic symptoms [104,105]. Other possible causes of postural headache (eg, migraine, headache associated with postural orthostatic tachycardia) may occur coincidentally after dural puncture, and may be excluded




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Other possible causes of postural headache (eg, migraine, headache associated with postural orthostatic tachycardia) may occur coincidentally after dural puncture, and may be excluded based on history, symptoms, and physical examination. Some headaches may improve but are not completely abolished with rest, including in the supine position (eg, migraine)
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che (ie, beyond five to seven days), whose headaches become non-positional, who do not improve or worsen after an epidural blood patch (EBP), or who develop focal neurologic symptoms [104,105]. <span>Other possible causes of postural headache (eg, migraine, headache associated with postural orthostatic tachycardia) may occur coincidentally after dural puncture, and may be excluded based on history, symptoms, and physical examination. Some headaches may improve but are not completely abolished with rest, including in the supine position (eg, migraine). PDPH related to neuraxial anesthesia is most common in obstetric patients. Headache in the postpartum period is remarkably common, with a reported incidence as high as 39 percent in th




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Mild PDPH — Patients with PDPH who can tolerate an upright position and perform activities of daily living are considered to have mild PDPH; obstetric patients with mild PDPH are able to care for their baby. Patients with mild PDPH may benefit from an initial trial of conservative treatment including bed rest as needed, and a brief course of oral analgesics (see 'Drug therapy' below) and antiemetics as necessary. Vigorous oral and/or intravenous (IV) hydration are also routinely encouraged in postpartum patients as a noninvasive, low-risk therapy [108]
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cy and postpartum", section on 'Evaluation of postpartum patients'.) TREATMENT — The treatment of PDPH depends upon the severity of headache and its impact on the patient's ability to function. <span>Mild PDPH — Patients with PDPH who can tolerate an upright position and perform activities of daily living are considered to have mild PDPH; obstetric patients with mild PDPH are able to care for their baby. Patients with mild PDPH may benefit from an initial trial of conservative treatment including bed rest as needed, and a brief course of oral analgesics (see 'Drug therapy' below) and antiemetics as necessary. Vigorous oral and/or intravenous (IV) hydration are also routinely encouraged in postpartum patients as a noninvasive, low-risk therapy [108]. Debilitating PDPH — Patients with PDPH who are unable to tolerate sitting or standing, or are unable to perform activities of daily living (including obstetric patients unable to care




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Debilitating PDPH — Patients with PDPH who are unable to tolerate sitting or standing, or are unable to perform activities of daily living (including obstetric patients unable to care for their baby) and whose headache is refractory to a brief trial of conservative measures are considered to have moderate to severe PDPH. These patients should be offered an epidural blood patch (EBP), which may provide permanent symptomatic relief.
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Drug therapy' below) and antiemetics as necessary. Vigorous oral and/or intravenous (IV) hydration are also routinely encouraged in postpartum patients as a noninvasive, low-risk therapy [108]. <span>Debilitating PDPH — Patients with PDPH who are unable to tolerate sitting or standing, or are unable to perform activities of daily living (including obstetric patients unable to care for their baby) and whose headache is refractory to a brief trial of conservative measures are considered to have moderate to severe PDPH. These patients should be offered an epidural blood patch (EBP), which may provide permanent symptomatic relief. Epidural blood patch — EBP is considered the definitive treatment for PDPH. A systematic review published in 2010 noted that EBP reduced the duration and intensity of post-dural punctur




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Similar to epidural anesthesia, EBP is contraindicated in patients with coagulopathy or on anticoagulation, and in patients with systemic infection or infection at the site for epidural needle placement. Patients with HIV present a theoretical risk for developing central nervous system (CNS) infection after EBP. However, HIV is known to be a neurotropic virus, infecting the CNS in its earliest stages, and no adverse effects have been reported after either neuraxial anesthesia or EBP in HIV-infected patients [118].
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ate for a second EBP, if it is required [10,110,113-116]. The success rate for EBP may be lower if dural puncture occurs with a larger diameter needle (ie, ≥20 gauge) [117]. Contraindications — <span>Similar to epidural anesthesia, EBP is contraindicated in patients with coagulopathy or on anticoagulation, and in patients with systemic infection or infection at the site for epidural needle placement. Patients with HIV present a theoretical risk for developing central nervous system (CNS) infection after EBP. However, HIV is known to be a neurotropic virus, infecting the CNS in its earliest stages, and no adverse effects have been reported after either neuraxial anesthesia or EBP in HIV-infected patients [118]. Patients with PDPH after an initially challenging neuraxial anesthetic may benefit from fluoroscopically-guided EBP placement. The decision to place EBP must always be weighed against t




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Once the epidural space has been identified in this manner, a syringe of autologous venous blood is drawn by a second operator using aseptic technique; the blood is slowly injected through the epidural needle. Typically, headache symptoms will improve within seconds to minutes of the completion of the procedure, although a transient sensation of "fullness" in the back is common
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sistance to saline to identify the epidural space, without inserting a catheter (see "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Epidural anesthesia technique'). <span>Once the epidural space has been identified in this manner, a syringe of autologous venous blood is drawn by a second operator using aseptic technique; the blood is slowly injected through the epidural needle. Typically, headache symptoms will improve within seconds to minutes of the completion of the procedure, although a transient sensation of "fullness" in the back is common. Upon completion of the EBP, the patient is instructed to lie flat (or at a maximum 30 degree angle) for one to two hours with minimal movement. After this, the patient may stand and re




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Upon completion of the EBP, the patient is instructed to lie flat (or at a maximum 30 degree angle) for one to two hours with minimal movement. After this, the patient may stand and resume normal activities. It is reasonable to avoid heavy lifting and strenuous activity within the first 24 hours of EBP, although evidence is lacking to support this recommendation. Patients should also be instructed to taper analgesic medications (eg, butalbital-acetaminophen-caffeine) to avoid the possibility of a rebound headache from sudden medication withdrawal
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the epidural needle. Typically, headache symptoms will improve within seconds to minutes of the completion of the procedure, although a transient sensation of "fullness" in the back is common. <span>Upon completion of the EBP, the patient is instructed to lie flat (or at a maximum 30 degree angle) for one to two hours with minimal movement. After this, the patient may stand and resume normal activities. It is reasonable to avoid heavy lifting and strenuous activity within the first 24 hours of EBP, although evidence is lacking to support this recommendation. Patients should also be instructed to taper analgesic medications (eg, butalbital-acetaminophen-caffeine) to avoid the possibility of a rebound headache from sudden medication withdrawal. ●Optimal volume of blood for EBP – We aim to inject 20 mL of blood for blood patch, and stop injection if the patient complains of significant pain or pressure. A randomized trial that




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Mechanism of action — The mechanism by which EBP relieves PDPH is unclear, and may be multifactorial. It is thought that the injection of blood directly compresses the thecal sac, thereby increasing lumbar and intracranial cerebrospinal fluid (CSF) pressure. Once the injected blood clots, it may plug the CSF leak and/or initiate an inflammatory reaction that facilitates healing of the puncture site.
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performed with the patient in the lateral decubitus position [123]. The blood spread a mean of 4.6 interspaces, approximately 3.5 interspaces cephalad and 1 interspace caudad to the injection. <span>Mechanism of action — The mechanism by which EBP relieves PDPH is unclear, and may be multifactorial. It is thought that the injection of blood directly compresses the thecal sac, thereby increasing lumbar and intracranial cerebrospinal fluid (CSF) pressure. Once the injected blood clots, it may plug the CSF leak and/or initiate an inflammatory reaction that facilitates healing of the puncture site. Regardless of the mechanism, clotting appears to be important to the success of injectates used for EBP, as whole blood, fibrin glue, and possibly platelet-rich plasma more effectively




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Complications — The most common complication of EBP is back pain, which occurs in 25 to 35 percent of patients [113,126,127]. Back pain usually resolves within 48 hours of EBP.
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EBP, as whole blood, fibrin glue, and possibly platelet-rich plasma more effectively maintain CSF pressure than saline, anticoagulated blood, or dextran solutions in animal models [89,124,125]. <span>Complications — The most common complication of EBP is back pain, which occurs in 25 to 35 percent of patients [113,126,127]. Back pain usually resolves within 48 hours of EBP. However, in one prospective observational study of women who underwent EBP for PDPH, back pain lasted from 3 to 100 days (mean 28 days) in 16 percent of patients [113]. Rare complicatio




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Rare complications include misplacement of blood resulting in spinal subdural hematoma [128] or intrathecal injection and arachnoiditis [126,129]. Other rare complications include infection, subdural abscess [130], facial nerve paralysis [113,131-133], spastic paraparesis, and cauda equina syndrome [134,135].
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within 48 hours of EBP. However, in one prospective observational study of women who underwent EBP for PDPH, back pain lasted from 3 to 100 days (mean 28 days) in 16 percent of patients [113]. <span>Rare complications include misplacement of blood resulting in spinal subdural hematoma [128] or intrathecal injection and arachnoiditis [126,129]. Other rare complications include infection, subdural abscess [130], facial nerve paralysis [113,131-133], spastic paraparesis, and cauda equina syndrome [134,135]. Drug therapy — A number of drugs have been investigated for the treatment of PDPH in small trials and studies, but none have been proven beneficial for this specific indication. Neverth




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Drug therapy — A number of drugs have been investigated for the treatment of PDPH in small trials and studies, but none have been proven beneficial for this specific indication. Nevertheless, oral caffeine is a low-risk option for most patients, and caffeine and oral analgesics are options for the symptomatic treatment of PDPH.
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and arachnoiditis [126,129]. Other rare complications include infection, subdural abscess [130], facial nerve paralysis [113,131-133], spastic paraparesis, and cauda equina syndrome [134,135]. <span>Drug therapy — A number of drugs have been investigated for the treatment of PDPH in small trials and studies, but none have been proven beneficial for this specific indication. Nevertheless, oral caffeine is a low-risk option for most patients, and caffeine and oral analgesics are options for the symptomatic treatment of PDPH. ●Caffeine – Caffeine has commonly been used for treatment of PDPH (sometimes in combination with butalbital and/or acetaminophen), without high-quality supporting evidence [86]. We enco




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Caffeine – Caffeine has commonly been used for treatment of PDPH (sometimes in combination with butalbital and/or acetaminophen), without high-quality supporting evidence [86]. We encourage self-administered oral caffeine in patients who normally drink caffeinated beverages on a daily basis, in order to avoid headache and other symptoms of caffeine withdrawal.
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beneficial for this specific indication. Nevertheless, oral caffeine is a low-risk option for most patients, and caffeine and oral analgesics are options for the symptomatic treatment of PDPH. ●<span>Caffeine – Caffeine has commonly been used for treatment of PDPH (sometimes in combination with butalbital and/or acetaminophen), without high-quality supporting evidence [86]. We encourage self-administered oral caffeine in patients who normally drink caffeinated beverages on a daily basis, in order to avoid headache and other symptoms of caffeine withdrawal. A 2015 systematic review of the literature on drug therapy for PDPH found two small randomized trials (approximately 40 patients in each) that compared oral and IV caffeine with placebo




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Hearing loss may occur after dural puncture, and has been variably reported in up to 10 to 50 percent of patients after spinal anesthesia, though less than 25 percent of these patients are aware of the deficit [153,154]. It may be unilateral or bilateral, and may occur even in the absence of headache.
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ich are activated by dural stretch in PDPH [151,152]. OTHER COMPLICATIONS OF DURAL PUNCTURE — PDPH is the most common adverse outcome of dural puncture and is generally self-limited and benign. <span>Hearing loss may occur after dural puncture, and has been variably reported in up to 10 to 50 percent of patients after spinal anesthesia, though less than 25 percent of these patients are aware of the deficit [153,154]. It may be unilateral or bilateral, and may occur even in the absence of headache. Hearing loss is usually transient, but there are reported cases of hearing loss lasting for years after spinal anesthesia [155], unintentional dural puncture (UDP) [156], and diagnostic




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Injection of air into the subarachnoid space during placement of neuraxial block may result in acute onset of severe headache and other neurologic signs and symptoms [160,161]. This complication may occur with an UDP if air, rather than saline, is used for loss of resistance to identify the epidural space (see "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Epidural anesthesia technique'). A pneumocephalus headache can occur within a few seconds if the epidural is placed with the patient in the sitting position, but may be delayed until the patient sits up if the epidural is placed in the lateral decubitus position. Regardless of onset delay, the headache is usually maximal at onset (ie, "thunderclap") [162]
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r needle size [158] and cutting needles have been associated with increased incidence of hearing loss [159]. Epidural blood patch (EBP) has been performed with resolution of hearing loss [157]. <span>Injection of air into the subarachnoid space during placement of neuraxial block may result in acute onset of severe headache and other neurologic signs and symptoms [160,161]. This complication may occur with an UDP if air, rather than saline, is used for loss of resistance to identify the epidural space (see "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Epidural anesthesia technique'). A pneumocephalus headache can occur within a few seconds if the epidural is placed with the patient in the sitting position, but may be delayed until the patient sits up if the epidural is placed in the lateral decubitus position. Regardless of onset delay, the headache is usually maximal at onset (ie, "thunderclap") [162]. Treatment of pneumocephalus headache is symptomatic. Limited data suggest that normobaric oxygen therapy leads to more rapid resolution [163,164]; hyperbaric oxygen therapy may be indi




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In rare cases, dural puncture has been associated with reversible cerebral vasoconstriction syndrome (RCVS) [177,178] and posterior reversible encephalopathy syndrome (PRES) [179-181], but causation is uncertain; several of these reports involved obstetric patients with possible preeclampsia or eclampsia, which are also associated with RCVS and PRES.
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ent for any of these complications. (See "Subdural hematoma in adults: Etiology, clinical features, and diagnosis" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis".) <span>In rare cases, dural puncture has been associated with reversible cerebral vasoconstriction syndrome (RCVS) [177,178] and posterior reversible encephalopathy syndrome (PRES) [179-181], but causation is uncertain; several of these reports involved obstetric patients with possible preeclampsia or eclampsia, which are also associated with RCVS and PRES. (See "Reversible cerebral vasoconstriction syndrome", section on 'Risk factors and associated conditions' and "Reversible posterior leukoencephalopathy syndrome", section on 'Related co




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Risk factors – Risk factors for PDPH include patient age (highest among adults 18 to 50 years of age), female gender, pregnancy, possibly prior history of headache, the use of cutting versus pencil point spinal needles, and the use of larger needles. For patients undergoing LP or spinal anesthesia, we recommend performing the procedure with spinal needles that have a pencil point (atraumatic) tip, rather than needles with a sharp cutting tip (Grade 1A).
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approximately 10 percent of patients after dural puncture with a spinal needle, and up to approximately 85 percent of patients who have an UDP with an epidural needle. (See 'Incidence' above.) ●<span>Risk factors – Risk factors for PDPH include patient age (highest among adults 18 to 50 years of age), female gender, pregnancy, possibly prior history of headache, the use of cutting versus pencil point spinal needles, and the use of larger needles. For patients undergoing LP or spinal anesthesia, we recommend performing the procedure with spinal needles that have a pencil point (atraumatic) tip, rather than needles with a sharp cutting tip (Grade 1A). (See 'Risk factors' above.) ●Prevention – Measures to prevent PDPH after dural puncture (eg, bed rest, placement of a spinal catheter after UDP, medications) have not been proven effect




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Prevention – Measures to prevent PDPH after dural puncture (eg, bed rest, placement of a spinal catheter after UDP, medications) have not been proven effective.
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hesia, we recommend performing the procedure with spinal needles that have a pencil point (atraumatic) tip, rather than needles with a sharp cutting tip (Grade 1A). (See 'Risk factors' above.) ●<span>Prevention – Measures to prevent PDPH after dural puncture (eg, bed rest, placement of a spinal catheter after UDP, medications) have not been proven effective. (See 'Prevention of PDPH after dural puncture' above.) ●Clinical features – PDPH is a postural headache (ie, worse when upright, improved when supine) that usually occurs within 72 hour




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Clinical features – PDPH is a postural headache (ie, worse when upright, improved when supine) that usually occurs within 72 hours of dural puncture. In most cases, PDPH resolves within one week, even without treatment. Other causes of headache must be ruled out (table 1).
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o prevent PDPH after dural puncture (eg, bed rest, placement of a spinal catheter after UDP, medications) have not been proven effective. (See 'Prevention of PDPH after dural puncture' above.) ●<span>Clinical features – PDPH is a postural headache (ie, worse when upright, improved when supine) that usually occurs within 72 hours of dural puncture. In most cases, PDPH resolves within one week, even without treatment. Other causes of headache must be ruled out (table 1). (See 'Clinical Features' above and 'Differential diagnosis' above.) ●Diagnosis – The diagnosis of PDPH is made clinically by identifying the typical positional headache within 72 hours




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Treatment – Conservative treatment for patients with mild PDPH includes bed rest and a brief course of oral caffeine and/or oral analgesics. (See 'Mild PDPH' above and 'Drug therapy' above.)

For patients with moderate to severe PDPH that is prolonged (>24 hours) and refractory to conservative measures, we recommend treatment with epidural blood patch (EBP) (Grade 1B).

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ours after a dural puncture. In patients with atypical features, other causes may need to be excluded (table 1 and table 2). (See 'Diagnosis of PDPH' above and 'Differential diagnosis' above.) ●<span>Treatment – Conservative treatment for patients with mild PDPH includes bed rest and a brief course of oral caffeine and/or oral analgesics. (See 'Mild PDPH' above and 'Drug therapy' above.) For patients with moderate to severe PDPH that is prolonged (>24 hours) and refractory to conservative measures, we recommend treatment with epidural blood patch (EBP) (Grade 1B). EBP is performed by injecting autologous blood through an epidural needle immediately after drawing the blood under sterile conditions. (See 'Debilitating PDPH' above and 'Epidural bloo