This is a frequent complication that curiously occurs
more often when the cerebrospinal fluid is normal than when it shows evidence
of disease. According to Davenport (1964), up to 30% of patients develop
headache following lumbar puncture. The anesthesia literature indicates a much
lower incidence with the use of new techniques and smaller size needles. It
apparently occurs from a fall in intracranial pressure and continues during the
period when the pressure remains low as a result of leakage of fluid through
the puncture wound in the dura. It is thought that traction of the dural
membranes may be responsible for the headache. The size of the needle used, the
amount of fluid withdrawn, and multiple punctures are factors that influence
the development of headache.
The headache, which is best described as
``bursting,'' is often extremely severe. The pain is usually worse in the
occipital region and forehead, but it may extend into the neck and shoulders.
It is significantly, and occasionally, completely relieved when the patient
lies down with the feet at a higher level than the head. The headache usually
lasts for only about 2 or 3 days but may persist for as long as 2, or even 3,
weeks, and rarely for many months, if untreated.
Cisternal and ventricular punctures are rarely
followed by severe headaches, but when air, anesthetic, or radiographic
contrast material (pantopaque or metrizamide) are injected into the ventricles
or particularly when they are injected into the subarachnoid space by the lumbar
route, severe and prostrating headaches may occur.
The frequency and severity of headaches following
lumbar puncture may be reduced by using a fine gauge needle, having the patient
lie prone for 4 hours after lumbar puncture, and maintaining bed rest for 24
hours after the procedure. Lying flat in bed and drinking large quantities of
fluids, particularly those with caffeine (tea, coffee, some soft drinks) often
give significant relief (Mathew, 1978).
Lumbar puncture headache, ordinarily disabling only for
a few days, has no serious sequelae. Occasionally, however, lumbar puncture may
produce subarachnoid bleeding from laceration of vessels of an unexpected
spinal cord arteriovenous malformation. Subarachnoid hemorrhage may also occur
from rupture of a congenital aneurysm. In other cases where there is an
intracranial mass lesion, particularly when it is situated in the posterior
fossa, lumbar puncture may result in herniation of the medulla into the foramen
magnum and thus cause sudden death of the patient.
Dr. Frank B. Walsh (Walsh and Hoyt, 1969) observed an
individual who suffered from severe vascular hypertension but did not complain
of headache except following lumbar puncture. On three successive taps, the
spinal fluid pressure was 575, 405, and 600 mm of water.
As emphasized by Raskin (1988), headache following
lumbar puncture usually begins within 48 hours and is dramatically positional:
it begins when the patient stands or sits upright; there is relief upon
reclining or with abdominal compression. It is believed that the mechanism is
the loss of the CSF position to the brain so that when a patient is upright
there is probably dilatation and tension based on the brainís anchoring
structures, the pain-sensitive dural sinuses, resulting in pain.
A spinal headache can occur any
time you receive a spinal anesthetic. The chances of having a spinal headache
depend on many factors including age, weight and size of needle used for the
procedure. A typical spinal headache may occur following the puncture of one of
the layers of tissue surrounding the spinal cord called the dura during the
administration an epidural injection. The cause of the headache is the decrease
of fluid around your brain and spinal cord (cerebral spinal fluid) that is
leaking into the epidural space.
A spinal headache may occur up to
5 days after the anesthetic is administered. This headache is often described
as a headache like no other. This type of headache is much more severe when the
you sit up and gets better when you lie down.
If you think you or a member of
your family may be developing a spinal headache the first treatment is
considered conservative. This includes adequate fluids to try to increase the
pressure of the fluid around your spinal cord. Sometimes this is accomplished
by IV 's or drinking things high in caffeine, such as Mountain Dew, to make the
blood vessels get tiny and try to increase CSF pressure in this way. Another
treatment may be staying in bed and not getting out for any reason for 24-48
hours. A IV of salt water into the area around your spinal cord space may also
be used as a conservative treatment if the you still has the epidural catheter
in place.
If conservative treatment fails,
there are more things to try. One that is commonly done is called a blood
patch. This is done by inserting a needle into the same space or a space just
next to the space that was used for the anesthetic. A small amount of your
blood is injected into the epidural space. (I know it sound weird but it works
- and since it's your bloodÖ. And if your head hurts this bad, quite frankly
you'll be glad someone is helping you in this way.) Once injected, the blood
clots and seals the hole where the CSF was leaking, this once again increases
the CSF to adequate levels. After the procedure is performed you have to lay
flat for about and hour, to make sure the blood remains at the puncture site
and to give the blood time to clot. Relief from the spinal headache is felt
very quickly, and sometimes immediately after the blood patch is complete.
Normal activities may be resumed shortly after the blood patch has had time to
congeal. Very rarely does the blood patch not provide relief, but if it does
not work the procedure may have to be repeated. Success rates for blood patches
are 90% for the first blood patch, and 95% for the second blood patch.
Contraindications to this
procedure include a whole body infection, localized infection at the area of
insertion, and active neurological disease.