Letter

Headache after diagnostic lumbar puncture

BMJ 2001; 322 doi: 10.1136/bmj.322.7292.993/b (Published 21 April 2001)
Cite this as: BMJ 2001;322:993.3

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Using 20 gauge needle is blunderbuss technique

  1. James S Smeltzer, consultant, maternal fetal medicine (James.Smeltzer@wellstar.org)
  1. Wellstar Physicians' Group, Northwest Women's Care, 787 Campbell Hill Street, Marietta, GA 30060, USA
  2. Department of Anaesthesia, Lancaster Acute Hospitals NHS Trust, Royal Lancaster Infirmary, Lancaster LA1 4RP
  3. University of Sheffield, Sheffield S10 2RX
  4. Royal Hallamshire Hospital, Sheffield S10 2JF
  5. Southern General Hospital, Glasgow G51 4TF
  6. Leeds General Infirmary, Leeds LS1 3EX

    EDITOR—The results of Thomas et al's trial of atraumatic versus standard needles for diagnostic lumbar puncture1 confirm those of others on this topic,2–5 as well as my own personal experience. As both gauge and needle type matter,5 I am curious as to why they did not use a finer needle, consistent with most previous efforts to reduce spinal headache.

    Use of a 20 gauge needle improved the study's power by increasing the overall rate of spinal headaches versus rates in other studies,22-5 but it can hardly be recommended as standard technique. The fact that one can kill houseflies with a shotgun does not mean that it is better to do so.

    References

    1. 1.↵
      1. Thomas SR,
      2. Jamieson DRS,
      3. Muir KW
      .Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture.BMJ2000; 321:986–990. (21 October.)
      OpenUrlFREE Full Text
    2. 2.↵
      1. Eriksson AL,
      2. Hallen B,
      3. Lagerkranser M,
      4. Persson E,
      5. Skoldefors E
      .Whitacre or Quincke needles—does it really matter?Acta Anaesthesiol Scand Suppl1998; 113:17–20.
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    3. 3.
      1. Holst D,
      2. Mollmann M,
      3. Ebel C,
      4. Hausman R,
      5. Wendt M
      .In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles.Anesth Analg1998; 87:1331–1335.
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    4. 4.
      1. Corbey MP,
      2. Bach AB,
      3. Lech K,
      4. Frorup AM
      .Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles.Acta Anaesthesiol Scand1997; 41:779–784.
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    5. 5.↵
      1. Morewood GH
      .A rational approach to the cause, prevention and treatment of postdural puncture headache.Can Med Assoc J1993; 149:1087–1093.
      OpenUrlFREE Full Text

    Smaller is better where needles are concerned

    1. John R Davies (john.r.davies@k.bay-tr.nwest.nhs.uk), consultant anaesthetist.
    1. Wellstar Physicians' Group, Northwest Women's Care, 787 Campbell Hill Street, Marietta, GA 30060, USA
    2. Department of Anaesthesia, Lancaster Acute Hospitals NHS Trust, Royal Lancaster Infirmary, Lancaster LA1 4RP
    3. University of Sheffield, Sheffield S10 2RX
    4. Royal Hallamshire Hospital, Sheffield S10 2JF
    5. Southern General Hospital, Glasgow G51 4TF
    6. Leeds General Infirmary, Leeds LS1 3EX

      EDITOR—It is unfortunate that Thomas et al devoted so much effort towards reducing the risk of headache after lumbar puncture from 50% to 28% by using an atraumatic needle1 when a smaller needle would have had a much more beneficial effect. In a line or two they dismissed anaesthetic and radiological practice, where atraumatic needles as small as 24 gauge are routine and an incidence of headache of <10% after lumbar puncture is expected.

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      Odds ratios and confidence intervals in meta-analysis looking at design of spinal needles and headache after lumbar puncture2

      A large meta-analysis, which included 12 studies from 1966 to 1993, found that the incidence of headache after lumbar puncture was significantly reduced by both the use of smaller needles and the use of an atraumatic point (table). …

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