Most doctors are unaware of features of headache after lumbar puncture

EDITOR—Serpell et al's survey of lumbar puncture practice in the United Kingdom reminds us that small (22-26 gauge), atraumatic needles, which reduce the incidence of headache after lumbar puncture, are not being routinely used.1 The incidence of headache after lumbar puncture is roughly 35% with 20 gauge standard needles, 5% with 22 gauge atraumatic needles, and 1% with 25 gauge atraumatic needles.2 Adequate cerebrospinal fluid can be obtained by aspirating with smaller needles. The cost of an atraumatic (Whitacre or Sprotte) needle is about £4, compared with £1 for the standard (Quincke) needle. Using 22 gauge atraumatic needles would therefore cost £10 per headache prevented. A third of headaches after lumbar puncture are described as severe, prolonged, or debilitating and unresponsive to simple measures.3 Prolonged headache after lumbar puncture can lead to subdural haematoma.4

The authors mention that epidural blood patching is a successful way of treating persistent headache after lumbar puncture. Epidural blood patching is widely used by anaesthetists for the more severe headache after lumbar puncture caused accidentally by large 16 gauge or 18 gauge epidural needles.5

I conducted an audit at a district general hospital that performs about 150 lumbar punctures annually. Only three out of 26 doctors were aware of the option of epidural blood patching for headache after lumbar puncture (eight junior house officers, 10 middle grade doctors, and eight consultant or staff grade doctors were surveyed). In addition, less than half (of all grades) were able to state correctly the characteristic features of headache after lumbar puncture—fronto-occipital distribution, relief when the patient lies down, onset up to several days …