Headache and Backache After Lumbar Puncture in Children and Adolescents: A Prospective Study
From the University Pediatric Hospital, Department of Child Neurology, Heidelberg, Germany
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. After lumbar puncture, many adults develop headaches or backaches. Postpuncture complaints are believed to be rare in children and adolescents, but their exact incidence is unclear because there is a paucity of data derived from general pediatric patients. In a prospective study of general pediatric and neuropediatric patients, we investigated the frequency of postlumbar puncture headaches or backaches and factors that might influence their occurrence.
Methods. Conducted over 12 months, the prospective study included 112 patients aged 2 to 16 years. We evaluated them for factors that might influence the rate of postpuncture complaints: age, gender, use of local anesthesia, cannula gauge, bevel orientation, number of puncture attempts, volume of cerebrospinal fluid (CSF) aspirated, and cell count in CSF.
Results. Twenty-seven percent of the patients experienced headaches (positional headache in 9%), and 40% developed backache. Frequency of complaints increased in relation to patients' age. In older children, girls reported complaints more frequently than did boys. Patients with higher cell counts in CSF had more frequent headaches than did patients without pleocytosis. Cannula gauge or bevel orientation did not influence outcome.
Conclusion. The frequency of positional and nonpositional headaches after lumbar puncture is lower in children than in adults. Backaches contribute significantly to postpuncture morbidity. With puberty, the incidences of postpuncture complaints increase, and girls start to become more prone to develop postpuncture headaches. Recommendations regarding cannula gauge or bevel orientation that derive from studies in adults are not confirmed for children.
Key Words: postlumbar puncture headache • postlumbar puncture backache • children • adolescents • age • gender • pleocytosis • cannula gauge • bevel orientation
Abbreviations: CSF, cerebrospinal fluid
Lumbar puncture is one of the most frequently performed invasive diagnostic procedures in children and adolescents. Hence, it is remarkable that few studies have been devoted to the indication for and method of lumbar puncture in pediatric patients and to postpuncture complaints, a phenomenon recognized since the close of the 19th century.1 Although postpuncture complaints are generally believed to be rare in children and adolescents, their exact incidence remains unknown.2
Most studies on postpuncture complaints in children and adolescents concern spinal anesthesia (eg, 3–6). Additional studies reported on oncologic patients, whose lumbar punctures were performed under general anesthesia,7–11 and on institutionalized children with mental retardation12 or with disruptive behavior disorders.13 One other study included both neuropediatric and oncopediatric patients.14The only data relating to the frequency of postpuncture complaints in a general pediatric patient group are in a study dealing primarily with the indications for puncture and its role in the diagnostic process.15 In the present prospective study, we investigated the frequency of postpuncture complaints in children and adolescents who underwent lumbar puncture.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The prospective observational study was conducted over 12 months at the Children's Hospital of the University of Heidelberg in conjunction with neighboring clinics. Included in the study were patients who were 2 years of age and older and undergoing diagnostic lumbar puncture. Not admitted to the study were oncologic patients, all of whom received intrathecal therapy, as well as severely ill children in significantly impaired general condition.
Included in the study were 61 girls and 51 boys aged 2 to 16 years (mean: 8.2 years); 73 patients were at our Heidelberg hospital, and the remainder were at children's hospitals in Heilbronn (13 patients), Kaiserslautern (12 patients), and Ludwigshafen (14 patients). Punctures were performed by the attending pediatrician. We did not demand a specific method for lumbar puncture but simply requested that it be done "as usual." In 40 (36%) patients, local anesthesia was applied, which consisted of cutaneous anesthetic cream in all patients. All patients underwent puncture with cannulas characterized by the classic cutting Quincke bevel. Special atraumatic cannulas were not used in any patient. Puncture was performed in 76 (68%) patients using 22-G cannulas and in 34 (30%) children using 20-G cannulas. In 2 children, a 19-G cannula was used. Nearly all punctures were performed with the patient in a sitting position (n = 105; 94%). In all cases, the puncture needle was introduced between the lower spinal processes at midline. In 44 (39%) punctures, the cannula was held with the bevel directed laterally, whereas in the majority of cases, the bevel was directed upward in cranial direction. Repeated puncture attempts were necessary in 19 (13%) patients. The amount of cerebrospinal fluid (CSF) aspirated ranged from 1 to 20 mL (median: 6 mL). Analysis of the CSF revealed pleocytosis of >5 cells/µL in 30 (27%) patients; the corresponding diagnoses were facial palsy caused by borreliosis in 7 patients, meningitis in 24 patients, and herpes encephalitis in 1 patient. As usual in our hospitals, all patients were instructed to maintain bed rest for 24 hours after lumbar puncture.
For the days after puncture, reports of headaches or backaches were recorded by the patient and his or her parents and/or the nursing staff. Headaches that occurred or worsened on standing up and disappeared or improved on lying down were described as positional, but nonpositional headaches were included, too. In addition, other problems such as nausea were registered. Only complaints that started or became more severe after lumbar puncture and were at least of moderate severity sufficient to have an impact on patients' well-being were recorded. Onset of symptoms was recorded for the first 3 days after puncture. Patients who were already discharged from the hospital from inpatient care were contacted by telephone. Patients' complaints were assessed by the same person (C. K.) each day.
Statistical evaluation of the data were performed using SPSS, Version 11. Four-field tables were used to assess frequency distribution using either Pearson 
2 test or Fisher exact test. Logistic regression analyses were performed with "positional headache," "all headaches," "backaches," or "headaches or backaches" as dependent variables. The independent variables were age, gender, cannula gauge, bevel orientation, necessity of repeated puncture attempts, volume of aspirated CSF, and pleocytosis. Using an SPSS procedure giving allowance also for categorical data as independent variables, they were selected for inclusion by the likelihood-quotient method. P < .05 was considered statistically significant.
The study protocol was designed in accordance with the principles of the Helsinki Declaration. The protocol was submitted to the ethics commission of the University of Heidelberg and approved.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Headaches were reported in 30 (27%) of 112 patients who underwent lumbar puncture. In 10 (9%) patients, these headaches were clearly positional in nature. Forty-five (40%) developed backaches, which were temporarily radiating into the thighs in 3 patients. At least 1 pain-related symptom (headache or backache) was reported by 59 (53%) patients, and 16 (14%) developed both headache and backache. Concerning other symptoms that could arise after lumbar puncture,2 26 (23%) patients complained of transient nausea. Vertigo, tinnitus, diplopia, or blurred vision were not reported. In all cases, onset of symptoms was on the day of puncture or on the first or second postpuncture days. Symptoms lasted 2 days, on average. In no case did symptoms fail to resolve within 1 week. Table 1 lists the results of those variables that influenced complaints' rate significantly.
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Headaches or backaches occurred in children as young as 2 years of age. The youngest patient reporting clearly positional headaches was a 5-year-old boy. Although 33% of children younger than 10 years complained of headaches or backaches, this proportion rose to 82% of patients 10 years of age and older. The frequency of backaches was 24% for the younger patients and 64% for the older ones; for headaches, the respective rates were 18% and 40%. These differences were statistically significant (Table 1). With positional headaches occurring in 5% of the younger patients and in 16% of the older patients, the difference did not achieve statistical significance.
Regarding all age groups together, there were no clear gender differences in the frequencies of symptoms. In patients 10 years of age and older, however, girls reported significantly more headaches than did boys (Table 2). In younger patients, there was no significant difference between the genders. For any of the other factors studied, we did not find any difference with respect to the age groups.
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Although with the application of cutaneous anesthetic cream the frequency of backaches was only insignificant lower than without local anesthesia, it was connected with a significantly higher frequency of positional headache (18% vs 4%; Table 1). The frequency of general headaches was not influenced. Patients who exhibited pleocytosis >5 cells/µL developed headaches significantly more often than did patients with lower cell counts (43% vs 21%; Table 1). The different diagnoses connected with pleocytosis (facial palsy with borreliosis, meningitis, and encephalitis) did not influence outcome. There were no significant differences in the rate of headaches or backaches in relation to the gauge of the puncture needle, the orientation of the bevel (cranial vs lateral), the need for multiple puncture attempts, or the amount of CSF aspirated at lumbar puncture (Table 3).
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Logistic regression analysis considering the covariates age, gender, use of cutaneous anesthetic cream, needle gauge, orientation of bevel at puncture, multiple puncture attempts, amount of CSF aspirated, and pleocytosis revealed that for "headaches or backaches" and for backaches only the factor "age" achieved statistical significance (Table 4). For all headaches, this was the case for the variables pleocytosis, age, and gender, whereas the frequency of positional headache was influenced by the patient's age and by the use of anesthetic cream. Considering other possible postpuncture symptoms, eg, the incidence of nausea, we did not find any influencing variable either by 4-field tables or by logistic regression analysis.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The present study is the first since that of Plaut15 in 1968 to consider the frequency of headache and backache after diagnostic lumbar puncture in a general pediatric patient group. Positional postpuncture headache in the strict sense begins or worsens within minutes of standing up and improves or disappears on lying down.2 It is encountered in approximately one third of adult patients.2 In young adults, aged 20 to 40 years, the reported frequency is even higher.16,17 Our findings put the rate of positional headache much lower, at 9%. Considering that not all studies differentiate positional and nonpositional headaches, our frequency of all headaches is 27%, which is also lower than the rate generally reported for adults.
In the pediatric studies published, the headache rates after spinal anesthesia3–6 are lower than our findings. Headache frequencies after diagnostic12–14 or therapeutic7–11 punctures, however, approximate our findings. Plaut15 observed headaches in only 3% of his general pediatric patients. Postpuncture complaints, however, were not the focus of his study; hence, it is likely that headaches escaped detection. The incidence of backaches after diagnostic lumbar puncture is given between 22% and 45%13,14; nausea is reported in 14% to 20%.12,14 These data correspond to the findings of the present study.
In literature, postpuncture complaints are reported in children as young as 2 years,7 which is in accordance with the present study. Nevertheless, in most7–9,11 but not all10,14 studies that differentiated between adolescents older than 10 to 12 years and younger children, older children reported significantly more pain-related complaints than did younger children. Our results confirm these findings.
Studies in adults report a higher frequency of postpuncture symptoms in women than in men.16–18 Pediatric studies so far have not shown any gender difference of postpuncture complaints.9,11 The present study is the first to show that among patients 10 years of age and older, girls report headaches significantly more often than do boys.
Hormone-caused gender difference in the consistency of the connective tissue has been postulated as a reason for the different frequencies of postpuncture headaches. This interpretation is based on the pathophysiologic concept of this phenomenon originally formulated more than a century ago.19 It supposes that postpuncture headache is caused by persistent leakage of CSF through a puncture-induced dural rent that may result in direct traction on intracranial pain-sensing structures and to intracranial venodilation being apt to activate nociceptors.2
This concept is supported by findings in adults that the use of noncutting, atraumatic cannulas may exert a protective effect20 and that larger gauge needles, which cause a more severe leakage of CSF,21 are associated with a higher rate of postpuncture symptoms.17 Pediatric studies concerning cannula characteristics, hitherto all deal with patients undergoing spinal anesthesia. They do not show a clear advantage to the use of either atraumatic puncture needles6 or smaller gauge puncture cannulas.5 Also in our patients who underwent diagnostic punctures, which in the vast majority were performed using 20-G or 22-G cannulas, we could not document a significant effect exerted by cannula diameter. Thinner needles, as used for spinal anesthesia, are associated with a significantly slower rate of flow22 and can be problematic in pediatric settings.5
Puncturing the dura mater with the cannula bevel oriented laterally instead of cranially is believed to displace the dura fibers rather than cut them through.23 This technique was associated with a lower rate of postpuncture complaints in adults.24 After repeated puncture attempts25 or aspiration of large volumes of CSF,26 adults more frequently report symptoms. Relating to these observations, there are no pediatric data published so far. We could not demonstrate a significant effect of any of these factors.
We are not aware of any study to report whether the frequency of postpuncture complaints is influenced by the use of anesthetic cream. In the present study, contrary to expectations, its use did not influence the incidence of backaches significantly, but, most surprising, it was connected with a higher rate of positional headaches. We suspected that this result was caused not by the cream itself but by characteristics of the patients in whom the cream was applied, but data analysis did not disclose any peculiarity of this group, so we have no plausible explanation for this result.
In children who had viral meningitis, preexisting symptoms improved after lumbar puncture.27 In contrast, we observed a higher rate of new or worsening headache occurring after puncture in patients with elevated cell counts in the CSF.
To our knowledge, the possible effect of patients' lying or sitting during lumbar puncture on the frequency of postpuncture complaints has not been studied during the last decades. Older studies in adults (cf 26) had contradictory results; pediatric data are lacking. In the present study, nearly all punctures were performed with the patient in a sitting position, and there was an insufficient number of punctures with the patient lying to analyze this question.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In the present study of general pediatric and neuropediatric patients, the frequency of headaches after lumbar puncture is lower than that reported for adults. Backaches also contribute significantly to postpuncture morbidity. The risk of postpuncture complaints increases significantly with age. In older children and adolescents, we observed the same gender-specific differences recognized in adults with an increased frequency of postpuncture headaches in girls. In contrast to results in adults, cannula gauge or bevel orientation did not influence outcome.
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ACKNOWLEDGMENTS |
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We thank the participating patients and the physicians of the cooperating hospitals.
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FOOTNOTES |
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Received for publication Jul 15, 2003; Accepted Oct 10, 2003.
Reprint requests to (F.E.) University Pediatric Hospital, Department of Child Neurology, Im Neuenheimer Feld 150 69120, Heidelberg, Germany. E-mail: friedrich_ebinger{at}med.uni-heidelberg.de
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