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## Complete Summary

#### GUIDELINE TITLE

\(1\) Assessment: prevention of post-lumbar puncture headaches. Report
of the Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology. (2) Addendum to assessment: prevention of
post-lumbar puncture headaches. Report of the Therapeutics and
Technology Assessment Subcommittee of the American Academy of Neurology.

#### BIBLIOGRAPHIC SOURCE(S)

Armon C, Evans RW. Addendum to assessment: prevention of post-lumbar
puncture headaches: report of the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. Neurology 2005 Aug
23;65(4):510-2. \[9 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16116106)

Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of
post-lumbar puncture headaches: report of the Therapeutics and
Technology Assessment Subcommittee of the American Academy of Neurology.
Neurology 2000 Oct 10;55(7):909-14. \[52 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Post-lumbar puncture headache

#### GUIDELINE CATEGORY

Prevention\
Technology Assessment

#### CLINICAL SPECIALTY

Anesthesiology\
Family Practice\
Internal Medicine\
Neurology\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

**2000 Guideline**

To identify risk factors that could be modified to reduce the frequency
of post-lumbar puncture headaches (PLPHAs) in patients undergoing
diagnostic lumbar punctures

**2005 Addendum**

To classify the new literature and to affirm or modify the
recommendations of the original assessment, as appropriate. A particular
focus of this update was to identify any new evidence to support the use
of the atraumatic or pencil-point needle over the use of the
conventional \"cutting\" needle in performance of diagnostic lumbar
punctures (LPs) to reduce post-lumbar puncture headaches.

#### TARGET POPULATION

Patients undergoing spinal anesthesia or diagnostic lumbar punctures

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Lumbar puncture, including the following procedural or practice
variables**:

1.  Needle size

2.  Direction of the bevel

3.  Replacement of the stylet before withdrawing the needle

4.  Needle design (Note: use of atraumatic spinal needle vs. cutting
    needle was a particular focus of the 2005 addendum)

5.  Volume of spinal fluid removed

6.  Duration of recumbency after the lumbar puncture

7.  Increase hydration following the lumbar puncture

#### MAJOR OUTCOMES CONSIDERED

Frequency of post-lumbar puncture headaches in patients undergoing
lumbar punctures

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**2000 Guideline**

A literature search conducted by one of the authors served as the basis
for this report. Appropriate literature was identified by MEDLINE
searches back to 1966 using the following key words and phrases:
post-lumbar puncture head-ache, prevention of post-lumbar puncture
headache, complications of lumbar puncture, atraumatic and pencil point
lumbar puncture needles, and Whitacre and Sprotte lumbar puncture
needles. Additional articles were found through bibliographies of these
articles and by checking pertinent textbooks. Articles deemed pivotal
for making recommendations were reviewed by members of the Therapeutics
and Technology Assessment (TTA) Subcommittee for the purpose of
classification of the evidence as it pertained to the recommendations at
hand. Some of the background literature was also reviewed independently
by the Therapeutics and Technology Assessment Subcommittee members.

**2005 Addendum**

A MEDLINE search was conducted by one of the authors in June 2004, using
the terms \"post lumbar puncture headache\" and \"postdural puncture
headache.\" Articles linked electronically to the original assessment
were also considered. Abstracts of articles comparing needle types were
reviewed. Full texts only of articles pertaining to diagnostic lumbar
punctures (LPs) were retrieved for detailed analysis. Accompanying
editorials and related letters to the editors were reviewed for relevant
critique.

#### NUMBER OF SOURCE DOCUMENTS

**2000 Guideline**

Not stated

**2005 Addendum**

Five articles were identified initially, reporting on diagnostic lumbar
punctures (LPs). Two additional case series were reviewed.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**2000 Guideline**

**Quality of Evidence Ratings for Therapeutic Modalities**

**Class I**. Evidence provided by one or more well-designed randomized
controlled clinical trials.

**Class II**. Evidence provided by one or more well-designed clinical
studies, such as case-control, cohort studies, etc.

**Class III**. Evidence provided by expert opinion, nonrandomized
historical controls, or reports of one or more.

**2005 Addendum**

**Classification of Evidence**

**Class I**: Prospective, randomized, controlled clinical trial with
masked outcome assessment, in a representative population. The following
are required:

a.  Primary outcome(s) is(are) clearly defined.

b.  Exclusion/inclusion criteria are clearly defined.

c.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias.

d.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences.

**Class II**: Prospective matched group cohort study in a representative
population with masked outcome assessment that meets A through D above
OR a randomized, controlled trial in a representative population that
lacks one criterion A through D.

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independently
assessed or independently derived by objective outcome measurement
(objective outcome measurement is an outcome measure that is unlikely to
be affected by an observer\'s (patient, treating physician,
investigator) expectation or bias \[e.g., blood tests, administrative
outcome data\]).

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion.

**Note**:

For the 2005 Addendum, in comparing atraumatic to cutting needle design,
articles had to meet the following criteria, specified in the original
assessment, to be considered class I evidence:

1.  Prospective study design.

2.  Randomization.

3.  Double masking: neither patient nor evaluator of post-lumbar
    puncture headaches (PLPHA) aware of needle design used.

4.  Equal needle diameter.

5.  When using cutting needle, needle bevel parallel to dural fibers
    stated explicitly.

6.  Stylet replaced before needle withdrawn documented explicitly.

7.  Active ascertainment of occurrence of PLPHA by the investigators.

For the purposes of this update, any article failing in one of these
areas was automatically classified as Class IV. The classification of
the articles and the underlying justification are summarized in the
annotated reference list and expanded selectively in the results section
of the original guideline document.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**2000 Guideline**

**Definitions for Strength of Recommendations**

**Type A**. Strong positive recommendation based on Class I evidence, or
based on overwhelming Class II evidence when circumstances preclude
randomized clinical trials.

**Type B**. Positive recommendation based on Class II evidence.

**Type C**. Positive recommendation based on strong consensus of Class
III evidence.

**Type D**. Negative recommendation based on inconclusive or conflicting
Class II evidence.

**Type E**. Negative recommendation based on Class II or Class I
evidence of ineffectiveness or lack of efficacy.

**2005 Addendum**

**Classification of Recommendations**

**A**: Established as effective, ineffective, or harmful for the given
condition in the specified population. (Level A rating requires at least
two consistent Class I studies.)

**B**: Probably effective, ineffective, or harmful for the given
condition in the specified population. (Level B rating requires at least
one Class I study or at least two consistent Class II studies.)

**C**: Possibly effective, ineffective, or harmful for the given
condition in the specified population. (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**U**: Data inadequate or conflicting given current knowledge; treatment
is unproven.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

**2000 Guideline**

Approved by the Therapeutics and Technology Assessment Subcommittee on
May 2, 2000; by the Practice Committee on May 5, 2000; and by the
American Academy of Neurology Board of Directors on June 9, 2000.

**2005 Addendum**

Approved by the Therapeutics and Technology Assessment Subcommittee on
November 19, 2004; by the Practice Committee on April 13, 2005; and by
the American Academy of Neurology Board of Directors on June 26, 2005.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**2000 Guideline**

The quality of evidence ratings, I-III, and the strength of
recommendations (Type A-Type E) are defined at the end of the \"Major
Recommendations\" field.

1.  Class I and Class II data in the anesthesiology literature and
    either Class I or Class II data in the neurology series show that
    smaller needle size is associated with reduced frequency of
    post-lumbar puncture headache (PLPHA) (Type A). The actual choice of
    needle size will be influenced by balancing other considerations,
    such as ease of use, the need to measure pressures, and the flow
    rate, with the desire to prevent PLPHA.

2.  Class I data in the anesthesiology literature show that, when using
    a cutting needle, ensuring that the bevel direction is parallel to
    the dural fibers reduces the frequency of PLPHA. (Type A).

3.  Class I data using a noncutting needle show that replacement of the
    stylet before the needle is withdrawn is associated with lower
    frequency of PLPHA. (Type A).

4.  For spinal anesthesia, Class I data show that non-cutting needles
    reduce the frequency of PLPHA (Type A). However, for diagnostic
    lumbar punctures (LPs), the data are inconclusive.

5.  Class I and Class II data have not demonstrated that the duration of
    recumbency following a diagnostic lumbar puncture influences the
    occurrence of PLPHA.

6.  There is no evidence that the use of increased fluids prevents
    PLPHA.

**2005 Addendum**

Definitions of the classification of the recommendations (A, B, C, U)
and classification of the evidence (Class I through Class IV) are
provided at the end of the \"Major Recommendations\" field.

1.  *New conclusion*: Most studies in the anesthesiology literature,
    across several needle sizes, and now also one study providing Class
    I evidence in a patient population undergoing diagnostic lumbar
    punctures with a 22-gauge needle support the use of an atraumatic
    spinal needle to reduce the frequency of PLPHA (Type A).

*Reaffirmation of a previous conclusion*: Class I and Class II data in
the anesthesiology and the neurology literature show that smaller needle
size is associated with reduced frequency of PLPHA (Type A).

**[Definitions]{.underline}**:

**2000 Guideline**

**Quality of Evidence Ratings for Therapeutic Modalities**

**Class I**. Evidence provided by one or more well-designed randomized
controlled clinical trials.

**Class II**. Evidence provided by one or more well-designed clinical
studies, such as case-control, cohort studies, etc.

**Class III**. Evidence provided by expert opinion, nonrandomized
historical controls, or reports of one or more.

**Strength of Recommendations**

**Type A**. Strong positive recommendation based on Class I evidence, or
based on overwhelming Class II evidence when circumstances preclude
randomized clinical trials.

**Type B**. Positive recommendation based on Class II evidence.

**Type C**. Positive recommendation based on strong consensus of Class
III evidence.

**Type D**. Negative recommendation based on inconclusive or conflicting
Class II evidence.

**Type E**. Negative recommendation based on Class II or Class I
evidence of ineffectiveness or lack of efficacy.

**2005 Addendum**

**Classification of Evidence**

**Class I**: Prospective, randomized, controlled clinical trial with
masked outcome assessment, in a representative population. The following
are required:

a.  Primary outcome(s) is/are clearly defined.

b.  Exclusion/inclusion criteria are clearly defined.

c.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias.

d.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences.

**Class II**: Prospective matched group cohort study in a representative
population with masked outcome assessment that meets A through D above
OR a randomized, controlled trial in a representative population that
lacks one criterion A through D.

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independently
assessed or independently derived by objective outcome measurement
(objective outcome measurement is an outcome measure that is unlikely to
be affected by an observer\'s (patient, treating physician,
investigator) expectation or bias \[e.g., blood tests, administrative
outcome data\]).

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion.

**Classification of Recommendation**

**A** = Established as effective, ineffective, or harmful for the given
condition in the specified population. (Level A rating requires at least
two consistent Class I studies.)

**B** = Probably effective, ineffective, or harmful for the given
condition in the specified population. (Level B rating requires at least
one Class I study or at least two consistent Class II studies.)

**C** = Possibly effective, ineffective, or harmful for the given
condition in the specified population. (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**U** = Data inadequate or conflicting; given current knowledge,
treatment is unproven.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on a review of the literature. The type of
supporting evidence is identified and graded for each recommendation on
the prevention of post-lumbar puncture headaches (see \"Major
Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Reduction in the frequency of post-lumbar puncture headaches

**Subgroups Most Likely to Benefit**:

-   Younger female patients with small body mass index (between the ages
    of 18-30)

-   Patients with headaches before the lumbar puncture

-   Patients with a history of post-lumbar puncture headaches

#### POTENTIAL HARMS

*Replacement of the stylet before withdrawing the needle*: Rarely, a
nerve root can herniate through the dura due to aspiration by the needle
during withdrawal. There is a single case report of transection and
withdrawal of a nerve filament due to replacement of the stylet (into a
hollow needle with an end-hole-side-hole needle) following a lumbar
myelogram. Bacterial meningitis, a rare complication of diagnostic
lumbar puncture, might theoretically be caused by reintroducing a stylet
contaminated with respiratory droplets. The stylet should always be used
on insertion through the skin and the subcutaneous tissue whether using
a Quincke or atraumatic needle. Rarely, a needle without a stylet may
implant a plug of skin which can grow into an intraspinal epidermoid
tumor.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The statement of this guideline is provided as an educational
    service of the American Academy of Neurology. It is based on an
    assessment of current scientific and clinical information. It is not
    intended to include all possible proper methods of care for a
    particular neurologic problem or all legitimate criteria for
    choosing to use a specific procedure. Neither is it intended to
    exclude any reasonable alternative methodologies. The American
    Academy of Neurology recognizes that specific patient care decisions
    are the prerogative of the patient and the physician caring for the
    patient, based on all of the circumstances involved.

-   Post-lumbar puncture headache (PLPHA) has been defined in different
    ways. Definitions range from any headache after lumbar puncture to
    headache after lumbar puncture with definite characteristics \-- in
    particular, a constant headache appearing or worsening significantly
    upon assuming the upright position and resolving or improving
    significantly upon lying down. Some of the definitions used do not
    permit excluding possible overlap between the PLPHA described and
    migraine without aura, at least in some of the patients. We elected
    to accept all definitions of PLPHA uncritically, but recommend that
    future studies of PLPHA adhere to rigorous definitions that will
    permit excluding other etiologies of headaches. Similarly, there is
    no uniform definition of \"severe\" PLPHA. Future studies should use
    established and well-defined criteria for PLPHA and its severity.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Armon C, Evans RW. Addendum to assessment: prevention of post-lumbar
puncture headaches: report of the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. Neurology 2005 Aug
23;65(4):510-2. \[9 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16116106)

Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of
post-lumbar puncture headaches: report of the Therapeutics and
Technology Assessment Subcommittee of the American Academy of Neurology.
Neurology 2000 Oct 10;55(7):909-14. \[52 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Oct (revised 2005 Aug)

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology

#### GUIDELINE COMMITTEE

Therapeutics and Technology Assessment Subcommittee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Carmel Armon, MD, MHS; Randolph W. Evans, MD

*Committee Members*: Douglas S. Goodin, MD (*Chair*); Yuen T. So, MD,
PhD (*Vice-Chair*); Carmel Armon, MD, MHS; Richard M. Dubinsky, MD, MPH:
Mark Hallett, MD; David Hammond, MD; Cynthia Harden, MD; Chung Hsu, MD,
PhD (ex officio); Andres M. Kanner, MD (*ex officio*); David S.
Lefkowitz, MD; Janis Miyasaki, MD; Michael A. Sloan, MD, MS; James C.
Stevens, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**2001 Guideline**

Not stated

**2005 Addendum**

The authors report no conflicts of interest.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies of the original document and the addendum: Available
from the [American Academy of Neurology (AAN) Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Addendum to assessment: prevention of post-lumbar puncture
    headaches. St. Paul (MN): American Academy of Neurology. 2005. 4 p.
    Available for personal digital assistant (PDA) download from the
    [American Academy of Neurology (AAN) Web
    site](https://www.aan.com/professionals/practice/guidelines/pda/Post_lumbar_headache.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 12, 2002. The information
was verified by the guideline developer as of March 29, 2002. This
summary was updated by ECRI on December 23, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008