Correspondence

Should One Reinsert the Stylet during Lumbar Puncture?

N Engl J Med 1997; 336:1190April 17, 1997

Article

To the Editor:

The post–lumbar puncture syndrome may be due to prolonged leakage of cerebrospinal fluid because of delayed closure of a dural defect, which causes low cerebrospinal fluid pressure. The reported frequency of the syndrome ranges from less than 1 percent to 70 percent. Its incidence depends on the diameter of the needle,1 the shape of the needle,2 and whether a diagnostic lumbar puncture is performed or spinal anesthesia is administered.3 The incidence of the post–lumbar puncture syndrome is much lower after spinal anesthesia than after diagnostic lumbar puncture.3,4 The reason for this difference may be that a strand of arachnoid enters the needle with the outflowing cerebrospinal fluid during diagnostic lumbar puncture; when the needle is removed, the strand may then be threaded back through the dural defect and produce prolonged cerebrospinal fluid leakage along the arachnoid.

We evaluated the effect of reinserting the stylet (mandrin) before removing the needle on the incidence of the post–lumbar puncture syndrome. By reinserting the stylet to the tip of the needle, any strand of arachnoid should be pushed out or cut off, which may reduce the frequency of the syndrome. For lumbar puncture, we used Sprotte's atraumatic needle (21 gauge), a modification of Whitacre's “pencil-point needle.” 5

A total of 600 patients were randomly assigned to one of two groups. In 300 patients, the stylet was reinserted to the tip of the needle; in the other 300, it was not reinserted. We performed all the lumbar punctures. The patients were questioned about their symptoms (headache, tinnitus, dizziness, or nausea) every day for the first seven days after the lumbar puncture. Symptoms were recorded only if they were reproduced by a change in position and improved when the patient lay flat.

The post–lumbar puncture syndrome developed in 49 of the 300 patients without reinsertion (16 percent) but in only 15 of the 300 patients with reinsertion (5 percent, P<0.005 by the chi-square test). This significant difference supports our hypothesis.

It is essential to use the stylet with insertion of the needle, but controversy persists about whether the stylet should be reinserted before removing the needle.3 From our study, we conclude that the stylet should always be reinserted before removing the needle, since reinsertion reduces the incidence of the post–lumbar puncture syndrome.

Michael Strupp, M.D.
Thomas Brandt, M.D.
University of Munich, 81366 Munich, Germany

5 References

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   Fishman RA. Cerebrospinal fluid in diseases of the nervous system. 2nd ed. Philadelphia: Saunders, 1992.
   

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   Hart JR, Whitacre RJ. Pencil-point needle in prevention of postspinal headache. JAMA 1951;147:657-658
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Citing Articles (9)

Citing Articles

1. 1

   M. Strupp, Z. Katsarava. (2009) Postpunktionelles und spontanes Liquorunterdrucksyndrom. Der Nervenarzt 80:12, 1509-1519
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2. 2

   Katherine Arendt, Bart M. Demaerschalk, Dean M. Wingerchuk, William Camann. (2009) Atraumatic Lumbar Puncture Needles. The Neurologist 15:1, 17-20
   CrossRef

3. 3

   J. Popp, M. Riad, K. Freymann, F. Jessen. (2007) Ambulante Durchführung einer diagnostischen Lumbalpunktion in der Gedächtnissprechstunde. Der Nervenarzt 78:5, 547-551
   CrossRef

4. 4

   Christopher L. Wu, Andrew J. Rowlingson, Seth R. Cohen, Robert K. Michaels, Genevieve E. Courpas, Emily M. Joe, Spencer S. Liu. (2006) Gender and Post???Dural Puncture Headache. Anesthesiology 105:3, 613-618
   CrossRef

5. 5

   Estelle Traurig Baer. (2006) Post???Dural Puncture Bacterial Meningitis. Anesthesiology 105:2, 381-393
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6. 6

   R Foster, D Olajide, I P Everall. (2003) Antiretroviral therapy-induced psychosis: case report and brief review of the literature. HIV Medicine 4:2, 139-144
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7. 7

   Hannu Kokki, Marjut Salonvaara, Eila Herrgard, Pekkariik Onen. (1999) Postdural puncture headache is not an age-related symptom in children: a prospective, open-randomized, parallel group study comparing a22-gauge Quincke with a 22-gauge Whitacre needle. Pediatric Anesthesia 9:5, 429-434
   CrossRef

8. 8

   Pamela Angle, Dorothy Thompson, Stephen Halpern, Donna B. Wilson. (1999) Second stage pushing correlates with headache after unintentional dural puncture in parturients. Canadian Journal of Anesthesia/Journal canadien d'anesthésie 46:9, 861-866
   CrossRef

9. 9

   Randolph W. Evans. (1998) COMPLICATIONS OF LUMBAR PUNCTURE. Neurologic Clinics 16:1, 83-105
   CrossRef