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Reinsertion of the stylet before needle removal in diagnostic lumbar puncture
  1. Matthew Deibel,
  2. Jeffrey Jones, Senior Resident,
  3. Michael Brown
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; s.carley1btinternet.com

    Abstract

    A short cut review was carried out to establish whether re-insertion of the stylet before needle removal changed the incidence of post-lumbar puncture syndrome and headache. Altogether 235 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Matthew Deibel,Senior ResidentChecked by Jeffrey Jones, Michael Brown, Research Director and Director of the Emergency Medicine Residency programme respectively

    Clinical scenario

    A 31 year old woman presents to the emergency department with a sudden onset severe headache. After a normal head computed tomogram, you prepare for lumbar puncture with a small gauge non-traumatic needle. You remember a colleague telling you it is also important to replace the stylet before removing the needle to prevent a post-lumbar puncture headache. You wonder what is found in the literature.

    Three part question

    In [patients undergoing diagnostic lumbar puncture] does [reinsertion of the stylet prior to needle removal] reduce [the incidence of post-lumbar puncture headache]?

    Search strategy

    Medline 1966-09/04 using the OVID interface and Cochrane database 2004 Edition 3 via NeLH. Medline: [exp spinal puncture OR (spinal adj5 tap).af OR (spinal adj5 puncture).af OR (spinal adj5 injection).af OR (lumbar adj5 tap).af OR (lumbar adj5 puncture).af OR (lumbar adj5 injection).af OR (dural adj5 tap).af OR (dural adj5 puncture).af OR (dural adj5 injection).af] AND [exp headache OR exp headache disorders OR headache.af OR post-lumbar puncture syndrome.mp OR PDPH.mp OR PLPS.mp] AND [needle.mp OR exp needles OR stylet.mp] LIMIT to human AND English language. Cochrane: [lumbar] next [puncture].

    Search outcome

    Altogether 235 papers were found, two of which addressed the three part question (same article published as correspondence then full study) (table 3). No additional references were found in the Cochrane database.

    Table 3

    Comment(s)

    The theory is when CSF is removed, strands of arachnoid enter the needle. When the needle is removed, the strand may then be threaded back through the dural defect and produce prolonged CSF leakage resulting in the post-lumbar puncture syndrome. This was postulated on the finding that the post-lumbar puncture syndrome is much lower after spinal anaesthesia than after diagnostic lumbar puncture. Replacing the stylet would then push out or cut off any strand of arachnoid. The authors also rotated the needle 90 degrees before removal (see Evans). This is the only study performed looking at replacing the stylet. Some aspects of the study are not clearly described—randomisation, intensity scale, follow up. Nevertheless, there seems to be minimal risk and likely benefit in replacing the stylet prior to removing the needle.

    CLINICAL BOTTOM LINE

    Replacing the stylet before removal of the spinal needle may help decrease the incidence of post-lumbar puncture headaches.

    Report by Matthew Deibel,Senior ResidentChecked by Jeffrey Jones, Michael Brown, Research Director and Director of the Emergency Medicine Residency programme respectively

    References

    View Abstract

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