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On the Brain
May 2, 2022

When a Neurologist Gets a Cerebrospinal Fluid Leak

Author Affiliations
  • 1Stanford University Hospital, Palo Alto, California
JAMA Neurol. 2022;79(7):647-648. doi:10.1001/jamaneurol.2022.0863

It was a routine diagnostic lumbar puncture, requiring only the smallest bit of lidocaine. As the procedure flew by, I was reminded of previous struggles to perfectly position the patient in alignment to minimize pain. This was nothing like that. As a neurologist, I already knew how to prepare, keeping my free arm straight and balanced atop my knee, my other hand resting under my pillow to align my neck. There was almost no pain, just the usual sensation of pressure, and in what felt like minutes, my physician was applying a small bandage to my nonbleeding back.

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5 Comments for this article
CSF Leak in Differential
Steven Reid, M.D., F.A.A.N.S. | Doctor Lifeline, Incorporated
Did you intend to write "postural" rather than "postdural"? As a neurosurgeon, I've evaluated a number of CSF leaks, some spontaneous and some iatrogenic. Of note, occult CSF leak can be the etiology of otherwise unexplainable diffuse leptomeningeal enhancement on CT scan.
Author Reply to Comment by Stephan Reid, MD, FAANS
Liza Smirnoff, M.D. | Stanford Healthcare
Dr. Reid, thank you for sharing your insights. In my practice, I have also seen a number of cases of previously unexplained leptomeningeal enhancement which were later discovered to represent spontaneous CSF leaks - these cases can be hard to diagnose, and I believe deserve more attention in both work up and the literature. In my case I was thinking “postdural,” although certainly “postural,” is very relevant as well!
Atraumatic lumbar punctures?
Markus Leweke, MD | Brain and Mind Centre, The University of Sydney
Thanks for sharing your experience with a lumbar puncture from a patient's perspective. Given the importance of CSF investigations and the relatively low risk of more prominent complications like yours, I think it is most relevant to note that the technique and the shape and diameter of the needles used are essential for the risk of postdural puncture complications. In my experience, unfortunately, using Quincke needles is still common because they are easy to handle and have a diameter that allows for a brief procedure. However, atraumatic Sprotte needles have a substantially better outcome regarding postdural puncture headache (relative risk of pp-headache about 0.45) and further complications, even with the same 22G diameter. We all should keep your experience in mind when choosing our needles and techniques to reduce the risk of postdural puncture complications and improve the view on lumbar punctures not only in the general population but also among fellow neurological and psychiatric colleagues.
Quincke vs Sprotte (pencil tip) spinal needle
Lawrence Kerson, M.D. | Penn Medicine, Philadelphia
I wonder if the initial LP was done with the optimal needle size and type. In my practice in neurology over the years I evolved to using Sprotte/Whitacre needles of 22g with introducer as a routine since the 1990s, unless the patient was very large or not cooperative. With this size Sprotte needle CSF flow is similar to that with a 20 gauge Quincke spinal needle. My experience and literature indicate much lower post spinal headache incidence with smaller needle gauge and especially with Sprotte type.spinal needles. Latter is the routine type used by anesthesiologists for the past several decades, usually with 24-26 gauge needles.(1,2) Like many situations in medicine, the Sprotte needles are more expensive, but there is also a cost for suffering, ED visits, and epidural blood patches. Learning the technique is easy.

1. L. D. Vandam, R.D. Dripps, JAMA, 1956;161(7):586-591
2. A. Bertolotto et al, Cephalgia, 2016;36(2):131-138
Why not an anesthesiologist?
Gail Van Wingerden, MD FACOG | Mt Sinai Hospital
As an obstetrician gynecologist, I am very familiar with patients who have these extreme symptoms to occult dural punctures from epidural anesthesia. We just call the Anesthesia service back and they administer a blood patch after confirming our diagnosis. I am sorry this physician had to suffer over the weekend waiting for that blood patch. If that hospital had obstetrical services, I am sure that an anesthesiologist could have done the blood patch in fairly short order!