Severe Headache in a Patient After Lumbar Puncture

Case Study

A rapid response event was initiated by a nurse for a patient with a severe headache and nausea. The patient was found walking around the unit by the unit coordinator, trying to find a snack machine after coming up from the emergency room (ER) about 30 min before. She was brought back to her room, where she reported noticing a severe headache when she was walking around. Her pain had improved when she was back in bed and lying down. The bedside nurse informed the rapid response team that the patient was a 20-year-old female college student without any significant past medical history admitted for suspicion of meningitis.

Vital Signs

Temperature: 101.6 °F, axillary
Blood Pressure: 142/70 mmHg
Heart Rate: 92 beats per min (bpm) – normal sinus rhythm on telemetry
Respiratory Rate: 16 breaths per min
Pulse Oximetry: 98% saturation on room air

Focused Physical Examination

A focused exam revealed a young female lying completely flat and still in her bed. She was awake, alert, and appropriately oriented. Her cranial nerve testing was unremarkable. Finger-nose-finger testing did not demonstrate any dysmetria. Sensations were equal and intact to all of her extremities. There was no gross motor weakness noted. The patient was cooperative with the physical exam, but she was confused regarding recent events. She was warm to the touch. There was positive nuchal rigidity and Brudzinski’s sign. Her cardiac exam demonstrated regular rhythm and rate. Her lungs were clear. She did not have any abdominal tenderness. She stated that any movement whatsoever makes her headache worse, but her pain does not seem as bad if she lays still. She reported that she did not have any vision problems but would like the rapid response team to shut off the lights if possible.

Interventions

The rapid response team reviewed the ER notes, laboratory test reports, and imaging studies. The patient had an elevated white blood cell count of 14.2 K/uL with the rest of the complete blood count without any significant abnormalities. Her basal metabolic panel was normal. She had a computed tomography (CT) scan of her head, which was also normal. She had a lumbar puncture in the ER, and her cerebr ospinal fluid (CSF) studies were consistent with bacterial meningitis. There was a large number of red blood cells in the first CSF tube but an almost negligible number in the last CSF tube. The CSF gram stain and culture were still pending at the time of the rapid response. The rapid response team did not order any additional labs or imaging, but interventional radiology was contacted to perform an epidural blood patch urgently. After returning from the radiology department, the patient reported that her headache was gone, and she could move around in bed without having any distress.

Final Diagnosis

Post lumbar Puncture Headache (PLPH)

Post Lumbar Puncture Headache

A lumbar puncture is usually a safe and effective procedure that is performed to obtain CSF for lab testing and to deliver drugs for anesthesia or chemotherapy. As with any invasive procedure, there are always risks and possible complications. PLPH is the most common side effect for lumbar punctures, occurring in up to one-third of patients.

As a lumbar puncture is performed, a needle is driven through the skin, subcutaneous tissues, and back musculature. It passes through the epidural space, penetrates the dura and arachnoid mater of the spinal cord, and ultimately ends up in the subarachnoid space where CSF bathes and protects the cauda equina, spinal cord, and brain ( Fig. 49.1 ).

The actual cause of PLPH is unknown, but it is hypothesized that there is a leakage of CSF through the hole caused by the needle puncture through the dura and arachnoid mater and into the epidural space. Symptoms arise when the leakage rate into the epidural space exceeds the production rate of new CSF by the choroid plexus. Once there is an overall net loss of CSF into the epidural space, the support and cushioning provided by CSF is lost, which results in a stretch of the sensory part of the nerves resulting in pain. The intracranial pressure could also play a role because if the intracranial pressure drops because of increased CSF leakage, the venous vasculature dilates, which causes acute distention leading to pain.

The diagnosis of PLPH is dependent on the patient’s history. The obvious clue to the correct diagnosis is having a lumbar puncture performed within the last seven days. Another big clue that points to PLPH is the positional nature of the headache. PLPH tends to resolve if the patient is completely supine and not moving. PLPH tends to acutely worsen with sitting, standing, or rapid body movements. There are three main severity classes of PLPH, which are discussed in Table 49.1 .

Table 49.1

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