THE CAUSE OF LUMBAR PUNCTURE HEADACHE

RUSSELL G. MacROBERT
1918 Journal of the American Medical Association (JAMA)  
has no foundation in fact. There seems to be an extraordinary misconception on the part of the pro¬ fession as to the present status of the operation on the ganglion or root. It is usually represented as a court of last resort, a sort of kill-or-cure method, as a result of which the patient, if he survives, will be paralyzed on one side of the face and will lose his eyesight. Because of the frame of mind in which the patient consults the surgeon, the former needs some reassuring. In stating the
more » ... ing. In stating the risks of the operation, I shall refer only to my own clinic. Since 1901, there have been, all told, four deaths in 160 operations. Two of these were due to apoplexy, and all of them were among-subjects of the 121 intracranial operations. There was one death in 1904, and one in 1910, and there were two in 1912. In a series of eighty-seven consecutive operations there have been no deaths since 1912. Over other radical operations, such as the removal of the ganglion, the Abbe operation or the Hutchinson operation, avulsion of the sensory root has so many advantages that it should be and is recognized as the operation of choice. It. is easier of execution than any other, it subjects adjacent structures to no risk, and it is attended with a smaller percentage of corneal complications and with a lower mortality. On the whole, it is the most satisfactory surgical procedure with which I have had to deal. Associate Physician, Neurological Institute NEW YORK Lumbar puncture headache differs from all others in that, being present when the patient is sitting up, it completely disappears when he lies down. It is throb-Fig. 1.-Section of the spinal cord within its membranes and subarachnoidal space which contains the cerebrospinal fluid (Key and Retzius, Schaf er's Histology) : a, dura mater ; b, arachnoid ; k, I, subarachnoid space. bing and severe, and felt mostly in the frontal and occipital regions. No drugs give sufficient relief to allow its victim to walk about and attend to his affairs, or even to sit up. The pain comes on quickly when he sits up, being fully present in twenty seconds. It takes about the same length of time to subside when he lies down. This situation usually persists for about seven days with full severity, and then ends somewhat abruptly in the course of twenty-four hours. The only effective treatment is a week's stay in bed with the head low. While in this position the patient is quite comfortable, and there are no clinical signs of trouble present. Dora Mater /Houe in Dura-Covered by Arachnoid Arachnoid Hole Arachnoid Hole Arachnoid/ Fig. 2.-Spinal membranes with normal closure of puncture hole: no epidural leakage; no headache. Regarding causative or influencing factors of the headache, various speculations have been made concerning the importance of such points as the rapidity with which the fluid is withdrawn ; the position of the patient during the puncture; the degree of pressure existing in the spinal fluid at the time of puncture ; the disease condition of the patient, and his age. All these points are now generally regarded as unimpor¬ tant. There are three other points that linger with some observers, and these have been made interesting by discussion. They are: (1) lying flat on the back for twenty-four hours following puncture; (2) perfor¬ mance of puncture when the fluid shows signs of active syphilis, and (3) the amount of fluid withdrawn. 1. It has been our custom at the Neurological Insti¬ tute to have the patient lie flat on his back for twentyfour hours following lumbar puncture. The small amount of fluid collected for examination must by this time be easily compensated for, and the chances TjVJRA MATCR Puncture Holes InvaoinATco f.piD<i«AL Space ArWCHUOtl tig. 3.-Nonclosure of puncture hole, because of arachnoid tissue being pulled through durai opening as needle was withdrawn, resulting in prolonged epidural leakage and lumbar puncture headache. of headache appearing were expected to be consider¬ ably lessened. In the spring of 1915, by a series of thirty consecutive cases in which this procedure should be strictly adhered to, I determined to establish its value. Twelve of the thirty developed the typical severe headache. 2. Some information concerning these thirty cases is included here, to illustrate the fallacy of a statement Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/04/2015
doi:10.1001/jama.1918.02600190006002 fatcat:naibqhmdbbbzpjhv4eoo2oluui