Opening pressure, closing pressure, volume of cerebrospinal fluid, and pressure-volume index does not appear to influence the overall risk for postdural puncture headache in patients who undergo a lumbar puncture, a study in Headache suggests.

The investigators performed a case-control study, retrospectively identifying patients with postdural puncture headache who underwent an outpatient lumbar puncture at the Mayo Clinic Arizona Department of Neurology (n=53). Patients included in the case-control study had postdural puncture headache based on International Classification of Headache Disorders-3 criteria. In this portion of the study, the researchers assessed whether cerebrospinal fluid pressure-volume indices correlated with postdural puncture headache vs age- and sex-matched controls (n=53). Differences in pressure-volume index comprised the primary outcome, whereas secondary outcomes included opening pressure, closing pressure, volume of cerebrospinal fluid, and elastance measures.

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Additionally, the researchers also performed a systematic review to identify studies that evaluated whether opening pressure, closing pressure, and/or volume of cerebrospinal fluid correlates with an increased risk for postdural puncture headache in patients who undergo a diagnostic lumbar puncture. A total of 22 references were selected, with analyses of volume of cerebrospinal fluid (n=14), opening pressure (n=11), and/or closing pressure (n=4).

In the case-control analysis, a headache indication was more common in patients with postdural puncture headache (difference in proportion, 28.3; 95% CI, 11.5-45.2; P =.001). No paired difference was found in median elastance (paired difference, 0.05; 95% CI, −0.09 to 0.11; P =.503) or pressure-volume index (paired difference, 4.53; 95% CI, −7.98 to 19.97; P =.678). In the systematic review, no evidence was found to suggest an association between postdural puncture headache with opening pressure or closing pressure. Approximately 18% of studies that evaluated opening pressure found an association with postdural puncture headache. In a small number of studies that found an association between postdural puncture headache and volume of cerebrospinal fluid, patients predominantly had high-volume cerebrospinal fluid removal.

Limitations of the case-control study and systematic review included the retrospective design, small sample sizes in each study, and the reliance on pressure-volume index estimates.

“Future revision of diagnostic criteria should consider the possibility of immediate and delayed [postdural puncture headache] subtypes,” the researchers wrote, “and not presume intracranial hypotension as mandatory for the diagnosis.”

Disclosure: None of the study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Smith JH, Mac Grory B, Butterfield RJ, Khokar B, Falk BL, Marks LA. CSF pressure, volume, and post-dural puncture headache: a case-control study and systematic review [published online July 24, 2019]. Headache. doi:10.1111/head.13602