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LETTERS TO THE EDITOR

Neurologic Complications of Cerebrospinal Fluid Drainage Catheters

Department of Neuroanaesthesia The National Hospital for Neurology & Neurosurgery London WC1N 3BG, England

Mark J. L. Scrutton, FRCA

Department of Anaesthesia St Michael’s Hospital Bristol BS2 8EG, England

We read with interest Grady et al.’s (1) paper surveying neurological complications after spinal catheters for cerebrospinal fluid drainage. It is reassuring that no nerve injuries were reported in 530 patients. However, we were surprised that the reported incidence of postdural puncture headache (PDPH) was only 2.5%. Headaches are common in pituitary disease, but we believe that PDPH after surgery is underreported by patients and poorly documented by physicians. As this paper was a retrospective case note survey, it would be interesting to know whether patients were routinely followed up by the anesthesiologist and asked specifically about headaches both pre- and postoperatively. PDPH can be severe, delay hospital discharge, and potentially cause long term sequelae (2,3).

We are conducting a prospective audit of headache after lumbar drains placed to facilitate transsphenoidal hypophysectomy and have interviewed patients both before and after surgery. Drains were inserted under general anesthesia in the left lateral position using a 14-gauge Tuohy needle and silicone catheter and were normally removed in the recovery room or the next day. In the first 34 patients studied, the incidence of PDPH was 47%, with symptoms generally the worst 24 h after drain removal.

Using 14-gauge Tuohy needles in all patients undoubtedly contributed to the increased incidence of PDPH in our study. However, we feel that the remarkably low incidence reported by Grady et al. (1) results, in part, from assessing retrospectively the incidence of a symptom of which there has been inadequate awareness in the past.

References

1. Grady RE, Horlocker TT, Brown RD, et al. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999;88:388–92.[Abstract/Free Full Text]
2. MacArthur C, Lewis M, Knox EG. Accidental dural puncture in obstetric patients and long term symptoms. BMJ 1993;306:883–5.
3. Reynolds F. Dural puncture and headache: avoid the first but treat the second. BMJ 1993;306:874–6.

Response

Department of Anesthesiology Mayo Clinic Rochester, MN 55905

We appreciate the interest that Drs. McLeod, Hirsch, and Scrutton have shown in our article (1). Our study was designed as a retrospective analysis of spinal drain insertions under general anesthesia to assess the frequency of neurologic complications, particularly nerve root or spinal cord injury. Aware that spinal drainage can produce postdural puncture headache (PDPH), we also collected data on PDPH from our study population as a means of validating our chart review process.

There is an obvious disparity in the incidence of PDPH between our study and the preliminary findings of McLeod et al. It is difficult to reconcile the disparity given the limited information provided in their letter. However, a higher incidence of PDPH would be expected from their prospective study using 14-gauge needles compared with our retrospective study in which 19-gauge needles were used in the majority (89%) of cases. Other potential factors that could influence the results are patient age and gender, needle type, and length of time the catheter was indwelling. Furthermore, transsphenoidal surgery itself can cause a cerebrospinal fluid leak, producing a headache with the same characteristics as PDPH.

Although we may have missed patients with minor or short-lived headaches, we do have objective evidence of severe headaches from the 1.3% of patients in our study who required epidural blood patch. Unfortunately, McLeod et al. did not provide data on epidural blood patch in their letter. It would be interesting to know, however, if their increased incidence of PDPH produced a proportionate increase in the incidence of epidural blood patch. Epidural blood patches are not devoid of side effects and complications. Therefore, the spinal drain technique that requires fewer epidural blood patches may be more advantageous.

We agree that the topic of headache after transsphenoidal pituitary surgery has garnered little attention in the literature. Therefore, we look forward to seeing the final results of their study in published form.

References

1. Grady RE, Horlocker TT, Brown RD, et al. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999;88:388–92.

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