Lomber Ponksiyon Sonrası Gelişen Başağrısı ve Meningismus

Year 2012, Volume: 3 Issue: 3, 86 - 88, 01.07.2012

Fırat Bektaş Seçgin Söyüncü

Abstract

Lomber ponksiyon sonrası en sık görülen komplikasyon baş ağrısıdır. Bu durumun persistant iğne giriş yerinde ortaya çıkan persistant beyin omurilik sıvı kaçağına ve beyin omurilik sıvı basıncının
düşmesine ve meningeal ve kafa içi venlerin traksiyonu sonucu
olduğu düşünülmektedir. Buna bağlı olarak bulantı, kusma ve vestibüler belirtiler ortaya çıkabilir. Meningeal irritasyon bulguları sunaraknoid kanama veya menenjit olmadığı sürece beklenmeyen
klinik bulgulardır. Lomber ponksiyon sonrası ortaya çıkan başağrısı
ve meningismus ile prezente olan bir olgu sumunu yaptık. Onyedi yaşında bayan hasta lomber pnksiyon yapıldıktan bir gün sonar
ortaya çıkan baş ağrı, bulantı ve kusma şikayeti ile acil servise getirildi. Hastanın yaşamsal bulguları, fiziksel ve detaylı nörolojik muayenesi ense sertliği ve Brudziski bulgusu varlığı dışında normaldi.
Bu bulgular olması nedeniyle menenjit veya sunaraknoid kanama tanısını araştırmak için lomber ponksiyon tekrarlandı. Beyin
omurilik sıvı basıncı, protein, glukoz ve mikroskobik muayene ile
kan ve beyin omurilik sıvı kültürleri normaldi. Son olarak yapılan
manyetik rezonans görüntüleme tekniği ile meningeal tutulum
araştırması da normaldi. Bu hastalardaki control edilmeyen iğne
boyutu, hasta oryantasyonu, travmatilk lomber ponksiyondan kaçınma gibi nedenler çok dajha ciddi sonuçlar ortaya çıkarabilir.
Ense sertliği, brudziski, kernig bulgusu gibi meningeal irritasyon
bulguları lomber ponksiyon sonrası beklenmeyen fizik muayene
bulgularıdır. Bu hastalarda mutlaka sunaraknoidal kanama ve meningeal infeksiyonların varlığı mutlaka araştırılmalıdır.

Keywords

Baş ağrısı, meningismus, lomber ponksiyon

Headache and Meningismus Following Lumbar Puncture

Abstract

Post-lumbar puncture headache is the most common complication of lumbar puncture. This condition is thought to be the result of persistent cerebrospinal fluid leakage at the puncture site, leading to low cerebrospinal fluid pressure and traction on the meninges and intracranial veins. Associated symptoms may include nausea, vomiting, auditory and vestibular symptoms. Meningeal irritation signs are unexpected as clinical findings unless serious medical conditions such as subarachnoid hemorrhage or meningitis occur. We are present a case of headache and meningismus following by lumbar puncture. A 17-year-old female presented to the emergency department suffering from headache, nausea and vomiting, starting one day after a lumbar puncture procedure. The characteristics of the headache were different and more severe than the previous form. Her vital signs and physical and detailed neurological examination were normal, except meningismus findings such as neck stiffness and Brudzinksy’s sign. Since the meningismus findings were unexpected, lumbar puncture was performed again to diagnose meningitis and subarachnoid hemorrhage. Cerebrospinal fluid pressure, protein, glucose, microscopic examination, blood and cerebrospinal fluid cultures were normal. Finally, magnetic resonance imaging of the brain revealed no pathological meningeal enhancement. In patients harboring uncontrollable factors, variables such as needle size, bevel orientation and the avoidance of traumatic lumbar puncture should be taken into consideration more seriously than ever. Furthermore, since, meningeal irritation signs such as neck stiffness and Brudzinksy’s and Kernig’s signs are not the expected clinical findings of post-lumbar puncture headache, serious medical conditions such as subarachnoid hemorrhage and meningeal infections should be investigated in the emergency setting

Keywords

Headache, meningismus, lumbar puncture

References

• Leibold RA, Yealy DM, Coppola M, Cantees KK. Post-dural-puncture he- adache: characteristics, management, and prevention. Ann Emerg Med 1993; 22: 1863-70. [CrossRef]
• Sudlow C, Warlow C. Posture and fluids for preventing post-dural punc- ture headache. Cochrane Database Syst Rev 2001; 2: CD001790.
• Sicuteri F. Headache and meningismus evoked by lumbar puncture and subarachnoid hemorrhage: a biochemical interpretation. Headache 1966; 5: 108-10. [CrossRef]
• Vilming ST, Kloster R. Post-lumbar puncture headache: clinical features and suggestions for diagnostic criteria. Cephalalgia 1997; 17: 778-84. [CrossRef]
• Fong B, VanBendegon JM. Lumbar Puncture. In: Reichman EF, Simon RR eds. Emergency Medicine Procedure. NewYork: McGraw Hill: 859-80.
• Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diag- nosis and management. Postgrad Med J 2006; 82: 713-6. [CrossRef]
• Seebacher J, Ribeiro V, LeGuillou JL, Lacomblez L, Henry M, Thorman F, et al. Epidural blood patch in the treatment of post dural puncture head ache : a double blind study. Headache 1989; 29: 630-2. [CrossRef]
• Lance JW, Branch GB. Persistent headache after lumbar puncture. Lancet 1994; 343: 414. [CrossRef]
• Gass H, Goldstein AS, Ruskin R, Leopold NA. Chronic postmyelogram headache. Isotopic demonstration of dural leak and surgical cure. Arch Neurol 1971; 25: 168-70. [CrossRef]
• Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and tech- nology assessment subcommittee of the american academy of neuro- logy. Neurology 2000; 55: 909-14. [CrossRef]
• Tourtellotte WW, Henderson WG, Tucker RP, Gilland O, Walker JE, Kokman E. A randomized, double blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache 1972; 12: 73-8. [CrossRef]
• Mihic DN. Postspinal headache and relationship of needle bevel to longi- tudinal dural fibers. Reg Anesth 1985; 10: 76-81.
• Hilton-Jones D, Harrad RA, Gill MW, Warlow CP. Failure of postural mane- uvers to prevent lumbar puncture headache. J Neurol Neurosurg Psychi- atry 1982; 45: 743-6. [CrossRef]
• Carbaat PA, van Crevel H. Lumbar puncture headache: Controlled study on the preventative effect of 24 hours bed rest. Lancet 1981; 1: 1133-5. [CrossRef]