Journal of Emergencies, Trauma, and Shock

LETTER TO EDITOR
Year
: 2015  |  Volume : 8  |  Issue : 1  |  Page : 73-

Gillen-Hackstadt maneuver


James Patrick Gillen 
 Department of Emergency Medicine, University of South Florida Emergency Medicine Residency Program, Tampa General Hospital, Florida, USA

Correspondence Address:
James Patrick Gillen
Department of Emergency Medicine, University of South Florida Emergency Medicine Residency Program, Tampa General Hospital, Florida
USA




How to cite this article:
Gillen JP. Gillen-Hackstadt maneuver.J Emerg Trauma Shock 2015;8:73-73


How to cite this URL:
Gillen JP. Gillen-Hackstadt maneuver. J Emerg Trauma Shock [serial online] 2015 [cited 2020 Jun 1 ];8:73-73
Available from: http://www.onlinejets.org/text.asp?2015/8/1/73/150409


Full Text

Dear Editor,

Post-lumbar puncture headache (PLPHA) or post-dural puncture headache occurs up to 32% after a lumbar puncture is performed or attempted and associated with considerable discomfort, morbidity, and rare mortality. The first patient to suffer from a PLPHA was August Bier, the father of spinal anesthesia, in 1898. [1] Needle size, bevel direction, needle design, replacement of stylet, number of attempts, interspace location, female gender, headache history and younger age (ages 20-40) have all been documented as contributing or associated risk factors for PLPHA. [1],[2]

We propose that all patients, after a lumbar puncture is completed or attempted, lie in the prone position (Gillen-Hackstadt maneuver) for the remainder of their emergency department stay and for the next 48 h after discharge or admission to the hospital. By simply placing the patient in the prone position, the hydrostatic pressure at the dural puncture site is markedly lower, resulting in reduced cerebrospinal fluid leakage and lower incidence of PLPHA. The hydrostatic physics involved is obvious. Consideration of placing the patient in trendelenburg position also may further reduce cerebrospinal fluid leakage at the dural puncture site. The standard practice of lying our patient supine on their backs after a lumbar puncture is counterintuitive to basic hydrostatic and puncture healing principles. Placing the patient at bedrest in the supine position or allowing patients to become ambulatory immediately post-procedure does not change the incidence of PLPHA. [3] Amazingly in 1958, Brocker reported a post LP headache reduction from 36.5% to 0.5% when patient were prone for 3 h after using 18-gauge spinal needles. [4] Regretfully, the practice of laying the patient prone after LP never became popularized despite Brocker's 1958 paper in JAMA. [4]

In conclusion, we strongly encourage all health care providers incorporate the "Gillen-Hackstadt maneuver" after lumbar puncture is completed or attempted and for the following 48 h post-procedure as tolerated. We also encourage physicians treating PLPHA to place their patients in the prone position as well. Reducing the pressure at the dural puncture site and stopping the slow cerebrospinal fluid leak, analogous to stopping a slowly dripping faucet, more readily promotes healing at the dural puncture site.

When treating PLPHA patient in the emergency department, one might also consider the "modified Gillen-Hackstadt technique," placing the patient prone with the stretcher in the head down (trendelenburg) position. Direct pressure to the skin puncture site in children (and small adults) and possibly intravenous tranexamic acid should also be considered for future study in the treatment of PLPHA.

Lumbar puncture is a common procedure performed in emergency departments, hospitals, and outpatient medical specialty clinics worldwide. We describe in this letter to your editorial board the "Gillen-Hackstadt maneuver" in hopes of reducing the international incidence of PLPHA.

Respectfully submitted,

References

1Raskin NH. Lumbar puncture headache: A review. Headache 1990;30: 197-200.
2Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: Diagnosis and management. Postgrad Med J 2006;82:713-6.
3Arevalo-Rodriguez I, Ciapponi A, Munoz L, Roqué i Figuls M, Bonfill Cosp X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 2013;7:CD009199.
4Brocker RJ. Technique to avoid spinal-tap headache. J Am Med Assoc 1958;168:261-3.