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A protocol to reduce self-reported pain scores and adverse events following lumbar punctures in older adults



Lumbar punctures (LPs) are important for obtaining CSF in neurology studies but are associated with adverse events and feared by many patients. We determined adverse event rates and pain scores in patients prospectively enrolled in two cohort studies who underwent LPs using a standardized protocol and 25 g needle.


Eight hundred and nine LPs performed in 262 patients age ≥ 60 years in the MADCO-PC and INTUIT studies were analyzed. Medical records were monitored for LP-related adverse events, and patients were queried about subjective complaints. We analyzed adverse event rates, including headaches and pain scores.


There were 22 adverse events among 809 LPs performed, a rate of 2.72% (95% CI 1.71–4.09%). Patient hospital stay did not increase due to adverse events. Four patients (0.49%) developed a post-lumbar puncture headache (PLPH). Twelve patients (1.48%) developed nausea, vasovagal responses, or headaches that did not meet PLPH criteria. Six patients (0.74%) reported lower back pain at the LP site not associated with muscular weakness or paresthesia. The median pain score was 1 [0, 3]; the mode was 0 out of 10.


The LP protocol described herein may reduce adverse event rates and improve patient comfort in future studies.

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The members of the MADCO-PC and INTUIT Investigators Teams are: CL Amundsen, P Avasarala, MF Berry, DG Blazer, MP Bolognesi, R Brassard, BE Brigman, JN Browndyke, V Cai, J Carter, J Chapman, C Chen, V Cheong, S Christensen, HJ Cohen, JK DeOrio, TA D’Amico, D Erdmann, RM Esclamado, B Funk, S Grant, J Guercio, DK Gupta, DH Harpole, MG Hartwig, ST Hollenbeck, E Iboaya, BA Inman, DW Jang, J Kaisen, A Khan, R Huang, S Lagoo-Deenadayalan, PS Lee, WT Lee, J Lemm, H Levinson, ME Lipkin, D McDonagh, D Murdoch, CR Mantyh, DL McDonagh, J Migaly, SK Mithani, P Mosca, D Murdoch, MF Newman, K Ni, MW Onaitis, D Oyeyemi, TN Pappas, AN Perez, AC Peterson, TJ Polascik, A Podgoreanu, P Potash, GM Preminger, QJ Quinones, EN Rampersaud, A Renne, CN Robertson, SA Roman, S Runyon, CD Scales, S Smani, K Smith, M Stang, A Syed, L Talbot, JKM Thacker, J Thomas, BC Tong, Y Toulgoat-Dubois, A Tu, SN Vaslef, N Waldron, X Wang, K Weinhold, SS Wellman, H Whitson, T Wickenheisser, S Zani.


This work was supported by National Institutes of Health (Bethesda, Maryland) T32 Grant No. GM08600 (to MB), an International Anesthesia Research Society (IARS; San Francisco, California) Mentored Research Award (to MB), National Institutes of Health R03 AG050918 (to MB), National Institutes of Health Beeson K76 AG057022 (to MB), a Jahnigen Scholars Fellowship award from the American Geriatrics Society (New York, New York) and the Foundation for Anesthesia Education and Research (to MB), additional support from National Institutes of Health P30AG028716, and Duke Anesthesiology departmental funds.

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Corresponding author

Correspondence to Miles Berger.

Ethics declarations

Conflicts of interest

MB acknowledges income from legal consulting cases related to postoperative cognition in older adults, and material support from Massimo for a study unrelated to the data presented here. MB has also taken part in a peer-to-peer consulting session for Massimo, for which his honorarium was donated (at his request) to the Foundation for Anesthesia Education and Research. The other authors declare that they have no conflict of interest.

Ethical standards

These studies were conducted with approval from the Duke IRB (Pro00083288, Pro00045180) and are registered with (NCT01993836, NCT03273335). All persons gave their informed consent prior to their inclusion in the study.

Additional information

The members of the MADCO-PC and INTUIT Investigators Teams are listed in “Acknowledgements”.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1. Supplemental Figure 1. Video showing the lumbar puncture procedure. (MP4 40391 kb)


Supplementary file2. Supplemental Figure 2. Ultrasound image showing spine anatomy to guide needle placement during LP. AP articular process, L lamina, TP transverse process, AC anterior complex (anterior dura and posterior longitudinal ligament of vertebrae). Red arrowheads: posterior complex (posterior dura and ligamentum flavum). Dotted line: distance from skin to posterior complex (in this case, about 3.2 cm). Solid line: anteroposterior diameter of the spinal canal. (TIFF 2033 kb)


Supplementary file3. Supplemental Figure 3. Plot of pain scores compared by pre-operative (BL), 24-h, 6-week, and 1-year post-operative LPs. Means are plotted with Q1, Q3 and SD. Non-parametric Kruskal–Wallis test was used to compare scores over time. There was no evidence of a difference in score by visit (p = 0.44). (TIFF 26 kb)

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Nobuhara, C.K., Bullock, W.M., Bunning, T. et al. A protocol to reduce self-reported pain scores and adverse events following lumbar punctures in older adults. J Neurol 267, 2002–2006 (2020).

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  • Lumbar puncture
  • Protocol
  • Pain
  • Headache