Indication to use a non-pencil-point lumbar puncture needle

In their article in the BMJ , Rochwerg and colleagues recommend using an atraumatic pencil-point lumbar puncture (LP) needle.1 We would point out one potential exception to this recommendation: idiopathic intracranial hypertension (IIH). Resolution of IIH has been noted after single2 3 or multiple LPs.4 The mechanism has never been clearly understood. We have reported elsewhere our experience that inducing a postdural puncture cerebrospinal fluid (CSF) leak sometimes leads to immediate and sustained resolution of IIH.5–8 Although the references cited refer to observational studies and case reports, in the great majority of individuals IIH does not normally remit in the short term without weight loss, medical or surgical intervention. This dramatic change in the natural history with an LP-induced CSF leak suggests that the observations are valid. In our experience over the last 5 years, this approach has resulted in avoiding long-term use of acetazolamide and CSF shunts in patients with IIH. Based on these observations, we have developed a recommended technique to maximise the chances of sustaining a lowering of the CSF pressure. This is contrary to the normal …