Despite the commonly held belief that lumbar puncture is a dangerous procedure, it is very rare that serious complications arise. Recent articles relating to the risks of LP are shown below with access to full articles at the bottom of the page.
lumbar puncture and subdural hygroma and hematomas in hematopoietic cell transplant patients.
Bone Marrow Transplant. 2008 Feb 4;
Authors: Openshaw H, Ressler JA, Snyder DS
We reviewed records of hematopoietic cell transplantation (HCT) patients seen over the past 10 years who had head scan documentation of subdural fluid collections. A total of 17 patients were identified: 13 with allogeneic and 4 with autologous HCT (0.71% of allogeneic and 0.13% of autologous HCT patients seen in this time interval). Although less than 20% of HCT patients have lumbar puncture, 8 of the 17 subdural patients had lumbar puncture. The lumbar puncture was done 5-112 days (median 46 days) before subdural detection. Acute lymphocytic leukemia was the diagnosis in five of these eight; whereas, either acute myelogenous leukemia or myelodysplasia was the diagnosis in seven of the nine patients without lumbar puncture. In the patient group with lumbar puncture, subdurals were diagnosed earlier after HCT (median 25 days versus 5 months in the patient group without lumbar puncture) and were more often hygromas (37.5 versus 0%). These results support the suggestion of lumbar puncture or intrathecal therapy as a risk factor for subdurals. The presumptive mechanism involves lumbar cerebrospinal leak, low intracranial pressure, downward displacement of the brain, cerebrospinal fluid accumulation into the inner dural layers of the cerebral convexities (hygromas) and bleeding into these fluid collections (hematomas).Bone Marrow Transplantation advance online publication, 4 February 2008; doi:10.1038/sj.bmt.1705971.
PMID: Risks of lumbar puncture 18246118 [PubMed - as supplied by publisher]
Incidence of postdural puncture headache and backache following diagnostic/therapeutic lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle.
Paediatr Anaesth. 2008 Mar;18(3):230-4
Authors: Lowery S, Oliver A
Background: Postdural puncture headache (PDPH) after lumbar puncture (LP) is as common in children as adults. 22G needles are routinely used in adults and children for diagnostic/therapeutic LP, in contrast to 25G or less as standard for spinal anesthesia. We sought to identify incidence of PDPH and backache in oncology children undergoing LP at Royal Marsden Hospital, and whether this could be reduced by a change from 22G to 25G pencil point needle. Methods: Symptom questionnaires were given to parents for completion 7 days following LP, and incidence of side effects ascertained. The standard needle was a 22G Quincke. A 25G pencil point spinal needle was subsequently introduced and incidence of side effects reaudited. Number of attempts with the pencil point needle was documented. Results: Fifty-six of 83 questionnaires were completed for the 22G Quincke (67%). Incidence of headache was 33%, with 11% classified as PDPH (6 children, 2 > 7 days). Nausea/vomiting occurred in 25% and backache in 11%; 43 of 79 questionnaires were completed for the 25G pencil point needle (54%). Incidence of headache was 30% with 7% classified as PDPH (3 children, none >7 days). Nausea/vomiting occurred in 23%, and backache in none. Seventy percentage of needle insertions by pediatricians were successful on first attempt, 89% on second, and 100% on third. Conclusions: We have confirmed a significant incidence of PDPH in oncology patients and suggest that a 25G pencil point needle can be used successfully for diagnostic/therapeutic LP, with significantly reduced incidence of back pain, and a small tendency towards a shorter duration of PDPH symptoms.
PMID: Risks of lumbar puncture 18230066 [PubMed - in process]
Sensory neuron targeting by self-complementary AAV8 via lumbar puncture for chronic pain.
Proc Natl Acad Sci U S A. 2008 Jan 22;105(3):1055-60
Authors: Storek B, Reinhardt M, Wang C, Janssen WG, Harder NM, Banck MS, Morrison JH, Beutler AS
lumbar puncture (LP) is an attractive route to deliver drugs to the nervous system because it is a safe bedside procedure. Its use for gene therapy has been complicated by poor vector performance and failure to target neurons. Here we report highly effective gene transfer to the primary sensory neurons of the dorsal root ganglia (DRGs) with self-complementary recombinant adeno-associated virus serotype 8 (sc-rAAV8) modeling an LP. Transgene expression was selective for these neurons outlining their cell bodies in the DRGs and their axons projecting into the spinal cord. Immunohistochemical studies demonstrated transduction of cells positive for the nociceptive neuron marker vanilloid receptor subtype 1, the small peptidergic neuron markers substance P and calcitonin gene-related peptide, and the nonpeptidergic neuron marker griffonia simplicifolia isolectin B4. We tested the efficacy of the approach in a rat model of chronic neuropathic pain. A single administration of sc-rAAV8 expressing the analgesic gene prepro-beta-endorphin (ppbetaEP) led to significant (P < 0.0001) reversal of mechanical allodynia for >/=3 months. The antiallodynic effect could be reversed by the mu-opioid antagonist naloxone 4 months after gene transfer (P < 0.001). Testing of an alternative nonopioid analgesic gene, IL-10, alone or in combination with ppbetaEP was equally effective (P < 0.0001). All aspects of the procedure, such as the use of an atraumatic injection technique, isotonic diluent, a low-infusion pressure, and a small injection volume, are consistent with clinical practice of intrathecal drug use. Therefore, gene transfer by LP may be suitable for developing gene therapy-based treatments for chronic pain.
Ultrasonographic control of the puncture level for lumbar neuraxial block in obstetric anaesthesia.
Br J Anaesth. 2008 Feb;100(2):230-4
Authors: Schlotterbeck H, Schaeffer R, Dow WA, Touret Y, Bailey S, Diemunsch P
BACKGROUND: Errors in the judgement of puncture level during neuraxial anaesthesia can lead to significant complications. The aim of this study was to assess, in obstetric anaesthesia, the accuracy of clinical determination of the lumbar spinal interspace level, using surface ultrasound imaging as control. METHODS: At the anaesthesia follow-up visit, women who had received lumbar neuraxial anaesthesia during labour were prospectively included. The intervertebral level of needle insertion, located by the needle scar position, was identified by ultrasonography and compared with the clinical level reported on the chart by the anaesthetist who performed the block. RESULTS: Ninety-nine women were studied. The clinical puncture level was accurate in 36.4% of patients. Ultrasound examination showed the puncture level to be more cephalad than the level noted in the anaesthetic record in almost 50% of patients. In 15% of patients, the puncture level was more caudad than the anaesthetist had assessed. Factors including type of anaesthesia, indication, time period, level of anaesthetic experience, BMI, and spinal pathology did not seem to influence the frequency of errors. CONCLUSIONS: The observed differences between clinical and ultrasonic identification of spinal puncture level highlight the potential for serious complications associated with the performance of neuraxial blocks above the spinous process of L3 in the parturient. With the increase in popularity of techniques involving puncture of the dura mater for labour anaesthesia, we feel that awareness of this risk is important.
Is the Combination of Negative Computed Tomography Result and Negative lumbar puncture Result Sufficient to Rule Out Subarachnoid Hemorrhage?
Ann Emerg Med. 2008 Jan 10;
Authors: Perry JJ, Spacek A, Forbes M, Wells GA, Mortensen M, Symington C, Fortin N, Stiell IG
STUDY OBJECTIVE: Current clinical practice assumes a negative computed tomography (CT) head scan result and a negative lumbar puncture result together are adequate to rule out subarachnoid hemorrhage in patients with acute headache. Our objective is to determine the sensitivity of a negative CT result combined with a negative lumbar puncture result to exclude subarachnoid hemorrhage. METHODS: This prospective cohort study was conducted at 2 tertiary care emergency departments (EDs) during 3 years. We enrolled all patients who were older than 15 years, had a nontraumatic acute headache and normal neurologic examination result, and who had a CT head scan and a lumbar puncture if the CT result was negative (ie, no blood in the subarachnoid space). Patients were followed up with a structured telephone questionnaire 6 to 36 months after their ED visit and electronic hospital records review to ensure no missed subarachnoid hemorrhage. We calculated sensitivity, specificity, and likelihood ratios of the strategy of CT and then lumbar puncture for subarachnoid hemorrhage. RESULTS: Five hundred ninety-two patients were enrolled, including 61 with subarachnoid hemorrhage. The mean patient age was 43.6 years, with 59.1% female patients. All cases of subarachnoid hemorrhage were identified on initial CT or lumbar puncture. One patient without subarachnoid hemorrhage was subsequently diagnosed with cerebral aneurysm, requiring surgery. The strategy classified patients with subarachnoid hemorrhage with sensitivity, specificity, and positive and negative likelihood ratios (with 95% confidence intervals [CIs]) of 100% (95% CI 94% to 100%), 67% (95% CI 63% to 71%), 3.03 (95% CI 2.69 to 3.53), and 0. For diagnosis of subarachnoid hemorrhage or aneurysm, these were 98% (95% CI 91% to 100%), 67% (95% CI 63% to 71%), 2.98 (95% CI 2.63 to 3.38), and 0.02 (95% CI 0.00 to 0.17), respectively. CONCLUSION: To our knowledge, this is the largest prospective study evaluating the accuracy of a strategy of CT and lumbar puncture to rule out subarachnoid hemorrhage in alert ED patients with an acute headache. This study validates clinical practice that a negative CT with a negative lumbar puncture is sufficient to rule out subarachnoid hemorrhage.
PMID: Risks of lumbar puncture 18191293 [PubMed - as supplied by publisher]
Hemosiderin-laden macrophages in the cerebrospinal fluid of a neonate after traumatic lumbar puncture.
Pediatr Infect Dis J. 2008 Jan;27(1):83-4
Authors: Wusthoff CJ, Abend NS, Tennekoon G
Macrophages in cerebrospinal fluid are described as indicators of pathology. We present findings from the lumbar puncture of a child without neurologic disease. Cerebrospinal fluid obtained after an initial, traumatic lumbar puncture attempt included a high proportion of macrophages, some containing erythrocyte fragments and hemosiderin. This suggests that although macrophages may indicate pathology, they can also accumulate after traumatic lumbar puncture.
[Comparison of 3D C-arm fluoroscopy-based and CT-based navigation systems in the lumbar pedicle puncture: in vitro experiment on a cadeveric lumbar trunk specimen]
Zhonghua Yi Xue Za Zhi. 2007 Oct 9;87(37):2606-9
Authors: Jiang JY, Ma X, Lin YJ, Lü FZ, Gu SX, Huang HY
OBJECTIVE: To compare the accuracy and operating features of 3D C-arm fluoroscopy-based and CT-based navigation systems in the lumbar pedicle punctures. METHODS: A specimen of cadaveric lumbar trunk underwent lumbar pedicle punctures at the levels of L3, L4, and L5 under the guidance of the 3D C-arm fluoroscopy-based and CT-based navigation systems. During the procedure C-arm fluoroscopy was used to monitor the accuracy of the puncture. Generally, in comparison with the 3D C-arm fluoroscopy-based navigation system, the best operation route and protocol could be drawn up pre-operatively, matched registration needed to be renewed for each vertebra, and the images thus obtained were of high quality in CT-based navigation. RESULTS: Both navigation systems had excellent accuracy in the guidance of lumbar pedicle punctures, and had different operating features. CONCLUSION: Both navigation systems had its special advantages. The operating process of the 3D C-arm fluoroscopy-based navigation system was more convenient and rapid, and suitable for percutaneous vertebral puncture. CT based navigation system had clearer pictures, especially for the osteoporotic vertebral bodies, and it had less requirements for the equipments.
PMID: Risks of lumbar puncture 18162146 [PubMed - in process]
Is early bladder activity in radionuclide cisternography an indirect sign of spontaneous intracranial hypotension or sequence of lumbar puncture?
Clin Nucl Med. 2007 Nov;32(11):850-3
Authors: Halaç M, Albayram S, Ceyhan E, Ozer H, Dogan I, Sager S, Uslu I
Spontaneous intracranial hypotension (SIH) is characterized by severe postural headache and low cerebrospinal fluid (CSF) pressure. Radionuclide cisternography (RC) is of some value in diagnosing CSF leakage causing SIH. However, the sensitivity of RC is too low to demonstrate the site of leakage. In these cases, the early appearance of the radioactivity in the urinary bladder has also been used as an indirect finding in the diagnosis of SIH. The aim of this study was to evaluate the diagnostic reliability of early urinary bladder activity as an indirect sign of SIH. We investigated early bladder activity in 21 patients with suspicion of normal pressure hydrocephalus. Of the 21 subjects, 13 (62%) showed early bladder activity. We demonstrated that early bladder activity is observed in patients without CSF leakage such as normal pressure hydrocephalus. Therefore, this indirect finding of RC is not a reliable finding in diagnosing SIH.
lumbar puncture and Post-Dural Puncture Headaches: Implications for the Emergency Physician.
J Emerg Med. 2007 Sep 17;
Authors: Frank RL
lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Post-dural puncture headaches occur frequently after this procedure and can be associated with significant morbidity and, occasionally, even death. There is also a lot of variation in how post-dural puncture headaches are treated once they occur. This article seeks to examine the science behind post-dural puncture headaches, their prevention and treatment.
PMID: Risks of lumbar puncture 17976786 [PubMed - as supplied by publisher]
Unsuccessful lumbar puncture in a paediatric patient with achondroplasia.
Anaesth Intensive Care. 2007 Oct;35(5):780-3
Authors: Burgoyne LL, Laninghamt E, Zero JT, Bikhazi GB, Pereiras LA
We present a case of an unsuccessful lumbar puncture performed on an anaesthetised 17-year-old girl with achondroplasia who was diagnosed with and being treated for acute lymphoblastic leukaemia. Magnetic resonance imaging (MRI) subsequently showed spinal stenosis and no observable cerebrospinal fluid around the nerve roots at the levels of the lumbar pedicles and discs. A recommendation is made to obtain MRI scans before proceeding with lumbar puncture and/or spinal anaesthesia in this patient group to ensure that the anatomical features of the insertion site are favourable to a successful outcome.
[lumbar puncture: its indications, contraindications, complications and technique]
Rev Neurol. 2007 Oct 1-15;45(7):433-6
Authors: Sempere AP, Berenguer-Ruiz L, Lezcano-Rodas M, Mira-Berenguer F, Waez M
INTRODUCTION: Although first described over 100 years ago, lumbar puncture is still an important tool in the diagnosis of neurological diseases. In this article we review its indications, contraindications, the technique for carrying it out, the analysis of the cerebrospinal fluid and possible complications. DEVELOPMENT: The lumbar puncture has diagnostic and therapeutic indications. The chief diagnostic indications include infectious, inflammatory and neoplastic diseases affecting the central nervous system. Complications are infrequent, except for headaches and low back pain, but can be severe. Analysis of the cerebrospinal fluid must include a cell count and determination of the glucose and protein concentrations. The other analytical studies of cerebrospinal fluid must be conducted according to the diagnostic suspicion. CONCLUSION: The lumbar puncture in expert hands is a safe test. The health professional should be suitably familiar with its contraindications, the regional anatomy and the technique used to perform it.
lumbar puncture success rate is not influenced by family-member presence.
Pediatrics. 2007 Oct;120(4):e777-82
Authors: Nigrovic LE, McQueen AA, Neuman MI
OVERVIEW: The presence of a family member during invasive pediatric procedures such as lumbar puncture has been shown to reduce patient anxiety. However, family presence might also affect clinicians' stress and anxiety, with uncertain consequences for procedural success. OBJECTIVE: Our goal was to evaluate the association between family-member presence and lumbar puncture success rates. DESIGN/METHODS: We performed a prospective cohort study of all children who underwent a lumbar puncture in a single pediatric emergency department between July 2003 and January 2005. The presence of a family member was documented by the physician who performed the lumbar puncture. Success rates were assessed by using 2 main outcomes: (1) the rate of traumatic (cerebrospinal fluid red blood cells > or = 10,000 cells per microL) or unsuccessful lumbar puncture (no cerebrospinal fluid sent for cell counts) and (2) the number of lumbar puncture attempts. Multivariate analyses were adjusted for patient age, race, time of day, physician experience, use of local anesthetic, catheter stylet removal, and patient movement during the procedure. RESULTS: Of the 1474 eligible lumbar punctures, 1459 (99%) were included in the analysis. A family member was present for 1178 (81%) of the procedures studied. A total of 1267 (87%) lumbar punctures were nontraumatic, and 192 (13%) were traumatic or unsuccessful. Neither the rate of traumatic or unobtainable lumbar punctures nor the number of lumbar puncture attempts differed based on whether a family member was present for the procedure. CONCLUSIONS: The presence of a family member was not associated with an increased risk of traumatic or unobtainable lumbar puncture, nor was it associated with more attempts at the procedure. The benefits of having a family member present during the procedure were not counterbalanced by adverse effects on procedural success.
A randomized controlled trial of ultrasound-assisted lumbar puncture.
J Ultrasound Med. 2007 Oct;26(10):1341-8
Authors: Nomura JT, Leech SJ, Shenbagamurthi S, Sierzenski PR, O'Connor RE, Bollinger M, Humphrey M, Gukhool JA
OBJECTIVE: Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound-assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients. METHODS: This was an Institutional Review Board-approved, randomized, prospective, double-blind study conducted at the emergency department of a teaching institution. Patients undergoing LP from January to December 2004 were eligible for enrollment. Patients were randomized to undergo LP using palpation landmarks (PLs) or ultrasound landmarks (ULs). Data collected included age, body mass index, number of attempts, ease of performance and patient comfort on a 10-cm Visual Analog Scale, procedure time, success, and traumatic LP. Statistical analysis of data included relative risk (RR), the Mann-Whitney U test, and the Student t test. RESULTS: A total of 46 patients were enrolled, 22 randomized to PLs and 24 to ULs. There were no differences between the groups in mean age or body mass index. Six of 22 attempts failed with PLs versus 1 of 24 with ULs (RR, 1.32; 95% confidence interval, 1.01-1.72). In 12 obese patients, 4 of 7 PL attempts failed versus 0 of 5 UL attempts (RR, 2.33; 95% confidence interval, 0.99-5.49). The ease of the procedure was better with ULs versus PLs. There were no statistical differences in the number of attempts, traumatic LPs, patient comfort, or procedure length. CONCLUSIONS: The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.
Symptomatic spinal epidural collections after lumbar puncture in children.
AJNR Am J Neuroradiol. 2007 Oct;28(9):1811-6
Authors: Koch BL, Moosbrugger EA, Egelhoff JC
BACKGROUND AND PURPOSE: Complications from lumbar puncture (LP) include headache; mild puncture-site pain; and, rarely, subdural, epidural, or subarachnoid hemorrhage. In infants, asymptomatic leakage of CSF documented with ultrasound is common. We report the MR imaging findings and clinical course of 25 symptomatic patients with spinal epidural collections after LP. MATERIALS AND METHODS: MR imaging and clinical records of 25 children with new symptoms following LP were retrospectively reviewed. RESULTS: All patients had abnormal dorsal spinal epidural collections. Signal-intensity characteristics of the collections were most commonly isointense to CSF on all pulse sequences. Significant anterior displacement of the dura with effacement of the subarachnoid space was frequently noted. All patients had fluid surrounding small foci of epidural fat, elevating them from their native interspinous fossa, resulting in a "floating" appearance. Eighteen collections involved the thoracic and lumbar spine; 4 involved the thoracic, lumbar, and sacral spine; 2 extended from the lumbar to the cervical level; and 1 was isolated to the lumbar spine. Five patients had follow-up MR imaging showing complete resolution of collections. The size of the collections was not directly related to the number of puncture attempts. Clinical symptoms resolved with time in all patients with conservative management. CONCLUSION: Symptomatic epidural fluid collections after LP are often extensive and may compromise the thecal sac. These collections are not usually the result of a difficult LP and have signal intensity characteristics most consistent with CSF leak rather than hemorrhage. Signs and symptoms typically resolve with time, without treatment and with no serious sequelae.
Authors: Nelson AS, Jafari A, Shah P, Eljamel S, O'Riordan JI
A 50-year-old woman developed pneumoencephaly following a CSF examination for evaluation of dysequilibrium. Previous investigations had demonstrated a number of high signal T2 lesions on MRI of the brain. In addition, there was what was thought to be an asymptomatic cystic lesion in the left frontal lobe communicating with the lateral ventricle. After the lumbar puncture she developed extensive pneumoencephaly with pressure dilatation of the ventricular system. There was CSF rhinorrhoea. Further CT scans showed an osteoma in the ethmoidal air sinus with protrusion into the cystic area. This was the site of both the CSF leak and air entry. Caution must be taken when considering a CSF examination in the presence of either a presumed asymptomatic porencephalic cyst or ethmoid osteoma.
CASE REPORT: Two cases are presented in which the complication of dural puncture is documented in the context of a lumbar transforaminal epidural steroid injection. The hazard of dural puncture during transforaminal epidural injections, the anatomy of the dural and thecal sac, the potential for subdural injections, and relevant literature are reviewed. DESIGN: Report of two cases. BACKGROUND: Lumbar transforaminal epidural steroid injections are a commonly employed procedure for the treatment of lumbar radiculopathy. The optimal target point lies at the "6 o' clock" position of the pedicle. Contrast is injected to confirm proper placement of the needle and correct flow of the medication through the epidural space. Despite apparent proper placement of the needle, a potential complication exists of puncturing the dura while performing this procedure. Spinal injectionists should recognize the subsequent contrast patterns associated with this complication. CONCLUSION: Subdural and intrathecal spread of contrast is rarely seen with transforaminal injections and thus can be easily overlooked. Becoming familiar with the images presented in these cases may help alert the interventionalist of a dural puncture, and thus avoid injection of medications into the intrathecal and subdural spaces.
Normal-pressure hydrocephalus: white matter lesions correlate negatively with gait improvement after lumbar puncture.
Clin Neurol Neurosurg. 2007 Nov;109(9):774-8
Authors: Bugalho P, Alves L
OBJECTIVES: To test relations between white matter lesions (WML) load in Normal Pressure Hydrocephalus (NPH) patients and gait characteristics at baseline, duration of symptoms, gait improvement after lumbar puncture (LP), vascular risk factors. PATIENTS: Fifteen idiopathic NPH patients. METHODS: Patients underwent a timed walking test, before and after LP. Five gait variables were assessed and improvement percentages were calculated. WML load was rated regionally and globally in T2 weighted MRI images, using a simple visual scale. Spearman or Pearson correlation coefficients were used to test relations between variables. RESULTS: Significant negative correlations were found between WML scores and gait improvement after CSF removal but not with duration of symptoms or gait variables before LP. CONCLUSIONS: WML seem to contribute to the irreversibility of symptoms in NPH but not to the pathophysiological mechanisms that lead to them.
lumbar puncture and brain herniation in acute bacterial meningitis: a review.
J Intensive Care Med. 2007 Jul-Aug;22(4):194-207
Authors: Joffe AR
There has been controversy regarding the risk of cerebral herniation caused by a lumbar puncture (LP) in acute bacterial meningitis (ABM). This review discusses in detail the issues involved in this controversy. Cerebral herniation occurs in about 5% of patients with ABM, accounting for about 30% of the mortality. In many reports, LP is temporally strongly associated with this event of herniation and is most likely causative based on pathophysiologic arguments. Although a computed tomography (CT) scan of the head is useful to find contraindications to an LP, a normal CT scan in ABM does not mean that an LP is safe. Clinical signs of "impending" herniation are the best predictors of when to delay an LP because of the risk of precipitating herniation, even with a normal CT scan. Some of these clinical signs to be considered are deteriorating level of consciousness (particularly to a Glasgow Coma Scale of
Iatrogenic epidermoid tumor: late complication of lumbar puncture.
J Child Neurol. 2007 Mar;22(3):332-6
Authors: Per H, Kumandaş S, Gümüş H, Yikilmaz A, Kurtsoy A
Intraspinal epidermoid tumors can be congenital and acquired. Acquired intraspinal epidermoid tumors are extremely rare. Epidermal elements are implanted into the arachnoid space by trauma, spinal anesthesia, surgery, bullet wounds, myelography, or lumbar puncture. Approximately 40% of acquired epidermoid tumors are considered a late complication of lumbar puncture. The authors report the case of an 8-year-old boy who presented with a 1-year history of back and hip pain and radiating pain to both thighs posterior. lumbar puncture was performed in the neonatal intensive care unit to rule out meningitis in the patient's past medical history. The patient underwent total surgical excision of the epidermoid tumor. Pathologic examination revealed the diagnosis of epidermoid tumor. Keywords: intraspinal epidermoid tumor; lumbar puncture; children.
The role of lumbar puncture in the diagnosis of subarachnoid hemorrhage when computed tomography is unavailable.
CJEM. 2002 Mar;4(2):102-5
Authors: Mann D
Subarachnoid hemorrhage (SAH) is an important but uncommon condition in the differential diagnosis of acute headache. Most authorities recommend that patients with suspected SAH undergo noncontrast computed tomography (CT) as a first diagnostic intervention. If the results of the CT scan are negative, a lumbar puncture should be performed. Many nonurban Canadian hospitals do not have CT scanners and must either transfer patients or consider performing lumbar puncture prior to CT. In selected patients, performing lumbar puncture first may be an option, but timing of the procedure and the interpretation of results is important.
PMID: Risks of lumbar puncture 17612428 [PubMed - in process]
Magnetic resonance tracking of magnetically labeled autologous bone marrow CD34+ cells transplanted into the spinal cord via lumbar puncture technique in patients with chronic spinal cord injury: CD34+ cells' migration into the injured site.
Stem Cells Dev. 2007 Jun;16(3):461-6
Authors: Callera F, de Melo CM
The purpose of this study was to demonstrate the possibility of delivering autologous bone marrow precursor cells into the spinal cord via lumbar puncture technique (LP) in patients with spinal cord injury (SCI). Magnetic resonance imaging provides a noninvasive method for studying the fate of transplanted cells in vivo. Considering these propositions, we studied magnetic resonance tracking of autologous bone marrow CD34(+) cells labeled with magnetic nanoparticles delivered into the spinal cord via LP in patients with SCI. Sixteen patients with chronic SCI were enrolled and divided into two groups; one group got their own labeled-CD34(+) cells injected into the spinal cord via LP (n = 10); the others received an injection, but it contained magnetic beads without stem cells (controls, n = 6). CD34(+) cells were magnetically labeled with magnetic beads coated with a monoclonal antibody specific for the CD34 cell membrane antigen. Magnetic resonance images were obtained by a standard turbospin echo-T2 weighted sequences before and 20 and 35 days after post-transplantation. The median number of CD34(+) cells injected via LP was 0.7 x 10(6) (range 0.45 to 1.22 x 10(6)). Magnetically labeled CD34(+) cells were visible at the lesion site as hypointense signals in five patients of the labeled-CD34(+) group 20 and 35 days after transplantation; these signals were not visible in any patient of the control group. We suggested for the first time that autologous bone marrow CD34(+) cells labeled with magnetic nanoparticles delivered into the spinal cord via LP technique migrated into the injured site in patients with chronic SCI.
Traumatic vs. atraumatic 22 G needle for therapeutic and diagnostic lumbar puncture in the hematologic patient: a prospective clinical trial.
Haematologica. 2007 Jul;92(7):1007-8
Authors: Lavi R, Rowe JM, Avivi I
We investigated the impact of needle type on post lumbar puncture headache (PLPH) in hematologic patients undergoing LP. We prospectively compared traumatic (TN) vs. atraumatic 22G needles. Twenty-seven patients underwent 48 LPs, 22 with chemotherapy injection. PLPH occurred almost exclusively with TN (4% vs. 30% p=0.02), irrespective of chemotherapy injection.
Prevention and management of post-lumbar puncture headache in pediatric oncology patients.
J Pediatr Oncol Nurs. 2007 Jul-Aug;24(4):200-7
Authors: Lee LC, Sennett M, Erickson JM
Pediatric oncology patients are at risk for developing a headache after they undergo a lumbar puncture for diagnostic or therapeutic purposes. These headaches are likely due to leakage of cerebrospinal fluid at the puncture site. While usually mild and self-limited, some headaches may be persistent and severe, adding to the distress of these young patients. In the past 10 years, refinements in lumbar needle size and shape as well as procedural techniques have reduced the tissue trauma that predisposes patients to headache. A number of interventions, such as bed rest, hydration, caffeine administration, and epidural blood patching, have been suggested to prevent and relieve the headaches that follow lumbar punctures. This article outlines the pathophysiology and incidence of headaches related to lumbar punctures in the pediatric oncology setting and reviews the evidence from research trials to suggest which interventions clinicians should adopt into their practice to minimize this complication of lumbar punctures.
Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Use of ultrasonography for lumbar puncture.
Emerg Med J. 2007 Jul;24(7):492-3
Authors: Cummings T, Jones JS
A short cut review was carried out to establish whether ultrasonography can assist in the performing of a lumbar puncture. Fifty-one citations were reviewed of which three answered the three part question. The clinical bottom line is that ultrasound shows early promise as a tool to assist in achieving a successful lumbar puncture.
Evidence-based emergency medicine/rational clinical examination abstract. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?
Authors: Coccia P, Ruggiero A, Attinŕ G, Lazzareschi I, Maurizi P, Riccardi R
In pediatric oncology, LPs are frequently performed for diagnostic and therapeutic purposes. A LP procedure may be helpful in diagnosing many diseases and disorders. In addition, a LP may be performed therapeutically, to inject medications directly into the spinal canal. Intrathecal administration of antineoplastic drugs allows to bypass the selective filter of BBB and to achieve significant concentrations of the antineoplastic agents in CSF reducing the likelihood of systemic toxicity. lumbar puncture is generally well tolerated but might be characterized by several disadvantages and risks.
The postdural puncture headache is a frequent iatrogenic complication due to an excessive leakage of cerebrospinal fluid. The leak through the dural perforation mainly depends on the size and design of the needle. The diagnostic is based on the notion of dural puncture, headache worsening in upright posture and other symptoms as neck stiffness, tinnitus, hypacusia, photophobia or nausea. Symptoms resolve spontaneously within 1 week or within 48 hours after autologous epidural blood patch. Prevention is based on using small-gauge pencil-point needles whereas the duration of bed rest has no effect on the incidence of postlumbar puncture headache.
Lumbar epidural hematoma following lumbar puncture: the role of high dose LMWH and late surgery. A case report.
Neurocirugia (Astur). 2007 Feb;18(1):52-5
Authors: Gurkanlar D, Acikbas C, Cengiz GK, Tuncer R
Spinal epidural hematoma (SEH) is a known complication of spinal surgery, but the incidence of post-surgical SEHs that result in neurologic deficits is extremely rare (0.1%). Patients that require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk of developing an epidural hematoma. The introduction of higher dose of low molecular weight heparin (LMWH) twice daily 30 mg regimen) increased the reported incidence of neuroaxial hematomas. Surgery performed within 8 hours makes good or partial recovery of neurologic function. Our patient was also started on higher dose of LMWH and developed neurological deficits due to a SEH following lumbar puncture. She underwent operation after six days and she had a mild recovery following the operation. Current administration of high doses of LMWH can cause SEH even after a lumbar puncture, which was performed without multiple attempts. Although surgery performed within 8 hours makes good or partial recovery of neurologic function, laminectomy and epidural hematoma evacuation performed after three days can also have successful results.
The use of ultrasound to identify pertinent landmarks for lumbar puncture.
Am J Emerg Med. 2007 Mar;25(3):331-4
Authors: Stiffler KA, Jwayyed S, Wilber ST, Robinson A
OBJECTIVE: This study was conducted to assess the ultrasound's (US's) ability to identify pertinent landmarks for lumbar puncture (LP) in patients of various body mass indices (BMIs) and establish spatial relationships of pertinent LP landmarks across BMIs. METHODS: In this institutional review board-approved cross-sectional study, we calculated the BMIs of eligible patients and then categorized them as normal (BMI < or =24.9), overweight (BMI 24.9-30), or obese (BMI > or =30). We recorded the difficulty in palpating traditional LP landmarks. Identification and measurement of the spatial relationships of the sacrum; spinous processes of lumbar vertebrae L3, L4, and L5; ligamentum flavum; and the spinal canal by US was attempted. RESULTS: Successful identification of pertinent structures (L4-L5 spinous processes and the spinal canal) occurred in 100% of patients with normal BMI, 95% of those who were overweight, and 74% of those who were obese (P = .011). Difficulty in palpating landmarks was noted in 5% of patients with normal BMI, 33% of those who were overweight, and 68% of those who were obese (P < .0001). In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16 of 21 (76%; 95% confidence interval, 53-92). The average distance from skin to ligamentum flavum was 44 mm in those with normal BMI, 51 mm in those who were overweight, and 64 mm in those who were obese (P < .00001); measurements between spinous processes did not vary by BMI. Overall, there was a moderate correlation (0.62) between BMI and the distance from skin to ligamentum flavum. CONCLUSION: The usefulness of US in identifying structures for LP is inversely related to BMI. Even with this limitation, US is still able to identify obese patients' pertinent landmarks almost 75% of the time. In addition, US may be helpful in identifying pertinent structures for LP in those patients with difficult-to-palpate landmarks. In patients who were obese with structures not palpable by hand or identifiable by US, other modalities should be considered.
Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture.
Am J Emerg Med. 2007 Mar;25(3):291-6
Authors: Ferre RM, Sweeney TW
INTRODUCTION: Although ultrasound has been used in administering epidural anesthesia, it is unknown if emergency physicians (EPs) can obtain ultrasound images useful for lumbar puncture. OBJECTIVE: The objective of the study was to determine EPs' ability to apply a standardized ultrasound technique for visualizing landmarks surrounding the dural space. METHODS: Two EPs sought to identify relevant anatomy in emergency patients. Visualization time for 5 anatomical structures (spinous processes or laminae, ligamentum flavum, dura mater, epidural space, subarachnoid space), body mass index, and perception of landmark palpation difficulty were recorded. RESULTS: Seventy-six subjects were enrolled. Soft tissue and bony anatomical structures were identified in all subjects. Mean body mass index was 31.4 +/- 9.8 (95% confidence interval, 29.1-33.6). High-quality images were obtained in less than 1 minute in 153 (87.9%) scans and in less than 5 minutes in 174 (100%) scans. Mean acquisition time was 57.19 seconds; SD, 68.14 seconds; range, 10 to 300 seconds. CONCLUSION: In this cohort, EPs were able to rapidly obtain high-quality ultrasound images relevant to lumbar puncture.
Utility of lumbar puncture in diagnosis of Vogt-Koyanagi-Harada disease.
Int Ophthalmol. 2007 Apr-Jun;27(2-3):189-94
Authors: Tsai JH, Sukavatcharin S, Rao NA
PURPOSE: To determine the significance of lumbar puncture in diagnosis of Vogt-Koyanagi-Harada disease (VKH). METHOD: A retrospective analysis was conducted on 116 consecutive patients diagnosed with VKH. Two additional patients who presented with acute VKH were included in the analysis. Demographic characteristics, including gender, age, and ethnicity, were extracted from the medical record. The stage of disease at presentation was documented. Pertinent laboratory results and diagnostic procedures such as lumbar puncture, fluorescein angiography, and echography that contributed to the diagnosis of VKH were collected. RESULTS: lumbar puncture results for 10 patients were available. Eight of these patients presented with pleocytosis consistent with a diagnosis of VKH. Clinical features and fluorescein angiography confirmed the diagnosis in these patients. Both of the patients who did not exhibit cerebrospinal fluid (CSF) pleocytosis presented with headache, vision loss, and bilateral uveitis. Fluorescein angiography disclosed multiple foci of leakage at the retinal pigment epithelium level with accumulation of dye under the retina and disc leakage, confirming diagnosis of VKH. CONCLUSION: The utility of lumbar puncture as a diagnostic criterion for VKH should be re-evaluated given that clinical features and fluorescein angiography alone often support the diagnosis. The inherent risks and complications associated with the procedure must prompt the clinician to reserve this evaluation for atypical presentations.
Pediatric and emergency medicine residents' attitudes and practices for analgesia and sedation during lumbar puncture in pediatric patients.
Pediatrics. 2007 Mar;119(3):e631-6
Authors: Breakey VR, Pirie J, Goldman RD
OBJECTIVE: Analgesia and sedation for painful procedures in children are safe and effective, yet our experience is that pain management during lumbar puncture is suboptimal. We aim to document factors that influence residents' decisions to use analgesia and sedation during lumbar puncture and to compare pediatric and emergency medicine residents' practices. METHODS: A survey was developed and sent to pediatric and emergency medicine residents from across Canada that inquired about clinical practices, learning experiences, current use of analgesia and sedation for lumbar puncture, and their clinical reasoning for using or abstaining from using analgesia and sedation. The Student's t and chi2 tests were used to compare the 2 resident groups. RESULTS: Of the 374 residents to whom the survey was sent, 245 completed the survey. Pediatric residents reported performing lumbar punctures with no local anesthetic much more frequently. Pediatric residents used EMLA (AstraZeneca, Wilmington, DE) more frequently and injectable lidocaine less frequently. Pediatric residents used sedation for lumbar puncture at least once, more frequently than emergency medicine residents, and used mostly benzodiazepines. Both groups used ketamine at a similar rate. Pediatric residents reported that they witnessed adverse events of sedation more frequently. Although pediatric residents were responsible for teaching trainees the lumbar-puncture procedure significantly more frequently, they reported less educational opportunities during residency themselves and that they were less likely to recommend the use of local anesthetic during lumbar puncture when teaching the procedure. CONCLUSIONS: Several significant differences exist between the pediatric residents and emergency medicine residents we surveyed. Pediatric residents were using less injectable local anesthesia for lumbar puncture in children and more sedation for the procedure and have had notably less training in the use of sedation. Pediatric residents have more teaching responsibilities than their emergency medicine residents colleagues and are inconsistently recommending the use of local anesthetics for lumbar puncture.
Utility of lumbar puncture in the afebrile vs. febrile elderly patient with altered mental status: a pilot study.
J Emerg Med. 2007 Jan;32(1):15-8
Authors: Shah K, Richard K, Edlow JA
We conducted a pilot study to compare the diagnostic utility of a lumbar puncture (LP) in febrile vs. afebrile elderly patients with altered mental status (AMS). Our null hypothesis was that there is no utility of performing an LP on the afebrile elderly patient with AMS. A retrospective study was conducted at an urban, university tertiary care referral center. The study population included all elderly patients (age 65 years and older) who had cerebrospinal fluid (CSF) samples sent to the laboratory over 1 year. A structured chart review was performed. Exclusion criteria were normal mental status, recent neurosurgical procedure or presence of a ventricular shunt, and missing medical records. An LP was considered diagnostically useful if it yielded a diagnosis. There were 185 CSF samples from elderly patients recorded over 1 year. Sixty samples were excluded for the following reasons: normal mental status (36), recent neurosurgical procedure (2), presence of ventricular shunt (11), missing medical record (4), repeat LP on same admission (7). Of the 125 patients who met the study criteria, 84 patients were afebrile and 41 patients were febrile. Of the 84 afebrile patients with AMS, 15 patients (18%; 95% confidence interval [CI] 10-26%) had an abnormal LP. Ten (12%) had some form of meningitis and five (6%) had unclear diagnoses. Of the 41 febrile patients with AMS, 10 patients (24%; 95% CI 11-38%) had an abnormal LP. Three (7%) had some form of meningitis or encephalitis. Comparing the elderly patient group without fever with the elderly patient group with fever, there was no statistical difference in the incidence of abnormal LPs or diagnostically useful LPs. Based on the results of this pilot study, we were unable to reject the null hypothesis that there is no utility of performing LP on afebrile elderly patients with altered mental status. We would advocate not relying solely on the presence or absence of fever to determine management in the elderly.
