lumbar puncture
| Dictionary: lumbar puncture |
n.
The insertion of a hollow needle beneath the arachnoid membrane of the spinal cord in the lumbar region to withdraw cerebrospinal fluid for diagnostic purposes or to administer medication.
| 5min Related Video: lumbar puncture |
| Oncology Encyclopedia: Lumbar Puncture |
Key Terms: Acute lymphoblastic leukemia, Encephalitis, Guillain-Barré syndrome, Immune system, Intrathecal therapy, Manometer, Meningitis, Multiple sclerosis, Spinal canal,
Definition
Lumbar puncture (LP) is the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal. CSF is the clear, watery liquid that protects the central nervous system from injury and cushions it from the surrounding bone structure. It contains a variety of substances, particularly glucose (sugar), protein, and white blood cells from the immune system.
Purpose
Lumbar puncture, or spinal tap, is used to diagnose some malignancies, such as certain types of brain cancer and leukemia, as well as other medical conditions that affect the central nervous system. It is sometimes used to assess patients with certain psychiatric symptoms and conditions.
It is also used for injecting chemotherapy directly into the CSF. This type of treatment is called intrathecal therapy. Other medical conditions diagnosed with lumbar puncture include:
- viral and bacterial meningitis
- syphilis, a sexually transmitted disease
- bleeding (hemorrhaging) around the brain and spinal cord
- multiple sclerosis, a disease that affects the myelin coating of the nerve fibers of the brain and spinal cord
- Guillain-Barré syndrome, an inflammation of the nerves
Precautions
In some circumstances, a lumbar puncture to withdraw a small amount of CSF for analysis may lead to serious complications. Lumbar puncture should be performed only with extreme caution, and only if the benefits are thought to outweigh the risks, in certain conditions. For example, in people who have blood clotting (coagulation) or bleeding disorders or who are on anticoagulant treatment, lumbar puncture can cause bleeding that can compress the spinal cord. The term for this condition is spinal subdural hematoma, and it is a rare complication. However, it is of concern to some cancer patients whose low platelet counts (thrombocytopenia) make them more susceptible to bleeding. In some cases, these patients are given a platelet transfusion prior to lumbar puncture, but this procedure is still under investigation. A 1984–88 study, supported in part by the National Cancer Institute, researched the risk of lumbar puncture on children with acute lymphoblastic leukemia (ALL). No serious lumbar puncture complications were observed in this study of over 5,000 children.
Lumbar puncture has been shown to be less precise than some other methods in monitoring intracranial fluid pressure. A transducer provides more accurate information about changes in the flow of blood and cerebrospinal fluid within the brain.
A traumatic lumbar puncture (TLP) occurs when a blood vessel is inadvertently ruptured during the procedure. If this happens as part of a diagnostic leukemia workup, there is the potential of contaminating the CSF specimen that has been removed with leukemia cells, causing a false positive test result.
If there is a large brain tumor or other mass, removal of CSF can cause pressure shifts within the brain (herniation), causing compression of the brain stem and other vital structures, and leading to irreversible brain damage or death. These problems are easily avoided by checking blood coagulation through a blood test and by doing a computed tomography scan (CT) or magnetic resonance imaging (MRI) scan before attempting the lumbar puncture. In addition, a lumbar puncture procedure should never be performed at the site of a localized skin infection on the lower back because the infection may be introduced into the CSF and may spread to the brain or spinal cord.
Description
In a lumbar puncture, the area of the spinal column used to obtain the CSF sample is in the lumbar spine, or lower section of the back. In rare instances, such as a spinal fluid blockage in the middle of the back, a doctor may perform a spinal tap in the neck. The lower lumbar spine (usually between the vertebrae known as L4–5) is preferable because the spinal cord stops near L2, and a needle introduced below this level will miss the spinal cord and encounter only nerve roots, which are easily pushed aside.
A lumbar puncture takes about 15–30 minutes. Patients can undergo the test in a doctor's office, laboratory, or outpatient hospital setting. Sometimes it requires an inpatient hospital stay. If the patient has severe osteoarthritis of the spine, is extremely uncooperative, or obese, it may be necessary to introduce the spinal needle using x-ray guidance.
In order to get an accurate sample of cerebrospinal fluid, it is critical that a patient is in the proper position. The spine must be curved to allow as much space as possible between the lower vertebrae, or bones of the back, for the doctor to insert a lumbar puncture needle between the vertebrae and withdraw a small amount of fluid. The most common position is for the patient to lie on his or her side with the back at the edge of the exam table, head and chin bent down, knees drawn up to the chest, and arms clasped around the knees. (Small infants and people who are obese may need to curve their spines in a sitting position.) People should talk to their doctors if they have any questions about their position because it is important to be comfortable and to remain still during the entire procedure. In fact, the doctor will explain the procedure to the patient (or guardian) so that the patient can agree in writing to have it done (informed consent). If the patient is anxious or uncooperative, a short-acting sedative may be given.
During a lumbar puncture, the doctor drapes the back with a sterile covering that has an opening over the puncture site and cleans the skin surface with an antiseptic solution. Patients receive a local anesthetic to minimize any pain in the lower back.
The doctor inserts a thin hollow needle in the space between two vertebrae of the lower back and slowly advances it through ligamentous tissues toward the spine. A steady flow of clear cerebrospinal fluid, normally the color of water, will begin to fill the needle as soon as it enters the spinal canal. The doctor measures the cerebrospinal fluid pressure with a special instrument called a manometer and withdraws several vials of fluid for laboratory analysis. The amount of fluid collected depends on the type and number of tests needed to diagnose a particular medical disorder.
In some cases, the doctor must remove and reposition the needle. This occurs when there is not an even flow of fluid, the needle hits bone or a blood vessel, or the patient reports sharp, unusual pain.
Preparation
Patients can go about their normal activities before a lumbar puncture. Experts recommend that patients relax before the procedure to release any muscle tension, since the lumbar puncture needle must pass through muscle tissue before it reaches the spinal canal. A patient's level of relaxation before and during the procedure plays a critical role in the test's success. Relaxation may be difficult for those patients who face frequent lumbar punctures, such as children with leukemia. In these cases, it is especially important for the child to receive psychological support before and after each procedure. It may be helpful to praise a child who remained still and quiet during the procedure, and to remind the child of his or her good behavior before the next lumbar puncture.
Aftercare
After the procedure, the doctor covers the site of the puncture with a sterile bandage. Patients must avoid sitting or standing and remain lying down for as long as six hours after the lumbar puncture. They should also drink plenty of fluids to help prevent lumbar puncture headache, which is discussed in the next section.
Risks
The most common side effect of lumbar puncture is a headache. This problem occurs in 10–20% of adult patients and in up to 40% of children. It is caused by decreased CSF pressure related to a small leak of CSF through the puncture site. These headaches usually are a dull pain, although some people report a throbbing sensation. A stiff neck and nausea may accompany the headache. A lumbar puncture headache typically begins within a few hours to two days after the procedure and usually persists a few days, although it can last several weeks or months.
In some cases, the headache can be prevented by lying flat for an hour after the lumbar puncture, and taking in more fluids for 24 hours after the procedure. Since an upright position worsens the pain, lying flat also helps control the pain, along with prescription or non–prescription pain relief medication, preferably one containing caffeine. In rare cases, the puncture site leak is "patched" using the patient's own blood. People may also experience back pain. Headaches and backaches appear to be more common in adolescents than in younger children, and more common in girls than in boys.
Patients who receive anticancer drugs through lumbar puncture sometimes have nausea and vomiting. Intrathecal methotrexate can cause mouth sores. Some of these symptoms may be relieved by anti-nausea drugs prescribed by the physician.
In a very few cases, lumbar puncture in infants can lead to such complications as paraplegia. These complications are associated with the smaller size of the infant's central nervous system and increased difficulty in avoiding certain parts of the spinal cord when performing an LP.
People should talk to their doctors about complications from a lumbar puncture. In most cases, this procedure is safe and effective. Some patients experience pain, difficulty urinating, infection, or leakage of cerebrospinal fluid from the puncture site after the procedure.
Normal Results
Normal CSF is clear and colorless. It may be straw or yellow–colored if there is excess protein, which may occur with cancer or inflammation. It may be cloudy in infections; blood–tinged if there was recent bleeding; or yellow to brown (xanthochromic) if caused by an older instance of bleeding.
A series of laboratory tests analyze the CSF for a variety of substances to rule out cancer or other medical disorders of the central nervous system. The following are normal values for commonly tested substances:
- CSF pressure: 50–180 mmH2O
- Glucose: 40–85 mg/dL
- Protein: 15–50 mg/dL
- Leukocytes (white blood cells) total less than 5 per mL
- Lymphocytes (specific type of white blood cell): 60–70%
- Monocytes (a kind of white blood cell): 30–50%
- Neutrophils (another kind of white blood cell): none
Normally, there are no red blood cells in the CSF unless the needle passes though a blood vessel on route to the CSF. If this is the case, there should be more red blood cells in the first tube collected than in the last.
Questions to Ask the Doctor
- What is the purpose of my lumbar puncture?
- What aftercare will be needed?
- Will lumbar puncture be used for chemotherapy, and if so, how often will I receive treatments?
- What are the risks for diagnostic procedures or treatments through lumbar puncture?
- What do the test results mean?
- What techniques are suggested to relax children before and after a lumbar puncture?
Abnormal Results
A lumbar puncture is sometimes used as part of a diagnostic cancer workup. Abnormal test result values in the pressure or any of the substances found in the cerebrospinal fluid may suggest a number of medical problems including a tumor or spinal cord obstruction; hemorrhaging or bleeding in the central nervous system; infection from bacterial, viral, or fungal microorganisms; or an inflammation of the nerves. If there is a tumor in the meninges (membranes around the brain and spinal cord), the CSF may have higher protein levels, lower glucose levels, and a mild increase in lymphocytes (pleocytosis). It is important for patients to review the results of a cerebrospinal fluid analysis with their doctor and to discuss any treatment plans.
Resources
Books
Braunwald, Eugene, et al., editors. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2001.
Periodicals
Czosnyka, M., and J. D. Pickard. "Monitoring and Interpretation of Intracranial Pressure." Journal of Neurology, Neurosurgery, and Psychiatry 75 (June 2004): 813–821.
Ebinger, F., C. Kosel, J. Pietz, and D. Rating. "Headache and Backache after Lumbar Puncture in Children and Adolescents: A Prospective Study." Pediatrics 113 (June 2004): 1588–1592.
Gajjar, Amar, et al. "Traumatic Lumbar Puncture at Diagnosis Adversely Affects Outcome in Childhood Acute Lymphoblastic Leukemia." Blood 15 (November 2000): 3381–84.
Howard, Scott C., et al. "Safety of Lumbar Puncture for Children With Acute Lymphoblastic Leukemia and Thrombocytopenia." Journal of the American Medical Association (JAMA) 284 (November 2000): 2222–24.
Tubbs, R. S., M. D. Smyth, J. C. Wellons, III, and W. J. Oakes. "Intramedullary Hemorrhage in a Neonate after Lumbar Puncture Resulting in Paraplegia: A Case Report." Pediatrics 113 (May 2004): 1403–1405.
Zun, L. S., R. Hernandez, R. Thompson, and L. Downey. "Comparison of EPs' and Psychiatrists' Laboratory Assessment of Psychiatric Patients." American Journal of Emergency Medicine 22 (May 2004): 175–180.
Organizations
American Academy of Neurology. 1080 Montreal Ave., St. Paul, MN 55116–2325. (800) 879–1960.
—Martha Floberg Robbins; Rebecca J. Frey, Ph.D.
| Medical Test: Lumbar Puncture (LP) |
General information
Other names
| Where It's Done | Who Does It | How Long It Takes | Discomfort/Pain |
| Doctor's office or hospital outpatient suite. | Doctor and possibly a nurse or technician. | 20-30 minutes. | Position patient must assume may be uncomfortable. Some discomfort when needle is inserted. |
| Results Ready When | Special Equipment | Risks/Complications | Average Cost |
| A few hours to a few days. | Syringe, lumbar-puncture needle, and manometer. | Headache, backache, or bleeding from the puncture site; dangerous if there is infection on the lower back, such as an infected pressure sore. | $-$$ |
Cerebrospinal fluid (CSF) analysis, spinal fluid analysis, and spinal tap.
Purpose- To detect infection, inflammation, or bleeding in the brain or spinal cord.
- To diagnose or rule out leukemia and lymphoma or other cancers involving the brain or central nervous system.
- To diagnose central nervous system disorders that are characterized by tissue destruction, such as multiple sclerosis, and neuropathies (nerve diseases).
- To diagnose some forms of hydrocephalus (water on the brain), for example, normal pressure hydrocephalus.
- As treatment, to lower the pressure of the spinal fluid or to administer drugs to the spinal canal.
By measuring the pressure and withdrawing cerebrospinal fluid and analyzing it for such substances as antibodies, blood, bacteria, cancer cells, and excess protein or white blood cells, diagnoses of various disorders can be made.
Preparation- You will have a CT scan first to see if there is an increase in pressure within the skull, possibly from a brain tumor or an abscess.
- You remove all clothing and wear a surgical gown.
- The site of the needle puncture on your back is cleaned, and local anesthesia is administered to the site.
- You lie on your side with your back to the person performing the test, your knees drawn up to the abdomen, and your forehead bent toward the knees. (Less commonly, the test may be performed while you are sitting.) This opens up the spaces between the vertebrae, making it easier to insert the needle. (See also Variations below.)
- The needle is inserted through your lower back into the spinal canal.
- A sample of cerebrospinal fluid (CSF) is withdrawn (which takes about five minutes) and sent to the laboratory for analysis. Some tests may need to be sent to specialized regional laboratories.
- If you experience discomfort during the procedure, the needle can be repositioned.
- Pressure of the CSF is measured by attaching a manometer to the lumbar-puncture needle.
If you have a problem with the lower back, such as a fused spine, that precludes assuming the curled position necessary for the spinal tap, the fluid sample may be drawn at the top of the spine at the back of the neck. In this case, the procedure is known as a cisternal puncture.
After the test- A small adhesive bandage is placed over the puncture site.
- You lie down for 10 to 15 minutes, which helps distribute the CSF to the brain. (The amount removed will be replaced by the body in about one hour.)
- Unless you are among the less than 1% of patients who experience a severe headache, you are free to leave. Otherwise you will remain in the facility until the headache subsides.
- You should drink extra fluids for the next 24 hours.
- If headache occurs, it is usually relieved by bed rest. If severe, you should call your doctor.
A punctured blood vessel may lead to blood in the cerebrospinal fluid sample.
InterpretationThe doctor receives an immediate impression about the CSF from its appearance. Normal CSF is clear and contains no blood. The presence of blood or a yellowish color may indicate spinal cord obstruction or bleeding in the brain or spinal cord. High pressure of the CSF may indicate the presence of a tumor, swelling, or bleeding. In addition, the CSF will be analyzed in a laboratory for the presence of various substances (see above).
AdvantagesIt can quickly identify the presence of infection and other abnormalities in cerebrospinal fluid.
DisadvantagesIt's invasive.
The next stepOther imaging studies, which may include CT scan or MRI.
DID YOU KNOW?
Twenty years ago, needles used for spinal taps were dull and crudely made, making the procedure painful. Today's needles are so thin and flexible that you could wrap them around your fingers and they wouldn't break. This has reduced the discomfort of the procedure considerably.
| Veterinary Dictionary: rachicentesis |
Puncture into the lumbar spinal canal. See also spinal puncture.
| Wikipedia: Lumbar puncture |
 |
This article needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (December 2007) |
In medicine, a lumbar puncture (colloquially known as a spinal tap) is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very rarely as a treatment ("therapeutic lumbar puncture") to relieve increased intracranial pressure.
Contents |
Indications
The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a case of suspected meningitis, since there is no other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded. Young infants commonly require lumbar puncture as a part of the routine workup for fever without a source, as they have a much higher risk of meningitis than older persons and do not reliably show signs of meningeal irritation (meningismus). In any age group, subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension and many other diagnoses may be supported or excluded with this test.
Lumbar punctures may also be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularly for spinal anesthesia or chemotherapy. Lumbar punctures can be unpleasant for some people, due to increased sensitivity when the needle is inserted to collect the cerebrospinal fluid.
Contraindications
Lumbar puncture should not be performed when idiopathic (unidentified cause) increased intracranial pressure (ICP) is present. The exception is therapeutic use of lumbar puncture to relieve ICP. Ideally, a CT scan should be performed prior to lumbar puncture to rule out space occupying lesions. Lumbar puncture should not be attempted when there is coagulopathy, or when there are decreased levels of platelets in the blood (less than 50 x 109/L). Lumbar puncture in cases of vertebral deformities (scoliosis or kyphosis) is also contraindicated in hands of an unexperienced physician.[1][2]
Procedure
In performing a lumbar puncture, first the patient is usually placed in a left (or right) lateral position with his/her neck bent in full flexion and knees bent in full flexion up to his/her chest, approximating a fetal position as much as possible. It is also possible to have the patient sit on a stool and bend his/her head and shoulders forward. The area around the lower back is prepared using aseptic technique. Once the appropriate location is palpated, local anaesthetic is infiltrated under the skin and then injected along the intended path of the spinal needle. A spinal needle is inserted between the lumbar vertebrae L3/L4 or L4/L5 and pushed in until there is a "give" that indicates the needle is past the dura mater. The stylet from the spinal needle is then withdrawn and drops of cerebrospinal fluid are collected. The opening pressure of the cerebrospinal fluid may be taken during this collection by using a simple column manometer. The procedure is ended by withdrawing the needle while placing pressure on the puncture site. In the past, the patient would often be asked to lie on his/her back for at least six hours and be monitored for signs of neurological problems, though there is no scientific evidence that this provides any benefit. The technique described is almost identical to that used in spinal anesthesia, except that spinal anesthesia is more often done with the patient in a sitting position.
The upright seated position is advantageous in that there is less distortion of spinal anatomy which allows for easier withdrawal of fluid. It is preferred by some practitioners when a lumbar puncture is performed on an obese patient where having them lie on their side would cause a scoliosis and unreliable anatomical landmarks. On the other hand, opening pressures are notoriously unreliable when measured on a seated patient and therefore the left or right lateral (lying down) position is preferred if an opening pressure needs to be measured.
Patient anxiety during the procedure can lead to increased CSF pressure, especially if the person holds their breath, tenses their muscles or flexes their knees too tightly against their chest. Diagnostic analysis of changes in fluid pressure during lumbar puncture procedures requires attention both to the patient's condition during the procedure and to their medical history.[citation needed]
Reinsertion of the stylet may decrease the rate of post lumbar puncture headaches.[2]
Risks
Headache with nausea is the most common complication; it often responds to analgesics and infusion of fluids and can often be prevented by strict maintenance of a supine posture for two hours after the successful puncture. Merritt's Neurology (10th edition), in the section on lumbar puncture, notes that intravenous caffeine injection is often quite effective in aborting these so-called "spinal headaches." Contact between the side of the lumbar puncture needle and a spinal nerve root can result in anomalous sensations (paresthesia) in a leg during the procedure; this is harmless and patients can be warned about it in advance to minimize their anxiety if it should occur. A headache that is persistent despite a long period of bedrest and occurs only when sitting up may be indicative of a CSF leak from the lumbar puncture site. It can be treated by more bedrest, or by an epidural blood patch, where the patient's own blood is injected back into the site of leakage to cause a clot to form and seal off the leak.
Serious complications of a properly performed lumbar puncture are extremely rare.[citation needed] They include spinal or epidural bleeding, and trauma to the spinal cord or spinal nerve roots resulting in weakness or loss of sensation, or even paraplegia. The latter is exceedingly rare, since the level at which the spinal cord ends (normally the inferior border of L1, although it is slightly lower in infants) is several vertebral spaces above the proper location for a lumbar puncture (L3/L4). There are case reports of lumbar puncture resulting in perforation of abnormal dural arterio-venous malformations, resulting in catastrophic epidural hemorrhage; this is exceedingly rare.
The procedure is not recommended when epidural infection is present or suspected, when topical infections or dermatological conditions pose a risk of infection at the puncture site or in patients with severe psychosis or neurosis with back pain. Some authorities believe that withdrawal of fluid when initial pressures are abnormal could result in spinal cord compression or cerebral herniation; others believe that such events are merely coincidental in time, occurring independently as a result of the same pathology that the lumbar puncture was performed to diagnose. In any case, computed tomography of the brain is often performed prior to lumbar puncture if an intracranial mass is suspected.
Removal of cerebrospinal fluid resulting in reduced fluid pressure has been shown to correlate with greater reduction of cerebral blood flow among patients with Alzheimer's disease. Its clinical significance is uncertain.
Diagnostics
Increased CSF pressure can indicate congestive heart failure, cerebral edema, subarachnoid hemorrhage, hypo-osmolality resulting from hemodialysis, meningeal inflammation, purulent meningitis or tuberculous meningitis, hydrocephalus, or pseudotumor cerebri.
Decreased CSF pressure can indicate complete subarachnoid blockage, leakage of spinal fluid, severe dehydration, hyperosmolality, or circulatory collapse. Significant changes in pressure during the procedure can indicate tumors or spinal blockage resulting in a large pool of CSF, or hydrocephalus associated with large volumes of CSF. Lumbar puncture for the purpose of reducing pressure is performed in some patients with idiopathic intracranial hypertension (also called pseudotumor cerebri.)
The presence of white blood cells in cerebrospinal fluid is called pleocytosis. A small number of monocytes can be normal; the presence of granulocytes is always an abnormal finding. A large number of granulocytes often heralds bacterial meningitis. White cells can also indicate reaction to repeated lumbar punctures, reactions to prior injections of medicines or dyes, central nervous system hemorrhage, leukemia, recent epileptic seizure, or a metastatic tumor. When peripheral blood contaminates the withdrawn CSF, a common procedural complication, white blood cells will be present along with erythrocytes, and their ratio will be the same as that in the peripheral blood.
Several substances found in cerebrospinal fluid are available for diagnostic measurement.
- Measurement of chloride levels may aid in detecting the presence of tuberculous meningitis.
- Glucose is usually present in the CSF; the level is usually about 60% that in the peripheral circulation. A fingerstick or venipuncture at the time of lumbar puncture may therefore be performed to assess peripheral glucose levels in order to determine a predicted CSF glucose value. Decreased glucose levels can indicate fungal, tuburculous or pyogenic infections; lymphomas; leukemia spreading to the meninges; meningoencephalitic mumps; or hypoglycemia. A glucose level of less than one third of blood glucose levels in association with low CSF lactate levels is typical in hereditary CSF glucose transporter deficiency also know as De Vivo disease.
- Increased glucose levels in the fluid can indicate diabetes, although the 60% rule still applies.
- Increased levels of glutamine are often involved with hepatic encephalopathies, Reye's syndrome, hepatic coma, cirrhosis and hypercapnia.
- Increased levels of lactate can occur the presence of cancer of the CNS, multiple sclerosis, heritable mitochondrial disease, low blood pressure, low serum phosphorus, respiratory alkalosis, idiopathic seizures, traumatic brain injury, cerebral ischemia, brain abscess, hydrocephalus, hypocapnia or bacterial meningitis.
- The enzyme lactate dehydrogenase can be measured to help distinguish meningitides of bacterial origin, which are often associated with high levels of the enzyme, from those of viral origin in which the enzyme is low or absent.
- Changes in total protein content of cerebrospinal fluid can result from pathologically increased permeability of the blood-cerebrospinal fluid barrier, obstructions of CSF circulation, meningitis, neurosyphilis, brain abscesses, subarachnoid hemorrhage, polio, collagen disease or Guillain-Barré syndrome, leakage of CSF, increases in intracranial pressure or hyperthyroidism. Very high levels of protein may indicate tuberculous meningitis or spinal block.
- IgG synthetic rate is calculated from measured IgG and total protein levels; it is elevated in immune disorders such as multiple sclerosis, transverse myelitis, and neuromyelitis optica of Devic.
- Numerous antibody-mediated tests for CSF are available in some countries: these include rapid tests for antigens of common bacterial pathogens, treponemal titers for the diagnosis of neurosyphilis and Lyme disease, Coccidioides antibody, and others.
- The India ink test is still used for detection of meningitis caused by Cryptococcus neoformans, but the cryptococcal antigen (CrAg) test has a higher sensitivity.
- CSF can be sent to the microbiology lab for various types of smears and cultures to diagnose infections.
- Polymerase chain reaction (PCR) has been a great advance in the diagnosis of some types of meningitis. It has high sensitivity and specificity for many infections of the CNS, is fast, and can be done with small volumes of CSF. Even though testing is expensive, it saves cost of hospitalization.
History
The first technique for accessing the dural space was described by the London physician Dr Walter Essex Wynter. In 1889, he developed a crude cut down with cannulation in 4 patients with tuberculous meningitis. The main purpose was the treatment of raised intracranial pressure rather than for diagnosis.[3] The technique for needle lumbar puncture was then introduced by the German physician Heinrich Quincke, who credits Wynter with the earlier discovery; he first reported his experiences at an internal medicine conference in Wiesbaden in 1891.[4] He subsequently published a book on the subject.[5][6]
The lumbar puncture procedure was taken to the United States by Arthur H. Wentworth M.D., an assistant professor at the Harvard Medical School, based at Children's Hospital. In 1893, he published a long paper on diagnosing cerebro-spinal meningitis by examining spinal fluid. His career took a nosedive, however, when the antivivisectionists prosecuted him for having obtained spinal fluid from children. He was acquitted, but he was disinvited from the then forming Johns Hopkins Medical School where he would have been the first professor of pediatrics.[citation needed]
References
- ^ Roos KL (March 2003). "Lumbar puncture". Semin Neurol 23 (1): 105–14. doi:. PMID 12870112.
- ^ a b Straus SE, Thorpe KE, Holroyd-Leduc J (October 2006). "How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?". JAMA 296 (16): 2012–22. doi:. PMID 17062865.
- ^ Wynter WE (1891). "Four cases of tubercular meningitis in which paracentesis of the theca vertebralis was performed for the relief of fluid pressure". Lancet 1: 981–2. doi:.
- ^ Quincke HI (1891). Verhandlungen des Congresses für Innere Medizin, Zehnter Congress, Wiesbaden. 10. pp. 321–331.
- ^ Quincke HI (1902). Die Technik der Lumbalpunktion. Berlin & Vienna.
- ^ Heinrich Irenaeus Quincke at Who Named It?
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Mentioned in
- Intrathecal therapy (in medicine)
- Cerebrospinal Fluid (CSF) Analysis: Preparation
- Cerebrospinal Fluid (CSF) Analysis: Aftercare
- Cerebrospinal Fluid (CSF) Analysis: Precautions
- puncture
- encephalography (medicine)
- Hydrocephalus: Diagnosis
- tap
- Cerebrospinal Fluid (CSF) Analysis: Risks
- lumbar
- Arteriovenous Malformations: Diagnosis
- Central Nervous System Infections: Diagnosis
- Polio: Diagnosis
- Movement Disorders: Diagnosis
