Lumbar Puncture

1. Lumbar Puncture 8/8/07 – HVA 8/9/07 – LUMC

2. This Is A Spinal Tap

3. The Lumbar Puncture History Heinrich Irenaus Quincke …Quincke’s most notable contribution, however, was his introduction of the lumbar puncture as a diagnostic and therapeutic technique. He arrived at this in an interesting and local fashion. Following his earlier work on the physiology of the cerebrospinal fluid he reasoned that infants with hydrocephalus might be benefited by the removal of some of the spinal fluid and thus break the over-production and/or under-absorption of liquor caused by compression of the pachonian granulations. As Friedrich Theodor von Frerichs' (1819-1885) assistant, he had studied in 1872 the anatomy and physiology related to the cerebrospinal fluid in dogs by injecting red sulphide of mercury into the spinal subarachnoid space. The knowledge gained thereby encouraged him to insert a fine needle with a stylet into the lumbar interspace of an infant, a procedure which he thought might cause slight injury to a root fibre of the cauda but would not cause paralysis.From the first he recognized its diagnostic potential (1891) and took accurate pressure measurements at the beginning and the end of the procedure. He also measured protein and sugar values and described the low sugar occurring in the CSF in purulent meningitis. He diagnosed tuberculous meningitis by demonstrating tubercle bacilli in the CSF and was the first person to puncture the lateral ventricle to obtain CSF in infants with hydrocephalus. When he first reported the technique at the Wiesbaden Congress in 1891 it excited little comment. However, over the years he had the satisfaction of seeing it become the premier diagnostic approach in neurological disorders. www.whonamedit.com James Leonard Corning Walter Essex Winter

4. Indications Diagnostic Infectious Meningitis Encephalitis Inflammatory Multiple Sclerosis Gullain-Barre syndrome Oncologic Metabolic Therapeutic Analgesia Anesthesia Antibiotics Antineoplastics

5. Contraindications Increased intracranial pressure Cerebral herniation Impending herniation Possible increased ICP and focal neuro signs Coagulopathy Prior lumbar surgery Severe vertebral osteoarthritis or degenerative disc disease Significant cardiorespiratory compromise

6. Technique Tips Raise the bed Prepare your tray (i.e. the tubes) Use your landmarks Sytlet in with insertion, in with removal Unless you hand them to a runner yourself, carry the specimens to the lab

7. Lab Studies Protein Glucose Cell count with differential Gram stain and culture PCR Myelin basic protein Smear Lactate Pyruvate

8. Complications Herniation Cardiorespiratory compromise Pain Headache (36.5%) Bleeding Infection Subarachnoid epidermal cyst CSF leakage

10. Results Typical Cerebrospinal Fluid Findings in Various Types of Meningitis Test Bacterial Viral Fungal Tubercular Opening pressure Elevated Usually normal Variable Variable White blood cell count =1,000 per mm3 <100 per mm3 Variable Variable Cell differential Predominance of Predominance of Predominance Predominance PMNs* lymphocytes† of lymphocytes of lymphocytes Protein Mild to marked Normal to elevated Elevated Elevated elevation CSF-to-serum glucose Normal to marked Usually normal Low Low ratio decrease CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes. *—Lymphocytosis present 10 percent of the time. †—PMNs may predominate early in the course.

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