What Is a Spinal Tap Used to Diagnose

Process to collect cerebrospinal fluid

This article is nigh the medical procedure. For other uses, run across spinal tap.

Lumbar puncture
Lumbar puncture in a sitting position. The reddish-brown swirls on the patient'southward dorsum are tincture of iodine (an antiseptic).
Other names	Spinal tap
ICD-9-CM	03.31
MeSH	D013129
eMedicine	80773
[edit on Wikidata]

Lumbar puncture (LP), besides known as a spinal tap, is a medical process in which a needle is inserted into the spinal canal, nigh usually to collect cerebrospinal fluid (CSF) for diagnostic testing. The primary reason for a lumbar puncture is to help diagnose diseases of the key nervous organization, including the brain and spine. Examples of these conditions include meningitis and subarachnoid hemorrhage. Information technology may too be used therapeutically in some conditions. Increased intracranial force per unit area (pressure level in the skull) is a contraindication, due to risk of brain matter existence compressed and pushed toward the spine. Sometimes, lumbar puncture cannot be performed safely (for example due to a severe bleeding tendency). It is regarded as a prophylactic procedure, merely post-dural-puncture headache is a common side effect if a small atraumatic needle is non used.^[1]

The procedure is typically performed nether local anesthesia using a sterile technique. A hypodermic needle is used to access the subarachnoid space and collect fluid. Fluid may be sent for biochemical, microbiological, and cytological analysis. Using ultrasound to landmark may increase success.^[ii]

Lumbar puncture was first introduced in 1891 past the German physician Heinrich Quincke.

Medical uses [edit]

The reason for a lumbar puncture may be to make a diagnosis^{[iii] [4] [5]} or to treat a illness.^[4]

Diagnosis [edit]

The chief diagnostic indications of lumbar puncture are for collection of cerebrospinal fluid (CSF). Analysis of CSF may exclude infectious,^{[4] [6]} inflammatory,^[4] and neoplastic diseases^[4] affecting the central nervous system. The most common purpose is in suspected meningitis,^[7] since there is no other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded. A lumbar puncture tin also be used to notice whether someone has 'Stage 1' or 'Stage two' Trypanosoma brucei. Young infants usually crave lumbar puncture equally a function of the routine workup for fever without a source. This is due to college rates of meningitis than in older persons. Infants likewise do not reliably show classic symptoms of meningeal irritation (meningismus) like cervix stiffness and headache the way adults do.^[vii] In whatever historic period group, subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension, and many other diagnoses may be supported or excluded with this test. It may also exist used to detect the presence of malignant cells in the CSF, as in carcinomatous meningitis or medulloblastoma. CSF containing less than 10 red blood cells (RBCs)/mm³ constitutes a "negative" tap in the context of a workup for subarachnoid hemorrhage, for example. Taps that are "positive" have an RBC count of 100/mm³ or more than.^[8]

Handling [edit]

Lumbar punctures may too be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularly for spinal anesthesia^[ix] or chemotherapy.

Serial lumbar punctures may be useful in temporary treatment of idiopathic intracranial hypertension (IIH). This disease is characterized by increased pressure of CSF which may crusade headache and permanent loss of vision. While mainstays of treatment are medication, in some cases lumbar puncture performed multiple times may improve symptoms. It is not recommended as a staple of treatment due to discomfort and risk of the procedure, and the short duration of its efficacy.^{[10] [11]}

Additionally, some people with normal pressure hydrocephalus (characterized past urinary incontinence, a changed ability to walk properly, and dementia) receive some relief of symptoms after removal of CSF.^[12]

Contraindications [edit]

Lumbar puncture should non exist performed in the following situations:

• Idiopathic (unidentified cause) increased intracranial force per unit area (ICP)
  • Rationale: lumbar puncture in the presence of raised ICP may cause uncal herniation
  • Exception: therapeutic use of lumbar puncture to reduce ICP, but simply if obstruction (for case in the tertiary ventricle of the brain) has been ruled out
  • Precaution
    • CT encephalon, especially in the post-obit situations
      • Age >65
      • Reduced GCS
      • Recent history of seizure
      • Focal neurological signs
      • Abnormal respiratory pattern
      • Hypertension with bradycardia and deteriorating consciousness
    • Ophthalmoscopy for papilledema
• Bleeding diathesis (relative)
  • Coagulopathy
  • Decreased platelet count (<50 10 10⁹/Fifty)
• Infections
  • Skin infection at puncture site
• Vertebral deformities (scoliosis or kyphosis), in hands of an inexperienced physician.^{[13] [14]}

Adverse effects [edit]

Headache [edit]

Post spinal headache with nausea is the most common complication; it often responds to pain medications and infusion of fluids. It was long taught that this complication can be prevented by strict maintenance of a supine posture for two hours after the successful puncture; this has not been borne out in modern studies involving large numbers of people. Doing the procedure with the person on their side might decrease the risk.^[15] Intravenous caffeine injection is often quite effective in aborting these spinal headaches. A headache that is persistent despite a long menstruation of bedrest and occurs only when sitting upwards may be indicative of a CSF leak from the lumbar puncture site. It can be treated by more bedrest, or past an epidural blood patch, where the person's own blood is injected back into the site of leakage to cause a clot to grade and seal off the leak.^{[ citation needed ]}

The risk of headache and need for analgesia and blood patch is much reduced if "atraumatic" needles are used. This does non touch on the success rate of the procedure in other ways.^{[sixteen] [17]} Although the cost and difficulty are similar, adoption remains low - just 16% ca. 2014.^[18]

Other [edit]

Contact between the side of the lumbar puncture needle and a spinal nerve root tin result in anomalous sensations (paresthesia) in a leg during the procedure; this is harmless and people can be warned about it in advance to minimize their feet if it should occur.

Serious complications of a properly performed lumbar puncture are extremely rare.^[4] They include spinal or epidural bleeding, agglutinative arachnoiditis and trauma to the spinal string^[9] or spinal nervus 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.^[9]

The process is non recommended when epidural infection is present or suspected, when topical infections or dermatological atmospheric condition pose a chance 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 outcome in spinal cord compression or cerebral herniation; others believe that such events are only coincidental in fourth dimension, occurring independently as a result of the same pathology that the lumbar puncture was performed to diagnose. In whatever case, computed tomography of the brain is often performed prior to lumbar puncture if an intracranial mass is suspected.^[xix]

Technique [edit]

Mechanism [edit]

The brain and spinal string are enveloped by a layer of cerebrospinal fluid, 125–150 ml in total (in adults) which acts every bit a shock absorber and provides a medium for the transfer of nutrients and waste products. The majority is produced by the choroid plexus in the brain and circulates from in that location to other areas, before existence reabsorbed into the circulation (predominantly by the arachnoid granulations).^[20]

The cerebrospinal fluid can exist accessed most safely in the lumbar cistern. Beneath the first or second lumbar vertebrae (L1 or L2) the spinal cord terminates (conus medullaris). Nerves continue downward the spine below this, but in a loose bundle of nerve fibers chosen the cauda equina. There is lower run a risk with inserting a needle into the spine at the level of the cauda equina considering these loose fibers move out of the way of the needle without beingness damaged.^[20] The lumbar cistern extends into the sacrum upwards to the S2 vertebra.^[20]

Procedure [edit]

Illustration depicting lumbar puncture (spinal tap)

Spinal needles used in lumbar puncture.

Illustration depicting mutual positions for lumbar puncture procedure.

The person is usually placed on their side (left more commonly than right). The patient bends the cervix so the chin is close to the breast, hunches the dorsum, and brings knees toward the chest. This approximates a fetal position as much as possible. Patients may besides sit on a stool and bend their caput and shoulders frontwards. The surface area around the lower back is prepared using aseptic technique. Once the appropriate location is palpated, local anaesthetic is infiltrated under the pare and then injected along the intended path of the spinal needle. A spinal needle is inserted betwixt the lumbar vertebrae L3/L4, L4/L5^[9] or L5/S1^[9] and pushed in until in that location is a "give" as it enters the lumbar cistern wherein the ligamentum flavum is housed. The needle is again pushed until there is a 2d 'give' that indicates the needle is now past the dura mater. The arachnoid membrane and the dura mater be in flush contact with one some other in the living person's spine due to fluid pressure from CSF in the subarachnoid space pushing the arachnoid membrane out towards the dura. Therefore, in one case the needle has pierced the dura mater it has also traversed the thinner arachnoid membrane. The needle is then in the subarachnoid space. The stylet from the spinal needle is then withdrawn and drops of cerebrospinal fluid are nerveless. The opening force per unit area of the cerebrospinal fluid may be taken during this collection by using a elementary column manometer. The process is ended by withdrawing the needle while placing pressure on the puncture site. The spinal level is and so selected to avoid spinal injuries.^[ix] In the past, the patient would lie on their back for at least six hours and be monitored for signs of neurological problems. At that place is no scientific testify that this provides whatsoever benefit. The technique described is nigh identical to that used in spinal anesthesia, except that spinal anesthesia is more often done with the patient in a seated position.^{[ citation needed ]}

The upright seated position is advantageous in that in that location is less baloney of spinal anatomy which allows for easier withdrawal of fluid. Some practitioners prefer information technology for lumbar puncture in obese patients, where lying on their side would cause a scoliosis and unreliable anatomical landmarks. However, opening pressures are notoriously unreliable when measured in the seated position. Therefore, patients will ideally lie on their side if practitioners demand to measure out opening pressure.^{[ citation needed ]}

Reinsertion of the stylet may subtract the rate of mail lumbar puncture headaches.^[14]

Although not available in all clinical settings, use of ultrasound is helpful for visualizing the interspinous space and assessing the depth of the spine from the skin. Use of ultrasound reduces the number of needle insertions and redirections, and results in college rates of successful lumbar puncture.^[21] If the procedure is difficult, such as in people with spinal deformities such as scoliosis, it tin can likewise be performed under fluoroscopy (under continuous X-ray imaging).^[22]

Children [edit]

In children, a sitting flexed position was as successful as lying on the side with respect to obtaining non-traumatic CSF, CSF for culture, and jail cell count. There was a higher success rate in obtaining CSF in the first attempt in infants younger than 12 months in the sitting flexed position.^[23]

The spine of an baby at the fourth dimension of birth differs from the developed spine. The conus medullaris (bottom of the spinal cord) terminates at the level of L1 in adults, just may range in term neonates (newly built-in babies) from L1–L3 levels.^[24] Information technology is important to insert the spinal needle below the conus medullaris at the L3/L4 or L4/L5 interspinous levels.^[25] With growth of the spine, the conus typically reaches the developed level (L1) by two years of historic period.^[24]

The ligamentum flavum and dura mater are non as thick in infants and children every bit they are in adults. Therefore, it is difficult to appraise when the needle passes through them into the subarachnoid space because the characteristic "pop" or "requite" may exist subtle or nonexistent in the pediatric lumbar puncture. To decrease the chances of inserting the spinal needle too far, some clinicians use the "Cincinnati" method. This method involves removing the stylet of the spinal needle one time the needle has avant-garde through the dermis. Afterward removal of the stylet, the needle is inserted until CSF starts to come out of the needle. Once all of the CSF is collected, the stylet is and then reinserted before removal of the needle.^[25]

Estimation [edit]

Assay of the cerebrospinal fluid generally includes a cell count and decision of the glucose and protein concentrations. The other belittling studies of cerebrospinal fluid are conducted co-ordinate to the diagnostic suspicion.^[iv]

Pressure determination [edit]

Lumbar puncture in a kid suspected of having meningitis.

Increased CSF pressure can bespeak congestive heart failure, cognitive edema, subarachnoid hemorrhage, hypo-osmolality resulting from hemodialysis, meningeal inflammation, purulent meningitis or tuberculous meningitis, hydrocephalus, or pseudotumor cerebri.^[20] In the setting of raised pressure level (or normal force per unit area hydrocephalus, where the pressure is normal but there is excessive CSF), lumbar puncture may be therapeutic.^[20]

Decreased CSF pressure tin indicate complete subarachnoid blockage, leakage of spinal fluid, astringent aridity, hyperosmolality, or circulatory collapse. Significant changes in pressure during the procedure tin signal tumors or spinal blockage resulting in a large pool of CSF, or hydrocephalus associated with large volumes of CSF.^[20]

Jail cell count [edit]

The presence of white claret cells in cerebrospinal fluid is called pleocytosis. A small number of monocytes tin exist normal; the presence of granulocytes is always an abnormal finding. A large number of granulocytes frequently heralds bacterial meningitis. White cells can also indicate reaction to repeated lumbar punctures, reactions to prior injections of medicines or dyes, fundamental nervous system hemorrhage, leukemia, recent epileptic seizure, or a metastatic tumor. When peripheral blood contaminates the withdrawn CSF, a common procedural complication, white claret cells will be present along with erythrocytes, and their ratio volition be the same as that in the peripheral claret.^{[ citation needed ]}

The finding of erythrophagocytosis,^[26] where phagocytosed erythrocytes are observed, signifies haemorrhage into the CSF that preceded the lumbar puncture. Therefore, when erythrocytes are detected in the CSF sample, erythrophagocytosis suggests causes other than a traumatic tap, such as intracranial haemorrhage and haemorrhagic herpetic encephalitis. In which case, further investigations are warranted, including imaging and viral culture.^{[ citation needed ]}

Microbiology [edit]

CSF can be sent to the microbiology lab for various types of smears and cultures to diagnose infections.

• Gram staining may demonstrate gram positive bacteria in bacterial meningitis.^[27]
• Microbiological civilisation is the gilded standard for detecting bacterial meningitis. Bacteria, fungi, and viruses tin all be cultured past using different techniques.
• Polymerase concatenation reaction (PCR) has been a cracking advance in the diagnosis of some types of meningitis, such as meningitis from herpesvirus and enterovirus. It has high sensitivity and specificity for many infections of the CNS, is fast, and can be done with small volumes of CSF. Fifty-fifty though testing is expensive, cost analyses of PCR testing in neonatal patients demonstrated savings via reduced cost of hospitalization.^{[28] [29]}
• 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.^{[ commendation needed ]}
• The India ink test is still used for detection of meningitis caused by Cryptococcus neoformans,^{[30] [31]} just the cryptococcal antigen (CrAg) test has a higher sensitivity.^[32]

Chemistry [edit]

Several substances institute in cerebrospinal fluid are available for diagnostic measurement.

• Glucose is present in the CSF; the level is usually nigh lx% that in the peripheral circulation.^[33] A fingerstick or venipuncture at the time of lumbar puncture may therefore be performed to assess peripheral glucose levels and make up one's mind a predicted CSF glucose value. Decreased glucose levels^[34] can indicate fungal, tuberculous^[35] or pyogenic infections; lymphomas; leukemia spreading to the meninges; meningoencephalitic mumps; or hypoglycemia. A glucose level of less than one third of claret glucose levels in clan with low CSF lactate levels is typical in hereditary CSF glucose transporter deficiency as well known as De Vivo affliction.^[36]
• Increased glucose levels in the fluid tin can indicate diabetes, although the 60% rule however applies.^{[37] [38]}
• Increased levels of glutamine^[39] are often involved with hepatic encephalopathies,^{[twoscore] [41]} Reye's syndrome,^{[42] [43]} hepatic blackout, cirrhosis,^[41] hypercapnia and low.^[44]
• Increased levels of lactate can occur the presence of cancer of the CNS, multiple sclerosis, heritable mitochondrial disease, depression claret pressure, low serum phosphorus, respiratory alkalosis, idiopathic seizures, traumatic brain injury, cerebral ischemia, brain abscess, hydrocephalus, hypocapnia or bacterial meningitis.^[37]
• The enzyme lactate dehydrogenase tin can exist 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.^[45]
• Changes in total poly peptide content of cerebrospinal fluid tin can effect from pathologically increased permeability of the blood-cerebrospinal fluid bulwark,^[46] obstructions of CSF circulation, meningitis, neurosyphilis, brain abscesses, subarachnoid hemorrhage, polio, collagen illness or Guillain–Barré syndrome, leakage of CSF, increases in intracranial pressure, or hyperthyroidism. Very loftier 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. Oligoclonal bands may be detected in CSF but not in serum, suggesting intrathecal antibody production.

Infection	Appearance[47]	WBCs / mm3 [27]	Protein (g/fifty)[27]	Glucose[27]
Normal	Articulate	<5	0.15 to 0.45	> 2/3 of blood glucose
Bacterial	Yellow, turbid	> 1,000 (mostly PMNs)	> 1	Low
Viral	Clear	< 200 (mostly lymphocytes)	Mild increase	Normal or mildly low
Tuberculosis	Xanthous and viscous	Pocket-size increase	Markedly Increased	Decreased
Fungal	Yellowish and gummy	< 50 (more often than not lymphocytes)	Initially normal than increased	Normal or mildly low

History [edit]

Lumbar puncture, early 20th century.

The showtime technique for accessing the dural space was described by the London physician Walter Essex Wynter. In 1889 he adult a crude cutting downward with cannulation in iv patients with tuberculous meningitis. The main purpose was the treatment of raised intracranial pressure rather than for diagnosis.^[48] The technique for needle lumbar puncture was then introduced by the German medico Heinrich Quincke, who credits Wynter with the earlier discovery; he first reported his experiences at an internal medicine briefing in Wiesbaden, Germany, in 1891.^[49] He afterward published a book on the bailiwick.^{[fifty] [51]}

The lumbar puncture process was taken to the Us by Arthur H. Wentworth an assistant professor at the Harvard Medical Schoolhouse, based at Children's Hospital. In 1893 he published a long paper on diagnosing cerebrospinal meningitis by examining spinal fluid.^[52] Notwithstanding, he was criticized by antivivisectionists for having obtained spinal fluid from children. He was acquitted, merely, nevertheless, he was uninvited from the then forming Johns Hopkins School of Medicine, where he would have been the get-go professor of pediatrics.^{[ citation needed ]}

Historically lumbar punctures were also employed in the process of performing a pneumoencephalography, a nowadays obsolete X-ray imaging study of the brain that was performed extensively from the 1920s until the advent of modern non-invasive neuroimaging techniques such as MRI and CT in the 1970s. During this quite painful procedure, CSF was replaced with air or some other gas via the lumbar puncture in order to raise the advent of certain areas of the brain on plain radiographs.

References [edit]

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Further reading [edit]

• Ellenby, MS; Tegtmeyer, M; Lai, S; Braner, DA (28 September 2006). "Lumbar puncture". Videos in clinical medicine. The New England Journal of Medicine. 355 (13): e12. doi:10.1056/NEJMvcm054952. PMID 17005943.

External links [edit]

• Media related to Lumbar puncture at Wikimedia Commons

peacockreste1943.blogspot.com

Source: https://en.wikipedia.org/wiki/Lumbar_puncture

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