Lumbar Puncture - Medical Malpractice Lawyer
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Lumbar Puncture - Overview
A lumbar puncture, also called a spinal tap or LP, can be diagnostic or therapeutic. It is performed under aseptic technique and local anesthesia to make it as painless as possible. The procedure involves inserting a hollow needle into the subarachnoid space so as to get a sampling of fluid from around the spinal cord.
The main diagnostic purpose of a lumbar puncture us to collect cerebrospinal fluid to check for cancer, infections or inflammations around the spinal cord. The main infection is meningitis, an infection of the meninges, which can be life threatening. Another disease looked for in an LP is a subarachnoid hemorrhage, benign intracranial hypertension and hydrocephalus. Spinal taps are often used in infants to rule out fever of unknown origin.
Lumbar punctures can be used for therapeutic reasons. For example, it can be used to inject medications into the spinal cavity. Some of these medications include pain medication in spinal anesthesia and in the use of chemotherapy. LPs can be used as management of increased intracranial pressure as when a person is suffering from cryptococcal meningitis.
There are reasons behind not doing a lumbar puncture. These include the following:
- Increased intracranial pressure of unknown cause
- Bleeding diathesis
- Skin infections at lumbar puncture site
- Abnormal respiratory pattern
- Vertebral deformities like scoliosis or kyphosis
- Hypertension with bradycardia and lowering level of consciousness
When performing an LP, the patient is placed on his or her side or sitting up with the spine bent forward. The patient is curled up into a fetal position as much as possible. The lumbar area is prepped with betadine and anesthetized with local anesthesia. A spinal needle is pushed in until there are two “gives” indicating the ligamentum flavum and the dura mater are penetrated. This automatically pushes through the arachnoid membrane and into the spinal fluid. The needle is then used to collect spinal fluid into several vials to be checked for various things. The opening pressure is sometimes determined before any fluid is taken out. This is done using a manometer. When all the fluid has been collected, the hollow needle is removed and a bandage is applied. The patient must lie flat for 6 hours following the procedure.
The upright position for doing LPs is preferred over the side lying position because there is less distortion of the spinal anatomy and fluid is more easily withdrawn. It is better done on those people who are obese because side lying produces scoliosis in these people. If the stylet must be reintroduced during the procedure, there is an increased rate of headaches after the procedure.
There are several things that go into the analysis of the cerebrospinal fluid. The first is the pressure determination. Increased cerebrospinal fluid pressure is seen in a number of infections, cerebral edema, subarachnoid hemorrhage and many other diseases. If abnormal, it is just one measure that says something abnormal is going on. Decreased CSF can mean a number of things, including severe dehydration.
Cell counts are important. If there are a large amount of granulocytes in the cerebral spinal fluid, it usually means meningitis. It can also mean the person has had a number of spinal taps recently, leukemia, recent seizure or metastatic cancer in the spinal area. If peripheral blood contaminates the CSF, there will be white blood cells and red blood cells both in the fluid. Chewed up erythrocytes means there has been a hemorrhage prior to the spinal tap.
The cerebrospinal fluid can be sent for Gram staining to look for bacterial meningitis. Polymerase chain reaction can be done to diagnose other types of infections of the CSF. There are antibody tests to check for things like Lyme disease and neurosyphilis.
There are chemical test for things like glucose, found decreased in certain diseases and increased in others, particularly diabetes, and glutamine, which is found increased in certain types of encephalitis.
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