Incidence of Traumatic Lumbar Puncture

OBJECTIVE: To determine the incidence of traumatic lumbar puncture (LP). METHODS: A retrospective study was conducted at an urban, university tertiary care referral center with 50000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. RESULTS: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). CONCLUSIONS: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital.     

Sonographically Guided Lumbar Puncture in Pediatric Patients

Our aim with this study was to develop a user‐friendly method for pediatric sonographically guided lumbar punctures so that we can visualize intrathecal anatomy, confirm intrathecal injection at the time of injection, and, most importantly, avoid ionizing radiation to a child's already radiosensitive pelvis. Sonographically guided lumbar puncture was prospectively performed in children aged 7 weeks to 16 years. All attempts (n = 9) were successful. We were able to identify relevant anatomy (including the conus in children 10 years and younger), confirm intrathecal injection, visualize intrathecal hematoma, and avoid radiation. Sonography is a promising modality for image‐guided lumbar punctures without radiation in children.     

不同体位对腰穿后头痛的影响

目的 评价不同体位对腰穿后头痛的影响,为临床选择最佳腰穿后体位提供依据。方法 用随机单盲法将符合条件的164例患者分成4组:A组(去枕平卧6h)、B组(平行位头抬高5cm平卧6h)、C组(头低脚高俯卧1h,左右交替侧卧或平卧5h)、D组(头低脚高俯卧1h,左右交替侧卧或平卧2h),观察其在腰穿术后6、24、48、72h头痛发生率、头痛程度、头痛持续时间及不适指标。结果 4组体位头痛发生率分别是23.80％、22.50％、27.50％、19.05％,头痛发生率、头痛程度、持续时间无显著差异(P>0.05);B组舒适率显著低于其他3组(P<0.05)。结论 D组体位为最佳腰穿后体位。     

Pediatric Lumbar Puncture and Cerebrospinal Fluid Analysis

Background

Lumbar puncture (LP) is a commonly performed procedure in pediatrics. Accurate analysis of cerebrospinal fluid (CSF) profile is essential in diagnosing and managing a variety of infectious and inflammatory conditions involving the brain, meninges, and spinal cord. It can also provide useful diagnostic information in the evaluation of possible subarachnoid hemorrhage and demyelinating syndromes, and aid in the diagnosis and management of pseudotumor cerebri.

Objectives

To review anatomic, physiologic, and pathologic aspects of performing pediatric lumbar puncture and CSF analysis.

Discussion

Although still a commonly performed procedure in the outpatient setting, effective vaccines to prevent invasive infection due to Streptococcus pneumoniae and Haemophilus influenzae type b have greatly reduced pediatric bacterial meningitis rates due to these pathogens, resulting in decreased opportunity for physician-trainees to perfect this important skill (among nonneonates) during the 3 years of supervised residency training. Success in performing pediatric LP is augmented by a thorough understanding of medical aspects related to this procedure. This article discusses technical aspects involved in successfully performing a lumbar puncture to obtain CSF, and interpreting a CSF profile in children.

Conclusion

A thorough understanding of anatomic, physiologic, and pathologic considerations regarding performing lumbar puncture and CSF analysis can augment success in diagnosing a variety of potentially serious pediatric conditions.     

Ultrasound-assisted Lumbar Puncture in Pediatric Emergency Medicine

Background

Ultrasound-assisted lumbar puncture in the pediatric emergency medicine setting has not been well established, but ultrasound could serve as a valuable tool in this setting.

Objective

To assess whether ultrasound increases provider confidence in identifying an insertion point for lumbar puncture.

Methods

A feasibility study was conducted using a convenience sample of pediatric emergency patients requiring lumbar puncture. Provider confidence in selecting a needle insertion site for lumbar puncture using ultrasound assistance was compared to provider confidence using traditional landmarks alone. A simple technique using a linear probe is described.

Results

Nineteen patients were included in the study, with the primary end point the mean confidence score (based on a five-point Likert scale) in identifying a needle insertion site prior to and after using ultrasound. Using the Wilcoxon signed-rank test, the mean confidence score was 2.89 with the landmark procedure alone, and 4.79 with ultrasound assistance, yielding an average score difference of 1.90 (95% confidence interval 1.23–2.56; Wilcoxon p < 0.001, paired t-test p < 0.001). Thus, compared to the landmark procedure, the use of ultrasound was associated with a significantly higher average confidence score.

Conclusion

The use of ultrasound in the pediatric emergency setting can be a valuable adjunct with lumbar puncture.     

An MRI Study of Lumbar Puncture Headaches

We studied 11 patients undergoing a routine lumbar puncture to determine if there were cerebrospinal fluid leaks at the puncture site and whether the maximum volume of leakage correlates with a lumbar puncture headache. Patients completed a headache questionnaire before and after the lumbar puncture. Limited magnetic resonance imaging of the lumbar spine was obtained 8 to 36 hours after the lumbar puncture and two patients also had later imaging. In a blinded fashion, the largest diameter of cerebrospinal fluid leakage into the paraspinous area was determined from T2 weighted magnetic resonance images and the maximum possible fluid volume was calculated. Six patients had a small cerebrospinal fluid leakage (< 10 mL), two had a medium leakage (10 to 110 mL), and three had a large leakage (> 110 mL). The volume of cerebrospinal fluid leakage did not corre late with occurrence of a lumbar puncture headache. The study demonstrates that cerebrospinal fluid usually leaks into the paraspinous area after a lumbar puncture, but the volume of escaped fluid does not correlate with a lumbar puncture headache.     

老年患者腰椎穿刺后两种卧位的效果对比

目的探讨提高老年患者腰穿术后舒适且又安全的合适卧位。方法将符合条件的64例老年患者随机分成两组:对照组(34例)患者腰穿术后采取去枕平卧4~6 h;观察组(30例)患者术后6 h内可左右交替侧卧或平卧,但避免坐起、抬高床头。观察两组患者出现头痛、腰背酸痛、皮肤压红及血压升高的情况。结果两组患者头痛的发生率及程度无统计学差异(P>0.05);而观察组患者出现腰背酸痛、皮肤压红的程度及术后4 h和6 h血压升高的例数均低于对照组(P<0.05)。结论老年患者腰穿术后6 h采取行左右交替侧卧或平卧的改良方式,既能保证患者的安全、减少不良反应,又能满足其生理需求,提高舒适度。     

老年患者腰椎穿刺后两种卧位的效果对比

目的探讨提高老年患者腰穿术后舒适且又安全的合适卧位。方法将符合条件的64例老年患者随机分成两组：对照组（34例）患者腰穿术后采取去枕平卧4～6h；观察组（30例）患者术后6h内可左右交替侧卧或平卧，但避免坐起、抬高床头。观察两组患者出现头痛、腰背酸痛、皮肤压红及血压升高的情况。结果两组患者头痛的发生率及程度无统计学差异（P〉0．05）；而观察组患者出现腰背酸痛、皮肤压红的程度及术后4h和6h血压升高的例数均低于对照组（P〈0．05）。结论老年患者腰穿术后6h采取行左右交替侧卧或平卧的改良方式，既能保证患者的安全、减少不良反应，又能满足其生理需求，提高舒适度。     

神经外科患者腰椎穿刺术后最佳卧床时间的循证实践

目的 探讨基于最佳证据的缩短神经外科腰椎穿刺术后卧床休息时间方案的临床实践并评价其效果。方法 采用JBI证据应用模式,检索关于腰椎穿刺术后卧床的相关证据,采用JBI证据预分级及证据推荐级别系统（2014版）进行证据等级及推荐级别的划分,并运用FAME结构从可行性、适宜性、临床意义和有效性4个方面对证据进行评价。将采纳的证据转化为临床审查指标,通过查看护理记录、现场审查和问卷法的方式收集资料。比较证据应用前后腰椎穿刺术后患者的舒适度、头痛和腰背部疼痛率、压疮风险及护士知晓率。结果 证据应用后,腰椎穿刺术后患者舒适度高于证据应用前（P<0.001）;术后头痛及腰背部疼痛率无统计学差异（P>0.05）;压疮风险较证据应用前降低（P=0.005）;6项审查指标中,指标1~2在证据应用前执行率已是100%,其余4项指标证据应用后执行率高于证据应用前,差异均有统计学意义（P<0.001）。结论 将基于循证的最佳证据应用于临床实践,缩短神经外科患者腰椎穿刺术后卧床休息时间,可降低患者不适感,减少并发症的发生,从而提升临床护理质量。     

Unique Case of “Post‐Lumbar Puncture Headache”

Lumbar puncture (LP) is associated with complications that include post‐LP orthostatic headache, local bleeding, and subdural hematoma. We report a unique case of a spontaneous frontal epidural hematoma following a therapeutic lumbar puncture in a patient with a history of idiopathic intracranial hypertension. This case highlights the importance of symptomatology in patients following LPs by revealing a rare intracranial presentation that would be devastating if not discovered promptly and appropriately managed.     

Color Flow Doppler Point of Care Ultrasound to Evaluate Vessels before Infant Lumbar Puncture

Background

Infant lumbar punctures (LPs) are common procedures performed in the emergency department. However, 10% to 35% of these LPs are unsuccessful or grossly bloody, which can lead to increased hospitalization, increased costs, and prolonged exposure to antibiotics or antivirals. Point of care ultrasound (POCUS) may help to surmount the intrinsic causes of LP failure by providing a visual guide of the vascular structures in the needle path before a LP is performed.

Lumbar Puncture First: An Alternative Model for the Investigation of Lone Acute Sudden Headache

Subarachnoid hemorrhage (SAH) is a diagnosis often considered in patients presenting to the ED with acute sudden headaches, but with normal physical examinations. Standard of care today is for these patients to be investigated by noncontrast CT scan followed by lumbar puncture (LP) for negative CTs. However, given that most investigated patients have benign headaches, most of the CT and LP results are normal. The authors studied, by means of a theoretical analysis, the impact of an alternative diagnostic model, in which LP would be the first (and, in most cases, only) diagnostic test for patients suspected of SAH who met lone acute sudden headache (LASH) criteria. Given reasonable assumptions, for every 100 patients investigated, the "LP-first" model would result in 79 to 83 fewer CT scans and only seven to 11 additional LPs, as compared with traditional strategies. Among ED headache patients meeting LASH criteria, the authors believe use of this model could result in more efficient use of resources, minimal additional morbidity, and equal diagnostic accuracy for SAH.     

Improving Bedside Procedures Through the Implementation of Case-Based Simulation and Mastery Learning for Lumbar Puncture Training in Novice Advanced Practice Providers

Lumbar punctures are common bedside procedures. Complications are strongly associated with provider skill. Best practices for procedural training have been well established in the literature, although the practicality of their implementation is often a perceived barrier. Best practices in bedside procedural training were used in a mastery-based lumbar punctures training program for advanced practice providers with no previous lumbar puncture experience at a large academic medical center. After a 3-day training program, all 9 participants demonstrated mastery through evaluation with the Lumbar Puncture Assessment Tool and submitted for independent privileges. Implementing best practices for procedure training is practical, effective, and efficient.     

Postdural Puncture Headache

ABSTRACT

Questions from patients about pain conditions, analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The causes and presentation of postdural headache is described in response to a query from a patient about this syndrome and its management. The normal clinical course and management using a blood patch are discussed.     

Lumbar puncture

Lumbar puncture has been in widespread clinical use for nearly a century. It is used in emergency medicine primarily as a tool for the diagnosis of meningoencephalitis and subarachnoid hemorrhage. The development of computed tomography has changed the position that lumbar puncture has held in the diagnostic sequence of a number of clinical entities. The procedure is contraindicated if there is soft-tissue infection adjacent to the puncture site and if there are findings of increased intracranial pressure due to a mass lesion. Performance in the setting of a coagulopathy may also be hazardous. The most serious potential complication is cerebral herniation. The commonest complication is postlumbar puncture headache, which is due to CSF hypotension resulting from persistent spinal fluid leakage through the meningeal puncture site. Spinal hematoma, diplopia, and intraspinal dermoid tumor formation are less common complications. Meningitis has been found to follow lumbar puncture in children with bacteremia. The lumbar puncture is a useful test for providing information regarding the cellular, chemical, and microbiologic composition of the CSF. Fluid obtained should be evaluated for cell count, Gram's stain, bacterial culture, glucose and protein levels, and other tests as clinically indicated.     

Lumbar Puncture Ordering and Results in the Pediatric Population: A Promising Data Source for Surveillance Systems

Background: The Centers for Disease Control and Prevention is incorporating laboratory data into real-time surveillance systems. When normal patterns of laboratory test orders and results are modeled, aberrations can be detected. Because many test orders are available electronically well before results, atypical patterns of test ordering may signal outbreaks.
Objectives: The authors sought to characterize baseline patterns in the ordering and early results of lumbar punctures, motivated by the possibility of using these data for real-time surveillance for early detection of meningitis or encephalitis outbreaks.
Methods: Retrospective cohorts of pediatric emergency department patients at a single hospital (1993–2003) and from the National Hospital and Ambulatory Medical Care Survey (1992–2000) were used for analysis.
Results: Test ordering exhibits seasonal patterns, with monthly peaks in January and August (p < 0.0001). For the hospital cohort, the rate of cerebrospinal fluid pleocytosis exhibits seasonal patterns (p < 0.0001), with a peak from August to October. This is strongly associated with the rate and pattern of clinical neurologic disease (p < 0.0001). A long-term secular decline in daily test ordering is evident, dropping from 5.3 to 2.9 in the hospital sample, and from 371.8 to 185.3 in the national sample (p < 0.001). The long-term rate of pleocytosis has declined (p < 0.0001), though the yield of testing for pleocytosis has improved (p = 0.0104).
Conclusions: Laboratory test patterns correspond with those of clinical disease and are a promising source of surveillance data. Using such data for real-time monitoring requires specific adjustments for patient age, periodicities, and secular trends.     

McKenzie法结合运动疗法及腰椎牵引治疗腰椎间盘突出症

目的：探讨McKenzie法结合运动疗法及牵引治疗腰椎间盘突出症的临床疗效及其力学效应。方法：90例确诊患有该病的患者随机分为2组各45例,A组采用McKenzie法结合运动疗法及牵引,B组采用中医推拿配合中频电疗及牵引治疗。治疗前后均使用日本矫形外科学会（JOA）下背痛评分标准评分,并进行疗效评价。结果：治疗前2组患者JOA下背痛评分差异无统计学意义;治疗20d后2组JOA评分与治疗前比较均有提高（P〈0．01）,2组间比较,A组明显高于B组（P＜0．05）。临床疗效比较,A组痊愈率及总有效率均明显高于B组（P〈0．05）。结论：McKenzie法结合运动疗法及腰椎牵引治疗腰椎间盘突出症能显著提高康复疗效。     

腰椎穿刺术后两种体位的比较研究

目的 :探讨腰椎穿刺术后两种不同体位的护理并发症发生率。方法 :将3 2 0例首次行腰椎穿刺术的病人随机分为两组 ,观察组病人术后取去枕屈膝平卧位和抬平头侧卧 ,每2h交替更换 1次 ;对照组病人术后取传统的去枕平卧位 ,观察术后病人头痛、腰背痛及皮肤受压情况。结果 :观察组病人术后头痛、腰背痛及皮肤受压的发生率低于对照组 (P <0 .0 1)。结论 :观察组体位护理能显著减少病人术后并发症的发生 ,提高病人的生存质量和促进病人康复。     

过度换气治疗腰椎穿刺术后头痛的临床研究

目的:探讨腰椎穿刺术后头痛的护理方法。方法:通过对56例腰穿剌后头痛患者经颅多普勒观察,发现腰穿后头痛与脑血管扩张有关。采用过度换气方法即让患者平卧位或侧卧位,过度换气3min,每分钟呼吸约40次,于3min后测定PaCO2。结果:有效42例,有效率75%。结论:腰穿后头痛患者采用过度换气方法,可造成轻度碱中毒,使脑血管收缩,纠正代偿性脑血管扩张,缓解头痛。该方法简便易行,见效快,护理中易实施。