COMPLICATIONS OF LUMBAR PUNCTURE
Section snippets
Fluid or Ether?
Before the lumbar puncture procedure could be developed, an understanding of the cerebrospinal fluid (CSF) circulation was necessary. The first written record of the CSF, in the Edwin Smith Surgical Papyrus, is in association with head injury from about seventeenth century B.C. Egypt. In the fifth century B.C. Hippocrates reported the presence of fluid around the brain, which he believed was pathologic. Galen (129–199 A.D.) described the cerebral ventricles, which he concluded were filled with
Brain Masses
Even in the presence of a brain neoplasm, abscess, or hematoma, uncal or tonsillar herniation leading to neurologic deterioration or death is quite uncommon. When a complication occurs, it can be difficult to determine whether the lumbar puncture was responsible if deterioration is not immediate or if the procedure is performed on an obtunded or comatose patient who might have gotten worse or died in a short time anyway.
Lubic and Marotta72 reported a total of 447 lumbar punctures performed on
Characteristics
Post–lumbar puncture headache, which is more precisely termed PDPH, is the most common complication of lumbar puncture, occurring in up to 40 % of patients after diagnostic lumbar puncture.28 The headache begins within 48 hours in about 80 % and within 72 hours in about 90 % of patients.66, 75 The onset can be immediately after the lumbar puncture81 or delayed for as long as 14 days.127 The duration of the headache is less than 5 days in about 80 %,75 although the headache can persist for 12
CRANIAL NEUROPATHIES
Dysfunction of cranial nerves III, IV, V, VI, VII, and VIII have been reported after lumbar puncture.45, 125 The cranial neuropathies, which are usually transient, are presumably due to intracranial hypotension leading to traction on the nerves. In a large series of patients who had spinal anesthetics, 0.4 % reported visual symptoms (including diplopia, blurred vision, spots before the eyes, photophobia, and scintillation), and 0.4 % had auditory complaints (including dizziness, tinnitus,
NERVE ROOT IRRITATION AND LOW BACK PAIN
During lumbar puncture, contact with the sensory roots causing transient electric shocks or dysesthesias is common, reported by 13 % of patients in one series.32 Permanent sensory and motor loss can rarely occur.24 If the procedure is performed at the improper level, the spinal cord may be injured by the needle. Two cases of reflex sympathetic dystrophy after lumbar myelograms have been reported.86
Patients frequently complain of backache (35 % in one study1) for several days after a lumbar
COMPLICATIONS OF USING OR NOT USING THE STYLET
The stylet should always be used on insertion through the skin and the sub cutaneous tissue. Rarely a needle without a stylet may implant a plug of skin, which can grow into an intraspinal epidermoid tumor.80, 103
There are rare reports of nerve complications with both reinserting and not reinserting the stylet before removing the needle. Because a nerve root can rarely herniate through the dura owing to aspiration by the needle during rapid with drawal, the argument can be made that the stylet
INFECTIONS
Lumbar puncture can cause infectious complications as a result of the following: using a contaminated needle (i.e., contamination owing to respiratory drop lets), disseminating skin flora without adequate disinfection of the skin, performing a lumbar puncture when an infection in present in the area (i.e., cellulitis, furunculosis, or epidural abscess), and introducing blood in the subarachnoid space in the presence of bacteremia.40, 45 In patients with CSF leaks, lumbar puncture can reverse
BLEEDING COMPLICATIONS
A variety of bleeding complications may occur after lumbar puncture. Locations include intracranial and spinal subdural hematoma, intracranial and spinal subarachnoid hemorrhage, and spinal epidural hematoma.
SUMMARY
Before the first lumbar puncture, knowledge of the cerebrospinal fluid path ways was essential. Galen's concept that pneuma, a gaseous substance, filled the ventricles was widely believed for 16 centuries until disproven by Cotugno in 1764 and Magendie in 1825. Wynter performed the first lumbar puncture via an incision of the skin and theca in February 1889. Quincke performed the first per cutaneous lumbar puncture in December 1890. Death as a result of lumbar puncture performed on patients
ACKNOWLEDGMENTS
I am grateful to Barbara Leighton, MD, for reviewing the manuscript and her suggestions. I also thank Thomas Brandt, MD, Harvey Carp, MD, Andreas Engelhardt, MD, Michael Serpell, MB BCH, and Wallace Tourtellotte, MD, for discussing their studies with me, and Charles Manner, MD, for discussing laboratory studies for bleeding disorders.
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Address reprint requests to Randolph W. Evans, MD 1200 Binz #1370 Houston, TX 77004
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From the Department of Neurology, University of Texas at Houston Medical School; and Neurology Section, Park Plaza Hospital, Houston, Texas