Diagnostic Lumbar Puncture Research Articles

CSF IMMUNOPHENOTYPING IN PATIENTS WITH NEUROINFLAMMATORY DISEASE

Introduction Multiple sclerosis (MS) has a presumed autoimmune aetiology involving complex interactions between at risk genotypes and environmental factors. Immune reactivity mediated by CD4+ and CD8+ T-cells in particular is thought to drive disease pathogenesis. As part of a wider research project, we used polychromatic flow cytometry to conduct a high definition analysis of infiltrating T-cell populations in the cerebrospinal fluid (CSF) of patients with neuroinflammatory disease. Methods Patients attending for routine diagnostic lumbar puncture as part of their neuroinflammatory disease work-up at the University Hospital of Wales were consented to participate in this study. Sample collection started in August 2013 and is currently ongoing. In each case, the entire cell population from 10 mL of CSF was stained with a purpose-built panel comprising 13 directly conjugated monoclonal antibodies. Phenotypic analysis was performed using a custom-modified FACS Aria II flow cytometer with FlowJo software. Results Across all patients (n=16), CD4 T-cells (mean=3,548/10 mL) predominated over CD8 T-cells (mean=545/10 mL) in CSF. The majority of CD8+ T cells had an effector memory phenotype with approximately 60% exhibiting a TEMRA phenotype (CD45RA+CCR7−). Discussion These data extend previous immunophenotypic studies and define highly characteristic subsets of memory T-cells in the CSF of patients with neuroinflammatory disease.

Effect of Patient Positioning on Cerebrospinal Fluid Opening Pressure

Prone is the preferred patient position for fluoroscopic-guided lumbar puncture (LP). Normative data for cerebrospinal fluid (CSF) opening pressure (OP) exist for lateral decubitus (LD) positioning only and have not been defined for the prone position. This study compares CSF OP values in the prone and LD positions and examines the effect of body mass index (BMI) on OP. Patients undergoing diagnostic or therapeutic fluoroscopic-guided LP were recruited prospectively at 2 tertiary care centers from 2009 to 2012. Following prone fluoroscopic-guided LP, patients were rolled to the LD position for repeat CSF OP measurement. In addition to comparing the mean OP in each position, the relationships between OP, body position, and BMI were also explored. Fifty-two patients were enrolled. A mean OP difference of 1.2 cm H2O was observed (prone: 26.5 cm H2O; LD: 27.7 cm H2O; P = 0.07). No correlation between CSF OP and BMI was seen in either position. No statistically or clinically significant difference between prone and LD OP was identified. BMI does not appear to affect CSF OP measurement in either position.

Intracranial Hypertension and Intracranial Hypotension Causing Headache in the Same Patient

Intracranial hypertension and intracranial hypotension are on the opposite end of the intracranial pressure spectra. It is extremely uncommon for both to cause headache in the same patient within a span of several days. This report describes a young man with intracranial hypertension who developed a severe excruciating headache due to intracranial hypotension after a diagnostic lumbar puncture. It is paradoxical that lumbar puncture, which is supposed to be a treatment option for patients with idiopathic intracranial hypertension, leads to headache due to intracranial hypotension.

Treatment of post-dural puncture headache using epidural injection of fibrin sealant as an alternative to autologous epidural blood patch (case report)

BackgroundPost dural puncture headache (PDPH) is an iatrogenic cause of patient morbidity in pain management after spinal or epidural anaesthesia, as well as after diagnostic lumbar puncture. Most patients respond to conservative treatment or to epidural blood patch, yet limited options for effective treatment are available for patients who fail these treatments or present with theoretical contraindication. Case reportWe present a case of a patient with previously diagnosed human immunodeficiency virus and hepatitis C, who presented with signs of PDPH, which placed him at a theoretical risk of meningeal seeding of the virus during the blood patching procedure. ConclusionWe successfully treated the post dural puncture headache and avoided the risk of viral seeding of the meninges by using a fibrin sealant.

Cerebrospinal Fluid Mitochondrial DNA

Danger-associated molecular patterns (DAMPs) are nuclear or cytoplasmic proteins that are released from the injured tissues and activate the innate immune system. Mitochondrial DNA (mtDNA) is a novel DAMP that is released into the extracellular milieu subsequent to cell death and injury. We hypothesized that cell death within the central nervous system in children with traumatic brain injury (TBI) would lead to the release of mtDNA into the cerebrospinal fluid (CSF) and has the potential to predict the outcome after trauma. Cerebrospinal fluid was collected from children with severe TBI who required intracranial pressure monitoring with Glasgow Coma Scale (GCS) scores of 8 or less via an externalized ventricular drain. Control CSF was obtained in children without TBI or meningoencephalitis who demonstrated no leukocytes in the diagnostic lumbar puncture. The median age for patients with TBI was 6.3 years, and 62% were male. The common mechanisms of injury included motor vehicle collision (35.8%), followed by falls (21.5%) and inflicted TBI (19%); six children (14.2%) died during their intensive care unit course. The mean CSF mtDNA concentration was 1.10E+05 ± 2.07E+05 and 1.63E+03 ± 1.80E+03 copies/μL in the pediatric TBI and control populations, respectively. Furthermore, the mean CSF mtDNA concentration in pediatric patients who later died or had severe disability was significantly higher than that of the survivors (1.63E+05 ± 2.77E+05 vs. 5.05E+04 ± 6.21E+04 copies/μL) (P < 0.0001). We found a significant correlation between CSF mtDNA and high mobility group box 1, another prototypical DAMP, concentrations (ρ = 0.574, P < 0.05), supporting the notion that both DAMPs are increased in the CSF after TBI. Our data suggest that CSF mtDNA is a novel DAMP in TBI and appears to be a useful biomarker that correlates with neurological outcome after TBI. Further inquiry into the components of mtDNA that modulate the innate immune response will be helpful in understanding the mechanism of local and systemic inflammation after TBI.

O28: Comparison of the language lateralizations suggested by magnetoencephalography and navigated transcranial magnetic stimulation in healthy subjects using a picture naming task

O28: Comparison of the language lateralizations suggested by magnetoencephalography and navigated transcranial magnetic stimulation in healthy subjects using a picture naming task

Sensitivity and specificity of cerebrospinal fluid flow cytometry for the diagnosis of leukemic meningitis in acute lymphoblastic leukemia/lymphoma

The presence of leukemic blasts detected by light microscopy in cerebrospinal fluid (CSF) establishes the diagnosis of leukemic meningitis in acute lymphoblastic leukemia/lymphoma (ALL). Flow cytometry immunophenotyping (FCI) is a very sensitive method that detects a minute number of aberrant cells, and is increasingly performed on CSF samples. We sought to determine the sensitivity and specificity of CSF FCI for the diagnosis of leukemic meningitis in ALL. Between November 2007 and August 2011, 800 CSF samples from 80 patients with ALL were available from diagnostic lumbar punctures (LPs; n = 80), follow-up LPs (n = 687) and at the time of relapse (n = 33). FCI was performed on 267 samples, and only identified aberrant cells in cytologically confirmed cases of leukemic meningitis. A blinded review of all cases with detectable CSF nucleated cells confirmed these findings. We conclude that CSF FCI has a 100% sensitivity and specificity for the detection of lymphoblasts. However, additional studies are needed to define the role this procedure plays in the diagnosis of leukemic meningitis.

(490) Spontaneous Intracranial Hypotension: a cause of postural headache?

Positional headache following dural puncture is well documented. Their occurrence outside of this procedure may go unrecognized or misdiagnosed and may be caused by spontaneous CSF leaks, a phenomenon known as spontaneous intracranial hypotension (SIH). We present a case of a 51 year-old male machine operator with a 6-week history of debilitating positional headache accompanied by blurred vision. Diagnostic lumbar puncture revealed mild leukocytosis with elevated protein and negative cultures, consistent with aseptic meningitis.

Cerebral venous thrombosis in post-lumbar puncture intracranial hypotension: case report and review of literature

The spectrum of presentation of intracranial hypotension is clinically perplexing. We report a case of 31-year-old post-partum woman who underwent an uneventful caesarean section under spinal anesthesia. From the second day of surgery she developed postural headache, the headache lost its postural character after few days. She then developed seizures and ataxic hemiparesis. Magnetic resonance imaging showed features of severe intracranial hypotension in the brain and the spinal cord, and magnetic resonance venography showed cortical vein and partial superior sagittal sinus thrombosis. Prothrombotic (etiological) work-up showed Protein C and S deficiency. She responded to anticoagulation therapy and recovered completely. On review of literature two distinct groups could be identified obstetric and non-obstetric. The non-obstetric group included patients who underwent diagnostic lumbar puncture, intrathecal injection of medications and epidural anesthesia for non-obstetric surgeries. Poor outcome and mortality was noted in non-obstetric group, while obstetric group had an excellent recovery.

Acanthamoeba meningoencephalitis in immunocompetent: A case report and review of literature

A 30-year-old manual laborer from Karnataka, India presented with intermittent low grade fever and diffuse headache for 1 month. On examination, patient had enlarged supraclavicular and cervical lymph nodes. Patient had positive Kernig's sign and neck stiffness. Motor, sensory and cranial nerve examinations were within the normal limits. Abdominal, cardiovascular and chest examination did not yield any positive findings. Contrast enhanced computed tomography head was normal. Patient was suspected to have extrapulmonary tuberculosis. Patient was started on antitubercular drugs. Diagnostic lumbar puncture was performed. Wet mount and Giemsa smear preparation of cerebrospinal fluid (CSF) showed trophozoites suggestive of Acanthamoeba. CSF was cultured onto non-nutrient agar with an overlay of Escherichia coli. Wet mount made from the culture media yielded cysts and trophozoites of Acanthamoeba spp. Patient was diagnosed with Acanthamoeba meningitis and was started on specific therapy with Rifampicin 600 mg once a day, Cotrimoxazole 960 mg twice-a-day and Fluconazole 400 mg once daily for 2 weeks. Patient had a complete recovery and was discharged from the hospital.

Repeat Lumbar Puncture: CSF Lactic Acid Levels are Predictive of Cure with Acute Bacterial Meningitis.

A common clinical problem concerns the utility of repeat lumbar puncture (LP) in adults with acute bacterial meningitis (ABM), e.g., pneumococcal meningitis [1]. An LP is initially done for diagnostic purposes in patients with suspected ABM, i.e., diagnostic lumbar puncture (DLP). A repeat LP (RLP) may be done 1-3 days after the initial DLP, if the patient shows no improvement. If a patient with ABM is not doing well after three days, adequacy of antimicrobial therapy is the main concern. Other reasons for RLP is to detect possible intracranial complications of ABM unrelated to adequacy of therapy [1-2].

Change practice now! Using atraumatic needles to prevent post lumbar puncture headache

Lumbar puncture (LP) is a key diagnostic procedure in medicine. Post lumbar puncture headache (PLPHA) is a well recognized complication of LP. Evidence suggests that using atraumatic needles for diagnostic LP (ATNLP) reduces risk of PLPHA. However, clinicians in Europe and the USA routinely use traumatic needles for diagnostic LP (TNLP). The occurrence of PLPHA following ATNLP and TNLP was compared in a clinical setting. Further, a survey was performed exploring use of ATNLP amongst UK neurologists. Service development study. Patients were followed up 2 and 7 days after LP using blinded telephone assessment. A questionnaire was developed to assess use of ATNLP amongst UK neurologists. Frequency, onset, duration and severity of PLPHA were recorded as were use of analgesia, general practitioner consultations, hospital readmissions, days off work due to PLPHA and cost. Neurologists were asked about their familiarity with, and use of, ATNLP. One hundred and nine participants attending the Royal London Hospital were included, and 74 attendees of the Association of British Neurologists 2012 conference completed an on-site questionnaire. ATNLP reduced the rate of PLPHA (27.1% vs. 60.4%; P < 0.01). In those participants who developed PLPHA symptoms were short lived (mean 50 h vs. 94 h, P = 0.02) and less severe after ATNLP. Use of ATNLP led to significant cost savings. Only one in five UK neurologists regularly use ATNLP stating lack of training and availability of atraumatic needles as main reasons. ATNLP significantly reduces the risk of PLPHA. Training is required 3 to facilitate a change from TNLP to ATNLP amongst clinicians.

Cesarean delivery in a parturient with chronic myeloid leukemia

To the Editor, Leukemia rarely occurs during the course of pregnancy, with a reported incidence of 1:75,000-1,000,000 pregnancies. Chronic leukemias account for only 10% of these cases, with the majority being chronic myeloid leukemia (CML). This disease is characterized by a reciprocal translocation between chromosomes 9 and 22 with the resultant fusion of the breakpoint cluster region (BCR) gene with the Abelson leukemia virus (ABL) gene – ‘‘Philadelphia chromosome’’; t(9;22)(q34;q11). We report a case of newly diagnosed CML in a patient’s third trimester. She had been treated for two weeks with hydroxyurea prior to lower uterine segment Cesarean delivery. At that time, the patient’s white blood cell count was 194.4 9 10 L with 5% myeloblasts in the peripheral blood. General endotracheal anesthesia was administered uneventfully, and a normal healthy baby was delivered uneventfully. Two weeks later, the patient was started on molecular targeted therapy. Both mother and child were doing well after two years of follow-up. One important consideration for choosing general anesthesia in this case was the potential for blast crisis (BC), a major challenge in the management of leukemia. Blast crisis is defined as the presence of a high blast count, 30% blasts cells, in the blood/marrow or, in a small proportion of patients, presence of extramedullary blastic infiltrates in the lymph nodes, skin, soft tissues, serosal surfaces, bone, and gastrointestinal and genitourinary tracts. Although rare, leukemic infiltration of meninges and brain, including nerves, can occur even while on therapy. Development of neurological involvement predicts a poorer prognosis with poorer response to treatment and a three-month median survival after the onset. Chronic myeloid leukemia is routinely diagnosed by an elevated white blood cell count with left shift, frequently with basophilia, and splenomegaly. The presence of BCRABL is confirmed with fluorescence in situ hybridization or with polymerase chain reaction (PCR). Bone marrow aspiration and cytogenetic analysis is mandatory for staging the disease as chronic phase (CP), accelerated, or blastic phase (BP). In comparison, all newly diagnosed patients with acute leukemia are routinely subjected to a spinal tap for prognostication. When circulating blast cells are present in the blood in acute lymphocytic leukemias, it is well documented that a traumatic lumbar puncture (TLP) may introduce leukemic blasts from the systemic circulation into the cerebrospinal fluid (CSF) with a resultant two to threefold higher risk of treatment failure. Accordingly, instituting intrathecal therapy early in the course is part of the treatment protocol in patients who have undergone more than one TLP in the presence of peripheral circulating blast cells. A diagnostic spinal tap is not part of the routine investigations in CML unless there is a clinical suspicion of involvement of the central nervous system. Reports of initiating a BC through a TLP for CML are lacking, and the incidence of diagnostic spinal punctures being performed in CML-CP is also not known. There is a lack of consensus on what constitutes TLP based on CSF rheology because there is no specific threshold for the number of red blood R. Datta, MD (&) Department of Anesthesiology and Critical Care, Army Hospital (Research & Referral) Delhi, Delhi, India e-mail: drrashmidatta@gmail.com

Why should we use atraumatic needles in lumbar puncture?

Diagnostic lumbar puncture is essential to the diagnosis of central nervous system infections, subarachnoid haemorrhage and others neurological diseases. Myeloradicular involvement or life-threatening adverse events due to the procedure are rare, but less severe complications are more frequent. Post-lumbar puncture headache is the most common complication, by spinal fluid leakage due to delayed closure of a dural defect. Therefore, the development of fine needles, with differentiated atraumatic bevel, has contributed to minimize that problem. These generically called atraumatic needles cause less deformation of the dura mater then the Quincke(®) ones. So, why don't we use these atraumatic needles?

Abducens palsy after lumbar drain placement

To study reports of abducens nerve palsy following dural puncture procedures and to discuss possible etiologic theories, treatment, and prognosis. Systematic review of peer-reviewed literature. A systematic literature review was conducted (PubMed, 1950 to September 2011) for cases of sixth cranial nerve palsy following dural puncture procedures. We report a case of abducens nerve palsy following lumbar drain placement for endoscopic trans-sphenoidal pituitary macroadenoma resection. Sixth nerve palsy was noted immediately after surgery. Postoperative computed tomography and magnetic resonance imaging revealed no injury to the nerve or surrounding structures. A systematic literature review conducted for cases of abducens nerve palsy following dural puncture procedures found 22 studies (17 case reports and five case series). Twenty-eight patients with temporary or permanent abducens nerve palsy were reported. Procedures included diagnostic lumbar puncture, spinal anesthesia, intrathecal catheterization, and shunting. Traction and local ischemia due to intracranial hypotension at the petroclival junction were proposed as causes of palsy. Lumbar puncture procedures carry a rare risk of abducens nerve palsy from ischemic or traction injury. Routine use of lumbar drain during endoscopic skull base surgery is not without risk, and need for its placement should be carefully determined. Knowledge of such rare complications is helpful in risk-benefit analysis as endoscopic skull base techniques gain popularity.

Hypothermia Decreases Cerebrospinal Fluid Asymmetric Dimethylarginine Levels in Children With Traumatic Brain Injury

Pathological increases in asymmetric dimethylarginine, an endogenous nitric oxide synthase inhibitor, have been implicated in endothelial dysfunction and vascular diseases. Reduced nitric oxide early after traumatic brain injury may contribute to hypoperfusion. Currently, methods to quantify asymmetric dimethylarginine in the cerebrospinal fluid have not been fully explored. We aimed to develop and validate a method to determine asymmetric dimethylarginine in the cerebrospinal fluid of a pediatric traumatic brain injury population and to use this method to assess the effects of 1) traumatic brain injury and 2) therapeutic hypothermia on this mediator. An ancillary study to a prospective, phase II randomized clinical trial of early hypothermia in a tertiary care pediatric intensive care unit for children with Traumatic brain injury admitted to Children's Hospital of Pittsburgh. None. A UPLC-MS/MS method was developed and validated to quantitate asymmetric dimethylarginine. A total of 56 samples collected over 3 days with injury onset were analyzed from the cerebrospinal fluid of consented therapeutic hypothermia (n = 9) and normothermia (n = 10) children. Children undergoing diagnostic lumbar puncture (n = 5) were enrolled as controls. Asymmetric dimethylarginine was present at a quantifiable level in all samples. Mean asymmetric dimethylarginine levels were significantly increased in normothermic Traumatic brain injury children compared with that in control (0.19 ± 0.08 µmol/L and 0.11 ± 0.02 µmol/L, respectively, p = 0.01), and hypothermic children had significantly reduced mean asymmetric dimethylarginine levels (0.11 ± 0.05 µmol/L) vs. normothermic (p = 0.03) measured on day 3. Patient demographics including age, gender, and nitric oxide levels (measured as nitrite and nitrate using liquid chromatography coupled with Griess reaction) did not significantly differ between normothermia and hypothermia groups. Also, nitric oxide levels did not correlate with asymmetric dimethylarginine concentrations. Asymmetric dimethylarginine levels were significantly increased in the cerebrospinal fluid of traumatic brain injury children. Early hypothermia attenuated this increase. The implications of attenuated asymmetric dimethylarginine on nitric oxide synthases activity and regional cerebral blood flow after traumatic brain injury by therapeutic hypothermia deserve future study.

Céphalées post-brèches méningées et blood-patch : aspects théoriques et pratiques

ObjectiveTo review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH). Data sourcesArticles published to December 2011 were obtained through a search of Medline for the MeSh terms “epidural blood-patch” and “post-dural puncture headache”. Study selectionSix hundred and eighty-two pertinent studies were included and 200 were analysed. Data synthesisResulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the “gold standard” in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24–48hours of onset of headache; the optimum volume of epidural blood appears to be 15–20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.

Delayed cerebral vasospasm and systemic inflammatory response syndrome following intraoperative rupture of cerebral hydatid cyst

Dear Editor, Treatment for symptomatic cerebral hydatid cyst is usually surgical excision. Surgery for cerebral hydatid cyst remains tricky, as inadvertent rupture may cause dissemination and occasionally allergic shock [3]. We report an unusual complication of delayed cerebral vasospasm and systemic inflammatory response syndrome (SIRS) following intraoperative rupture of hydatid cyst. A twenty-two-year old male presented with bifrontal headache for 5 years that worsened over the last 4 months, along with vomiting and left brachio-facial weakness in the last 1 month. Radiology revealed multiloculated large cystic lesion in the right temporal lobe, with the cyst walls partly enhancing (Fig. 1a–d). The lesion was approached through middle temporal gyrus, and multiple white translucent cysts were encountered, adhered to the medial temporal lobe and tentorium. Though the cysts were excised completely, there was some spillage of fluid from the inadvertent rupture (due to adhesions) of the first cyst into the cisternal spaces. Thereafter, 10 % betadine-soaked gauze was put over the operative cavity for 30 min, followed by thorough saline lavage. The cyst fluid showed scolices of echinococcus granulosus with several protoscolices and hooklets. The immediate pos operative period was uneventful. Twenty-four hours later, the patient became drowsy and developed left grade 3/5 hemiparesis with low grade fever. Blood examination showed marked leucocytosis. CT scan of the head showed diffuse brain edema with no infarcts (Fig. 1e– g). In view of new focal neurological deficit after a day, vasospasm was suspected. Cerebral digital subtraction angiography (DSA) revealed diffuse vasospasm of bilateral vertebral, basilar posterior cerebral arteries and focal vasospasm of the right posterior communicating artery. Intraarterial nimodipine was infused in bilateral vertebral and internal carotid arteries that showed radiological improvement of vasospasm (Fig. 1i–l). However, there was no clinical improvement. Diagnostic lumbar puncture and cerebrospinal fluid (CSF) examination revealed cell count of 170/dl (55 % neutrophils) and normal sugar. CSF culture was sterile. His sensorium worsened over the next 2 days, alongwithworsening of hemiparesis to left hemiplegia. High grade fever had set in and leucocytosis persisted. Blood, urine and tracheal aspirate culture did not show any growth. Steroids were administered. On the fourth post-operative day, the patient became hemodynamically unstable. Haematological workup showed pancytopenia. He expired a day later. Repeat CT head showed no new findings (Fig. 1h). Unfortunately, an autopsy was not performed. Cerebral hydatidosis is often encountered in developing countries [3]. The intraparenchymal cysts are usually unilocular cysts and tend to occur in the middle cerebral artery territory. These are non-enhancing spherical cystic lesions without perilesional edema. With progressive neurological deficits and raised intracranial pressure (ICP), surgical excision remains the treatment of choice. A high index of suspicion is necessary as intraoperative cyst rupture is not desirable. The preoperative diagnosis, however, may be missed in case of multiple loculations and wall enhancement as in the index case. Besides, despite all attempts to avoid cyst Not presented at any conference.

Epidural blood patch in a patient with multiple sclerosis: is it safe?

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system resulting in demyelination and axonal injury. Epidural blood patch (EBP) to treat postdural puncture headache (PDPH) in an MS patient may be of concern because of the potential for this to interfere with axonal conduction. Even with normal axons, pressure can interfere with impulse conduction, and it is unknown whether affected axons of the MS patient are particularly vulnerable to the increase in epidural pressure that occurs as a consequence of the EBP. We describe our experience with EBP in an MS patient. While peridural pressure changes were not measured, we attempted to quantify any pressure-induced interference with axonal conduction by measuring changes in somatosensory evoked responses. A 50-yr-old female MS patient required an EBP for a PDPH after a diagnostic lumbar puncture. The first EBP (20 mL autologous blood, L3-4 interspace) was followed by a transient improvement in PDPH and then a worsening with increased lower-extremity weakness. A second EBP was performed (12 mL autologous blood, L3-L4 interspace) with concomitant evoked potential recordings (stimulating electrodes over the left posterior tibial nerve and recording electrodes at CZ-FZ coordinates). Postdural puncture headache symptoms were permanently relieved, and the effects of the EBP on evoked P40 latency responses (39.7 msec and 44.3 msec pre- and post-EBP, respectively) were considered to be physiologically insignificant. A report of EBP to treat PDPH in an MS patient is presented. We postulate that this type of patient may be at risk for impaired conduction of impulses in affected axons due to the increase in pressure produced by epidural injection of blood. Literature review indicates that pressure increases may be reduced by injecting the blood slowly. When EBP is considered in patients with axon conduction deficits, consideration should be given to concomitant monitoring of somatosensory evoked responses to help quantify interference with axonal conduction as a consequence of injection of blood into the epidural space.

Reinsertion of the Stylet does not affect Incidence of Post Dural Puncture Headaches (PDPH) after Spinal Anesthesia

Background and objectives: This study was conducted to investigate the effects of reinsertion of the stylet after a spinal anesthesia procedure on the Post Dural Puncture Headache (PDPH) MethodsWe have enrolled into this study 630 patients who were undergoing elective operations with spinal anesthesia and randomized them to Group A (stylet replacement before needle removal) and Group B (needle removal without stylet replacement). These patients were observed for the duration of 24 hours in the hospital and they were checked for PDPH on the 3rd and the 7th day of the study. ResultsOverall, the PDPH incidence was at 10.8% (68 patients). Thirty-three of these patients (10.5%) who were in Group A (stylet replacement before needle removal) and the other 35 patients (11.1%) who were in Group B (needle removal without stylet replacement) experienced PDPH. There was no significant difference between the two groups with respect to the PDPH. ConclusionsIn contrary to the diagnostic lumbar puncture, reinsertion of the stylet after spinal anesthesia with 25-gauge Quincke needles does not reduce the incidence of PDPH.