Lumbar Puncture Needle Research Articles

Lumbar puncture for the generalist

ABSTRACTThe safe and successful performance of a lumbar puncture demands a working and yet specific knowledge as well as competency in performance. This review aims to aid understanding of the knowledge framework, the pitfalls and complications of lumbar puncture. It includes special reference to three dimensional relationships, functional anatomy, imaging anatomy, normal variation and living anatomy. A lumbar puncture is a commonly performed procedure for diagnostic and therapeutic purposes. Epidural and spinal anaesthesia, for example, are common in obstetric practice and involve the same technique as a lumbar puncture except for the endpoint of the needle being in the epidural space and subarachnoid space respectively. The procedure is by no means innocuous and some anatomical pitfalls include inability to find the correct entry site for placement of the lumbar puncture needle and lack of awareness of structures in relation to the advancing needle. Headache is the most common complication and it is imp...

Simple method of vocal cord lateralization in bilateral abductor cord paralysis in paediatric patients

Objective: To simplify the procedure of suture lateralization of a vocal cord in children with bilateral abductor cord palsy and to evaluate its results. Methods: Ten tracheostomised infants and children with bilateral abductor cord palsy where there was either minimal or no recovery of vocal cord movement even after 2 years’ observation were taken up for suture lateralization of one vocal cord. In this simplified procedure needles were passed twice through the larynx from one side of neck to the other. The aim was to reduce the microlaryngoscopic or telescopic manipulation inside the small larynx. Two techniques (1 and 2) were used to carry out this procedure. In technique 1 the needle used was one with a slit in the eye situated at its tail end whereas in technique 2 it was a lumbar puncture needle. Patient follow-up ranged from 6 months to 5 years. Results: Intraoperative manipulation inside the larynx was considerably reduced. The technique 2 was even simpler and faster than technique 1. With both techniques the placement of suture was accurate without any knot inside the larynx. All the patients could be decanulated with only minimal stridor on exertion in two and an acceptable voice in all. Conclusions: Suture lateralization of one vocal cord using technique 2 can be tried as the first line of management in cases of bilateral abductor cord palsy requiring lateralization.

Aid for impacted foreign body ear

Foreign body ear is a common problem. When it is impacted it can tax the resorces of each of us. An attempt is made in this paper to make a customable foreign body removal hook using a lumbar puncture needle.

A procedure for direct lumbar puncture in rats

We have set out to establish a fast, simple and innocuous method for repeatedly obtaining cerebrospinal fluid (CSF) samples from rats that are undergoing different experimental procedures or suffering pathological conditions. Here, we report a method that has been optimized to repeatedly collect 30–50 μl of CSF in rats by direct lumbar puncture using a procedure that generally takes 15–20 min to perform and presents very little hazard to the animal. The rats are anaesthetized with isofluorane and placed on a board in such a way that the spine is curved at the level of the L3–L5 vertebrae. After performing a small incision in the skin of the back, a neonatal lumbar puncture needle is introduced into the intrathecal space and CSF is passively collected in the needle cup (facilitating maneuvers are described herein). Moreover, we have further adapted this method to permit the intrathecal delivery of pharmacological agents and cell suspensions. In such experiments, behavioral tests can be conducted 10–15 min after the intrathecal injection and the activity of the implanted cells can be assessed by sampling lumbar CSF at later times.

Abducens palsy after lumbar puncture

Objective: We report the case of a 43-year-old patient with neuralgic shoulder amyotrophy who developed abducens palsy on the left 4 days after diagnostic lumbar puncture (LP), which recovered completely within 4 months. Results: Side effects after spinal tap are due to prolonged spinal fluid leakage and delayed closure of a dural defect causing intracranial hypotension. Downward ‘sagging’ of the brain and traction on cranial nerves may lead to abducens palsy. This case and a review of the literature illustrate the higher risk with the use of large-size traumatic needles in LP for cranial sixth nerve palsies. Conclusion: The presented case emphasizes the use of atraumatic small-size needles for lumbar puncture.

Intralesional cryosurgery using lumbar puncture and/or hypodermic needles for large, bulky, recalcitrant keloids

Keloids are notoriously difficult to treat. A variety of treatment modalities are currently in use, indicating that none is totally satisfactory. Surface cryosurgery is effective for smaller keloids, but not for larger ones. It often results in widespread depigmentation over the surface of the keloids, which may not be desirable, especially in patients with dark skin. To determine the efficacy of intralesional (IL) cryosurgery in large, bulky keloids unresponsive to IL steroids, and to observe the extent of depigmentation and other complications produced by the technique. Twelve patients with large, bulky, symptomatic keloids unresponsive to at least five injections of IL triamcinolone acetonide were included in the study. The age of the patients and the duration of the keloids were in the range 19-50 years and 1-12 years, respectively. The IL cryosurgery device was assembled using a small liquid nitrogen Dewar cylinder, a rubber and a plastic tube taken from a drip-set, adhesive tape, and hypodermic and lumbar puncture needles. The lumbar puncture or injection needle was introduced through the lesion until it appeared at the other side. Liquid nitrogen was then passed through the needle. The freezing time was between 20 and 30 s. The procedure was repeated for a second freeze-thaw cycle in the same session. The patients underwent a minimum of five up to a maximum of 10 sessions of IL cryosurgery. Seven out of 12 patients showed > 75% flattening. Depigmentation was observed along the tracks of the needles in all the patients, which improved during follow-up due to pigment spread from the normally pigmented areas in between. At the end of follow-up, 1-25% of the area remained hypo- or depigmented in four patients, 26-50% in six patients, and 51-75% in the remaining two patients. IL cryosurgery should be the preferred mode of therapy for large, bulky keloids, which are unresponsive to IL steroids.

Use of atraumatic spinal needles among neurologists in the United States.

To evaluate atraumatic spinal needle use among US neurologists. Postdural puncture headache following lumbar puncture may be dramatically reduced through the use of atraumatic pencil-point spinal needles. It was hypothesized that atraumatic spinal needles are rarely used by members of specialties outside of anesthesiology. To determine the extent to which atraumatic spinal needles are currently being used for lumbar puncture in the United States, American neurologists (one group of physicians who regularly perform lumbar punctures) were surveyed. A questionnaire was mailed to all 7798 members of the American Academy of Neurology listed in the membership directory. The questionnaire included items pertaining to age, practice setting, knowledge of pencil-point (atraumatic) spinal needles, and lumbar puncture practices. Only a fraction (2%) of the neurologists surveyed routinely use atraumatic spinal needles. Almost half of the responding neurologists reported having no knowledge of pencil-point spinal needles. Among those who did have knowledge of these new spinal needles, the most common reasons given for not using them were nonavailability and expense. Atraumatic spinal needles for lumbar puncture have been shown to dramatically decrease the risk of postdural puncture headache. Although the use of these needles is standard practice among anesthesiologists, they have not been adopted by other medical specialties. This may lead to unnecessary morbidity among patients undergoing lumbar puncture.

Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture

Objective: To compare the ease of use of atraumatic needles with standard needles for diagnostic lumbar puncture and the incidence of headache after their use.Design: Double blind, randomised controlled trial.Setting:...

Depth of insertion of a lumbar puncture needle

The depth of lumbar puncture needle insertion was recorded in 107 children. Height provided the best guide to the minimum and maximum depths of insertion. Mean depth of insertion (cm)...

Differential dissection of the rat E16 ventral mesencephalon and survival and reinnervation of the 6-OHDA-lesioned striatum by a subset of aldehyde dehydrogenase-positive TH neurons

The retinoic acid-generating enzyme, aldehyde dehydrogenase (AHD), is expressed in a subpopulation of dopaminergic neurons found in the substantia nigra. Using AHD and tyrosine hydroxylase (TH) as immunohistochemical markers, we determined whether differential dissection of the embryonic (E16) ventral mesencephalon (VM) into its lateral and medial portions contributed equally to the number of TH cells surviving transplantation, if grafted AHD/TH neurons reinnervate the host striatum according to their normal projection patterns, and examined the functional recovery caused by the implanted cells as assessed by amphetamine-induced rotation in a 6-OHDA-lesioned model of Parkinson's disease. The embryonic tissue was transplanted as solid pieces injected via a 20-gauge lumbar puncture needle into the center of the deafferented striatum. Groups received either one complete ventral mesencephalic piece (VM), two medial pieces of ventral mesencephalic tissue (MVM), or two lateral pieces of ventral mesencephalic tissue (LVM). Both VM and MVM groups showed a significant decrease in amphetamine-induced rotation over time and, there was no difference in the degree of reduction observed between the two groups. Histological evaluation of the transplants revealed a much larger total number of surviving TH cells in grafts from the VM and MVM groups compared to the LVM group. Surviving AHD/TH neurons were found in all groups. Whereas TH staining of the transplanted striatum displayed a halo of graft-derived fibers all around the transplant and integration of these fibers into the host neuropil, AHD staining showed a preferential reinnervation of the dorsolateral striatum corresponding to the normal projection pattern of AHD/TH neurons. In summary, selective dissection of the embryonic ventral mesencephalon is possible, functional recovery as assessed by amphetamineinduced rotation in animals transplanted with MVM is similar to that seen in animals grafted with VM, and AHD/TH neurons have a selective reinnervation pattern in the PD transplantation paradigm. These findings may have implications for the grafting of fetal mesencephalic tissue in PD patients.

Differential dissection of the rat E16 ventral mesencephalon and survival and reinnervation of the 6-OHDA-lesioned striatum by a subset of aldehyde dehydrogenase-positive TH neurons.

The retinoic acid-generating enzyme, aldehyde dehydrogenase (AHD), is expressed in a subpopulation of dopaminergic neurons found in the substantia nigra. Using AHD and tyrosine hydroxylase (TH) as immunohistochemical markers, we determined whether differential dissection of the embryonic (E16) ventral mesencephalon (VM) into its lateral and medial portions contributed equally to the number of TH cells surviving transplantation, if grafted AHD/TH neurons reinnervate the host striatum according to their normal projection patterns, and examined the functional recovery caused by the implanted cells as assessed by amphetamine-induced rotation in a 6-OHDA-lesioned model of Parkinson's disease. The embryonic tissue was transplanted as solid pieces injected via a 20-gauge lumbar puncture needle into the center of the deafferented striatum. Groups received either one complete ventral mesencephalic piece (VM), two medial pieces of ventral mesencephalic tissue (MVM), or two lateral pieces of ventral mesencephalic tissue (LVM). Both VM and MVM groups showed a significant decrease in amphetamine-induced rotation over time and, there was no difference in the degree of reduction observed between the two groups. Histological evaluation of the transplants revealed a much larger total number of surviving TH cells in grafts from the VM and MVM groups compared to the LVM group. Surviving AHD/TH neurons were found in all groups. Whereas TH staining of the transplanted striatum displayed a halo of graft-derived fibers all around the transplant and integration of these fibers into the host neuropil, AHD staining showed a preferential reinnervation of the dorsolateral striatum corresponding to the normal projection pattern of AHD/TH neurons. In summary, selective dissection of the embryonic ventral mesencephalon is possible, functional recovery as assessed by amphetamine-induced rotation in animals transplanted with MVM is similar to that seen in animals grafted with VM, and AHD/TH neurons have a selective reinnervation pattern in the PD transplantation paradigm. These findings may have implications for the grafting of fetal mesencephalic tissue in PD patients.

Choosing the best needle for diagnostic lumbar puncture: Carson D, Serpell M. Neurology. 1996;47:33–37

Choosing the best needle for diagnostic lumbar puncture: Carson D, Serpell M. Neurology. 1996;47:33–37

Choosing the best needle for diagnostic lumbar puncture.

A new generation of Atraumatic (blunt tipped) needles now exists in addition to the traditional Quincke (cutting tip) needles for LP. We wished to identify the optimal size and type of needle that should be used for this technique. Requirements include rapid and accurate transduction of CSF pressure and adequate flow rate for CSF collection purposes while minimizing headache and other neurologic sequelae. Different types of available Atraumatic and Quincke needles were tested in two models that simulated normal and raised CSF pressures. The flow rates and the time required for an accurate transduction of CSF pressure onto a standard spinal manometer through each needle type was measured. Overall, Atraumatic-tipped needles compared favorably with similarly sized Quincke needles tested. The 20-gauge needles displayed suitable flow and pressure transduction characteristics. Some of the 22-gauge Atraumatic needles rapidly measured CSF pressure, but their flow rates were only suitable for small volume CSF collection. There is extensive literature to support that neurologic sequelae are reduced using Atraumatic needles. Diagnostic LP can be easily and accurately performed by using a large Atraumatic needle with the potential for considerable reduction in post-LP headache and related neurologic sequelae.

First line immunochemotherapy with cisplatin-based protocol by intraperitoneal and intravenous routes in ovarian cancer: technique and results of 82 cases

Objectives: The aim of this study, initiated in 1982, was to determine the feasibility and the interest of a first-line immunochemotherapy delivered by intraperitoneal (i.p.) and intravenous (i.v.) routes combined in ovarian cancer. Study design: Eighty-two naive patients with a common epithelial cancer entered the study from January 1982 to December 1990 (median follow up > 70 months). For i.p. infusion, we used a simple lumbar puncture needle left in situ for < 2 h. The first 18 patients received monthly by i.p. route: Adriamycin (DXR) 40 mg/m 2, Fluorouracil 1000 mg/m 2, Cisplatin (CDDP) 90 mg/m 2, Bleomycin 30 mg — DGZ (extract of vibrio cholerae) 60 mg/m 2. For the remaining 64 patients Aracytin 500 mg/m 2 replaced DXR and the dose of CDDP was more than doubled (200 mg/m 2) thanks to the use of sodium thiosulfate. All 82 patients received Ifosfamid 1300 mg/m 2 intravenously. Results: Local toxicity consisted in one subcutaneous abscess and one bacterial peritonitis out of 1508 abdominal punctures. Stage III turned out to be the most interesting group to evaluate the efficacy of a first-line protocol. In this group 34 out of 47 patients (72.3%) who underwent an initial incomplete surgery were in complete remission (CR) at second-look. Nevertheless, 21 out of the 34 patients in CR relapsed (61.7%) and 14 died (43.2%). Conclusion: These results show the efficacy of our regimen administered i.p., and the safety of the delivery by a simple needle which avoids the complications of the implantable systems. Nevertheless, the usefulness of a systematic second-line chemotherapy (Paclitaxel?), despite a prognosis situation as favorable as a CR at second-look, must be taken into consideration.

The role of nonionic myelography in the diagnosis of lumbar disc herniation.

The accuracy and safety of nonionic myelography, unenhanced computed tomography (CT), and magnetic resonance (MR) in the diagnosis of lumbar disc herniation are reviewed. The comparative costs of these tests are also considered. The accuracy of imaging tests that diagnose disc herniations was established by conducting a Medline search between 1985 and 1992. The morbidity associated with these tests are less formally established from selected articles. Finally, the mediocre reimbursement rates of these tests are reviewed. The evolution of nonionic contrast media from the first to the second generation has been accompanied by a notable decrease in adverse reactions. Although nonionic myelograms are now better tolerated by patients, noninvasive imaging with CT and MR imaging has become as accurate as or more accurate than lumbar myelography, and should replace it as a screening test. Computed tomography may have advantages over MR imaging when issues of availability and cost are considered. In contrast to lumbar myelography, CT myelography may continue to be a useful method for clarifying ambiguous results of noninvasive tests. The morbidity associated with CT myelography can be minimized by using low doses of a nonionic agent, keeping the patient well hydrated, and using a small lumbar puncture needle. The incidence of adverse reactions can be expected to decrease further as new nonionic dimers become clinically available.

Le syndrome post-ponction lombaire

About 30% of lumbar punctures are complicated by the lumbar puncture syndrome the main symptom of which is a characteristically posture-dependent headache (the so-called "spinal headache"), sometimes accompanied by nausea, vomiting and stiff neck. The syndrome usually begins in the days which follow lumbar puncture and subsides within 10 days. The most common pathogenetic theory is that perforation of the dura mater results in CSF leakage responsible for a fall in intrathecal pressure. Treatment of the lumbar puncture syndrome consists of rest in supine position and copious hydration, usually by the oral route. The epidural blood patch technique is seldom used. Prevention relies entirely on the use of small calibre lumbar puncture needles; keeping the patient lying supine after the puncture is a classical recommendation, but its preventive value has not yet been fully demonstrated.

Orientation of Fibers in Human Dorsal Lumbar Dura Mater in Relation to Lumbar Puncture

Longitudinal insertion of a lumbar puncture needle bevel is less likely to cause post-lumbar puncture headache than is transverse insertion. The reason for this has not been entirely clear. We investigated the direction of dural fibers in posterior L3-4 dura mater obtained from three autopsies and tallied it in three orthogonal planes. Under low-power light microscopy the tissue appeared to be composed of lamellae branching irregularly and directed concentrically to the spinal cord. Electron micrographs (x5000) revealed that the lamellae consisted mainly of bundles of collagen fibers that pursued wavy courses in various directions. The lamellae also contained branching elastic fibers, many of which were directed longitudinally. This arrangement of fibers probably minimizes the tendency of a dural puncture hole to gape under tension if the needle bevel is directed longitudinally.

Chemotherapy by the intravenous and intraperitoneal routes combined in ovarian cancer

Intraperitoneal (ip) administration allows delivery of concentrations of cytotoxic drugs to the site of tumor development that could not be attained by the intravenous (iv) route. Rather than leaving ip delivery systems (Tenckhoff catheter, Port à Cath, etc.) in position for several months, with the attendant risk of complications, we prefer to use a simple needle for lumbar puncture and leave it in place between 1 and 2 hr at each infusion of chemotherapy. Results observed at second-look laparotomy in 31 patients with stage III (FIGO) common epithelial carcinoma, treated from January 1980 to December 1986, are reported after six to ten courses of ip and iv chemotherapy combined. In five patients in whom complete surgical excision had been possible, there was still complete remission (CR). In 26 patients in whom initial surgical excision had been incomplete, there was complete remission in 20 (76%). In the other 6 cases, there were small residual masses (incomplete remission), which could readily be excised by the surgeon. Following second-look laparotomy, these 6 patients received ip maintenance chemotherapy for a further 6 months. During follow-up periods of 22 to 105 months (average 45 months), 8 recurrences were observed (4 of them died); 23 of 31 patients are disease free. At 4 years, actuarial survival was 81.5% and actuarial disease-free survival was 66.2%.

Orientation of Fibers in Human Dorsal Lumbar Dura Mater in Relation to Lumbar Puncture

Longitudinal insertion of a lumbar puncture needle bevel is less likely to cause post-lumbar puncture headache than is transverse insertion. The reason for this has not been entirely clear. We investigated the direction of dural fibers in posterior L3-4 dura mater obtained from three autopsies and tallied it in three orthogonal planes. Under low-power light microscopy the tissue appeared to be composed of lamellae branching irregularly and directed concentrically to the spinal cord. Electron micrographs (x5000) revealed that the lamellae consisted mainly of bundles of collagen fibers that pursued wavy courses in various directions. The lamellae also contained branching elastic fibers, many of which were directed longitudinally. This arrangement of fibers probably minimizes the tendency of a dural puncture hole to gape under tension if the needle bevel is directed longitudinally.

Dural Trauma During Lumbar Puncture-Reply

In Reply .—The point raised by Dr de Boer concerning the lack of studies correlating the plane of insertion of the lumbar puncture needle and the occurrence of post–lumbar puncture headaches is well taken. A study of post–lumbar puncture headache that takes into account variables like needle size, plane of insertion of the needle, and patient position is very much needed.