Multiple Lumbar Punctures Research Articles

Multiple lumbar punctures aiming to relieve headache results in iatrogenic spinal hematoma: a case report

BackgroundMultiple lumbar punctures have historically been a strategy to relieve headaches associated with idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur. Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis.Case presentationWe report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina syndrome. Multiple lumbar punctures had been the long-term management for the patient’s chronic headaches associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy. Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent 48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma, which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbar-puncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor, it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified.ConclusionsThis case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk–benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base for the long-term benefit of headache relief by repeat lumbar puncture is low.

INTRIGUING LUNG FUNCTION TESTS IN NEUROMUSCULAR WEAKNESS

INTRIGUING LUNG FUNCTION TESTS IN NEUROMUSCULAR WEAKNESS

A CRYPTIC COUGH: A RARE CASE OF CRYPTOCOCCAL PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal pneumonia is an opportunistic fungal infection caused by Cryptococcus neoformans. Many cases initially present in the lungs of those suffering from HIV/AIDS, diabetes, or on chronic immunosuppressants1. We present a case of a 28-year-old woman with no prior medical history who develops a severe case of cryptococcal pneumonia with factors of exposure or risk. CASE PRESENTATION: 28-year-old female with no prior medical history presents in the setting of a productive cough with yellow-brown sputum for 2 weeks that increased with frequency and severity. The patient presented to the emergency department and an initial computed tomography (CT) angiogram of the chest was performed that revealed a significant left lower lobe pneumonia, leading to her admission (Figure 1). The patient was initially started on levofloxacin and linezolid;however, MRSA, blood and sputum cultures, viral panel, HIV, and Covid-19 tests were all negative. A bronchoalveolar lavage was performed which also had negative cultures and cytology. The patient began to develop fevers, and a cryptococcal antigen was tested that was positive. The patient was started on fluconazole IV, and underwent a successful left video-assisted thoracoscopic surgery (VATS) with lower lobe resection, with the pathology revealing non-necrotizing and focal necrotizing granulomas. A GMS stain revealed numerous yeast forms with narrow based budding, morphologically consistent with Cryptococcus neoformans. The patient had a lumbar puncture that was negative for Cryptococcal antigen, and patient was discharged on oral fluconazole. The fungal culture from the BAL was eventually positive for C. neoformans, 2 weeks later. DISCUSSION: Cryptococcal pneumonia of this magnitude is incredibly rare in an immunocompetent patient, especially someone as young as this patient. The patient did not have any exposure nor risk factors, yet required a VATS procedure to confirm the infection. It would be expected with a cryptococcal pneumonia this severe would produce a more systemic response;however, multiple blood cultures and lumbar punctures were negative for any dissemination. The etiology in this case is still unknown, albeit a significant amount of the population has been exposed to Cryptococcus at some point as a child, especially those living in urban areas2. Our patient was fortunate and has responded quite well to fluconazole therapy, and continues to follow up outpatient without complications. CONCLUSIONS: Cryptococcal pneumonia caused by Cryptococcus neoformans is an opportunistic fungal infection, but has the ability to cause severe illness in those immunocompetent. Blood cryptococcal antigen, lumbar puncture, and at times surgical pathology may be required for those with severe illness, and early antifungal therapy may hasten recovery. REFERENCE #1: Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2010;50(3):291-322. doi:10.1086/649858 REFERENCE #2: Goldman DL, Khine H, Abadi J, et al. Serologic evidence for Cryptococcus neoformans infection in early childhood. Pediatrics. 2001;107(5):E66. doi:10.1542/peds.107.5.e66 DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Joseph Kim, source=Web Response No relevant relationships by Christian von Gizycki, source=Web Response No relevant relationships by Momina Zaman, source=Web Response

What happened to cauda equina fibers? Adhesive arachnoiditis

Spinal arachnoiditis may present with low back pain, foot pain, loss of sensation and motor weakness. In addition, some people may have syringomyelia due to impaired flow of cerebrospinal fluid. In the etiology, there are infections, intrathecal steroid or anesthetic injection, trauma, subarachnoid hemorrhage, myelographic contrast media, multiple spinal surgery and lumbar puncture history. The patient’s past treatment history, clinical and MRI examination are important in diagnosis. In this case, we aimed to discuss postoperative adhesive arachnoiditis which caused low back pain, and imaging findings in the light of literature.
 Key words: Adhesive arachnoiditis; Cauda equina; Pain; Anesthesia; Surgery; Imaging; MRI
 Citation: Kara T, Davulcu O, Ates F, Arslan FZ, Sara HI, Akin A. What happened to cauda equina fibers? Adhesive arachnoiditis. Anaesth. pain intensive care 2020;24(5):
 Received: 29 April 2020, Reviewed: 17 June 2020, Accepted: 18 June 2020

S1672 A Case Description of Clostridium Glycolicum and Clostridium Paraputrificum Bacteremia From Complicated Diverticulitis

INTRODUCTION: Clostridium species are anaerobic gram-positive bacilli that can cause a broad range of invasive infections in humans, including bacteremia and intra-abdominal infections. Clostridium glycolicum and Clostridium paraputrificum in particular are infrequent isolates in bacteremia with incidence less than 1%. We describe a rare case of Clostridium paraputrificum and Clostridium glycolicum bacteremia resulting in septic shock secondary to a diverticular abscess. CASE DESCRIPTION/METHODS: A 66-year-old female was admitted with high fevers and seizure like activity. She had a history of Non-Hodgkin’s Lymphoma and breast cancer both of which were confirmed to be in remission. Prior to presentation, her husband had noticed the patient acting unusual and staring to the left with a fixed gaze. On arrival to the ER, she had a rectal temperature of 106.5F and needed vasopressor support. A computer tomography (CT) of the head showed no acute abnormalities and multiple lumbar punctures attempted were unsuccessful. She was empirically treated with levetiracetam/fosphenytoin for possible seizures and vancomycin/meropenem/metronidazole for sepsis. CT of the chest, abdomen and pelvis showed sigmoid diverticulitis with an adjacent small foci of gas which may have been a micro-perforation without fluid collections or pneumoperitoneum. Multiple blood cultures grew Clostridium glycolicum and Clostridium paraputrificum. Subsequent CT of abdomen and pelvis demonstrated a sigmoid diverticulitis with an adjacent abscess measuring 2.4 × 1.3 cm (Figure 1). She was treated with ceftriaxone and metronidazole for 3 weeks given her allergies to penicillin and ciprofloxacin. The patient is planned to have follow up imaging to check for resolution of the abscess. DISCUSSION: Presumably, the source of our patient's Clostridium bacteremia was the complicated diverticulitis given the imaging findings. Most species of Clostridium are considered to be harmless soil saprophytes but there are a few case reports of these strains causing bacteremia. Clostridium bacteremia in humans is usually caused by dissemination of gut colonizing strains due to disturbed host defenses locally or systemically. In our case, sigmoid diverticulitis could be considered a pre-disposing factor but given her past history she will need an outpatient work-up rule out malignancy. This case should heighten the awareness of these particular clostridium species as a clinically important organism and every effort should be made to investigate them further.Figure 1.: Transverse view of a computer tomography of the abdominal/pelvis showing an 2.4 × 1.3 cm abscess (blue arrow) on the anterior wall of the sigmoid colon with reactive thickening of the adjacent urinary bladder wall without evidence of a fistula.

Clinical analysis of 69 cases of non-HIV-related cryptococcal meningitis

The clinical data of 69 patients with non-HIV-related cryptococcal meningitis admitted in the Second Hospital of Hebei Medical University from January 2013 to May 2019 were analyzed retrospectively.The main presentations of 69 patients are headache,fever,nausea,vomiting, visual impairment, hearing damage.Among them, 36 cases (52%) had underlying diseases, 30 cases (43%) were misdiagnosed, and 38 cases (55%) were complicated with high intracranial pressure. Cerebrospinal fluid examination showed that leukocytes increased in 47 cases, protein increased in 55 cases, chloride decreased in 41 cases, glucose decreased in 34 cases. The imaging findings were cerebral ischemia, hydrocephalus, meningeal or cerebral parenchyma enhancement. During the induction period, 63 cases were treated with combined antifungal drugs and 6 cases were treated with single antifungal drugs. The clinical symptoms were improved in 54 cases, 9 cases were discharged automatically and 6 cases died. The clinical manifestations, routine and biochemical examination of cerebrospinal fluid, imaging findings are not specific for patients with non-HIV-related cryptococcal meningitis.So early and multiple lumbar puncture should be performed to find etiological evidence to reduce misdiagnosis. The combination of antifungal drugs during the induction period is safe and effective. Key words: Meningitis,cryptococcal; Antifungal agents; Intracranial pressure; Neurosurgical procedures

Characterising the patient experience of diagnostic lumbar puncture in idiopathic intracranial hypertension: a cross-sectional online survey

ObjectivesPatients with idiopathic intracranial hypertension (IIH) usually require multiple lumbar punctures (LPs) during the course of their disease, and often report significant morbidity associated with the procedure. The aim of...

Safe Use of Low–Molecular-weight Heparin in Pediatric Acute Lymphoblastic Leukemia and Lymphoma Around Lumbar Punctures

Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.

P14.24 Are lateral cervical punctures under-utilized?

OBJECTIVE: To investigate the safety and utility of fluoroscopy guided lateral cervical punctures in current neuro-oncologic practice. BACKGROUND: CSF examination is indicated in various neurological disorders including infection, inflammation, and malignancy. Suspicion of leptomeningeal metastases may require multiple lumbar punctures before a definitive diagnosis is reached. Despite multiple lumbar punctures, a diagnosis oftentimes remains elusive. Although the classic cisternal puncture is associated with morbid risks of medullary hemorrhage, fluoroscopy guided lateral cervical puncture has been noted to be safe alternative in obtaining CSF from a high cervical level. Evidence for the utility of cervical puncture after non-diagnostic lumbar punctures remains lacking. METHODS: Single institution retrospective review of fluoroscopy guided lateral cervical punctures performed at Memorial Sloan Kettering Cancer Center from 12/2009 to 1/2016. Results: CSF samples were obtained from 3193 patients between 12/2009 and 1/2016. Fluoroscopy guided lateral cervical puncture was used to obtain CSF from 52 of these patients. Previous lumbar puncture was non-diagnostic in 37 patients. In 15 patients, no prior lumbar puncture was done. Fluoroscopy guided lateral cervical punctures were performed for both therapeutic (n=2) and diagnostic (n=50) indications. Diagnostic lateral cervical punctures were undertaken in 50 patients to evaluate suspected leptomeningeal metastases (n=47) and CNS infection (n=3). Analysis of CSF from these cervical punctures altered clinical management in 15 patients (32%): 10 began chemotherapy, 1 received IVIG for confirmed paraneoplastic syndrome, CNS infection was ruled out in 2 patients; 2 others were treated for confirmed CNS infections. In 5 out of 37 patients with prior non-diagnostic lumbar punctures, leptomeningeal metastasis was diagnosed by subsequent cervical punctures. There were no immediate or delayed complications related to the fluoroscopy guided lateral cervical puncture procedures. Conclusions: Fluoroscopy guided lateral cervical puncture is both diagnostically and therapeutically useful in both malignant and non-malignant CNS disease. The procedure is well-tolerated and can alter clinical management. Fluoroscopy guided lateral cervical puncture should be considered in patients for whom LP is contraindicated or non-diagnostic.

Use of an Intrathecal Catheter for Analgesia, Anesthesia, and Therapy in an Obstetric Patient With Pseudotumor Cerebri Syndrome

(A A Case Rep. 2016;6:160–162) In this case report, a 32-year-old primigravida woman with a history of idiopathic intracranial hypertension (IIH) presented to the labor and delivery suite at 40 weeks gestation in active labor and with pseudotumor cerebri syndrome (PTCS). PTCS, which includes IIH, is a rare disorder mainly of obese women of childbearing age, characterized by increased intracranial pressure in the absence of a space-occupying lesion, ventriculomegaly, or abnormal cerebrospinal fluid (CSF) composition. Symptoms include headache, pulsatile tinnitus, back pain, dizziness, photophobia, neck pain, cognitive dysfunction, radicular pain, diplopia, and in some cases, permanent vision loss. This patient was diagnosed with IIH at age 14 and was treated with multiple lumbar punctures and diuretics until age 18 years. She was then asymptomatic until 23 years of age, at which time she had a recurrence and resumed diuretic therapy until her pregnancy.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Pleocytosis in cerebrospinal fluid following multiple lumbar punctures in healthy volunteers

Pleocytosis in cerebrospinal fluid following multiple lumbar punctures in healthy volunteers

Infiltrative lymphomatous optic neuropathy in non-Hodgkin lymphoma

We report a 67-year-old man with non-Hodgkin lymphoma who presented with fluctuating visual loss which responded partially to steroid treatment. Multiple lumbar punctures did not show lymphoblastic cells and multiple MRI did not show any central nervous system disease except for isolated optic nerve enhancement. A fundus examination revealed combined arterial and venous occlusion and optic disc swelling. Due to conflicts between the examinations and investigations, there was a reluctance to initiate radiotherapy until progressive changes involving both eyes occurred. The man died 8months after he was diagnosed with lymphoma. A post mortem optic nerve biopsy showed lymphomatous infiltration, confirming that the initial suspicion based on the clinical findings was correct.

Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy.

Post-lumbar puncture headaches (PLPHs) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures, placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPHs in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty-four articles were deemed appropriate for use and were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions used to treat PLPHs once they occur. There is a need for additional, pediatric-specific studies to further examine the issue of PLPH prevention and treatment.

Safe lumbar puncture under analgo-sedation in children with acute lymphoblastic leukemia

Children with acute lymphoblastic leukemia (ALL) undergo multiple lumbar punctures (LPs) during their course of treatment for diagnostic and therapeutic purposes. LP is a stressful and painful procedure, affecting the quality of life of these children. Procedural analgo-sedation might improve the child's comfort and prevent the child's movements, reducing the risk of traumatic lumbar puncture with blasts (TLP+), mainly at diagnosis, when higher numbers of blast cells are circulating in the peripheral blood. The aim of this study was to evaluate the safety and efficacy of procedural analgo-sedation in children with ALL. From September 2006 to November 2008, we performed a total of 252 lumbar punctures under deep sedation with propofol and ketamine in 25 children with ALL treated at our division. During the procedures, vital parameters were monitored and side effects were recorded. The efficacy of deep sedation was evaluated using Ramsay and Children's Hospital Eastern Ontario Pain scales. Cerebrospinal fluid was collected for chemical and cytological examinations. In all patients a satisfactory sedation and analgesia were achieved. The evaluation of vital parameters did not show any significant variation compared to baseline values. No side effects were recorded. Only 3 (1.2 %) of 252 lumbar punctures resulted in traumatic effects. To strongly improve comfort and quality of life of children with ALL and reduce the risk of TLP+ mainly at diagnosis, we recommend performing the lumbar punctures under analgo-sedation because it is a safe and effective procedure.

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Case Reports: Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a condition in which anti-NMDA receptor antibodies cause severe neurological disorders. The condition usually requires transfer to the intensive care unit and prolonged ventilatory support. There are five stages: prodromal phase, psychotic phase, unresponsive phase, hyperkinetic phase, and gradual recovery phase. We report a case of a young man with severe agitation, requiring extremely large amounts of sedation with an initial unknown diagnosis. The patient initially presented with confusion to an outside hospital; he was diagnosed with and treated for seizures. One week later, he presented to an outside hospital with lower extremity weakness and further confusion and agitation, requiring high amounts of sedation and intubation. He was transferred to our institution for further work-up of his fevers, delirium, and agitation. MRI was unrevealing and EEG demonstrated severe diffuse encephalopathy without active seizures. Multiple lumbar punctures were performed with a bland CSF. Empiric antibiotics were discontinued. A variety of sedative cocktails were attempted without yielding any success for managing his extreme agitation. Without a definitive cause, it appeared that the patient would be subjected to on-going mechanical ventilation and combinations of high amounts of sedatives. However, final CSF findings revealed positive NMDA receptor antibody. The patient then underwent tests to evaluate for possible source of neoplasm. The ultrasound of the testicles and PET scan were both negative for cancer. He was placed on steroids and had several rounds of plasmapheresis. Due to minimal improvement, the patient was started on Rituximab and Cyclophosphamide. Agitation subsided and the patient was weaned off the ventilator. He began some rehabilitation in the hospital and was successfully discharged to the LTAC. This is a case of how severe agitation was not due to poor management with sedation but required diligent work-up to diagnosing a treatable condition. Anti-NMDA receptor encephalitis is an emerging diagnosis that should be considered in cases of psychosis and delirium, particularly in the ICU setting.

Iatrogenic Spinal Epidermoid Cyst After Lumbar Puncture Using Needles with Stylet

Iatrogenic spinal epidermoid tumors are extremely rare and may be caused by implanted skin fragments in the spinal canal, most commonly due to lumbar punctures using hollow needles without a stylet. The authors report for the first time an iatrogenic spinal epidermoid tumor that developed 26 months after several lumbar punctures, performed using disposable spinal needles with stylet, in an 8-year-old boy with persistent lower back pain. The authors hypothesize that an ill-fitting stylet compounded by multiple therapeutic lumbar punctures and young age as possible risk factors for the development of the tumor in the present case. A total excision of the tumor with laminectomy yielded good symptomatic recovery.

Keeping an open mind about meningitis: a case report of carcinomatous meningitis

Carcinomatous meningitis is defined as leptomeningeal infiltration by malignant cells. A case of carcinomatous meningitis, originally diagnosed as viral meningitis, is presented here to highlight the importance of maintaining a broad differential diagnosis in patients with evidence of meningeal irritation. Clinical and laboratory clues that suggest a diagnosis of carcinomatous meningitis in a patient with meningeal irritation include the presence and type of underlying malignancy (more common with breast cancer, lung cancer, and melanoma), absence of fever, presence of radicular pain, evidence of both cranial and spinal involvement, consistent cerebrospinal fluid (CSF) findings (increased opening pressure, elevated protein concentration, decreased glucose, increased white cell count), and supportive neuroimaging. Diagnosis is based on positive CSF cytology results, which may require multiple lumbar puncture procedures to obtain. For patients with a known primary malignancy who present to the emergency department with symptoms and/or signs of meningeal irritation, carcinomatous meningitis should be included in the differential diagnosis.

Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.

Idiopathic Intracranial Hypertension in Pregnancy Treated with Serial Lumbar Punctures

Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure with normal CSF composi-tion and no evidence of hydrocephalus or mass lesion. We describe the anesthetic management of a parturient with IIH who required multiple lumbar punctures during pregnancy and delivery secondary to worsening neurological symp-toms.