Queckenstedt Test Research Articles

Cerebrospinal fluid pressure dynamics reveal signs of effective spinal canal narrowing in ambiguous spine conditions.

Spinal canal narrowing with consecutive spinal cord compression is considered a key mechanism in degenerative cervical myelopathy (DCM). DCM is a common spine condition associated with progressive neurological disability, and timely decompressive surgery is recommended. However, the clinical and radiological diagnostic workup is often ambiguous, challenging confident proactive treatment recommendations. Cerebrospinal fluid pressure dynamics (CSFP) are altered by spinal canal narrowing. Therefore, we aim to explore the potential value of bedside CSFP assessments for qualitative and quantitative assessment of spinal canal narrowing in DCM. In this prospective case series, seven patients with DCM underwent bedside lumbar puncture with measurement of CSFP dynamics and routine CSF analysis (NCT02170155). The patients were enrolled when standard diagnostic algorithms did not permit a clear treatment decision. Measurements include baseline CSFP, cardiac-driven CSFP peak-to-trough amplitude (CSFPp), and the Queckenstedt's test (firm pressure on jugular veins) in neutral and reclined head position. From the Queckenstedt's test, proxies for craniospinal elastance (i.e., relative pulse pressure coefficient; RPPC-Q) were calculated analogously to infusion testing. CSFP metrics were deemed suspicious of canal narrowing when numbers were lower than the minimum value from a previously tested elderly spine-healthy cohort (N = 14). Mean age was 56 ± 13 years (range, 38–75; 2F); symptom severity was mostly mild to moderate (mean mJOA, 13.5 ± 2.6; range, 9–17). All the patients showed some extent of cervical stenosis in the MRI of unclear significance (5/7 following decompressive cervical spine surgery with an adjacent level or residual stenosis). Baseline CSFP was normal except for one patient (range, 4.7–17.4 mmHg). Normal values were found for CSFPp (0.4–1.3 mmHg) and the Queckenstedt's test in normal head positioning (9.-25.3 mmHg). During reclination, the Queckenstedt's test significantly decreased in one, and CSFPp in another case (>50% compared to normal position). RPPC-Q (0.07–0.19) aligned with lower values from spine-healthy (0.10–0.44). Routine CSF examinations showed mild total protein elevation (mean, 522 ± 108 mg/ml) without further evidence for the disturbed blood brain barrier. Intrathecal CSFP measurements allow discerning disturbed from normal CSFP dynamics in this population. Prospective longitudinal studies should further evaluate the diagnostic utility of CSFP assessments in DCM.

Queckenstedt's Test Affects More than Jugular Venous Congestion in Rat

Jugular venous compression by the Queckenstedt's test (Q-test) increases the intracranial pressure, but the effects of isolated jugular venous congestion are not well known. Intraventricular pressure (IVP) was compared during direct obstruction of the common jugular veins (bilateral CJV clipping) and during external compression of bilateral CJV flows (Q-test) in a rat model. Intracerebroventricular catheters were inserted into the right lateral ventricle of nine male Sprague-Dawley rats (371.1±44.8 g, 82.2±12.0 days old). The initial mean IVP, arterial pressure (MAP), and pulse rate were 2.8±1.3 mmHg, 88.8±12.7 mmHg, and 348.3±69.1 beats/min, respectively. The mean IVP increment and MAP decrement were 6.5±2.5 and 13.5±5.7 mmHg, respectively, during the Q-test, compared to 2.3±1.5 and 7.3±3.8 mmHg, respectively, during bilateral CJV clipping (all p = 0.008). The IVP increment and MAP decrement were greater during the Q-test than during bilateral CJV clipping (p = 0.008 and p = 0.038). Although the Q-test and bilateral CJV clipping showed similar effects, the response with the Q-test was greater. Thus, the Q-test appears to obstruct other collateral cerebral veins in addition to bilateral CJV flows. Since this model revealed significant differences between the manual Q-test and bilateral CJV clipping, the finding should be taken into account in future studies on the Q-test in SD rats.

Confirmation of epidural catheter position by using the epidural Queckenstedt test (E-QST) method

Confirmation of epidural catheter position by using the epidural Queckenstedt test (E-QST) method

Throbbing Pain is Related to Queckenstedt's Test Effect in Migraine Patients

The Queckenstedt's (Q)-test can aggravate headache intensity during migraine attacks (Q-test effect). The objective of this study was to delineate the Q-test effect in patients experiencing migraine attacks. We performed a 30-s Q- and a sham test on 39 patients with acute migraine attacks in both supine and sitting positions. Headache intensities during and 30 s after the Q- or sham tests were recorded on a 0-10 verbal scale. Brushing allodynia (BA) was recorded after using a gauze-brushing test over the patient's face and forearms. The Q- but not the sham test aggravated headache intensity in both sitting and supine positions. The presence of throbbing pain and higher pain intensities was associated with the Q-test effect in the supine position. However, the presence or absence of BA was not correlated. We concluded that the Q-test effect is likely to be related to peripheral sensitization of the meninges but not central sensitization. The Q-test effect may be used as an objective marker for peripheral sensitization.

Continuous monitoring of lower thoracic epidural pressure

Purpose: The aim of this study was to examine whether the epidural pressure (EPIP) can be monitored for a long period of time using the continuous epidural infusion via the lower thorax. Materials and Methods: Twenty-one adult patients undergoing gastrointestinal surgery had an epidural catheter inserted via the lower thoracic interspace. After induction of general anesthesia, continuous infusion of local anesthetic at a rate of 4 to 5 mL/h was applied epidurally. A pressure transducer was connected to the epidural catheter and the EPIP was monitored. During surgery, changes in the EPIP were monitored at 0, 5, and 10 cm H2O of positive end-expiratory pressure (PEEP). On postoperative day 1, 2, and 3, the EPIP was measured in the supine position, the Queckenstedt test, and the 30° head-up position. Results: The EPIP was monitored continuously and stably during surgery and until postoperative day 3, it increased significantly at 5 and 10 cm H2O PEEP, and increased and decreased significantly in the Queckenstedt test and the head-up position, respectively. Conclusion: Continuous epidural infusion at a rate of 4 to 5 mL/h via the lower thorax allows stable monitoring of the EPIP over a long period of time. Copyright © 2000 by W.B. Saunders Company

Oral premedication of cloridine to reduce cerebrospinal pressure in patients with spinal anesthesia

S351 INTRODUCTION: Clonidine, an alpha2-agonist, has been reported to decrease cerebral blood flow [1,2]. The purpose of this study was to examine the effect of oral clonidine on cerebrospinal pressure. METHODS: The study protocol was approved by our Ethical Committee. We studied 40 ASA I or II adult patients scheduled for spinal anesthesia. The Queckenstedt's test was given to all patients to exclude spinal occlusion. They were randomly allocated to two groups. Group 1 (n=20) was the control group given no premedication. Group 2 (n=20) received 0.05 mg/kg of clonidine orally approximately 1 hr before the anesthesia. Each patient was given an intravenous infusion of lactated Ringer's solution 7-10 ml/kg 1 hr before anesthesia. After recording control blood pressure and heart rate, the patient was placed in a lateral recumbent position. After lumbar puncture, cerebrospinal pressure was measured through a 23G needle before the injection of local anesthetics. RESULTS: The mean age, weight and height of the patients were not significantly different between the two groups. The heart rate and mean blood pressure in the operation room and during the lumber puncture were significantly decreased in Group 2 (p < 0.05). Cerebrospinal pressure was significantly lower in Group 2 (p < 0.05). CONCLUSIONS: In this study, cerebrospinal pressure was reduced by oral clonidine administration. We assumed that reduction of cerebrospinal pressure was affected by the cerebral blood flow decreased which was affected by the use of clonidine. The anxiolysis effect of clonidine also supposed to reduce cerebrospinal pressure. We concluded that oral clonidine premedication reduced cerebrospinal pressure and that it is therefore useful for patients with intracranial hypertension. (Figure 1)Figure 1

Clinical and neuroimaging features of Chiari type I malformations with and without associated syringomyelia.

The clinical and neuroimaging characteristics of 22 consecutive patients with Chiari type I malformations were evaluated to investigate the pathogenesis of syrinx formation. All patients underwent magnetic resonance imaging and x-ray tomography before surgery. The electric manometric Queckenstedt test was performed on 16 patients pre- and postoperatively. Syringomyelia was present in 17 patients and absent in five patients. All patients without syringomyelia suffered from foramen magnum compression syndrome, with a wider basal angle, more acute clivo-axial angle, shorter clivus, and more prominent tonsillar ectopia than patients with syringomyelia. Low brain stem position, basilar impression, and beaking of the cervicomedullary junction were also more prominent in patients without syringomyelia. Marked to complete block with the neck in flexed position by Queckenstedt test was present in all patients except one. Patients with Chiari malformation not associated with syringomyelia have more pronounced compression of the brain stem at the foramen magnum. Therefore, despite a block of the cerebrospinal fluid pathway at the foramen magnum, syrinx formation may be prevented by severe compression.

Use of Magnetic Resonance Imaging and Magnetic Resonance Angiography in Diagnosis of Sigmoid Sinus Thrombosis

Magnetic resonance angiography is an established radiologic technique which is rapidly becoming useful in imaging the head and neck. Currently, this imaging modality is important in the diagnosis of sigmoid sinus thrombosis caused by otologic disease. Since the introduction of antibiotic therapy, the percentage of deaths attributed to intracranial complications from otitic disease has decreased from 2.5 to approximately 0.25% of documented deaths. Also, the incidence of sinus thrombosis within this group has decreased, but it is still a serious and potentially lethal condition. Sinus thrombosis is suspected clinically when mastoid disease progresses, with picket fence fever pattern, chills, headaches and signs of papilledema. Definitive diagnosis is necessary before surgical treatment. The Queckenstedt test is unreliable, computed tomography is better suited for demonstrating thrombosis of the sagittal sinus rather than the sigmoid sinus, and conventional angiography (although it provides excellent visualization) has the hazard of ionizing radiation and requires vessel puncture and the use of intraarterial contrast agents. We present two cases of thrombosis of the sigmoid sinus as an intracranial otologic complication which were diagnosed definitively with magnetic resonance imaging and magnetic resonance angiography. The combination of magnetic resonance imaging, which showed the thrombosis displaying abnormal signal intensity, and magnetic resonance angiography, which demonstrated the absence of flow in the sinus, was an ideal diagnostic tool. For both patients, treatment consisted of mastoidectomy, sigmoid sinus decompression and antibiotics.

Significance of positive Queckenstedt test in patients with syringomyelia associated with Arnold-Chiari malformations

Ten patients with syringomyelia associated with Arnold-Chiari Type I malformations were evaluated. In each patient, a manometric Queckenstedt test was performed with the neck in various positions. No patient showed evidence of a block to the flow of cerebrospinal fluid (CSF) with the neck in the extended position; however, all showed a complete CSF block with the neck in a flexed position. Posterior fossa decompression with a C1-2 laminectomy was performed in nine cases, after which Queckenstedt test demonstrated free CSF communication in all nine with the neck in extension, in a neutral position, and in flexion. Postoperative magnetic resonance imaging showed shrinkage of the syrinx in the patients who underwent surgery. It is suggested that obstruction of the CSF pathway at the foramen magnum produced by neck movement is of importance in the formation and progression of a syrinx.

Queckenstedt's test in spinal anaesthesia

Queckenstedt's test in spinal anaesthesia

Clinical recording of pressure on the spinal cord and cauda equina. Part 1: the spinal block infusion test: method and clinical studies.

When an intraspinal expanding lesion causes a spinal block, a segment of the spinal cord or cauda equina will be subjected to general pressure from the surrounding tissue. This spinal block pressure, the spinal equivalent to intracranial pressure, was measured by lumbar infusion of fluid and simultaneous recording of the volume-pressure curve caudal to the block. The point of deviation from or breakthrough of the exponential volume-pressure curve indicated the spinal block pressure. Spinal block pressure of about 500 mm H2O and more could be determined by this method, and, when it was combined with Queckenstedt's test, lower pressures could be assessed as well. In the static (thoracic) part of the spine, spinal block pressure up to the level of arterial blood pressure was recorded. In the dynamic part of the spine, however, spinal block pressure could exceed arterial blood pressure due to external compressive forces during extension of the spine. There was a general tendency for more severe neurological deficits in patients with high spinal block pressure; but the duration of the pressure, additional focal pressure, and spinal cord compared with nerve root compression seemed equally important factors. The recording has implications for diagnosis, positioning of patients for myelography and surgery, selection of high-risk patients for the most appropriate surgical procedure, and detection of postoperative hematoma. There were no complications associated with the recordings.

Diagnostic capabilities of lumbar puncture in patients who have suffered in the past closed brain trauma and neuroinfection

Our task was to find out the possibility of wider use of lumbar puncture for diagnostic purposes and to unify the registration of the data obtained. To do this, we performed the Queckenstedt test in patients with sequelae of closed brain trauma who had no contraindications to lumbar puncture with the study of CSF dynamics (fundus congestion, Bruns syndrome, bulbar syndrome). The following six indicators were recorded: CSF pressure (LD) in the patient's lying position; LD in the sitting position of the patient; maximum LD with Kvekkenstedt's test (after 10 s of continuous compression of the jugular veins); minimum LD at Kvekkenstedt's test (10 s after the termination of compression of the jugular veins); LD after the release of a certain (usually 3-6 ppm) amount of cerebrospinal fluid required for laboratory research; the total amount of released liquor, usually collected in three test tubes - for clinical (protein, cytosis, sediment microscopy), biochemical (sugar, chlorides, calcium, etc.) and serological (Wasserman river, etc.) studies.

Simultaneous cerebral and spinal fluid pressure recordings

Cerebrospinal fluid pulsation is likely to be responsible for the progression of some diseases, and it is differences in pressure which are significant in causing the imposition of energy upon tissues. The normal range of such differences has not been extensively documented. A technique for measuring intracranial and intraspinal pressures simultaneously in erect conscious patients is described. Normally the pressures are in a continual state of pulsation in response to changes in pressure in the arteries and veins. The measurements of CSF pressure fluctuations in response to normal cardiac pulsation, respiratory changes, coughing, Queckenstedt's test, and a variation of Valsalva's manoeuvre have been recorded, and the physiology has been discussed.

Surgery for myelopathy in cervical spondylosis: safety measures and preoperative factors related to outcome.

In 85 patients with myelopathy and cervical spondylosis, Queckenstedt's test was used as a guide in deciding upon laminectomy under local anesthesia or anterior surgery under general anesthesia. Laminectomy was carried out in patients with marked block phenomena. The operations were laminectomy (51), anterior surgery (24), and laminectomy plus anterior surgery (10). None of the patients was made worse as a result of the surgical procedure. Improvement in the legs occurred in 73 patients. Block phenomena and arm symptoms were preoperative factors related to improvement in the legs after surgery. Improvement in the arms occurred in 63 of 73 patients who had such symptoms.

Functional Queckensted's test in rheumatoid atlanto-axial luxation.

Queckenstedt's test was carried out in 15 patients with marked rheumatoid atlanto-axial luxation. The test was done when moving the neck stepwise between flexion and extension, and with the patient in both lateral and sitting positions. The test performed in the sitting position was termed the functional Queckenstedt's test. The flexed position of the neck and the sitting body position, either alone or in combination, were factors contributing to a manometric block. Six more block phenomena were recorded in the sitting compared with the lateral position. As the sensitivity of the test seemed unaffected by body position, this indicated an increased atlanto-axial luxation in the sitting position. This applied to the neutral as well as the flexed position of the neck. There was a fairly good correlation between neurological symptoms and signs and the functional Queckenstedt's test. The use of the test as an aid supplmentary to the clinical and roentgenological findings when deciding on the treatment of patients with rheumatoid atlanto-axial luxation is outlined.

Cerebrospinal fluid pressure changes in response to coughing.

CSF pressure recordings have been taken from the lumbar region and the cisterna magna of 16 patients during coughing in the sitting position. Isolated coughs of low amplitude have been studied. The lumbar pressure waves occur sooner and lower. Thus there is a phase during which the lumbar pressure exceeds the cisternal, followed by one in which the cisternal exceeds the lumbar. These phenomena may be conveniently displayed on a differential trace. The phase during which the cisternal pressure exceeds the lumbar may be protracted. It is suggested that Froin's syndrome, central subarachnoid pouches and syringobulbia may be associated with upward pressure waves. Cough headache, the filling stages of communicating syringomyelia and tonsillar herniation may be associated with valve-like blockage at the foramen magnum which produces craniospinal pressure dissociation by interfering with downward or rebound pulsation. Decompensation of hydrocephalus after birth may be related to pulsation in association with crying; also after removal of a meningocele sac decompensation may be related to the effects of similar pulsation modified by changes in capacitance following operation. The cord destruction of syringomyelia, and the mechanisms which fill spinal subarachnoid cysts may be related to pressure waves directed both upwards and downwards. The merits and limitations of cough impulse as a clinical test for spinal blockage are discussed, and the suggestion is made that after further evaluation they may provide a more sensitive indication of spinal blockage than Queckenstedt's test.

Postural Scintimyelography and Dynamic CSF-Pressure Measurements in Cervical Myelopathy

Postural scintimyelography is a refinement of scintimyelography and in combination with Queckenstedt's test proved to be an exellent screening method for possible space occupying lesions in the cervical subarachnoid space. The results in a material of 96 patients are reported. Agreement between both methods is of high clinical significance.

Postural scintimyelography of the cervical spine (author's transl)

This study discusses the clinical validity of 101 postural scintimyelograms as a screening method for cervical myelopathy. The RIHSA or Ytterbium isotope-examination are not an extra burden to the patient if the radiopharmacon is introduced into the dural sac following Queckenstedt's test. If there is a normal rise and fall of CSF pressure after bilateral jugular compression and postural scintimyelography is judged normal as well, a cervical subarachnoid obstruction may be excluded. If both examinations yield pathological results an obstructive process in the cervical spinal canal is made certain; and in cases of spondylotic myelopathy a positive contrast myelogrpahy may thus be superfluous. If the results of these two examinations are contradictory then further neuroradiolocal studies are indicated.

Dynamics of Intracranial Pressure Changes During the Queckenstedt Test and Valsalva Maneuver: Case Report

Dynamics of Intracranial Pressure Changes During the Queckenstedt Test and Valsalva Maneuver: Case Report

The spinal manometric examination (Queckenstedt's test). The effects of certain factors as seen in a hydraulic model.

✓ Queckenstedt's dynamic manometry has been studied in a model constructed of clinical manometers, spinal needles, and commonly available items. Experiments with the model were made with the system unblocked, partially blocked, and totally blocked in ways to simulate clinical conditions. In clinical manometry what one observes is flow of fluid and its actual pressure. Poiseuille's law is predictive. Impedance to flow is governed by that segment of the system having the smallest cross section, whether it is the pathological block or the spinal needle chosen. If a blocking lesion contains fluid which the rising cerebrospinal fluid pressure can displace (as venous blood), a block may exist on myelography but not on manometry. When, in the presence of partial block, the manometer indication does not fall to the initial pressure but holds up at a new resting pressure, this new pressure probably represents the pressure of the lesion upon the cord and dura. When fluid cannot be displaced from a blocking lesion, as when it is totally solid, no amount of CSF pressure rise produced by jugular compression will overcome the block.