The Worst Spinal Tap
The lumbar puncture is one of my favorite procedures. Over the past 15 years, I reckon I've done hundreds, and I'm rarely unsuccessful. I've performed the procedure on tiny babies, thrashing demented octogenarians, comatose patients on mechanical ventilators, and plenty of healthy young folks. When things go smoothly, the patient hardly even knows it's happening.My favorite part of the procedure is the feel of the needle as it pierces the dura mater, the tough membrane surrounding the spinal canal. The needle, if passed slowly and delicately through the successive layers of skin, fat, and connective tissue, will tell you exactly where you are if you listen to it. There is a little quiet space without resistance right before you reach the dura, called the epidural space. As the needle touches the relatively thick dura and is slowly advanced, it stretches the membrane inward ever so slightly before it passes through with a delicate "pop." Ah, there it is.
One of my more memorable taps was surprisingly uncomplicated. Truthfully, I doubted that I was going to get what I needed that time; I even called our radiologist to check his availability to do the procedure under flouroscopy in case I failed. My patient had taken a drastic turn for the worse and could barely follow commands, and her generous girth made me fear that the 3 1/2" spinal needle would be insufficient to the task at hand. Proper positioning of the patient and identification of the anatomical landmarks are the keys to a successful lumbar puncture, and both aspects of this case were relatively daunting. But once I felt the pop, I knew I was homefree, and I still had a half inch to spare.
As I withdrew the stylet, a nasty turbid yellow fluid spurted out of the end of the needle. Normally, the crystal clear spinal fluid should barely drip out of the end like a leaky faucet. Maybe it was my imagination, but this foul brew actually seemed to make a noise as it initially spewed forth, and I probably jumped back a little bit reflexively. After hooking up the pressure manometer, I turned off the stopcock as the fluid rapidly passed the 45cm mark, afraid that it would overflow out the top of the device. I actually felt a bit sickened as I filled the tubes with this foul omen of death. This liquid would have looked more natural in a bedpan than in these clear plastic laboratory tubes.
For the medicos, the final CSF tally:
WBC 14,000 (normal 0-5)
RBC 140 (normal 0-5)
protein 290 (normal 15-45)
glucose 0 (normal 50-80)
segs 100%
rapid antigen panel positive for pneumococcus
Labels: ER, medical, spinal tap
posted by scalpel at 2:21 PM
14 Comments:
Being terrified of needles myself, I've no idea how patients and doctors manage to go through this procedure. When the emerg doc at my old hospital thought I had an infection in my ankle instead of gout, warned me that if I didn't treat it I might walk funny for life, and said the treatment was to take a needle and push it into the joint - I said "Give me the gout medication".
Doesn't it make you - queasy when it pops through?
As for the labs - yikes! Those are worse than the patient I type up the other night with a creatinine well over 1,000.
I hope everything went well with the patient you had. Or, rather, as well as could be expected.
Ewwww! That poor woman... did she make it? (Or maybe you don't know because she disappeared into the MICU and ED docs don't get regular updates from the inpatient team?) Let us know... we're all worried for her.
Yikes! What would have caused that?
Man. Impressive. I've never seen a true meningitis before.
She is an older diabetic with a pretty bad otitis media. Coincidentally, the second worst-looking spinal fluid I've seen also was an older diabetic woman with otitis media. I've never seen or heard of CSF numbers like these though.
She's currently still hanging in there in the ICU, although now she's on a mechanical ventilator. I've treated several of her relatives over the years, so I've got a bit more of an emotional investment in this case than most. It's interesting how well you get to know some of the frequent flyers. Sometimes that's an impediment to their care, however; a point which I might expand upon in a later post.
Just out of curiosity, what abx are you guys using for it?
Hey scapel just curious and since I'm a med student (1st year second semester) i still know nothing but the normal values you put for the labs confused me.
I thought normal WBC is between 4-11,000. What does (0-5) mean? I know this is a basic question considering some of the other commenters obviously know what u mean but I'm confused. My email is raveen.shenoi@gmail.com
Thanks
we recently treated (unsuccessfully) a young person who developed meningitis secondary to poorly treated strep throat. They died. I wonder if it wasn't a nastier strain of strep as the person had been on an appropriate antibiotic for a couple days but had worsened anyway. The CSF looked like pus. It didn't drip out of the needle, it oozed.
I used the antibiotics recommended by the Sanford Guide (for empiric treatment of meningitis in patients over age 50): Rocephin + Vancomycin + Ampicillin + Decadron. The admitting team discontinued the Ampicillin when Listeria was ruled out.
The normal value for white blood cells in CSF is less than 5 per cubic mm. The normal value for WBC in the serum is 4-10K/cubic mm. Interestingly, the number of WBC in the CSF of this patient (14K/cubic mm)were greater than the number of WBC in the serum (12K/cubic mm).
This morning she is awake, alert, and looking terrific. She wants the ETT out and is communicating with her family. Amazing.
Only an ER doc can understand exactly what you describe as the pinnacle of self-satisfaction during an LP: that subtle but grand "pop" felt only by your fingers as you advance the spinal needle through the dura mater. I tapped an unfortunate young man yesterday who presented with new onset seizures and unresponsiveness. CSF that resembled the consistency and appearance of old fashioned lemonade drained out the spinal needle. WBCs-11,000. It grew out strep pneumoniae today.
This discussion was very interesting to read for me... not a medical student... My 25 year old son presented with a 3 day umremitting and unresponsive severe headache, some fever, and vomiting. I went to the ER with him and his wife. Prior blood work was normal as was a CT scan. I observed his LP. The CSF was clear and dripped - Labs showed an WC of "8" and he was treated with pain medications and IV antibiotics pending the determination of Viral versus Bacterial Menningitis. Interesting note about this, his 29 year old sister (Whom he had contact with 5 days prior to his symptoms) went through the exact same symptoms and tests yesterday. She has a breast fed 6 month old and another girl 2.5 years old - should that be a concern? Thanks for any input!
the pop feels like what we used to call a "swish" in hoops - all net - when you get in with one smooth stick in an HIV+, hep c+, DTer thrashing around trying to bite people, you feel like a matador - hitting the sweet spot (cervical interspace) at risk of your own demise
I am a PT who is treating a 35 year old male for injury to his right knee from repeated "Drop Attacks" i.e. his knee gives way. MRI of knee is normal. He may have developed this after a spinal tap. How is a "Leaky dura" diagnosed? Could orthostatic hypotension be a symptom? He doesn't have the clinical picture I researched for spinal dural fistula. Help!
Hi!
Can someone please explian in detail what layers the needle goes through with a spinal tap. Is it as follows
Skin
Periosteum
Epidural space
Dura mater
???
I'm lost and would really like to know.
Thanks!
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