Before the first lumbar puncture, knowledge of the cerebrospinal fluid pathways was essential. Galen's concept that pneuma, a gaseous substance, filled the ventricles was widely believed for 16 centuries until disproven by Cotugno in 1764 and Magendie in 1825. Wynter performed the first lumbar puncture via an incision of the skin and theca in February 1889. Quincke performed the first percutaneous lumbar puncture in December 1890. Death as a result of lumbar puncture performed on patients with cerebral neoplasms was first reported in 1896. In 1899, Bier reported the first cases of PDPH, including his own, as a complication of his new discovery, spinal anesthesia. Multiple complications can occur after lumbar puncture, including cerebral and spinal herniation, PDPH, cranial neuropathies, nerve root irritation, low back pain, style-associated problems, infectious complications, and bleeding complications Cerebral herniation in adults with lesions causing mass effect follows lumbar puncture in perhaps 1% of cases. Cerebral herniation is a significant risk of lumbar puncture in small children with suspected neurologic symptoms who have focal neurologic findings or are comatose. In a number of settings, lumbar puncture can result in reversible descent of the cerebellar tonsils. Spinal coning can occur in perhaps 14% of patients who undergo lumbar myelography in the presence of a more rostral subarachnoid block. PDPH occurs in up to 40% of patients. There are numerous demographic risk factors, including female gender, the 18 to 30 years age range, lesser body mass index, and a history of prior headaches. The incidence of PDPH is greater the greater the diameter of the lumbar puncture needle. To reduce the incidence of PDPH, when using a Quincke needle, the flat portion or face of the bevel (on the same side of the needle as the notch in the hub for the stylet) should point in the direction of the patient's side, not toward the patient's head or feet. The Whitacre and Sprotte atraumatic needles can significantly reduce the incidence of PDPH. For diagnostic lumbar puncture, the Sprotte 20-gauge or 21-gauge needle may be preferred because of its excellent flow rate and rapid measurement of the opening pressure. For physicians used to the Quincke needle, however, a few lumbar punctures may need to be performed with the Sprotte needle before they feel comfortable. When using the Sprotte and probably the Quincke needle, the stylet should be reinserted and the needle rotated 90 degrees before removing the needle to decrease the incidence of PDPH. Bed rest for up to 24 hours, various body positions, and intake of oral fluids after the lumbar puncture do not reduce the incidence of PDPH. Depending on the persistence and severity, PDPH can be treated with bed rest, oral caffeine and theophylline, intravenous caffeine, and a lumbar EBP. Dysfunction of cranial nerves III, IV, V, VI, VII, and VIII have been reported after lumbar puncture. The most common cause of diplopia is abducens paresis, which follows 0.25% of the procedures. Dizziness and reversible hearing loss are fairly common. During lumbar puncture, contact with the sensory roots causing transient electric shocks or dysesthesias occurs in about 13% of patients. Permanent motor and sensory loss can rarely occur. About 35% of patients complain of low back pain usually lasting for several days. Rarely, lumbar puncture can result in a herniated intervertebral disc. A variety of infectious complications can occur, including bacterial meningitis, discitis, lumbar epidural abscess, and spinal cord abscess. Bacterial meningitis is usually due to spread by droplets from the upper respiratory and oral flora to the needle and then to the CSF. The responsible organisms are usually of the streptoccal species. Bleeding complications include intracranial and spinal subdural hematomas, intracranial and spinal subarachnoid hemorrhages, and spinal epidural hematoma. Traumatic lumbar puncture is usually due to puncture of the radicular vessels that accompany each nerve root along the length of its surface and only rarely from the epidural veins. Thrombocytopenia, bleeding disorders, and anticoagulation are risk factors for spinal hemorrhage.
ASJC Scopus subject areas
- Clinical Neurology