Lidocaine necessary for lumbar puncture?

[Angry Birds]

Lidocaine often messes up my landmarks for LP. Everything gets too squishy and I can't repalpalpate as well for spinous processes to make sure I'm dead center. What are your thoughts on Versed +/- Fentanyl and just using the spinal needle without local? Crazy? Cruel?

EDIT: OK everyone has answered unanimously on this one: Yes, it is crazy and cruel not to give Lido.

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[Zebra Hunter]

Use a surgical pen to mark then, or just go where you placed the lidocaine, or just go in blindly and just tap down the vertabrae until you find the space, or use the ultrasound guided approach.

 

[deleted497653]

One of my attendings when I was a second year resident told me getting good anesthetic is half the battle for a successful lumbar puncture. Mark site with a sterile pen then anesthetize and be generous. It really makes a big difference. I don't think giving them iv pain meds works as well and would consider it below average care.

 

[exsanguination]

Use topical aesthetics as well

 

[RustedFox]

I modestly sedate all my LPs with a touch of fentanyl/versed. Less anxiety = better positioning and better success rates.

 

[Robotic Wis-Hipple]

So I browse your guys forum out of curiosity and for the purpose of familiarizing myself with common acute acute management scenarios. I'm anesthesia, so take this however you wish.

I 100% would use local, it makes neuraxial intervention much more comfortable and increases patient cooperability imo.

In those thin pts I make a skin wheal then advance my needle thru the wheal and gain tactile feedback of interspinous ligament. I typically inject in multiple passes at different angles to imitate potential changes in spinal/touhy angle of attack.

In those pts that are larger, and landmarks may be difficult to assess, I definitely use local, much the same as above only in addition I use the local needle essentially as a finder needle if I hit spinous process etc. In order to maintain the location of my insertion point I often hub the needle and use pressure to create a small circular skin dimple that assists in keeping me focused on location of pt moves etc.

 

[shookwell]

I modestly sedate all my LPs with a touch of fentanyl/versed. Less anxiety = better positioning and better success rates.

I do this too. I usually use oral or intranasal midazolam, especially for kids, so I don't have to put in an IV.

I also sometimes use low dose (30-40mg for adult) ketamine before minor procedures.

 

[Tiger26]

If someone didn't use lido on me or a family member, I'd go to a different hospital. I frequently have patient's tell me they couldn't feel a thing after the initial poke for lido, of which I routinely use 4-6 cc. I've done them on plenty of intubated patients, but I really can't remember the last time I've had to sedate anyone (including kids) aside from maybe some intranasal versed.

The things that have really improved my LPs are:
1) Positioning: almost always sitting up
2) When you feel spinous land marks, do it with your index and middle finger with the spinous process in between the two. Most people palpate just the spinous process with one finger and then end up poking lateral. Instead of feeling for the middle of the spinous process, try to feel the edges of it. It sounds crazy, but makes a huge difference.
3) Grab a sharpie (the standard skin markers wash away with skin prep). I mark the entire spinous process line in the lower back and the iliac crests

 

[Janders]

I basically say DITTO to the post above.

I use a lot of lido. I'll bring a second bottle with me.
I do them sitting up.
I haven't used sedation for an LP in years.
People who've had LPs before compliment me and say they are shocked how little it hurt.
I'm not that good, I just very liberally use lidocaine fanned out slowly in all directions, and I give it 2 minutes to set up.
Most of my lido is going 1+ cm deep. At the skin use just need a little wheal. You don't mess your palpation up this way...

 

[emergentmd]

I have never given anything to sedate during LPs. Mark the area, sterilize field, Go where mark is and you should be good. If you don't hit bone immediately, you are usually good.

 

[WilcoWorld]

The 3 P's of procedural success:

Pain control.
Positioning (of the patient).
Positioning (of the proceduralist).

Yes to Janders' and Tiger's posts above. I would add that taking the time to get your self in a good position with all your equipment just where you're going to want it to be when you need it pays big dividends on first pass success.

 

[Zebra Hunter]

I feel like the people saying they never use sedation for an LP are clearly not doing LPs on everyone that needs one. The encephalopathic individual who is agitated and mildly to moderately combative is not going to sit still for an LP. I feel like this is a third or fourth of the patients I do an LP on.

 

[southerndoc]

We had to do LP's in Zambia without lidocaine ("lignocaine" as it's called there). No way I would do that in the US like that. It's not a painless procedure.

 

[Alvarez13]

Lidocaine is all that's needed. For the fatties, sitting up and US greatly improves chances of success.

 

[Old Grunt]

I use ketamine on pediatrics for an LP. Otherwise, I use local for adults. Generally lidocaine with epi to try and reduce traumatic taps. I sit them up, palpate the interspace and use the needle cap to make an indent or just keep my thumb there, make a wheal and then use the local needle as a finder needle and use the spinal needle through the same needle mark.

 

[sum dude]

Yes. If you don't think so, have someone inject a needle into your back, and see how it feels. Just mark the landmarks with a surgical pen if it's a big deal (i personally smudge the iodine at the two spinous processes and go inbetween the two smudges.
If they're normal, I give a small pre-dose of Fentanyl. If they're crazy, I give them Ativan. I'd probably give Angry Birds Ativan, b/c they think you don't need lido for an LP

 

[deleted59964]

excuse me for crashing your forum ... i'm an aussie anaesthetist - i usually hang out in the anaesthesiology forum, but the political discussion there is getting me down.

I do spinals rather than LPs obviously -- but often need to get them in a time critical manner (obstetrics)
my advice for whatever it's worth.

-- position the patient carefully, assemble all your equipment so it is in easy reach of your dominant hand
-- push hard (really hard in fatties) with your non dominant hand to palpate the spinous processes and intervertebral space in the midline
-- once you've got your space, don't move your non dominant hand AT ALL
-- put some local in, and use it as a seeker for bone if necessary. withdraw your local needle and set aside, while NOT moving your non dominant hand.
-- put an introducer needle in the same spot, then a 25g pencil point spinal needle - not some friggin harpoon (unless they're old and then it doesn't matter)

if you don't move your non dominant hand it doesn't matter if you use a truck load of local.
i never give sedation for a spinal, but i do use ketamine sometimes to position patients with #NOF laterally for spinals -- works fine
kids - can't help you there.

 

[n2b8me]

I am definitely on the use lots of lidocaine side. I do start by marking 2 vertical lines on either side of the spinous process so I can see where the center is. I also bring a second bottle with me (lido+epi) and I usually use like 8-10cc. it does make a large wheal. I spend a couple of minutes doing "back massage" on the area to spread out the wheal and palpate the bones again - it also lets the anesthesia set up. usually people only feel the small pinch when it punctures the dura. Never with IV meds, Always sitting up.

 

[RNR]

Yes - use lidocaine.

I almost never use sedation to LP, occasionally a dose of midazolam.

I don't LP nearly as many people as I did in residency, and with the addition of shared decision making for low probability patients - many patients refuse LP's.

I did have a CTH neg, LP + true SAH patient in the last week though...

 

[BoardingDoc]

I did have a CTH neg, LP + true SAH patient in the last week though...

How many hours passed between onset of their HA and the time they got their NCHCT?

 

[mauricekenter]

1: sit the patient up unless you need opening pressure.

2: inject lidocaine about 10 minutes before doing the LP. I always ask the patient how painful the procedure was on a scale of 1-10 and usually get 1-2s after waiting longer on the lidocaine. I use at least 5ml and inject a wheel and all over the place deeper.

3: an anesthesia colleague taught me this one. If you have the needle in and you hit bone, hold the needle with the thumb and index finger of your hand, which is not advancing the needle, at the point in which it comes out of the skin (so you get a landmark on how deep your needle is when you hit bone). Then pull the needle almost all the way out and redirect whichever way you feel you need to go. If you hit bone again and your thumb and index finger aren't hitting the skin like last time (the are more shallow), you know you are moving up the spinus process in the wrong direction, so redirect the other way and now you know you are moving in the right direction towards the canal between the 2 spinous processes.

4: I take the stylet out after I get a few cm through the skin. This way I don't have to keep advancing and taking the stylet out and then put it back in and advance again. The CSF just starts to come out when I slowly inch forward and hit the sweet spot. I do insert the stylet back in if I hit bone and I have to redirect up or down, then I remove it again once farther in.

 

[WildcatS11]

How many hours passed between onset of their HA and the time they got their NCHCT?

Same. Mine was CT head neg 3-4 hours after onset, at OSH, then came to us and had what looked like just straight blood from her LP. Ending up being blood AND xanthochromia (not just traumatic tap) and had a huge SAH. It was now clearly visible on the MR ordered by neurosurgery later that night. If we had CT'ed her ourselves, I think we would have seen blood.

 

[Angry Birds]

\If they're crazy, I give them Ativan. I'd probably give Angry Birds Ativan, b/c they think you don't need lido for an LP

Haha, I actually didn't think or say that one doesn't need lido for an LP. I've always used lido, and I was simply asking a question to the forum. I got my answer pretty loud and clear: NO! (Or rather, YES it is crazy and cruel not to give lido, so always give lido!)

I had a difficult LP recently, and I think part of it was that I had gone a long stretch without doing one, and this patient was altered and uncooperative. Because of all this, I tried it lying down, and didn't get it. Then, I sat the patient up, gave sedation, and finally got it. I realized that my initial attempts were off center and I lined up my successful shot because of being able to palpate the spinous processes, but found it harder to palpate in the area where I had injected tons of lido. Hence, the question asked to the board.

But, in any case, question answered. One takeaway from this thread is the idea of injecting 10 minutes before the procedure. (I already use a skin marker but I guess I just messed up when I initially marked up this particular patient.)

 

[RustedFox]

I fail LPs all the time. Generally in my 90+ year old patients with terrible arthritis and kypholordoscoliosis.

Man, this place (Florida) just keeps getting O.L.D.E.R.

 

[BoardingDoc]

I fail LPs all the time. Generally in my 90+ year old patients with terrible arthritis and kypholordoscoliosis.

O.L.D.E.R.

Old Lonely and Dying Emergency Room?

 

[da8s0859q]

Same. Mine was CT head neg 3-4 hours after onset, at OSH, then came to us and had what looked like just straight blood from her LP. Ending up being blood AND xanthochromia (not just traumatic tap) and had a huge SAH. It was now clearly visible on the MR ordered by neurosurgery later that night. If we had CT'ed her ourselves, I think we would have seen blood.

Well within that arbitrary six hour cutoff for CTs and sensitivity for bleeding, eh? Sigh. Wasn't there a paper on this saying that even relatively recent tech CTs within six hours should be considered adequate if no neuro findings, etc?

 

[Tenk]

I actually use a separate bottle of lido from the Pyxis to do extra numbing because the one in the kit is tiny. I then have the one in the kit as backup.

 

[Old Grunt]

excuse me for crashing your forum ... i'm an aussie anaesthetist - i usually hang out in the anaesthesiology forum, but the political discussion there is getting me down.

I do spinals rather than LPs obviously -- but often need to get them in a time critical manner (obstetrics)
my advice for whatever it's worth.

-- position the patient carefully, assemble all your equipment so it is in easy reach of your dominant hand
-- push hard (really hard in fatties) with your non dominant hand to palpate the spinous processes and intervertebral space in the midline
-- once you've got your space, don't move your non dominant hand AT ALL
-- put some local in, and use it as a seeker for bone if necessary. withdraw your local needle and set aside, while NOT moving your non dominant hand.
-- put an introducer needle in the same spot, then a 25g pencil point spinal needle - not some friggin harpoon (unless they're old and then it doesn't matter)

if you don't move your non dominant hand it doesn't matter if you use a truck load of local.
i never give sedation for a spinal, but i do use ketamine sometimes to position patients with #NOF laterally for spinals -- works fine
kids - can't help you there.

Thanks. That's basically the way one of my favorite attendings taught me to do it ("don't move your thumb and go right over the top of it"). Have to be honest, it's pretty hard to find a 25 gauge spinal needle in an ED. Our kits come with a 20 gauge cutting needle. I don't think I've ever seen a Quincke needle in the ED.

 

[Old Grunt]

I fail LPs all the time. Generally in my 90+ year old patients with terrible arthritis and kypholordoscoliosis.

Man, this place (Florida) just keeps getting O.L.D.E.R.

Those patients are impossible. Sometimes I am tempted to get an L-spine prior to the procedure just so I can see how much gnarled back bone my wishful thinking has to overcome. I have never been good at a paramedian approach so I don't do it.

 

[Old Grunt]

Well within that arbitrary six hour cutoff for CTs and sensitivity for bleeding, eh? Sigh. Wasn't there a paper on this saying that even relatively recent tech CTs within six hours should be considered adequate if no neuro findings, etc?

Does a Normal Head CT Within 6 Hours of Onset of Headache Rule Out SAH? - R.E.B.E.L. EM - Emergency Medicine Blog

(It gives the links to the original articles).

I still recommend an LP if it's a good story and/or I am worried.

 

[deleted59964]

Thanks. That's basically the way one of my favorite attendings taught me to do it ("don't move your thumb and go right over the top of it"). Have to be honest, it's pretty hard to find a 25 gauge spinal needle in an ED. Our kits come with a 20 gauge cutting needle. I don't think I've ever seen a Quincke needle in the ED.

i know - it's the same here in EDs and the physicians do the same ... but it does increase the number of dural puncture headaches... and referrals for blood patches

 

[Kittyinthesun]

Re think doing these lumbar punctures. Especially on babies. I am of course not a baby.....but I had a spinal injection (ablation and steroid) and I ended up with a CSF leak. As you know your brain and its tail (your cord) float in the dura sac...well a few holes poked in that and it would not seal and the leak kept leaking...no blood patch would seal it either..had 4..the longest lasted 2 days...any way it created a suction and it ended up sucking my hind brain (cerebellum) through the foramen magnum into my neck over a few months until my brain was sitting on my 2nd vertebrae and my cord looked like and accordion in my neck and lumbar area. I had terrible "brain freeze headaches" with every valsalva..which happens with standing up quickly, turning over in bed, going to the bathroom....it was terrible. the only way to make the pain go away was to lean over and shake my head like an elephant...its called a Chiari malformation (Arnold-Chiari)....anyway...had to have brain surgery ..specifically they cut the skull to make the foramen magnum larger so the brain isn't stuck in that small hole anymore...it does not fix the leak....my point?...I never had a headache in my life...now I had a constant 4/10 headache and 30 debilitating brain freeze headaches a day until the surgery....I could tell something wasn't right, I got an MRI and by brain got sucked down into my neck from 3mm to 1.8 cm by the time I had it repaired...my point is a baby can not tell you they have a headache, and we never CT or MRI a baby after we do a lumbar puncture on them...so they could be screaming with brain freeze no one will understand why they are screaming....it will cause waist up paralysis and blindness and it can cause syringomyelia (sort of like an abscess/callus which never goes away even after the surgical repair. This really had me re-thinking all these lumbar punctures we do just because we can't find the source of a fever in an infant...and they don't show any signs of meningitis...we do it because its expected of us by the receiving doc.....poor excuse to possibly ruin a persons life....and no, I did not have this before...I just happened to have some actual hard films of a CT entire spine from 10 years previously and I was not born with a chiari malformation....so yes there are acquired malformations...thank god I never had a headache before so I knew there was something wrong...even still my greedy doctor lied to me and told me the MRI was normal and I did not get the results because I was the pt....so I suffered for months until I actually did go blind ....for only abut 20 seconds, but that is an eternity when it first happens...remember the eye sight is in the back of the brain, and it is the back which starts to slide down the foramen and gets stuck...and yes use lidocaine...otherwise sticking someone in the back would really hurt...if you are not sure...have your fellow doctor stick you in the spinal column with no lidocaine! Even the lidocaine hurts really bad..imagine without lidocaine.

 

[WildcatS11]

Re think doing these lumbar punctures. Especially on babies. I am of course not a baby.....but I had a spinal injection (ablation and steroid) and I ended up with a CSF leak. As you know your brain and its tail (your cord) float in the dura sac...well a few holes poked in that and it would not seal and the leak kept leaking...no blood patch would seal it either..had 4..the longest lasted 2 days...any way it created a suction and it ended up sucking my hind brain (cerebellum) through the foramen magnum into my neck over a few months until my brain was sitting on my 2nd vertebrae and my cord looked like and accordion in my neck and lumbar area. I had terrible "brain freeze headaches" with every valsalva..which happens with standing up quickly, turning over in bed, going to the bathroom....it was terrible. the only way to make the pain go away was to lean over and shake my head like an elephant...its called a Chiari malformation (Arnold-Chiari)....anyway...had to have brain surgery ..specifically they cut the skull to make the foramen magnum larger so the brain isn't stuck in that small hole anymore...it does not fix the leak....my point?...I never had a headache in my life...now I had a constant 4/10 headache and 30 debilitating brain freeze headaches a day until the surgery....I could tell something wasn't right, I got an MRI and by brain got sucked down into my neck from 3mm to 1.8 cm by the time I had it repaired...my point is a baby can not tell you they have a headache, and we never CT or MRI a baby after we do a lumbar puncture on them...so they could be screaming with brain freeze no one will understand why they are screaming....it will cause waist up paralysis and blindness and it can cause syringomyelia (sort of like an abscess/callus which never goes away even after the surgical repair. This really had me re-thinking all these lumbar punctures we do just because we can't find the source of a fever in an infant...and they don't show any signs of meningitis...we do it because its expected of us by the receiving doc.....poor excuse to possibly ruin a persons life....and no, I did not have this before...I just happened to have some actual hard films of a CT entire spine from 10 years previously and I was not born with a chiari malformation....so yes there are acquired malformations...thank god I never had a headache before so I knew there was something wrong...even still my greedy doctor lied to me and told me the MRI was normal and I did not get the results because I was the pt....so I suffered for months until I actually did go blind ....for only abut 20 seconds, but that is an eternity when it first happens...remember the eye sight is in the back of the brain, and it is the back which starts to slide down the foramen and gets stuck...and yes use lidocaine...otherwise sticking someone in the back would really hurt...if you are not sure...have your fellow doctor stick you in the spinal column with no lidocaine! Even the lidocaine hurts really bad..imagine without lidocaine.

Wow. Rough experience. Obviously there are complications, and it is an invasive procedure, but to suggest LP's should be completely done away with, or to not do them in babies only because many babies don't have meningitis, is an over-correction. LP's are quite necessary at times. And neonates, just like they can't you when they have a HA, can't always "tell you" (read: don't have the same signs/symptoms of older humans) when they have a CNS infection.

 

[deleted109597]

i know - it's the same here in EDs and the physicians do the same ... but it does increase the number of dural puncture headaches... and referrals for blood patches

25 ga is too small for an LP. The amount of fluid we need (we should get ~14mL for an adequate sample with all cultures), would take an eon through that needle. You want to push meds through it, sure. But to draw with? It just takes too long.
I'm with you on the pencil point needles. But I'm not buying them myself because they likely wouldn't be approved by hospital in case of negative outcome, and the hospital refuses to pay for them. I generally try with the 22ga, as my kits come with 18s.

 

[Apollyon]

Re think doing these lumbar punctures. Especially on babies. I am of course not a baby.....but I had a spinal injection (ablation and steroid) and I ended up with a CSF leak. As you know your brain and its tail (your cord) float in the dura sac...well a few holes poked in that and it would not seal and the leak kept leaking...no blood patch would seal it either..had 4..the longest lasted 2 days...any way it created a suction and it ended up sucking my hind brain (cerebellum) through the foramen magnum into my neck over a few months until my brain was sitting on my 2nd vertebrae and my cord looked like and accordion in my neck and lumbar area. I had terrible "brain freeze headaches" with every valsalva..which happens with standing up quickly, turning over in bed, going to the bathroom....it was terrible. the only way to make the pain go away was to lean over and shake my head like an elephant...its called a Chiari malformation (Arnold-Chiari)....anyway...had to have brain surgery ..specifically they cut the skull to make the foramen magnum larger so the brain isn't stuck in that small hole anymore...it does not fix the leak....my point?...I never had a headache in my life...now I had a constant 4/10 headache and 30 debilitating brain freeze headaches a day until the surgery....I could tell something wasn't right, I got an MRI and by brain got sucked down into my neck from 3mm to 1.8 cm by the time I had it repaired...my point is a baby can not tell you they have a headache, and we never CT or MRI a baby after we do a lumbar puncture on them...so they could be screaming with brain freeze no one will understand why they are screaming....it will cause waist up paralysis and blindness and it can cause syringomyelia (sort of like an abscess/callus which never goes away even after the surgical repair. This really had me re-thinking all these lumbar punctures we do just because we can't find the source of a fever in an infant...and they don't show any signs of meningitis...we do it because its expected of us by the receiving doc.....poor excuse to possibly ruin a persons life....and no, I did not have this before...I just happened to have some actual hard films of a CT entire spine from 10 years previously and I was not born with a chiari malformation....so yes there are acquired malformations...thank god I never had a headache before so I knew there was something wrong...even still my greedy doctor lied to me and told me the MRI was normal and I did not get the results because I was the pt....so I suffered for months until I actually did go blind ....for only abut 20 seconds, but that is an eternity when it first happens...remember the eye sight is in the back of the brain, and it is the back which starts to slide down the foramen and gets stuck...and yes use lidocaine...otherwise sticking someone in the back would really hurt...if you are not sure...have your fellow doctor stick you in the spinal column with no lidocaine! Even the lidocaine hurts really bad..imagine without lidocaine.

You don't have to explain physiology to anyone here. And, in babies, the sutures are open, so, even with a bleed, they can tolerate it better. Not perfectly, but better.

 

[e30ftw]

LP can be a painful procedure so I generously inject local prior to the stick.

In residency though I did get a champagne tap on an 18 year old using only the skin wheal. She had great landmarks and was making a big deal about the skin wheal, so I just stuck it.. she basically felt nothing, and asked me, "Did you get it?" while I was filling up the first tube... lucky.

If you spend 5 minutes slicing the vertebral periosteum doing a tap on an old guy though, you should probably inject a lot of lidocaine.

 

[deleted59964]

25 ga is too small for an LP. The amount of fluid we need (we should get ~14mL for an adequate sample with all cultures), would take an eon through that needle. You want to push meds through it, sure. But to draw with? It just takes too long.
I'm with you on the pencil point needles. But I'm not buying them myself because they likely wouldn't be approved by hospital in case of negative outcome, and the hospital refuses to pay for them. I generally try with the 22ga, as my kits come with 18s.

That's a good point, I can imagine getting impatient waiting for the drips. CSF still comes out pretty fast in my obstetric patients but pregnancy probably increases the pressure ... you need less local in a pregnant patient because of this.

 

[Old_Mil]

Lidocaine often messes up my landmarks for LP. Everything gets too squishy and I can't repalpalpate as well for spinous processes to make sure I'm dead center. What are your thoughts on Versed +/- Fentanyl and just using the spinal needle without local? Crazy? Cruel?

EDIT: OK everyone has answered unanimously on this one: Yes, it is crazy and cruel not to give Lido.

Ultrasound + skin marking pen.

What's a landmark?

 

[anbuitachi]

Use lido. it shouldn't really distort your land mark... perhaps you are giving way too much

 

[Venko]

I have only done an LP without lidocaine a handful of times on intubated people.

I see the local analgesia as being two steps, there is the skin anesthesia and the anesthesia for the track of the needle.

I use a very small amount for the skin itself and I never lose my landmarks. I use plenty more for the track(s) because that part has some variability in trajectory.

Also, if I know an Lp will be needed but there are many steps I want to accomplish first, I will apply topical lidocaine cream or gel immediately and then get the labs, ct, etc and then I only need to provide the lidocaine for the tracks.


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[Venko]

Re think doing these lumbar punctures. Especially on babies. I am of course not a baby.....but I had a spinal injection (ablation and steroid) and I ended up with a CSF leak. As you know your brain and its tail (your cord) float in the dura sac...well a few holes poked in that and it would not seal and the leak kept leaking...no blood patch would seal it either..had 4..the longest lasted 2 days...any way it created a suction and it ended up sucking my hind brain (cerebellum) through the foramen magnum into my neck over a few months until my brain was sitting on my 2nd vertebrae and my cord looked like and accordion in my neck and lumbar area. I had terrible "brain freeze headaches" with every valsalva..which happens with standing up quickly, turning over in bed, going to the bathroom....it was terrible. the only way to make the pain go away was to lean over and shake my head like an elephant...its called a Chiari malformation (Arnold-Chiari)....anyway...had to have brain surgery ..specifically they cut the skull to make the foramen magnum larger so the brain isn't stuck in that small hole anymore...it does not fix the leak....my point?...I never had a headache in my life...now I had a constant 4/10 headache and 30 debilitating brain freeze headaches a day until the surgery....I could tell something wasn't right, I got an MRI and by brain got sucked down into my neck from 3mm to 1.8 cm by the time I had it repaired...my point is a baby can not tell you they have a headache, and we never CT or MRI a baby after we do a lumbar puncture on them...so they could be screaming with brain freeze no one will understand why they are screaming....it will cause waist up paralysis and blindness and it can cause syringomyelia (sort of like an abscess/callus which never goes away even after the surgical repair. This really had me re-thinking all these lumbar punctures we do just because we can't find the source of a fever in an infant...and they don't show any signs of meningitis...we do it because its expected of us by the receiving doc.....poor excuse to possibly ruin a persons life....and no, I did not have this before...I just happened to have some actual hard films of a CT entire spine from 10 years previously and I was not born with a chiari malformation....so yes there are acquired malformations...thank god I never had a headache before so I knew there was something wrong...even still my greedy doctor lied to me and told me the MRI was normal and I did not get the results because I was the pt....so I suffered for months until I actually did go blind ....for only abut 20 seconds, but that is an eternity when it first happens...remember the eye sight is in the back of the brain, and it is the back which starts to slide down the foramen and gets stuck...and yes use lidocaine...otherwise sticking someone in the back would really hurt...if you are not sure...have your fellow doctor stick you in the spinal column with no lidocaine! Even the lidocaine hurts really bad..imagine without lidocaine.

It's possible that I'm the only one not familiar with the literature on this, but can you share any publications documenting an acquired Arnold chiari after LP?

As a doc who does LP for all ages, and a parent of an infant who had an emergent LP (which I would consent again in a heartbeat), I am personally invested in this space.

Thank you in advance for sharing the papers.




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[Old Grunt]

Re think doing these lumbar punctures. Especially on babies. I am of course not a baby.....but I had a spinal injection (ablation and steroid) and I ended up with a CSF leak. As you know your brain and its tail (your cord) float in the dura sac...well a few holes poked in that and it would not seal and the leak kept leaking...no blood patch would seal it either..had 4..the longest lasted 2 days...any way it created a suction and it ended up sucking my hind brain (cerebellum) through the foramen magnum into my neck over a few months until my brain was sitting on my 2nd vertebrae and my cord looked like and accordion in my neck and lumbar area. I had terrible "brain freeze headaches" with every valsalva..which happens with standing up quickly, turning over in bed, going to the bathroom....it was terrible. the only way to make the pain go away was to lean over and shake my head like an elephant...its called a Chiari malformation (Arnold-Chiari)....anyway...had to have brain surgery ..specifically they cut the skull to make the foramen magnum larger so the brain isn't stuck in that small hole anymore...it does not fix the leak....my point?...I never had a headache in my life...now I had a constant 4/10 headache and 30 debilitating brain freeze headaches a day until the surgery....I could tell something wasn't right, I got an MRI and by brain got sucked down into my neck from 3mm to 1.8 cm by the time I had it repaired...my point is a baby can not tell you they have a headache, and we never CT or MRI a baby after we do a lumbar puncture on them...so they could be screaming with brain freeze no one will understand why they are screaming....it will cause waist up paralysis and blindness and it can cause syringomyelia (sort of like an abscess/callus which never goes away even after the surgical repair. This really had me re-thinking all these lumbar punctures we do just because we can't find the source of a fever in an infant...and they don't show any signs of meningitis...we do it because its expected of us by the receiving doc.....poor excuse to possibly ruin a persons life....and no, I did not have this before...I just happened to have some actual hard films of a CT entire spine from 10 years previously and I was not born with a chiari malformation....so yes there are acquired malformations...thank god I never had a headache before so I knew there was something wrong...even still my greedy doctor lied to me and told me the MRI was normal and I did not get the results because I was the pt....so I suffered for months until I actually did go blind ....for only abut 20 seconds, but that is an eternity when it first happens...remember the eye sight is in the back of the brain, and it is the back which starts to slide down the foramen and gets stuck...and yes use lidocaine...otherwise sticking someone in the back would really hurt...if you are not sure...have your fellow doctor stick you in the spinal column with no lidocaine! Even the lidocaine hurts really bad..imagine without lidocaine.

My wife had a post lumbar puncture spinal HA. It was awful. It has definitely made me think twice before being willy nilly about it, and I definitely discuss this possibility with patients and tell them about my wife's experience. It resolved after three days of recumbency thankfully.

Seriously. It was awful, and I was only a spectator.

 

[deleted109597]

It's possible that I'm the only one not familiar with the literature on this, but can you share any publications documenting an acquired Arnold chiari after LP?

As a doc who does LP for all ages, and a parent of an infant who had an emergent LP (which I would consent again in a heartbeat), I am personally invested in this space.

Thank you in advance for sharing the papers.