Calibre e formato de agulhas e sua relação com a incidência de cefaleia pós-punção dural: uma revisão sistemática / Needles gauge and shape and its relation to post-dural puncture headache incidence: a systematic review

Introdução: A cefaleia pós punção dural (CPPD) é uma complicação da punção lombar, um procedimento que, apesar de bem tolerado, está sujeito a adversidades, ocorrendo devido a um vazamento persistente do líquido cefalorraquidiano (LCR) do local da punção dural. A incidência de CPPD pode estar relacionada às características dos pacientes e dos procedimentos. Notou-se que em mulheres jovens até 30 anos, o risco de CPPD é maior quando comparado aos homens, não apresentando diferença a partir da quinta década de vida. Objetivo: investigar os diferentes sintomas e efeitos gerados pelos diferentes tipos de agulha, como calibre e modo de inserção, que visem reduzir a CPPD. Métodos: Trata-se de uma revisão sistemática de literatura realizada no período de 2 de agosto a 20 de novembro de 2023 por meio de pesquisas no PubMed. Foram utilizados os descritores: "Post-Dural Puncture Headache" e suas variações do MeSH, sendo submetidos aos critérios de inclusão: estudos em humanos, nos últimos 10 anos, ensaios clínicos e ensaios clínicos controlados e randomizados. Para garantir a qualidade da revisão sistemática foi aplicada a lista de verificação PRISMA de 2020. Resultados: Após investigação estatística, observou-se que as agulhas 25W e 25S demandaram maior tempo médio para a coleta de LCR (15 e 7 min, respectivamente). Ao se comparar 25W com 20Q (3 min), 22S (5 min) e 25S quanto à esta variável, observouse diferença significativa em todas as comparações. Conclusão: As agulhas do tipo atraumática foram associadas com redução do risco de desenvolvimento de CPPD quando comparadas às convencionais. Foi constatado que, dentre as agulhas convencionais, a traumática de 25G é melhor para a prevenção de CPPD que a de 22G.

Introduction: Post-Dural Puncture Headache (PDPH) is a complication of lumbar puncture, a procedure that, despite being well-tolerated, is subject to adversities, occurring due to a persistent leakage of cerebrospinal fluid (CSF) from the site of dural puncture. The incidence of PDPH may be related to patient and procedural characteristics. It has been noted that in young women up to 30 years old, the risk of CPPD is higher compared to men, with no difference between sexes from the fifth decade of life onward. Objective: To investigate the different symptoms and effects generated by different types of needles, such as gauge and insertion method, aiming to reduce CPPD. Methods: Is a systematic literature review conducted from August to October 2023 through searches on PubMed. The descriptors "Post-Dural Puncture Headache" and its MeSH variations were used. A total of 1,839 articles were found, which were then subjected to inclusion criteria: studies conducted in the last 10 years, controlled trials, and randomized clinical trials. Results: After statistical investigation, it was observed that the 25W and 25S needles required a longer average time for cerebrospinal fluid collection (15 and 7 minutes, respectively). When comparing 25W with 20Q (3 minutes), 22S (5 minutes), and 25S regarding this variable, a significant difference was observed in all comparisons. Conclusion: Atraumatic needles were associated with a reduction in the risk of developing CPPD compared to conventional needles. It was found that among conventional needles, the traumatic 25G needle is better for preventing CPPD than the 22G needle.

Prevalence, Risk Factors and Clinical Features of Post Dural Puncture Headache (PDPH): A Prospective Study

Background: Post-dural puncture headache (PDPH), formerly known as post-lumbar puncture headache, is a well-known adverse event that follows diagnostic and/or therapeutic puncture of the dura, or accidentally, following spinal anesthesia. Material & Methods: This prospective study was carried out on 152 patients at Shaheed Ziaur Rahman Medical College Hospital in Bogura, from 2013 to 2015 and North Bengal Medical College from 2016 to 2022, Bangladesh. Results: A total of 152 patients were enrolled into the study where 122(80.3%) were aged between 18-28 years, 30(19.7%) were 29-39 years, 38(25%) were male and 114(75%) were female. 122(80.3%) patients were non obese (<25) and 30(19.7%) were obese (>25). 17(11.2%) patients had previous history of anaesthesia and 17(11.2%) had previous history of PDPH. On majority 100 patients were used big size needle (18-23 G) and rest of the patients were used small (23-25G). 146 (96.1%) patients position was lateral and 92(60.5%) were used less than two or equal three drops. 61(40.1%) patients were needed one attempt, 64(42.1%) were needed two and 27(27.8%) were needed greater than two. The prevalence of PDPH was found in 44(28.9%) cases out of 152 where severity of 29(65.9%) percent was mild, 20(45.5%) cases headache onset were at the first day and mean duration of headache was 2.6. There was a statistically significant association between development of PDPH and younger age (26.3±8.7 years vs 32.6±7.4, p< 0.001), female gender (p=00.009), previous history of PDPH (p<0.001), number of attempts (3.1±1.2 vs 1.2±0.8, p<0.001), small needles (p=0.04), pre LP headache (p<0.001) and CSF RBS (2.6±2.1 vs 13.8±1.3, p= 0.48). Conclusion: This study recommends that the neurologists should be treating this population in the manner so that it may help to prevent this painful adverse event, and identification of risk variables is vital in predicting PDPH.

Lumbar puncture for neurosyphilis investigation in asymptomatic patients with HIV-syphilis coinfection: a cross-sectional study among infectious disease specialists

ABSTRACT BACKGROUND: Syphilis is a major public health issue worldwide. In people living with human immunodeficiency virus (PLHIV), there are higher incidences of both syphilis and neurosyphilis. The criteria for referring PLHIV with syphilis for lumbar puncture is controversial, and the diagnosis of neurosyphilis is challenging. OBJECTIVE: To describe the knowledge, attitudes, and practices of infectious disease specialists and residents in the context of care for asymptomatic HIV-syphilis coinfection using close-ended questions and case vignettes. DESIGN AND SETTING: Cross-sectional study conducted in three public health institutions in São Paulo (SP), Brazil. METHODS: In this cross-sectional study, we invited infectious disease specialists and residents at three academic healthcare institutions to answer a self-completion questionnaire available online or in paper form. RESULTS: Of 98 participants, only 23.5% provided answers that were in line with the current Brazilian recommendation. Most participants believed that the criteria for lumbar puncture should be extended for people living with HIV with low CD4+ cell counts (52.0%); in addition, participants also believed that late latent syphilis (29.6%) and Venereal Disease Research Laboratory (VDRL) titers ≥ 1:32 (22.4%) should be conditions for lumbar puncture in PLHIV with no neurologic symptoms. CONCLUSION: This study highlights heterogeneities in the clinical management of HIV-syphilis coinfection. Most infectious disease specialists still consider syphilis stage, VDRL titers and CD4+ cell counts as important parameters when deciding which patients need lumbar puncture for investigating neurosyphilis.

Preliminary construction of evaluation index system of lumbar puncture teaching for medical students based on Delphi method and analytic hierarchy process / 中华医学教育探索杂志

Objective:To construct the evaluation index system of lumbar puncture teaching for medical students, aiming to create a scientific assessment and evaluation method covering theoretical knowledge, skill practice, and professional accomplishment, so as to comprehensively evaluate the teaching effect of lumbar puncture for medical students, and improve the practical ability of clinical skills of medical students more effectively.Methods:The evaluation index scheme of lumbar puncture teaching for medical students was initially formulated through literature review and group discussion, and 20 experts related to clinical front-line work and medicine were invited to revise the scheme by applying Delphi expert consultation and applying analytic hierarchy process to quantify the entries and establish the final index weights at all levels.Results:The valid recovery rate of both rounds of expert consultation questionnaires in this study was 100%. The second round of expert consultation was conducted without changing experts, with an authority factor of 0.88. Kendall's coefficient of harmony was 0.136 and 0.184, respectively. After two rounds of expert consultation, the evaluation index system of lumbar puncture teaching for medical students, including 3 primary indicators (theoretical knowledge, comprehensive clinical ability and professionalism), 7 secondary indicators and 22 tertiary indicators, was initially constructed.Conclusion:The evaluation index system of lumbar puncture teaching for medical students constructed in this study is scientific and credible, which can provide quantitative basis for the training and assessment of medical students, and is of great theoretical and practical significance.

Rachianesthésie en ambulatoire au Centre Hospitalier Universitaire Andrainjato Fianarantsoa, Madagascar: tolérance et efficacité / Ambulatory spinal anaesthesia at the Andrainjato University Hospital of Fianarantsoa, Madagascar: tolerance and effectiveness

La rachianesthésie ambulatoire est une des méthodes d'anesthésies loco- régionales de plus en plus utilisées car permet une réhabilitation précoce. L'objectif de l'étude est d'évaluer la tolérance et l'efficacité de la rachianesthésie réalisée en ambulatoire. Méthodes : Il s'agit d'une étude rétrospective, analytique réalisée au Centre Hospitalier Universitaire Andrainjato Fianarantsoa pendant cinq ans (du mois de janvier 2016 au mois de décembre 2020). La tolérance de la rachianesthésie était évaluée par la fréquence et la gravité des incidents peropératoires et complications postopératoires. Son efficacité était estimée par le taux de sortie le jour de l'intervention et la ré-hospitalisation. Résultats : Soixante-quatre patients âgés de 44 [14-85] ans ont bénéficié d'une chirurgie viscérale, gynécologique, traumatologique ou vasculaire sous rachianesthésie. L'hypotension artérielle (n=04) et les nausées et vomissements peropératoires (n = 01) étaient les incidents retrouvés. Les complications postopératoires étaient la céphalée (n = 13), la douleur postopératoire d'intensité modérée à intense (n = 05) et les nausées et vomissements (n = 02). L'âge supérieur à 50 ans (p = 0,012) et une dose supérieure à 12 mg de bupivacaïne (p = 0,011) étaient corrélés à l'hypotension artérielle peropératoire. Le genre féminin (p = 0,004) et l'utilisation de la bupivacaïne hyperbare (p = 0,027) étaient associés aux complications postopératoires. Tous ces patients étaient sortis le jour même de l'intervention sans ré-hospitalisation. Conclusion : La rachianesthésie ambulatoire connaît actuellement un grand essor dans la pratique anesthésique. La prévention de certaines complications devrait être systématique afin d'optimiser sa tolérance et son efficacité

Estudio de líquido cerebroespinal en el síndrome de Ramsay-Hunt: controversia a raíz de un caso clínico / Study of cerebrospinal fluid in Ramsay-Hunt syndrome: controversy because of a clinical case

El Síndrome de Ramsay-Hunt (SRH), es la segunda causa de parálisis facial periférica (PFP). Causado por el virus Varicella zoster (VVZ), ipsilateral a la PFP,presenta unaerupción herpetiforme y cefalea en distribución del nervio facial. Presentamos el caso de una mujer, 54 años, con SRH y cefalea persistente cuyo líquido cerebroespinal (LCE) fue compatible con meningitis. Se indicó aciclovir endovenoso (EV). La literatura no recomienda estudio de LCE en PFP; y en SRH se sugiere en inmunosuprimidos y complicaciones del SRH como queratopatía, accidentes-cerebrovasculares, y meningitis. Un LCE alterado en SRH, indica modificar la conducta terapéutica.

Ramsay-Hunt Syndrome (RHS) is the second leading cause of peripheral facial palsy (PFP). Caused by the Varicella zoster virus (VZV), ipsilateral to the PFP, it presents a herpetiform rash and headache in the facial nerve distribution. We present the case of a 54-year-old woman with RHS and persistent headache whose cerebrospinal fluid (CSF) was compatible with meningitis. Intravenous acyclovir was indicated. The literature does not recommend an CSF study in PFP; in RHS it is suggested in immunosuppressed patients and complications of RHS such as keratopathy, cerebrovascular accidents, and meningitis. An altered CSF in RHS indicates modifying the therapeutic conduct.

Punción lumbar en pacientes con espondilitis anquilosante, precauciones y sugerencias / Lumbar puncture in patients with ankylosing spondylitis, precautions and suggestions

Las espondiloartropatías son un grupo de enfermedades reumáticas que se caracterizan por la presencia de un proceso inflamatorio crónico y mantenido. Entre sus manifestaciones clínicas y complicaciones se incluye la toma de la columna vertebral donde existe una calcificación de los ligamentos vertebrales que limita considerablemente la movilidad de los distintos segmentos de la columna vertebral. Los cambios anatomofuncionales que se generan en estos segmentos traen consigo dificultades a la hora de realizar procedimientos como la punción lumbar. La presente investigación tiene como objetivo describir las precauciones, sugerencias y recomendaciones para realizar la punción lumbar con fines diagnósticos o terapéuticos. Los principales resultados se enfocan en la idenficación y socialización de precauciones y sugerencias a tener en cuenta a la hora de realizar una punción lumbar en pacientes con espondilitis anquilosante(AU)

Spondyloarthropathies are a group of rheumatic diseases characterized by the presence of a chronic and sustained inflammatory process. Among its clinical manifestations and complications, the seizure of the spine is included where there is calcification of the vertebral ligaments that considerably limits the mobility of the different segments of the spine. The anatomical and functional changes that are generated in these segments bring with them difficulties when performing procedures such as lumbar puncture. This research aims to describe the precautions, suggestions and recommendations to perform lumbar puncture for diagnostic and/or therapeutic purposes. The main results focus on the identification and socialization of precautions and suggestions to take into account when performing a lumbar puncture in patients with ankylosing spondylitis(AU)

Multi-disciplinary team of human herpes virus-6B encephalitis after liver transplantation / 器官移植

Objective To evaluate the role of multi-disciplinary team (MDT) in improving the diagnosis and treatment of human herpes virus-6B (HHV-6B) encephalitis after liver transplantation. Methods MDT consultation was delivered for one rare case of HHV-6B encephalitis after liver transplantation to establish an effective individualized treatment regime. Results On the 16 d after liver transplantation, the patient developed headache, and suddenly presented with unresponsiveness, unconsciousness, coma complicated with involuntary limb twitching on the 18 d. Blood ammonia level was increased. Brain CT scan showed cerebral ischemic changes. Electroencephalography prompted the epileptic seizure. After MDT consultation, the possibility of nervous system infection after liver transplantation was considered, and medication therapy was given to control the epileptic seizure. Cerebrospinal fluid examination via lumbar puncture hinted increased intracranial pressure. Real-time fluorescent quantitative polymerase chain reaction (RT-qPCR) of the cerebrospinal fluid demonstrated that the patient was tested positive for HHV-6B nucleic acid, which confirmed the diagnosis of HHV-6B encephalitis. The immunosuppressant regime was adjusted, intravenous ganciclovir was given for antiviral treatment, and active interventions were delivered to prevent and treat relevant complications. Epileptic seizure disappeared after 4 d, and neurological symptoms were significantly alleviated after 2 weeks. After 4-week antiviral treatment, the patient was tested negative for virology testing, and the neurological function was restored to normal. Conclusions HHV-6B encephalitis rarely occurs after adult liver transplantation, which is primarily associated with the virus reactivation after use of immunosuppressant. MDT pattern may be employed to deepen the understanding of the patient's condition, formulate more effective individualized treatment regime, and enhance the clinical efficacy and safety.

Study on demographic factors of discharge against medical advice in pediatric population

Background: Discharge against medical advice (DAMA) is of serious concern among the pediatrics population. Parent(s)/guardians understanding about the disease and various other factors play role in their decision of DAMA. The aim of this study is to know the prevalence of DAMA in a tertiary care center and to observe the gender stratification in DAMA.Methods: A retrospective survey of medical records of children discharge against medical advice during the period January 2017 to January 2019. Demographic data, length of hospital stay, clinical diagnosis and procedure refused was collected.Results: Total 12977 were discharged during the study period of which, 387 children were DAMA, prevalence of DAMA was 2.9%, male to female ratio among DAMA patients is 1.2:1. The mean length of stay was 4.8 days. Among the DAMA patients' newborns were predominant (61.6 %), p value = 0.0001, highly significant. No significant difference with respect to age and gender (p value = 0.535). Out of 370 DAMA patients, 211 patients who required further investigations and procedure was refused by parents/guardians (p value = 0.0001) highly significant. Phototherapy refusal was most common among newborn (59.7%), followed by neuroimaging and lumbar puncture in children (10.9%).Conclusions: DAMA was observed more among the newborns compared to infants, toddlers and children. Among newborns, phototherapy refusal was most common. In infants and children neuroimaging and lumbar puncture was the most commonly refused procedure. There was no gender bias.

Best practice implementation of bedtime and position after diagnostic adult lumbar puncture / 中国实用护理杂志

Objective@#By implementing the best practice of bedtime and position after diagnostic adult lumbar puncture,we hope to establish a scientific and standardized nursing routine for lumbar puncture, shorten the bed-rest time after lumbar puncture, and improve the comfort of patients.@*Methods@#By reviewing literatures related to positions after adult lumbar puncture and post-dural puncture headache, six best practice were concluded. By combining the best evidence and the clinical circumstances, the evidenced-based criteria were established and then applied in the Neurology Department.@*Results@#After two rounds of reviews, the results showed that except the 93.3% compliance with the new evidence, all other four criteria had 100% complacence. Comparing before and after applying the evidence, there was no statistically significant difference for the occurrence of post-dural puncture headache or dizziness(P>0.05), there was a statistically significant reduction of back pain from 28.3%(30/106) to 15.1%(18/119)(χ2 value was 5.799, P<0.05) when the evidence was applied.@*Conclusions@#The best practice shows that patients needn′t lie on bed for 4 to 6 hours after lumbar puncture, the occurrence of back pain is lowered and the comfort level of the patient is improved in those who rest with pillow or activities.

Association between potential intracranial pressure and optic nerve sheath diameter evaluated by transcranial Doppler and ultrasonographic measurement in encephalitis patients / 中国脑血管病杂志

Objective To explore the association between potential intracranial pressure (ICP) and optic nerve sheath diameter ( ONSD) evaluated by transcranial Doppler( TCD) and ultrasonographic measurement in encephalitis patients. Methods A total of 17 patients with encephalitis received lumbar puncture were enrolled continuously in the Department of Neurology and Neuroscience of the First Hospital of Jilin University from October 2019 to January 2020. The ONSD and TCD examinations were performed before the operation of lumbar puncture, and the relevant data were recorded. All patients were divided into the elevated ICP group (more than 200 mmH2O) (n = 10 ) , the normal ICP group (80 -200mmH2O) (n=7) according to the results of the initial ICP. The difference of baseline data, ONSD, and the parameters of TCD such as peak systolic velocity (PSV) , end-diastolic velocity ( EDV) , mean blood flow velocity (MV) , and pulse index (PI) , were compared between the two groups. Moreover, the correlation between ICP and ONSD was analyzed. Results (1 ) The difference of gender, age, body mass index, systolic blood pressure, and diastolic blood pressure was not statistically different between the normal and the elevated ICP groups (all P >0. 05). The ONSD was significantly lower in the normal ICP group compared with that in the elevated ICP group ([4.2±0.4] mm vs. [ 4.9 ± 0.4 ] mm, t = - 3. 873, P = 0.002). (2) TCD related parameters (PSV, EDV, MV and PI) were not significantly different between the elevated ICP group and the normal ICP group (all P >0. 05). (3) Univariate analyses revealed that ICP was significantly associated with ONSD (r =0. 87 ,P < 0. 01). Conclusion Results of the study indicate that ONSD is a predictive index for elevated ICP in encephalitis patients.

Adherence to the IDSA guidelines for brain imaging before lumbar puncture in communityacquired meningitis

@#Background: The Infectious Diseases Society of America (IDSA) has published guidelines indicating the criteria for brain imaging before lumbar puncture (LP) among patients with community-acquired meningitis (CAM). However, data on adherence to the guidelines and associated outcomes are currently limited. Methods: We conducted a prospective observational study among patients with CAM from January 2018 to March 2019 in the emergency department (ED) of a tertiary-care hospital in Thailand. Physicians’ IDSA guidelines adherence rate for brain imaging before LP was determined. Clinical outcomes were compared between patients undergoing the procedures according and not according to the guidelines. Results: Of the 101 patients screened, 69 were included. The physicians’ guidelines non-adherence rate for brain imaging before LP was 38%. The most common non-adherent practice wasperforming brain imaging despite no indication (96%). By multivariable logistic regression analysis, the only independent factor associated with non-adherence to the guidelines was caring patients with no indications for brain imaging before LP (P<0.001). The patients in the guidelines-adherent group were more-likely than those in the guidelines-non-adherent group to have underlying AIDS and present with seizure, while the 30-day survival rates were not different between the two groups (88% vs. 85%). Conclusions: Our study suggests a significant non-adherence to the guidelines due to the overinvestigation of the physicians in patients with no indications for brain imaging before LP. Interventions to improve physicians’ knowledge about these indications and practice are needed for better care of patients with CAM.

The influence of gestational age and postnatal age on neonatal cerebrospinal fluid parameters / 中国新生儿科杂志

Objective To study the influence of gestational age (GA) and postnatal age on neonatal cerebrospinal fluid parameters.Method From January 2013 to December 2015,the results of WBC counts,glucose and protein concentrations of cerebro-spinal fluid(CSF) were collected from neonates admitted to neonatal department of our hospitals.The neonates were assigned into different groups according to their GA and postnatal age.The CSF parameters were compared between different groups,and the changes of CSF parameters were analyzed.STATA 12.0 software was used for statistical analysis.Result A total of 1 410 infants were included.516 (36.6％) cases were preterm infants.1 208 cases (85.7％) received antibiotics before lumbar puncture.WBC counts in CSF between preterm and term infants showed no significant differences (upper reference limit,12.5 × 106/L).CSF glucose in term infants (lower reference limit,1.8 mmol/L) was higher than preterm infants (lower reference limit,1.6 mmol/L).CSF protein in preterm infants (upper reference limit,226.6 mg/ dl) was significantly higher than term infants (upper reference limit,140.3 mg/dl).CSF WBC counts decreased with the growth of postnatal age in preterm infants (regression coefficients-0.030,P=0.035).CSF protein also declined significantly with the increase of postnatal age in term infants (regression coefficients-1.254,P＜0.001).CSF glucose showed no significant decrease with the increase of postnatal age (regression coefficients-0.009,P=0.012).Conclusion GA and postnatal age did not produce an effect on WBC counts of CSF.The preterm infants had lower glucose level and higher protein level in CSF.CSF protein declined significantly with the increase of GA and postnatal age.

Clinical characteristics of febrile young infants with serious bacterial infection in the emergency departments in Korea and validation of Philadelphia criteria and modified Philadelphia criteria: retrospective multicenter study

OBJECTIVE: This study examined the characteristics of febrile young infants with a serious bacterial infection (SBI) who visited emergency centers in Korea and validated the Philadelphia criteria and modified Philadelphia criteria to predict the risk of SBI. METHODS: This was a retrospective study conducted on 450 infants aged 31 days to 56 days who visited three emergency centers with fever from September 2014 to August 2017. The characteristics of the SBI patients were analyzed, and the validation of the Philadelphia and modified Philadelphia criteria sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were checked. RESULTS: Of 450 patients, 165 patients (36.7%) had SBI, such as urinary tract infection (33.3%), bacteremia (4.0%), acute osteomyelitis (0.2%), and bacterial meningitis (BM) in two patients (0.4%). The most common pathogen of invasive bacterial infection was Escherichia coli. In the Philadelphia criteria, the sensitivity, specificity, PPV, NPV, and accuracy were 73.9%, 47.0%, 44.7%, 75.7%, and 56.9%, respectively. In the modified Philadelphia criteria that excluded lumbar puncture as a predictor, the sensitivity, specificity, PPV, NPV, and accuracy were 93.3%, 31.9%, 44.3%, 89.2%, and 54.4%, respectively. The most common failed low risk criteria was appearance (43.3%). Two patients with bacterial meningitis were excluded from low risk group by the modified Philadelphia criteria. Although one out of 2 patients met the failed low risk criteria due to their poor condition, this factor is not objective, so BM can be missed. CONCLUSION: Bacterial meningitis was too rare in this study. New criteria are needed to predict SBI. The Philadelphia and modified Philadelphia criteria were not useful for predicting SBI in this study. Other prediction models will be needed to predict SBI in the vaccination era.

Mechanical arm assisted lumbar puncture ultrasound scanning control and structural reconstruction / 国际生物医学工程杂志

Objective To design a mechanical arm assisted lumbar puncture ultrasound scanning system to realize automatic scanning imaging of the lumbar vertebrae and visualize the three-dimensional reconstruction of the acquired two-dimensional ultrasound image,so as to obtain the three-dimensional image of the scanning lumbar and provide a basis for path planning and assisted puncture.Methods The main control program of the robotic arm was programmed by C language which can control the robotic arm to scan the lumbar vertebrae of the patient by a clamped ultrasound.The acquired 2D ultrasound image was reconstructed and visualized using a VTK-based 3D reconstruction visualization program.The lumbar vertebrae model reconstruction was conducted by Enovo Medical Model in water and CIRS 034 lumbar vertebral phantom,respectively,and the experimental results were compared and analyzed.Results By using the lumbar puncture ultrasound scanning system,the obtained two-dimensional ultrasound image of the lumbar spine model was clear and the anatomy was basically complete.The results of three-dimensional reconstruction showed that the spinous processes and their gaps of the scanned lumbar model were clearly visible,and the structure was intact,indicating that the system was operating normally and could achieve the expected function.By comparing the reconstruction results of the bent-knee lateral position and prone position,it can be concluded that the body position has an important influence on the reconstruction results of the lumbar spine ultrasound image.The bent-knee lateral position should be used in the follow-up study of lumbar puncture.Conclusions A lumbar puncture ultrasound scanning system assisted by a mechanical arm was proposed.The system can effectively capture the clear ultrasound image of the model and realize the visualization of 3D reconstruction,which can provide a basis for puncture path planning and assisted puncture.

Reconsideration of Diagnostic Lumbar Puncture in Childhood Enteroviral Meningitis / 대한소아신경학회지

PURPOSE: Despite the fact that enteroviral meningitis is the most common cause of meningitis in children with signs of meningeal irritation and has benign course, most clinicians routinely perform an invasive lumbar puncture (LP) that result in inadequate antibiotic therapy and unnecessary long-term hospitalization. This study was aimed to compare the clinical characteristics of childhood enteroviral meningitis according to LP. METHODS: Children over 2 years of age who can clearly express signs of meningeal irritation in the pediatric department of Eulji university hospital from July 2013 and August 2016 were enrolled. The patients were diagnosed by reverse transcriptase polymerase chain reaction in stool and/or cerebrospinal fluid. We retrospectively reviewed their clinical records. RESULTS: A total of 257 patients were diagnosed with enterovirus meningitis and median age was 6.3 (2.1–7.9) years. One hundred fifteen patients (44.7%) with confirmed enterovirus in the stools underwent supportive care without LP. Mostly, there was no statistically significant difference in age, sex, clinical symptoms, except gastrointestinal involvement (abdominal pain, diarrhea), and serologic findings when compared with patients who underwent LP. But patients who underwent LP had longer hospital stay (4 vs 3 days, P < 0.001). Four of them (2.8%) were re-admitted with back pain and persistent headache, probably related to LP procedure. All patients were discharged without neurologic complications. CONCLUSION: Rapid detection of enteroviruses in stool specimens that can be easily obtained in children with signs of meningeal irritation may reduce invasive LP.

Identificación de necesidades de aprendizaje en la realización de la Punción Lumbar en niños / Identification of the learning needs in the lumbar puncture realization in children

Introducción: la punción lumbar diagnóstica es un procedimiento frecuente en los servicios de urgencia y hospitalización infantiles, esencial para el diagnóstico de enfermedades infecciosas, inflamatorias, oncológicas y metabólicas. La Punción lumbar fallida o traumática necesariamente implica el ingreso y tratamiento antibiótico del paciente. Objetivos: identificar las causas subjetivas de la Punción lumbar fallida, según categoría ocupacional y orden de importancia y necesidades de aprendizaje, para el diseño de estrategias de capacitación. Método: estudio descriptivo, transversal mediante encuesta anónima a 63 profesionales de las áreas de atención de urgencias, que incluye especialistas, residentes y enfermeros. Resultados: las causas subjetivas más frecuentes fueron: la mala inmovilización del niño, mala técnica/habilidad del proceder y trócar no adecuado a la edad del paciente. Conclusiones: es necesario diseñar estrategias de capacitación al personal médico en formación y al personal de enfermería, para la adecuada competencia en la realización de la Punción lumbar en niños(AU)

Introduction: Diagnostic lumbar puncture is a frequent procedure in the emergency and hospitalization services for children, essential for the diagnosis of infectious, inflammatory, oncological and metabolic diseases. Failed or traumatic lumbar puncture necessarily implies the patient's antibiotic treatment and admission. Objectives: To identify the subjective causes of failed lumbar puncture, according to the occupational category and order of importance and learning needs, for the design of training strategies. Method: Descriptive, cross-sectional study by anonymous survey of 63 professionals from the emergency care areas, which includes specialists, residents and nurses.Results: The most frequent subjective causes were the children's poor immobilization, poor technique or ability to proceed, and trocar not adequate to the patient's age. Conclusions: It is necessary to design training strategies for the medical personnel being trained and for the nursing staff, for the appropriate competence in performing the lumbar puncture in children(AU)

Iatrogenic Spinal Subarachnoid Hematoma after Diagnostic Lumbar Puncture

Spinal subarachnoid hematoma (SSH) following diagnostic lumbar puncture is very rare. Generally, SSH is more likely to occur when the patient has coagulopathy or is undergoing anticoagulant therapy. Unlike the usual complications, such as headache, dizziness, and back pain at the needle puncture site, SSH may result in permanent neurologic deficits if not properly treated within a short period of time. An otherwise healthy 43-year-old female with no predisposing factors presented with fever and headache. Diagnostic lumbar puncture was performed under suspicion of acute meningitis. Lumbar magnetic resonance imaging was performed due to hypoesthesia below the level of T10 that rapidly progressed after the lumbar puncture. SSH was diagnosed, and high-dose steroid therapy was started. Her neurological symptoms rapidly deteriorated after 12 hours despite the steroids, necessitating emergent decompressive laminectomy and hematoma removal. The patient’s condition improved after the surgery from a preoperative motor score of 1/5 in the right leg and 4/5 in the left leg to brace-free ambulation (motor grade 5/5) 3-month postoperative. The patient was discharged with no neurologic deficits. Critical complications such as SSH can be fatal. Therefore, a patient undergoing lumbar puncture must be carefully observed. A hematoma that convincingly compresses the spinal cord or cauda equina on imaging results requires early surgical decompression and hematoma removal.

What factors determine the need for lumbar puncture in patients with fever and headache?

<p><b>INTRODUCTION</b>We performed this study to find clinical features and laboratory parameters that could facilitate the process of selecting patients who should receive lumbar punctures from among those who present with headache and fever.</p><p><b>METHODS</b>We selected patients aged ≥ 16 years who presented to and received lumbar puncture in the emergency department of Kangwon National University Hospital, South Korea, between 2011 and 2013. Patients who received lumbar punctures were divided into two groups - those who were diagnosed with viral meningitis and those who were not. We compared the clinical features and laboratory data between the two groups. Key indices were then used to develop a scoring system to diagnose viral meningitis in patients and identify those who should receive lumbar punctures.</p><p><b>RESULTS</b>Among the patients who were included in the study, 42 had viral meningitis and 96 did not. The variables of C-reactive protein level ≤ 1.291 mg/dL, neck stiffness and vomiting were assigned 3 points, 2 points and 1 point, respectively, in the scoring system. Overall scores ≥ 4 yielded a positive likelihood ratio of 7.79 (sensitivity 0.600, specificity 0.923), while negative likelihood ratio decreased to less than 0.1 (0.072) for overall scores < 3.</p><p><b>CONCLUSION</b>Using the proposed scoring system, we were able to determine the likelihood of viral meningitis in patients presenting with fever and headache, and to successfully identify those who should receive lumbar punctures.</p>

Post lumbar puncture headache: Case report of a serious adverse event in first-in-human study

A lumbar puncture can be used to measure the concentrations of drugs and/or pharmacodynamic biomarkers during clinical trials of central nervous system drugs. We report a case of a post lumbar puncture headache (PLPH) in a first-in-human study, which was reported as a serious adverse event. A 20-year-old man received 200 mg of the investigational product (IP) for 7 days and underwent a lumbar puncture for cerebrospinal fluid sampling before IP administration (Day 1, pre-dose) and after 7 days and multiple IP administrations (Day 7, 1 hour post-dose). After discharge on Day 8, the subject complained of headache, nausea, vomiting, neck stiffness, and numbness of the extremities. The symptoms occurred when he got up and disappeared after he remained in the supine position for several minutes. Five days later, he visited the neurology clinic of the main hospital. The neurologist recommended hospitalization for further evaluation and symptom management, and the subject was then admitted to the hospital. There were no abnormal findings in vital signs, laboratory results, or brain-computed tomography. His symptoms disappeared during the hospitalization period. It was important to distinguish whether the headache was IP-related or lumbar puncture-related. Therefore, knowledge of clinical characteristics and differential diagnosis of PLPH is paramount. Furthermore, if severe PLPH occurs, a consultation with a neurologist and imaging studies should be considered for a differential diagnosis of PLPH.