Issues in cerebrospinal fluid management. Acid-fast bacillus smear and culture.

Meningeal tuberculosis is an uncommon disease in the United States with an annual incidence of fewer than 200 cases. This study evaluates three approaches to improving the use of the cerebrospinal (CSF) acid-fast bacillus (AFB) smear and culture procedure: (1) education alone; (2) optional screening by which physicians can select to have the AFB analysis stopped if the initial CSF findings are unremarkable; and (3) mandatory screening before the performance of all CSF AFB analyses. With education alone, the CSF AFB culture rate decreased from 20.6% of all CSF acquisitions to 15.7% (P less than 0.001); however, the effect may have been related to a decrease in all types of AFB testing. Optional screening had no impact on the AFB testing rate. Mandatory screening significantly decreased the CSF AFB rate to 6.7% (P less than 0.001), unrelated to changes in other types of AFB testing. Laboratories that employ mandatory screening should report the screening results immediately and have a mechanism whereby physicians can bypass the screen, providing CSF AFB analysis on unremarkable fluid from high-risk patients.

Management of cerebrospinal fluid.

In traditional practice, doctors order tests and the laboratory performs them. A series of tests are requested before the results of any of the tests are known. The authors of this paper examine the interface between the clinicians and the laboratory. They produce a cost effective and clinically useful routine for handling spinal fluid. They bring to their practice an excellent example of quality assurance which is genuine, improves practice and is not "busy work." The editor heard Dr. Albright present this material and urged him to make it available to North Carolina doctors.

CSF TRAP: a procedure to improve laboratory testing with myelography.

CSF TRAP (Transport and Rapid Accessioning for Additional Procedures) is a procedure that provides storage of and rapid access to cerebrospinal fluid (CSF) specimens and allows clinicians to review initial findings before ordering low-yield CSF studies. The cost-effectiveness of routinely using the CSF TRAP procedure with myelography is examined in a study group of 819 patients, 74% with disc diseases, spinal stenosis, spondylolisthesis, or pain syndromes, 10% with cancer, and 16% with neuropathies and miscellaneous conditions. Routine studies on CSF obtained during myelography provided little additional clinical information, except for patients with cancer (of 80 patients with cancer, the results of cytological examination of the CSF were positive in 12) and patients with multiple sclerosis, for whom oligoclonal band and IgG analysis provided supportive diagnostic data. The utilization of the CSF TRAP procedure with elimination of unnecessary culture and cytological studies on patients with disc diseases, spinal stenosis, spondylolisthesis, and pain syndromes, reduces myelographic CSF procedures by 20%, for a savings exceeding $14,000. The CSF TRAP procedure allows for a more cost-efficient analysis of CSF obtained using myelography, while providing fluid for analysis in patients with unexpected findings.