New and not diagnosed, lumbar puncture question

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New and not diagnosed, lumbar puncture question

Postby lamom » Sun Dec 23, 2007 1:04 pm

hi there-

Saw Neurologist a couple of days ago and he ordered a lp for next friday along with spinal mri's- I am very nervous about having the lp done and was wondering if you all could give me some advice about pain etc- or just experiences with this? I want to be prepared- of course dr. says it doesn't hurt, but my brother had one a year or two ago with meningitis and said it was horrible. The dr. gave me xanax to take- but honestly I'm more worried about this stupid spinal tap than i am about being diagnosed with ms! I'll be relieved to know whats wrong and get some help-

Also- how many of you had to have lps to be diagnosed? I have one (1cm) lesion on brainstem, but due to hand weakness i had for 7 weeks last month he has ordered new tests. After seeing him, and having him ask me about feeling electric shock feelings in my spine (which I dont) I remembered that three years ago after my twins were born I had what I thought was meningits- horrible headache, neck ache- but I also had the horrible squeezing in my chest and for several weeks after I had strange feelings in my spine-

3 years before this incident, I had the flu and it also turned into the horrible chest squeezing (wondering if this could be the "ms hug" ?)- I thought I was having a heart attack. This incident was also after the birth of a child.

These two incidents have always stuck with me as being strange- like nothing else I've ever gone through- Now, thinking about the possibility that I have MS, I'm wondering if those could have been flare ups? If so do you think I should call the neuro and fill him in? Would it change whether he wants to do a spinal tap?

I'm worried about the pain and the possible headache afterward and wonder if he knew about these possible symptoms if he would diagnose me without the lp.

Thanks so much for your help!

jennifer

btw- I am a 33 year old mother to 4
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Postby Lyon » Sun Dec 23, 2007 1:27 pm

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Postby Loobie » Sun Dec 23, 2007 2:23 pm

Actually, the less tense you are, the better chance it will hurt less. It's not unbearable. It's just and unusual type of pain. I won't BS you, it does hurt and is uncomfortable, but just relax as much as possible and also stay horizontal as much as possible after it for a good while. Also take a Mt. Dew or some coffee. I've heard that caffeine helps with not getting the headache afterwards. I didn't get it, but I did drind a Mt. Dew and stayed flat on my back; even in the car on the way home.

I've heard that if you try and be up and about after the LP, that the headache is worse than the actual LP.

Good luck, I'm sure you'll be ok.
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Postby lamom » Sun Dec 23, 2007 2:48 pm

thanks for the answers-

as far as being prone afterwards- the neuro has me going immediately in to have the spinal mri done after the lp- and then across the street to take my spinal fluid to the lab at the hospital and have some blood drawn- this seems like a lot of activity to me when I keep hearing you are supposed to lay flat-

It all feels rushed and I just don't know what to do- I cannot be bedridden with a headache for a week- I have 8 nine year olds coming over two days later for a slumber party!

I guess I need to just call the neuro or his nurse and ask away-
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Postby ssmme » Sun Dec 23, 2007 3:21 pm

Hi Lamom,

I had an LP as the final confirmation on my ms dx. The LP itself was not actually painful but was very uncomfortable. I hope the doctor that performs your LP has a good bedside manner. Mine was an A-hole who bragged that none of his patients ever get the headache and of course I got it. I followed the hospital's post-LP procedures to the "t" but still got it. If you have any inkling that the headache is coming on have a phone number on hand to call your dr asap to schedule a blood patch.
The headache is usually caused by the hole into your epidural space not closing back causing you to leak spinal fluid. To me it felt like there was nothing holding my brain up in my skull, it was "crushing" down on the base of my skull. Your body continually makes spinal fluid but you never "fill back up".
With the blood patch, the dr will extract blood from your arm and inject it into the place where the hole in your epidural space is. The blood will somehow stop the flow of spinal fluid maybe by coagulating and allow the hole to mend. Once this procedure is completed you will have almost immediate cessation of the pain.
Hindsight being 20/20 I wish I would have requested the blood patch be done right after the LP then it would have been darn near impossible to get the headache.
I'm no medical professional so I'm not sure the terminology I used here is absolutely correct but hopefully this information will allow you to have a good conversation with whichever dr is performing the LP and that you'll be able to keep the headache from coming on.
Let us know how it goes. Good luck!!

Marcia
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Postby Lyon » Sun Dec 23, 2007 3:54 pm

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Postby lamom » Sun Dec 23, 2007 4:22 pm

well- thanks for the replies. I've been reading the archives and am not as worried about the pain as I was- I've had two epidurals which are basically the same thing...

I am going to call them after xmas and ask about the mri and all of that-

thanks everyone :)
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Re: Lumbar puncture question

Postby NHE » Sun Dec 23, 2007 5:17 pm

I had a spinal tap during my diagnosis. The actual procedure was not painful although I did feel a slight sting as the needle went through the skin. I was told to stay horizontal afterwards. However, I was stubborn and told the nurse that I felt fine. I showered and then had dinner in the hospital cafeteria. Halfway through my dinner I started getting really nauseous from the headache and had to go lie down. The headache stuck around for about 5 days and I had to go back to the hospital to get a blood patch. It sounds like your doctor wants you to do a lot of walking around after your tap. Getting an MRI should not be a problem as you'll be horizontal, though I would make sure that the wheel you there on a gurney and that you not walk around. My MRIs would typically last for about 30 - 45 minutes. However, I would try staying horizontal for about an hour or two in total.

Another factor is the needle bevel orientation. The fibers of the dura are oriented longitudinally. Thus, if the needle bevel is perpendicular to the fibers, then it tends to cut them and do more damage creating a higher likelihood that there will be a prolonged fluid leak at the puncture site. However, if the needle bevel is parallel to the longitudinal fibers, the damage at the puncture site will be less and hopefully there will be less problems with fluid leaking from the puncture site.

It might be a good idea to read this thread first and make sure that the doctor doing the tap is aware of the issue raised by jimmyleggs concerning the needle bevel orientation.
Needle bevel direction and headache after inadvertent dural puncture.
Norris MC, Leighton BL, DeSimone CA.
Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania.
Anesthesiology. 1989 May;70(5):729-31.


To study the effect of needle bevel direction on the incidence and severity of headache following inadvertent dural puncture occurring during the identification of the epidural space, the authors randomly assigned obstetric anesthesia residents to identify epidural space with the bevel of the epidural needle oriented either parallel or perpendicular to the longitudinal dural fibers. If dural puncture occurred, an observer unaware of the needle bevel direction, daily assessed the presence and severity of any subsequent headache. Of the 1,558 women who received epidural analgesia during this study, 41 women suffered dural puncture, 20 with the needle bevel oriented perpendicular to the longitudinal dural fibers and 21 with the needle bevel inserted parallel to the dural fibers (NS). Fourteen of 20 women in the group in which the needle bevel was perpendicular to dural fibers developed a moderate to severe headache, whereas only five of 21 in the group in which the needle bevel was parallel to dural fibers did so (P less than 0.005). Similarly, we administered a therapeutic blood patch to ten of 20 women in the perpendicular group but to only four of 21 in the parallel group (P less than 0.05). Thus, identifying the epidural space with the needle bevel oriented parallel to the longitudinal dural fibers limits the size of the subsequent dural tear and, therefore, lowers the incidence of headache should dural perforation occur.

NHE
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Postby lamom » Sun Dec 23, 2007 5:24 pm

thanks NHE- yeah after reading so much about the LB I saw something about that- I have a lot of faith in my dr so far- he seems to be a bit of an ms specialist (or a lot of one, I don't know) so I'm going to assume he knows about all of that! he has an mri facility attached to his office, but I don't know if he will be the one doing it?

I was fortunate to be referred to a dr that seems to have a lot of ms knowledge an is pretty proactive- so I think (even though I've had weird health stuff for 5 or more years) that I will know pretty quickly one way or the other about ms.
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Re: Lumbar puncture question

Postby NHE » Sun Dec 23, 2007 5:26 pm

Here's a more recent paper that performed a meta-analysis of multiple studies.

Bevel direction and postdural puncture headache: a meta-analysis.
Neurologist. 2006 Jul;12(4):224-8.
    BACKGROUND: The effect of lumbar puncture needle bevel direction on the incidence of postdural puncture headache (PDPH) is somewhat controversial. We performed a meta-analysis of available trials to determine if bevel direction during lumbar puncture would influence the incidence of PDPH. REVIEW SUMMARY: Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to November 29, 2004) and abstracts from several national meetings (American Society of Anesthesiology, International Anesthesia Research Society, American Society of Regional Anesthesia, Society of Obstetric Anesthesia and Perinatology) for terms related to needle and bevel direction. Inclusion criteria were assessment of the incidence of PDPH after lumbar puncture with a cutting needle (eg, Quincke, Tuohy), comparison of a "parallel" (bevel oriented in a longitudinal or cephalad to caudad direction) to "perpendicular" (bevel oriented in a transverse direction) orientation during needle insertion, randomized trials, and trials primarily in adult populations. Data on study characteristics and incidence of PDPH were abstracted from qualified studies and subsequently analyzed. The search resulted in 52 abstracts from which the original articles were obtained and data abstracted, with ultimately a total of 5 articles meeting all inclusion criteria. Insertion of a non-pencil-point/cutting needle with the bevel oriented in a parallel/longitudinal fashion resulted in a significantly lower incidence of PDPH compared with that oriented in a perpendicular/transverse fashion (unadjusted rates of 10.9% versus 25.8%; odds ratio = 0.29 [95% CI = 0.17-0.50]). CONCLUSIONS: Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.

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Postby jimmylegs » Sun Dec 23, 2007 5:36 pm

good one NHE i missed this thread somehow
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Postby DM » Sun Dec 23, 2007 6:14 pm

Hi Lamom,

Had an LP in January 2007. I wasn't really looking forward to it but hey, it apparently was necessary. I dreaded it. Actually, the worst part was when they apply this super cooled alcohol before pushing in the needle. Its not great, but not as bad as one would think.

Unfortunately for me, my neurologist was unable to find the fluid after making several attempts. He then sent me down to XRAY where another doctor performed the same, this time with live action camera. However, since he was entering my back in another spot, he had to freeze me once again.

Once the intial freezing starts to numb your area, subsequent needles aren't bothersome at all. You feel the pinch, but that is about it. The DR in xray actually tpuched some nerves along my spinal cord and the sensation down my leg did not feel wonderful at all. Kind of whacking your funny bone, b ut from the inside.

Anyways, I am a 52 year old male, 51 when it was done, and I really wouldn't worry about it.

BTW, lie down for at least an hour, if not two, to hopefully not incur any headaches. During the week of, when I coughed, I felt the pain in my head, but it immediately went away.

Dan
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Postby MattB » Mon Dec 24, 2007 2:06 pm

The procedure itself is nothing to worry about. It is not exactly comfortable but the most actual pain comes from the needle with the anesthetic so no worries. My best advice is to take it very easy afterwards. I did not and I think I payed a price for it. I could not stand or sit up for more than a week without the most painful headache I ever had. This is not typical however. I would expect that you'll be fine. Don't worry.

I wasn't diagnosed with the lp though. All of the numbers came back perfectly normal and I was only diagnosed when I had my optical neuritis combined with multiple cases of lesions. Now I am getting the electric sensation I assume your neuro is talking about. I start treatment soon.

Good luck!
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Postby whyRwehere » Tue Dec 25, 2007 3:29 am

I was under the impression, that it was no longer necessary to have a LP done for diagnosis....that history and MRI are enough. My husband had one done, because at the time we knew nothing...didn't even suspect MS, and just did what the doctor said. My husband said it didn't hurt, but he also wouldn't do it again...why have an unnecessary procedure done, that could make you feel ill. I remember the doctor said something like "well, the fluid is positive, so that's good news, because we know he has some illness"..... good news, huh?
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Postby jimmylegs » Tue Dec 25, 2007 7:33 am

i'm probably teaching grandmothers to suck eggs here but let's not forget that "dx" is just a stats-based checklist. LP looks for chronic central inflammation based on whether oligoclonal bands are present in greater numbers than a serum comparison test. so no, you don't need it for dx. if done, it just adds to the list of ways you fit or do not fit into the statistical picture of ms.
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