Go gogiwa metsi a mokwatla/monyetsane - Breaking down the myths around a life saving medical procedure
We all come from societies rich with folktales, myths, and legends. Even though the factuality of these stories is often found wanting, these tales serve as a framework through which we interpret the world around us. When these narratives begin to cross paths with principles of science, there is often an unsettling feeling. This is perhaps even more exaggerated when our core believes are in direct contradiction to medical sciences. As a physician, it’s always heartbreaking to see one loose their lives because of false belief. Today I hope to demystify a lifesaving procedure and perhaps help to save lives of many.
What is lumbar puncture?
This procedure also known as a spinal tap or just LP, involves sampling of fluid that surrounds the spinal cord and brain mainly for diagnosis of infectious of the brain and spinal cord.
Other indications for this procedure is related to diagnosis of
l Central nervous system cancers
l Bleeding in the brain (Subarachnoid hemorrhage)
l Neuron diseases of the brain such as Guillain Barre Syndrome
How is it done?
Before this is done, consent is required from the patient or their health care proxy. Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care. Successful communication in the patient-physician relationship fosters trust and supports shared decision-making. As such, a detailed explanation of the procedure and all the possible complications are discussed beforehand.
Following an informed consent, the procedure is done under sterile conditions to prevent infections. Standard surgical protocols are followed to ensure that the correct procedure is being carried out on the correct patient. Patients are often advised on bed rest for about 30 minutes.
What are some of the complications
associated with this procedure?
LP is a relatively safe procedure, but minor and major complications can occur even when standard infection control measures and good techniques are used. These complications include: Post-LP headache Infection
Bleeding
Cerebral herniation
Minor neurologic symptoms such as nerve pain or numbness
Back pain
More details on the different complications…
Dr Rodgers Moeng, who is an internist and a fellow in clinical infectious disease at Beth Israel Deaconess Medical Center and the Harvard Medical School in Boston, continues to discuss about these possible complications
l Post-LP headache - occurs in 10-30% of patients. It is one of the most common complications following LP. It usually resolves in 24-48 hours. Oral pain medicines are usually adequate to help with this.
l Infections are rare after LP because it is done under sterile condition. In very rare cases, bacteria from the skin can be inoculated in underlying tissues such as spinal bone and cause infection, but this is extremely rare
l Bleeding - Serious bleeding that results in spinal cord compromise is rare in the absence of bleeding risk. It is important to stop blood thinners such as warfarin before this procedure to lower risk of bleeding
l Cerebral (Brain) herniation - This is the most serious complication of LP. Brain herniation occurs when pressure within the skull (intracranial pressure) is increased, causing the brain to be pushed sideways and downward through small natural openings in the skull.
When should we be concerned
about cerebral herniation?
This complication, though very serious, does not occur completely. Some studies have shown incidence rates up to five percent and maybe less in settings where CT scans of the brain are done before this procedure. However, not all patient require CT scan of the brain.
We tend to worry for risk of brain herniation with the following findings
l Altered mental status, severe confusion and decreased responsiveness
l Abnormal neurological examination
l Increase pressure in the eyes also called papilledema
l Recent seizures or epileptic convulsions
l Those with severe immunocompromise such as AIDS and leukemia patients
Most of these patients will often require CT scan of the brain to assess the risk of brain herniation
Why are Batswana concerned about the safety of this procedure?
LP is perhaps one of the most feared procedures in the medical world. As doctors, we often face a great challenge when trying to perform this. There is always a lot of hesitance, anxiety and pushback from patients and family members.
Most report that they have lost friends and relatives after this procedure. There is a general feeling that patients can die from this procedure.
To answer this question, let me first say infections of the brain are very serious and boast very high mortality and death rates. A lot of patients still die with appropriate therapy. These figures are, however, exaggerated when there is a delay in diagnosis and treatment. Infections of the brain and spinal require rapid diagnosis and treatment to stand a better chance at survival.
Most patients who pass away from complications of this very bad infection will pass within two weeks. Most of these patients die in the hospital after undergoing this procedure. So it is perhaps not surprising that people will tend to attribute the death to the procedure while in actual fact the death is a result of the infection. About 30% of patient with meningitis will die even with therapy because it’s a very aggressive disease.
I want to allay these fears by reassuring Batswana that this is a very safe procedure. It is very similar to the procedure we perform in anesthesia for pregnant women who are about given birth. As we know, we don’t see a lot of these women die from it.
Knowledge is power and power is freedom. Let us continue to march together to build an informed nation, for us and for our children.