Lumbar puncture - Knowledge (XXG)

38: 1171: 600: 646:. The procedure is ended by withdrawing the needle while placing pressure on the puncture site. The spinal level is so selected to avoid spinal injuries. In the past, the patient would lie on their back for at least six hours and be monitored for signs of neurological problems. There is no scientific evidence that this provides any benefit. The technique described is almost identical to that used in 733: 706:

inserting the spinal needle too far, some clinicians use the "Cincinnati" method. This method involves removing the stylet of the spinal needle once the needle has advanced through the dermis. After removal of the stylet, the needle is inserted until CSF starts to come out of the needle. Once all of the CSF is collected, the stylet is then reinserted before removal of the needle.

592: 294:(IIH). This disease is characterized by increased pressure of CSF which may cause headache and permanent loss of vision. While mainstays of treatment are medication, in some cases lumbar puncture performed multiple times may improve symptoms. It is not recommended as a staple of treatment due to discomfort and risk of the procedure, and the short duration of its efficacy. 3672: 584: 690:(bottom of the spinal cord) terminates at the level of L1 in adults, but may range in term neonates (newly born babies) from L1–L3 levels. It is important to insert the spinal needle below the conus medullaris at the L3/L4 or L4/L5 interspinous levels. With growth of the spine, the conus typically reaches the adult level (L1) by 2 years of age. 490:. The latter is exceedingly rare, since the level at which the spinal cord ends (normally the inferior border of L1, although it is slightly lower in infants) is several vertebral spaces above the proper location for a lumbar puncture (L3/L4). There are case reports of lumbar puncture resulting in perforation of abnormal dural 1995:

Nath, Siddharth; Koziarz, Alex; Badhiwala, Jetan H; Alhazzani, Waleed; Jaeschke, Roman; Sharma, Sunjay; Banfield, Laura; Shoamanesh, Ashkan; Singh, Sheila; Nassiri, Farshad; Oczkowski, Wieslaw; Belley-Côté, Emilie; Truant, Ray; Reddy, Kesava; Meade, Maureen O; Farrokhyar, Forough; Bala, Malgorzata M;

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Lumbar punctures are often used to diagnose or verify an infection in very young babies and can cause quite a bit of pain unless appropriate pain control is used (analgesia). Managing pain is important for infants undergoing this procedure. Approaches for pain control include topical pain medications

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as much as possible. Patients may also sit on a stool and bend their head and shoulders forward. The area around the lower back is prepared using aseptic technique. Once the appropriate location is palpated, local anaesthetic is infiltrated under the skin and then injected along the intended path of

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Rochwerg, Bram; Almenawer, Saleh A; Siemieniuk, Reed A C; Vandvik, Per Olav; Agoritsas, Thomas; Lytvyn, Lyubov; Alhazzani, Waleed; Archambault, Patrick; D’Aragon, Frederick; Farhoumand, Pauline Darbellay; Guyatt, Gordon; Laake, Jon Henrik; Beltrán-Arroyave, Claudia; McCredie, Victoria; Price, Amy;

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Visintin, C.; Mugglestone, M. A.; Fields, E. J.; Jacklin, P.; Murphy, M. S.; Pollard, A. J.; Guideline Development Group; National Institute for Health and Clinical Excellence (28 June 2010). "Management of bacterial meningitis and meningococcal septicaemia in children and young people: summary of

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are not as thick in infants and children as they are in adults. Therefore, it is difficult to assess when the needle passes through them into the subarachnoid space because the characteristic "pop" or "give" may be subtle or nonexistent in the pediatric lumbar puncture. To decrease the chances of

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is helpful for visualizing the interspinous space and assessing the depth of the spine from the skin. Use of ultrasound reduces the number of needle insertions and redirections, and results in higher rates of successful lumbar puncture. If the procedure is difficult, such as in people with spinal

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for two hours after the successful puncture; this has not been borne out in modern studies involving large numbers of people. Doing the procedure with the person on their side might decrease the risk. Intravenous caffeine injection is often quite effective in aborting these spinal headaches. A

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In children, a sitting flexed position was as successful as lying on the side with respect to obtaining non-traumatic CSF, CSF for culture, and cell count. There was a higher success rate in obtaining CSF in the first attempt in infants younger than 12 months in the sitting flexed position.

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levels can indicate fungal, tuberculous or pyogenic infections; lymphomas; leukemia spreading to the meninges; meningoencephalitic mumps; or hypoglycemia. A glucose level of less than one third of blood glucose levels in association with low CSF lactate levels is typical in hereditary CSF

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Alshamsi, Fayez; Krag, Mette; Etxeandia-Ikobaltzeta, Itziar; Kunz, Regina; Nishida, Osamu; Matouk, Charles; Selim, Magdy; Rhodes, Andrew; Hawryluk, Gregory; Almenawer, Saleh A (March 2018). "Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis".

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Sempere, AP; Berenguer-Ruiz, L; Lezcano-Rodas, M; Mira-Berenguer, F; Waez, M (2007). "Punción lumbar: indicaciones, contraindicaciones, complicaciones y técnica de realización" [Lumbar puncture: its indications, contraindications, complications and technique].

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is present in the CSF; the level is usually about 60% that in the peripheral circulation. A fingerstick or venipuncture at the time of lumbar puncture may therefore be performed to assess peripheral glucose levels and determine a predicted CSF glucose value. Decreased

878:. It has high sensitivity and specificity for many infections of the CNS, is fast, and can be done with small volumes of CSF. Even though testing is expensive, cost analyses of PCR testing in neonatal patients demonstrated savings via reduced cost of hospitalization. 444:

The risk of headache and need for analgesia and blood patch is much reduced if "atraumatic" needles are used. This does not affect the success rate of the procedure in other ways. Although the cost and difficulty are similar, adoption remains low, at only 16%

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Cascino, A.; Cangiano, C.; Fiaccadori, F.; Ghinelli, F.; Merli, M.; Pelosi, G.; Riggio, O.; Rossi Fanelli, F.; Sacchini, D.; Stortoni, M.; Capocaccia, L. (September 1982). "Plasma and cerebrospinal fluid amino acid patterns in hepatic encephalopathy".

243:. Young infants commonly require lumbar puncture as a part of the routine workup for fever without a source. This is due to higher rates of meningitis than in older persons. Infants also do not reliably show classic symptoms of meningeal irritation ( 653:

The upright seated position is advantageous in that there is less distortion of spinal anatomy which allows for easier withdrawal of fluid. Some practitioners prefer it for lumbar puncture in obese patients, where lying on their side would cause a

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The brain and spinal cord are enveloped by a layer of cerebrospinal fluid, 125–150 mL in total (in adults) which acts as a shock absorber and provides a medium for the transfer of nutrients and waste products. The majority is produced by the

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Pessano, Sara; Romantsik, Olga; Olsson, Emma; Hedayati, Ehsan; Bruschettini, Matteo (2023). Cochrane Neonatal Group (ed.). "Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants".

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Analysis of the cerebrospinal fluid generally includes a cell count and determination of the glucose and protein concentrations. The other analytical studies of cerebrospinal fluid are conducted according to the diagnostic suspicion.

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and unreliable anatomical landmarks. However, opening pressures are notoriously unreliable when measured in the seated position. Therefore, patients will ideally lie on their side if practitioners need to measure opening pressure.

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erythrocytes are observed, signifies haemorrhage into the CSF that preceded the lumbar puncture. Therefore, when erythrocytes are detected in the CSF sample, erythrophagocytosis suggests causes other than a traumatic tap, such as

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in four patients with tuberculous meningitis. The main purpose was the treatment of raised intracranial pressure rather than for diagnosis. The technique for needle lumbar puncture was then introduced by the German physician

3704: 237:, since there is no other reliable tool with which meningitis, a life-threatening but highly treatable condition, can be excluded. A lumbar puncture can also be used to detect whether someone has Stage 1 or Stage 2 571:. There is lower risk with inserting a needle into the spine at the level of the cauda equina because these loose fibers move out of the way of the needle without being damaged. The lumbar cistern extends into the 3273:

Watanabe, A; Takei, N; Higashi, T; Shiota, T; Nakatsukasa, H; Fujiwara, M; Sakata, T; Nagashima, H (October 1984). "Glutamic acid and glutamine levels in serum and cerebrospinal fluid in hepatic encephalopathy".

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pushing the arachnoid membrane out towards the dura. Therefore, once the needle has pierced the dura mater it has also traversed the thinner arachnoid membrane. The needle is then in the subarachnoid space. The

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The person is usually placed on their side (left more commonly than right). The patient bends the neck so the chin is close to the chest, hunches the back, and brings knees toward the chest. This approximates a

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headache that is persistent despite a long period of bedrest and occurs only when sitting up may be indicative of a CSF leak from the lumbar puncture site. It can be treated by more bedrest, or by an

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from the spinal needle is then withdrawn and drops of cerebrospinal fluid are collected. The opening pressure of the cerebrospinal fluid may be taken during this collection by using a simple column

163:(pressure in the skull) is a contraindication, due to risk of brain matter being compressed and pushed toward the spine. Sometimes, lumbar puncture cannot be performed safely (for example due to a 993:

can be measured to help distinguish meningitides of bacterial origin, which are often associated with high levels of the enzyme, from those of viral origin in which the enzyme is low or absent.

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Patel, R.; Urits, I.; Orhurhu, V.; Orhurhu, M. S.; Peck, J.; Ohuabunwa, E.; Sikorski, A.; Mehrabani, A.; Manchikanti, L.; Kaye, A. D.; Kaye, R. J.; Helmstetter, J. A.; Viswanath, O. (2020).

520:; others believe that such events are merely coincidental in time, occurring independently as a result of the same pathology that the lumbar puncture was performed to diagnose. In any case, 3697: 1241:

in the 1970s. During this quite painful procedure, CSF was replaced with air or some other gas via the lumbar puncture in order to enhance the appearance of certain areas of the brain on

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Numerous antibody-mediated tests for CSF are available in some countries: these include rapid tests for antigens of common bacterial pathogens, treponemal titers for the diagnosis of

779:. Significant changes in pressure during the procedure can indicate tumors or spinal blockage resulting in a large pool of CSF, or hydrocephalus associated with large volumes of CSF. 3690: 271:(RBCs)/mm constitutes a "negative" tap in the context of a workup for subarachnoid hemorrhage, for example. Taps that are "positive" have an RBC count of 100/mm³ or more. 3309:

Levine, J; Panchalingam, K; Rapoport, A; Gershon, S; McClure, RJ; Pettegrew, JW (1 April 2000). "Increased cerebrospinal fluid glutamine levels in depressed patients".

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IgG synthetic rate is calculated from measured IgG and total protein levels; it is elevated in immune disorders such as multiple sclerosis, transverse myelitis, and

233:(CSF). Analysis of CSF may exclude infectious, inflammatory, and neoplastic diseases affecting the central nervous system. The most common purpose is in suspected 3566: 3127: 1450:

Gröschel, K; Schnaudigel, S; Pilgram, S; Wasser, K; Kastrup, A (19 December 2007). "Die diagnostische Lumbalpunktion" [The diagnostic lumbar puncture].

807:. White cells can also indicate reaction to repeated lumbar punctures, reactions to prior injections of medicines or dyes, central nervous system hemorrhage, 2295: 4120: 326:

Exception: therapeutic use of lumbar puncture to reduce ICP, but only if obstruction (for example in the third ventricle of the brain) has been ruled out

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Chabot, Christian; Zervakis, Tracy; Badhiwala, Jetan; St-Onge, Maude; Szczeklik, Wojciech; Møller, Morten Hylander; Lamontagne, Francois (22 May 2018).

259:, and many other diagnoses may be supported or excluded with this test. It may also be used to detect the presence of malignant cells in the CSF, as in 508:

is present or suspected, when topical infections or dermatological conditions pose a risk of infection at the puncture site or in patients with severe

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Zorrilla-Vaca, A; Makkar, JK (May 2017). "Effectiveness of Lateral Decubitus Position for Preventing Post-Dural Puncture Headache: A Meta-Analysis".

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with back pain. Some authorities believe that withdrawal of fluid when initial pressures are abnormal could result in spinal cord compression or

301:(characterized by urinary incontinence, a changed ability to walk properly, and dementia) receive some relief of symptoms after removal of CSF. 69: 2668:"Real-Time Polymerase Chain Reaction Detection of Herpes Simplex Virus in Cerebrospinal Fluid and Cost Savings from Earlier Hospital Discharge" 1264:"The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis" 2320:

Wright, Ben L. C.; Lai, James T. F.; Sinclair, Alexandra J. (26 January 2012). "Cerebrospinal fluid and lumbar puncture: a practical review".

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Gierson, HW; Marx, JI (April 1955). "Tuberculous meningitis: the diagnostic and prognostic significance of spinal fluid sugar and chloride".

2567: 2502: 1229:, a nowadays obsolete X-ray imaging study of the brain that was performed extensively from the 1920s until the advent of modern non-invasive 471:) in a leg during the procedure; this is harmless and people can be warned about it in advance to minimize their anxiety if it should occur. 291: 2981:"Defective Glucose Transport across the Blood-Brain Barrier as a Cause of Persistent Hypoglycorrhachia, Seizures, and Developmental Delay" 2979:

De Vivo, Darryl C.; Trifiletti, Rosario R.; Jacobson, Ronald I.; Ronen, Gabriel M.; Behmand, Ramin A.; Harik, Sami I. (5 September 1991).

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Matata, C; Michael, B; Garner, V; Solomon, T (24–30 October 2012). "Lumbar puncture: diagnosing acute central nervous system infections".

3635: 3617: 1971:"Epidural Blood Patch - Imaging Glossary - Patients - UR Medicine Imaging Sciences (Radiology) - University of Rochester Medical Center" 864:

is the gold standard for detecting bacterial meningitis. Bacteria, fungi, and viruses can all be cultured by using different techniques.

819:. When peripheral blood contaminates the withdrawn CSF, a common procedural complication, white blood cells will be present along with 715:(anaesthetics such as lidocaine). The most effective approach for pain control in infants who require a lumbar puncture is not clear. 4039: 3149:

Hourani, Benjamin T.; Hamlin, EM; Reynolds, TB (1 June 1971). "Cerebrospinal Fluid Glutamine as a Measure of Hepatic Encephalopathy".

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Serious complications of a properly performed lumbar puncture are extremely rare. They include spinal or epidural bleeding, adhesive

1675: 1210:. In 1893 he published a long paper on diagnosing cerebrospinal meningitis by examining spinal fluid. However, he was criticized by 997: 666: 3497:"Four Cases of Tubercular Meningitis in Which Paracentesis of the Theca Vertebralis Was Performed for the Relief of Fluid Pressure" 3977: 3831: 1215: 256: 2267: 4010: 314: 1021: 633:

and the dura mater exist in flush contact with one another in the living person's spine due to fluid pressure from CSF in the

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for having obtained spinal fluid from children. He was acquitted, but, nevertheless, he was uninvited from the then forming

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in the brain and circulates from there to other areas, before being reabsorbed into the circulation (predominantly by the

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Lumbar punctures may also be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularly for

3868: 441:, where the person's own blood is injected back into the site of leakage to cause a clot to form and seal off the leak. 421: 168: 3529:(1891). "Verhandlungen des Congresses für Innere Medizin" [Negotiations of the Congress of Internal Medicine]. 3883: 491: 20: 996:

Changes in total protein content of cerebrospinal fluid can result from pathologically increased permeability of the

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Ellenby, MS; Tegtmeyer, K; Lai, S; Braner, DA (28 September 2006). "Lumbar puncture". Videos in clinical medicine.

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Leen, Wilhelmina G.; Willemsen, Michèl A.; Wevers, Ron A.; Verbeek, Marcel M.; Mendelson, John E. (6 August 2012).

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Contact between the side of the lumbar puncture needle and a spinal nerve root can result in anomalous sensations (

37: 2627:"Cost Analysis of Enteroviral Polymerase Chain Reaction in Infants With Fever and Cerebrospinal Fluid Pleocytosis" 1202:

The lumbar puncture procedure was taken to the United States by Arthur H. Wentworth an assistant professor at the

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Shaikh, F.; Brzezinski, J.; Alexander, S.; Arzola, C.; Carvalho, J. C. A.; Beyene, J.; Sung, L. (26 March 2013).

1624:"The role of lumbar puncture in the diagnosis of subarachnoid hemorrhage when computed tomography is unavailable" 1238: 867: 4102: 3025:"Cerebrospinal Fluid Glucose and Lactate: Age-Specific Reference Values and Implications for Clinical Practice" 1242: 832: 741: 625:

is housed. The needle is again pushed until there is a second 'give' that indicates the needle is now past the

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Joffe, Ari R. (29 June 2016). "Lumbar Puncture and Brain Herniation in Acute Bacterial Meningitis: A Review".

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and infusion of fluids. It was long taught that this complication can be prevented by strict maintenance of a

3916: 3682: 2365:"Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis" 904: 861: 749: 248: 152: 2439:

Hanson, Amy L.; Ros, Simon; Soprano, Joyce (May 2014). "Analysis of Infant Lumbar Puncture Success Rates".

4075: 4044: 3718: 2042:"Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline" 1203: 1126: 983: 968: 144: 1721:

Biousse, V. (October 2012). "Idiopathic intracranial hypertension: Diagnosis, monitoring and treatment".

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The reason for a lumbar puncture may be to make a diagnosis or to treat a disease, as outlined below.

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Pearson, Justin; Fuller, Geraint (August 2012). "Lumbar punctures and cerebrospinal fluid analysis".

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Pearson, Justin; Fuller, Geraint (August 2012). "Lumbar punctures and cerebrospinal fluid analysis".

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Kesler, Anat; Kupferminc, Michael (June 2013). "Idiopathic Intracranial Hypertension and Pregnancy".

1080: 1032: 870:(PCR) has been a great advance in the diagnosis of some types of meningitis, such as meningitis from 776: 438: 771:

Decreased CSF pressure can indicate complete subarachnoid blockage, leakage of spinal fluid, severe

4156: 4025: 3791: 1179: 931: 761: 521: 495: 230: 132: 2228:"Caffeine, is it effective for prevention of postdural puncture headache in young adult patients?" 4146: 4110: 3878: 3807: 3560: 3477: 3334: 3213: 2607: 2464: 2345: 2249: 2208: 2165: 2118: 2021: 1873: 1781: 1703: 1557: 1475: 972: 941:

Increased glucose levels in the fluid can indicate diabetes, although the 60% rule still applies.

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Conly, John M.; Ronald, Allan R. (July 1983). "Cerebrospinal fluid as a diagnostic body fluid".

3388:"Proteins in cerebrospinal fluid and blood: Barriers, CSF flow rate and source-related dynamics" 949: 768:, where the pressure is normal but there is excessive CSF), lumbar puncture may be therapeutic. 3353: 2807:"The role of cryptococcal antigen assay in diagnosis and monitoring of cryptococcal meningitis" 2521:

Bonadio, William (January 2014). "Pediatric Lumbar Puncture and Cerebrospinal Fluid Analysis".

1170: 567:). Nerves continue down the spine below this, but in a loose bundle of nerve fibers called the 524:

of the brain is often performed prior to lumbar puncture if an intracranial mass is suspected.

3714: 3652: 3602: 3437: 3402: 3359: 3326: 3291: 3255: 3205: 3166: 3105: 3064: 3002: 2961: 2926: 2877: 2836: 2787: 2746: 2697: 2648: 2563: 2538: 2498: 2456: 2421: 2386: 2337: 2200: 2157: 2110: 2071: 2013: 1952: 1917: 1896:"How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis?" 1865: 1830: 1773: 1738: 1695: 1645: 1604: 1549: 1510: 1467: 1432: 1383: 1365: 1334: 1293: 1285: 1192: 1145: 695: 647: 599: 280: 183: 179: 64: 3613: 2717:"Modified India ink preparation for Cryptococcus neoformans in cerebrospinal fluid specimens" 2557: 4059: 3945: 3644: 3544: 3526: 3508: 3469: 3429: 3318: 3283: 3247: 3197: 3158: 3095: 3054: 3044: 2992: 2953: 2916: 2908: 2867: 2826: 2818: 2777: 2736: 2728: 2687: 2679: 2638: 2599: 2530: 2490: 2448: 2413: 2376: 2329: 2239: 2192: 2149: 2102: 2061: 2053: 2005: 1944: 1907: 1857: 1820: 1812: 1765: 1730: 1687: 1635: 1600: 1592: 1541: 1502: 1459: 1424: 1373: 1324: 1275: 1188: 1103: 1036: 839:. In which case, further investigations are warranted, including imaging and viral culture. 788: 564: 321: 210: 175: 2805:

Antinori, S; Radice, A; Galimberti, L; Magni, C; Fasan, M; Parravicini, C (November 2005).

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Cramer, Gregory D.; Yu, Shi-Wei (2014). "Unique Anatomic Features of the Pediatric Spine".

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Several substances found in cerebrospinal fluid are available for diagnostic measurement.

753: 650:, except that spinal anesthesia is more often done with the patient in a seated position. 622: 433: 268: 264: 42:

Lumbar puncture in a sitting position. The reddish-brown swirls on the patient's back are

3233:"Improved Assay for Spinal Fluid Glutamine, and Values for Children with Reye's Syndrome" 3162: 1191:, who credits Wynter with the earlier discovery; he first reported his experiences at an 3585: 3040: 2364: 1178:

The first technique for accessing the dural space was described by the London physician

96: 3904: 3816: 3059: 3024: 2921: 2896: 2831: 2806: 2692: 2667: 2494: 2138:"A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache" 2066: 2041: 1825: 1800: 1378: 1353: 745: 618: 609: 545: 358: 3512: 3322: 2854:

Nigrovic, Lise E.; Kimia, Amir A.; Shah, Samir S.; Neuman, Mark I. (9 February 2012).

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Maranhao, B.; Liu, M.; Palanisamy, A.; Monks, D. T.; Singh, P. M. (17 December 2020).

986:, cerebral ischemia, brain abscess, hydrocephalus, hypocapnia or bacterial meningitis. 803:

is always an abnormal finding. A large number of granulocytes often heralds bacterial

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may be detected in CSF but not in serum, suggesting intrathecal antibody production.

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Reinsertion of the stylet may decrease the rate of post lumbar puncture headaches.

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Subjected to Science: Human Experimentation in America Before the Second World War

3084:"Variation in polyol levels in cerebrospinal fluid and serum in diabetic patients" 1028:. Very high levels of protein may indicate tuberculous meningitis or spinal block. 732: 3049: 2452: 1769: 1734: 82: 4049: 3955: 3911: 3796: 3786: 3763: 3735: 3580: 3473: 3251: 2997: 2980: 2603: 1225:

Historically lumbar punctures were also employed in the process of performing a

1211: 1112: 960: 875: 871: 820: 800: 792: 772: 671: 560: 479: 468: 362: 156: 2957: 2766:"Unusual morphological forms of Cryptococcus neoformans in cerebrospinal fluid" 2643: 2626: 2244: 2227: 2153: 3972: 3743: 2333: 2089:

Davis, A; Dobson, R; Kaninia, S; Giovannoni, G; Schmierer, K (February 2016).

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The spine of an infant at the time of birth differs from the adult spine. The

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Straus, Sharon E.; Thorpe, Kevin E.; Holroyd-Leduc, Jayna (25 October 2006).

1428: 1369: 1313:"Ultrasound-assisted Lumbar Punctures: A Systematic Review and Meta-Analysis" 1289: 617:

L3/L4, L4/L5 or L5/S1 and pushed in until there is a "give" as it enters the

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Cauley, Keith A. (October 2015). "Fluoroscopically Guided Lumbar Puncture".

2137: 1196: 953: 945: 899: 655: 643: 591: 509: 505: 429: 400: 244: 90: 3656: 3406: 3330: 3068: 2965: 2930: 2881: 2840: 2791: 2701: 2652: 2542: 2460: 2425: 2390: 2341: 2204: 2161: 2114: 2091:"Atraumatic needles for lumbar puncture: why haven't neurologists changed?" 2075: 2017: 1956: 1948: 1921: 1869: 1834: 1777: 1742: 1699: 1649: 1608: 1553: 1514: 1471: 1463: 1436: 1387: 1338: 1297: 3671: 3648: 3441: 3295: 3259: 3209: 3170: 3109: 3006: 2912: 2750: 229:

The chief diagnostic indications of lumbar puncture are for collection of

3937: 3856: 3842: 3773: 2872: 2855: 2417: 1861: 1816: 1801:"The diagnosis and treatment of idiopathic normal pressure hydrocephalus" 1005: 882: 808: 796: 756:, meningeal inflammation, purulent meningitis or tuberculous meningitis, 614: 513: 502: 404: 383: 140: 247:) like neck stiffness and headache the way adults do. In any age group, 3201: 3100: 3083: 1329: 1312: 1280: 1263: 1183: 1009: 926: 921: 812: 583: 2381: 2057: 1545: 147:, including the brain and spine. Examples of these conditions include 106: 2897:"The blood and spinal fluid sugar and chloride content in meningitis" 2764:

Shashikala.; Kanungo, R; Srinivasan, S; Mathew, R; Kannan, M (2004).

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Gallia, Gary L; Rigamonti, Daniele; Williams, Michael A (July 2006).

1199:, Germany, in 1891. He subsequently published a book on the subject. 964: 851:

lab for various types of smears and cultures to diagnose infections.

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Illustration depicting common positions for lumbar puncture procedure

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Lumbar puncture should not be performed in the following situations:

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Lumbar puncture was first introduced in 1891 by the German physician

136: 3496: 2856:"Relationship between Cerebrospinal Fluid Glucose and Serum Glucose" 908:, but the cryptococcal antigen (CrAg) test has a higher sensitivity. 823:, and their ratio will be the same as that in the peripheral blood. 320:

Rationale: lumbar puncture in the presence of raised ICP may cause

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the spinal needle. A spinal needle is inserted between the lumbar

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is a common side effect if a small atraumatic needle is not used.

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This article is about the medical procedure. For other uses, see

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Rand, Kenneth; Houck, Herbert; Lawrence, Robert (October 2005).

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Serial lumbar punctures may be useful in temporary treatment of

127:, is a medical procedure in which a needle is inserted into the 3686: 3387: 858:

may demonstrate gram positive bacteria in bacterial meningitis.

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deformities such as scoliosis, it can also be performed under

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López, T; Sánchez, FJ; Garzón, JC; Muriel, C (January 2012).

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Hypertension with bradycardia and deteriorating consciousness

559:. Below the first or second lumbar vertebrae (L1 or L2) the 2268:"Iatrogenic CSF Leaks from Lumbar Punctures – a commentary" 1628:

Journal of the Canadian Association of Emergency Physicians

975:, heritable mitochondrial disease, low blood pressure, low 555:

The cerebrospinal fluid can be accessed most safely in the

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The headaches may be caused by inadvertent puncture of the

2282:"Cerebrospinal Fluid (CSF) Leak: Symptoms & Treatment" 486:

roots resulting in weakness or loss of sensation, or even

1024:, leakage of CSF, increases in intracranial pressure, or 902:

test is still used for detection of meningitis caused by

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Lumbar puncture in a child suspected of having meningitis

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Although not available in all clinical settings, use of

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Nigrovic, Lise E.; Chiang, Vincent W. (1 August 2000).

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is the most common complication; it often responds to

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Gottlieb, M; Holladay, D; Peksa, GD (January 2019).

135:(CSF) for diagnostic testing. The main reason for a 4101: 4068: 3996: 3954: 3936: 3892: 3840: 3805: 3771: 3762: 3734: 3231:Glasgow, Allen M.; Dhiensiri, Kamnual (June 1974). 2487:

Clinical Anatomy of the Spine, Spinal Cord, and Ans

587:

Illustration depicting lumbar puncture (spinal tap)

89: 75: 63: 55: 30: 2715:Zerpa, R; Huicho, L; Guillén, A (September 1996). 1218:, where he would have been the first professor of 948:are often involved with hepatic encephalopathies, 1526: 1524: 332:CT brain, especially in the following situations 2631:Archives of Pediatrics & Adolescent Medicine 1352:Doherty, Carolynne M; Forbes, Raeburn B (2014). 3455: 3453: 3451: 2516: 2514: 3182: 3180: 2480: 2478: 2226:Ragab, Ashraf; Facharzt, Khalid Noman (2014). 1577: 1575: 1573: 1571: 982:, respiratory alkalosis, idiopathic seizures, 3698: 1182:. In 1889 he developed a crude cut down with 530:can result from a lumbar puncture procedure. 8: 3358:. Elsevier Health Sciences. pp. 1408–. 174:The procedure is typically performed under 167:). It is regarded as a safe procedure, but 4121:National Institutes of Health Stroke Scale 3768: 3705: 3691: 3683: 3616:has a reference to an 1896 publication in 3565:: CS1 maint: location missing publisher ( 1848:Roos, KL (March 2003). "Lumbar puncture". 826:The finding of erythrophagocytosis, where 407:), in hands of an inexperienced physician. 36: 3099: 3058: 3048: 2996: 2920: 2871: 2830: 2781: 2740: 2691: 2642: 2380: 2315: 2313: 2311: 2309: 2307: 2305: 2296:"Cerebrospinal Fluid Leak (CSF Leak) FAQ" 2243: 2065: 1911: 1824: 1676:"Spinal anesthesia in pediatric patients" 1639: 1409: 1407: 1405: 1403: 1401: 1399: 1397: 1377: 1328: 1279: 190:and collect fluid. Fluid may be sent for 3126:. clinicallabtesting.com. Archived from 1669: 1667: 1665: 1663: 1661: 1659: 1042: 764:. In the setting of raised pressure (or 731: 16:Procedure to collect cerebrospinal fluid 3555:] (in German). Berlin & Vienna. 3082:Servo, C; Pitkänen, E (December 1975). 3018: 3016: 1889: 1887: 1585:Cochrane Database of Systematic Reviews 1254: 3558: 3395:Restorative Neurology and Neuroscience 2770:Indian Journal of Medical Microbiology 595:Spinal needles used in lumbar puncture 501:The procedure is not recommended when 27: 7: 3163:10.1001/archinte.1971.00310180049005 2672:The Journal of Molecular Diagnostics 740:Increased CSF pressure can indicate 292:idiopathic intracranial hypertension 3636:The New England Journal of Medicine 3531:Proceedings of the Zehnter Congress 1452:Deutsche Medizinische Wochenschrift 1174:Lumbar puncture, early 20th century 1000:, obstructions of CSF circulation, 102: 2495:10.1016/b978-0-323-07954-9.00013-x 2185:Journal of Intensive Care Medicine 1805:Nature Clinical Practice Neurology 1758:Clinical Obstetrics and Gynecology 837:haemorrhagic herpetic encephalitis 674:(under continuous X-ray imaging). 206:to landmark may increase success. 14: 2523:The Journal of Emergency Medicine 2406:American Journal of Roentgenology 2142:Current Pain and Headache Reports 1156:Initially normal, then increased 998:blood-cerebrospinal fluid barrier 791:in cerebrospinal fluid is called 752:, hypo-osmolality resulting from 3978:Intervertebral disc annuloplasty 3832:Intracranial pressure monitoring 3670: 3553:The technique of lumbar puncture 3422:The American Journal of Medicine 2901:Archives of Disease in Childhood 2823:10.1128/JCM.43.11.5828-5829.2005 2811:Journal of Clinical Microbiology 2721:Journal of Clinical Microbiology 1692:10.1111/j.1460-9592.2011.03769.x 1216:Johns Hopkins School of Medicine 313:Idiopathic (unidentified cause) 257:benign intracranial hypertension 3190:Digestive Diseases and Sciences 3124:"Cerebrospinal Fluid Glutamine" 2985:New England Journal of Medicine 2860:New England Journal of Medicine 2733:10.1128/JCM.34.9.2290-2291.1996 2232:Egyptian Journal of Anaesthesia 2107:10.1136/practneurol-2014-001055 1507:10.7748/ns2012.10.27.8.49.c9364 799:can be normal; the presence of 394:Skin infection at puncture site 315:increased intracranial pressure 297:Additionally, some people with 3549:Die Technik der Lumbalpunktion 2535:10.1016/j.jemermed.2013.08.056 1597:10.1002/14651858.CD015594.pub2 267:. CSF containing less than 10 159:in some conditions. Increased 1: 4116:Mini–mental state examination 3513:10.1016/S0140-6736(02)16784-5 3323:10.1016/S0006-3223(99)00284-X 3151:Archives of Internal Medicine 2783:10.1016/S0255-0857(21)02835-8 2684:10.1016/S1525-1578(10)60582-X 2010:10.1016/S0140-6736(17)32451-0 1153:< 50 (mostly lymphocytes) 956:, hypercapnia and depression. 766:normal pressure hydrocephalus 446: 299:normal pressure hydrocephalus 3869:Multiple subpial transection 3434:10.1016/0002-9343(83)90080-3 3288:10.1016/0006-2944(84)90076-0 3050:10.1371/journal.pone.0042745 2453:10.1097/PEC.0000000000000119 1770:10.1097/GRF.0b013e31828f2701 1735:10.1016/j.neurol.2012.07.018 1354:"Diagnostic Lumbar Puncture" 498:; this is exceedingly rare. 494:, resulting in catastrophic 492:arterio-venous malformations 422:Post-dural-puncture headache 350:Abnormal respiratory pattern 169:post-dural-puncture headache 3884:Anterior temporal lobectomy 3474:10.1016/j.mpmed.2012.05.005 2998:10.1056/NEJM199109053251006 2946:Annals of Internal Medicine 2604:10.1016/j.mpmed.2012.05.005 1534:BMJ (Clinical Research Ed.) 1317:Academic Emergency Medicine 131:, most commonly to collect 21:Spinal tap (disambiguation) 4178: 3601:. JHU Press. p. 216. 2958:10.7326/0003-4819-42-4-902 2644:10.1001/archpedi.154.8.817 2562:. Thieme. pp. 45–46. 2245:10.1016/j.egja.2013.11.005 2154:10.1007/s11916-020-00860-0 1358:The Ulster Medical Journal 1075:> 2/3 of blood glucose 963:can occur the presence of 18: 4103:Clinical prediction rules 3749:Decompressive craniectomy 3725: 3597:Susan E. Lederer (1997). 3581:Heinrich Irenaeus Quincke 3386:Reiber, Hansotto (2003). 3252:10.1093/clinchem/20.6.642 2334:10.1007/s00415-012-6413-x 1641:10.1017/s1481803500006205 934:deficiency also known as 868:Polymerase chain reaction 344:Recent history of seizure 103: 35: 2441:Pediatric Emergency Care 2197:10.1177/0885066607299516 1913:10.1001/jama.296.16.2012 1429:10.33588/rn.4507.2007270 833:intracranial haemorrhage 742:congestive heart failure 347:Focal neurological signs 261:carcinomatous meningitis 165:severe bleeding tendency 3917:Amygdalohippocampectomy 2895:Hendry, E (June 1939). 1680:Minerva Anestesiologica 1274:(8). Wiley: 1098–1110. 1022:Guillain–Barré syndrome 905:Cryptococcus neoformans 862:Microbiological culture 847:CSF can be sent to the 750:subarachnoid hemorrhage 575:up to the S2 vertebra. 399:Vertebral deformities ( 249:subarachnoid hemorrhage 153:subarachnoid hemorrhage 4076:Electroencephalography 4045:Magnetoencephalography 3719:central nervous system 1975:www.urmc.rochester.edu 1949:10.36076/ppj.2017.E529 1464:10.1055/s-2008-1017470 1204:Harvard Medical School 1175: 1150:Yellowish and viscous 1131:Yellowish and viscous 1020:, collagen disease or 984:traumatic brain injury 775:, hyperosmolality, or 737: 728:Pressure determination 604: 596: 588: 550:arachnoid granulations 186:is used to access the 155:. It may also be used 145:central nervous system 4021:Pneumoencephalography 3862:Bilateral cingulotomy 3827:Suboccipital puncture 3649:10.1056/NEJMvcm054952 3495:Wynter W. E. (1891). 3352:Jay H. Stein (1998). 3311:Biological Psychiatry 2913:10.1136/adc.14.78.159 2559:Atlas of CSF cytology 2556:Harald Kluge (2007). 1850:Seminars in Neurology 1501:(8): 49–56, quiz 58. 1417:Revista de Neurología 1227:pneumoencephalography 1173: 1159:Normal or mildly low 1121:Normal or mildly low 991:lactate dehydrogenase 895:antibody, and others. 735: 602: 594: 586: 386:count (<50 x 10/L) 161:intracranial pressure 4162:Veterinary diagnosis 4152:Diagnostic neurology 4030:Transcranial Doppler 4016:Cerebral angiography 3968:Spinal decompression 3679:at Wikimedia Commons 3533:(in German): 321–31. 3276:Biochemical Medicine 2873:10.1056/NEJMc1111080 2489:. pp. 566–585. 2418:10.2214/AJR.14.14028 2322:Journal of Neurology 2004:(10126): 1197–1204. 1862:10.1055/s-2003-40758 1817:10.1038/ncpneuro0237 1622:Mann, David (2002). 1033:neuromyelitis optica 959:Increased levels of 944:Increased levels of 795:. A small number of 777:circulatory collapse 439:epidural blood patch 139:puncture is to help 4026:Echoencephalography 3792:Thalamic stimulator 3618:Boston Med. Surg. J 3041:2012PLoSO...742745L 2270:. 20 February 2015. 2095:Practical Neurology 1233:techniques such as 1212:antivivisectionists 1208:Children's Hospital 1180:Walter Essex Wynter 1137:Markedly Increased 1088:> 1,000 (mostly 932:glucose transporter 811:, recent epileptic 762:pseudotumor cerebri 522:computed tomography 518:cerebral herniation 496:epidural hemorrhage 231:cerebrospinal fluid 133:cerebrospinal fluid 123:), also known as a 4111:Glasgow Coma Scale 3879:Corpus callosotomy 3808:Ventricular system 3240:Clinical Chemistry 3202:10.1007/BF01391377 3101:10.1007/BF01222109 2375:(mar26 1): f1720. 1723:Revue Neurologique 1330:10.1111/acem.13558 1281:10.1111/anae.15320 1176: 1085:Yellowish, turbid 973:multiple sclerosis 815:, or a metastatic 738: 635:subarachnoid space 631:arachnoid membrane 605: 597: 589: 478:and trauma to the 372:Bleeding diathesis 240:Trypanosoma brucei 188:subarachnoid space 44:tincture of iodine 4134: 4133: 3932: 3931: 3675:Media related to 3608:978-0-8018-5709-6 3365:978-0-8151-8698-4 3355:Internal Medicine 3130:on 11 August 2013 2569:978-3-13-143161-5 2504:978-0-323-07954-9 2382:10.1136/bmj.f1720 2058:10.1136/bmj.k1920 1546:10.1136/bmj.c3209 1243:plain radiographs 1193:internal medicine 1163: 1162: 1111:< 200 (mostly 1037:Oligoclonal bands 789:white blood cells 696:ligamentum flavum 648:spinal anesthesia 623:ligamentum flavum 305:Contraindications 281:spinal anesthesia 184:hypodermic needle 180:sterile technique 114: 113: 4169: 4060:Microneurography 3946:Meningeal biopsy 3845: 3810: 3780: 3769: 3707: 3700: 3693: 3684: 3674: 3660: 3620: 3612: 3594: 3588: 3577: 3571: 3570: 3564: 3556: 3541: 3535: 3534: 3523: 3517: 3516: 3492: 3486: 3485: 3457: 3446: 3445: 3417: 3411: 3410: 3392: 3383: 3377: 3376: 3374: 3372: 3349: 3343: 3342: 3306: 3300: 3299: 3270: 3264: 3263: 3237: 3228: 3222: 3221: 3184: 3175: 3174: 3146: 3140: 3139: 3137: 3135: 3120: 3114: 3113: 3103: 3079: 3073: 3072: 3062: 3052: 3020: 3011: 3010: 3000: 2976: 2970: 2969: 2941: 2935: 2934: 2924: 2892: 2886: 2885: 2875: 2851: 2845: 2844: 2834: 2802: 2796: 2795: 2785: 2761: 2755: 2754: 2744: 2712: 2706: 2705: 2695: 2663: 2657: 2656: 2646: 2622: 2616: 2615: 2587: 2581: 2580: 2578: 2576: 2553: 2547: 2546: 2518: 2509: 2508: 2482: 2473: 2472: 2436: 2430: 2429: 2412:(4): W442–W450. 2401: 2395: 2394: 2384: 2360: 2354: 2353: 2328:(8): 1530–1545. 2317: 2300: 2299: 2292: 2286: 2285: 2278: 2272: 2271: 2264: 2258: 2257: 2247: 2223: 2217: 2216: 2180: 2174: 2173: 2133: 2127: 2126: 2086: 2080: 2079: 2069: 2036: 2030: 2029: 1992: 1986: 1985: 1983: 1981: 1967: 1961: 1960: 1943:(4): E521–E529. 1932: 1926: 1925: 1915: 1891: 1882: 1881: 1845: 1839: 1838: 1828: 1796: 1790: 1789: 1753: 1747: 1746: 1718: 1712: 1711: 1671: 1654: 1653: 1643: 1619: 1613: 1612: 1603: 10535798. 1579: 1566: 1565: 1532:NICE guidance". 1528: 1519: 1518: 1495:Nursing Standard 1490: 1484: 1483: 1447: 1441: 1440: 1411: 1392: 1391: 1381: 1349: 1343: 1342: 1332: 1308: 1302: 1301: 1283: 1259: 1189:Heinrich Quincke 1134:Modest increase 1043: 952:, hepatic coma, 787:The presence of 688:conus medullaris 565:conus medullaris 451: 448: 430:pain medications 322:uncal herniation 211:Heinrich Quincke 202:analysis. Using 176:local anesthesia 143:diseases of the 107:edit on Wikidata 99: 85: 40: 28: 4177: 4176: 4172: 4171: 4170: 4168: 4167: 4166: 4137: 4136: 4135: 4130: 4097: 4093:Polysomnography 4081:Lumbar puncture 4064: 3992: 3950: 3928: 3900:Pituitary gland 3888: 3874:Hemispherectomy 3841: 3836: 3822:Ventriculostomy 3806: 3801: 3778:globus pallidus 3772: 3758: 3730: 3721: 3711: 3677:Lumbar puncture 3667: 3632: 3629: 3627:Further reading 3624: 3623: 3609: 3596: 3595: 3591: 3578: 3574: 3557: 3543: 3542: 3538: 3525: 3524: 3520: 3507:(3531): 981–2. 3494: 3493: 3489: 3459: 3458: 3449: 3419: 3418: 3414: 3390: 3385: 3384: 3380: 3370: 3368: 3366: 3351: 3350: 3346: 3308: 3307: 3303: 3272: 3271: 3267: 3235: 3230: 3229: 3225: 3186: 3185: 3178: 3148: 3147: 3143: 3133: 3131: 3122: 3121: 3117: 3081: 3080: 3076: 3022: 3021: 3014: 2991:(10): 703–709. 2978: 2977: 2973: 2943: 2942: 2938: 2894: 2893: 2889: 2853: 2852: 2848: 2804: 2803: 2799: 2763: 2762: 2758: 2714: 2713: 2709: 2665: 2664: 2660: 2624: 2623: 2619: 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196:microbiological 157:therapeutically 117:Lumbar puncture 110: 95: 81: 51: 31:Lumbar puncture 24: 17: 12: 11: 5: 4175: 4173: 4165: 4164: 4159: 4154: 4149: 4139: 4138: 4132: 4131: 4129: 4128: 4123: 4118: 4113: 4107: 4105: 4099: 4098: 4096: 4095: 4090: 4089: 4088: 4078: 4072: 4070: 4066: 4065: 4063: 4062: 4057: 4052: 4047: 4042: 4037: 4032: 4023: 4018: 4013: 4008: 4002: 4000: 3994: 3993: 3991: 3990: 3985: 3980: 3975: 3970: 3964: 3962: 3952: 3951: 3949: 3948: 3942: 3940: 3934: 3933: 3930: 3929: 3927: 3926: 3921: 3920: 3919: 3909: 3908: 3907: 3905:Hypophysectomy 3896: 3894: 3890: 3889: 3887: 3886: 3881: 3876: 3871: 3866: 3865: 3864: 3859: 3848: 3846: 3838: 3837: 3835: 3834: 3829: 3824: 3819: 3817:Cerebral shunt 3813: 3811: 3803: 3802: 3800: 3799: 3794: 3789: 3783: 3781: 3766: 3760: 3759: 3757: 3756: 3751: 3746: 3740: 3738: 3732: 3731: 3726: 3723: 3722: 3717:involving the 3712: 3710: 3709: 3702: 3695: 3687: 3681: 3680: 3666: 3665:External links 3663: 3662: 3661: 3628: 3625: 3622: 3621: 3607: 3589: 3572: 3536: 3518: 3487: 3468:(8): 459–462. 3447: 3428:(1): 102–108. 3412: 3401:(3–4): 79–96. 3378: 3364: 3344: 3301: 3265: 3246:(6): 642–644. 3223: 3176: 3141: 3115: 3074: 3012: 2971: 2936: 2907:(78): 159–72. 2887: 2866:(6): 576–578. 2846: 2817:(11): 5828–9. 2797: 2756: 2707: 2678:(4): 511–516. 2658: 2637:(8): 817–821. 2617: 2598:(8): 459–462. 2582: 2568: 2548: 2529:(1): 141–150. 2510: 2503: 2474: 2447:(5): 311–314. 2431: 2396: 2355: 2301: 2287: 2273: 2259: 2238:(2): 181–186. 2218: 2191:(4): 194–207. 2175: 2128: 2081: 2031: 1987: 1962: 1937:Pain Physician 1927: 1883: 1840: 1811:(7): 375–381. 1791: 1764:(2): 389–396. 1748: 1713: 1655: 1634:(2): 102–105. 1614: 1567: 1520: 1485: 1442: 1419:(in Spanish). 1393: 1344: 1303: 1253: 1252: 1250: 1247: 1195:conference in 1167: 1164: 1161: 1160: 1157: 1154: 1151: 1148: 1142: 1141: 1138: 1135: 1132: 1129: 1123: 1122: 1119: 1118:Mild increase 1116: 1109: 1106: 1100: 1099: 1096: 1093: 1086: 1083: 1077: 1076: 1073: 1070: 1067: 1064: 1060: 1059: 1056: 1055:Protein (g/L) 1053: 1050: 1047: 1041: 1040: 1029: 994: 987: 957: 942: 939: 914: 911: 910: 909: 896: 879: 865: 859: 844: 841: 784: 781: 746:cerebral edema 729: 726: 720: 719:Interpretation 717: 711: 708: 679: 676: 619:lumbar cistern 610:fetal position 580: 577: 557:lumbar cistern 546:choroid plexus 540: 537: 535: 532: 464: 461: 434:supine posture 418: 415: 413: 410: 409: 408: 397: 396: 395: 389: 388: 387: 380: 369: 368: 367: 366: 365: 359:Ophthalmoscopy 356: 355: 354: 351: 348: 345: 342: 336: 327: 324: 306: 303: 276: 273: 226: 223: 218: 215: 112: 111: 104: 101: 100: 93: 87: 86: 79: 73: 72: 67: 61: 60: 57: 53: 52: 41: 33: 32: 15: 13: 10: 9: 6: 4: 3: 2: 4174: 4163: 4160: 4158: 4155: 4153: 4150: 4148: 4145: 4144: 4142: 4127: 4124: 4122: 4119: 4117: 4114: 4112: 4109: 4108: 4106: 4104: 4100: 4094: 4091: 4087: 4084: 4083: 4082: 4079: 4077: 4074: 4073: 4071: 4067: 4061: 4058: 4056: 4053: 4051: 4048: 4046: 4043: 4041: 4038: 4036: 4033: 4031: 4027: 4024: 4022: 4019: 4017: 4014: 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