今日の臨床サポート

髄液検査

著者: 松原崇一朗1) 熊本大学病院 脳神経内科

著者: 永山正雄2) 国際医療福祉大学大学院医学研究科 脳神経内科学

監修: 永山正雄 国際医療福祉大学大学院医学研究科 脳神経内科学

著者校正/監修レビュー済:2020/11/19
参考ガイドライン:
  1. The EU Joint Programme – Neurodegenerative Disease Research(JPND):Consensus guidelines for lumbar puncture in patients with neurological diseases(2017)
  1. Infectious Disease Society of America(IDSA): Practice guidelines for the management of bacterial meningitis (2004)
  1. 日本神経学会日本神経治療学会日本神経感染症学会:細菌性髄膜炎診療ガイドライン2014
  1. 日本神経学会日本神経治療学会日本神経感染症学会単純ヘルペス脳炎診療ガイドライン2017
  1. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. American Society of Regional Anesthesia and Pain Medicine(ARSA)Evidence-Based Guidelines(Fourth Edition)(2018)
  1. The 2018 European Heart Rhythm Association(EHRA)Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation(2018)
患者向け説明資料

概要・推奨   

脳脊髄液検査:
  1. 様々な感染性(細菌、真菌、ウイルス等)および非感染性神経学的疾患(脱髄性疾患、炎症性疾患、悪性腫瘍、クモ膜下出血等)の、診断および治療効果判定のために重要な検査である[1][2][3][4](推奨度1)。髄液検査実施方法および分析の一般的事項は各論で記載する。
  1. 腰椎穿刺(Lumbar puncture:LP)は脳脊髄液を得るための比較的安全な手技である。しかし、稀だが重篤になる可能性のある感染症、出血、脳ヘルニアの他、軽微だが少なくない頭痛や神経根の痛みやしびれなどの神経症状を含む、合併症が発生する可能性があることを十分に説明する必要がある(推奨度1)。
  1. LP施行前には必ず呼吸パターンの異常や瞳孔や眼位の所見を評価する。特に眼底の観察が重要である(推奨度1)。
  1. 全ての患者でLP施行前に頭部画像検査(頭部CT等)を行う適応はないが、頭蓋内圧(ICP)亢進が疑われる患者(頭痛、嘔気・嘔吐、意識障害、精神症候、局在性の神経学的兆候、眼底視神経乳頭浮腫、最近のてんかん発作、および細胞性免疫低下)や高齢者(60歳以上)では、致命的な脳ヘルニアを避けるため、頭部CTを撮影し、腫瘤病変や他のICP亢進の原因を除外する必要がある[1][2][3][4][5](推奨度2)。
  1. 細菌性髄膜炎が疑われる患者でLP施行開始が遅れる場合、血液培養も採取し、抗菌薬治療を迅速に開始することが重要である[2][3][5](推奨度2)。
  1. 出血性合併症:
    LP後の硬膜外腔または硬膜下腔での出血性合併症は、主に血小板減少症または他の出血障害のある患者、または抗凝固療法を受けた患者で発症しやすく[6][7][8]、最大2%の患者で発生する可能性がある[9](エビデンスランクO)。またtraumatic tapになった場合にも上記出血性合併症のリスクは上昇するため[6]、その場合には抗凝固療法の再開には注意する(推奨度2)。各薬剤の休薬期間については各論に記載する。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必 要とな り ます。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧には ご契約が必要 と なります。閲覧にはご契約が必要となり ます。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 腰椎穿刺後頭痛(post-LP headache:PLPH):
    LPの最も一般的な合併症は、LP後の背部痛と頭痛である。ペンシル型ルンバール針(atraumatic needle)を使用することで、PLPHのリスクを減少させる[10](エビデンスランクM、推奨度2)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松原崇一朗 : 特に申告事項無し[2021年]
永山正雄 : 未申告[2021年]
監修:永山正雄 : 未申告[2021年]

各論

検査方法  
  1. 体位:基本的に髄液圧を正確に測定するため、左右どちらかの側臥位で行う。この際に被検者に指示を行い、できる限り膝関節・股関節を屈曲させ、足で抱え込んでもらうことが重要である。左右の腸骨稜を結んだJacoby線上あるいは近傍に第4腰椎棘突起を探し、L4/5もしくはL3/4を穿刺部位に選択する。脊髄円錐が稀にL3まで達していることがあるのでこれより上方では行わない。
  1. 穿刺:穿刺部位を消毒しドレープをかけ局所麻酔を行う。20〜23Gの穿刺針を確認した方向へゆっくりと進める。針は皮膚、皮下組織、靭帯(棘上靭帯、棘間靭帯、黄色靭帯)、硬膜外脂肪層、硬膜およびクモ膜を通過しクモ膜下腔に到達する。靭帯を通っている間は抵抗感があるが、硬膜外脂肪層に達すると抵抗が落ちるので、あとは1mmずつ進めていくと良い。とくに棘間靭帯と硬膜を穿刺する際に膜が破れるような感触があるが、高齢者等ではわかりにくい場合もある。クモ膜下腔に達したと思ったら内筒を抜き髄液の流出を確認する。髄液の流出がない場合内筒を元に戻して、また数mmずつ進めて流出を確認する。髄液の流出を確認したら三方活栓を装着したマノメーターを接続し、初圧を測定する。必要最小量の髄液を採取したら初圧同様に終圧を測定し、終了後内筒を戻し、針を抜去する。
  1. 穿刺困難への対応:
  1. 傍脊柱アプローチ(Taylor法)[11]:L5-S1の傍脊柱部から15°程度の角度をつけて穿刺する。脊柱変形や脊椎強直例では有効である。
  1. 画像補助:X線透視下[12]やエコーガイド下[13]での穿刺は、有用性および安全性が示されており、特にエコー補助下についてはtraumatic tapのリスクが減少したことがメタ解析で示されている[14]
  1. 採取した検体を採取順でどの項目を提出するかについては明確な指標はないが、各病態に応じた検体提出の工夫はある。癌性髄膜炎や悪性リンパ腫を診断するための髄液細胞診や結核菌や真菌の培養には検体量が多いと検出感度が上昇することが知られている。
合併症  
  1. 一般的に頭蓋内圧(ICP)亢進患者での脳ヘルニア、穿刺局所の硬膜外・硬膜下血腫(特に抗血栓薬使用下や出血傾向患者の場合)、穿刺部からの感染(特に穿刺部位に感染がある場合)、腰椎穿刺後頭痛、その他(悪心・嘔吐、神経根痛など)がある。臨床的に重篤なものから記載する。合併症を回避するために必要な項目について、JPNDガイドラインでの推奨を次の<図表>に記す。

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文献 

著者: Sebastiaan Engelborghs, Ellis Niemantsverdriet, Hanne Struyfs, Kaj Blennow, Raf Brouns, Manuel Comabella, Irena Dujmovic, Wiesje van der Flier, Lutz Frölich, Daniela Galimberti, Sharmilee Gnanapavan, Bernhard Hemmer, Erik Hoff, Jakub Hort, Ellen Iacobaeus, Martin Ingelsson, Frank Jan de Jong, Michael Jonsson, Michael Khalil, Jens Kuhle, Alberto Lleó, Alexandre de Mendonça, José Luis Molinuevo, Guy Nagels, Claire Paquet, Lucilla Parnetti, Gerwin Roks, Pedro Rosa-Neto, Philip Scheltens, Constance Skårsgard, Erik Stomrud, Hayrettin Tumani, Pieter Jelle Visser, Anders Wallin, Bengt Winblad, Henrik Zetterberg, Flora Duits, Charlotte E Teunissen
雑誌名: Alzheimers Dement (Amst). 2017;8:111-126. doi: 10.1016/j.dadm.2017.04.007. Epub 2017 May 18.
Abstract/Text INTRODUCTION: Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.
METHODS: We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III).
RESULTS: Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications.
DISCUSSION: When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.

PMID 28603768  Alzheimers Dement (Amst). 2017;8:111-126. doi: 10.1016/・・・
著者: Allan R Tunkel, Barry J Hartman, Sheldon L Kaplan, Bruce A Kaufman, Karen L Roos, W Michael Scheld, Richard J Whitley
雑誌名: Clin Infect Dis. 2004 Nov 1;39(9):1267-84. doi: 10.1086/425368. Epub 2004 Oct 6.
Abstract/Text
PMID 15494903  Clin Infect Dis. 2004 Nov 1;39(9):1267-84. doi: 10.1086・・・
著者: R Hasbun, J Abrahams, J Jekel, V J Quagliarello
雑誌名: N Engl J Med. 2001 Dec 13;345(24):1727-33. doi: 10.1056/NEJMoa010399.
Abstract/Text BACKGROUND: In adults with suspected meningitis clinicians routinely order computed tomography (CT) of the head before performing a lumbar puncture.
METHODS: We prospectively studied 301 adults with suspected meningitis to determine whether clinical characteristics that were present before CT of the head was performed could be used to identify patients who were unlikely to have abnormalities on CT. The Modified National Institutes of Health Stroke Scale was used to identify neurologic abnormalities.
RESULTS: Of the 301 patients with suspected meningitis, 235 (78 percent) underwent CT of the head before undergoing lumbar puncture. In 56 of the 235 patients (24 percent), the results of CT were abnormal; 11 patients (5 percent) had evidence of a mass effect. The clinical features at base line that were associated with an abnormal finding on CT of the head were an age of at least 60 years, immunocompromise, a history of central nervous system disease, and a history of seizure within one week before presentation, as well as the following neurologic abnormalities: an abnormal level of consciousness, an inability to answer two consecutive questions correctly or to follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language (e.g., aphasia). None of these features were present at base line in 96 of the 235 patients who underwent CT scanning of the head (41 percent). The CT scan was normal in 93 of these 96 patients, yielding a negative predictive value of 97 percent. Of the three misclassified patients, only one had a mild mass effect on CT, and all three subsequently underwent lumbar puncture, with no evidence of brain herniation one week later.
CONCLUSIONS: In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

PMID 11742046  N Engl J Med. 2001 Dec 13;345(24):1727-33. doi: 10.1056・・・
著者: Terese T Horlocker, Erik Vandermeuelen, Sandra L Kopp, Wiebke Gogarten, Lisa R Leffert, Honorio T Benzon
雑誌名: Reg Anesth Pain Med. 2018 Apr;43(3):263-309. doi: 10.1097/AAP.0000000000000763.
Abstract/Text
PMID 29561531  Reg Anesth Pain Med. 2018 Apr;43(3):263-309. doi: 10.10・・・
著者: Jan Steffel, Peter Verhamme, Tatjana S Potpara, Pierre Albaladejo, Matthias Antz, Lien Desteghe, Karl Georg Haeusler, Jonas Oldgren, Holger Reinecke, Vanessa Roldan-Schilling, Nigel Rowell, Peter Sinnaeve, Ronan Collins, A John Camm, Hein Heidbüchel, ESC Scientific Document Group
雑誌名: Eur Heart J. 2018 Apr 21;39(16):1330-1393. doi: 10.1093/eurheartj/ehy136.
Abstract/Text The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

PMID 29562325  Eur Heart J. 2018 Apr 21;39(16):1330-1393. doi: 10.1093・・・
著者: M T Pitkänen, U Aromaa, D A Cozanitis, J G Förster
雑誌名: Acta Anaesthesiol Scand. 2013 May;57(5):553-64. doi: 10.1111/aas.12064. Epub 2013 Jan 11.
Abstract/Text BACKGROUND: Analyses of closed claims provide insight into the characteristics of rare complications. Serious complications related to spinal and epidural blocks are relatively rare. In Finland, all malpractice cases are primarily handled by the Patient Insurance Centre (PIC) within a 'no-fault scheme'.
METHODS: All claims attributed to central neuraxial blocks and settled by the PIC during the period, 2000-2009 were analysed. The number of spinal and epidural procedures performed during this time was estimated based on a questionnaire sent to all surgical hospitals in Finland in 2009, surveying the numbers and types of neuraxial blocks carried out in 2008.
RESULTS: During the study period, 216 closed claims were flagged with spinal or epidural blocks. In 41 of 216 instances, the neuraxial block was apparently responsible for a serious (fatal or critical or lasting >1 year) complication. These included six fatalities and 13 epidural haematomata (two in conjunction with fondaparinux, three with excessive doses of low molecular weight heparins, six where present guidelines were not observed). Fatalities occurred in 1 : 775,000 spinals for surgery, 1 : 62,000 in epidurals for surgery or acute pain relief, 1 : 12,000 epidurals for chronic pain relief, 1 : 89,000 in combined spinal and epidural for surgery, and 1 : 144,000 epidurals for labour. The incidence of neuraxial haematoma after spinal block was 1 : 775,000, that for epidural block 1 : 26,400, and in the case of combined spinal and epidural, 1 : 17,800. Irrespective of the method of neuraxial technique, the majority of patients suffering serious complications were the elderly having comorbidities.
CONCLUSIONS: In this closed claims analysis, major problems related to neuraxial blocks were rare. Epidural or a combined spinal and epidural technique resulted in more complications than did spinal procedure.

© 2013 The Acta Anaesthesiologica Scandinavica Foundation.
PMID 23305109  Acta Anaesthesiol Scand. 2013 May;57(5):553-64. doi: 10・・・
著者: R L Ruff, J H Dougherty
雑誌名: Stroke. 1981 Nov-Dec;12(6):879-81. doi: 10.1161/01.str.12.6.879.
Abstract/Text The complications associated with lumbar puncture (LP) were compared in 2 groups of 342 patients. The first group of patients was anticoagulated after the LP, and the second was not. The incidence of minor headache or back pain was similar in the 2 groups (Group 1--62%, Group 2--64%). The anticoagulated patients had a higher incidence of paraparesis (Group 1, 5 patients, Group 2, No patients; p less than .05) and severe back or lumbosacral radicular pain lasting more than 48 hours (Group 1, 18 patients, Group 2, 6 patients; p less than .025). Seven of the anticoagulated patients developed spinal hematomas (5 with paraparesis, 2 with severe back pain). Among the anticoagulated patients the risk of a major complication was increased by a traumatic LP (p less than .001), starting anticoagulation within one hour of the LP (p less than .001), or aspirin treatment at the time of the LP (p less than .001). This study suggests that if LP is done, delaying anticoagulation for at least one hour and avoiding concurrent aspirin therapy may decrease the risk of developing an extraparenchymal spinal hematoma.

PMID 7303081  Stroke. 1981 Nov-Dec;12(6):879-81. doi: 10.1161/01.str.・・・
著者: Siddharth Nath, Alex Koziarz, Jetan H Badhiwala, Waleed Alhazzani, Roman Jaeschke, Sunjay Sharma, Laura Banfield, Ashkan Shoamanesh, Sheila Singh, Farshad Nassiri, Wieslaw Oczkowski, Emilie Belley-Côté, Ray Truant, Kesava Reddy, Maureen O Meade, Forough Farrokhyar, Malgorzata M Bala, Fayez Alshamsi, Mette Krag, Itziar Etxeandia-Ikobaltzeta, Regina Kunz, Osamu Nishida, Charles Matouk, Magdy Selim, Andrew Rhodes, Gregory Hawryluk, Saleh A Almenawer
雑誌名: Lancet. 2018 Mar 24;391(10126):1197-1204. doi: 10.1016/S0140-6736(17)32451-0. Epub 2017 Dec 7.
Abstract/Text BACKGROUND: Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles.
METHODS: In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546.
FINDINGS: We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation.
INTERPRETATION: Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.
FUNDING: None.

Copyright © 2018 Elsevier Ltd. All rights reserved.
PMID 29223694  Lancet. 2018 Mar 24;391(10126):1197-1204. doi: 10.1016/・・・
著者: Kumkum Gupta, Bhawna Rastogi, Prashant K Gupta, Avinash Rastogi, Manish Jain, V P Singh
雑誌名: Anesth Essays Res. 2012 Jan-Jun;6(1):38-41. doi: 10.4103/0259-1162.103370.
Abstract/Text BACKGROUND: Subarachnoid anesthesia is used as the sole anesthetic technique for below umbilical surgeries, but patients with deformed spine represent technical difficulty for its establishment. This study was aimed to find out whether training of Taylor's approach to residents on normal spine is beneficial for establishing subarachnoid block in patients with deformed spine.
MATERIALS AND METHODS: The total of 174 patients of ASA I-III with normal and deformed spine of both genders scheduled for below umbilical surgeries under the subarachnoid block and met the inclusion criteria, were enrolled for this two-phased clinical teaching study. All participating residents have performed more than 100 subarachnoid block with the median and paramedian approach. Residents were randomized into two equal groups. During the first phase program, Group I was taught Taylor's approach by hands on method for the subarachnoid block while Group II kept on observation for the technique. During the second phase of program, Group II was also taught Taylor's approach for establishing the subarachnoid block. Block success was defined according to clinical efficacy.
RESULTS: The results of teaching of Taylor's approach were encouraging. Initially, the residents faced difficulty for establishing the subarachnoid block in deformed spine but after learning by observation and practical hands on, both groups had successfully performed the subarachnoid block by Taylor's approach in one or more attempts in patient with deformed spine with the acceptable failure rate of 15%.
CONCLUSION: Taylor's approach for establishing subarachnoid block in deformed spine should be taught to residents on normal spine.

PMID 25885500  Anesth Essays Res. 2012 Jan-Jun;6(1):38-41. doi: 10.410・・・
著者: A S Abel, J R Brace, A M McKinney, A R Harrison, M S Lee
雑誌名: AJNR Am J Neuroradiol. 2012 May;33(5):823-5. doi: 10.3174/ajnr.A2876. Epub 2012 Jan 19.
Abstract/Text BACKGROUND AND PURPOSE: Evidenced-based protocols for fluoroscopically guided LP do not exist. This study analyzed the fluoroscopically guided LP techniques currently used by practicing neuroradiologists.
MATERIALS AND METHODS: An anonymous Web-based survey was e-mailed to members of ASNR. The results were compiled and tabulated on a spreadsheet.
RESULTS: A total of 577 neuroradiologists completed the survey. Most neuroradiologists perform fluoroscopically guided LPs with the patient in the prone position by using a 22-ga needle at the L2-L3 or L3-L4 intervertebral space. The OP measurement technique is quite variable. Only a minority of patients are rotated to the left LD position for OP measurement. Most neuroradiologists observe patients for 1-2 hours after the procedure and require strict bed rest.
CONCLUSIONS: Most neuroradiologists have similar protocols for thecal sac puncture. Normative adult OP data exist only for the LD position, and the accuracy of prone OP measurements is not known. We found that the OP measurement technique is not consistent and a standard protocol is warranted.

PMID 22268077  AJNR Am J Neuroradiol. 2012 May;33(5):823-5. doi: 10.31・・・
著者: P H Conroy, C Luyet, C J McCartney, P G McHardy
雑誌名: Anesthesiol Res Pract. 2013;2013:525818. doi: 10.1155/2013/525818. Epub 2013 Jan 10.
Abstract/Text Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1-6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83-4.1) demonstrating the feasibility of this technique in routine clinical practice.

PMID 23365568  Anesthesiol Res Pract. 2013;2013:525818. doi: 10.1155/2・・・
著者: Furqan Shaikh, Jack Brzezinski, Sarah Alexander, Cristian Arzola, Jose C A Carvalho, Joseph Beyene, Lillian Sung
雑誌名: BMJ. 2013 Mar 26;346:f1720. doi: 10.1136/bmj.f1720. Epub 2013 Mar 26.
Abstract/Text OBJECTIVE: To determine whether ultrasound imaging can reduce the risk of failed lumbar punctures or epidural catheterisations, when compared with standard palpation methods, and whether ultrasound imaging can reduce traumatic procedures, insertion attempts, and needle redirections.
DESIGN: Systematic review and meta-analysis of randomised controlled trials.
DATA SOURCES: Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2012, without restriction by language or publication status.
REVIEW METHODS: Randomised trials that compared ultrasound imaging with standard methods (no imaging) in the performance of a lumbar puncture or epidural catheterisation were identified.
RESULTS: 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). Risk reduction was similar when subgroup analysis was performed for lumbar punctures (risk ratio 0.19 (0.07 to 0.56), P=0.002) or epidural catheterisations (0.23 (0.09 to 0.60), P=0.003). Ultrasound imaging also significantly reduced the risk of traumatic procedures (risk ratio 0.27 (0.11 to 0.67), P=0.005), the number of insertion attempts (mean difference -0.44 (-0.64 to -0.24), P<0.001), and the number of needle redirections (mean difference -1.00 (-1.24 to -0.75), P<0.001).
CONCLUSIONS: Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.

PMID 23532866  BMJ. 2013 Mar 26;346:f1720. doi: 10.1136/bmj.f1720. Epu・・・
著者: J KOREIN, H CRAVIOTO, M LEICACH
雑誌名: Neurology. 1959 Apr;9(4):290-7. doi: 10.1212/wnl.9.4.290.
Abstract/Text
PMID 13644562  Neurology. 1959 Apr;9(4):290-7. doi: 10.1212/wnl.9.4.29・・・
著者: Ari R Joffe
雑誌名: J Intensive Care Med. 2007 Jul-Aug;22(4):194-207. doi: 10.1177/0885066607299516.
Abstract/Text There has been controversy regarding the risk of cerebral herniation caused by a lumbar puncture (LP) in acute bacterial meningitis (ABM). This review discusses in detail the issues involved in this controversy. Cerebral herniation occurs in about 5% of patients with ABM, accounting for about 30% of the mortality. In many reports, LP is temporally strongly associated with this event of herniation and is most likely causative based on pathophysiologic arguments. Although a computed tomography (CT) scan of the head is useful to find contraindications to an LP, a normal CT scan in ABM does not mean that an LP is safe. Clinical signs of "impending" herniation are the best predictors of when to delay an LP because of the risk of precipitating herniation, even with a normal CT scan. Some of these clinical signs to be considered are deteriorating level of consciousness (particularly to a Glasgow Coma Scale of
PMID 17712055  J Intensive Care Med. 2007 Jul-Aug;22(4):194-207. doi: ・・・
著者: Julie Dubourg, Etienne Javouhey, Thomas Geeraerts, Mahmoud Messerer, Behrouz Kassai
雑誌名: Intensive Care Med. 2011 Jul;37(7):1059-68. doi: 10.1007/s00134-011-2224-2. Epub 2011 Apr 20.
Abstract/Text PURPOSE: To evaluate the diagnostic accuracy of ultrasonography of optic nerve sheath diameter (ONSD) for assessment of intracranial hypertension.
METHODS: Systematic review without language restriction based on electronic databases, with manual review of literature and conference proceedings until July 2010. Studies were eligible if they compared ultrasonography of ONSD with intracranial pressure (ICP) monitoring. Data were extracted independently by three authors. Random-effects meta-analysis and meta-regression were performed.
RESULTS: Six studies including 231 patients were reviewed. No significant heterogeneity was detected for sensitivity, specificity, positive and negative likelihood ratios or diagnostic odds ratio. For detection of raised intracranial pressure, pooled sensitivity was 0.90 [95% confidence interval (CI) 0.80-0.95; p for heterogeneity, p (het) = 0.09], pooled specificity was 0.85 (95% CI 0.73-0.93, p (het) = 0.13), and the pooled diagnostic odds ratio was 51 (95% CI 22-121). The area under the summary receiver-operating characteristic (SROC) curve was 0.94 (95% CI 0.91-0.96).
CONCLUSIONS: Ultrasonography of ONSD shows a good level of diagnostic accuracy for detecting intracranial hypertension. In clinical decision-making, this technique may help physicians decide to transfer patients to specialized centers or to place an invasive device when specific recommendations for this placement do not exist.

PMID 21505900  Intensive Care Med. 2011 Jul;37(7):1059-68. doi: 10.100・・・
著者: Estelle Traurig Baer
雑誌名: Anesthesiology. 2006 Aug;105(2):381-93. doi: 10.1097/00000542-200608000-00022.
Abstract/Text A fatal case of viridans streptococcus meningitis is reported, which occurred as a complication of epidural anesthesia. One hundred seventy-nine reported cases of post-dural puncture meningitis are reviewed. Evidence suggests that most cases are probably caused by contamination of the puncture site by aerosolized mouth commensals from medical personnel, some are caused from contamination by skin bacteria, and, less frequently, other cases are caused directly or hematogenously by spread from an endogenous infectious site. Controversy exists regarding prevention, surveillance, incidence, and treatment of this serious complication.

PMID 16871073  Anesthesiology. 2006 Aug;105(2):381-93. doi: 10.1097/00・・・
著者: R Prat Acín, I Galeano
雑誌名: Acta Neurochir (Wien). 2008 Apr;150(4):413-4. doi: 10.1007/s00701-008-1490-9. Epub 2008 Feb 28.
Abstract/Text The origin of cranial epidermoid cysts (EC) remains controversial, and although generally considered to be congenital, acquired origin has been reported. EC represent 0.2 to 1.8% of all brain tumours, and only one fourth are intradiploic in location. We report of a 44-year-old woman with a giant intradiploic EC of the occipital bone with intracranial extension confirmed on brain MRI. Three years previously, in the same location, she underwent resection of an intradermal melanocytic naevus of the skin under local anaesthesia with lidocaine infiltration of skin and periosteum. Brain CT scan performed at the time of naevus surgery because of associated headache did not show a lesion of the cranial vault. Iatrogenic epidermoid tumours are extremely rare, and although seeding of epidermal cells has been classically described only after lumbar puncture, the same mechanism may be involved after head injury, cranial surgery or cranial periosteal iatrogenic puncture.

PMID 18301860  Acta Neurochir (Wien). 2008 Apr;150(4):413-4. doi: 10.1・・・
著者: Philippe Béchard, Gino Perron, Denis Larochelle, Mélanie Lacroix, Annie Labourdette, Pierre Dolbec
雑誌名: Can J Anaesth. 2007 Feb;54(2):146-50. doi: 10.1007/BF03022012.
Abstract/Text PURPOSE: To describe a case of iatrogenically induced abducens nerve palsy following a diagnostic lumbar puncture, and to review the evidence for blood patching in the management of sixth cranial nerve palsy after dural puncture.
CLINICAL FEATURES: A 45-yr-old woman developed post-dural puncture headache with bilateral abducens palsy following a diagnostic lumbar puncture. Magnetic resonance imaging showed findings compatible with intracranial hypotension. An epidural blood patch was performed five days after the onset of diplopia and ten days following the dural puncture. After blood patching, the patient reported relief of the headache, but still complained of diplopia. The palsies recovered spontaneously 21 months after the dural puncture.
CONCLUSION: Experience from this case as well as other case report evidence suggest that an epidural blood patch performed more than 24 hr after the onset of a sixth cranial nerve palsy consistently fails to relieve diplopia. An epidural blood patch executed within 24 hr from the onset of diplopia could possibly lead to partial improvement and/or earlier resolution of symptoms.

PMID 17272255  Can J Anaesth. 2007 Feb;54(2):146-50. doi: 10.1007/BF03・・・
著者: K Hasegawa, N Yamamoto
雑誌名: Spine (Phila Pa 1976). 1999 May 1;24(9):915-7. doi: 10.1097/00007632-199905010-00015.
Abstract/Text STUDY DESIGN: A very rare case of nerve root herniation secondary to lumbar puncture is reported.
OBJECTIVE: To describe the characteristic clinical features of this case and to discuss a mechanism of the nerve root herniation.
SUMMARY OF BACKGROUND DATA: There has been no previous report of nerve root herniation secondary to lumbar puncture.
METHODS: A 66-year-old woman who experienced intermittent claudication as a result of sciatic pain on her right side was evaluated by radiography and magnetic resonance imaging, the results of which demonstrated central-type canal stenosis at L4-L5. The right sciatic pain was exacerbated after lumbar puncture. Myelography and subsequent computed tomography showed marked stenosis of the thecal sac that was eccentric to the left, unlike the previous magnetic resonance imaging finding.
RESULTS: At surgery, a herniated nerve root was found through a small rent of the dorsocentral portion of the thecal sac at L4-L5, presenting a loop with epineural bleeding. The herniated nerve root was put back into the intrathecal space, and the dural tear was repaired.
CONCLUSION: Lumbar puncture can be a cause of nerve root herniation in cases of lumbar canal stenosis. The puncture should not be carried out at an area of stenosis.

PMID 10327516  Spine (Phila Pa 1976). 1999 May 1;24(9):915-7. doi: 10.・・・
著者: R W Evans
雑誌名: Neurol Clin. 1998 Feb;16(1):83-105.
Abstract/Text This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.

PMID 9421542  Neurol Clin. 1998 Feb;16(1):83-105.
著者: Jeffrey J Perry, Bader Alyahya, Marco L A Sivilotti, Michael J Bullard, Marcel Émond, Jane Sutherland, Andrew Worster, Corinne Hohl, Jacques S Lee, Mary A Eisenhauer, Merril Pauls, Howard Lesiuk, George A Wells, Ian G Stiell
雑誌名: BMJ. 2015 Feb 18;350:h568. doi: 10.1136/bmj.h568. Epub 2015 Feb 18.
Abstract/Text OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture.
DESIGN: A substudy of a prospective multicenter cohort study.
SETTING: 12 Canadian academic emergency departments, from November 2000 to December 2009.
PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage.
MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death.
RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%).
CONCLUSION: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

© Perry et al 2015.
PMID 25694274  BMJ. 2015 Feb 18;350:h568. doi: 10.1136/bmj.h568. Epub ・・・
著者: Felipe Francisco Tuon, Hermes Ryoiti Higashino, Max Igor Banks Ferreira Lopes, Marcelo Nóbrega Litvoc, Angela Naomi Atomiya, Leila Antonangelo, Olavo Munhoz Leite
雑誌名: Scand J Infect Dis. 2010 Mar;42(3):198-207. doi: 10.3109/00365540903428158.
Abstract/Text Tuberculous meningitis (TBM) is a severe infection of the central nervous system, particularly in developing countries. Prompt diagnosis and treatment are necessary to decrease the high rates of disability and death associated with TBM. The diagnosis is often time and labour intensive; thus, a simple, accurate and rapid diagnostic test is needed. The adenosine deaminase (ADA) activity test is a rapid test that has been used for the diagnosis of the pleural, peritoneal and pericardial forms of tuberculosis. However, the usefulness of ADA in TBM is uncertain. The aim of this study was to evaluate ADA as a diagnostic test for TBM in a systematic review. A systematic search was performed of the medical literature (MEDLINE, LILACS, Web of Science and EMBASE). The ADA values from TBM cases and controls (diagnosed with other types of meningitis) were necessary to calculate the sensitivity and specificity. Out of a total of 522 studies, 13 were included in the meta-analysis (380 patients with TBM). The sensitivity, specificity and diagnostic odds ratios (DOR) were calculated based on arbitrary ADA cut-off values from 1 to 10 U/l. ADA values from 1 to 4 U/l (sensitivity >93% and specificity <80%) helped to exclude TBM; values between 4 and 8 U/l were insufficient to confirm or exclude the diagnosis of TBM (p = 0.07), and values >8 U/l (sensitivity <59% and specificity >96%) improved the diagnosis of TBM (p < 0.001). None of the cut-off values could be used to discriminate between TBM and bacterial meningitis. In conclusion, ADA cannot distinguish between bacterial meningitis and TBM, but using ranges of ADA values could be important to improve TBM diagnosis, particularly after bacterial meningitis has been ruled out. The different methods used to measure ADA and the heterogeneity of data do not allow standardization of this test as a routine.

PMID 20001225  Scand J Infect Dis. 2010 Mar;42(3):198-207. doi: 10.310・・・
著者: D C Tanner, M P Weinstein, B Fedorciw, K L Joho, J J Thorpe, L Reller
雑誌名: J Clin Microbiol. 1994 Jul;32(7):1680-4.
Abstract/Text Although kits to detect cryptococcal antigen are used widely to diagnose cryptococcal infection, the comparative performance of commercially available assays has not been evaluated in the past decade. Therefore, we compared the sensitives and specificities of five commercially available kits for detecting cryptococcal antigen (four latex agglutination test kits--Calas [Meridian Diagnostics])--Crypto-LA [International Biological Labs], Myco-Immune [MicroScan], and Immy [Immunomycologics]--and an enzyme immunoassay kit, Premier [Meridian Diagnostics]) with culture for the diagnosis of cryptococcal meningitis and fungemia. Of 182 cerebrospinal fluid (CSF) and 90 serum samples submitted for cryptococcal antigen and fungal culture, 49 (19 and 30 samples, respectively) from 20 patients had a culture positive for Cryptococcus neoformans. For CSF specimens, the sensitivities and specificities of all kits were comparable (sensitivity, 93 to 100%; specificity, 93 to 98%). There was a significant difference in sensitivities of the kits when serum samples were tested with the International Biological Labs and MicroScan kits, which do not pretreat serum with pronase. These kits were less sensitive (sensitivity, 83%) than the Immy and Meridian latex kits (sensitivity, 97%), which do pretreat with pronase. The sensitivity of the Meridian enzyme immunoassay kit was comparable to that of the pronase-containing latex kits. These kits were of equivalent specificities (93 to 100%) when testing serum. Some of the currently available kits have limitations that need to be recognized for proper interpretation of results. Specifically, the use of pronase on serum samples reduces the number of false-positive results, and a titer of < or = 1:4 can be a false-positive result when CSF samples are being tested.

PMID 7929757  J Clin Microbiol. 1994 Jul;32(7):1680-4.

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