Friday, 2 March 2018

Atraumatic Needles: times are changing but we need to do more

Are you about to have a lumbar puncture? If yes, what needle is your neurology team going to use to perform the lumbar puncture? If you want a simple guide to LPs please visit our LP web app.



One of the biggest successes we have had at Barts-MS is the derisking of lumbar punctures. This was driven by our PROXIMUS trial and subsequently informed our clinical practice. LPs are also becoming more important as CSF analysis is now center-stage with the new rendition of the McDonald diagnostic criteria. The presence of oligoclonal immunoglobulin bands, or OCBs, in the spinal fluid now confirm dissemination in time. So if you are having a lumbar puncture for diagnostic, or monitoring, purposes please ask your neurologist to make sure they use an atraumatic or non-cutting needle. This reduces the risk of post-LP headaches by an order of magnitude and if you do get a headache they tend to be mild and self-limiting.

What do we mean by monitoring LP? We are increasingly doing LPs to assess spinal fluid neurofilament levels. Neurofilaments are released in response to axonal and neuronal damage. If you have a raised neurofilament levels it means there is ongoing damage and something should be done about it. Knowing your spinal fluid neurofilament levels helps decision making about treatment initiation and switching.  It adds more information about your MS and prognosis and simply helps us get a better picture of your disease. 

I am confident that within a year, or two, almost all MSologists will be using spinal fluid and possibly blood neurofilament levels as part of their clinical decision making. This has been a long time coming. I have been working on neurofilaments for over 20 years. Who said research translates quickly into clinical practice? 



ProfG    

3 comments:

  1. Thanks for that. In the last 12 months I have had two LP's for MS diagnosis and then treatment. The first was with a cutting needle - took the practitioner ages to get the fluid, and lots of discomfort during this with me feeling the needle at various stages. This was followed by 10 days of the worst headache I've ever had, abating only when I lay down - absolutely incapacitated. All the solutions I tried did nothing (e.g. paracetamol, drinking lots of fluids, cafine, etc). I was apprehensive for my second LP but it needed doing, but this used a atraumatic needle. After a few minutes I asked the practitioner how the process was going as he seemed to be doing something else rather than prodding me poking the needle in me. Oh.. He had finished! I hadn't even noticed him starting. After lying down for a while I then sat up, expecting pain to descend and the end of the world once again looking like a positive way out. It didn't come - a completely normal week afterwards. My experience mirrors the article above - if your practitioner is using a cutting needle, ask them why and try to get them to change. 10 days of being bed bound set back my physio & exercise routine and contributed to reducing my mobility significantly. Thanks to Prof G and team for leading the way.

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  2. Can a LP be carried out on someone with spinal osteoarthritis?

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  3. This is interesting. What is the new rendition of the MacDonald criteria? My wife didn't have an LP as part of her dx. She has just been treated with alemtuzumab and had her first LP nine days post round two to rule out meningitis when she became unwell. That showed her as OCB negative, which has greatly confused me. We're thinking of asking our neuro to re-test her down the line, when cells have re-populated so this info about atraumatic needles is very useful to know.

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