How to Ensure a Painless and Successful Lumbar Puncture

We embattled MS souls have had our blood sucked into tubes through tiny butterfly needles, our bodies buzzed with tuning forks, stabbed with pins, pummeled with reflex hammers, stuck with electrodes, imprisoned in head cages and thrust inside giant magnets. But the single test that makes many of us quake in anticipatory anxiety is a spinal tap, also known as a lumbar puncture. Frankly, after having had six of them—that’s right, six—both terms seem a tad misleading. Spinal tap sounds like a specialty beer offered at the local micro brewery, while lumbar puncture sounds like an innocuous shot in the lower back. Perhaps most frightening is that fear of being at the mercy of the doctor who will perform it.

But we don’t have to be at anyone’s mercy. We can exercise a great degree of control over the process and dramatically improve the odds that it will be painless and successful. We can accomplish this feat by learning about some of the possible complications and their solutions. Here are a few of them. (Source material quoted is from the article: “Lumbar puncture for the generalist.”)

Headache.

Headache is the most common complication, occurring in up to one-third of all lumbar punctures. Usually it starts 48 hours after the procedure and is most often caused by cerebrospinal fluid leaking through the puncture site.  Make sure you lie down for an hour after the procedure. If a headache develops, contact the doctor right away. A blood patch will be applied to stop the leakage.

Shooting pains down the legs after needle is inserted.

If you experience a shooting pain down a leg during the procedure, a nerve root may have been hit. Tell the doctor immediately and insist that the needle be withdrawn. You’re done for the day. An alternate method will be discussed later in this article.

Difficulty in finding landmarks.

It may be difficult to find the landmarks in obese patients. However, access to the spinal canal may [also] be impeded in patients with osteoarthritis or suffering from ankylosing spondylitis, kyphoscoliosis or had previous lumbar spine surgery. A traditional LP should not, in my experience, be attempted. An alternate method will be discussed below.

What can we do to prepare for a lumbar puncture and reduce the chances of these outcomes?

Johns Hopkins recommends that the prospective LP patient discuss her history and list of medications with the doctor days before the procedure. The LP should be postponed if you might be pregnant, taking a course of antibiotics, or taking an anticoagulant. Stop all blood-thinning NSAIDS several days prior as well, including aspirin, ibuprofen and naproxy.

Alternate method to traditional LP.

The best way to ensure a painless and successful LP is to have it done in radiology with a fluoroscope, which is a real-time x-ray that takes the guesswork out of finding the subarachnoid space and drawing out cerebrospinal fluid. Think of it this way: Picture yourself trying to thread a needle blindfolded, then try it using a magnifying glass (and without the blindfold, of course). You would likely have success with the glass on the very first try.

Based on personal experience, I strongly recommend the radiology/fluoroscopy method right out of the gate. If you’ve never had an LP and you’re afraid of pain and other risk factors, insisting on this method will ensure that it is smooth sailing. You can have a sedation drip, too, during the procedure if you like. The amount of radiation exposure is minimal and does not linger in the body after the procedure is over.

If you have an arthritic lumbar spine, lumbar stenosis, and degenerative disc disease like I do, then definitely insist on fluoroscopy. A traditional LP will be torturous. After two painful and unsuccessful traditional LPs, one successful one, and three fluoroscopic LPs, a radiologist took me aside and advised me to demand fluoroscopy from now on. He had disc disease himself and always insisted on a radiology procedure. I only wish someone had taken me aside sooner. Nobody should go through what I did. I had told him why I was in his radiology suite that morning, that a traditional LP had gone horribly awry and the doctor wouldn’t stop sticking me despite my tears and screaming; after the fifth stick I lost count and almost lost consciousness. Once again, we must be proactive, vigilant, and advocate for ourselves.

A lumbar puncture should not be painful.

If you are having a traditional LP and you get two painful sticks, stop the procedure, you’re done for the day. A professional that goes beyond two unsuccessful sticks is being insensitive at the very least and abusive at the worst. Remember that an LP is not an innocuous procedure, it is an invasive one that carries risks.

If you are scheduled for an LP, discuss all your concerns with the doctor and have your current medications list on hand. If you’re worried about pain and other risk factors, emphasizing these should prompt the doctor to take extra measures to ensure your safety and comfort.

For a complete list of details and risks, see the View References section below.^1-4