This case involves a female patient with a history of long-standing low back pain with a previous lumbar fusion performed at L3-S1. The patient was referred to the defending physician for a diagnostic myelogram and CT scan with consideration for a possible nerve stimulator. The patient sustained significant neural injury after this procedure and the plaintiff alleged that the physician entered at the incorrect level of T12-L1, which allowed the conus medullaris to be punctured. The patient experienced paralysis of the lower limbs and chronic neuropathy as a result of the procedure.
Question(s) For Expert Witness
- 1. When should a lumbar puncture be avoided?
Expert Witness Response E-001730
It is important to avoid lumbar puncture in patients where the disease process has progressed to a point in which neurologic findings may be associated with impending cerebral herniation (ie, deteriorating level of consciousness and brainstem signs that include pupillary changes, posturing, irregular respirations, and very recent seizure). Cerebral herniation is the most serious complication of a lumbar puncture. It is very rare, and there is considerable debate in the literature regarding whether it is caused by the lumbar puncture or by the underlying disease process. There is increasing evidence that a diagnostic lumbar puncture is safe even in patients with increased intracranial pressure (ICP), such as most patients with meningitis, but there is no firm consensus regarding the safety of lumbar puncture in patients with ICP.