Meningitis after Spinal Analgesia
Authors: M. Kremer
Journal: BMJ (1945)

The possibility of introducing infection into the subarachnoid space by spinal tap has been recognized from the time that lumbar puncture was first performed, and this possibility must be considerably increased if anything is injected into the theca.Though Babcock (1932), when reviewing the causes of death following spinal analgesia, says meningitis is extremely rare, it is probable that the percentage of infections is higher after this procedure than after any other necessitating lumbar puncture.The literature would appear to support the infrequency claimed by Babcock, for only scattered references can be found, but this may be accounted for by a natural reluctance to report what should be a preventable happening.Six cases of meningitis after simple lumbar puncture have been described.Siebert (1922), Spiller and Payne (1924), Symonds (1925), and Reynolds and Wilson (1934) gave the details of this group, in which one death occurred.After spinal analgesia there are more frequent reports.Barrie (1941) describes 11 cases with one death in 96 consecutive spinal analgesias in three months.Livingstone, Wellman, Clark, and Lambros (1943) describe 2 cases which they label " aseptic chemi- cal meningitis," and quote 8 further cases with three deaths from the earlier literature.Evans (1945) gives an account of two deaths from such a meningitis, but does not indicate whether these were the only cases or whether they were the fatalities in a series.The clinical details of all these cases are scanty, and for this reason the group below is reported.If infection is introduced along a needle track it may obviously lodge anywhere in the course of that track.With lumbar puncture the possible localities are the skin, subcutaneous tissues, vertebrae, epidural space, and subarachnoid space.Each localiz- ation gives -a fairly typical clinical picture.In this paper are reported seven cases, occurring in the Middle East, of infectiorn of the subarachnoid space after spinal analgesia.One of these patients died, and a post-mortem examination was carried out.Because of its importance in the argument on aetiology and pathogenesis a precisely similar case following diagnostic lumbar puncture is included.The clinical course of this condition is so prolonged that only the first case is given in full detail.The others are briefly summarized.For ease of comparison the C.S.F.findings are collected in the accompanying Table .Case I: Male aged 22 Jan. 9, 1942.-Herniotomywas performed after the administration of 13 c.cm. of nupercaine.He remained well for seven days and then headache and pyrexia occurred, but it was not until Jan. 29 that he developed clinical meningitis-confirmed by lumbar puncture (Table , L.P.1).Sulphapyridine was given with apparent improvement, but he relapsed very soon.These remissions and relapses continued in spite of treatment, and the patient was transferred to the neurological unit on March 4.He was then fairly well and had a positive Kernig's sign as his only abnormality On March 18 he relapsed (L.P.5) and was given a course of sulphathiazole.No real improvement occurred (L.P.6), and the next relapse on March 26 was treated with sulphadiazine.March 29.-Felt very much better.No headache and temperature settled.Neck and back felt easier (L.P.8).April 1.-He had been very well until the early hours of this.morn- ing, when he had a sudden onset of severe renal colic, more marked on the left, with haematuria.The total dosage of sulphadiazine was 100 g., and no more was given.The patient was put on a glucose- saline intravenous drip and given I dr. of sodium citrate by mouth every three hours.As no urine was passed between 10 a.m. and 6 p.m., the ureters were catheterized by Lieut.-Col.Ogier Ward.Small clots protruded from the ureteric orifices, and the renal pelves were washed out with bicarbonate solution until the return was clear.After this his urine became normal.April 3.-He now felt fine and had no complaints apart from slight stiffness in the legs (L.P.9).May 17.-Until this date he continued to improve apart from residual stiffness in the legs.He developed a headache in the night, and temperature rose to 102°F.On examination no physical signs could be made out-certainly nothing to suggest a recrudescence of meningitis.This settled after two days.May 25.-Blood count: