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subsequent injection. |
Approximately |
5–10 mini-boluses are injected, using a total of ∼5 mL |
of lidocaine. |
Even a delay of 5 min will help to |
reduce pain. |
If there is still no fluid, |
the stylet is reinserted and the needle is advanced slightly. |
The needle can then be reinserted at the same |
level or at an adjacent one. |
Once the SAS is reached, a manometer is attached |
to the needle and the opening pressure measured. |
CSF is allowed to drip into collection tubes; it should |
not be withdrawn with a syringe. |
Note that the shoulders and hips are in a vertical |
plane; the torso is perpendicular to the bed. |
(From RP Simon |
et al [eds]: Clinical Neurology, 7th ed. |
In general 20–30 mL |
may be safely removed from adults. |
POST-LP HEADACHE |
The principal complication of LP is headache, occur- |
ring in 10–30% of patients. |
Younger age and female |
gender are associated with an increased risk of post-LP |
headache. |
Headache usually begins within 48 h but |
may be delayed for up to 12 days. |
The longer the patient is upright, the |
longer the latency before head pain subsides. |
The pain |
is usually a dull ache but may be throbbing; its location |
is occipitofrontal. |
7]) and antiemetics. |
For |
some patients, beverages with caffeine can provide tem- |
porary pain relief. |
This procedure is most often performed by |
a pain specialist or anesthesiologist. |
The acute benefit may be due to compression of the CSF |
space by the clot, increasing CSF pressure. |
Strategies to decrease the incidence of post-LP head- |
ache are listed in Table 6-1. |
6-2). |
There is a low risk of needle dam- |
age, e.g., breakage, with the Sprotte atraumatic needle. |
CSF glu- |
cose concentrations <2.2 mmol/L (<40 mg/dL) are |
abnormal. |
bIgG index = CSF IgG (mg/dL) × serum albumin (g/dL)/serum IgG (g/ |
dL) × CSF albumin (mg/dL). |
SECTION II |
CLINICAL |
MANIFESTATIONS OF |
NEUROLOGIC DISEASE |
James P. |
Rathmell ■ Howard L. |
Fields |
40 |
The task of medicine is to preserve and restore health |
and to relieve suffering. |
Understanding pain is essen- |
tial to both of these goals. |
The function of the pain sensory system is |
to protect the body and maintain homeostasis. |
It is the |
physician’s responsibility to provide rapid and effective |
pain relief. |
THE PAIN SENSORY SYSTEM |
Pain is an unpleasant sensation localized to a part of the |
body. |
These properties illustrate the duality of pain: it |
is both sensation and emotion. |
7-1 ) . |
In normal individuals, |
the activity of these fi bers does not produce pain. |
7-1 ). |
These fi bers are present |
in nerves to the skin and to deep somatic and visceral |
structures. |
Some tissues, such as the cornea, are inner- |
vated only by Aδ and C fi ber afferents. |
Individual primary afferent nociceptors can respond |
to several different types of noxious stimuli. |
Following injury and resultant sensitization, nor- |
mally innocuous stimuli can produce pain. |
Sensitization is of particular importance for pain and |
tenderness in deep tissues. |
Nociceptor-induced inflammation |
Primary afferent nociceptors also have a neuroeffec- |
tor function. |
7-2). |
An example |
is substance P, an 11-amino-acid peptide. |
Substance P |
is released from primary afferent nociceptors and has |
multiple biologic activities. |
ganglion. |
All sympathetic postganglionic fibers are |
unmyelinated. |