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Lumbar puncture (LP) carries a certain risk if the CSF pressure is very high (evidenced by headache and papilledema), for it increases the possibility of a fatal cerebellar or transtentorial herniation The risk is considerable when papilledema is due to an intracranial mass, but it is much lower in patients with subarachnoid hemorrhage or pseudotumor cerebri, conditions in which repeated LPs have actually been employed as a therapeutic measure In patients with purulent meningitis, there is also a small risk of herniation, but this is far outweighed by the need for a de nitive diagnosis and the institution of appropriate treatment at the earliest moment With this last exception, therefore, LP should be preceded by computed tomography (CT) or MRI whenever an elevation of intracranial pressure is suspected If radiologic procedures do disclose a mass lesion that is causing displacement of brain tissue toward the tentorial opening or into the foramen magnum (the presence of a mass alone is of less concern) and if it is considered absolutely essential to have the information yielded by CSF examination, the LP maybe performed with certain precautions A ne-bore (no 22 or 24) needle should be used, and if the pressure proves to be very high over 400 mmH2O one should obtain the necessary sample of uid and then, according to the suspected disease and patient s condition, administer mannitol (or urea) and observe a fall in pressure on the manometer Dexamethasone or an equivalent corticosteroid may also be given, in an initial intravenous dose of 10 mg, followed by doses of 4 to 6 mg every 6 h in order to produce a sustained reduction in intracranial pressure Cisternal puncture and lateral cervical subarachnoid puncture, although safe in the hands of an expert, are too hazardous to entrust to those without experience LP is preferred except in obvious instances of spinal block requiring a sample of cisternal uid or myelography above the lesion Technique of Lumbar Puncture Experience teaches the importance of meticulous technique LP should be done under sterile conditions Local anesthetic is injected in and beneath the skin, which should render the procedure almost painless Warming of the analgesic by rolling the vial between the palms seems to diminish the burning sensation that accompanies cutaneous in ltra-.

Figure 11 A C A productive Web site for a cosmetic practice includes a menu of services available, a map to the practice, registration paperwork, and of ce policies

Copyright 2005, 2001, 1997, 1993, 1989, 1985, 1981, 1977, by The McGraw-Hill Companies, Inc Click here for terms of use

Bacterial infection Viral, fungal, spirochetal infection Tuberculous infection Subarachnoid hemorrhage

4 8 12 16 20

100 250 mg%

50 200 mg%

20 50 mg%; usually lower than half of blood glucose level Normal or slightly reduced 50, often markedly reduced Normal

702 Appendix A 20 1 B 5 A 9 B 13 C 17 B 2 D 6 A 10 D 14 A 18 A 3 C 7 D 11 B 15 C 19 C 4 B 8 C 12 A 16 D 20 A

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Gram s stain shows organisms; pressure increased Special culture techniques required; pressure normal or slightly increased Special culture techniques and PCR may be needed to detect organisms Must be distinguished from traumatic lumbar puncture by presence of xanthochromia of spun sample; greatly increased pressure Pressure may be elevated

100 1000 mg% 60 150 mg%

RBC 500/mm3; slight increase in WBC RBC 50 200/mm3; higher if ventricular rupture of blood Normal or few WBC Normal or few WBC

3 7 11 15 19

.

awake human subject arouses different sensations, depending on which bers are stimulated and not on the frequency of stimulation On the other hand, the frequency of stimulation does govern the intensity of sensation, as does the number of sensory units that are stimulated Stated somewhat differently, afferent impulse frequency (temporal summation) is encoded by the brain in terms of magnitude or intensity of sensation In addition, as the intensity of stimulation increases, more sensory units are activated (spatial summation) Localization of a stimulus was formerly thought to depend on the simultaneous activation of overlapping sensory units Tower de ned a peripheral sensory unit as a monopolar dorsal root ganglion cell, its central and distal axon extensions, and all the sensory endings in the territory supplied by the distal extension (receptive eld) In the very sensitive pulp of the nger, where the error of localization is less than 10 mm, there are 240 overlapping, lowthreshold mechanoreceptors per square centimeter Highly re ned physiologic techniques have demonstrated that activation of even a single sensory unit is suf cient to localize the point stimulated and that the body map in the parietal lobe is capable, by its modular columnar organization, of encoding such re ned topographic information Noteworthy also is the fact that each point in the skin that is stimulated may involve more than one type of receptor A stimulus, in order to gain access to its receptor, must pass through the skin and possess suf cient energy to transduce, ie, depolarize, the nerve ending Not only does the threshold of stimulation vary but the nerve impulse that is generated is a graded one, not an allor-none phenomenon like an action potential in nerve This poorly understood peripheral generator potential determines the frequency of impulse in the nerve and to what degree it is sustained or fades out (ie, adapts to the stimulus or fatigues) The mechanism by which a stimulus is translated into a sensory experience, ie, is encoded, is now partially understood Special molecules tranduce physical alterations by opening cationic channels As mentioned in Chap 8, these changes lead to the opening of voltage-gated sodium channels, which generates an action potentional It is probably fair to say that each type of specialized ending has a membrane structure that facilitates the transducive process for a particular type of stimulus In general, the encapsulated endings are more deeply situated, are of low-threshold type, variably adaptable to continued stimulation (the Meissner and pacinian corpuscles are rapidly adapting; the Merkel disc and Ruf ni endings are slowly adapting) and connected to large sensory bers (see Lindblom and Ochoa) Pain receptors lie deeper in the skin than those for touch.

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