Spinal Infection – Causes, Symptoms and Treatments

Spinal infections can be classified by the anatomical location involved: the vertebral column, intervertebral disc space, the spinal canal and adjacent soft tissues. Infection may be caused by bacteria or fungal organisms and can occur after surgery. Most postoperative infections occur between three days and three months after surgery.

Vertebral osteomyelitis is the most common form of vertebral infection. It can develop from direct open spinal trauma, infections in surrounding areas and from bacteria that spreads to a vertebra from the blood.

Intervertebral disc space infections involve the space between adjacent vertebrae. Disc space infections can be divided into three subcategories: adult hematogenous (spontaneous), childhood (discitis) and postoperative.

Spinal canal infections include spinal epidural abscess, which is an infection that develops in the space around the dura (the tissue that surrounds the spinal cord and nerve root). Subdural abscess is far rarer and affects the potential space between the dura and arachnoid (the thin membrane of the spinal cord, between the dura mater and pia mater). Infections within the spinal cord parenchyma (primary tissue) are called intramedullary abscesses.

Adjacent soft-tissue infections include cervical and thoracic paraspinal lesions and lumbar psoas muscle abscesses. Soft-tissue infections generally affect younger patients and are not seen often in older people.

• Vertebral osteomyelitis affects an estimated 26,170 to 65,400 people annually.
• Epidural abscess is relatively rare, with 0.2 to 2 cases per every 10,000 hospital admissions. However, 5-18% of patients with vertebral osteomyelitis or disc space infection caused by contiguous spread will develop an epidural abscess.
• Some studies suggest that the incidence of spinal infections is now increasing. This spike may be related to increased use of vascular devices and other forms of instrumentation and to a rise in intravenous drug abuse.
• About 30-70% of patients with vertebral osteomyelitis have no obvious prior infection.
• Epidural abscess can occur at any age, but is most prevalent in people age 50 and older.
• Although treatment has improved greatly in recent years, the death rate from spinal infection is still an estimated 20%.

Risk factors for developing spinal infection include conditions that compromise the immune system, such as:

• Advanced age
• Intravenous drug use
• Human immunodeficiency virus (HIV) infection
• Long-term systemic usage of steroids
• Diabetes mellitus
• Organ transplantation
• Malnutrition
• Cancer

Surgical risk factors include surgeries of long duration, high blood loss, implantation of instrumentation and multiple, or revision, surgeries at the same site. Infections occur in 1-4% of surgical cases, despite numerous preventative measures that are followed.

Spinal infections can be caused by either a bacterial or a fungal infection in another part of the body that has been carried into the spine through the bloodstream. The most common source of spinal infections is a bacterium called staphylococcus aureus, followed by Escherichia coli.

Spinal infections may occur after a urological procedure, because the veins in the lower spine come up through the pelvis. The most common area of the spine affected is the lumbar region. Intravenous drug abusers are more prone to infections affecting the cervical region. Recent dental procedures increase the risk of spinal infections, as bacteria that may be introduced into the bloodstream during the procedure can travel to the spine.

Intervertebral disc space infections probably begin in one of the contiguous end plates, and the disc is infected secondarily. In children, there is some controversy as to the origin. Most cultures and biopsies in children are negative, leading experts to believe that childhood discitis may not be an infectious condition, but caused by partial dislocation of the epiphysis (the growth area near the end of a bone), as a result of a flexion injury.

Symptoms vary depending on the type of spinal infection but, generally, pain is localized initially at the site of the infection. In postoperative patients, these additional symptoms may be present:

• Wound drainage
• Redness, swelling or tenderness near the incision

• Severe back pain
• Fever
• Chills
• Weight loss
• Muscle spasms
• Painful or difficult urination
• Neurological deficits: weakness and/or numbness of arms or legs, incontinence of bowels and/or bladder

Patients may initially have few symptoms, but eventually develop severe back pain. Generally, younger, preverbal children do not have a fever nor seem to be in pain, but they will refuse to flex their spines. Children age three to nine typically present with back pain as the predominant symptom

Postoperative disc space infection may be present after surgery, occurring, on average, one month after surgery. The pain is usually alleviated by bed rest and immobilization, but increases with movement. If left untreated, the pain gets progressively worse and intractable, unresponsive even to prescription painkillers.

Adult patients often progress through the following clinical stages:

1. Severe back pain with fever and local tenderness in the spinal column
2. Nerve root pain radiating from the infected area
3. Weakness of voluntary muscles and bowel/bladder dysfunction
4. Paralysis

In children, the most overt symptoms are prolonged crying, obvious pain when the area is palpated and hip tenderness.

In general, symptoms are usually nonspecific. If a paraspinal abscess is present, the patient may experience flank pain, abdominal pain or a limp. If a psoas muscle abscess is present, the patient may feel pain radiating to the hip or thigh area.

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Seek medical care if symptoms of a spinal infection are present. Early diagnosis and treatment can prevent progression of the infection and may limit the degree of intervention required to treat the infection. Delaying care may result in progression of the infection causing irreversible damage to boney and soft tissue structures of and around the spine.

Signs of spinal infection emergency (Seek care immediately):

• Development of new neurological deficits, such as weakness of arms or legs and/or bowel/bladder incontinence.
• Fever not controlled with medication.

The biggest challenge is making an early diagnosis before serious morbidity occurs. Diagnosis typically takes an average of one month, but can take as long as six months, impeding effective and timely treatment. Many patients do not seek medical attention until their symptoms become severe or debilitating.

Laboratory Tests

Specific laboratory tests can be useful in helping to diagnose a spinal infection. It may be beneficial to get blood tests for acute-phase proteins, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Both ESR and CRP tests are often good indicators as to whether any inflammation is present in the body (the higher the level, the more likely it is that inflammation is present). As inflammation is the body’s natural response to infection, these markers can monitored to assess the presence of infection and the effectiveness of treatment. These tests alone however, are limited, and other diagnostic tools are usually required.

Identification of the organism is essential, and this can be accomplished through computed tomography-guided biopsy sampling of the vertebra or disc space. Blood cultures, preferably taken during a fever spike, can also help identify the pathogen involved in the spinal infection. Proper identification of the of the pathogen is necessary to narrow the antibiotic treatment regiment.

Imaging Tools

Imaging studies are necessary to pinpoint the location and extent of a lesion. The choice of specific imaging techniques varies slightly, depending on the location of the infection.

Computed Tomography Scan (CT Scan)

The degree of bone destruction is best imaged on a CT scan. Vertebral osteomyelitis can destroy the vertebral body and lead to spinal deformity (typically kyphosis). By assessing the degree of boney destruction, the amount of spinal instability can be determined and can aid in deciding between non-surgical and surgical treatment options.

The CT scan above shows vertebral osteomyelitis at L3-L4 resulting in destruction of the L3 and L4 vertebral bodies. The second CT shows a thoracic spinal compression fracture due to osteomyelitis causing a kyphotic deformity of the spine.

Magnetic Resonance Imaging (MRI)

MRI with and without gadolinium contrast enhancement has become the gold standard in identifying spinal infection and assessing the neural elements. MRI allows for visualization of the soft tissues that include the nerves, spinal cord, and paraspinal muscles, and adjacent soft tissue around the spinal column. Enhancement of the vertebral body, disc space or epidural space is a key sign of infection; however, other pathologies such as inflammation or tumors must be ruled out.

Spinal infections often require long-term intravenous antibiotic or antifungal therapy and can equate to extended hospitalization time for the patient. Immobilization may be recommended when there is significant pain or the potential for spine instability. If the patient is neurologically and the spinal column is structurally stable, antibiotic treatment should be administered after the organism causing the infection is properly identified. Patients generally undergo antimicrobial therapy for a minimum of six to eight weeks. The type of medication is determined on a case-by-case basis depending on the patient’s specific circumstances, including his or her age.

Nonsurgical treatment should be considered first when patients have minimal or no neurological deficits and the morbidity and mortality rate of surgical intervention is high. However, surgery may be indicated when any of the following situations are present:

• Significant bone destruction causing spinal instability
• Neurological deficits
• Sepsis with clinical toxicity caused by an abscess unresponsive to antibiotics
• Failure of needle biopsy to obtain needed cultures
• Failure of intravenous antibiotics alone to eradicate the infection

The primary goals of surgery are to:

• Debride (clean and remove) the infected tissue
• Enable the infected tissue to receive adequate blood flow to help promote healing
• Restore spinal stability with the use of instrumentation to fuse the unstable spine
• Restore function or limit the degree of neurological impairment

Once it is determined that the patient requires surgery, imaging tools such as plain x-rays, CT scans or MRI can help further pinpoint the level at which to perform surgery.

Proper and timely follow-up is necessary to ensure that the spinal infection has been controlled and is responding to the treatment protocol. Repeat lab work and imaging studies should reflect improvement in the infection. CT and x-ray studies will allow the surgeon to assess the integrity of the boney structures of the spine and ensure that spinal instrumentation has not failed.

Current treatment protocols for spinal infections require treatment by a multidisciplinary team of physicians, including infectious disease experts, neuroradiologists and spine surgeons. The team will be able to assess the best treatment approach on an individualized basis, whether it is surgical or nonsurgical.

Case Example: Osteomyelitis of L3 and L4 vertebral bodies

MRI (left) and CT (middle) scan showing osteomyelitis of the L3 and L4 vertebral bodies causing destruction of the spinal column. This leads to spinal instability and compression of the lumbar nerve roots. Patient underwent surgery for debridement of the L3 and L4 vertebral bodies and implantation of a titanium graft, pedicle screws, and rods to reconstruct the spinal column (right).

Shashank V. Gandhi, MD; Michael Schulder, MD, FAANS
Department of Neurosurgery
Zucker School of Medicine at Hofstra/Northwell
Manhasset, NY

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified Neurosurgeon online tool.

Lumbar Puncture | Johns Hopkins Medicine

A lumbar puncture (LP) or spinal tap may be
done to diagnose or treat a condition. For this procedure, your healthcare
provider inserts a hollow needle into the space surrounding the spinal column
(subarachnoid space) in the lower back to withdraw some cerebrospinal fluid
(CSF) or inject medicine.

CSF is a clear fluid that bathes and
cushions the brain and spinal cord. It is continuously made and reabsorbed in
the brain. CSF is made up of cells, water, proteins, sugars, and other
substances that are essential to maintain balance in the nervous system.

Why might I need a lumbar puncture?

A lumbar puncture may be done for various
reasons. The most common reason is to remove a small amount of CSF for testing.
This can help in the diagnosis of various disorders. The fluid is tested for
red and white blood cells, protein, and glucose (sugar). The clarity and color
of the fluid are also checked and it is tested to see whether bacteria,
viruses, or abnormal cells are present. Excess CSF may also be removed in
people who have an overproduction or decreased absorption of the fluid.

A lumbar puncture procedure may be helpful
in diagnosing many diseases and disorders, including:

• Meningitis. An inflammation of the membrane covering the
  brain and spinal cord. The inflammation is usually the result of a viral,
  bacterial, or fungal infection.

• Encephalitis.
  
  An inflammation of the brain that is usually caused by a virus.

• 
  Certain cancers involving the brain and spinal cord
  

• Bleeding
  in the area between the brain and the tissues that cover it
  (subarachnoid space)

• Reye syndrome. A sometimes fatal disease that causes severe
  problems with the brain and other organs. Although the exact cause of the
  disease is not known, it has been linked to giving aspirin to children. It is
  now advised not to give aspirin to children during illnesses, unless prescribed
  by your child’s healthcare provider.

• Myelitis.
  An inflammation of the spinal cord or bone marrow.

• Neurosyphilis.
  A stage of syphilis during which the bacteria invades the central
  nervous system.

• Guillain-Barré syndrome.
  
  A disorder in which the body’s immune system attacks part of the
  nervous system.

• Demyelinating diseases.
  Diseases that attack the protective coating that surrounds certain
  nerve fibers – for example, multiple sclerosis or acute
  demyelination polyneuropathy.

• Headaches

  of unknown cause.
  
  After evaluation and head imaging if necessary, a lumbar puncture
  may be done to diagnose certain inflammatory conditions that can
  result in a headache.

• Pseudotumor cerebri

  (also called idiopathic intracranial hypertension, or IIH).
  
  In this condition,pressure within the subarachnoid space is
  elevated for reasons that are not clear. A lumbar puncture is only
  done in this condition after evaluation and head imaging.

• Normal pressure hydrocephalus.
  
  A rare condition affecting mainly older people in which there is a
  triad of loss of urinary control, memory problems, and an unsteady
  gait. A lumbar puncture is done to see if the pressure of the CSF
  is elevated or not.

In addition, a lumbar puncture may be used
to measure the pressure of the CSF. The healthcare provider uses a special tube
(called a manometer) to measures the pressure during a lumbar puncture.

Finally, a lumbar puncture may be done to
inject medicine directly into the spinal cord. These include:

• Spinal anesthetics before a surgical procedure
• Contrast dye for X-ray studies – for example, myelography
• Chemotherapy drugs used to treat cancer

Your healthcare provider may have other
reasons to recommend a lumbar puncture.

Pseudotumor Cerebri | Ashley’s Story

After visiting 30+ physicians, Ashley was diagnosed with the rare condition known as pseudotumor cerebri. She and her family turned to the experts at Johns Hopkins who worked as a team to implant a stent, a new approach to treating this condition that is typically treated with a shunt.

What are the risks of a lumbar puncture?

Because this procedure involves the spinal cord and brain, the following
complications may occur:

• A small amount of CSF can leak from the needle insertion site. This can cause headaches after the procedure. If the leak continues, your headache can be severe.
• You may have a slight risk of infection because the needle breaks the skin’s surface, providing a possible way for bacteria to enter the body.
• Short-term numbness of the legs or lower back pain may be experienced.
• here is a risk of bleeding in the spinal canal.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I prepare for a lumbar puncture?

If you are having a lumbar puncture at Johns Hopkins Hospital or Bayview Medical Center, a neuroradiologist or radiology nurse will contact you by phone two or three days prior to your lumbar puncture to discuss the procedure and answer any questions you may have.

Please inform the neuroradiology physician if:

• You are on antibiotics – you may need to wait to do the procedure if currently on antibiotics for an in infection in your blood. If you have an active infection or fever, your procedure may need to be rescheduled.
• You are allergic to any local anesthetics (lidocaine)
• There is any chance that you could be pregnant
• You are on anticoagulant therapy (blood thinners)

PRECAUTIONS: If you are pregnant or think you might be pregnant, please check with your doctor before scheduling the exam. Other options should be discussed with you and your doctor.

CLOTHING: You may be asked to change into a gown. A gown will be provided for you. However, the procedure may also be done while you remain in your clothes from home. For this reason, try to wear non-restrictive, comfortable clothing and slip on shoes if possible. Please remove all piercings and leave all jewelry and valuables at home

EAT/DRINK: Try to increase your fluid intake (such as water and juice) for the two days leading up to your procedure unless a medical condition does not allow you to safely do so. If you are not sure if it is safe for you, contact your primary care provider or referring provider.

However, on the day of the procedure, do not eat for three hours before the procedure. You may have liquids and can take your usual medications unless previously advised to hold certain medications in preparation for the lumbar puncture.

MEDICATION: All patients can take their prescribed medications as usual unless instructed to hold certain medications such as blood thinners. Please bring a current list of your medications and allergies with you.

TRAVEL: You must have an adult driver accompany you so they can drive you home after the procedure. This is for your safety and comfort.

• Arrive one hour prior to the scheduled procedure time for check-in and to be prepped for the procedure.
• Please note: You will be unable to drive for 24 hours after the procedure. If you are taking a cab or using public transportation, you need to bring a friend or family member to accompany you after the procedure to your home or hotel. A cab or public transportation driver is not considered an escort.

What happens during a lumbar puncture?

A lumbar puncture procedure may be done on an outpatient basis or as part
of your stay in a hospital. Procedures may vary depending on your condition
and your doctor’s practices. Some healthcare providers may prefer to do
this procedure at the bedside or may opt to have it done using a type of
live X-ray called fluoroscopic guidance.

Generally, a lumbar puncture follows this process

• You will remove any clothing, jewelry, or other objects that may
  interfere with the procedure
• You will be given a gown to wear.
• You will be reminded to empty your bladder prior to the start of
  the procedure.
• During the lumbar puncture you may lie on the exam table on your
  side with your chin tucked to your chest and knees tucked to your
  abdomen. Or, you may sit on the edge of an exam table with your
  arms draped over a table positioned in front of you. In either
  position the back is arched, which helps to widen the spaces
  between your vertebrae.
• Therefore, your back will be cleansed with an antiseptic solution
  and draped with sterile towels. The healthcare provider will wear
  sterile gloves during the procedure.
• The provider will numb the skin by injecting a local anesthetic.
  This injection may sting for a few seconds, but makes the lumbar
  puncture less painful.
• The hollow needle will be inserted through the numbed skin and into
  the space where the CSF is located. You will feel some pressure
  while the needle is inserted. You must remain absolutely still
  during the insertion of the needle.
• The CSF will begin to drip out of the needle and a small amount,
  about one tablespoon, will be collected into test tubes.
• If the provider needs to inject medicine into the spinal canal, it
  will be given through the same needle after the CSF is collected.
• When the procedure is done, the needle will be removed and a
  bandage will be placed over the injection site. The test tubes will
  be taken to the lab for testing
• Tell the healthcare provider if you feel any numbness, tingling,
  headache, or light-headedness during the procedure.

You may have discomfort during a lumbar puncture. Your healthcare providers
will use all possible comfort measures and complete the procedure as
quickly as possible to minimize any discomfort or pain.

What happens after a lumbar puncture?

This helps reduce the incidence of a headache. You will be allowed to roll from side to side as long as your head is not elevated. If you need to urinate, you may need to do so in a bedpan or urinal during the time that you need to stay flat.

You will be asked to drink extra fluids to rehydrate after the procedure. This replaces the CSF that was withdrawn during the spinal tap and reduces the chance of developing a headache.

After recovery, you may be taken to your hospital room or discharged to your home. If you go home, usually your healthcare provider will advise you to rest for the remainder of the day

Once you are at home, notify your provider of any abnormalities, such as:

• Numbness and tingling of the legs
• Drainage of blood or pain at the injection site
• Inability to urinate
• Headaches

If the headaches persist for more than a few hours after the procedure, or when you change positions, contact the neuroradiology team with the phone number provided on your discharge instructions.

You may be instructed to limit your activity for 24 hours following the procedure.

Your healthcare provider may give you other specific instructions about what you should do after a lumbar puncture.

Lumbar puncture – preparation, indications and performance of a puncture in Moscow

Lumbar puncture is performed to collect cerebrospinal fluid (CSF) (synonymous with CSF) that bathes the brain and spinal cord. Normally, viruses, bacteria, inflammatory cells – leukocytes, and oligoclonal antibodies should not be detected in the cerebrospinal fluid. If we find any pathological agent in the cerebrospinal fluid, then it becomes possible to accurately determine the cause of the disease. For example, the detection of oligoclonal antibodies and the 2nd type of their synthesis makes it possible to establish the diagnosis of multiple sclerosis with a high probability.

How is the procedure carried out?

The patient is asked to lie on his side, bend his head and press his bent knees to his stomach, ie. assume the fetal position. Sometimes the puncture is done in a sitting position, then they are also asked to lean forward as much as possible. Flexion of the back is necessary in order to increase the distance between adjacent vertebrae in the lumbar region and to reduce the distance from the skin to the spinal canal. Before the puncture, local anesthesia is performed. I perform a puncture in the lower back into the space between the spinal processes of 5 or 4 lumbar vertebrae. You may feel some discomfort during the insertion of the needle, but there is usually no pain due to local anesthesia. After the needle enters the spinal canal, cerebrospinal fluid begins to drain from the lumen of the needle. Usually 3-5 ml of liquid is taken. The entire procedure usually takes about 10 minutes. Within a day or two after the puncture, discomfort at the injection site may disturb. However, pain is more likely associated with the irritating effect of the anesthetic than directly with microtrauma when the needle is inserted. They try to perform the puncture in the morning in order to have time to send the CSF sample to the laboratory.

Is it possible to damage the spinal cord during a puncture?

Despite the fact that the needle is inserted into the space where the spinal cord is located, its injury is excluded during the standard CSF collection procedure in adults. The fact is that the spinal cord fills the canal throughout only in infants. The growth of the spine significantly outstrips the growth of the spinal cord, so the latter, as it were, “lifts up”, and its lower border is at the level of the 1st lumbar vertebra. The remaining space is a fluid-filled sac that contains the spinal nerve roots that travel down to “their” foramina in the spine. It is as difficult to damage a spine with a needle as it is to pierce vermicelli in broth with a needle. Trauma to the intervertebral disc is excluded, since the needle is inserted from the opposite side of the vertebra.

What side effects can be expected after the puncture?

The most common (approximately 20% of patients) adverse effect of a lumbar puncture is headache. A decrease in CSF pressure can cause irritation of the meninges containing pain receptors. This pressure drop is most significant when moving to a vertical position. Therefore, immediately after the puncture, it is necessary to lie down for 2 hours. Also, over the next 2-3 days, it is recommended to exclude physical activity and, if possible, lie down 2-3 times a day for 30 minutes. Headache occurs in an upright position and disappears in a horizontal position. Conventional pain medications for post-puncture headache are usually ineffective, the best treatment is to lie down.

How much CSF is taken during a lumbar puncture?

Total adult CSF volume is 140 to 270 ml. 600-700 milliliters of fluid are produced daily, that is, the cerebrospinal fluid is completely renewed about 4 times a day. During a lumbar puncture, 3-5 ml of fluid is usually removed. Thus, the extracted volume of CSF is rather insignificant in comparison with the total volume of its circulation. It is preferable to perform a lumbar puncture with the thinnest possible needle so that CSF does not leak through the puncture. To quickly replenish the volume of cerebrospinal fluid, you can speed up its production. To this end, it is recommended to take a sufficient amount of liquid (at least 2 liters of mineral water per day), as well as coffee (2-3 cups per day).

How important is a lumbar puncture?

Although lumbar puncture is an invasive procedure, it is generally well tolerated, no more painful than blood sampling, and the diagnostic information obtained after lumbar puncture is invaluable. And this, in turn, speeds up the diagnosis and allows you to prescribe treatment as early as possible.

Lumbar puncture in Moscow at the Moscow Multiple Sclerosis Center

There are many negative opinions about lumbar puncture. But these are precisely the opinions of non-specialists, many of whom have not had a lumbar puncture at all. “This is a very painful procedure”, “the puncture cannot be done – it is very harmful”, “the legs will fail”, “you will not be able to walk”, “you will have meningitis” and much more can be heard from our patients and read on the Internet. But in reality, these words are groundless. First, lumbar puncture is a routine procedure throughout the world. In recent years, the range of diseases has significantly expanded, in which a lumbar puncture is performed, followed by analysis of the cerebrospinal fluid (CSF). Multiple sclerosis and other demyelinating diseases, motor neuron disease, polyneuropathy, dementia, Alzheimer’s disease, CNS tumors are diseases that require a lumbar puncture to be diagnosed.

How is a puncture done

What does a puncture provide for diagnosis?

After this procedure, we get liquor (stress on the first syllable). Liquor is a fluid (also called cerebrospinal fluid) that bathes the brain and spinal cord. It has a unique composition, we know which substances should be normal and which should not be. We can determine their number. Moreover, in various diseases, due to changes in the brain and spinal cord, substances begin to appear in the cerebrospinal fluid that directly indicate which CNS cells die and by what mechanism. All this information for the doctor is invaluable. It will allow you to distinguish between certain diseases that are very similar to each other in manifestations (symptoms), confirm or accelerate the diagnosis.

What can we detect in the cerebrospinal fluid in multiple sclerosis?

The primary diagnosis of multiple sclerosis is no longer complete without a lumbar puncture. Of course, it can not be carried out, but, because. there are many similar diseases, without a puncture it is possible to be mistaken in the diagnosis. In addition, if you have radiologically or clinically isolated syndromes, then the analysis of cerebrospinal fluid allows you not to wait for the next exacerbation, and together with the MRI data, you can establish a diagnosis much faster and prescribe treatment much faster. And we know that starting therapy earlier increases its effectiveness and is more likely to slow down the accumulation of disability in the future.

So, we remember that with multiple sclerosis, autoimmune inflammation occurs in the central nervous system. Immune cells enter the inflammation zone (which we see on MRI as an active focus) and begin, among other things, to produce antibodies. Antibodies belong to the class of immunoglobulins. In the cerebrospinal fluid, immunoglobulins are normal, their small amount corresponds to the spectrum of immunoglobulins in the blood. Those. we have a great many (millions) of antibodies to various bacteria, viruses, etc. in our blood. Each antibody is found in approximately equal concentrations in the blood, and when we do an analysis, we find many small peaks – “noise” from antibodies. The same “noise” is detected in the liquor. Then we say that both in the cerebrospinal fluid and in the blood (serum) the synthesis of antibodies is polyclonal (normal, type 1 synthesis). But in multiple sclerosis, when autoimmune inflammation occurs in the brain and spinal cord, in the focus of this inflammation, immune cells (B-lymphocytes) begin to produce antibodies of a certain specificity (to myelin). These antibodies penetrate into the cerebrospinal fluid (but not into the blood), and in the analysis there is one very large peak against the background noise, indicating that the concentration of one antibody (out of millions) has increased dramatically. I repeat, since inflammation occurs precisely in the central nervous system, the concentration of these specific antibodies appears there, but not in the blood. Then we see that the synthesis of immunoglobulins in the blood serum remains “noisy”, polyclonal, and an increased level of certain immunoglobulins appears in the cerebrospinal fluid – oligoclonal synthesis. This combination of polyclonal synthesis in blood serum and oligoclonal synthesis in CSF is referred to as type 2 synthesis or simply oligoclonal. If oligoclonal antibodies are detected in the cerebrospinal fluid, then this confirms multiple sclerosis with a very high degree of probability. But if oligoclonal immunoglobulins are not detected, then this does not reject the diagnosis – such a collision. The method is very specific, but may not be very sensitive. Why is this happening? It depends on the activity of inflammation in the CNS: if active foci are detected on MRI, then oligoclonal antibodies appear in the cerebrospinal fluid (if these foci are due to multiple sclerosis). And if there are no oligolonal immunoglobulins in the presence of active foci in the cerebrospinal fluid, then doctors think very strongly that there may be a diagnosis different from multiple sclerosis. If there are no active foci, then the absence of oligoclonal antibodies does not exclude the diagnosis, because. the amount of their production may be insufficient for the appearance of a peak of oligoclonal immunoglobulins. But still more often, if you already have multiple sclerosis, there are no active foci on MRI, then oligoclonal antibodies will still be detected in the cerebrospinal fluid.

In addition to detecting oligoclonal antibodies, the analysis of cerebrospinal fluid makes it possible to exclude other causes, other diseases: viral, bacterial damage, i. e. infection, and other demyelinating diseases.

How is a puncture performed?

First, the procedure is painless: it is performed under local anesthesia. You will not feel pain, only a small prick with a thin needle when lidocaine or other local anesthetic is injected. The very introduction of the puncture needle will be painless. When it enters the spinal canal, it is rare, but it happens that the needle touches the spinal root passing in the canal (it does not damage it, but it touches it). In this case, for a fraction of a second, you may feel a shot along the spine, usually in the leg.

Secondly, the puncture is not made into the spinal cord, but into the spinal canal containing the spinal cistern. The spinal cord is a thin cord that ends at the level of the last, 12th thoracic or first lumbar vertebrae. Next come only the spinal roots. We insert the needle significantly below the point of termination of the spinal cord – between the 4th and 5th lumbar vertebrae. Therefore, if performed correctly, there can be no damage to the spinal cord, and hence weakness of the legs.

The procedure itself is performed lying on your side or in a sitting position. After the introduction of lidocaine between the fourth and fifth vertebrae, a special puncture needle is inserted into the spinal cistern. Inside the needle there is a lumen, into which the cerebrospinal fluid begins to flow. Liquor is collected in a volume of 2-4 ml in special test tubes and sent to the laboratory. Usually the result is required to wait from 5 to 10 days.

After the puncture, lie down on your side or stomach, preferably without a pillow for two hours, longer if possible. When the “freeze” goes away, you may feel a little soreness at the puncture site, which will completely disappear the next day. The next day or the day after, a post-puncture headache may occur – the only complication after a puncture. Headache does not always occur, in a smaller proportion of patients, more often in young people, lasting from one day to a week.