November 14, 2019
Diagnosing MS – Lumbar puncture

Diagnosing MS – Lumbar puncture

So you might be surprised to hear that
lumber functions are now being done increasingly frequently in the diagnosis
of MS. We went through a phase where they weren’t done very often, but just in the
last couple of years some new diagnostic criteria have been suggested which means
that lumbar punctures are now back in the fray, particularly at the very
beginning of the illness. So that now with one MRI scan and one lumbar
puncture you can definitively diagnose MS. So
What’s a lumbar puncture like? Well the first thing is that people often have
real fears and anxieties about lumbar punctures they may well have heard
terrible stories and if they haven’t heard terrible stories, they’ve got all
sorts of imaginings of huge needles and terrible pain and all the rest of it. And
99% of people that have lumbar puncture say “well I really didn’t think it was
going to be as good as that”. So if your doctor asks you to have a lumbar
puncture then I’d encourage you to accept because
it will make the diagnosis of MS or not or whatever else much more secure and
confident. You would only ever have to have one you know there’s no need to
have repeated one so this is a one-off moment to really secure the diagnosis of
MS so that you can go into the future knowing that you do or don’t have the
disease and make plans accordingly. Lumbar punctures are done in a hospital
setting and the whole process takes half a day a morning or an afternoon. Where
people come in meet the nurse or the doctor who’s doing the lumbar puncture
and then the actual lumbar puncture it take itself takes about half an hour and
then people are usually asked to lie on a bed for one or two hours afterwards,
and then they can go. So the the key thing that can go wrong in a lumbar
puncture and the main cause of side effects is
once you’ve taken the needle out you can get you’ve got a hole in the covering
around the spinal fluid and some spinal fluid can leak out of that hole. And if
that happens a lot then people can have a relatively dehydrated brain with less
spinal fluid than there should be which people will notice with a headache.
And that headache is particularly prominent if you stand up, you can
imagine the spinal fluid draining down as you stand up and the brain is
dehydrated and the brain doesn’t like that. Now the best thing you can do to
avoid that leak is remain relatively still and relatively flat for a while to
allow the leak to clot up literally with with blood clotting products and not do
too much active over the next day or two after that. So the procedure is very
awkward and uncomfortable. You have to lie sort of curled up in a
ball and you can’t see what’s going on, and that is a bit of a worry because you
thinking “oh my goodness what’s going on” but if the doctor or nurse who is doing it,
is doing their job properly they will make you feel at ease. The the most
painful bit is actually the injection of the local anesthetic so that’s done with
an ordinary needle that you would use to take blood from someone or whatever. And
most people have had experience of those sort of local anaesthetic injections and
that’s there to numb the back and if that’s done well then the spinal needle
itself shouldn’t be painful. People can feel it, and it certainly feels odd to
have someone putting a needle through your skin but it shouldn’t be painful.
Very occasionally the needle can touch one of the nerves go into the leg and
that can result in a feeling of electric shock down the leg and people might
imagine “oh my goodness something’s gone wrong,
you know they hit my spinal cord” or whatever but
actually that’s not the case, and it doesn’t mean anything bad has happen, but
that can happen and can be a source of discomfort Well the key thing about a lumbar
puncture is it shows the presence of something called “Oligoclonal bands”
and people will see that phrase a lot when they look up MS, and all that
actually means is a few Oligoclonal bands of antibodies. So all it’s saying is
that there are some antibodies in the spinal fluid that aren’t normally there.
And 90% or more of people who have definite MS will have these antibodies
in their spinal fluid so if the spinal fluid is normal that goes a long way to
saying someone doesn’t have multiple sclerosis and a very typical example of
that where it might be useful is if in an older person, say someone aged 60 who
has some symptoms that might do for MS their MRI scan may well have a few
rather nonspecific blobs on them because we get those blobs as we get older so
the MRI scan is less useful in discriminating for diagnosis and a CSF,
for spinal fluid, a lumbar puncture is really helpful then, because if it shows
these antibodies you can say “yeah that person has MS” if it doesn’t show them
you say “no they don’t have MS”. It’s very helpful. The other situations where
lumbar punctures are being used in the diagnosis of progressive MS, so primary
progressive MS or secondary progressive MS and that’s particularly the case now
that treatments are starting to be licensed and being considered to be
available for primary progressive MS so in that context people need to know the
diagnosis is secure before giving an expensive treatment. And then the final
situation which is becoming more and more frequent, is if someone goes to
their doctor with just one attack, let’s say of numbness. And an MRI scan
shows a few lesions that might be compatible with MS. The question is “well
is this a one-off? Or is this going to recur and become multiple sclerosis?” Now
in the bad old days we would wait for another attack and there’ll be people
who can remember being told well you just have to wait. In the less bad days
we would repeat a scan a few months or a year later and see if anything new it
emerged but now we can do a lumbar puncture then and there and if it shows
antibodies in the spinal fluid we say we don’t need to wait
you definitely have relapsing remitting multiple sclerosis even though the
person hasn’t had relapses or remissions have just had one attack. And the reason
why that’s helpful is because potentially that person could be put on
treatment at that point

2 thoughts on “Diagnosing MS – Lumbar puncture

  1. This video is very helpful. Lots of knowledge on what to expect and treatment plans available. Knowing this, I can go to my doctor and engage in useful conversation about getting help/treatment plans/or tests instead of relying on the physician telling me to "just come back in 6 months to a year ".

  2. I'm a part of that 1% who had a terrible (perhaps the worst) experience of my life when the doctor did the Lumbar puncture during my diagnosis.

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