Indication for LP?

[clubdeac]

Wanted to get the input from a few other neurologists. Have a patient with headaches, neck pain, tinnitus, tremors, hallucinations and multiple falls sent to me for a cervical ESI. Cervical MRI notable for multilevel cervical stenosis. Neurosurgery does not want to operate due to patient's other co-morbidities. Psych attributing hallucinations to grieving process as patients dtr recently died. Neurology obtained a brain MRI, head CT and EEG which were unrevealing and attributed his constellation of symptoms to cervical stenosis and psych overlay. Problem is he has an elevated WBC (14k) w/left shift which has been present for the last 6 months. I obtained inflammatory markers and his CRP was 3.0 and ESR 30. UA and CXR were normal. I referred back to neuro for an LP which they say isn't indicated. I did call the neurologist and he said if it was a bacterial meningitis it would have become more serious by this point and viral would've resolved. My gestalt is that he just wants to turf this to another service. Do you all agree or is there no place for an LP in this setting??

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[typhoonegator]

There is more to be gained from an LP than r/o bacterial meningitis, and not all infectious processes present fulminantly. I don't want to present consultative advice on this forum but I think LP would be at least a reasonable and defensible test to request. Spirochetal diseases can present with a mixture of ill-defined CNS and radicular symptoms that are not always obvious on imaging, and CNS forms of spirochetal disease require different therapeutics, so serologic workup alone is not sufficient.

 

[Thama]

Don't think I would ever let someone like this go without at the very least making sure they didn't have a CSF pleocytosis or high protein. That said, literally anyone who has graduated a real medical school should be comfortable doing an LP so that isn't necessarily limited by a neurology consult.

 

[deathmerchant]

"If you are ever questioning whether a patient needs an LP or not, you should probably do it". It is an easy, quick, cheap and safe procedure which has the potential to diagnose life threatening and treatable diseases.

 

[Neurologo]

It would be helpful to know the age of the patient to narrow the differentials. Besides the above, CSF would also help looking into more rare neoplastic or non-neoplastic limbic encephalitis which can also have all of the mentioned symptoms and more.

 

[oopsy]

Or more simply, depending on which subset of symptoms ( headaches, neck pain, tinnitus, tremors, hallucinations and multiple falls) can be attributable to just this versus comorbid disease, CSF pressure could be very relevant. In comparable situations, I would generally favor getting LP with opening and closing pressures.

 

[neglect]

Wanted to get the input from a few other neurologists. Have a patient with headaches, neck pain, tinnitus, tremors, hallucinations and multiple falls sent to me for a cervical ESI. Cervical MRI notable for multilevel cervical stenosis. Neurosurgery does not want to operate due to patient's other co-morbidities. Psych attributing hallucinations to grieving process as patients dtr recently died. Neurology obtained a brain MRI, head CT and EEG which were unrevealing and attributed his constellation of symptoms to cervical stenosis and psych overlay. Problem is he has an elevated WBC (14k) w/left shift which has been present for the last 6 months. I obtained inflammatory markers and his CRP was 3.0 and ESR 30. UA and CXR were normal. I referred back to neuro for an LP which they say isn't indicated. I did call the neurologist and he said if it was a bacterial meningitis it would have become more serious by this point and viral would've resolved. My gestalt is that he just wants to turf this to another service. Do you all agree or is there no place for an LP in this setting??

Weird chronic meningitis COULD be on the differential and could be missed by MRI. Hallucinations in an older person goes for possible DLB (so does a gait disorder with falls), and an LP will not help you there. But one can never say there is "no place for an LP" in almost any setting.

The nearly criminal problem here, which any neurologist will attest to, is that LPs take a long time, take quite a bit of expertise, take a before and after talk with the patient, and are compensated for sh1t. If LP's followed anything like a market rate, then I'd personally change about 200-300 (about the same as a new patient). As part of a trial, I negotiate 3-5 times that amount, plus overhead. So given the false market of medicine, insurance and Medicare will pay tens of thousands of dollars for a new hip (which is usually preventable with exercise and weight loss, and is barely improved over older models), but about 100 dollars for a possibly life-preserving test. It is not fair. But taking an economic view allows one to see why it is easier to get an MRI than an LP.