Straus Sharon E, Thorpe Kevin E, Holroyd-Leduc Jayna
Division of General Internal Medicine, University of Calgary, Alberta.
JAMA. 2006 Oct 25;296(16):2012-22. doi: 10.1001/jama.296.16.2012.
Diagnostic lumbar punctures (LPs), commonly used to rule out meningitis, are associated with adverse events.
To systematically review the evidence about diagnostic LP techniques that may decrease the risk of adverse events and the evidence about test accuracy of cerebrospinal fluid (CSF) analysis in adult patients with suspected bacterial meningitis.
We searched the Cochrane Library, MEDLINE (using Ovid and PubMed) from 1966 to January 2006 and EMBASE from 1980 to January 2006 without language restrictions to identify relevant studies and identified others from the bibliographies of retrieved articles.
We included randomized trials of patients aged 18 years or older undergoing interventions to facilitate a successful diagnostic LP or to potentially reduce adverse events. Studies assessing the accuracy of biochemical analysis of the CSF for possible bacterial meningitis were also identified.
Two investigators independently appraised study quality and extracted relevant data. For studies of the LP technique, data on the intervention and the outcome were extracted. For studies of the laboratory diagnosis of bacterial meningitis, data on the reference standard and test accuracy were extracted.
We found 15 randomized trials. A random-effects model was used for quantitative synthesis. Five studies of 587 patients compared atraumatic needles with standard needles and found a nonsignificant decrease in the odds of headache with an atraumatic needle (absolute risk reduction [ARR], 12.3%; 95% confidence interval [CI], -1.72% to 26.2%). Reinsertion of the stylet before needle removal decreased the risk of headache (ARR, 11.3%; 95% CI, 6.50%-16.2%). The combined results from 4 studies of 717 patients showed a nonsignificant decrease in headache in patients who were mobilized after LP (ARR, 2.9%; 95% CI, -3.4 to 9.3%). Four studies on the accuracy of biochemical analysis of CSF in patients with suspected meningitis met inclusion criteria. A CSF-blood glucose ratio of 0.4 or less (likelihood ratio [LR], 18; 95% CI, 12-27]), CSF white blood cell count of 500/muL or higher (LR, 15; 95% CI, 10-22), and CSF lactate level of 31.53 mg/dL or more (> or =3.5 mmol/L; LR, 21; 95% CI, 14-32) accurately diagnosed bacterial meningitis.
These data suggest that small-gauge, atraumatic needles may decrease the risk of headache after diagnostic LP. Reinsertion of the stylet before needle removal should occur and patients do not require bed rest after the procedure. Future research should focus on evaluating interventions to optimize the success of a diagnostic LP and to enhance training in procedural skills.
诊断性腰椎穿刺（LP）常用于排除脑膜炎，但与不良事件相关。
系统评价关于可能降低不良事件风险的诊断性LP技术的证据，以及关于疑似细菌性脑膜炎成年患者脑脊液（CSF）分析检测准确性的证据。
我们检索了考克兰图书馆、1966年至2006年1月的MEDLINE（使用Ovid和PubMed）以及1980年至2006年1月的EMBASE，无语言限制以识别相关研究，并从检索文章的参考文献中识别其他研究。
我们纳入了18岁及以上患者接受干预以促进成功诊断性LP或潜在降低不良事件的随机试验。还识别了评估CSF生化分析对可能的细菌性脑膜炎准确性的研究。
两名研究者独立评估研究质量并提取相关数据。对于LP技术的研究，提取干预和结果的数据。对于细菌性脑膜炎实验室诊断的研究，提取参考标准和检测准确性的数据。
我们发现15项随机试验。采用随机效应模型进行定量综合。对587例患者的5项研究比较了无创伤针与标准针，发现使用无创伤针头痛几率无显著降低（绝对风险降低[ARR]，12.3%；95%置信区间[CI]，-1.72%至26.2%）。在拔针前重新插入针芯可降低头痛风险（ARR，11.3%；95%CI，6.50%-16.2%）。对717例患者的4项研究的综合结果显示，LP后活动的患者头痛无显著降低（ARR，2.9%；95%CI，-3.4至9.3%）。4项关于疑似脑膜炎患者CSF生化分析准确性的研究符合纳入标准。CSF与血糖比值≤0.4（似然比[LR]，18；95%CI，12-27）、CSF白细胞计数≥500/μL（LR，15；95%CI，10-22）以及CSF乳酸水平≥31.53mg/dL（≥3.5mmol/L；LR，21；95%CI，14-32）可准确诊断细菌性脑膜炎。
这些数据表明，小口径无创伤针可能降低诊断性LP后头痛的风险。应在拔针前重新插入针芯，且患者术后无需卧床休息。未来研究应侧重于评估优化诊断性LP成功率的干预措施以及加强操作技能培训。
