CSF taps first opinion practice

Re: CSF taps first opinion practice

listhestar — Tue, 04 Jun 2013 16:42:17 GMT

Thanks everyone. All good points. It was just a case with seizures but otherwise well, with no neuro deficits etc, assumed idiopathic but tricky to get stabilised. Owner did not want CSF tap initially or referral despite discussing it but now thinking about it. Was just thinking about it as I am writing it up as a case and would have been nice to rule out other things first. Limits of practice sometimes I guess. I will have a practice seeing as so many people do it. Interestingly do many of you do serum antibody levels for toxo or neo in your neuro cases? I was under the impression reading around that doing that on csf tap is more useful. Any thoughts?

Lisa

Re: CSF taps first opinion practice

John Flynn — Tue, 04 Jun 2013 08:07:13 GMT

[quote user="Michael Woodhouse"]

One of those things that is nice in theory, but without the facilities to do spinal surgery can't see the use of a mylogram.

If steroids and clindamycin can't cure the other neuro things then it's PTS. Most of my clients don't have the money for referral.

Not sure what CSF adds to the picture.

[/quote]

I agree to an extent, Michael.

Re myelogram: even if you're not going to be doing hemilaminectomies yourself (and I understand if you don't wish to), I do think there are some occasions when you could consider this. If you have a nearby referral facility, then perhaps those occasions are going to be pretty sparse though. If it's going to be a 6 hr round trip to a referral centre, or they're only open weekdays for referrals, then a case on a Friday evening to check consistent with a disc and not more likely to be FCE for example (dependent on history also), then a myelogram which demonstrates compression, or lack thereof, can be pretty handy in decision making re referral. Obviously if there's a competent 24/7 referral clinic within 30mins drive specialising in such matters and able to provide the service at a price your clients can afford, then there can't be much reason why you would want to do a myelogram yourself. Same applies if you have a choice of referral options, perhaps a GP locally who does hemi's after a myelogram or a specialist with MRI facilities quite some distance away - a myelogram showing generalised cord swelling and you know there's no point referring locally?

Re steroids and clindamycin: I think it's often pretty obvious when a patient has SRMA and certainly offer to start treatment based on this assumption, however I do tend to recommend CSF tap first. It's not expensive and once you've started the steroids, then you really can't get meaningful info at a later date if you start to doubt yourself and perhaps it was a traumatic neck injury instead... What CSF adds to this picture is usually confirmation of your diagnosis, based on which you're proabably going to give a long course of steroids at reasonably high doses. And then there's the cases that AREN'T consistent with SRMA much to your surprise.... If you give everything steroids and clindamycin, what dose of these and for what duration do you treat?? (Also, you're missing furosemide off your neuro drug inventory - it can work magic sometimes )

Re: CSF taps first opinion practice

Robin Grimmer — Mon, 03 Jun 2013 22:43:39 GMT

I did them when I did my medicine certificate and in the days when we used to do myelograms. I never had any problems. I generally would remive the stylet quite early and stop if I got any blood back. I was struggling to find a decent neurological case for my medicine certificate until our receptionists nova scotia duck tolling retriever got steroid responsive meningitis.

Re: CSF taps first opinion practice

Michael Woodhouse — Mon, 03 Jun 2013 22:23:05 GMT

The bevel on a hypodermic needle is much longer and you have that point so much closer to the spine than a proper spinal needle.

One of those things that is nice in theory, but without the facilities to do spinal surgery can't see the use of a mylogram.

If steroids and clindamycin can't cure the other neuro things then it's PTS. Most of my clients don't have the money for referral.

Not sure what CSF adds to the picture.

Re: CSF taps first opinion practice

Anthony Dennison — Mon, 03 Jun 2013 22:01:48 GMT

I've been told at CPD that a 1.5" 21G needle is fine for the job, and practicing on cadavers the way forward. Think I may be adding his option to my euthanasia consent forms so I can practice before going on to the real thing.

Somethingabout I'm desperate to do though!

Re: CSF taps first opinion practice

John Flynn — Mon, 03 Jun 2013 21:37:53 GMT

As an assistant, I watched my then boss of 30+yrs experience take a 1.5" 21G needle and stab it around until he found some CSF.

As he had reportedly never killed a dog like this, I thought I'd be safe enough to give it a go with a spinal needle and a little care!

Don't do it that often, but no problems to report yet. Main times are when I think a dog has steroid-responsive meningitis-arteritis, but want to confirm that before starting steroids, or prior to myelogram (always seems like I might regret not collecting CSF even if I do think is going to be a disc...)

I still remember the first time I took a blood sample out of a cat's neck - I was terrified with all the important structures I could lacerate, or the first time I did a conscious cystocentesis on a cat - what if the bladder pops? Years on, no serious incidents from these procedures to report, and I don't fret quite so much.

My top tip would be to be prepared - think in advance, why am I doing this? what sample requirements do I need? If the first bit is haemorrhagic, which tube will I collect that in? What is my tube priority? Am I going to do an in-house cell count using an appropriate counting chamber or post it away? If posting away then what is length of time from sampling to analyzing going to be? Will I make a sedimented slide for differential count and cytology? culture? any biochemical testing? etc. etc.

Collecting the sample is only half the job, it's important to think through how you're going to make sure you get diagnostic info from that sample...

This is one of those situations that I think you'll surprise yourself how easy it is - there's loads of texts with guides and tips - pick your favourite. Having said that, I think there is no harm in practising this one on a cadaver first, and I think you can do so without clipping hair etc and (controversial comment coming...) if you feel happy doing so, I think a cadaver going for routine cremation belonging to an owner that you genuinely don't think would mind (farm dogs always spring to mind) is fine even if you haven't asked for permission for this (it's not like you're cutting off a leg or dismembering its body or anything) - just stick the needle in and poke around until you get fluid and you'll be doubly confident when you come to do on live patient.

Re: CSF taps first opinion practice

Louise6732 — Mon, 03 Jun 2013 21:30:23 GMT

I cracked on with the first one I did. I chatted to the O' options of referral vs medical management vs getting a diagnosis (5m Great Dane so very big already! With steroid responsive meningitis, it turned out). I discussed the risks with them and they were fine with it. I think as long as you explain what could potentially go wrong then you're fine. And I think it is a procedure we can do in 1st opinion. Practicing on cadavers certainly helps.

Louise

Re: CSF taps first opinion practice

Andrew Kent — Mon, 03 Jun 2013 21:23:10 GMT

There is no reason you shouldn't do them unless you have reason to suspect increased ICP. And maybe not in CKCS. I practiced on cadavers first but otherwise just got on with it! (BSAVA procedures guide is great if you need som guidance!)

Re: CSF taps first opinion practice

Utlendigur — Mon, 03 Jun 2013 20:16:16 GMT

[quote user="Evelyn Barbour-Hill"]

I just cracked on and did it. It seems scary but then you find there's nothing to be scared of.

[/quote]

Unless the first one you've seen done (at university) resulted in the dog dying on the table Never fancied doing one after that!

Re: CSF taps first opinion practice

Evelyn Barbour-Hill — Mon, 03 Jun 2013 19:51:12 GMT

I just cracked on and did it. It seems scary but then you find there's nothing to be scared of.