Pain Clinic 101: How not to Perform a Lumbar Puncture

Class, today we will examine a case study of a patient who received a test dose of intrathecal baclofen. (Groans from the undergraduates in the back row.)

Now class, this is an exceptional case. The patient, Kim Dolce, arrived at the hospital to undergo an eight-hour test of observation and PT exams after first receiving a bolus of liquid baclofen delivered via lumbar puncture. She had not taken any oral baclofen for the previous twenty-four hours. An I.V. puncture was attempted during the first two hours after Kim was admitted, but after two failed sticks, an ultrasound machine was used to locate a vein in her forearm and the I.V. was successfully placed. She was asked permission to have four doctors from other states observe the procedure, to which she agreed. She was first placed on her side in the fetal position. The pain doctor then gave her an injection of lidocaine in her lower back to numb the area.

“Ouch!” Kim yelled, after which she fell silent.

Her doctor then inserted a needle into the spinal cavity. “Jesus f*@$ing Christ!” Kim screamed. The doctor withdrew the needle.

“Is it the pressure or is it pain?” asked the nurse.

“Pain, pain,” Kim growled between clenched teeth. The doctor again inserted the needle. “Aaaach!” Kim wailed. As the doctor continued probing with the needle, Kim began to use the breathing method employed by women in labor. She was instructed to tighten into a ball and tuck her chin to her chest. Several more attempts were made while Kim yelled in pain, but the doctor could not penetrate the canal.

“Let’s try having Kim sit up,” suggested the doctor. Kim was shaking, her muscles now tightened and spastic. She struggled to sit up and then bent forward over a pillow, tucking her chin to her chest. She could not stop shaking. Another shot of lidocaine was administered. The doctor then inserted the needle.

“Stop!” Kim screamed. “I need a break!”

“Okay, I’ll give you a break,” said the doctor. Although Kim sat for a minute, she could not compose herself and felt a cry coming on, but she held back. Her gown, which had been untied at the beginning of the procedure, had fallen down and she pulled it up to cover her chest, but it kept sliding down her shoulders. She suddenly felt freezing cold, the shivers making it increasingly more difficult to pull up the corners of her gown.

“Let’s try this again,” said the doctor. She inserted the needle and Kim felt the searing pain again and jerked away from it. The doctor inserted the needle again, and Kim felt it like a knife. “Did you move off the edge of the bed?” asked the doctor. “Move backwards onto the bed.” The needle was still in Kim’s back and she could not move.

“I—can’t—move—with—the—needle—in,” she gasped. The doctor removed the needle. Kim struggled backwards onto the bed, yanking on her gown that had again fallen down and now revealed some breast, and again the needle went in. “Aaaahhh---fuck, stop!” she cried. She told the doc how the last time this happened, two residents were experimenting on her. Like a Greek chorus, the visiting doctors voiced a collective oh, dear, yeah, as though they all knew what she meant.

The doctor explained that this has never happened before, it usually goes very well, and launched into told a story about how one patient wound up on the floor after failed attempts to open the spinal canal, arching his back against the bed so the doctor could finally achieve entry. Then Kim began to weep.

“She’s crying,” the nurse told the doctor. Kim’s husband, who was sitting in a chair working on a laptop, walked over to her and held her hand.

“The last time this happened,” Kim said haltingly between sobs, “they sent me down to the fluoroscopy guy and that worked out just fine.”

“Okay,” said the doctor, “I’ll call down there and see if we can get you in right away.”

Kim yanked up her gown and nodded, wiping away tears. She reached around and massaged her back, which now ached near the site of the puncture. Her muscles were so tight that she found it difficult to lie down and straighten her legs.

“Do you want some Ativan?” asked the nurse. “Have you ever taken Percocet? Ativan will relax you and take care of the muscle spasticity, too. Percocet should relieve that back pain.”

“I haven’t taken either, but yes, I’d like them both,” Kim said. The doctor reminded Kim that when she has the surgery for the ITB pump, she’ll be under general anesthesia. “Thank the baby Jesus,” Kim muttered. The visiting doctors laughed, much to her relief. The nurse pushed a bolus of Ativan directly into her I.V., and she felt instant relief. She swallowed a Percocet pill and lay on her side, falling into a relaxed stupor. After an hour, the doctor informed her that they couldn’t get her into fluoroscopy in time to complete the test, so Kim would be rescheduled another day and report directly to Radiology to have it done—with Ativan and, if she wanted, perhaps some Versed as well.

“Yes, put me out, I don’t want to feel a thing,” Kim said. After another hour’s rest, she got dressed and left with her husband. “Let’s eat at Pita Pita,” she told her husband, “I need some good Lebanese food.” She dined on fatoush and chicken shawarma.

For dessert, she ordered a simple demitasse of Turkish coffee, savoring that first sweet, citrusy burst of cardamom. “Ah,” she sighed, grateful that the meal was as good as it had always been at her favorite Lebanese place. “Best cup of Turkish coffee,” she told her husband.

“I’m sorry you had such a shitty day,” he said. But she barely heard him, clutching the tiny cup and grinning at him. She tasted the gritty bloom of flavors on the back of her tongue and peered at the bottom of her cup, wondering how they could make such a perfect thing.

One of the students in the back row raised his hand. “Uh, why didn’t the doc send her to Radiology in the first place?”

The teacher closed his book and said “That will be our next class discussion. See you all on Friday.”