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THE ROLE OF THE CEREBROSPINAL FLUID TAP

IN THE NEUROLOGICAL EXAMINATION


OF THE DOG
N. Palumbo*

INTRODUCTION
THE NERVOUS SYSTEM is complex, inadequately understood and a system where
little investigation is being done by clinicians. Probably the single most im-
portant reason for this is the fact that the central nervous system is so inaccessible.
The cerebrospinal fluid tap is but a minor part of the neurological examina-
tion. It can provide additional information, but alone means little. The results
of this test must be interpreted in association with the physical and neurological
examination.
The first description of cerebrospinal fluid with regard to its normal and
abnormal constituents was recorded in 1912 by Mestrezat (5). Teunissen and
Vermer (9) described the cerebrospinal fluid in dogs. Frankhauser (1) in
Germany and Huff and Schirmer (3) at M.S.C. have added to the veterinary
literature. Roberts (6) has a collection of over 300 cerebrospinal fluid taps and
is currently preparing his records for publication. The most complete cerebro-
spinal fluid studies in dogs yet published has been carried out by McGrath (4).

PHYSIOLOGY
The cerebrospinal fluid functions to protect the soft nervous tissue as a
hydraulic shock absorber. The fluid filled pia-arachnoid membrane also helps to
transmit and so disseminate the impact of a localized blow. In addition to the
protective function, the cerebrospinal fluid transports waste products out of the
central nervous system. It also acts as a space compensating mechanism in the
regulation of cranial contents.
The cerebrospinal fluid is formed in the lateral ventricles and to a lesser extent
in the fourth ventricle by means of the choroid plexuses. They have a structure
and function similar to the glomeruli of the kidney. The difference is that in
the capillaries of the choroid plexuses the tissue fluid produced must pass
through an epithelial membrane (Ependymal cells) and in so doing is modified
by the secretory activity of these cells. Cerebrospinal fluid, then, is referred to as
a "modified tissue fluid" by Ham (2).
Samples of cerebrospinal fluid taken from the lateral ventricles, third ventricle,
fourth ventricle and subarachnoid space show a progressive increase in nitro-
genous waste products. This suggests the normal direction of flow and circulation
and points out the lack of rationale of introducing medication to the brain
via the cisternal tap.
Cerebrospinal fluid is produced continuously and is continuously reabsorbed,
'Practitioner, Honolulu, Hawaii.
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CANADIAN VETERINARY JOURNAL
otherwise catastrophically high intracranial pressures would soon be produced.
In this respect a paradoxical phenomenon is at work, the higher the pressure
rises within the cranium, the greater the fluid production will be. The absorption
of cerebrospinal fluid in man occurs through specialized projection of the
arachnoid into venous sinuses of the dura. Cerebrospinal diffuses through these
arachnoid villi to join the venous blood of the sinus. In the dog these villi are
not obvious and McGrath (4) suggests that the fluid is absorbed by the subdural
venous sinuses.
The mechanism of formation and absorption of cerebrospinal fluid is similar
to that of tissue fluid in other parts of the body. The high hydrostatic pressure
of the capillaries of the choroid plexuses and the lower hydrostatic pressure in
the venous sinuses coupled with the higher osmotic pressure there would
encourage reabsorption. One of the striking differences is the absence of lympha-
tics in the central nervous system to drain off excessive fluid.
TABLE I
NORNIAL CEREBROSPINAL FLUID VALUES (FANKHAUSER) (1)
Minimum Maximutm Average
(1) Quantity 0.9 cc. 16.0 6.5-7.0
(2) Character Clear-Colorless
(3) Pressture 24.0 mm. H1,O 172.0 86.5
(4) Specific Gravity 1.003 1.012 1.005
(5) Cells/cu. mm. 0.0-4.0 25.0 14.0
(6) Total Protein 11.0 mg.% 55.0 27.5
(7) Globulin 5.5 mg.% 16.5 9.0
(8) Albumin 16.5 mg.% 37.5 27.0
(9) Glob/alb. 0.14 0.75 0.35
(10) Sugar 61.0 mg.% 116 74.0
Normal cerebrospinal fluid then is clear, colorless and slightly alkaline. Its
specific gravity averages 1.005. It consists chiefly of water and contains inorganic
salts of blood plasma in about the same concentration as in the plasma. Its
protein content consists chiefly of albumin and globulin and averages about
10 to 40 mg. per cent. Less than 15 cells are present per cu. mm. and they
resemble lymphocytes.

TECHNIQUE OF THE CEREBROSPINAL FLUID TAP


General anesthesia is required, pentothal' or surital2 are preferred. The
syringe is taped to the animal's leg and the anesthetic is given to effect until a
deep plane of surgical anesthesia is produced. Intubation with an endotracheal
catheter with an inflatable cuff should be routine.
A liberal area of hair is clipped from the atlanto-occipital region and the area
is prepared for surgery. Every precaution should be taken to prevent sepsis at
the puncture site and the use of gloves and drapes should be routine.
The best position for the dog is left lateral recumbency. The dog's neck is
moderately flexed to provide a larger target. The area in which the needle is to
be inserted is determined by drawing imaginary lines across the dog's neck.
'Abbott Laboratories, Montreal, Quebec.
2Parke-Davis Laboratories, Mlontreal, Quebec.
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CEREBRAL SPINAL FLUID TAP IN THE DOG

(1) The first line is from the most lateral prominences of the wings of the
atlas.
(2) The second line is at the external occipital protuberance.
(3) A third line is drawn parallel to and half-way between one and two.
(4) The last line is drawn in the median plane and where this line transects
the third line is the exact point for puncture (4) (Fig. 1).

CZ L \lI FIGURE 2. Radiograph depicting needle in


position for cerebrospinal fluid tap in dog.

B Foramen magnum
C Atlas
D Axis
1. Line between the most lateral promi-
f4 nences of the wings of the atlas.
2. Line at the external occipital protuber-
FIGURE 1. Altanto-occipital space, head ance.
flexed. Redrawn from Miller, Dissection 3. Line parallel to, and half-way between,
Guide of the Dog. lines one and two.
A External occipital protuberance 4. Median line.
Perhaps a brief review of the anatomy of the cisterna magna is in order:
Between the pia and arachnoid there are trabeculae and the remaining space
is filled with cerebrospinal fluid. The pia follows the convolutions of the brain in
intimate association with its sulci and fissures, but the arachnoid does not.
Hence, there are areas known as cisternae where the distance between the
arachnoid and pia is greatly increased. In these areas there is an accumulation
of cerebrospinal fluid. Such is the case of the cisterna magna in the dog. Accord-
ing to Sisson (7), the cisterna magna is formed between the posterior face of
the cerebellum and the dorsal surface of the medulla oblongata. It communicates
with the fourth ventricle through lateral openings and behind with the wide
subarachnoid space of the spinal cord.
Following the introduction of the needle the operator must be assured that
anesthesia is being maintained adequately to restrain the animal for another
three to four minutes and that the dog's neck is not twisted so as to interfere with
respiration or drainage of the jugular veins. Roberts (6) reports that struggling
or interference with jugular return will cause an abnormal rise in pressure to as
high as three times the normal in 20 seconds.
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CANADIAN VETERINARY JOURNAL
With an assistant standing by with a three-way valve, manometer and syringe
attached, the canula is removed from the needle. Fluid loss should be kept to a
minimum. Normally the fluid will well up into the hub of the needle when the
cannula is withdrawn. Team practice and co-ordination are required to become
proficient. When the cerebrospinal fluid is under abnormally high pressure it
will sometimes stream out of the needle hub and in spite of rapid efficient
attachment of the manometer, a considerable volume of fluid is lost. This results
in an inaccurate reading.
The initial pressure is recorded. Normal fluctuation occurs within 0.5-1.5 cm.
in the manometer and is synchronized with respiration. A two ml. sample is
collected at the rate of one ml. per 30 seconds. Rapid withdrawal may result in
rupture of vessels in the subarachnoid space causing the sample to be con-
taminated with blood. In tumors of the posterior fossa, rapid withdrawal may
result in fatal prolapse of the medulla or cerebellum into the foramen magnum.
When the sample is collected within the syringe, the three-way valve is again
switched back to the manometer and a final pressure reading is made.

INTERPRETATION
An elevation of cerebrospinal fluid pressure may be interpreted as resulting
from an increase in the cranial contents (tumor, cerebrospinal fluid blood).
When the initial pressure is high and the final pressure is very low it indicates
a small reservoir of fluid. Tumor or abscess or any space occupying lesions within
the cranial cavity could be responsible. In a situation in which there is interfer-
ence with reabsorption of cerebrospinal fluid (meningitis or communication
hydrocephalus) there will be a large fluid reservoir and a smaller difference
between the initial and final readings.
LABORATORY TESTING
1. The color and character should be recorded.
2. Since the cellular elements are very fragile, if smears are to be made, this
should be done within 20 minutes after collection. WVrights or Geimsas stains
are suitable.
3. The specific gravity can be determined by making up a series of small vials
of different specific gravities. A drop of cerebrospinal fluid is dropped into each
vial until one finds the SG that coincides with that of the cerebrospinal fluid
sample.
4. The two most important procedures are the cell count and the protein
determination.
A-Cell Count
1. Undiluted and well mixed cerebrospinal fluid is used to fill both sides of
the counting chamber.
2. All 18 squares are counted. The total is multiplied by 10 and divided by 18
for the total cell count/cu. mm.
3. Cell counts are increased in encephalitis, abscesses, meningitis and hemor-
rhage.
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CEREBRAL SPINAL FLUID TAP IN THE DOG

4. A differential cell count can be made at the same time the total count is
being run. The "high dry" lens of the microscope is used and cells are dif-
ferentiated as polymorphs, small mononuclears or large mononuclears.
B-Protein Determination
1. Schirmer (3) compared the Pandy test and the Nonne-Apelt test and was
satisfied with them although both are qualitative and are known to show false
positives.
(a) Pandy. Add one or more drops of saturated phenol solution to one ml.
of cerebrospinal fluid. A white cloudy appearance indicates an elevated
protein.
(b) Nonne-Apelt. Mix equal parts of cerebrospinal fluid and saturated
ammonium sulphate. Mix by inverting. Cloudy to white ppt. indicates
an excessive amount of protein.
2. Whenever red blood cells are seen the protein can be expected to be above
the normal limits.
3. The protein is also elevated in inflammatory processes (infection, encepha-
litis, brain abscesses), any process causing capillary permeability, destructive
lesions and tumors too.
4. The protein is always high when the central nervous system is affected
with toxoplasmosis.
C-Other Determinations
1. Glucose. It parallels blood sugar levels. Gluicose is decreased in septic
infection of the brain as the organisms convert glucose to lactic acid.
2. Chloride. Chloride levels are decreased in any situation where there is an
increase in protein (Donnan's Membrane Theory).

CONCLUSION
The cerebrospinal fluid examination is not a panacea for neurological diagnosis.
It is intended to be and should be simply an adjunct to the physical and neuro-
logical examinations: it can increase the quality of diagnosis and is worthy of
becoming a standard clinical laboratory procedure.
REFERENCES
1. FRANKHAUSER, R. Der Liquor Cerebrospinalis in der Veterinarmedizin, Zeutral blatt
fur Veteriarmedizin, Band I, Heft. 2: 136. 1953.
2. HANIf, A. W. Histology. 2nd ed. Philadelphia: J. B. Lippincott Co. 1950.
3. HUFF, R. W., and SCHIRMER, R. G. Cerebrospinal Fluid Sttudies. To be published.
4. MCGRATH, J. T. Neurologic Examination of the Dog. 2nd ed. Philadelphia: Lea and
Febiger. 1960.
5. MESTREZAT, W. Le liquide cephalo-rachidien normal et pathologique. Valeur dinique de
l'examen chimique. Syndromes humoraux dans les diverses affections. Paris, 1912.
6. ROBERTS, R. Intern Research Paper presented at the Friday Morning Seminar, Angell
Memorial Animal Hospital, Boston, Mlass., September, 1949.
7. SISSON, S., and GROSSMrAN, J. D. The Anatomy of the Domestic Animals. 4th ed.
Philadelphia: W. B. Sounders Co. 1953.
8. SCHIRNIER, R. G. Cerebrospinal Fluid Analysis and Its Significance in Diagnosis. Gaines
Vet. Symposium, Kanakee, Illinois. 1957.
9. TEUNISSEN, G. H. B., and VERMXER, MI. A. S. Cerebrospinal Fluid In Dogs. Proc. XV
Int. Vet. Cong., 1: 1022. 1953.
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