Background:Novel diagnostic techniques and neurologic biomarkers have greatly expanded clinical indications for cerebrospinal fluid (CSF) studies. CSF is most commonly obtained via lumbar puncture (LP). Although it is generally believed that LPs are well tolerated, there is a lack of supportive data for this claim and patients anticipate LP to be painful. The objective of this study was to prospectively investigate discordance between patient perception and tolerability of LP.Methods:Adult patients were surveyed before and after LP regarding their perceptions and experience of LP. Physician perceptions were gathered though a web-based survey. Relative risk and Spearman correlation were used to assess the relationship between responses. Paired binomial and paired ordinal responses were compared by McNemar and paired Wilcoxon rank-sum tests.Results:A total of 178 patients completed the surveys. About half of the patients (58%) reported anxiety pre-LP, at median 3.0 out of 10. Physicians over-predicted patients’ pre-LP anxiety (median score 5.0, p<0.001). Experienced pain was significantly less than predicted pain (median scores 0 and 3.0 respectively, p<0.001). Patients who predicted pain were more likely to report pain from LP (RR 1.3). Predicting pain was also correlated with anxiety prior to LP (p<0.001).Conclusions:LP was generally well-tolerated. The majority of patients experienced minimal pain. Anticipation of pain was correlated with both feeling anxious and experiencing pain. The results of this study can be used to reassure patients and providers that LP is indeed not as painful as imagined, which may both reduce pre-LP anxiety and improve LP tolerability.

BACKGROUND:Immune checkpoint blockade has shown significant antitumor responses and is approved for the treatment of multiple cancer types. Immune checkpoint inhibitors (ICI) are associated with a unique set of toxicities termed irAEs. This study seeks to review the incidence and clinical manifestations of patients who developed neuro-toxicity with ICIs. METHODS: An IRB approved retrospective study involved review of charts and institutional databases. We identified patients who developed neurotoxicity while on at least one of the following ICIs: anti-CTLA4, anti-PD1 or anti-PD-L1 over a 6 year period (1/1/2010-5/15/2016). RESULTS: We identified a total of 3,804 patients who were treated with one or more ICI during the period of review. Neuro-toxicity was observed in 99 patients (2.6%) affecting both central and peripheral nervous systems. 35 patients (34.7%) received more than one ICI. Median number of cycles prior to developing toxicity was 3 (1-29). Ten patients had more than 1 neuro-toxicity. The various neurologic phenotypes observed in patients included: Sensory neuropathy (34), encephalopathy (18), headache ( 16), aseptic meningitis (13), Myasthenia Gravis like syndrome ( 6), myopathy (6), autonomic neuropathy (5), aphasia syndromes (3), radiculopathy (2), brachial plexitis (2), mononeuritis multiplex (2), AIDP (1), and PRES (1). 58 patients required hospital admission and 2 required ICU level of care. A diagnosis of neuro-toxicity was based upon the temporal association with ICIs and appropriate workup including but not limited to neurologic consultation, lumbar puncture, and neuro-imaging. Patients were treated with drug holiday, observation, corticosteroids, plasmapheresis and/or IVIG. CONCLUSIONS: As ICI's are being used with increased frequency, treating oncologists should be aware of the varied manifestations of neuro-toxicity in order to ensure appropriate diagnosis, work up and treatment. Prompt treatment may relay a benefit in regards to outcome.

OBJECTIVE To investigate patients’ and physicians’ perceptions of lumbar puncture (LP) and tolerability. METHODS Adult patients were surveyed prior to and after the procedure regarding patient perceptions and actual experience of LP. Presence of symptoms pre- and post-LP were compared by McNemar test; symptom severity score was rated 0–10, compared by Wilcoxon test; and relative risks were compared by Fisher’s exact test. In addition to patient surveys, email requests to complete an eight-question survey regarding LP tolerability was sent to faculty physicians at two academic centers. RESULTS A total of 154 patients and 302 physicians completed the surveys during 1/2017-5/2019. Ninety-one patients (59%) reported anxiety prior to-LP compared to 52 (34%) who reported anxiety after the LP (p< 0.0001). Whereas 74% of patients predicted LP to be painful prior to LP, only 48% reported that LP was painful after the procedure (p< 0.0001). On an 11-point scale, patients anticipated significantly greater pain from LP than they reported after the procedure (mean 3.4 and 2.0 respectively, p< 0.0001). Patients who anticipated pain were more likely to experience pain (RR=1.65, 95% CI 1.07–2.73). There was no significant difference in symptoms such as headache, nausea, generalized pain, vision or gait disturbance before and after the procedure. After the LP, 117 patients (77%) answered they would repeat LP if recommended by their doctors. Out of 302 physicians (40% women), the majority (81%) felt that the LP induces anxiety or worry in patients, and 50% answered that the LP is painful for patients in general. CONCLUSION We observed that although anticipation of pain contributed to pre-procedure anxiety, LP was generally well-tolerated. The majority of patients experienced minimal pain. The results of this study suggest that measures to reduce pre-procedure anxiety may improve the tolerability of LP, an important diagnostic tool in neuro-oncology.