Luol Deng out for Game 2: Examining His Illness, Lingering Post-Spinal Headache

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Luol Deng out for Game 2: Examining His Illness, Lingering Post-Spinal Headache
Jonathan Daniel/Getty Images

Luol Deng's recent illness, hospitalization and headache serve as a sobering reminder of one painful truth: Sometimes, medicine doesn't go according to plan.

On Tuesday, K.C. Johnson of the Chicago Tribune tweeted Deng will sit out game two of the Eastern Conference semifinals. He is still recovering from what is likely a post-spinal headache stemming from a spinal tap procedure performed to test for viral meningitis. It marks the fourth straight playoff contest he will miss due to the condition (h/t ESPN Chicago).

Deng is certainly itching to play, and during the playoffs, players frequently try to push through some types of injuries or illnesses. Unfortunately, a post-spinal headache is a different story.

 

What Is Meningitis? Why Is It a Big Deal?

According to the ESPN Chicago report, when Deng fell ill, doctors grew concerned about the possibility of meningitis. Defined as inflammation of the meninges—the protective tissue that lines the brain and spinal cord—meningitis usually occurs as a result of a bacterial or viral infection.

Fortunately, according to Johnson, Deng eventually tested negative. Yet whenever doctors suspect meningitis, they must act, as depending on the cause, meningitis can quickly progress to a serious, life-threatening condition.

Unfortunately, it can also come on very subtly.

The meninges consists of three layers of tissue covering the brain and spinal cord. Cerebrospinal fluid (CSF) sits between the arachnoid and pia mater. Photo from Wikimedia Commons.

Though exact details regarding Deng's illness are unavailable, imagine the following hypothetical scenario: A patient comes to the ER feeling unwell. He or she feels achy, looks dehydrated and complains of a headache.

The flu is probably to blame, and in the majority of cases, basic blood tests, re-hydration and anti-inflammatory medications are all that are needed.

However, it isn't always so simple.

Suppose, over the course of several hours, the patient's symptoms do not respond to treatment. Perhaps his or her headache worsens and extends to the neck. Then, a fever develops. Maybe he or she grows fatigued.

All of the above developments suggest meningitis, yet not one confirms it. In fact, neither do all of them together, as the above constellation of symptoms is also common to many less-serious illnesses.

What's more, meningitis is actually relatively rare. According to Medscape, bacterial meningitis affects only 0.6-4 out of 100,000 people per year. Viral meningitis is a bit more common, coming in at a rate of 10.9 per 100,000 per year.

Nevertheless, untreated bacterial meningitis is nearly universally fatal. It even requires all who come into contact with a confirmed case to receive just-in-case antibiotic therapy.

To muddle the picture even further, bacterial meningitis can initially appear very similar to its less-severe viral counterpart. Due to the similarities, it is highly likely doctors wanted to rule out both forms despite reports claiming suspicion for only the viral disease.

In other words, if there exists even a shred of suspicion for meningitis, doctors must investigate. The tool to do so? A lumbar puncture.

 

What Is a Lumbar Puncture?

As mentioned, blood tests and symptoms can point toward or away from meningitis, but if suspicion remains, doctors must use a lumbar puncture (LP) to officially confirm or reject the diagnosis.

Normal CSF is clear and colorless. However, clear and colorless CSF is not necessarily normal. Photo from Wikimedia Commons.

Also known as a spinal tap, doctors perform an LP to collect cerebrospinal fluid (CSF)—the fluid responsible for helping cushion the brain and spinal cord within the skull and spine, respectively.

To perform an LP, a doctor inserts a needle between two vertebrae in the lower back. He or she then advances it forward, through two layers of the meninges and into the subarachnoid space. Within the subarachnoid space lies CSF, which then slowly flows outward through the needle and into a waiting test tube.

Since the meninges and CSF are in direct contact, one affects the other. As a result, analyzing collected CSF can help diagnose the various forms of meningitis.

For instance, white blood cells—the cells responsible for fighting infection—are not normally found in the CSF. Conversely, their presence suggests infection, as do abnormal CSF protein and sugar levels. In addition, entirely normal CSF findings essentially eliminate the possibility of serious forms of meningitis.

 

What Is a Post-Spinal Headache? How Did Deng's LP Cause One?

CSF circulation around the brain and spinal cord is a closed circuit—imagine a balloon (brain) and string (spinal cord) floating within a thin bag of water. However, by performing an LP and poking a hole in the meninges, doctors open that circuit.

The above video demonstrates the normal circulation pattern of CSF. The site of a lumbar puncture—the lower spine—is not shown.

Immediately following the procedure, the body usually closes the circuit back up on its own.

Sometimes, though, it doesn't.

While the circuit remains open, CSF leaks out of the subarachnoid space through the needle-sized hole in the meninges. As it leaks out, the pressure within the metaphorical bag of water drops.

Low pressure due to a CSF leak creates a downward, "sucking" traction on the brain. As a result, the brain moves slightly down within the skull, stretching the meninges and pain-sensitive nerves in and around it.

The end result is a debilitating headache relieved only by lying down, as a horizontal position counteracts the downward motion of the brain. Nausea, vomiting, dizziness, troubles with balance and vision problems often accompany the headache as well.

 

How Common Are Post-Spinal Headaches? Did Deng's Doctors Make a Mistake?

Deng's doctors certainly did nothing wrong. Regrettably, even with the best doctors practicing the best medicine—as is certainly the case with the Bulls' small forward—post-spinal headaches are sometimes inevitable.

They are also not uncommon.

A review published by Dr. S. V. Ahmed and colleagues in the Postgraduate Medical Journal states post-spinal headaches occur after 32 percent of LPs (h/t Pub Med). Other studies cite lower rates, but most claims fall within 10 to 30 percent.

As may be expected, larger-diameter needles are associated with a higher likelihood of developing symptoms. The larger hole may lead to a faster CSF leak, take longer to close or both.

 

What's Next for Deng and the Bulls?

Luol Deng watched the Bulls' Monday night victory over the Miami Heat from the hospital. (Credit: http://instagram.com/luoldeng9)

Unfortunately, painkillers and rest do not cure a post-spinal headache. Rather, one way or another, the body must plug the CSF leak.

In the vast majority of cases, it will. Sometimes, however, it can take days or longer.

While active, post-spinal headaches and their associated symptoms can—quite literally—completely incapacitate the sufferer. If the pain worsens to the point of requiring narcotic pain medications, hospitalization and close monitoring are needed.

Dr. Tad Seifert, neurologist and director of the Sports Concussion Program at the Norton Neuroscience Institute in Louisville, Kentucky, weighed in on Deng's situation:

"The pain associated with a post-spinal tap headache is typically severe and disabling," he explained. "Much like a severe migraine, physical activity for these patients is nearly unbearable, and in the case of a professional athlete such as Luol Deng, it would be nearly impossible to compete at an elite level while still symptomatic." 

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On Saturday, Deng received what is called an "epidural blood patch" in an attempt to speed his recovery (h/t K.C. Johnson, Chicago Tribune). Essentially, doctors removed some of Deng's own blood and injected it around the LP site.

Infusing blood around the leak site accomplishes two goals. First, adding extra liquid to an enclosed space squeezes the meninges and increases pressure inside of it. Second, clotting proteins within the blood help seal the leak.

Once the patch is complete, symptoms usually resolve.

Usually.

"A blood patch usually results in rapid plugging of the leak and near immediate relief of symptoms.," Dr. Seifert continued. "However, there is a small subset of patients that initially experience limited or no improvement. In these cases, the procedure may need to be repeated to be successful. In extremely rare instances, surgical correction of the leak may be required."

Nothing yet suggests Deng has needed or will need surgery, and eventually, Deng will return to action. In fact, it appears he is well on his way:

Perhaps his remaining symptoms are left over from the original illness. Perhaps not. Regardless, as Dr. Seifert discusses, Deng cannot effectively contribute on the basketball court until his post-spinal headache effects are fully clear.

After all, nothing is more important than Deng's health, and the Bulls must exercise patience when it comes to bringing back their star—even if it causes, well, quite the headache.

 

Dave Siebert is a medical writer for Bleacher Report who will join the University of Washington as a resident physician in June. Except when otherwise cited, medical information discussed above is based on his own knowledge, and quotes were obtained firsthand unless otherwise noted.

Follow Dave on Twitter for more sports, medicine and Sports Medicine.

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