Spinal Taps: A troubling trend

I’ve noticed a troubling trend in Lyme disease care. Some patients are being told they need a spinal tap (lumbar puncture) to “rule out neurological Lyme disease.” While spinal taps are important in cases like suspected meningitis, their role in evaluating Lyme is much more limited. Too often, patients go through this invasive procedure without it providing clear answers — and sometimes when it isn’t truly necessary.

Clinical Reality

I have encountered patients who underwent spinal taps as part of their neurology evaluation for Lyme disease, even when the clinical need was uncertain.

The diagnostic yield is consistently low. In patients without clear neurological signs, a spinal tap for Lyme disease almost never provides new information. What it does provide is an invasive procedure with very real risks.

False Sense of Security

One of the most troubling patterns I see is that patients with neurological Lyme disease are dismissed based on a normal spinal tap (CSF).

1. False reassurance: Early and even chronic neuroborreliosis can present with normal CSF. In a landmark study by Logigian, 25 out of 27 patients with chronic neurologic Lyme were negative on spinal fluid antibody testing — yet all had confirmed disease.¹

2. Overinterpretation: Mild protein or white cell elevations are often incorrectly attributed to Lyme disease.

3. Complications: Post-lumbar puncture headaches, bleeding risk, and procedure-related anxiety — all for results that rarely change treatment decisions.

Does a Spinal Tap Rule Out Lyme Disease?

A normal spinal tap does not rule out neurological Lyme disease.

This is the core problem with overreliance on CSF testing in Lyme disease: patients can still have active infection even when spinal fluid appears normal.

What the Logigian Study Showed

One of the most important studies on neurological Lyme was published by Logigian, Kaplan, and Steere in the New England Journal of Medicine (1990). They followed 27 patients with chronic neurologic Lyme disease and found:

1. 25 of 27 patients had negative spinal fluid antibody tests despite confirmed disease.

2. Patients presented with memory issues, encephalopathy, and peripheral neuropathy.

3. Most improved with antibiotic treatment — even though their CSF did not show diagnostic confirmation.

This landmark study illustrates a critical truth: spinal taps for Lyme disease often fail to detect active neurologic infection and should not be the deciding factor in diagnosis or treatment.

The Limits of Spinal Taps in Lyme

Spinal taps for Lyme disease cannot confirm most cases of neuroborreliosis and they certainly cannot rule it out. However, they’re still helpful in ruling out other medical conditions such as viral meningitis, fungal infections, or autoimmune diseases.

In other words, the spinal tap is often more useful for what it rules out than for what it can prove about Lyme. This is why I rely on a careful medical history, symptoms, exposure risk, blood testing, and imaging before considering invasive procedures.

My Cost-Benefit Reality Check

Becoming more selective has improved care in my practice:

1. Fewer complications from unnecessary procedures

2. Less anxiety for patients facing invasive testing

3. Improved diagnostic precision by testing only when clinically indicated

My Risk-Benefit Learning Curve

Neurological Lyme doesn’t behave like bacterial meningitis. CSF findings are often mild and non-specific. I’ve had patients with neuroborreliosis and normal CSF, and others with abnormal CSF who ultimately had alternative diagnoses.

Meanwhile, risks are tangible:

1. Post-lumbar puncture headaches

2. Bleeding, especially in patients on blood thinners

3. Procedure-related anxiety and discomfort

My Approach

I approach spinal taps for Lyme disease cautiously. They may have value when there are clear neurological concerns, but most patients can be managed without CSF analysis. Clinical judgment, careful history, and non-invasive testing usually provide more reliable guidance than routine screening with a spinal tap.

Bottom Line

Careful clinical evaluation, thoughtful use of blood serology, and targeted treatment protect my patients far more effectively than protocol-driven invasive testing ever could.

Have you been told you needed a spinal tap for Lyme? Share your experience below — your story may help others facing the same dilemma.

Resources

1. 1. 1. Logigian et al paper – Chronic Neurologic Manifestations of Lyme Disease
      2. Dr. Cameron’s blog – Lumbar puncture not all that helpful for diagnosing Lyme neuroborreliosis?
      3. Dr. Cameron’s blog – Can you have neurologic Lyme disease even if your spinal tap is normal?
      4. CDC  – Clinical Care and Treatment of Neurologic Lyme Disease