🧠 When a Patient Hears “Spinal Tap,” They Often Ask:

“Do I really need one just to check for Lyme disease?”

It’s a reasonable question. A spinal tap—more formally, a lumbar puncture—is invasive, uncomfortable, and not without risks. But the conversation around spinal taps and Lyme disease is often oversimplified.

So today, let’s unpack the science and the clinical reality—in the form of a conversation.

💬 A Clinical Dialogue on Spinal Taps for Lyme Disease

Cameron: I had a patient the other day who asked, “Do I really need a spinal tap to know if I have Lyme?”

Colleague: That’s becoming a common question. Especially when patients show neurological symptoms.

Cameron: Right. But spinal taps aren’t required in every case of neurologic Lyme.

Colleague: The CDC recommends one if there’s suspicion of meningitis, encephalitis, or radiculopathy.

Cameron: True. But not every neurologic Lyme patient presents that way. Take the Logigian et al. study from 1990. They followed 27 patients with chronic neurologic Lyme—brain fog, pain, paresthesias, memory problems—that had gone on for more than six months.

Colleague: Did their spinal taps confirm the diagnosis?

Cameron: That’s the key point. Only 2 of the 27 patients had CSF findings suggestive of Lyme—one had pleocytosis (elevated white cells), and another had intrathecal antibody production. But no one had both, which is what’s typically required to meet the strict definition of neuroborreliosis.

Colleague: So most of them had normal or non-specific CSF?

Cameron: Exactly. And yet—most of them improved significantly with intravenous ceftriaxone.

Colleague: So the CSF test missed it?

Cameron: It shows that CSF testing often lacks sensitivity, especially in chronic cases. We can’t rely on it alone to make or rule out the diagnosis.

Colleague: That’s concerning. I’ve seen patients dismissed after a “normal” spinal tap.

Cameron: Me too. That’s why I don’t treat spinal taps as a gatekeeper. If the clinical picture fits, I treat. A negative spinal tap doesn’t mean the disease isn’t real.

🔬 What the Logigian 1990 Study Found

In this landmark study of 27 patients with chronic neurologic Lyme disease:

• All had chronic symptoms lasting more than 6 months

• All had positive Lyme serology (ELISA), and most had confirmatory Western blot

• Only 1 patient had pleocytosis, and only 1 had intrathecal antibody production—but no patient had both, which is typically required for a definitive diagnosis of neuroborreliosis

• Despite this, the majority improved significantly after 2–4 weeks of IV ceftriaxone, especially in cognition, pain, and paresthesia

Takeaway: Even without textbook spinal tap results, patients had active, treatable Lyme affecting the nervous system.

🩺 Why Clinical Judgment Still Matters

• Neurologic Lyme can present without classic spinal tap findings

• CSF testing has low sensitivity, especially in chronic cases

• Requiring “proof” via CSF can delay diagnosis and worsen outcomes

• Empirical treatment is sometimes the only way forward in real-world care

That’s why I don’t let a “normal” spinal tap override the full clinical picture.

✅ What I Do Instead in My Practice

Here’s how I handle neurologic Lyme symptoms in my clinic:

• I use spinal taps selectively, not reflexively

• I don’t rule out Lyme based on a “normal” spinal tap

• I treat empirically when the exposure and symptom pattern fit

• I consider co-infections and autonomic dysfunction in neurologic cases

• I follow up closely to assess treatment response and adjust as needed

🧭 Final Thoughts

Spinal taps have a role—but they shouldn’t be used to deny care.

The Logigian study reminds us: patients can have debilitating neurologic Lyme with minimal CSF findings—and still improve with appropriate treatment.

If we want to prevent long-term suffering, we need to treat what we see—not just what a test confirms.