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Fluoroscopically Guided Lumbar
PunctureAustin C. Bourgeois, Austin R. Faulkner, Yong C. Bradley,
Kathleen B. Hudson, R. Eric Heidel and Alexander S. Pasciak
University of Tennessee Medical Center
Knoxville, TN 37922
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Indications
Investigate/exclude meningitisViral, bacterial, fungal, carcinomatous
Investigate demyelinating diseaseMultiple sclerosis, Guillian Barre
Investigate subarachnoid hemorrhage
Indications
Evaluate intracranial pressurePseudotumor cerebri, intracranial
hypotension Infuse contrast for myelogram Intrathecal therapy
Chemotherapy, antibiotics, baclofen, anesthesia
Remove CSF to treat intracranial hypertension or cryptococcal meningitis
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Contraindications
Regional cellulitis Uncorrected Coagulopathy
Poorly studied, based on best clinical judgment and institutional protocol
INR > 1.5Platelets < 50,000Hold Heparin and low-molecular weight
heparin for at least 1 half-life
Contraindications
Suspect Increased Intracranial Pressure (ICP) Clinical manifestations: papilledema, focal
neurological deficit CT findings of hydrocephalus or intracranial
hypertension Allergy to medication (relative)
Lidocaine and latexContrast if myelogram
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Cerebrospinal fluid (CSF) Dynamics
Opening Pressure60 to 200 mm H2O is normal in patients
greater than 8 years old60 to 250 mm H2O in obese patientIntracranial hypotension diagnosed with
opening pressure less than 60mm H20
Cerebrospinal fluid (CSF) Dynamics
Adults have 125-150 mL of CSF CSF is Produced at 0.3 mL/min 9-10 mL – “Standard” amount removed
Replaced in 30 Minutes
Cerebrospinal fluid (CSF) Collection Common CSF tests
MicrobiologyXanthochromiaCytologyOligoclonal bandsLactateAngiotensin converting enzymeViral PCRCytospin (CNS lymphoma evaluation)
Each of the above require 20 drops of CSF each with the exception of cytology, which requires 50 drops
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Most Common Complication: Spinal Headache Positional headache occurs in approximately
32% patients after LPOnset usually 24-48 hours after LP, can occur up to
12 days Greater than 85% of headaches after LP will
spontaneously resolve Can have clinical symptoms similar to meningitis
Photophobia, nausea, stiff neck Pain worse in the upright position and with
coughing/straining, better when supine
Other complications
Incidence of each of these is quite rareBleeding
○ Epidural hematoma rareInfection
○ Wear a mask and use sterile techniqueHerniation
○ Reported in the setting of normal pre-procedural CT
Arachnoiditis and nerve root injury
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Anatomic Landmarks
Conus medullaris terminates at the L1 level in approximately half of adults
Conus medullaris terminates just below L1 level in a significant minority
Take-home point: Go below L1/2
Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image #4617. Accessed 12/10/2014. Used with permission
Fluoroscopic Anatomy
Important landmarksPedicleSpinous processesVertebral body corticesFacets
Easy to get disorientated
Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image #4617. Accessed 12/10/2014. Used with permission
Superior articular facet
Inferior articular facet
Pedicle
Spinal process
Technique
Multiple tissue planes crossed Tactile feedback commonly experienced
at two tissue planesInterspinous ligamentLigamentum flavum
Technique
Frank H. Netter; Netterimages.com; “Lumbar Puncture and Epidural Anesthesia”. Image #8083. Accessed 12/10/2014. Used with permission
Benefits of oblique approach
Improved visualization Larger access window
Avoid spinous process Avoid thick interspinous ligaments
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
Prevent Spinal Headache
Larger bore needle increases risk16G to 19G – 70% risk 20G to 22G – 20-40% risk24G to 27G – 5-12% risk
Bevel direction matters: Studies of spinal anesthesia have shown at least 50% decrease in HA when bevel is parallel to dural fibers
Prevent Spinal Headache
Insert stylet when removing needleReduces headache and rare incidences of
meningitis and epidermoid tumor formation
Use atraumatic needlesLevel 1 evidence in anesthesia literature
that atraumatic needles such as Whitacre and Sprotte reduce spinal headache
Prevent Spinal Headache
Atraumaticneedles
Image by Shannon K. Campbell, University of Tennessee Medical Center. Artwork created for this publication.
Prevent Spinal Headache
Amount of spinal fluid removed is NOT as risk factor
No convincing evidence that fluid hydration decreases risk
Data is inconclusive whether recumbency after procedure reduced headache
Treat Spinal Headache
Epidural blood patch 20cc autologous blood administered into
epidural spaceSuccess rate lower if performed within first
24 hours Success rates 70-98% have been reported
Caffeine Small studies showed doses of 500mg
relieved 75% of spinal headaches~ 6 Red Bull drinks
Complications: improper needle placement
Common problemsToo shallow – problematic in larger patientsToo deep – into disk space or vertebral body
in the setting of osteoporosisOff target – osteophytes can be difficult to
resolve fluoroscopically Can always evaluate depth with cross
table lateral radiograph
X
Optimal targeting, but no CSF return
Too shallow needle placement
Optimal placement in the spinal canal
Needle into disk space
Needle into bone (osteoporosis)
Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications
References1. Seehusen, D. A., Reeves, M. M. & Fomin, D. A. Cerebrospinal fluid analysis. American
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2. Wright, B. L. C., Lai, J. T. F. & Sinclair, A. J. Cerebrospinal fluid and lumbar puncture: a practical review. J Neurol 259, 1530–1545 (2012).
3. Schievink, W. I. et al. Diagnostic criteria for headache due to spontaneous intracranial hypotension: a perspective. Headache 51, 1442–1444 (2011).
4. Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).
5. Ahmed, S. V., Jayawarna, C. & Jude, E. Post lumbar puncture headache: diagnosis and management. Postgraduate Medical Journal 82, 713–716 (2006).
6. Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).
7. DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).
8. Demiryurek, D., Aydingoz, U., Aksit, M. D., Yener, N. & Geyik, P. O. MR imaging determination of the normal level of conus medullaris. Journal of Clinical Imaging 26, 375–377 (2002).