Difficult Lumbar Puncture: Pitfalls and Tips from the Trenches

Rhyner, Patricia A.; Fountain, Arthur J.; Chapman, Philip R.; Shah, Lubdha M.

doi:10.3174/ajnr.a5128

Cited by 48 publications

(50 citation statements)

References 25 publications

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“…Intrathecal access is obtained in a manner similar to a typical myelography. 7 However, the combination of lateral decubitus positioning and CSF hypotension can make the needle positioning difficult at times. The needle is advanced slowly as the needle position is checked in anterior-posterior and lateral views, and once the needle position is confirmed to be in the center of the bony spinal canal, a small amount of iodinated contrast is injected while observing under fluoroscopy in the lateral view to confirm intrathecal positioning.…”

Section: Procedures Techniquementioning

confidence: 99%

Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls

Kim¹,

Brinjikji²,

Morris³

et al. 2019

AJNR Am J Neuroradiol

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Digital subtraction myelography is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate appropriate diagnosis and treatment of spontaneous spinal CSF leaks. Digital subtraction myelography is an excellent diagnostic tool for assessment of various types of CSF leaks, and lateral decubitus digital subtraction myelography is increasingly being used to diagnose CSF-venous fistulas. Lateral decubitus digital subtraction myelography differs from typical CT and fluoroscopy-guided myelograms in many ways, including equipment, supplies, and injection and image-acquisition techniques. Operators should be familiar with techniques, common pitfalls, and artifacts to improve diagnostic yield and prevent nondiagnostic examinations.

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Section: Procedures Techniquementioning

confidence: 99%

Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls

Kim¹,

Brinjikji²,

Morris³

et al. 2019

AJNR Am J Neuroradiol

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“…This result is in correlation with previous studies indicating an overall increase in FGLPs performed by radiologists in the past two decades mostly due to the indication of obesity. [ 9 ] Obese patients present with multiple potential difficulties with longer FT for LP access, limited ability to visualize bony landmarks, particularly as the radiation dose decreases, and the absence of anatomical landmarks with increasing subcutaneous fat. [ 10 ] Patients in the study and control groups had nearly identical BMI which removes any bias of one group being more difficult than the other.…”

Section: Discussionmentioning

confidence: 99%

Radiation Reduction in Low Dose Pulsed Fluoroscopy versus Standard Dose Continuous Fluoroscopy during Fluoroscopically-Guided Lumbar Punctures: A Prospective Controlled Study

Sabat

Slonimsky

2018

Journal of Clinical Imaging Science

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Purpose:The purpose of this study was to evaluate radiation dose reduction in fluoroscopically guided lumbar punctures (FGLP) using “pulsed fluoroscopy in a low dose mode” compared with the commonly used “continuous fluoroscopy in a standard dose mode” while maintaining the technical success.Materials and Methods:Thirty-five consecutive patients who underwent FGLP divided randomly to seventeen patients in the control group with standard dose continuous FGLP and eighteen patients in the study group with low-dose low-frame-rate of 3 frames per second (fps) FGLP. Entrance surface dose measurements from a dosimeter device were recorded as well as the dose area product (DAP).Results:A total of 35 patients with average age of 52 years (range: 15–87 [±17 standard deviation [SD]]) were evaluated. Average entrance surface dose of the study group was significantly lower (3.81 mGy [range: 0.21–11.14, [±2.8 SD]]) compared with the control group (22.45 mGy [range: 1.23–73.44, [±19.41 [SD]]). The average DAP of the study group (10 mGy·cm2 [range: 1–41, [±9.8 SD]]) was also significantly lower than the control group (65 mGy·cm2 [range: 5–199, [±53 SD]]). Success rate was similar between the study and control groups.Conclusion:Low dose pulsed fluoroscopy of 3 fps significantly reduces radiation exposure by about 600% compared with standard dose continuous fluoroscopy in FGLP. Utilizing this radiation saving strategy will allow to dramatically reduce radiation exposure, without impacting the technical success rate.

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“…But also beyond that, a considerable shift of the LP burden to radiologists has been observed over the last two decades, with radiologists performing 46.6% of diagnostic and therapeutic LPs in a study analyzing 97,246 LPs performed in the United States 21 . Reasons for the need of image guidance are prior surgeries, extensive degenerative changes at the level of the spine, or the inability to identify osseous landmarks routinely used to plan LP, such as present in obese patients 22,23 . Moreover, LP is required for many therapeutic reasons, e.g.…”

Section: R1 R2mentioning

confidence: 99%

Radiation dose reduction for CT-guided intrathecal nusinersen administration in adult patients with spinal muscular atrophy

Cordts

Deschauer

Lingor

et al. 2020

Sci Rep

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intrathecal administration of nusinersen in adult spinal muscular atrophy (SMA) patients with scoliosis and spondylodesis requires image guidance, which is preferably achieved with multi-detector computed tomography (MDct). As long-term treatment is necessary and patients are young, radiation doses should be reduced to a minimum whilst a sufficient image quality for precise interventional performance should be kept. We compared 44 MDCT standard-dose scans (133.0-200.0 mA) with a hybrid iterative reconstruction (iDose4) to 20 low-dose scans (20.0-67.0 mA) with iterative model reconstruction (IMR), which were performed for procedure planning of intrathecal nusinersen administration in 13 adult patients with SMA and complex spinal conditions. Qualitative image evaluation, including confidence for intervention planning, was performed by two neuroradiologists for standard-and low-dose scans. All 64 MDCT-guided intrathecal administrations of nusinersen were successful. The dose length product (DLP) was significantly lower when using low-dose scanning with IMR (median DLP of standard-dose scans: 92.0 mGy•cm vs. low-dose scans: 34.5 mGy•cm; p < 0.0001). Image quality was significantly reduced for low-dose compared to standard-dose scanning. However, bone/soft tissue contrast and confidence for intervention planning were not significantly impaired in low-dose MDCT according to both readers, showing good inter-reader agreement. thus, we hereby demonstrate a low-dose MDct protocol combined with advanced image reconstruction for scanning during procedure planning as a viable option for image guidance in intrathecal nusinersen treatment of adult SMA patients with complex spinal conditions. Spinal muscular atrophy (SMA) is an autosomal-recessive neurodegenerative disease caused by mutations in the survival motor neuron 1 (SMN1) gene 1. The lack of SMN protein results in progressive degeneration of motor neurons causing muscle weakness and atrophy with varying severity. In June 2017, the European Medicines Agency approved nusinersen as the first drug to treat SMA. Nusinersen, an antisense oligonucleotide (ASO), does not efficiently cross the blood-brain barrier and thus has to be administered directly into the cerebrospinal fluid (CSF), which is commonly achieved by a lumbar puncture (LP). Intrathecal drug administration presents challenges in adult SMA patients due to severe neuromuscular scoliosis and frequent preceding spinal fusion surgeries. Recent studies showed intrathecal treatment with nusinersen to be feasible and safe when using image guidance in patients with scoliosis 2,3. Generally, guidance by computed tomography (CT) was evaluated to be superior to fluoroscopy-assistance in patients with a complex spinal architecture 2,3. However, CT-guided interventions are accompanied by radiation exposure and, therefore, radiation risks need to be taken into account, such as an increased risk of cancer induction 4,5. Particularly in patients with SMA efforts must be made to keep radiation exposure as low as possible since pat...

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Difficult Lumbar Puncture: Pitfalls and Tips from the Trenches

Cited by 48 publications

References 25 publications

Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls

Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls

Radiation Reduction in Low Dose Pulsed Fluoroscopy versus Standard Dose Continuous Fluoroscopy during Fluoroscopically-Guided Lumbar Punctures: A Prospective Controlled Study

Radiation dose reduction for CT-guided intrathecal nusinersen administration in adult patients with spinal muscular atrophy

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