Impact of Obesity on Lumbar Puncture Outcomes in Adults with Acute Lymphoblastic Leukemia and Lymphoma: Experience at an Academic Reference Center

Abstract

Background: Lumbar puncture (LP) is a hematology procedure that can require repeated attempts leading to traumatic LP (TLP), which has been related to the central nervous system (CNS) relapse. LP success can depend on the size and anatomy of the patient and the skill of the hematologist. The main objective was to determine the influence of body mass index (BMI) on LP outcomes.
 Materials and Methods: Adults with lymphoid malignancies requiring LP were included prospectively over one year; hematology residents performed most procedures. A 22-gauge Quincke needle was employed. Comparison between non-traumatic vs. traumatic LPs according to BMI, CNS relapse, and residents’ year was performed.
 Results: Fifty-four patients with a mean age of 31.5±15.57 years were included. Diagnosis was Acute Lymphoblastic Leukemia-B (74%), Acute Lymphoblastic Leukemia-T (13%) and Non-Hodgkin Lymphoma (13%). 227 LPs were performed, 121 (53.3%) successful, 98 (43.2%) traumatic, 11 (11.2%) TLPs were macroscopically detectable and 87 (88%) microscopic; 8 (3.5%) were dry-taps. Median time between punctures was 11 days (1-202). Median BMI was 25 (22.8-39.6). Main indication for LP was prophylactic (74.5%); 39.2% were performed by first-year, 35.2% by second-year, 19.6% by third-year hematology residents. No difference (p = 0.145) for a TLP was found among residents. A BMI ≥30 (p = 0.040), non-palpable intervertebral space (p = 0.001) and more than one attempt (p = 0.001) were significant for TLP. TLP was not associated with CNS relapse (p = 0.962).
 Conclusion: Obesity predicted a TLP. A traumatic puncture did not increase the risk of CNS relapse at one-year follow-up.

Bioimpedance spinal needle provides high success and low complication rate in lumbar punctures of pediatric patients with acute lymphoblastic leukemia

“…Clinically, the most relevant result of the present study is that the success of LP at the first attempt was significantly associated with almost four times lower incidence of TLP compared to LP procedures where two or more attempts were required. This finding not only underlines the importance of the first attempt in getting a high-quality CSF sample but also compares well to halved incidences of TLPs reported after successful first attempts in adults with leukemia or neurologic problems 16 , 27 , and children in general 17 . The present 10% incidence of TLP associated with the successful first attempts agrees well with the 16% incidence observed in a recent study where the overall success rate at the first attempt was 90% 15 .…”

“…In pediatric patients with ALL, the success of LP with single skin penetration is generally good varying from 70 13 to 90% or more 14 , 15 . In adults with leukemia, the success is associated with about halved incidence of TLP 16 , but to our knowledge, this issue is not specifically addressed in children with ALL. Generally, in pediatric patients, a successful LP at the first attempt is associated with about 50% lower incidence of TLP as well 17 .…”

Incidence of traumatic lumbar punctures in adults: the impact of a patient's first procedure

“…In haemato-oncology, a short time (ie a week or less) between successive LP procedures is a known risk factor of TLPs, but longer times (about 2 weeks or more) seem not to increase the risk. [23][24][25][26] However, this evidence comes from haematology patients, mostly paediatric ones. Root causes of a higher odds ratio of TLP in the second procedure await further investigations but may speculatively pertain to a persistent (not fully recovered) trauma of the dura mater at the puncture site, coagulation disorders preventing or postponing proper healing of the site, or local inflammation that compromises the composition and structure of the dura mater at the time of the successive procedure.…”

Technological features of blast identification in the cerebrospinal fluid: A systematic review of flow cytometry and laboratory haematology methods

“…There are several potential reasons for haemodilution of specimens. These include (1) tube order; (2) technique‐related issues with lumbar puncture (LP) procedure technique; (3) needle diameter; and (4) patient‐related comorbidities such as obesity 47,60 . Apart from its diagnostic implications, there is a potential, albeit controversial, link between traumatic lumbar puncture (TLP) and outcome that suggests frequent surveillance CSF specimen collection could be hazardous 61–63 .…”

“…(3) needle diameter; and (4) patient-related comorbidities such as obesity. 47,60 Apart from its diagnostic implications, there is a potential, albeit controversial, link between traumatic lumbar puncture (TLP) and outcome that suggests frequent surveillance CSF specimen collection could be hazardous. [61][62][63] Based on a multivariate analysis of 546 paediatric ALL patients, Gajjar et al reported that patients with ≥2 sequential TLPs had poor 5-year survival 61 ; the authors hypothesised that leukaemic blasts from the blood may have seeded the CSF.…”