Radicular vessels are the most probable source of needle-induced blood in lumbar puncture. Significance for the thrombocytopenic cancer patient

Abstract

Despite knowledge of the bleeding hazard to thrombocytopenic cancer patients undergoing lumbar puncture (LP), a retrospective analysis of physician behavior at one hospital revealed no consistent use of platelet transfusions in patients with less than 20,000 platelets/mm3 on the day of LP. A review of the literature and laboratory cerebrospinal fluid (CSF) data in two institutions, and the performance of an LP experiment revealed that: (1) Batson's epidural venous plexus is an unlikely source and spinal radicular vessels are the most probable source of needle‐induced blood in lumbar puncture; (2) the frequency of encountering needle‐induced blood at LP is high, 73% (3) the frequency of brushing a nerve root, with the associated risk of lacerating the radicular artery or vein on its surface with the bevel of the LP needle, is high and may be on the order of 26%; and (4) while the passage of an LP needle, obturator in place, through a blood filled vein may carry red cells into a red cell‐free medium, this does not always occur. These new considerations argue for more consistent adherence to the already published recommendation of platelet transfusion immediately prior to LP in patients with low platelets. This issue is of particular relevance to the rapidly growing population of thrombocytopenic cancer patients with extended survival on multiple chemotherapeutic regimens requiring lumbar puncture.

Spinal subdural hematoma: a rare case of spinal subdural hematoma complicating routine, minimally invasive lumbar discectomy and decompression and relevant literature review

“…Some authors have proposed that blood products can be traumatically introduced into the subdural by rupturing either a radicular artery accompanying a nerve root or disrupting the epidural plexus of Batson (less likely given its lateral positioning), attracting further fluid by creating an osmotically favorable gradient and negative hydrostatic pressure driving fluid extravasation into this space (19,27,(29)(30)(31). Bleeding and extravasation of fluid into the subdural space may be exacerbated by alterations in intraabdominal or intrathoracic pressure leading to additional vessel rupture, even in a delayed fashion (22,31).…”

Spinal subarachnoid hematoma following spinal anesthesia in a patient with HELLP syndrome

“…5 They analyzed CSF obtained from 130 patients undergoing spinal anesthesia. 7,8 It has been postulated that copious bleeding in the subarachnoid space at levels in excess of the flow of CSF may lead to hematoma formation and the presence of coagulopathy may promote formation of a larger hematoma. Such bleeding may be more common than is usually assumed, but only becomes clinically significant in patients with particular conditions such as coagulopathy.…”

Cerebrospinal Fluid

“…The needle lacerates the veins that course along the crowded nerve roots of the cauda equina in 75% of LPs, 15 and this can create diagnostic problems. The needle lacerates the veins that course along the crowded nerve roots of the cauda equina in 75% of LPs, 15 and this can create diagnostic problems.…”