Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access

Abstract

Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1-2 level was used in 2; the L2-3 level, in 10; the L3-4 level, in 12; and the L4-5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture.

Magnetic resonance imaging anatomy and morphometry of lumbar intervertebral foramina to guide safe transforaminal subarachnoid punctures

“…In future studies, we will aim to extend our analysis to three other patient populations: older patients with degenerative changes of the spine, patients with spinal fusions (e.g., postsurgical or in presence of ankylosing spondylitis), and patients with SMA. Although Nascene et al () have reported some preliminary successful experience of TFLPs in SMA patients, it is presently unknown if SMA affects the anatomy and morphometry of their IVFs. We will aim to study this important issue in our growing population of SMA patients requiring intrathecal nusinersen injections.…”

“…The middle segment of the posterior crescent is in line with the top half of the L4–L5 intervertebral disc, a useful landmark during procedure guidance when using fluoroscopy or CT. However, in reports of early TFLP experiences to date (Nascene et al, ), most procedures were performed through IVFs at the L3–L4 level, and less so at the L4–L5 level. It is unclear if there was a precise anatomic rationale for this.…”

“…Recently, several reports have outlined preliminary experiences with an alternative technique, transforaminal lumbar puncture (TLFP), especially when used for the administration of intrathecal drugs, for example, nusinersen for treatment of spinal muscular atrophy (SMA) patients (Nascene et al, ; Towbin et al, ; Weaver et al, ). The usual therapeutic course requires that nusinersen be administered intrathecally on multiple occasions (Pane et al, ).…”

“…In recent initial experiences with TFLP, investigators have recommended that the intended target for a percutaneously positioned needle aimed at traversing the intervertebral foramen (IVF, TA code: A02.2.01.008) on a path to puncturing the thecal sac should be within an imaginary crescent approximating the dorsal concave margin of a lumbar IVF (Nascene et al, ). More precisely, the ideal location should be along the inferior aspect of such an imaginary crescent.…”

C1 Posterior Arch Flare Point: A Useful Landmark for Fluoroscopically Guided C1–2 Puncture

“…5 Although other novel techniques for collection of CSF, including atlanto-occipital and transforaminal lumbar puncture approaches, have been reported, they are not currently in widespread use. [13][14][15][16] The cervical puncture can be safely performed under image guidance using either fluoroscopy or CT/CT fluoroscopy. With the conventional technique, a 22-or 25-ga spinal needle is advanced into the posterior third of the spinal canal at the level of the C1-2 interspace from a lateral approach, with the patient in a prone, supine, or decubitus position.…”