1. Fluoroscopically Guided Lumbar Puncture
Austin 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

2. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

3. Indications Investigate/exclude meningitis
Viral, bacterial, fungal, carcinomatous
Investigate demyelinating disease
Multiple sclerosis, Guillian Barre
Investigate subarachnoid hemorrhage
Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).

4. Indications Evaluate intracranial pressure
Pseudotumor cerebri, intracranial hypotension
Infuse contrast for myelogram
Intrathecal therapy
Chemotherapy, antibiotics, baclofen, anesthesia
Remove CSF to treat intracranial hypertension or cryptococcal meningitis
Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).

5. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

6. Contraindications Regional cellulitis Uncorrected Coagulopathy
Poorly studied, based on best clinical judgment and institutional protocol
INR > 1.5
Platelets < 50,000
Hold Heparin and low-molecular weight heparin for at least 1 half-life

7. 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 latex
Contrast if myelogram
Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).

8. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

9. Cerebrospinal fluid (CSF) Dynamics
Opening Pressure
60 to 200 mm H2O is normal in patients greater than 8 years old
60 to 250 mm H2O in obese patient
Intracranial hypotension diagnosed with opening pressure less than 60mm H20
Seehusen, D. A., Reeves, M. M. & Fomin, D. A. Cerebrospinal fluid analysis. American family physician 68, 1103–1108 (2003).
Schievink, W. I. et al. Diagnostic criteria for headache due to spontaneous intracranial hypotension: a perspective. Headache 51, 1442–1444 (2011).

10. Cerebrospinal fluid (CSF) Dynamics
Adults have mL of CSF
CSF is Produced at 0.3 mL/min
9-10 mL – “Standard” amount removed Replaced in 30 Minutes
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).

11. Cerebrospinal fluid (CSF) Collection
Common CSF tests
Microbiology
Xanthochromia
Cytology
Oligoclonal bands
Lactate
Angiotensin converting enzyme
Viral PCR
Cytospin (CNS lymphoma evaluation)
Each of the above require 20 drops of CSF each with the exception of cytology, which requires 50 drops
Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).

12. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

13. Most Common Complication: Spinal Headache
Positional headache occurs in approximately 32% patients after LP
Onset usually 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
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).
Ahmed, S. V., Jayawarna, C. & Jude, E. Post lumbar puncture headache: diagnosis and management. Postgraduate Medical Journal 82, 713–716 (2006).

14. Other complications Incidence of each of these is quite rare Bleeding
Epidural hematoma rare
Infection
Wear a mask and use sterile technique
Herniation
Reported in the setting of normal pre-procedural CT
Arachnoiditis and nerve root injury

15. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

16. 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
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).
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).

17. DePhilip, R. M. Atlas of Human Anatomy, by Frank H
DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).
Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image # Accessed 12/10/2014. Used with permission

18. Fluoroscopic Anatomy Important landmarks Easy to get disorientated
Pedicle
Spinous processes
Vertebral body cortices
Facets
Easy to get disorientated

20. DePhilip, R. M. Atlas of Human Anatomy, by Frank H
DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).
Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image # Accessed 12/10/2014. Used with permission

21. Superior articular facet

22. Inferior articular facet

23. Pedicle

24. Spinal process

25. Technique Multiple tissue planes crossed
Tactile feedback commonly experienced at two tissue planes
Interspinous ligament
Ligamentum flavum

26. Technique
DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).
Frank H. Netter; Netterimages.com; “Lumbar Puncture and Epidural Anesthesia”. Image # Accessed 12/10/2014. Used with permission

27. Benefits of oblique approach
Improved visualization
Larger access window
Avoid spinous process
Avoid thick interspinous ligaments

28. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

29. Prevent Spinal Headache
Larger bore needle increases risk
16G to 19G – 70% risk
20G to 22G – 20-40% risk
24G 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
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).

30. Prevent Spinal Headache
Insert stylet when removing needle
Reduces headache and rare incidences of meningitis and epidermoid tumor formation
Use atraumatic needles
Level 1 evidence in anesthesia literature that atraumatic needles such as Whitacre and Sprotte reduce spinal headache
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).

31. Prevent Spinal Headache
Atraumatic
needles
Image by Shannon K. Campbell, University of Tennessee Medical Center. Artwork created for this publication.
Image by Shannon K. Campbell, University of Tennessee Medical Center. Artwork created for this publication.

32. 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
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).

33. Treat Spinal Headache Epidural blood patch Caffeine
20cc autologous blood administered into epidural space
Success 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
 Ahmed, S. V., Jayawarna, C. & Jude, E. Post lumbar puncture headache: diagnosis and management. Postgraduate Medical Journal 82, 713–716 (2006).

34. Complications: improper needle placement
Common problems
Too shallow – problematic in larger patients
Too deep – into disk space or vertebral body in the setting of osteoporosis
Off target – osteophytes can be difficult to resolve fluoroscopically
Can always evaluate depth with cross table lateral radiograph

35. Optimal targeting, but no CSF returnX

36. Too shallow needle placement

37. Optimal placement in the spinal canal

38. Needle into disk space

39. Needle into bone (osteoporosis)

40. Fluoroscopically Guided Lumbar Puncture (FGLP)
Indications
Contraindications
CSF dynamics
Complications
Anatomic considerations
Avoiding complications

41. References
Seehusen, D. A., Reeves, M. M. & Fomin, D. A. Cerebrospinal fluid analysis. American family physician 68, 1103–1108 (2003).
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).
Schievink, W. I. et al. Diagnostic criteria for headache due to spontaneous intracranial hypotension: a perspective. Headache 51, 1442–1444 (2011).
Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).
Ahmed, S. V., Jayawarna, C. & Jude, E. Post lumbar puncture headache: diagnosis and management. Postgraduate Medical Journal 82, 713–716 (2006).
Doherty, C. M. & Forbes, R. B. Diagnostic Lumbar Puncture. Ulster Med J 83, 93–102 (2014).
DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).
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).