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

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

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).

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).

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

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

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).

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

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).

Cerebrospinal fluid (CSF) Dynamics Adults have 125-150 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).

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).

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

Most Common Complication: Spinal Headache Positional headache occurs in approximately 32% patients after LP Onset usually 24-48 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).

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

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

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).

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 #4617. Accessed 12/10/2014. Used with permission

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

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 #4617. Accessed 12/10/2014. Used with permission

Superior articular facet

Inferior articular facet

Pedicle

Spinal process

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

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 #8083. Accessed 12/10/2014. Used with permission

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

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

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).

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).

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.

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).

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).

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

Optimal targeting, but no CSF return X

Too shallow needle placement

Optimal placement in the spinal canal

Needle into disk space

Needle into bone (osteoporosis)

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

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).