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

Lowering Platelet Threshold to 20,000/μL for Fluoroscopy-Guided Lumbar Puncture Does Not Result in Observed Clinical Adverse Outcomes

PURPOSE

Fluoroscopic-guided lumbar puncture (FG-LP) is a common neuroradiologic procedure. Traditionally, a minimum platelet count (MPC) of 50,000/μL for this procedure has been required; however, we recently adopted a lower MPC threshold of 20,000/μL. The purpose of this study was to compare adverse events in patients undergoing FG-LP with MPCs above to those below the conventional 50,000/μL threshold.

MATERIALS

This was an institutional review board-approved, retrospective study on adult patients with hematologic malignancy undergoing FG-LP in the neuroradiology division between May 2021 and December 2022, after lowering the minimal required MPC to 20,000/μL. Recorded data included indication for FG-LP, preprocedure and postprocedure MPC, need for and number of platelet transfusions within 24 hours of FG-LP, presence of traumatic tap, FG-LP-related complications, and any platelet transfusion-related adverse event. Patients were classified into 2 groups based on MPC: (1) those above 50,000/μL and (2) those below 50,000/μL. Descriptive statistics were used comparing these 2 groups.

RESULTS

One hundred twenty-eight patients underwent FG-LP, with 46 having an MPC between 20,000 and 50,000/μL and 82 having an MPC above 50,000/μL. No postprocedural complications were encountered in either group. Traumatic taps occurred in 10/46 (22%)​ with MPC below 50,000/μL versus 10/82 (12%)​ in those with MPC above 50,000/μL. Forty of 46 patients (87%) were transfused with platelets within 24 hours prior to FG-LP. One patient developed a transfusion-related reaction.

CONCLUSION

Lowering the MPC threshold from 50,000/μL to 20,000/μL for FG-LP did not result in a higher incidence of spinal hematoma.

Paramedian versus midline approach of spinal anesthesia: a systematic review and meta-analysis with trial sequential analysis

PURPOSE

Midline approach of spinal anesthesia has been widely used for patients undergoing surgical procedures. However, it might not be effective for obstetric patients and elderly with degenerative spine changes. Primary objective was to examine the success rate at the first attempt between the paramedian and midline spinal anesthesia in adults undergoing surgery.

METHODS

Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting date until February 2023. Randomized clinical trials (RCTs) comparing the paramedian versus midline approach of spinal anesthesia were included. The primary outcome was the success rate at the first attempt of spinal anesthesia.

RESULTS

Our review included 36 RCTs (n = 5379). Compared to the midline approach, paramedian approach may increase success rate at the first attempt but the evidence is very uncertain (OR: 0.47, 95% CI 0.27-0.82, ρ = 0.007, level of evidence:very low). Our pooled data indicates that the paramedian approach likely reduced incidence of post-spinal headache (OR: 2.07, 95% CI 1.51-2.84, ρ < 0.00001, level of evidence:moderate). The evidence suggests that the paramedian approach may result in a reduction in the occurrence of paresthesia (OR: 1.61, 95% CI 1.06-2.45, ρ = 0.03, level of evidence:low).

CONCLUSIONS

Our meta-analysis of 36 RCTs showed that paramedian approach may result in little to no difference in success rate at the first attempt owing to its very low level of evidence. However, given the low level of evidence and studies with small sample sizes, these findings need to be interpreted with caveat.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42023397781.

Report of cerebral vasospasm as a complication of intracranial subarachnoid hemorrhage following traumatic lumbar puncture

Background:

This case report is the first documented and illustrated case of the identification and treatment of intracranial vasospasm as a sequalae of traumatic lumbar puncture (LP). LP is a routine procedure performed for both diagnostic and therapeutic purposes. Although rare, this procedure has risks and complications that should be considered before performing.

Case Description:

A 58-year-old male was found to have intracranial subarachnoid hemorrhage (SAH) 2 days after a traumatic LP which occurred in the setting of subtherapeutic international normalized ratio. During his hospitalization, the patient developed both clinical and radiographic signs of vasospasm. He was taken for angiography, which demonstrated significant vasospasm of bilateral middle cerebral arteries and bilateral anterior cerebral arteries. All vasospasms resolved and the patient improved clinically after intra-arterial spasmolytic therapy.

Conclusion:

LP is a routine procedure with complications that are often overlooked. The authors describe intracranial vasospasm from traumatic LP before correction of patient’s coagulopathy. Cases with similar hemorrhage occurring in the spine resulting in non-aneurysmal SAH and vasospasm were reviewed.

Postoperative spinal subdural hygroma without incidental durotomy: illustrative cases

BACKGROUND

Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.

OBSERVATIONS

The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the “flying bat” sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.

LESSONS

Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.

Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy

IMPORTANCE

Coagulopathy may deter physicians from performing a lumbar puncture.

OBJECTIVE

To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy.

DESIGN, SETTING, AND PARTICIPANTS

Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.

EXPOSURES

Coagulopathy at the time of lumbar puncture.

MAIN OUTCOMES AND MEASURES

Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.

RESULTS

A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).

CONCLUSIONS AND RELEVANCE

In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.

Risk factors for blood-contaminated cerebrospinal fluid collection in dogs

OBJECTIVE

To determine the risk factors for blood contamination during cerebrospinal fluid (CSF) collection in dogs.

STUDY DESIGN AND METHODS

This is a prospective study of 170 CSF samples. Data collected included signalment of the patient, body condition score, site of CSF collection (cerebellomedullary cistern (CMC) or lumbar cistern (LC)), number of attempts, clinician expertise, final diagnosis, time of day, skull conformation and day of the week. Analysis of the CSF samples was then performed, and the presence of blood contamination (red blood cells >500/µl) was recorded. Logistic regression was used to quantify the association of potential risk factors of the procedure. Multivariate analysis was performed on the variables that were statistically significant.

RESULTS

Of the 170 CSF samples, 53 per cent were collected from the CMC (n=90) and 47 per cent from the LC (n=80). Blood contamination was seen in 20 per cent (n=34) of the samples, 8.9 per cent (n=8) in CMC and 32.5 per cent (n=26) in LC samples. Increased odds of obtaining a contaminated CSF sample were associated with lower level of clinician expertise (odds ratio: 2.5; 95 per cent confidence interval: 0.9-6.7; P=0.046) and with LC versus CMC collection site (odds ratio: 8.1; 95 per cent confidence interval: 2.1-12.9; P=0.001).

CLINICAL SIGNIFICANCE

There is increased likelihood of blood contamination when collecting CSF from the LC compared with the CMC site. Increased clinician experience reduced the risk of CSF blood contamination, but none of the other variables examined significantly influenced this.

Lumbar puncture under fluoroscopy guidance: a technical review for radiologists

There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists. Even within the same institution, there are a variety of preferences among proceduralists with individual perspectives based on the literature, training, and/or experience. Our aim is to provide familiarity with various techniques involved in FG-LP and provide insight on how to improve patient outcomes. The pertinent anatomy and physiology, indications, contraindications, patient management, complications of the procedure, and procedural techniques for performing an FG-LP are reviewed in detail. Potentially controversial topics regarding FG-LP are also addressed. There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists (1). Even within the same institution, there are a variety of individual preferences among physicians with different perspectives based on a combination of literature familiarity, training, and personal experience. Our aim is to provide familiarity with various techniques involved in FG-LP, improve efficiency, and improve patient outcomes. We will also address possible controversial issues regarding FG-LPs using an evidence-based approach.

Technological advances and changing indications for lumbar puncture in neurological disorders

Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitvity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer's disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that an atraumatic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice.

Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

BACKGROUND

People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count).

SEARCH METHODS

We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018.

SELECTION CRITERIA

We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively.

MAIN RESULTS

We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 10⁶/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 10⁶/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.

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

We present a case of apparently uncomplicated lumbar decompression and discectomy with delayed postoperative neurological deterioration secondary to subdural hematoma at the thoracolumbar level of the spinal cord. Previously described subdural hematomas have occurred spontaneously or related to iatrogenic injury. Hitherto, no case of acute postoperative subdural hematoma has been reported in the postoperative setting in the absence of known iatrogenic dural injury. A 76-year-old male with central and lateral recess spinal stenosis underwent apparently uncomplicated bilateral L3-4 and left sided L4-5 decompressive partial laminectomies and discectomy. No incidental dural injury or cerebrospinal fluid leak was detected. On postoperative day two, he developed progressive, profound weakness, sensory changes and urinary retention. Magnetic resonance imaging (MRI) demonstrated a compressive subdural fluid collection extending between T11-L2, which was confirmed to be xanthochromic and under pressure superficial to an undisturbed arachnoid at emergent surgical exploration and evacuation. The mechanism of this complication is unknown. The patient went on to a complete recovery following surgical evacuation of the fluid via durotomy. While this is a very rare event, it reminds that a high index of suspicion is required with a low threshold for urgent imaging and intervention in the postoperative period upon development of unexpected, progressive and/or profound neurological findings regardless of intraoperative course.

Platelet transfusion: a clinical practice guideline from the AABB

BACKGROUND

The AABB (formerly, the American Association of Blood Banks) developed this guideline on appropriate use of platelet transfusion in adult patients.

METHODS

These guidelines are based on a systematic review of randomized, clinical trials and observational studies (1900 to September 2014) that reported clinical outcomes on patients receiving prophylactic or therapeutic platelet transfusions. An expert panel reviewed the data and developed recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RECOMMENDATION 1

The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 109 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective. (Grade: strong recommendation; moderate-quality evidence).

RECOMMENDATION 2

The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 × 109 cells/L. (Grade: weak recommendation; low-quality evidence).

RECOMMENDATION 3

The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence).

RECOMMENDATION 4

The AABB suggests prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence).

RECOMMENDATION 5

The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass. The AABB suggests platelet transfusion for patients having bypass who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction. (Grade: weak recommendation; very-low-quality evidence).

RECOMMENDATION 6

The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous). (Grade: uncertain recommendation; very-low-quality evidence).

Ultrasound evaluation of lumbar spine anatomy in newborn infants: implications for optimal performance of lumbar puncture

An ultrasound evaluation of lumbar spine anatomic landmarks relevant for lumbar puncture was performed in 199 newborn infants. Effects of 6 patient positions and gestational age on interspinous process distance, subarachnoid space width, predicted needle entry angle, and needle insertion depth were assessed. Our results identify optimized conditions for lumbar puncture: sitting the infant with hips flexed, a needle entry angle of 65-70 degrees, and proper needle insertion depth (calculated as 2.5 × weight in kilograms + 6 in millimeters).

[Periprocedural management of hemostasis risk in interventional radiology]

Given the increasing demand for interventional image-guided procedures, radiologists are increasingly sollicited by clinicians to participate in the management of patients prior to and after the interventional procedure, especially with regards to hemostasis. Therefore, radiologists should be familiar with the risk of procedure related hemorrhage. Based on consensus guidelines published by the Society of Interventional Radiology (SIR), the risk of hemorrhage for each interventional procedure will be classified. Recommendations for preprocedure testing based on the type of procedure planned will be reviewed. Finally, limitations of hemostasis parameters will be discussed along with management of anticoagulants and antiplatelet agents before the procedure.

Thrombocytopenia and platelet transfusions in patients with cancer

Platelet transfusions are a critical component of the supportive care for patients receiving intensive therapy for hematologic malignancies. The platelet count "triggering" prophylactic transfusion has decreased over the years, and studies comparing a prophylactic versus a therapeutic transfusion approach are in progress. The evidence supporting the need for platelet transfusions prior to different invasive procedures is reviewed. Lastly, studies evaluating the use of thrombopoietic stimulating agents to reduce hemorrhage and decrease the need for platelet transfusions are discussed. To date, there is no evidence that this approach is of clinical utility.

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

A case of subarachnoid hematoma following spinal anesthesia for cesarean section in a patient with HELLP syndrome is reported. A 39-year-old woman underwent cesarean section under spinal anesthesia for worsening preeclampsia with HELLP syndrome. Despite full recovery from the spinal anesthetic, on the second postoperative day she felt numbness on the posterior aspect of her right leg, noticed she was insensitive to bladder fullness and had mild flaccid paraparesis. Magnetic resonance imaging revealed a spinal subarachnoid hematoma with cauda equina compression. With conservative management she made an almost complete recovery within three months. Serial magnetic resonance imaging showed spontaneous regression of the hematoma. The risk of spinal subarachnoid hematoma following obstetric regional anesthesia is exceedingly small even in a patient with coagulopathy and, to our knowledge, this is only the second reported case following obstetric regional anesthesia. Anesthesia for HELLP syndrome in patients with an adequate platelet count but without disseminated intravascular coagulation is controversial. It is therefore important for clinicians to recognize the symptoms and signs of spinal subarachnoid hematoma to avoid delay in treatment that might result in severe neurological deficit.

A positioning pillow to improve lumbar puncture success rate in paediatric haematology-oncology patients: a randomized controlled trial

Background

Lumbar punctures (LPs) are common in children with cancer. Although pain management during the lumbar puncture has been well standardized, dealing with stress and anxiety is not well addressed yet. Our objective was to evaluate the potential improvement of the LP success rate using a positioning pillow, to ensure maximum lumbar flexion, and allow paravertebral muscles to relax, in children who are awake, with either conscious sedation or no sedation.

Methods

Children aged 2–18 years undergoing LP were randomly assigned to a positioning pillow or no intervention. The primary outcome was the rate of success, i.e. achieving the LP (sampling or injection) at the first attempt, without bleeding (RBC < 50/mm³). The secondary outcomes included: the child's pain, assessed by a self-administered visual analogical scales (VAS) for children over 6 years of age; the parents' and caregivers' perception of the child's pain; the satisfaction of the children, the parents, the caregivers and the physician. The child's cooperation and the occurrence of post-LP syndrome were also evaluated.

Results

124 children (62 in each group) were included. The LP pillow tended to increase the success rate of LPs (67% vs. 57%, p = 0.23), and decreased the post-LP syndromes (15% vs. 24%, p = 0.17) but the differences were not statistically significant. In children over 6-year of age (n = 72), the rate of success was significantly higher in the pillow group (58.5% vs. 41.5%, p = 0.031), with a tendency to feel less pain (median VAS 25 vs. 15 mm, p = 0.39) and being more satisfied (84.4% vs. 75.0%, p = 0.34).

Conclusion

Overall results do not demonstrate a benefit in using this pillow for lumbar punctures. This study results also suggest a benefit in the sub group of children over 6-year of age; this result needs confirmation.

Trial Registration

The trial was registered with Clinical Trials.gov (number NCT00775112).

Intramedullary hemorrhage in a neonate after lumbar puncture resulting in paraplegia: a case report

We present the case of a premature infant with decreased spontaneous movement of the lower extremities. Imaging was demonstrative of a lesion of the conus medullaris. Operatively and with histologic confirmation, the mass was determined to be a blood clot originating from the conus. Retrospectively, the patient had a known lumbar puncture. There were no clotting abnormalities in this patient. At long-term follow-up, the child continues to have lower extremity paresis and incontinence of bowel and bladder. Clinicians should consider the lower termination of the conus medullaris in the infant, especially in the preterm infant.

Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine the most effective, evidence-based approach to the use of platelet transfusions in patients with cancer.

OUTCOMES

Outcomes of interest included prevention of morbidity and mortality from hemorrhage, effects on survival, quality of life, toxicity reduction, and cost-effectiveness.

EVIDENCE

A complete MedLine search was performed of the past 20 years of the medical literature. Keywords included platelet transfusion, alloimmunization, hemorrhage, threshold and thrombocytopenia. The search was broadened by articles from the bibliographies of selected articles.

VALUES

Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly related to one of the primary outcomes in a randomized design. BENEFITS/HARMS/COST: The possible consequences of different approaches to the use of platelet transfusion were considered in evaluating a preference for one or another technique producing similar outcomes. Cost alone was not a determining factor.

RECOMMENDATIONS

Appendix A summarizes the recommendations concerning the choice of particular platelet preparations, the use of prophylactic platelet transfusions, indications for transfusion in selected clinical situations, and the diagnosis, prevention, and management of refractoriness to platelet transfusion.

VALIDATION

Five outside reviewers, the ASCO Health Services Research Committee, and the ASCO Board reviewed this document.

SPONSOR

American Society of Clinical Oncology

Acute neurologic complications in children with systemic cancer

Neurologic complications are common in children with cancer, but the literature dealing with this subject is sparse. Using a symptoms and signs approach, the most common causes for requesting a neurologic evaluation for this population are reviewed. The spectrum of neurologic symptoms in children with cancer differs from adults and requires the consulting neurologist to have a thorough knowledge of childhood cancer and its effects on the nervous system.

Vascular trauma associated with routine spinal anaesthesia

Samples of cerebrospinal fluid obtained from 130 patients undergoing spinal anaesthesia were examined microscopically. Subarachnoid puncture was performed using either a 25G Whitacre or 25G Quincke spinal needle. Two samples were collected from each patient and the red blood cell count of the second sample collected was taken as a measure of the vascular trauma associated with the procedure. Red blood cells were seen in 50 (38%) of these samples, of which 18 (14%) contained > 100 red blood cells.mm-3. Paraesthesia was felt by 11 (8.5%) patients and the occurrence of paraesthesia was associated with significantly raised red blood cell counts (p < 0.0001). There was also a correlation between the number of needle passes made at lumbar puncture and the red blood cell count in the sample (p < 0. 0001). Neither spinal needle type nor antiplatelet drug therapy influenced red blood cell counts (p = 0.66 and 0.37, respectively). These findings suggest that routine spinal anaesthesia is often complicated by minor degrees of vascular trauma, especially when paraesthesiae or technical difficulty occur at subarachnoid puncture.

Serial magnetic resonance imaging findings for a spontaneously resolving spinal subdural hematoma: case report

OBJECTIVE AND IMPORTANCE

Spinal subdural hematoma (SSDH) is a rare entity, and cases are usually managed as surgical emergencies. We describe a patient with a SSDH who demonstrated incomplete clinical resolution with nonsurgical management, despite continued anticoagulation treatment. We provide the most complete demonstration of the magnetic resonance imaging (MRI) characteristics of a large SSDH from its initiation to its radiological resolution.

CLINICAL PRESENTATION

A 61-year-old woman developed a large SSDH as a complication of a lumbar puncture. Her only neurological deficit was urinary retention.

INTERVENTION

Because of the extensiveness of the hematoma and the relative neurological preservation of the patient, she was treated conservatively. Serial MRI scans were obtained at 4, 7, 13, and 25 days. The evolution of deoxyhemoglobin in the hematoma to methemoglobin was observed. By 25 days, MRI scans showed virtual resolution.

CONCLUSION

SSDHs undergo MRI signal changes that are similar to those of brain hematomas. In certain cases, even large SSDHs demonstrate swift and dramatic spontaneous resolution, despite continued anticoagulation treatment. This report suggests that there is a role for conservative management for selected cases of SSDHs.

Complications of lumbar puncture

This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.

Intraventricular blood after "traumatic" lumbar puncture: a report of two cases

Blood was detected in the lateral ventricles on head computed tomograms performed after "traumatic" lumbar punctures in two children. This finding has not previously been observed or reported. The likely mechanisms by which blood from the spinal thecal sac reached the ventricles are discussed. This potentially confusing observation, if not correctly accounted for, may lead to an unnecessary, fruitless search for the site of a supposed "primary" intraventricular haemorrhage.