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Palati R, Lv J, Yu J, He L, Sun Y. Innovative Computed Tomography-Assisted Intrathecal Nusinersen Injection in a Pediatric Patient. Clin Pediatr (Phila) 2024; 63:746-749. [PMID: 37997668 DOI: 10.1177/00099228231210708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
- Reheman Palati
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jishou Lv
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jing Yu
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Lei He
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Yan Sun
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
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Balaji L, Farrar MA, D'Silva AM, Kariyawasam DS. Decision-making and challenges within the evolving treatment algorithm in spinal muscular atrophy: a clinical perspective. Expert Rev Neurother 2023; 23:571-586. [PMID: 37227306 DOI: 10.1080/14737175.2023.2218549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The clinical application of disease modifying therapies has dramatically changed the paradigm of the management of people with spinal muscular atrophy (SMA), from sole reliance on symptomatic care directed toward the downstream consequences of muscle weakness, to proactive intervention and even preventative care. AREAS COVERED In this perspective, the authors evaluate the contemporary therapeutic landscape of SMA and discuss the evolution of novel phenotypes and the treatment algorithm, including the key factors that define individual treatment choice and treatment response. The benefits achieved by early diagnosis and treatment through newborn screening are highlighted, alongside an appraisal of emerging prognostic methods and classification frameworks to inform clinicians, patients, and families about disease course, manage expectations, and improve care planning. A future perspective of unmet needs and challenges is provided, emphasizing the key role of research. EXPERT OPINION SMN-augmenting therapies have improved health outcomes for people with SMA and powered the practice of personalized medicine. Within this new proactive diagnostic and treatment paradigm, new phenotypes and different disease trajectories are emerging. Ongoing collaborative research efforts to understand the biology of SMA and define optimal response are critical to refining future approaches.
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Affiliation(s)
- Lakshmi Balaji
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
| | - Michelle A Farrar
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Arlene M D'Silva
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Didu S Kariyawasam
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
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3
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Yang H, Tao Q, Li D, Yang J, Cai Q, Gan J, Huang S, Luo R. Assessment of motor function and nutritional status in children with spinal muscular atrophy treated with nusinersen after loading period in Western China: a retrospective study. BMC Neurol 2023; 23:35. [PMID: 36690929 PMCID: PMC9869561 DOI: 10.1186/s12883-023-03063-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a progressive degenerative neuromuscular disease. Nusinersen, with its quick onset of action, can benefit patients early in the treatment course. However, there are currently no clinical studies regarding the improvement in motor function and nutritional status of patients after loading period treatment with nusinersen. Here, we aimed to determine the efficacy of nusinersen in improving motor function and nutritional status in children with SMA treated with nusinersen after loading period in Western China. METHODS In this retrospective study, data for all pediatric patients (aged < 18 years), with genetically confirmed diagnosis of SMA who were treated with nusinersen, were collected before initiation of treatment and after 2 months of treatment. We assessed motor function using standardized scales and nutritional status of patients with SMA as well as side effects of nusinersen. RESULTS Forty-six pediatric patients aged < 18 years were enrolled in this study. After 2 months of treatment, the motor function of patients with SMA type 1, 2, and 3 improved. The difference in Revised Upper Limb Module scores from M0 to M2 was significant in patients with SMA type 2 and 3 (P = 0.004, P = 0.042, respectively). The difference in Hammersmith Functional Motor Scale Expanded scores from M0 to M2 in patients with SMA type 2 was also significant (P = 0.000). No significant differences were found for Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorder (CHOP-INTEND), Hammersmith Infant Neurologic Examination-Part 2 (HINE-2), and 6-Minute Walking Test (6MWT) scores between M0 and M2, but the scores of CHOP-INTEND, HINE-2, and 6MWT were all increased after loading period treatment. The overall improvement in nutritional status was not statistically significant. No serious adverse effects were observed. CONCLUSIONS Our study provides evidence for the efficacy and safety of nusinersen and the nutritional status of pediatric patients with SMA after the loading period treatment. Motor function of all patients improved after 2 months of loading period nusinersen treatment. Patients with a shorter disease duration showed better response to treatment. Careful surveillance of nutritional status is needed in patients with SMA.
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Affiliation(s)
- Hua Yang
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.13291.380000 0001 0807 1581Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Qiuji Tao
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.461863.e0000 0004 1757 9397Department of Pediatrics of neurology Nursing, West China Second University Hospital, Chengdu, China
| | - Dan Li
- grid.43169.390000 0001 0599 1243The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Jie Yang
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.13291.380000 0001 0807 1581Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Qianyun Cai
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.13291.380000 0001 0807 1581Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Jing Gan
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.13291.380000 0001 0807 1581Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Shaoping Huang
- grid.43169.390000 0001 0599 1243The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Rong Luo
- grid.461863.e0000 0004 1757 9397Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,grid.13291.380000 0001 0807 1581Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
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Cone-beam computed tomography guided nusinersen administrations in adult spinal muscular atrophy patients with challenging access: a single- center experience. Radiol Oncol 2022; 56:319-325. [PMID: 35962954 PMCID: PMC9400441 DOI: 10.2478/raon-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The challenging anatomic predispositions in adult patients with spinal muscular atrophy (SMA) preclude the conventional lumbar punctures. Consequently, an introduction of alternative method for intrathecal delivery of nusinersen is required. Cone-beam CT (CBCT) allows volumetric display of the area of interest, pre-procedural planning and real time needle guidance which results in accurate anatomic navigation. The aim of the study was to evaluate technical success, safety, and feasibility of CBCT lumbar intrathecal delivery of nusinersen in the adult SMA patients with challenging anatomical access. PATIENTS AND METHODS Thirty-eight adult SMA patients were treated in our institution. Patients with challenging access were selected by multidisciplinary board for image guided administration of nusinersen either due to implantation of the posterior fusion instrumentation, severe scoliosis defined as Cobb's angle > 40º or body mass index over 35. Technical success, radiation exposure and occurrence of adverse events were assessed. RESULTS Twenty patients were selected, and 108 CBCT-guided procedures were performed. Each patient underwent at least 4 administrations. Transforaminal approach was performed in 82% of patients. The technical success was 100%, with primary success of 93.5%. The median radiation effective dose of the administrations was 5 mSv, the mean value equalled 10 mSv. Only mild adverse events were reported in the study. CONCLUSIONS CBCT-guided lumbar intrathecal administrations of nusinersen in an adult SMA population with challenging access was feasible and safe image guided method.
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Madan E, Carrié S, Donado C, Lobo K, Souris M, Laine R, Beers E, Cornelissen L, Darras BT, Koka A, Riley B, Dinakar P, Stone S, Snyder B, Graham RJ, Padua H, Sethna N, Berde C. Nusinersen for Patients With Spinal Muscular Atrophy: 1415 Doses via an Interdisciplinary Institutional Approach. Pediatr Neurol 2022; 132:33-40. [PMID: 35636280 DOI: 10.1016/j.pediatrneurol.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Spinal deformity and prior spinal fusion pose technical challenges to lumbar puncture (LP) for nusinersen administration for patients with spinal muscular atrophy (SMA). In this retrospective study over two study phases, we evaluated (1) factors associated with difficult LP or unscheduled requirement for image guidance and (2) effectiveness of a triage pathway for selective use of image guidance and nonstandard techniques, particularly for patients with spinal instrumentation/fusion to the sacrum. METHODS With institutional review board approval, electronic health records, imaging, and administrative databases were analyzed for patients receiving nusinersen from January 2012 through September 2021. Descriptive statistics and univariate analyses were used. RESULTS From January 2012 to March 2018 (phase 1), among 82 patients with SMA, 461 of 464 (99.4%) LP attempts were successful. Univariate analyses associated difficulty with prior spinal instrumentation, higher body mass index, and severity of the spinal deformity. Based on this experience, starting in April 2018 (phase 2), 125 patients were triaged selectively for ultrasound, fluoroscopy, or Dyna computed tomography. Patients with spinal instrumentation/fusion to the sacrum were treated primarily via intrathecal ports (137 doses) or transforaminal LP (55 doses). From April 2018 through September 2021, 704 of 709 (99.3%) LPs were successful. In total from January 2012 to September 2021, 1415 doses were administered. Over 50% of LPs were performed by neurology nurse practitioners without image guidance. Safety outcomes were excellent. CONCLUSIONS A stratified approach resulted in successful intrathecal nusinersen delivery and efficient resource allocation for patients with SMA, with or without complex spinal anatomy.
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Affiliation(s)
- Elena Madan
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sabrina Carrié
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Carolina Donado
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michelle Souris
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Regina Laine
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Beers
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Cornelissen
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Basil T Darras
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anjali Koka
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bobbie Riley
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pradeep Dinakar
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian Snyder
- Department of Orthopaedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert J Graham
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Horacio Padua
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Navil Sethna
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charles Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
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Berde C, Formanek A, Khan A, Camelo CR, Koka A, Riley BL, Padua H. Transforaminal lumbar puncture for spinal anesthesia or novel drug administration: a technique combining C-arm fluoroscopy and ultrasound. Reg Anesth Pain Med 2022; 47:380-383. [PMID: 35321920 PMCID: PMC9046743 DOI: 10.1136/rapm-2021-103242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/02/2022] [Indexed: 12/26/2022]
Abstract
Background Lumbar puncture (LP) may be challenging for patients with scoliosis and other conditions following previous posterior fusion and instrumentation from thoracic to sacral levels. Interventional radiologists have described CT approaches to transforaminal LP. We hypothesized that combined C-arm fluoroscopy and ultrasound could be a feasible approach to transforaminal LP for interventional pain physicians and regional anesthesiologists. Methods With institutional review board approval, we reviewed medical records and imaging of six patients with spinal muscular atrophy and prior spine fusion. Non-cutting needles of 24 or 25 gage were advanced through 20-gage introducers. Prior imaging guided selection of a preferred side and spinal level. Initial procedures were performed in the interventional radiology suite. Subsequent procedures were performed in an operating room (OR). We report on technical success and complications and describe a case using this approach for spinal anesthesia. Results Six patients underwent a total of 54 transforaminal LPs, including 51 for administration of the antisense oligonucleotide nusinersen, 2 for myelography, and 1 for spinal anesthesia; 45 of these procedures were performed using OR C-arm fluoroscopy and ultrasound. Transient paresthesias and short-term headaches occurred; none required intervention. No other complications were noted. Conclusions Transforaminal LP appears technically feasible for patients with full-spine fusions using a straight-needle approach with combined fluoroscopy and ultrasound guidance. Larger case series and prospective studies may better define the success rates, risks, and benefits of this approach relative to alternative approaches to intrathecal access for patients with previous long-segment posterior spine fusions.
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Affiliation(s)
- Charles Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Formanek
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Asif Khan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Rafael Camelo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Anjali Koka
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Bobbie L Riley
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Horacio Padua
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Radiology, Harvard Medical School, Boston, Massachusetts, USA
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Hjartarson HT, Nathorst-Böös K, Sejersen T. Disease Modifying Therapies for the Management of Children with Spinal Muscular Atrophy (5q SMA): An Update on the Emerging Evidence. Drug Des Devel Ther 2022; 16:1865-1883. [PMID: 35734367 PMCID: PMC9208376 DOI: 10.2147/dddt.s214174] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022] Open
Abstract
SMA (5q SMA) is an autosomal recessive neuromuscular disease with an estimated incidence of approximately 1 in 11,000 live births, characterized by progressive degeneration and loss of α-motor neurons in the spinal cord and brain stem, resulting in progressive muscle weakness. The disease spectrum is wide, from a serious congenital to a mild adult-onset disease. SMA is caused by biallelic mutations in the SMN1 gene and disease severity is modified primarily by SMN2 copy number. Before the advent of specific disease altering treatments, SMA was the second most common fatal autosomal recessive disorder after cystic fibrosis and the most common genetic cause of infant mortality. Nusinersen, risdiplam, and onasemnogene abeparvovec are presently the only approved disease modifying therapies for SMA, and the aim of this review is to discuss their mode of action, effects, safety concerns, and results from real-world experience. All exert their action by increasing the level of SMN protein in lower motor neuron. Nusinersen and risdiplam by modifying the SMN2 gene product, and onasemnogene abeparvovec by delivering SMN1 gene copies into cells. All have an established clinical efficacy. An important feature shared by all three is that early intervention is associated with a better treatment outcome, such that in cases where treatment is initiated in an early pre-symptomatic period, it may result in normal – or almost normal – motor development. Thus, early diagnosis followed by swift initiation of treatment is fundamental for the treatment response and consequently long-term prognosis in SMA type 1, and probably SMA type 2. The same principle similarly applies to the milder phenotypes. All three therapies are relatively novel, with risdiplam being the latest addition. Except for nusinersen, real-world data are still scarce, and long-term data are quite naturally lacking.
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Affiliation(s)
- Helgi Thor Hjartarson
- Department of Neuropediatrics, Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kristofer Nathorst-Böös
- Department of Neuropediatrics, Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Sejersen
- Department of Neuropediatrics, Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Thomas Sejersen, Department of Women’s and Children’s Health, Karolinska Institute, Karolinska Vägen 37A, Stockholm, 171 76, Sweden, Tel +46 8 51777342, Email
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Xu B, Wei C, Hu X, Li W, Huang Z, Que C, Qiu J, Li C, Xiong H. Scoliosis Orthopedic Surgery Combined With Nusinersen Intrathecal Injection Significantly Improved the Outcome of Spinal Muscular Atrophy Patient: A Case Report. Front Neurol 2022; 13:869230. [PMID: 35547367 PMCID: PMC9082934 DOI: 10.3389/fneur.2022.869230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is an autosomal recessive disorder caused by pathogenic variation of the survival motor neuron (SMN) 1 gene. Symptoms of SMA include progressive limb muscle weakness, atrophy, and severe scoliosis. Nusinersen is an antisense oligonucleotide that can enhance the production of the SMN protein. Here, we report a case with scoliosis who received orthopedic surgery combined with Nusinersen intrathecal injections. Case Presentation Scoliosis orthopedic surgery followed by Nusinersen intrathecal injections was given to a 16-year-old girl who had thoracic and lumbar scoliosis and type 3 SMA. Surgery was performed for T3-S2 posterolateral fusion (PLF), with a channel left on the vertebral laminae of L3-L4. The balance of the spine and pelvis was significantly improved and the height increased by 9 cm. Lumbar puncture was conducted with local anesthesia under ultrasound and CT guidance through the laminae channel and Nusinersen was successfully injected. Comparing the two approaches, real-time ultrasound guidance for intrathecal Nusinersen injections after spinal surgery is preferred, however, CT guidance is an alternative if the initial puncture procedure is difficult. After the aforementioned multidisciplinary treatment, a good outcome was achieved, as demonstrated by a 2-point increase in RULM and MFM32 scores 2 months later. Conclusion Scoliosis orthopedic surgery combined with Nusinersen intrathecal injection is an effective treatment for SMA patients with scoliosis.
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Affiliation(s)
- Beiyu Xu
- Department of Orthopedic/Spine Surgery, Peking University First Hospital, Beijing, China
| | - Cuijie Wei
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xiao Hu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wenzhu Li
- Department of Rehabilitation Medicine, Peking University First Hospital, Beijing, China
| | - Zhen Huang
- Department of Rehabilitation Medicine, Peking University First Hospital, Beijing, China
| | - Chengli Que
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Jianxing Qiu
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Chunde Li
- Department of Orthopedic/Spine Surgery, Peking University First Hospital, Beijing, China
| | - Hui Xiong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Snoj Ž, Salapura V. Ultrasound‐guided transforaminal approach for nusinersen delivery in adult
SMA
patients with challenging access. Muscle Nerve 2022; 65:585-589. [DOI: 10.1002/mus.27518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Ž. Snoj
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7 Ljubljana Slovenia
- Faculty of Medicine University of Ljubljana, Vrazov trg 2 Ljubljana Slovenia
| | - V. Salapura
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7 Ljubljana Slovenia
- Faculty of Medicine University of Ljubljana, Vrazov trg 2 Ljubljana Slovenia
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Jablonka S, Hennlein L, Sendtner M. Therapy development for spinal muscular atrophy: perspectives for muscular dystrophies and neurodegenerative disorders. Neurol Res Pract 2022; 4:2. [PMID: 34983696 PMCID: PMC8725368 DOI: 10.1186/s42466-021-00162-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Major efforts have been made in the last decade to develop and improve therapies for proximal spinal muscular atrophy (SMA). The introduction of Nusinersen/Spinraza™ as an antisense oligonucleotide therapy, Onasemnogene abeparvovec/Zolgensma™ as an AAV9-based gene therapy and Risdiplam/Evrysdi™ as a small molecule modifier of pre-mRNA splicing have set new standards for interference with neurodegeneration. MAIN BODY Therapies for SMA are designed to interfere with the cellular basis of the disease by modifying pre-mRNA splicing and enhancing expression of the Survival Motor Neuron (SMN) protein, which is only expressed at low levels in this disorder. The corresponding strategies also can be applied to other disease mechanisms caused by loss of function or toxic gain of function mutations. The development of therapies for SMA was based on the use of cell culture systems and mouse models, as well as innovative clinical trials that included readouts that had originally been introduced and optimized in preclinical studies. This is summarized in the first part of this review. The second part discusses current developments and perspectives for amyotrophic lateral sclerosis, muscular dystrophies, Parkinson's and Alzheimer's disease, as well as the obstacles that need to be overcome to introduce RNA-based therapies and gene therapies for these disorders. CONCLUSION RNA-based therapies offer chances for therapy development of complex neurodegenerative disorders such as amyotrophic lateral sclerosis, muscular dystrophies, Parkinson's and Alzheimer's disease. The experiences made with these new drugs for SMA, and also the experiences in AAV gene therapies could help to broaden the spectrum of current approaches to interfere with pathophysiological mechanisms in neurodegeneration.
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Affiliation(s)
- Sibylle Jablonka
- Institute of Clinical Neurobiology, University Hospital of Wuerzburg, Versbacher Str. 5, 97078, Wuerzburg, Germany.
| | - Luisa Hennlein
- Institute of Clinical Neurobiology, University Hospital of Wuerzburg, Versbacher Str. 5, 97078, Wuerzburg, Germany
| | - Michael Sendtner
- Institute of Clinical Neurobiology, University Hospital of Wuerzburg, Versbacher Str. 5, 97078, Wuerzburg, Germany.
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Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Improves the Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Biopsy for Peripheral Pulmonary Lesions. Diagnostics (Basel) 2021; 12:diagnostics12010041. [PMID: 35054208 PMCID: PMC8774719 DOI: 10.3390/diagnostics12010041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of peripheral pulmonary lesions (PPLs), but the diagnostic yield is not adequate. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) can be utilized to assess the location of PPLs and biopsy devices, and has the potential to improve the diagnostic accuracy of bronchoscopic techniques. The purpose of this study was to verify the contribution of CBCT-AF to EBUS-TBB. Methods: Patients who underwent EBUS-TBB for diagnosis of PPLs were enrolled. The navigation success rate and diagnostic yield were used to evaluate the effectiveness of CBCT-AF in EBUS-TBB. Results: In this study, 236 patients who underwent EBUS-TBB for PPL diagnosis were enrolled. One hundred fifteen patients were in CBCT-AF group and 121 were in non-AF group. The navigation success rate was significantly higher in the CBCT-AF group (96.5% vs. 86.8%, p = 0.006). The diagnostic yield was even better in the CBCT-AF group when the target lesion was small in size (68.8% vs. 0%, p = 0.026 for lesions ≤10 mm and 77.5% vs. 46.4%, p = 0.016 for lesions 10–20 mm, respectively). The diagnostic yield of the two study groups became similar when the procedures with a failure of navigation were excluded. The procedure-related complication rate was similar between the two study groups. Conclusion: CBCT-AF is safe, and effectively enhances the navigation success rate, thereby increasing the diagnostic yield of EBUS-TBB for PPLs.
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Shashi KK, Stone SSD, Berde CB, Padua HM. Intrathecal catheter and port placement for nusinersen infusion in children with spinal muscular atrophy and spinal fusion. Pediatr Radiol 2021; 51:2588-2595. [PMID: 34254153 DOI: 10.1007/s00247-021-05126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/18/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spinal administration of medications is challenging in patients with complete posterior spinal fusion. We describe percutaneous image-guided intrathecal port placement for administration of the antisense oligonucleotide nusinersen for children and young adults with spinal muscular atrophy. OBJECTIVE To describe and present our initial experience with a new technique for administering nusinersen in patients with spinal muscular atrophy and posterior spinal fusion. MATERIALS AND METHODS We reviewed medical records of 13 patients who received intrathecal ports using DynaCT, biplane fluoroscopy and iGuide from April 2018 through June 2019, and we describe the clinical course over 1 year. RESULTS Image-guided catheter and port implantation was successful in all cases. Two ports were subsequently removed, one for persistent cerebrospinal fluid leak and one for superficial infection. The other 11 have functioned successfully for a minimum of 23 months. CONCLUSION We report our experience with image-guided intrathecal port placement in children with complete posterior spine fusion. The implanted port permits dosing in an outpatient setting and avoids the need for multiple future radiologic procedures, and it reduces discomfort, procedural costs and potential risks and sequelae of multiple anesthetics and radiation exposures. Further studies are needed to define the relative risks and benefits of intrathecal ports compared to other approaches such as repeated transforaminal lumbar punctures.
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Affiliation(s)
- Kumar K Shashi
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Scellig S D Stone
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Horacio M Padua
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
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Zanfini BA, Catarci S, Patanella AK, Pane M, Frassanito L, Filipponi E, Mercuri E, Sabatelli M, Draisci G. Ultrasound assisted lumbar intrathecal administration of nusinersen in adult patients with spinal muscular atrophy: A case series. Muscle Nerve 2021; 64:594-599. [PMID: 34396547 DOI: 10.1002/mus.27400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION/AIMS Intrathecal nusinersen administration can be challenging in certain adult spinal muscular atrophy (SMA) patients with difficult spinal anatomy who require imaging techniques (fluoroscopy or computed tomography scans) or invasive approaches (catheter placement, laminotomy) to identify the intrathecal space. We used ultrasound (US) assistance to access the lumbar intrathecal space in patients with SMA who experienced previous difficulties or failures with intrathecal dosing. METHODS Eighteen adult patients with difficult spines were enrolled. We used US assistance, and we recorded the successful administrations, number of attempts, procedure times, and "patient satisfaction." RESULTS There were 57 consecutive successful nusinersen spinal administrations in all patients enrolled. In 50% of patients, two or fewer attempts were needed to obtain a successful administration, with four or fewer attempts in 83.3%; only three patients reported more than four attempts because of both severe scoliosis and severe spine rotation (two patients) and obesity (one patient). The mean procedure time was 11.8 min (range, 1.7-28.9). Patient satisfaction was 4.97/5 (range, 4-5; median, 5) on Likert scale at 5 min and at 72 h. No major adverse events were reported, and two post dural puncture headaches were managed with medical therapy and with complete resolution within 72 h. DISCUSSION US assistance seems to be a valid option among treatment choices for intrathecal nusinersen administration in patients with difficult spine. The absence of radiation exposure and the lack of need for intravenous sedation or general anesthesia are additional potential advantages to US assisted administration.
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Affiliation(s)
- Bruno Antonio Zanfini
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Catarci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Agata Katia Patanella
- Centro Clinico Nemo, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Marika Pane
- Centro Clinico Nemo Pediatrico, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Filipponi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eugenio Mercuri
- Centro Clinico Nemo Pediatrico, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Mario Sabatelli
- Centro Clinico Nemo, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Gaetano Draisci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Zhang J, Cui X, Chen S, Dai Y, Huang Y, Zhang S. Ultrasound-guided nusinersen administration for spinal muscular atrophy patients with severe scoliosis: an observational study. Orphanet J Rare Dis 2021; 16:274. [PMID: 34120632 PMCID: PMC8201867 DOI: 10.1186/s13023-021-01903-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This observational study describes our experience delivering nusinersen through lumbar puncture with real-time ultrasound guidance in spinal muscular atrophy (SMA) patients with severe scoliosis. RESULTS Intrathecal nusinersen via real-time ultrasound-guided lumbar puncture was given to three patients who had severe thoracic and lumbar scoliosis: a 34-year-old female with type 3a SMA, a 28-year-old male with type 2a SMA, and a 14-year-old girl with type 3a SMA. Lumbar puncture was performed without sedation under ultrasound guidance using a 22G echogenic needle in the interlaminar aspect of the L4-L5 or L5-S1 interspace and a full dose of nusinersen (12 mg/5 mL) was injected after visualizing free cerebrospinal fluid flow. Patients completed their four loading doses and one maintenance dose of nusinersen. All 15 procedures were successful and well tolerated. CONCLUSIONS Real-time ultrasound-guided lumbar puncture is an effective and radiation-free technique to administer intrathecal nusinersen in SMA patients with severe scoliosis when done by practitioners with expertise in this procedure.
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Affiliation(s)
- Jiao Zhang
- Anaesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Beijing, 100730, China
| | - Xulei Cui
- Anaesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Beijing, 100730, China.
| | - Si Chen
- Anaesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Beijing, 100730, China
| | - Yi Dai
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
| | - Yuguang Huang
- Anaesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Beijing, 100730, China
| | - Shuyang Zhang
- Cardiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Beijing, 100730, China.
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Johannsen J, Weiss D, Schlenker F, Groth M, Denecke J. Intrathecal Administration of Nusinersen in Pediatric SMA Patients with and without Spine Deformities: Experiences and Challenges over 3 Years in a Single Center. Neuropediatrics 2021; 52:179-185. [PMID: 33276405 DOI: 10.1055/s-0040-1718916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Spinal muscular atrophy (SMA) is a rare neurodegenerative disease leading to progressive muscular atrophy, respiratory failure, and premature death. Secondary thorax and spine deformities are frequent. In July 2017, the antisense oligonucleotide nusinersen (Spinraza) was approved for the recurrent lifelong intrathecal treatment of SMA in Europe. Lumbar punctures are challenging especially in SMA patients with severe spine deformities and after spine surgery. In the light of alternative SMA therapies that are available or are expected to be available soon and which are administered orally or via one-time infusion, an appraisal of the established therapy is significant. Discussion about which therapy is the best for each individual patient will have to include not only the safety and efficacy of data but also the application form and its burden for the patient and the health care system. Therefore, we analyzed our 3-year experiences and challenges with 478 lumbar puncture procedures in 61 pediatric SMA patients with and without spine deformities or instrumentation.
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Affiliation(s)
- Jessika Johannsen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Deike Weiss
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friderike Schlenker
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Groth
- Department of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mendonça RDH, Fernandes HDS, Pinto RBS, Matsui Júnior C, Polido GJ, Silva AMSD, Grossklauss LF, Reed UC, Zanoteli E. Managing intrathecal administration of nusinersen in adolescents and adults with 5q-spinal muscular atrophy and previous spinal surgery. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:127-132. [PMID: 33759979 DOI: 10.1590/0004-282x-anp-2020-0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease of lower motor neurons associated with frequent occurrence of spinal deformity. Nusinersen is an antisense oligonucleotide that increases SMN protein level and is administrated by frequent intrathecal lumbar injections. Thus, spinal deformities and previous spinal surgery are important challenges for drug delivery in SMA. OBJECTIVE To report imaging methods used for Nusinersen injection in SMA patients. METHODS Nusinersen injection procedures in SMA types 2 and 3 patients who had previous spinal surgery were analyzed retrospectively to describe the imaging and puncture procedures, as well as the occurrence of complications. RESULTS Nine SMA patients (14 to 50 years old) underwent 57 lumbar punctures for nusinersen injection. Six patients had no interlaminar space available; in five of them, a transforaminal approach was used, and another one underwent a surgery to open a posterior bone window for the injections. Transforaminal puncture was performed using CT scan in three cases and fluoroscopy in the other two, with a similar success rate. One patient in the transforaminal group had post-procedure radiculitis, and another one had vagal reaction (hypotension). In three cases, with preserved interlaminar space, injections were performed by posterior interlaminar puncture, and only one adverse event was reported (post-puncture headache). CONCLUSION In SMA patients with previous spinal surgery, the use of imaging-guided intervention is necessary for administering intrathecal nusinersen. Transforaminal technique is indicated in patients for whom the interlaminar space is not available, and injections should always be guided by either CT or fluoroscopy.
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Affiliation(s)
| | | | | | - Ciro Matsui Júnior
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Graziela Jorge Polido
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Luis Fernando Grossklauss
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão Neuromusculares, São Paulo SP, Brazil
| | - Umbertina Conti Reed
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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Pediatric SMA patients with complex spinal anatomy: Implementation and evaluation of a decision-tree algorithm for administration of nusinersen. Eur J Paediatr Neurol 2021; 31:92-101. [PMID: 33711792 DOI: 10.1016/j.ejpn.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/23/2022]
Abstract
The approval of nusinersen for the treatment of spinal muscular atrophy (SMA) has significantly changed the natural history of the disease. Nevertheless, scoliosis secondary to axial muscle weakness occurs at some point in most of patients with SMA and a conventional posterior interlaminar approach for intrathecal administration of nusinersen can be particularly challenging to perform in patients with severe scoliosis and/or previous spine fusion surgeries. We developed a protocol for the administration of nusinersen in pediatric patients, which includes a decision-tree algorithm that categorizes patients according to the estimated technical difficulty for the intrathecal administration. Complex spine patients were defined as those with a Cobb angle greater than 50° and/or a history of spinal surgery, while the rest of patients were considered non-complex. Nusinersen was successfully administered through a conventional non-CT-guided lumbar puncture in all 14 non-complex spine patients (110 out of 110 procedures; 100%). The feasibility of the intrathecal injection in the 15 complex spine patients was assessed by 3D CT. Administration was considered unfeasible in 7 out of these 15 patients according to imaging. In the 8 complex spine patients in whom the administration was considered feasible, conventional non-CT-guided lumbar punctures were successful only in 19 out of 53 procedures (36%). The remaining 34 procedures (64%) were guided by CT scan, all successful. Our work demonstrates that a cut-off point of 50° in Cobb angle and history of spinal surgery can reliably be used to anticipate the need for CT guidance in nusinersen administration.
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18
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Rosiak G, Lusakowska A, Milczarek K, Konecki D, Fraczek A, Rowinski O, Kostera-Pruszczyk A. Ultra-low radiation dose protocol for CT-guided intrathecal nusinersen injections for patients with spinal muscular atrophy and severe scoliosis. Neuroradiology 2021; 63:539-545. [PMID: 33512541 PMCID: PMC7965851 DOI: 10.1007/s00234-021-02643-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
Purpose Intrathecal injection of nusinersen is an approved treatment of spinal muscular atrophy (SMA). CT-guided injection is a method of nusinersen administration in patients with severe scoliosis, in whom standard lumbar puncture is not feasible. The injections are repeated every 4 months for life, and accumulated radiation doses absorbed by the patient can increase the risk of cancer. In this study, we present the results of CT-guided intrathecal nusinersen injections with an ultra-low radiation dose protocol. Methods Eighteen patients (15 adults and three children) in whom standard lumbar puncture was not feasible due to severe scoliosis or spinal stabilization were included in this retrospective study. The first 23 injections were performed with a standard radiation dose protocol and the next 42 injections with an ultra-low-dose protocol. The radiation doses, measured as total dose length product (DLP), were acquired and compared between the protocols. Results Injections were successful in 100% of patients with both ultra-low-dose and standard protocols. The radiation dose, measured as DLP, was 111.2–1100.7 (Me = 248.1) mGy*cm for the standard protocol. For the ultra-low-dose protocol, the dose range was 5.0–54.4 (Me = 26.7) mGy*cm, which was significantly lower than with the standard protocol (p < 0.001, η2 = 0.67). Conclusion Radiation doses can be significantly decreased in the CT-guided injection of nusinersen. The proposed protocol allows for effective CT-guided intrathecal nusinersen administration in patients with SMA and severe scoliosis.
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Affiliation(s)
- Grzegorz Rosiak
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Anna Lusakowska
- Department of Neurology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Krzysztof Milczarek
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Dariusz Konecki
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Anna Fraczek
- Department of Neurology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Olgierd Rowinski
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
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Iwayama H, Wakao N, Kurahashi H, Kubota N, Hattori A, Kumagai T, Okumura A. Administration of nusinersen via paramedian approach for spinal muscular atrophy. Brain Dev 2021; 43:121-126. [PMID: 32773161 DOI: 10.1016/j.braindev.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the success rate, procedure time, and adverse events of intrathecal administration of nusinersen via the paramedian approach in adolescents and adults with spinal muscular atrophy (SMA) associated with scoliosis. METHODS Seven patients with genetically confirmed SMA (age, 12-40 years) were included. Intrathecal administration of nusinersen was performed via paramedian approach using fluoroscopy after determination of the largest interlaminal foramen among L2-L3, L3-L4, or L4-L5 by three-dimensional computed tomography. We measured the times for preparation, positioning, and puncture, and the total time of stay. Adverse effects of intrathecal administration were noted. RESULTS Intrathecal administration via paramedian approach was successful for all 38 opportunities. The median total time of stay was 44.0 min (interquartile range, 37.3-50.0 min). The total time of stay was significantly longer in patients with SMA type 1 than in those with SMA type 2, but was not different according to the severity of scoliosis. Adverse effects included oxygen supplementation, headache, and back pain. Sedation was correlated with oxygen supplementation and headache. CONCLUSIONS Intrathecal administration of nusinersen via the paramedian approach had the advantages of a high success rate and short procedure time with fewer adverse events in SMA patients associated with scoliosis.
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Affiliation(s)
- Hideyuki Iwayama
- Department of Pediatrics, Aichi Medical University, Aichi, Japan.
| | - Norimitsu Wakao
- Department of Orthopedics, Aichi Medical University, Aichi, Japan
| | - Hirokazu Kurahashi
- Department of Pediatrics, Aichi Medical University, Aichi, Japan; Department of Pediatric Neurology, Aichi Prefectural Colony Central Hospital, Aichi, Japan
| | - Norika Kubota
- Department of Pediatrics, Matsue Medical Center, Shimane, Japan
| | - Ayako Hattori
- Department of Pediatrics and Neonatology, Nagoya City University, Aichi, Japan
| | - Toshiyuki Kumagai
- Department of Pediatric Neurology, Aichi Prefectural Colony Central Hospital, Aichi, Japan; Kuma Home Medical Care Clinic, Aichi, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Aichi, Japan
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Konersman CG, Ewing E, Yaszay B, Naheedy J, Murphy S, Skalsky A. Nusinersen treatment of older children and adults with spinal muscular atrophy. Neuromuscul Disord 2020; 31:183-193. [PMID: 33608138 DOI: 10.1016/j.nmd.2020.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/01/2020] [Accepted: 12/14/2020] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to determine how effective administration of nusinersen was at improving motor function in older adolescent and adult patients with spinal muscular atrophy, using standardized motor outcome measures. Data were gathered through a retrospective chart review of older spinal muscular atrophy patients (ages 5-58) being treated at Rady Children's Hospital and the University of California, San Diego with nusinersen from April 2017-June 2019. Linear mixed effects analyses found that, for older children and adult patients with SMA 1, 2, and 3, motor scores as measured by the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders for non-sitters improved by 6 points (p = .01) and the Hammersmith Infant Neurological Examination-2 by 2.6% (p = .008) over the 22-month study period. Over the same period, sitters improved on the Revised Upper Limb Module by 4.4 points (p = .02) and on the Hammersmith Functional Motor Scale-Expanded by 3.3% (p = .00005) post treatment with nusinersen. Older spinal muscular atrophy patients (5-58 years) being treated with nusinersen at our institutions are improving. Not only have symptoms stabilized, but their motor function has shown incremental improvements. Based on the results of this study, we suggested that nusinersen is well-tolerated and efficacious when treating older children and adult patients with spinal muscular atrophy 1, 2, and 3.
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Affiliation(s)
- Chamindra G Konersman
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States.
| | - Emily Ewing
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital, San Diego, California, United States
| | - Burt Yaszay
- Department of Orthopedic Surgery, University of California, San Diego, California, United States; Division of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, United States
| | - John Naheedy
- Department of Radiology, Rady Children's Hospital, San Diego, California, United States
| | - Susan Murphy
- Department of Physical Therapy, Rady Children's Hospital, San Diego, California, United States
| | - Andrew Skalsky
- Division of Pediatric Rehabilitation Medicine, Rady Children's Hospital, San Diego, California, United States; Department of Orthopedic Surgery, University of California, San Diego, California, United States
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21
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Vu-Han TL, Weiß C, Pumberger M. Novel therapies for spinal muscular atrophy are likely changing the patient phenotype. Spine J 2020; 20:1893-1898. [PMID: 32858169 DOI: 10.1016/j.spinee.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery Berlin Mitte; Charité University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany.
| | - Claudia Weiß
- Center for chronically sick children, Department of Neuropediatrics; Charité University, Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery Berlin Mitte; Charité University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany
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22
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Veiga-Canuto D, Cifrián-Pérez M, Pitarch-Castellano I, Vázquez-Costa JF, Aparici F. Ultrasound-guided lumbar puncture for nusinersen administration in spinal muscular atrophy patients. Eur J Neurol 2020; 28:676-680. [PMID: 33051940 DOI: 10.1111/ene.14586] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/16/2020] [Accepted: 10/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE The purpose was to report the results of ultrasound-guided lumbar puncture for the administration of nusinersen in spinal muscular atrophy (SMA) patients with complex spines. METHODS Eighteen SMA patients (five children, five adolescents and eight adults) with either severe scoliosis or spondylodesis were evaluated for ultrasound-guided lumbar puncture. Ultrasound was performed with a 3.5 MHz transducer to guide a 22 gauge × 15 mm needle, which was placed in the posterior lumbar space following a parasagittal interlaminar approach. RESULTS Twelve patients had undergone spinal instrumentation (nine growing rods and three spinal fusion) whilst the other six showed severe scoliosis. Success was achieved in 91/94 attempts (96.8%), in 14/18 patients (77.8%), including 100% of children and adolescents and 50% of adult patients. In two of the unsuccessfully treated patients, computed tomography and fluoroscopy-guided transforaminal lumbar punctures were also tried without success. After a median follow-up of 14 months, only few adverse events, mostly mild, were observed. CONCLUSION The ultrasound-guided lumbar puncture, following an interlaminar parasagittal approach, is a safe and effective approach for intrathecal treatment with nusinersen in children, adolescents and carefully selected adult SMA patients with complex spines and could be considered the first option in them.
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Affiliation(s)
- D Veiga-Canuto
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - M Cifrián-Pérez
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - I Pitarch-Castellano
- Neuromuscular Research Unit, Instituto de Investigación Sanitaria la Fe, Valencia, Spain.,Pediatrics Department, Pediatric Neurology Section, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J F Vázquez-Costa
- Neuromuscular Research Unit, Instituto de Investigación Sanitaria la Fe, Valencia, Spain.,Motor Neuron Disease Unit, Department of Neurology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - F Aparici
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
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Skip constructs in spinal muscular atrophy: outcomes of a novel approach for posterior spinal instrumentation and fusion. Spine Deform 2020; 8:1093-1097. [PMID: 32253736 DOI: 10.1007/s43390-020-00107-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Many children with spinal muscular atrophy (SMA) develop progressive spinal deformity, worsening already compromised pulmonary function and global spinal balance. Early results demonstrate that intrathecal administration of nusinersen, a recent FDA-approved drug, improves motor function and ventilator-free survival, necessitating preservation of intrathecal access when considering PSIF. The purpose of this study is to assess medium-term outcomes of a specialized approach for posterior spinal instrumentation and fusion (PSIF) to preserve intrathecal access in patients with SMA. METHODS A retrospective review of patients with SMA undergoing PSIF at a single tertiary academic medical center during a 3-year period was completed. To facilitate intrathecal drug administration, the traditional approach to PSIF was modified to "skip" one or more intervertebral levels at the thoracolumbar junction. Clinical notes and radiographs were reviewed for postoperative outcomes including major coronal curve correction and complications, including loss of correction, hardware failure and surgical revision. RESULTS Eight patients were identified, with a mean age of 12.7 ± 1.6 years and follow-up of 4 years. These patients had a mean preoperative major coronal curve of 56.4°, with mean curve correction of 35.2°. At follow-up, no patients experienced rod breakage, loss of correction, or postoperative chronic pain. Only one patient required revision surgery due to bony overgrowth at the skipped level after three and a half years. CONCLUSION Implementing the skip construct approach for PSIF in patients with SMA allows for scoliosis correction without compromising intrathecal drug delivery. Follow-up at 4 years reveals no adverse clinical events, hardware failure or loss of correction. LEVEL OF EVIDENCE IV.
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24
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Ultrasound-assisted intrathecal injection of nusinersen in a patient with severe vertebral deformity: a case report. JA Clin Rep 2020; 6:61. [PMID: 32783149 PMCID: PMC7419389 DOI: 10.1186/s40981-020-00367-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/04/2020] [Indexed: 11/12/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is a mostly autosomal recessive genetic disease characterized by progressive muscle weakness from anterior horn degeneration. Nusinersen has recently been approved as a disease-modifying drug for SMA that needs to be administered intrathecally. Its injection is often associated with extreme difficulty since patients with SMA have severe vertebral deformity and may be with vertebral instrumentation. Case description A 21-year-old female with type 2 SMA and spinal deformity underwent a series of intrathecal injections of nusinersen. The intrathecal injections have been safely and successfully done by using computed tomography imaging and ultrasonography-assisted technique. Conclusion This the first report in which ultrasound-assisted technique has been used for the injection of nusinersen through a lumbar puncture in patients with severe spinal deformity. Use of preprocedural ultrasound imaging is highly recommended for treatments that repeatedly require intrathecal access.
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25
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Trinh A, Hashmi SS, Massoud TF. Imaging anatomy of the vertebral canal for trans-sacral hiatus puncture of the lumbar cistern. Clin Anat 2020; 34:348-356. [PMID: 32323367 DOI: 10.1002/ca.23612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 12/18/2022]
Abstract
A standard lumbar puncture may be impossible for many anatomic or technical reasons. Previous accounts of caudal epidural anesthesia and other procedures via the sacral hiatus prompted us to test if image-guided percutaneous trans-sacral hiatus access to the lumbosacral subarachnoid cistern would be anatomically feasible. To study vertebral canal morphometry and curvature, we analyzed midsagittal computed tomography-myelogram images of 40 normal subjects and digitally measured sacral curvatures between S1 to S5 and S2 to S4 using two methods whereby a lower angle signifies a straighter sacrum. We measured midsagittal vertebral canal area, hiatus width, dural sac termination levels, and distance from sacral hiatus to the dural sac tip (needle distance). Subjects were F:M = 25:15, with a mean age of 44.9 years. The two S1-S5 full sacral curvature mean angles were 57.3° and 60.4°. Almost all sacral hiatuses were at S4, and dural sac terminations were at S1-S2. The mean S2-S4 sacral curvature was 25.1°, and the mean needle distance was 57.7 mm. Using two-way analysis of variance, there were significant sex differences for needle distances (p = .001), and full and limited sacral curvatures (p = .02, and p = .046, respectively). There were no significant linear regression correlations between age and sacral curvature, needle distance, canal area, or hiatus width. Therefore, despite a frequently prominent full sacral curvature, the combination of S1-S2 dural sac termination plus a relatively straight trajectory of the lower vertebral canal between S2 and S4 support the theoretical feasibility of percutaneous trans-sacral hiatus and vertebral canal access to the lumbosacral cistern using a standard spinal needle.
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Affiliation(s)
- Austin Trinh
- Division of Neuroimaging and Neurointervention, and Stanford Initiative for Multimodality Neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Syed S Hashmi
- Division of Neuroimaging and Neurointervention, and Stanford Initiative for Multimodality Neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, and Stanford Initiative for Multimodality Neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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26
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Spiliopoulos S, Reppas L, Zompola C, Palaiodimou L, Papadopoulou M, Filippiadis D, Palialexis K, Ploussi A, Efstathopoulos E, Tsivgoulis G, Brountzos E. Computed-tomography-guided transforaminal intrathecal nusinersen injection in adults with spinal muscular atrophy type 2 and severe spinal deformity. Feasibility, safety and radiation exposure considerations. Eur J Neurol 2020; 27:1343-1349. [PMID: 32250518 DOI: 10.1111/ene.14245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The purpose was to investigate our centre's experience on computed-tomography-guided (CT-guided), transforaminal, intrathecal administration of nusinersen in adult subjects with spinal muscular atrophy (SMA) type 2 and severe spinal deformity. METHOD This is a retrospective, single-centre study investigating the feasibility and safety of CT-guided, transforaminal, lumbar puncture for the intrathecal administration of nusinersen (Spinranza®; Biogen; Cambridge, MA, USA) in a cohort of adult subjects with SMA type 2, severe neuromuscular scoliosis and previous spinal surgery. Between January 2019 and October 2019, five male, adult, SMA type 2 subjects were eligible to be treated in our centre with nusinersen. The mean age of the patients was 31 ± 9 years (range 19-43 years). The study's outcome measures were technical success, adverse events and radiation exposure. RESULTS In total, four patients completed the four loading doses, whilst the fifth patient received only one loading dose; two patients also received their first maintenance doses. Overall, 20 consecutive transforaminal, intrathecal treatments were analysed. Technical success was 100% (20/20 intrathecal infusions). No adverse events were documented following the procedures. Mean dose-length product (DLP) value per injection was 665.4 ± 715.5 mGy*cm. Estimated mean effective dose per injection was 12.7 ± 12.9 mSv. Subgroup analysis between the chronologically first 10 versus subsequent 10 procedures demonstrated a clear trend towards less radiation exposure in the latter, although this difference did not reach statistical significance (DLP: 984.7 ± 903.3 vs. 436.7 ± 321.5 mGy*cm, P = 0.165; respectively). CONCLUSIONS In this retrospective series, CT-guided transforaminal access for intrathecal injection of nusinersen was proven feasible and safe. A decrease in radiation dose over time was noted. Protocols to minimize radiation exposure are essential.
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Affiliation(s)
- S Spiliopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - L Reppas
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - C Zompola
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - L Palaiodimou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - M Papadopoulou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - D Filippiadis
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - K Palialexis
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - A Ploussi
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - E Efstathopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - G Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - E Brountzos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
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27
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Weaver JJ, Hallam DK, Chick JFB, Vaidya S, Shin DS, Natarajan N, Rad N, Reis J, Koo KSH, Shivaram GM, Thibodeau A, Apkon S, Monroe EJ. Transforaminal intrathecal delivery of nusinersen for older children and adults with spinal muscular atrophy and complex spinal anatomy: an analysis of 200 consecutive injections. J Neurointerv Surg 2020; 13:75-78. [PMID: 32471828 DOI: 10.1136/neurintsurg-2020-016058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Nusinersen is the only approved treatment for all spinal muscular atrophy (SMA) subtypes and is delivered intrathecally. Distorted spinal anatomy and instrumentation preclude standard approaches for intrathecal access, necessitating alternative techniques for delivery. The purpose of this study is to report technical success and adverse events of transforaminal intrathecal delivery of nusinersen. METHODS 28 patients, mean age 24.1±9.8 years (range 10.0-51.0 years), with intermediate or late onset SMA, underwent a combined 200 transforaminal nusinersen injections. All patients had osseous fusion or spinal instrumentation precluding standard posterior access routes. Patients who underwent nusinersen injections using a technique other than transforaminal lumbar puncture (n=113) were excluded. Technical success, adverse events (AEs) and radiation exposure were recorded. RESULTS 200 (100%) procedures were technically successful; 6 (3%) required a second level of attempt for access. 187 (93.5%) interventions were completed using cone beam computed tomography (CBCT) with two-axis fluoroscopic navigational overlay. 13 (6.5%) procedures were performed with fluoroscopic-guidance only at subsequent sessions. There were 8 (4.0%) mild AEs and 2 (0.5%) severe AEs; one patient received antibiotics for possible traversal of the large bowel but did not develop meningitis, and one patient developed aseptic meningitis. Mean air kerma was 74.5±161.3 mGy (range 5.2-1693.0 mGy). CONCLUSION Transforaminal intrathecal delivery of nusinersen is feasible and safe for gaining access in patients with distorted spinal anatomy. The use of CBCT delineates anatomy and optimizes needle trajectory during the initial encounter, and may be used selectively for subsequent procedures.
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Affiliation(s)
- John J Weaver
- Radiology, University of Washington, Seattle, Washington, USA
| | - Danial K Hallam
- Radiology, University of Washington, Seattle, Washington, USA
| | | | - Sandeep Vaidya
- Radiology, University of Washington, Seattle, Washington, USA
| | - David S Shin
- Radiology, University of Washington, Seattle, Washington, USA
| | - Niranjana Natarajan
- Neurology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Nassim Rad
- Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Joseph Reis
- Radiology, University of Washington, Seattle, Washington, USA.,Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kevin S H Koo
- Radiology, University of Washington, Seattle, Washington, USA.,Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Giridhar M Shivaram
- Radiology, University of Washington, Seattle, Washington, USA.,Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ashley Thibodeau
- Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Susan Apkon
- Rehabilitation Medicine, Chilren's Hospital Colorado, Denver, CO, USA
| | - Eric James Monroe
- Radiology, University of Washington, Seattle, Washington, USA .,Radiology, Seattle Children's Hospital, Seattle, Washington, USA
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28
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Cartwright MS, Ward ZT, White EP, West TG. Intrathecal delivery of nusinersen in individuals with complicated spines. Muscle Nerve 2020; 62:114-118. [PMID: 32319101 DOI: 10.1002/mus.26899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/12/2020] [Accepted: 04/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The treatment of spinal muscular atrophy (SMA) with nusinersen requires intrathecal medication administration, which can be challenging in individuals with complicated spines. This retrospective case series reviews the nusinersen treatment experience at one academic medical center with children and adults with SMA and complicated spines. METHODS Twenty medical records of individuals receiving nusinersen were reviewed and administration methods summarized and assessed. RESULTS Ten children and 10 adults were treated, and 55% had complicated spines. In total, 163 treatments were given, 91 in those with complicated spines. In the complicated spines, 74% of treatments were done by means of fluoroscopic lumbar puncture, 22% by means of intrathecal Ommaya reservoir, 3% by means of palpation, and < 1% by means of computed tomography-guided transforaminal approach. CONCLUSIONS A large majority of individuals with complicated spines can receive intrathecal nusinersen using fluoroscopic guidance in the lumbar region. Other delivery methods are available but less frequently used.
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Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zachary T Ward
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Eric P White
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas G West
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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29
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Nakao S, Yamada S, Tsuda K, Yokomizo T, Sato T, Tanoue S, Hiraki T. Intrathecal administration of nusinersen for spinal muscular atrophy: report of three cases with severe spinal deformity. JA Clin Rep 2020; 6:28. [PMID: 32314319 PMCID: PMC7171013 DOI: 10.1186/s40981-020-00334-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is a genetic disease characterized by degeneration of the spinal cord, resulting in progressive muscle atrophy. Recently, nusinersen has been approved for treating SMA, which should be administered intrathecally. Case presentation Patient 1 was a 36-year-old woman with SMA type 2. Patients 2 and 3 were 10- and 17-year-old girls with SMA type 1. In patients 1 and 2, the needle was inserted into the spinal column, but outflow of cerebrospinal fluid was unable to be confirmed. CT revealed that the dural sac terminated at the L5 level in patients 1 and 3 and at the L5/S1 level in patient 2. Conclusions Patients with SMA often present with high-grade scoliosis, making intrathecal administration difficult. In addition, the dural sac may terminate at a level higher than normal. To ensure intrathecal administration, the level of dural sac termination must be confirmed by CT before puncture.
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Affiliation(s)
- Sayo Nakao
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shinichi Yamada
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Katsuya Tsuda
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Taishi Yokomizo
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Teruyuki Sato
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
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30
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Shokuhfar T, Abdalla RN, Hurley MC, Nazari P, Ansari SA, Ajroud-Driss S, Kuntz N, Azmi S, Rao V, Shaibani A. Transforaminal Intrathecal Access for Injection of Nusinersen in Adult and Pediatric Patients with Spinal Muscular Atrophy. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0039-1697583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AbstractThe main purpose of this article is to assess the safety and efficacy of transforaminal lumbar puncture for the injection of nusinersen (Spinraza) in patients with extensive spinal fusion and/or scoliosis.A retrospective chart reviews of all spinal muscular atrophy patients (adults and children) were conducted. Demographic data, procedure details, follow-ups, and related complications were recorded.We performed 85 transforaminal injections in nine pediatric patients (5 male and 4 female) aged between 8 and 17 years (mean = 11 years) and seven adult patients (5 females and 2 males) aged between 24 and 41 years (mean= 30 years). Fluoroscopy guidance was used in 87% of our patients. No major complication was reported.Fluoroscopy-guided transforaminal nusinersen injection is a safe and successful alternative approach in adult and pediatric patients with severe spinal scoliosis, interlaminar osseous fusion, and spinal fusion hardware.
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Affiliation(s)
- Tahaamin Shokuhfar
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Ramez N. Abdalla
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Michael C. Hurley
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Pouya Nazari
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Sameer A. Ansari
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Nancy Kuntz
- Department of Pediatric Neurology, Lurie Children’s Hospital, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Subhan Azmi
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Vamshi Rao
- Department of Pediatric Neurology, Lurie Children’s Hospital, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Ali Shaibani
- Department of Radiology; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
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31
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Ramdas S, Servais L. New treatments in spinal muscular atrophy: an overview of currently available data. Expert Opin Pharmacother 2020; 21:307-315. [PMID: 31973611 DOI: 10.1080/14656566.2019.1704732] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Introduction: Spinal muscular atrophy (SMA) is one of the most common inherited neuromuscular disorders. It causes progressive muscle weakness and results in significant disability. Until recently, there were no drugs available for the treatment of SMA. Several phase 1-3 studies, including three double-blind randomized placebo-controlled studies have demonstrated the efficacy of disease-modifying approaches including gene replacement therapy, antisense oligonucleotides, and splicing modifiers.Areas covered: This article covers the publically available data on therapeutic strategies that address the underlying cause of SMA and clinical data available on approved treatments and drugs in the pipeline.Expert opinion: The newer therapeutic options in SMA have a good safety profile and deliver a therapeutic benefit in most patients. It is essential that the recommended standards of care are delivered along with the drugs for the best outcomes. No biomarkers to distinguish responders from non-responders are available; it is important that biomarkers be identified. Early treatment is essential for the maximum efficacy of the newly available treatments.
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Affiliation(s)
- Sithara Ramdas
- MDUK Neuromuscular Center, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Laurent Servais
- MDUK Neuromuscular Center, Department of Paediatrics, University of Oxford, Oxford, UK.,Division of Child Neurology, Centre de Références des Maladies Neuromusculaires, Department of Pediatrics, University Hospital Liège & University of Liège, Belgium
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32
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Velayudhan V, Patel S, Danziger A, Grigorian A, Waite S, Efendizade A. Transforaminal lumbar puncture for intrathecal access: Case series with literature review and comparison to other techniques. J Clin Neurosci 2020; 72:114-118. [PMID: 31980274 DOI: 10.1016/j.jocn.2019.12.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/30/2019] [Indexed: 11/30/2022]
Abstract
Fluoroscopic-guided lumbar puncture (LP) is a procedure commonly performed by radiologists, which in some circumstances may be difficult or impossible using a traditional posterior interspinous or interlaminar approach. Alternatives to LP include cervical and cisternal punctures, placement of an Ommaya reservoir, and lumbar laminectomy. More recently, however, there has been a move toward access of the thecal sac through a transforaminal approach in patients with challenging anatomy. This report outlines our approach and experience using transforaminal LP (TFLP) in patients with spinal muscular atrophy (SMA) with a 100% success rate. We discuss its utility in other patients with difficult access and compare TFLP with other techniques to access the intrathecal space.
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Affiliation(s)
- Vinodkumar Velayudhan
- Department of Diagnostic Radiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States.
| | - Suraj Patel
- Department of Diagnostic Radiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Andrew Danziger
- Department of Neurosurgery, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, United States
| | - Arcadi Grigorian
- Department of Diagnostic Radiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Stephen Waite
- Department of Diagnostic Radiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Aslan Efendizade
- Department of Diagnostic Radiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
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Cordts I, Lingor P, Friedrich B, Pernpeintner V, Zimmer C, Deschauer M, Maegerlein C. Intrathecal nusinersen administration in adult spinal muscular atrophy patients with complex spinal anatomy. Ther Adv Neurol Disord 2020; 13:1756286419887616. [PMID: 32010224 PMCID: PMC6974755 DOI: 10.1177/1756286419887616] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/27/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Intrathecal administration of nusinersen in adult spinal muscular atrophy
(SMA) patients presents challenges owing to severe scoliosis and previous
spinal surgery with metal implantation. In patients with a complex spinal
situation, the potential risks of the intrathecal administration may lead to
delayed treatment initiation. Methods: In this study, we analyzed 53 CT-guided lumbar punctures of 11 adult
nonambulatory SMA type 2 and 3 patients. All patients had scoliosis and six
patients had previously undergone metal implantation. Results: Drug administration was successful in 100% of the patients and none of the
patients opted for treatment discontinuation. Complete osseous fusion
precluded conventional posterior interlaminar access in eight lumbar
punctures in four patients, which required alternative routes including
transforaminal punctures and translaminar drilling. Median duration of all
lumbar punctures was 9 min and median radiation exposure was 100 mGy* cm.
The most common adverse event was post-lumbar puncture syndrome that
occurred in five lumbar punctures (9.4%). Conclusions: Our data demonstrate that nusinersen can be successfully, safely, and rapidly
administered in adult SMA patients with complex spinal conditions and
suggest the translaminar drilling technique as an alternative delivery
route. Therefore, intrathecal nusinersen treatment should not be withheld
from patients because of severe spine deformities, however, drug efficacy in
adult SMA patients needs to be investigated in further studies.
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Affiliation(s)
- Isabell Cordts
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, Munich, 81675, Germany
| | - Paul Lingor
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Verena Pernpeintner
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Marcus Deschauer
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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34
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Khalaf AM, Yedavalli V, Massoud TF. Magnetic resonance imaging anatomy and morphometry of lumbar intervertebral foramina to guide safe transforaminal subarachnoid punctures. Clin Anat 2019; 33:405-413. [DOI: 10.1002/ca.23533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Alexander M. Khalaf
- Division of Neuroimaging and Neurointervention, Department of RadiologyStanford University School of Medicine Stanford California
| | - Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Department of RadiologyStanford University School of Medicine Stanford California
| | - Tarik F. Massoud
- Division of Neuroimaging and Neurointervention, Department of RadiologyStanford University School of Medicine Stanford California
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Jacobson JP, Cristiano BC, Hoss DR. Simple Fluoroscopy-Guided Transforaminal Lumbar Puncture: Safety and Effectiveness of a Coaxial Curved-Needle Technique in Patients with Spinal Muscular Atrophy and Complex Spines. AJNR Am J Neuroradiol 2019; 41:183-188. [PMID: 31831464 DOI: 10.3174/ajnr.a6351] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/21/2019] [Indexed: 01/20/2023]
Abstract
Patients with spinal muscular atrophy often have complete interlaminar osseous fusion, precluding lumbar puncture via the standard interlaminar approach. Recently, we have developed a new coaxial curved-needle variation of fluoroscopy-guided transforaminal lumbar puncture for intrathecal injections in this patient population. Between October 2017 and November 2018, fifty-nine consecutive transforaminal lumbar punctures using this technique were performed in 12 patients with spinal muscular atrophy for intrathecal nusinersen injection, with a 100% technical success rate and no C1-2 punctures required. One major complication occurred, consisting of a post-dural puncture headache, which required a therapeutic transforaminal epidural blood patch. Two minor complications occurred, both of which involved inadvertent puncture of a dorsal muscular arterial branch, without clinical sequelae. A fluoroscopy-guided curved-needle transforaminal approach is an effective technique for lumbar puncture in difficult cases, such as in this cohort of patients with spinal muscular atrophy and complete interlaminar osseous fusion undergoing intrathecal nusinersen injections.
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Affiliation(s)
- J P Jacobson
- From the Department of Radiology, Neuroradiology Section, Loma Linda University Medical Center, Loma Linda, California
| | - B C Cristiano
- From the Department of Radiology, Neuroradiology Section, Loma Linda University Medical Center, Loma Linda, California
| | - D R Hoss
- From the Department of Radiology, Neuroradiology Section, Loma Linda University Medical Center, Loma Linda, California.
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Towbin R, Schaefer C, Kaye R, Abruzzo T, Aria DJ. The Complex Spine in Children with Spinal Muscular Atrophy: The Transforaminal Approach-A Transformative Technique. AJNR Am J Neuroradiol 2019; 40:1422-1426. [PMID: 31296522 DOI: 10.3174/ajnr.a6131] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Spinal muscular atrophy, a genetic disease resulting in loss of motor function, presents from in utero to adulthood. Depending on progression and secondary scoliosis, spinal stabilization may be necessary. When planning intrathecal access in these patients, spinal anatomy is the most important factor. Therefore, when planning intrathecal nusinersen injections, we subdivided patients with spinal muscular atrophy into simple-versus-complex spine subgroups. Our purpose was to present our experience with our first 42 transforaminal intrathecal nusinersen injections. MATERIALS AND METHODS We reviewed 31 consecutive patients with spinal muscular atrophy types 1-3 who presented for intrathecal nusinersen injections from March 2017 to September 2018. Nine children had complex spines (ie, spinal instrumentation and/or fusion) and required preprocedural imaging for route planning for subarachnoid space access via transforaminal or cervical approaches. RESULTS A total of 164 intrathecal nusinersen injections were performed in 31 children 4-226 months of age, with 100% technical success in accessing the subarachnoid space. Nine patients with complex spinal anatomy underwent 45 intrathecal nusinersen injections; 42 of 45 procedures were performed via a transforaminal approach with the remaining 3 via cervical techniques. There were no complications. CONCLUSIONS Our initial experience has resulted in a protocol-driven approach based on simple or complex spinal anatomy. Patients with simple spines do not need preprocedural imaging or imaging-guided intrathecal nusinersen injections. In contrast, the complex spine subgroup requires preprocedural imaging for route planning and imaging guidance for therapy, with the primary approach being the transforaminal approach for intrathecal nusinersen injections.
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Affiliation(s)
- R Towbin
- From the Department of Radiology (R.T., C.S., R.K., T.A., D.J.A.), Phoenix Children's Hospital, Phoenix, Arizona
- University of Arizona College of Medicine, Phoenix (R.T., C.S., R.K., D.J.A.), Phoenix, Arizona
| | - C Schaefer
- From the Department of Radiology (R.T., C.S., R.K., T.A., D.J.A.), Phoenix Children's Hospital, Phoenix, Arizona
- University of Arizona College of Medicine, Phoenix (R.T., C.S., R.K., D.J.A.), Phoenix, Arizona
| | - R Kaye
- From the Department of Radiology (R.T., C.S., R.K., T.A., D.J.A.), Phoenix Children's Hospital, Phoenix, Arizona
- University of Arizona College of Medicine, Phoenix (R.T., C.S., R.K., D.J.A.), Phoenix, Arizona
| | - T Abruzzo
- From the Department of Radiology (R.T., C.S., R.K., T.A., D.J.A.), Phoenix Children's Hospital, Phoenix, Arizona
| | - D J Aria
- From the Department of Radiology (R.T., C.S., R.K., T.A., D.J.A.), Phoenix Children's Hospital, Phoenix, Arizona
- University of Arizona College of Medicine, Phoenix (R.T., C.S., R.K., D.J.A.), Phoenix, Arizona
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Scoliosis and spinal muscular atrophy in the new world of medical therapy: providing lumbar access for intrathecal treatment in patients previously treated or undergoing spinal instrumentation and fusion. J Pediatr Orthop B 2019; 28:393-396. [PMID: 30932967 DOI: 10.1097/bpb.0000000000000632] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study describes a new procedure for a safer and easier access for the intrathecal injection of the recently approved nusinersen therapy in spinal muscular atrophy. This therapy changed the natural history of the disease, but, to date, scoliosis surgery was an excluding criteria for nusinersen therapy. The bone mass, due to the posterior spinal fusion of the scoliosis surgery, prevents the needle for the nusinersen administration from intervertebral access. This is a single-center, single-surgeon case series descriptive study. A laminotomy at the L3-L4 level was performed to provide safer access for the intrathecal injection. The procedure was carried out during the scoliosis surgery in patients who underwent posterior spinal fusion (PSF) after the nusinersen therapy was introduced, whereas for those who underwent PSF earlier, a second procedure was necessary to perform a laminotomy. A fat grafting was used to prevent bone overgrowth in the laminotomy. Markers were applied as radiographic references for the intrathecal injection. Five patients were enrolled, four females and one male. The mean age of the patients was 11 years. Three patients underwent PSF before the introduction of the nusinersen therapy. Two patients underwent PSF after the nusinersen therapy was available. All of them underwent a laminotomy with a fat grafting at the L3-L4 laminotomy level and received nusinersen therapy without complications. The procedure described is simple and effective in providing safe intrathecal access to make these patients eligible for such important therapy.
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Ko D, Blatt D, Karam C, Gupta K, Raslan AM. Lumbar laminotomy for the intrathecal administration of nusinersen for spinal muscular atrophy: technical note and outcomes. J Neurosurg Spine 2019; 31:217-221. [PMID: 31003222 DOI: 10.3171/2019.2.spine181366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/05/2019] [Indexed: 12/12/2022]
Abstract
Nusinersen (Spinraza) is a US Food and Drug Administration-approved intrathecal medication for the treatment of spinal muscular atrophy (SMA). Adult patients with SMA often undergo thoracolumbar fusion to treat neurogenic scoliosis, preventing thecal access. The authors report a laminotomy technique and the ease of intrathecal access in three SMA patients with prior thoracolumbar fusions.Patients were positioned in the lateral decubitus position or prone. Lumbar laminotomy was performed below the conus, between the lateral longitudinal rods, to preserve mechanical stability. Fluoroscopy provided real-time identification of instruments. Hardware was contoured with a carbide drill bit to develop the surgical window. Fiducial screws were placed along the perimeter for demarcation. Sublaminar wire removal caused dural defects that were repaired with a layer of dural substitute onlay and sealant. All patients successfully received nusinersen thecal injections via lumbar puncture by an interventional radiologist. Fluoroscopy time ranged from 6 to 36 seconds. No postoperative pseudomeningoceles, cerebrospinal fluid leaks, or wound complications occurred.For patients with SMA and posterior fusion from prior scoliosis treatment, lumbar laminotomy is an effective method for creating thecal access for the administration of nusinersen.
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Affiliation(s)
| | | | | | - Kunal Gupta
- 3Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Ahmed M Raslan
- 3Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Ortiz CB, Kukreja KU, Lotze TE, Chau A. Ultrasound-guided cervical puncture for nusinersen administration in adolescents. Pediatr Radiol 2019; 49:136-140. [PMID: 30167764 DOI: 10.1007/s00247-018-4240-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/25/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is an autosomal-recessive disease affecting motor neurons and is the most common genetic cause of death in infants. Intrathecal nusinersen is the only therapy approved by the U.S. Food and Drug Administration for SMA. Deformities and spinal instrumentation from orthopedic surgeries are common in children with SMA, complicating traditional intrathecal access for nusinersen delivery. Cervical punctures are routinely performed in adults for cervical myelograms and should be considered for children with SMA as a viable form of intrathecal access. OBJECTIVE This retrospective study assessed technical feasibility and complications of ultrasound-guided cervical puncture for nusinersen administration. MATERIALS AND METHODS We reviewed 14 consecutive ultrasound-guided cervical punctures for nusinersen administration with local anesthesia. We reviewed technical success and complications. RESULTS All procedures were technically successful. There were no major complications. Two minor complications included headaches that resolved by observation within 24 h after the procedure. CONCLUSION Our series describes a successful novel method of ultrasound-guided cervical spine access for intrathecal administration of nusinersen, adding to the armamentarium of procedures for delivering nusinersen to adolescents with challenging lumbar spine access caused by scoliosis and spinal instrumentation. This technique has the advantages of real-time ultrasound guidance and potential avoidance of general anesthesia in children.
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Affiliation(s)
| | - Kamlesh U Kukreja
- Baylor College of Medicine, Houston, TX, USA. .,Department of Interventional Radiology, Texas Children's Hospital, 6621 Fannin St., Houston, TX, 77030, USA.
| | - Timothy E Lotze
- Baylor College of Medicine, Houston, TX, USA.,Department of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA
| | - Alex Chau
- Baylor College of Medicine, Houston, TX, USA.,Department of Interventional Radiology, Texas Children's Hospital, 6621 Fannin St., Houston, TX, 77030, USA
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Wurster CD, Winter B, Wollinsky K, Ludolph AC, Uzelac Z, Witzel S, Schocke M, Schneider R, Kocak T. Intrathecal administration of nusinersen in adolescent and adult SMA type 2 and 3 patients. J Neurol 2018; 266:183-194. [PMID: 30460449 DOI: 10.1007/s00415-018-9124-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/10/2018] [Accepted: 11/13/2018] [Indexed: 03/25/2023]
Abstract
Spinal muscular atrophy is a genetic motor neuron disease that leads to progressive muscular atrophy and muscle weakness. In December 2016, the Food and Drug Administration, and in June 2017, the European Medicines Agency approved the antisense oligonucleotide nusinersen for treatment of spinal muscular atrophy. Nusinersen has to be repeatedly administered intrathecally. Due to the clinical features of SMA, the application of the ASO by lumbar puncture can be challenging in symptomatic patients considering the frequently observed scoliosis, previous spine fusion surgeries, joint contractures, and respiratory insufficiency. To evaluate safety and feasibility of the intrathecal treatment in adolescent and adult SMA type 2 and 3 patients, we analyzed 93 lumbar punctures, monitored number of lumbar puncture attempts, duration of the procedure, injection site, and needle length. Oxygen saturation during the intervention, medication for sedation and local anesthesia, adverse events related to lumbar punctures, and macroscopic analysis of CSF were recorded. Moreover, we analyzed the use of CT-scans for performing lumbar punctures and its associated radiation exposure. Performing lumbar puncture for the intrathecal administration of nusinersen in adolescent and adult patients with later-onset SMA is feasible and safe, even in patients with complex spinal anatomies and respiratory insufficiency. To guarantee the quality of the procedure, we recommend establishing an experienced interdisciplinary team consisting of neurologists and/or neuropediatricians, anesthesiologists, orthopedic surgeons, and/or neuroradiologists.
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Affiliation(s)
- Claudia D Wurster
- Department of Neurology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany.
| | | | - Kurt Wollinsky
- Department of Anesthesiology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Albert C Ludolph
- Department of Neurology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Zeljko Uzelac
- Department of Neurology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Simon Witzel
- Department of Neurology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Michael Schocke
- Department of Neuroradiology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Ralf Schneider
- Department of Neuroradiology, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
| | - Tugrul Kocak
- Department of Orthopedic Surgery, RKU-University and Rehabilitation Clinics, Ulm University, Ulm, Germany
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Michelson D, Ciafaloni E, Ashwal S, Lewis E, Narayanaswami P, Oskoui M, Armstrong MJ. Evidence in focus: Nusinersen use in spinal muscular atrophy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2018; 91:923-933. [PMID: 30315070 DOI: 10.1212/wnl.0000000000006502] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/10/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To identify the level of evidence for use of nusinersen to treat spinal muscular atrophy (SMA) and review clinical considerations regarding use. METHODS The author panel systematically reviewed nusinersen clinical trials for patients with SMA and assigned level of evidence statements based on the American Academy of Neurology's 2017 therapeutic classification of evidence scheme. Safety information, regulatory decisions, and clinical context were also reviewed. RESULTS Four published clinical trials were identified, 3 of which were rated above Class IV. There is Class III evidence that in infants with homozygous deletions or mutations of SMN1, nusinersen improves the probability of permanent ventilation-free survival at 24 months vs a well-defined historical cohort. There is Class I evidence that in term infants with SMA and 2 copies of SMN2, treatment with nusinersen started in individuals younger than 7 months results in a better motor milestone response and higher rates of event-free survival than sham control. There is Class I evidence that in children aged 2-12 years with SMA symptom onset after 6 months of age, nusinersen results in greater improvement in motor function at 15 months than sham control. Nusinersen was safe and well-tolerated. CLINICAL CONTEXT Evidence of efficacy is currently highest for treatment of infantile- and childhood-onset SMA in the early and middle symptomatic phases. While approved indications for nusinersen use in North America and Europe are broad, payer coverage for populations outside those in clinical trials remain variable. Evidence, availability, cost, and patient preferences all influence decision-making regarding nusinersen use.
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Affiliation(s)
- David Michelson
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Emma Ciafaloni
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Stephen Ashwal
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Elliot Lewis
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Pushpa Narayanaswami
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Maryam Oskoui
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
| | - Melissa J Armstrong
- From the Department of Pediatrics, Division of Child Neurology (D.M., S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (E.C.), University of Rochester Medical Center, NY; Beth Israel Deaconess Medical Center (P.N.), Harvard Medical School, Boston, MA; Department of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Canada; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville
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Peckham ME, Shah LM, Tsai AC, Quigley EP, Cramer J, Hutchins TA. C1 Posterior Arch Flare Point: A Useful Landmark for Fluoroscopically Guided C1-2 Puncture. AJNR Am J Neuroradiol 2018; 39:1562-1567. [PMID: 29930095 DOI: 10.3174/ajnr.a5706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/04/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE The C1-2 intrathecal puncture is routinely performed when lumbar puncture is not feasible. Usage has steadily decreased in part because of the perceived high risk of injury to the cervical cord. Up to this point, vague fluoroscopic guidelines have been used, creating uncertainty about the actual needle location relative to the spinal cord. We present a novel osseous landmark to aid in C1-2 intrathecal puncture, corresponding to the posterior spinal cord margin on lateral fluoroscopic views. This landmark, which we have termed the "flare point," represents the triangular "flaring" of the posterior C1 arch at its junction with the anterior arch. MATERIALS AND METHODS Cervical spine CT myelograms were reviewed. High-resolution axial images were reformatted into the sagittal plane, and maximum-intensity-projection images were created to simulate a lateral fluoroscopic view. Tangential lines were drawn along the superior cortices of the anterior and posterior C1 arches, with the point of intersection used to approximate the flare point. Chart review was performed for all C1-2 punctures using the flare point technique in the past 3 years. RESULTS Forty-two cervical myelograms were reviewed. The average flare point was 0.2 ± 0.5 mm posterior to the dorsal spinal cord margin. In 37/42 subjects, the flare point was localized posterior to the spinal cord. Targeting by means of the flare point was used in 16 C1-2 punctures without complications. CONCLUSIONS The C1 posterior arch flare point accurately approximates the dorsal spinal cord margin on myelography. Targeting between the flare point and the spinolaminar line, at the mid-C1-2 interspace, allows safe and optimal needle positioning.
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Affiliation(s)
- M E Peckham
- From the Departments of Radiology and Imaging Sciences (M.E.P., L.M.S., A.T., E.P.Q., T.A.H.), University of Utah, Salt Lake City, Utah
| | - L M Shah
- From the Departments of Radiology and Imaging Sciences (M.E.P., L.M.S., A.T., E.P.Q., T.A.H.), University of Utah, Salt Lake City, Utah
| | - A C Tsai
- From the Departments of Radiology and Imaging Sciences (M.E.P., L.M.S., A.T., E.P.Q., T.A.H.), University of Utah, Salt Lake City, Utah
| | - E P Quigley
- From the Departments of Radiology and Imaging Sciences (M.E.P., L.M.S., A.T., E.P.Q., T.A.H.), University of Utah, Salt Lake City, Utah
| | - J Cramer
- Department of Radiology (J.C.), University of Nebraska Medical Center, Omaha, Nebraska
| | - T A Hutchins
- From the Departments of Radiology and Imaging Sciences (M.E.P., L.M.S., A.T., E.P.Q., T.A.H.), University of Utah, Salt Lake City, Utah
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Monroe EJ, Amlie-Lefond CM. Cone beam computed tomography-guided transpterygoidal aspiration of a carotid space abscess in Lemierre's syndrome. Radiol Case Rep 2018; 13:618-621. [PMID: 30042808 PMCID: PMC6054713 DOI: 10.1016/j.radcr.2018.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 03/08/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Eric J. Monroe
- Department of Radiology, Division of Interventional Radiology, University of Washington and Seattle Children's Hospital, 4800 Sand Point Way NE, M/S R-5417, Seattle, WA 98105, USA
- Corresponding author.
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Nascene DR, Ozutemiz C, Estby H, McKinney AM, Rykken JB. Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access. AJNR Am J Neuroradiol 2018; 39:986-991. [PMID: 29567652 DOI: 10.3174/ajnr.a5596] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
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.
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Affiliation(s)
- D R Nascene
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - C Ozutemiz
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - H Estby
- University of Minnesota Medical School (H.E.), Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - J B Rykken
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
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Preliminary Safety and Tolerability of a Novel Subcutaneous Intrathecal Catheter System for Repeated Outpatient Dosing of Nusinersen to Children and Adults With Spinal Muscular Atrophy. J Pediatr Orthop 2018; 38:e610-e617. [PMID: 30134351 PMCID: PMC6211782 DOI: 10.1097/bpo.0000000000001247] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many patients with spinal muscular atrophy (SMA) who might benefit from intrathecal antisense oligonucleotide (nusinersen) therapy have scoliosis or spinal fusion that precludes safe drug delivery. To circumvent spinal pathology, we designed a novel subcutaneous intrathecal catheter (SIC) system by connecting an intrathecal catheter to an implantable infusion port. METHODS Device safety and tolerability were tested in 10 SMA patients (age, 5.4 to 30.5 y; 80% with 3 copies of SMN2); each received 3 sequential doses of nusinersen (n=30 doses). Pretreatment disease burden was evaluated using the Revised Hammersmith Scale, dynamometry, National Institutes of Health pegboard, pulmonary function testing, electromyography, and 2 health-related quality of life tools. RESULTS Device implantation took ≤2 hours and was well tolerated. All outpatient nusinersen doses were successfully administered via SIC within 20 minutes on the first attempt, and required no regional or systemic analgesia, cognitive distraction, ultrasound guidance, respiratory precautions, or sedation. Cerebrospinal fluid withdrawn from the SIC had normal levels of glucose and protein; cerebrospinal fluid white blood cells were slightly elevated in 2 (22%) of 9 specimens (median, 1 cell/µL; range, 0 to 12 cells/µL) and red blood cells were detected in 7 (78%) specimens (median, 4; range, 0 to 2930 cells/µL). DISCUSSION Preliminary observations reveal the SIC to be relatively safe and well tolerated in SMA patients with advanced disease and spinal fusion. The SIC warrants further study and, if proven effective in larger trials of longer duration, could double the number of patients able to receive nusinersen worldwide while reducing administration costs 5- to 10-fold.
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