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Zhang Y, Zheng K, Liang C, Zheng R, Chen J, Jiang M, Zhou Z, Zhao Y, Rao M, Yang S, Chen W, Liu L. Modified nusinersen intrathecal injection method: inclusion of a septal needle-free closed infusion connector. Front Neurol 2023; 14:1234442. [PMID: 37808480 PMCID: PMC10551161 DOI: 10.3389/fneur.2023.1234442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Nusinersen, an extremely expensive biologic drug (around 100,000 US$ per dose) that needs to be administered intrathecally, is approved for the treatment of 5q-spinal muscular atrophy (SMA). Because of the low muscle tone of the back muscles of pediatric SMA patients, especially type 1 SMA patients, the safe, effective, and fast execution of sheath injection is needed. Therefore, a modified intrathecal injection method was developed accordingly. This paper aims to describe the applicability and safety of this modified method. Methods The modified intrathecal injection method (MIIM) mainly includes a septal needle-free closed infusion connector between the lumbar puncture needle and the syringe, besides the procedures of routine lumbar puncture. Its applicability and safety were evaluated through clinical observation. Results A total of 92 children with SMA have successfully received nusinersen treatment at our hospital using the modified method since 2019 without obvious adverse events related to the modified injection method. Based on the clinical feedback of operators, the advantages of the modified method include successfully injecting the total dose of nusinersen with constant injection rate and a more stable fixation of the puncture needle, as well as making the operator more relaxed. However, compared with the routine method, the procedure of the modified method has additional steps. Conclusion The modified intrathecal injection method is an effective and safe method to inject nusinersen when weighing the pros and cons, and it may also be used for administering intrathecal injections of other expensive medicines or for patients with other strict requirements for intrathecal injection.
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Affiliation(s)
- Yani Zhang
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Cuili Liang
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ruidan Zheng
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinghui Chen
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Minyan Jiang
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhizi Zhou
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuan Zhao
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Min Rao
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sida Yang
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Liu
- Department of Endocrinology and Genetic Metabolism, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
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Dempsey PJ, Yates A, Power JW, MacMahon PJ, Kavanagh EC. An evaluation of the practice of image-guided lumbar puncture. Br J Radiol 2023; 96:20220143. [PMID: 37066810 PMCID: PMC10230400 DOI: 10.1259/bjr.20220143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 04/18/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the technical success and complication rates of image-guided lumbar puncture (IGLP) and to evaluate for differences in approach employed to help establish the optimum technique. METHODS A retrospective search of the hospital picture archiving and communications system was performed to identify all IGLPs that had taken place over a 5-year period. Radiology reports and the electronic medical record were examined to identify technical parameters and complications associated with each procedure. RESULTS The technical success rate was 96% (219/228). 69.4% (n = 161) had a previously failed bedside attempt. The rate of complications was 0.01% (n = 2). No major complications were observed. There was no difference in the rates of failure (2.4% vs 3.6%, p = 0.68) or complications (0.008% vs 0.012%, p = 1) between interlaminar and interspinous approaches. CONCLUSION IGLP is a safe procedure with a high rate of technical success. Where a difficult bedside attempt is anticipated, it is reasonable to forego this and proceed directly to IGLP. ADVANCES IN KNOWLEDGE: This paper helps to confirm what is already assumed about a common radiological procedure. This is important as there has been a shift from bedside technique to most lumbar punctures being performed via image guidance.
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Affiliation(s)
| | - Andrew Yates
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jack W Power
- Mater Misericordiae University Hospital, Dublin, Ireland
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Papaliagkas V, Foroglou N, Toulios P, Moschou M, Gavriilaki M, Notas K, Chatzikyriakou E, Zafeiridou G, Arnaoutoglou M, Kimiskidis VK. Intrathecal Administration of Nusinersen Using the Ommaya Reservoir in an Adult with 5q-Related Spinal Muscular Atrophy Type 1 and Severe Spinal Deformity. Case Rep Neurol 2021; 13:710-715. [PMID: 34950009 PMCID: PMC8647073 DOI: 10.1159/000519831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a hereditary neuromuscular disorder, typically caused by survival motor neuron 1 (SMN1) gene deletion in chromosome 5q resulting in loss of SMN protein. SMA type 1 progresses rapidly leading to increased mortality usually before the age of 2 years. Nusinersen, the first approved disease-modifying treatment for all 5q-SMA types and ages, is an antisense oligonucleotide administered intrathecally via repeated lumbar punctures. However, adult SMA patients typically present with severe scoliosis and spinal deformity. We present a 28-year-old patient with SMA type 1 and severe spinal deformity, who received nusinersen via a subcutaneously implanted Ommaya reservoir connected with an intrathecal catheter at the thoracic level. The repetitive administrations were completed uneventfully, obviating the need for repeated laborious lumbar punctures and eliminating radiation exposure. In adult SMA patients, performing recurrent lumbar punctures can be technically challenging raising the need for an alternative route of administration. The use of Ommaya reservoirs is a viable, practical for repeated infusions, and safe option for the intrathecal delivery of nusinersen for select cases such as an adult SMA type 1 survivor with severe spinal deformity.
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Affiliation(s)
- Vasileios Papaliagkas
- Department of Biomedical Sciences, School of Health Sciences, International Hellenic University, Thessaloniki, Greece
| | - Nikolaos Foroglou
- 1st Department of Neurosurgery, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Maria Moschou
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Notas
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Chatzikyriakou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgia Zafeiridou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marianthi Arnaoutoglou
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios K Kimiskidis
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Klotz J, Tesi Rocha C, Dunaway Young S, Duong T, Buu M, Sampson J, Day JW. Advances in the Therapy of Spinal Muscular Atrophy. J Pediatr 2021; 236:13-20.e1. [PMID: 34197889 DOI: 10.1016/j.jpeds.2021.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Jenna Klotz
- Stanford University School of Medicine, Palo Alto, CA.
| | | | | | - Tina Duong
- Stanford University School of Medicine, Palo Alto, CA
| | - MyMy Buu
- Stanford University School of Medicine, Palo Alto, CA
| | | | - John W Day
- Stanford University School of Medicine, Palo Alto, CA
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Grayev A, Schoepp M, Kuner A. A Systematic Review of Procedural Complications from Transforaminal Lumbar Puncture for Intrathecal Nusinersen Administration in Patients with Spinal Muscular Atrophy. AJNR Am J Neuroradiol 2021; 42:980-985. [PMID: 33632735 DOI: 10.3174/ajnr.a7009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy is a progressive neurodegenerative disorder that can be treated with intrathecal antisense oligonucleotide therapy (nusinersen). However, administration is often complicated by posterior spinal fusion and neuromuscular scoliosis, necessitating a transforaminal approach. PURPOSE To assess the safety profile of the transforaminal approach for intrathecal access. DATA SOURCES Searches of the PubMed, Web of Science, and SCOPUS databases. STUDY SELECTION Thirteen articles were selected based on inclusion of transforaminal access and appropriate clinical information about the procedure. DATA ANALYSIS Complications were taken from the included articles and aggregated based on Cardiovascular and Interventional Radiological Society of Europe scale adverse event grading. DATA SYNTHESIS Total number of complications and grade of complications were analyzed, by year and in total. LIMITATIONS Selection bias in publication, small patient population size, and variability of the procedure limits the available data. CONCLUSIONS Transforaminal approach is a safe alternative for intrathecal access in patients with spinal muscular atrophy and may be applicable to a larger patient population.
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Affiliation(s)
- A Grayev
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.
| | - M Schoepp
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - A Kuner
- From the School of Medicine and Public Health, University of Wisconsin, Madison, WisconsinFrom the School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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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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