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

Proportion of Successful Lumbar Punctures in Infants Younger Than Three Months

It is important to perform lumbar punctures (LPs) without a single traumatic tap in infants younger than three months owing to the risk of serious complications. The proportion of LPs in which clear cerebrospinal fluid (CSF) was obtained has been previously reported, but some of the procedures involved a traumatic tap. The present study aimed to identify the proportion of LPs in which clear CSF was obtained without a single traumatic tap and the factors associated with successful LPs in infants younger than three months. This retrospective, observational study included children younger than three months who underwent an LP in the pediatric emergency department between April 2018 and March 2021. The primary outcome was the proportion of successful LPs, defined as LPs obtaining clear CSF without a single traumatic tap. Multiple logistic regression analysis was used to identify factors related to successful LPs. Of 126 eligible patients, 121 were included. Among these, 83 (69%) were in the successful group. No factors significantly associated with successful LPs were found. Larger studies based on an accurate definition of successful LPs, such as that provided by this study, are needed to investigate related factors to increase the rate of successful LPs in this age group.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.99, 95% CI 0.88 to 1.12; RD 0.00, 95% CI -0.06 to 0.05; I2 = 47% and 46% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts as specified in this review. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position (I2 = not applicable; 2 studies; 1102 infants; high-certainty evidence; in one of the study median and IQR to report time to perform the lumbar puncture were 8 (5-13) and 8 (5-12) in the lateral and sitting position, respectively, I2 = not applicable; 1 study, 1082 infants; in the other study: mean difference 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I2 = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Indications, Measurements, and Complications of Ten Essential Neonatal Procedures

About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.

Do Spinal Needle Sizes Affect the Development of Traumatic CSF in Neonatal LP Procedures?

Lumbar puncture (LP) is widely employed to evaluate infectious, neurological and metabolic diseases in the newborn. Neonatal LP is a difficult procedure with 45–54% success rates. Although there are studies examining traumatic LP failure, studies on the effects of needle sizes are limited. This study was intended to investigate the effect of needle sizes on LP traumatization. Term and premature babies who underwent LP in the neonatal intensive care unit between 30 November 2017 and 30 July 2019 were included in the study by retrospective file scanning. LP was performed by a pediatric or neonatal specialist using a 22 Gauge pen (G) or 25 G pen spinal needle in all cases, with all patients being placed in the lateral decubitus position. The primary outcome was to evaluate the effect of needle sizes used in LP on traumatization. The secondary outcome was to evaluate traumatization rates and complications. A statistically significant difference was determined in the rate of traumatized LP and desaturation development between needle sizes and CSF microscopic findings (p = 0.031, p = 0.005, and p = 0.006, respectively). The study data show that 25 G pen-tip spinal needles cause less traumatic LP in neonates than 22 G pen-tip spinal needles.

Serious infections are rare in well-appearing neonates with hypothermia identified incidentally at routine visits

OBJECTIVES

It is not established whether diagnostic testing and antimicrobial treatment are warranted in well-appearing neonates without other signs or symptoms who have hypothermia identified incidentally at a routine visit with their primary care provider.

METHODS

This was a retrospective observational study of well-appearing neonates who were noted at a routine visit to be hypothermic (<97.7°F or <36.5°C) and referred to a pediatric emergency department over an 8.5-year period. Excluded were those transferred from an outside hospital and those with signs of illness, including apnea, bradycardia, fever, hypoglycemia, ill appearance, lethargy, poor feeding, respiratory distress, tachycardia, or vomiting. Patient characteristics, laboratory results, antimicrobial treatment, and clinical outcomes were recorded.

RESULTS

Among a final cohort of 212 neonates with incidental hypothermia, no urine (n = 195) or blood (n = 198) culture grew a bacterial pathogen. No CSF culture (n = 168) grew a bacterial pathogen and no CSF PCR test (n = 142) was positive for herpes simplex virus. Contaminants were isolated in 3 urine and 3 blood cultures.

CONCLUSION

Well-appearing neonates with incidentally noted hypothermia at a routine visit are at low risk for serious infection and may not warrant a full sepsis evaluation.

Material and sedation-analgesia in the neonatal lumbar puncture procedure

INTRODUCTION

Lumbar puncture (LP) is a frequent procedure during the neonatal period. Correctly performing this technique can avoid many of its complications.

OBJECTIVE

To evaluate the LP procedure in neonates in Spanish hospitals, studying the type of material and the sedation-analgesia used.

MATERIAL AND METHODS

Cross-sectional study conducted in Spain gathering data through a survey research distributed by email through the Segurneo-SEN Hospital Network and the Spanish Neonatal Society. Data on the LP technique in neonates were collected.

RESULTS

A total of 301 participants were analysed. Most professionals used a trocar needle with a stylet as the first option (89.7%); however, when the LP failed or was blood-stained, 32.2% changed the type of needle. A total of 143 doctors gave their subjective feeling about the type of needle: they only use trocar needles with stylet (41.3%), the technique is easier using scalp-vein needles (32.2%), there is less probability of a blood-stained LP, or failed using scalp-vein needles (7.7%), they choose the type of needle depending on the size of the newborn (10.5%), indifference when using one type or another needle (8.4%). Almost all (99%) of the surveyed doctors used some type of analgesia. The most widely used measures were topical anaesthetics (90.3%) and sucrose (82.2%).

CONCLUSIONS

Currently, the LP procedure in the neonatal period is mainly performed with a trocar needle with a stylet and with the widespread use of different analgesic measures.

[Material and sedation-analgesia in the neonatal lumbar puncture procedure]

INTRODUCTION

Lumbar puncture (LP) is a frequent procedure during the neonatal period. Correctly performing this technique can avoid many of its complications.

OBJECTIVE

To evaluate the LP procedure in neonates in Spanish hospitals, studying the type of material and the sedation-analgesia used.

MATERIAL AND METHODS

Cross-sectional study conducted in Spain gathering data through a survey research distributed by email through the Segurneo-SEN Hospital Network and the Spanish Neonatal Society. Data on the LP technique in neonates were collected.

RESULTS

A total of 301 participants were analysed. Most professionals used a trocar needle with a stylet as the first option (89.7%); however, when the LP failed or was blood-stained, 32.2% changed the type of needle. A total of 143 doctors gave their subjective feeling about the type of needle: they only use trocar needles with stylet (41.3%), the technique is easier using scalp-vein needles (32.2%), there is less probability of a blood-stained LP, or failed using scalp-vein needles (7.7%), they choose the type of needle depending on the size of the new-born (10.5%), indifference when using one type or another needle (8.4%). Almost all (99%) of the surveyed doctors used some type of analgesia. The most widely used measures were topical anaesthetics (90.3%) and sucrose (82.2%).

CONCLUSIONS

Currently, the LP procedure in the neonatal period is mainly performed with a trocar needle with a stylet and with the widespread use of different analgesic measures.

Neonatal lumbar puncture: are clinical landmarks accurate?

BACKGROUND

The intercristal line (ICL), defined by the superior aspect of the iliac crest, is used to clinically identify the entry point for lumbar puncture (LP) in neonates. Accepted practice is to insert the needle at the L3/4 or L4/5 intervertebral space.

AIM

To investigate the vertebral level crossed by the ICL as determined by manual palpation and the ability of manual palpation to reliably identify a specified intervertebral space.

METHOD

A total of 30 term neonates were recruited. Paediatricians identified and marked the ICL and the intervertebral space above, with babies in left lateral position. The anatomical positions of both points and the end of the conus medullaris were confirmed using ultrasonography.

RESULTS

The ICL was marked from L2/3 to L5/S1. In 25 babies (83%), the ICL was identified at the desired vertebral level between L3/4 and L4/5. The intervertebral space above this line was marked between L1/2 to L4/5. The potential site for LP was identified higher than intended in 11 cases (36%). The end of the conus medullaris ranged from L1 to L3 terminating at L2 or lower in 11 cases (36%).

CONCLUSIONS

There are wide variations in the positions of the ICL and potential LP site. Using the ICL to guide LP does not appear to be accurate, raising the possibility of potential spinal cord damage.

Iatrogenic spinal hematoma as a complication of lumbar puncture: What is the risk and best management plan?

Background:

Lumbar puncture (LP) rarely results in complications such as spinal hematomas. However, it remains unclear if certain variables increase likelihood of these events, or if surgical intervention improves outcome.

Methods:

In addition to two clinical vignettes, we evaluated the post-1974 literature for cases of spinal hematoma and subsequent intervention. Based on our compilation of data, we evaluated outcome relative to numerous distinct variables.

Results:

Based on 35 LP-related spinal hematoma cases in the post-1974 literature and our encounters, we found 28.6% of patients presenting with preexisting coagulopathy had poor outcomes regardless of intervention, relative to 14.3% of patients without coagulopathy; a highly significant difference (P = 0.02). Once diagnosed, 21 patients were treated surgically and 14 nonsurgically. Of the 60% surgical patients, 57.1% had good outcomes, and 42.9% had poor outcomes within 12 months. Of 40% nonsurgical patients, 57.1% had good outcomes and 42.9% had poor outcomes. Results in these groups were not statistically different.

Conclusions:

We found a significant correlation between preexisting coagulopathy and poor neurological outcome irrespective of intervention. However, outcomes for these patients may be confounded by comorbidities including underlying conditions contributing to their coagulopathy. No significant correlation between type of surgical intervention and good outcome was found, possibly attributable to the paucity of details in existing case reports and the difficulty defining the degree of spinal cord compromise from a given lesion. Despite our findings, emergent neurosurgical intervention may be beneficial for the management of complications such as cauda equina syndrome secondary to intrathecal spinal hematoma.

Congenital neuroblastoma presenting with paraplegia following spinal puncture in a neonate. Case report and review of the literature

Neuroblastoma is the most common intraspinal solid tumor of childhood. Neurological deterioration due to an intratumoral hemorrhage following a spinal puncture is extremely rare. We report on the case of a 23-day-old neonate who was admitted to our institution for the onset of a paraplegia following a diagnostic lumbar puncture. The MRI showed an epidural tumor with massive intratumoral hemorrhage. Operatively and with histologic confirmation, the mass was determined to be a neuroblastoma. Following surgery, neurological function improved.

Accuracy of manual palpation vs ultrasound for identifying the L3-L4 intervertebral space level in children

BACKGROUND

Insertion of needles into the spinal or epidural space is an important component of modern anesthetic practice. Needles are usually inserted at or below the L3-L4 intervertebral space to minimize the risk of spinal cord injury. Manual palpation is the most common method for identifying intervertebral spaces. However, anesthesiologists are increasingly using ultrasonography to guide the placement of regional, including neuraxial, anesthetic, and analgesic blocks. We undertook an observational study to compare the accuracy of manual palpation and ultrasound for determining the L3-L4 intervertebral space level.

METHODS

Thirty children 0-12 years of age undergoing lumbar puncture were enrolled. For each subject, an anesthesiologist, using the landmark palpation method, determined the point on a radio-opaque ruler that corresponded to the L3-L4 intervertebral space. A different anesthesiologist using the ultrasound method repeated this measurement. Fluoroscopy was then used to confirm the accuracy of each technique. The proportion of inaccurate measurements and the effects of anesthesiologists' experience, patient age, and size on the accuracy of each technique were compared.

RESULTS

Thirty-seven percent of measurements by the landmark palpation method were inaccurate by ≥1 levels cephalad to the L3-L4 intervertebral space. However, less experienced anesthesiologists (residents and fellows) made a disproportionate number of inaccurate measurements compared to consultants. Twenty-three percent of measurements by the ultrasound method were inaccurate by ≥1 cephalad levels. The BMI-for-age percentile/weight-for-length percentile was higher in patients in whom either technique was inaccurate.

CONCLUSION

This observational study found no difference in the accuracy of landmark palpation, when performed by a consultant anesthesiologist, and ultrasound for determining the L3-L4 intervertebral space in children.

A case of infantile star anise toxicity

Chinese star anise (Illicium verum) is a popular herbal remedy for infantile colic. Contamination with a related species of Japanese star anise (Illicium anisatum) has been related to cases of toxicity in infants. We report the case of a 3-month-old infant girl who presented to the emergency department with signs and symptoms of toxicity after recent star anise ingestion. Her presentation is consistent with other reports of toxicity that include particular gastrointestinal and neurological findings. A discussion of the clinical aspects of star anise toxicity, differential diagnosis, and management follows.

Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication

Lumbar puncture is a commonly practiced bedside technique for acquiring cerebrospinal fluid for the purposes of examination, spinal anesthesia, and as therapeutic trial for normal pressure hydrocephalus. Headache and backache after lumbar puncture are not uncommon. We report an elderly woman who suffered from altered consciousness and acute neurologic deficit after a difficult lumbar puncture. Serial imaging studies revealed active bleeding from the left first lumbar artery with the formation of spinal epidural hematoma and coexisting acute cranial intraventricular hematoma and subarachnoid hemorrhage. Lumbar puncture may rarely associate with life-threatening complications. Acute spinal subdural hemorrhage or subarachnoid hemorrhage after lumbar puncture is a timely diagnosis and needs urgent interventions. Clinicians should be aware of these rare but life-threatening complications after lumbar puncture. A cranial unenhanced CT is mandatory for patients having acute altered consciousness after lumbar puncture. A thorough vascular imaging evaluation from the lumbar spine to the brain is warranted in selected cases.

[A case of hematomyelia caused by coagulation--fibrinolysis abnormality accompanied with colon cancer and its metastasis]

A 76-year-old woman developed weakness and sensory loss in the lower limbs and urinary disturbance in four days. She had a history of operation for the ascending colon cancer and lung metastasis one year ago. Neurological examination revealed flaccid paraplegia, absent Achilles tendon reflex, severe disturbance of superficial and deep sensation below the L3 level, and vesicorectal abnormality. Magnetic resonance imaging (MRI) studies showed an intramedullary T1-iso, T2-low lesion with Gd-DTPA contrast enhancement in conus medullaris at LI level. The laboratory examination revealed the elevated level of serum FDP. D-dimer and TAT. She was diagnosed as hematomyelia, which may be caused by the activation of coagulation and fibrinolysis system. We suggested that the ascending colon cancer and lung metastasis may contribute to the coagulation-fibrinolysis abnormality.

[Hematomyelia in systemic lupus erythematosus and secondary antiphospholipid syndrome: case report]

Intraspinal hemorrhage is very rare and intramedullary hemorrhage, also called "hematomyelia," is the rarest form of intraspinal hemorrhage. There are few reports in medical literature. We report the case of a woman of 43 years with diagnosis of systemic lupus erythematosus and secondary antiphospholipid syndrome under anticoagulant therapy that presented hematomyelia. We describe the clinical course, the findings in the image studies and surgery, and the available information in the literature.

Technique that better localizes the dura mater during intrathecal catheterization should reduce inadvertent multiple dural punctures and reduce complications

We present here a technique to mitigate the complication of multiple needle entries into the thecal sac when attempting to place an intrathecal catheter into the thecal sac. Our technique of injecting radio-opaque contrast material after entering the epidural space and before entering the thecal sac allows for visualization of the thecal sac within the spinal canal, thus obviating the technique of "fell and pop" to enter the sac. In our hands, this technique has improved outcomes for our patients and has decreased the incidence of post dural puncture headache, neural trauma and technical failures.

Intraspinal and intracranial hemorrhage after lumbar puncture

Two cases of spinal epidural hematoma and two cases of intracranial subdural hematoma after lumbar puncture (LP) are reported in children receiving chemotherapy for acute lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was asymptomatic but interfered with treatment in one case, and caused either severe backache or headache but no neurological deficit in the other three patients. The platelet counts were 8 and 46 x 10(9)/L in two patients and were normal in the other patients at the time of LP. All recovered without surgical treatment. There is an inherent, albeit uncommon, risk of bleeding into the central nervous system associated with LP in children with cancer and should be distinguished from postdural puncture headache (PDPH). Thrombocytopenia is not always an accompanying factor.

Part 1: recognizing neonatal spinal cord injury

Neonatal spinal cord injury can occur in utero, as well as after either a difficult delivery or a nontraumatic delivery. Spinal cord injury can also be related to invasive nursery procedures or underlying neonatal pathology. Early clinical signs of spinal cord injury that has occurred in utero or at delivery includes severe respiratory compromise and profound hypotonia. Knowledge of risk factors and awareness of symptoms is required for early recognition and appropriate treatment. This article reviews the embryological development of the spinal column highlighting mechanisms of injury and identifying underlying factors that increase the risk of spinal cord injury in newborns. Signs and symptoms of injury, cervical spine immobilization, and the differential diagnosis are discussed. Nursing implications, general prognosis, and research in spinal cord injury are provided.