Lumbar puncture under fluoroscopy guidance: a technical review for radiologists

Cerebrospinal Fluid-Basic Concepts Review

Cerebrospinal fluid plays a crucial role in protecting the central nervous system (CNS) by providing mechanical support, acting as a shock absorber, and transporting nutrients and waste products. It is produced in the ventricles of the brain and circulates through the brain and spinal cord in a continuous flow. In the current review, we presented basic concepts related to cerebrospinal fluid history, cerebrospinal fluid production, circulation, and its main components, the role of the blood-brain barrier and the blood-cerebrospinal fluid barrier in the maintenance of cerebrospinal fluid homeostasis, and the utility of Albumin Quotient (Q_Alb) evaluation in the diagnosis of CNS diseases. We also discussed the collection of cerebrospinal fluid (type, number of tubes, and volume), time of transport to the laboratory, and storage conditions. Finally, we briefly presented the role of cerebrospinal fluid examination in CNS disease diagnosis of various etiologies and highlighted that research on identifying cerebrospinal fluid biomarkers indicating disease presence or severity, evaluating treatment effectiveness, and enabling understanding of pathogenesis and disease mechanisms is of great importance. Thus, in our opinion, research on cerebrospinal fluid is still necessary for both the improvement of CNS disease management and the discovery of new treatment options.

Ultrasound-Guided vs. Landmark-Guided Lumbar Puncture for Obese Patients in Emergency Department

Objective

Emergency patients are in severe and urgent condition. If the patient is obese, the traditional lumbar puncture method is more difficult. This study was to observe the comparison of ultrasound-guided and landmark-guided lumbar puncture for obese patients in the emergency department.

Methods

Sixty patients suspected of intracranial infection, subarachnoid hemorrhage, and intraventricular hemorrhage from January 2018 to June 2020 were selected in the Department of Emergency Medicine, Shengjing Hospital of China Medical University. They were randomly assigned to two groups according to the order of enrollment: Group A (Landmark-guided group, n = 30) and Group B (Ultrasound-guided group, n = 30). Follow-up assessments were performed to observe lumbar puncture time, the number of bloody CSF, Visual Analog Scale (VAS), the complications, and satisfaction.

Results

Compared with group A, group B had less lumbar puncture time, lower puncture attempts, and a higher first puncture success rate (P <0.05). In group B, the number of bloody CSF was less (P <0.05), postprocedural low back pain was less (P <0.05), intraprocedural sciatic nerve irritation and postprocedural paresthesia were less, but the difference was not statistically significant (P > 0.05). Compared with group A, the postprocedural VAS in group B was lower, and the difference was statistically significant (P <0.05). The total satisfaction of group A and group B was 60.0 and 86.7%, respectively. The total satisfaction of group B was higher than that of group A (P <0.05).

Discussion

Ultrasound-guided lumbar puncture can be used for obese patients with difficulty in the lumbar puncture. It is worthy of clinical application and promotion.

Retrospective Comparative Analysis of Fluoroscopic-Guided Lumbar Puncture in the Routine Prone Versus Lateral Decubitus Position

Objective: We sought to investigate patient outcomes such as success rate, fluoroscopy time, and radiation dose for fluoroscopic-guided lumbar puncture procedures performed in the prone position versus the lateral decubitus (LD) position.

Methods: Retrospective chart analysis was performed at a single institution from 2013 to 2019. Cases were separated by performance in the prone or lateral decubitus positions. Data collected include patient characteristics, fluoroscopy time, radiation dose (DAP), puncture level, indication, opening pressure, and success rate. Exclusion criteria include trainee participation and procedures where positioning was unspecified. Mean fluoroscopy time, DAP, and procedure success rate were calculated and compared between groups.

Results: Mean fluoroscopy time (min) was 0.97 and 1.07 in the LD and prone groups respectively (p = 0.21). Mean DAP (mGy) was 43.18 and 42.06 in the LD and prone groups respectively (p = 0.38). Success rate was 98.3% and 89.1% in the LD and prone groups respectively (p = 0.04). Room time (minutes) was 64.46 and 77.77 in the LD and prone groups respectively (p = 0.04).

Conclusion: Our study found no statistically significant difference in terms of fluoroscopic time or radiation dose when comparing fluoroscopic-guided lumbar punctures in the prone versus lateral decubitus positions. Further analysis did show a statistically significant increased success rate and a shorter room time for the lateral decubitus position.

Nusinersen injections in adults and children with spinal muscular atrophy: a single-center experience

PURPOSE

Nusinersen is a drug approved in December 2016 for treatment of spinal muscular atrophy (SMA). We want to share our initial experience with image-guided, non-image-guided, and port-delivered nusinersen injections in a large single-center SMA patient cohort, treating both pediatric and adult patients with focus on technical considerations and other patient concerns from a combined perspective of patient, neurologist, and radiologist.

METHODS

All nusinersen injections between February 2017 and September 2018 were retrospectively reviewed. We obtained age, sex, SMA type and technical details of the injections and postprocedure complications for each procedure.

RESULTS

A total of 52 patients (24 women [46%]; 4 patients with SMA-1 [7.6%]; 30 patients with SMA-2 [57.8%]; 18 patients with SMA-3 [34.6%]; mean age, 25.5 years [7 months to 62 years]) with a total of 265 injections were included. Of the 265 injections, 206 (77.9%) were performed with local anesthetic, 25 (9.4%) with moderate sedation, and 23 (8.6%) under general anesthesia. We performed 65 CT-guided transforaminal injections in 13 patients, 106 fluoroscopy-guided lumbar punctures in 24 patients and 83 lumbar punctures in 16 patients using conventional technique. Only 6 of 265 injections (2.2%) ended up with a post-lumbar puncture headache (PLPH) requiring medical treatment. None required an epidural blood patch. Fourteen PLPH (5.2%) occurred and resolved at the same day without any treatment. After 6 of 265 injections (2.2%), patients reported soreness at the injection site which resolved spontaneously. Three elected to have an intrathecal reservoir placement (2 lumbar, 1 intraventricular) with a total of 11 injections. One patient with lumbar catheter developed infection after surgery with subsequent meningitis and treatment delay. After the resolution of meningitis, a new intraventricular reservoir was placed without any complication in the following injections.

CONCLUSION

With the introduction of nusinersen treatment, neurologists and radiologists play an important role in treatment of SMA patients and therefore should be familiar with different techniques and complications of drug administration. Using good technique, it is possible to have very low complication rates even in this complex patient population, and various image-guided procedures can be a safe alternative to surgical approach, even in the most difficult cases.

[Lumbar transforaminal epidural block for treatment of low back pain with radicular pain]

OBJECTIVE

To evaluate the efficacy of lumbar transforaminal epidural block (LTEB) for treatment of low back pain with radicular pain.

METHODS

We retrospectively analyzed the clinical data of 78 patients with low back pain and radicular pain admitted to the Department of Orthopedics of Beijing Chuiyangliu Hospital from March, 2017 to April, 2019. Thirty-three of the patients received treatment with LTEB (LTEB group), and 45 received comprehensive conservative treatment including traction, massage, acupuncture and physiotherapy (control group). The demographic and clinical data of the two groups were compared. The patients were followed up for 3 to 24 months, and numerical rating scale (NRS) and Oswestry disability index (ODI) scores of the patients were evaluated before the treatment and at 2 weeks, 1 month and 3 months after discharge to assess the efficacy of the treatment.

RESULTS

The mean operation time of LTEB was 25.7 7.5 min (15-45 min). After the operation, 5 patients developed weakness of the lower limbs but all recovered within 24-72 h. The patients receiving LTEB all showed significantly decreased NRS scores for low back and radicular pain and ODI scores after the operation (P=0.001). At 2 weeks after the operation, the patients receiving LTEB showed significant relief of low back pain as compared with the patients in the control group (t=2.224, P=0.034), and the difference in NRS scores for low back pain between the two groups tended to diminish over time (F=1.743, P=0.183). Treatment with LTEB resulted in obvious relief of radicular pain and significant reduction of the ODI score of the patients (P < 0.001), and such improvements became more obvious over time after LTEB (P < 0.01).

CONCLUSIONS

As a minimally invasive approach, LTEB is effective for treatment of low back pain with radicular pain and can produce good short-term effects of pain relief and functional improvement.

Lumbar Puncture: Indications, Challenges and Recent Advances

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Comparison Of Digital Manometer And Water Column Manometer Pressures Measurements During Lumbar Puncture

Background

Cerebrospinal fluid (CSF) pressure measurement is routinely performed via a conventional water column manometer. There is increasing interest in using a digital manometer in measuring CSF pressures. The aim of this study is to compare column and digital manometers, in addition to measuring time to acquire the pressure readings.

Research design and methods

This prospective study included 27 patients who were referred for a fluoroscopically guided lumbar puncture. Opening pressure and closing pressure measurements were done with a digital manometer and then a traditional water column manometer. The time to obtain each pressure measurement was also recorded and compared.

Results

Mean time to obtain pressure reading was significantly lower in the digital manometer group when compared to the water column manometer group (8.1 seconds vs. 42.2 seconds, P<0.05 for opening pressure and 8.92 seconds vs. 45.15 seconds, P<0.05 for closing pressure). Correlation between the opening pressure measurements (Pearson coefficient r= 0.98) and closing pressure (Pearson coefficient r= 0.89) was strong. However, the digital manometer reading consistently read higher.

Conclusion

Digital manometry during an LP yielded is faster however there might be a clinical difference between the devices. Clinicians must be careful in using the device across all cases.