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Lumbar puncture is a standard procedure to obtain cerebrospinal fluid for diagnostic purposes and an essential procedure to perform myelography. There has been more and more demand from patients and physicians to perform a fluoroscopy-guided lumbar puncture. Hence, health professionals should understand the indications, contraindications. They should be familiar with the methods of fluoroscopy-guided lumbar puncture. This activity reviews indications, pre-procedure assessment of the patient, details of techniques used by the interprofessional team, and the potential complications. Objectives: Review the indications for the lumbar puncture. Review the indications for the fluoroscopy-guided lumbar puncture. Identify the high-risk factors and contraindications for the lumbar puncture. Summarize the material and techniques for the lumbar puncture procedure. Access free multiple choice questions on this topic.

Heinrich Irenaeus Quincke and Walter Essex Wynter independently developed techniques to perform lumbar punctures in 1888, and 1889 respectively.[1] Lumbar puncture (LP) is one of the most common procedures, with over 90,000 procedures performed in 2018 on the Medicare population. Currently, radiologists are becoming the largest provider for LP.[2] There is an increasing trend of performing LP under image guidance in hospital settings.[3] Fluoroscopy-guided lumbar puncture (FGLP) is the most common imaging method. Physicians have used computed tomography (CT) guidance lumbar puncture in certain difficult situations. FGLP is necessary when a patient has spinal hardware, scoliosis, and severe degenerative changes. Prior failed attempts and inability to find the bony landmarks such as in obese patients also require image guidance for the procedure.[2] FGLP is associated with a 3.5% frequency of a traumatic tap, which is much lower than the 10.1% associated with the blind bedside technique.[4]

Vasovagal syncope: Patients can experience a hot feeling, the feeling of throwing up during the procedure, which is generally reversible after taking a short break. Herniation: Although it is highly uncommon to occur, post puncture uncal herniation is an essential and dangerous complication. CT or MRI of the head is recommended before lumbar puncture to rule out obstructive hydrocephalus. Nerve injury: LP can cause direct harm to the roots of the cauda equina. Spinal cord injury: LP needles can damage the conus, especially in low-lying conus or achondroplasia. It is best to consult neurology, neurosurgery in these patients. Meningitis: Proper techniques of disinfection avoid infection. Headache: Typically, 20 or 22G needles have a reported incidence of 2.2% for FGLP while varies between 20.5 to 26.4% under blind technique.[13] The headache takes one day to appear, peaks after an additional day, and takes one day to disappear. Post lumbar puncture headache increases with lower gauge needles. Unlike cutting Quincke needles (regular spinal needles), non-cutting Sprotte or Whitacre needles cause fewer headaches. Single dural puncture and replacing the stylus before withdrawing the needle decreases the probability of post-spinal headache. The bevel position perpendicular to the long axis of the nerves while entering the dura also reduced the risk of headache.[14][15] Many patients improve without any treatment.[16] Although advised and practiced universally, the strict bed rest after the LP has no demonstrable bearing on the headache; however, patients generally are recommended to take 2-hour bed rest.[17] Caffeine may help reduce the headache.[18] In refractory cases, a fluoroscopy-guided epidural blood patch is an effective treatment.[19]

Many patients improve without any treatment.[16] Although advised and practiced universally, the strict bed rest after the LP has no demonstrable bearing on the headache; however, patients generally are recommended to take 2-hour bed rest.[17] Caffeine may help reduce the headache.[18] In refractory cases, a fluoroscopy-guided epidural blood patch is an effective treatment.[19] Vascular injury: A long needle can injure the posterior wall of the aorta by passing through the intervertebral disc, causing hematoma and pseudo-aneurysm. When the needle penetrates the aortic wall, fresh arterial blood spurts through the needle, the needle also pulsates along with the aortic pulsations. A lateral radiograph can confirm the retroperitoneal extent of the needle. When the arterial injury is suspected, we recommend consulting a vascular surgeon. It is essential to closely monitor the patient for hemodynamic stability. The reduction of the aortic pressure also helps to stabilize the hematoma. CT angiogram can be performed to look for active extravasation and stability of the hematoma. If the hematoma is felt to be stable, consider slowly removing the needle and then placing the patient supine for the tamponade effect on the aorta to stabilize the hematoma.[20] Radiation: The average procedure time for the FGLP ranges between 12 min (range 12-30 min, SD 6) and the average radiation dose area product DAP of 10 Gy×cm(2) (range 0.1-70, SD 11) and average effective dose estimate of 2.9 mSv (range 0.9-9.4, SD 1.9).[21]

FGLP is a significantly superior procedure to blind LP. It is associated with reduced postlumbar puncture headache (Level 1).[13] FGLP is a moderately skilled procedure and might injure patients significantly due to spinal cord injury if not performed correctly. Hence, it is essential to master the technique of the FGLP to obtain desired results safely. It is important to note that sedation doesn't always benefit the patient, as patients can not tell if they had root pain while steering the needle within the spinal canal. FGLP is a commonly performed procedure in radiology departments either for diagnostic or therapeutic purposes. We generally recommend that the clinical team try at least one attempt using the nonimage-guided bedside LP; however, this will negatively impact the radiology department.[2] [Level 3] The interprofessional clinical team requesting FGLP should understand this implication and comprehend that the clinicians might lose the skill of blind LP in the future. Clinicians should be aware of the contraindications and complications of the FGLP. It is important to note that FGLP is not immune to the complications of blind LP; however, they occur less frequently. Experienced nursing staff can assist the clinicians during the procedure and perform patient monitoring. Interprofessional coordination and communication will yield the best results from these diagnostic tests. [Level 5]