Abstract ID: A13
Abstract Title: Intentional Lumbar Puncture Via Caudal and Trans-Sacral Approaches
Authors: Berde C1, Wellington J2, Madsen J3, Nimec D4
Children's Hospital, Boston Boston MA USA1, Indiana University School of Medicine Indianapolis IN USA2, Children's Hospital, Boston Boston MA USA3, Children's Hospital, Boston Boston MA USA4
Poster Type: Either
ABSTRACT BODY
Introduction
Textbooks and review articles on pediatric regional anesthesia commonly admonish clinicians performing caudal blockade to avoid advancing the needle too far cephalad into the sacral canal, in order to avoid inadvertent dural puncture. Posterior spinal fusion and instrumentation for patients with neuromuscular scoliosis commonly involves extension of the fusion from upper thoracic levels caudally to include the sacrum. In these patients, diagnostic or therapeutic lumbar puncture by standard landmarks at lower lumbar levels is generally not technically feasible. We describe here a series of cases in which fluoroscopically-guided lumbar puncture was performed by cephalad advancement of needles via either the caudal space or via posterior midline sacral defects. Cases of similar approaches have been reported in the radiology literature for myelography (1,2), but we were not able to identify reports in the anesthesiology or pain medicine literature, or uses beyond myelography.
Methods
Informed consent for the procedures was obtained from parents in all cases. (The adult patients had severe developmental delay and their parents retained legal guardianship and health care decision-making.) Medical records were reviewed. Following administration of sedation or general anesthesia as appropriate, and following sterile preparing and draping, the needle (in most cases, 22 gauge 5 inch, bent slightly into a curve to follow the course of the sacrum)was advanced using fluoroscopic guidance using both antero-posterior and lateral views to follow the internal canal of the sacrum.
Results
Lumbar puncture was attempted via the caudal or trans-sacral route in 5 patients, and CSF was obtained in 4 cases. Ages ranged from 10 - 24 years. Four patients had the primary diagnosis of cerebral palsy, with associated spasticity and developmental delay. The fifth patient, age 10, had a progressive neuromuscular disorder, with a presumptive diagnosis of infantile ascending hereditary spastic paralysis. All had previously undergone full-spine posterior spinal fusion and instrumentation for scoliosis with extension of rods and bony fusion to the sacrum. Indications for lumbar puncture included: test injection of baclofen (4)and evaluation for possible meningitis(1).
In 2 of the 4 successful cases, entry was performed via the true caudal space. In the other two cases, a midline entry into the sacrum was performed via a more proximal defect roughly at the S2-S3 interspace. The position of the needle tip when dural puncture was identified ranged from L5 to S1 levels. In the unsuccessful case, contributing factors to lack of success may have included extreme kyphotic curvature of the sacrum, a sharp lumbo-sacral angle, and medial positioning of sacral pedicle screws. No complications were noted.
Discussion
Patients with posterior fusion and instrumentation from thoracic to sacral levels occasionally may require lumbar puncture for diagnostic or therapeutic purposes. Caudal and trans-sacral approaches under fluoroscopic guidance may provide an additional option for lumbar puncture in selected cases.
References
1. Acta Radiologica 1972; 12:1-6
2. American Journal of Roentgenology 1997; 169:1179-8
ATTACHED FILES
Reg Anesth Pain Med 2005; 30(3):A13