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Lumbar puncture under fluoroscopy guidance: a technical review for radiologists

2019; Volume: 25; Issue: 2 Linguagem: Inglês

10.5152/dir.2019.18291

1305-3612

Can Özütemiz, Jeffrey Rykken,

Spinal Fractures and Fixation Techniques

T here are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists (1).Even within the same institution, there are a variety of individual preferences among physicians with different perspectives based on a combination of literature familiarity, training, and personal experience.Our aim is to provide familiarity with various techniques involved in FG-LP, improve efficiency, and improve patient outcomes.We will also address possible controversial issues regarding FG-LPs using an evidence-based approach. Relevant anatomy and physiologyOver the years, we have observed an increase in the number of requests for FG-LP, attributed to several contributing factors.For instance, FG-LPs are less likely to result in a traumatic tap when compared to non-image-guided lumbar punctures (LP) (2).A traumatic tap may affect laboratory results, potentially leading to elevated cell counts and cerebrospinal fluid (CSF) protein levels.Second, an increasing number of patients with degenerative spondylosis and/or obesity, could lead to an increase in failed bedside attempts.Additionally, fear of malpractice litigation might urge some practitioners to shift the responsibility of such procedures to interventionalists.Moreover, with the increased number of complex spine surgeries, surgeons may request more computed tomography (CT) myelography examinations instead of magnetic resonance imaging (MRI) due to magnetic susceptibility artifacts from the surgical hardware and to assess surgical complications such as CSF leak.Lastly, an increase in intrathecal medication regimens and a preference for imaging confirmation might sway providers to favor FG-LP.Therefore, familiarity with CSF physiology and the pertinent anatomy is essential for the interventionalist to increase the success rate of this simple diagnostic and therapeutic intervention, to avoid potential complications, and to best manage complications when they occur.Most of the CSF is produced by the choroid plexus, while small amounts are secreted by the ependymal surfaces of the ventricles and by the arachnoid membranes (3).CSF passes through the ventricular system and exits from the fourth ventricle through the foramina of Luschka and Magendie, entering the contiguous subarachnoid space surrounding the brain and spinal cord.CSF is absorbed through a combination of lymphatic absorption and by arachnoid villi within the venous sinuses, ultimately returning to the systemic circulation (4).