Fluoroscopy guided lumbar puncture

Fluoroscopy-guided lumbar puncture (LP) is a minimally invasive, image-guided diagnostic and therapeutic procedure that involves the removal of a small volume of cerebrospinal fluid (CSF) from, or an injection of medication or other substance (e.g. radiotracer, chemotherapy agents) into the lumbar cistern of the spinal column. In addition to improving success rates, fluoroscopic guidance may reduce the incidence of a so-called traumatic LP (the presence of xanthochromia in the CSF sample could indicate a traumatic LP rather than subarachnoid hemorrhage in patients with multiple LP attempts).

Please see the article lumbar puncture for non-technique specific indications, contraindications, complications, etc.

Indications

Fluoroscopic guidance for LP may be required for the following reasons ¹:

• failed attempts without imaging

• for patients who have difficult anatomy due to obesity, prior spine surgery or other reasons

Contraindications

See main lumbar puncture article.

Procedure

Preprocedural evaluation

• reason for referral and history of presenting complaint

• relevant medical and surgical history

• review relevant laboratory results and assess for coagulopathies

• review prior imaging, especially lumbar spine images

• discuss the procedure and its potential risks and complications to obtain informed consent

• perform time-out to confirm correct patient, procedure, and site

Positioning/room set up

Correct patient positioning is an important determinant of success in obtaining CSF. LPs can be performed with the patient in the lateral recumbent or prone positions. The prone position is generally preferred for LPs performed under fluoroscopic guidance with the patient being instructed to lie face down. Pillows placed under the abdomen and pelvis may improve patient comfort as well as aid in flexion of the lower lumbar spine. 

The lumbar spinous processes of L3, L4, and L5, and the interspaces between can usually be directly identified by fluoroscopy. The conus medullaris (or terminal part) of the spinal cord most commonly ends at the L1/2 intervertebral disc level in children and adults ^5,6. Thus, the spinal needle can be safely inserted under fluoroscopic guidance at L3-L4 or L4-L5 via a right oblique sublaminar approach since this is well below the conus.

Equipment

Besides a standard fluoroscopic table, fluoroscopy-guided LP requires the following items:

• sterile dressing

• sterile gloves

• sterile drapes

• antiseptic solution with skin swabs

• local anesthetic, e.g. lidocaine 1% without epinephrine

• syringe: 3 mL

• needles: 20 and 25 gauge

• spinal needles: 20 and 22 gauge

• three-way stopcock

• manometer

• three plastic test tubes with caps: numbered 1-3

• syringe: 10 mL

• pulse oximetry +/- ECG leads and other monitoring devices if sedation is required or in seriously ill patients

Technique

Following informed consent, the patient should be placed in the prone or prone oblique position on a standard fluoroscopic table. Local anesthetic can be administered to the skin and subcutaneous tissues.

Once numb, a spinal needle is inserted under strict aseptic conditions using intermittent-pulse fluoroscopy to identify the appropriate site for the LP (often L2-L3 or L3-L4 intervertebral space). The course of the advancing needle is monitored during the procedure until the subarachnoid space is entered via a left or right oblique sublaminar approach, which is confirmed by the reflux of clear CSF. Needle position can be assessed with a lateral projection if there is uncertainty about depth. 

Opening pressure measurement

The technique for correctly measuring opening pressure is somewhat controversial, despite some evidence that prone and lateral decubitus positioning leads to the same results ². The three generally encountered approaches are ³: 

1. needle inserted into CSF prone, measurement prone (most common)

2. needle inserted into CSF prone, measurement lateral decubitus (patient rotated with the needle in situ)

3. needle inserted into CSF in lateral decubitus, measurement lateral decubitus

Although uncommon, the third (lateral decubitus option) has the advantage that it mimics traditional ward positioning and does not require the decision of whether or not to add needle length to the prone opening pressure, which is another variably performed step in calculations ³. 

CSF collection

Finally, the required amount of CSF is collected in test tubes and sent to a laboratory for investigations.

Postprocedural care

See main lumbar puncture article.

Complications

See main lumbar puncture article.