Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.
Reg Anesth Pain Med. 2022 Jun;47(6):380-383. doi: 10.1136/rapm-2021-103242. Epub 2022 Mar 23.
Lumbar puncture (LP) may be challenging for patients with scoliosis and other conditions following previous posterior fusion and instrumentation from thoracic to sacral levels. Interventional radiologists have described CT approaches to transforaminal LP. We hypothesized that combined C-arm fluoroscopy and ultrasound could be a feasible approach to transforaminal LP for interventional pain physicians and regional anesthesiologists.
With institutional review board approval, we reviewed medical records and imaging of six patients with spinal muscular atrophy and prior spine fusion. Non-cutting needles of 24 or 25 gage were advanced through 20-gage introducers. Prior imaging guided selection of a preferred side and spinal level. Initial procedures were performed in the interventional radiology suite. Subsequent procedures were performed in an operating room (OR). We report on technical success and complications and describe a case using this approach for spinal anesthesia.
Six patients underwent a total of 54 transforaminal LPs, including 51 for administration of the antisense oligonucleotide nusinersen, 2 for myelography, and 1 for spinal anesthesia; 45 of these procedures were performed using OR C-arm fluoroscopy and ultrasound. Transient paresthesias and short-term headaches occurred; none required intervention. No other complications were noted.
Transforaminal LP appears technically feasible for patients with full-spine fusions using a straight-needle approach with combined fluoroscopy and ultrasound guidance. Larger case series and prospective studies may better define the success rates, risks, and benefits of this approach relative to alternative approaches to intrathecal access for patients with previous long-segment posterior spine fusions.
对于先前接受过从胸到骶水平的后路融合和器械固定的脊柱侧凸和其他疾病的患者，腰椎穿刺（LP）可能具有挑战性。介入放射学家已经描述了经椎间孔 LP 的 CT 方法。我们假设，对于介入疼痛医师和区域麻醉师来说，C 臂荧光透视和超声联合使用可能是一种可行的经椎间孔 LP 方法。
在机构审查委员会批准的情况下，我们回顾了六例患有脊髓性肌萎缩症和先前脊柱融合的患者的病历和影像学资料。使用 24 或 25 号的非切割针通过 20 号的导入器推进。先前的影像学引导选择首选的一侧和脊柱水平。初始程序在介入放射学套房中进行。随后的程序在手术室（OR）中进行。我们报告了技术成功率和并发症，并描述了一例使用该方法进行脊髓麻醉的病例。
六名患者共进行了 54 次经椎间孔 LP，其中 51 次用于注射反义寡核苷酸 nusinersen，2 次用于脊髓造影，1 次用于脊髓麻醉；这些程序中有 45 次是在 OR C 臂荧光透视和超声引导下进行的。出现短暂的感觉异常和短期头痛；均无需干预。未发现其他并发症。
对于全脊柱融合的患者，使用直针方法和透视与超声联合引导，经椎间孔 LP 似乎在技术上是可行的。更大的病例系列和前瞻性研究可能会更好地定义这种方法相对于其他经后路脊柱融合患者鞘内入路的成功率、风险和益处。
