Efficacy of three-dimensional rotational fluoroscopic unit guidance for lumbar cerebrospinal fluid drainage among patients with unsuccessful initial attempt at bedside

Abstract

Lumbar cerebrospinal fluid drainage has been widely performed in patients at the bedside; however, technical failure can occasionally occur as a result of blind maneuvering. Herein, we present the use of rotational fluoroscopic unit-guided lumbar drainage for patients with an unsuccessful initial attempt at bedside. In four of the 24 patients with aneurysmal subarachnoid hemorrhage, initial lumbar drainage could not be performed at bedside. Thus, a three-dimensional rotational technology guided by a high-quality fluoroscopic unit was used. After a cone-beam computed tomography scan was performed, an accurate puncture point and a target thecal sac were identified using the software. The fluoroscopic unit helped us to identify the puncture point and trajectory with a laser pointer on the patient. A needle was inserted along the tract until the cerebrospinal fluid was collected. The lumbar drainage tube was successfully inserted with a single puncture in all four patients. Rotational fluoroscopic technology helps to identify a suitable puncture point, trajectory and target site for lumbar spinal drainage. Our technique is considerably useful in an era wherein minimally invasive procedures are preferred.

Introduction

Lumbar cerebrospinal fluid drainage (LCSFD) has been widely used to relieve intracranial hypertension or to continuously control the cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH).¹ The initial attempts of LCSFD are usually performed at the bedside; however, technical failure can occasionally occur as a result of the blind maneuvering. Since several patients have undergone spinal surgery, and with the present increase in the body mass index of the general population, physicians face several challenges. Persistent repeat procedures may be considered as torture in an era wherein minimally invasive procedures are preferred. Therefore, some authors have reported procedures such as fluoroscopic-, computed tomography (CT)-, and ultrasonography-guided LCSFD.^2–4

Herein, we present the usage of rotational fluoroscopic unit (RFU)-guided LCSFD, which is a less-invasive procedure than a conventional blind one, in particular for patients with an unsuccessful initial attempt.

Methods

Patients

LCSFD was initially performed at the bedside of patients who were in the acute stage of aneurysmal SAH, wherein it was treated with emergency coil embolization. We routinely performed the continuous spinal drainage in all patients for about 14 days during the period of vasospasm after SAH. An informed consent was obtained from all patients or their relatives before the initial simple procedures. Between January 2016 and July 2018, we performed 24 initial LCSFD in 21 postoperative patients with aneurysmal SAH. Four (16.7%) initial procedures were unsuccessful.

Initial lumbar drainage

The patient was positioned in the left lateral decubitus position. A midline approach to the L4—5 interspinous space was preferred in a majority of the cases, followed by L3—4 and L5—S1. The skin was prepped and draped in a sterile fashion. After the local subcutaneous administration of 1% lidocaine, a puncture was attempted using a 14-gauge × 80-mm Tuohy needle. When CSF was obtained, the Tuohy needle was rotated to orient the bevel in the cranial direction, and the 5-Fr spinal catheter was slowly advanced by 15 cm without resistance.

RFU-guided lumbar drainage

When the LCSFD at bedside was unsuccessful, an RFU-guided LCSFD was performed. The failed attempts of the initial LCSFD included both failed CSF tap and catheter navigation. Another informed consent stating the possible use of contrast media before the procedures was obtained. The patient was in prone position on the operating table. All procedures were performed under local anesthesia. A cushion of approximately 20 cm in height was placed under the patient’s abdomen to protrude the puncture site. After the skin around the L3–S1 was prepped and draped in a sterile fashion, a cone-beam CT scan of the lower back portion was performed using the RFU (Artis Q BA Twin Pure VD11C; Siemens Healthineers, Forchheim, Germany). Thereafter, an ideal puncture point and adequate trajectory in the interspinous space were designed using a workstation (Syngo X-Workplace VD20B; Siemens Healthineers, Forchheim, Germany) (Figure 1). The information was sent to the RFU, and the flat panel detector was automatically positioned according to the design. The ideal puncture point was indicated on the patient’s skin with crossed red laser lines, and the accurate perpendicular position of the flat panel detector against the ideal trajectory was maintained. Furthermore, after administering 1% lidocaine, a 14-gauge × 80-mm Tuohy needle was advanced under fluoroscopic guidance (Figure 2). The following procedure was similar to the initial LCSFD. Eventually, the level of the spinal catheter tip was confirmed on fluoroscopy (Figure 3).

Figure 1.

Images of two-dimensional and three-dimensional (3D) reconstructions on the workstation. (a) Sagittal view. (b) Coronal view. (c) Axial view. (d) 3D rotational model. The vectors indicate an accurate direction and depth from the ideal puncture point to the ideal thecal sac. The depth is 56.72 mm in length.

Figure 2.

Lateral view of the X-ray image during puncture. The information of the ideal puncture point and the trajectory is sent from the workstation to the rotational fluoroscopic unit, and the flat panel detector is automatically positioned according to the design. The ideal puncture point is indicated on the patient’s skin with crossed red laser lines, and the accurate perpendicular position of the flat panel detector against the ideal trajectory is maintained. A: anterior; P: posterior.

Figure 3.

Postprocedural image. A: anterior; white arrowheads: catheter; white arrow: tip of the catheter.

Results

The clinical summary of the four patients is presented in Table 1. Among the patients, three were obese based on their high body mass index (Cases 1, 2 and 4). Two patients could not be assessed using a spinal catheter even though CSF was observed in Cases 2 and 3). Meanwhile, CSF could not be obtained in the two other cases (Cases 1 and 4). In all four cases, the RFU-guided LCSFD with a single puncture was successfully performed without any complications. Postprocedural comments were obtained from three patients (Cases 1, 3 and 4). They assumed that the latter LCSFD was less harmful than the initial attempt.

Table 1.

Summary of patients who failed an initial LD attempt at bedside.

Case no.	Age/Sex	GCS	BMI	Initial punc. (times)	Cause of failure	RAU punc. (times)
1	72/Female	13	35.9	7	Unable to tap	1
2	71/Male	8	27.4	8	Unable to deliver CA	1
3	84/Female	15	22.5	5	Unable to deliver CA	1
4	66/Female	15	43.5	11	Unable to tap	1

BMI: body mass index; CA: catheter; GCS: Glasgow Coma Scale; LD: lumbar drainage; punc.: puncture; RAU: rotational angiographic unit.

Discussion

Initial attempts at LCSFD are usually performed at the bedside; however, technical failure can occasionally occur as a result of the blind maneuvering. Image guidance is often requested in case of a postoperative instrument and/or osseous fusion, extensive degenerative change, or scoliosis.⁵ Bedside LCSFD has been more challenging for physicians owing to the increasing incidence of obesity in the general population. In fact, three (75%) of the four patients in the present study were obese (Table 1: Cases 1, 2 and 4). Obese patients cannot usually roll on the bed in the lateral decubitus position. Their lumbar spinous processes cannot be palpated. Moreover, a longer needle, which makes lumbar puncture more difficult to perform, is required because of excessive subcutaneous fat. Persistent repeat procedures may be considered as torture in an era wherein minimally invasive procedures are preferred. Therefore, some authors have reported procedures, such as fluoroscopic-, CT-, and ultrasonography-guided lumbar puncture and LCSFD.^2–4

Despite the fact that ultrasonography can be used at the bedside without radiation exposure, the success rate of lumbar puncture was approximately 76%–96%.^4,6 Various results have suggested that ultrasonography is strongly dependent on the operator’s skill. Moreover, it can locate only the interspinous space. In contrast, the success rate both of the fluoroscopic- and CT-guided lumbar puncture and LCSFD was approximately 100% ^2,3 Although CT guidance is advantageous because it can directly visualize the thecal sac, radiation exposure both for patients and operators remains an issue.

Rotational acquisition is a useful supplementary tool to percutaneous vertebroplasty for patients with vertebral body compressed fracture. The radiation exposure to a patient with a single rotational acquisition may be reduced compared to a standard CT study with the quality of images similar to that of CT scans.⁷ Rotational acquisitions with 2D and 3D reconstruction were immediately obtained, and they provided operators a visualized surgical plan on the workstation. Once an ideal puncture point is determined, it is indicated by a laser pointer on the patient’s skin surface. We can make a trajectory of the needle at the widest interspinous space. The live fluoroscopy helps the needle to advance forward to the correct direction and depth. The placement of the spinal catheter can be confirmed. Although we did not use contrast media, it may be useful in procedures, such as dry tap. We did not feel the issue of the motion gap by respiration during the procedures. When the gap is wide, we can notice by the discrepancy between the crossed red laser lines and the live fluoroscopy.

The present study had several limitations. First, the small sample size was the major limitation of the study. Second, the patients, who were receiving intensive care, were required to transfer to a narrow operative table in the prone position in the RFU. Third, the cost cannot be excluded when the current procedure becomes routine practice.

Conclusions

Herein, we present the use of RFU-guided LCSFD for patients with an unsuccessful initial attempt at bedside. In our four cases, the RFU-guided LCSFD with a single puncture was successfully performed without any complications. Persistent repeat procedures using a large-caliber needle may be considered as torture in an era wherein minimally invasive procedures are preferred. Postprocedural comments were obtained from three patients. They assumed that the latter LCSFD was less harmful than the initial attempt. Therefore, RFU-guided LCSFD is a technically reliable procedure and is less harmful than a conventional blind procedure for patients who encounter difficulties during the procedure.

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.