Lumbar Puncture / Myelogram:

 

How to do a fluoro guided Lumbar Puncture

by sgmd

as done by LB DO Neuroradiologist

 

review prior imaging:  MR, CT

*for myelo, want to put contrast into thecal sac to look at nerve roots, possibly rule out dural tear

 

LB likes pt. prone

he prefers going between spinous processes at the l2-l3 level, can also go in the interlaminar space

pt. prone on table

use metal marker and marking pen to find the l2-l3 level

use the natural longitudinal line in the patients back as help

Can move tube and I.I. from PA to lateral to check needle position (how deep needle is within patient)

clean skin, prep skin, drape skin

use two needles for lido, one superficial, one deep, inject lido as your withdraw and make sure to numb deep

advance needle through spinous processes, want to drive needle right between spinous processes

spinous processes are angled, you can tilt tube, radiator goes cranial, I.i goes caudal, this helps you look down the barrel of the spinous processes

can check on lateral to see if between spinous processes

sometimes hit the edge of the lamina and have to "walk off the bone into thecal sac

once in the sac, if no return of fluid when removing stylet, can ask pt. to valsava or lower feet to help csf flow

take samples now

 

if doing myelogram:

then take 20 cc syringe filled with contrast attached to tubing ( no bubbles **)

when csf flush to the hub, attach tubing

inject 12 cc of contrast as per LB, slowly about 1-2 cc/ sec

take fluoro shots to save the image of the myelogram

then remove needle and place ban aid

 

procedure compete

send for CT

 

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Kyphoplasty:

As per JF

 

Helpful to have kyphon guy around

 

For single level bipedicular approach

 

Localize level using biplane fluoro. Want to see end on appearance of the pedicles.  Can mag up if needed.

Prep and drape.

Use towel holder device to mark sites for trocar needle advancement. 

Give lidocaine, advance needle to pedicle and give local at this site.

Start with side closest you, usually left.

Make skin nick.

Start with 12G trocar needle (stylet-cannula device).  The stylet may be diamond tipped or beveled

Using sterile hammer, guide trocar needle down pedicles and into vertebral body.  Take time, use biplane fluoro for guidance.  Avoid medial placement and injury to central canal.  Want slight angulation of cannulas toward midline.  Want to avoid cranial or caudad angulation on lateral.  Use towel clamp to change angle of cannulas.

Once have cannula well seated within vertebral body (both sides for bipedicular), can create cavity using gun like device

Use device to carve out space medially.

Once cavity is created, can perform height augmentation.

Fill up insufflation devices with dilute contrast, purge air from device. 

Attach to specifc port on balloon device.

Advance balloons through cannulas and insufflate for 2-3 minutes.

Make cement mixture

Pour cement into mixer, add liquid from the glass bottle, mix virgorously for 30 sec-1 min

The device will then fill two capsules worth of cement.  The device is set up with multiple luer connectors which you can figure out

Use plunger to fill both capsules with cement.  Have to work relatively quickly.

Using the cement infusion device, attach cement capsule.

Pump up device to increase pressure and start infusing cement into cavities under fluoro guidance

Want to fill cavity and interstices of fracture without extrav’ing cement.  Of note, more runny cement has more chance of causing nontarget embolization which is known complication.

After satifsfied with cement infusion, remove all devices from patient.

Take post image and store.

 

For post procedure, neuro checks are needed for slim possibility of causing cord or cauda equina injury.

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LESI

 

lumbar epidural steroid injection

 

CG method

loc l3-l4 level on biplane

advance 22g spinal through interspinous or interlaminar line

watch on lateral

want to get to spinolaminar line

attach glass syringe and put pressure to compress air

when air decompresses, you are within epidural space

if you get CSF- your in too deep

inject contrast- you should see epidural lining

should see some filing defects- air you injected

injected steroid mixture - various mixtures out there 

pull needle and done

can do air phase if wanted