Lumbar Puncture
Q: What is the purpose of reviewing the patient's imaging prior to the procedure?
A: Review images of the head to exclude mass effect, mass lesion.
Review imaging of the lumbar region (including body CT, MRI) to see that levels are possible candidates for LP.
If the conus ends at a relatively high position, you can consider a higher level.
If the thecal sac is large inferiorly, you can consider a lower level.
CT can often show you the level with the most space, which side to use, etc.
Please refer to the attached LP checklist created by Hannah Rappaport BI '14
Q: What contrast do we use for myelography?
A: Omnipaque 240 for adults (Use 180 for children)
Q: What does 240 mean?
A: 240 mg Iodine/ml
Q: How much can we use?
A: About 3 grams of iodine, for Omnipaque 240 about 12 ml or for Omnipaque 300 10ml
Package insert states 3060 mg which works out to 12.75 ml (why such a random number? Original clinical trial used 17 ml of Omnipaque 180 or 3060 mg of Iodine)
for pediatric cases, see the package insert!
Q: What dose do you use for cisternogram?
A: 8 ml of Omnipaque 240
Q: What happens if we use the wrong contrast (e.g. hypaque)
A: Spinal seizures, death
See this case from 2014 in Boston
They apparently used MD-76 instead of Omnipaque.
package insert is attached below
or google " md-76 contrast" for the package insert
From the package insert for Hypaque:
Severe adverse reactions have been reported due to the inadvertent intrathecal administration of iodinated contrast media that are not indicated for intrathecal use. These serious adverse reactions include: death, convulsions, cerebral hemorrhage, coma, paralysis, arachnoiditis, acute renal failure, cardiac arrest, seizures, rhabdomyolysis, hyperthermia, and brain edema. Special attention must be given to insure that this drug product is not administered intrathecally.
Reference:
Package insert for Omnipaque (note that some concentrations are not approved for myelography)
ACR Guideline for Myelography
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/myelog-cisternog.pdf
Masks for procedures
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516477/pdf/nihms-1025152.pdf
Q: Who was Semmelweiss
A: He was an advocate of antiseptic procedures during childbirth. No on listened to him. He went insane. He died 2 weeks after being committed after a beating by guards, in 1865 at age 47.
http://en.wikipedia.org/wiki/Ignaz_Semmelweis
Then Louis Pasteur came up with germ theory
http://en.wikipedia.org/wiki/Louis_Pasteur
Compare and contrast this to the fate of Joseph Lister
http://en.wikipedia.org/wiki/Joseph_Lister,_1st_Baron_Lister
Who was the inspriation for the name "Listerine" first formulated as a surgical antiseptic by Lawrence and Lambert
Its use as a mouthwash became popular in the 1920s
http://en.wikipedia.org/wiki/Listerine
References
https://jamanetwork.com/journals/jama/fullarticle/203808