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Cerebrospinal Fluid Leakage After Lumbar Puncture in Neonates: Incidence and Sonographic Appearance

¹ All authors: Department of Pediatrics, University Hospital Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.

Received September 23, 2002; accepted after revision January 2, 2003.

 
Address correspondence to I. Gaßner.

Abstract

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OBJECTIVE. The purpose of this article is to review the incidence and sonographic appearance of cerebrospinal fluid leakage after lumbar puncture in the neonatal period. Thirty-three neonates underwent spinal sonography after diagnostic lumbar puncture. A total of 21 of these patients showed cerebrospinal fluid leakage into the epidural space extending from the level of the cauda equina to the lumbar (n = 9), the thoracic (n = 8), or the cervical (n = 4) region. In eight patients, the subarachnoid space was markedly compressed by the epidural fluid collection.

CONCLUSION. Cerebrospinal fluid leakage into the epidural space is a frequent complication of lumbar puncture in neonates and has a characteristic appearance on sonograms. Leakage after lumbar puncture must be differentiated from cerebrospinal fluid leakage due to perinatal meningeal injury. If cerebrospinal fluid leakage at the puncture site compresses the subarachnoid space, sonography assists in the performance of subsequent lumbar puncture.

Introduction

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Lumbar puncture for cerebrospinal fluid sampling is a routine procedure in the evaluation of fever and sepsis in the neonate and infant [1, 2]. Severe complications after lumbar puncture, such as compressive subdural hematoma, have been well documented and described in adults [3, 4]. Corresponding data in neonates are particularly scarce [5, 6], and to our knowledge, the incidence and sonographic appearance of cerebrospinal fluid leakage after lumbar puncture have not been described previously.

Using sonography, we systemically investigated 33 neonates after diagnostic lumbar puncture to determine the occurrence and extension of any abnormal fluid collection.

Subjects and Methods

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In this prospective study conducted at the department of pediatrics of University Hospital Innsbruck, sonography of the spine was performed in neonates who underwent lumbar puncture for the evaluation of sepsis, meningitis, or seizures. Four experienced operators conducted all examinations within 24 hr of lumbar puncture. During the study period—between February 1998 and October 2001—all neonates with diagnostic lumbar puncture were enrolled, except those who required ventilation or were clinically unstable and a few for whom a sonographic evaluation could not be obtained within 24 hr. The study follows the guidelines of the local ethics committee.

Lumbar puncture was performed using a 25-gauge, 25-mm spinal needle with a stylet (Yale spinal thin wall neonatal lumbar puncture needle 0.5 x 25 mm, Becton Dickinson, Madrid, Spain). Lumbar punctures were performed following a standardized protocol [7]. In all patients, spinal sonography was performed in the prone position with a high-resolution linear array transducer (5-12–MHz) using an HDI 5000 sonography unit (ATL, Bothell, WA). The presence and extent of fluid leakage was assessed.

Results

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In all, 33 neonates were eligible for this study. Mean patient age was 9.6 days (range, 0–21 days), and average gestational age was 35.9 weeks. In 10 infants, findings of spinal sonography performed before lumbar puncture were normal. Sonography after lumbar puncture was performed within a 24-hr period (usually within 8 hr). Sonographic findings fell into three categories: normal (n = 12) (Figs. 1A, 1B, 1C); visible fluid collection in the epidural space without significant compression of the subarachnoid space (n = 13); and visible fluid collection in the epidural space with nearly complete compression of the subarachnoid space (n = 8) (Figs. 2A, 2B, 2C). There was no significant difference between cerebrospinal fluid leakage in newborns with traumatic (6/9 neonates) and those with atraumatic (15/24 neonates) lumbar puncture. Fluid collections in the epidural space were characteristically anechoic, which is consistent with cerebrospinal fluid. They contained heterogeneous echogenic undulating structures, presumably "floating fat" (fat tissue of the epidural space with undulating and pulsatile movements). Typically, this epidural fat surrounded by anechoic cerebrospinal fluid showed a characteristic echogenic wave in the longitudinal view (Fig. 3A) and a triangular structure in the axial view (Fig. 2C).

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —14-day-old premature female infant (gestational age, 35 weeks) with normal spinal canal. Longitudinal sonogram of thoracic spine shows spinal cord (arrowheads) surrounded by anechoic cerebrospinal fluid (asterisks). Dura mater (arrows lies close to wall of spinal canal. V = vertebral bodies.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —14-day-old premature female infant (gestational age, 35 weeks) with normal spinal canal. Longitudinal sonogram of lumbar spine shows conus medullaris (arrowheads) and cauda equina (C) surrounded by anechoic cerebrospinal fluid (asterisks). Note dura mater (arrows). V = vertebral bodies.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —14-day-old premature female infant (gestational age, 35 weeks) with normal spinal canal. Axial sonogram of lumbar spine shows conus medullaris (arrowheads). + = epidural veins.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —27-day-old male neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Longitudinal sonograms of lumbar (A) and (B) spine show epidural cerebrospinal fluid collection (asterisks) with markedly compressed subarachnoid space and bundled cauda equina (C). Note floating fat (F) and shifted dura mater (arrows).

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —27-day-old male neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Longitudinal sonograms of lumbar (A) and sacral (B) spine show epidural cerebrospinal fluid collection (asterisks) with markedly compressed subarachnoid space and bundled cauda equina (C). Note floating fat (F) and shifted dura mater (arrows).

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —27-day-old male neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Floating fat (F) shows characteristic triangular structure on axial sonogram of sacral spine. Bundled cauda equina (C) is surrounded by epidural cerebrospinal fluid collection (asterisk). Note dura mater (arrows).

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —1-day-old male neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Longitudinal thoracic sonogram shows fluid accumulation asterisks (extending to high-thoracic level. Floating fat (F) shows characteristic wavy appearance.

In 12 of 21 neonates, fluid collections were extensive, involving the thoracic–lumbosacral spine in eight (Fig. 4A) and tapering to the cervical region in four patients. All patients who were reexamined 2–10 days after lumbar puncture (n = 5) showed complete resorption of fluid collection with no apparent sequelae (Fig. 4B).

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —3-day-old female neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Longitudinal sonogram of thoracic spine shows epidural cerebrospinal fluid collection (asterisks) tapering cranially at high-thoracic level. Note spinal cord (arrowheads) and shifted dura mater (arrows).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —3-day-old female neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Longitudinal sonogram at same level as A obtained 3 days after lumbar puncture shows complete resorption of epidural cerebrospinal fluid collection. Dura mater (arrows) lies close to wall of spinal canal. Note spinal cord (arrowheads).

Discussion

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Lumbar puncture for cerebrospinal fluid sampling is part of the routine evaluation of neonates suspected of having sepsis, meningitis, or seizures [1, 2]. Lumbar puncture cerebrospinal fluid may leak through the original puncture hole into the epidural space, thereby creating a confluent subarachnoid–epidural fluid reservoir. This phenomenon is well known as a complication from myelography, in which contrast material injected into the subarachnoid space may leak into the extradural space [8, 9]. This condition has been visualized on MR imaging after lumbar puncture in only a small series of pediatric patients, 3 weeks to 10 years old [6]. Compression of the thecal sac presumably due to hemorrhage after lumbar puncture was described by Coley et al. [5] as a reason for further futile lumbar puncture attempts. The frequency and extent of cerebrospinal fluid leakage in neonates is so far unknown. In this age group, there are no reliable clinical means to differentiate potential symptoms of cerebrospinal fluid leakage from those that prompted performance of lumbar puncture.

In our case series of 33 neonates, 21 showed cerebrospinal fluid leakage after lumbar puncture, as depicted on spinal sonography. Sonography is particularly suitable for the evaluation of epidural fluid collection after lumbar puncture in neonates because the incompletely ossified posterior arches allow an acoustic window to the thecal sac and cord structures [10]. In eight (38%) neonates with cerebrospinal fluid leakage, the fluid collection was prominent and extended to the thoracic region; in four patients, it extended to the cervical space. The anechoic sonographic appearance observed is characteristic of cerebrospinal fluid. This fluid contains heterogeneous echogenic undulating structures in the epidural space corresponding to the previously described MR imaging finding of "floating fat" [6] (Figs. 2B and 3B). This condition must be differentiated from cerebrospinal fluid leakage due to spinal meningeal injury during delivery. In such cases, the cervical and upper thoracic segments of the spine and its contents are more involved [11, 12]. Epidural fluid collections complicating such injuries usually taper caudally (Figs. 5A, 5B). Conversely, fluid collections occurring after lumbar puncture taper cranially (Fig. 4A).

View larger version (173K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —1-day-old male neonate born at term with cerebrospinal fluid leakage after lumbar puncture. Axial thoracic sonogram shows epidural fluid accumulation (asterisk) with floating fat (F). Note spinal cord (arrowheads) and shifted dura mater (arrows).

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —6-day-old male neonate born at term with brachial palsy and diaphragmatic paralysis after breech delivery. Longitudinal high-thoracic (A) and midthoracic (B) sonograms show marked epidural cerebrospinal fluid collection (asterisks) due to traumatic cervical meningeal tear tapering caudad to midthoracic level. Note spinal cord (arrowheads) and shifted dura mater (arrows)

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —6-day-old male neonate born at term with brachial palsy and diaphragmatic paralysis after breech delivery. Longitudinal high-thoracic (A) and midthoracic (B) sonograms show marked epidural cerebrospinal fluid collection (asterisks) due to traumatic cervical meningeal tear tapering caudad to midthoracic level. Note spinal cord (arrowheads) and shifted dura mater (arrows).

In eight (38%) of all neonates with cerebrospinal fluid leakage, marked or almost complete compression of the subarachnoid space occurred because of extensive epidural fluid collections (Figs. 2A, 2B, 2C). A completely obliterated subarachnoid space is one of the reasons for futile subsequent lumbar puncture attempts. On the other hand, a flow of spinal fluid may originate from a fluid collection in the epidural space in patients who have undergone a previous lumbar puncture. Therefore, obtaining a flow of fluid does not necessarily indicate a correct subarachnoid position of the needle tip. For this reason, it is generally recommended that diagnostic puncture should not be performed for several days before myelography [8].

In conclusion, we have shown that cerebrospinal fluid leakage is a frequent condition after lumbar puncture in neonates. We have illustrated the typical sonographic appearance of these fluid collections. These collections may be extensive and may completely compress the thecal sac.

References

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