AJR 2003; 181:231-234
© American Roentgen Ray Society
Cerebrospinal Fluid Leakage After Lumbar Puncture in Neonates: Incidence and Sonographic Appearance
Ursula Kiechl-Kohlendorfer1,
Karin Maria Unsinn,
Barbara Schlenck,
Rudolph Trawöger and
Ingmar Gaßner
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
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
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
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
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).
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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.
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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.
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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).
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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).
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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).
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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.
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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).
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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).
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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).
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Discussion
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).
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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).
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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)
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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).
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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.
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Abstract
Introduction
