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1598 Procedures, Interventions, Operations

97 Miscellaneous Surgical Procedures

97.1 Percutaneous ventricular puncture

97.1.1 Indications
In pediatrics, may be used to remove hemorrhagic ventricular fluid following intraventricular hem-
orrhage, or to obtain CSF specimen in cases of suspected ventriculitis. May be used emergently in
pediatrics or adults as a temporizing measure in patients herniating from obstructive
hydrocephalus.

97.1.2 Peds
Clip hair. 5 minute Betadine® prep.
The right side is preferred. Enter through coronal suture just lateral to anterior fontanelle (AF)
using a 20–22 Ga spinal needle. If a CT scan has been done, it may be used to help judge angulation
(usually varies between contra- and ipsi-lateral medial canthus and intersection with EAM).

97.1.3 Adult
See reference.1
Only used emergently. Takes advantage of thin orbital roof in adult.
Prep conjunctiva and skin with antiseptic (e.g. ophthalmic betadine). Elevate the eyelid and
depress the globe. Using a 16–18 Ga spinal needle, penetrate the anterior third of orbital roof (1–
2 cm behind orbital rim) with firm pressure (may need gentle tapping). Aim at coronal suture in the
midline. The frontal horn should be about 3–4 cm deep.

97.2 Percutaneous subdural tap

97.2.1 Indications
Utilized in pediatrics. Used to be done for diagnostic purposes, but this has been supplanted by CT,
MRI & ultrasound. Currently, this procedure may be used emergently for decompression, to drain
subdural collections and to obtain fluid for diagnostic tests, such as culture (repeat taps may be used,
but surgery should be considered after ≈ 5–6 taps).

97.2.2 Technique
Clip hair. Prep 5 minutes with povidone iodine (Betadine®). Using a short 20–21 Ga spinal needle
(spinal needle is recommended because the stylet may reduce the risk of implanting epidermal cells
into the CNS), penetrate the lateral margin of the anterior fontanelle (AF) or coronal suture at least
2 cm off midline. Remove the stylet and aspirate. With bilateral fluid collections, bilateral taps should
be done.

97 97.3 Lumbar puncture

97.3.1 Contraindications
1. risk of tonsillar herniation (see below)
a) known or suspected intracranial mass
b) non-communicating hydrocephalus
2. infection in region desired for puncture: choose another site if possible
3. coagulopathy
a) platelet count should be > 50,000/mm3 (p. 168)
b) patient should not be on anticoagulants because of risk of epidural hematoma (p. 1184) or
subarachnoid hemorrhage2 with secondary cord compression
4. use caution in suspected aneurysmal SAH: excessive lowering of the CSF pressure increases the
transmural pressure (pressure across the aneurysm wall) and may precipitate rerupture
5. caution in patients with complete spinal block: 14% will deteriorate after LP3
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Miscellaneous Surgical Procedures 1599

6. relative contraindication: Chiari malformation. There is some evidence that draining CSF may
precipitate herniation. This is less of a concern with successfully surgically treated Chiari
malformation.

Elevated ICP and/or papilledema by themselves are NOT contraindications (e.g. LP is actually used
diagnostically and as a treatment in idiopathic intracranial hypertension, see below).

97.3.2 Technique
Background and anatomy
The spinal cord and column are the same length in a 3-month fetus. After that, the spinal column
grows faster than the cord. As a result, the conus medullaris is located rostral to the termination of
the thecal sac in the adult, situated between the middle thirds of the vertebral bodies of L1 and L2 in
51–68% of adults (the most common location), T12–1 in ≈ 30%, and L2–3 in ≈ 10% (with 94% of cords
terminating within the territory of L1 and L2 vertebral bodies).4 The thecal sac ends ≈ S2. The tips of
the spinous processes as palpated on the surface are located caudal to the corresponding VB. The
intercristal line (connecting the superior border of the iliac crests) crosses the spine at the L4 spinous
process or between the L4 and L5 spinous processes in most adults.

Procedure
Position: the procedure is usually performed in the lateral decubitus position. As the needle is
advanced, it is helpful to have the patient bring the knees up and to flex the neck in order to open
up the spaces between the posterior elements of the spine.
For diagnostic LP, a 20 Ga spinal needle is often selected. Larger needles (e.g. 18 Ga) may be used
e.g. with pseudotumor cerebri to encourage post-procedure drainage of CSF into the soft tissues of
the back.
The back is prepped and draped to create a sterile working area.
Entry point: in an adult, use the L4–5 interspace in most cases (located at or just below the inter-
cristal line) or 1 level higher (L3–4). Peds: L4–5 is preferred over L3–4.
The needle is always advanced with the stylet in place at least through the skin and some subcuta-
neous tissue to avoid introducing epidermal cells, which may cause iatrogenic epidermoid tumors;
see Complications following LP (p. 1600). The needle is aimed slightly cranially (to parallel the spi-
nous processes) and usually a little down towards the bed (aiming towards the umbilicus). If a
Quincke LP (standard) needle is used, the bevel is turned parallel to the length of the spinal column
to reduce the risk of post-LP H/A (p. 1603). In general, if bone is encountered it is more often due to
deviation from a true midline trajectory rather than a failure to aim correctly in the rostral-caudal
direction. The needle should be withdrawn to just below the skin surface before attempting a new
trajectory.
If during insertion of the needle the patient experiences pain radiating down one LE, this usually
indicates that a nerve root has been encountered. The needle should be withdrawn immediately and
reinserted aiming more towards the side contralateral to the extremity that experienced the pain.
The stylet is removed at intervals during the insertion to look for CSF (a distinct pop is sometimes
felt as the needle penetrates the dura).
Once CSF flows, the needle is connected to a manometer through a 3-way stopcock, the pressure
is measured and recorded (see below), and CSF is drained into sterile tubes (1–2 ml for each tube)
for laboratory analysis (see below). The practitioner should also note the color of the fluid (clear, 97
blood tinged, xanthochromic…) and the clarity (clear, cloudy, purulent…).
At the end of the procedure, the stylet should be replaced before the needle is withdrawn (to
reduce post-LP H/A, see below).
Opening pressure: The opening pressure (OP) should be measured and recorded for every LP. To
be meaningful, the patient should be lying down and as relaxed as possible (should not be in forced
fetal position), with the bed flat. The variation of pressure with respirations is usually a good indica-
tion of a communicating fluid column (the fluctuation is in-phase with the respiratory pressures in
the inferior vena cava, rising with inspiration and falling with expiration5). Normal values: in the left
lateral decubitus position, average OP = 12.2 ± 3.4 cm H2O (8.8 ± 0.9 mm Hg).6 Also, see ▶ Table 23.1
for peds.
Queckenstedt’s test: if a subarachnoid block is suspected (e.g. from spinal tumor), compress the
jugular vein (JV) first on one side then on both (do not compress carotid arteries). If there is no block,
the pressure will rise to 10–20 cm of fluid, and will drop to the original level within 10 seconds of
release of the JV.7 (p 11) Do not do JV compression if intracranial disease is suspected.
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1600 Procedures, Interventions, Operations

Table 97.1 Routine tests for CSF

Test If there is no concern about possible If there is concern
traumatic tap about traumatic tap
cell count Tube 1
gram stain + C & S (culture & sensitivity) Tube 1 Tube 2
protein and glucose Tube 2 Tube 3
cell count Tube 3 Tube 4

97.3.3 Laboratory analysis

Routinely, three tubes are sent for analysis as shown in ▶ Table 97.1. See ▶ Table 23.4 for interpreting
the results of the laboratory analysis.
If the tap is possibly traumatic (i.e., bloody), or if having an accurate cell count is essential (e.g. to
R/O SAH) then 4 tubes are collected, and the first and last are sent for cell counts and are compared;
see Traumatic tap (p. 1600).
If special cultures are required (e.g. acid-fast, fungal, viral) they are also specified on the tube for
culture & sensitivity (C & S).
If CSF for cytology is desired (e.g. to R/O carcinomatous meningitis or CNS lymphoma), then at least
10 ml of CSF must be sent in one tube to pathology (where it is spun down, and examined for cells).

97.3.4 Mining useful data with a traumatic tap

General information
A traumatic tap (TT) occurs when the spinal needle damages a blood vessel with the result that (usu-
ally venous) blood either alone or admixed with CSF will be obtained.

Estimating true WBC count in CSF with a traumatic tap

When many RBCs and WBCs are present in the CSF due to a traumatic tap (TT), it is difficult to know
if there is a true leukocytosis on the CSF. It may help to determine if the WBCs are elevated or if they
are present in the same ratio as in the peripheral blood. In non-anemic patients, there should be ≈
1–2 WBCs for every 1000 RBCs (as a correction8 (p 176): subtract 1 WBC for every 700 RBCs8 (p 176)). In
the presence of anemia or peripheral leukocytosis, use Fishman’s formula8 (p 176) shown in Eq (97.1)
to estimate the original WBC count in the CSF before the TT,

WBCBlood # RBCCSF
WBCCSF Original ¼ WBCCSF " ð97:1Þ
RBCBlood

where WBCCSF original = WBC count in the CSF before the TT, WBCCSF & RBCCSF = WBC & RBC counts
measured in the CSF, and WBCBlood & RBCBlood = WBC & RBC per mm3 in the peripheral blood.

Estimating true total CSF protein content with a traumatic tap

97 If the hemogram and peripheral protein are normal, then have the cell count and protein content
run on the same tube, and the correction is8 (p 176):
● subtract 1 mg per 100 ml of protein for every 1000 RBC per mm3

Differentiating SAH from traumatic tap

See typical findings in SAH (p. 1221). Some features helpful in differentiating SAH from TT are shown
in ▶ Table 97.2.

97.3.5 Complications following LP

General information
The overall risk of disabling or persistent symptoms (defined as severe H/A lasting > 7 days, cranial
nerve palsies, major exacerbation of preexisting neurological disease, prolonged back pain, aseptic
meningitis, and nerve root or peripheral nerve injuries) has been estimated at 0.1–0.5%.9 Severe side
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Miscellaneous Surgical Procedures 1601

Table 97.2 Features distinguishing traumatic tap from SAH

Feature Traumatic tap (TT) SAH
RBC count (and gross declines as CSF drains usually > 100,000 RBCs/mm3 , changes little
appearance of bloodiness) (compare first tube to last as CSF drains
tube)
ratio of WBC:RBC similar to the ratio in peripheral usually promotes a leukocytosis (elevated
blood (above) WBC count)
supernatant clear xanthochromica (rarely in < 2 hrs, present in
70% by 6 hrs, and > 90% by 12 hrs after SAH)
clotting of fluid usually clots if erythrocyte usually does not clot
count > 200,000/mm3
protein concentration fresh bleeding elevates CSF blood breakdown products elevate this more
protein from normal by only ≈ than TT (measured protein exceeds the sum
1 mg per 1000 RBC of normal protein + 1 mg protein/1000 RBC)
repeat LP at higher level usually clear remains bloody
opening pressure usually normal usually elevated
aNB: other conditions can cause xanthochromia

effects, which include brainstem herniation, infection, subdural hematoma or effusion, and SAH, are
rare.10 (p 171–2)

Possible complications
1. tonsillar herniation
a) acute herniation in the presence of mass lesion (see below)
b) chronic tonsillar herniation (acquired Chiari 1 malformation): this has been reported after
multiple traumatic LPs with presumed post-LP CSF leak11
2. infection (spinal meningitis)
3. “spinal headache”: usually positional (diminishes with recumbency) (see below)
4. spinal epidural hematoma (p. 1184): usually seen only with coagulopathy
5. spinal epidural CSF collection: may be fairly common in patients with post-LP H/A. Usually
resolves spontaneously
6. epidermoid tumor: risk may be increased by advancing LP needle without stylet (transplanting
a core of epidermal tissue)12,13,14
7. impinging nerve root with needle: usually causes transient radicular pain, may cause perma-
nent radiculopathy in some
8. intracranial subdural hygroma or hematoma15,16 (rare)
9. vestibulocochlear dysfunction17:
a) subclinical (demonstrated on audiogram) or moderate reduction in hearing may occur, and
seems to correlate with post-procedure CSF leakage. Most studies show reduction is at
frequencies < 1000 Hz
b) sudden hearing loss may occur. Perform audiogram to quantify loss. Treat with bedrest for
several days, prednisone 60 mg/d tapered over 2–3 weeks
c) pathogenesis: reduced CSF pressure may reduce perilymph pressure through the cochlear aqueduct 97
(may be especially pronounced with a patent aqueduct),18 producing endolymphatic hydrops
10. ocular abnormalities
a) abducens palsy: almost invariably unilateral. Often delayed 5–14 days post-LP, usually
recovers after 4–6 wks19
11. dural sinus thrombosis20 (usually with underlying thrombophilia)

Risk of acute tonsillar herniation following lumbar puncture

The question of when to do LP first (to save time) and when to obtain CT scan first to R/O intracranial
mass (for safety) before performing an LP is controversial.

Issues
The time delay to initiating antibiotics is the most important variable in the outcome of meningitis.
Mortality increase 13% per hour delay in treatment.21 Time may be more crucial in community