Lumbar puncture &Bone marrow aspiration Dr.M.Torfehnezhad Pediatrician

Cardinal Symptoms of Cancer in Children. Unusual mass or swelling Cardinal Symptoms of Cancer in Children Unusual mass or swelling Unexplained paleness & loss of energy Sudden tendency to bruise Persistent, localized pain or limping Prolonged, unexplained fever/illness Frequent headaches, often with vomiting Sudden eye or vision changes Excessive, rapid weight loss Fever and pain are common symptoms seen in pediatrics-so it’s understandable how diagnosis could be delayed if these signs/symptoms are brushed off as minor ailments

Common Forms of Childhood Cancer. Leukemia. Lymphoma Common Forms of Childhood Cancer Leukemia Lymphoma Brain & CNS tumors Bone Solid tumors Soft tissue tumors Luekemia- Acute Lymphoctyic Leukemia & Acute Myelogenous Leukemia (Acute nonlymphoblastic leukemia) Lymphoma- Non-Hodgkin & Hodgkin Brain & CNS Tumors- gliomas, medulloblastomas, cerebellar astocyoma, ependymoma Bone- Osteosarcoma & Ewing sarcoma Soft tissue sarcomas-A cancer that begins in the muscle, fat, fibrous tissue, blood vessels, or other supporting tissue of the body- like Rhabdomyocarcoma Solid tumors are tumors that do no contain cysts or liquids like Wilms tumor

Peak incidence of tumors vary by age-here is a breakdown by ages-Under the age of 14- leukemia most prevalent

Diagnostic Tests. Lumbar puncture. Bone marrow aspiration Diagnostic Tests Lumbar puncture Bone marrow aspiration Bone marrow biopsy Radiographic examinations CT MRI Ultrasound Biopsy of tumor LP- looking for infection, cancer cells Bone marrow aspiration-examine the bone marrow to determine type of leukemia, biopsy Intrathecal-Describes the fluid-filled space between the thin layers of tissue that cover the brain and spinal cord. Drugs can be injected into the fluid or a sample of the fluid can be removed for testing.

Lumbar Puncture

The history 1889- First procedure to access the dural space consisted of a cut down procedure to help decrease intracranial pressure in people in TB meningitis by Walter Essex Wynter 1891- The first needle was used to access the dural space by Heinriche Quincke 1898- Karl August Bier and his assistant August Hildebrandt attempted first spinal anesthetic by doing lumbar punctures on each other with injection cocaine into the intrathecal spaces

Indications for Lumbar Puncture Diagnosis of central nervous system (CNS) infection Diagnosis of subarachnoid hemorrhage (SAH) Evaluation and diagnosis of demylinating or inflammatory CNS processes Infusion of anesthetic, chemotherapy, or contrast agents into the spinal canal Treatment of idiopathic intracranial hypertension

Diagnostic Test for infectious and noninfectious neurologic conditions Rarely diagnostic as a single agent Combine with history, physical and selected lab tests

Contraindications Skin infection near site of LP Suspicion of intracranial pressure due to cerebral mass Uncorrected coagulopathy Acute spinal cord trauma

Contraindications Elevated Intracranial pressure- head trauma, Intracranial mass (especially in the posterior fossa) Cutaneous infection overlying the site Noncommunicating hydrocephalus Coagulopathy (thrombocytopenia is relative contraindication though no trials show increased risk of bleeding)

Technique Lateral Recumbent position Sitting upright

Procedure Determine correct level of entry Highest points of the iliac crests should be identified and palpated Direct line joining the crests identifies L4 Spinous processes L3, L4, and L5 can be directly palpated Goal: Subarachnoid space at L3/4 or L4/5

Positioning: Key to Success Fetal position with neck, back, and limbs held in flexion Lower lumbar spine flexed with back perfectly perpendicular to edge of bed Hips and legs should be parallel to each other and perpendicular to table

Positioning INCORRECT CORRECT

Skin Preparation Overlying skin cleaned with povidone-iodine Sterile drape placed with an opening over the LS

Spinal Needle Insertion Local anesthesia infiltrated 20 or 22 gauge spinal needle with stylet Advance spinal needle slowly, angling slightly toward the head Flat surface of bevel of needle positioned to face patient’s flanks

Collecting CSF 4 – tubes 8-12 drops, 1-2 ml. Cytology more than 4 ml. Ordering/labeling your CSF samples correctly.

Anatomy 4 5

Lumbar Puncture needles of all sizes

The Procedure Palpate the posterior superior iliac crest bilaterally, and move medially to the spine and find the L3-L4 intervertebral space with the patient in either fetal position in a lateral recumbent position or hunched over in a sitting position as determined by your needs Palpate the L2-L3 and L4-L5 spaces above and below, mark the appropriate space that you want to enter, preferably with the cap of a pen or something that causes an indentation that won’t be erased during sterilization Open the kit, and put on sterile and prep the kit, assembling the opening pressure gauge and opening the bottles and having them lined up and numbered, and having the lidocaine drawn up Prep the area with betadine, avoid chloroprep as this can cause an aseptic meningitis, then drape the area to create a sterile field

Procedure Continued…. Anesthetize the area using initially a 25 gauge needle to raise a wheal, and then a 20 gauge needle to hit deeper structure create a wide arc during anesthetizing, in case another level will need to be done, the needle should aspirated each time prior to administration to ensure no blood is present (The lumbar puncture needle itself can be used for deeper structures Insert the needle in a cephalic direction towards the umbilicus, orient the bevel parallel to the longitudinal dural fibers, to decrease the chance of you cutting them (** in a lateral recumbent position this should mean the bevel is facing up, in a sitting position, means the bevel should be facing sideways ) Advance the needle with occasionally removing the stylet to ensure no fluid return, in normal adults the needle will have to inserted 4-5cm before getting close to the dural space, if no fluid is returned replace the stylet and either advance or withdraw the needle and recheck if bone is struck at shallow depth, redirect needle more cephalad; if at deeper depth – more caudally

Complications Uncal herniation Epidural/perivertebral abscess Paresthesias- temporary or permanent Post lumbar puncture headache Spinal or epidural bleeding Adhesive arachnoiditis Late onset of epidermoid tumours to thecal sac Back pain

CSF analysis Gram stain: Sensitive in 60-80% of bacterial meningitis and 40-60% range in partially treated bacterial meningitis Cytology: determyning the type & number of cells Protein - can be adjusted to RBC by decreasing protein concentration by 1 mg/dL or .01g/L for every 1,000 RBC/mm3 but both levels have to be drawn from the same tube. Is the most sensitive indicator of intracranial pathology but not very sensitive. Also, normal levels vary a lot from lab to lab. Glucose- normally 60% of serum glucose, though in severe hyperglycemia this ratio breaks down as CSF glucose levels do not exceed 300mg/DL

The End

Aspiration of the BM Satisfactory samples can usually be aspirated from the Sternum Anterior or posterior iliac spines Aspiration from only one site can give rise to misleading information; this is particularly true in aplastic anaemia as the marrow may be affected partially.

Bone Marrow Aspiration

BM Aspiration BM Biopsy

Normal marrow

BM biopsy hypocellular ,increased fat spaces Hypoplastic marrow Case History My oncologists explained Aplastic Anemia, and my treatment options. A bone marrow transplant was one option, but even with a related donor match, at age 41, my odds of survival were quoted at around 60%. A third option that they presented was High Dose Cyclophosphamide which was experimental (the same chemotherapy that they use before a bone marrow transplant), without the Bone Marrow Transplant. Immunosuppressent treatment (ATG) was another option. BM biopsy hypocellular ,increased fat spaces

There is little advantage in aspirating more than 0 There is little advantage in aspirating more than 0.3 ml of marrow fluid from a single site for morphological examination as this increases peripheral blood dilution.

Bone marrow aspirate A bone marrow film should first be examined macroscopically to make sure that particles or fragments are present. Bone marrow aspirates which lack particles may be diluted with peripheral blood and may therefore be unrepresentative. An ideal bone marrow film with particles is shown.

Cells of the bone marrow Erythroid series Myeloid series Megakaryocytic series

Systemic scheme for Examining aspirated BM films Low power (x10) Determine cellularity Identify megakaryocytes Look for clumps of abnormal cells Identify macrophages

Systemic scheme for Examining aspirated BM films Higher power (x40, x100) Identify all stages of maturation of myeloid and erythroid cells. Determine the M:E ratio Perform a differential count Look for areas of BM necrosis. Assess the iron content.

Only after the bone marrow has been carefully assessed on low and medium power should the X100 oil be used to assess cellular detail.

Points to be considered in BMA reporting The M:E ratio is the ratio of all granulocytic plus monocytic cells (Myeloid) to all erythroblasts (Erythroid). For all bone marrow aspirates examined, the report should specify the M:E ratio and the percentage of lymphocytes and plasma cells. A differential count of at least 200-300 cells should be performed. If there is any borderline abnormality, e.g. in the number of blasts, lymphocytes or plasma cells, a 500 cell differential count should be performed.

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