Is spinal anesthesia not enough for major abdominal procedures of neonates?

Intrathecal Injections in Children With Spinal Muscular Atrophy: Nusinersen Clinical Trial Experience

Nusinersen (ISIS-SMNRx or ISIS 396443) is an antisense oligonucleotide drug administered intrathecally to treat spinal muscular atrophy. We summarize lumbar puncture experience in children with spinal muscular atrophy during a phase 1 open-label study of nusinersen and its extension. During the studies, 73 lumbar punctures were performed in 28 patients 2 to 14 years of age with type 2/3 spinal muscular atrophy. No complications occurred in 50 (68%) lumbar punctures; in 23 (32%) procedures, adverse events were attributed to lumbar puncture. Most common adverse events were headache (n = 9), back pain (n = 9), and post-lumbar puncture syndrome (n = 8). In a subgroup analysis, adverse events were more frequent in older children, children with type 3 spinal muscular atrophy, and with a 21- or 22-gauge needle compared to a 24-gauge needle or smaller. Lumbar punctures were successfully performed in children with spinal muscular atrophy; lumbar puncture-related adverse event frequency was similar to that previously reported in children.

Modified 45-degree head-up tilt increases success rate of lumbar puncture in patients undergoing spinal anesthesia

PURPOSE

Lumbar puncture (LP) is one of the most common procedures performed in medicine. The aim of this prospective study is to determine the success rate of LP in lateral decubitus with 45-degree head-up tilt position, and compare it with traditional positions like sitting and lateral decubitus.

METHODS

Three hundred and thirty patients between 25 and 85 years of age who had undergone abdominal, urologic, and lower limb extremities surgeries were enrolled and 300 patients were divided into three different groups. The LP was performed with a 25-G atraumatic needle, either in the standard sitting position (group S, n = 100), lateral decubitus, knee-chest position (group L, n = 100) or lateral decubitus, knee-chest position with a 45-degree head-up tilt (group M, n = 100). The free flow of clear cerebrospinal fluid (CSF) upon first attempt was considered to be evidence of a successful LP.

RESULTS

Total LP success rate was significantly higher in group M (85 %) than in groups S and L (70 and 65 %, respectively) (p = 0.004). When the significance between the groups was evaluated according to age, the increase in the LP success rate was not significant for ≤65 and >65 age groups. There were no differences among the three groups in terms of bloody CSF (p = 0.229) and the number of attempts before dural puncture (p = 0.052).

CONCLUSIONS

The lateral decubitus in knee-chest position with a 45-degree head-up tilt may be the preferred position for spinal anesthesia in young and elderly patients, due to the high success rate.

Sitting or tilt position for infant lumbar puncture does not increase ultrasound measurements of lumbar subarachnoid space width

OBJECTIVE

The objective of this study was to determine whether subarachnoid space width at the site of lumbar puncture in infants changed between 3 positions: flat lateral decubitus, 45-degree tilt, and sitting.

METHODS

Healthy infants younger than 4 months presenting electively to a pediatric radiology department were enrolled. Exclusion criteria included signs of dehydration, illness, or previous spine/brain surgery. Subarachnoid space width at L3-L4 was measured by ultrasound with the subject placed in 3 randomly ordered positions: flat lateral decubitus, 45-degree tilt lateral decubitus, and sitting. The 3 positions were collectively compared using both repeated-measures analysis of variance and linear mixed models (LMMs) adjusted for potential confounders. Pairs of positions were compared using LMM adjusted for potential confounders.

RESULTS

Fifty subjects were enrolled (15 male and 35 female patients). Patient weight was significantly correlated with subarachnoid space width (P = 0.02). There was no statistically significant difference in subarachnoid space width between the 3 positions (repeated-measures analysis of variance P = 0.32, LMM P = 0.40). Comparisons of pairs of positions were not significantly different: flat and 45 degrees P = 0.24, 45 degrees and sitting P = 0.98, and flat and sitting P = 0.23.

CONCLUSIONS

The subarachnoid space width did not significantly change between the 3 positions. An increase in lumbar puncture success rate with sitting or tilt position could be due to other factors such as increased cerebrospinal fluid pressure, increased interspinous space widening, or improved identification of landmarks.

Repair of duodenal atresia under spinal anesthesia in a low-birth-weight preterm neonate: case report

Duodenal atresia is a well-recognized cause of neonatal bowel obstruction. General anesthesia with tracheal intubation is the traditional anesthetic technique for surgical correction of this condition. Metabolic abnormalities and fluid deficits coupled with residual anesthetics are known to increase the risk of postoperative apnea, prolonging the operating room time and delaying extubation. Spinal anesthesia (SA) is an accepted alternative to general anesthesia in formerly preterm infants. In the current literature, there are reports of successful use of SA for simple infraumbilical surgery and, occasionally, for upper abdominal surgery, but there is no information on the use of SA in neonates for duodenal atresia repair. We present a case of duodenal atresia in a preterm infant at a gestational age of 30 weeks with coexisting bronchopulmonary dysplasia successfully repaired under SA. Further studies that compare the adverse effects with the potential advantages of SA are warranted before future recommendations are made for neonates who are undergoing upper abdominal surgery.