| OCR Text |
Show Interpretation of Lumbar Puncture Opening Pressure Measurements in Children Robert A. Avery, DO, MSCE Background: Understanding the reference range of cerebro-spinal fluid opening pressure (CSFOP) in children is essential to the diagnosis of elevated intracranial pressure. Recent studies have highlighted several clinical elements that need to be considered when interpreting CSFOP measures. Evidence Acquisition: This review and recommendations are based on peer-reviewed literature, primarily from the past decade, as well as the author's clinical and research experience. Results: CSFOP measures #28 cm H2O can be considered "normal" for most children. The patient's depth of sedation, body mass index, and sedation medication can sometimes result in small increases in CSFOP. Patient age and leg position (flexed vs extended) in the lateral decubitus posi-tion do not seem to significantly impact CSFOP measures. Conclusions: The threshold of a normal CSFOP should not be interpreted in isolation, but instead, in concert with other clinical and examination findings to help the physician make a well-informed assessment of whether a child has elevated intracranial pressure. Journal of Neuro-Ophthalmology 2014;34:284-287 doi: 10.1097/WNO.0000000000000154 © 2014 by North American Neuro-Ophthalmology Society CASE REPORT A12-year-old boy presents with 3 months of unremitting holocephalic headache in the setting of an unremark-able comprehensive neuro-ophthalmologic examination without papilledema. He takes no medication, and his body mass index is 90th percentile for age. He underwent a sedated lumbar puncture (LP) using midazolam and fen-tanyl. The cerebrospinal fluid opening pressure (CSFOP) was 28 cm H2O and, on awakening, the child stated he had relief of headache. His headache returned the next day, so he was placed on topiramate for headache prophylaxis. One month later, he underwent a second LP with a CSFOP of 27 cm H2O, resulting in 1 day of headache relief. Neuro-ophthalmologic examination and magnetic resonance imag-ing (MRI) remain normal without any objective findings suggestive of elevated intracranial pressure (ICP). Does he have idiopathic intracranial hypertension (IIH)? The CSFOP is a relatively noninvasive surrogate measure of ICP and an essential component of the diagnostic LP. An accurate interpretation of this commonly performed pro-cedure is essential for the diagnosis and management of IIH (1,2). The reference range for a normal CSFOP in children has been described in the literature and seminal textbooks for over a century, despite the lack of empiric evidence to sup-port these recommendations (2). In the past decade, a num-ber of studies have questioned the previously recommended reference ranges for a normal CSFOP in both adults and children (3-5). These studies and others have also examined the impact of clinical factors, such as patient age, body mass index (BMI), depth of sedation, sedation medication, and body position that have long been speculated to influence the CSFOP values (3,4,6-13). This review examines the current data on CSFOP in children and attempts to provide a framework on how to interpret CSFOP. ESTABLISHMENT OF A PEDIATRIC REFERENCE RANGE Numerous studies and textbooks have listed a wide range of values for a normal CSFOP in infants and children (2). Rangwala and Liu (2) were the first to describe how many authors had cross referenced or incorrectly attributed their data to other articles, along with the lack of scientific rigor Departments of Neurology, Ophthalmology, Pediatrics, The Gilbert Family Neurofibromatosis Institute, Center for Neuroscience and Behavior (RAA), Children's National Health System, Washington, District of Columbia. R. A. Avery receives support from the National Eye Institute/National Institutes of Health grant K23-EY022673, the National Institutes of Health/National Eye Institute Pediatric Research Loan repayment program and the Gilbert Family Neurofibromatosis Institute. The author reports no conflicts of interest. Address correspondence to Robert A. Avery, DO, MSCE, Neuro- Ophthalmology Service, Department of Neurology, Children's National Medical Center, 111 Michigan Avenue, North West Washington, DC 20010; Email: ravery@childrensnational.org 284 Avery: J Neuro-Ophthalmol 2014; 34: 284-287 State-of-the-Art Review Section Editors: Valérie Biousse, MD Steven Galetta, MD Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. in developing these norms. It is likely that the normative values from the adult literature were adapted to pediatrics. In 1983, Corbett and Mehta (8) suggested that some nor-mal adults may demonstrate a CSFOP as high as 25 cm H2O. However, the pediatric literature did not adapt this range and continued to endorse values of 20 cm H2O and lower as being normal (2,8). A decade later, Ellis (5) per-formed LPs on pediatric oncology patients and concluded that the normal range of CSFOP was from 10 to 28 cm H2O. Unfortunately, these findings frequently were not included in the pediatric literature, possibly due to the atypical method (i.e., counting the number of CSF drops for 21-39 seconds) of determining the CSFOP (5). Ultimately, a large prospective study of adults confirmed the findings of Corbett and Mehta (8) and suggested that, at times, a normal CSFOP could be as high as 28 cm H2O (3). This was soon followed by a large prospective study of children undergoing diagnostic LP and reported the mean CSFOP to be 19.7 cm H2O and the 90th percentile being as high as 28 cm H2O (4). Findings from a smaller cohort of pediatric patients also supported the fact that some children may have a CSFOP of up to 28 cm H2O and can still be considered normal (14). Avery et al (15) provided additional support of their findings by reporting that 98% of children with optic nerve head edema believed to be secondary to elevated ICP demonstrated CSFOP measures $30 cm H2O. The recent studies mentioned above have helped guide clinicians and researchers in new directions. Specifically, the current CSFOP pressure data have been incorporated into the new diagnostic criteria for pediatric IIH (1). Second, the large adult (3) and pediatric (4) prospective studies listed above also highlighted the potential influence of clinical variables, such as BMI, age, depth of sedation, sedation medication, and body position that have long been specu-lated to influence the CSFOP values. FACTORS AFFECTING CSFOP Age Many clinicians believe that CSFOP increases in early childhood until it reaches values similar to adults. Eight years of age has been discussed as a cutoff between pediatric and adult values (2). The study by Seiden et al (4), limited to children between 1 and 18 years old, did not find a sta-tistically significant relationship between age and CSFOP. Even when age was dichotomized to above and below 10 years old, age and CSFOP were not related. When age was dichotomized above and below 7 years old, Ellis (5) also did not find a difference in mean CSFOP (19.1 vs 19.0, respec-tively). If differences in CSFOP exist between younger and older children, it is likely that interpatient variability, level of sedation, sedation medication, and other yet to be dis-covered factors have cluttered our ability to firmly establish this relationship. Until further research can prove a reliable influence of age on CSFOP, the same normative values can be applied to all children between 1 and 18 years old. Body Mass Index A statistically significant relationship between BMI and CSFOP previously has been reported in both pediatric and adult cohorts (3,4,14,16). Yet, a recently published large prospective study of adults with IIH found that CSFOP and BMI were not correlated (17). Similar to the results of Whiteley et al (3), the large pediatric study demonstrated that CSFOP increased by approximately 3 cm H2O for every 10-unit increase in BMI after adjust-ing for the influence of other factors, such as sedation and age (4). Despite the statistical significance, these relatively small changes in CSFOP are unlikely to be clinically significant. Sedation Given the variability in sedation algorithms both within and between institutions, understanding the influence of specific medications on CSPOP has proven to be difficult. Ket-amine has long been suggested to increase ICP and the CSFOP measures in children, (9,11,18), although some investigators have published data to the contrary (19,20). To date, only 1 prospective, randomized study has specifi-cally evaluated the effect of ketamine on CSFOP and concluded that CSFOP was higher than in non-ketamine-sedated patients (9). Seiden et al (4) did not find a statisti-cally significant relationship between ketamine and CSFOP, although this study was not specifically designed to address this question and the analysis was limited by the relatively low number of patients receiving ketamine compared with other sedative agents. Not only is class of sedation medication relevant, but also the patient's depth of the sedation is equally impor-tant. Pediatric patients who received moderate-to-deep sedation were found to have a CSFOP of nearly 3.5 cm H2O higher than those not receiving any sedation medi-cation (4). It is hypothesized that children deeply sedated likely experience a relative hypercapnia that contributes to elevated CSFOP (21). Lim and Lin (12) performed con-tinuous monitoring of CSFOP while evaluating pediatric subjects' end-tidal pCO2 and demonstrated a higher pCO2 resulted in elevated CSFOP. Eidlitz-Markus et al (21) also demonstrated a decrease in CSFOP as sedation was reduced and the child regained consciousness. Pediatric neurologists and neuro-ophthalmologists who perform LPs have suspected that deep sedation can result in even larger increases in CSFOP than have reported. To avoid sedating the child a second time, many LPs are performed immediately after completing a sedated MRI. Because the child has been sedated for approximately 1 hour, clinicians should be aware of the potential false elevation in CSFOP after prolonged sedation. Avery: J Neuro-Ophthalmol 2014; 34: 284-287 285 State-of-the-Art Review Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Currently, there is no agreed-on sedation protocol for performing a LP. When possible, using a low dose benzodiazepine for anxiolysis or no sedation altogether is preferred to avoid the known increase in CSFOP when undergoing moderate or deep sedation (4). For children who are awake or only receive anxiolysis, they should be monitored closely for agitation, which may increase intra-abdominal pressure and falsely elevate the CSFOP (22). To reduce procedural discomfort, application of topical lidocaine-based cream 45 minutes before the LP can obviate the need for a subdermal injection of lidocaine. Patient Position Most pediatric LPs are performed in the lateral recombi-nant position with the legs flexed. Although it was commonly believed that the legs had to be extended to obtain an accurate CSFOP, many practitioners were hesitant to move the legs of a sedated or anxious child for fear of needle displacement or arousing the child. The difference of CSFOP between flexed and extended leg position does not result in a clinically meaningful change in CSFOP measures (6,7,23,24). Therefore, it is not nec-essary to move the awake or sedated child from the flexed to extended position. CLINICAL SYMPTOMS Headache relief after a diagnostic LP is frequently interpreted as proof that the child has elevated ICP. To date, no study has been performed to either support or refute this interpretation. The analgesic effect of com-monly used sedation medications, such as narcotics, benzodiazepines, or barbiturates should be considered when interpreting headache relief after a LP. Furthermore, greater than one third of subjects reported by Michalczyk et al (9) never reported headache or other symptoms of elevated ICP despite having a CSFOP .27 cm H2O. Other studies have also reported CSFOP .28 cm H2O in subjects without signs or symptoms (including head-ache) of elevated ICP (3,4,13,14). CASE FOLLOW-UP Despite continued therapy, the child's headache persisted. Repeated neuro-ophthalmologic examinations and MRI/ magentic resonance venography remained normal. A third LP demonstrated a CSFOP of 28 cm H2O. Given the lack of therapeutic benefit from medications, an ICP monitor was placed and revealed consistently normal ICP readings (12 cm H2O) over a 48-hour period. Because the child did not meet all of the necessary criteria for IIH (1), he was diagnosed as having chronic daily headache. SUMMARY AND RECOMMENDATIONS FOR INTERPRETATION The above case highlights both the inaccuracy of CSFOP measures by LP and inherent variability of ICP (25). It further reinforces that a single CSFOP value should not be considered in isolation and as the sole determinant of elevated ICP. When the CSFOP is below 28 cm H2O, the clinician should be reassured that the subject likely does not have elevated ICP, especially in the absence of other objective findings. If clinical suspicion of elevated ICP persists, a follow-up examination is recommended. In children whose CSFOP is greater than 28 cm H2O, it is not recommended that the value be classified as "abnormal," but instead the clinician should assess both the clinical findings and the circumstances of the LP (i.e., sedation, sedation medications, BMI, and patient agitation during the LP). Clinicians cannot be expected to calculate multivariable regression models in real time to interpret how 1 or more variables (i.e., sedation and BMI) have influenced their patient's CSFOP. So although a strict cutoff above or below 28 cm H2O can be useful for research purposes, it certainly will not apply to all children. Instead, the threshold of 28 cm H2O should be inter-preted in concert with other clinical and examination re-sults to help the clinician make a well-informed assessment of whether a child has elevated ICP. REFERENCES 1. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 2013;81:1159-1165. 2. Rangwala LM, Liu GT. Pediatric idiopathic intracranial hypertension. Surv Ophthalmol. 2007;52:597-617. 3. Whiteley W, Al-Shahi R, Warlow CP, Zeidler M, Lueck CJ. CSF opening pressure: reference interval and the effect of body mass index. Neurology. 2006;67:1690-1691. 4. Seiden JA, Huh JW, Boswinkel J, Ruppe MD, Chew A, Mistry RD, Liu GT. Reference range for cerebrospinal fluid opening pressure in children. N Engl J Med. 2010;363:891-893. 5. Ellis R III. Lumbar cerebrospinal fluid opening pressure measured in a flexed lateral decubitus position in children. Pediatrics. 1994;93:622-623. 6. Abbrescia KL, Brabson TA, Dalsey WC, Kelly JJ, Kaplan JL, Young TM, Jenkins D, Chu J, Emery MS; Lumbar Puncture Study Group. The effect of lower-extremity position on cerebrospinal fluid pressures. Acad Emerg Med. 2001;8:8-12. 7. Avery RA, Mistry RD, Shah SS, Boswinkel J, Huh JW, Ruppe MD, Borasino S, Licht DJ, Seiden JA, Liv GT. Patient position during lumbar puncture has no meaningful effect on cerebrospinal fluid opening pressure in children. J Child Neurol. 2010;25:616-619. 8. Corbett JJ, Mehta MP. Cerebrospinal fluid pressure in normal obese subjects and patients with pseudotumor cerebri. Neurology. 1983;33:1386-1388. 9. Michalczyk K, Sullivan JE, Berkenbosch JW. Pretreatment with midazolam blunts the rise in intracranial pressure associated with ketamine sedation for lumbar puncture in children. Pediatr Crit Care Med. 2013;14:e149-e155. 10. Talke P, Caldwell JE, Richardson CA. Sevoflurane increases lumbar cerebrospinal fluid pressure in normocapnic patients undergoing transsphenoidal hypophysectomy. Anesthesiology. 1999;91:127-130. 286 Avery: J Neuro-Ophthalmol 2014; 34: 284-287 State-of-the-Art Review Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. 11. Ben Yehuda Y, Watemberg N. Ketamine increases opening cerebrospinal pressure in children undergoing lumbar puncture. J Child Neurol. 2006;21:441-443. 12. Lim MJ, Lin JP. The effects of carbon dioxide on measuring cerebral spinal fluid pressure. Childs Nerv Syst. 2009;25:783-784. 13. Gallagher A, Pike M, Berg S. Beware CSF pressure measured under general anaesthesia. Arch Dis Child. 2004;89:691. 14. Lee MW, Vedanarayanan VV. Cerebrospinal fluid opening pressure in children: experience in a controlled setting. Pediatr Neurol. 2011;45:238-240. 15. Avery RA, Licht DJ, Shah SS. CSF opening pressure in children with optic nerve head edema. Neurology. 2011;76:1658- 1661. 16. Berdahl JP, Fleischman D, Zaydlarova J, Stinnett S, Allingham RR, Fautsch MP. Body mass index has a linear relationship with cerebrospinal fluid pressure. Invest Ophthalmol Vis Sci. 2012;53:1422-1427. 17. Wall M, Kupersmith MJ, Kieburtz KD, Corbett JJ, Felen SE, Friedman DI, Katz DM, Keltner JL, Schron EB, McDermott MP. The Idiopathic Intracranial Hypertension Treatment Trial: clinical profile at baseline. JAMA Neurol. 2014;71:693-701. 18. Belopavlovic M, Buchthal A. Modification of ketamine-induced intracranial hypertension in neurosurgical patients by pretreatment with midazolam. Acta Anaesthesiol Scand. 1982;26:458-462. 19. Albanese J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997;87:1328-1334. 20. Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4:40-46. 21. Eidlitz-Markus T, Stiebel-Kalish H, Rubin Y, Shuper A. CSF pressure measurement during anesthesia: an unreliable technique. Paediatr Anaesth. 2005;15:1078-1082. 22. Neville L, Egan RA. Frequency and amplitude of elevation of cerebrospinal fluid resting pressure by the Valsalva maneuver. Can J Ophthalmol. 2005;40:775-777. 23. Dinsmore J, Bacon RC, Hollway TE. The effect of increasing degrees of spinal flexion on cerebrospinal fluid pressure. Anaesthesia. 1998;53:431-434. 24. Sithinamsuwan P, Sithinamsuwan N, Tejavanija S, Udommongkol C, Nidhinandana S. The effect of whole body position on lumbar cerebrospinal fluid opening pressure. Cerebrospinal Fluid Res. 2008;5:11. 25. Czosnyka M, Pickard JD. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg Psychiatry. 2004;75:813-821. Avery: J Neuro-Ophthalmol 2014; 34: 284-287 287 State-of-the-Art Review Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
