Transforaminal Intrathecal Access for Injection of Nusinersen in Adult and Pediatric Patients with Spinal Muscular Atrophy

Abstract

The main purpose of this article is to assess the safety and efficacy of transforaminal lumbar puncture for the injection of nusinersen (Spinraza) in patients with extensive spinal fusion and/or scoliosis.A retrospective chart reviews of all spinal muscular atrophy patients (adults and children) were conducted. Demographic data, procedure details, follow-ups, and related complications were recorded.We performed 85 transforaminal injections in nine pediatric patients (5 male and 4 female) aged between 8 and 17 years (mean = 11 years) and seven adult patients (5 females and 2 males) aged between 24 and 41 years (mean= 30 years). Fluoroscopy guidance was used in 87% of our patients. No major complication was reported.Fluoroscopy-guided transforaminal nusinersen injection is a safe and successful alternative approach in adult and pediatric patients with severe spinal scoliosis, interlaminar osseous fusion, and spinal fusion hardware.

Computed‐tomography‐guided transforaminal intrathecal nusinersen injection in adults with spinal muscular atrophy type 2 and severe spinal deformity. Feasibility, safety and radiation exposure considerations

“…Weaver et al [8] recently proposed come-beam CT as an alternative guidance modality, with 100% technical success (all 15 cases) and a low radiation dose ranging between 16.9 and 138.9 mGy. Others reported a lower, but acceptable, technical success rate (87%) using fluoroscopic guidance in patients with severe spinal scoliosis, interlaminar osseous fusion and spinal fusion hardware, as opposed to lower radiation doses compared to those reported in studies using CT guidance [11]. Comparative studies between various radiological modalities such as conventional CT, come-beam CT and fluoroscopy for transforaminal nusinersen injection would provide data on technical success, and the possibility of reducing procedural time and radiation exposure.…”

“…Nonetheless, other investigators have recently reported a considerable number of adverse events, including one severe subarachnoid haemorrhage [6]. Notably, published data regarding nusinersen intrathecal administration via the transforaminal approach include approximately 50 patients and 200 punctures [5][6][7][8][9][10][11][12]. Therefore, the feasibility and safety of computed-tomography-guided (CT-guided) transforaminal nusinersen intrathecal injection has not yet been established, whilst radiation dose remains an issue.…”

Cone-beam computed tomography guided nusinersen administrations in adult spinal muscular atrophy patients with challenging access: a single- center experience

“…11 Shokuhfar et al recorded one case (10%) of bilateral radiculopathy. 19 Although no severe AEs were noted in our study, the aforementioned studies raise attention to the potential risks one must take into consideration before the procedure. In the study we also report AEs from the patients that underwent conventional lumbar punctures.…”

“…This problem was so far addressed in only one study in a patient with BMI of 28, in which the intrathecal administration was performed under CT-guidance. 10 Only few studies have reported their experience in CBCT-guided intrathecal administrations 11,18,19 An early study utilized CBCT for needle positioning in three TF procedures in children. 18 The authors reported later switch to fluoroscopy guidance as the performing physicians gained confidence with the intrathecal deliveries.…”

“…18 A later study analyzed lumbar punctures with TF approach in seven adult patients. 19 The latest study by Weaver et al presented the largest group of 28 patients for CBCT-guided intrathecal nusinersen delivery. 11 In these studies the CBCTguided lumbar intrathecal delivery was performed in both children and adult patients, whereas our study focused only on adult patients.…”