Difficult lumbar puncture
A traumatic CSF tap can affect laboratory results showing falsely elevated cell counts and CSF protein. Increasing degenerative spondylosis and obesity has increased the number of failed attempts. Also, the fear of negligence suit has persuaded physicians to refer such procedures to radiologist.29 Further, there is an increase in the number of complex spinal surgeries, leading to further restriction of access to the CSF through bedside blind trials. With an increase number of complex spine surgeries, the access to the CSF space is better with image-guided Lumbar puncture than blind trials. There is an increase in number intrathecal medications , which are costly and therefore preference is being given for imaging confirmation leading to the favor of image guided LP.29 All these have led to an increase in the number requests for image guided LPs for both diagnostic and therapeutic procedures, especially fluoroscopic guided LP. FG-LP is generally considered a safe procedure with a good efficacy,59 minimal radiation exposure (n= 2.9 mSv), 2.2 % developing PLPH, with only 0.8% requiring EDBP, nerve root irritation and infectious complications have not been reported yet, even from centres which perform 1000 FG-LPs per year.60,61However, these facilities are not available widely, especially in resource strained countries. In such settings, when physicians encounter a dry tap, they can first confirm the needle position with a cross-table lateral radiograph and correct dehydration. The following flowchart details the manoeuvres that can be applied in case of a dry tap.{Figure 5 } .62