Due to the blood-brain barrier, systemic chemotherapy usually cannot destroy any blasts in the central nervous system (brain and spinal cord). Chemotherapy drugs must be directly injected into the cerebrospinal fluid to kill any blasts present and prevent a possible central nervous system relapse. The drugs most commonly used intrathecally are methotrexate, ARA-C, and hydrocortisone. The number of spinal taps required varies depending on the child's risk level, the clinical study involved, and whether radiation is used.
Some hospitals routinely sedate children for spinal taps, and others do not. If the child is not sedated, EMLA cream is usually prescribed. EMLA is an anesthetic cream put on the spinal tap site one to two hours prior to the procedure. It anesthetizes deep into the tissue, preventing some or all of the pain associated with the procedure.
To perform a spinal tap, the physician or nurse practitioner will ask the child to lie on her side with her head tucked close to the chest and knees drawn up. A nurse usually helps hold the child in this position. The doctor will feel the designated spot in the lower back, and will swab it with antiseptic several times. The antiseptic feels very cold on the skin. A sterile sheet may drape the area, and the doctor will wear sterile gloves. One or two shots of an anesthetic (usually xylocaine) may be injected into the skin and deeper tissues. This causes a painful stinging or burning sensation that lasts about a minute. If EMLA was used, the doctor may still inject anesthetic into the deep tissues. A few minutes' wait is necessary to ensure that the area is fully anesthetized.
My 4-year-old daughter had finished eighteen months of her treatment for ALL when EMLA was first prescribed. She had been terrified of going to the clinic. After using EMLA for her next LP, a dramatic change occurred. She was no longer frightened to go for treatment, and her behavior at home improved unbelievably. We use it for everything now: finger pokes, accessing port, bone marrows, even flu shots.
It is essential that the child hold very still for the rest of the procedure. The doctor will push a needle between two vertebrae into the space where cerebrospinal fluid (CSF) is found. The CSF will begin to drip out of the hollow needle into a container. After a small amount is collected, a syringe is attached to the needle in the back and the medicine is slowly injected, causing a sensation of coldness or pressure down the leg. The needle is then removed and the spot bandaged. The CSF is sent to the laboratory to see if any cancer cells are present and to measure glucose and protein.
During spinals, Brent listens to rock and roll on his Walkman, but he keeps the volume low enough so that he can still hear what is going on. He likes me to lift up the earpiece and tell him when each part of the procedure is finished and what's coming next.
If your child or teen develops a persistent severe headache following the procedure that lessens while he lies flat, but throbs when he sits up, notify your physician or nurse. Keep your child lying flat, and offer high-caffeine beverages, such as Mountain
Dew. If these measures fail to give your child relief, an anesthesiologist sometimes does a procedure called a "blood patch." Your child lies in the same position as for the spinal tap. The anesthesiologist will draw a small amount of blood from your child's arm or central line. She will then inject it at the site of the prior spinal tap where CSF may be slowly leaking from the canal into the tissues. If this is the cause of the headache, the relief is immediate. This procedure is generally performed in the recovery room, emergency room, clinic, or inpatient unit. You can stay with your child during the procedure.
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