CPT® Code 61000

1. Indications

The subdural tap through the fontanelle or suture is indicated for several specific conditions and symptoms in infants. These include:

• Diagnostic Evaluation: The procedure is performed to obtain cerebrospinal fluid for laboratory analysis, which can help diagnose infections, hemorrhages, or other neurological disorders.
• Suspected Subdural Hematoma: It is indicated when there is a clinical suspicion of a subdural hematoma, which may present with symptoms such as altered consciousness, irritability, or seizures.
• Hydrocephalus Assessment: The procedure may be utilized to assess conditions related to hydrocephalus, where there is an accumulation of cerebrospinal fluid within the ventricles of the brain.

2. Procedure

The procedure for performing a subdural tap through the fontanelle or suture involves several critical steps to ensure safety and effectiveness.

• Step 1: The infant is positioned appropriately, typically lying supine, to allow easy access to the anterior fontanelle. The scalp over the planned tap site is shaved to maintain a sterile field.
• Step 2: The Z-track insertion technique is employed, where the skin is displaced laterally over the anterior fontanelle. This technique helps to minimize tissue trauma and prevent leakage of cerebrospinal fluid.
• Step 3: A subdural or spinal needle is then advanced at a 90-degree angle through the skin at the lateral aspect of the coronal suture of the anterior fontanelle. This precise angle is crucial for proper access to the subdural space.
• Step 4: The needle is advanced through the dura mater into the subdural space. Once the needle is in the correct position, the stylet is removed to allow for the drainage of cerebrospinal fluid and blood.
• Step 5: After the necessary fluid is collected, the stylet is replaced into the needle, and the needle is carefully removed from the infant's head.
• Step 6: A dressing is applied to the site to protect it and promote healing. If necessary, the procedure can be repeated on the opposite side to obtain additional samples.

3. Post-Procedure

After the subdural tap procedure, the infant is monitored for any signs of complications, such as bleeding or infection at the tap site. Careful observation of the infant's neurological status is essential to ensure there are no adverse effects from the procedure. The dressing applied to the site should be kept clean and dry, and any signs of increased swelling, redness, or discharge should be reported to a healthcare provider. The infant may be allowed to resume normal activities as tolerated, but close follow-up is recommended to assess the results of the cerebrospinal fluid analysis and to monitor for any potential complications.