CPT® Code 61001

1. Indications

The subdural tap through the fontanelle or suture is indicated for various clinical scenarios, particularly in infants. The following conditions may warrant the performance of this procedure:

• Diagnostic Evaluation: The procedure is often performed to obtain cerebrospinal fluid for diagnostic analysis, which can help identify infections, bleeding, or other neurological conditions.
• Monitoring: It may be indicated for monitoring intracranial pressure or assessing the presence of subdural hematomas.
• Therapeutic Intervention: In some cases, the procedure may be used to relieve pressure or drain fluid accumulation in the subdural space.

2. Procedure

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

• Step 1: Preparation of the infant is essential. The scalp over the planned tap site is shaved to create a sterile field, minimizing the risk of infection during the procedure.
• Step 2: The Z-track insertion technique is employed. This involves displacing the skin laterally over the anterior fontanelle to create a pathway for the needle. This technique helps to reduce 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 successful access to the subdural space.
• Step 4: Once the needle penetrates the skin, it is further advanced through the dura mater into the subdural space. This step requires careful technique to avoid injury to surrounding structures.
• Step 5: After the needle is in the correct position, the stylet is removed. This allows cerebrospinal fluid and any blood present to be drained for analysis.
• Step 6: Following the drainage, the stylet is replaced back into the needle, and the needle is carefully removed from the infant's head.
• Step 7: A dressing is then 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, it is important to monitor the infant for any signs of complications, such as bleeding or infection at the tap site. The infant should be observed for any neurological changes or adverse reactions following the procedure. Caregivers should be instructed on how to care for the tap site and when to seek further medical attention. Recovery is typically straightforward, but close monitoring is essential to ensure the infant's safety and well-being.