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Turandot Saul, M.D. St. Luke’s Roosevelt Hospital Center. Ultrasound Guided Lumbar Puncture. Preparation. Consent Lateral decubitus position Arch lower back with knees drawn to chest Sterile field Local anesthesia Don mask, gloves. Line at level of iliac crests – L4 spinous process

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turandot saul m d st luke s roosevelt hospital center
Turandot Saul, M.D.

St. Luke’s Roosevelt Hospital Center

Ultrasound Guided Lumbar Puncture

preparation
Preparation
  • Consent
  • Lateral decubitus position
  • Arch lower back with knees drawn to chest
  • Sterile field
  • Local anesthesia
  • Don mask, gloves
surface landmark guidance

Line at level of iliac crests – L4 spinous process

Spinal cord ends at L1

Interspace above or below

Surface landmark identification accuracy 30%1

Surface Landmark Guidance

1Furness, G. et al. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anesthesia, 57. 277-280; 2002.

surface landmark guidance4

Inability to identify landmarks leads to

    • reluctance to perform procedure
    • higher rates of complication
    • patient discomfort
  • Alternatives
    • treatment without CSF sample
    • fluoroscopy - transport, radiation, availability
    • ultrasound guidance
Surface Landmark Guidance
ultrasound for lumbar puncture

Easy to use

  • Non-invasive
  • Increasingly available
  • Information essential to a successful LP
    • site of needle introduction
    • angle needed to approach sub-arachnoid space
    • distance needed to obtain CSF
Ultrasound for Lumbar Puncture
the difficult lumbar puncture

Morbid obesity

Scoliosis / Arthritis

Anxious

Failed Attempts

The Difficult Lumbar Puncture
equipment

Lumbar puncture kit

Linear array, high frequency probe – thin

Curved array, low frequency probe - obese

Equipment
anatomy
Anatomy
  • Ligaments
    • supraspinal: connects spinous processes
    • interspinal: inferior to superior border spinous processes
    • ligamentum flavum - interlaminar space
median vs paramedian approach
Median vs. Paramedian Approach

Images: Ferre, RM and Sweeney, TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

ultrasound median a pproach
Ultrasound - Median Approach
  • a: spinous processes
  • b: dura mater /

ligamentum flavum

  • c: subarachnoid space

Images: Ferre, RM and Sweeney, TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

ultrasound paramedian approach
Ultrasound – Paramedian Approach
  • a: spinous process
  • b: ligamentum flavum
  • c: epidural space
  • d: dura mater
  • e: subarachnoid space

Images: Ferre, RM and Sweeney, TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

median vs paramedian

Paramedian

    • more anatomic elements seen
    • small window between spinous processes
    • differentiate dura matter and ligamentum flavum
    • dynamic guidance
Median vs. Paramedian ?
radiology and anesthesia

US to localize intervertebral levels

    • epidural spaces for anesthetic catheters
    • guidance of neonatal and infant lumbar puncture
Radiology and Anesthesia
ultrasound guidance for lp

Ultrasonography in neonatal and infant lumbar puncture

    • 47 patients referred for image guided LP
    • ultrasound provided information
      • presence or absence of CSF
      • cause of the failed lumbar puncture
      • whether to proceed with further attempts
Ultrasound Guidance for LP
  • Coley, BD, et al. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture Pediatric Radiology (2001) 31; 399-402.
eps can obtain ultrasound images of lp anatomical landmarks

2 emergency physicians

    • 5 structures (spinous processes, ligamentum flavum, dura, epidural space, subarachnoid space)
  • 76 patients, all landmarks identified
    • average BMI = 31
    • 88% < 1 minute, 100% < 5 minutes
eps can obtain ultrasound images of LP anatomical landmarks

Ferre, RM and Sweeney, TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

the use of ultrasound to identify pertinent landmarks for lp

Stratified patients by BMI

Recorded difficulty in palpating landmarks

US to identify spinous process of L3, L4, L5, ligamentum flavum and spinal canal

The use of ultrasound to identify pertinent landmarks for lp

Stiffler, KA et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

the use of ultrasound to identify pertinent landmarks for lp22

Difficulty in palpating landmarks - 21 patients

    • 5% normal BMI (< 24.9)
    • 33% overweight (24.9 - 30)
    • 68% obese (> 30)
  • US identified pertinent structures
    • 16/21 (76%)
The use of ultrasound to identify pertinent landmarks for lp

Stiffler, KA et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

the use of ultrasound to identify pertinent landmarks for lp23

Distance: skin to ligamentum flavum

    • 44mm normal BMI (< 24.9)
    • 51mm overweight (24.9 - 30)
    • 64mm obese (> 30)
The use of ultrasound to identify pertinent landmarks for lp

Stiffler, KA et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.

future studies

Does ultrasound:

    • increase rate of LP success?
    • decrease length of procedure
    • decrease complication rate of procedure
    • static vs. dynamic
Future Studies
resources

Roberts: Clinical Procedures in Emergency Medicine, 4th ed. Philadelphia, Saunders; 2004.

  • Goetz: Textbook of Clinical Neurology, 3rd ed. Philadelphia, Saunders; 2004.
  • Stiffler, KA et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.
  • Furness, G. et al. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anesthesia, 57. 277-280; 2002.
  • Ferre, RM and Sweeney, TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. American Journal of Emergency Medicine. 25(3); 2007.
Resources