Ultrasound for Routine Lumbar Puncture

Peterson, Michael A.; Pisupati, D.; Heyming, Theodore; Abele, Jennifer; Lewis, Roger J.

doi:10.1111/acem.12305

Cited by 47 publications

(69 citation statements)

References 22 publications

(18 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[24][25][26][27][28] It is not clear if routine use of ultrasound guidance in lean patients is superior to landmark-based LP. 15,29 As a multidisciplinary panel of procedural experts from different institutions, we concur with a recent recommendation for routine use of ultrasound guidance for patients in whom risk of a failed procedure is high due to poorly palpable landmarks or atypical spinal anatomy. 30 We would further advocate for the routine use of ultrasound in all patients because ultrasound reveals anatomical information, such as width of interspinous spaces and depth of ligamentum flavum, not elucidated by physical examination and can guide procedural decisionmaking.…”

Section: Literature Reviewsupporting

confidence: 80%

“…At least 20 randomized trials and 2 meta-analyses have since compared landmark-based vs ultrasound-guided techniques for lumbar puncture or epidural/spinal anesthesia. Key findings from these studies [9][10][11][12][13][14][15][16][17] are summarized in the table. A systematic review and meta-analysis of 14 randomized controlled trials evaluated whether ultrasound decreased the risk of failed LPs or epidural catheterizations compared to standard palpation of landmarks.…”

Section: Literature Reviewmentioning

confidence: 99%

“…15 Success of LP depends on patient factors (body habitus, spinal anatomy, previous spinal surgery, positioning, cooperation), operator factors (LP skills, ultrasound skills, experience), and system factors (ultrasound equipment, equipment availability, procedure supplies). Although randomized trials may control for most patient and system factors, the operator's ultrasound skill is an important and underappreciated potential source of bias in current studies.…”

Section: Real-time Ultrasound Guidancementioning

confidence: 99%

“…A recent randomized trial comparing routine use of ultrasound guidance vs landmark-based techniques for LP did not demonstrate a benefit of using ultrasound; however, trainees were the primary operators and inexperience combined with convenience sampling may explain the negative results. 15 On the contrary, studies with highly experienced operators may exaggerate benefits of ultrasound by demonstrating perfect success rates with only a small number of procedures. 29 Therefore, a multicenter comparative trial using a standard protocol for routine use of ultrasound-guided vs landmark-based LP is needed.…”

Section: Real-time Ultrasound Guidancementioning

confidence: 99%

See 3 more Smart Citations

Ultrasound guidance for lumbar puncture

et al. 2016

View full text Add to dashboard Cite

Purpose of review: To review the literature and describe techniques to use ultrasound to guide performance of lumbar puncture (LP). Recent findings:Ultrasound evaluation of the lumbar spine has been shown in randomized trials to improve LP success rates while reducing the number of attempts and the number of traumatic taps. Summary: Ultrasound mapping of the lumbar spine reveals anatomical information that is not obtainable by physical examination, including depth of the ligamentum flavum, width of the interspinous spaces, and spinal bone abnormalities, including scoliosis. Using static ultrasound, the lumbar spine anatomy is visualized in transverse and longitudinal planes and the needle insertion site is marked. Using real-time ultrasound guidance, the needle tip is tracked in a paramedian plane as it traverses toward the ligamentum flavum. Future research should focus on efficient methods to train providers, costeffectiveness of ultrasound-guided LP, and the role of new needle-tracking technologies to facilitate the procedure. Neurol Clin Pract 2016;6:358-368 P oint-of-care ultrasound is being increasingly used to guide bedside procedures. For certain bedside procedures, such as central venous catheterization, use of ultrasound guidance is now considered the standard of care. For other procedures, such as lumbar puncture (LP), ultrasound can facilitate performance of the procedure by revealing underlying anatomy. Although many clinicians can perform LP based on landmarks with high success rates, an increasing body of evidence supports the use of ultrasound guidance, particularly in obese patients with less palpable landmarks. A recent study demonstrated a 19% failure rate of LPs performed in a neurology clinic when landmarks alone were used. A strong correlation between body mass index (BMI) and procedure failure was shown with half of the failed LPs in patients with a BMI .35.

show abstract

Section: Literature Reviewsupporting

confidence: 80%

Section: Literature Reviewmentioning

confidence: 99%

Section: Real-time Ultrasound Guidancementioning

confidence: 99%

Section: Real-time Ultrasound Guidancementioning

confidence: 99%

See 2 more Smart Citations

Ultrasound guidance for lumbar puncture

et al. 2016

View full text Add to dashboard Cite

show abstract

“…The authors advocate for routine use of ultrasound in all patients undergoing LP, although they highlight a recent randomized trial comparing routine use of ultrasound-guided vs landmark-based techniques that failed to demonstrate a benefit of using ultrasound localization for LP insertion. 1,2 Who uses a cannon to kill a fly? An excess of what is necessary or appropriate for a particular end is not standard of care.…”

mentioning

confidence: 99%

Ultrasound guidance for lumbar puncture

et al. 2016

View full text Add to dashboard Cite

Torgovnick, MD: I read the article by Soni et al. 1 line by line. Because of my association with a hospital at the epicenter of the AIDS epidemic, I have performed many thousands of lumbar punctures (LPs) for all of the usual reasons. Many patients were tapped repeatedly. I am right-handed and so the LP is performed with the patient in the left lateral decubitus position. This is essential to measure the opening pressure. I mark the back in the usual fashion using the line between the superior iliac crests to identify the L4-L5 interspace. I prefer the L2-L3 interspace for the procedure. Once identified, I begin the procedure. I use the same words with each patient and prep and drape the patient in the same fashion each time. I use local anesthesia. Once I again have the L2 spinous process identified, I keep my left thumb firmly pressed there for guidance and support and to distract the patient. The needle is advanced perpendicular to the skin and once it has passed the bone is at times angled cephalad. What I have described is a ritual. It is the ritual that makes the successful LP and this can be taught.Langone Medical Center, New York. Disclosures: The author reports no disclosures.Nitin K. Sethi, MD: I read with interest the article by Soni et al.1 on the use of ultrasound guidance for LP. The authors advocate for routine use of ultrasound in all patients undergoing LP, although they highlight a recent randomized trial comparing routine use of ultrasound-guided vs landmark-based techniques that failed to demonstrate a benefit of using ultrasound localization for LP insertion.1,2 Who uses a cannon to kill a fly? An excess of what is necessary or appropriate for a particular end is not standard of care. The use of ultrasound for LP is neither cost-effective nor logistically possible in low-and middle-income countries. Instead of wasting precious resources in future studies looking at the effect of ultrasound in clinical decision-making, emphasis should be on teaching LP clinical and procedural skills to residents in training. In the hands of an experienced operator, landmark-guided LP has a very high success rate. "See one, do one, teach one" is a long-established medical adage and it shall be our folly to forget it. 1 The recent randomized trial by Peterson et al. 2 did not find a difference between landmark-based vs ultrasound-guided LP, but some important limitations must be recognized. Most important, the operators were residents with "varying degrees of experience performing ultrasound examinations, from no documented experience to over 100 documented examinations." Thus, the investigators did not control for a critically important variable: operator skill level. Second, convenience sampling likely introduced selection bias prior to randomization. Third, this study is likely underpowered based on a power calculation using the mean difference in insertion attempts (20.44) reported in the meta-analysis of 14 randomized trials by Shaikh et al.3 that 468

show abstract

Safety and predictors of the success of lumbar punctures performed by a medicine procedure service

Short,

Dunneback,

Stephens

et al. 2023

Journal of Hospital Medicine

View full text Add to dashboard Cite

Background Medicine procedure services (MPS) increasingly perform bedside procedures, including lumbar punctures (LPs). Success rates and factors associated with LP success performed by MPS have not been well described. Objective We identified patients undergoing LP by an MPS September 2015 to December 2020. We identified demographic and clinical factors, including patient position, body mass index (BMI), use of ultrasound, and trainee participation. We performed multivariable analysis to identify factors associated with LP success and complications. Main Outcome and Measures We identified 1065 LPs among 844 patients. Trainees participated in 82.2%; ultrasound guidance was used in 76.7% of LPs. The overall success rate was 81.3% with 7.8% minor and 0.1% major complications. A minority of LPs were referred to radiology (15.2%) or were traumatic (11.1%). In multivariable analysis, BMI > 30 kg/m2 (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.21–0.48), prior spinal surgery (OR 0.50, 95% CI 0.26–0.87), and Black race (OR 0.62, 95% CI 0.41–0.95) were associated with decreased odds of successful LP; trainee participation (OR 2.49, 95% CI 1.51–4.12) was associated with increased odds. Ultrasound guidance (OR 0.53, 95% CI 0.31–0.89) was associated with lower odds of traumatic LP. Results In a large cohort of patients undergoing LP by an MPS, we identified high success and low complication rates. Trainee participation was associated with increased odds of success, while obesity, prior spinal surgery, and Black race were associated with decreased odds of success. Ultrasound guidance was associated with lower odds of a traumatic LP. Our data may help proceduralists in planning and assist in shared decision‐making.

show abstract

Ultrasound for Routine Lumbar Puncture

Cited by 47 publications

References 22 publications

Ultrasound guidance for lumbar puncture

Ultrasound guidance for lumbar puncture

Ultrasound guidance for lumbar puncture

Safety and predictors of the success of lumbar punctures performed by a medicine procedure service

Contact Info

Product

Resources

About