Ultrasound guidance for lumbar puncture

Abstract

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.

3D ultrasound registration-based visual servoing for neurosurgical navigation

“…In both cases, X-ray fluoroscopy guidance is recommended and considered gold standard [2]. Several studies have reported that US-guided injections show no significant difference in diagnostic accuracy and therapeutic efficacy compared to guidance using fluoroscopy or CT, yet substantially reduce the radiation exposure of both patient and clinicians [3][4][5]. Nevertheless, the limited field of view and difficulties in interpreting US images are common obstacles to guarantee accurate needle placement [2].…”

Ultrasound guidance for lumbar puncture

“…We appreciate the feedback on our article. 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."…”

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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.

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“…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.…”

“…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.…”