Use of the Ultrasound to Determine the Level of Lumbar Puncture in Pregnant Women

Locks, Giovani de Figueiredo; Almeida, Maria Cristina Simões de; Pereira, Amanda Amaro

doi:10.1016/s0034-7094(10)70002-7

Cited by 38 publications

(39 citation statements)

References 17 publications

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“…23 Palpation of lumbar spinous processes is inaccurate in both lean and obese patients, and inferior in prediction of lumbar level compared to ultrasound. [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.…”

Section: Literature Reviewmentioning

confidence: 99%

Ultrasound guidance for lumbar puncture

et al. 2016

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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.

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Section: Literature Reviewmentioning

confidence: 99%

Ultrasound guidance for lumbar puncture

et al. 2016

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“…Biorąc pod uwagę fakt, że tradycyjne metody wykorzystujące znajomość anatomii i anatomicznych punktów orientacyjnych w większości przypadków umożliwiają wykonanie skutecznej blokady centralnej, a także uwzględniając, że okolica kręgosłupa u pacjentów dorosłych jest trudna do obrazowania ultrasonograficznego ze względu na dużą ilość struktur kostnych, USG w tym obszarze nie stosuje się tak często jak w przypadku blokad obwodowych. Ostatnio w piśmiennictwie pojawiło się jednak wiele prac wykazujących korzyści związane z wykorzystaniem tej techniki w blokadach centralnych, szczególnie w przypadku kobiet ciężarnych [8][9][10][11][12]. Wszyscy autorzy wskazują na rozbieżność w ocenie na podstawie badania przedmiotowego oraz obrazu ultrasonograficznego w tej grupie pacjentek.…”

Section: Dyskusjaunclassified

“…Ultrasonografia jest stosowana do określenia położenia splotów i nerwów obwodowych, jak również do wyznaczenia wysokości przestrzeni międzykręgowych oraz oceny głębokości położenia przestrzeni zewnątrzoponowej i podpajęczynówkowej. Jak wskazują wyniki badań, ocena wysokości przestrzeni międzykręgowych na podstawie anatomicznych punktów orientacyjnych jest często rozbieżna z oceną dokonaną według obrazowania ultrasonograficznego [8][9][10][11][12].…”

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Ocena wysokości przestrzeni międzykręgowej na podstawie punktów anatomicznych w celu wykonania nakłucia lędźwiowego zawodzi w ponad 30% przypadków

Duniec¹,

Nowakowski²,

Kosson³

et al. 2013

Anaesthesiol Intensive Ther

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Background. The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. Methods. Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting--up' approach starting with the L5-S1 space was applied. Results. One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. Conclusions. The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

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“…It should be noted that both Furness et al (12) and Whitty et al (13) investigated subjects with a range of body weights and not specifically on obese subjects. In a more recent study by de Figueiredo Locks et al, no significant differences were found when obese and non-obese obstetric patients were compared in terms of accuracy in locating the L3-L4 IVS (14).…”

Section: Original Research Articlementioning

confidence: 87%

“…This could have affected our results when we compared anaesthesiologists of various levels of experience. Lastly, in order to better appreciate the difficulties encountered in obese subjects, a "control" group of non-obese individuals could have been included in our study, as was done in the study by de Figueiredo Locks et al (14).…”

Section: Discussionmentioning

confidence: 99%

Identification of Lumbar Intervertebral Space: Palpation versus Ultrasound Technique among Obese Subjects

Selvakumar¹,

Lee²

2017

JSA

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Accurate identification of the intervertebral space (IVS) is necessary during central neuraxial blockade, especially in spinal anaesthesia, to avoid untoward spinal cord injury. Ultrasound guided examination has been shown to be more accurate compared to palpation, but these studies were performed on subjects of various body weights. We conducted our prospective observational study on obese subjects and compared the performance by anaesthesiologists of various levels of anaesthetic experience. Obese subjects with body mass index (BMI) ≥ 30 kg/m 2 scheduled for elective surgery were recruited following explanation and written consent. With the subjects in the sitting position, an investigator located the L3-L4 IVS by ultrasound and used an invisible ultraviolet marker pen to mark the upper border, lower border and midpoint ("Point M") of the space. Two anaesthesiologists of varying levels of experience, categorized as Performer 1 and Performer 2, then located the L3-L4 IVS by palpation. The distance between this point and Point M was measured and recorded. Thirty-two subjects with mean BMI 35.4±6.0 kg/m 2 were recruited. The mean intervertebral distance at L3-L4 on ultrasound was 1.5 cm [range 1.2-1.8 cm]. By palpation, the L3-L4 IVS was correctly identified by 56.3%, while a higher IVS was mistaken to be L3-L4 by 23.4% of all performers. The space was correctly identified by 50% of junior anaesthesiologists and 62.5% of the senior counterparts. There was fair agreement between the two categories, with kappa = 0.375 and p = 0.028. In conclusion, there was a sizeable discrepancy between the anaesthesiologists' estimation by palpation and the actual location of the L3-L4 IVS by ultrasound among obese subjects. This observation was in fair agreement among anaesthesiologists of various levels of anaesthetic experience. The ultrasound-guided technique is useful for better identification of lumbar IVS especially in obese subjects.

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Use of the Ultrasound to Determine the Level of Lumbar Puncture in Pregnant Women

Abstract: The L3-L4 space is correctly identified in a low percentage of obese and non-obese pregnant women. Spinal ultrasound can reduce the incidence of mistaken identification of the L3-L4 space in obese and non-obese pregnant women.

Cited by 38 publications

References 17 publications

Ultrasound guidance for lumbar puncture

Ultrasound guidance for lumbar puncture

Ocena wysokości przestrzeni międzykręgowej na podstawie punktów anatomicznych w celu wykonania nakłucia lędźwiowego zawodzi w ponad 30% przypadków

Identification of Lumbar Intervertebral Space: Palpation versus Ultrasound Technique among Obese Subjects

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