Turandot Saul, M.D.St. Luke’s Roosevelt Hospital Center

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

Spinal cord ends at L1

Interspace above or below

Surface landmark identification accuracy 30%1

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

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

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

Morbid obesity Scoliosis / Arthritis Anxious Failed Attempts

Lumbar puncture kit Linear array, high frequency probe –

thin Curved array, low frequency probe -

obese

Ligaments supraspinal: connects

spinous processes

interspinal: inferior to superior border spinous processes

ligamentum flavum - interlaminar 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.

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.

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.

Paramedian more anatomic elements seen small window between spinous processes differentiate dura matter and ligamentum

flavum dynamic guidance

US to localize intervertebral levels

epidural spaces for anesthetic catheters

guidance of neonatal and infant lumbar puncture

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

Coley, BD, et al. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture Pediatric Radiology (2001) 31; 399-402.

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

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.

Stratified patients by BMI

Recorded difficulty in palpating landmarks

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

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

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%)

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

Distance: skin to ligamentum flavum 44mm normal BMI (< 24.9) 51mm overweight (24.9 - 30) 64mm obese (> 30)

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

Does ultrasound: increase rate of LP success? decrease length of procedure decrease complication rate of procedure static vs. dynamic

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.