Ultrasound Guided Lumbar Puncture

1
Ultrasound Guided Lumbar Puncture

• Turandot Saul, M.D.
• St. Lukes Roosevelt Hospital Center

2
Preparation

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

3
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 301

1Furness, G. et al. An evaluation of ultrasound
imaging for identification of lumbar
intervertebral level. Anesthesia, 57. 277-280
2002.
4
Surface Landmark Guidance

• 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

5
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

6
The Difficult Lumbar Puncture

• Morbid obesity
• Scoliosis / Arthritis
• Anxious
• Failed Attempts

7
Equipment

• Lumbar puncture kit
• Linear array, high frequency probe thin
• Curved array, low frequency probe - obese

8
Anatomy

• Ligaments
• supraspinal connects spinous processes
• interspinal inferior to superior border spinous
  processes
• ligamentum flavum - interlaminar space

9
Ultrasound - Longitudinal
10
Ultrasound - Transverse
11
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.
12
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.
13
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.
14
Median vs. Paramedian ?

• Paramedian
• more anatomic elements seen
• small window between spinous processes
• differentiate dura matter and ligamentum flavum
• dynamic guidance

15
Direction and depth
16
US Guidance for lumbar puncture
17
US Guidance for lumbar puncture
18
Radiology and Anesthesia

• US to localize intervertebral levels
• epidural spaces for anesthetic catheters
• guidance of neonatal and infant lumbar puncture

19
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

Coley, BD, et al. Diagnostic and interventional
ultrasonography in neonatal and infant lumbar
puncture Pediatric Radiology (2001) 31 399-402.
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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 lt 1 minute, 100 lt 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.
21
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

Stiffler, KA et al. The use of ultrasound to
identify pertinent landmarks for lumbar puncture.
American Journal of Emergency Medicine. 25(3)
2007.
22
The use of ultrasound to identify pertinent
landmarks for lp

• Difficulty in palpating landmarks - 21 patients
• 5 normal BMI (lt 24.9)
• 33 overweight (24.9 - 30)
• 68 obese (gt 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.
23
The use of ultrasound to identify pertinent
landmarks for lp

• Distance skin to ligamentum flavum
• 44mm normal BMI (lt 24.9)
• 51mm overweight (24.9 - 30)
• 64mm obese (gt 30)

Stiffler, KA et al. The use of ultrasound to
identify pertinent landmarks for lumbar puncture.
American Journal of Emergency Medicine. 25(3)
2007.
24
Future Studies

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

25
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.