 Reasons for US assisted LP

o Surface landmark identification of underlying structures only accurate 30% of the

time (Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for
identification of lumbar intervertebral level. Anaesthesia. 2002 Mar. 57(3):277-
80.
o Most useful in patients in whom surface landmark-guided LP is difficult (eg: pts
who are obese or have spinal disorders)
 US can help operators identify the pertinent landmarks for LP in
approximately 75% of the time (Stiffler KA, Jwayyed S, Wilber ST, et al.
The use of ultrasound to identify pertinent landmarks for lumbar
puncture. Am J Emerg Med. 2007 Mar. 25(3):331-4.)
o Can decrease number of attempts and minimize complications (Stiffler KA,
Jwayyed S, Wilber ST, et al. The use of ultrasound to identify pertinent landmarks
for lumbar puncture. Am J Emerg Med. 2007 Mar. 25(3):331-4.)
 Particularly true in patients with BMI of 30+ (Nomura JT, Leech SJ,
Shenbagamurthi S, et al. A randomized controlled trial of ultrasound-
assisted lumbar puncture. J Ultrasound Med. 2007 Oct. 26(10):1341-8.)
 Saw similar improvements in pediatric patients (Kim S, Adler DK.
Ultrasound-assisted lumbar puncture in pediatric emergency medicine. J
Emerg Med. 2014 Jul. 47(1):59-64.)
o An alternative method when a blind approach is not successful is fluoroscopic-
guided LP, but this has limited availability, difficulty visualizing the spinal canal,
and radiation exposure
o Can also use the color flow US to identify vascular structures in infants (Brunhild
M. Halm, David O. Kessler, Color Flow Doppler Point of Care Ultrasound to
Evaluate Vessels before Infant Lumbar Puncture, In The Journal of Emergency
Medicine, Volume 52, Issue 1, 2017, Pages 70-73, ISSN 0736-4679,
https://doi.org/10.1016/j.jemermed.2016.06.050.
(http://www.sciencedirect.com/science/article/pii/S073646791630378X))
 This can help identify interspinous spaces with greater odds of a non-
bloody LP, as the spinal canal and vascular structures in infants are easily
visualized from the back
 Changing the patient’s position (eg supine to sitting) or changing to
another suitable interspace could help minimize the incidence of
traumatic LPs, although further research is necessary as this is based
primarily off case studies
 How to perform
o Should use high frequency probe (linear) on patients with a normal weight, and
low-frequency probe (curvilinear) in patients with high BMI
o Position the patient in either the lateral decubitus or seated position as you
normally would for an LP
o Position probe transversely over midline of the back at the level of the iliac crests
o Identify the spinous process which will appear as a hyperechoic structure with
shadowing
 o Center the spinous process on the screen, placing the probe directly over the
midline of the spine
o Mark the midline of the spine at the center of the probe using a surgical marker,
then move the probe inferior or superiorly to identify the next spinous process
and mark it
o Rotate the transducer to the longitudinal place with the marker pointing toward
the patient’s head
 Keep the probe between the spinous processes that were just marked
o Identify the interspinous space – the gap between the 2 spinous processes which
appear as crescent-shaped, hyperechoic, upward convexities with shadowing
o Center the interspinous space and mark the level on both sides of the probe
o Measure the depth required to penetrate the subarachnoid space
 This can also help identify the right size needle in peds patients
o The point of intersection between the 2 lines represents the middle of the
interspace and the ideal location to insert the LP needle
 Potential mistakes
o Do not let the pt move after making the marks
 If the pt moves substantially, the markings may be less accurate
 FAQ
o OK, but does this really actually improve success rates of LPs? I mean, I’m pretty
good at them…
 A randomized, prospective, double-blind study revealed the use of
ultrasound for LP significantly reduced the number of failures in all
patients and improved the ease of the procedure in obese patients (6 of
22 failed with palpation landmarks vs 1 of 24 with US, 4 of 7 failed in
obese patients with palpation of landmarks vs 0 of 5 with US) (Nomura,
Jason T. et al. A randomized controlled trial of ultrasound-assisted lumbar
puncture. Journal of Ultrasound. Oct 1 2007, 1341-1348.)
o Fine. But it’s going to add a lot of time to the procedure to get good pictures, I
don’t have time for that!
 Soft tissue and anatomical structures were identified in all subjects (76)
with a mean BMI of 31.4. Images were obtained in less than 1 minute in
87.9% of scans, and within 5 minutes for 100% of scans, average scan
time was 57.9 seconds (Ferre, Robinson M. Sweeney, Timothy W.
Emergency physicians can easily obtain ultrasound images of anatomical
landmarks relevant to lumbar puncture. Am Jour EM. March 2007. 291-
296.)
o