Turandot Saul M D St Lukes Roosevelt Hospital

Turandot Saul, M. D. St. Luke’s Roosevelt Hospital Center ULTRASOUND GUIDED LUMBAR PUNCTURE

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

SURFACE LANDMARK GUIDANCE Line at level of iliac crests – L 4 spinous process Spinal cord ends at L 1 Interspace Surface landmark identification accuracy 30%1 G. et al. 1 Furness, above or below An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anesthesia, 57. 277 -280; 2002.

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

ULTRASOUND FOR LUMBAR PUNCTURE Easy to use Non-invasive Increasingly available Information site essential to a successful LP of needle introduction angle needed to approach sub-arachnoid space distance needed to obtain CSF

THE DIFFICULT LUMBAR PUNCTURE Morbid obesity Scoliosis / Arthritis Anxious Failed Attempts

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

ANATOMY Ligaments supraspinal: connects spinous processes interspinal: inferior to superior border spinous processes ligamentum flavum interlaminar space

ULTRASOUND - LONGITUDINAL

ULTRASOUND - TRANSVERSE

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.

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.

ULTRASOUND – PARAMEDIAN APPROACH a: b: c: d: e: spinous process ligamentum flavum epidural space dura mater 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.

MEDIAN VS. PARAMEDIAN ? Paramedian more anatomic elements seen small window between spinous processes differentiate dura matter and ligamentum flavum dynamic guidance

DIRECTION AND DEPTH

US GUIDANCE FOR LUMBAR PUNCTURE

US GUIDANCE FOR LUMBAR PUNCTURE

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

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.

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% < 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.

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 L 3, L 4, L 5, 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.

THE USE OF ULTRASOUND TO IDENTIFY PERTINENT LANDMARKS FOR LP 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.

THE USE OF ULTRASOUND TO IDENTIFY PERTINENT LANDMARKS FOR LP Distance: skin to ligamentum flavum 44 mm normal BMI (< 24. 9) 51 mm overweight (24. 9 - 30) 64 mm 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.

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

RESOURCES Roberts: Clinical Procedures in Emergency Medicine, 4 th ed. Philadelphia, Saunders; 2004. Goetz: Textbook of Clinical Neurology, 3 rd 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. 277280; 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.