Ahhh, the lumbar puncture… This seemingly simple procedure seems to be the Achilles's heel or many resus docs! If you have a good baseline knowledge of how to do the lumbar puncture correctly, it is super easy. If you have bad habits, then you will make your poor patient look like a pin cushion.
In this episode, I review my 20 years worth of tips and tricks to excel at the Lumbar Puncture (LP) as well as how to avoid the most common pitfalls I see all the time.
Ingredients
Indications/Contra-indications
Make a Checklist with this stuff and equipment
- Is the INR <1.6
- Is the PLT > 50,000 (some would say 100,000 but a bunch of papers in the literature saying it is safe even down to 10,000 in peds)
- PTT if they have been on heparin
- The patient is not on Plavix or NOACs
When to Get a CT Scan [NEJM. 2001;345(24):1727-33]
CT Findings with which LP Contraindicated
- Lateral shift of midline structures
- Loss of suprachiasmatic and basilar cisterns
- Obliteration of the fourth ventricle, or obliteration of the superior cerebellar and quadrigeminal plate cisterns with sparing of the ambient cistern
- I would add hydrocepahlus or mass
(Arch Intern Med 159:2681 December 13/27, 1999)
Anatomical Knowledge
Microskills
Consent
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loved this. I always use 22 3.5. often hit bone. ill try the more complete numbing procedure. may try the paramedian approach soon- look forward to it .
Love this. Do you have recipes for other procedures (like TV pacer) … like ingredients / equipments list / recipe? Thanks for all you do.
Thank you mister Scott
yes the rate of platelets accepted to perform a lumbar puncture varies between 50000 and 70000 depending on the gauge of the needle, experimentation of the practitioner the technical difficulty (obesity, agitation…) the risk of several attempts
Hi Scott,
Thanks for this podcast. I was wondering if any of the other listeners would, as I would, need a visual to go with the audio, to fully get the description in the podcast.
I think I followed it but there were points where I became unsure if I’d understood this completely.
Thank you. Really liked this content.
Dean
I do inject lidocaine through the spinal needle if the patient is having any discomfort when advancing the needle. I saw this while watching the interventional radiologist do an LP under fluoro (for one I couldn’t get). It works well. One of my older partners suggested going with my patient to radiology to learn how to do the procedure with flouro guidance-good advice. After doing LPs in the lateral position for 25 years I started trying doing it on patients in the sitting position for the very young and the heavier patients where it is hard to visualize the midline… Read more »
In my shop we go paramedian for anyone > 40y or any positioning/ anatomic issues ( fêmur fx, pregnancy , scoliosis,spastic paralysis, closet spaces)
We go 1 cm caudal, 1 cm down perpendicular to skin, touch transverse process, and redirect medial and up until it penetrantes the space.
it has been described in anesthesia and Analgesia as the ” white cane”/” blind man cane” approach
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9426741/
Works wonders for epidurals too.
Some great YT vídeos IMHO
https://youtu.be/Ou-Z-uVASmE
https://youtu.be/EKVwsO9VEIA
https://youtu.be/G3Ek-UAkHSI
Anesthesia/ CCM Md from Brazil
I love doing LPs. I think what is most helpful in patients where you can’t feel their anatomy is grabbing the ultrasound, and often you will find midline is not where you thought and that the dura is much deeper too. This procedure really is about feeling and just doing enough to get that feeling down.
Hey Scott, Thoughts from the anaesthetist perspective: – The biggest problem I see is people not visualizing the anatomy or systematically approaching the procedure. Being midline is EVERYTHING. Spend a bit of time feeling up and down the back to be confident you are midline but please have your local needle ready so you don’t have to do it again. Use the ultrasound if you aren’t sure. Use the local needle to explore the space while injecting local. You don’t need much angle in lumbar region – maybe 15 degrees if you are in the middle of the space between spinous… Read more »
Fantastic!! Thanks, Michael
Thanks Scott, quick question for you, why does clopidogrel make it onto your contraindication list? Are you specifically referring to DAPT? My quick review of the literature seems that most articles found this to be safe but was wondering if this is simply institutional policy at your site.
Cheers!
Taylor
https://emcrit.org/emcrit/cqir-lp-asa-plavix/
I also tend to believe that “aspirin safer than clopidogrel” may be a myth. My belief grew stronger since my extra quick review a few months ago, where it seemed the concept comes from a low-quality recomendation from the anesthesia field (but maybe I’m wrong). Supporting my belief, we already have some data supporting clopidogrel safer than aspirin in other fields, specially in the cardiovascular field (see HOST-EXAM, Lancet 2021). Why would it be riskier in a LP maneuver? Never got a good explanation, but maybe there is one and I am not seeing it straight. Open to be convinced… Read more »
Fantastic Episode ! 45min on LP.. i love it 😉 Personally, i think another key concept is to always try to aim a bit higher when choosing the interspinal space. When looking at MRI, it’s L3L4 is clearly wider than L4L5. I know there’s literature on how we are poor at spotting the right spinous process, but for me, if at the iliac crest i feel a spinous process, i go higher, if i feel a space, i go there. I always remove the stylet and advance the needle as you described, there’s pediatric literature that support this practice. I… Read more »
reason to measure opening pressure (outside of an AIDS/immunocomp situation in which it is a toxo tipoff) is b/c this is your one shot to get an ICP. This will give you valuable information in meningitis/enceph and may diagnose IIH in headache w/u
Even if you forget to measure (me all the time) you can tell if someone has elevated icp by how fast / sluggish csf drains from the needle … and if there is clinical improvement after removing csf I feel confident they have elevated icp .. but hopefully their brain ct has findings to clue you in (effaced sulci, effaced cisterns , loss of grey white , MLS, mass effect , transependymal edema , dilated ventricles , etc)
I have rarely injected lido via the LP needle I specifically make sure I have the preservative free single dose vials, which are NOT your run of the mill single dose vials, and I’ve not needed to waste any CSF given there is no organism killing properties to this form or lido- I’ve double checked with my PharmDs and I think I’m on safe ground unless you believe o/w
Great learning! Thank you. Three questions: 1 – Good tip on midazolam. Do you know literature on the topic and which dose you generally use? 2 – Consent is a topic which in generally interests and challenges me, always have legal and philosophical doubts. I would be very interested if you decided one day to do a full podcast on “Consent and Procedures” including things such as “oral vs. written”, etc. Meanwhile, do you know some literature, podcast or blog post on the topic? 3 – I think we don’t have “lido+epi” in my ED. Do you have some tip… Read more »
same thing as push dose epi (1:100,000)
so 9 mls of lidocaine 2% and 1 ml of cardiac (1:10,000) epinephrine