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Ultrasound guidance for difficult lumbar puncture in children: pearls and pitfalls

Abstract

Pediatric lumbar puncture can be challenging or unsuccessful for several reasons. At the same time, the excellent sonographic window into the pediatric spine provides a distinct opportunity for ultrasound-guided lumbar puncture. Minimal cerebrospinal fluid and thecal displacement by subdural or epidural hematomas are common after failed clinical attempts. Ultrasound is useful for determining a safe infraconal level for subarachnoid access. Real-time guidance increases not only the success rate but also the safety of diagnostic lumbar puncture and injections for chemotherapy and myelography. In this article, we discuss clinical and technical factors for ultrasound-guided pediatric lumbar puncture.

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Correspondence to Prakash Muthusami.

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Appendix 1 Land-marking technique for lumbar puncture using ultrasound

Appendix 1 Land-marking technique for lumbar puncture using ultrasound

  • Patient is positioned in left lateral decubitus, flexed at hip and knee.

  • Sagittal ultrasound image is obtained to identify upper sacral margin (S1).

  • Ultrasound probe is moved cephalad to identify L3 and L4 vertebral body levels, which are marked by horizontal lines on the skin on either side of the probe.

  • Axial ultrasound scanning is performed to identify the midline (spinous process) at the L3 and L4 levels, and is marked by vertical lines on the skin to transect the previously marked horizontal lines.

  • Axial scanning is performed on the midline (vertical line) in the interspinous space (between the two horizontal lines) with gradual cephalad angulation of the transducer to obtain a clear view of the ligamentum flavum–posterior dura echogenicity. This transducer angle is eyeballed to determine the angle of needle entry.

  • Measurement of skin-to-posterior-dura distance is obtained in the last axial image.

  • Skin preparation and sterile draping are conducted.

  • The spinal needle is introduced into the L3–L4 interspace on the previously marked vertical line, along the predetermined angle.

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Muthusami, P., Robinson, A.J. & Shroff, M.M. Ultrasound guidance for difficult lumbar puncture in children: pearls and pitfalls. Pediatr Radiol 47, 822–830 (2017). https://doi.org/10.1007/s00247-017-3794-0

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Keywords

  • Cerebrospinal fluid
  • Interventional radiology
  • Lumbar puncture
  • Meningitis
  • Neonate
  • Subdural hematoma
  • Ultrasound