open access

Vol 45, No 1 (2013 Jan-Mar)
Original and clinical articles
Published online: 2013-03-19
Submitted: 2013-03-19
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Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%

Larysa Duniec, Piotr Nowakowski, Dariusz Kosson, Tomasz Łazowski
DOI: 10.5603/AIT.2013.0001
·
Anaesthesiol Intensive Ther 2013;45(1):1-6.

open access

Vol 45, No 1 (2013 Jan-Mar)
Original and clinical articles
Published online: 2013-03-19
Submitted: 2013-03-19

Abstract

BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4–L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment.

METHODS: Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The ‘counting-up’ approach starting with the L5–S1 space was applied.

RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture.

CONCLUSIONS: The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

Abstract

BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4–L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment.

METHODS: Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The ‘counting-up’ approach starting with the L5–S1 space was applied.

RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture.

CONCLUSIONS: The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

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Keywords

level of lumbar puncture, orthopedia, spinal anaesthesia, ultrasound, ultrasound guided regional anaesthesia

About this article
Title

Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%

Journal

Anaesthesiology Intensive Therapy

Issue

Vol 45, No 1 (2013 Jan-Mar)

Pages

1-6

Published online

2013-03-19

DOI

10.5603/AIT.2013.0001

Bibliographic record

Anaesthesiol Intensive Ther 2013;45(1):1-6.

Keywords

level of lumbar puncture
orthopedia
spinal anaesthesia
ultrasound
ultrasound guided regional anaesthesia

Authors

Larysa Duniec
Piotr Nowakowski
Dariusz Kosson
Tomasz Łazowski

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