Ultrasound guidance for lumbar puncture

Abstract

I read the article by Soni et al.1 line by line. Because of my association with a hospital at the epicenter of the AIDS epidemic, I have performed many thousands of lumbar punctures (LPs) for all of the usual reasons. Many patients were tapped repeatedly. I am right-handed and so the LP is performed with the patient in the left lateral decubitus position. This is essential to measure the opening pressure. I mark the back in the usual fashion using the line between the superior iliac crests to identify the L4-L5 interspace. I prefer the L2-L3 interspace for the procedure. Once identified, I begin the procedure. I use the same words with each patient and prep and drape the patient in the same fashion each time. I use local anesthesia. Once I again have the L2 spinous process identified, I keep my left thumb firmly pressed there for guidance and support and to distract the patient. The needle is advanced perpendicular to the skin and once it has passed the bone is at times angled cephalad. What I have described is a ritual. It is the ritual that makes the successful LP and this can be taught.