Ultrasound-guided Lumbar Puncture Research Articles

‘UltraGUD LP’—A Randomized Controlled Trial: Traditional Landmark-based Lumbar Puncture Is as Effective as Ultrasound-guided Lumbar Puncture in Outpatient Neurology Settings (P7-4.012)

‘UltraGUD LP’—A Randomized Controlled Trial: Traditional Landmark-based Lumbar Puncture Is as Effective as Ultrasound-guided Lumbar Puncture in Outpatient Neurology Settings (P7-4.012)

USINE-PAMS Artificial Intelligence Driven, Ultrasound-guided Lumbar Puncture to Improve Procedural Accuracy—A Pilot Usability Study (S3.008)

uSINE-PAMS Artificial Intelligence Driven, Ultrasound-guided Lumbar Puncture to Improve Procedural Accuracy—A Pilot Usability Study (S3.008)

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Implementation of a Bedside Point-of-Care Ultrasound Program in a Large Academic Neonatal Intensive Care Unit.

In the adult and pediatric critical care population, point-of-care ultrasound (POCUS) can aid in diagnosis, patient management, and procedural accuracy. For neonatal providers, training in ultrasound and the use of ultrasound for diagnosis and management is increasing, but use in the neonatal intensive care unit (NICU) is still uncommon compared with other critical care fields. Our objective was to describe the process of implementing a POCUS program in a large academic NICU and evaluate the role of ultrasound in neonatal care during early adaption of this program. A POCUS program established in December 2018 included regular bedside scanning, educational sessions, and quality assurance, in collaboration with members of the cardiology, radiology, and pediatric critical care divisions. Core applications were determined, and protocols outlined guidelines for image acquisition. An online database included images and descriptive logs for each ultrasound. A total of 508 bedside ultrasounds (76.8% diagnostic and 23.2% procedural) were performed by 23 providers from December 2018 to December 2020 in five core diagnostic applications: umbilical line visualization, cardiac, lung, abdomen (including bladder), and cranial as well as procedural applications. POCUS guided therapy and influenced clinical management in all applications: umbilical line assessment (26%), cardiac (33%), lung (14%), abdomen (53%), and cranial (43%). With regard to procedural ultrasound, 74% of ultrasound-guided arterial access and 89% of ultrasound-guided lumbar punctures were successful. Implementation of a POCUS program is feasible in a large academic NICU and can benefit from a team approach. Establishing a program in any NICU requires didactic opportunities, a defined scope of practice, and imaging review with quality assurance. Bedside clinician performed ultrasound findings can provide valuable information in the NICU and impact clinical management. · Use of point-of-care ultrasound is increasing in neonatology and has been shown to improve patient care.. · Implementation of a point-of-care ultrasound program requires the definition of scope of practice and can benefit from the support of other critical care and imaging departments and providers.. · Opportunities for point-of-care ultrasound didactics, imaging review, and quality assurance can enhance the utilization of bedside ultrasound..

Ultrasound-Guided vs. Landmark-Guided Lumbar Puncture for Obese Patients in Emergency Department.

ObjectiveEmergency patients are in severe and urgent condition. If the patient is obese, the traditional lumbar puncture method is more difficult. This study was to observe the comparison of ultrasound-guided and landmark-guided lumbar puncture for obese patients in the emergency department.MethodsSixty patients suspected of intracranial infection, subarachnoid hemorrhage, and intraventricular hemorrhage from January 2018 to June 2020 were selected in the Department of Emergency Medicine, Shengjing Hospital of China Medical University. They were randomly assigned to two groups according to the order of enrollment: Group A (Landmark-guided group, n = 30) and Group B (Ultrasound-guided group, n = 30). Follow-up assessments were performed to observe lumbar puncture time, the number of bloody CSF, Visual Analog Scale (VAS), the complications, and satisfaction.ResultsCompared with group A, group B had less lumbar puncture time, lower puncture attempts, and a higher first puncture success rate (P <0.05). In group B, the number of bloody CSF was less (P <0.05), postprocedural low back pain was less (P <0.05), intraprocedural sciatic nerve irritation and postprocedural paresthesia were less, but the difference was not statistically significant (P > 0.05). Compared with group A, the postprocedural VAS in group B was lower, and the difference was statistically significant (P <0.05). The total satisfaction of group A and group B was 60.0 and 86.7%, respectively. The total satisfaction of group B was higher than that of group A (P <0.05).DiscussionUltrasound-guided lumbar puncture can be used for obese patients with difficulty in the lumbar puncture. It is worthy of clinical application and promotion.

Cost-Effective Training Models in Point-of-Care Ultrasound for Medical Students in Emergency Medicine: An Evaluation of Current Resources.

BackgroundUltrasound is becoming more widely utilized in clinical practice; however, its effectiveness is limited by the operator’s skills. Simulation models are attractive options for developing skills because they allow inexperienced users to practice without the risk of endangering patients.ObjectiveThe purpose of this study was to identify commercially available and homemade ultrasound models to describe them in terms of materials, cost, and whether they are high- or low-fidelity for medical student education.MethodsThis is an investigational study on cost-effective ultrasound training methods for medical students. Our study was performed using search engines in Google, Google Scholar, and PubMed to search for models for the following five modalities: foreign body identification, intravenous (IV) injection training, abdominal ultrasound, ocular ultrasound, and ultrasound-guided lumbar puncture training.ResultsMost homemade models for foreign body identification, IV injection training, and ocular ultrasound could be created for less than $20. IV injection training models were the cheapest commercially available models. There are multiple commercially available options for abdominal ultrasound models, but no options were found for homemade construction. The construction cost for lumbar puncture models was larger due to the need to purchase an anatomically accurate set of lumbar vertebrae.ConclusionsThis study provides initial guidance and suggestions for ultrasound training models that are currently available. Ultrasound models that can be cheaply made or purchased increase accessibility for medical students to gain early exposure in a cost-effective and safe manner.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine.

Real-time ultrasound-guided lumbar puncture in the neonatal intensive care unit.

To determine the rates of traumatic lumbar puncture (LP) and overall success rates using the real-time ultrasound-guided technique when performed by a neonatal point-of-care ultrasound provider. Retrospective observational study of 17 infants in the neonatal intensive care unit who underwent a real-time ultrasound-guided LP between March 2015 and November 2016. Spearman's correlation was calculated. The first attempt and overall success rates were 65% and 100%, respectively. The rate of nontraumatic LP was 69%. CSF RBC count was inversely correlated with both PMA (Spearman's correlation coefficient (rs) = -0.74, p = 0.0017) and weight (rs = -0.74, p = 0.0015) at the time of LP. This study is the first to provide evidence of high success rates with real-time ultrasound-guided LP when performed by a neonatologist. Our data demonstrate feasibility in neonates over a broad range of weights, including premature infants as small as 750 g.

Ultrasound-guided nusinersen administration for spinal muscular atrophy patients with severe scoliosis: an observational study

BackgroundThis observational study describes our experience delivering nusinersen through lumbar puncture with real-time ultrasound guidance in spinal muscular atrophy (SMA) patients with severe scoliosis.ResultsIntrathecal nusinersen via real-time ultrasound-guided lumbar puncture was given to three patients who had severe thoracic and lumbar scoliosis: a 34-year-old female with type 3a SMA, a 28-year-old male with type 2a SMA, and a 14-year-old girl with type 3a SMA. Lumbar puncture was performed without sedation under ultrasound guidance using a 22G echogenic needle in the interlaminar aspect of the L4–L5 or L5–S1 interspace and a full dose of nusinersen (12 mg/5 mL) was injected after visualizing free cerebrospinal fluid flow. Patients completed their four loading doses and one maintenance dose of nusinersen. All 15 procedures were successful and well tolerated.ConclusionsReal-time ultrasound-guided lumbar puncture is an effective and radiation-free technique to administer intrathecal nusinersen in SMA patients with severe scoliosis when done by practitioners with expertise in this procedure.

Ultrasound-guided lumbar puncture for nusinersen administration in spinal muscular atrophy patients.

The purpose was to report the results of ultrasound-guided lumbar puncture for the administration of nusinersen in spinal muscular atrophy (SMA) patients with complex spines. Eighteen SMA patients (five children, five adolescents and eight adults) with either severe scoliosis or spondylodesis were evaluated for ultrasound-guided lumbar puncture. Ultrasound was performed with a 3.5MHz transducer to guide a 22gauge×15mm needle, which was placed in the posterior lumbar space following a parasagittal interlaminar approach. Twelve patients had undergone spinal instrumentation (nine growing rods and three spinal fusion) whilst the other six showed severe scoliosis. Success was achieved in 91/94 attempts (96.8%), in 14/18 patients (77.8%), including 100% of children and adolescents and 50% of adult patients. In two of the unsuccessfully treated patients, computed tomography and fluoroscopy-guided transforaminal lumbar punctures were also tried without success. After a median follow-up of 14months, only few adverse events, mostly mild, were observed. The ultrasound-guided lumbar puncture, following an interlaminar parasagittal approach, is a safe and effective approach for intrathecal treatment with nusinersen in children, adolescents and carefully selected adult SMA patients with complex spines and could be considered the first option in them.

Ultrasound guided lumbar puncture reduces failed punctures, spent time and number of attempts in emergency department

Introduction: The present study was an attempt to evaluate the role of ultrasonography on decreasing the number of attempts, failed punctures, time needed to perform the procedure and patients’ pain. Methods: This study is a prospective case-control. Patients were divided in two groups randomly. A two-dimensional probe was used to localize intervertebral space in the ultrasound guidance (US group). In manual palpation (MP group) however, insertion level was determined using the standard technique by manual palpation. The number of attempts (needle insertion) required for a successful tap and successful/unsuccessful attempts were considered as the primary outcome measures. Results: Male patients with an average age of 44.08±15.83 years accounted for 60% (30 individuals) of the population. Success rate was 92% in the US group and 34% in the MP group (P&lt;0.001). It took 79.64± 19.91 and 85.4±11.62 minutes to identify the proper location in US and MP groups respectively (P=0.21). In the first attempt, it took 6.33±0.95 and 6.87±0.7 minutes to collect cerebrospinal fluid (CSF) in US and MP groups respectively (P=0.02). Average time taken to localize the sites in two attempts were 8.28±2.44 and 13.17±3.32 in US and MP groups respectively (P&lt;0.001). Average number of attempts made in the US and MP groups were 1.08±0.27 and 1.64±0.66 (P&lt;0.001) respectively. Conclusion: Ultrasonography has reduced the time needed for locating puncture to collect CSF, pain management in patients, determining the number of attempts, and defining the risk of traumatic puncture. Moreover, this technique is characterized by a higher success rate. Using ultrasonography in obese patients and people with lumbar problems is more important.

Ultrasound-guided lumbar puncture improves success rate and efficiency in overweight patients.

Approximately 400,000 diagnostic lumbar punctures (LPs) are performed by neurologists yearly in the United States. There has been a transition from neurologists performing >40% of LPs 2 decades ago to now <15% of the time. High body mass index (BMI) is one of the key obstacles of LP for neurology residents, and the success rates drop to 58% when BMI is >35 kg/m2. A prospective intervention study was conducted from March 2017 to March 2018 at an academic medical center. Patients were divided into ultrasound-guided LP or conventional LP. The primary outcome was the success rate of LP. The secondary outcome was the parameters regarding LP performance, the patients' feedback after procedures, and the residents' feedback about the learning modules. Eighty-two patients were enrolled with inclusion criteria of age >18 years, BMI ≥25 kg/m2, and able to give written informed consent. The ultrasound-guided LP group showed higher success rate (92.7% vs 68.3%, p < 0.05) and less duration of time (17.02 vs 37.63 minutes, p < 0.05) compared with the conventional LP group. It also showed advantages of decreased trials of needle insertions and redirections and reduced pain levels perceived by patients. This study suggests that using ultrasound to localize before LP could increase the LP success rate and improve other related LP outcomes in the overweight populations. Our study also provides evidence that brief, targeted teaching modules are feasible and effective for ultrasound-guided LP training. This study provides Class III evidence that for patients with BMI ≥25 kg/m2 undergoing LP, ultrasound guidance increases the LP success rate.

Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine.

When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.

Ultrasound Guided Lumbar Puncture and Remote Guidance for Potential In-Flight Evaluation of VIIP/SANS.

INTRODUCTION: Changes of visual function/neuro-opthalmic structures during spaceflight have been described as visual impairment and intracranial pressure syndrome (VIIP)/spaceflight-associated neuro-ocular syndrome (SANS). Although theories are suggested, the mechanism is unknown. Only indirect measurements of intracranial pressure (ICP) have been performed in spaceflight. Direct determination of in-flight ICP is crucial to understanding VIIP. Current "gold standard" is lumbar puncture (LP). The only direct evaluation has occurred with postflight LP. In-flight measurements would allow correlation of opening pressures/possible contributing factors. The only imaging modality on the International Space Station (ISS) is ultrasound. With appropriate methodology, remotely guided ultrasound-guided lumbar puncture (USGLP) may allow safe performance in flight. Therefore, we sought to develop a novel ultrasound approach for definitive placement of an LP needle, and to show this can be achieved with remote guidance by those without training.METHODS: Literature review and round-table discussions with multiple medical fields was performed. Volunteers were scanned with ultrasound for optimizing technique. A cadaver was used to perform this technique by a radiologist, then taught to volunteers not experienced in image guided procedures, and finally was repeated multiple times by volunteers with simulated remote guidance.RESULTS: Optimal visualization was in the fetal and seated exaggerated kyphotic [corrected] positions. Technical success was achieved by the radiologist in all attempts and achieved in 9 of 11 attempts by the trainees.DISCUSSION: Given ultrasound experience at NASA and the ability to educate non-image-guided trained personnel, these could make this technique feasible and aid in direct in-flight measurements to further research VIIP.Lerner DJ, Chima RS, Patel K, Parmet AJ. Ultrasound guided lumbar puncture and remote guidance for potential in-flight evaluation of VIIP. Aerosp Med Hum Perform. 2019; 90(1):58-62.

Utilization of Ultrasound Guided Lumbar Puncture to Improve the Efficacy and Outcome in an Overweight Patient Population: A Resident Driven Quality Improvement Project (S14.004)

Utilization of Ultrasound Guided Lumbar Puncture to Improve the Efficacy and Outcome in an Overweight Patient Population: A Resident Driven Quality Improvement Project (S14.004)

Abstract No. 596 Ultrasound-guided lumbar puncture in pediatric patients: technical success and safety

Abstract No. 596 Ultrasound-guided lumbar puncture in pediatric patients: technical success and safety

Ultrasound-guided lumbar puncture in pediatric patients: technical success and safety.

Disadvantages of fluoroscopically guided lumbar puncture include delivery of ionizing radiation and limited resolution of incompletely ossified posterior elements. Ultrasound (US) allows visualization of critical soft tissues and the cerebrospinal fluid (CSF) space without ionizing radiation. To determine the technical success and safety of US-guided lumbar puncture in pediatric patients. A retrospective review identified all patients referred to interventional radiology for lumbar puncture between June 2010 and June 2017. Patients who underwent lumbar puncture with fluoroscopic guidance alone were excluded. For the remaining procedures, technical success and procedural complications were assessed. Two hundred and one image-guided lumbar punctures in 161 patients were included. Eighty patients (43%) had previously failed landmark-based attempts. One hundred ninety-six (97.5%) patients underwent lumbar puncture. Five procedures (2.5%) were not attempted after US assessment, either due to a paucity of CSF or unsafe window for needle placement. Technical success was achieved in 187 (95.4%) of lumbar punctures attempted with US guidance. One hundred seventy-seven (90.3%) were technically successful with US alone (age range: 2days-15years, weight range: 1.9-53.1kg) and an additional 10 (5.1%) were successful with US-guided thecal access and subsequent fluoroscopic confirmation. Three (1.5%) cases were unsuccessful with US guidance but were subsequently successful with fluoroscopic guidance. Of the 80 previously failed landmark-based lumbar punctures, 77 (96.3%) were successful with US guidance alone. There were no reported complications. US guidance is safe and effective for lumbar punctures and has specific advantages over fluoroscopy in pediatric patients.

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

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.

Comparison of a GPS needle-tracking system, multiplanar imaging and 2D imaging for real-time ultrasound-guided epidural anaesthesia: A randomized, comparative, observer-blinded study on phantoms

BackgroundThe real-time ultrasound-guided paramedian sagittal oblique approach for neuraxial blockade is technically demanding. Innovative technologies have been developed to improve nerve identification and the accuracy of needle placement. The aim of this study was to evaluate three types of ultrasound scans during ultrasound-guided epidural lumbar punctures in a spine phantom. MethodsEleven sets of 20 ultrasound-guided epidural punctures were performed with 2D, GPS, and multiplanar ultrasound machines (660 punctures) on a spine phantom using an in-plane approach. For all punctures, execution time, number of attempts, bone contacts, and needle redirections were noted by an independent physician. Operator comfort and visibility of the needle (tip and shaft) were measured using a numerical scale. ResultsThe use of GPS significantly decreased the number of punctures, needle repositionings, and bone contacts. Comfort of the physician was also significantly improved with the GPS system compared with the 2D and multiplanar systems. With the multiplanar system, the procedure was not facilitated and execution time was longer compared with 2D imaging after Bonferroni correction but interaction between the type of ultrasound system and mean execution time was not significant in a linear mixed model. There were no significant differences regarding needle tip and shaft visibility between the systems. ConclusionsMultiplanar and GPS needle-tracking systems do not reduce execution time compared with 2D imaging using a real-time ultrasound-guided paramedian sagittal oblique approach in spine phantoms. The GPS needle-tracking system can improve performance in terms of operator comfort, the number of attempts, needle redirections and bone contacts.

Feasibility of real-time workflow segmentation for tracked needle interventions.

Computer-assisted training systems promote both training efficacy and patient health. An important component for providing automatic feedback in computer-assisted training systems is workflow segmentation: the determination of what task in the workflow is being performed. Our objective was to develop a workflow segmentation algorithm for needle interventions using needle tracking data. Needle tracking data were collected from ultrasound-guided epidural injections and lumbar punctures, performed by medical personnel. The workflow segmentation algorithm was tested in a simulated real-time scenario: the algorithm was only allowed access to data recorded at, or prior to, the time being segmented. Segmentation output was compared to the ground-truth segmentations produced by independent blinded observers. Overall, the algorithm was 93% accurate. It automatically segmented the ultrasound-guided epidural procedures with 81% accuracy and the lumbar punctures with 82% accuracy. Given that the manual segmentation consistency was only 84%, the algorithm's accuracy was 93%. Using Cohen's d statistic, a medium effect size (0.5) was calculated. Because the algorithm segments needle-based procedures with such high accuracy, expert observers can be augmented by this algorithm without a large decrease in ability to follow trainees in a workflow. The proposed algorithm is feasible for use in a computer-assisted needle placement training system.