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Positioning for lumbar puncture in children evaluated by bedside ultrasound
Alyssa Abo1, Lei Chen, Patrick Johnston
1Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA. alyssa.abo@gmail.com
Insights
The optimal position for pediatric lumbar punctures is sitting with flexed hips, maximizing the lumbar interspinous space for easier needle insertion. Neck flexion does not improve space and may increase risks.
Area of Science:
- Pediatric Emergency Medicine
- Ultrasound Imaging
- Anatomy
Background:
- Lumbar punctures are frequently performed in pediatric emergency settings.
- No standardized optimal positioning exists for pediatric lumbar punctures.
- Maximizing interspinous space is crucial for successful lumbar puncture.
Purpose of the Study:
- To identify the optimal position for pediatric lumbar punctures.
- To maximize the lumbar interspinous space using bedside ultrasound.
- To guide procedural positioning for improved outcomes.
Main Methods:
- Prospective study of children under 12 years old.
- Ultrasound measurement of L3-L4 or L4-L5 interspinous distance.
- Comparison of five positions: sitting (flexed/neutral hips), lateral recumbent (flexed/neutral hips, with/without neck flexion).
Main Results:
- The sitting position with flexed hips significantly increased interspinous distance (P < .05).
- Hip flexion enhanced interspinous space in both sitting and lateral positions (P < .05).
- Neck flexion showed no significant impact on interspinous space (P = .998).
Conclusions:
- The sitting position with flexed hips is recommended for pediatric lumbar punctures.
- Avoid neck flexion in the lateral recumbent position to prevent potential morbidity.
- Standardizing position can improve lumbar puncture success rates and patient safety.
Background:
Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
Objective:
To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
Methods:
A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
Results:
There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P < .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P < .05). Flexion of the neck, did not significantly change the interspinous space (P = .998).
Conclusions:
The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
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