Two-operator real-time ultrasound-guided lumbar puncture in neonates: a case series

Lumbar puncture (LP) is a common but challenging procedure in neonates, with reported high rates of failure and traumatic taps. Real-time ultrasound (US) guidance may improve accuracy and safety, but evidence in the neonatal population remains limited. We retrospectively reviewed five neonates who underwent two-operator real-time US-guided LP in a tertiary neonatal intensive care unit between 2023 and 2024. Both static pre-procedural assessment and dynamic real-time guidance were applied. Demographic data, operator experience, procedural details, and outcomes were collected. The median gestational age at birth was 38 weeks (range 32-41). At the time of LP, postmenstrual age ranged from 33 to 44 weeks and weight from 1820 to 3960 g. Three procedures were performed by inexperienced operators, one by an intermediate, and one by an experienced operator. All LPs were successfully completed on the first attempt, irrespective of operator experience or patient position (lateral or seated). No traumatic LPs occurred, and no complications were observed. Cerebrospinal fluid (CSF) analysis yielded diagnostic results in all cases, including one case of parechovirus meningitis.Conclusion: Our case series demonstrates that real-time US guidance allows safe and effective LP in neonates, achieving 100% success without trauma even when performed by inexperienced operators. These findings support the feasibility of incorporating US-guided LP into routine neonatal practice. Larger prospective studies are warranted to confirm its benefits and define standardized protocols. What is Known: • Lumbar puncture (LP) in neonates has a high failure and traumatic tap rate compared to older children • Real-time ultrasound guidance can increase LP success and reduce complications in pediatric patients What is New: • Ultrasound guidance proved effective regardless of operator experience, suggesting a role in training and skill acquisition • These findings support the feasibility of systematically implementing ultrasound-guided LP in neonatal clinical practice.