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SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)

SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)

Podcast Link:SGEM41
Date:  June 16, 2013
Title: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)

Case Scenario: A 66YO man presents with a 48hr history of fever, lethargy and headache. No significant past medical history. On physical examination he has a temperature of 38.8C, GCS 15, stiff neck on flexion and no rash. Urinalysis and CXR are normal. Laboratory testing reports an elevated WBC with a left shift. You decide he needs a LP to check for meningitis.

Screen Shot 2013-04-28 at 8.14.15 PM

Question:  Can ultrasound be used to improve successful LP attempts?

Background: The following procedures may decrease the risk of post-LP headache. Listen to SGEM#34: This is Spinal Tap for all the details.

  1. Small-gauge atraumatic needles
  2. Reinsertion of the stylet prior to the removal of the spinal needle
  3. Mobilization of patients after completing the LP

Screen Shot 2013-04-28 at 8.14.33 PMReference:  Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. Shaikh F et al. BMJ 2013;346:f1720 doi: 10.1136/bmj.f1720

  • Population: 14 studies (n=1334)
  • Intervention:  U/S assisted LPs (5 studies) and epidurals (9 studies)
  • Control: Unassisted
  • Outcome: Reduction of failed attempts

Results: Screen Shot 2013-06-16 at 1.12.04 PM

  • Failed procedures 12 studies (n=1234) 79% RRR (95% CI: 57-90) NN 16 (95% CI: 12-25)
  • Traumatic Procedures 5 studies (n=?) 73% RRR (95% CI: 33-89) NN 17 (95% CI: 11-44)

Authors Conclusion: “Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterizations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.”

BEEM Comments: There was no blinding for the patients. This might effect subjective outcomes such as post-LP headaches. It would be easy to do a sham ultrasound. However, the lack of blinding should not effect objectives outcomes such as failed or traumatic attempts.

Only 5 of 14 studies were done for LPs with the rest for epidurals. Half of the patients in the studies were obstetrical patients. All the physicians involved were ultrasound ‘keeners”. These things weaken the external validity of the results to the emergency department setting.

BEEM Bottom Line: There needs to be an adequately powered blinded RCT of ED doctors on consecutive ED patients in need of an LP showing a difference in patient oriented outcomes. Until then we suggest maximizing the methods proven to improve LP technique before we start adding unproven modalities (Straus et al).

Case Resolution: You successfully perform the LP without an ultrasound and send off the CSF to the lab for analysis to rule out meningitis.

KEENER KONTEST: The hoser who won last week was Constant Coolsma from the Netherlands. He knew that Tim Horton was a Canadian ice hockey defence man who later founded a coffee house/doughnut shop named after him.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

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Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Have a great Father’s Day and talk with you next week.

 

  • Maxim Ben-Yakov

    Great summary … tried to do an U/S guided LP today on an obese pt for r/o SAH. Seems that my U/S got discouraged by the pt habitus too; finally Anesthesia got it with superb technique. Maybe we should just utilize our colleagues more than our technology?

    • TheSGem

      Glad you enjoyed the summary hot off the press (March 2013 published). Trying to cut that KT window down to less than 1 year. Have you seen the article by Dr. David Newman about the 700 Club for r/o SAH? I agree we should utilize our colleagues they can have a wealth of knowledge and skills. Emergency medicine is a “team sport”.