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Subramanian S, Reshma BM, Salim Iqbal M, Harsoor SS. A comprehensive, bed-side scoring system to predict difficult lumbar puncture. J Anaesthesiol Clin Pharmacol 2023; 39:38-44. [PMID: 37250250 PMCID: PMC10220197 DOI: 10.4103/joacp.joacp_77_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 05/20/2021] [Indexed: 03/21/2023] Open
Abstract
Background and Aims Spinal anesthesia (SA) is the most widely practiced neuraxial anesthesia. Lumbar puncture (LP) at multiple levels and multiple attempts due to any reason may cause discomfort and even serious complications. Hence the study was conducted to evaluate the patient variables that can predict difficult LP thus allowing for the use of alternate techniques. Material and Methods We included 200 patients of ASA physical status I-II, scheduled to undergo elective infra-umbilical surgical procedures under spinal anesthesia. During preanesthetic evaluation, difficulty score was assessed using the 5 variables: Age, abdominal circumference, spinal deformity - assessed as axial trunk rotation (ATR) value, anatomical spine assessed by spinous process landmark grading system (SLGS) and patient position, by assigning a score of 0- 3 for each variable, with a total score of 0 - 15. The difficulty of LP was graded as easy, moderate or difficult based on total number of attempts and spinal levels by independent experienced investigator. The scores obtained during preanesthetic evaluation and the data collected after performing LP were analyzed using multivariate analysis and P value noted. Results Our study showed that above patient variables correlated well with difficult LP scoring (P < 0.001). SLGS was noted to be a strong predictor, while ATR value a weak predictor. The correlation between the total score and grades of SA had a positive association (R = 0.6832, P < 0.00001) and was statistically significant. A median difficulty score of 2, 5 and 8 predicted easy, moderate and difficult LP respectively. Conclusion The scoring system provides for a useful tool to predict difficult LP and helps both patient and anesthesiologist to choose an alternative technique.
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Affiliation(s)
- Shobha Subramanian
- Department of Anesthesiology, Dr. B. R. Ambedkar Medical College and Hospital, Gandhi Nagar, Kadugondanahalli, Bengaluru, Karnataka, India
| | - BM Reshma
- Department of Anesthesiology, Dr. B. R. Ambedkar Medical College and Hospital, Gandhi Nagar, Kadugondanahalli, Bengaluru, Karnataka, India
| | - M. Salim Iqbal
- Department of Anesthesiology, Dr. B. R. Ambedkar Medical College and Hospital, Gandhi Nagar, Kadugondanahalli, Bengaluru, Karnataka, India
| | - SS Harsoor
- Department of Anesthesiology, Dr. B. R. Ambedkar Medical College and Hospital, Gandhi Nagar, Kadugondanahalli, Bengaluru, Karnataka, India
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Dobson SW, Weller RS, Turner JD, Lack CM, Henshaw DS. Surface Landmarks in the Lateral Decubitus Position Are Unreliable for Thoracic Epidural Catheter Placement: A Case Series. A A Pract 2022; 16:e01649. [PMID: 36599018 DOI: 10.1213/xaa.0000000000001649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thoracic epidurals remain the optimal method for providing postoperative analgesia after complex open abdominal and thoracic surgeries. However, they can be challenging to both place and maintain, as evidenced by a failure rate that exceeds 30%.1 Proper identification of the epidural space and accurate placement of the catheter are critical in order to deliver effective postoperative analgesia and avoid failure.2,3 This case series investigated the difficulty in correctly identifying the proper vertebral level for thoracic epidural catheter procedures when performed in the lateral decubitus position.
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Affiliation(s)
| | | | | | - Christopher M Lack
- Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Shi D, Perice L, Grimaldi C, Perera T, Nelson M. Ultrasound Measurement of the Intervertebral Space in the Lateral Recumbent Versus Sitting Positions. J Emerg Med 2021; 61:705-710. [PMID: 34465511 DOI: 10.1016/j.jemermed.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/19/2021] [Accepted: 07/03/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Diagnostic lumbar puncture (LP) is an invasive procedure routinely performed within the emergency department (ED). LP is traditionally performed with the patient in either the lateral recumbent or sitting position. We investigated if the intervertebral space is larger in one of these positions. If one position is larger than the other, this would imply that one position offers a higher chance of a successful lumbar puncture than the other position. OBJECTIVE We sought to determine if there is a significant size difference of the L4/L5 intervertebral space in the lateral recumbent compared with the sitting position. METHODS Point-of-care ultrasound (POCUS) was performed to measure the size of each volunteer's L4/L5 intervertebral space in both the seated and lateral recumbent positions. All volunteers >18 years of age were eligible for the study. Thirty volunteers had measurements taken. Three measurements were taken by each investigator in both positions for each volunteer. RESULTS The median L4/L5 intervertebral space distance was 1.7511 cm in the lateral recumbent position and 1.9511 cm in the seated position with a Wilcoxon signed rank p value <.0001. The interspinous space in the seated position was found to be significantly larger than in the lateral recumbent position. CONCLUSION The size of the interspinous space in the seated position on ultrasound was found to be larger than the lateral recumbent position, suggesting that LP may be more successful in the seated position.
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Affiliation(s)
- Dorothy Shi
- Department of Emergency Medicine, North Shore University Hospital-Northwell Health, Manhasset, New York
| | - Leland Perice
- Department of Emergency Medicine, North Shore University Hospital-Northwell Health, Manhasset, New York
| | - Christina Grimaldi
- Department of Emergency Medicine, North Shore University Hospital-Northwell Health, Manhasset, New York
| | - Thomas Perera
- Department of Emergency Medicine, North Shore University Hospital-Northwell Health, Manhasset, New York
| | - Mathew Nelson
- Department of Emergency Medicine, North Shore University Hospital-Northwell Health, Manhasset, New York.
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Kim H, Won D, Chang JE, Lee JM, Ryu JH, Min SW, Jun K, Row HS, Hwang JY. Ultrasound assessment of the anatomic landmarks for spinal anesthesia in elderly patients with hip fracture: A prospective observational study. Medicine (Baltimore) 2019; 98:e16388. [PMID: 31277196 PMCID: PMC6635173 DOI: 10.1097/md.0000000000016388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Tuffier line is a common landmark for spinal anesthesia. The 10th rib line has been suggested as a new landmark to predict the intervertebral levels. We evaluated the accuracy of these 2 anatomic landmarks for identifying the L4-L5 intervertebral space using ultrasonography in elderly patients with hip fracture.Seventy-nine elderly patients scheduled for hip fracture surgery under spinal anesthesia were included. In the lateral decubitus position with the fracture side up, the L4-L5 intervertebral space was identified alternately using Tuffier line, a line drawn between the highest points of both iliac crests, and the 10th rib line. The 10th rib line, an imaginary line that joints the 2 lowest points of the rib cage, passes through the L1-L2 intervertebral space or the body of L2. The L4-L5 intervertebral space was determined by the counting-down method from the 10th rib line. Then, the estimated intervertebral spaces were evaluated using ultrasonography.The L4-L5 intervertebral space was correctly identified in 47 (59%) patients with Tuffier line and 45 (57%) patients with the 10th rib line (P = .87). The estimation ratio related to the intervertebral levels was not different between the 2 landmarks (P = .40). The wrong identifications of intervertebral level with Tuffier line and the 10th rib line was observed in the following order: L3-L4 intervertebral space: 27% vs 24%, L5-S1 intervertebral space: 9% vs 16%, and L2-L3 intervertebral space: 5% vs 3%, respectively.Tuffier line and the 10th rib line may be unreliable to estimate the intervertebral space for spinal anesthesia in elderly patients with hip fracture.
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Affiliation(s)
- Hyerim Kim
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
| | - Dongwook Won
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
| | - Jee-Eun Chang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumiro, Seongnam-si, Gyeonggido
- College of Medicine, Seoul National University, Seoul
| | - Seong-Won Min
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
- College of Medicine, Seoul National University, Seoul
| | - Kwanghoon Jun
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Daehakro, Jongnogu, Seoul, Republic of Korea
| | - Hyung Sang Row
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Daehakro, Jongnogu, Seoul, Republic of Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul
- College of Medicine, Seoul National University, Seoul
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Jaime-Pérez JC, Sotomayor-Duque G, Aguilar-Calderón P, Salazar-Cavazos L, Gómez-Almaguer D. Impact of Obesity on Lumbar Puncture Outcomes in Adults with Acute Lymphoblastic Leukemia and Lymphoma: Experience at an Academic Reference Center. Int J Hematol Oncol Stem Cell Res 2019; 13:146-152. [PMID: 31649805 PMCID: PMC6801327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: Lumbar puncture (LP) is a hematology procedure that can require repeated attempts leading to traumatic LP (TLP), which has been related to the central nervous system (CNS) relapse. LP success can depend on the size and anatomy of the patient and the skill of the hematologist. The main objective was to determine the influence of body mass index (BMI) on LP outcomes. Materials and Methods: Adults with lymphoid malignancies requiring LP were included prospectively over one year; hematology residents performed most procedures. A 22-gauge Quincke needle was employed. Comparison between non-traumatic vs. traumatic LPs according to BMI, CNS relapse, and residents' year was performed. Results: Fifty-four patients with a mean age of 31.5±15.57 years were included. Diagnosis was Acute Lymphoblastic Leukemia-B (74%), Acute Lymphoblastic Leukemia-T (13%) and Non-Hodgkin Lymphoma (13%). 227 LPs were performed, 121 (53.3%) successful, 98 (43.2%) traumatic, 11 (11.2%) TLPs were macroscopically detectable and 87 (88%) microscopic; 8 (3.5%) were dry-taps. Median time between punctures was 11 days (1-202). Median BMI was 25 (22.8-39.6). Main indication for LP was prophylactic (74.5%); 39.2% were performed by first-year, 35.2% by second-year, 19.6% by third-year hematology residents. No difference (p = 0.145) for a TLP was found among residents. A BMI ≥30 (p = 0.040), non-palpable intervertebral space (p = 0.001) and more than one attempt (p = 0.001) were significant for TLP. TLP was not associated with CNS relapse (p = 0.962). Conclusion: Obesity predicted a TLP. A traumatic puncture did not increase the risk of CNS relapse at one-year follow-up.
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Shah AA, Lemans JV, Zavatsky J, Agarwal A, Kruyt MC, Matsumoto K, Serhan H, Agarwal AK, Goel V. Spinal Balance/Alignment - Clinical Relevance and Biomechanics. J Biomech Eng 2019; 141:2733054. [PMID: 31049580 DOI: 10.1115/1.4043650] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 02/28/2024]
Abstract
In the normal spine due to its curvature in various regions, C7 plumb line (C7PL) passes through the sacrum so that the head is centered over the pelvis-ball and socket hip joints and ankle joints. This configuration leads to the least muscular activities to maintain the spinal balance. For any reason like deformity, scoliosis, kyphosis, trauma, and/or surgery this optimal configuration gets disturbed requiring higher muscular activity to maintain the posture and balance. Several parameters like the thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), Hip- and leg position influence the sagittal balance and thus the optimal configuration of spinal alignment. Global sagittal imbalance is energy consuming and often painful compensatory mechanisms are developed, that in turn negatively influence the quality of life. This review looks at the clinical aspects of spinal imbalance, and the biomechanics of spinal balance as dictated by the deformities- ankylosing spondylitis, scoliosis and kyphosis; surgical corrections- pedicle subtraction osteotomies and long segment stabilizations and consequent postural complications like the proximal and distal junctional kyphosis. This review suggests several potential research topics as well.
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Affiliation(s)
- Anoli A Shah
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | | | | | - Aakash Agarwal
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | - Moyo C Kruyt
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Koji Matsumoto
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | | | - Anand K Agarwal
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | - Vijay Goel
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
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Cooperstein R, Truong F. Would adopting a revised landmark rule for the spinal level of the iliac crests improve the accuracy of lumbar level identification? THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2019; 63:26-35. [PMID: 31057175 PMCID: PMC6493207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This is a secondary analysis of two previous systematic reviews demonstrating cephalad bias in using palpation to enumerate lumbopelvic levels, based on the conventional landmark rule that the spinal level of the palpated iliac crests=L4. Our study included 7 articles which enumerated lumbopelvic levels based on this rule, and furthermore reported data such that the direction and magnitude of errors could be abstracted from the article. The primary goal was to determine if enumeration accuracy would have improved had examiners known that the spinal level of palpated crests was closer to the L3-4 or L3 spinal level, as shown in our previous review. For the articles included, the mean error in spinal level enumeration diminished from 0.79 to -0.21 spinal levels, while accuracy increased from 26.3% to 46.9%. Since accuracy remained <50%, further refinements in iliac crest palpation are unlikely to improve enumeration accuracy, suggesting another method might best be sought.
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Cooperstein R, Truong F. Systematic review and meta-analyses of the difference between the spinal level of the palpated and imaged iliac crests. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2017; 61:106-120. [PMID: 28928494 PMCID: PMC5596973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The purpose of this study was to undertake a systematic review of the literature to determine and compare, for patient sub-groups, the spinal level of the iliac crests as commonly measured through manual palpation and radiographic imaging procedures. METHODS Relevant citations were retrieved by searching the PubMed, ICL, CINAHL, AMED, Osteopathic Research Web, OstMed, and MANTIS biomedical databases, and included articles were rated for quality. Search terms included Tuffier*, intercristal line, intercrestal line, Jacoby's line, lumbar spine, lumbar landmark, pelvic landmark, palpation, and TL (Tuffier's Line). Meta-analyses were performed on the full datasets as well as subsets based on various patient demographics. RESULTS Original search strategies retrieved 1301 citations; 47 articles were used for qualitative synthesis and 31 for meta-analyses. Across these studies imaged crests were found to be most consistent with and closest to the L4-5 interspace in females and L4 spinous process in males. In comparison, the spinal level for the palpated crests was nearest to the L3-4 interspace in males and females. The palpated crest line was 0.7 levels cephalad to the imaged crest line in males, and 1.0 levels cephalad to the imaged line in females. DISCUSSION AND CONCLUSIONS During manual palpation, the examiner's fingers contact soft tissue overlying the iliac crests, thereby usually identifying the L3-4 spinal level rather than the assumed L4-5 level. Palpating iliac crests to guide anesthetic injections or manual therapy without appreciating these findings can be hazardous or lead to suboptimal patient care.
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Ambulkar R, Patil V, Doctor JR, Desai M, Shetty N, Agarwal V. Accuracy of ultrasound imaging versus manual palpation for locating the intervertebral level. J Anaesthesiol Clin Pharmacol 2017; 33:348-352. [PMID: 29109634 PMCID: PMC5672528 DOI: 10.4103/joacp.joacp_285_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background and Aims: Efficacy of epidural analgesia depends on placement of the epidural catheter at the appropriate level. Manual palpation using surface landmarks to identify the desired intervertebral level may not be a reliable method. Ultrasonography (USG) is an alternative technique but requires training and may increase procedure time. The objective of this study was to compare the accuracy of ultrasound (US) imaging with manual palpation for locating the intervertebral level. Material and Methods: We included postoperative adult patients without an epidural catheter who were scheduled to have a chest radiograph in the recovery room. A radio-opaque marker was placed at random at an intervertebral space along the thoracic or lumbar spine of the patient (in the field of the chest radiograph). The level of intervertebral space corresponding to the radio-opaque marker was determined by palpation technique by one anesthetist. Two other anesthetists (A and B) blinded to the result of manual palpation, independently used USG to determine the level of intervertebral space. A consultant radiologist assessed the radiographs to determine the correct position of the marker, which was judged to be the accurate space. Results: We recruited a total of 71 patients, of which 64 patients were included in the final analysis. Accurate identification by manual method was 31/64 (48%), by US A was 27/64 (42%) and by US B was 22/64 (34%). The difference in accuracy between manual palpation and US imaging was not statistically significant (P = 0.71). Conclusion: US imaging may not be superior to manual palpation for identifying intervertebral level.
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Affiliation(s)
- Reshma Ambulkar
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Vijaya Patil
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Jeson R Doctor
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Madhavi Desai
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Nitin Shetty
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Vandana Agarwal
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India
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