Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound Alyssa Abo, Lei Chen, Patrick Johnston and

Karen Santucci Pediatrics 2010;125;e1149; originally published online April 19, 2010; DOI: 10.1542/peds.2009-0646

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound

AUTHORS: Alyssa Abo, MD,a Lei Chen, MD,a Patrick Johnston, MMath,b and Karen Santucci, MDa
aSection of Pediatric Emergency Medicine, Department of Pediatrics Yale-New Haven Childrens Hospital, New Haven, Connecticut; and bClinical Research Program, Childrens Hospital Boston, Boston, Massachusetts

WHATS KNOWN ON THIS SUBJECT: Lumbar punctures are routinely performed in the pediatric emergency department. Children undergoing the procedure are generally placed in the sitting or lateral recumbent position. The interspinous distance changes in adults in the different positions when measured by bedside ultrasound. WHAT THIS STUDY ADDS: For children undergoing lumbar punctures, the sitting position with hip exion maximally increases the interspinous space as measured by bedside ultrasound. In the lateral recumbent position, neck exion does not increase the space and is not recommended.

KEY WORDS lumbar puncture, ultrasound www.pediatrics.org/cgi/doi/10.1542/peds.2009-0646 doi:10.1542/peds.2009-0646 Accepted for publication Dec 4, 2009 Address correspondence to Alyssa Abo, MD, Division of Emergency Medicine, University of California, Davis, 4150 V St, PSSB 2100, Sacramento, CA 95817. E-mail: alyssa.abo@gmail.com PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.

abstract
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 exion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in exion, both with and without neck exion. 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-exed position provided a signicantly 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 signicantly change the interspinous space (P .998). CONCLUSIONS: The interspinous space of the lumbar spine was maximally increased with children in the sitting position with exed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck exion 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 exion. Pediatrics 2010;125:e1149e1153

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Lumbar punctures are a routine procedure in the pediatric emergency department. In the emergency setting, the procedure is primarily diagnostic and used to rule out various infectious and neurologic processes. When undergoing a lumbar puncture, children are generally placed in the sitting or lateral recumbent position. There are variations of each position; therefore, there is not 1 standard position. Patient position is decided in each instance by the clinician who is performing the lumbar puncture. Positioning for lumbar punctures, to determine maximal interspinous space, has been evaluated in adults by using ultrasound1 and radiography.2 In both studies the results indicated that the position for lumbar punctures in adults with the widest interspinous space is sitting with maximal hip exion. In pediatrics, there has been no literature on the optimal position for lumbar puncture as it relates to maximal interspinous space. In this study, we used ultrasound to measure the interspinous space of children in various positions to determine if 1 particular position maximally increases the interspinous space.

investigators were available. Infants and children were excluded from the study if they were clinically unstable, had meningeal signs, or were undergoing lumbar punctures for diagnostic purposes. The rationale to exclude children who had meningeal signs or required lumbar punctures was twofold: (1) it would presumably be uncomfortable to sustain 5 different positions for lumbar punctures for patients with meningeal signs; and (2) if physicians were aware that the interspinous space was larger in 1 position over another, their decision for positioning may have been inuenced when performing the procedure. Infants and children were placed in 5 different positions: 3 lateral recumbent and 2 upright positions. The lateral recumbent positions were L1, lateral recumbent with the hips at a neutral position (lateral); L2, lateral recumbent with hip exion (lateral exed); and L3, lateral recumbent with hip exion and neck exion (lateral exed with neck exion). The upright positions were S1, sitting without exing the hips (sitting); and S2, sitting with maximal exion of the hips (sitting exed) (Fig 1). The SonoSite (Bothell, WA) 180 ultrasound machine with a high-frequency linear transducer (L38) was used to obtain the ultrasound images. The

transducer was placed on the spine in the sagittal plane at the level of an imaginary line between the 2 posterior-superior iliac crests. This landmark correlates with the L3-L4 and L4-L5 interspaces, which are appropriate sites for lumbar puncture in all ages. The same interspinous space was measured with the subject in 5 different positions. Digital still images were obtained. The primary outcome was the measurement of the interspinous space. The maximal interspinous space was measured from the points of maximal curvature (Fig 2) between the adjacent posterior spinous processes. The point of maximal curvature of the spinous process was used for the measurement because it presumably represents the part of the vertebral body that is palpated by the clinician because it is closest to the skin. Five measurements were recorded for each patient by the principal investigators (Drs Abo and Chen). Demographic data including age, gender, and weight were recorded for each patient. z scores, the SD for weight for age, were calculated. Data were evaluated by using SAS 9.1.3 (SAS Institute, Inc, Cary, NC).3 Pairwise comparisons were performed by using

METHODS
A prospective study of a convenience sample of children was performed in the pediatric emergency department and the pediatric primary care center at Yale-New Haven Childrens Hospital from January to June 2005. The study was approved by the human investigation committee and was compliant with the Health Information Portability and Accountability Act of 1996. Parental consent was obtained, as was patient assent for patients older than 7 years. Patients younger than 12 years who presented to the pediatric emergency department or primary care center were evaluated for enrollment when
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Lateral (L1)

Lateral Flexed (L2)

Lateral Flexed With Neck Flexion (L3)

Sitting (S1)

Sitting Flexed (S2)

Neutral

Hip flexion

Hip and neck flexion

Neutral

Hip flexion

FIGURE 1
Positions for measurement of lumbar interspinous space.

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FIGURE 2
Ultrasound image of the spinous processes and the distance between them.

The interspinous space of patients was evaluated with pairwise comparisons with the simulate adjustment yielding adjusted P values (Table 3). The mean difference as well as the percent change was calculated with a 95% condence interval. The sitting-exed (S2)
TABLE 1 Demographics and Age Distribution

an analysis-of-variance model with a random-intercept term, which allowed each subject to have his or her own intercept. Multiple tests were accommodated by using adjusted P values such that the probability of the experiment-wise type I error rate was kept at 5%. Adjusted P values were calculated by using the simulate adjustment of Edwards and Berry.4

Age, y Mean 5.5

Weight, kg 22.4

z score 0.4

Frequency According to Age

SD

2.7

10.3

1.3

Minimum

0.5

7.7

3.5

Median

5.0

19.3

0.5

Maximum

11.0

45.0

2.5

RESULTS
Twenty-eight children between the ages of 6 weeks and 12 years were enrolled in the study (13 girls and 15 boys). Five patients were younger than 15 months. The median and mean age for those enrolled was 5 years (Table 1). Four subjects were excluded for 1 of 2 reasons: (1) unable to sustain all 5 positions; or (2) body habitus hindered visualization of the spinous process. The 2 patients who could not sustain all positions were a 1-month-old and a 12-month-old who could not hold still long enough for us to obtain ultrasound images. The 2 patients who were excluded for body habitus were obese, with z scores of 3.3 and 3.42, correlating to the 97th percentile. The lumbar interspinous space of 24 subjects was measured in 5 different positions. The mean interspinous space measurement for each space is shown in decreasing order of magnitude in Table 2. The interspinous space measurements were plotted for each subject in each position to demonstrate the trend of how the interspinous space changes in different positions (Fig 3).
PEDIATRICS Volume 125, Number 5, May 2010

TABLE 2 Means and Medians of Each Position in Decreasing Order of Magnitude

Position Sitting Flexed (S2) Sitting (S1) Lateral Flexed (L2) Lateral Flexed With Neck Flexion (L3) Lateral (L1)

Mean, cm SD Minimum, cm Median, cm Maximum, cm

2.38 0.42 1.44 2.41 3.05

2.28 0.50 1.20 2.40 2.88

2.27 0.41 1.43 2.31 3.00

2.26 0.43 1.27 2.33 3.02

2.05 0.44 0.92 2.14 2.73

FIGURE 3
Interspinous space measurement for each subject in each position. The centered red line is the mean, with the outer red lines indicating the 95% condence intervals.

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TABLE 3 Pairwise Comparisons of the Lumbar Interspinous Spaces

Difference of the Means, mm S1 vs S2 L1 vs L2 L1 vs L3 L1 vs S1 L1 vs S2 L2 vs S1 L2 vs S2 L3 vs L2 L3 vs S1 L3 vs S2 3 3 3 3 3 3 3 3 3 3 1.1 2.1 2.0 2.2 3.3 0.1 1.2 0.1 0.2 1.3 Difference, % (95% CI) 4.8 (0.4 to 1.7) 10.4 (1.5 to 2.8) 9.9 (1.4 to 2.7) 10.9 (1.6 to 2.9) 16.1 (2.7 to 3.9) 0.4 (0.5 to 0.7) 5.2 (0.5 to 1.8) 0.4 (0.5 to 0.7) 0.8 (0.4 to 0.8) 5.6 (0.6 to 1.9) Adjusted P .012 .001 .001 .001 .001 .998 .005 .998 .975 .002

the etiology of failed lumbar punctures and to guide lumbar punctures.9 However, bedside ultrasound is not routinely used for lumbar punctures in the pediatric emergency department. Ultrasound can be a useful adjunct in the pediatric emergency department for identifying landmarks as well as a guide after failed lumbar punctures. The success of a lumbar puncture in which spinal uid is obtained is inuenced by several factors in pediatrics. These factors include patient age, the use of local anesthetic, and stylet techniques.10 It is possible that patient position may also inuence the success. Although the space between vertebrae is a matter of millimeters, given that a 1.5-inch, 22 gauge spinal needle (BD Medical, Franklin Lakes, NJ) has a diameter of 0.7 mm, this may be signicant clinically. Future studies that randomize between the sitting and lateral positions should be performed to determine whether the sitting position leads to an increase in successful lumbar punctures on the rst attempt, as well as a decrease in the number of traumatic lumbar punctures. Research in preterm infants has evaluated positioning for spinal taps while monitoring parameters such as vital signs as well as PO2 and PCO2. Gleason et al11 evaluated 2 lateral recumbent positions, 1 with full neck exion and 1 with partial neck extension, as well as the sitting-upright position in preterm infants undergoing lumbar punctures. The authors determined that the lateral recumbent position with full neck exion was associated with a signicant decrease in transcutaneous PO2. In addition, there was a higher risk for potential morbidity. Therefore, they recommended that lumbar punctures be performed with the patient upright or that the lateral recumbent position be modied to include neck extension. Lumbar-puncture position was also evaluated in sick neonates to deter-

S1 indicates sitting exed; S2, sitting; L1, lateral; L2, lateral exed; L3, lateral exed with neck exion.

position resulted in the largest mean interspinous space (P .012). Flexion of the hips in both the sitting and lateral positions (ie, sitting [S1] to sitting exed [S2] and lateral [L1] to lateral exed [L2]) signicantly increased the interspinous space (P .012 and P .001, respectively). The lateral neutral position (L1) was signicantly worse than all other positions. When exing the neck, lateral exed with neck exion (L3) showed no signicant change in the interspinous space (P .998) compared with the lateral exed (L2) position, in which only the hips were exed.

recumbent position with one hand on the head, creating forcible exion of the neck. This practice may be unnecessary, given that it does not increase in the interspinous space and may actually cause respiratory compromise. Holding infants from the shoulders, and not the head or neck, should provide an adequate hold for lumbar punctures in the lateral recumbent position. In the adult population, bedside ultrasound has been used for difcult lumbar punctures5 and has been shown to reduce the number of failed lumbar punctures and to improve the ease of performance in obese patients.6 In a recent study, adult emergency physicians were able to obtain ultrasound images of anatomic landmarks that relate to lumbar punctures in less than 5 minutes.7 Furthermore, Stifer et al8 reported that identifying structures for lumbar puncture by using ultrasound is inversely related to BMI; however, even among patients whose landmarks were difcult to palpate clinically, images were obtained in 76% of them. There have been studies of infants in which ultrasound was used to evaluate

DISCUSSION
The position for lumbar punctures in which the interspinous space is maximized is the sitting-exed position. In both the sitting and lateral recumbent positions, exion of the hips increases the interspinous space from the neutral position. Neck exion does not inuence the interspinous space and, therefore, is not indicated when holding a patient for a lumbar puncture. It is common practice, especially for infants, to hold them tightly in the lateral
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mine whether hypoxemia was positiondependent.12 Two lateral recumbent positions were evaluated, 1 with kneechest exion (standard) and 1 without (modied), as well as a sitting position. The neck was not exed or extended. Results indicated that transcutaneous PO2 was lower in the lateral knee-chest position. Therefore, the recommendation for positioning was sitting or a modied lateral position. In the pediatric emergency department, infants are a large subset of patients undergoing lumbar punctures as part of the evaluation for sepsis. It is not common practice to have infants on the monitor while undergoing the procedure. The parameters described above raise concern regarding the effects of positioning during lumbar punctures. Sitting with hip exion not only has the potential to increase the interspinous space but also may be safer for our patients. There were several limitations in our study. Excluding patients who were not REFERENCES
1. Sandoval M, Shestak W, Sturmann K, et al. Optimal patient position for lumbar puncture, measured by ultrasonography. Emerg Radiol. 2004;10(4):179 181 2. Fisher A, Lupu L, Gurevitz B, et al. Hip exion and lumbar puncture: a radiological study. Anaesthesia. 2001;56(3):262266 3. SAS Software [computer program]. Release 9.1.3. Cary, NC: SAS Institute; 2002 4. Edwards D, Berry JJ. The efciency of simulation-based multiple comparisons. Biometrics. 1987;43(4):913928 5. Peterson MA, Abele J. Bedside ultrasound

undergoing lumbar punctures limits the ability to determine if there is clinical relevance of the various positions. Specically, we could not answer the question of whether identifying a position in which the interspinous space is maximized will have clinical implications. Furthermore, the sample size and age range were limited; therefore, the data could not be stratied according to age. Given the low number of infants in this study, the applicability of the data is limited in this age group; however, we believe the trend of how the interspinous space changes in different positions is consistent among all ages. One challenge that was notable in infants was the ability to evaluate 5 different positions. Evaluation of 3 positions, sitting and lateral recumbent with and without neck exion, may be more feasible in this age group. Future studies should aim to increase the sample size and age range of the children investigated. In our study, the sonographers who measured the interspinous space

were not blinded. Ideally, sonographers should be blinded, and multiple measurements of each position should be obtained and then averaged. Lastly, patients who are undergoing lumbar punctures should be studied in various positions to determine whether there is increased success in 1 position versus another as it correlates to the interspinous space distance.

CONCLUSIONS
We recommend that the sitting position be considered preferable for children who undergo lumbar punctures, because the interspinous space is maximized and morbidity is potentially decreased. For medical professionals who prefer the lateral recumbent position, we recommend holding the child from the shoulders to avoid neck exion. Positioning of the child affects the interspinous space; however, neck exion does not increase in the interspinous space.

for difcult lumbar puncture. J Emerg Med. 2005;28(2):197200 6. Nomura JT, Leech SJ, Shenbagamurthi S, et al. A randomized controlled trial of ultrasound-assisted lumbar puncture. J Ultrasound Med. 2007;26(10):13411348 7. Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med. 2007;25(3):291296 8. Stifer KA, Jwayyed S, Wilber ST, et al. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med. 2007;25(3):331334

9. Coley BD, Shiels WE II, Hogan MJ. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture. Pediatr Radiol. 2001;31(6):399 402 10. BaxterAL,WelchJC,BurkeBL,etal.Pain,position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians. PediatrEmergCare. 2004;20(12):816820 11. Gleason CA, Martin RJ, Anderson JV, et al. Optimal position for a spinal tap in preterm infants. Pediatrics. 1983;71(1):3135 12. WeismanLE,MerensteinGB,SteenbargerJR.The effect of lumbar puncture position in sick neonates. Am J Dis Child. 1983;137(11):10771079

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Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound Alyssa Abo, Lei Chen, Patrick Johnston and Karen Santucci Pediatrics 2010;125;e1149; originally published online April 19, 2010; DOI: 10.1542/peds.2009-0646
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/125/5/e1149.full. html This article cites 11 articles, 2 of which can be accessed free at: http://pediatrics.aappublications.org/content/125/5/e1149.full. html#ref-list-1 This article has been cited by 4 HighWire-hosted articles: http://pediatrics.aappublications.org/content/125/5/e1149.full. html#related-urls One P3R has been posted to this article: http://pediatrics.aappublications.org/cgi/eletters/125/5/e1149 Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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