Ultrasound Evaluation of Lumbar Spine Anatomy in Newborn Infants: Implications for Optimal Performance of Lumbar Puncture
2014; Elsevier BV; Volume: 165; Issue: 4 Linguagem: Inglês
10.1016/j.jpeds.2014.06.038
ISSN1097-6833
AutoresIgnacio Oulego‐Erroz, María Mora-Matilla, Paula Alonso‐Quintela, Silvia Rodríguez‐Blanco, D. Mata Zubillaga, S. Lapeña López de Armentia,
Tópico(s)Anesthesia and Pain Management
ResumoAn ultrasound evaluation of lumbar spine anatomic landmarks relevant for lumbar puncture was performed in 199 newborn infants. Effects of 6 patient positions and gestational age on interspinous process distance, subarachnoid space width, predicted needle entry angle, and needle insertion depth were assessed. Our results identify optimized conditions for lumbar puncture: sitting the infant with hips flexed, a needle entry angle of 65-70 degrees, and proper needle insertion depth (calculated as 2.5 × weight in kilograms + 6 in millimeters). An ultrasound evaluation of lumbar spine anatomic landmarks relevant for lumbar puncture was performed in 199 newborn infants. Effects of 6 patient positions and gestational age on interspinous process distance, subarachnoid space width, predicted needle entry angle, and needle insertion depth were assessed. Our results identify optimized conditions for lumbar puncture: sitting the infant with hips flexed, a needle entry angle of 65-70 degrees, and proper needle insertion depth (calculated as 2.5 × weight in kilograms + 6 in millimeters). Thousands of lumbar puncture (LP) procedures are performed in hospitalized neonates each year. Improvements in the success rate may limit morbidity and improve care. In recent years, ultrasound (US) has been used to assess spinal anatomy and facilitate LP in children and adults1Shaikh F. Brzezinski J. Alexander S. Arzola C. Carvalho J.C. Beyene J. et al.Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis.BMJ. 2013; 346: f1720Crossref PubMed Scopus (159) Google Scholar, 2Nomura J.T. Leech S.J. Shenbagamurthi S. Sierzenski P.R. O'Connor R.E. Bollinger M. et al.A randomized controlled trial of ultrasound-assisted lumbar puncture.J Ultrasound Med. 2007; 26: 1341-1348PubMed Google Scholar, 3Peterson M.A. Abele J. Bedside ultrasound for difficult lumbar puncture.J Emerg Med. 2005; 28: 197-200Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 4Ferre R.M. Sweeney T.W. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture.Am J Emerg Med. 2007; 25: 291-296Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 5Cadigan B.A. Cydulka R.K. Werner S.L. Jones R.A. Evaluating infant positioning for lumbar puncture using sonographic measurements.Acad Emerg Med. 2011; 18: 215-218PubMed Google Scholar, 6Abo A. Chen L. Johnston P. Santucci K. Positioning for lumbar puncture in children evaluated by bedside ultrasound.Pediatrics. 2010; 125: e1149-e1153Crossref PubMed Scopus (36) Google Scholar; however, few studies have been performed in newborns, and most published studies have been hindered by small sample size, nonblinded US measurements for patient position, and limited evaluation of spinal anatomy.5Cadigan B.A. Cydulka R.K. Werner S.L. Jones R.A. Evaluating infant positioning for lumbar puncture using sonographic measurements.Acad Emerg Med. 2011; 18: 215-218PubMed Google Scholar, 7Öncel S. Günlemez A. Anik Y. Alvur M. Positioning of infants in the neonatal intensive care unit for lumbar puncture as determined by bedside ultrasonography.Arch Dis Child Fetal Neonatal Ed. 2013; 98: F133-F135Crossref PubMed Scopus (23) Google Scholar We aimed to investigate the effects of gestational age and patient positioning on lumbar spine anatomic landmarks and propose recommendations for performing LP in newborns. This prospective observational study was conducted in the inborn neonatal unit at University Hospital of León between January 2012 and October 2012 and involved healthy term and preterm newborns. LP was not performed as a part of the study. The study protocol was approved by the hospital's Institutional Review Board, and written parental consent was obtained for each subject. Subject selection was stratified by birth weight blocks of 250 g. US was performed with the infants in 6 positions, 3 lateral (L1, L2, and L3) and 3 sitting (S1, S2, and S3; Figure 1), assigned to 8 different randomized sequences. The occurrence of oxygen saturation <85% or heart rate <80 bpm in each position was recorded. All US studies were performed by the same investigator using a Vivid I portable ultrasound unit (General Electric, Haifa, Israel) with a linear 12-Hz transducer. The medialsagittal plane was used to obtain all images. To ensure consistent placement of the transducer across the cohort of infants, the L4-L5 interspace was marked with a pen on each infant's skin, and the center of the transducer was placed at this point. The skin adjacent to the edges of the transducer also was marked. Images were analyzed offline by a second investigator who was blinded to the patient data, body position, and sequence of image acquisition. The external interspinous distance (EID) was defined as the distance between the maximum curvature of 2 adjacent posterior spinous processes. This point is the closest to the skin and represents the anatomic landmark for LP on palpation6Abo A. Chen L. Johnston P. Santucci K. Positioning for lumbar puncture in children evaluated by bedside ultrasound.Pediatrics. 2010; 125: e1149-e1153Crossref PubMed Scopus (36) Google Scholar (Figure 2). The internal interspinous distance was defined as the distance between the inner facets of 2 adjacent spinous processes5Cadigan B.A. Cydulka R.K. Werner S.L. Jones R.A. Evaluating infant positioning for lumbar puncture using sonographic measurements.Acad Emerg Med. 2011; 18: 215-218PubMed Google Scholar, 8Sandoval M. Shestak W. Stürmann K. Hsu C. Optimal patient position for lumbar puncture, measured by ultrasonography.Emerg Radiol. 2004; 10: 179-181Crossref PubMed Scopus (48) Google Scholar (Figure 2). Needle entry angle (NEA) was measured between the outer edge of the image (considered the skin surface) at the more caudal spinous process and the midpoint of the epidural space (Figure 2). Needle insertion depth (NID) was defined as the distance between the outer edge of the image and the midpoint of the medullar canal measured in a line drawn according to the NEA, obtained as above (Figure 2). Subarachnoid space width (SSW) was defined as the distance from the dura mater to the posterior surface of the filum terminalis9Molina A. Fons J. Factors associated with lumbar puncture success.Pediatrics. 2006; 118: 842-844Crossref PubMed Scopus (16) Google Scholar, 10Coley B.D. Shiels II, W.E. Hogan M.J. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture.Pediatr Radiol. 2001; 31: 399-402Crossref PubMed Scopus (66) Google Scholar, 11Koch B.L. Moosbrugger E.A. Egelhoff J.C. Symptomatic spinal epidural collections after lumbar puncture in children.AJNR Am J Neuroradiol. 2007; 28: 1811-1816Crossref PubMed Scopus (31) Google Scholar (Figure 2). All measurements were performed in millimeters using a digital caliper (Video; available at www.jpeds.com). Data were analyzed by repeated-measures ANOVA. The effects of position, gestational age, and gestational age-by-position interaction were assessed. Profile graphs and Bonferroni-adjusted multiple paired comparisons were performed to interpret the results. A total of 198 subjects were required for a desired power of 0.9 and a type I error of 0.05. Of the 247 newborn infants enrolled, 199 completed the analysis. Patient characteristics are presented in the Table. The position had a significant effect on external and internal interspinous process distance, NEA, and SSW (P < .001), but not on NID. Gestational age had a significant effect on interspinous distance, NID, and SSW (P < .001), with higher values in term infants. In contrast, gestational age had no significant effect on NEA (Figure 3; available at www.jpeds.com). Gestational age-by-position had a significant effect only on EID (P < .01). Examination of the profile graphs in Figure 3 aids the interpretation of this result, showing nearly parallel lines for all variables, indicating that the effect of position was similar in term infants and preterm infants (Figure 3).TableBaseline characteristics of study subjects (n = 199)CharacteristicsValueGestational age, wk, median (IQR), range38 (35-40), 24-41Gestational age, n (%) <34 wk45 (22.6) 34-36 wk31 (15.6) ≥37 wk123 (61.8)Male sex, n (%)100 (50.3)Birth weight, g, median (IQR)2.721 (1.922-3.314)Length, cm, median (IQR)48 (45-50)US examination Days of postnatal life, median (IQR)1 (1-7) Gestational age, wk, median (IQR), range38 (36-40), 25-41 Weight, kg, median (IQR)2.670 (2.060-3.310) Length, cm, median (IQR)48 (45.5-50) Abdominal circumference, cm, median (IQR)30 (28.5-32) Open table in a new tab The S2 position resulted in increased external and internal interspinous process distance compared with all other positions (P < .01). S2 also increased SSW compared with all other positions (P < .001) except for S3 (P = 1.00). Statistically significant differences in NEA among positions were observed, but the difference in mean value was always <5 degrees. There was no significant difference in NID among positions. Weight had a strong linear relationship to mean NID by Pearson correlation (R2 = 0.929; P = .001). The following simplified equation was derived by linear regression:NID(mm)=2.5×weight(kg)+6(R2=0.863;P=.001). Raw data for paired comparisons are available from authors on request. No episode of bradycardia occurred. Hypoxemic episodes (oxygen saturation <85%) were more frequent with neck flexion (S3 and L3) (P < .05 compared with all other positions). Factors that have been implicated in influencing the success of LP include age, operator experience, advancement of the needle without the stylet in place, type of stylet, use of topical anesthesia, and patient position.12Nigrovic L.E. Kuppermann N. Neuman M.I. Risk factors for traumatic or unsuccessful lumbar punctures in children.Ann Emerg Med. 2007; 49: 762-771Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 13Baxter A.L. Fisher R.G. Burke B.L. Goldblatt S.S. Isaacman D.J. Lawson M.L. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success.Pediatrics. 2006; 117: 876-881Crossref PubMed Scopus (80) Google Scholar, 14Baxter A.L. Welch J.C. Burke B.L. Isaacman D.J. Pain, position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians.Pediatr Emerg Care. 2004; 20: 816-820Crossref PubMed Scopus (31) Google Scholar, 15Pinheiro J.M. Furdon S. Ochoa L.F. Role of local anesthesia during lumbar puncture in neonates.Pediatrics. 1993; 91: 379-382PubMed Google Scholar, 16Porter F.L. Miller J.P. Cole F.S. Marshall R.E. A controlled clinical trial of local anesthesia for lumbar punctures in newborns.Pediatrics. 1991; 88: 663-669PubMed Google Scholar Among these factors, only patient position can directly impact lumbar spine anatomy. Abo et al,6Abo A. Chen L. Johnston P. Santucci K. Positioning for lumbar puncture in children evaluated by bedside ultrasound.Pediatrics. 2010; 125: e1149-e1153Crossref PubMed Scopus (36) Google Scholar testing a small sample of 28 children, found that S2 position increased the EID. Only 1 previous study has assessed the effect of positioning on the interspinous distance; Öncel et al7Öncel S. Günlemez A. Anik Y. Alvur M. Positioning of infants in the neonatal intensive care unit for lumbar puncture as determined by bedside ultrasonography.Arch Dis Child Fetal Neonatal Ed. 2013; 98: F133-F135Crossref PubMed Scopus (23) Google Scholar evaluated 51 hospitalized preterm infants and found that S2 provided a larger EID. Our present study confirms that the S2 increases not only EID, but also internal interspinous distance, and shows that adding neck flexion does not produce any further increase in interspinous distance. Our study is the first to evaluate the NEA for LP in newborns. One previous study assessed NEA using US in children; however, that study included only 5 newborns.17Bruccoleri R.E. Chen L. Needle-entry angle for lumbar puncture in children as determined by using ultrasonography.Pediatrics. 2011; 127: e921-e926Crossref PubMed Scopus (14) Google Scholar We found that a NEA of approximately 65-70 degrees is optimal for all positions in both term infants and preterm infants. Absence of visible cerebrospinal fluid (CSF) or narrowing of the subarachnoid space by US results in a very difficult or impossible LP.10Coley B.D. Shiels II, W.E. Hogan M.J. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture.Pediatr Radiol. 2001; 31: 399-402Crossref PubMed Scopus (66) Google Scholar, 11Koch B.L. Moosbrugger E.A. Egelhoff J.C. Symptomatic spinal epidural collections after lumbar puncture in children.AJNR Am J Neuroradiol. 2007; 28: 1811-1816Crossref PubMed Scopus (31) Google Scholar Moreover, it has been observed that radicular nerve plugging of the needle bevel may cause bloody LP.18Breuer A.C. Tyler H.R. Marzewski D.J. Rosenthal D.S. Radicular vessels are the most probable source of needle-induced blood in lumbar puncture: significance for the thrombocytopenic cancer patient.Cancer. 1982; 49: 2168-2172Crossref PubMed Scopus (53) Google Scholar For these reasons, increasing SSW may facilitate obtaining CSF and reduce the incidence of bloody CSF. Our study clearly shows that sitting position and body flexion increase SSW measured posterior to the filum terminalis. Our study is the first to evaluate the effect of positioning on the NID and to take into account the predicted NEA in this measurement. We found that the NID is independent of position and can be readily derived from the newborn's weight. Along with the ease of technique, safety and tolerability are the main concerns regarding LP, especially in highly vulnerable preterm infants. In agreement with previous studies, our results indicate that neck flexion during LP is less well tolerated in newborns.19Gleason C.A. Martin R.J. Anderson J.V. Carlo W.A. Sanniti K.J. Fanaroff A.A. Optimal position for a spinal tap in preterm infants.Pediatrics. 1983; 71: 31-35PubMed Google Scholar, 20Weisman L.E. Merenstein G.B. Steenbarger J.R. The effect of lumbar puncture position in sick neonates.Am J Dis Child. 1983; 137: 1077-1079PubMed Google Scholar Our study shows that besides potentially causing harm, neck flexion does not improve anatomic conditions for LP compared with hip flexion only. Thus, neck flexion should be abandoned. The main limitation of our study is that LP was not actually performed in our subjects. A future randomized trial is warranted to assess whether our findings result in improved LP outcomes. We thank Fernando Calvo for his advice during the performance of the study, as well as the pediatric residents of Complejo Asistencial Universitario de León for their help in the recruitment of patients. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlZWFiN2VlNDYxNDE3OWEwNzIyY2NhNWMzMzAwMTU2MiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjY2Nzk3MjI2fQ.O9slkygujyKDB_s8FTyn7bQSbQJHE4nXEeZBvYinbi7CN9UGxUVhiLym4BCKN-ZcPxW8CZyMayhfwb9_mcUH0975QXYdvoaTCGZWa6mO-Bh8F4H3E_rIzV1KbR9MQMf3JRlybLTso4zBRhCOaWQTFZ_zjLPBoSdGd0YrtNCHTWmDsq8ykLBv7g4MmyOzQfWH-8fLqxu6ayiKmVT-_Pf0EkEvfPX8x2UmVvIAwgWzjiPtogyT6KqtSeHfcZYIaarRj5lK2BmrJi7FIQyBx6AQjZkEqMO4tGE3IDoHlJmkHzlij3O2oylnq53B1HEYN6tcKidPr5XFIAVq7GzHg2c4FQ Download .mp4 (23.79 MB) Help with .mp4 files Video CorrectionThe Journal of PediatricsVol. 167Issue 2PreviewIn the article, "Ultrasound Evaluation of Lumbar Spine Anatomy in Newborn Infants: Implications for Optimal Performance of Lumbar Puncture," by Oulego-Erroz et al, J Pediatr 2014;165:862-865, the authors inadvertently transposed the key for Figure 3, which has been corrected below. Full-Text PDF
Referência(s)