Puntos de referencia anatómicos para evaluar el nivel espacio intravertebral para la punción lumbar es erróneo en más de 30%
Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%.
Duniec L, Nowakowski P, Kosson D, Łazowski T.
Department of Teaching Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. dunieclarysa@gmail.com
Anaesthesiol Intensive Ther. 2013 Jan-Mar;45(1):1-6. doi: 10.5603/AIT.2013.0001.
Abstract
BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. METHODS:Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbarpuncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting-up' approach starting with the L5-1 space was applied. RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences fund in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. CONCLUSIONS:The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.
http://czasopisma.viamedica.pl/ait/article/view/AIT.2013.0001/24858
Uso del ultrasonido para determinar el nivel de punción lumbar en la mujer embarazada
Use of the ultrasound to determine the level of lumbar puncture in pregnant women.
Locks Gde F, Almeida MC, Pereira AA.Maternidade Carmela Dutra, Hospital Universitário, Universidade Federal de Santa Catarina. giovanilocks@gmail.com
Rev Bras Anestesiol. 2010 Jan-Feb;60(1):13-9.
Abstract
BACKGROUND AND OBJECTIVES: An imaginary line connecting both iliac crests is used to determine the vertebral level for lumbar puncture. This line crosses the spine at the level of L4 or the L4-L5 space. This anatomical reference can be inaccurate in a large proportion of patients. The objective of the present study was to determine whether the identification of the L3-L4 space by the physical exam differs from that of the ultrasound in obese and non-obese pregnant women. METHODS:Adult patients undergoing elective cesarean sections under spinal block participated in this study. Patients were divided in two groups: obese and non-obese. The L3-L4 space was determined by physical exam with the patient in the sitting position. This was followed by a lumbarultrasound. After the sacrum was identified, the transducer was directed in the cephalad direction to identify the spinous processes of the lumbarvertebrae. The clinically estimated L3-L4 level was recorded. RESULTS: Ninety patients, 43 obese and 47 non-obese, were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all patients. The L3-L4 space clinically identified corresponded to the ultrasound identification in 53% and 49% of the cases in the non-obese and obese groups, respectively. There was no significant difference between groups. CONCLUSIONS:The L3-L4 space is correctly identified in a low percentage of obese and non-obese pregnant women. Spinal ultrasound can reduce the incidence of mistaken identification of the L3-L4 space in obese and non-obese pregnant women.
http://www.scielo.br/pdf/rba/v60n1/en_v60n1a02.pdf
Evaluación de ultrasonido del nivel vertebral de la línea intercristal en el embarazo.
Ultrasound assessment of the vertebral level of the intercristal line in pregnancy.
Lee AJ, Ranasinghe JS, Chehade JM, Arheart K, Saltzman BS, Penning DH, Birnbach DJ.
Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, 1611 NW 12th Ave. (C-301), Miami, FL 33136, USA. alee@med.miami.edu
Anesth Analg. 2011 Sep;113(3):559-64. doi: 10.1213/ANE.0b013e318222abe4. Epub 2011 Jun 16.
Abstract
BACKGROUND: The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women. METHODS: Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest. RESULTS: The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%). CONCLUSION: The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.
http://www.anesthesia-analgesia.org/content/113/3/559.full.pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%.
Duniec L, Nowakowski P, Kosson D, Łazowski T.
Department of Teaching Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. dunieclarysa@gmail.com
Anaesthesiol Intensive Ther. 2013 Jan-Mar;45(1):1-6. doi: 10.5603/AIT.2013.0001.
Abstract
BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. METHODS:Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbarpuncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting-up' approach starting with the L5-1 space was applied. RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences fund in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. CONCLUSIONS:The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.
http://czasopisma.viamedica.pl/ait/article/view/AIT.2013.0001/24858
Uso del ultrasonido para determinar el nivel de punción lumbar en la mujer embarazada
Use of the ultrasound to determine the level of lumbar puncture in pregnant women.
Locks Gde F, Almeida MC, Pereira AA.Maternidade Carmela Dutra, Hospital Universitário, Universidade Federal de Santa Catarina. giovanilocks@gmail.com
Rev Bras Anestesiol. 2010 Jan-Feb;60(1):13-9.
Abstract
BACKGROUND AND OBJECTIVES: An imaginary line connecting both iliac crests is used to determine the vertebral level for lumbar puncture. This line crosses the spine at the level of L4 or the L4-L5 space. This anatomical reference can be inaccurate in a large proportion of patients. The objective of the present study was to determine whether the identification of the L3-L4 space by the physical exam differs from that of the ultrasound in obese and non-obese pregnant women. METHODS:Adult patients undergoing elective cesarean sections under spinal block participated in this study. Patients were divided in two groups: obese and non-obese. The L3-L4 space was determined by physical exam with the patient in the sitting position. This was followed by a lumbarultrasound. After the sacrum was identified, the transducer was directed in the cephalad direction to identify the spinous processes of the lumbarvertebrae. The clinically estimated L3-L4 level was recorded. RESULTS: Ninety patients, 43 obese and 47 non-obese, were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all patients. The L3-L4 space clinically identified corresponded to the ultrasound identification in 53% and 49% of the cases in the non-obese and obese groups, respectively. There was no significant difference between groups. CONCLUSIONS:The L3-L4 space is correctly identified in a low percentage of obese and non-obese pregnant women. Spinal ultrasound can reduce the incidence of mistaken identification of the L3-L4 space in obese and non-obese pregnant women.
http://www.scielo.br/pdf/rba/v60n1/en_v60n1a02.pdf
Evaluación de ultrasonido del nivel vertebral de la línea intercristal en el embarazo.
Ultrasound assessment of the vertebral level of the intercristal line in pregnancy.
Lee AJ, Ranasinghe JS, Chehade JM, Arheart K, Saltzman BS, Penning DH, Birnbach DJ.
Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, 1611 NW 12th Ave. (C-301), Miami, FL 33136, USA. alee@med.miami.edu
Anesth Analg. 2011 Sep;113(3):559-64. doi: 10.1213/ANE.0b013e318222abe4. Epub 2011 Jun 16.
Abstract
BACKGROUND: The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women. METHODS: Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest. RESULTS: The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%). CONCLUSION: The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.
http://www.anesthesia-analgesia.org/content/113/3/559.full.pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
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