Frustrated with Lumbar Punctures


Full Member
10+ Year Member
May 3, 2011
  1. Resident [Any Field]
    I've tried LPs 10 times now and no matter how careful I am, I always end up missing that sweet spot beneath the LF. I'm really frustrated. My seniors say I'm calmer and my technique is better, but still no CSF on any of my tries.

    Is there something I can do outside of actual LPs to actually get the CSF? Or do I just need to try more?


    Full Member
    10+ Year Member
    Jul 7, 2009
      I totally feel your pain--it seems like it should be totally easy. There is a bit of a "feel" to it though that can't really be formally taught--just keep plugging away (I always thought it was a little odd to just give up the ability to do LP's, which is what will happen if you take the easy way out).

      You probably know all these, but things that helped for me:

      1) Sitting up is vastly easier in my experience, so consider if opening pressure will be helpful. If it is necessary, you could also consider having them sit up, get in the spot, and then slowly lay down to check OP.

      2) Prep and positioning are key. Make sure they are not turned in any way--the shoulders and hips should be in the same plane, if that makes sense.

      3) Most of the times patients try to bend forward at the waist to help you; often any assistant will give them one of those bedside tables to lean forward on--unfortunately this doesn't help open up the space. What they need to be doing is more like a crunch then a situp--I ask them to shortening of a line between their chin and their belly button. Sometimes having the assistant push down and in on their shoulders can help too; also if they need to hang onto something using a pillow instead of the table.

      4) You should actually angle slightly up--aim for the belly button.

      5) Palpate, palpate. Use the tip of either a pen (pre-prep) or the plastic needle holder (post-prep) to make an indent in the skin mark your spot (pen obviously gets scrubbed away). Feel the paraspinal muscles on either side and then the dip in between, feel the spinous processes up and down to make sure you are on the correct spot right to left. Have them positioned as you want them before making the mark because otherwise this will be off a bit as the skin moves compared to the deep tissue. It can be surprisingly easy to get off course, especially in obese patients. You only have a few attempts to re-adjust once the needle goes in, so you should feel very comfortable you are in the right spot before putting the needle in.

      6) If looking from the ceiling the needle should be perpendicular to the back, so really the only angle that should vary is the up/down angle. If you hit bone, slightly readjust the needle up/down, not right/left.

      I have a real gift for making simple things sound complicated, but I hope this helps. Good luck!
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