1. Don't "just try it" or do it because you heard it on SDN from me. Ask someone who knows how to do it, show you how to do it. It's not rocket science. It's just moving a needle a couple cm laterally and a couple cm down with zero increase in procedural risk, and increased ease of access.
2. Most "don't do it" precisely because most EM attendings don't teach it, because they are teaching what they were taught. It's "turtles all the way down." That's how medical dogma works. But that's not the same as proof of superiority.
3. With all do respect, quoting stats you heard on you tube is not credible. Posting a relevant link from a
reputable medical source, like the link above I posted from ACEP, is credible. Also, threading a catheter like in a labor epidural (or spinal cord stimulator lead, for example) is not the same as simply getting access with a needle. When threading a catheter or lead, staying midline is more important because if your introducer needle penetrates the epidural space laterally, your catheter or lead will drift into the lateral recess of the canal, get caught up on exiting nerve roots laterally or even go anterior, which is not what you want. When doing an LP, you just need to penetrate the thecal sac and get fluid. You don't need to be 100% midline. You're comparing apples to oranges.
Regardless, when you do a paramedian LP, if you're doing it right, your needle heads towards the midline, anyways. Similarly, if you're not doing your midline LP correctly, your needle can drift laterally anyways. For some reason, there's an anxiety amongst some EP's in training in doing LPs (I think primarily due to patient anxiety) but it's an extremely safe procedure. The complications you can get (post dural puncture headache, epidural hematoma or abscess) have nothing to do with your needle ending up too far laterally. If you go to far laterally, you just hit the bone of the facet joint.
Do your LPs however you want. But I'm telling you, as someone who struggled with midline non-image guided LPs during EM training, who now does spine injections under fluoro, without a shadow of a doubt, using a paramedian approach, with a steeper angle, starting a level below your target, opens up your entry space dramatically, avoids the painful interspinous ligaments, and avoids trying to thread the needle between a narrow interspinous space. Seeing all this bony anatomy under fluoro, I cringe when I think of all the times I went midline and struggled. I never choose that approach now (for my fluoro-guided epidural injections) and that's even with the luxury of having imaging which makes getting through a tighter space so much easier. Even when I want my needle tip to penetrate at the midline (sometimes I want that, sometimes I don't, based on laterality of symptoms) I still use a paramedian approach. It's simply a less painful technique, that's easier for the patient and doctor and faster, with no increase in procedural risk. I think more EPs should try it for their LPs.
