When the Easy LP Isn't Easy

Mercury Fountain - https://upload.wikimedia.org/wikipedia/commons/1/13/Mercury_Fountain_%28432691647%29.jpg

Mercury Fountain - https://upload.wikimedia.org/wikipedia/commons/1/13/Mercury_Fountain_%28432691647%29.jpg

Lumbar punctures can be mercurial procedures.  There are certainly patients in whom it can be predicted that a lumbar puncture will be challenging.  Obesity, patients with known degenerative changes, and agitated patients all present unique challenges when it comes to successfully completing a lumbar puncture.  There are patients, however, who throw you a bit of a curveball.  Sometimes cooperative patients with good landmarks, in whom you had every expectation that you would find success, become seemingly impossible to successfully complete a lumbar puncture.  

For the provider, knowing how to troubleshoot the unexpectedly difficult lumbar puncture can be the difference between success and failure.  For an educator, knowing how to coach a trainee through these situations can be challenging as well.  As a procedure mostly guided by feel, it is difficult to know exactly in what way the procedure is going wrong (and how how to institute corrective actions) if your hands are not on the needle advancing through the tissues.

The knowledge of how to perform a lumbar puncture is relatively easy to find in any procedural textbook.  However, it is often through experience that we learn the crucial troubleshooting techniques.  I have summarized my collected experience on our new Lumbar Puncture Procedural Page.  But experiential knowledge is most powerful when a lot of voices contribute, so tell us:

What are your tips and tricks for troubleshooting LPs?