How can bedside grading method predict difficult lumbar puncture?

The clinical uses of spinal anesthesia (SA) are many. The use of this technique is prevalent among patients who are having infra-umbilical procedures with a predetermined duration. The procedure in question is generally considered to be safe and offers many benefits. However, in cases when a challenging lumbar puncture (LP) is encountered, it might result in patient pain and elevate the occurrence of postdural puncture headache, spinal hemorrhage, and nerve injury. Therefore, it is important to have a scoring system in place that assesses the likelihood of encountering challenges throughout the execution of linear programming (LP). The research assessed the patient factors that might be indicative of challenging lumbar puncture procedures, so enabling the consideration of alternative approaches.

The study included a sample of 200 patients with ASA physical status I-II who were slated to have elective infra-umbilical surgical operations under spinal anesthesia. During the preanesthetic evaluation, the difficulty score was determined by assessing five variables: age, abdominal circumference, spinal deformity (measured as axial trunk rotation (ATR) value), anatomical spine (evaluated using the spinous process landmark grading system (SLGS)), and patient position. Each variable was assigned a score ranging from 0 to 3, resulting in a total score ranging from 0 to 15. The amount of difficulty associated with LP procedures was assessed by an independent investigator with expertise in the field, taking into consideration the overall number of tries made and the specific spinal levels involved. This assessment categorized the difficulty level as either easy, moderate, or severe. The scores acquired during the preanesthetic examination and the data gathered subsequent to doing a lumbar puncture were subjected to multivariate analysis, and the resulting P value was recorded.

The research demonstrated a strong correlation (P < 0.001) between the aforementioned patient factors and the rating of difficult lumbar punctures. The study found that the SLGS variable exhibited a high level of predictability, whilst the ATR variable shown a comparatively lower level of predictability. There was a statistically significant positive link between the total score and grades of SA, as shown by a correlation coefficient of 0.6832 (p < 0.00001). The median difficulty scores of 2, 5, and 8 were used to predict the levels of ease, moderation, and difficulty in the linear programming (LP) tasks.

The authors' conclusion is that the implementation of a complete bedside scoring system, which incorporates clinically observable variables, would be advantageous in forecasting the likelihood of encountering difficulties during a lumbar puncture (LP). Consequently, this scoring system might potentially contribute to a decrease in the occurrence of several tries during the procedure. Moreover, it has been shown that the SLGS variable exhibits a high degree of predictability, but the ATR value variable demonstrates a relatively low degree of predictability in relation to the challenging LP condition.

Reference-

Subramanian, Shobha; Reshma, BM; Salim Iqbal, M.; Harsoor, SS. A comprehensive, bed-side scoring system to predict difficult lumbar puncture. Journal of Anaesthesiology Clinical Pharmacology 39(1):p 38-44, Jan–Mar 2023. | DOI: 10.4103/joacp.JOACP_77_21