Medical Minute: Early Stylet Removal in Lumbar Puncture

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August 3, 2017 by dailybolusoflr

By: Derrick Ashong

Adopted from: Brad Sobolewski


Clinical Pearl: Early stylet removal (after going deep to the dermis) is a viable, and encouraged option for improved lumbar puncture (LP) success.

Pic 1.png


Why Do It: You avoid overshooting the subarachnoid space and hitting the vascular plexus of the ventral epidural space

Pic 2.png


Risk: Historical Risk of intraspinal epidermoid tumors in pediatric patients. Historical anecdote and case studies of unstyleted needles (butterfly needles) ultimately pushing epidermal cells into the intraspinal space leading to late forming epidermoid tumors. These can create a mass effect.


Evidence: Not many adult studies, however in Pediatrics, Baxter et al published a prospective observational study in Pediatrics that reviewed the success rate of lumbar punctures by trainees for infant LPs.

  • They reviewed 428 / 594 (72%) infant LPs – 377 of which were performed by trainees
  • 279/377 (74%) of the trainee LPs were successful
    • Local anesthesia was used for 280/377 (74%)
    • Early stylet removal was performed in 255/377 (60%)

Take home message: Consider early stylet removal for LPs


References

Photo: Access Emergency Medicine. Emergency Medicine Procedures, 2e., Chapter 15

Baxter, AL., et al. Local anesthetic and stylet styles: Factors associated with resident lumbar puncture success. Pediatrics. 2006, March ; 117 (3): 876-81

Photo and Adaptation: Brad Sobolweski, PEMBlog. 2014, November 11. Pediatric Emergency at Cincinnati Children’s Hospital Medical Center.

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