• Alyssa Abo, Lei Chen, Patrick Johnston, and Karen Santucci.
• Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA. alyssa.abo@gmail.com
• Pediatrics. 2010 May 1;125(5):e1149-53.

BackgroundLumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.ObjectiveTo determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.MethodsA prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.ResultsThere were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P < .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P < .05). Flexion of the neck, did not significantly change the interspinous space (P = .998).ConclusionsThe interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.

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