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Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis

BMJ 2013; 346 doi: (Published 26 March 2013) Cite this as: BMJ 2013;346:f1720
  1. Furqan Shaikh, research fellow1,
  2. Jack Brzezinski, clinical fellow1,
  3. Sarah Alexander, assistant professor1,
  4. Cristian Arzola, assistant professor2,
  5. Jose C A Carvalho, professor2,
  6. Joseph Beyene, associate professor3,
  7. Lillian Sung, associate professor1
  1. 1Division of Haematology and Oncology, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada M5G 1X8
  2. 2Department of Anaesthesia and Pain Management, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
  3. 3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
  1. Correspondence to: F Shaikh furqan.shaikh{at}
  • Accepted 18 February 2013


Objective To determine whether ultrasound imaging can reduce the risk of failed lumbar punctures or epidural catheterisations, when compared with standard palpation methods, and whether ultrasound imaging can reduce traumatic procedures, insertion attempts, and needle redirections.

Design Systematic review and meta-analysis of randomised controlled trials.

Data sources Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2012, without restriction by language or publication status.

Review methods Randomised trials that compared ultrasound imaging with standard methods (no imaging) in the performance of a lumbar puncture or epidural catheterisation were identified.

Results 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). Risk reduction was similar when subgroup analysis was performed for lumbar punctures (risk ratio 0.19 (0.07 to 0.56), P=0.002) or epidural catheterisations (0.23 (0.09 to 0.60), P=0.003). Ultrasound imaging also significantly reduced the risk of traumatic procedures (risk ratio 0.27 (0.11 to 0.67), P=0.005), the number of insertion attempts (mean difference −0.44 (−0.64 to −0.24), P<0.001), and the number of needle redirections (mean difference −1.00 (−1.24 to −0.75), P<0.001).

Conclusions Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.


  • We thank Elizabeth Uleryk for her expert assistance with the literature search and Jisun Kim for her assistance in translating non-English papers.

  • Contributors: Both FS and JB contributed as co-first authors to this work. All authors contributed to the conception of the study. FS, JB, and LS were responsible for the study design, data collection, statistical analysis, and manuscript drafting. SA, CA, JCAC, and JB were responsible for manuscript drafting, providing important intellectual content throughout the manuscript’s production, and approval of the final version to be published. FS is the guarantor.

  • Funding: FS is supported by a research fellowship from the Pediatric Oncology Group of Ontario research unit. LS is supported by a New Investigator Award from the Canadian Institutes of Health Research. The funders had no role in the design, execution, and writing up of the study. All researchers were independent from funders.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: support from the Pediatric Oncology Group of Ontario and the Canadian Institutes of Health Research for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval: Ethics approval not required.

  • Data sharing: Full data in RevMan files available from corresponding author on request.

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