What to do when the needle encounters the bone during spinal or lumbar puncture

Have you ever experienced or witnessed a “difficult” spinal puncture in a young, slim patient with landmarks visible from a mile? In these cases, no matter what you do, you always seem to hit the bone. In fact, I will dare to say that most struggles with spinal that I have witnessed were in skinny patients with easy landmarks. In this video, you will learn 4 specific tips and techniques that will make your next spinal anesthesia or lumbar puncture MUCH easier and more predictable. Here’s the KEY to success when the needle hits bone all the time. Ask yourself: Which bone is preventing me from placing the needle successfully? Or which osseous structure is on my way to the subarachnoid space? In this video we first review the anatomical structures the needle is passing through when performing a midline approach to spinal anesthesia or lumbar puncture: Skin, SQ tissue, Supraspinous ligament, Interspinous ligament, Ligamentum flavum, Dura, Subarachnoidal space. Dr Hadzic then moves on to describe WHAT you need to do AFTER encountering the bone on your way to the CSF in 4 typical scenarios.

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[juliocastro]

And may I also add that every time I hit a bone I ask the patient on which side they feel it and I use that to correct my direction and I helps 100 % of the time.

[beezeeflower]

These tips are SO invaluable!!! THANK YOU!!!

[dranneshirley]

I wish I knew this in my first year of residency...Extremely useful tips. Thank you!

[tassawarhussain]

Very useful video. If you are performing the lumbar puncture in lateral position and flexing the spine and bringing the flexed knees close to abdomen, make sure both the shoulders and both the knees are exactly in the same vertical axis. The purpose is to prevent rotation of the spine which can make orientation of the needle more difficult.

[whatsinaname]

Thanks bud. Much needed at a much vital time. Gratitude!!!

[MHJ]

OMG…this is the best explanation of why we struggle to do a spinal…many many thanks. Can you please make a video about paramedian spinal and practical tips for novices as well as experiences anesthetists.

[ettaharikpo]

Awesome! You are indeed a Chief of service. Thank you.

[Kusumdubey]

High on demand video.. Thank you Dr. Hadzic for sharing this video 👍 really helpful!

[peterphiri]

I really appreciate for these very educational tips

[SKRD]

I finally understand the importance of this video, great job doctor!4

[felicialababana-vvzq]

Thank you Dr. Hadzic. Im an Anaesthetic resident and your video helped me to realize some of my mistakes so the next time I believe I will do better. 😊🙏

[UsmanKhan]

I appreciate these tips. Infact, patient's position also matters alot while doing lumber puncture/intrathecal approach. Correction of position while keeping in mind the alignment of vertebrae will take you right inside the intrathecal space.

[karimham]

Thank you Dr Hadzic for this video. I'm a haematology resident, and we tend to do a lot of Lumbar punctures (for intrathecal chemotherapy). And your video made me confident about doing any of the difficult ones my colleagues or even my mentors had problems with. Thank you again !

[senhaji]

You do a great job, bravo for your professionalism👏

[austinsrna]

I would challenge the idea of "removing your needle and reinserting" we need to think of our patient in these situations and realize you can pull skin as much as 2cm in any direction with minimal discomfort to your patient, almost to a completely different interspace, without making a new puncture (unnecessary risk for infection, tissue trauma, and the patient likely isn't localized where you are moving to re-puncture). If you simply think you're a little too low or too high (hitting bone shallow) withdraw the needle but not completely out of the skin, and pull the skin to where you want to reposition. Something I learned from the best neuraxial practitioners I've trained with that helps with hitting bone deep is letting go of the needle and seeing which way it is naturally hanging, this will give you insight into which direction your flimsy/thin spinal needle may have drifted or been deflected and will help you correct it back to midline. "leading" with your introducer and even tenting the skin inward on bigger patients as you drive in deeper will also make your needle less likely to drift once it's ahead of the introducer. Great video!

[dr.vineetrai]

This is one of the best clinical observations regarding spinal anaesthesia I've come across...Hats off to you sir for reading our minds and presenting solutions for it

[rehanaferoze]

Thank you for giving logical explanation. Honestly I didn't know where is the needle when hitting bone. I will keep this in mind now.

[satyashila]

Recently this video helped me to get spinal in 105kgs female Pt. Thank u so much!

[VyewVyew]

Dear Dr Hadzic, by following your tips I did my first successful LP today! Thanks for the teaching 😊

[gerardomiralrio]

I experienced that just yesterday. Thanks for the advice.