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LUMBAR PUNCTURE Brought to you by:
Task Trainer Development Team- Medical Student Reserves,
Resident Fellow
and Student Section, Society of Interventional Radiology
For comments or suggested edits, please email
[email protected]
AUTHOR: EDITORS:
● Erum Chowdhry,
University of Nevada,
Reno School of
Medicine, Class of 2022
● Mathew Macey, NYIT
College of Osteopathic
Medicine, Class of 2020
● Siddhant Thukral,
University of Missouri -
Kansas City School of
Medicine, Class of 2021
LUMBAR PUNCTURE TASK TRAINER
Purpose
This task trainer is designed to help trainees practice
performing a lumbar
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puncture procedure, with the guidance of ultrasound. As one of
the most
commonly performed procedures in clinical medicine, lumbar
puncture is an
essential skill to learn and perform when indicated in practice,
commonly used
to diagnose infectious and noninfectious neurologic conditions
(Uptodate). The
lumbar puncture procedure with ultrasound guidance is used to
improve the
success rates of acquiring the cerebrospinal fluid sample from
the subarachnoid
space (AAN, BMJ).
Materials:
This task trainer can be made with a premade lumbar vertebrae
model or can be
made from the materials outlined below. A list of the materials
with
corresponding prices and purchase link can be found on page
17.
For construction of vertebral column:
● 1 ¼” diameter wooden dowel ● 1 ½” angle brackets (8 - sold as
2 packs of 4) ● 1 ¼” drywall screws (8) ● #8 x ⅜” machine screws
(8) ● #8 hex nuts (18) ● #8 12” threaded rod ● ⅜” pvc vinyl tubing
● Body of plastic pen (optional: purchase ½” aluminum/nylon spacers
x
8) ● Electric drill or drill press ● Pliers ● Hand saw
OR
● Premade human lumbar vertebral model
For construction of the subcutaneous tissues:
● Synthetic gelatin ● 2 identical molding containers ● Water ●
Dark colored food dye ● Hemostat ● Tape
For lumbar puncture procedure:
● Lumbar puncture kit ● Ultrasound machine
Total cost using self-made vertebral model: ~$55 (cost w/o
tools)
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Total cost using premade vertebral model: ~$58
Assembly
*Note: Steps 1-5 can be followed to create a self-made vertebral
column on
which to practice the lumbar puncture procedure using low-cost
supplies.
Alternatively, a pre-made model of a lumbar vertebral spine can
be
purchased and step 1 of the assembly can be followed from page
12.
1. Cut vertebral bodies from wooden dowel a. Mark 1 ⅛”
sections
b. Cut 4 sections using either a table saw or hand saw
2. Drill holes through vertebral bodies a. Mark the halfway
point (⅝”) in both directions
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b. Extend your lines to find center
c. By holding the piece with pliers to ensure safety, drill
through the center point using a drill press or electric drill
3. Assemble transverse/spinous processes a. Screw pairs of angle
brackets to each other using the #8
machine screws and nuts.
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b. Tighten with pliers, or with a wrench, screwdriver, etc. 4.
Assemble vertebrae
a. Cut ½” segments (x8) from plastic pen body using a hand saw
(skip this step if you purchased spacers)
b. Align transverse/spinous process unit centered
horizontally
and vertically with a vertebral body.
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c. Inserting a drywall screw with a small angle, press into the
wood to create a mark. Flip the assembly over and repeat on
the other side.
d. Using an electric drill, create a shallow hole (⅛” - ¼”)
perpendicular to each mark
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e. Insert a drywall screw, followed by a spacer through each
transverse process. Again at a slight angle, start turning
(about
1 revolution) each screw into the pre-drilled holes using a
screwdriver.
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f. Tweak the assembly until everything is roughly centered
and
finish screwing in the screws.
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5. Align the vertebrae threaded rod a. Thread on a #8 nut,
followed by a vertebral unit, followed by a
2nd nut.
b. Repeat this until all vertebrae are on the threaded rod. i.
Tip: if you have a drill press, you can speed up the
process by securing the threaded rod in the chunk and
gripping a nut as the assembly spins. However, be
careful, and do not let go of the nut while spinning!
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c. Adjust the nuts so the vertebrae are about ½” apart and
tighten in place. Finally, slide the pvc vinyl tubing into the
vertebral
canal; this will mimic the ligamentum flavum/dura complex.
Tie one end of the pvc vinyl tubing into a knot.
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For construction of subcutaneous tissues overlaying vertebral
column:
1. If starting construction with the premade lumbar vertebral
model, start with the pvc vinyl tube and knot one of its free ends
and place it
through the spinal canal of the vertebral model.
Fill the pvc vinyl tubing with water from the unknotted end and
then
clamp that same end with the hemostat. The water filled tubing
will
mimic the contained cerebrospinal fluid (CSF) in the
subarachnoid
space.
2. Place the vertebral column model in the molding container,
with the spinous processes face downward and in direct contact with
the
molding container/vessel.
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(image from Morrow et al, 2016)
3. Tape the lumbar vertebral bodies to the sides of the molding
container to secure the vertebral column in one position.
4. Make the gelatin liquid a. Mix 8 oz of gelatin powder with 2
quarts of water. Tip: place
water in first and then add the powder to minimize the
amount
of lumps.
b. Mix the gelatin and water mixture and place in the
refrigerator.
c. Once the gelatin has been hydrated and chilled, set the
gelatin over a pan of water on the stove to heat/melt the gelatin
down.
While the gelatin is melting, stir it.
d. Let the gelatin cool down as to not melt the plastic of the
premade vertebral model.
e. Pour the melted gelatin in the molding container that
contains the vertebral column. Fill it just enough so that the
spinous
processes are completely submerged while the transverse
processes are exposed. Pour the remaining melted gelatin
into
the second molding container and add the food dye to this
container and stir.
f. Allow the gelatin to solidify in the refrigerator. Once
solidified, you can remove the model from the molding
container.
(image from Morrow et al, 2016)
g. Remove the other gelatin only layer from the second molding
container containing the dye and add it on top of the vertebral
column containing gelatin layer. This added gelatin layer
will
mimic the subcutaneous tissue and the dye serves to opacify
the gelatin so that the spinous processes and lumbar
vertebral
landmarks are not as visible through the clear colored
gelatin.
The two layers of gelatin will easily adhere to each other.
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(images from Morrow et al, 2016)
5. Place the lumbar vertebral model face down so that the
gelatin layer is at the top. Tip: you can use an empty egg carton
to hold the lumbar
vertebrae bodies in place to ensure the gelatin layer is
flat.
6. Use the ultrasound probe to get a view of the landmarks.
Optional: Once located, draw a line on top of the spinous processes
to serve as a
reference point.
a. Obtain a paramedian sagittal oblique view of the spinal canal
by holding the ultrasound probe approximately 1 cm lateral to
the midline (M) and holding the probe medially at angle of
approximately 60 degrees. Adjust as necessary to obtain a
clear view of the spinal canal.
(image from Backhaus, 2018)
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b. The ligamentum flavum/dura mater complex (LF/DM) can be
visualized as a hyperechoic line (due to the water contained in
the pvc vinyl tubing) in the middle of 2 adjacent laminae
(L).
(image from Backhaus, 2018)
c. Once this view is attained, mark the midpoints of the four
borders of the ultrasound probe as shown below.
(image from Backhaus, 2018)
d. Using a pen or marker, connect the midpoints of the four
borders of the probe such that a cross is formed with the
center point indicating the needle insertion point. Finally,
insert the lumbar puncture needle, angled medially, in the
same direction as the ultrasound probe was angled. Advance
until the ligamentum flavum/dura mater complex is
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penetrated. Withdraw the stylet from the needle and drops of
water will be collected.
(image from Backhaus, 2018)
Practice
As noted in the Assembly on page 4, this task trainer can be
made with less
procedures by using a premade lumbar vertebral model.
Alternatively, the
lumbar vertebral model can be built from scratch with low-cost
supplies. In
practicing this task trainer, one can gain a better appreciation
of the anatomical
relationships which is especially useful when having to perform
a procedure
such as lumbar puncture in which a foundational understanding of
the anatomy
is critical.
Application to IR
Ultrasound-guided lumbar puncture provides a better
visualization of the lumbar
spine anatomy that is not ascertainable from physical exam
alone. With the
assistance of ultrasound, the needle tip can be more accurately
tracked, resulting
in a reduced risk of “failed and traumatic procedures (risk
ratio [RR] = 21 and
0.27, respectively), as well as the number of needle insertions
and redirections”
(Johnson 2018). The visuospatial image from ultrasound can
consequently allow
for the determination of the interspinous space that is widest
and can be used as
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the puncture site; with real-time ultrasound, the distance from
the tip of the
needle to the ligamentum flavum can be more readily determined.
This can
prove to be especially beneficial “in patients with poorly
palpable landmarks
most commonly due to obesity… [or] abnormal spinal anatomy, such
as
scoliosis, previous spinal surgery, or history of difficult LP”
(Soni 2016).
Overall, ultrasound has improved the success rates of the lumbar
puncture
procedure, including reducing the number of attempts and
traumatic taps.
Price List
Vertebral Column
Pricing
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Name
Cost
per
item
Qua-
ntity Price Link
1 ¼” diameter wooden
dowel 5.31 1 5.31
https://www.homedepot.com/p/64
20U-1-1-4-in-x-1-1-4-in-x-48-in-
Hardwood-Round-Dowel-
10001811/203334072
1 ½” corner braces (4-
pk) 3.97 2 7.94
https://www.homedepot.com/p/Su
perstrut-4-Hole-90-Degree-Angle-
Strut-Bracket-Silver-Galvanized-
ZAB205EG-10/202077397
1 ¼” drywall screws
(8-pk) 1.18 1 1.18
https://www.homedepot.com/p/Gr
ip-Rite-6-x-1-1-4-in-Philips-
Bugle-Head-Coarse-Thread-
Sharp-Point-Drywall-Screws-1-lb-
Pack-114CDWS1/100152392
#8 x ⅜” machine
screws 1.18 2 2.36
https://www.homedepot.com/p/8-
32-x-3-8-in-Phillips-Oval-
Stainless-Steel-Machine-Screw-4-
Pack-801781/204282627
#8 hex nuts 4.68 1 4.68
https://www.homedepot.com/p/Ev
erbilt-8-32-Stainless-Steel-
Machine-Screw-Nut-50-Pack-
802822/204276144
#8 12” threaded rod 1.52 1 1.52
https://www.homedepot.com/p/Ev
erbilt-3-8-in-x-12-in-Zinc-
Threaded-Rod-802117/204276648
⅜” ID pvc tubing 5.21 1 5.21
https://www.homedepot.com/p/Ev
erbilt-1-2-in-O-D-x-3-8-in-I-D-x-
10-ft-Clear-PVC-Vinyl-Tubing-
702229/207144365
28.2
optional: nylon
spacers
can use body of plastic
pens instead 0.54 8 4.32
https://www.homedepot.com/p/Ev
erbilt-1-2-in-x-1-in-x-257-I-D-
Nylon-Spacer-815018/204276572
Tools
https://www.homedepot.com/p/6420U-1-1-4-in-x-1-1-4-in-x-48-in-Hardwood-Round-Dowel-10001811/203334072https://www.homedepot.com/p/6420U-1-1-4-in-x-1-1-4-in-x-48-in-Hardwood-Round-Dowel-10001811/203334072https://www.homedepot.com/p/6420U-1-1-4-in-x-1-1-4-in-x-48-in-Hardwood-Round-Dowel-10001811/203334072https://www.homedepot.com/p/6420U-1-1-4-in-x-1-1-4-in-x-48-in-Hardwood-Round-Dowel-10001811/203334072https://www.homedepot.com/p/Superstrut-4-Hole-90-Degree-Angle-Strut-Bracket-Silver-Galvanized-ZAB205EG-10/202077397https://www.homedepot.com/p/Superstrut-4-Hole-90-Degree-Angle-Strut-Bracket-Silver-Galvanized-ZAB205EG-10/202077397https://www.homedepot.com/p/Superstrut-4-Hole-90-Degree-Angle-Strut-Bracket-Silver-Galvanized-ZAB205EG-10/202077397https://www.homedepot.com/p/Superstrut-4-Hole-90-Degree-Angle-Strut-Bracket-Silver-Galvanized-ZAB205EG-10/202077397https://www.homedepot.com/p/Grip-Rite-6-x-1-1-4-in-Philips-Bugle-Head-Coarse-Thread-Sharp-Point-Drywall-Screws-1-lb-Pack-114CDWS1/100152392https://www.homedepot.com/p/Grip-Rite-6-x-1-1-4-in-Philips-Bugle-Head-Coarse-Thread-Sharp-Point-Drywall-Screws-1-lb-Pack-114CDWS1/100152392https://www.homedepot.com/p/Grip-Rite-6-x-1-1-4-in-Philips-Bugle-Head-Coarse-Thread-Sharp-Point-Drywall-Screws-1-lb-Pack-114CDWS1/100152392https://www.homedepot.com/p/Grip-Rite-6-x-1-1-4-in-Philips-Bugle-Head-Coarse-Thread-Sharp-Point-Drywall-Screws-1-lb-Pack-114CDWS1/100152392https://www.homedepot.com/p/Grip-Rite-6-x-1-1-4-in-Philips-Bugle-Head-Coarse-Thread-Sharp-Point-Drywall-Screws-1-lb-Pack-114CDWS1/100152392https://www.homedepot.com/p/8-32-x-3-8-in-Phillips-Oval-Stainless-Steel-Machine-Screw-4-Pack-801781/204282627https://www.homedepot.com/p/8-32-x-3-8-in-Phillips-Oval-Stainless-Steel-Machine-Screw-4-Pack-801781/204282627https://www.homedepot.com/p/8-32-x-3-8-in-Phillips-Oval-Stainless-Steel-Machine-Screw-4-Pack-801781/204282627https://www.homedepot.com/p/8-32-x-3-8-in-Phillips-Oval-Stainless-Steel-Machine-Screw-4-Pack-801781/204282627https://www.homedepot.com/p/Everbilt-8-32-Stainless-Steel-Machine-Screw-Nut-50-Pack-802822/204276144https://www.homedepot.com/p/Everbilt-8-32-Stainless-Steel-Machine-Screw-Nut-50-Pack-802822/204276144https://www.homedepot.com/p/Everbilt-8-32-Stainless-Steel-Machine-Screw-Nut-50-Pack-802822/204276144https://www.homedepot.com/p/Everbilt-8-32-Stainless-Steel-Machine-Screw-Nut-50-Pack-802822/204276144https://www.homedepot.com/p/Everbilt-3-8-in-x-12-in-Zinc-Threaded-Rod-802117/204276648https://www.homedepot.com/p/Everbilt-3-8-in-x-12-in-Zinc-Threaded-Rod-802117/204276648https://www.homedepot.com/p/Everbilt-3-8-in-x-12-in-Zinc-Threaded-Rod-802117/204276648https://www.homedepot.com/p/Everbilt-1-2-in-O-D-x-3-8-in-I-D-x-10-ft-Clear-PVC-Vinyl-Tubing-702229/207144365https://www.homedepot.com/p/Everbilt-1-2-in-O-D-x-3-8-in-I-D-x-10-ft-Clear-PVC-Vinyl-Tubing-702229/207144365https://www.homedepot.com/p/Everbilt-1-2-in-O-D-x-3-8-in-I-D-x-10-ft-Clear-PVC-Vinyl-Tubing-702229/207144365https://www.homedepot.com/p/Everbilt-1-2-in-O-D-x-3-8-in-I-D-x-10-ft-Clear-PVC-Vinyl-Tubing-702229/207144365https://www.homedepot.com/p/Everbilt-1-2-in-x-1-in-x-257-I-D-Nylon-Spacer-815018/204276572https://www.homedepot.com/p/Everbilt-1-2-in-x-1-in-x-257-I-D-Nylon-Spacer-815018/204276572https://www.homedepot.com/p/Everbilt-1-2-in-x-1-in-x-257-I-D-Nylon-Spacer-815018/204276572
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Drill 35.43 1
35.4
3
https://www.amazon.com/BLACK
-DECKER-Corded-5-2-Amp-
DR260C/dp/B07SCPD6XS/ref=sx
in_3_ac_d_rm?ac_md=2-2-
Y29yZGVkIGRyaWxs-
ac_d_rm&cv_ct_cx=drills&keywo
rds=drills&pd_rd_i=B00T2VJ93C
&pd_rd_r=ace998c7-ac71-49b5-
8956-
1fa01392caea&pd_rd_w=cwgOU
&pd_rd_wg=azv7I&pf_rd_p=6d2
9ef56-fc35-411a-8a8e-
7114f01518f7&pf_rd_r=SN4Z5K
JC4BQ2WS35XR9T&qid=15787
13400&th=1
Pliers 8.9 1 8.9
https://www.amazon.com/Tools-
VISE-GRIP-Pliers-6-Inch-
2078216/dp/B000A0OW2M/ref=s
r_1_4?keywords=pliers&qid=157
8713468&s=hi&sr=1-4
Premade Vertebrae 31
https://www.amazon.com/4-Part-
Human-Lumbar-Vertebrae-
Anatomy/dp/B001L7VUXM/ref=
sr_1_8?crid=1SIN2B02ZC14C&k
eywords=lumbar+vertebrae+mode
l&qid=1578717062&sprefix=lum
bar+vert%2Caps%2C185&sr=8-8
Subcutaneous Tissue
Pricing
Molding containers 7.99 2 7.99
https://www.amazon.com/Snapwa
re-Solution-Rectangular-Storage-
Container/dp/B00HC631Q0/ref=s
r_1_14?keywords=rectangular+co
ntainers&qid=1578894660&sr=8-
14
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19
Gelatin 1.98 1 1.98
https://www.amazon.com/Knox-
Gelatine-Unflavored-Count-
Ounce/dp/B00BCMU7T4/ref=sr_
1_1_sspa?almBrandId=QW1hem9
uIEZyZXNo&fpw=alm&keyword
s=gelatin&qid=1578713550&sr=8
-1-
spons&psc=1&spLa=ZW5jcnlwd
GVkUXVhbGlmaWVyPUExOEF
MWUVPQTNDMUlWJmVuY3J5
cHRlZElkPUEwNzY3MzIyMzg1
QUVSNE9HVFlRUiZlbmNyeXB
0ZWRBZElkPUEwNjgyMDY1M
VE4OFpORU5NMThVNiZ3aWR
nZXROYW1lPXNwX2F0ZiZhY3
Rpb249Y2xpY2tSZWRpcmVjdC
Zkb05vdExvZ0NsaWNrPXRydW
U=
Black Food Coloring 5.5 1 5.5
https://www.amazon.com/Americ
olor-Paste-Color-Super-Black-0-
75/dp/B000Q6I5CS/ref=sr_1_2_s
spa?crid=33MKJ5LTGRAD1&ke
ywords=black+food+coloring&qi
d=1578713890&s=home-
garden&sprefix=black+food%2Cg
arden%2C187&sr=1-2-
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GVkUXVhbGlmaWVyPUEzQVl
WREVRM0NGSlpSJmVuY3J5c
HRlZElkPUEwNzE1MzUyMVV
XRElNT0VBSzhERyZlbmNyeX
B0ZWRBZElkPUEwNjE3NDQ2
M1U0UUtaUDZORFFQNyZ3aW
RnZXROYW1lPXNwX2F0ZiZh
Y3Rpb249Y2xpY2tSZWRpcmVj
dCZkb05vdExvZ0NsaWNrPXRy
dWU=
Hemostat 5.6 1 5.6
https://www.amazon.com/Fishing-
Straight-Hemostat-Forceps-
Locking/dp/B072J826MN/ref=sr_
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