Accurate prediction of the needle depth required for successful lumbar puncture

Introduction

The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.

Methods

This is a prospective study of pediatric oncology patients who had lumbar punctures in the course of their treatment. The distance from skin entry point to the tip of the spinal needle was measured after lumbar punctures were performed. The relationship between the depth of needle insertion with weight, height, body surface area, body mass index, intervertebral space used, ethnicity, and sex of patient were studied. Predictive statistical models were used for the formulation of the ideal lumbar puncture needle depth.

Results

Two hundred seventy-nine patients who had nontraumatic lumbar punctures were studied. The patient characteristics were as follows: age, 0.5 to 15 years; weight, 7 to 63 kg; and height, 70 to 162 cm. Analysis using multiple regression tests with stepwise approach showed a strong relationship between the lumbar puncture needle depth and weight/height ratio. By using a predictive regression model, ideal depth of needle insertion (cm) = 10 [weight(kg)/height(cm)] + 1, with a regression coefficient r = 0.77.

Conclusion

This formula is accurate and practical with less complex calculations. However, further validation in a prospective study will be needed.     

Comparison of cosyntropin versus caffeine for post-dural puncture headaches: A randomized double-blind trial

BACKGROUND:

Cosyntropin has been reported to be effective in the treatment of post-dural puncture headaches, but there is a lack of data on its effectiveness. We compared the efficacy of cosyntropin with that of caffeine in the treatment of post-dural puncture headaches.

METHODS:

We performed an interim analysis of a prospective, double blinded, trial of adult patients presenting to the emergency department with a post-dural puncture headache. Patients were randomized to receive either intravenous caffeine or intravenous cosyntropin. Values on a 100-mm visual analog scale (VAS) were recorded at 0, 60, and 120 minutes to assess pain. Rescue therapy was documented on the study data forms. Its effectiveness was determined by the need for this therapy.

RESULTS:

Thirty-seven patients were included and four patients were excluded from the analysis because of protocol violations or incomplete data. Analysis was based on intention-to-treat. Caffeine was 80% (95% CI 60–100%) effective and cosyntropin was 56% (95% CI 33–79%) effective in treating post-dural puncture headaches. The group’s VAS scores at 0, 60, and 120 minutes were 80 mm, 41 mm, 31 mm for caffeine and 80 mm, 40 mm, 33 mm for cosyntropin, respectively (P=0.66).

CONCLUSION:

Caffeine was not more effective than cosyntropin in treating patients with post-dural puncture headaches, and there was no difference in the degree of pain relief on VAS assessment.KEY WORDS: Cosyntropin, Post-dural puncture headaches, Caffeine, Lumber     

Anesthesia (13)

An in vitro study of dural lesions produced by 25‐gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. (Hospital de Mostoles, Madrid Spain) Reg Anesth Pain Med 2000;25:393–402. This study evaluated the dural lesions produced by Whitacre and Quincke spinal needles in the external and internal surface of the dura mater of the lower spine area in an attempt to gain more insight into the pathophysiology of postdural puncture headaches (PDPH). The T11‐L4 dural membranes from 5 fresh (immediately after extraction of organs for transplantation) male patients declared brain dead, ages 23, 46, 48, 55, and 60, were excised by anterior laminectomy. Morphologic orientation of the membrane and normal pH were maintained; 100 punctures at 90‐degree angles were done with a new needle each time, 50 with 25‐gauge Whitacre and 50 with 25‐gauge Quincke needles. Half of the punctures with the Quincke needles were done with the bevel in the parallel direction to the axis of the spinal cord, and the rest with the bevel perpendicular to it. Fixation in solutions of 2.5% glutaraldehyde phosphate buffer, followed by dehydration with acetone, was done 15 min after the punctures. The acetone was removed and the specimens were metallized with carbon followed by gold and inspected under a scanning electron microscope. When the area of the dural lesions found in the external and internal surfaces produced by the 2 types of needles was compared, no significant differences were found. The percentage of lesion closing area with the Quincke needles was 88.3% and 82.7% in the external and internal surfaces, respectively. With the Whitacre needles, the percentage of closing was 86.8% and 84.8% in the epidural and arachnoid surfaces, respectively. There were differences noted in the morphology of the lesions. The Whitacre needles produced coarse lesions with significant destruction in the dura's fibers while the Quincke needles produced a “U”‐shaped lesion (flap) that mimics the opened lid of a tin can, regardless of the tip's direction. Conclude that the needles produced lesions in the dura with different morphology and characteristics. Lesions with the Quincke needles resulted in a clean‐cut opening in the dural membrane while the Whitacre needle produced a more traumatic opening with tearing and severe disruption of the collagen fibers. The lower incidence of PDPH seen in the Whitacre needles may be explained, in part, by the inflammatory reaction produced by the tearing of the collagen fibers after dural penetration. The inflammatory reaction may result in a significant edema, which may act as a plug limiting the leakage of the cerebrospinal fluid. Comment by Andrew D. Rosenberg, MD. This is an interesting article that explains why a patient will develop a postdural puncture headache (PDPH) after receiving a spinal with a Quincke needle and not after a Whitacre‐type needle. The explanation is based more upon an inflammatory reaction than the direction of the needle cut. The Quincke needle appears to make a sharp cut while the Whitacre needle induced an inflammatory response including edema, which could block off the dura from leaking. It is very interesting that the response seen after the Whitacre needle was utilized occurred as quickly as it did. The article introduces the question as to whether a Quincke needle or a Whitacre needle is associated with more trauma to the dura, and which is better for decreasing the incidence of PDPD.     

Diagnostic lumbar puncture. Comparative study between 22–gauge pencil point and sharp bevel needle

Post-lumbar puncture headache is a frequent clinical problem. Needle design is expected to reduce post-puncture headache. In this study, we compared two different lumbar puncture needle designs in diagnostic lumbar puncture and analysed post-dural puncture headache (PDPH) and social and economical harm associated with the diagnostic lumbar puncture procedure. This prospective, controlled study consisted of 80 consecutive adult patients requiring elective diagnostic lumbar puncture due to various neurological symptoms. Lumbar puncture was completed either with Spinocan 22 G sharp bevel needle or Whitacre 22G pencil point needle. Patients were asked about previous headache symptoms and pain provoked by puncture. One week after the lumbar puncture all patients were interviewed by telephone and occurrence and type of headache, headache intensity, medication and frequency of impairment in activities of daily living were asked. Need for epidural blood patch was also recorded. Thirty-three of 78 (42%) patients experienced headache after diagnostic lumbar puncture and in 26 (33%) the headache could be classified as PDPH. There were no statistically significant differences between needle types in the frequency of common headache, PDPH, puncture pain intensity, need for epidural blood patch or sick leave. Also, there were no other complications except local back pain or headache. In this study, the needle design did not affect the frequency of PDPH. Also, PDPH was common, occurring in 33% cases and caused a considerable amount of disturbance in daily activities. Seeking help for this condition was insufficient and only part of these PDPH patients were treated with epidural blood patch.     

Effect of spinal needle characteristics on measurement of spinal canal opening pressure

Objective

A wide variety of spinal needles are used in clinical practice. Little is currently known regarding the impact of needle length, gauge, and tip type on the needle's ability to measure spinal canal opening pressure. This study aimed to investigate the relationship between these factors and the opening-pressure measurement or time to obtain an opening pressure.

Lumbale CT-gezielte Radiofrequenzablationen des Ramus medialis rami dorsalis nervi spinalis

Background

The success of radiofrequency ablation (RF) of the medial branch of the dorsal ramus in patients with facet joint pain depends on the effective coagulation distance. To date, computed tomography(CT)-guided techniques do not reach the nerve in parallel but rather than punctually. We report a new CT-guided technique to enhance parallelism and proximity of the RF needle to the nerve.

Materials and methods

Two examiners with different experience with CT-guided procedures in corpses performed all punctures at the lumbar spine on 10 corpses. A RF needle was inserted 1?cm lateral to the spinous process of the vertebra located caudal to the target nerve. The needle was advanced under CT guidance at a flat angle between the superior articular process and the base of the costal or transverse process of the cranial vertebra. The position was verified by dissection. Needle position was judged successful provided the needle could be positioned in the first attempt with no more than one angle correction.

Results

In 86 out of 100 possible cases (50 per side) at the 5 lumbar segments, the RF needle could be depicted by CT in the target area with no more than one correction of the needle position. Anatomical dissections revealed that 47 out of 86 needles (54.6%) fulfilled the requirements of parallelism and proximity to the nerve. The dorsal ramus was never reached by the RF needle. Higher success rates were obtained in the middle segments compared to the border segments of L1–L2 and L5–S1.

Conclusions

We could demonstrate that the principle of parallelism and proximity of the needle to the nerve could be fulfilled with this new technique; however, needle positioning requires practice due to the oblique puncture direction.

     

Sonographically guided puncture of the pancreas: incidence of complications, and risk factors

Purpose

Data yielded by transabdominal ultrasound-guided puncture techniques are valuable for determining the malignancy of inoperable mass lesions of the pancreas. In this study we analyzed the incidence of complications and the risk factors.

Methods

A total of 430 punctures of the pancreas were performed for 281 patients. Risk factors were prospectively assessed and complications were recorded. All punctures were sonographically guided.

Results

The 281 patients underwent a total of 351 puncture procedures including 430 punctures and 901 passes. The maximum diameter of the pancreatic mass lesion was documented; the mean diameter was 48.3 ± 29.1 mm. 75.8 % of punctures were performed with a needle diameter of 0.7–0.95 mm, and 23.0 % of punctures were performed as cutting biopsies producing a tissue sample 1.2 or 1.6 mm in diameter. In 77.8 % of punctures, one puncture was performed, and in 21.9 %, two punctures were performed. Three punctures were performed for one patient (0.3 %) only. The incidence of major complications was 0.3 %. None of the assessed risk factors was associated with an elevated incidence of complications.

Conclusion

Our findings demonstrate the safety of transabdominal percutaneous puncture of the pancreas but do not enable conclusions to be drawn with regard to individual risk factors.     

Duration of Postural Headache After Lumbar Puncture: Effect of Needle Size

SYNOPSIS
The effect of needle size on postural headache after diagnostic lumbar puncture was studied in 300 patients at the Outpatient Department of Neurology, University of Helsinki. In three groups of 100 patients a needle size of 0.9mm (20 gauge), 0.7mm (22 gauge) and 0.6mm (23 gauge) were used, respectively. The total number of days with incapacitating postural headache in the groups diminished significantly with the decreasing needle size from 282 through 181 to 76 days. An analysis of CT scans performed in 95 patients showed that the incidence of post-lumbar puncture headache significantly decreased with brain atrophy seen on CT independently of the needle size. The results suggest that the thinnest needle (0.6mm) usable without special techniques should be chosen for diagnostic lumbar punctures at outpatient departments.     

Tactile thresholds are preserved yet complex sensory function is impaired over the lumbar spine of chronic non-specific low back pain patients: a preliminary investigation

Objectives

To investigate impairments in sensory function in chronic non-specific low back pain patients, and the relationship between any impairment and the clinical features of the condition.

Design

A cross-sectional case–control study.

Setting

Laboratory-based study.

Participants

Nineteen chronic non-specific low back pain patients and 19 healthy controls.

Main outcome measures

Tactile threshold, two-point discrimination distance and accuracy at a task involving recognising letters drawn over the skin of the lower back (graphaesthesia) were assessed over the lumbar spine in both groups. Pain duration, pain intensity, physical function, anxiety and depression were assessed by questionnaire in the back pain group.

Results

No difference was found in tactile threshold between the two groups [median difference 0.0 mg, 95% confidence interval (CI) −0.04 to 0.04]. There was a significant difference between controls and back pain patients for two-point discrimination (mean difference 17.9 mm, 95% CI 5.9 to 29.8) and graphaesthesia accuracy (mean difference 6.1, 95% CI 1.3 to 11.0). Low back pain patients had a larger lumbar two-point discrimination distance threshold and a greater letter recognition error rate. In the back pain group, no relationship was found between clinical profile and sensory function, and no relationship was found between the sensory tests.

Conclusions

These data support existing findings of perceptual abnormalities in chronic non-specific low back pain patients, and are suggestive of cortical rather than peripheral sensory dysfunction. Amelioration of these abnormalities may present a target for therapeutic intervention.     

The effect of spinal needle design, size, and penetration angle on dural puncture cerebral spinal fluid loss

Postdural puncture headache (PDPH) is a debilitating side effect of spinal anesthesia, the result of dural puncture and cerebrospinal fluid (CSF) leakage with an incidence of 3% to 75% in patient populations. Despite numerous in vitro and in viva studies that have identified predictors associated with PDPH, debate continues on the best technique to reduce CSF leak after dural puncture. The purpose of this in vitro study was to evaluate the relationship between spinal needle type (pencil tipped or cutting), needle size (22 or 25 gauge), and dura penetration angle from perpendicular (90 or 30 degrees), with the resulting CSF leak measured after dural puncture. Spinal needle designs continue to be studied and modified to reduce the incidence of PDPH in identified high-risk groups. For the study, 103 cadaver dura samples were punctured with randomly assigned needles at predetermined angles. The relationship between variables was analyzed. Our results found between needle tip designs a 5-fold increase in mean leak (Quincke > Whitacre) and between needle diameters (25 > 22 gauge), a 6-fold greater mean leakage. Puncture angle demonstrated no significant effect.     

Ultrasound-assisted Lumbar Puncture in Pediatric Emergency Medicine

Background

Ultrasound-assisted lumbar puncture in the pediatric emergency medicine setting has not been well established, but ultrasound could serve as a valuable tool in this setting.

Objective

To assess whether ultrasound increases provider confidence in identifying an insertion point for lumbar puncture.

Methods

A feasibility study was conducted using a convenience sample of pediatric emergency patients requiring lumbar puncture. Provider confidence in selecting a needle insertion site for lumbar puncture using ultrasound assistance was compared to provider confidence using traditional landmarks alone. A simple technique using a linear probe is described.

Results

Nineteen patients were included in the study, with the primary end point the mean confidence score (based on a five-point Likert scale) in identifying a needle insertion site prior to and after using ultrasound. Using the Wilcoxon signed-rank test, the mean confidence score was 2.89 with the landmark procedure alone, and 4.79 with ultrasound assistance, yielding an average score difference of 1.90 (95% confidence interval 1.23–2.56; Wilcoxon p < 0.001, paired t-test p < 0.001). Thus, compared to the landmark procedure, the use of ultrasound was associated with a significantly higher average confidence score.

Conclusion

The use of ultrasound in the pediatric emergency setting can be a valuable adjunct with lumbar puncture.     

Comparison of 3 Needle Sizes for Trigger Point Injection in Myofascial Pain Syndrome of Upper- and Middle-Trapezius Muscle: A Randomized Controlled Trial

Yoon S-H, Rah UW, Sheen SS, Cho KH. Comparison of 3 needle sizes for trigger point injection in myofascial pain syndrome of upper- and middle-trapezius muscle: a randomized controlled trial.

Objectives

To investigate (1) the relation between needle diameter and treatment efficacy of myofascial pain syndrome and (2) the relation between needle diameter and pain intensity during injection.

Design

Randomized controlled trial.

Setting

University-affiliated tertiary-care hospital.

Participants

Volunteers (N=77) with myofascial pain syndrome affecting upper- and middle-trapezius muscles with at least 3 months' duration of pain.

Intervention

Participants were randomly assigned to receive trigger point injections on 1 side of the trapezius with a 21-, 23-, or 25-gauge needle. After a 1-time injection, participants were followed up for 14 days. Participants and the assessor were blinded for group assignment.

Main Outcome Measures

Treatment efficacy was measured with the visual analog scale (VAS; at pretreatment, and posttreatment on days 1, 4, 7, 14) for neck and upper-back pain, the Neck Disability Index (NDI; at pretreatment, and posttreatment on days 7, 14), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36, at pretreatment and posttreatment on days 7, 14) for health-related quality of life. Pain intensity during injection was evaluated immediately after injection with VAS.

Results

VAS scores for posttreatment on days 4, 7, and 14 decreased significantly compared with pretreatment scores in all groups; NDI scores on days 7 and 14 decreased significantly compared with pretreatment scores in all groups; SF-36 scores on days 7 and 14 decreased significantly compared with pretreatment scores in the 21- and 23-gauge needle groups; and SF-36 score on day 14 showed significant difference between the 21- and 25-gauge needle groups. For pain intensity during injection, VAS scores indicated no significant difference between the 3 groups.

Conclusions

No difference between the needle types was observed in terms of VAS or NDI, or in terms of pain intensity felt by patients during injection. In terms of SF-36 scores, injections with 21- or 23-gauge needles were found to be more effective. However, a well-controlled investigation is needed to explore the effect of needle thickness on health-related quality of life.     

Rückenbeschwerden und Wirbelsäulenform

Background

Despite controversial reports in the literature the use of video raster stereography and multivariate procedures leads to a reasonable model of spinal form parameters associated with lower back pain.

Patients and methods

A total of 201 male subjects (no pain: n=113, lower back pain: n=84, facet syndrome: n=4) were examined by means of video raster stereography in a controlled cross-sectional investigation.

Results

Multivariate factor and discriminant analyses revealed spinal form variables which showed significant differences (p<0.01) between pain-free volunteers and back pain patients (e.g. trunk imbalance, lumbar lordosis, trunk inclination). The spinal form in facet syndrome patients did not differ from lower back pain patients but showed specific lumbar curve patterns.

Conclusion

The physiological range of individual variations of spinal shape and individually exposed spinal form deviations associated with lower back pain syndromes hamper a simple differentiation of spinal form findings. Multivariate analyses are helpful to discriminate spinal form variations according to clinical disorders and video raster stereography appears to be useful in the quality management of exercise therapy.     

Changes in Intervertebral Disk Dimensions After a Loading Task and the Relationship With Stature Change Measurements

Lewis SE, Fowler NE. Changes in intervertebral disk dimensions after a loading task and the relationship with stature change measurements.

Objective

To test the hypothesis that there would be a linear relationship between overall stature change determined by stadiometry and markers of lumbar disk height loss determined from magnetic resonance imaging (MRI).

Design

The short-term loading response of the lumbar spine was evaluated with both stadiometry and MRI, using a within-subject repeated-measures design. Measures were obtained both before and after 15 minutes of walking wearing a weighted vest (20% of body mass). Stature loss measured on the stadiometer was compared with change in lumbar spine length assessed from the MRI images.

Setting

A university laboratory.

Participants

Participants (N=13; mean age ± SD, 28.5±5.2y; mean height ± SD, 1.76±0.10m; mean body mass ± SD, 76.6±14.9kg) were invited to take part in the investigation. The group was mixed (9 men, 4 women) and comprised people with no history of low back pain.

Interventions

Not applicable.

Main Outcome Measures

Lumbar spine length assessed via MRI and stature change measured via stadiometry.

Results

A significant height loss was observed over the complete lumbar spine (P<.05), and a significant correlation was found between the decrease in posterior spine length and stature loss (r=.61).

Conclusions

The results were supportive of the use of stadiometry as an indirect measure of changes in intervertebral disk height.     

A Randomised Controlled Study of the Outcome of Hydrotherapy for Subjects with Low Back or Back and Leg Pain

Background and purpose:

Exercise is frequently selected by physiotherapists to treat patients with low back pain (LBP) or with back and leg pain. Anecdotally a particular form of exercise, group hydrotherapy, is widely accepted as a beneficial and cost-effective method of management. This study was designed to investigate the claimed benefits of group hydrotherapy for subjects with chronic low back pain (CLBP) and back and leg pain.

Subjects:

A total of 109 adults with LBP or back and leg pain of more than three months duration were randomly assigned to either a hydrotherapy (experimental) or control (delayed hydrotherapy) group; 95 subjects completed the study.

Methods:

Before and after the four-week‘intervention period’ the following measures were recorded for all subjects in both groups: the ranges of active lumbar flexion and extension and of passive straight leg raise; the levels of lower limb strength, reflex responses, light touch sensation, functional disability using the Oswestry Low Back Pain Disability Questionnaire, and pain using the McGill Pain Questionnaire. All measurements were made and recorded by an experienced physiotherapist unaware of the group assignment of subjects.

Results:

Analysis with chi-square showed a statistically significant greater number of subjects in the experimental group improved in their function and fewer deteriorated. Subjects whose condition improved on the other measures were typically in the experimental group, while those whose condition deteriorated were typically in the control group.

Conclusion and discussion:

The findings offer qualified support to anecdotal evidence that group hydrotherapy can benefit subjects with CLBP or back and leg pain.     

Self-Management of Chronic Neck and Low Back Pain and Relevance of Information Provided During Clinical Encounters: An Observational Study

Escolar-Reina P, Medina-Mirapeix F, Gascón-Cánovas JJ, Montilla-Herrador J, Valera-Garrido JF, Collins SM. Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study.

Objective

To assess the relative influence of information provided during physical therapy on a patient's adherence to self-management strategies in relation to other predictors of adherence (patient and pain characteristics, use of self-management strategies before intervention).

Design

A longitudinal observational study of the relationship between the information provided during physical therapy and adherence to self-management strategies.

Setting

Data came from a clinical-based population in 8 primary health care centers.

Participants

Patients (N=184) with chronic neck or low back pain (77% under the age of 59y) were surveyed at the beginning and 1 month after completion of physical therapy.

Interventions

Not applicable.

Main Outcome Measures

Specific and overall adherence to 2 types of strategies: (1) nonpharmacologic pain management strategies, and (2) neck/back care in activities of daily life.

Results

Adherence to strategies of nonpharmacologic self-management of pain was more probable when patients received information explaining the effectiveness of the self-management strategies (adjusted odds ratio [AOR]=10.1; P<.05) and information about their illness (AOR=3.4; P<.05) during clinical encounters. Information provided by the physical therapist did not have any influence on the adherence to neck/back care in activity of daily life (P>.05).

Conclusions

Information provided during clinical encounters is associated with adherence to different kinds of self-management strategies. While further study is required, it is suggested that more attention be given to clinical practice strategies for improving adherence to self-management of chronic pain.     

Classifying subgroups of chronic low back pain patients based on lifting patterns

Slaboda JC, Boston JR, Rudy TE, Lieber SJ. Classifying subgroups of chronic low back pain patients based on lifting patterns.

Objective

To compare self-reported measures of chronic lower back pain (CLBP) patients who were assigned to 2 subgroups based on their lifting patterns performed during a repetitive lifting task.

Design

Cross-sectional study.

Setting

Research laboratory

Participants

CLBP subjects (n=81) and pain-free controls (n=53).

Interventions

Not applicable.

Main Outcome Measures

Measures of lifting patterns and self-reported disability, pain, and psychosocial aspects.

Results

Two CLBP subgroups were found: 1 group that lifts similarly to control subjects (n=35) and 1 group that lifts very differently from controls (n=46). The CLBP group that lifted differently than controls reported higher pain intensity (P=.005), higher pain severity (P=.025), and lower self-efficacy (P=.013) than the CLBP group that lifted similarly to controls.

Conclusions

A classification system based on lifting patterns identified 2 CLBP subgroups that were significantly different on lifting and self-reported measures, indicating the importance of physical functioning measures in classification systems.     

Syndrome myofascial du muscle piriforme et sciatalgie persistante chez le lombalgique en rééducation

Background

Myofascial syndrome affecting the piriformis is quite common in rehabilitation patients with low back pain and may present as persistent sciatica.

Goals

Based upon a clinical case, define the symptomatology and treatment of myofascial piriformis muscle syndrome.

Results

Computerized tomography-controlled corticoid injections and specific rehabilitation relieve muscle contracture and pain, allowing the back pain program to be resumed.

Discussion

The physiotherapist’s knowledge of myofascial syndrome affecting the piriformis may help early diagnosis and treatment, thus avoiding unnecessary lumbar investigations.     

Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial

Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial.

Objectives

To examine whether the addition of motivational enhancement treatment (MET) to conventional physical therapy (PT) produces better outcomes than PT alone in people with chronic low back pain (LBP).

Design

A double-blinded, prospective, randomized, controlled trial.

Setting

PT outpatient department.

Participants

Participants (N=76) with chronic LBP were randomly assigned to receive 10 sessions of either MET plus PT or PT alone.

Intervention

MET included motivational interviewing strategies and motivation-enhancing factors. The PT program consisted of interferential therapy and back exercises.

Main Outcome Measures

Motivational-enhancing factors, pain intensity, physical functions, and exercise compliance.

Results

The MET-plus-PT group produced significantly greater improvements than the PT group in 3 motivation-enhancing factors; proxy efficacy (P<.001), working alliance (P<.001), and treatment expectancy (P=.011). Furthermore, they performed significantly better in lifting capacity (P=.015), 36-Item Short Form Health Survey General Health subscale (P=.015), and exercise compliance (P=.002) than the PT group. A trend of a greater decrease in visual analog scale and Roland-Morris Disability Questionnaire scores also was found in the MET-plus-PT group than the PT group.

Conclusion

The addition of MET to PT treatment can effectively enhance motivation and exercise compliance and show better improvement in physical function in patients with chronic LBP compared with PT alone.     

Color Flow Doppler Point of Care Ultrasound to Evaluate Vessels before Infant Lumbar Puncture

Background

Infant lumbar punctures (LPs) are common procedures performed in the emergency department. However, 10% to 35% of these LPs are unsuccessful or grossly bloody, which can lead to increased hospitalization, increased costs, and prolonged exposure to antibiotics or antivirals. Point of care ultrasound (POCUS) may help to surmount the intrinsic causes of LP failure by providing a visual guide of the vascular structures in the needle path before a LP is performed.