If you are unsuccessful with an LP, consider ditching the midline angle and instead approaching laterally.

The lateral approach allows you to avoid the supraspinous and interspinous ligaments, which are often crunchy and calcified in older patients.

  • Prep the patient the same way you would as the traditional approach.
    • Patients can be in either the lateral decubitus or sitting position.
  • Insert the needle 1.5 – 2.0 cm lateral to the midline
    • If lateral decubitus, approach from the inferior aspect
    • If sitting, it doesn’t matter if you approach from the right or left.
  • Direct the needle 10-15° cephalad and 10-20° midline
  • If you hit bone, withdraw the needle and redirect more cephalad.

For other LP tips and tricks, check out Randy’s LP Pearls from August 2016.

Happy graduation day!


Chapter 115. Lumbar Puncture. In: Reichman EF. eds. Emergency Medicine Procedures, 2e New York, NY: McGraw-Hill; 2013. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343758. Accessed June 20, 2017.



Roberts & Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013.