ARTICLE

Local Anesthetic and Stylet Styles: Factors Associated

With Resident Lumbar Puncture Success
Amy L. Baxter, MDa, Randall G. Fisher, MDa, Bonnie L. Burke, MSb, Sidney S. Goldblatt, BSN, RNc, Daniel J. Isaacman, MDa,
M. Louise Lawson, PhDd

aDepartment of Pediatrics, bEpidemiology and Biometry Core, cResearch Support Services, and dClinical Outcomes, Research, and Epidemiology, Eastern Virginia Medical

School, Children’s Hospital of the King’s Daughters, Norfolk Virginia

Financial Disclosure: Dr Baxter has received donated EMLA from AstraZeneca. There are no other financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. To assess the effects of procedural techniques, local anesthetic use, and
postgraduate training level on lumbar puncture (LP) success rates.
www.pediatrics.org/cgi/doi/10.1542/
METHODS. In this prospective observational study, medical students and residents peds.2005-0519
(“trainees”) reported techniques used for infant LPs in an urban teaching emer- doi:10.1542/peds.2005-0519
gency department. Data on postgraduate year, patient position, draping, total and This research was presented in part at the
American Academy of Pediatrics meeting;
trainee numbers of attempts, local anesthetic use, and timing of stylet removal October 19 –23, 2002; Boston, MA.
were collected. Logistic regression analysis was used to identify predictors of Dr Isaacman’s current affiliations are:
successful LP, with success defined as the trainee obtaining cerebrospinal fluid Department of Pediatrics, University of
with ⬍1000 red blood cells per mm3. Pennsylvania School of Medicine,
Philadelphia, PA; and Clinical Affairs,
Vaccines, Global Medical Affairs, Wyeth
RESULTS. We collected data on 428 (72%) of 594 infant LPs performed during the
Pharmaceuticals, Collegeville, PA 19426.
study period. Of 377 performed by trainees, 279 (74%) were successful. Local Key Words
anesthesia was used for 280 (74%), and 225 (60%) were performed with early lumbar puncture, resident, procedure,
stylet removal. Controlling for the total number of attempts, LPs were 3 times pain, stylet

more likely to be successful among infants ⬎12 weeks of age than among younger Abbreviations
LP—lumbar puncture
infants (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.2– 8.5). Controlling CSF— cerebrospinal fluid
for attempts and age, LPs performed with local anesthetic were twice as likely to ED— emergency department
EMLA— eutectic mixture of local
be successful (OR: 2.2; 95% CI: 1.04 – 4.6). For infants ⱕ12 weeks of age, early anesthetics
stylet removal improved success rates (OR: 2.4; 95% CI: 1.1–5.2). Position, drape OR— odds ratio
use, and year of training were not significant predictors of success. CI— confidence interval
Accepted for publication Jul 19, 2005
CONCLUSIONS. Patient age, use of local anesthetic, and trainee stylet techniques were Address correspondence to Amy L. Baxter,
associated with LP success rates. This offers an additional rationale for pain control. MD, Pediatric Emergency Medicine Associates,
PO Box 422002, Atlanta, GA 30342. E-mail:
Predictors identified in this study should be considered in the training of physi- amy_baxter@pema-llc.com
cians, to maximize their success with this important procedure. PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2006 by the
American Academy of Pediatrics

876 BAXTER, et al
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O NE OF THE first procedures learned by pediatric and
emergency medicine residents is the lumbar punc-
ture (LP). For febrile infants needing cerebrospinal fluid
(CSF) evaluation, failure to obtain fluid or contamina-
tion with peripheral blood (“traumatic LP”) can result in
unnecessary hospitalizations or a prolonged antibiotic
course. Unsuccessful and traumatic LPs are especially
common when procedures are performed by trainees,
occurring 20% to 55% of the time.1–3
Although the importance of a good holder is legend-
ary, other controllable factors influencing LP success
have not been well evaluated. Use of topical anesthetics
for an emergency department (ED) population improved
attending physician success rates in one abstract,4 but
other studies in teaching hospitals found that injected
lidocaine did not help1 or even hurt3 success rates. To our
knowledge, other techniques, including patient posi-
tioning (sitting or decubitus position)5 and drape re-
moval, have not been evaluated with respect to LP suc-
cess rates.
One technique purported to improve LP success rates
involves removal of the stylet immediately after passage
through the epidermal and subcutaneous tissues (early
stylet removal, also called the Cincinnati method).6 The
needle is then advanced through the dura without a
stylet, theoretically allowing observation of CSF flow
immediately after the subarachnoid space is entered.
Although several case series allude to this method,7,8 to
our knowledge there are no prospective studies address-
ing the prevalence of its use, its effects on success rates,
or complications.
The purposes of this study were to identify variations
in technique that were independently predictive of
trainees’ LP success. The primary study hypotheses were
that early stylet removal and local anesthetic use would
be associated independently with successful LPs among
infants.
METHODS
Study Sample Population
We conducted this prospective observational study from
October 1, 2001, through February 25, 2003, in the ED
of an urban pediatric teaching hospital (Children’s Hos-
pital of the King’s Daughters, Norfolk, VA). The study
was approved, with informed consent waived, by the
institutional review board of Eastern Virginia Medical
School.
Our 40 000 patient visits per year are triaged to an
attending physician-run fast track or a teaching ED.
Almost all of the 25 000 patients triaged to the ED are
examined first by trainees, including fourth-year medi-
cal students and pediatric, emergency medicine, and
family practice residents. Of trainee shifts, pediatric res-
idents cover two thirds, emergency medicine residents
cover one fourth, and family practice residents or fourth-
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year medical students cover the rest. Surveys adminis-
tered previously at our institution indicated that pediat-
ric and emergency medicine residents have performed
⬎50 LPs by their third year of postgraduate training.
The typical LP protocol is for a resident to examine
the patient, to order laboratory tests, and then to present
the patient to an attending physician. For neonates with
fever, blood and urine collection and any topical anes-
thetic applications are initiated before presentation and
LP. Our hospital uses Cardinal Health pediatric/infant
Safe-T-LP sets (Cardinal Health, Dublin, OH) with steel-
hub, 1.5-inch, 22-gauge, spinal needles. ED technicians
(paramedics) hold the infants for all LPs. At the time of
the study, the holders had between 5 and ⬎15 years of
ED experience.
The patient study population included all infants from
birth to 12 months of age who required LP as part of an
ED evaluation. Exclusion criteria included prior LPs for
the study, prior LPs at another hospital before transfer to
our institution, congenital abnormalities of the lumbar
spine, history of a bleeding disorder, and evidence of
vasculitis or cellulitis over the lumbar spine. Children
with subsequently diagnosed subarachnoid bleeding
from a traumatic brain injury or herpes simplex infec-
tion were excluded from the analysis.
Local anesthetics available during the study period
included lidocaine, a eutectic mixture of local anesthet-
ics (EMLA LMX4; Ferndale Laboratories, Ferndale, MI),
and a 4% liposomal formulation of lidocaine (AstraZen-
eca, Wilmington, DE). When ordered, topical local an-
esthetic is applied before blood and urine collection for
patients undergoing evaluation for sepsis. If anesthetic is
not in place long enough to be effective, then lidocaine
use is encouraged but routine LP delay is not.
Study Design
Questions regarding LP techniques were written on a
1-page form attached to all LP trays. To evaluate any
influence of reporting bias on success and to assess the
interrater reliability of reported techniques, 10% of trays
had a duplicate form in another color. The duplicate
forms required a fellow or attending physician to ob-
serve the entire procedure and to record LP data inde-
pendently. Trainees were not directed to perform LPs
with any particular technique and were blinded with
respect to the hypotheses of the study. Medical students,
residents, fellows, and attending physicians recorded
anonymously their level of training, the patient’s age
and medical record number, the position of the infant,
the use of anesthetics, whether the paper drape was over
the patient, the method of LP (early stylet removal or
traditional), and the numbers of needles used and at-
tempts required before CSF was obtained. If the initial
physician was unable to obtain CSF, then the number of
subsequent attempts by an upper-level physician was
PEDIATRICS Volume 117, Number 3, March 2006 877
recorded. Holder experience was not recorded. Com-
pleted forms were placed in a collection box in the ED.
The primary outcome measure was LP success, de-
fined as the trainee obtaining adequate CSF for culture
and cell count with ⬍1000 red blood cells per mm3.1–4
When a trainee asked another resident, fellow, or at-
tending physician to obtain CSF, the LP was considered
a failure. If the CSF obtained was too traumatic to dis-
tinguish from peripheral blood or too scant to yield cell
count data, then it was sent to the laboratory for “culture
only,” which also counted as a failure. Data were ob-
tained weekly from the hospital computer system to
determine the total numbers of CSF cultures and cell
counts from all ED infant LPs. In no case was CSF sent
for other studies but not culture.
Statistical Analyses
Factors predicting success were modeled with ␹2 and
multivariate logistic regression analyses with backward
elimination. To determine the agreement between the
practitioners’ and observers’ reported data for the same
LPs, ␬ values were calculated with 95% confidence in-
tervals (CIs) for nominal data and Spearman’s correla-
tion coefficients were calculated for ordinal data. The
baseline success rate of the traditional LP technique was
assumed to be 60% for an infant ED population.1,3 De-
tection of an absolute difference of 15% in success rates
with 80% power required 152 patients in each group for
any given predictor. Statistical analyses were performed
with the SAS software package (SAS Institute, Cary,
NC).
RESULTS
During the study period, 594 infant LPs from the ED
yielded enough CSF for a culture or had data forms
collected. Data forms for 428 infant LPs (72%) were
collected. One patient was excluded because of previous
enrollment, 4 because of LPs at other hospitals, 1 be-
cause of inflicted traumatic brain injury, and 1 because
the medical record number and date of birth were not
FIGURE 1
Comparison of success rates for LPs with completed
forms and for CSF samples sent to the laboratory without
data forms, with adjustment for expected proportions of
dry LPs. aRed blood cell count of ⬎1000 cells per mm3 or
CSF sent for culture only. bAdding expected dry LP fail-
ures not captured with CSF laboratory sample data.
878 BAXTER, et al
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recorded. There were no diagnosed cases of herpes en-
cephalitis in this population.
Overall success rates did not differ significantly be-
tween LPs with and without completed data forms (␹2 ⫽
1.26) (Fig 1). Success rates during the first 3 months of
the study (October to December 2001) were not statis-
tically different from those during the last 3 months of
the study (December 2002 to February 2003).
Twenty-nine LPs were performed by attending phy-
sicians or fellows and were not included in the remain-
der of this analysis. Of the remaining 392 LPs, 15 forms
did not indicate training level. The total number of LPs
available for analysis of trainee techniques was 377.
The overall success rate for LPs performed by medical
students or residents was 74% (SE: 0.0226; 95% CI:
69.6 –78.4%), and rates differed significantly according
to the age of the patient (Table 1). Trainees reported
using early stylet removal for 225 LPs (60%) and tradi-
tional stylet removal for 149 of 374 LPs; 3 forms were
missing method data. Some type of local anesthetic was
used for 280 (74%) of 377 LPs. In ␹2 analyses, there was
no difference in success rates according to trainee level,
anesthetic use, early stylet removal, drape use, or infant
position.
In addition to age, the total number of attempts by all
providers was identified as a strong confounder, with
goodness-of-fit testing indicating that modeling this fac-
tor as a continuous variable resulted in the best model fit
(␹2 likelihood ratio: 192; P ⬍ .0001). Multivariate logistic
regression analysis with backward elimination was used
to evaluate the independent contribution of each factor
to the success of the LP. Variables examined included
total anesthetic use, stylet technique, position, drape,
training level, and patient age, with the cutoff point for
age of ⬎12 weeks or ⬍12 weeks maximizing model fit.
Results of the logistic regression model after elimination
of the least-significant variables, with ␣ to remain set at
P ⫽ .1, are presented in Table 2. For the subset of
patients ⬍12 weeks of age, early stylet removal im-
 TABLE 1 Successful LP Rates According to Patient Age
No. of LPs No. of LPs No. of LPs With Overall Success Success Rate With Success Rate With
Using Early Local Anesthetic Rate, % Early Stylet Removal Local Anesthesia
Stylet Removala vs Traditional, % vs None, %
Overall 377 225 280 (70% liposomal lidocaine formulation, 74 75 vs 73 75 vs 70
12% EMLA, 4% lidocaine)b
Age (P ⬍ .01)
⬍6 wk 194 116 139 66 68 vs 64 68 vs 64
6–12 wk 103 65 77 78 77 vs 79 78 vs 77
3–12 mo 80 44 64 88 89 vs 89 89 vs 81
a Three LPs were missing method data.
b The remainder did not report the type/brand of anesthetic.

TABLE 2 Relative Odds of LP Success in Logistic-Regression Analysis With Backward Elimination

Step Variable Wald ␹2 Final Adjusted OR
Removed (P Value at Removal (95% CI)
From Model)
Age of ⬎12 wk 3.1 (1.2–8.5)
Local anesthetic 2.2 (1.04–4.6)
Early stylet removala 1.9 (0.95–3.9)
3 Drape in place 1.8 (P ⫽ .41)
2 Sitting or lying 1.1 (P ⫽ .7)
1 Training level: medical student or first-year 0 (P ⫽ .9)
resident vs second- or third-year resident
a For infants ⬍12 weeks of age, early stylet removal improved success rates (OR: 2.4; 95% CI: 1.1–5.2).

proved success rates significantly (odds ratio [OR]: 2.4;
95% CI: 1.1–5.2).
Observers were present for 24 (6.4%) of 377 LPs and
simultaneously recorded the same data as the person
performing the LP. One of the 24 LPs was missing
method information from either the practitioner’s or
observer’s data record. With regard to LP stylet method,
21 of 23 agreed (␬ ⫽ 0.74; 95% CI: 0.41–1.08). The ␬
values for all other nominal variables (LP position, top-
ical anesthetic, and drape use) ranged between 0.70 and
1, except for lidocaine use (␬ ⫽ 0.62). The weighted ␬
values were 1.0 for both the number of attempts and the
number of needles used. The success rate for observed
LPs was 75%, which was not significantly different from
the overall success rate.
DISCUSSION
In the past 5 decades, most pediatric LP literature has
dealt with the implications of CSF results, rather than
the procedure itself. Articles that discuss procedural
techniques have done so in the context of hospitalized
neonates,1,2,5,9,10 rather than febrile infants in the ED.3,4
For such a common procedure, there is a surprising
lack of controlled data underlying textbook recommen-
dations for procedural nuances such as bevel orienta-
tion, patient position, and pain control. Only the need
for a stylet at insertion has fairly robust support.7,8
Findings in the infant pain control literature have
been contradictory.1,3,11 Although pediatric procedure
textbooks dictate that “withholding local analgesia for
this procedure is strongly discouraged,”12 establishing
the efficacy of pain relief for neonatal LPs has been
problematic. Kaur et al10 performed the only study that
demonstrated diminished heart rate elevation and facial
pain response, randomly assigning 60 neonates to topi-
cal local anesthetic (EMLA) or placebo. Other studies
used similar physiologic data and failed to show a statis-
tical difference, perhaps because the pain response was
overwhelmed by the effect of positioning.1,9 Lack of
demonstrated or perceived pain control may be why
⬎50% of pediatric emergency medicine physicians sur-
veyed do not use analgesia for patients ⬍3 months of
age.13 What has not been established prospectively is
whether local anesthesia influences LP success.
Pinheiro et al1 found injected lidocaine to be neutral
for success, although it decreased neonatal struggling.
Among 99 children 0 to 36 months of age, Carraccio et
al3 found that injected lidocaine actually increased the
rate of traumatic LPs (1000 cells per high-power field). If
this were attributable to loss of palpable bony land-
marks, then one would not expect a topical anesthetic to
cause the same problem. Indeed, in the topical anes-
thetic study by Kaur et al,10 2 of 30 LPs were traumatic in
the EMLA group and 3 in the placebo group. One ab-
stract by Shenkman et al4 found EMLA to reduce the
number of traumatic LPs by ED attending physicians,
compared with a historical cohort, for patients ⬍2
months of age (OR: 0.31; 95% CI: 0.13– 0.73). Ours is
the first prospective study that found the use of pain
control to be predictive of increased success rates and the
only study that examined resident LP performance ex-
plicitly. Because only 4% of anesthetic users injected

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lidocaine in our study, the potential confounding issue
of loss of landmarks was minimal.
Beyond describing the relationship between pain con-
trol and infant LPs, we were interested in quantifying
and describing the technique of early stylet removal.
Historically, adult LPs were performed with a stylet in
place, to avoid spinal headache and obstruction of the
needle with tissue. By the middle 1950s, it had become
common practice among children to omit the stylet to
improve success rates.8 In 1956, Choremis et al14 con-
nected 5 cases of pediatric spinal epidermoid tumors to
repeated use of nonstyletted LP needles in tuberculous
meningitis. Multiple case reports supporting the associ-
ation between even a single LP and the development of
these tumors 1.5 to 23 years later were published.7,8,14–16
This ultimately led to an editorial practice guideline stat-
ing that “a stylet should always be used”17 and censure15
of Greensher et al,18 who stated that the use of butterfly
needles gave their group a 100% success rate without
complications over 2.5 years of observation. Partially in
response to observations by Greensher et al,18 Schreiner
and Kleiman2 conducted a prospective study of 246 LPs
among 181 NICU patients and found no difference in the
rates of traumatic LPs with styletted spinal needle versus
butterfly needle usage.
Although current texts recommend the traditional LP
method with stylet always in place,19,20 the concept of
early stylet removal once past the epidermis is not dis-
cussed. This method was mentioned as a “perfectly safe”
option in the epidermoid tumor case reports.7,8 In 1992,
Bonadio6 published a review referring to early stylet
removal as the “Cincinnati method,” which was pur-
ported to reduce the risk of unsuccessful LPs, but cited
no data. In a recent national survey of pediatric emer-
gency medicine physicians, 16% of 188 stated that they
prefer early stylet removal and almost twice that number
sometimes advance the needle without a stylet in
place.13
Because early stylet removal has never been formally
studied, it is difficult to know whether it is safe or
effective. Gibson and Norris21 found that ⬃70% of nee-
dle insertions through skin without a stylet yielded a
core of epidermis, but they noted that there were only
rarely fat fragments. Because subcutaneous tissues are
endodermal, not ectodermal, and because fat is “cored”
infrequently by beveled needles, early stylet removal
should carry little risk of tumor formation. A difficulty is
in knowing exactly when the practitioner is past the
epidermis.
Our findings indicated that, for younger infants, early
stylet removal was associated with increased success
rates. Logically, the method’s advantages should be
more pronounced in situations in which the dural “pop”
is subtler and the diameter of the spinal canal is smaller.
Assessing safety would require long-term follow-up
monitoring for a very rare event and would be particu-
880 BAXTER, et al
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larly difficult because use of this method might not be
documented explicitly.
Our study was limited by several factors. Most nota-
bly, because we did not dictate who used which method,
we could perform neither randomization nor control.
Thought was given to having residents perform proce-
dures with and without various techniques, to serve as
their own control subjects, but residents indicated a
strong belief in the merits of their chosen preferences. In
particular, many considered withholding anesthetic to
be unethical. We decided that success with forced unfa-
miliar techniques might bias performance more than
letting all practitioners perform their perceived best
techniques.
Another limitation could be reporting bias based on
our outcome measure, ie, success. Success rates for LPs
with completed forms and without forms were not sig-
nificantly different, however, even assuming propor-
tional numbers of “dry” LPs without laboratory sample
collection. Our attempt to assess reporting bias by using
interrater assessment fell short, with only 6.4% of LPs
being observed, rather than the 10% of kits with dupli-
cate forms. When an attending physician was unavail-
able to observe the procedure in a timely manner, many
residents performed the LP anyway or chose a kit with-
out double forms. Because the residents could not know
their success or failure before the observed LP perfor-
mance, this should not have biased reporting. Rather
than revealing decreased success rates, observed LPs
were slightly more likely to be successful. This could be
attributable to coaching by the upper-level observer,
because their instructions did not prohibit them from
giving advice.
We did not collect data on the infant holder or on
characteristics of individual practitioners beyond the
year of training. An experienced holder might be able to
coach an inexperienced resident to success or an inex-
perienced holder might allow more patient movement
and decrease success rates. However, because the hold-
ers were assigned after the topical anesthetic decision
was made, these results should not have been influ-
enced. Type of residency and number of previously per-
formed LPs could confound the effects of pain and stylet
manipulation. The lack of statistical difference in success
rates according to postgraduate year might simply indi-
cate a plateau in the learning curve for all practitioners.
The majority of studies on which we based our power
analysis involved neonates. In light of our finding that
success rates improved with infant age, the inclusion of
older infants decreased the power to detect a difference.
Given our large number of successful “cases” versus
controls, the logistic regression model amply supported
the number of variables modeled.22 However, to estab-
lish prospectively the efficacy of early stylet removal
among older infants, a much larger number would be
needed.
 The confounding relationship between the total num-
ber of attempts and decreased success rates could simply
reflect more blood in the CSF after multiple attempts.
We propose that the number of attempts may be a proxy
variable for the inherent difficulty of LP. This is sup-
ported by the fact that the number of attempts was
modeled best as a continuous variable, rather than a
categorical variable.
CONCLUSIONS
Both pain control and early stylet removal decreased the
rates of failed LPs, controlling for number of attempts
and age. Although we cannot recommend primarily
teaching the early stylet removal method, because of
lack of safety data, instructors training residents should
be aware of this technique, particularly for young in-
fants. Our data indicate that local anesthesia is feasible
for a large number of febrile infants who require LP. In
addition to compassionate considerations, the associa-
tion with improved success offers another rationale for
the use of pain control.
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PEDIATRICS Volume 117, Number 3, March 2006 881
Local Anesthetic and Stylet Styles: Factors Associated With Resident Lumbar
Puncture Success
Amy L. Baxter, Randall G. Fisher, Bonnie L. Burke, Sidney S. Goldblatt, Daniel J.
Isaacman and M. Louise Lawson
Pediatrics 2006;117;876
DOI: 10.1542/peds.2005-0519

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Local Anesthetic and Stylet Styles: Factors Associated With Resident Lumbar
Puncture Success
Amy L. Baxter, Randall G. Fisher, Bonnie L. Burke, Sidney S. Goldblatt, Daniel J.
Isaacman and M. Louise Lawson
Pediatrics 2006;117;876
DOI: 10.1542/peds.2005-0519

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http://pediatrics.aappublications.org/content/117/3/876

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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