ACEP Now - By Crespo M and Jones R - June 13, 2017
..."An alternative method to the traditional lumbar puncture is the paramedian approach. Although scarce in the emergency medicine literature, it has been a successful option that has been performed by anesthesiologists for decades. Advantages of this approach include a larger target through the interlaminar space as well as avoidance of the supraspinous and interspinous ligaments. The paramedian approach allows for faster catheter insertion, fewer attempts at needle insertion, and a lower incidence of post lumbar puncture headache. This approach can be performed in the neutral spine position. The paramedian approach is associated with fewer technical problems compared to the midline approach, and because it avoids the supraspinous and interspinous ligaments, the procedure is less painful and ideal in elderly patients with calcified ligaments. This approach penetrates the ligamentum flavum directly after passing through the paraspinal muscles. First-attempt success rates with the paramedian approach have been reported to be 30 percent to 40 percent higher when compared to the midline approach..."