DEFINITION
LUMBAR PUNCTURE or SPINAL TAP is carried out by inserting a needle into Lumbar
subarachnoid space to withdraw C S F
PURPOSE
1.To obtain C S F for analysis & diagnosis of:
◦ Meningitis
◦Meningoencephalitis
◦ Subarachnoid hemorrhage
◦ Malignancy – diagnosis and treatment
◦ Pseudotumor Cerebri
◦ Other neurologic syndromes
2.To drain C S F & reduce intracranial space
3.To instill medications
COMPLICATIONS
1. Increased intracranial pressure
2. Head CT before study if focal neurologic findings present to rule out impending cerebral
mass herniation
3. If platelet count is less than 40,000 and Prothrombin time is less than 50% of control
LUMBAR PUNCTURE IN CERTAIN DISEASES
1. Hydrocephalus- Enlarged ventricle size & in suspected normal pressure Hydrocephalus
2. Coma- If C T is negative and I C P increased
3. Meningitis- Exclude mass lesion & confirm diagnosis
TECHNIQUE
Use smallest possible gauge [20/22]
Prefer atraumatic rather than cutting needle
•1.5 in for < 1 yr
•2.5 in for 1 year to middle childhood
•3.5 in for older children and adolescents
•Larger for large adolescents
INSERTION OF NEEDLE
Needle is inserted into subarachnoid space through intervertebral space
POSITION OF PATIENT
1. Spinal cord ends at L1-L2, so sites for puncture are located at L3-L4 or L4-L5
2. Restrain patient in lateral decubitus position
3. Maximally flex spine without compromising airway
4. Keep alignment of feet, knees and hips
5. Position head to left if right handed or vice versa
ARTICLES
•Sterile CSF tray with
•Spinal needle
•Anesthetic such as: Topical- Zylocaine cream or Lidocaine 1% with 25 gauge needle and
syringe
•Povidone-iodine solution & sponge
•Drapes, gauze, and bandages
•Manometer, stopcock, tubing and specimen bottles
PRE-PROCEDURE
1. Obtain a written consent for the procedure
2. Explain the procedure to the patient
3. Determine whether patient have any doubts or misconceptions
4. Reassure the patient
5. Instruct patient to void after procedure
PROCEDURE
•Position the patient at one side of edge of bed
•Place a small pillow under patient’s head & another between the legs
•Assist the patient to maintain position
•Encourage patient to relax & to breath normally
•Describe the procedure step by
•The physician cleanses the site with antiseptic solution and drapes the site
•Local anesthetic is injected to numb the site and a spinal needle is inserted to subarachnoid
space with stylet with bevel up to keep
A specimen of C S F is collected usually in three test tubes
Needle is withdrawn & a small dressing is applied at puncture site
Sent specimen to lab immediately
POST-PROCEDURE
1. Instruct patient to lie on prone for 2 to 3 hours
2. Monitor patient for any complications
3. Encourage increased fluid intake
COMPLICATIONS
Headache Back pain [Occasionally with short-lived ]
Disc herniation if needle advanced too far
Bleeding or fluid leak around spinal cord
Infection, pain, hematoma
Subarachnoid epidermal cyst
Ocular muscle palsy (1%) Nerve Trauma
Brainstem herniation
POST LUMBAR PUNTURE HEADACHE
Throbbing bifrontal & occipital headache
Dull and deep in character
Severe on sitting or standing
IT CAN BE AVOIDED BY:
Using small gauge needle
Keep patient prone after procedure for 2 hours, then side-lying for 2-3 hours, then supine
or prone for 6 or more hours
MANAGEMENT
Bed rest
Analgesics
Hydration
Epidural blood patch
CSF ANALYSIS
Clear and colourless
Secreted by choroid plexus
Exists in subarachnoid space
It is about 150-200ml acts as shock absorber transports nutrients
STANDARD TESTS
Usually obtained for cell count, culture, glucose and protein testing
R B C and Differential W B C
Bacteriological –Gram stain and culture
Biochemical-Protein[0.15-0.45g/l] - glucose [0.45-0.70g/l]
SPECIAL TESTS
SAH : Spectrophotometry
Malignant Tumor: Cytology
Tuberculosis: Polymerase chain reaction, Jensen Culture
Non-bacterial Infection: Virology, fungal & parasitic studies
Demyelinating Disease: Oligoclonal bands
Neurosyphilis: V D R L test
Cryptococcus: culture, antigen detection
H I V : culture, antigen detection & antiviral antibodies
