LUMBAR PUNCTURE
CME
9/12/2019
By Sharon Jesicca
OVERVIEW
• What is Lumbar Puncture (LP)?
• Relevant Anatomy
• Indication
• Contraindication
• Preparing for LP
-Patient
-Equipment
• The procedure
• Interpretation of LP results
• Risks & Complications
• Take home message
About Lumbar Puncture
• An invasive procedure that is often performed to obtain information
regarding the cerebrospinal fluid (CSF)
• usually used for diagnostic purposes to rule out potential life-
threatening conditions such as meningitis and subarachnoid
haemorrhage.
• It is also sometimes used for therapeutic purposes in cases of
pseudotumor cerebrii
• CSF fluid analysis can also aid in the diagnosis of monay other
conditions
Relevant Anatomy
• The lumbar spine consists of 5
moveable vertebrae L1-L5.
• The lumbar vertebrae have a
vertical height that is less than
their horizontal diameter
• Comprised of 3 functional parts:
-Vertebral body: weight-bearing
-Vertebral (neural) arch: to
protect neural elements
-Bony processes (spinous &
transverse)
Indications for LP
DIAGNOSTIC
meningitis
subarachnoid hemorrhage THERAPEUTIC
(SAH)
Guillain-Barre Syndrome
(GBS)
Contraindications
• Cutaneous infection over the needle entry site
• presence of unequal pressures between the
supratentorial and infratentorial compartments.
• Increased intracranial pressure (ICP)
• Coagulopathy
• Brain abscess
Preparing for LP
PATIENT
EQUIPMENT &
• Informed consent
PERSONNEL
• Explain the procedure
• Assess the patient
The Procedure
• Wearing nonsterile gloves,
locate the L3-L4 interspace by
palpating the right and left
posterior superior iliac crests
and moving the fingers
medially toward the spine
• Palpate that interspace (L3-
L4), the interspace above (L2-
L3), and the interspace below
(L4-L5) to find the widest
space.
• Mark the entry site
• Ask the patient to practice
pushing the entry site area out
toward the practitioner.
• Open the spinal tray, change to sterile gloves, and
prepare the equipment.
• Open the numbered plastic tubes, and place them upright
• Assemble the stopcock on the manometer, and draw the
lidocaine into the 10-mL syringe.
• Use the skin swabs and antiseptic solution to clean the
skin in a circular fashion, starting at the L3-L4 interspace
and moving outward to include at least 1 interspace
above and 1 below
• Place a sterile drape below the patient and a fenestrated
drape on the patient
• Use the 10-mL syringe to administer a local anesthetic
• Raise a skin wheal using the 25-gauge needle, then
switch to the longer 20-gauge needle to anesthetize the
deeper tissue.
• Insert the needle all the way ,aspirate to confirm that the
needle is not in a blood vessel, and then inject a small
amount as the needle is withdrawn a few centimeters.
• Stabilize the 20- or 22-gauge needle with the index
fingers, and advance it through the skin wheal using the
thumbs
• Insert the needle at a slightly cephalad angle, directing it
toward the umbilicus.
• Advance the needle slowly but smoothly.
• Occasionally, a characteristic “pop” is felt when the needle
penetrates the dura.
• The stylet should be withdrawn after approximately 4-5
cm and observed for fluid return. If no fluid is returned,
replace the stylet, advance or withdraw the needle a few
millimeters, and recheck for fluid return.
• Collect at least 10 drops of cerebrospinal fluid (CSF) in
each of the 4 plastic tubes
• If the CSF flow is too slow, ask the patient to cough or
bear down
• Replace the stylet, and remove the needle.
• Clean off the skin preparation solution. Apply a sterile
dressing, and place the patient in the supine position.
Collection & Interpretation of CSF
• Tube 1 - Cell count and differential
• Tube 2 - Glucose and protein levels
• Tube 3 - Gram stain, culture and sensitivity (C&S)
• Tube 4 - Cell count and differential
• Other tests: (VDRL) tests, Cryptococcus antigen assays,
India ink stains, angiotensin-converting enzyme (ACE)
levels – when indicated
Complications
• begins 24-48 hours after the procedure and is more
common in young adults.
Post lumbar • continued leakage of CSF from the puncture site.
puncture headache • fronto-occipital and improves in the supine position.
• This condition is usually self-limited
• More than 50% of lumbar punctures are falsely
Bloody tap positive for RBCs in the CSF as a result of
microtrauma caused by the spinal needle
• patient is dehydrated, a falsely negative dry tap may
Dry tap be obtained as a result of very low CSF volume and
pressure.
• Cellulitis, skin abscesses, epidural
abscesses, spinal abscesses, or diskitis
Infection can result from a contaminated spinal
needle.
• Epidural, subdural and subarachnoid
Hemorrhage hemorrhages are rare
• Irritation of nerves or nerve roots by the
Dysesthesia spinal needle can cause different lower-
extremity dysesthesias
Take Home message
• Lumbar puncture is an aseptic invasive procedure of
obtaining the CSF for analysis
• It is crucial to know the indications and contraindications
of lumbar puncture to provide prompt treatment as well as
avoid unnecessary procedures
• Patient’s should be well informed and consent must be
taken cautiously.
• The post procedural complications should be thoroughly
explained to patient during taking consent
