THERAPEUTIC AND DIAGNOSTIC

PROCEDURES OF NEUROLOGICAL
DISORDER
 TOPICS
I. LUMBAR PUNCTURE (SPINAL TAP)
II. Magnetic resonance Image(MRI)and
Computed Tomography (CT scan)
I. LUMBAR PUNCTURE (SPINAL TAP,
SPINAL PUNCTURE)
 Objectives:
At the end of this lesson, the learner/student will be able to:
1. Define lumbar puncture
2. Assemble the necessary equipments for lumbar puncture
3. Assist in preparing and positioning the patient for the
procedure
4. Properly label and send the sample of CSF to the laboratory
5. Monitor the patient for possible post-procedure
complication
6. Define MRI &CT scan
7. Describe nursing responsibilities for patient undergo for MRI
&CT scan
CSF circulation around the brain and upper spinal cord.
 PHYSIOLOGY
• Cerebrospinal fluid (CSF) is formed in special
areas of the brain called choroid plexuses.
• CSF circulation around the brain and upper
spinal cord.
• The CSF flows through the subarachnoid
space to bathe the brain and spinal cord. The
CSF is absorbed back into the venous system
by way of arachnoids villi.
 Characteristics &Normal values (CSF)
• CSF opening pressure: 50–180 mmH2O( should average 130 mmH2O)
• Glucose: 40–85 mg/dL.
• Protein (total): 15–45 mg/dL.
• Lactate dehyrogenase: 1/10 of serum level.
• Lactate: less than 35 mg/dL.
• Leukocytes (WBC): 0–5/µL (adults / children); up to 30/µL (newborns).
• Gram stain: negative.
• Culture: sterile.
• Specific gravity: 1.006–1.009.
• Syphilis serology: negative.
• Gross appearance: Normal CSF is clear and colorless.
• Differential: 60–70% lymphocytes; up to 30% monocytes and macrophages;
other cells 2% or less.
• Appearance clear alkaline/ lymph like fluid
• CSF is continuously produced (about 800 mL/day)
 Function of CSF
1. Acts as a buffer against injury to brain and
spinal cord
2. Carries oxygen and nourishment to brain and
spinal cord
3. Removes waste and toxic substances
LUMBAR PUNCTURE (spinal tap, Lps)
Definition:-It is a procedure that involves the removal
of a sample of cerebrospinal fluid (CSF) from the
subarachnoid space
Indications for lumbar puncture include:
A. Diagnostic
• To Measurement of CSF pressure
 Therapeutic reduction of cerebrospinal fluid (CSF)
pressure
• Evaluation of spinal dynamics for signs of CSF flow
• To remove some cerebrospinal fluid to decrease
pressure in the spinal canal (hydrocephalus)
 Diagnostic …
• Collection of CSF for laboratory analysis
 bacterial, fungal and viral infections, including
meningitis and encephalitis.
• bleeding around the brain (subarachnoid
hemorrhage)
 To determine the presence or absence of blood in the
CSF
• cancers involving the brain and spinal cord
 Diagnostic cont’d
• Injection of radio-opaque dye to visualise part of the
nervous system radiologically (myelography) – to
diagnose brain tumors
• Identification of patients requiring lumbar puncture,
two or more of the following features are present:
1. Headache
2. Fever (100.4° F or 38° C)
3. Neck stiffness
4. Altered mental status (delirium or confusional
state)
Indications for lumbar puncture include…

B. Therapeutics
1) Introduction of spinal anaesthesia for surgery
2) Administration of intrathecal drug/s or
chemotherapeutic agents (methotrexate,
hydrocortisone and cytarabine).
 lumbar puncture …
Pre procedure patient education
 Obtain informed consent
 Inform patient of possibility of complications
( persistent headache, and infection) and their treatment
 Explain the major steps of the procedure, positioning,
and post procedure care
 Patient should void the urine (empty the bladder)
 Check to allergic to anesthetics.
 Check for bleeding problems
 EQUIPMENT NEEDED

• Sterile gloves • Four plastic test tubes,

• Manometer numbered 1 to 4, with
• Sterile dressing caps
• Antiseptic solution with skin • Adequate lighting
swabs • Blood pressure monitor
• Sterile drape (fenestration 100
• Gauze squares
x 160mm)
• 1% Lidocaine • cotton balls
• 3-cc syringe • gallipots /kidney dish
• 20- and 25-gauge needle • adhesive plaster & scissors
• 20- and 22-gauge spinal • sterile normal saline to fill
needle – in the manometer
 Procedure
• Explain the procedure to the patient
• Obtain informed consent from the patient
• Open iv line with normal saline solution
• Place the patient in a sitting position on the
edge of the bed (much like the position for a
spinal ) or in a lateral recumbent position
(lying on the side with knees tucked to chest
and chin to chest)
• find the iliac crests and move your fingers
medially from the crests to the spine.
 Patient positioning
1. Lateral recubitus position
• Fetal Position
• Back at right angles to bed
2. Sitting position -- Leaning forward, holding a
pillow
 lumbar puncture position
Sitting position Lateral recumbent position
Position…
Paediatric position
 Procedure cont’d
• Mark the entry site with your thumbnail or a
marker
• Open and prepare the spinal tray in a sterile
manner
• Use the skin swabs and sterile antiseptic solution to
clean the skin at the interspace you have chosen,
along with the space below
• Choose a good interspaces: L3-4 or L4-5. Clean in a
circular fashion starting at the center and moving
outward
 Procedure cont’d
• Place the sterile drape on the patient.
• Use the 25-gauge needle and the 3-cc syringe to
administer the 1% lidocaine intradermally.
• Insert the spinal needle (20- or 22-gauge) through the
skin wheal between the L3 and L4 or L4 and L5.
• Advance the needle slowly but smoothly. Usually a
characteristic “pop” is felt as the needle passes
through the dura (usually 4 to 5 cm into the skin).
• Stop and remove the stylus to observe for fluid return
once you think you have felt the pop ,If no fluid see,
you have not yet passed through the dura replace the
stylus and advance a few millimeters to recheck.
lumbar puncture needle
 Procedure cont’d
Removal of stylus Cerebrospinal fluid collection
 Procedure cont’d
• once cerebrospinal fluid (CSF) is seen, collect about 3
cc of CSF in the four plastic numbered tubes
• Remove the needle from the patient’s back.
• Place a sterile dressing on the site and have the patient
stay in the supine position for 2 hours
Send the four tubes for the following labs:
a. Tube 1, bacteriology: Gram stain, culture and
sensitivity, acid-fast bacilli.
b. Tube 2, biochemistry: glucose, protein, and
electrophoresis
c. Tube 3, hematology: cell count with differential
d. Tubes 4-: Specialized tests: cryptococcal antigen,
cytology
 Cerebral Spinal Fluid
Normal CSF Abnormal CSF
• Clear odorless • Turbid, cloudy
• WBC’s 0 – 5 • WBC’s 1000 – 2000
• Protein 15 to 45 • Protein 100 – 500
• Glucose 50 – 80 • Glucose lower than blood
• Pressure 50 to 180 sugar
• Pressure 180 or greater
NORMAL CSF VALUES.
CSF VALUES IN VARIOUS NEUROLOGICAL CONDITIONS.
 Post procedure care

Observations
• Monitor and record the patient’s condition
• Vital signs – blood pressure, pulse, respirations, and
temperature,
• Neurological status – Glasgow coma score (The
maximum score is 15 indicating an awake, alert and
fully responsive patient. )
Puncture site
• Ensure that the puncture wound is covered with an
occlusive dressing.
• Check the site hourly for four hours then once per 8
hours for the following 24 hours to ensure that there
is no leakage of CSF, bleeding, or inflammation
GLASCOW COMA SCALE
 GLASCOW COMA SCALE…
scale permits the following classification of
traumatic brain injury (TBI) after clinical
examination:
mild head injury (GCS 13–15);
moderate head injury (GCS 9–12);
severe head injury (GCS 3–8)
 Contraindication of lumbar puncture
• Any clinical evidence of raised intracranial
pressure.
• Where the patient cannot be positioned
appropriately e.g. unstable fractured spine.
• Local infection or pressure sore over lumbar
area
• Lack of patient cooperation
• Abnormal posture
 Contraindications …

• seizures
• Glasgow Coma Scale Score < 13
• inappropriately low pulse, elevated BP and irregular
respirations.
• Coagulopathy (Bleeding disorders)
• Current anticoagulation (warfarin or heparin etc)
• A history of spina bifida or skin appearances of spina
bifida occulta (hair patch over lumbar region)
 Complications
Headache
• due to a reduced volume of cerebrospinal fluid and reduced
pressure, is the most common complication of lumbar puncture,
occurring in up to 40% of patients.
• usually starts within 48 hours after lumbar puncture but may be
delayed for up to 14 days
Symptoms associated with post dural puncture headache
 Nausea and vomiting
 Anorexia
 Diaphoresis
 Dizziness
 neck stiffness
 Blurred vision
 Diplopia
• relieved by lying down flat and giving analgesia
 Complications cont’d

Transient voiding problems

• Due to altered motor or sensory status in the
lower extremities, and bladder dysfunction.
Infection
• bacterial meningitis, lumbar epidural abscess,
and spinal cord abscess
Bleeding – apply heavy pressure to the site for
at least 2 minutes
 Complications cont’d
• Seizures - Observe for changes in consciousness by
performing a Glasgow coma score (GCS). Notify the
doctor of a decrease in GCS
• Spinal/epidural abscess
• epidural haematoma (bleeding)
• trauma to the spinal cord or spinal nerve roots
(paraplegia)
• Backache or spasm
• Slight elevation of body temperature
 Care after the procedure
• „ Avoid strenuous or vigorous exercise for a
day.
• „ If patient has headache, instinct him/her lie
down as much as possible.
• „ analgesics &Drink 2 ½ quarts of liquid the
day of the lumbar puncture and the day after
(regardless of headache).
II. Magnetic resonance Image
(MRI)
and
Computed Tomography
(CT scan)
 Magnetic resonance image and Computed tomography (CT
scan)

Magnetic resonance image

• An MRI (or magnetic resonance imaging) scan
is a radiology technique that uses magnetism,
radio waves, and a computer to produce
images of body structures.
• magnets strength is more than 20000 times
that of earth’s magnetic field.
 Magnetic resonance image

• MRI (Magnetic resonance imaging) – uses

magnetic fields and radiofrequency pulses to
produce anatomical images. In some cases,
contrast agents are injected.
• Definition: Magnetic resonance imaging (MRI)
is a noninvasive medical test that physicians
use to diagnose and treat medical conditions.
 Magnetic resonance image
MR imaging of the body is performed to evaluate:
• organs of the chest and abdomen—including the heart,
liver, biliary tract, kidneys, spleen, bowel,
pancreas, and adrenal glands.
• pelvic organs including the bladder and the reproductive
organs such as the uterus and ovaries in
females and the prostate gland in males.
• blood vessels (including MR Angiography).
• lymph nodes
 Preparation of patient for MRI scan
cont’d
• All metallic objects on the body are removed
prior to obtaining an MRI scan.
• A mild sedative can be given prior to the MRI
scan to decrease anxiety and relax the patient
during the procedure.
• MRI scanning requires that the patient lie still
for best accuracy. Patients lie within a closed
environment inside the magnetic machine.
Relaxation is important during the procedure
and patients are asked to breathe normally.
 Procedure
• The patient will enter the machine head first or
feet first, depending on the area to be scanned
Once the target is centered, the scan can begin.
• The patient has a coil that is placed in the target
area, to be scanned. A radio frequency is passed
through the coils that excites the hydrogen protons
in the target area.
• The gradient magnets are then activated in the
main magnet and alter the magnetic field in the
area that is being scanned.
• Most MRI exams take between 15 to 45 minutes to
complete depending on the body part imaged .
 Procedure cont’d

• When MRI procedure begins, you may breathe

normally, however, for certain examinations it may
be necessary for you to hold your breath for a
short period of time.
• During your MRI examination, the MR system
operator will be able to speak , hear and observe
the patient at all times.
• MRI procedure is over, patient wait until the
images are examined to determine if more images
are needed. After the scan, no restrictions and
patient can go his/her normal activities.
• MRI scanning is painless.
Procedure cont’d
 MRI

• Advantages
1 -has a good visualization of the spinal cord
2-Provide very detailed diagnostic pictures of
most of the important organs and tissues in
your body.
3-Sometimes able to show unique information
that other tests are unable to show.
4-Are generally painless.
5-Do not use radiation and are therefore
suitable for use in children and pregnant
women.
 MRI
• Disadvantages
1 -MRI scan is done in an enclosed space, so the
people who are claustrophobic, i.e. fearful
of being in a closely enclosed surface, are
facing problems with MRI to be done.
2-MRI scans involve really loud noises while
processing because they involve a really high
amount of electric current supply.
3-MRI scanners are usually expensive.
 MRI Safety

• The most dangerous part of an MRI scanner is

its powerful magnetic field. The magnetic field
in an MRI scanner is stronger than those used
industrially to move cars. This magnetic field
will cause objects made of ferromagnetic
materials to be pulled into the scanner. It will
also pull on ferromagnetic objects implanted in
the body.
 MRI Safety
• The following metals are ferromagnetic and
are not MRI compatible:
i. Iron
ii. Nickel
iii. Cobalt
NOTE: Objects made of these materials should
not be taken into the MRI scanner room.
 MRI Safety
• Patients should be screened for the following:
i. Pacemakers
ii. Surgical clips
iii. Implants made of a ferromagnetic metal
NOTE: Never send anyone for an MRI without
screening them first!
 Computed Tomography Scan (CT scan)
• A CT (computed tomography) scan uses
special X-ray equipment to take multiple
images from different angles around the body
• uses X-rays to make detailed pictures of
structures inside of the body.
• The image can be made even clearer by using
a special contrast agent, which can be
swallowed as a liquid, injected into a vein, or
given as an enema.
Computed Tomography (CT)
 Use of CT scan
• Diagnose disease, trauma or abnormality
• internal injuries & Plan and guide
interventional or therapeutic procedures
• Diagnosis cancer & Monitor the effectiveness
of therapy (e.g., cancer treatment)
• muscle and bone disorders, such as tumors
and fractures , infections, or blood clots
 Procedure
• remove take off any jewelry
• patient take off all or most of clothes, depending
on which area is studied butgown to use during
the test.
• During the test, patient will lie on a table that is
attached to the CT scanner.
• The table slides into the round opening of the
scanner, and the scanner moves around patients
body
• patient will need to remain very still for up to 30
seconds during each scan set.
• The test will take about 30 to 60 minutes
 Computed tomography (CT)

• Computed tomography (CT)

• Advantages
1 - painless.
2- Shows internal body structures.
3- View of a large portion of the body.
4- Rapid acquisition of images.
• Disadvantages
1 - Spinal cord is poorly visualized
2- Expensive.
3- Not available in small hospitals.
4- uses more radiation then x-ray.
 Risks of CT scan
There is a rare risk of a major allergic reaction to
the contrast agent
pregnant exposing the baby/fetus to radiation
small chance of developing cancer from radiation
diabetes patient who take metformin
(Glucophage), the dye may cause problems
several previous CT scans to the same part of your
body damage normal tissue
 Differences between MRT and CT scan
MRI CT scan

An MRI does not use X-rays; it uses A CT scan uses X-rays

magnets and radio waves

MRI show tendons and ligaments A CT scan does not show tendons and
ligaments

MRI is better for soft tissue views CT is better for bone structure
 THE TABLE BELOW OUTLINES WHICH IMAGE MODALITY MRI OR CT

S.NO HEAD/ BRAIN

1 MRI CT
 Arteriovenous malformations  Acute trauma
 Encephalomalacia  Calcified lesions
 Epilepsy and adult onset seizures  Suspected acute intracerebral
 Hemangiomas hemorrhage
 Hydrocephalus  Suspected subarachnoid
 Infection / Inflammation hemorrhage (“The worse
 Infratentorial tumors headache of my life.”)
 Lacunar infarcts
 Lyme disease
 Meningiomas
 Multiple sclerosis
 Orbit and optic nerve disease
 Pituitary dysfunction
 Posterior fossa abnormalities (acoustic neuroma
and skull base pathology)
 Space occupying lesions
 Stroke—(Use diffusion-weighted MR imaging)
 Supratentorial tumors
 Syringomyelia and Chiari malformations
 Vascular/congenital abnormalities
 White matter disease
 THE TABLE BELOW OUTLINES WHICH IMAGE MODALITY MRI OR CT…

S.NO ENT
1 MRI CT
 Disease of the larynx (staging)  Cholesteatoma
 Paranasal sinus diseases (soft  Conductive hearing loss
tissue masses, CA staging)  Evaluation of the oro-, hypo-,
 TMJ meniscal and soft tissue and nasopharynx
evaluations  Facial bone trauma
 Sensorineural hearing los  Orbital trauma
 Ossicular or vestibulocochlear
deformities
 Otosclerosis/otospongiosis
continuum
 Sinusitis
 Salivary gland disease
 TMJ – bone destruction or
arthritis
 THE TABLE BELOW OUTLINES WHICH IMAGE
MODALITY MRI OR CT…
S.NO SPINE
1 MRI CT
 Any intrinsic disease of the cord  Post discography to assess the
 Infection / inflammation morphology of an intervertebral disc
 Disc disease (cervical, thoracic, lumbar)  Scoliosis (CT best for bone detail)
 Multiple sclerosis and demyelinating  Vertebral fractures – all levels
disease
 Myelopathy – all levels
 Paraspinal masses
 Postoperative evaluation (differentiate disc
herniation from scar tissue)
 Scoliosis (MRI best to evaluate cord)
 Spinal cord tumors
 Syringomyelia, Chiari malformations,
hydromyelia
 Syrinx
 Tethered cord
 Vascular abnormalities
 Vertebral column bone destruction by
tumor (evaluation of spinal canal integrity
only)
 Vertebral osteomyelitis
THE TABLE BELOW OUTLINES WHICH IMAGE
MODALITY MRI OR CT…
S.NO CHEST
1 MRI CT
 Assessment of cardiac  Aortic dissection
function  Hilar and parenchymal
 Brachial plexus and axillary nodules
pathology  Lung disease
 Congenital heart lesions or
cardiac abnormalities
 Great vessel anomalies
 Intracardiac or pericardial
masses
 Mediastinal masses
 Vascular structures of the
mediastinum and chest
 Valvular disease
THE TABLE BELOW OUTLINES WHICH IMAGE
MODALITY MRI OR CT…
S.NO ABDOMEN
1 MRI CT
Evaluation of renal vasculature Abdominal aortic aneurysm
(MRA) Benign and malignant disease of
MRCP recommended when the liver
Diagnostic component needed Diagnosis and staging of non-
before therapeutic ERCP hepatic intra-abdominal
When ERCP is impossible infections and tumors
Patients who have failed ERCP Screening examination for
Patients who only require a symptoms when detail of the
diagnostic study liver, spleen, kidneys or
To exclude sclerosing cholangitis, pancreas is needed
pancreatic neoplasm or chronic
pancreatitis
Tumor invasion of vena cava
THE TABLE BELOW OUTLINES WHICH IMAGE
MODALITY MRI OR CT…
S.NO PELVIS

1 MRI CT

 Bladder carcinoma  Nodal assessment

staging  Pelvic Mass (useful,
 Prostate carcinoma but ultrasound still
staging preferred)
 Uterine carcinoma  Pelvic pain
staging
 Seminal vesical tumor
invasion
THE TABLE BELOW OUTLINES WHICH IMAGE
MODALITY MRI OR CT…
S.NO MUSCULOSKELETAL
1 MRI CT
 Achilles tendon injury  Complex fractures (3-D CT
 Ankle – ligamentous injuries reconstruction)
 Avascular necrosis
 Bone and soft tissue tumors
 Knee injury including meniscal,
cartilaginous and tendinous
 Metastatic disease of bone
 Occult fractures not apparent
on plain films
 Osteoarthritis of hip, knee,
shoulder and ankle
 Osteochondritis dissecans
 Osteomyelitis
 Rotator cuff injuries
 Tendon injuries of the elbow