LUMBAR

PUNCTURE ADELEKE
BOLUWATITO
ARIKPO
WOBASE
AYEKU
ESTHER
TABLE OF CONTENT

• ANATOMY
• DEFINITION
• INDICATION
• CONTRAINDICATION
S
• EQUIPMENTS
• PRE-PROCEDURE
CARE
• PROCEDURE
• POST-PROCEDURE
CARE
• COMPLICATIONS
• CONCLUSION
• REFERENCES
DEFINTION

• Lumbar puncture, also known as Spinal Tap is a medical

procedure that is often performed in the emergency department
to obtain information about the cerebrospinal fluid (CSF) through
the subarachnoid space. Although usually used for diagnostic
purposes to rule out potential life- threatening conditions (e.g.
subarachnoid hemorrhage), it is also sometimes used for
therapeutic purposes (e.g. in pseudomotor cerebri).
• CSF fluid analysis can also aid in the diagnosis of various other
conditions (e.g., demyelinating diseases and carcinomatous
meningitis).
•Lumbar puncture should be performed only after a neurologic
examination but should never delay potentially life-saving
interventions.
ANATOMY

• During development, the vertebral column outgrows the spinal

cord. In older children, the spinal cord terminates at the inferior
border of the first lumbar vertebra(L1) or in some people, the
superior border of the second lumbar vertebra (L2).
• In the newborn infant it ends slightly at the inferior border of the
third lumbar vertebra (L3) but reaches the lower border of the
first lumbar vertebrae(L1) as they grow older. The dural and
arachnoid sacs extends up to the level of the second sacral
vertebra (S2) and this cavity contains the CSF. Thus the region
between the second lumbar vertebra and the second sacral
vertebra is suitable for the withdrawal of CSF, as there is no
danger of injury to the spinal cord.
ANATOMY

• The CSF is mainly produced by the choroid plexus within the

lateral ventricles. Once CSF leaves the lateral ventricles, it
flows through the foramen of Monroe into the midline third
ventricle and passes through the cerebral aqueduct of
Sylvius into the fourth ventricle where it flows through the
foramen of Magendie and foramen of Luschka into the
cisterna magna. The cisterna magna is continuous with the
subarachnoid space surrounding both the brain and the
spinal cord. The CSF is then reabsorbed back into the
venous circulation via arachnoid villi.
ANATOMY

• The lumbar spine consists of 5 moveable vertebrae numbered

L1-L5.The lumbar vertebrae have a vertical height that is less
than their horizontal diameter. They are composed of the
following 3 functional parts:
• The vertebral body, designed to bear weight
• The vertebral (neural) arch, designed to protect the neural
elements
• The bony processes (spinous and transverse), which function to
increase the efficiency of muscle action
The lumbar vertebral bodies are distinguished from the thoracic
bodies by the absence of rib facets. The lumbar vertebral bodies
(vertebrae) are the heaviest components, connected together by
the intervertebral discs.
 ANATOM
•YThe size of the vertebral body increases from L1 to L5, indicative of the increasing loads that
each lower lumbar vertebra absorbs. Of note, the L5 vertebra has the heaviest
body,
smallest spinous process, and thickest transverse process. From a point of view
needle, the structures that are penetrated from superficial to deep, are as
of a spinal
follows :
• skin
• subcutaneous connective tissue
• supraspinous ligament
• interspinous ligament
• ligamentum flavum
• epidural space
• dura mater (dural sac)
• subarachnoid space, where the CSF is present.
CSF
CHARACTERISITICS
INDICATIONS

DIAGNOSTIC
• Suspicion of CNS infections e.g. Meningitis, Encephalitis
• Suspicion of subarachnoid hemorrhage (SAH)
• Suspicion of demyelinating diseases such as Guillan Barre syndrome,
Multiple Sclerosis
• Suspicion of malignancy e.g. Carcinomatous Meningitis
• Metabolic studies
• Neurotransmitter disorders
• Undiagnosed infantile or pediatric epilepsy
THERAPEUTIC
• Therapeutic relief of pseudomotor cerebri
• Administration of intrathecal medications, e.g. antibiotics
and chemotherapy or spinal anesthesia or contrast agents
(in csf leaks)
• Therapeutic relief of raised intracranial pressure only if
an obstruction or the presence of a mass has been
ruled out e.g. Hydrocephalus, Idiopathic Intracranial
Hypertension
CONTRAINDICATIONS

• Lumbar puncture is a very invasive procedure with associated complications.

Attention should therefore be paid to the contraindications.
• ABSOLUTE CONTRAINDICATIONS
• Presence of infected skin over the needle entry site
• Presence of unequal pressure between the supratentorial and infratentorial
compartments and this is usually inferred from the following characteristics
findings on computed tomography(CT) of the brain:
1. Midline shift
2. Loss of suprachiasmatic and basilar cisterns
3. Posterior fossa mass
4. Loss of superior cerebellar cistern
5. Loss of quadrigeminal plate cistern
CONTRAINDICATIONS

• RELATIVE CONTRAINDICATIONS
• Increased intracranial pressure with brain damage or due to Arnold-Chiari malformation :
drowsiness, diplopia, abnormal pupillary responses, unilateral or
bilateral motor positioning or papilledema,
• Coagulopathy: a. thrombocytopenia with platelet count< 50×10 /L9

b. international normalized ratio>1.5

c. active bleeding
• Brain abscess
• Vertebral anomalies e.g.
• Cardiovascular compromise/ shock
• Respiratory compromise
CONTRAINDICATIONS

• Deep coma: absent or non-purposeful response to painful

stimulus-
squeeze earlobe firmly for up to 10seconds. A child over 3
months of age should be able to push you away and seek a
parent
• The febrile child with purpura where meningococcal
infection is suspected
• Recent seizures (within 30 minutes or not regained normal
conscious levels afterwards)
CT SCANNING

• Indications for performing brain CT scanning before lumbar

puncture in patients with suspected meningitis include the
following:
• Patients who are immunocompromised
• Patients with known CNS lesions
• Patients who had had a seizure within 1 week of presentation
• Patients with abnormal level of consciousness
• Patients with focal findings on neurologic examination
• Patients with papilledema seen on physical examination, with
clinical suspicion of elevated ICP
EQUIPMEN
• Sterile dressing
TS
•Sterile gloves
• Sterile drape
• Antiseptic solution (iodine) with skin swabs
• Lidocaine 1% without epinephrine
• Syringe, 3ml
• Needles, 20 and 25 gauge
• Spinal needles: 0.5 inch for neonates, 20 and 22 gauge
• Three-way stopclock
• Manometer
• Flexible tubing
PRE-PROCEDURE CARE

• Assess the risk of raised intracranial pressure (any

evidence on imaging)
• Check the platelet count and clotting profile
• Ensure absence of infection at lumbar puncture site
• If doing the lumbar puncture for possible
subarachnoid hemorrhage, ensure 12 hours have
passed since the onset of symptoms
• Document informed consent (written if possible)
• Communicate possible complications to parent and
the child
PROCEDURE

• It is important to obtain an informed verbal consent

before commencement of a lumbar puncture procedure
and this should include a detailed discussion of the
benefits of the procedure in terms of possible diagnoses
and potential complications.
PREPARATION AND METHOD

• Administer a mild sedative if necessary, and apply local

anesthetic to area of anticipated puncture with 1%
lignocaine infiltrated over the site in an alert older child.
• It is preferable to draw blood for a random blood sugar
estimation before the performer does the procedure, but at
least not more than 15 minutes interval. This would allow
for an appropriate comparison with what is referred to a
simultaneous CSF sugar.
POSITION OF PATIENT

• For infants and younger children, it generally performed in the left

lateral decubitus position with neck, body, hips and knees flexed
in the Knee-Chest position. The lumbar spine should be flexed to
enlarge the intervertebral space as much as possible, but not the
neck in neonates, as the airway is short and should not be
compromised. For older children, it may be performed in sitting
position.
• A pillow is placed under the head to keep it in the same
plane as the spine.
• Shoulders and hips are positioned perpendicular to the table.
• Lower back should be arched towards the practitioner.
PRELUDE TO PROCEDURE

• Place child in position. SpO2 should be monitored

continuously using Pulse oximeter as aide,
• The ideal site for lumbar puncture is either between L3-L4 or L4-
L5. Visualize a vertical line between superior iliac crests and its
transection with the midline of the spine,
• Clean area using standard aseptic techniques: povidone-iodine
and 70% alcohol. Scrub the hands and wear sterile gloves.
• Gently puncture skin with spinal needle at the identified mark
and direct tip towards the umbilicus. The entry point is usually
distal to the palpated spinous process L4. An initial slight
resistance is noticed due to ligaments between the vertebral
processes.
PROCEDURE CONTINUED

• Gently advance a few millimeters at a time until you feel a

'give' or a quiet 'pop' and thereafter, there is a backflow of
CSF. Then withdraw the stylet in every 2 to 3-mm advance
of the need e to check for CSF return. The feeling of a 'pop'
is due to entrance into the dura mater before the CSF
backflow occurs. It should be noted that the experience of a
feeling of 'give' and decreased resistance as the needle
advances MAY BE ALL that indicates a successful puncture
of the dura mater and subsequently the entrance into the
subarachnoid space.
• If the needle meets the bone or if blood returns, withdraw
to the skin and redirect the needle.
PROCEDURE CONTINUED

• Proceed immediately to attach a three-way stopcock

and a manometer, if available, to the lumbar
puncture needle for determination of the CSF
pressure.
• It is important to note that in a crying or struggling
child, CSF pressure is increased.
• Start collecting CSF in designated bottles.
• On completing CSF collection, gently withdraw needle,
clean the puncture site with alcohol or methylated spirit,
and cover area with dry gauze and bandage or plaster.
CONCERNS

• Great caution must be exercised when lumbar tap contemplated

in the presence of raised intracranial pressure, especially if a
space-occupying lesion is suspected. Lumbar puncture performed
under such circumstancesmay result in trans tentorial or
transforaminal herniation.
• If a space occupying lesion is suspected, a CT scan should be
obtained to confirm that the mass is small and is not causing any
shift of cerebral structures.
• When meningitis is strongly suspected, and there are fears about
possible significant raised intracranial pressure, the pressure
should be reduced by the fastest possible means and about 2 ml
of CSF cautiously withdrawn, using a small bore needle with a
stylet.
POST-CARE

• As soon as the needle is withdrawn, puncture site should

be sealed help prevent any leakage of spinal fluid after the
procedure.
• Patient should be laid flat on the procedure table without a
pillow for a minimum of 30 minutes-1 hour.
• Continuous monitoring of child is done till he or she
recovers from the sedation, if given, or from the stress of
the procedure.
• Ensure that the child lies supine for as long as they can in
the first 12-24hours following the procedure to relieve the
headache.
POST-CARE

• If the child develops a post puncture headache, follow

these precautions:
• a. Darken the room
• b. Give plenty of fluids which should be continued for
the next 48-72 hours
• c. Analgesics should be administered
• d. Raising the foot end of the bed
COMPLICATIONS

• 1. Post Lumbar Puncture headache (PLPH)- Fairly common and

occurs in
up to 5-15% of patients). It majorly occurs as a result of loss of
CSF, other
factors are needle gauge (the higher larger the needle, the
higher the incidence rate of PLPH), the operator's skill, needle
orientation etc. It:
• * Usually begins within minutes after arising and
resolves with recumbent position.
• * Pain is mild to incapacitating and is usually cervical
and sub- occipital, but may involve the shoulders and the
entire cranium.
• 2. Post Lumbar Puncture Lower back pain- following the procedure
due to arachnoiditis although it is usually short-lived.
• 3. Local edema and hematoma
COMPLICATIONS

• 4. Tonsillar herniation associated with raised intracranial

pressure; Very rare.
• 5. Disc herniation.
• 6. Bleeding into CSF; and Bleeding around the cord
(extra-spinal hematoma).
• 7. Infection and meningitis
• 8. Subarachnoid epidermal cyst
• 9. Apnea
• 10. Spinal fluid leak
COMPLICATIONS

• 11. Transient/persistent
paresthesia/numbness
• 12. Transient Ocular muscle palsy (1%)
• 13. Nerve Trauma
• 14. Brainstem herniation
• 15. Respiratory arrest from positioning
(Rare)
• 17. Acquired epidermal spinal cord tumor.
CONCLUSION

• Lumbar Puncture is a very important procedure that helps

diagnose CNS disorders, it is important for the physician to
understand the common indications, contraindications, the
procedure and possible complications as this could impact
the management of patient's condition.
REFERENCES

• Pediatrics and Child Health in the tropics by

Azubuike and Nkanginieme
• Medscape
• ResearchGate: https://www.researchgate.net/journal/BMC-
Neurology-1471-2377/publication/
332428545_Optimal_management_after_paediatric_lumbar_
punctu re_A_randomized_controlled_trial/links/
5fc20c8e92851c933f6a7f0d/Optimal-management-after-
paediatric- lumbar-puncture-A-randomized-controlled-
trial.pdf