Lumbar Puncture

Lumbar puncture, also known as a spinal tap, is a sterile medical procedure in

which a needle is inserted into the spinal canal, most commonly to collect
cerebrospinal fluid for diagnostic testing.
The main reason for a lumbar puncture is to help diagnose diseases of the
central nervous system, including the brain and spine

Contraindications
Indications : ► skin infections over proposed
puncture site (absolute
Diagnostic contraindication)
► Suspected CNS infection ► Raised intracranial pressure (ICP);
exception is pseudotumor cerebri
► Sampling of CSF for any other
► Suspected spinal cord mass or
reason: demyelinating disease intracranial mass lesion (based on
lateralizing neurological findings or
Therapeutic: papilledema)
► Therapeutic reduction of ► coagulopathies
cerebrospinal fluid (CSF) ► Spinal column deformities (may
pressure require fluoroscopic assistance)
► Lack of patient cooperation/no
consent
Indications for performing brain CT scanning before lumbar
puncture in patients with suspected meningitis include the
following:

- Patients who are older than 60 years

- Patients who are immunocompromised
- Patients with known CNS lesions
- Patients who have had a seizure within 1 week of presentation
- Patients with a decreased level of consciousness
- Patients with focal findings on neurologic examination
- Patients with papilledema seen on physical examination, with
clinical suspicion of an elevated ICP
- Cranial CT scanning should be obtained before lumbar puncture in
all patients with suspected Subaracnoid haemorrhage in order to
diagnose obvious intracranial bleeding
 Pre-procedure:

► Lumbar puncture should be performed only after a neurologic

examination
► Obtain a signed informed consent
► Explain the procedure, benefits, risks, complications, and alternative
options to the patient or the patient’s representative
► Ask about previous anaesthetic allergies.
Technical considerations:

► The smaller the needle used for the lumbar puncture, the lower the risk
that the patient will experience a post–lumbar puncture headache. 22G
or 24G needle
► Always done in a sterile environment
Equipment:

A spinal or lumbar puncture tray should include the following items:

► Sterile dressing
► Sterile gloves
► Sterile drape
► Manometer
► Antiseptic solution with skin swabs
► Lidocaine 1% without epinephrine
► Needles, 20 and 25 gauge
► Spinal needles
► Four plastic test tubes, numbered 1-4, with caps
► Syringe, 10 mL (optional)
Procedure

► Assess indications for procedure and obtain informed consent as

appropriate
► Provide necessary analgesia and/or sedation as required
► Position patient: lateral position, or seated and leaning over ; both
these positions will open up the intralaminar space.
► The sitting position may be a helpful alternative, especially in obese
patients, because it makes it easier to confirm the midline. In order to
open the interlaminar spaces, the patient should lean forward and be
supported by a stand with a pillow on it, by the back of a stool, or by
another person
Cont…

► 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.
► Tuffier’s line
► 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 with a thumbnail or a
marker. To help open the interlaminar spaces, ask the patient to practice pushing
the entry site area out toward the practitioner.
► Scrub your hands
► With the spinal tray open and change into to sterile gloves, and prepare the
equipment. Open the numbered plastic tubes, and place them upright and draw the
Lidocaine into the 10-mL syringe (4-5mg/kg)
► Prep and drape the area after identifying landmarks. Use lidocaine 1% with or
without epinephrine to anesthetize the skin and the deeper tissues under the
insertion site
Cont….

► Use the 10-mL syringe to administer a local anaesthetic. 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 to the hub, 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
centimetres. Continue this process above, below, and to the sides very slightly.
► Next, 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 cephalic angle, directing it toward the umbilicus.
Advance the needle slowly but smoothly. Occasionally, a characteristic “pop” is felt
when the needle penetrates the Dura.
► Otherwise, 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 millimetres, and recheck for fluid return. Continue this process until fluid
is successfully returned.
Cont..

► For measurement of the opening pressure, the patient must be in the

lateral recumbent position.
► After fluid is returned from the needle, attach the manometer through
the stopcock, and note the height of the fluid column. The patient’s
legs should be straightened during the measurement of the open
pressure, or a falsely elevated pressure will be obtained
► If CSF does not flow, or you hit bone, withdraw needle partially, recheck
landmarks, and re-advance
Cont..

• Once the ICP has been recorded, remove the 3-way stopcock, and begin filling
collection tubes 1-4 with 1-2 ml (at least 10drops) of CSF each.
• Inspected the color
• Tubes :
- Tube 1: Chemistry for glucose, protein, protein electrophoresis
- Tube 2: Hematology for a cell count and differential
- Tube 3: Microbiology for Gram’s stain, bacterial and viral cultures
- Tube 4: Reserve tube for any special tests if needed
► After tap, remove needle, and place a bandage over the puncture site. Instruct
patient to remain lying down for 1-2 hours before getting up
Cont..

► When indicated, viral titers or cultures, Venereal Disease Research

Laboratory (VDRL) tests, Cryptococcus antigen assays, India ink stains,
angiotensin-converting enzyme (ACE) levels, or other studies are
ordered. Additional tests may be warranted, depending on the clinical
situation.
► All specimens should be taken to the laboratory promptly to prevent
haemolysis and specimen misplacement
Once results of the CSF analysis are
available, they can be appended to
your note

Parameter Normal Values

Protein 15-45 mg/dl
Glucose 50-80 mg/dl
WBC < 5 mm3
RBC 0-5
Opening pressure 5-20 cm
Clarity, color Clear and colorless
Protein assessment
► Assessment of CSF protein level, though nonspecific, can be a clue to otherwise unsuspected
neurologic disease.
► The high protein levels in demyelinating polyneuropathies, or post infectious states, can be
informative. A traumatic tap can introduce protein into the CSF. An approximation of 1 mg of
protein for every 750 RBCs may be used, but a repeat tap is preferable.
Glucose assessment
► The CSF glucose level normally approximates 60% of the peripheral blood glucose level at the
time of the tap. A simultaneous measurement of blood glucose (especially if the CSF glucose
level is likely to be low) is recommended.
► A low CSF glucose level is usually associated with bacterial infection (due to enzymatic inhibition
rather and bacterial consumption of the glucose). This finding is also seen in tumour infiltration
and may be one of the hallmarks of meningeal carcinomatosis, even with negative cytologic
findings. A high CSF glucose level has no specific diagnostic significance and is most often spill
over from an elevated blood glucose level.
► Cytologic assessment
► A larger than usual number of white blood cells suggests an
infection or, more rarely, leukemic infiltration.
► Bacterial infections are traditionally associated with a
preponderance of polymorph nuclear leukocytes however many
cases of Viral meningitis, Tb meningitis and encephalitis also show
a high percentage of PMNs in the acute phase of the illness (when
most lumbar punctures are done).
► In addition, inflammation from any source (e.g., CNS vasculitis)
can raise the WBC count.
► Elevated lymphocytes indicate viral and Tb meningitis
► Xanthochromia- yellowish appearance of cerebrospinal fluid.
► The best way of distinguishing RBCs related to intracranial bleeding is to examine the centrifuged
supernatant CSF for Xanthochromia (yellow colour). Although Xanthochromia can be confirmed visually,
it is more accurately identified and quantified in the laboratory.
► AXanthochromia can be produced by spill over from a very high serum bilirubin level (> 15 mg/dL),
patients with severe hyperbilirubinemia (e.g., from jjuandice or known liver disease). usually have been
identified before lumbar puncture. With this exception, Xanthochromia in a freshly spun specimen is
evidence of pre-existent blood in the subarachnoid space. However, it should be remembered that an
extremely high CSF protein level, as seen in lumbar punctures below a complete spinal block, also
renders the fluid xanthochromic, though without RBCs.
► Xanthochromia can persist for as long as several weeks after a subarachnoid haemorrhage (SAH). Thus,
it has greater diagnostic sensitivity than computed tomography (CT) of the head without contrast,
especially if the SAH occurred more than 3-4 days before presentation. Patients with aneurysmal leaks
(e.g., sentinel haemorrhages) may present days after the onset of headache, and this increases the
likelihood of a false-negative head CT scan.
► In some cases, the CSF may be another colour that strongly suggests a diagnosis. For example,
pseudomonal meningitis may be associated with bright-green CSF.
 Complications:

Complication Prevention Management

Bleeding from
puncture site post- None Local pressure
tap
Bloody spinal fluid None Withdraw needle and perform tap
at interspace either above or
below
Infection Do not perform tap through Antibiotics
infected skin
Use sterile technique
Post-tap persisting Use pencil-tipped needle if Analgesics paraetamol 1g 4-6hrly
headache possible; insert needle bevel-up Caffeine 300-500mg 4-6hrly
Post-procedure epidural blood
patch by anesthesia consultant
Documentation in the medical record

► Include in your note a brief history and physical examination of the

patient,, the reasons for performing the lumbar puncture, and consent.
► Note in particular a brief examination of the cranial nerves, presence or
absence of papilledema, or any other lateralizing neurological finding.
► Also include a brief note of examination of the patient’s spine with
attention to any obvious spinal deformity.
► Document position of patient during the procedure, opening pressure,
and clarity/color of the CSF.
That will be all