BM6711

BM6711
HOSPITAL TRAINING

Lumbar Puncture

Presented to Presented by

BME Faculty J.B.Rosheema Bala

312213121043
BME IV Year

Date : 29.07.2016
 Overview
• What is it?
• Why do we need this?
• How do we do this?
• What is the actual technique?
• What happens after?
• Indications & Contraindications?
• What risks are involved?
 Lumbar Puncture

http://www.lymphomas.org.uk/sites/default/files/Lumbar-puncture-cropped.jpg

Cerebrospinal fluid drawn from

between
two lumbar vertebrae
 What is a lumbar puncture?
• Lumbar puncture or a spinal tap is a procedure that is
often performed in the emergency department to obtain
information about the cerebrospinal fluid (CSF).
• It is a medical procedure where a needle is inserted into
the lower part of the spine to test for conditions affecting
the brain, spinal cord or other parts of the nervous
system.

http://www.macmillan.org.uk/_images/Lumbar-
puncture_tcm9-45584.jpg
 A History
The first technique for accessing the dural space was described by the
London physician Walter Essex Wynter. The main purpose was the
treatment of raised intracranial pressure rather than for diagnosis.

Lumbar puncture was first introduced in 1891 by the German physician

Heinrich Quincke.

https://upload.wikimedia.org/wikipedia/commons/thumb/7/77/Meningitis_-
_Lumbar_puncture.jpg/220px-Meningitis_-_Lumbar_puncture.jpg
 Indications
Diagnostic Therapeutic
• Bacterial, fungal and Injecting medication into the CSF.
viral infections. Ex: Meningitis,
encephalitis, syphilis etc • antibiotics for bacterial
• Subarachnoid meningitis
Haemorrhage-Bleeding • chemotherapy
around brain medicines for cancers affecting
• Guillain-Barré the central nervous system
syndrome - Inflammatory • spinal anaesthetic
conditon
• Certain cancers involving A lumbar puncture can also be used
brain and spinal cord to relieve a pressure build-up within
the skull (known as raised intracranial
A lumbar puncture doesn’t pressure) by removing some CSF.
necessarily mean you have one of
these conditions; it may be used to
rule them out
 Contraindications

• Presence of infected skin over the needle entry site

• Idiopathic increased intracranial pressure (ICP)

• Coagulopathy

• Brain abscess

• Vertebral deformities

http://healthwire.makemeok.com/wp-
content/uploads/2015/11/
shutterstock_46957648.jpg
 Anatomy
• The lumbar spine consists of 5 moveable vertebrae numbered L1-L5.

• 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 (vertebrae) are the heaviest components,

connected together by the intervertebral discs.

• The size of the vertebral body increases from L1 to L5, indicative of

the increasing loads that each lower lumbar vertebra absorbs.
 Anatomy - Cont.

https://s-media-cache-ak0.pinimg.com/736x/10/5a/df/105adfa6e01ffcdc3b6df4361d300567.jpg
 Tools Needed
• Sterile dressing
• Sterile gloves
• Sterile drape
• Antiseptic solution with skin swabs
• Lidocaine 1% without epinephrine
• Syringe, 3 mL
• Needles, 20 and 25 gauge
• Spinal needles, 20 and 22 gauge
• Three-way stopcock
• Manometer
• Four plastic test tubes, numbered 1-4, with caps
• Syringe, 10 mL (optional)
Tools Needed - Cont

Lumbar puncture disposable tray. Image courtesy of Gil Z Shlamovitz, MD.

 Before the test
• Explain the procedure, benefits, risks, complications, and
alternative options to the patient or the patient’s representative.
• Before performing the lumbar puncture, ensure that patients
are hydrated so as to avoid a dry tap.
• Never allow a lumbar puncture or a pre–lumbar puncture CT
scan to delay administration of intravenous (IV) antibiotics.

https://www.jeffersonradiology.com/files/4_1_x_content_vein_embolization2.jpg
Method
 1. Positioning the Patient
The patient is placed in the lateral recumbent position with the hips,
knees, and chin flexed toward the chest so as to open the interlaminar
spaces.

The sitting position is 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.
 2. Locating the Lumbar
Locate the L3-L4 interspace by palpating the right and left posterior
superior iliac crests and moving the fingers medially toward the spine
(see the image below). 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.
 3. Disinfecting
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
 4. Local Anaesthesia
Use a syringe to administer a local anaesthetic. 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
 5. Withdrawing CSF
Insert the needle at a slight angle. 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 millimeters, and
recheck for fluid return. Continue this process until fluid is successfully
returned.

https://www.mdguidelines.com/images/Illustrations/
lumbar_p.jpg
 6. Measuring Pressure
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.

http://emedicine.medscape.com/article/80773-technique
 7. Dressing the site
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.

http://emedicine.medscape.com/article/80773-technique
 After the procedure
• Plan to rest. Don't participate in strenuous activities the day
of your procedure. You may return to work if your job doesn't require
you to be physically active. Discuss your activities with your doctor if
you have questions.

• Take a pain medication. A nonprescription pain-relieving

medication that contains acetaminophen can help reduce headache
or back pain.

http://www.crossfitdfw.com/wp-content/uploads/2013/09/rest-af.jpg
 What to do with CSF?
If the CSF has been collected under sterile conditions, microbiologic
studies can now be performed.The classic approach is to send the 4
CSF tubes for the following studies:
• 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

CSF collection tubes. Image courtesy of Gil Z Shlamovitz, MD.

 CSF Analysis

http://image.slidesharecdn.com/csfanalysispresentation-111109103327-phpapp01/95/csf-analysis-presentation-41-728.jpg?cb=1320836496
 Results
The spinal fluid samples are sent to a laboratory for analysis. Lab
technicians check for a number of things when examining spinal fluid,
including:

• General appearance. Spinal fluid is normally clear and

colorless. If it's cloudy, yellow or pink in color, it may indicate
infection.

• Protein (total protein and the presence of certain

proteins). Elevated levels of total protein — greater than 45
milligrams per deciliter (mg/dL) — may indicate infection or another
inflammatory condition. Specific lab values may vary from medical
facility to medical facility.
 Results - Cont
• White blood cells. Spinal fluid normally contains up to 5
mononuclear leukocytes (white blood cells) per microliter. Increased
numbers may indicate infection. Specific lab values may vary from
medical facility to medical facility.

• Sugar (glucose). A low glucose level in spinal fluid may

indicate infection or another condition.

• Microorganisms. The presence of bacteria, viruses, fungi or

other microorganisms can indicate infection.

• Cancer cells. The presence of abnormal cells in spinal fluid

— such as tumor or immature blood cells — can indicate certain
types of cancer.
 Complications
• Post-lumbar puncture headache. Up to 25 percent of
people who have undergone a lumbar puncture develop a
headache afterward due to a leak of fluid into nearby tissues.

• Back discomfort or pain. You may feel pain or tenderness in

your lower back after the procedure. The pain might radiate down
the back of your legs.

• Bleeding. Bleeding may occur near the puncture site or,

rarely, into the epidural space.

• Brainstem herniation. Increased pressure within the skull

(intracranial), due to a brain tumor or other space-occupying
lesion, can lead to compression of the brainstem after a sample of
cerebrospinal fluid is removed.
 Complications - Cont
• Dysesthesia - Impairment of senses

• Bloody tap/Dry tap.

Bloody : micro trauma caused by spinal needle.
Dry : misplaced patient (low csf acquired)

• Infection to CSF - Can occur with breaks in sterile environment,

use of contaminated equipment.
 Treatment
• In case of severe head ache post procedure, place in supine
position for at least 2 hours, hydrate, administer caffeine through
IV. Use of atraumatic needles can reduce the incidence of the
head ache.

• If herniation occurs, instantly remove needle and raise the head

to 30 - 45 degrees. Immediate neurosurgical consult.

• Dysesthesia - Remove needle immediately, if pain or motor

weakness persists use corticosteroids. Perform EMG and nerve
conduction velocity studies if pain continues.
Summary
 References
• http://emedicine.medscape.com/article
/80773-technique
• http://www.mayoclinic.org/tests-proced
ures/lumbar-puncture/basics/results/pr
c-20012679
• https://en.wikipedia.org/wiki/Lumbar_p
uncture#Contraindications
• http://www.slideshare.net/aravin8292/l
umbar-puncture
Thank You