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Lumbar puncture

Lumbar puncture

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Published by Mitko
In medicine, a lumbar puncture (colloquially known as a spinal tap) is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very rarely as a treatment ("therapeutic lumbar puncture") to relieve increased intracranial pressure.
In medicine, a lumbar puncture (colloquially known as a spinal tap) is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or very rarely as a treatment ("therapeutic lumbar puncture") to relieve increased intracranial pressure.

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Published by: Mitko on Nov 09, 2010
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02/03/2014

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Lumbar puncture1
Lumbar puncture
A patient undergoes a lumbar puncture at thehands of a neurologist. The reddish-brown swirlson the patient's back are tincture of iodine (anantiseptic).
In medicine, a
lumbar puncture
(colloquially known as a
spinal tap
)is a diagnostic and at times therapeutic procedure that is performed inorder to collect a sample of cerebrospinal fluid (CSF) for biochemical,microbiological, and cytological analysis, or very rarely as a treatment("therapeutic lumbar puncture") to relieve increased intracranialpressure.
Indications
The most common purpose for a lumbar puncture is to collectcerebrospinal fluid in a case of suspected meningitis, since there is noother reliable tool with which meningitis, a life-threatening but highlytreatable condition, can be excluded. Young infants commonly requirelumbar puncture as a part of the routine workup for fever without a source, as they have a much higher risk of meningitis than older persons and do not reliably show signs of meningeal irritation (meningismus). In any agegroup, subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension and many other diagnoses may besupported or excluded with this test.Lumbar punctures may also be done to inject medications into the cerebrospinal fluid ("intrathecally"), particularlyfor spinal anesthesia or chemotherapy. It may also be used to detect the presence of malignant cells in the CSF, as incarcinomatous meningitis or medulloblastoma.
Contraindications
Lumbar puncture should not be performed in the following situationsIdiopathic (unidentified cause) increased intracranial pressure (ICP)Rationale: lumbar puncture in the presence of increased ICP may cause uncal herniationException: therapeutic use of lumbar puncture to reduce ICPPrecautionCT brain is advocated by some, especially in the following situationsAge >65Reduced GCS or conscious stateRecent history of seizureFocal neurological signsOphthalmoscopy for papilledemaBleeding diathesisCoagulopathyDecreased platelet count (<50 x 10
9
 /L)Infections
[1]
Skin infection at puncture siteSepsisAbnormal respiratory patternHypertension with bradycardia and deteriorating consciousnessVertebral deformities (scoliosis or kyphosis), in hands of an unexperienced physician or physician assistant.
[2]
 
[3]
 
Lumbar puncture2
Procedure
Spinal needles used in lumbar puncture.
In performing a lumbar puncture, first the patient is usually placed in aleft (or right) lateral position with his/her neck bent in full flexion andknees bent in full flexion up to his/her chest, approximating a fetalposition as much as possible. It is also possible to have the patient siton a stool and bend his/her head and shoulders forward. The areaaround the lower back is prepared using aseptic technique. Once theappropriate location is palpated, local anaesthetic is infiltrated underthe skin and then injected along the intended path of the spinal needle.A spinal needle is inserted between the lumbar vertebrae L3/L4 orL4/L5 and pushed in until there is a "give" that indicates the needle ispast the dura mater. The needle is again pushed until there is a second'give' that indicates the needle is now past the arachnoid mater, and in the subarachnoid space. The stylet from thespinal needle is then withdrawn and drops of cerebrospinal fluid are collected. The opening pressure of thecerebrospinal fluid may be taken during this collection by using a simple column manometer. The procedure isended by withdrawing the needle while placing pressure on the puncture site. In the past, the patient would often beasked to lie on his/her back for at least six hours and be monitored for signs of neurological problems, though thereis no scientific evidence that this provides any benefit. The technique described is almost identical to that used inspinal anesthesia, except that spinal anesthesia is more often done with the patient in a sitting position.The upright seated position is advantageous in that there is less distortion of spinal anatomy which allows for easierwithdrawal of fluid. It is preferred by some practitioners when a lumbar puncture is performed on an obese patientwhere having them lie on their side would cause a scoliosis and unreliable anatomical landmarks. On the other hand,opening pressures are notoriously unreliable when measured on a seated patient and therefore the left or right lateral(lying down) position is preferred if an opening pressure needs to be measured.Patient anxiety during the procedure can lead to increased CSF pressure, especially if the person holds their breath,tenses their muscles or flexes their knees too tightly against their chest. Diagnostic analysis of changes in fluidpressure during lumbar puncture procedures requires attention both to the patient's condition during the procedureand to their medical history.Reinsertion of the stylet may decrease the rate of post lumbar puncture headaches.
[3]
Risks
Post spinal headache with nausea is the most common complication; it often responds to analgesics and infusion of fluids. It was long taught that this complication can often be prevented by strict maintenance of a supine posture fortwo hours after the successful puncture; this has not been borne out in modern studies involving large numbers of patients.
 Merritt's Neurology
(10th edition), in the section on lumbar puncture, notes that intravenous caffeineinjection is often quite effective in abortingthese so-called "spinal headaches." Contact between the side of the lumbar puncture needle and a spinal nerve root can result in anomalous sensations (paresthesia) in a leg during theprocedure; this is harmless and patients can be warned about it in advance to minimize their anxiety if it shouldoccur. A headache that is persistent despite a long period of bedrest and occurs only when sitting up may beindicative of a CSF leak from the lumbar puncture site. It can be treated by more bedrest, or by an epidural bloodpatch, where the patient's own blood is injected back into the site of leakage to cause a clot to form and seal off theleak.Serious complications of a properly performed lumbar puncture are extremely rare. They include spinal or epiduralbleeding, and trauma to the spinal cord or spinal nerve roots resulting in weakness or loss of sensation, or evenparaplegia. The latter is exceedingly rare, since the level at which the spinal cord ends (normally the inferior border
 
Lumbar puncture3of L1, although it is slightly lower in infants) is several vertebral spaces above the proper location for a lumbarpuncture (L3/L4). There are case reports of lumbar puncture resulting in perforation of abnormal duralarterio-venous malformations, resulting in catastrophic epidural hemorrhage; this is exceedingly rare.The procedure is not recommended when epidural infection is present or suspected, when topical infections ordermatological conditions pose a risk of infection at the puncturesite or in patients with severe psychosis or neurosis with back pain. Some authorities believe that withdrawal of fluid when initial pressures are abnormal could result inspinal cord compression or cerebral herniation; others believe that such events are merely coincidental in time,occurring independently as a result of the same pathology that the lumbar puncture was performed to diagnose. Inany case, computed tomography of the brain is often performed prior to lumbar puncture if an intracranial mass issuspected.Removal of cerebrospinal fluid resulting in reduced fluid pressure has been shown to correlate with greater reductionof cerebral blood flow among patients with Alzheimer's disease. Its clinical significance is uncertain.
Diagnostics
Lumbar puncture in a newborn suspected of havingmeningitis.
Increased CSF pressure can indicate congestive heart failure,cerebral edema, subarachnoid hemorrhage, hypo-osmolalityresulting from hemodialysis, meningeal inflammation, purulentmeningitis or tuberculous meningitis, hydrocephalus, orpseudotumor cerebri.Decreased CSF pressure can indicate complete subarachnoidblockage, leakage of spinal fluid, severe dehydration,hyperosmolality, or circulatory collapse. Significant changes inpressure during the procedure can indicate tumors or spinalblockage resulting in a large pool of CSF, or hydrocephalusassociated with large volumes of CSF. Lumbar puncture for thepurpose of reducing pressure is performed in some patients withidiopathic intracranial hypertension (also called pseudotumor cerebri.)The presence of white blood cells in cerebrospinal fluid is called pleocytosis. A small number of monocytescan be normal; the presence of granulocytes is always an abnormal finding. A large number of granulocytes often heraldsbacterial meningitis. White cells can also indicate reaction to repeated lumbar punctures, reactions to prior injectionsof medicines or dyes, central nervous system hemorrhage, leukemia, recent epileptic seizure, or a metastatic tumor.When peripheral blood contaminates the withdrawn CSF, a common procedural complication, white blood cells willbe present along with erythrocytes, and their ratio will be the same as that in the peripheral blood.The finding of erythrophagocytosis
[4]
, where phagocytosed erythrocytes is observed, signifies haemorrhage into theCSF that preceded the lumbar puncture. Therefore, when erythrocytes are detected in the CSF sample,erythrophagocytosis suggests causes other than a traumatic tap, such as intracranial haemorrhage and haemorrhagicherpetic encephalitis. In which case, further investigations are warranted, including imaging and viral culture.Several substances found in cerebrospinal fluid are available for diagnostic measurement.Measurement of chloride levels may aid in detecting the presence of tuberculous meningitis.Glucose is usually present in the CSF; the level is usually about 60% that in the peripheral circulation. Afingerstick or venipuncture at the time of lumbar puncture may therefore be performed to assess peripheralglucose levels in order to determine a predicted CSF glucose value. Decreased glucose levels can indicate fungal,tuberculous or pyogenic infections; lymphomas; leukemia spreading to the meninges; meningoencephaliticmumps; or hypoglycemia. A glucose level of less than one third of blood glucose levels in association with lowCSF lactate levels is typical in hereditary CSF glucose transporter deficiency also known as De Vivo disease.

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