ASSIGNMENT ON

LUMBAR PUNCTURE
 LUMBAR PUNCTURE

DEFINITION

A lumbar puncture, or spinal tap, is a medical test that involves collecting

a small sample of cerebrospinal fluid (CSF) for examination. This clear,

colorless liquid helps "cushion" the brain and spinal cord, or central nervous

system.

PURPOSE

■ To measure cerebrospinal fluid (CSF) pressure

■ To aid in the diagnosis of viral or bacterial meningitis, subarachnoid or

intracranial hemorrhage, tumors and brain abscesses, and neurosyphilis

and chronic central nervous system infections

INDICATIONS

 Suspected meningitis or encephalitis

 Suspected sub-arachnoid haemorrhage with a normal CT

 Diagnosis, monitoring and treatment (using intrathecal medications) of a

range of haematological, malignant and neurological disorders

Contraindications

Absolute
  GCS <8 or deteriorating/fluctuating level of consciousness

 Signs of raised intracranial pressure (ICP): diplopia, abnormal pupillary

responses, decerebrate or decorticate posture, low HR + elevated BP +

irregular respirations, papilloedema

 A bulging fontanelle in the absence of other signs of raised ICP is not a

contraindication

Relative

 Septic shock or haemodynamic compromise

 Significant respiratory compromise (eg apnoeas in a baby)

 New focal neurological signs or seizures

 Seizure within previous 30 min +/- normal conscious level has not

returned following a seizure

 INR >1.5 or platelets <50 or child on anticoagulant medication

PATIENT PREPARATION

■ Make sure that the consent form is signed by the child’s parents or legal

guardians.

■ Note and report all allergies.

■ Inform the child and his parents that there are no food or fluid

restrictions.

■ Instruct the child to empty his bladder and bowels before the procedure.

■ Explain the importance of remaining still throughout the procedure.

■ Inform the child and his parents that the test takes at least 15 minutes.

■ Explain that headache is the most common adverse effect.

■ Confirm the child’s identity by checking two patient identifiers.

■ Position the child on his side at the edge of the bed with his knees

drawn up to his abdomen and his chin tucked against his chest (the fetal

position), or position the child sitting while leaning over a bedside table.

■ If the child is in a supine position, provide pillows to support the spine

on a horizontal plane.

■ Gently hold even a cooperative child during the procedure to prevent

injury from unexpected or involuntary movement.

■ The skin site is prepared and draped.

■ A local anesthetic is injected.

■ Monitor the child’s vital signs and neurologic status throughout the

procedure.
 ■ The spinal needle is inserted in the midline between the spinous

processes of the vertebrae (usually between L3 and L4 or L4 and L5).

■ The stylet is removed from the needle; CSF will drip out of the needle

if properly positioned.

■ A stopcock and manometer are attached to the needle to measure the

initial (opening) CSF pressure.

■ Specimens are collected and placed in the appropriate containers.

■ The needle is removed and a small sterile dressing is applied.

ALERT During lumbar puncture, observe the child closely for signs of an

adverse reaction (elevated pulse rate, pallor, or clammy skin).

POSTPROCEDURE CARE

■ Keep the child in a reclined position for up to 12 hours after the

procedure to avoid the discomfort of potential post procedure spinal

headache.

LUMBAR PUNCTURE POSITIONING

When positioning a child for a lumbar puncture, follow these steps:

1. Have the child lie on his side at the edge of the bed, with his chin tucked

to his chest and his knees drawn up to his abdomen.

 2. Make sure that the child’s spine is curved and his back is at the edge of

the bed (as shown below); this position widens the spaces between the

vertebrae, easing needle insertion.

3. To help the child maintain this position, place one of your hands behind

his neck; place the other hand behind his knees, and pull gently.

POSITIONING A YOUNG CHILD

Hold the child firmly in this position throughout the procedure to prevent

accidental needle displacement. (Typically, the physician inserts the needle

between L3 and L4.) The sitting position may be used for infants. However,

because the flexed position may interfere with the infant’s breathing, monitor

his color and respiratory status closely during the procedure.

POSITIONING AN INFANT

■ Inform the child that he can turn from side to side.

■ Encourage the child to drink increased amounts of fluid with a straw to

replace the CSF removed during the procedure. Drinking with a straw

allows the patient to keep his head flat.

■ Give analgesics as ordered.

■ Monitor the child’s vital signs, neurologic status, and intake and output.

Assess for numbness, tingling, and decreased movement of the

 extremities; pain at the injection site; drainage of blood or CSF at the

injection site; and an inability to void.

■ Monitor the puncture site for redness, swelling, and drainage.

NORMAL RESULTS

■ Pressure: 50 to 180 mm H2O

■ Appearance: clear, colorless

■ Protein: 10 to 30 mg/dl (SI, 100 to 300 mg/L) – Neonates: 15 to 100

mg/dl (SI, 150 to 1,000 mg/dl)

■ Gamma globulin: 3% to 12% of total protein

■ Glucose: 40 to 80 mg/dl – Neonates (0 to 14 days): 60 to 80 mg/dl

■ Cell count: 0 to 5 white blood cells; no red blood cells (RBCs)

■ Venereal Disease Research Laboratory (VDRL) test: nonreactive

■ Chloride: 115 to 130 mEq/L

■ Gram stain: no organisms

ABNORMAL RESULTS

■ Increased intracranial pressure (ICP), indicating tumor, hemorrhage, or

edema caused by trauma

■ Decreased ICP, indicating spinal subarachnoid obstruction

■ Cloudy appearance, suggesting infection

■ Yellow or bloody appearance, suggesting intracranial hemorrhage or

spinal cord obstruction

■ Brown or orange appearance, indicating increased protein level or RBC

breakdown

■ Increased protein, suggesting tumor, trauma, diabetes mellitus, or blood

in CSF

■ Decreased protein, indicating rapid CSF production

■ Increased gamma globulin, associated with demyelinating disease or

Guillain-Barré syndrome

■ Increased glucose, suggesting hyperglycemia

■ Decreased glucose, which could result from hypoglycemia, infection,

or meningitis

■ Increased cell count, indicating meningitis, tumor, abscess, or

demyelinating disease

■ Presence of RBCs from hemorrhage

■ Positive VDRL test result, indicating neurosyphilis

■ Decreased chloride, pointing to infected meninges

 ■ Gram-positive or gram-negative organisms, indicating bacterial

meningitis

COMPLICATIONS

 Failure to obtain a specimen/traumatic bloody tap (common)

 Post-dural puncture headache (uncommon) 5-15%

 Transient/persistent paraesthesia/numbness (very uncommon)

 Respiratory arrest from positioning (rare)

 Infection introduced by needle causing meningitis, epidural abscess or

osteomyelitis (very rare)

 Spinal haematoma (very rare)

 Brain herniation (extremely rare in the absence of contraindications

above)