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Lumbar Puncture: Anatomical Review of a Clinical Skill
J.M. BOON,1* P.H. ABRAHAMS,2 J.H. MEIRING,1
Department of Anatomy, Unit of Clinical Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa 2 Kigezi International School of Medicine, Cambridge, Girton College, Cambridge, United Kingdom, St. George’s University Grenada and St. Vincent, West Indies 3 Kigezi International School of Medicine, Cambridge, Queen’s College, Cambridge, United Kingdom
The safe and successful performance of a lumbar puncture demands a working and speciﬁc knowledge of anatomy. Misunderstanding of anatomy may result in failure or complications. This review attempts to aid understanding of the anatomical framework, pitfalls, and complications of lumbar puncture. It includes special reference to 3D relationships, functional and imaging anatomy, and normal variation. Lumbar puncture is carried out for diagnostic and therapeutic purposes. Epidural and spinal anesthesia, for example, are common in obstetric practice and involve the same technique as diagnostic lumbar puncture except that the needle tip is placed in the epidural space in the former. The procedure is by no means innocuous and anatomical pitfalls include inability to ﬁnd the correct entry site and lack of awareness of structures in relation to the advancing needle. Headache is the most common complication and it is important to avoid traumatic and dry taps, herniation syndromes, and injury to the conus medullaris. With a thorough knowledge of the contraindications, regional anatomy and rationale of the technique, and adequate prior skills practice, a lumbar puncture can be carried out safely and successfully. Clin. Anat. 17:544 –553, 2004. © 2004 Wiley-Liss, Inc. Key words: clinical procedures; cerebrospinal ﬂuid; subarachnoid space; spinal anatomy
Many authors (Abrahams and Webb, 1975; McMinn et al., 1984; Beahrs et al., 1986; Crisp, 1989; Ger and Evans, 1993; American Association of Clinical Anatomists, 1999; Cottam, 1999; Boon et al., 2001) have highlighted the crucial role of sound anatomical understanding in the safe and successful performance of clinical procedures. Many medicolegal cases are based upon inadequate knowledge or misunderstanding of anatomy and the prolongation of any procedure due to lack of detailed knowledge leads to increased morbidity and mortality (Beahrs et al., 1986; Graney, 1996). Even for so-called minor procedures such as lumbar puncture, complications may result if carried out without a proper understanding of the anatomical implications (Ger, 1996). In the United Kingdom, the landmark paper ‘Tomorrow’s Doctors’ (General Medical Council, 1993) focuses on the acquisition of practical skills. Similarly, the Association of American Medical Colleges (1998) states that, before graduation, a student should dem©
onstrate the ability to perform routine technical procedures including the following minimum: venepuncture, inserting an intravenous catheter, arterial puncture, thoracocentesis, lumbar puncture, inserting a nasogastric tube, inserting a Foley’s catheter, and suturing lacerations. The General Medical Council (2002) also stated that one of the duties of a registered doctor is to keep his/her professional knowledge and skills up to date. Kneebone (1999) pointed out that conﬁdence in performing a procedure comes from a knowledge base that knows what to expect. Similarly, Wigton (1992) mentioned that the most important elements of procedural competency are the cognitive
*Correspondence to: Dr. J.M. Boon, Department of Anatomy, Section of Clinical Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa. E-mail: firstname.lastname@example.org Received 2 December 2002; Revised 19 September 2003 Published online in Wiley InterScience (www.interscience.wiley. com). DOI 10.1002/ca.10250
2004 Wiley-Liss, Inc.
Never aspirate with a syringe for a small amount of negative pressure can cause subdural hemorrhage or herniation. remove the stylet at each 2 mm interval of needle advancement to check for ﬂow of CSF.5 ml/ . the patient is positioned with the neck and back fully ﬂexed. Deeper structures are less pain sensitive and increased volume may distort the tissues and make the procedure more difﬁcult.” The neck is best maintained in the neutral position. Re-palpate the back to make sure the needle is in the midline and try again. Step 2: Determine Site of Insertion A line joining the most superior part of both iliac crests (Tufﬁer’s line) will intersect the midline at the L4 spinous process or L4/L5 interspace (Ievins.” which results in less hypoxemia than the “lateral recumbent knees-to-chest position. In the lateral recumbent position. Cook. For diagnostic collection of cerebrospinal ﬂuid (CSF). if required. 1997). The bevel should be in the sagittal plane. Step 4: Insert Needle For spinal anesthesia. Pass the needle through the ligamentum ﬂavum. A second ‘pop’ represents penetration of the needle through the dura mater into the subarachnoid space. The L4/5 or L5/S1 interspace should be used in children as the spinal cord ends at L3. Both these spaces are below the termination of the spinal cord at L1/L2 in the majority of adults (Ellis and Feldman. the L3/L4 or L4/L5 interspace (Abrahams and Webb. withdraw the needle partially to the subcutaneous tissue. 1994. a larger gauge needle (18. Weisman et al. 1997). pressure measurement. i. 3. 1991. For diagnostic lumbar puncture. parallel to the ﬂoor. Failure to enter the lumbar subarachnoid space may be overcome by doing the puncture with the patient in the sitting position and then moving the patient to the recumbent position for ﬂuid collection and. Insert the needle at the superior aspect of the spinous process that lies inferior to the space to be entered. 20. (1983) suggested the sitting or “lateral recumbent without knees-to-chest position. It starts with a step-by-step description of the procedure and focuses on the anatomical pitfalls and complications. if any pressure measurements are done (Van Dellen and Bill. This ensures that the needle stays in the midline. Flexion facilitates the course of the needle by widening the gap between adjacent lumbar spinous processes. The coronal plane of the trunk should be at right angles to the ﬂoor with one hip exactly above the other. When the L3/4 or L5/S1 interspace is used the needle should also be directed toward the umbilicus. If bone is encountered. the patient must be in the lateral recumbent position. Adams et al. Cerebrospinal ﬂuid drips directly into the specimen tube. Step 3: Inﬁltrate PROCEDURE Step 1: Position Inﬁltrate local anesthetic only subcutaneously. the patient may be in the sitting or the lateral recumbent position depending on the level of anesthesia required. Ill patients are generally unable to sit up and the sitting position increases the risk of headaches post-puncture. The needle is passed horizontally. 1978. The amount of CSF collected for diagnostic purposes should be restricted to the smallest volume necessary. 2000). the patient should be positioned with the back ﬂexed as far as possible. the left lateral recumbent position (for right-handed physicians) is preferred. it is worth rotating the needle through 90° as the needle opening may be obstructed by a nerve root (Van Dellen and Bill.5-cm long needle for neonates. Ask the patient to try to touch the ﬂexed knees with his/her chin (Ellis and Feldman. and 21 standard gauge needles. 20 gauge 5-cm long needle for children) should be used.’ After entering the ligamentum ﬂavum. 1975). There may be a sudden yielding sensation or ‘give’ as it is penetrated. Furthermore. This article reviews the clinical anatomy of lumbar puncture. In the sitting position. often referred to by clinicians as a ‘pop..Lumbar Puncture 545 aspects. The needle is inserted at A pencil-point needle (22–25 gauge) is indicated for spinal anesthesia. 1978). In preterm infants. Anatomy plays a major role in this domain. For children this is typically 0.. Pass the needle through the supraspinous ligament that connects the tips of spinous processes and the interspinous ligaments between adjacent borders of spinous processes.. This is to overcome the lumbar lordosis that narrows the interspace between adjacent spinous processes and laminae.e. Clear ﬂuid will appear if the subarachnoid space is penetrated. If not. It is hoped that it will be useful to medical students and to qualiﬁed clinicians. 1999). 1997). 1997). probably because the CSF pressure and ﬂow is higher than in the lateral recumbent position (Norris et al. This diminishes injury to the dura mater by separating its longitudinal ﬁbers rather than cutting through them. 22 gauge. and reduces leakage of CSF. Aim for the umbilicus (15° cephalad) if the L4/5 interspace is used (American Association of Clinical Anatomists. Ellis and Feldman.
and in children between 30 – 60 mm water. 1944). Similarly. may be the presence of lumbosacral transition vertebrae in 8 –15% of subjects. from the middle third of T12 to the upper third of L3. Saifuddin et al. a higher level than usually stated. (1998) studied the position of the conus medullaris in 504 adult patients without spinal deformity. ligamentum ﬂavum. and immunoglobulins. 1991). They found the mean level of the conus medullaris to be the lower third of L1 with no signiﬁcant differences between the sexes or with increasing age. 1997). (2000) reported an incidence of 19% of spinal cord terminations below L1 in a series of 100 patients undergoing spinal MRI scans. Only 6 of 504 cords terminated lower than the L2/L3 disc. Saifuddin et al. MacDonald et al. protein. End of Spinal Cord Adults. for in a study on injury to the conus medullaris after spinal anesthesia. and lumbar puncture needle (11). Only 25% of cords ended below the L1/L2 disc. and ﬁnally the subarachnoid space (Figs. interspinous ligament (5) between the spinous processes (4). 1975).. culture. biochemistry. for in their study a signiﬁcant proportion of the cords terminated higher than L2. (1998) suggested lumbar puncture be carried out at the L2/L3 level (higher than conventional practice) in cases of spinal stenosis (most severe at L3-4 and L4-5) or where posterior spinal fusion had been carried out. epidural space containing the internal vertebral venous plexus. intervertebral disc (10). The position ranged Fig. including bacteriologic and virological cultures. interspinous ligament. Reynolds (2001) strongly advised not to insert a spinal needle above L3. In a recent magnetic resonance imaging (MRI) study of 136 adults. subcutaneous tissue. differential cell counts and cytology. Normal pressure in the adult ranges from 100 –180 mm water (8 –14 mm Hg). Reimann and Anson’s (1944) study of 129 cadavers became the standard reference for the vertebral level of the termination of the spinal cord with the mean level lying opposite the L1/L2 disc. This ranged from the middle one-third of T11 to the middle one-third of L3. subcutaneous tissue (2). supraspinous ligament. In another MRI study. 1.2). Sagittal section of lumbar vertebrae illustrating the course of the lumbar puncture needle through skin (1). 1. The vertebral level at which the spinal cord terminates varies widely from T12 to the L3/L4 intervertebral disc (Reimann and Anson. ANATOMICAL PITFALLS Course of the Lumbar Puncture Needle The lumbar puncture needle pierces in order: skin. compared to the 49% of cords below this level reported by Reimann and Anson (1944) in cadavers. supraspinous ligament (3). The spinal cord extends to the L1/L2 disc in 51% of people and to the L2/L3 disc or below in 12% (Ievins. Different specimen tubes are available for different tests. One source of error in determining the end of the spinal cord. seven patients (ﬁve . and microscopy. and sensitivity. Pressure 200 mm water with a relaxed patient and straightened legs reﬂects an increased intracranial pressure (Adams et al.546 Boon et al. With the patient in the lateral recumbent position CSF pressure may be measured with a manometer. dura. dura mater (8). Puncture is usually carried out at either the L3/L4 or L4/L5 interspace (Abrahams and Webb. The three standard investigations are glucose. Various analyses can be done on CSF. Lumbar vertebral bodies (9). arachnoid. glucose. Broadbent et al. into the subarachnoid space and between the nerve roots of the cauda equina (7). ligamentum ﬂavum (6). (1999) showed that the median level of termination of the spinal cord for both males and females was the middle one-third of L1 vertebra. tube and not more than 3 ml in total.
2). growth involves the mesoderm more than the neurectoderm with resultant relative displacement of the conus medullaris cranially and the vertebral column caudally (Vettivel. (1987) carried out translumbar myelograms on 146 spontaneously aborted fetuses and showed that between 25–33 weeks. the spinal needle is directed somewhat superiorly that. epidural space (6). Spinal nerve roots emerge from the spinal cord and cross the epidural space. whereas from 30 mm CRL onwards a disproportion in growth rate occurs. the lowest limit of the spinal cord lies at the level of S1 (Moore and Persaud. as Reynolds (2001) has illustrated convincingly. and small infarcts) was associated with neurological symptoms (foot drop. The injury (ﬂuid collection seen on MRI. At 6 months of fetal life. Up to 30 mm crown-rump-length (CRL). stretches through the whole vertebral canal with the nerve roots leaving the intervertebral foramina in a horizontal fashion. numbness. 1978). having cesarean section) had neurological damage when the needle was introduced at the L2/L3 interspace. sphincter disturbance. dura mater (7). 1991). Epidural Space The epidural space lies between the inner surface of the spinal canal and the outer surface of the dural sac. Needle placement should therefore be at L4/5 or L5/S1. Embryologically. Wall et al. subcutaneous tissue (2). intramedullary haemorrhage. Lumbar vertebral body (9) and lumbar puncture needle (10). (1990) demonstrated that a web of arachnoid membrane holds the nerve roots together at the level of the conus medullaris with the nerve roots forming a peripheral rim around the cord. 1993). but that signiﬁcant variation was noted before 25 weeks. Fitzgerald (1978) and Moore and Persaud (1993) stated that the spinal cord.Lumbar Puncture 547 Fig. the cord terminates at the level of L3 or above. which is artiﬁcially enlarged when the dura is separated from the vertebral canal by solutions such as local anesthetics. may be the reason for injuring the conus medullaris in 4 –20% of people when using the L2/L3 interspace. Newell (1999) stated that the epidural space is a ‘true . Five of seven cases went to litigation. Parkin and Harrison (1985) stated in a cadaver-based study that the epidural space is a region containing fat. weakness) involving more than one nerve root. The spinal cord ends at L3. areolar tissue and the internal vertebral venous plexus (Fig. into the subarachnoid space and between the nerve roots of the cauda equina (8). The differences between adults and children are due to differential longitudinal growth of the spinal canal and the cord. Infants. Growth of the vertebral column causes the lower part of the spinal cord to ascend relative to the vertebrae as the upper end is attached to the brain. Horizontal section of lumbar vertebra illustrating the course of the lumbar puncture needle through skin (1). Hawass et al. the spinal cord and vertebral column grow at the same rate. early in fetal life. 2. At birth the conus medullaris is mostly found at the level of L3 (Fitzgerald. between the spinous processes (3) and laminae (4). During insertion. to their respective intervertebral foraminae. ligamentum ﬂavum (5).
With the veins of bones of the vertebral column. In older patients the ligament may provide signiﬁcant resistance because it is often calciﬁed. The ventral spinal roots contain axons of neurons in the ventral and lateral spinal grey columns and emerge from the cord as bundles of rootlets. Fibers are stretched in the ﬂexed position and can be more easily penetrated at lumbar puncture. gathered around the ﬁlum terminale. the extent of the ligamentum ﬂavum exposed is much greater than in the extended spine (Ellis and Feldman. especially in the lower lumbar spine. and therefore passes through either the left or right ligamentum ﬂavum to a site in the lateral epidural space. a ventral and dorsal ramus are found. The epidural contents are contained in a series of circumferentially discontinuous compartments separated by zones where the dura contacts the wall of the vertebral canal (Hogan. spinous processes. perhaps a mesothelial layer. 1998) show that the needle is usually not perfectly in the midline. The external vertebral plexus. azygos and lumbar veins. before piercing the dura. The external vertebral venous plexus (Williams et al. This distance depends on where exactly the epidural space is traversed. (1999) found in their MRI study that the median level of termination of the dural sac was the middle one-third of S2 (the . 1985. 1998) showed by means of cryomicrotome studies that the epidural fat increases proportionately at descending lumbar spine levels... Meninges The lumbar cistern represents the expansive portion of the subarachnoid space inferior to the spinal Dura mater.5 cm from the skin (Hogan. Brockstein et al. 1985). At higher spinal levels the epidural space is empty in large areas where the dura contacts the spinal canal wall (Hogan. in contrast. The dorsal and ventral rami of S1–S4 spinal nerves pass through the posterior and anterior sacral foramina. This resistance is felt at a depth of 4 –7 cm. 1975. There is a deﬁnite fat-ﬁlled space. Practical experience and observations by CT (Hogan. Hogan (1991. 1998). lies peripheral to the vertebrae. 1998).. 1994) and may be involved in a bloody or traumatic tap (Mehl. The plexus consists of four interconnecting longitudinal vessels. If the needle is exactly in the midline. It seems that this distribution is variable for the posterior internal vertebral veins may be rudimentary (Parkin and Harrison. Away from the midline the distance may be very small as the epidural space diminishes to the lateral side (Hogan. similar to pleura or peritoneum.’ lined by a ‘uniform delicate translucent lining layer’ investing the epidural fat. It can be up to 1-cm thick in the lumbar region and spans the interlaminar space between adjacent vertebrae. respectively. 1998) but is not adherent to the canal wall. The lumbar and sacral ventral rami form the lumbar and sacral plexuses. caudal spinal roots run varying distances to enter their corresponding intervertebral foramina. 1998). where the spinal needle can be safely introduced (American Association of Clinical Anatomists. whereas each dorsal spinal root has a spinal ganglion just proximal to its junction with a ventral root in the intervertebral foramen and attaches to the cord as a series of rootlets along the posterolateral sulcus. 1998). MacDonald et al.5 cm). In large areas the dura contacts the bone and ligaments of the spinal canal wall (Hogan. Beyond the intervertebral foramen.548 Boon et al. 1998). MRI studies indicate the space is ﬁlled with fat. The distance a needle advances after entering the epidural space through the ligamentum ﬂavum before penetrating the dura. The sacral spinal ganglia are found inside the vertebral canal (Williams et al. The lumbar dorsal rami pass back dividing into medial and lateral branches and supply the erector spinae muscles and overlying skin. 1975). The cauda equina lies within the cistern and is composed of the dorsal (mostly afferent axons) and ventral roots (efferent axons) of spinal nerves L2 to Co1. Local anesthetic in the epidural space must spread through volume displacement. In a ﬂexed spine. These veins communicate with the segmental veins of the neck. Parkin and Harrison. 1997). the internal and external vertebral plexuses form Batson’s plexus (Domisse. which is on average 4. transverse processes and articular processes respectively. potential space. 1989) includes the anterior and posterior external vertebral plexuses situated anterior to the vertebral bodies and in relation to the laminae. Ligamentum Flavum The internal vertebral venous plexus is located in the epidural space (Domisse. two anterior and two posterior. 1999). 1986). which can be opened easily without tissue damage. the intercostal. it may pass through the gap between the right and left ligamenta ﬂava (Hogan. Lumbar Cistern The ligamentum ﬂavum is a strong yellow elastic ligament.5–5. Vertebral Venous Plexuses cord. Because the cord is shorter than the vertebral column. 1989). The dura mater lines the spinal canal to the level of S2. These roots cross the subarachnoid space and pierce the dura separately to unite in or close to the intervertebral foramen to form a ‘mixed’ spinal nerve. is about 7 mm (range 2 mm to 2.
an inferior or superior . The subarachnoid space thus continues down to S2 level. reaches a maximum diameter in the late teens. 1986). 1999). The internal vertebral venous plexus in the epidural space may be involved in a bloody tap. direction of the needle. Associated risk factors for headache are: female. Arachnoid mater. The presence of a clot in one of the tubes strongly favours a traumatic tap.. 1992). Entry to the internal vertebral venous plexus. and adults 120 –150 ml. Fluid generally clears after the ﬁrst and second tubes in a traumatic tap.. 1972). vertigo. 1958). even if the needle is not exactly in the midline. Pia mater. The arachnoid mater lines the dural sac to the level of the middle one-third of S2 (MacDonald et al. usually too superior. poses a slight risk of neurological symptoms. Spinal Canal Porter et al. The pencil-point needle separates. 1990). Infants have a total of 40 – 60 ml of CSF. large needle size. Traumatic Tap COMPLICATIONS Headache Headache is the most common complication of dural puncture (Olsen. If the needle is directed too laterally. Leakage leads to low CSF pressure. as clots may compress the spinal nerve roots or nerves (American Association of Clinical Anatomists. a larger gauge needle (18. This is often due to inappropriate. giving a signiﬁcantly lower incidence of post-spinal headaches (Lynch et al. often on to bony structures. Reduction of the brain’s supportive cushion and may also explain the headache. bevel of needle cutting longitudinal dural ﬁbers (Brocker. tinnitus. vomiting. the level of the posterior superior iliac spines or “Dimples of Venus.Lumbar Puncture 549 upper one-third in males and the middle one-third in females). The spinal canal thus seems of adequate dimension in both adults and children to allow a lumbar puncture. young age. bevelled needle type compared to pencil-point needle of same size. 20. and reduces slightly in later adulthood. For diagnostic use. through the dural ﬁbers. (1980) showed in a diagnostic ultrasound-based study involving more than 700 people (from infancy to 65 years of age) that the lumbar spinal canal (vertebral canal) is fairly wide in children. diminished hearing. 1990). lower body mass index. it was found that at 4 years of age the midsagittal diameter of the spinal canal was even larger than in the adult. Sometimes it is accompanied by nausea.” seen especially distinctly in females. A child produces CSF at a rate of about 20 ml/hr (Dalens.. and blurred vision. 1999). On the level of L5. 1999) is usually due to incorrect positioning of the patient and consequent misdirection of the needle. The pencil-point needle (22–25 gauge) is indicated for anesthesia. Clotting does not occur in a subarachnoid hemorrhage due to deﬁbrinated blood being present in the CSF.. The headache is due to leakage of CSF through the dural puncture site into the epidural and paravertebral spaces faster than its production rate (Tourtellote et al. with obstruction by the lamina or spinous process of the superior or inferior vertebra. but not for diagnostic use. Dry Tap A dry tap (American Association of Clinical Anatomists. and 21 standard gauge needles with a short needle for children) should be used for collection of CSF (Van Dellen and Bill. occurring in up to 36. rather than cuts. Headache is commoner with a large needle because of a larger leakage of CSF through the rent made in the dura. children below 15 kg have approximately twice the volume of CSF per kilogram body weight (4 ml/kg) than adults (2 ml/kg). The range extended from the upper border of S1 to the upper border of S4.5% of spinal taps (Kuntz et al.3 ml/min. and multiple punctures. A traumatic tap should be distinguished from a subarachnoid hemorrhage. especially the basal dura (Raskin. In an adult the removal of 10 ml of CSF is replaced in 30 min at the normal rate of CSF production of 0. The smallest possible atraumatic needle with a stylet should be used for spinal anesthesia and multiple punctures should be avoided. 1987). as it does not allow free ﬂow of CSF with resultant difﬁculty in obtaining sufﬁcient CSF. The CSF collected for diagnostic purposes should be restricted to the smallest volume necessary. A traumatic tap (macroscopic blood in CSF) usually occurs due to the needle being placed too far laterally or advanced too far anteriorly (Mehl. young children about 60 –100 ml. 1991). absolute reduction of CSF volume below the cisterna magna with resultant downward movement of the brain and traction on pain-sensitive structures in the cranial cavity. Although less total CSF. The pia mater leaves the spinal cord at the conus medullaris to form the ﬁlum terminale that traverses the subarachnoid space and terminates on the periosteum of the coccyx. Usually it starts 48 hr after the procedure (Raskin. 1990) and may last 1–2 days or even 2 weeks. 1978). The incidence of headache after lumbar puncture is directly related to the size of the needle. after penetrating the dura and arachnoid at the level of S2.
Many conditions such as osteoarthritis. postural and respiratory changes. 2000). When the pressure in the spinal compartment is lowered by a lumbar puncture. quadriparesis. 1997). Disc herniation has been reported due to the needle passing beyond the subarachnoidal space (needle advanced too far) into the annulus ﬁbrosus. 2000). pain. 1997). Multiple attempts may lead to paraspinal muscle spasm. with the metacarpal heads against the patient’s back. although this may already have caused nerve damage (Reynolds. Broadbent et al. (2000) concluded that one should not assume identiﬁcation of the correct interspace when using Tufﬁer’s line. (2003). This high misplacement ﬁgure is diminished to 4% if Tufﬁer’s line is used to determine L4. consider Tufﬁer’s line unreliable in determining the lumbar interspaces. presenting as backache. Some authors. Samsoon and Grewal (2001) considered the spinal insertion technique important in avoiding nerve trauma. while the right hand pushes the needle in a controlled way. (1993). The needle was probably angled away from the midline toward the side of the pain. and degenerative disc disease with collapse of the intervertebral space may cause problems in needle access (Ellis and Feldman. Finding the landmarks may be difﬁcult in obese patients. The risk of nerve injury increases if uncontrolled pressure is applied and the dura overshot. a nerve root may have been hit. In a study (Broadbent et al. With atraumatic pencil point needles. The plunger of a syringe should not be withdrawn if it is attached to the needle or when injecting anesthetic solution. 2000) to determine the success of identiﬁcation of lumbar interspaces by using Tufﬁer’s line. transtentorial and foramen magnum herniation may occur.. recommended insertion of the needle one space lower. The needle is gripped with a gloved left hand (if the operator is right-handed) between the thumb and the entire ﬁst. (2000). often select a space of insertion one or two segments higher than they estimated using Tufﬁer’s line (Reynolds. Advancement of the needle until a dural ‘pop’ is experienced should be discouraged and a periodic stop and check method for CSF whether a dural ‘pop’ has been felt or not seems to be safer. In this way the left hand. Anesthetists. 2001). 1991). The level indicated by Tufﬁer’s line may vary from L3/L4 –L5/S1. therefore. The negative pressure may pull a spinal nerve root against the needle tip and produce paresthesia. Herniation Syndromes If the patient complains of a shooting pain down a leg during the procedure. Broadbent et al. This may make lumbar puncture more difﬁcult. Possibly the best technique for avoiding uncontrolled plunging through the dura is that described by Bromage et al. ankylosing spondylitis. It protects the underlying nervous structures by signaling the precise moment to stop the spinal needle. kyphoscoliosis. no ‘pops’ may be experienced when passing through the different tissue layers. with resultant herniation of the nucleus pulposus (Van Dellen and Bill. however. 30% of needles are misplaced at L2/L3. previous spinal surgery. If this happens. consistent and amenable to easy localization of the epidural and subarachnoid space (Kopacz. Broadbent et al. 1996). Cousins and Bromage (1988) suggested a paramedian approach if needle access is difﬁcult in the presence of such conditions. guides and stabilizes the needle in the correct direction. as determined by a cadaveric study (Ievins. with the gaps between the lumbar spinous processes not widened (Ellis and Feldman. or injury (American Association of Clinical Anatomists. . Duffy (1969) reported on 30 patients with post-lumbar puncture herniation syndromes of whom half lost consciousness immediately after the lumbar puncture. Pain Referred to Lower Limb procedure started again. the needle should be withdrawn completely and the Large pressure gradients occur between the cranial and lumbar compartments in supratentorial mass lesions. 1978).550 Boon et al. Difﬁculty in Finding Landmarks If only one iliac crest is used to locate L4. This can be diagnosed by ﬁndings of pupillary and oculomotor ﬁxation. for example. In a study by Boon et al. 1999). measurements on antero-posterior lumbar spine radiographs indicated that the interlaminar area reduced in height and width with age. articular process may be struck and may also injure the spinal nerve in the intervertebral foramen. The back may not be fully ﬂexed. correct identiﬁcation was only seen in 29% of cases and the space identiﬁed was one space higher than expected in 51% of cases. In young patients the vertebral anatomy is well deﬁned. (2000) showed that the accurate identiﬁcation of the correct lumbar interspace was signiﬁcantly impaired by obesity. The left hand can halt the needle in a fraction of a millimetre at the very moment CSF is observed. Highly controlled pushing of the needle is now possible with a gloved right hand. although there is no better alternative (Reynolds. Pre-existing tentorial herniation is a contraindication to a lumbar puncture.
will cause downward movement of the transtentorial and cerebellar tonsillar structures (Gower et al. premature baby using the traditional lateral recumbent position with neck ﬂexion. the medial part of the temporal lobe. Principles of neurology. Transtentorial herniation displaces the brain stem inferiorly. The following phenomena may occur in herniation: 1. 1997. 1975. The authors hope this review of the technique and its pitfalls and complications will be helpful to young clinicians. Beware of too long a period of ﬂexion of the neck while positioning the child.. 1987). 2. Webb P. for this may produce dangerous airway obstruction. The stylet should not be REFERENCES Abrahams PH.Lumbar Puncture 551 Anatomy of Herniation The decrease of pressure in the spinal canal precipitated by removal of CSF. which produces brainstem ischemia. The earliest sign is a slightly dilated pupil unilaterally. Transient unilateral or bilateral sixth nerve palsy may be caused by stretching of the abducens nerve as it crosses the superior border of the petrous temporal bone. may result in signiﬁcant respiratory ventilation-perfusion imbalance leading to hypoxemia. Ropper AH. The clinical anatomy of several invasive procedures. cerebral peduncle and third cranial nerve. American Association of Clinical Anatomists. Weisman et al. Anyone is theoretically at risk of herniation during a lumbar puncture but the risk is greater with a pressure gradient between the intracerebral and intraspinal CSF (Gower et al. Educational Affairs Committee. 1999. Retroperitoneal Abscess One case of a retroperitoneal abscess has been reported. Tonsillar herniation. (1983) compared the grade of hypoxemia in three different positions. The sitting and lateral position without knees-to-chest position gave less hypoxemia than the lateral knees-to-chest position. Lumbar puncture is an essential procedure in the armamentarium of clinicians. Kinking of the cerebral aqueduct may interfere with CSF drainage. for diagnostic and therapeutic purposes. (1983) demonstrated that lumbar puncture on an ill. The oculomotor nerve and posterior cerebral artery may be caught between the swollen uncus and the free edge of the tentorium.. 1982). Hypoxia and Ventilation-Perfusion Mismatches in Children Gleason et al. 1987). Maurice V. 5. New York: McGraw-Hill.. Intraspinal Epidermoid Tumor removed until the needle tip has passed the skin and unstyletted lumbar puncture needles should be avoided. p 13–15. Lumbar puncture remains a common procedure in various specialties. Posterior midline displacement compresses the great cerebral vein. 6. This complication usually arises due to the failure to use a stylet (McDonald and Klump. Positioning is best accomplished by an assistant holding the child and maintaining the spine in a ﬂexed position by holding the child behind the shoulders and knees. CONCLUSION In the absence of contraindications and with a thorough knowledge of the anatomy and technique as well as adequate prior skills practice. arising from viable epithelial cells introduced into the spinal canal by the spinal needle. A careful neurological examination should always precede lumbar puncture. medially over the notch of the tentorium and compress the midbrain. The patient developed a psoas abscess due to leakage of infected CSF into the retroperitoneal space. 3. but the neck in the neutral position in order not to compromise the airway. Clin Anat 12:43–54. Compression of the posterior cerebral artery at the tentorial notch can produce occipital lobe infarction. a lumbar puncture can be carried out without complications. London: Pitman Medical. 4.. The anterior cerebral artery may be compressed against the falx and increase ischemia and edema. Clinical anatomy of practical procedures. 6th Ed. Uncal herniation. 1987). such as epidural and spinal anesthesia. and usually is carried out safely and successfully. p 13–14. Skin tissue can easily be detached by a hollow needle and implanted into the subarachnoid space. 1986) and constitutes a mass of desquamated keratinized cells. . produced by dural laceration in a patient with meningitis (Levine et al. stretching the medial perforating branches of the basilar artery. the cerebellar tonsils compress the medulla at the foramen magnum. Adams RD. A CT scan should ﬁrst be carried out if there is any indication or history suggesting raised intracranial pressure (Gower et al. expanding lesions in the middle cranial fossa shift the uncus. 7.
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