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Clinical Skills Learning Centre


Diagnostic Lumbar Puncture: Page 1

Diagnostic Lumbar Puncture
Aims o To measure CSF pressure in the subarachnoid space. o To obtain cerebrospinal fluid (CSF) for laboratory examination. Indications The utility of lumbar puncture (LP) has been superceded by CT and MRI in the diagnosis of most intracranial mass lesions but diagnostic LP is still useful in the following conditions: o o o o o o o CNS infection (bacterial, viral, fungal, protozoan). Subarachnoid hemorrhage. Encephalitis. Guillain-Barre syndrome. Multiple sclerosis. Systemic lupus erythematosus. Meningeal carcinomatosis.

Contraindications o Skin infection at puncture site. o Bleeding diathesis, including severe thrombocytopenia. o Raised intracranial pressure. The procedure • Confirm identity of patient to have the procedure. • Review his medical history, physical findings, and indication for LP. • Make sure there are no factors contraindicating LP. • Explain the procedure to patient, including potential discomfort and complications. • Obtain an informed consent signed by the patient. • Have an assistant available. • Position patient close to the edge of the bed in the lateral decubitus position with hips, knees, and spine maximally flexed (the so-called fetal position). The sitting position is also appropriate, but only for obtaining CSF specimens and not for measuring CSF pressure.

• Open the sterile inner wrapping of the LP tray and ask the assistant to fill the antiseptic containers with Betadine and 75% alcohol. A line joining the highest point of the iliac crests crosses this interspace or the L4 spinous process. but should be reserved for experienced specialists only. • Don a surgical mask. Spinal tap has been performed safely at higher interspaces. although safe in most instances. Identify this site by palpating for the iliac crest of the patient. L4-5 and L5-S1 spaces are safe alternative puncture sites. Using the L2-3 space for lumbar puncture. and put on a pair of sterile gloves. wash your hands. has the lowest tolerance for error. . • Ask assistant to open the outer wrapping of the LP tray without touching the inner wrapping.Clinical Skills Learning Centre 2009-10 Diagnostic Lumbar Puncture: Page 2 • L3-4 is a common puncture site. The spinal cord may end as low as L2 in some adult patients. double-checking the contents of the containers as it is being done.

Clinical Skills Learning Centre 2009-10 Diagnostic Lumbar Puncture: Page 3 • Also ask the assistant to add to the tray the following equipment in a sterile manner: a 2 or 3 ml syringe. (Test tubes used at the Prince of Wales Hospital in the LP tray are labeled sequentially. obtain a sample of venous blood to check plasma glucose for comparison. • Wash off excess Betadine with alcohol. CSF glucose concentration is normally approximately 65% of plasma glucose concentration. adjust the 2-way stopcock to allow CSF to fill the manometer tube. and read the pressure as mm of CSF as the fluid level stabilizes. If they are not labeled. • Adjust the 2-way stopcock again. Turn the patient supine with the help of the assistant. Bending it will not only not change its direction but also cause it to snap in mid-shaft. • Reconfirm intended puncture site. • Attach the 2-way stopcock and the manometer to the hub of the needle. a 23G or finer hypodermic needle. withdraw the needle all the way to subcutaneous tissue before re-inserting it. put them aside in the correct sequence and labeled them afterwards. • Check the equipment and fill the 2 or 3 ml syringe with 1% lignocaine dispensed by the assistant into the drug dish. (Of the 3 channels in a 2-way stopcock. extending from side to side on the patient’s back and from the low thoracic to the sacral level. feeling for the resistance as its tip traverses the supraspinous and interspinous ligaments. . the slightly increased in resistance as its tip penetrates the ligamentum flavum. • Withdraw the needle and apply a dressing to the puncture site. and infiltrate more deeply. The needle is fragile. remove the detachable manometer tube and sample 1 to 2 ml of CSF sequentially into each of 3 plain sterile test tubes. • Square-drape the puncture site with sterile towels. no more than 10 ml of CSF should be lost by the patient in a diagnostic LP. sample 1 to 2 ml of CSF into a fresh and sterile 2 or 3 ml syringe for transfer to a non-sterile fluoride test tube later. May have to readjust the angle of entry if the needle hits bone. If that is the case. After the procedure. CSF should appear drop by drop without hindrance if the tip of the spinal needle is in the dural sac away from the cauda equina. All in all. • Remove the stilette and wait for the appearance of CSF. usually by pointing the needle more cephalad. and the loss of resistance as its tip enters the subarachnoid space. a CSF manometer. Do not attempt changing direction by simply bending the needle. use the 23 gauge needle and the syringeful of lignocaine to raise a skin weal at the center of the interspace. • Sit down comfortably with the puncture site at arm level.) • If measurement of CSF glucose concentration is required. Alternatively pass the tubes to the assistant for labeling as they are filled and maintain sterility until the procedure is completed. Return the stilette into the shaft of the needle if you have to advance it more deeply.) Normal range of CSF pressure ranges between 80 and 180 mm. • Insert the 22G spinal needle with stilette in place at the center of the space with shaft of the needle pointing slightly cephalad. and 3 sterile test tubes. the tap handle points in the direction of the channel being shut “off”. • Use the sponge forceps and the cotton balls to apply Betadine around the puncture site widely.

Potential complications • Tonsillar herniation (herniation of cerebellar tonsil through the foramen magnum. the bevel separates the longitudinal dural fibers and the hole it makes seals itself once the needle is removed. disposable needles and blades) into the puncture-proof container.. In the first instance (upper panel). It is good practice to put all contaminated and sharp consumables into the kidney dish for disposal at the end of the procedure. A brain shift that can occur in patients with raised intracranial pressure (ICP) and is the result of an increased in pressure gradient between the .g. patient can resume activities as tolerated. Also leave orders to observe patient’s neurological status and vital signs until stable. the bevel cuts the longitudinal dural fibers. More about insertion of the spinal needle As needle is being inserted.Clinical Skills Learning Centre 2009-10 Diagnostic Lumbar Puncture: Page 4 • Dispose of contaminated consumables (e. Breached dural fibers take time to heal. • Leave instructions for the patient to lie flat for about 2 hours and maintain oral fluid intake if not contraindicated. Once condition is stable. • Document in writing what you have done and any difficulties you may have encountered. leaving an opening for CSF leak. manometer. also called “coning”). sponges. In the second instance (lower panel).g.. CSF leak is a major cause of post-dural puncture headache. and syringe without the needle) into the red garbage bag and sharp consumables (e. point its bevel facing the patient’s side rather than facing the patient’s head or feet.

Immediate relief is reported by 95% of the patients. It is. The oral dose is 300 mg but its effect may be transient. . It was customary to “push” fluid intake after lumbar puncture in the belief that hydration can replenish lost CSF. The discomfort is related to the patient’s posture: precipitated by assuming the erect position (sitting or standing) and relieved by returning to the supine position. • Infection. Patients suspected to have increased ICP require urgent CT/MRI and not urgent LP. Its tip is shaped like that of a pencil with a side hole. It was the belief that the hydrostatic pressure of the CSF fluid column at the dural puncture site in an erect patient can delay the healing of the dural hole. Prolonged bed rest should be avoided. and avoidance of probing for the subarachnoid space blindly. Use an opiate if the headache is severe. This invasive procedure is usually performed by anesthesiologists and should be reserved for patients with a debilitating headache refractory to conservative treatment. Typical complaint is neck stiffness or pain radiating to the frontal region. Prescribe an NSAID for mild headaches. (Pencil point spinal needle are commonly used by anesthesiologists for spinal anesthesia. o Bed rest. • Spinal cord or cauda equina injuries. Most treatment modalities are of an empirical nature. he should be encouraged to assume activities as tolerated. The etiology is believed to be intracranial hypotension from CSF leak. Can be minimized by careful identification of landmarks. however. o Autologous epidural blood patch. o Analgesics. o Oral fluid intake. o Caffeine. In this procedure up to 20 ml of fresh venous blood obtained from the patient is deposited into the patient’s epidural space at or near the LP puncture site “to seal” the dural hole. Avoidable by practising aseptic technique meticulously. • Post-dural puncture headache. This treatment modality is not evidence based. it will not disrupt the integrity of the longitudinal dural fibers. but any other beneficial effect is only anecdotal in nature. Resting supine alleviates the intensity of the postural headache. Occurs in up to 30% of patients. Since it does not have a bevel with cutting edges. Caffeine is a cerebral vasoconstrictor and relieves post-dural puncture headache in some patients. Once the patient’s condition is proved stable after the procedure.) Treatment of post-dural puncture headache The headache is self-limiting once the dural hole is sealed but time is required for the healing process to take effect.Clinical Skills Learning Centre 2009-10 Diagnostic Lumbar Puncture: Page 5 intracranial and spinal compartments following LP. exercising care in needle insertion. Jitteriness and insomnia are some of its unwanted side effects. Prevention is by limiting the size of the spinal needle to 22G and pointing its bevel to face the patient’s side. It was an age-old practice to keep the patient in complete bed rest after lumbar puncture. Use of pencil point needles will also reduce the risk of post-dural puncture headache. not unreasonable to maintain normal hydration and definitely avoid dehydration.