PUNGSI LUMBAL:

PROSEDUR DAN ANALISIS

I WAYAN TUNJUNG, dr. Sp.S

BAGIAN NEUROLOGI
RSU KOTA MATARAM

PREFACE
CEREBROSPINAL FLUID
A colourless fluid.
Around and inside thebrain
andspinal cord in thesubarachnoid
space and theventricular system.
Produced in the choroid plexus.
Mechanical and immunological
protection to the brain.
Composed of about 99% water.

Lumbar Puncture
An invasive procedure for obtaining

CSF.
insertion of a needle into the
subarachnoid space of the lumbar
(lower back) region.
for Dx.
or Tx. purposes.
The lumbar region is most often used.

HISTORY
First reports of CSF is in Edwin-Smith

Surgical Papyrus written 3700 yrs ago.

Hippocrates reported CSF presence in
brain cavities, 4 centuries B.C.
Galen described ventricular cavities 2
centuries A.C.
In 1891 Heinrich Quincke, of Kiel,
Germany, introduced this procedure as
we know it today.
In 1901: Widal introduced CSF
cytological studies.

Lumbar Puncture

INDICATIONS:
Suspicion ofmeningitis
Suspicion ofsubarachnoid

hemorrhage
Suspicion of central nervous system
diseases such asGuillain-Barr
syndrome and carcinomatous
meningitis
Therapeutic relief ofpseudotumor
cerebri
Injection of drugs and anesthetics

Lumbar Puncture
LP for Dx
LP for Tx.
Indications:
Infections, e.g.

Infections, e.g.

meningitis.
Demyelinating
diseases, e.g., GBS.
High ICP, e.g.,
pseudotumor
cerebri.
Bleeding, e.g., SAH.
Introducing contrast
agent for Dx., e.g.
Myelography

meningitis.
High ICP, e.g.,
pseudotumor
cerebri.
Malignancies,
e.g., leukemia.
Anesthesia
Others, e.g., CSF
leakage.

Lumbar Puncture
Contraindications
Infection or wound at the site of LP
Bleeding tendency.
Intracranial or intraspinal mass
lesions.

CONTRA INDICATIONS:
Increased intracranial pressure (ICP) of and

unidentified origin
- Can cause cerebral herniation
- Exception: therapeutic use of lumbar puncture to
reduce ICP
Infections
- Skin infections at puncture site may cause sepsis
Abnormal respiratory pattern
- Hypertension with bradycardia and deteriorating
consciousness
- Vertebral deformities (scoliosis orkyphosis), in
hands of an inexperienced physician.
Bleeding diathesis
-Coagulopathy
-Decreasedplatelet count (<50 x 109/L)

PROSEDUR

Lumbar Puncture

Quinke needles

Sprotte needle Touhy needle

Lumbar Puncture

Indications for CT prior to LP

(in

suspicion of meningitis)
Patients who are older than 60 years
Patients who are immunocompromised

Patients with known central nervous system

(CNS) lesions
Patients who have had a seizure within 1 week of
presentation
Patients with an abnormal level of consciousness
Patients with focal findings on neurologic
examination
Patients with papilledema seen on physical
examination, with clinical suspicion of an
elevated ICP

Lumbar puncture
The patient is placed in a lateral position

with the knees bent in full flexion up to the

chest (fetal position) (sit and bend position
also possible)
Introduction of 1% lidocain into the
subcutaneous space
Insertion of a spinal needle into the
subarachnoid space at the L3-L4 or L4-L5
spaces.
Removal of the stylet of the needle in order
to collect the fluid

Lumbar Puncture
Procedure:
Sitting
Lying down
L2/L3 level downwards
Needle between 2
spinal processes
30* cephalad direction
Beveled tip direction
depends to the aim of
LP

Lumbar puncture

Alternative Techniques
Sitting Position
Radiological Guidance
Cisternal Tap
Cervical Tap
LP Technique in Neonates and

Infants

Lumbar Puncture

Lumbar Puncture

Medicine School of Shandong University

2005-5-17

INTERPRETASI

CSF analysis - Colour

Crystal clear- normal finding, viral meningitis
Turbid- indicates the presence of >200WBCs or

>400 RBCs, bacterial meningitis

Xantochromia- yellow, orange or pink
discoloration (in more than 90% subarachnoid
hemorrhages), physiologic in newborns
Yellow: RBCs breakdown, high bilirrubin levels,
high protein levels >150mg/dL , tubercular and
fungal meningitis (viscous)
Pink: RBCs breakdown
Orange: RBCs breakdown; high carotenoid
intake
Green: hyperbiliruminemia, purulent CSF,
(bacterial meningitis)
Brown: meningeal melanomatosis

CSF analysis Pressure

Measured with a column manometer (fetal

position is optimal)
Increased pressure: congestive heart
failure,cerebral edema,subarachnoid
hemorrhage, hypo-osmolality resulting
fromhemodialysis, purulent or tuberculous
meningitis,hydrocephalus, orpseudotumor
cerebri.
Decreased pressure: complete subarachnoid
blockage, leakage of spinal fluid,
severedehydration, hyperosmolality,
orcirculatory collapse

Opening Pressure
Normal opening pressure:
in adults is 90 - 180mmH2O,
in children 10 - 100mmH2O.

ELEVATED PRESSURE

Congestive heart failure

Meningitis
Superior vena cava syndrome
Cerebral edema
Mass lesion

Medicine School of Shandong University

2005-5-17

DECREASED PRESSURE

Spinal-subarachnoid block
Dehydration
Circulatory collapse
CSF leakage

CSF analysis- cell count

Normal cell count: < 5 WBCs/mm in adults

and < 20 WBCs/mm in newborns (70%

lymphocytes, 30% monocytes).
99% of patients with bacterial meningitis
have >100 WBCs/mm (less than that is only
common for viral meningitis)
Viral meningitis: predominance of
lymphocytes T
Bacterial meningitis: predominance of PMNs
Fungal and tubercular meningitis:
predominance of lymphocytes and high
content of proteins, decrased glucose
RBCs: abnormal finding(be careful with
traumatic taps, 3 samples are needed)

Total cell count & DC

The normal leukocyte cell count in

adults is 0~5 cells/ul.

Increased neutrophils:
Bacterial Meningitis
cerebral abscess
subdural empyema
CNS hemorrhage
CNS infarct

 Increase Lymphocytes:
Viral meningitis
Multiple sclerosis

Medicine School of Shandong University

2005-5-17

GLUCOSE
The normal Glucose is about 60%

compared to serum level.

Normal 50~80mg/dl
Elevated Glucose:
Diabetes mellitus
Decreased Glucose:
Bacterial Meningitis

Medicine School of Shandong University

2005-5-17

TOTAL PROTEIN
Over 80% of CSF protein content

is derived from the plasma.

An increased CSF protein serves
as a useful but nonspecific
indicator of disease.
Normal level 15 45 mg/dl.

Medicine School of Shandong University

2005-5-17

ELEVATED CSF PROTEIN

Reason
Increased permeability of the
blood-brain barrier.
Decreased resorption
Mechanical obstruction of CSF
flow

Medicine School of Shandong University

2005-5-17

ELEVATED CSF PROTEIN

Arachnoiditis
Meningitis
Hemorrhage
Endocrine/Metabolic disorders

Medicine School of Shandong University

2005-5-17

 Lumbal Pungsi
Perbedaan Interpretasi Cairan Serebrospinal
Tes

Meningitis Bakterial

Meningitis Virus

Meningitis TBC

1.

Tekanan

1.

Meningkat

1.

Biasanya normal

1.

Bervariasi

2.

Warna

2.

Keruh

2.

Jernih

2.

Xanthochrom

3.

sel

3.

> 1000/ml

3.

< 100/ml

3.

Bervariasi

4.

Jenis sel

4.

Predominan PMN

4.

Predominan MN

4.

Predominan MN

5.

Protein

5.

Sedikit meningkat

5.

Normal/meningkat

5.

Meningkat

6.

Glukosa

6.

Normal/menurun

6.

Biasanya normal

6.

Rendah

(Saharso, 2006

CSF analysis other tests

Present compouds :

-cl: tuberculous meningitis

- lactate: cancer, MS, etc.
-LD: bacterial meningitis
-Glucose (60% of serum glucose): inflammations, lymphomas
-proteins (18-58mg/dL normal range): infections, MS, Guillain Barr
sy, malignancies, some medications, etc.
-IgG: multiple sclerosis, transverse myelitis, and neuromyelitis
optica of Devic.
-Glutamine: hepatic encephalopathies,Reye's syndrome, hepatic
coma,cirrhosisand hypercapnia.
India Ink test (cryptococcus neoformans)
PCR
Microbioloy: Gram stain, Acid fast

Complications

1.
2.
3.
4.
5.
6.
7.

Headache (Post LP Headache)

Painful Paresthesias
Persistent Pain or Paresthesias
Spinal Hematoma
Spinal Infection
Herniation
CSF leak

8. CSF Leak

Bloody Tap

TERIMA KASIH