LUMBAR

PUNCTURE
 INDICATIONS :
 Diagnostic  Therapeutic
: :
 Infectious  Analgesia
 Meningitis  Anesthesia
 Encephaliti  Antibiotics
s
 Antineoplasti
 Inflammato
cs
ry
 Multiple
Sclerosis
 Gullain-
Barre
syndrome

CONTRAINDICATIONS :
 Increased intracranial pressure
 Cerebral herniation
 Impending herniation
 Possible increased ICP and focal neuro signs
 Coagulopathy
 Prior lumbar surgery
 Severe vertebral osteoarthritis or degenerative disc
disease
 Significant cardiorespiratory compromise
 Infection near the puncture site
 Space occupying lesion
EQUIPMENT :
 Spinal needle
 Less than 1 yr: 1.5in
 1yr to middle childhood: 2.5in
 Older children and adults: 3.5in
 Three-way stopcock
 Manometer
 4 specimen tubes
 Local anesthesia
 Drapes
 Betadine
 PROCEDURE :
 Performed with the patient
in the lateral recumbent
position.
 A line connecting the
posterior superior iliac
crest will intersect the
midline at approx. the
L4 spinous process.
 Spinal needles entering the
subarachnoid space at this
point are well below the
termination of the spinal
cord.
 LP in older children may be
performed from L2 to L3
interspace to the L5 to S1
interspace.
 At birth, the cord ends at the
level of L3.
 LP in infant may be performed
at the L4 to L5 or L5 to S1
interspace.
 Position the
patient:
 Generally performed in the
lateral decubitus position.
 A pillow is placed under the
head to keep it in the same
plane as the spine.
 Shoulders and hips are
positioned. perpendicular
with the table.
 Lower back should be arched
toward practitioner.
a. Ligament flavum is a strong,
elastic, yellow membrane
covering the interlaminar
space between the vertebrae.
b. Interspinal ligaments join the
inferior and superior
borders of adjacent spinous
processes.
c. Supraspinal ligament
connects the spinous
processes
 A topical anesthetic (e.g. EMLA cream) can be applied 30 to 60
minutes before performing the puncture to minimize pain on
penetration.
 Either a sitting or lateral decubitus position can be used .
 Monitor the patient visually and with pulse oximetry for any
signs of respiratory difficulty as a result of assumed position.
 The subarachnoid space must be entered below the level of spinal
cord termination.
 The spine should be flexed maximally to increase spacing
between spinous processes.
 Extensive neck flexion, however, should be avoided to minimize
a chance of respiratory compromise.
 Make sure the hips and shoulders are aligned & are
perpendicular to the bed surface.
 The patient’s back should be carefully prepared and draped
using provided disinfecting solution and drapes.
 Orient yourself anatomically and find the L4 spinous
process at the level of iliac crests
 Palpate a suitable interspace distal to this level.
 Infiltrate 2% Lidocaine subcutaneously (without
epinephrine to prevent cord infarction should it be
introduced into the cord by accident) with a fine needle.
 A field block can be applied injecting into and on either
side of the interspinous ligaments.
 Identify the two spinal processes in between which the
needle will be introduced, penetrate the skin and slowly
advance the tip of the needle at about 10 degrees
cephalad (i.e. toward the patient’s umbilicus).
 Remove the stylet and check for clear fluid will flow
from the needle when the subarachnoid space has been
penetrated.
 The ligaments offer resistance to the needle, and a “pop” is
often felt as they are penetrated.
 Withdraw the needle leaving the tip in, recheck the
landmarks and slowly progress the needle again.
 Measure the opening pressure using the manometer
by attaching it via a stopcock to the spinal needle.
 Normal opening pressure ranges from 10 to 100 mm H2O in
young children and 60 to 200 mm H2O after eight years of
age
 CSF volume of 1cc obtained in 3 tubes.
 In the neonate, 2ml in total can be safely removed.
 In an older child 3 to 6 ml can be sampled
depending on the child’s size.
 Tube 1 is used for determining protein and glucose
 Tube 2 is used for microbiologic and cytologic
studies
 Tube 3 is for cell counts and serologic tests for
syphilis
COMPLICATIONS :

 Herniation
 Cardiorespiratory compromise
 Pain
 Headache (36.5%)
 Bleeding
 Infection
 Subarachnoid epidermal cyst
 CSF leakage
TERIMA KASIH
SGB
MS
MIELITIS
ONCOLOGI

 Doctors can also identify certain cancers, including 

leukemia, as the CSF analysis test may reveal increased
numbers of white blood cells. Doctors also use the CSF
analysis test to check for primary and metastatic
cancerous tumors in the CNS.
Alzheimer's disease

 The CSF analysis test can also diagnose 

Alzheimer's disease, by measuring levels of amyloid
beta 1-42 (Aß1-42) and p- and t- tau proteins.