KNOWLEDGE REGARDING VARIOUS MEDICAL PROCEDURES

LUMBAR PUNCTURE
SYNOPSIS – lumbar puncture is a procedure that is often
performed in the emergency department to obtain
information about cerebrospinal fluid (CSF).
REFERENCE – Medscape

Wikipedia
Objectives
To understand principles of lumbar puncture
To understand applied aspect of lumbar puncture
Definition
Indication
Contraindication
Procedure
Methodology – LP also known as a spinal tab, is a medical
procedure in which a needle is inserted into the spinal
canal, most commonly to collect cerebro spinal fluid (CSF)
for diagnostic testing. The main reason for a lumbar
puncture is to help diagnose diseases of the central nervous
system, including the brain and spine.
Materials and methods – LP is commonly done in meningitis
and sub arachnoid hemorrhage it may also be used
therapeutically in some conditions.
Indications –
lumbar puncture should be performed for the following
indications
Suspicion of meningitis
Suspicion of sub arachnoid hemorrage
Suspicion of CNS diseases such as GB Syndrome and
carcinomatous meningitis
Therapeutic relief of pseudo tumour cerbri
Contraindications-
absolute contraindications
for LP are presence of infected skin over the needle entry
site and the presence of unequal pressures between the
supratentorial and infratentorial compartments. The later is
usually informed from the following characterstic findings
on CT of the brain
Midline shift
Loss of suprachiasmatic and basilar cisterns
Posterior fossa mass
Loss of superior cerebellar cistern
Loss of quadrigeminal plate cistern

Relative contraindications for LP

Increased intracranial pressure
Coagulopathy
Brain abscess
Indications for performing brain CT scanning before lumbar
puncture in patients with suspected meningitis include the
following
Patients who are older than 60 years
Patients who are immunocompromised
Patients with known CNS lesion
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
Cranial CT scanning should be obtained before lumbar
puncture in all patients with suspected SAH in order to
diagnose obvious intracranial bledding or any significant
intracranial mass effect that might be present in awake and
alert SAH patients with a normal neurological examination.
Complication prevention
The following measures should be taken to help minimize
complications of lumbar puncture
Explain the procedure ,benefits, risks, complications, and
alternative options to the patient’s representative ,and
obtain a signed informed consent
Before performing the lumbar puncture, ensure that
patients are hydrated so as to avoid a dry tap
Never allow a lumbar puncture or apre – lumbar puncture
CT scan to delay administration of intravenous (IV)
antibiotics; meningitis can usually be inferred from the cell
count, antigen detection or both
Avoid lumbar puncture in patients in whom the disease
process has progressed to the neurologic findings
associated with impending cerebral herniation (i.e
deteriorating level of consciousness and brainstem signs
that include pupillary changes ,posturing ,irregular
respirations, and very recent seizure)
The smaller the needle used for the LP ,the lower the risk
that the patient will experience the post LP headache. a
data suggest an inverse linear relation between needle
gauze and headache incidence, and some authors
recommend using a 22 gauge needle regardless of what size
needle is supplied with a kit.
A use of atraumatic needle has been shown to significantly
reduced the incidence post LP headache (3 %)
When compared to use of standard spinal needle (appr
30%). In addition it may lead cost saving. however obtaining
pressures can be more difficult needles
Prophylactic bed rest after LP has not been shown to be of
benefit and should not be recommended
Procedure –
equipments
Sterile dressing
Sterile gloves
Antiseptic solution with skin swabs
Lidocaine 1% without equinephirne
Syringe ,3ml
Needles ,20 and 25 gauge
Three way stopcock
Manometer
Four plastic test tubes, numbered 1-4,with caps
Syringe,10ml
Wearing non sterile gloves, locate the L3 –L4 interspace by
palpating the right and left posterior superior iliac crests
and moving the fingers medially toward the spine. Palpate
the interspace (L3- L4), the interspace above (L2-L3), and
the interspace below (L4-L5) to find the widest space. mark
the entry site with a thumbnail or amarker.to help open the
inter laminar spaces, ask the patient to practice pushing the
entry site area out toward the practitioner.
Open the spinal tray, change to sterile gloves, and prepare
the equipment. open the numbered plastic tubes, and place
them upright. assemble the stopcock on the manometer,
and draw the lidocaine into the 10ml syringe.
Use the skin swabs and antiseptic solution to clean the skin
in a circular fashion, starting at the L3- L4 interspace and
moving outward to include at least 1 interspace above and
1 below .just before applying the skin swabs, warm the
patient that the solution is very cold; application of an
unexpectedly cold solution can be unnerving for the
patient.
Place a sterile drape below the patient and a fenestrated
drape on the patient. most spinal trays contain fenestrated
drapes with an adhesive tape that keeps the drape in place.
Use 10ml syringe to administer a local anaesthetic .raise the
skin wheal using the 25-gauge needle, then switch to the
longer 20 gauge needle to anesthetize the deeper tissue.
Insert the needle all the way to the hub, aspirate to confirm
that the needle is not in a blood vessel, and then inject a
small amount as the needle is withdrawn a few
centimeters. continue this process above, below, and to the
sides very slightly (using the same puncture site)
This process anesthetizes the entire immediate area so that
if redirection of the spinal needle is necessary, the area will
still be anesthetized. For this reason ,a 10ml syringe may be
more beneficial than the usual 3ml syringe supplied with
the standard lumbar puncture kit. the 20 gauge needle can
also be used as a guide for the general direction of the
spinal needle .in other words, the best direction in which to
aim the spinal needle can be confirmed if the 20 gauge
needle encounters bone in one direction but not in another.
Next, stabilize the 20 or 22 gauge needle with the index
fingers, and advance it through the skin wheal using the
thumbs ,orient the bevel parallel to the longitudinal dural
fibers to increase the chances that the needle will separate
the fibers rather than cut them, in the lateral recumbent
position, the bevel should face up, and in the sitting position
,it should face to one side or the other.
Insert the needle at a slightly cephalad angle, directing it
toward the umbilicus. Advance the needle slowly but
smoothly. occasionally, a characterstic pop is felt when the
needle penetrates the dura. otherwise, the stylet should be
withdrawn after approximately 4-5 cm and observed for
fluid return .if no fluid is returned, replace the stylet,
advance or withdraw the needle a few millimetres, and
recheck for fluid return .continue this process until fluid is
successfully returned.
For measurement of the opening pressure, the patient must
be in the lateral recumbent position. After fluid is returned
from the needle, attach fluid is returned from the needle,
attach the manometer through the stopcock, and note the
height of the fluid column. the patients legs should be
straightened during the measurement of the open pressure,
or a falsely elevated pressure will be obtained.
Collect at least 10 drops of CSF in each of the 4 plastic tubes,
starting with tube 1. If possible ,the CSF that is in the
manometer should be used for tube 1. If the CSF flow is too
slow ,ask the patient to cough or bear down, or ask an
assistant to press intermittently on the patients abdomen to
increase the flow alternatively ,the needle can be rotated 90
degree so that the bevel faces cephalad.
Replace the stylet, and remove the needle .clean off the
skin preparation solution. apply a sterile dressing, and place
the patient in the supine position.
LP in children –
The usual goal of lumbar puncture (LP) in children is to
obtain cerebrospinal fluid (CSF) to test for markers of
infection. Measuring opening pressure is not necessary, and
therefore the procedure is straightforward. The condition of
children with hypoxemia, respiratory distress, hypotension,
and tachycardia may deteriorate when they are positioned
for LP, so resuscitation and empiric administration of IV
antibiotics is needed prior to LP. In children with
thrombocytopenia or factor deficiencies, replace platelets
or factor before attempting LP.

Anticipate the procedure and its difficulties. Assemble a

needle of the correct size, the appropriate specimen
containers and preprinted labels, and ensure a quiet
environment without interruptions. Explain the procedure
to the caregivers. In some institutions, written informed
consent for LP is required. Describe the process of
procedural sedation if it is needed and obtain consent.

Apply a topical anesthetic cream or spray prior to needle

insertion to reduce pain and improve the success rate of the
LP.1,2 For infants, sucking on a pacifier dipped in sucrose
solution is analgesic, calming and decreases crying. Prepare
the skin using sterile technique.
Have an experienced health care provider, the “holder,”
restrain the infant or child. Wrapping the child in sheets
may help limit leg movement. Flexing the hips is more
important than flexing the neck. In addition, flexing the
neck may lead to respiratory difficulty. Whether to choose
the lateral recumbent position or the sitting position
depends upon the preference of the physician. In one study
using US to measure the width of the spinous processes, the
sitting position was found to be better than the lateral
decubitus position.3 Although the sitting position may
improve flexion of the hips, this position may be more
difficult for the holder to maintain.

Most LPs are performed with a 22-gauge LP needle, usually

11/2 in. in length for infants, 21/2 in. for children 2 years to
8 years, and 31/2 in. for older children. In obese patients,
choosing an LP needle may be more difficult. One study
calculated that an LP needle length (in centimeters) of 1 +
[17 × (weight in kilograms/height in centimeters)] was most
accurate.4 LP depth was measured on abdominal CT scans
to derive this formula. Lumbar needles with a clear hub
show CSF flow sooner than those with metal or opaque
hubs.
Insert the LP needle between the L4 and L5 spinous
processes, in the intervertebral space, in the midline of the
back, and direct the needle toward the umbilicus. This
interspace is easily located because it lies in line between
the iliac crests. Introduce the needle with the bevel of the
needle up. Insert the needle until the characteristic “pop”
identifies introduction into the subarachnoid space. An
alternative method is to remove the stylet from the needle5
after the needle pierces the skin. Advance the needle,
without the ...
COMPLICATIONS OF LP
Post spinal puncture headache
Bloody tap
Dry tap
Infection
Haemorrhage
Dysesthesia
Post dural puncture cerebral herniation
Applied aspects- if the CSF has been collected under
conditions ,microbiological sterile studies can now be
performed .stains ,cultures, and immunoglobulin titers may
be obtained; the last are of special importance with
diseases in which peripheral manifestations fade while cns
symptoms persist(syphilis and lyme disease)
The classic approach is to send the 4 csf tubes for the
following studies
Tube 1 – cell count and differential
Tube 2 – glucose and protein levels
Tube 3 – gram stain, culture and sensitivity
Tube 4 – cell count and differential
Hydrocephalus is an abnormal accumulation of csf in the
ventricles of the brain.
Csf pressure as measured by lumbar puncture,10 -18cm h2o
with the patient lying on the side and 20- 30 cm h2o with
patient sitting up. And in newborns csf pressure ranges
from 8 to 10 cm h2o. increased csf pressure can indicate
chf,cerebral edema,subarachnoid haemorrhage,purulrnt
meningitis
Decreased csf pressure can indicate complete subarachnoid
blockage,dehydration.

Discussion –
cytological studies – a larger than usual number of white
blood cells suggests an infection or more rarely, leukemic
infiltration.
The presence of white blood cells in csf is called
pleocytosis.a small number of monocyted can be normal
the presence of granulocytes is always an abnormal finding.
Csf can be sent to microbiology lab for various types of
smears and cultures to diagnose infections
Microbiological culture is the gold standard foe detecting
bacterial meningitis.
Glucose assessment- a low csf glucose level usually
associated with bacterial infection. This finding is also seen
in tumour infiltration and may be one of the hallmarks of
meningeal carcinomatosis, even with negative cytologic
findings
Increased level of lactate can occur the presence of cancer
of the CNS ,multiple scelerosis
Testing of CSF obtained from a lumbar puncture can provide
evidence of chronic inflammation in the CNS .the
cerebrospinal fluid is tested for oligoclonal bands of igg on
electrophoresis ,which are inflammation markers found in
75% -85% of people with MS.
Conclusion- LP has more complications and very diagnostic
criteria in CNS disorders