Clinical Skills:

Lumbar Puncture
Considerations
Why is an LP Being Done?
Is this the Only Test Available?
What Positive Information is
Expected?
Is the Patient Stable?
Indications
Diagnostic
Infection
Subarachnoid Hemorrhage
Multiple Sclerosis
Therapeutic
Neoplasm
Benign intracranial hypertension (BIH)
Incidental
Myelography : is a type of radiographic
examination that uses a contrast medium to
detect pathology of the spinal cord
Contraindications
Suspected Increase in ICP
Exception: therapeutic use of lumbar puncture to reduce ICP
Suspected Spinal Cord Compression
Infection at the Site of an LP
Coagulopathy.

Abnormal respiratory pattern
Hypertension with bradycardia and deteriorating
consciousness
Vertebral deformities , in hands of an inexperienced
physician.
Normal CSF Values
Appears to be clear and colorless
Opening Pressure ~ 120 mm/H
2
0
Protein level ~ 35 mg%
Glucose level ~ 60 mg %
(60% of serum glucose)
Cells < 5 lymphocytic/monocytic
CSF Profiles

Pressure Cells Protein Glucose

Bacterial
Meningitis




(PMNs)

to



Viral
Meningitis

N to

to
(Monos)



N


TECHNIQUE
Preparation An LP can be performed
with the patient in the lateral recumbent
position or sitting upright.
The lateral recumbent position is preferred
because it allows accurate measurement of
the opening pressure
Equipment
Most CSF trays come with:
Anesthetic such as:
Topical - Zylocaine cream
Lidocaine 1% with 25 gauge needle and
syringe
Povidone-iodine solution & sponge
wand
Drapes, gauze, and bandages
Manometer, stopcock and tubing in
non-infant kits
Equipment
Spinal needle, usually 22
gauge
1.5 in for < 1 yr
2.5 in for 1 year to
middle childhood
3.5 in for older
children and
adolescents
Larger for large
adolescents
Atraumatic needles, less spinal
headaches
Lateral Decubitus Position
Apply topical anesthetic 30-45 min prior to procedure
Spinal cord ends at L1-L2, so sites for puncture are located
at L3-L4 or L4-L5
Restrain patient in lateral decubitus position
Maximally flex spine without compromising airway
Keep alignment of feet, knees and hips
Position head to left if right handed or vice versa
Preparation for the LP (one)
Preparation for the LP (two)
Aseptic technique
The overlying skin should be cleaned with
alcohol and a disinfectant such as povidone-
iodine or chlorhexidine (0.5 percent in
alcohol 70 percent);
the antiseptic should be allowed to dry
before the procedure is begun.
Procedure
Insert spinal needle with stylet with bevel
up to keep cutting edge parallel with nerve
and ligament fibers
Procedure
Aim towards umbilicus
directing needle slightly
cephalad
Hold needle firmly

Procedure
A pop of sudden
decrease in
resistance indicates
that ligamentum
flavum and dura are
punctured
Remove stylet and
check for flow of
spinal fluid

Procedure
If no fluid, then:
Rotate needle 90
Reinsert stylet and advance needle slowly checking frequently for
CSF
Jugular vein compression can increase CSF pressure in low flow
situations
If bony resistance is felt immediately then you are not in the spinal
interspace
If bony resistance is felt deeply, then withdraw needle to the skin
surface and redirect more cephalad and increase patient flexion
If bloody fluid that does not clear or that clots results, then withdraw
needle and reattempt at a different interspace


Manometry
When CSF flows, attach manometer to obtain opening
pressure if desired
Pressure can only be accurately measured in lateral
decubitus position and in the relaxed patient
Attach manometer with a 3-way stopcock when free flow
of CSF is obtained
Read column when highest level is achieved and
respiratory variation is noted
Complications
Headache
Uncommon in < 10 y/o
Apnea (central or obstructive)
Back pain
Occasionally with short-lived referred limp
Disc herniation if needle advanced too far
Bleeding or fluid leak around spinal cord
Infection, pain, hematoma
Subarachnoid epidermal cyst
Ocular muscle palsy (transient)
Nerve Trauma
Brainstem herniation
Procedure
Collect 1ml of CSF in each of 3 vials for:
Tube 1: culture & gram stain
Tube 2: glucose, protein
Tube 3: cell count & differential
and extra CSF if desired for other lab tests
Check closing pressure with manometer, if desired
Reinsert stylet and remove needle in one quick motion
Cleanse back and cover puncture site
Sitting Position
Restrain infant in the seated position
with maximal spinal flexion
Hold infants hands between flexed
legs with one hand and flex head
with the other hand
Drape patient below buttocks and
fenestrated drape opening over puncture
site
Insert needle so bevel is parallel to
spinal cord (Bevel left or right)
Cannot measure pressure accurately in
this position
Paramedian (Lateral) Approach
Use for patients who have
calcifications from
repeated LPs or anatomic
abnormalities
Needle passes through
erector spinae muscles,
and ligamentum flavum
Bypasses supraspinal
and interspinal
ligaments
Less incidence of spinal
headache
Spinal Headache
Most common complication
Risk factors: female, age 18-30, lower BMI, hx of
HA, prior spinal HA
Can last hours to weeks

Treatment:
Supine position for at least 2 hours
Hydration
Caffeine either PO or IV
Epidural blood patch


Spinal Headache Prevention
Can avoid by:
Passing needle bevel parallel to longitudinal
fibers of dura
Replacing stylet before removing needle
Using small diameter needles
Using atraumatic needles
Bed rest or PO intake after LP does not
reduce incidence of headache


Nerve Root Trauma/Irritation
Can feel electric shocks or dysesthesias
Back pain can persist for months
Consider disc herniation
Rarely permanent
Withdraw needle immediately
If pain or motor weakness persists, start corticosteroids
Electromyogram/nerve conduction velocity studies should
be scheduled if pain persists
Herniation
Manifests initially as altered mental status, followed by
cranial nerve abnormalities and Cushing triad
May be rapidly fatal.
Immediately remove needle and raise the head of bed to
30-45 improve venous return from the brain.
Mannitol or 3% Saline
Intubate patient and hyperventilate
Emergent neurosurgical consult
Thanks for attention