LUMBAR PUNCTURE

DEFINITION

Lumbar Puncture is the introduction of a hollow needle with a stylet into the lumbar
subarachnoid space of the spinal canal using strict aseptic technique. The main reason for a
lumbar puncture is to help diagnose diseases of the central nervous system, including the
brain and spine. Examples of these conditions include meningitis and subarachnoid
hemorrhage. It may also be used therapeutically in some conditions.

FIRST LP TECHNIQUE

The first technique for accessing the dural space was described by the London physician Dr
Walter Essex Wynter. In 1889, he developed a crude cut down with cannulation in 4 patients
with tuberculous meningitis. The main purpose was the treatment of raised intracranial
pressure rather than for diagnosis. The technique for needle lumbar puncture was then
introduced by the German physician Heinrich Quincke in 1891.

FUNCTIONS OF CSF

Protective
Maintaining normal ICP
Nutritive
Excretory

PURPOSES

Diagnostic purposes

To measure CSF pressure.

Radiological visualization of parts of nerves system.
Evaluation of spinal dynamics.
Laboratory study of CSF.
Cytology
Biochemistry
 Microbiology

Therapeutic purpose

To administer spinal anesthesia

Intrathecal administration of antibacterial or other drugs.
Removal of CSF.

SITES OF NEEDLE INSERTION

usually inserted into the subarachnoid space between the L3-L4 or L4-L5 vertebrae.

ALTERNATIVE SITES

Alternative methods of CSF collection are rarely used, but may be necessary if the person has
a back deformity or an infection.

Ventricular tap

Rarely used. May be recommended in people with possible brain herniation .This test is
usually done in the operating room. A hole is drilled in the skull, and a needle is inserted
directly into one of brain's ventricles

Cisternal puncture

It uses a needle placed below the occipital bone (back of the skull). . It can be dangerous
because it is so close to the brain stem. It is always done with fluoroscopy. CSF may also be
collected from a tube that's already placed in the fluid, such as a shunt or a ventricular drain.
These tubes are usually placed in the intensive care unit

CSF CHARACTERISTICS

SL CSF Normal values

No:

1 Appearance Clear, colorless

2 Volume 130-150ml

3 Total protein 15-45mg/dl

4 Glucose 50-75mg/dl

5 Initial pressure 70-180mm of water

 6 Cell count 0-5 mononuclear cells

7 RBC nil

ABNORMAL FINDINGS IN CSF

SL NO: CSF Abnormal Findings

1 Yellow(xanthochromia) SAH, Complete spinal block

2 Bright green Pseudomonal meningitis

3 Cloudy WBC Protien

4 Increased protein Diabetes, polyneuritis, tumor, injury, or any inflammatory or i

condition.

5 Decreased protein Rapid CSF production

6 Decreased glucose Hypoglycemia(low blood sugar), bacterial or fungal infection ( menin

7 Increased CSF gamma Multiple sclerosis, neurosyphilis, or Guillain-Barre syndrome.

globulins.

INDICATIONS FOR LUMBAR PUNCTURE

Suspected CNS infection

Suspected subarachnoid hemorrhage
Therapeutic reduction of cerebrospinal fluid (CSF) pressure
Evaluation of the canal for the presence of CSF blockage.
Queckenstedt's test
Queckenstedts test detects a block in the circulation of CSF in spinal subarachnoid
space, which may be caused by a tumor of spinal cord or meninges.
Meningeal carcinomatosis Presence of cancer cells in the cerebrospinal fluid.
 Gullian Barr'e Syndrome (in which a very high protein count is seen)
Multiple Sclerosis (elevated IgG is present on electrophoresis of the CSF).
Intrathecal antibiotics and Chemotherapeutics

Loculation syndrome of Froins :

The fluid below the block coagulates spontaneously due to increased protein content and
becomes yellow (xanthochromia) due to altered blood pigment.

CONTRAINDICATION

Absolute

Local skin infections over proposed puncture site

Midline shift

Loss of suprachiasmatic and basilar cisterns

Posterior fossa mass

Relative

Raised intracranial pressure (ICP); exception is pseudotumor cerebri

Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological
findings or papilledema)

Uncontrolled bleeding diathesis

Spinal column deformities (may require fluoroscopic assistance)

Lack of patient cooperation.

LP needles

Traumatic spinal needles.

The standard spinal needle is the Quincke needle. It has a beveled tip.Associated with csf
leakage.

Atraumatic spinal needles

Sprotte needle,Whitacre needle and Gertie Marx needle . They have blunt pencil-tip, and
fluid is drained via a side port..Reduce trauma to the dura.

Size of needle

Infant- 1.5 inch/ 3.8cm

Child-2.5 inch/ 6.3 cm

Adult-3.5 inches /8.9cm

ARTICLES REQUIRED

A sterile tray containing

LP needle with stylet.

Sponge holding forceps.
Small bowl
Specimen bottles.
Hole towel
Cotton balls, gauze pieces etc.
Dressing articles

A clean tray containing

Mackintosh and towel

Kidney tray/paper bag
Spirit, iodine.
Lignocaine 2%
Sterile normal saline
Adhesive plaster and scissors.
Sterile gloves, gown and mask.
3-way adapter, manometer and tubings.
Syringe and needle for local anesthesia.

PREPROCEDURE PREPARATION

Obtain informed consent. Inform patient of possibility of complications (bleeding, persistent

headache, infection) and their treatment. Explain the major steps of the procedure,
positioning.

PRE PROCEDURE

Prepare equipment on trolley

Ensure patient has an empty bladder and bowel.
If monitoring is required ensure parameters are set appropriately.
Position patient:
Lateral recumbent position with fetal ball curling up,
Seated and leaning over a table top
Both these positions will open up the interspinous spaces.
Positioning infant for LP
Assess indications for procedure and obtain informed consent as appropriate.
Provide necessary analgesia and/or sedation as required.

PROCEDURE

1. Locate landmarks: between spinous processes at L4-5, L3-4, or L2-3 levels.

2. On obese patients, find the sacral promontory; the end of this structure marks the L5-
S1 interspace. Use this reference to locate L4-5 for the entry point
 3. The needle towards the navel.
4. Prepare and drape the area after identifying landmarks.
5. Use lignocaine 2% with or without epinephrine under the insertion site.
6. Insert needle bevel-up through the skin and advance through the deeper tissues.
7. Angle of insertion is on a slightly cephalad angle, between the vertebra.
8. When CSF flows, attach the 3-way stopcock and manometer. Measure ICPthis
should be 20 cm or less.
9. If CSF does not flow, or you hit bone, withdraw needle partially, recheck landmarks,
and re-advance
10. Fill collection tubes 1-4 with 1-2 ml of CSF each.
11. After tap, remove needle, and place a bandage over the puncture site.
12. Instruct patient to remain lying down for 2 -3 hours before getting up.

Label each tube with:

Patients first and last name

CR No.
Date and time of collection.
Specimen source (CSF and i.e. lumbar, shunt, EVD)
Tube identification number (1, 2, 3, 4) indicating order of collection.

Specimen Handling and Transport

Take CSF specimens immediately to the laboratory after collection.Do not refrigerate.Do not
leave specimen on the reception counter; give directly to laboratory staff.

POST PROCEDURE CARE

Monitor vital signs hourly

Administer analgesia as required/prescribed
Check puncture site for leakage (especially if headache is severe)
Cover the puncture site with a band-aid or occlusive dressing (eg Tegaderm)
An autologous epidural blood patch can be used to seal the site of CSF leakage for
prevention of severe headaches
Maintain patient in supine position for 1-2hrs.
Bed-rest following LP is of no benefit in preventing headache in children.
Encourage fluid intake.
Be aware of post LP complications.
Maintain a quiet environment.
Ensure specimens are sent to appropriate laboratory for analysis

COMPLICATIONS

Postspinal puncture headache.

Infection Cellulitis, skin abscesses, epidural abscesses, spinal abscesses, or diskitis
can result from a contaminated spinal needle.
Coning -most serious but rare.
Hemorrhage Epidural, subdural, and subarachnoid hemorrhage are rare
complications.
 Dysesthesia
Dry tap
Bloody tap

SUMMARY

Definition
Anatomy
CSF characteristics
CSF analysis
Indications of LP
Contraindications
Articles required
Pre procedure care
Procedure
Post procedure care
Complications

CONCLUSION

LP is helpful in the diagnosis of various diseases of the central nervous system, especially
infections, such as meningitis.The whole procedure will take only 20 -25 minutes.It can be
done in an inpatient and out patient setting.

REFERENCES

Brunner & suddarths ,Text book of Medical Surgical Nursing,11th edition,LWW

publication,pg no 356-378.
Tintinallis ,Text book of Emergency Medicine,6th edition,HTML file
http://www.pubmedcentral.nih.gov.
Joyce M Black ,Medical Surgical Nursing,7th edition,saunders publication,pg no
2433 -2476.
Nadrhg, k. (2006).lumbar puncture. Journal of Advanced Nursing. 67, 296-305.

Joffe, Ari R. (2007-07-01). "Lumbar Puncture and Brain Herniation in Acute

Bacterial Meningitis: A Review". Journal of Intensive Care Medicine. 22 (4): 194
207..
 Wright, B.L.; Lai, J.T.; Sinclair, A.J. (2012). "Cerebrospinal fluid and lumbar
puncture: a practical review". Journal of Neurology.

Goldenberg D, Bhatti N. Management of the impaired airway in the adult. In:

Cummings CW, Flint PW, Haughey BH, et al, eds. Otolaryngology: Head & Neck
Surgery. 4th ed. Philadelphia, PA: Elsevier Mosby; 2005:chap 106.

Greenwood JC, Winters ME. Tracheostomy care. In: Roberts JR, ed. Roberts and
Hedges Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA:
Elsevier Saunders; 2014:chap 7.