lumbar by bheru lal

8/9/2019 Lumbar BY BHERU LAL

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LUMBAR PUNCTURE

Indications

1. Suspected CNS infection

2. Suspected subarachnoid hemorrhage

3. Therapeutic reduction of cerebrospinal fluid (CSF) pressure

4. Sampling of CSF for any other reason

Contraindications

1. Local skin infections over proposed puncture site (absolute contraindication)

2. Raised intracranial pressure (ICP); exception is pseudotumor cerebri

3. Suspected spinal cord mass or intracranial mass lesion (based on lateralizing

neurological findings or papilledema)

4. Uncontrolled bleeding diathesis5. Spinal column deformities (may require fluoroscopic assistance)

6. Lack of patient cooperation

Materials

1. Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep

solution, manometer, drapes, tubes, and local anesthetic)

2. Universal precautions materials

Pre-procedure patient education

1. Obtain informed consent

2. Inform patient of possibility of complications (bleeding, persistent headache,

infection) and their treatment

3. Explain the major steps of the procedure, positioning, and postpocedure care

Procedure

1. Assess indications for procedure and obtain informed consent as appropriate2. Provide necessary analgesia and/or sedation as required

3. Position patient: lateral decubitus position with fetal ball curling up, or

seated and leaning over a table top; both these positions will open up the

interspinous spaces (see Figure 1)

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Figure 1: Positioning patient for lumbar puncture

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

(see Figure 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. You will

aim the needletowards the

navel.

Figure 2. Anatomy of

lumbar spine

5. Prep anddrape the area

after

identifying

landmarks.

Use lidocaine

1% with or

without

epinephrine to

anesthetize the skin

and the deeper tissuesunder the insertion

site

6. Assemble needle and

manometer. Attach

the 3-way stopcock to

manometer

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7. Insert Quinke needle bevel-up through the skin and advance through the

deeper tissues. A slight pop or give is felt when the dura is punctured. Angle

of insertion is on a slightly cephalad angle, between the vertebra (Figure 3). If

you hit bone,

partially withdraw

the needle,

reposition, and re-

advance

Figure 3

8. When CSF flows,

attach the 3-way

stopcock and

manometer.

Measure ICPthis

should be 20 cm orless. Note that the

pressure reading is not reliable if the patient is in the sitting position

9. If CSF does not flow, or you hit bone, withdraw needle partially, recheck

landmarks, and re-advance

10. Once the ICP has been recorded, remove the 3-way stopcock, and begin filling

collection tubes 1-4 with 1-2 ml of CSF each

Tube 1: glucose, protein, protein electrophoresis

Tube 2: Grams stain, bacterial and viral cultures

Tube 3: cell count and differential

Tube 4: reserve tube for any special tests

11. After tap, remove needle, and place a bandage over the puncture site. Instruct

patient to remain lying down for 1-2 hours before getting up

NOTES:

1. Insertion of the needle bevel-up minimizes dural trauma

2. A traumatic bloody tap occurs when a spinal venous plexus is penetrated.

Often the fluid will clear as succeeding tubes are filled. Spin down the first

tube: if red blood cells have been in the spinal fluid for some time (forexample, subarachnoid hemorrhage), xanthochromia will be present in the

supernatant fluid. If the fluid is clear after it is spun down, the tap was only

traumatic

3. In some cases, conscious sedation is helpful in reducing patient anxiety and

allowing maximal spinal flexion

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COMPLICATIONS, PREVENTION, AND MANAGEMENT

Complication Prevention Management

Bleeding from puncture

site post-tap

None

Local pressure

Bloody spinal fluid

None

Withdraw needle andperform tap at interspace

either above or below

Infection

Do not perform tap through

infected skin

Use sterile technique

Antibiotics

Post-tap persisting

headache

Use pencil-tipped needle if

possible; insert needle bevel-up

Post-procedure epidural

blood patch by anesthesia

consultant

Documentation in the medical record

Include in your note a brief history and physical examination of the patient, the

reasons for performing the lumbar puncture, and consent. Note in particular a brief

examination of the cranial nerves, presence or absence of papilledema, or any other

lateralizing neurological finding. Also include a brief note of examination of the patients

spine with attention to any obvious spinal deformity.

Document position of patient during the procedure, opening pressure, and

clarity/color of the CSF. Once results of the CSF analysis are available, they can be

appended to your note.

NORMAL CSF VALUES

Items for evaluation of person learning this procedure

1. Anatomy of lumbar spine

2. Indications of procedure

3. Contraindications for procedure

4. Interaction between physician, staff, patient, and/or family

5. Sterile technique, universal precautions

Parameter Normal Values

Protein 15-45 mg/dl

Glucose 50-80 mg/dl

WBC < 5 mm3

RBC 0-5

Opening pressure 5-20 cm

Clarity, color Clear and colorless

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6. Technical ability

7. Appropriate documentation

8. Understanding of potential complications and their correction

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