Lumbar Puncture

LUMBAR PUNCTURE

Indications

Suspected meningoencephalitis
Suspected subarachnoid hemorrhage despite negative CT

Contraindications

Risk for cerebral herniation:

Altered mentation
Focal neurologic signs
Papilledema
Seizure within the previous week
Impaired cellular immunity

Other:

Infected skin over the needle entry site
Coagulopathy (e.g. anticoagulant or antiplatelet use, renal failure) is a relative contraindication

Prior

Prepare the Patient

Inform the patient about the procedure
Position the patient in the lateral recumbant or sitting position with the hips, knees and chin flexed towards the chest
Identify the L3-L4 interspace which is at the level of the posterior superior iliac crests. Identify the L2-L3 interspace and the L4-L5 interspace. Mark the interspace which is widest.

Prepare the Equipment

Mentally rehearse the procedure steps and assemble the necessary equipment

Procedure

Sterilize and Drape

Don sterile gloves
Clean the skin over the L2-L4 area using antiseptic solution
Place sterile drapes around the work area

Analgesia

Administer local anesthetic under the surface of the skin at the target site +/- anesthetize the deeper tissue

Needle Insertion

Insert the spinal needle, with the bevel parallel to the spine, at a slightly cephalad angle, aiming towards the umbilicus, and advance the needle approximately 3-4 cm.
Remove the stylet and check for fluid return; if no fluid i obstained, replace the stylet, advance a few millimeters and repeat the process until CSF is obtained.
Attach the manometer and note the height of the fluid column. The patient’s legs should be straightened during pressure measurement.
Collect cerebrospinal fluid in each of 4-5 tubes (10 drops – 1 ml in each tube)
Replace the stylet and remove the needle
Apply a sterile dressing

Post

Cerebrospinal Fluid Analysis depending on the context:
Cell count and differential (first and the last tube)
Glucose and protein levels
Direct microscopy, Gram stain, bacterial cultures, PCR for HSV etc.
Spectrophotometry if the setting of suspected subarachnoid hemorrhage

Lumbar Puncture

LUMBAR PUNCTURE

Indications

Suspected meningoencephalitis

Suspected subarachnoid hemorrhage despite negative CT

Contraindications

Risk for cerebral herniation:

Altered mentation

Focal neurologic signs

Papilledema

Seizure within the previous week

Impaired cellular immunity

Other:

Infected skin over the needle entry site

Coagulopathy (e.g. anticoagulant or antiplatelet use, renal failure) is a relative contraindication

Prior

Prepare the Patient

Inform the patient about the procedure

Position the patient in the lateral recumbant or sitting position with the hips, knees and chin flexed towards the chest

Identify the L3-L4 interspace which is at the level of the posterior superior iliac crests. Identify the L2-L3 interspace and the L4-L5 interspace. Mark the interspace which is widest.

Prepare the Equipment

Mentally rehearse the procedure steps and assemble the necessary equipment

Procedure

Sterilize and Drape

Don sterile gloves

Clean the skin over the L2-L4 area using antiseptic solution

Place sterile drapes around the work area

Analgesia

Administer local anesthetic under the surface of the skin at the target site +/- anesthetize the deeper tissue

Needle Insertion

Insert the spinal needle, with the bevel parallel to the spine, at a slightly cephalad angle, aiming towards the umbilicus, and advance the needle approximately 3-4 cm.

Remove the stylet and check for fluid return; if no fluid i obstained, replace the stylet, advance a few millimeters and repeat the process until CSF is obtained.

Attach the manometer and note the height of the fluid column. The patient’s legs should be straightened during pressure measurement.

Collect cerebrospinal fluid in each of 4-5 tubes (10 drops – 1 ml in each tube)

Replace the stylet and remove the needle

Apply a sterile dressing

Post

Cerebrospinal Fluid Analysis depending on the context:

Cell count and differential (first and the last tube)

Glucose and protein levels

Direct microscopy, Gram stain, bacterial cultures, PCR for HSV etc.

Spectrophotometry if the setting of suspected subarachnoid hemorrhage

LUCEM