Clinical Skills Learning Centre

2009-10

Diagnostic Lumbar Puncture: Page 1

Diagnostic Lumbar Puncture

Aims o To measure CSF pressure in the subarachnoid space. o To obtain cerebrospinal fluid (CSF) for laboratory examination. Indications The utility of lumbar puncture (LP) has been superceded by CT and MRI in the diagnosis of most intracranial mass lesions but diagnostic LP is still useful in the following conditions: o o o o o o o CNS infection (bacterial, viral, fungal, protozoan). Subarachnoid hemorrhage. Encephalitis. Guillain-Barre syndrome. Multiple sclerosis. Systemic lupus erythematosus. Meningeal carcinomatosis.

Contraindications o Skin infection at puncture site. o Bleeding diathesis, including severe thrombocytopenia. o Raised intracranial pressure. The procedure Confirm identity of patient to have the procedure. Review his medical history, physical findings, and indication for LP. Make sure there are no factors contraindicating LP. Explain the procedure to patient, including potential discomfort and complications. Obtain an informed consent signed by the patient. Have an assistant available. Position patient close to the edge of the bed in the lateral decubitus position with hips, knees, and spine maximally flexed (the so-called fetal position). The sitting position is also appropriate, but only for obtaining CSF specimens and not for measuring CSF pressure.

Clinical Skills Learning Centre

2009-10

Diagnostic Lumbar Puncture: Page 2

L3-4 is a common puncture site. Identify this site by palpating for the iliac crest of the patient. A line joining the highest point of the iliac crests crosses this interspace or the L4 spinous process. L4-5 and L5-S1 spaces are safe alternative puncture sites. The spinal cord may end as low as L2 in some adult patients. Using the L2-3 space for lumbar puncture, although safe in most instances, has the lowest tolerance for error. Spinal tap has been performed safely at higher interspaces, but should be reserved for experienced specialists only. Don a surgical mask, wash your hands, and put on a pair of sterile gloves. Ask assistant to open the outer wrapping of the LP tray without touching the inner wrapping. Open the sterile inner wrapping of the LP tray and ask the assistant to fill the antiseptic containers with Betadine and 75% alcohol, double-checking the contents of the containers as it is being done.

Clinical Skills Learning Centre

2009-10

Diagnostic Lumbar Puncture: Page 3

Also ask the assistant to add to the tray the following equipment in a sterile manner: a 2 or 3 ml syringe, a 23G or finer hypodermic needle, a CSF manometer, and 3 sterile test tubes. Check the equipment and fill the 2 or 3 ml syringe with 1% lignocaine dispensed by the assistant into the drug dish. Use the sponge forceps and the cotton balls to apply Betadine around the puncture site widely, extending from side to side on the patients back and from the low thoracic to the sacral level. Wash off excess Betadine with alcohol. Square-drape the puncture site with sterile towels. Sit down comfortably with the puncture site at arm level. Reconfirm intended puncture site, use the 23 gauge needle and the syringeful of lignocaine to raise a skin weal at the center of the interspace, and infiltrate more deeply. Insert the 22G spinal needle with stilette in place at the center of the space with shaft of the needle pointing slightly cephalad, feeling for the resistance as its tip traverses the supraspinous and interspinous ligaments, the slightly increased in resistance as its tip penetrates the ligamentum flavum, and the loss of resistance as its tip enters the subarachnoid space. May have to readjust the angle of entry if the needle hits bone, usually by pointing the needle more cephalad. If that is the case, withdraw the needle all the way to subcutaneous tissue before re-inserting it. Do not attempt changing direction by simply bending the needle. The needle is fragile. Bending it will not only not change its direction but also cause it to snap in mid-shaft. Remove the stilette and wait for the appearance of CSF. Return the stilette into the shaft of the needle if you have to advance it more deeply. CSF should appear drop by drop without hindrance if the tip of the spinal needle is in the dural sac away from the cauda equina. Attach the 2-way stopcock and the manometer to the hub of the needle, adjust the 2-way stopcock to allow CSF to fill the manometer tube, and read the pressure as mm of CSF as the fluid level stabilizes. (Of the 3 channels in a 2-way stopcock, the tap handle points in the direction of the channel being shut off.) Normal range of CSF pressure ranges between 80 and 180 mm. Adjust the 2-way stopcock again, remove the detachable manometer tube and sample 1 to 2 ml of CSF sequentially into each of 3 plain sterile test tubes. (Test tubes used at the Prince of Wales Hospital in the LP tray are labeled sequentially. If they are not labeled, put them aside in the correct sequence and labeled them afterwards. Alternatively pass the tubes to the assistant for labeling as they are filled and maintain sterility until the procedure is completed.) If measurement of CSF glucose concentration is required, sample 1 to 2 ml of CSF into a fresh and sterile 2 or 3 ml syringe for transfer to a non-sterile fluoride test tube later. After the procedure, obtain a sample of venous blood to check plasma glucose for comparison. CSF glucose concentration is normally approximately 65% of plasma glucose concentration. All in all, no more than 10 ml of CSF should be lost by the patient in a diagnostic LP. Withdraw the needle and apply a dressing to the puncture site. Turn the patient supine with the help of the assistant.

Clinical Skills Learning Centre

2009-10

Diagnostic Lumbar Puncture: Page 4

Dispose of contaminated consumables (e.g., sponges, manometer, and syringe without the needle) into the red garbage bag and sharp consumables (e.g., disposable needles and blades) into the puncture-proof container. It is good practice to put all contaminated and sharp consumables into the kidney dish for disposal at the end of the procedure. Document in writing what you have done and any difficulties you may have encountered. Leave instructions for the patient to lie flat for about 2 hours and maintain oral fluid intake if not contraindicated. Also leave orders to observe patients neurological status and vital signs until stable. Once condition is stable, patient can resume activities as tolerated.

More about insertion of the spinal needle

As needle is being inserted, point its bevel facing the patients side rather than facing the patients head or feet. In the first instance (upper panel), the bevel separates the longitudinal dural fibers and the hole it makes seals itself once the needle is removed. In the second instance (lower panel), the bevel cuts the longitudinal dural fibers. Breached dural fibers take time to heal, leaving an opening for CSF leak. CSF leak is a major cause of post-dural puncture headache.

Potential complications Tonsillar herniation (herniation of cerebellar tonsil through the foramen magnum; also called coning). A brain shift that can occur in patients with raised intracranial pressure (ICP) and is the result of an increased in pressure gradient between the

Clinical Skills Learning Centre

2009-10

Diagnostic Lumbar Puncture: Page 5

intracranial and spinal compartments following LP. Patients suspected to have increased ICP require urgent CT/MRI and not urgent LP. Spinal cord or cauda equina injuries. Can be minimized by careful identification of landmarks, exercising care in needle insertion, and avoidance of probing for the subarachnoid space blindly. Infection. Avoidable by practising aseptic technique meticulously. Post-dural puncture headache. Occurs in up to 30% of patients. Typical complaint is neck stiffness or pain radiating to the frontal region. The discomfort is related to the patients posture: precipitated by assuming the erect position (sitting or standing) and relieved by returning to the supine position. The etiology is believed to be intracranial hypotension from CSF leak. Prevention is by limiting the size of the spinal needle to 22G and pointing its bevel to face the patients side. Use of pencil point needles will also reduce the risk of post-dural puncture headache. (Pencil point spinal needle are commonly used by anesthesiologists for spinal anesthesia. Its tip is shaped like that of a pencil with a side hole. Since it does not have a bevel with cutting edges, it will not disrupt the integrity of the longitudinal dural fibers.) Treatment of post-dural puncture headache The headache is self-limiting once the dural hole is sealed but time is required for the healing process to take effect. Most treatment modalities are of an empirical nature. o Analgesics. Prescribe an NSAID for mild headaches. Use an opiate if the headache is severe. o Bed rest. It was the belief that the hydrostatic pressure of the CSF fluid column at the dural puncture site in an erect patient can delay the healing of the dural hole. It was an age-old practice to keep the patient in complete bed rest after lumbar puncture. Resting supine alleviates the intensity of the postural headache, but any other beneficial effect is only anecdotal in nature. Once the patients condition is proved stable after the procedure, he should be encouraged to assume activities as tolerated. Prolonged bed rest should be avoided. o Oral fluid intake. It was customary to push fluid intake after lumbar puncture in the belief that hydration can replenish lost CSF. This treatment modality is not evidence based. It is, however, not unreasonable to maintain normal hydration and definitely avoid dehydration. o Caffeine. Caffeine is a cerebral vasoconstrictor and relieves post-dural puncture headache in some patients. The oral dose is 300 mg but its effect may be transient. Jitteriness and insomnia are some of its unwanted side effects. o Autologous epidural blood patch. In this procedure up to 20 ml of fresh venous blood obtained from the patient is deposited into the patients epidural space at or near the LP puncture site to seal the dural hole. Immediate relief is reported by 95% of the patients. This invasive procedure is usually performed by anesthesiologists and should be reserved for patients with a debilitating headache refractory to conservative treatment.