Neurology Book

http://www.fpnotebook.com/

Lumbar Puncture

Aka: Lumbar Puncture
  1. See Also
    1. Cerebrospinal Fluid
  2. Precautions
    1. Obtain CT Head before Lumbar Puncture if significant risk factors for CNS mass
      1. Do not delay empiric antibiotics for CT Head if Bacterial Meningitis suspected (DO obtain Blood Cultures before antibiotics)
    2. Indications for CT Head before Lumbar Puncture
      1. CSF Shunt
      2. Hydrocephalus
      3. Trauma
      4. Space occupying lesion
      5. Recent neurosurgery
      6. Papilledema
      7. Focal neurologic deficit
      8. New onset Seizures
      9. Significantly Altered Level of Consciousness
  3. Contraindications
    1. Local infection at Lumbar Puncture site
    2. Cerebral mass lesion (risk of Herniation)
      1. Large Brain Abscess
      2. Brain Tumor (especially posterior fossa)
      3. Subdural Hematoma
      4. Intracranial Hemorrhage
    3. Papilledema
    4. Uncorrected Bleeding Disorder
      1. Coagulopathy secondary to Cirrhosis or Alcoholism
      2. Anticoagulation
      3. Severe Thrombocytopenia
  4. Indications
    1. Suspected CNS Infection
      1. Meningitis
      2. Encephalitis
    2. Evaluate for Hemorrhagic CVA (Subarachnoid Hemorrhage)
      1. Hemorrhage suspected despite negative Head CT
      2. Head CT not available
    3. Diagnostic Chemistry Evaluation
      1. CSF Gamma Globulin (Multiple Sclerosis)
    4. CSF Dynamics
      1. Spinal block diagnosis (Queckenstedt test)
      2. Normal Pressure Hydrocephalus evaluation
        1. Katzman infusion
        2. Radionucleotide cisternography
    5. CSF Cytology
      1. Carcinomatous Meningitis
      2. Lymphomatous Meningitis
    6. Therapeutic Lumbar Puncture
      1. Methotrexate infusion (CNS Leukemia)
      2. Amphotericin B infusion (fungal Meningitis)
      3. Removal of fluid to decrease Intracranial Pressure
        1. Pseudotumor Cerebri
        2. Headache associated with Subarachnoid Hemorrhage
  5. Complications
    1. Spinal Headache
    2. Unexpected rise in Intracranial Pressure
    3. Worsening of spinal block
    4. Spinal Epidural Hematoma
  6. Equipment: Needle types
    1. Standard spinal needle (Quincke Needle)
      1. Easier to obtain successful spinal tap
      2. Higher Incidence of post-dural Headache (22% in one study)
    2. Atraumatic or blunt spinal needle (Sprotte needle, Whitaker needle) - preferred
      1. Smaller tapered needle with blunt tip (typically 20-22 g)
      2. Requires first puncturing the skin with a larger bore needle (18 g) deep enough to draw a small amout of blood
      3. Then pass the blunt tipped needle through the created hole
      4. Significantly lower Spinal HeadacheIncidence (9% compared with 22% with cutting needle)
        1. Castrillo (2015) Spine J 15(7): 1572-6 +PMID: 25794941 [PubMed]
      5. Flow rates via blunt tipped needles are at least as fast as cutting needles
        1. Pelzer (2014) Neurol Sci 35(12): 1997-9 +PMID: 25139108 [PubMed]
    3. References
      1. Orman and Reed in Herbert (2017) EM:Rap 17(4): 7
      2. Thomas (2000) BMJ 321:986-90 [PubMed]
  7. Technique: Adults
    1. Patient positioning
      1. Lateral decubitus position
        1. Fetal Position
        2. Back at right angles to bed
      2. Sitting position (preferred)
        1. Leaning forward, holding a pillow
    2. Location
      1. Mark midline spinous process between iliac crests
      2. Corresponds with L3-L4 or L4-L5 interspace
    3. Spinal needle insertion
      1. Use 20 to 22 gauge spinal needle
      2. Insert needle bevel parallel to long axis of spine (faces laterally)
      3. Keep needle parallel with bed
      4. Angle needle toward Umbilicus
      5. Insert needle until pop is felt or CSF fluid flows
        1. Coughing or Valsalva Maneuver increases flow
    4. Mis-directed Needle hits bone
      1. Withdraw needle to skin level and redirect
    5. Adjuncts to difficult Lumbar Puncture
      1. Fluoroscopy
  8. Technique: Infants
    1. Spinal needle: 22 gauge 1.5 inch
    2. Location
      1. Stay below L3
    3. Positioning
      1. Infant sitting, with helper holding arms and legs
      2. Consider having a second assistant or parent stabilize head or neck
    4. Additional pearls
      1. May remove stylet after entering skin
      2. Avoid excessive neck flexion (head in relatively neutral position)
      3. Depth is superficial in an infant
  9. Standard CSF Orders
    1. Tube 1
      1. Gram Stain
      2. Culture and sensitivity
    2. Tube 2
      1. CSF Glucose
      2. CSF Protein
    3. Tube 3
      1. CSF Cell Count with Differential
    4. Tube 4
      1. CSF Latex Agglutination (Antigens)
  10. References
    1. Mount (2017) Am Fam Physician 96(5): 314-22 [PubMed]

Spinal Puncture (C0037943)

Definition (MSH) Tapping fluid from the subarachnoid space in the lumbar region, usually between the third and fourth lumbar vertebrae.
Definition (NCI_NCI-GLOSS) A procedure in which a thin needle called a spinal needle is put into the lower part of the spinal column to collect cerebrospinal fluid or to give drugs.
Definition (CSP) procedure where a needle is inserted into the spinal column between the lumbar vertebrae; preformed for both diagnostic and therapeutic reasons.
Concepts Diagnostic Procedure (T060) , Therapeutic or Preventive Procedure (T061)
MSH D013129
ICD10 30, 39000-00
SnomedCT 148731000, 68533006, 277762005, 44512002
English Lumbar Puncture, Lumbar Punctures, Punctures, Lumbar, Punctures, Spinal, Spinal Puncture, Spinal Punctures, Puncture, Lumbar, Puncture, Spinal, LP, Tap;spinal cord, spinal puncture, spinal tapping, spinal taps, diagnostic spinal tap, lumbar punctures, Taps, Spinal, Spinal Taps, Tap, Spinal, Spinal Tap, Spinal tap (procedure), lumbar puncture, spinal tap, Spinal tap, Spinal puncture and aspiration, Rachicentesis, Lumbar puncture, Spinal puncture, LP - Lumbar puncture, Lumbar puncture (procedure), Lumbar puncture, NOS, Spinal tap (procedure) [Ambiguous], spinal cord tap
Dutch lumbaalpunctie, Lumbaalpunctie, Punctie, lumbale, Ruggeprik
German LP, Lumbalpunktion, Spinalpunktion
Italian Rachicentesi, Puntura lombare
Portuguese Punção lombar, Punção Espinal, Punção Espinhal, Punção Lombar
Spanish Punción espinal, PL, punción raquídea (procedimiento), punción y aspiración raquídea, punción raquídea, raquicentesis, punción medular, aspiración y punción raquídea, punción lumbar (procedimiento), punción lumbar, punción raquídea (concepto no activo), Punción Lumbar, Punción Espinal
Japanese LP, LP, セキツイセンシ, 脊椎穿刺, クモ膜下穿刺, 腰椎穿刺
Swedish Spinalpunktion
Czech spinální punkce, LP (lumbální punkce), Lumbální punkce, lumbální punkce
Finnish Lannepisto
French Ponction spinale, PL, Ponction lombaire, Rachicentèse
Russian SPINNOMOZGOVAIA PUNKTSIIA, LIUMBAL'NAIA PUNKTSIIA, POIASNICHNAIA PUNKTSIIA, ЛЮМБАЛЬНАЯ ПУНКЦИЯ, ПОЯСНИЧНАЯ ПУНКЦИЯ, СПИННОМОЗГОВАЯ ПУНКЦИЯ
Polish Nakłucie lędźwiowe
Hungarian LP, Gerinc punctio
Norwegian Lumbalpunksjon, Spinalpunksjon
Sources
Derived from the NIH UMLS (Unified Medical Language System)


You are currently viewing the original 'fpnotebook.com\legacy' version of this website. Internet Explorer 8.0 and older will automatically be redirected to this legacy version.

If you are using a modern web browser, you may instead navigate to the newer desktop version of fpnotebook. Another, mobile version is also available which should function on both newer and older web browsers.

Please Contact Me as you run across problems with any of these versions on the website.

Navigation Tree