Procedure

Lumbar Puncture

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Lumbar Puncture

  • See Also
  1. Cerebrospinal Fluid
  • 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
    2. 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
  • 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
  • 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
  • Complications
  1. Spinal Headache
  2. Unexpected rise in Intracranial Pressure
  3. Worsening of spinal block
  4. Spinal Epidural Hematoma
  • 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]
  • 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
  • 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
      1. Consider having a second assistant or parent stabilize head or neck
    2. Alternatively, lateral decubitus position may offer better immobilization of infant
    3. Avoid excessive neck flexion (head in relatively neutral position)
      1. Neck flexion risks airway closure and apnea
  4. Additional pearls
    1. Depth is superficial in an infant
    2. Consider topical anesthetic
      1. LMX4 applied 30 minutes before procedure OR
      2. EMLA applied 60 minutes before procedure
    3. May remove stylet after entering skin
      1. Before entering skin, Epidermis may plug needle
      2. However, after skin entry, stylet removal makes it less likely to miss the space
    4. May allow for 1 additional CSF WBC for every 1000 CSF RBCs
      1. Lyons (2017) Ann Emerg Med 69(5): 622-31 [PubMed]
    5. Risk factors for failed Lumbar Puncture in infants
      1. Age <3 months
      2. Spinous processes not visible or palpable
      3. Patient movement
      4. Inexperienced provider
      5. Nigrovic (2007) Ann Emerg Med 49(6): 762-71 +PMID: 17321005 [PubMed]
  • 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)
  • References
  1. Claudius and Behar in Herbert (2017) EM:Rap 17(11): 5
  2. Mount (2017) Am Fam Physician 96(5): 314-22 [PubMed]