Lumbar Puncture

Lumbar puncture (aka spinal tap) is a

procedure to access subarachnoid space and
collect CSF.!

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Indications:
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1. Diagnostic: meningitis (bacterial, viral,

cryptococcal, TB, etc), multiple sclerosis,
neurosyphilis, subarachnoid hemorrhage!
2. Therapeutic: administration of antibiotics,
analgesics, anti-tumor agents,
anesthetics!
3. Myelography and neurosurgical
procedures

The structures that the spinal needle

sequentially traverses:!

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3.
4.
5.
6.
7.

subcutaneous fat!
supraspinosus!
interspinosus!
ligamentum flavum!
dura!
arachnoid!
pia (pia should not be traversed)

Dura is a strong, fibrous membrane which

forms a loose sheath around cord.!

Arachnoid is a thin delicate tubular

membrane investing surface of the cord.!

Contraindications:!

1. Infection at the puncture site!

2. Increased intracranial pressure (ICP)
(high risk for brainstem herniation)!
3. Coagulopathy (platelets <50,000)!

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Spinal cord anatomy important facts:!
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Pia covers the surface of the cord, to which it

is intimately attached.!

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1. In adults, the spinal cord ends at L1 level

and the subarachnoid space extends to
S2!
2. In children, the spinal cord ends at L3,
and the subarachnoid space extends to
S3!
3. The subarachnoid space lies between the
arachnoid and pia matter; this is where
CSF is found. It is the site of SAB.!
4. The epidural space is a potential space
that is bound by the dura and ligamentum
flavum.!
5. The widest epidural space is at L2 (5-6
mm)!

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Parry Center For Clinical Skills and Simulation!
Sanford School of Medicine, University of South Dakota, All rights reserved

Lumbar Puncture
Equipment for LP!

1.
2.
3.
4.
5.
6.
7.
8.
9.

sterile gloves!
eye protection!
cap and mask!
spinal needle (20, 22 gauge)!
manometer for opening pressure!
three way stopcock!
collection tubes!
1% lidocaine with 5 mL syringe!
22 or 25 gauge needles for topical
anesthesia!
10. sterile drapes!
11. material for skin sterilization !
12. adhesive dressing!

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Pre-procedural preparation!
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1. position the patient (most important)!

1. level the shoulders horizontally!
2. patient assumes fetal position!
3. decubitus vs sitting position!
2. set up all equipment beforehand!
3. explain the procedure to the patient!

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Procedure!
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1. Fundoscopic and neurologic exam to rule

out papiledema and focal neurologic
deficit.!
2. Positioning and alignment

3. Palpate the iliac crest and the vertebra!

4. Identify estimated puncture site (L4-L5
space)

5. Open the LP tray and put on sterile

gloves.!
6. Set up syringes, manometer, local
anesthetic, and collection tubes!
7. Prep the skin with Betadine in a circular
fashion from inside to outside!
8. Place a windowed sterile prep with the
opening at the puncture site!
9. Place sterile prep at the base of patient
on the bed!
10. Palpate landmarks over sterile drape
(keep sterile technique)!
11. Perform local anesthesia with 1%
lidocaine (skin and ligaments)!
12. Insert spinal needle in between the
spinous processes:!
1. stay midline!
2. keep parallel to sagittal plane!
3. 30 degrees cephalad!
13. Advance the needle till you fill a pop!
14. Withdraw the stylet to see if CSF is
returning!
15. Allow a few CSF drops to fall, and attach
the manometer to obtain the opening
pressure!
16. Remove the manometer, and collect CSF
samples!
17. Replace the stylet!
18. Withdraw the needle (with the stylet in)!
19. Apply sterile gauze to achieve
hemostasis!

Parry Center For Clinical Skills and Simulation!

Sanford School of Medicine, University of South Dakota, All rights reserved

Lumbar Puncture
20. Apply adhesive dressing over puncture
site!
21. Patient to remain supine for the next 6-12
hours (post puncture headache
prevention)!

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CSF specimens:!
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5. aggravated in upright position!

6. nausea, vomiting, photophobia, loss of
appetite, tearful!

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Treatment of post-puncture spinal

headache!

Tube 1: Gram stain, culture and sensitivity

(AFB, fungal cultures when applicable)!

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Tube 2: Glucose and protein!
!

Tube 3: Cell count (RBC, WBC with

differential!

Tube 4: Hold in the lab for future tests

(VDRL, India ink, electrophoresis, antigen
panel)

1. Hydration that hypothetically increases

CSF production (some authors discard
the theory that hydration increases CSF
production)!
2. Caffeine: in a study 500 mg of IV caffeine
sodium benzoate relieved 75% of HA!
3. Blood patch: relieves 89-95% of HA,
usually performed if conservative
treatment is ineffective (hydration +
caffeine)

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Please watch the instructional video from

The New England Journal of Medicine!

http://www.nejm.org/doi/full/10.1056/
NEJMvcm054952!

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Possible complications:!
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1. Backache (most common)!

2. Post puncture spinal headache (2nd
most common)!
3. Trauma to nerve root!
4. Brainstem herniation!
5. Infection!
6. Hemorrhage!

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Post-puncture spinal headache!
!

1. frequency 0.2% - 24%!

2. highest incidence in OB!
3. Occurs within several hours after LP,
usually during the first or second day
post-puncture!
4. HA is bifrontal; often involves head, neck
and shoulders!
Parry Center For Clinical Skills and Simulation!
Sanford School of Medicine, University of South Dakota, All rights reserved