The document provides information on performing lumbar punctures, including indications, contraindications, equipment, procedures, complications, and normal CSF findings. It describes how to position the patient laterally or sitting and insert the spinal needle between vertebrae to collect CSF samples. Potential complications discussed are headache, apnea, back pain, bleeding, infection, and brainstem herniation. Precautions and treatments for complications are also outlined.

1. 1
XVIII Semana Acadêmica de Medicina Ulbra
Workshop Punção Lombar
Liga Acadêmica de Neurologia e Neurocirurgia da Ulbra
http://neuroligaulbra.blogspot.com.br
Out 2015

2. 2
Objectives
 To learn the indications and contraindications for
performing lumbar puncture
 To learn lateral decubitus and sitting procedure for
lumbar puncture
 To learn the median and paramedian approach
 To review complications that can occur with lumbar
puncture, their precautions and treatments

3. 3
History
 CSF first examined in 19th
century using primitive
techniques (sharpened bird quills)
 Modern technique first performed by Quincke in
1890 on a small child and has changed little since
then

4. 4
Indications
 To obtain CSF for the diagnosis of:
• Meningitis
• Meningoencephalitis
• Subarachnoid hemorrhage
• Malignancy – diagnosis and treatment
• Pseudotumor Cerebri
• Other neurologic syndromes

5. 5
Contraindications
 Unstable patient with cardiovascular or respiratory
instability
 Localized skin/soft tissue infection over puncture
site
 Evidence of unstable bleeding disorder
• Platelets < 50,000 or clotting factor deficiency

6. 6
Contraindications
 Increased intracranial pressure
• Head CT before study if focal neurologic findings
present to rule out impending cerebral mass
herniation
• Normal CT does not preclude intracranial HTN
• Do not delay antibiotics to obtain imaging studies
when bacterial meningitis is strongly suspected
 Neurologic deterioration can occur if LP is done
below the level of a complete spinal subarachnoid
block
 Caution in patients with Chiari malformations

7. 7
Equipment
 Most CSF trays come with:
• Anesthetic such as:
 Topical - EMLA, Elamax, Zylocaine
cream
 Lidocaine 1% with 25 gauge needle
and syringe
• Povidone-iodine solution & sponge wand
• Drapes, gauze, and bandages
• Manometer, stopcock and tubing in non-
infant kits

8. 8
Equipment
 Spinal needle, usually
22 gauge
• 1.5 in for < 1 yr
• 2.5 in for 1 year to
middle childhood
• 3.5 in for older
children and
adolescents
• Larger for large
adolescents
 Atraumatic needles,
less spinal headaches

9. 9
Lateral Decubitus Position
 Apply topical anesthetic 30-45 min prior to procedure
 Spinal cord ends at L1-L2, so sites for puncture are
located at L3-L4 or L4-L5
 Restrain patient in lateral decubitus position
• Maximally flex spine without compromising airway
• Keep alignment of feet, knees and hips
• Position head to left if right handed or vice versa

10. 10
Procedure
 Cleanse skin with povidone iodine from puncture
site radially out to 10 cm and ALLOW TO DRY
 Drape below patient and around site with
fenestrated drape
 Anesthetize with lidocaine if topical not used by:
• Intradermally raising a wheal at needle insertion
site
• Advance needle through wheal to desired
interspace
 Careful not to inject into a blood vessel or
spinal canal

11. 11
Procedure
 Insert spinal needle with stylet with bevel up to
keep cutting edge parallel with nerve and ligament
fibers

12. 12
Procedure
 Aim towards umbilicus directing
needle slightly cephalad
 Hold needle firmly

13. 13
Layers

14. 14
Procedure
 A “pop” of sudden
decrease in resistance
indicates that
ligamentum flavum and
dura are punctured
 Remove stylet and
check for flow of spinal
fluid

15. 15
Procedure
 If no fluid, then:
• Rotate needle 90°
• Reinsert stylet and advance needle slowly
checking frequently for CSF
 Jugular vein compression can increase CSF
pressure in low flow situations
 If bony resistance is felt immediately then you are
not in the spinal interspace
 If bony resistance is felt deeply, then withdraw
needle to the skin surface and redirect more
cephalad and increase patient flexion
 If bloody fluid that does not clear or that clots
results, then withdraw needle and reattempt at a
different interspace

16. 16
Manometry
 When CSF flows, attach manometer to obtain
opening pressure if desired
 Pressure can only be accurately measured in
lateral decubitus position and in the relaxed patient
 Attach manometer with a 3-way stopcock when free
flow of CSF is obtained
 Read column when highest level is achieved and
respiratory variation is noted

17. 17
Procedure
 Collect 1ml of CSF in each of 3 vials for:
• Tube 1: culture & gram stain
• Tube 2: glucose, protein
• Tube 3: cell count & differential
• and extra CSF if desired for other lab tests
 Check closing pressure with manometer, if desired
 Reinsert stylet and remove needle in one quick
motion
 Cleanse back and cover puncture site

18. 18
Sitting Position
 Restrain infant in the seated position
with maximal spinal flexion
• Hold infant’s hands between
flexed legs with one hand and flex
head with the other hand
 Drape patient below buttocks and
fenestrated drape opening over
puncture site
 Insert needle so bevel is parallel to
spinal cord (Bevel left or right)
 Cannot measure pressure accurately
in this position

19. 19
Paramedian (Lateral) Approach
 Use for patients who
have calcifications from
repeated LPs or
anatomic abnormalities
 Needle passes through
erector spinae muscles,
and ligamentum flavum
• Bypasses
supraspinal and
interspinal ligaments
 Less incidence of
spinal headache

20. 20
Complications
 Headache
• Uncommon in < 10 y/o
 Apnea (central or obstructive)
 Back pain
• Occasionally with short-lived referred limp
• Disc herniation if needle advanced too far
 Bleeding or fluid leak around spinal cord
 Infection, pain, hematoma
 Subarachnoid epidermal cyst
 Ocular muscle palsy (transient)
 Nerve Trauma
 Brainstem herniation

21. 21
Spinal Headache
 Most common complication
 Risk factors: female, age 18-30, lower BMI, hx of
HA, prior spinal HA
 Bilateral HA, improves when supine
 Can last hours to weeks
 Supine position for at least 2 hours
 Hydration
 Caffeine either PO or IV
 Epidural blood patch

22. 22
Spinal Headache Prevention
 Can avoid by:
• Passing needle bevel parallel to longitudinal
fibers of dura
• Replacing stylet before removing needle
• Using small diameter needles
• Using atraumatic needles
 Bed rest or PO intake after LP does not reduce
incidence of headache

23. 23
Nerve Root Trauma/Irritation
 Can feel electric shocks or dysesthesias
 Back pain can persist for months
• Consider disc herniation
 Rarely permanent
 Withdraw needle immediately
 If pain or motor weakness persists, start
corticosteroids
 Electromyogram/nerve conduction velocity studies
should be scheduled if pain persists

24. 24
Herniation
 Manifests initially as altered mental status, followed
by cranial nerve abnormalities and Cushing triad
 May be rapidly fatal.
 Immediately remove needle and raise the head of
bed to 30-45° improve venous return from the brain.
 Mannitol or 3% Saline
 Intubate patient and hyperventilate
 Emergent neurosurgical consult

25. 25
Epidermal Inclusion Cyst
 Very rare due to use of stylet
 Occurs when a core of skin is driven into spinal or
paraspinal space with hollow needle
 Do not remove stylet until through the skin

26. 26
Failure of Procedure
 If sample of CSF is critical several
alternatives are available:
• Have someone else try
 Anesthesia
 Neurology
• Bedside ultrasound for difficult
LPs
• Radiographic guided
procedure
 Fluoroscopy
 Ultrasound
 CT
• Cisterna Magna tap

27. 27
Normal Bacterial Viral TB
Cells 0-5 WBC/mm3
>1000/mm3
<1000/mm3
25-500/mm3
Polymorphs 0 predominate early +/- increased
Lymphocytes 5 late predominate increased
Glucose 40-80 mg/dl decreased normal decreased
66% < 40% Normal < 30%
Protein 5-40 mg/dl increased +/-increased increased
Culture negative positive negative +TB
Gram stain negative positive negative positive
Summary of typical CSF findings

28. 28
Bibliography
 Kalpesh Patel, MD, Dept. of Pediatric Emergency Medicine: Lumbar Puncture
www.pediatrics.emory.edu/pem/_epg/documents/38653.ppt
 Fleisher GR, Ludwig S, Henretig FM. Textbook of Pediatric Emergency Medicine Fifth
Edition. Lippincott Williams & Wilkins 2006. p201-212.
 Levin DL, Morriss FC. Essentials of Pediatric Intensive Care Second Edition. Churchill
Livingstone 1997. p369-370,411-412.
 Robertson J, Shilkofski N. The Harriet Lane Handbook Seventeenth Edition. Elsevier
Mosby. 2005. p86-88.
 King C, Henretig Fred. Pediatric Emergency Procedures. Lippincott Williams & Wilkins
2000. p 124-128.
 Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and
analyze the results to diagnose bacterial meningitis? JAMA. 2006 Oct 25;296(16):2012-
22.
 Peterson MA, Abele J. Bedside ultrasound for difficult lumbar puncture. J Emerg Med.
2005 Feb;28(2):197-200.
 Runza M, Pietrabissa R, Mantero S. Lumbar Dura Mater Biomechanics: Experimental
Characterization and Scanning Electron Microscopy Observations. Anesthesia and
Analgesia. 1999;88:1317-21.
 Sucholeiki R, Waldman A. Lumbar Puncture (CSF Examination). E-medicine. 2006
http://www.emedicine.com/neuro/topic557.htm.
 Walter K. Manual of Common Bedside Surgical Procedures Second Edition. Lippincott
Williams & Wilkins 2000. p181-186.
 Boon JM, Abrahams, PH, Meiring JH, Welch T. Lumbar Puncture: Anatomical Review
of a Clinical Skill. Clinical Anatomy 2004;17:544-553
 Evans RW. Special Report: Complications of Lumbar Puncture and Their Prevention
with Atraumatic Lumbar Puncture Needles. Medscape 2000.
http://www.medscape.com/viewarticle/420288.

29. Many Thx to
Kalpesh Patel, MD
Dept. of Pediatric Emergency Medicine
(all rights to him, original material adapted from
www.pediatrics.emory.edu/pem/_epg/documents/38653.ppt)
Adaptado para o Workshop de Punção Lombar da Liga Acadêmica de Neurologia e
Neurocirurgia da Ulbra http://neuroligaulbra.blogspot.com.br