The document provides information about lumbar puncture and CSF analysis. It defines a lumbar puncture as inserting a needle into the spinal canal to obtain CSF samples. Key points include: - Lumbar puncture is done between the L3 and L4 vertebrae under local anesthetic to obtain CSF for analysis or inject medications. - CSF samples are analyzed to detect conditions like meningitis, tumors, or infections by examining appearance, pressure, cell count, glucose, and protein levels. - Complications are rare but include headache, nerve damage, or infection. Smaller needles and atraumatic needles reduce risks. - Nursing considerations involve proper patient positioning, encouraging hydration before and after, and keeping the patient

1. Lumbar Puncture & CSF
Analysis
Presenter: Shruti Shirke Evaluator: Mr. L Anand
M.Sc (N) Neuroscience Asso. Professor
CON AIIMS BBSR
02/9/2020

2. Introduction
• The procedure is carried out by the doctor, who will insert the
needle in the space between the third and fourth lumbar
vertebrae
• Insertion any higher up the spine would risk injury to the spinal
cord. The level is found by imagining a line drawn from one iliac
crest to the other, and noting where this line crosses the
vertebrae.

4. Definition
• A lumbar puncture is the insertion of a hollow tube needle
under local anesthetic into the subarachnoid space of the spinal
canal to obtain a sample of cerebrospinal fluid (CSF) for clinical
investigations or to inject medication (therapeutic & diagnostic)

5. Anatomy
• The three coverings of the brain and spinal cord (meninges), are
separated by small spaces. The outer membrane, the dura mater, is
in two layers, with a space between containing fluid, blood vessels
and venous sinuses. Beneath the dura mater is a small subdural
space, followed by the arachnoid mater, which has a spider’s weblike
structure. Below this, the subarachnoid space is filled with CSF. The
innermost layer, the pia mater, rests on the brain and cord surface.

10. Purpose of lumbar puncture
• Lumbar puncture is done for one of three reasons:
• To acquire a sample of CSF for analysis.
• To measure and relieve the CSF pressure
• To introduce drugs into the spinal canal (called an intrathecal
injection).

11. Purpose of lumbar puncture Cont..
• Lumbar puncture may also be carried out to introduce a contrast
radio-opaque medium (one that shows up on X-ray), to provide
radiographic images of the spinal canal that do not show on ordinary
X-rays. This type of X-ray is called a myelogram and is used for two
purposes - the diagnosis of spinal lesions and to help plan surgery by
isolating the level of the lesion and selecting the most suitable spinal
segment for operation.

12. Indications
• Suspicion of meningitis.
• Suspicion of subarachnoid hemorrhage (SAH)
• Suspicion of nervous system diseases such as Guillain-Barré
syndrome and carcinomatous meningitis.
• Therapeutic relief of pseudotumor cerebri.

13. Contraindications
• Absolute contraindications for lumbar puncture are the presence of
infected skin over the needle entry site and the presence of unequal
pressures between the supratentorial and infratentorial compartments. i.e.
• Midline shift
• Loss of suprachiasmatic and basilar cisterns
• Posterior fossa mass
• Loss of the superior cerebellar cistern
• Loss of the quadrigeminal plate cistern

15. Contraindications cont..
• Relative contraindications for lumbar puncture include the
following:
• Increased intracranial pressure (ICP)
• Coagulopathy
• Brain abscess

16. Pre-procedure care – Equipment
• Sterile dressing
• Sterile gloves
• Sterile drape
• Antiseptic solution with skin swabs
• Lidocaine 1% without epinephrine
• Syringe, 3 mL
• Needles, 20 and 25 gauge
• Spinal needles, 20 and 22 gauge
• Three-way stopcock
• Manometer
• Four plastic test tubes, numbered 1-4, with caps
• Syringe, 10 mL (optional)

17. Patient preparation
• The patient is placed in the lateral recumbent position with the
hips, knees, and chin flexed toward the chest so as to open the
interlaminar spaces. A pillow may be used to support the head.
• The sitting position may be a helpful alternative, especially in
obese patients, because it makes it easier to confirm the midline.
In order to open the interlaminar spaces.

18. Patient preparation cont..
• If the procedure is performed with the patient in the sitting
position and an opening pressure is required (as in the case of
pseudotumor cerebri), replace the stylet and have an assistant
help the patient into the left lateral recumbent position.

19. Procedure

20. Samples of CSF are taken for:
• Taking cell counts (a tiny number of white cells may normally be
present)
• Measuring glucose and protein (also present in small quantities)
• Cytology, i.e. looking for abnormal cells
• Immunoglobulin (antibody) studies
• Bacterial or viral tests
• Biochemical analysis.

21. Complications
• Post–spinal puncture headache
• Bloody tap
• Dry tap
• Infection
• Hemorrhage
• Dysesthesia (abnormal sensation of pain, itching, burning.)
• Post–dural puncture cerebral herniation

22. Complication prevention
• Explain the procedure, benefits, risks, complications, and alternative
options to the patient or the patient’s representative, and obtain a signed
informed consent.
• Before performing the lumbar puncture, ensure that patients are
hydrated so as to avoid a dry tap.
• Never allow a lumbar puncture or a pre–lumbar puncture CT scan to
delay administration of intravenous (IV) antibiotics; meningitis can
usually be inferred from the cell count, antigen detection, or both.

23. Complication prevention cont..
• Avoid lumbar puncture in patients in whom the disease process
has progressed to the neurologic findings associated with
impending cerebral herniation (ie, deteriorating level of
consciousness and brainstem signs that include pupillary changes,
posturing, irregular respirations, and very recent seizure)

24. Research evidence
• The smaller the needle used for the lumbar puncture, the lower the
risk that the patient will experience a post–lumbar puncture
headache. Data suggest an inverse linear relation between needle
gauge and headache incidence, and some authors recommend using
a 22-gauge needle regardless of what size needle is supplied with the
kit.
• Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production
of lumbar puncture headache. Reg Anesth. 1997 Jan-Feb. 22(1):66-72. [Medline].

27. Research evidence cont..
• The use of atraumatic needles has been shown to significantly
reduce the incidence of post–lumbar puncture headache (3%) when
compared to the use of standard spinal needles (approximately
30%). In addition, it may lead to cost savings. However, obtaining
pressures can be more difficult with atraumatic needles.
• Lavi R, Yarnitsky D, Yernitzky D, Rowe JM, Weissman A, Segal D. Standard vs atraumatic Whitacre
needle for diagnostic lumbar puncture: a randomized trial. Neurology. 2006 Oct 24. 67(8):1492-4.
[Medline].

32. CSF Analysis

33. Normal results in adults
• Appearance: Clear
• Opening pressure: 10-20 cm H2 O
• WBC count: 0-5 cells/µL (< 2 polymorphonucleocytes [PMN]);
normal cell counts do not rule out meningitis or any other pathology
• Glucose level: >60% of serum glucose
• Protein level: < 45 mg/dL

34. Bacterial meningitis
• Appearance: Clear, cloudy, or purulent
• Opening pressure: Elevated (>25 cm H2 O)
• WBC count: >100 cells/µL (>90% PMN); partially treated cases may have
as low as 1 WBC/ µL
• Glucose level: Low (< 40% of serum glucose)
• Protein level: Elevated (>50 mg/dL)
• Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF polymerase chain reaction (PCR), others
depending on clinical findings

35. Aseptic (viral) meningitis
• Appearance: Clear
• Opening pressure: Normal or elevated
• WBC count: 10-1000 cells/µL (lymph but PMN early)
• Glucose level: >60% serum glucose (may be low in HSV infection)
• Protein level: Elevated (>50 mg/dL)
• Consider additional tests: CSF Gram stain and cultures, blood cultures, CSF
bacterial antigens, CSF PCR (eg, herpes simplex virus [HSV], varicella-
zoster virus [VZV]), others depending on clinical findings

36. Fungal meningitis
• Appearance: Clear or cloudy
• Opening pressure: Elevated WBC count: 10-500 cells/µL
• Glucose level: Low
• Protein level: Elevated
• Consider additional tests: CSF Gram stain and cultures, blood
cultures, CSF bacterial antigens, CSF PCR, CSF India ink, others
depending on clinical findings.

37. Tubercular meningitis
• Appearance: Clear or opaque
• Opening pressure: Elevated
• WBC count: 50-500 cells/µL (early PMN then lymph)
• Glucose level: Low
• Protein level: Elevated
• Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF PCR, CSF tuberculosis culture/stain, others
depending on clinical findings.

38. Subarachnoid hemorrhage
• Appearance: Xanthochromia, bloody, or clear
• Opening pressure: Elevated
• WBC count: (1 additional WBC per 1000 RBCs is considered normal
correction)
• Glucose level: Normal
• Protein level: Elevated
• Consider additional tests: CSF Gram stain and cultures, others depending
on clinical findings

40. Multiple sclerosis
• Appearance: Clear
• Opening pressure: Normal WBC count: 0-20 cells/µL (lymph)
• Glucose level: Normal
• Protein level: Mildly elevated (45-75 mg/dL)
• Consider additional tests: Oligoclonal band analysis (serum and
CSF), others depending on clinical findings.

41. Guillian barre syndrome
• Appearance: Clear or xanthochromia
• Opening pressure: Normal or elevated
• WBC count: Normal or elevated
• Glucose level: Normal
• Protein level: Elevated
• Consider additional tests: Others depending on clinical findings

42. Nursing considerations
• Lumbar puncture is a strict aseptic technique requiring full sterile
procedures.
• Positioned the patient carefully, laying on one side in a curled up
position with the lumbar spine exposed (knees drawn up to the
chest). Moving the patient’s back closer to the edge of the bed will
make access to the lumbar spine easier. Support the patient in this
position throughout the procedure.

43. Nursing consideration cont..
• Encourage patients to drink well before and after the procedure.
• A small local sterile dressing is applied to the spinal site after
removal of the needle.
• Headache is a common complaint following lumbar puncture. The
patient should lay flat for 6-12 hours afterwards, as sitting up may
make any headache worse.

44. Nursing consideration cont..
• In myelograms, the patient’s head should be kept raised for up
to 24 hours afterwards to prevent contrast medium in the spinal
canal from entering the skull. This may caused seizures if it
passes around the brain.

45. Conclusion

48. Thankyou