The document provides a comprehensive overview of the lumbar puncture procedure, detailing its purpose, contraindications, complications, and the necessary techniques for performing and managing the procedure. It emphasizes the importance of aseptic technique, appropriate positioning, and post-procedure care to avoid complications. Additionally, it outlines the preparation required, the equipment used, and the follow-up procedures for monitoring and analyzing cerebrospinal fluid samples.

1. CLINICAL TEACHING ON
LUMBAR PUNCTURE
PRESENTED BY
TENZIN DOLMA

2. LUMBAR PUNCTURE
A Lumbar puncture is the insertion of a needle into the lumbar
region of the spine, in such a manner that the needle enters the
lumbar arachnoid space of the spinal canal below the level of
the spinal cord, so that the cerebrospinal fluid can be withdrawn
or a substance can be therapeutically or diagnostically injected.

4. POINTS TO REMEMBER :
 The cerebrospinal fluid is formed through the choroid villi
in each of the four ventricles of the brain
 It circulates freely through the ventricles, the
subarachnoid space and the central canal of the spinal
cord.
 It is then absorbed into the venous circulation via superior
sagittal sinus.

5.  During development, the vertebral column outgrows the
spinal cord.
 In adult, the spinal cord ends at the lower border of the
first lumbar vertebra;
 In the newborn infant it ends slightly at the lower level i.e.,
at the level of the third lumbar vertebra.
 The dural and arachnoid sacs extends up to the level of the
second sacral vertebra and this cavity contains the CSF.
 Thus the region between the second lumbar verterbra and
the second sacral vertebra is suitable for the withdrawal of
CSF, as there is no danger of injury to the spinal cord.

6. PURPOSE OF LUMBAR PUNCTURE

7. CONTRAINDICATION
Absolute contraindications for lumbar puncture are:
 Presence of infected skin over the needle entry site and .
 Midline shift

8. Relative contraindications for lumbar puncture include the
following:
 Increased intracranial pressure (ICP)
 Coagulopathy
 Brain abscess

9. COMPLICATIONS:
 Injury to the spinal cord and spinal nerves
 Infection introduced into the spinal cavity which may give
rise to meningitis
 Leakage of CSF through the puncture site and lowering the
intra-cranial pressure and may cause post puncture
headaches
 Damage to the intervertebral disc
 Local pain, edema and hematoma at the puncture site
 Temperature elevation

10.  Rapid reduction in the intracranial pressure caused by the
removal of CSF can cause herniation of the brain
structures into the foramen magmum. This in turn cause
pressure on the vital centres in the medulla causing
respiratory failure and sudden death.
 Pain radiating to the thighs due to trauma of the spinal
nerves

11. SITE OF LUMBAR PUNCTURE
AND THE POSITIONING OF THE
CLIENT:
 The spinal cord ends at the
level of the first lumbar
vertebra and the subarachnoid
space extends up to the second
sacral vertebra,
 Any site between these two
points may be used for the
puncture of the spine.
 In adults the site of the lumbar
puncture is usually between the
second and third or forth and
fifth lumbar vertebrae.

12.  In small children and infants, the site is still lower
because the spinal cord extends upto the third lumbar
vertebra. These sites are safe to prevent injury to the
spinal cord.
 The back should be vertical to the bed and with no lateral
flexion of the spine. The client is asked to draw both knee
up towards the chin.

13.  The head and neck are
flexed and brought towards
the chest.
 In order to maintain this
position, the client may
keep both his hands
between the knees. In this
position the intervertebral
spaces are widened and the
needle can be easily
inserted.

14.  If the client is not able to maintain this position, the
nurse helps him.
 The nurse stand in front of the client and keeps one hand
behind the knees and the other hand behind the neck
and tries to bring the client into the desired position.

15. PREPARATION OF ARTICLES:
STERILE TRAY
 L.P needles- 2 sizes with their stilette
 Sponge holding forceps
 Syringe (5 ml) with needles to give local anesthesia
 Small bowl to take cleaning lotion

16.  Specimen bottles
 Cotton balls, gauze pieces and cotton pads
 Gloves, gown and masks
 Dressing towels or slit
 Three way adaptor, manometer and tubing to measure the
pressure of the CSF

17. UNSTERILE TRAY CONTAINING:
 Mackintosh and towel
 Kidney tray and paper bag
 Spirit, iodine, tr.benzoin etc.
 Lignocaine 2%
 Sterile normal saline to fill in the manometer
 Adhesive plaster and scissors

18. PROCEDURE:
1. The client is positioned correctly.
2. The skin is prepared as for a surgical procedure
3. Under local anesthesia, the needle is inserted
between the second and third or between the third
and forth lumbar vertebrae.

19. 4. The position can be determined by drawing a vertical line
from the top of the iliac crest to the spine. This crosses the
spine at the 4th lumbar spine or L2-L3 interspace
5. One interspace L3-L4 is selected.
6. When needle has entered the subarachnoid space, the
stilette is removed and
7. The 3 way adaptor with the manometer filled with normal
saline is attached.
8. The pressure is noted. Normally the CSF oscillates in the
manometer readily responding to coughing, deep breathing
etc.

20. 9. The client is asked to relax as much as possible to get a
stabilized pressure. Normally it is 6 to 13 mm of Hg or 80-
180mm of H2O.
10. About 2-3 ml of CSF is allowed to drip into each of 3 sterile
test tubes an then the needle is withdrawn.
i. Tube#1: Gram stain, Culture and Sensitivity
ii. Tube#2: Glucose, Protein
iii. Tube#3: Cell Count and Differentials
iv. Tube#4: Any special studies you require
(fungal/viral/chemical studies) The puncture wound is sealed.

21. GENERAL INSTRUTIONS:
 Since any infection introduced into the spinal cavity would be
fatal for the client, strict aseptic techniques are to be followed.
 The doctor scrubs the hands thoroughly, put on gown gloves etc,.
to maintain asepsis.
 All articles used for the lumbar puncture should be autoclaved.

22.  The client should be placed in a position that will widen
the intervertebral space.
 Usually a side lying position with the knees drawn into the
chin or a sitting position with the head and neck flexed is
maintained during the procedure

23.  Uncooperative clients and children are to be restrained
during the procedure. The clients are to be warned to
remain still during the procedure to prevent injury to the
spinal cord or nerves.
 The client should be placed near the edge of the bed or
table for convenience of the doctor. The client’s back
should be at right angels to the bed.

24.  The L.P needles should be sharp, small in size and not curved.
 The flow of CSF vary in different conditions; when the
intracranial pressure is high, the fluid may spurt out in jets; when
the tension is low as in case of dehydration, the fluid may come
out only on straining or coughing.
 The pressure reading of the CSF is taken when the client is
relaxed and the fluid level remains fairly constant in the
manometer. The CSF will oscillate in the manometer as pressure
is applied (during coughing, straining and deep breathing).

25.  If QUECKENSTEDT’S test is to be carried out during the
procedure the nurse is asked to compress the jugular vein
first on one side, then on the other side and finally on
both sides at the same time.
 When normal, there is a sharp rise in the pressure
followed by a fall as the compression is released.

26.  If the test is negative, one must conclude that a block
exists between the ventricles of the brain and caused by
a. Spinal turmors,
b. Dislocation or fracture of the vertebrae etc.
c. Blockage of the spinal canal or t
d. Thrombosis of the jugular vein will result in the absence
or rise or only a sluggish rise and fall in the manometer
reading

27.  In order to compress the vein, the nurse spreads her
fingers on either sides of the neck, lateral to the tracheal
and the pressure is applied without compressing the
trachea.
 The QUECKENSTEDT’S test is contra-indicated in the
presence of intracranial disease particularly in the
presence of intracranial pressure and intracranial
hemorrhage.

28.  If the nurse has to hold the manometer tube for recording
the pressure she should hold it above the point where the
doctor’s hand need to come in contact with it, since her
hands are not sterile

29.  After the lumbar puncture, the client should lie flat on the bed.
 If the client develops headache, he should not be allowed to sit up in
bed even for a short period.
 Foot end may be raised to fill up the ventricles with the CSF.
 The client develops headache after the lumbar puncture due to
reduced intracranial pressure as a result of fluid removed from the
spinal cavity. It may also develop due to the leakage of CSF from the
subarachnoid space through the puncture wound. Therefore the nurse
should watch the puncture site for leakage of fluid

30. 11. The CSF collected should be sent to the laboratory without any delay.
Changes will take place in the fluid and we will get only a false result.
The CSF is tested for the following:
a. Physical findings, colour and appearance: normally the CSF is crystal clear.
Turbulence indicateds infection (e.g meningitis), blood indicates hemorrhage
(the initial appearance of the blood with the spinal fluid may be due to
puncture of the capillaries at the site of the puncture).

31. b. Cell count: Normally there is no RBC found in CSF.
Presences of RBC indicates hemorrhage in the CNS.
Increased number of WBC (above 5/cmm) indicates infection somewhere in the
CNS.
Tuberculosis and viral infections may cause an increase in lymphocytes, while
pyogenic infection may cause increase in polymorphonuclear leukocytes

32. c. Sugar Content: bacterial infection such as tuberculosis meningitis
often lower the sugar content from the normal level of 40 to 60 mg. per
100ml
d. Chloride level: Bacterial infection also redue the chloride level from
the normal of 720 to 750mg/100ml
e. Protein level: in the presence of degenerative diseases and brain
tumors, the protein content is increased from the normal level of 30 to
50 mg/100ml
f. Serological test: serological test for syphilis may be positive in the CSF
even when the blood serology is negative.

33. 12. Usually the CSF is collected in two or three containers. The first specimen
may contain a tinge of blood due to the capillary bleeding at the site of the
puncture. The specimen bottles should be numbered 1,2,3 as the specimens are
collected.
13. Drugs to be injected must be warmed to body tmeperatuer and ti should be
injected very slowly

34. 14. At the end of the procedure, the puncture site is sealed to prevent leakage of
fluid from the spinal cavity and infection entering into the spinal cavity
15. The client’s vital signs should be checked frequently during and after the
procedure to detect the early signs for complications.

35. PREPARATION OF THE CLIENT:
 1. Explain the procedure to the client to relieve his anxiety and fear.
 2. Explain how he can co-operate in the procedure.
 3. Teach the client how he should maintain the desired positon during the
procedure.
 4. The client should understand that the needles inserted will be well below
the end of the spinal cord. The explanations are given in simple language.

36. 2. Warn the client that any movement during the procedure may cause injury to
the spinal cord and its nerves. So he should lie still during the procedure.
3. Check the B.P. pulse and respiration before standing the client to the
operation room and record the finding on the nurse’s record for further
reference

37.  4. Prepare the skin as for a surgical procedure. Shave and clean the area
thoroughly with soap and water. Again the skin is disinfected with spirit and
iodine just before doing the spinal puncture.
5. Put on clean and loose garments.
6. Arrange the articles that are necessary for lumbar puncture at the bedside
table. Remove the unnecessary articles from the bedside. Arrange the articles for
the convenience of the doctor

38. 7. Fanfold the top bedding well below the hips and over the shoulders with a
bath blanket. Expose only the site of the spinal puncture.
8. Fold back the upper garments above the waist line and the lower garments wll
below the hip exposing the site
9. Protect the bed with mackintosh and towel
10. Provide a stool for the doctor to sit comfortabley during the procedure
11. The nurse should stand near the client throughout the procedure observing
the general condition and helping him to maintina the desired positon. If the
client cannot maintain the desired position by himself, the nurse helps him.
Instruct the client to breathe quietly and not talk or cough during the procedrue
unless it is asked by the doctor.

39. AFTER CARE OF THE CLIENT:
1. As soon as the needle is withdrawn, seal the puncture site to prevent leakage
of CSF
2. Place the client comfortabley on the bed in a supine position
He should be asekd to lie down flat on bed for 12 to 24 hours.
3. If the client develops post puncture headache, the following precautions are
taken:
a. Darken the room
b. Give plenty of oral fluids to re-establish the CSF level
c. Administer analgesics
d. Raise the foot end of the bed

40. 4. The client should be watched constantly for several hours after L.P. Any
changes in the client’s general condition should be reported immediately. Watch
for client’s colour, pulse, respiration, blood pressure and other signs of
complications such as nausea, vomiting, headache etc.

41. 5. Record the procedure on the clients’ chart with date and time. Record the
amount and character of the fluid withdrawn, the pressure of CSF measured,
client’s tolerance to the untoward reactions such as nausea, vomiting, headache
etc. developed in the post procedure period
6. The specimens of CSF collected should be sent to the laboratory without any
delay with proper label and a requisition form.
7. If there are no complications observed, the client may be allowed to be
upright after 8-12 hours.