3. CONTRAINDICATIONS :
Increased intracranial pressure
Cerebral herniation
Impending herniation
Possible increased ICP and focal neuro signs
Coagulopathy
Prior lumbar surgery
Severe vertebral osteoarthritis or degenerative disc
disease
Significant cardiorespiratory compromise
Infection near the puncture site
Space occupying lesion
4. EQUIPMENT :
Spinal needle
Less than 1 yr: 1.5in
1yr to middle childhood: 2.5in
Older children and adults: 3.5in
Three-way stopcock
Manometer
4 specimen tubes
Local anesthesia
Drapes
Betadine
5. PROCEDURE :
Performed with the patient
in the lateral recumbent
position.
A line connecting the
posterior superior iliac
crest will intersect the
midline at approx. the L4
spinous process.
Spinal needles entering the
subarachnoid space at this
point are well below the
termination of the spinal
cord.
6. LP in older children may be
performed from L2 to L3
interspace to the L5 to S1
interspace.
At birth, the cord ends at the
level of L3.
LP in infant may be performed
at the L4 to L5 or L5 to S1
interspace.
7. Position the patient:
Generally performed in the
lateral decubitus position.
A pillow is placed under the
head to keep it in the same
plane as the spine.
Shoulders and hips are
positioned. perpendicular with
the table.
Lower back should be arched
toward practitioner.
8. a. Ligament flavum is a strong,
elastic, yellow membrane
covering the interlaminar space
between the vertebrae.
b. Interspinal ligaments join the
inferior and superior borders
of adjacent spinous processes.
c. Supraspinal ligament connects
the spinous processes
9. A topical anesthetic (e.g. EMLA cream) can be applied 30 to 60
minutes before performing the puncture to minimize pain on
penetration.
Either a sitting or lateral decubitus position can be used .
Monitor the patient visually and with pulse oximetry for any signs
of respiratory difficulty as a result of assumed position.
The subarachnoid space must be entered below the level of spinal
cord termination.
The spine should be flexed maximally to increase spacing between
spinous processes.
Extensive neck flexion, however, should be avoided to minimize a
chance of respiratory compromise.
Make sure the hips and shoulders are aligned & are perpendicular
to the bed surface.
10. The patient’s back should be carefully prepared and draped
using provided disinfecting solution and drapes.
Orient yourself anatomically and find the L4 spinous process
at the level of iliac crests
Palpate a suitable interspace distal to this level.
Infiltrate 2% Lidocaine subcutaneously (without epinephrine
to prevent cord infarction should it be introduced into the
cord by accident) with a fine needle.
A field block can be applied injecting into and on either side
of the interspinous ligaments.
Identify the two spinal processes in between which the
needle will be introduced, penetrate the skin and slowly
advance the tip of the needle at about 10 degrees cephalad
(i.e. toward the patient’s umbilicus).
11. Remove the stylet and check for clear fluid will flow from
the needle when the subarachnoid space has been penetrated.
The ligaments offer resistance to the needle, and a “pop” is
often felt as they are penetrated.
Withdraw the needle leaving the tip in, recheck the
landmarks and slowly progress the needle again.
Measure the opening pressure using the manometer by
attaching it via a stopcock to the spinal needle.
Normal opening pressure ranges from 10 to 100 mm H2O in
young children and 60 to 200 mm H2O after eight years of
age
12. CSF volume of 1cc obtained in 3 tubes.
In the neonate, 2ml in total can be safely removed.
In an older child 3 to 6 ml can be sampled depending
on the child’s size.
Tube 1 is used for determining protein and glucose
Tube 2 is used for microbiologic and cytologic studies
Tube 3 is for cell counts and serologic tests for syphilis
15. INDICATIONS :
Diagnostic :
- Idiopathic Thrombocytopenic Purpura
- Aplastic Anemia
- Leukemia
- Megaloblastic Anemia
- Infections e.g. Kala Azar
- Storage disorders e.g. Gaucher’s disease
- PUO
- Myelofibrosis
Therapeutic :
- Bone Marrow Transplantation
16. CONTRAINDICATIONS :
Hemorrhagic disorders such as congenital
coagulation factor deficiencies (eg, hemophilia),
disseminated intravascular coagulation and
concomitant use of anticoagulants.
Skin infection or recent radiation therapy at the
sampling site.
Bone disorders such as osteomyelitis or
osteogenesis imperfecta.
17.
18. PROCEDURE :
Obtain consent from a parent or guardian.
If the posterior iliac crest is the chosen site, patients are
generally placed in the lateral decubitus position or the
prone position
Sterilize the site with the sterile solution
Place a sterile drape over the site, and administer local
anesthesia, letting it infiltrate the skin, soft tissues, and
periosteum.
After local anesthesia has taken effect, make an incision
through which the bone marrow aspiration needle can be
introduced .
19.
20.
21. If a guard is present, should be removed before starting
bone marrow aspiration, to ensure adequate depth of
penetration..
In general, the needle should be advanced at an angle
completely perpendicular to the bony prominence of the
iliac crest.
Once the needle passes through the cortex and enters the
marrow cavity, it should stay in place without being held.
Once the periosteum has been penetrated, pressure is used
to advance the needle through the cortex and rotate the
needle in a semicircular motion, alternating clockwise and
counterclockwise movements.
22. If the patient is in the lateral position, the hip may be
stabilized with the other hand to get a better feel for the
position and depth of the needle.
The thumb of this hand can be to mark the desired site
and to prevent accidental repositioning of the needle.
A slight give will be felt, after which you will feel that
the needle is fixed solidly within the bone.
Remove the stylet and aspirate approximately 1 ml of
unadulterated bone marrow into a syringe.
Specimen is taken and is assessed for the presence of
bony spicules.
23. If the specimen shows spicules, the specimen should be
used to make smear slides immediately.
If spicules are sparse or are not present, a new sample
should be obtained from a slightly different site.
The needle is left in place and sequential syringes are
filled that have been prepared with heparin or other
anticoagulants or preservatives, depending on the
requirements for specific studies to withdraw samples
for additional analysis.
Then remove the needle, either after reinserting the
stylet or with the syringe attached.
24. COMPLICATIONS :
Hemorrhage
Infection
Persistent pain at the marrow site
Retroperitoneal hematomas
Trauma to neighboring structures (e.g., lacerations
of a branch of the gluteal artery) and soft tissues
