1st Year MSc Nursing Medical Surgical Nursing MIMS CON

1. Prepared by
Ms.Theertha P Krishna
1st Year MSc Nursing
MIMS CON

2. INTRODUCTION
 A Lumbar puncture (or LP, and known as
a spinal tap) is a diagnostic and at times
therapeutic medical procedure.
Diagnostically it is used to collect
cerebrospinal fluid (CSF) to confirm or
exclude conditions such as meningitis and
subarachnoid hemorrhage and it may be
used in diagnosis of other conditions.

3. DEFINITION
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 arachanoid 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fluid can be withdrawn or a substance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.

5. INDICATION
Lumbar puncture may be done to:
 Collect cerebrospinal fluid for laboratory analysis.
 Measure the pressure of your cerebrospinal fluid
 Inject spinal anesthetics, chemotherapy drugs or
other medications
 Inject dye (myelography) or radioactive
substances into cerebrospinal fluid to make
diagnostic images of the fluid's flow.

6. 2.To obtain CSF for the diagnosis of:
 Meningitis
 Meningo encephalitis
 Subarachnoid hemorrhage
 Malignancy – diagnosis and treatment

7. CONTRAINDICATION
 Idiopathic or Suspicion of increased ICP
cerebral mass.
• Bleeding diathesis
• Skin infection
• Abnormal respiratory pattern
• Hypertension with bradycardia and
deteriorating consciousness.

8.  Obtunded state with poor peripheral
perfusion or hypotension.
 Seizures-prolonged or recent (within 30
minutes)
 Inexperienced physician
• Vertebral deformities (scoliosis or kyphosis)
• Acute spinal trauma.

9. WHERE TO INSERT THE NEEDLE ??

10. WHERE TO INSERT THE NEEDLE ??
The imaginary line that crosses
the lumbar region of the back
joining the posterior superior
iliac crests will cross the L3-L4
interspace

11. EQUIPMENTS
 A spinal or lumbar puncture tray should include the
following items:
Sterile dressing
Sterile gloves
Sterile drape
Antiseptic solution with skin swabs
Lidocaine 1% without epinephrine
Syringe, 3 mL
Needles, 20 and 25 gauge

12. Spinal needles, 20 and 22 gauge
Three-way stopcock
Manometer
Four plastic test tubes, numbered 1- 4, with
caps
Syringe, 10 mL (optional).

14. NEEDLE GAUGES

15. PROCEDURE
 Assess the general condition of the patient and check
all the laboratory investigations. Preapare all the
articles.
 Wash hands
 Wear the gloves and maintain sterile field.
 Performed with the patient in the lateral recumbent
 position.
 Spinal needles entering the subarachnoid space at this
 point are well below the termination of the spinal
cord.

16.  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.
 Cleanse skin with povidone iodine from puncture
site radially out to 10 cm and ALLOW TO DRY

17.  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.
 Insert spinal needle with stylet with bevel up to
keep cutting edge parallel with nerve and ligament
fibers.

18.  Hold needle firmly
 A “pop” of sudden decrease in resistance indicates that
ligamentum flavum and dura are punctured.
 Remove stylet and check for flow of spinal fluid.
 If no fluid, then:
 Rotate needle 90°.
 Reinsert stylet and advance needle slowly
checking frequently for CSF.

19.  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.

22.  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 freeflow of CSF is obtained.
 Read column when highest level is achieved
and respiratory variation is noted

24.  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

25. 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.

28. AFTER CARE
 Once the needle is removed, a small
bandage is placed over the hole in your skin
and you will be asked to remain flat on the
exam table for a minimum of 30 minutes to
help prevent any leakage of spinal fluid after
the procedure.
 You will be encouraged to drink extra fluid
while you recover and for the next two to
three days.

29.  A headache following spinal tap occurs in up to 20
percent of patients. It typically occurs upon standing
and is relieved by lying down.
 You should lie flat on your back or stomach (but not
your side) for as long as you can the first 24 hours after
the procedure or if you have a headache.
 Also, to minimize complications, it is recommended
that patients avoid bending and heavy lifting for two
to three days following the procedure.

30.  Even lifting a small child following this procedure
can cause the clot formation to become dislodged,
resulting in a headache.
 Your provider will tell you when it is safe to return
to work. Most people can generally return to work
in one to two days.
 Wash hands.
 Recording and reporting.

31. COMPLICATIONS
 Headache
 Apnea (central or obstructive)
 Back pain
 Bleeding or fluid leak around spinal cord
 Infection, pain, hematoma
 Subarachnoid epidermal cyst
 Ocular muscle palsy (transient)
 Nerve Trauma