Lumbar Puncture: Indications and Procedure Prepared by Dr. Manal Moussa Ibrahim

Session Objectives - Discuss the indications and contraindications for lumbar puncture (LP). - Review the procedure of LP. - Present techniques to minimize post LP headache.

Indications for Lumbar Puncture - Diagnosis of central nervous system (CNS) infection. - Diagnosis of subarachnoid hemorrhage (SAH). - Evaluation and diagnosis of inflammatory CNS processes. - Infusion of anesthetic, chemotherapy, or contrast agents into the spinal canal. - Treatment of intracranial hypertension. 15% Of seizures result in injury or death Head contusions and lacerations common Mortality rates 1.2% of all seizures 3 to 26% in SE Mortality rate 10 times higher in adults (vs children) SE mortality highest with hypoxic or ischemic insult DeLorenzo et al. Neurology 1996;46:1029; J Clin Neurophysiol 1995;12:316; Epilepsia 1992;33(Suppl 4):S15. Hauser. Neurology 1990;40(Suppl 2):9. Kirby and Sadler. Epilepsia 1995;36:25. Terrence et al. Ann Neurol 1981;9:458.

Contraindications - Skin infection near site of LP. - Alteration of intracranial pressure due to cerebral mass. - Uncorrected coagulopathy. - Acute spinal cord trauma.

Lumbar puncture procedure Equipment: - 18G or 20G sterile spinal needle with stylet (22G needle for children). -Three-way stopcock. - Manometer. Small adhesive bandage.- - Sterile gloves for the physician. - Sterile gloves for the nurse. - Sterile gauze pad.

Equipment: Cont. - Antiseptic solution (e.g. Iodine). - 25G sterile needle for injecting anesthetic. - Three sterile collection tubes with stoppers. - Overbed table. - 3-ml syringe for local anesthetic. - Laboratory request forms and laboratory biohazard transport bag. - Labels and light source. - Disposable lumber puncture trays contain most of the needed sterile equipment.

Preparation: 1- Determine whether written consent for the procedure has been obtained. 2- Explain the procedure to the patient. 3- Instruct the patient to void before the procedure.

Performance: 1- The patient is positioned on lateral recumbent position or sitting upright position. 2- Small pillow may be placed under the patient's head. 3- A pillow may be placed between the legs. 4- The patient is encouraged to relax and is instructed to breathe normally. 5- The physician cleanses the puncture site with an antiseptic solution and drapes the site.

Technique - Lateral Recumbent position Sitting upright

Positioning CORRECT INCORRECT

Skin Preparation - Overlying skin cleaned with povidone-iodine. - Sterile drape placed with an opening over the LS.

Performance: Cont. 6- The physician injects local anesthetic to numb the puncture site. 7- The physician inserts a spinal needle into the subarachnoid space through the third and fourth or fourth and fifth lumber interspace. 8- A specimen of CSF is removed and usually collected in three test tubes, labeled in order of collection. 9- A pressure reading may be obtained. 10- The needle is withdrawn.

Performance: Cont. 11- The physician applies a small dressing to the puncture site. 12- The tubes of CSF are sent to the laboratory immediately. 13- Instruct the patient to lie prone for 2 to 3 hours. 14- Monitor the patient for complications of lumber puncture. 15- Notify physician if complications occur. 16- Encourage increased fluid intake.

17- Documentation: - Record the initiation and completion of the procedure. - Patient's response. - Administration of drugs. - Number of specimen tubes collected. - Time of transport to the laboratory. - Specimen color, and any other characteristics.

Positioning: Key to Success - Fetal position with neck, back, and limbs held in flexion. - Lower lumbar spine flexed with back perfectly perpendicular to edge of bed. - Hips and legs should be parallel to each other and perpendicular to table.

Spinal Needle Insertion - Local anesthesia infiltrated. - 20 or 22 gauge spinal needle with stylet. - Advance spinal needle slowly, angling slightly toward the head. - Flat surface of bevel of needle positioned to face patient’s flanks. 15% Of seizures result in injury or death Head contusions and lacerations common Mortality rates 1.2% of all seizures 3 to 26% in SE Mortality rate 10 times higher in adults (vs children) SE mortality highest with hypoxic or ischemic insult DeLorenzo et al. Neurology 1996;46:1029; J Clin Neurophysiol 1995;12:316; Epilepsia 1992;33(Suppl 4):S15. Hauser. Neurology 1990;40(Suppl 2):9. Kirby and Sadler. Epilepsia 1995;36:25. Terrence et al. Ann Neurol 1981;9:458.

Post-LP Headache - Etiology: Prolonged leakage of cerebrospinal fluid due to delayed closure of dural defect. - Low CSF pressure. - Incidence 1-70%. - Contributing factors: - Diameter of needle, shape of needle, diagnostic vs. spinal anesthesia.

Minimizing Post-LP Headache - Techniques: - Needle choice. - Number of attempts. - Reinsertion of Stylet. - Bed Rest after Procedure.