The bevel of the needle is maintained in a horizontal position with the flat portion of the bevel pointing up and it should be parralel to the direction of the dural fibers. Once a subarachnoid space has been reached, a manometer can be attached to the needle to record the opening pressure. Fluid is then usually obtained for collection. Fifteen millilitres of CSF is usually sufficient for a sample. The fluid is then taken and may be analysed for a number of parameters according to the clinical presentation including:.
The minor risks and complications associated with a lumbar puncture include backache, post lumbar puncture headache , radicular pain and numbness. Major complications that rarely occur include infection, haemorrhage, damage to the spinal cord or nerve roots and herniation of cerebral tissue in patients with pre-existing increased intracranial pressure.
View more information about myVMC. Please be aware that we do not give advice on your individual medical condition, if you want advice please see your treating physician. Parenting information is available at Parenthub. Are you a Health Professional? In diagnostic or therapeutic lumbar puncture: Serially collect CSF without active aspiration up to 40 mL may be collected. After completion of puncture: Insert the stylet back into the puncture needle.
Recommend bedrest for 1—2 hours and sufficient fluid intake. Document the lumbar puncture in the patient's file. Cerebrospinal fluid analysis. Am Fam Physician. Guidelines on routine cerebrospinal fluid analysis. Report from an EFNS task force. Eur J Neurol. Drop metastases. Diagnostic lumbar puncture. Ulster Med J. Bloody or xanthochromic i. Although signs of sepsis and meningitis intertwine in the newborn period, some neonatologist deem it unnecessary to perform LP on neonates evaluated for sepsis, especially those with early neonatal sepsis [ 4 , 5 ], because the antibiotics for both conditions would be the same.
However, it should be kept in mind that blood cultures are negative in one-third of neonates with meningitis who are very-low-birth-weight and born over 34 weeks of gestation [ 6 ].
Thus, in case of LP is not performed, a significant portion of neonates with meningitis would not get a correct diagnosis and would not be observed for the likely complications of meningitis. For that reason, the author is in favor of the opinion that LP should always be performed as soon as the infant becomes clinically stable and can tolerate the procedure even if it has not been possible to be performed at the first suspicion of meningitis. CSF inflammation lasts for a considerably long duration of days, which would allow the clinician to diagnose or exclude the diagnosis of meningitis although CSF cultures may become negative within hours.
Among therapeutic uses of LP, removal of CSF in the treatment of idiopathic intracranial hypertension pseudotumor cerebri is noteworthy [ 8 ]. A contraindication to LP can be absolute or relative. Bleeding diathesis: Our knowledge regarding the safety of performing LP in patients with thrombocytopenia or coagulation factor deficiency is limited. The safety of LP in thrombocytopenia was investigated in LPs performed on children with acute lymphoblastic leukemia in a retrospective study.
Serious complications of LP were not observed, regardless of platelet count. Because of the risk of subdural or epidural hematoma formation, many experts are against performing LP in patients with coagulation defects who are bleeding, severely thrombocytopenic i. Cardiopulmonary instability: The position of the newborn during LP may result in cardiopulmonary compromise.
This issue will be addressed further in detail elsewhere in the text. Suspected meningococcal septicemia with extensive or spreading purpura [ 10 ]. Conditions listed below are conditions in which imaging is needed before LP to exclude brain shift, swelling, or space occupying lesion [ 10 ]:. Consequently, LP is sometimes contraindicated simply because the patient is too ill to safely undergo the procedure.
Since patients without appropriate decisional capacity cannot give their informed consent and written informed consent of the caregiver is required before the procedure, in many institutions including ours, it is customary for physicians to talk to parents for providing informed permission for an intervention like LP on their child. Sometimes parents refuse to give assent and physicians are forced to initiate and continue CNS infection treatment totally blindfolded—that is without being able to include or exclude the diagnosis, grow the etiologic organism, and confirm the treatment success.
Although LP is a relatively safe process, results from studies show that the most frequent concern that lay behind a dissent is that LP would cause a complication [ 12 , 13 ]. The decision to carry out imaging before LP should be done on a case-by-case basis. Children with the following conditions may have increased intracranial pressure ICP and, because of the assumption is that CT scan of the head can more or less reliably predict who will and who will not experience brain herniation after lumbar puncture, are advised to have a CT scan performed before LP [ 15 ]:.
Risk for brain abscess immunocompromise or congenital heart disease with a right-to-left shunt. It should be noted that a normal CT scan does not fully exclude the presence of elevated ICP or the possibility that elevated ICP will not develop thereafter.
It is also known from adult studies that even those not undergoing LP because of a mass effect on head CTs may experience brain herniation [ 16 ]. Thus, although imaging for this purpose has been questioned by some specialists of this field, we agree with the recommendation that LP can be considered within 6 hours of a normal CT scan and no other contraindications [ 8 , 17 ].
Once the informed consent is obtained and imaging is performed if necessary, it is time for:. Materials needed for a smooth LP may be listed as follows [ 8 ]:.
CSF circulates in the space between the pia mater and the arachnoid mater, called subarachnoid space that surrounds the brain, spinal cord, ventricles, aqueductus cerebri Sylvius , and central canal of the spinal cord. After the formation of most of its volume in the choroid plexuses of the lateral ventricles, CSF passes through the foramina of Luschka and Magendie into the subarachnoid space, which is around the spinal column and over the cerebrum.
The CSF is primarily absorbed by the arachnoid villi found next to the sagittal sinus and then drains into the venous circulation [ 7 , 20 , 21 ]. In full-term infants, the volume of total CSF is about 40 mL, a quarter of which is in the ventricles, and the remainder in the subarachnoid space. CSF serves as a cushion between bony structures and the brain, together with the spinal cord. Since brain has no lymphatics, CSF also has an important role of carrying chemical byproducts of metabolism out of the brain to the venous circulation [ 7 ].
In order to avoid an accidental nervous injury, LP should be performed distal to the spinal cord, at the level of the cauda equina.
In older children, LP can be performed from the L2-L3 interspace to the L5-S1 interspace, because these interspaces are below the termination of the spinal cord [ 8 ]. At birth, the inferior end of the spinal cord is opposite to the body of the third lumbar vertebra L3 ; therefore, LP in children younger than 12 months must be performed below the L2-L3 interspace. An imaginary line that connects the two posterior-superior iliac crests intersects the spine at approximately the fourth lumbar vertebra.
This landmark helps to locate the L3-L4 and L4-L5 interspaces [ 8 ]. Anatomic structures pierced during median LP in order are skin, subcutaneous fat, supraspinal ligament, interspinal ligament, ligamentum flavum, dura mater, and arachnoid mater [ 7 ]. Most of the time, LP is a relatively simple procedure, although it can sometimes prove challenging even for the most experienced physician. The potential for complications during and following LP makes it necessary that it be performed in an area with proper resuscitation equipment.
Although not technically complex, LP is not a procedure that may be taken lightly, and it should only be performed by or under the supervision of a knowledgeable and experienced health professional. HR, respiratory action, and oxygen saturation should be monitored closely during the procedure in neonates.
Airway and resuscitation equipment should be immediately at hand. The patient is placed on the examining table. The goals of positioning are to stabilize the infant, to stretch the ligamenta flava and to increase the interlaminar spaces.
The most common positions used for the pediatric LP are the lateral recumbent and sitting positions Figures 1 and 2.
The assistant should ensure that the spinal column is in no rotation by keeping the shoulders and hips perpendicular to the bed. In the sitting position, the assistant holds the patient in the position with an arm and a leg in each hand while supporting the head to prevent from dropping, that is, excess flexion of the neck.
The positions are important because they may be superior over one another in avoiding a traumatic tap peripheral blood staining the CSF specimen and to get sufficient amount of cerebrospinal fluid, which should be feasible in a still infant with the widest interspinous space the space between the spinous processes of two adjacent vertebrae possible. Change of position does not alter subarachnoid space width, thus does not have a role in lumbar puncture success via this mechanism [ 25 ].
Safety, as well as the ease of the LP is a very important issue in the neonatal period especially considering the vulnerability of infants hospitalized in neonatal intensive care units. In adults, studies have uniformly showed that the maximal interspinal distance can be obtained with maximal hip flexion [ 26 , 27 ]. If the spinal canal is not entered, do not try to reposition the needle by moving the tip to one side or another; this can damage tissue. Instead, withdraw the needle nearly to the skin surface ie, outside of the spinal ligament before changing the angle and direction of insertion.
Seat yourself comfortably close to the patient before doing the procedure in the lateral decubitus position. Avoid inserting the lumbar puncture needle through tattooed skin because of a theoretical possibility that tattoo ink could be introduced into the CSF and cause irritation or toxicity. If necessary, either use an adjacent interspace or make a small stab incision through the tattooed epidermis with a scalpel and then introduce the needle through the incision. After the needle is through the skin and into the spinous ligament, recheck the patient's alignment hips perpendicular to bed and direction of the needle perpendicular to spine before inserting further.
Draw blood to measure glucose level before eg, by up to 30 minutes lumbar puncture so that level can be accurately compared with the CSF glucose level. With this timing, serum and CSF oligoclonal bands can be compared also. If lumbar puncture is unsuccessful in the decubitus position, try the sitting position, which may be successful because of increased spinal flexion and intervertebral space opening.
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Additional Considerations. Relevant Anatomy. Step-by-Step Description of Procedure. Warnings and Common Errors. Tricks and Tips. Test your knowledge. A patient experiences a seizure in which tingling and numbness occur in her left leg. Dysfunction in which of the following lobes of the brain is most likely responsible for this finding?
More Content. Click here for Patient Education. Image courtesy of John Greenlee, MD. Reduction of intracranial pressure in idiopathic intracranial hypertension. Absolute contraindications. Lower back discomfort or pain that may radiate to the posterior legs self-limited. Sterile gloves, gown, face mask, and cap.
Bedside ultrasound device with a high-frequency linear array probe. Identify and prepare the site Place the patient in proper position, using an assistant if needed. For children, apply topical skin anesthetic and allow time for it to take effect. Place sterile equipment on a sterile equipment tray and cover with a sterile drape. Ensure smooth working motion of the stopcock and of the spinal needle and stylet. Palpate the iliac crest and spinous processes to reconfirm the insertion site.
Lumbar puncture This lumbar puncture is done with the patient in the lateral decubitus position and the lumbar puncture needle inserted at the L3-L4 interspace.
Remove the stylet from the spinal needle. Never aspirate CSF fluid.
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