MAIN ARTICLE

How to perform a lumbar puncture

Clarence Mwelwa Patrick Chikusu
Clinical Fellow, Acute and Elderly Care Medicine, Ashford and St Peter’s Hospitals NHS Foundation Trust
Correspondence to: Clarence Chikusu [email protected]

Background Contraindications

The first reports of a lumbar puncture (LP) being • Suspected intracranial mass lesion or space occupying
undertaken are from the late 19th century [1]. Heinrich lesion
Irenaeus Quince (with whom the Lumbar Puncture is • Disorders of coagulation or blood diathesis
commonly associated with) reported to the tenth congress
of Internal Medicine in April 1891¬¬ that he had • Underlying spinal abscess
performed in one case 3 lumbar punctures in a patient • Imaging evidence of midline shift
with suspected tuberculous meningitis who was comatose
• Posterior fossa tumour or other suspected 4th
[1,2]. The procedures were done at 3 day intervals and
ventricular lesion
the patient recovered. The other case was in a patient
that had chronic hydrocephalus and suffered headaches. Consent
Lumbar puncture in this patient relieved the symptoms. It is good practice that consent is obtained before
One month after Quincke’s report to the congress, Walter undertaking any invasive intervention or procedure, and
Essex Wynter, a Registrar at the time, published in the this is the case for performing a lumbar puncture.
Lancet 4 cases of cerebrospinal fluid (CSF) aspiration
in patients with meningitis suspected [3]. The Lumbar Equipment and Tools
Puncture was a procedure dedicated to the relief of • Up to 6 sample bottles (usually white top) depending
symptoms (at that time mainly meningitis or raised on the tests required from the sample. These should
intracranial pressure) [4]. It has subsequently become normally be pre-labelled with a number (1-6). Some
a procedure that can be diagnostic or therapeutic, and centres use up to three, others four, but this will
the technique has become more refined with improved depend on the number of tests needed.
instruments, awareness of aseptic techniques and the
increased availability and knowledge of anaesthesia. • A serum glucose bottle is part of the equipment
(a paired serum with CSF glucose is usually sent
Indications particularly in infective diagnosis).
• In cases of suspected subarachnoid haemorrhage • A serum bottle for electrophoresis paired with
(SAH) CSF when checking for oligoclonal bands (when
• Diagnosis of meningitis (bacterial, viral, fungal, diagnosing multiple sclerosis for instance).
malignant, atypical) • Drawing up needles for local anaesthetic, with 10-
• Treat raised intracranial pressure (idiopathic 20ml syringe for the administration of the local
intracranial hypertension or other causes such as anaesthetic including a needle for subcutaneous
meningitis) injection and deep tissue injection.

• Aid diagnosis of normal pressure hydrocephalus • Spinal needle (we advise 22G Whitcare or ‘pencil tip’
needle which is atraumatic and is the preferred choice
• Exclusion of neurological, vasculitic, autoimmune or over the cutting or Quincke needles)
paraneoplastic disorders and syndromes
• Manometer with 3 way tap
• Administration of therapeutic agents (for
chemotherapy, analgesia/anaesthesia, antimicrobial • Dressings pack with appropriate disinfectant, gauze
therapy) and sterile drapes
• For cytology in suspected cancer 10cc is best,
It important to note that in suspected SAH, a lumbar otherwise 1-2 cc per bottle. All these quantities are
puncture 12 hours after onset of symptoms is ideal, but safe if LP is safe in the first place!
can be diagnostic after 2 weeks of onset [8]. This is not
the case after 4 weeks. • If pressure is > 25cm I take 30 cc and don’t do closing
pressure (not reliable).

Vol 9. No 4. November 2016 85 South Sudan Medical Journal

 MAIN ARTICLE

Positioning As such is can be used as a guide in conjunction with

palpating for the spinous process of the lumbar vertebrae
There are two positions that a patient can be in for a and their interspaces.
lumbar puncture – see Figure 1. The preferred position is
lying on their side (left lateral) with the patients legs flexed The interspace of L3/L4 or L4/L5 are used as entry points
at the knee and pulled in towards their chest, and upper – see Figure 2.
thorax curved forward in an almost foetal position.
It is important to note that the point at which the needle
enters the spine needs to be at the same level as the midline
of the spine, which ideally should be at the same level as
the patients head to give the most accurate reading5, 6.
At times for comfort a pillow may be placed under the
patient’s head and / or between their legs. The patient’s
back should be perpendicular to the table.
The second position is the upright or sitting position.
This is used when the lateral position has failed. Sit the
patient on the edge of bed, with their legs resting on a
stool or chair, ask them to roll their shoulders and upper
back forwards and the chair is positioned to bring the
thighs up towards the abdomen. The opening pressure
where indicated is measured in the lateral position.
If the sitting position is adopted for whatever reason and
an opening pressure is sought, the patient should be moved Figure 2. Surface anatomy with markings on a training mannequin
carefully into the lateral position once the needle is in the for lumbar puncture -Doherty CM. & Forbes RB. Diagnostic Lumbar
correct space. Once the patient is in this position, the Puncture. Ulster Medical Journal 2014; 83(2): 93-102 – reproduced
stylet may be withdrawn. It is important not to remove with permission.
the stylet before the patient is safely positioned onto the
lateral side.
Technique
Once the correct entry point is identified, clean the skin
with antiseptic and proceed with local anaesthetic initially
subcutaneously, and then deeper into the layers ensuring
a wider distribution of anaesthetic.
After giving the anaesthetic enough time to work, the
spinal needle (see Figure 3) may be introduced into the
space. Advance the needle slowly towards the umbilicus.
When using a cutting needle it is important to ensure that
the bevel of the needle faces parallel to the direction of the
cord and spinal fibres. Therefore if in the sitting position,
Figure 1. Positioning the patient for Lumbar Puncture – illustration the bevel faces to the side, in the lying position it shall face
by Chirwa CA &Chirwa M reproduced with permission. upwards [6].
This reduces the likelihood of post procedure
complications such as headache. The atraumatic needle
Anatomy (‘pencil tip’) reduces the likelihood of this problem.

Locating the correct entry point is performed by The dural space is approximately 4-5cm (see Figure 4)
identifying the surface anatomy of the L3/L4 interspinal from the surface if the skin [5,6]. When the needle is
space (which is a few mm above the spinous process of advanced some practitioners will feel a give or a ‘pop’
L4). This is done generally by palpating the iliac crests. sensation when the needle enters into the space although
this is not always the case.
An imaginary line between the highest points of the iliac
crests usually bisects the L3/L4 space. However this will At times with the needle passing through the different
vary according to a number of variables, such as obesity. layers, there may be similar sensations felt but the needle

South Sudan Medical Journal 86 Vol 9. No 4. November 2016

 MAIN ARTICLE

is not yet in the correct space. As such, some practitioners

advance the needle and withdraw the stylet at intervals
until the space is entered and CSF is drawn.
If no fluid is obtained, replace the stylet replacing and
advance the needle again by a few more centimetres or
adjust the angle of the needle. Some patients may require
longer needles which are available.

Figure 5. Manometer with three way tap (stopcock) used for the
measurement of opening and closing pressures

The manometer (see Figure 5) is attached to measure the

opening pressure (if indicated) one CSF is drawn. This
is must be measured in the lying position. A pressure of
10-20cm H2O is normal.
If measuring opening pressures for diagnostic purposes or
for therapeutic purposes, a closing pressure is useful, but
if the opening pressure greater the 25cm H2O, the closing
pressure may not reliable.
Figure 3. Examples ofSpinal needles (Quincke’s) demonstrating the Normally 1-5mls of CSF is generally enough per bottle.
needle with stylet in situ before being withdrawn. Black is 22G In general terms up to 20mls in total of CSF can be
and Yellow is 20G. drawn safely. With idiopathic intracranial hypertension
for instance, greater volumes of up to 30-40mls may be
needed to aid symptomatic relief.
This may also be needed if the opening pressures are very
high (>25cmH2O). However, large volume LP’s can lead
to complications. It is therefore advisable to discuss this
with a neurologist and seek advice on other therapeutic
options for patients with high opening pressures.
On the whole fluid is the sent in the appropriate sample
bottles for:
• Cell Count and differential
• Biochemistry which includes protein and glucose (for
which a paired serum glucose is also sent)
• Microscopy, Culture and Gram Stain (MC+S)
Samples may also be sent for xanthochromia (for SAH),
viral PCR, oligloclonal bands, fungal, vasculitic and
Figure 4. Depicting the distance to the Ligamentum Flavum autoimmune screen, malignancy and prion disease to
through which the needle enters and passes through, at which name but a few. When testing for malignancy, up to 3
point CSF will be aspirated- Doherty CM. & Forbes RB. Diagnostic LP’s may be required. Refer to local lab guidelines for
Lumbar Puncture. Ulster Medical Journal 2014; 83(2): 93-102 – results interpretation.
reproduced with permission.

Vol 9. No 4. November 2016 87 South Sudan Medical Journal

 MAIN ARTICLE

After obtaining CSF, always replace the stylet before to infuse mannitol. Local guidelines for this should
withdrawing the needle. be sought.
Things to watch for post procedure [6,9] • Epidermoid tumour this is rare and may occur
after a few years, caused by epidermoid tissue being
• Headache (Post Lumbar Puncture Headache). This is transplanted into the spinal canal during procedure.
the most common complication, especially in young
adults. Can be managed with simple analgesics or
non-steroidal anti-inflammatories. Patients are References
advised to lay flat for 30-60mins post procedure.
They may require an additional 2 weeks depending 1. Quincke HI. Ueber hydrocephalus. Verhandlung des
on symptoms after this of strict bed rest. At times Congress Innere Medizin (X) 1891; 321-39
anaesthetic management using an epidural blood 2. Quincke HI. Die lumbalpunction des Hydrocephalus.
patch may be required for severe intractable cases. Berlin Klin Wochenschr 1891; 28: 929-33
• Infection can occur as cellulitis, abscesses or discitis, 3. Pearce JM. Walter Essex, Quincke, and lumbar
vertebral osteomyelitis, bacterial meningitis. puncture. Journal of Neurology Neurosurgery Psychiatry
• Back Painmay occur at the entry site or elsewhere 1994 February; 57(2): 179
in the back as a consequence of the trauma of the 4. Frederiks JAM. & Koehler PJ. The First Lumbar
procedure though mild. Puncture. Journal of the History of the Neurosciences: Basic
• Bleeding may occur at all levels of the dura. This will and Clinical Perspectives 1997; Volume 6 Issue 2: 147-53
be significantly worse in those with coagulopathies 5. Doherty CM. & Forbes RB. Diagnostic Lumbar
or anticoagulated (SAH, subdural or epidural Puncture. Ulster Medical Journal 2014; 83(2): 93-102
haematoma.
6. Johnson KS. & Sexton DJ. Lumbar Puncture:
• Nerve irritation or damage might occur if the spinal Technique, indications, contraindications, complications
needle impinges on a nerve or nerve root. Also as in adults. http://www.uptodate.com/contents/lumbar-
the needle is withdrawn, it is important that the puncture-technique-indications-contraindications-and-
stylet is replaced before had to prevent the likelihood complications-in-adults?source=search_result&search=lu
of a nerve being withdrawn. This also reduces the mbar+puncture+technique&selectedTitle=1~150
likelihood of post LP headache as mentioned before.
7. Fiorito-Torres F. Rayhill M. & Perloff M. Idiopathic
• Blood in the CSF can occur with initial aspiration of Intracerebral Hypertension (IIH)/Pseudotumor:
CSF and usually gives falsely raised red cell counts Removing Less CSF Is Best. Neurology April 8 2014; 82
in the first bottle sent to the lab. Subsequent bottles (10): Supplement I9-1.006
show a reduction in the red cell count.
8. Diagnosis and management of headache in adults. A
• Cerebral herniation is rare but a serious complication national clinical guideline. SIGN Scottish Intercollegiate
and vigilance for any symptoms or signs is advised. Guidelines Network. 107 November 2008
It is imperative that a pre LP CT scan of the brain is
undertaken in patients with reduced consciousness, 9. Ali Moghtaderi, Roya Alavi-Naini and SalehehSanatinia
papilloedema or other neurological features of (2012). Lumbar Puncture: Techniques, Complications
raised intracranial pressure. In bacterial meningitis, and CSF Analyses, Emergency Medicine - An
cerebral herniation may occur post LP. Other International Perspective, Dr. Michael Blaivas (Ed.),
intracerebral infections such as TB or malaria may ISBN: 978-953-51-0333-2, In Tech, Available from:
also. As such CT is useful in a diagnostic capacity http://www.intechopen.com/books/emergency-
for the cause of altered neurology as well as helping medicine-aninternational-perspective/lumbar-puncture-
determine the risk of raised intracranial pressure and techniques-complications-and-csf-analyses
cerebral herniation in LP. It must be noted that a
normal CT will not completely eliminate the risk of
herniation and neurological features mentioned must Acknowledgements Mr Chiloba A Chirwa and Mrs
be monitored nevertheless. Treatment of cerebral Mandee Chirwa for their help with the illustrations and
herniation or raised intracranial pressure is generally translations.

South Sudan Medical Journal 88 Vol 9. No 4. November 2016