Lumbar Puncture

LUMBAR PUNCTURE
OBJECTIVES:
1. To know the indications and contraindications of lumbar puncture/spinal tap.
2. Review functional anatomy
3. To know the proper procedure and technique for a successful and safe spinal tap
INDICATIONS:
Lumbar puncture (LP)/ spinal tap is the acquisition of cerebral spinal fluid (CSF) which
is essential or extremely useful in the diagnosis of CNS infections and, in certain
settings, for help in the diagnosis of subarachnoid hemorrhage SAH, CNS malignancies,
demyelinating diseases, etc.
LP is also required as a therapeutic or diagnostic maneuver in the following situations:
● Spinal anesthesia
● Intrathecal administration of chemotherapy
● Intrathecal administration of antibiotics
● Injection of contrast media for myelography or for cisternography
CONTRAINDICATIONAS:
Absolute contraindications:
● Patient refusal
● Infection at the site of infection
Relative contraindications: caution should be used in patients with:
● Possible raised ICP with risk for cerebral herniation due

to obstructive hydrocephalus, cerebral edema, or space-occupying
lesion.
● Thrombocytopenia or other bleeding diathesis, including ongoing

anticoagulant therapy.
● Suspected spinal epidural abscess.

FUNCTIONAL ANATOMY:
Vertebral segments: lumbar

Spinal Ligaments: posterior ligaments
Spinal Cord Membranes: Pia, Arachnoid, Dura

Conus medullaris
SURFACE LANDMARKS
WHEN PERFORMING A LUMBAR TAP USING THE MIDLINE APPROACH, THE LAYERS OF ANATOMY THAT
ARE TRAVERSED ARE (FROM POSTERIOR TO ANTERIOR):
• Skin
• Subcutaneous fat
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Dura mater
• Subdural space
• Arachnoid mater
• Subarachnoid space
EQUIPMENT
Prepackaged lumbar puncture kits are available. If not available, necessary equipment includes the
following:
 Sterile gloves; Mask

 Sterile drapes and/or towels
 Antiseptic solution (e.g., chlorhexidine, povidone-iodine, alcohol wipes)
 Sterile gauze
 Local anesthetic without epinephrine; Topical anesthetic (for children)
 Spinal needle with stylet: G 20 or 22; 9-cm-long for adults, 6 cm for children, 4 cm for
infants; (for spinal anesthesia G 25, 26, 27)
 4 CSF collection tubes (labeled 1 through 4) for laboratory studies
 Manometer and stopcock; optionally, short extension tubing
 Adhesive bandage
Needles: Usually Quincke, Sprotte, or Whitacre

POSITION OF THE PATIENT
• Proper positioning of the patient is essential for a fast, successful lumbar tap.
• Personnel trained in positioning patients are invaluable, and commercial positioning devices
may be useful.
• There are three main positions: the lateral decubitus, sitting, and prone positions.
The sitting position avoids the potential rotation of the spine that can occur with the lateral decubitus
position.
Using a stool for a footrest and a pillow for the patient to hold can be valuable in this position.
The patient should flex the neck and push out the lower back to open up the lumbar intervertebral
spaces.
Lateral decubitus position is a commonly used position.
Ideal positioning consists of having the back of the patient parallel to the edge of the bed closest to the
anesthesiologist, with the patient’s knees flexed to the abdomen and neck flexed.
It is beneficial to have an assistant to help hold and encourage the patient to stay in this position.
TECHNIQUE OF LUMBAR PUNCTURE
1. The midline should be palpated.

2. The iliac crests are palpated, and a line is drawn between them to find the body of L4 or
the L4–L5 interspace.
3. Skin asepsis and antisepsis; draping
4. The antiseptic solution should be allowed to dry, and unused skin preparation solution
must be removed from the workspace.
5. A small wheal of local anesthetic is injected into the skin at the planned site of insertion.
More local anesthetic is then administered along the intended path of the spinal needle
insertion to the estimated depth of the supraspinous ligament.
Care must be taken in thin patients to avoid dural puncture, and inadvertent spinal
anesthesia, at this stage.
Midline Approach:
1. The spinal needle is passed through the identified space where local anesthesia was
given.
2. The needle passes through the subcutaneous tissue, supraspinous ligament,
interspinous ligament, ligamentum flavum, epidural space, dura mater, arachnoid mater
to reach the subarachnoid space.
Resistance changes as the spinal needle passes through each level on the way to the
subarachnoid space.
Subcutaneous tissue offers less resistance to the spinal needle than ligaments.
When the spinal needle goes though the dura mater, a “pop” is often appreciated.
3. Once this pop is felt, the stylet should be removed from the needle to check for flow of
CSF.
A common cause of failure to obtain CSF flow is the spinal needle being off the midline. The
midline should be reassessed and the needle repositioned.
Three independent predictors of success when performing neuraxial nerve block/lumbar tap :
1. adequate positioning
2. the anesthesiologist’s experience
3. the ability to palpate anatomical landmarks.
COMPLICATIONS
LP is a relatively safe procedure, but complications can occur even when standard infection control
measures and good technique are used. These complications include:
●Post-LP headache/Post-dural puncture headache (PDPH)
●Infection
●Bleeding
●Cerebral herniation
●Minor neurologic symptoms such as radicular pain or numbness
●Late onset of epidermoid tumors of the thecal sac
●Back pain
Post-LP headache/PDPH :
Headache, which occurs in 10 to 30 percent of patients, is one of the most common complications
following LP.
Caused by leakage of cerebrospinal fluid (CSF) from the dura and traction on pain-sensitive structures.
Patients characteristically present with frontal or occipital headache within 24 to 48 hours of the
procedure, which is exacerbated in an upright position and improved in the supine position.
Associated symptoms may include nausea, vomiting, dizziness, tinnitus, and visual changes.
Bleeding:
Serious bleeding that results in spinal cord compromise is rare in the absence of bleeding risk.
Patients who have thrombocytopenia or other bleeding disorders or those who received anticoagulant
therapy prior to or immediately after undergoing LP have an increased risk of bleeding. This risk may be
further increased with other factors that increase bleeding risk, such as traumatic or repeated taps.
A high index of suspicion of spinal hematoma should be maintained in all patients who develop
neurologic symptoms after an LP, including those with no known coagulopathy.
Generally, it is advised not to perform an LP in patients with the ff: (Case to case or institution based)
 coagulation defects who are actively bleeding

 have severe thrombocytopenia (e.g., platelet counts <50,000 to 80,000/microL)
 an international normalized ratio (INR) >1.4, without correcting the underlying
abnormalities
Patients who have persistent back pain or neurologic findings (e.g., weakness, decreased sensation, or
incontinence) after undergoing LP require urgent evaluation (usually spinal MRI) for possible spinal
hematoma.
The appropriate treatment for patients with significant or progressing neurologic deficits is prompt
surgical intervention, usually a laminectomy, and evacuation of the blood.
Timely decompression of the hematoma is essential to avoid permanent loss of neurologic function.
Patients with mild symptoms or early signs of recovery may be managed conservatively with vigilant
monitoring; dexamethasone may be administered to mitigate neurologic injury.
Cerebral herniation:
The most serious complication of LP.
Suspected increased ICP due to an intracranial mass lesion, cerebral edema, or obstructive
hydrocephalus is a relative contraindication to performance of an LP.
Risk factors:
● Altered mentation
● Focal neurologic signs
● Papilledema
● Seizure within the previous week
● Impaired cellular immunity

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LUMBAR PUNCTURE

● Infection at the site of infection

Relative contraindications: caution should be used in patients with:

● Possible raised ICP with risk for cerebral herniation due

● Thrombocytopenia or other bleeding diathesis, including ongoing

● Suspected spinal epidural abscess.

Vertebral segments: lumbar

Spinal Cord Membranes: Pia, Arachnoid, Dura

 Sterile gloves; Mask

Needles: Usually Quincke, Sprotte, or Whitacre

Lateral decubitus position is a commonly used position.

1. The midline should be palpated.

2. the anesthesiologist’s experience

3. the ability to palpate anatomical landmarks.

●Post-LP headache/Post-dural puncture headache (PDPH)

●Minor neurologic symptoms such as radicular pain or numbness

●Late onset of epidermoid tumors of the thecal sac

 coagulation defects who are actively bleeding

The most serious complication of LP.

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