Procedures: Lumbar Puncture

LUMBAR PUNCTURE.: A procedure done to aspirate Cerebrospinal Fluid from
the spinal chord for diagnostic and therapeutic reasons.

Conditions where LP is indicated for diagnostic purposes

• Meningitis
• Encephalitis
• Subarachnoid hemorrhage
• Guillian Barre Syndrome
• Acute demylinating disease

Conditions where LP is indicated for therapeutic purposes

• Methotrexate in leukemia
• Spinal anaesthesia
• Benign intracranial hypertension

LP is contraindicated in these cases

• Raised intracranial pressure
• Spinal deformity
• Local infections

Procedure:
Patient is placed in a left lateral position with his neck bent and knees bent in full flexion up to the chest.However a sitting up position with patient bent forward is commonly done as it is easier to approach the site.

Patients back is cleaned properly with antiseptic solution and then draped. exposing only the preferred site. (between L4 and L5) .

Once the site is located through palpation(using the iliac crest as a marker..move medially), local anesthetic is injected subcutaneously around the site.

A spinal needle is then inserted, usually between the lumbar vertebrae L4/L5 and pushed in until there is a "give" that indicates the needle has passed the dura mater.

The stillet from the spinal needle is then withdrawn. If inserted properly drops of clear fluid will drip out slowly.If not, adjust needle till it does.These drops of cerebrospinal fluid are collected in a clear glass container. The opening pressure of the cerebrospinal fluid may be taken during this collection by using a simple column manometer.

The procedure is over by withdrawing the needle while placing pressure on the punctured site.

Patient is advised to not stand up or move around..complete bed rest is indicated for at least one hour


INSTRUMENTS REQUIRED

Material for sterile technique(only gloves and mask are necessary)
Spinal Needle, 20 and 22-gauge
Manometer
Three-way stopcock
Sterile drapes
1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
Material for skin sterilization (povidone iodine)
Adhesive dressing
Sponges

Complications:
There are a number of complications that might occur due to this procedure, hence why it is a very selective one and done with great caution

1) Headaches due to leakage of CSF
2) Herniation due to sudeen decrease in pressure
3) Haemorrhage
4) Infection is a high risk, as it is an invasive procedure


CSF Findings
A) Bacterial Meningitis

• Physical characteristics: Yellowish and turbid
• Cytology (cells/microL) : Lymphocytes: 5-50; Polymorphs: 200-2000
• Proteins (g/L) : 0.5 - 2.0
• Glucose (mmol/L) : <2.0

B) Tuberculous Meningitis

• Physical characteristics: Cob web appearance
• Cytology (cells/microL) : Lymphocytes: 100-300; Polymorphs: 0-100
• Proteins (g/L) : 5.0-15
• Glucose (mmol/L) : <2.0

LUMBAR PUNCTURE
Indications
1) Allows for immunologic confirmation of certain infections (eg, Lyme disease)
2) diagnosis of infections (eg, bacterial, mycobacterial, fungal, viral, protozoan)
3) diagnosis of certain inflammatory diseases (eg, multiple sclerosis, Guillain-Barre syndrome, vasculitis)
4) diagnostic tool in subarachnoid hemorrhage and leptomeningeal carcinomatosis
5) therapeutic particularly in benign intracranial hypertension (ie, pseudotumor cerebri), in which serial LPs may be used for treatment
6) as an access method, most commonly for spinal anesthesia, but also for introduction of radiopaque contrast media (eg, myelography), corticosteroids, antibiotics, and chemotherapeutic agents
7) Therapeutic reduction of cerebrospinal fluid (CSF) pressure
Contraindications
1) Local skin infections over proposed puncture site (absolute contraindication)
2) Raised intracranial pressure (ICP); exception is pseudotumor cerebri
3) Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or papilledema)
4) Uncontrolled bleeding diathesis
5) Spinal column deformities (may require fluoroscopic assistance)
6) Lack of patient cooperation
Preparation
1) Obtain informed consent
2) carefully explain the procedure to the patient and/or responsible caregiver, including the risks and benefits of the procedure
3) Inform patient of possibility of complications (bleeding, persistent headache, infection) and their treatment
4) Explain the major steps of the procedure, positioning, and postpocedure care
5) assistance of a nurse and/or other medical personnel may be needed
6) Sedative medication may be required in children or in the confused or combative patient.
7) Prepare procedure kit (aseptic)

Procedure

1) Obtain consent
2) Practice aseptic precautions and hygiene – wash hands, wear gloves
3) Position the patient - patient should be lying on his/her side (horizontal lateral decubitus position). The patient's body needs to be perfectly perpendicular to the bed. The patient should assume the fetal position (head, arms and legs to be flexed as much as possible)
4) Locate landmarks on body - The apex of the pelvic bone should be identified and a direct line should be visualized to the spine. The location so identified should be well below the tip of the conus. Two spinous processes in this area (ie, L4 and L5 levels) should be identified by palpation. On obese patients, find the sacral promontory; the end of this structure marks the L5-S1 interspace. Use this reference to locate L4-5 for the entry point.
5) Local anesthetic should be infiltrated and then the area should be prepared carefully and draped.
6) Assemble needle and manometer. Attach the 3-way stopcock to manometer
7) The spinal needle then is positioned between the 2 spinous processes already identified and introduced into the skin with the bevel of the needle facing up. The needle should be advanced slowly at a slightly upward angle (ie, toward the patient's head).
8) A slight pop or give is felt when the dura is punctured. If you hit bone, partially withdraw the needle, reposition, and re-advance
9) When CSF flows, attach the 3-way stopcock and manometer. Measure ICP…this should be 20 cm or less.
10) Once the ICP has been recorded, remove the 3-way stopcock, and begin filling collection tubes 1-4 with 1-2 ml of CSF each

Tube 1: glucose, protein, protein electrophoresis
Tube 2: Gram’s stain, bacterial and viral cultures
Tube 3: cell count and differential
Tube 4: reserve tube for any special tests

11) After tap, remove needle, and place a bandage over the puncture site. Instruct patient to remain lying down for 1-2 hours before getting up

Complications

1) Post–spinal tap headache
2) Nerve root trauma (eg, previous surgery in the area, scar tissue)
3) CNS infection (eg, immunocompromised patients)
4) Cranial, cervical, and lumbar subdural (more common) hematomas (eg, patients on anticoagulation therapy)
5) Rarely, discitis, system/portal venous gas (following a traumatic tap), clinical deterioration in the presence of dural arteriovenous fistula, symptomatic pneumocephalus in a patient with normal pressure hydrocephalus, cranial nerve palsies (4th and 6th)

Analysis of CSF fluid
Normal CSF values – Protein 15-45 mg/dl
Glucose 50-80 mg/dl
WBC count < 5 mm3
RBC 0-5
Opening pressure 5-20 cm
Clarity and colour clear

Colour of CSF – causes
Yellow - Blood breakdown products
- Hyperbilirubinemia
Orange - Blood breakdown products
- High carotenoid ingestion
Pink - Blood breakdown products
Green – Hyperbilirubinemia
Brown – Meningeal melanomatosis


Increase in WBC may be due to infection, inflammation, bleeding
Causes - meningitis (inflammation of the membranes covering the brain and spine)
-encephalitis (inflammation of the brain substance itself)
-acute infection
-tumor
-abscess
-infarct
-multiple sclerosis
-hemorrhage

INDICATIONS

1) DIAGNOSTIC
A) Absolute
-meningitis
-subarachnoid haemorrhage

B)Relative
-Neurosyphilis
-Unexplained coma
-Guillain Barre syndrome
-Multiple sclerosis

C)Radiological
-Myelography
-Pneumoencephalography

2) THERAPEUTIC
A)To introduce drugs :
1)Methotrexate,gentamicin, crystalline penicillin
B) to reduce raised intracranial tension in hypertensive encephalopathy
C) to administer spinal anaesthesia


CONTRAINDICATIONS
1)Raised intracranial tension(as shown by papilloedema) because of the risk of brain through foramen magnumand damaging the vital medularry centres causing death.
2)marked spinal deformity
3)local infections
4)suspected cord compression
5)Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or papilledema)
6) Uncontrolled bleeding diathesis
7) Lack of patient cooperation
8)Brain abscess

INSTRUMENTS
-Gloves and Mask
-Spinal Needle, 20 and 22-gauge
-Manometer
-Sterile drape
-1% lidocaine in a 5-cc syringe with a 22 and 25-gauge needles
-Povidone iodine solution and spirit.
-Adhesive dressing
-Sponges


PROCEDURE

1)Position : The patient is placed on his side at the edge of the bed with the knee drawn up and the head flexed.it can also be done with the patient sitting and bending forward.
2) Site : in the 3rd lumbar space. This space lies in the plan which joins the highest points on the iliac crest.the skin over the back from the lower thoracic vertebrae to the coccyx is sterilized with povidone iodine solution and spirit.The part is draped.
3)Local anaesthesia : the skin to be punctured is infiltrated with 5 ml of 2% lignocaine. Infiltration is done up to ligamentum flava.
4)Puncture : A lumbar puncture needle with a stiletto is introduced after 2-3 minutes into the anaesthesized space with the cutting edge of the bevel in the direction parallel to the fibres of lagamentum flava.The needle is introduced slightly upwards and forwards at 5 degrees to avoid injuries to the disc) through the resistance of supraspinous ligament. The interspinous ligament is then easily negotiated.at about 4-7 cm, the firmer resistance of ligamentum flavum popping sensation as the dura is breached. The stilette is then withdrawn and the cerebrospinal fluid begins to flow, discard the first few drops. Measure the opening pressure with a manometer. Remove the manometer and 1-2 ml of CSF collected slowly into 3 sterile tubes for biochemical,cylogical and serological tests.
Withdraw the needle without replacing the stylet.
5)dress the puncture site with bandage.

POST PROCEDURE ORDERS
-plenty of fluids are to be taken orally.
-head low position,with half to one block to prevent headache.
-bed rest
-salicylates if headache

COMPLICATIONS

1) Headache
This is the commonest problem.To minimize this problem plenty of fuid should be taken orally,head low position is to be given and salicylates if required.
2)Backache
3)Infection : Often causing gram negative meningitis
4)Medullary herniation leading to death
5)Injury to blood vessel, spinal cord or intervetebral disc.
6) Aggravation of symptoms from which the patient is suffering eg. Root pains,paraplegia etc.


CSF (BACTERIAL)

Appearance : turbid
Opening
Pressure : raised
Proteins : >40mg% (raised)
Sugar : <40mg%(decreased)
Cells : polymorphs large number(neutrophils predominate)
Stain deposit : Bacteria
Culture : positive

CSF ( TUBERCULOSIS)

Appearance : clear or slightly opaque
Opening
Pressure : raised
Proteins : > 40mg%( raised)
Sugar : <40mg% (decreased)
Cells : Lymphocytes large number
Stain deposit : tubercle bacilli
Culture : positive

LUMBAR PUNCTURE

Lumbar puncture is the procedure done to obtain cerebral spinal fluid for analysis. It has been done since the 19th century. Now days with the advent of CT scan and MRI, lumbar puncture is no longer done as often to come up with a diagnosis. However Lumbar puncture is still useful in diagnosing infectious problems like bacterial meningitis, inflammatory conditions like Guillain-Barre syndrome and also some inborn errors of metabolism. Lumbar puncture is also therapeutic in treating pseudomotor cerebri and other uses include insertion antibiotics, chemotherapy, induction of spinal anesthesia and also dye for myelography studies.

Indications for Lumbar Puncture

Meningitis
Encephalitis
Poliomyelitis
Guillian-Barre syndrome
Intracranial hemorrhage
Multiple sclerosis
Malignancy of cord and brain tissue
Spinal anesthesia
Chemotherapy

Contraindications for Lumbar Puncture

Intracranial pressure raised
Site injection is infected
Cardio respiratory compromise
Spinal deformity
Bleeding disorders

Materials for Lumbar Puncture

Material for sterile technique
Spinal Needle, 20 and 22-gauge
Three-way stopcock
Manometer
Sterile drapes
1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
Material for skin sterilization (iodine and swabs)
Adhesive dressing
Collecting tubes

Procedure for Lumbar Puncture


Explain to the patient, what’s the procedure about, why is it needed and what can be the side effects.
Make the patient lie down on the bed, on the left decubitus position in fetal position
Find the iliac crest and trace it to L4 spine, mark the L4 and L5 space.
Wash hands and put on gloves and mask.
Sterilize the skin area with iodine.
Check the manometer, prepare collecting tubes.
Inject 1% lidocaine about 0.25-0.5ml under the skin at the marked site.
Wait for 1 minute then insert the needle with the stiletto and bevel up, slowly feeling the resistance of the ligaments until the ‘give’.
Withdraw the stiletto and wait for the CSF
Check pressure with the manometer.
Collect the fluid in the containers required.
Remove the needle and plaster the region.
It is advisable for the patient to lay there for about an hour.

Complications of Lumbar Puncture

Post LT headache, which can be avoided by using smaller needles and also providing analgesics for pain relieve.

Post Procedure Care

Neurological assessment and monitoring BP. It is also advised for the patient to lie on the bed for about more than an hour.

Composition Of CSF


Normal
Bacterial
Tubeculosis
Pressure
50-180mm water.
Normal or increased
Normal or increased
Colour
Clear
Cloudy
Clear or cloudy (cobweb appearance)
RBC
0-4/mm³
Normal
Normal
WBC
0-4/mm³
1000-5000 polymorphs
50-5000 lymphocytes
Glucose
>60% of blood
decreased
decreased
Protein
< 0.45g/l
increased
increased
Microbiology
-
Based on Gram stain or culture
Acid fast bacilli present

Lumbar Puncture

Indications
1.Suspected CNS infection
2.Suspected subarachnoid hemorrhage
3.Therapeutic reduction of cerebrospinal fluid (CSF) pressure
4.Sampling of CSF for any other reason

Contraindications
1.Local skin infections over proposed puncture site (absolute contraindication)
2.Raised intracranial pressure (ICP); exception is pseudotumor cerebri
3.Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or papilledema)
4.Uncontrolled bleeding diathesis
5.Spinal column deformities (may require fluoroscopic assistance)
6.Lack of patient cooperation

Instruments
1.Material for sterile technique(only gloves and mask are necessary)
2.Spinal Needle, 20 and 22-gauge
3.Manometer
4.Three-way stopcock
5.Sterile drapes
6.1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
7.Material for skin sterilizationn
8.Adhesive dressing
9.Sponges - 10 X 10 cm

Procedures
1. Place the patient in the lateral decubitus position lying on the edge of the bed and facing away from operator. Place the patient in a knee-chest position with the neck flexed. The patient's head should rest on a pillow, so that the entire cranio-spinal axis is parallel to the bed. Sitting position is the second choice because there may be a greater risk of herniation and CSF pressure cannot be measured.

2. Find the posterior iliac crest and palpate the L4 spinous process, and mark the spot with a fingernail. Prepare the skin by starting at the puncture site and working outward in concentric circles. Put on sterile gloves. Drape the patient.

3. Anesthetize the skin using the 1% lidocaine in the 5 mL syringe with the 25-gauge needle. Change to 22-gauge needle before anesthetizing between the spinous process. Insert in the midline with the needle parallel to the floor and the point directed toward the patient's umbilicus.

4. Advance slowly about 2 cm or until a "pop'' (piercing a membrane of the dura) is heard. Then withdraw the stylet in every 2- to 3-mm advance of the needle to check for CSF return. If the needle meets the bone or if blood returns (hitting the venous plexus anterior to the spinal canal), withdraw to the skin and redirect the needle. If CSF return cannot be obtained, try one disk space down.

5. When cerebrospinal fluid begins to flow from the needle, discard the first few drops. Do not aspirated cerebrospinal fluid, because a nerve root may be trapped against the needle and injuried.

6. Measure the opening pressure with a manometer; allow the patient to relax, and check for good respiratory variation of the fluid level in the manometer to ensure that the needle is properly positioned.

7. Remove the manometer and allow 1 to 2 cc of CSF to flow into each of the three sterile tubes. Send the first for glucose and protein, the second for Gram stain and culture and sensitivity (C&S), and the third for cell count and differential. A fourth tube, when indicated, is collected for viral titer or cultures, India ink preparation, Cryptococcus antigen, VDRL, or cytology.

8. Withdraw the needle without replacing the stylet.

9. Dress the puncture site with a bandage. Have the patient lie in bed for a few hours.

Post-procedure care
1. Cover the puncture site with a band-aid or occlusive dressing.
2. Bed-rest following lumbar puncture is of no benefit in preventing headache in children or adults.
3. Warn parents that there may be a small amount of blood in the urine in the next day, but that they should re-present if there are large amounts or if they are concerned.

Complications
1. Local bleeding or an infection at the site where the needle was inserted 2. Elevated pressure in the skull
3. Headache
4. Backache
5. Allergic reaction to the anesthetic
6. Herniation and death
7. Local infection
8. Spinal, epidural, subdural, or subarachnoid hematomas (blood clots)
9. Inflammation of the arachnoid mater, a delicate membrane lining the nervous system
10.Temporary paralysis of a cranial nerve
11.Rupture of the soft, central portion of the intervertebral disk, called the nucleus pulposus
12.Delayed formation of intraspinal epidermoid tumors
13.Meningitis

CSF finding in bacterial meningitis
1. CSF Appearance - Cloudy and turbid (if severe)
2. CSF Protein - Raised >1.5 g/l
3. CSF Glucose - Glucose level is <50% of the plasma level
4. CSF Cell Count (per mm3) - Cell count is high (100 to 1000+) and mostly neutrophils
5. CSF Gram Stain - May see organisms e.g. gram negative diplococci in N. meningitidis

CSF finding in tubercular meningitis
1. CSF Appearance - Clear or slightly cloudy
2. CSF Protein - Raised >1.5 g/l, protein is high (much higher than bacterial meningitis)
3. CSF Glucose - Glucose level is <50% of the plasma level
4. CSF Cell Count (per mm3) - Cell count is high (100 to 1000+) and a mixed pleocytosis with mainly lymphocytes
5. CSF Gram Stain - Negative

1. Indications

a) Cerebrospinal fluid (CSF) evaluation

• Menengitis
• Encephalitis
• Subarachnoid haemorrhage
• Neoplastic disease
• Guilliain- Barre Syndrome
• Multiple sclerosis

b) CSF drainage

• Communucating hydrocephalus
• Pseudotumor cerebri
• CSF leak

c) Intracranial Presssure measurement

• Communicating hydrocephalus
• Pseudotumor cerebri

d) Intrathecal drug admin

• Radiopaque contrast
• Antibiotics
• Antineoplastic chemotherapy

2. Contraindications

• Nonommunicating hydrocephalus
• Intracranial mass (tumor, abcess,hematoma)
• Coagulopathy or platelets <50k
• Cellilitis at intended puncture site
• Cardiorespiratory compromise
• Tethered cord syndrome
• Bleeding diathesis
• increased intracranial pressure

3. Instruments

• Lidocaine (LA)
• Sterile prep solution
• Sterile gloves and towels
• 22G needle
• 22G/ 20G/ 18G spinal needle with stelet
• CSF collection vials
• Manaometer with stopcock

4. Procedure
a. Explain procedure and obtain consent
b. Position the patient:-
on her/ his side with chin & knees tucked into the chest or patient is
seated on the side of the bed, flexed forward over a pillow for support
( prefered for obese patients)
c. wash hands, wear a mask and sterile gloves.
d. Landmarks: plane of iliac crest through L4. In adults, spinal cord ends
at L1. Mark L4, L5 or L3, L4, intervertebral space by a gentle
indentation of a thumb nail on the overlying skin.
e. Sterilize back with tincture of iodine.
f. Inject 0.25 - 0,5ml 1% lignocaine under skin at marked site
g. Wait for 1min, then insert spinal needle (22G, stillette in place with
needle bevel kept facing up) through the mark, aiming towards
umbilicus. A 'give' way sensation is felt as the needle enters the
subarachnoid space.
h. Withdraw stillete. wait for CSF. If CSF appears blood stained allow
blood to drain and observe for clearance, if it does than the tap was
traumatic. If the blood does not stop and there is presence of clot,
then it is due to subarachnoid heamorrhage (where a semple should be
taken and sent to the lab to look for xanthochromia).
i. Measure CSF pressure with manometer.
j. Catch fluid in 3 sequentially numbered bottles (<5 - 10ml).
k. Remove needle and apply dressing.
l. Send CSF for microscopy, culture, protein and glucose. If applicable
also send for microscopy, fungal studies, TB culture, virology, syphilis
serelogy, oligodonal bands ifin multiple sclerosis suspected.
m. Replace stylet and withdraw needle.
n. Replace sterile gause over puncture site.
o. Monitoring of vitals, pupil size & reactivity, and any changes in mental
status is done.

5. Post - operative care

• restric activity for 24 hours following lumbar punture
• lie flat up to 8 hours to decrease incidenceof headache
• drink additional water to rehydrate after the procedure

6. Post- operative complications

• Herniation and death
• Infection
• Lower back pain
• Nerve root injury
• Spinal headache
• Aortic/ arterial puncture
• Hematoma
• Epidermoid

7.CSF findings in Bacterial and Tubercular menengitis

Bacterial menengitis:

• Pressure - increased
• colour/ apperance - cloudy
• cell type - polymorphs
• cell count - 1000 - 5000
• glucose - decreased
• protein - elevated/ normal
• CSF gram stain +ve

Tubercular menengitis

• Pressure - increased
• colour/ appearance - cob web appearance/cloudy
• cell type - polymorphs & lymphocytes
• cell count - 50 - 5000
• glucose - decreased
• CSF gram staining -ve
• protein - increased

lumbar puncture:

• Insertion of a needle between lumbar spinous process, through the dura and into the CSF under LA.

Indication:

• Meningitis
• Encephalitis
• Subarachnoid haemorrhage
• Guillan Barre Syndrome
• Acute demyelinating disease
• myelitis
• neurosyphilitis
• Reye syndrome
• demyelinating disease( multiple sclerosis)

Contraindication:

• Raised intracranial pressure
• Coagulopathy
• brain abscess
• spinal deformity
• concurrent spinal infection

Steps:

1. Take the consent from the patient and at the mean time explain the procedures to the patient.
2. Locate the 3rd and 6th lumbar spines.
3. BY using sterile precaution, patient's back must be cleared with antiseptics solution and draped.
4.Doctor must wear gloves during the procedures.
5. Anasthesize the skin with LA ( Lidocaine 2%). Inject into third and fourth interlumbar space.
6. when the needle get penetrated into the space, there will be drops of CSF fluid coming out.
7. Collect it into the test tubes.
8. Remove th needle when the procedures is completed.
9. Adhesive bandage must be placed over the injection site.
10. If the patient complains of pain at the site of injection, analgesic must be given.

Complication:

• Headache
• Nausea
• Paraplegia
• Herniation
• Bleeding at the spinal canal
• Lower back pain

CSF Findings:

1 Bacteria

• Normal / Increased bacterial pressure (50-180mm of water)
• Total WBC increased ( 1000-5000 polymorphs)
• Protein more 45mg/dl
• glucose low
• microbiolgy: Organism on Gram stain and /or culture.
• oligoclonal bands: positive

2. Tuberculous meningitis

• protein normal or increased
• clear/cloudy
  red cell counts are normal
• 50-5000 lymphocytes
• decreased glucose
• increased protein
• microbiology: Ziehl Neelsen / auramine stain or tuberculousis culture positive
• oligoclonal bands: positive

1. Indications

a) Cerebrospinal fluid (CSF) evaluation

• Menengitis
• Encephalitis
• Subarachnoid haemorrhage
• Neoplastic disease
• Guilliain- Barre Syndrome
• Multiple sclerosis

b) CSF drainage

• Communucating hydrocephalus
• Pseudotumor cerebri
• CSF leak

c) Intracranial Presssure measurement

• Communicating hydrocephalus
• Pseudotumor cerebri

d) Intrathecal drug admin

• Radiopaque contrast
• Antibiotics
• Antineoplastic chemotherapy

2. Contraindications

• Nonommunicating hydrocephalus
• Intracranial mass (tumor, abcess,hematoma)
• Coagulopathy or platelets <50k
• Cellilitis at intended puncture site
• Cardiorespiratory compromise
• Tethered cord syndrome
• Bleeding diathesis
• increased intracranial pressure

3. Instruments
1-Material for sterile technique(only gloves and mask are necessary)
2-Spinal Needle, 20 and 22-gauge
3-Manometer
4- Three-way stopcock
5-Sterile drapes
6-1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
7-Material for skin sterilizationn
8- Adhesive dressing
9- Sponges - 10 X 10 cm

4. Procedure
a. Explain procedure and obtain consent

1- Place the patient in the lateral decubitus position lying on the edge of the bed and facing away from operator. Place the patient in a knee-chest position with the neck flexed. The patient's head should rest on a pillow, so that the entire cranio-spinal axis is parallel to the bed. Sitting position is the second choice because there may be a greater risk of herniation and CSF pressure cannot be measured


2- Find the posterior iliac crest and palpate the L4 spinous process, and mark the spot with a fingernail. Prepare the skin by starting at the puncture site and working outward in concentric circles. Put on sterile gloves. Drape the patient

3- Anesthetize the skin using the 1% lidocaine in the 5 mL syringe with the 25-gauge needle. Change to 22-gauge needle before anesthetizing between the spinous process. Insert in the midline with the needle parallel to the floor and the point directed toward the patient's umbilicus

4- Advance slowly about 2 cm or until a "pop'' (piercing a membrane of the dura) is heard. Then withdraw the stylet in every 2- to 3-mm advance of the needle to check for CSF return. If the needle meets the bone or if blood returns (hitting the venous plexus anterior to the spinal canal), withdraw to the skin and redirect the needle. If CSF return cannot be obtained, try one disk space down

5- When cerebrospinal fluid begins to flow from the needle, discard the first few drops. Do not aspirated cerebrospinal fluid, because a nerve root may be trapped against the needle and injuried

6- Measure the opening pressure with a manometer; allow the patient to relax, and check for good respiratory variation of the fluid level in the manometer to ensure that the needle is properly positioned.

7- Remove the manometer and allow 1 to 2 cc of CSF to flow into each of the three sterile tubes. Send the first for glucose and protein, the second for Gram stain and culture and sensitivity (C&S), and the third for cell count and differential. A fourth tube, when indicated, is collected for viral titer or cultures, India ink preparation, Cryptococcus antigen, VDRL, or cytology
8- Withdraw the needle without replacing the stylet
9- Dress the puncture site with a bandage. Have the patient lie in bed for

5. Post - operative care

• restric activity for 24 hours following lumbar punture
• lie flat up to 8 hours to decrease incidenceof headache
• drink additional water to rehydrate after the procedure

6. Post- operative complications

Post–spinal tap headache
Nerve root trauma (eg, previous surgery in the area, scar tissue)
CNS infection (eg, immunocompromised patients)
Cranial, cervical, and lumbar subdural (more common) hematomas (eg, patients on anticoagulation therapy)


7.CSF findings in Bacterial and Tubercular menengitis

Bacterial menengitis:

1. CSF Appearance - Cloudy and turbid (if severe)
2. CSF Protein - >1.5 g/l-raised
3. CSF Glucose - <50% of the plasma level
4. CSF Cell Count (per mm3) - high (100 to 1000+) and mostly neutrophils
5. CSF Gram Stain - May see organisms e.g. gram negative diplococci in N. meningitidis


Tubercular menengitis:

cells/ml = 100 - 1000 ( mainly mononuclear )
protein mg/dl = moderately high (50 - 100)
glucose mg/dl = low (<45 )
causes = tuberculosis,partly treated becterial meningitis

Lumbar Puncture :

Definition : aspiration of the cerebrospinal fluid (CSF) from the spinal subarachnoid space by puncturing the spaces between L2 and L3 or L3 and L4 vertebrae.

Indications :

• Diagnostic : CSF for serology,bacteriology,cytology,

Absolute – meningitis (viral,bacterial,fungal)
Meningoencephalitis
Subarachnoid hemorrhage (if CT non conclusive)
Guillain Barre syndrome
Acute disseminated encephalomyelitis (eg. rabies)
Transverse myelitis
Unexplained coma / dementia
CNS Tumours : ependymomas, choriod plexus papillomas


Relative – Multiple sclerosis
Pyrexia of unknown origin
Neurosyphilis

• Radiological

- Myelography
- Pneumoencephalography

• Therapeutic

- To introduce drugs (intrathecal chemotherapy) – Methotrexate(leukemia), Antimicrobials (meningitis), Steroids
- Spinai anesthesia
- To reduce intracranial tension in hypertensive encephalopathy (esp . Benign Intracranial Hypertension)


Contraindications :
- raised ICT (eg.papilledema)
- marked spinal deformity
- local infection at site of LP
- suspected cord compression
- coagulation disorders ( thrombophilic states)


Instruments

• Materials for sterile technique (glove and masks)
• Spinal needle 20 or 22 gauge

• Manometer
• Three-way stopcock
• Sterile drapes
• 2% lidocaine/lignocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
• Material for skin sterilization (povidone iodine/alcohol)
• Adhesive dressing
• Sponges

Procedure :

• • Obtain informed consent and reassure the patient
  • Procedure is explained
  • Never attempt more than 3 times.
  • Can be done in 2 positions :

- lying down (Left/Right lateral) – side at the edge of bed,
head flexed and knee drawn up
- sitting and bending forwards

• • Sensitivity test should be done for xylocaine/lidocaine
  • Hands are washed and gloves worn.
  • Skin in the lumbar area is disinfected with surgical spirit or iodine.
  • Patient is put in left lateral position, with head and lower limbs flexed.
  • Lower back is draped (area covered by sterile towel except area of lumbar puncture)
  • The space for lumbar puncture is selected (L3 – L4 crresponding to intercrestal plane or L4 – L5)
  • Local anesthesia, 5 ml of Lignocaine is infiltrated around skin to be punctured (upto ligamentum flavum)
  • Anasthesia is left to act for about 5 minutes.
  • The lumbar puncture needle is then introduced into the anasthetized space with the cutting edge of the bevel in parallel with fibres of ligamentum flavum.
  • The needle is introduced slightly upwards & forwards at angle of 5^0 to the surface of skin.
  • The needle is pushed in slowly till the interspinous ligament is negotiated and giving away (popping) sensation is felt which indicates the point of dural breach.
  • The stilette is then withdrawn an dthe required amount of CSF is collected in a small bottle
  • The needle is then withdrawn and the puncture mark is sealed with a tincture benzoin seal.

Post procedure care :
- plenty of fluids to be taken by mouth
- Bed rest & head low position at least for next 24 hours; to avoid post spinal headache
- Salicylates (eg. Aspirin ) if severe headache
- Monitor Blood pressure regularly; CNS observation

Complications :
- Post spinal headache – due to negative pressure created by puncture & CSF loss
- Backache
- Infections (iatrogenic) ; Gram negative meningitis
- Medullary herniation (coning) and death – if underlying raised ICT
- Injury to blood vessels, spinal cord or intervertebral discs
- Aggravation of patient’s symptom (eg root pain, paraplegia)
- Epidermoid formation

CSF in Bacterial Meningitis

Appearance – turbid
Pressure – increased (180 mm H20)
Proteins – elevated markedly ( > 45mg/dl)
Sugar – markedly decreased (< 40 mg/dl)
Chlorides – slightly reduced
Cells – large number; polymorphs
Culture & stain (Gram’s) – Gram positive/ negative organisms

CSF in Tubercular Meningitis

Appearance – clear or slightly opaque (cob webbing)
Pressure – increased (180 mm H20)
Proteins – elevated markedly ( > 45mg/dl)
Sugar – markedly decreased (< 40 mg/dl)
Chlorides – slightly reduced
Cells – large number; lymphocyte predominant
Culture & stain (Ziehl Nielsen’s) – Acid fast bacilli (Mycobacterium)

Lumbar puncture is aspiration of cerebrospinal fluid(CSF) from the spinal sub-arachnoid space by puncturing the spaces between lumbar 2 &3 or lumbar 3 & 4 vertebrae.

Indications:

• suspected CNS infection
• suspected subarachnoid hemorrhage
• Therapeutic reduction of CSF pressure
• To obtain CSF sample
• To inject medications in CSF e.g spinal anesthesia, chemotherapy

Contraindication:

• bleeding diathesis
• infection at site of needle insertion
• raised intracranial pressure
• suspected spinal cord mass or intracranial mass lesion
• spinal columm deformities
• lack of patient coorperation

Instruments:

• spinal needle
• manometer
• sterile drapes
• local anesthetic agent
• 3-way stopcock
• sterile tubes
• adhesive dressing
• sponges

Procedure:

1. position patient - left lateral postion with head and knee as closed as possible.
2. locate landmark - between L3 & L4 or L4 & L5
3. wash hands, wear mask and sterile gloves
4. open spinal pack. Check manometer fittings
5. sterilize the back with tincture of iodine. Drape area.
6. give local anesthesia under skin at marked site.
7. wait for 1 minute, then insert spinal needle, bevel up through skin and advance into deeper tissues. A slight pop or give is felt when dura is punctured.
8. measure CSF pressure with manometer.
9. Collect CSF fluid in 4 tubes, 1-2ml each.
10. remove needle and apply dressing
11. advice patient to lie flat for 1-2hoursbefore getting up.

Post procedure care:

• Cover the puncture site with a band-aid or occlusive dressing.
• patient needs to be monitored continuously for 24 hours. Assess vital signs and neurological status.
• Bed rest, keep the patient recumbent for one to 12 hours.
• Given either orally or IV, fluids minimize dehydration.

Complications:

• Bleeding from puncture site.
• post-spinal tap headache.
• CNS infection.
• Nerve root trauma
• Hematoma

CSF analysis:
- Bacterial meningitis

• Appearance - Cloudy and turbid
• Protein - Raised, >1.5 g/L.
• Glucose - <50% of the plasma level.
• Cell Count - high (100 to 1000+), predominantly neutrophils.
• Gram Staining - gram positve/negative organisms

- Tubercular meningitis

• Appearance - clear
• Protein - Raised, >1.5g/L
• Glucose - <50% of the plasma level
• Cell Count - high (100 to 1000+), predominantly lymphocytes.
• Ziehl-Nielsen’s Staining - acid fast bacilli