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

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

4. 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.

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

6. 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.

7. 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.

8. 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.

9. 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.

10. Technique
- Lateral Recumbent position
Sitting upright

11. Positioning
CORRECT
INCORRECT

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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

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