- Diagnosis
- History
- Examination
- Investigations
- History
- Management
- Interventions
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The Lumbar Puncture
A lumbar punctures is a procedure in which a needle is used to access the subarachnoid space. This may be used to collect cerebrospinal fluid (CSF) for diagnostic purposes, or therapeutic purposes in order to deliver drugs.
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Equipment & Preparation
Sterile Gloves
Strile Gown
Goggles
Mask
Marking Pen
Decontaminant
E.g. chlorhexidine or povidone-iodine
Sterile Field
E.g. large dressing pack
- Fenestrated drape
Lumbar Puncture Needle
With stylet
Use an atraumatic needle where possible
Lumbar Puncture Set
3-way tap, spinal manometer
CSF Specimen Tubes
Local Anaesthetic
1% Lignocaine in a 5mL syringe with long needle
Dressing
Sterile impermeable adhesive dressing
Exit Strategy
Sharps container
Documentation
Test request form, patient labels
Identifying the Insertion Site
Insertion
- Explain the procedure and ask for patient's consent
- It is important to continually communicate with the patient and tell them what you are doing
Positioning
Sitting or lateral foetal position
Identify the L4/L5 Intervertebral Space
In the midline between iliac crests
Mark the Desired Site
L3/L4, L4/L5, L5/S1
Using the marking pen
Prepare Sterile Field
- Don goggles and mask
- Scrub, sterile glove and gown
Prepare Sterile Equipment
Place everything in the order it will be used
Prepare the Area
Decontaminate with chlorhexidine or povidone-iodine
- Apply the fenestrated drape
Reposition the Patient
To ensure maximum flexion of the lumbar spine
Identify the Site Again
Maintaining sterile conditions
Inject Local Anaesthetic
Make a small wheal over the insertion site
Insert the Needle into the Midline
Slowly, with bevel up and facing slightly superiorly
A ‘pop' may be felt on entry to the dura
Remove the Stylet
Look for CSF drainage
- If required - replace the stylet, remove the needle slightly and readvance at a different angle
Measure Opening Pressure
Attach the three-way tap and manometer
Collect CSF
Drain three 2mL samples into specimen containers
- Reinsert the stylet
Remove the Needle
- Look for CSF leakage
Apply the Dressing
Clean Up
Dispose of sharps and other waste
- Remove gloves and wash hands
Processing
Label the collection tubes and send to the lab
Bed Rest
Check local guidelines for bed rest post LP
Complications
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Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: Prevention of post-lumbar puncture headaches Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000 Oct 10;55(7):909-14.Spriggs DA, Burn DJ, French J, Cartlidge NE, Bates D. Is bed rest useful after diagnostic lumbar puncture?. Postgraduate medical journal. 1992 Jul 1;68(801):581-3.Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?. Jama. 2006 Oct 25;296(16):2012-22.Strupp M, Schueler O, Straube A, Von StuckradBarre S, Brandt T. Atraumatic Sprotte needle reduces the incidence of post-lumbar puncture headaches. Neurology. 2001 Dec 26;57(12):2310-2.Turnbull DK, Shepherd DB. Post?dural puncture headache: pathogenesis, prevention and treatment. British journal of anaesthesia. 2003 Nov 1;91(5):718-29.