- Diagnosis
- History
- Examination
- Investigations
- History
- Management
- Procedures
Lumbar Punctures
Lumbar Punctures
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
Finding the Site
Identifying the Right Site
- With the patient in the lateral or sitting position, use the index and middle fingers on either side to palpate the tops of the iliac crests. Once identified, bring the thumbs together into the midline and feel for the intervertebral space - this is L4/L5.
- The spinal cord ends at L1/L2, so the L3/L4, L4/L5 or L5/S1 interspaces can be used for lumbar puncture.
Last updated on January 1st, 2018
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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.