Lumbar Puncture
Lumbar Puncture
Lumbar Puncture
Background Contraindications
The first reports of a lumbar puncture (LP) being • Suspected intracranial mass lesion or space occupying
undertaken are from the late 19th century [1]. Heinrich lesion
Irenaeus Quince (with whom the Lumbar Puncture is • Disorders of coagulation or blood diathesis
commonly associated with) reported to the tenth congress
of Internal Medicine in April 1891¬¬ that he had • Underlying spinal abscess
performed in one case 3 lumbar punctures in a patient • Imaging evidence of midline shift
with suspected tuberculous meningitis who was comatose
• Posterior fossa tumour or other suspected 4th
[1,2]. The procedures were done at 3 day intervals and
ventricular lesion
the patient recovered. The other case was in a patient
that had chronic hydrocephalus and suffered headaches. Consent
Lumbar puncture in this patient relieved the symptoms. It is good practice that consent is obtained before
One month after Quincke’s report to the congress, Walter undertaking any invasive intervention or procedure, and
Essex Wynter, a Registrar at the time, published in the this is the case for performing a lumbar puncture.
Lancet 4 cases of cerebrospinal fluid (CSF) aspiration
in patients with meningitis suspected [3]. The Lumbar Equipment and Tools
Puncture was a procedure dedicated to the relief of • Up to 6 sample bottles (usually white top) depending
symptoms (at that time mainly meningitis or raised on the tests required from the sample. These should
intracranial pressure) [4]. It has subsequently become normally be pre-labelled with a number (1-6). Some
a procedure that can be diagnostic or therapeutic, and centres use up to three, others four, but this will
the technique has become more refined with improved depend on the number of tests needed.
instruments, awareness of aseptic techniques and the
increased availability and knowledge of anaesthesia. • A serum glucose bottle is part of the equipment
(a paired serum with CSF glucose is usually sent
Indications particularly in infective diagnosis).
• In cases of suspected subarachnoid haemorrhage • A serum bottle for electrophoresis paired with
(SAH) CSF when checking for oligoclonal bands (when
• Diagnosis of meningitis (bacterial, viral, fungal, diagnosing multiple sclerosis for instance).
malignant, atypical) • Drawing up needles for local anaesthetic, with 10-
• Treat raised intracranial pressure (idiopathic 20ml syringe for the administration of the local
intracranial hypertension or other causes such as anaesthetic including a needle for subcutaneous
meningitis) injection and deep tissue injection.
• Aid diagnosis of normal pressure hydrocephalus • Spinal needle (we advise 22G Whitcare or ‘pencil tip’
needle which is atraumatic and is the preferred choice
• Exclusion of neurological, vasculitic, autoimmune or over the cutting or Quincke needles)
paraneoplastic disorders and syndromes
• Manometer with 3 way tap
• Administration of therapeutic agents (for
chemotherapy, analgesia/anaesthesia, antimicrobial • Dressings pack with appropriate disinfectant, gauze
therapy) and sterile drapes
• For cytology in suspected cancer 10cc is best,
It important to note that in suspected SAH, a lumbar otherwise 1-2 cc per bottle. All these quantities are
puncture 12 hours after onset of symptoms is ideal, but safe if LP is safe in the first place!
can be diagnostic after 2 weeks of onset [8]. This is not
the case after 4 weeks. • If pressure is > 25cm I take 30 cc and don’t do closing
pressure (not reliable).
Locating the correct entry point is performed by The dural space is approximately 4-5cm (see Figure 4)
identifying the surface anatomy of the L3/L4 interspinal from the surface if the skin [5,6]. When the needle is
space (which is a few mm above the spinous process of advanced some practitioners will feel a give or a ‘pop’
L4). This is done generally by palpating the iliac crests. sensation when the needle enters into the space although
this is not always the case.
An imaginary line between the highest points of the iliac
crests usually bisects the L3/L4 space. However this will At times with the needle passing through the different
vary according to a number of variables, such as obesity. layers, there may be similar sensations felt but the needle
Figure 5. Manometer with three way tap (stopcock) used for the
measurement of opening and closing pressures
After obtaining CSF, always replace the stylet before to infuse mannitol. Local guidelines for this should
withdrawing the needle. be sought.
Things to watch for post procedure [6,9] • Epidermoid tumour this is rare and may occur
after a few years, caused by epidermoid tissue being
• Headache (Post Lumbar Puncture Headache). This is transplanted into the spinal canal during procedure.
the most common complication, especially in young
adults. Can be managed with simple analgesics or
non-steroidal anti-inflammatories. Patients are References
advised to lay flat for 30-60mins post procedure.
They may require an additional 2 weeks depending 1. Quincke HI. Ueber hydrocephalus. Verhandlung des
on symptoms after this of strict bed rest. At times Congress Innere Medizin (X) 1891; 321-39
anaesthetic management using an epidural blood 2. Quincke HI. Die lumbalpunction des Hydrocephalus.
patch may be required for severe intractable cases. Berlin Klin Wochenschr 1891; 28: 929-33
• Infection can occur as cellulitis, abscesses or discitis, 3. Pearce JM. Walter Essex, Quincke, and lumbar
vertebral osteomyelitis, bacterial meningitis. puncture. Journal of Neurology Neurosurgery Psychiatry
• Back Painmay occur at the entry site or elsewhere 1994 February; 57(2): 179
in the back as a consequence of the trauma of the 4. Frederiks JAM. & Koehler PJ. The First Lumbar
procedure though mild. Puncture. Journal of the History of the Neurosciences: Basic
• Bleeding may occur at all levels of the dura. This will and Clinical Perspectives 1997; Volume 6 Issue 2: 147-53
be significantly worse in those with coagulopathies 5. Doherty CM. & Forbes RB. Diagnostic Lumbar
or anticoagulated (SAH, subdural or epidural Puncture. Ulster Medical Journal 2014; 83(2): 93-102
haematoma.
6. Johnson KS. & Sexton DJ. Lumbar Puncture:
• Nerve irritation or damage might occur if the spinal Technique, indications, contraindications, complications
needle impinges on a nerve or nerve root. Also as in adults. http://www.uptodate.com/contents/lumbar-
the needle is withdrawn, it is important that the puncture-technique-indications-contraindications-and-
stylet is replaced before had to prevent the likelihood complications-in-adults?source=search_result&search=lu
of a nerve being withdrawn. This also reduces the mbar+puncture+technique&selectedTitle=1~150
likelihood of post LP headache as mentioned before.
7. Fiorito-Torres F. Rayhill M. & Perloff M. Idiopathic
• Blood in the CSF can occur with initial aspiration of Intracerebral Hypertension (IIH)/Pseudotumor:
CSF and usually gives falsely raised red cell counts Removing Less CSF Is Best. Neurology April 8 2014; 82
in the first bottle sent to the lab. Subsequent bottles (10): Supplement I9-1.006
show a reduction in the red cell count.
8. Diagnosis and management of headache in adults. A
• Cerebral herniation is rare but a serious complication national clinical guideline. SIGN Scottish Intercollegiate
and vigilance for any symptoms or signs is advised. Guidelines Network. 107 November 2008
It is imperative that a pre LP CT scan of the brain is
undertaken in patients with reduced consciousness, 9. Ali Moghtaderi, Roya Alavi-Naini and SalehehSanatinia
papilloedema or other neurological features of (2012). Lumbar Puncture: Techniques, Complications
raised intracranial pressure. In bacterial meningitis, and CSF Analyses, Emergency Medicine - An
cerebral herniation may occur post LP. Other International Perspective, Dr. Michael Blaivas (Ed.),
intracerebral infections such as TB or malaria may ISBN: 978-953-51-0333-2, In Tech, Available from:
also. As such CT is useful in a diagnostic capacity http://www.intechopen.com/books/emergency-
for the cause of altered neurology as well as helping medicine-aninternational-perspective/lumbar-puncture-
determine the risk of raised intracranial pressure and techniques-complications-and-csf-analyses
cerebral herniation in LP. It must be noted that a
normal CT will not completely eliminate the risk of
herniation and neurological features mentioned must Acknowledgements Mr Chiloba A Chirwa and Mrs
be monitored nevertheless. Treatment of cerebral Mandee Chirwa for their help with the illustrations and
herniation or raised intracranial pressure is generally translations.