1 lumbar puncture department of neurology faculty of medicine of unpad hasan sadikin hospital

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LUMBAR PUNCTURELUMBAR PUNCTURE

Department of NeurologyDepartment of NeurologyFaculty of Medicine of UNPADFaculty of Medicine of UNPAD

Hasan Sadikin Hospital Hasan Sadikin Hospital

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Lumbar PunctureLumbar Puncture

A procedure to collect cerebrospinal fluid A procedure to collect cerebrospinal fluid (CSF) that encircles the brain and spinal (CSF) that encircles the brain and spinal cordcord

Other sites that can be used to obtain Other sites that can be used to obtain CSF: CSF: below occipital tuberose below occipital tuberose sub occipital sub occipital

puncturepuncture babies: anterior fontanel babies: anterior fontanel

CSF|CSF|LPLP

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Lumbar PunctureLumbar Puncture

Aims:Aims:

Diagnostic of infection and inflammation in Diagnostic of infection and inflammation in the subarachnoid spacethe subarachnoid space Obtained by collecting sample for cellular, Obtained by collecting sample for cellular,

chemical, and bacteriological analyses of the chemical, and bacteriological analyses of the CSFCSF

Therapeutic:Therapeutic: chemotherapy for carcinomatosischemotherapy for carcinomatosis antibioticsantibiotics

Intrathecal anesthesiaIntrathecal anesthesia

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Indication:Indication:

Diagnosis of CNS infection: meningitis, Diagnosis of CNS infection: meningitis, encephalitis, tertiary syphilis,encephalitis, tertiary syphilis,Diagnosis of meningeal carcinomatosis, Diagnosis of meningeal carcinomatosis, meningeal leukemia, staging of lymphoma meningeal leukemia, staging of lymphoma Follow up for therapy of meningitis Follow up for therapy of meningitis Treatment for pseudo tumor cerebri Treatment for pseudo tumor cerebri Evaluation of several diseases: dementia, Evaluation of several diseases: dementia, Guillain-Barre Syndrome Guillain-Barre Syndrome Ruling out subarachnoid bleedingRuling out subarachnoid bleeding

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ContraindicationContraindication::

Infection at the site of punctureInfection at the site of puncture

History of anticoagulant useHistory of anticoagulant use

Presence of signs of increased intracranial Presence of signs of increased intracranial pressure pressure

Severe hemorrhagic diathesisSevere hemorrhagic diathesis

Proven intracranial mass (from Proven intracranial mass (from neuroimaging)neuroimaging)

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TechniqueTechnique

Prepare the equipments needed for the procedureGreet the patient. Explain the LP procedure to the patient, its advantages and disadvantages.Ask his/her consentAsk the patient to lay on his left side of the body (left lateral decubitus). Place the patient near the edge of the bed.Flex the neck, trunk, hips, and knees; the patient’s body should be perpendicular to the bed

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Technique (cont.)Technique (cont.)

Locate the site of puncture (L3 – L4) interspace in adult patient) by drawing an imaginary line between the highest points of the iliac crests (crista iliaca). The site is in the intersection of the imaginary line and vertebral axis

Wash your hands Put on a pair of sterile gloves

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Technique (cont.)Technique (cont.)

Apply alcohol swab to the puncture site and surrounding area with circular movement, followed by applying povidone-iodine solution with the same manner

Wipe with alcohol to remove all traces of the antiseptic to prevent it from entering the subarachnoid space; and wipe it once more using a dry gauze

Cover the LP area with perforated drape

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Technique (cont.)Technique (cont.)

Infiltrate the site of lumbar puncture with 2 mL of 2% lidocaine HCl for local anesthesia. Start with injecting up to 1 mL of lidocaine to the interspinous ligament and infiltrate the adjacent subcutaneous area with the remaining lidocaine. Wait several moments to let the anesthesia works

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Technique (cont.)Technique (cont.)

Take a sterile spinal needle. Make sure that the needle is equipped with stylet, lock the stylet inside the needle, and then insert it slowly with the bevel faces up (parallel to the long axis of the body) until it enters the subarachnoid space

Verify that the needle is indeed in the subarachnoid space, then turn the needle counterclockwise to 9 o’clock position

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Technique (cont.)Technique (cont.)

Withdraw the stylet

Collect the CSF in three sterile tubes:- Tube 1: 10 – 15 drops for cell count and

differentiation- Tube 2: up to 5 mL for bacteriological

workups- Tube 3: up to 2 mL for chemistry (protein,

glucose)

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Technique (cont.)Technique (cont.)

Reinsert the stylet, turn the needle back to 12 o’clock, and then withdraw the needle

Apply some pressure to the puncture site, and then cover it with sterile gauze soaked by povidone-iodine

Ask the patient to lay flat for at least 6 hours to prevent post-LP headache

Take off your gloves, wash your hands

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ComplicationComplication

HeadacheHeadache

BackacheBackache

Subdural HematomSubdural Hematomaa

InfectionInfection

CSCSFF leakage leakage

HerniationHerniation

CSF|CSF|LPLP

THANK YOUTHANK YOU

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