1. LUMBAR PUNCTURE

2. INDICATIONS : Diagnostic : Infectious Meningitis Encephalitis Inflammatory Multiple Sclerosis Gullain-Barresyndrome Oncologic Metabolic Spontaneoussubarachnoidhemorrhage Therapeutic : Analgesia Anesthesia Antibiotics Antineoplastics 3. CONTRAINDICATIONS : Increased intracranial pressure Cerebral herniation Impending herniation Possible increased ICP and focal neuro signs Coagulopathy Prior lumbar surgery Severe vertebral osteoarthritis ordegenerative disc disease Significant cardiorespiratory compromise Infection near the puncture site Space occupying lesion 4. EQUIPMENT : Spinal needle Less than 1 yr: 1.5in 1yr to middle childhood:2.5in Older children and adults:3.5in Three-way stopcock Manometer 4 specimen tubes Local anesthesia Drapes Betadine 5. PROCEDURE : Performed with thepatient in the lateralrecumbent position. A line connecting theposterior superior iliaccrest will intersect themidline at approx. theL4 spinous process. Spinal needlesentering thesubarachnoid space atthis point are wellbelow the terminationof the spinal cord. 6. LP in older children maybe performed from L2 toL3 interspace to the L5to S1 interspace. At birth, the cord ends atthe level of L3. LP in infant may beperformed at the L4 to L5or L5 to S1 interspace. 7. Position the patient: Generally performed inthe lateral decubitusposition. A pillow is placed underthe head to keep it in thesame plane as the spine. Shoulders and hips arepositioned. perpendicularwith the table. Lower back should bearched towardpractitioner. 8. a. Ligament flavum is astrong, elastic, yellowmembrane covering theinterlaminar spacebetween the vertebrae.b. Interspinal ligaments jointhe inferior and superiorborders of adjacentspinous processes.c. Supraspinal ligamentconnects the spinousprocesses 9. A topical anesthetic (e.g. EMLA cream) can be applied30 to 60 minutes before performing the puncture tominimize pain on penetration. Either a sitting or lateral decubitus position can beused . Monitor the patient visually and with pulse oximetry forany signs of respiratory difficulty as a result ofassumed position. The subarachnoid space must be entered below thelevel of spinal cord termination. The spine should be flexed maximally to increasespacing between spinous processes. Extensive neck flexion, however, should be avoidedto minimize a chance of respiratory compromise. Make sure the hips and shoulders are aligned & are 10. The patients back should be carefully preparedand draped using provided disinfecting solutionand drapes. Orient yourself anatomically and find the L4spinous process at the level of iliac crests Palpate a suitable interspace distal to this level. Infiltrate 2% Lidocaine subcutaneously (withoutepinephrine to prevent cord infarction should it beintroduced into the cord by accident) with a fineneedle. A field block can be applied injecting into and oneither side of the interspinous ligaments. Identify the two spinal processes in betweenwhich the needle will be introduced, penetrate theskin and slowly advance the tip of the needle atabout 10 degrees cephalad (i.e. toward the 11. Remove the stylet and check for clear fluid willflow from the needle when the subarachnoidspace has been penetrated. The ligaments offer resistance to the needle, anda pop is often felt as they are penetrated. Withdraw the needle leaving the tip in, recheckthe landmarks and slowly progress the needleagain. Measure the opening pressure using themanometer by attaching it via a stopcock to thespinal needle. Normal opening pressure ranges from 10 to 100mm H2O in young children and 60 to 200 mmH2O after eight years of age 12. CSF volume of 1cc obtained in 3 tubes. In the neonate, 2ml in total can be safelyremoved. In an older child 3 to 6 ml can be sampleddepending on the childs size. Tube 1 is used for determining protein andglucose Tube 2 is used for microbiologic andcytologic studies Tube 3 is for cell counts and serologic testsfor syphilis 13. COMPLICATIONS : Herniation Cardiorespiratory compromise Pain Headache (36.5%) Bleeding Infection Subarachnoid epidermal cyst CSF leakage 14. BONE MARROWASPIRATION 15. INDICATIONS : Diagnostic :- Idiopathic Thrombocytopenic Purpura- Aplastic Anemia- Leukemia- Megaloblastic Anemia- Infections e.g. Kala Azar- Storage disorders e.g. Gauchers disease- PUO- Myelofibrosis Therapeutic :- Bone Marrow Transplantation 16. CONTRAINDICATIONS : Hemorrhagic disorders such ascongenital coagulation factor deficiencies(eg, hemophilia), disseminatedintravascular coagulation and concomitantuse of anticoagulants. Skin infection or recent radiation therapyat the sampling site. Bone disorders such as osteomyelitis orosteogenesis imperfecta. 17. PROCEDURE : Obtain consent from a parent or guardian. If the posterior iliac crest is the chosen site,patients are generally placed in the lateraldecubitus position or the prone position Sterilize the site with the sterile solution Place a sterile drape over the site, andadminister local anesthesia, letting it infiltrate theskin, soft tissues, and periosteum. After local anesthesia has taken effect, make anincision through which the bone marrowaspiration needle can be introduced . 18. If a guard is present, should be removed beforestarting bone marrow aspiration, to ensureadequate depth of penetration.. In general, the needle should be advanced atan angle completely perpendicular to the bonyprominence of the iliac crest. Once the needle passes through the cortexand enters the marrow cavity, it should stay inplace without being held. Once the periosteum has been penetrated,pressure is used to advance the needle throughthe cortex and rotate the needle in asemicircular motion, alternating clockwise andcounterclockwise movements. 19. If the patient is in the lateral position, the hipmay be stabilized with the other hand to get abetter feel for the position and depth of theneedle. The thumb of this hand can be to mark thedesired site and to prevent accidentalrepositioning of the needle. A slight give will be felt, after which you willfeel that the needle is fixed solidly within thebone. Remove the stylet and aspirate approximately1 ml of unadulterated bone marrow into asyringe. Specimen is taken and is assessed for the 20. If the specimen shows spicules, the specimenshould be used to make smear slidesimmediately. If spicules are sparse or are not present, anew sample should be obtained from a slightlydifferent site. The needle is left in place and sequentialsyringes are filled that have been preparedwith heparin or other anticoagulants orpreservatives, depending on the requirementsfor specific studies to withdraw samples foradditional analysis. Then remove the needle, either afterreinserting the stylet or with the syringe 21. COMPLICATIONS : Hemorrhage Infection Persistent pain at the marrow site Retroperitoneal hematomas Trauma to neighboring structures (e.g.,lacerations of a branch of the glutealartery) and soft tissues