Lumber
puncture
Prepared by
AL / Mahmoud omara
2025
Overview
• The central nervous system consists of the
brain and the spinal cord
• The meninges
• The brain and spinal cord are completely
surrounded by three layers of tissue between
the
skull and the brain, and between the vertebral
foramina and the spinal cord
• dura mater
• arachnoid mater
• pia mater.
• The arachnoid and pia maters are separated
by the subarachnoid space, containing
cerebrospinal fluid.
CSF
formation
• The brain contains four
irregular-shaped
cavities, or ventricles
• right and left lateral
ventricles
• third ventricle
• fourth ventricle.
• Cerebrospinal fluid is
secreted into each
ventricle of the brain by
choroid plexuses
• CSF is secreted continuously at a rate of about
0.5 mL per minute, i.e. 720 mL per day.
• The pressure remains fairly constant at about
10 cm H2O when lying on one side and about
Csf 30 cm H2O when sitting up
constitution • consisting of:
• water
s • mineral salts
• glucose
• plasma proteins: small amounts of albumin
and globulin
• a few leukocytes
CSF supports and protects the brain and spinal cord by maintaining a
uniform pressure around these vital structures
Functions
of acting as a cushion or shock absorber between the brain and the skull.
cerebrosp
inal fluid
It keeps the brain and spinal cord moist
CSF is thought to be involved in regulation of breathing as it bathes the
surface of the medulla where the central respiratory chemoreceptors are
located .
Lumbar
Puncture
• Lumbar puncture (LP), also
known as a spinal tap, is a
medical and invasive
procedure in which a hollow
needle is inserted into
lumbar subarachnoid space,
usually between the third
and fourth lumbar vertebra,
and cerebrospinal fluid is
withdrawn for diagnostic
and therapeutic purposes.
• Diagnostic indications*
1. (CNS) infection (acute bacterial meningitis,
viral meningitis, encephalitis,
subacute or chronic meningitis)
2. Suspected multiple sclerosis
3. subarachnoid hemorrhage
4. metastases (carcinomatous meningitis)
Indications 5. To give a radiopaque contrast agent for
myelography
Therapeutic indication
1. Administration of intrathecal drugs (eg, spinal
or epidural anesthesia, intrathecal
chemotherapy)
• Absolute contraindications
• Suspected infection (eg, cellulitis, abscess) at
or near the site of needle insertion
• Relative contraindications
• Suspicion of increased intracranial pressure(7-
15mmhg) due to an intracranial mass (eg,
tumor, brain abscess, or blood) that could
precipitate cerebellar herniation
contraindication • Coagulopathy (eg, international normalized
s ratio [INR] >1.5thrombocytopenia [<
50,000/mcL, 50 x 109/L]
• Cardiopulmonary insufficiency or respiratory
distress, which can be exacerbated by
recumbent positioning during lumbar puncture
• Spinal column deformities.
Equipment
• Sterile gloves, gown, face mask,
and cap
• Sterile drapes and/or towels
• Spinal Needle, 20 and 22-gauge
• 2-Manometer
• 3- Three-way stopcock
• 4-Sterile drapes
• 5- Xylocaine 1%- 2%.
• 6-skin antiseptic
• 7- Adhesive dressing
• 8- Sponges - 10 X 10 cm
• 10- CSF specimen collection bottles
How to
locate
puncture
site
procedure of lumbar puncture
• Preparatory phase:
• Ask the patient to empty urinary bladder and bowel.
• - Explain procedure to patient
• Obtain informed consent
• Obtain baseline assessment( vital signs & neurology)
• Positioning:
• Lateral decubitus position:
• Place a pillow under the head to align the head
with the spine and between the knee
• The patient lies on the side in a fetal position
• Ensure the pelvis, back, and shoulders are
perpendicular to the bed
• Sitting position
• The patient sits at the edge of the bed with
their feet on a stool or chair to flex the hip
• leans forward with the head and shoulders
resting on a bedside table.
• Insertion and performance phase
• Skin is prepared with antiseptic solution and the skin
• Inject local anesthetic agent
• spinal puncture needle is introduced at L3-L4 interspaces
• Instruct the patient to breathe quietly.
• Ask the patient to not talk
• The opening pressure is obtained
• Obtain 3 or 4 sample as needed
• Closing pressure is obtained
• Remove the stylet and perform firm pressure on puncture
site with sterile gausze
• Do cell count and differential on the 1st and 3rd tubes so that counts
can be compared if red blood cells are present. (A sharp decrease in
red blood cell count from the 1st to the 3rd tube is consistent with a
traumatic puncture.)
• Do other tests, including protein and glucose levels, oligoclonal
bands (if needed) and microbiologic testing, from the 2nd tube
After procedure, the patient is
instructed to remain in prone position
without pillow for about 2 hours.
Post Ensure adequate hydration with oral or
puncture parental fluids
phase
Monitor for spinal headache, and
observe for cerebrospinal fluid leak.
Characteristic of normal cerebrospinal fluid:
1- Normal range of spinal fluid pressure 50-175 mm
H2o
2- clear and colorless appearance.
3- Ph 7.30 to 7.40
4- Fasting glucose 40 to 80mg/dl
5- White blood cells 0 to 5 small lymphocytes/mm3
1- Severe headache.
2- Herniation of brain due to sudden decrease in pressure.
3- Accidental puncture of spinal cord
4- Meningitis from introducing bacteria into CSF.
Complication:
5- Temporary voiding problems.
6- Slight elevation of temperature.
7- Back or leg pain/paresthesia.
Prevention of post lumbar headache
1 2 3
Use small gauge needle. Keep patient in prone If more than 20 ml CSF
position after procedure. removed patient should
positioned in prone position
for 2 hours, then flat in a side
lying position for 2-3 hours,
then in prone or supine for 6
more hours.
MCQ:
• A nurse is caring for a client post-lumbar puncture who reports a
throbbing headache when sitting upright for meals. Which of the
following are appropriate actions by the nurse? (Select all that apply)
• A. Use the Glasgow Coma Scale when assessing the client
• B. Assist client to eat meals while lying flat in bed
• C. Administer an opioid medication
• D. Encourage client to increase fluid intake
• E. Place client in a "cannonball" position
• Which is the best way to position a patient for lumbar puncture?
• a) Prone.
• b) Sitting.
• c) Left lateral.
• d) Right latera
• In which condition is lumbar puncture not helpful in diagnosis?
• a) Meningitis.
• b) Epilepsy.
• c) TB.
• d) Multiple sclerosis.
• At which spinal vertebral interspaces level is lumbar puncture not
performed?
• a) L1-L2.
• b) L2-L3.
• c) L3-L4.
• d) L4-L5.
• What laboratory investigation is not done on the CSF?
• a) Test for WBC, RBC.
• b) Cholesterol.
• c) Sugar.
• d) Proteins.
• A lumbar puncture is performed on a child suspected of having
bacterial meningitis. CSF is obtained for analysis. A nurse reviews the
results of the CSF analysis and determines that which of the following
results would verify the diagnosis?
• 1. Cloudy CSF, decreased protein, and decreased glucose
• 2. Cloudy CSF, elevated protein, and decreased glucose
• 3. Clear CSF, elevated protein, and decreased glucose
• 4. Clear CSF, decreased pressure, and elevated protein
