Lumber puncture

Aminu M Hussain
 Introduction
• In a lumbar puncture (LP, or spinal tap), cerebrospinal
fluid (CSF) is withdrawn through a needle inserted into
the subarachnoid space of the spinal canal between
the third and fourth lumbar vertebrae or between the
fourth and fifth lumbar vertebrae.
• At this level the needle avoids damaging the spinal
cord and major nerve roots.
• The client is positioned laterally with the head bent
toward the chest, the knees flexed onto the abdomen,
and the back at the edge of the bed or examining table
 Definition
• Lumbar puncture, also known as spinal tap, is
an invasive procedure where a hollow needle is
inserted into the space surrounding the
subarachnoid space in the lower back to obtain
samples of cerebrospinal fluid (CSF) for
qualitative analysis.
• Most of the disorders of the central nervous
system are diagnosed in relation to the changes
in the composition and dynamics of the CSF.
• A lumbar puncture may also be used to
measure CSF, instill medications, or introduce
a contrast medium into the spinal canal. The
procedure usually takes around 30 to 45
minutes and can be done on an outpatient
basis at a hospital or clinic.
 Responsibilities
• One of the responsibilities of the nurse during
a lumbar puncture is to provide information
and instructions before, during, and after the
procedure.
• It will decrease fear and anxiety among the
patient and their families, and it will also
lessen the occurrence of potential
complications post-lumbar puncture.
• A local anesthetic will be given to minimize
discomfort. Explain when and where the procedure
will occur (e.g., the bedside or in a treatment room)
and who will be present (e.g., the primary care
provider and the nurse).
• Explain that it will be necessary to lie in a certain
position without moving for about 15 min. A slight
pinprick will be felt when the local anesthetic is
injected and a sensation of pressure as the spinal
needle is inserted.
 Indication
• Measure cerebrospinal fluid (CSF) pressure
• Assist in the diagnosis of suspected CNS infections
(bacterial or viral meningitis,
meningoencephalitis), intracranial or
subarachnoid hemorrhage, and some malignant
disorders
• Evaluate and diagnose demyelinating or
inflammatory CNS processes such as
Multiple Sclerosis, Guillan-Barré Syndrome (GBS),
Acute Disseminated Encephalomyelitis (ADEM)
• Infuse medications which include spinal
anesthesia before surgery, contrast material
for diagnostic imaging such as CT-
myelography, and chemotherapy drugs
directly into the spinal canal
• Treat normal pressure hydrocephalus,
cerebrospinal fistulas, and idiopathic
intracranial hypertension (IIH).
• Placement of a lumbar CSF drainage catheter
 Contraindication
• Absolute contraindications for lumbar puncture are
as follows:
• Increased intracranial pressure due to a brain tumor
. Cerebral or cerebellar herniation with severe
neurological deterioration may occur after the
withdrawal of CSF fluid.
• Skin infection near the puncture site. The presence
of skin infection near the site of the lumbar puncture
increases the risk of contamination of infected
material into the CSF.
• Severe degenerative vertebral joint
disease. There will be difficulty in passing the
needle through the degenerated arthritic
interspinal space.
• Severe coagulopathy. Due to the significant
risk of epidural hematoma formation.
 Equipments
• The lumbar puncture kit contains:
• Sterile gloves
• Sterile drapes and procedure tray
• Sterile gauze pads
• Aseptic solution: povidone-iodine
solution (Betadine)
• Local anesthetic: Lidocaine 1% solution
• 25G needle
• 10ml syringe (1)
• Spinal needle with stylet (size 22G or 25G)
• CSF tube (2 to 4)
• Stopcock
• Manometer tubing
 Procedure
• Step-by-step procedure for a lumbar puncture (spinal
tap):
• Position the patient in a fetal position.
• The patient is positioned on his side at the edge of
the bed with his knees drawn up to his abdomen and
chin tucked against his chest (fetal position) or sitting
while leaning over a bedside table. When the patient
is positioned supine, pillows are provided to support
the spine on a horizontal plane.
• Sterilize the site of insertion. The skin site is
prepared and draped, and a local anesthetic is
injected.
• Insert the spinal needle. The spinal needle is
inserted in the midline between the spinous
processes of the vertebrae (usually between
the third fourth or fourth and fifth lumbar
vertebrae).
• Remove the stylet from the needle. The stylet
is removed from the needle. CSF will drip out of
the needle if it’s properly positioned. A stopcock
and manometer are attached to the needle to
measure the initial (opening) CSF pressure.
• Collect specimen. Specimens are collected and
placed in the appropriate containers.
• Remove the needle. The needle is removed,
and a small sterile dressing is applied.
 Nursing Responsibility for Lumbar
Puncture
• Before the procedure
• The following are the nursing interventions prior to a lumbar
puncture:
• Explain the procedure to the patient. Explain to the patient
the purpose of lumbar puncture, how and where it’s done,
and who will perform the procedure.
• Obtain informed consent. Make sure the patient has signed
a consent form if required by the institution.
• Reinforce diet. Advise the patient that fasting is not required.
• Promote comfort. Instruct the patient to empty
the bladder and bowel before the procedure.
• Establish baseline assessment data. Do vital signs
monitoring and neurologic assessment of the legs by
assessing the patient’s movement, strength, and sensation.
• Place the client in a lateral decubitus position. Assist the
client to assume a lateral decubitus (fetal) position, near the
side of the bed with the neck, hips, and knees drawn up to
the chest. An alternative position is to have the patient sit
on the edge of the bed while leaning over a bedside table.
• Instruct to remain still. Explain that he or she must lie very
still throughout the procedure. Any unnecessary movement
may cause traumatic injury.
• Reassure the client throughout the procedure by explaining
what is happening.
• Encourage normal breathing and relaxation.
• Observe the client’s color, respirations, and pulse during
the procedure. Ask the client to report headache or
persistent pain at the insertion site.
• Handle specimen tubes appropriately:
Wear gloves when handling test tubes.
Label the specimen tubes in sequence.
Send the CSF specimens to the laboratory immediately.
Place a small sterile dressing over the puncture site.
 After the procedure
• Apply brief pressure to the puncture site. Pressure will be applied to
avoid bleeding, and the site is covered by a small occlusive dressing or band-
aid.
• Place the patient flat on the bed. The patient remains flat on the bed for 4 to
6 hours depending on the physician. He or she may turn from side to side as
long as the head is not elevated.
• Monitor vital signs, neurologic status, and intake and output. Take vital signs,
measure intake, and output, and assess neurologic status at least every 4
hours for 24 hours to allow further evaluation of the patient’s condition.
• Monitor the puncture site for signs of CSF leakage and drainage
of blood. Signs of CSF leakage include positional
headaches, nausea and vomiting, neck stiffness, photophobia (sensitivity to
light), sense of imbalance, tinnitus (ringing in the ear), and phonophobia
(sensitivity to sound).
• Encourage increased fluid intake. An increased
amount of fluid intake (up to 3,000 ml in 24 hours)
will replace CSF removed during the lumbar puncture.
• Label and number the specimen tube
correctly. Ensure all samples are properly labeled and
sent to the laboratory immediately for further
evaluation.
• Administer analgesia as ordered. Headaches after
the procedure can last for a few hours or days and are
usually treated with analgesics.
• Document the procedure on the client’s chart:
• Date and time performed; the primary care
provider’s name; the color, character, and
amount of CSF; and the number of specimens
obtained.
• Also document CSF pressure and the nurse’s
assessments and interventions.
 Normal Results
• CSF samples for analysis with normal values typically range as
follows:
• Pressure: 70 to 180 mm H20.
• Appearance: CSF is normally clear and colorless.
• CSF total protein: 15-45 mg/dL
• Gamma globulin: 3 to 12% of the total protein
• CSF glucose: 50 to 80 mg/dl
• CSF cell count: Normal CSF contains no red blood cells (RBCs), and
the white blood cell (WBC) count is 0-5 WBCs per microliter (all
mononuclear)
• CSF Chloride: 118 to 130 mEq/L
• Gram stain: No microorganism (bacteria, fungi, or virus) is present.
 Abnormal Results
• Pressure:
– Increased intracranial pressure (ICP) occurs as a result of a tumor, hemorrhage, or
trauma-induced edema.
– Decreased intracranial pressure (ICP) may reveal a spinal subarachnoid obstruction.
• Appearance:
– Cloudy appearance indicating infection.
– Yellow to reddish appearance indicating spinal cord obstruction or intracranial
hemorrhage.
– Brown to orange appearance indicating increased protein levels or RBC breakdown.
• CSF Protein:
– Increased protein indicating tumor, trauma, diabetes mellitus, or blood in cerebrospinal
fluid (CSF).
– Decreased protein indicates rapid CSF production.
• Gamma globulin:
– Increased gamma globulin indicates a demyelinating disease such as multiple sclerosis,
neurosyphilis, or Guillan-Barré Syndrome.
• CSF Glucose:
– Increased glucose indicates high blood sugar (hyperglycemia).
– Decreased glucose indicates low blood sugar (hypoglycemia), bacterial
or fungal infection, tuberculosis, or meningitis.
• CSF cell count:
– Increased white blood cells in the CSF suggest meningitis, tumor,
abscess, acute infection, stroke, or demyelinating disease.
– Red blood cells in the CSF indicate bleeding into the spinal fluid or the
result of a traumatic lumbar puncture.
• CSF Chloride:
– Decreased chloride indicating infected meninges.
• Gram stain:
– Gram-positive or Gram-negative organisms indicate bacterial meningitis.
 Complications
• The possible complications after a lumbar puncture are:
• Post-lumbar puncture headache. The most common complication of LP
occurs due to the leakage of CSF from the puncture site or into the tissues
around it. The pain is aggravated while sitting, standing, or coughing and
resolves after lying down.
• Back pain. Pain or discomfort in the lower back may happen as a result of
trauma to the local soft tissue.
• Pain or numbness. A feeling of tingling sensation and numbness in the
lower back and legs is felt temporarily.
• Bleeding. Bleeding is usually noted in the area of the punctured site, or in
some rare cases into the subarachnoid, subdural, or epidural space.
• Brainstem herniation: The increased pressure caused by the removal of CSF
during LP will cause a sudden shifting of brain tissue that can lead to the
compression or herniation of the brainstem.