Download Lumbar Puncture - Emory Department of Pediatrics

Lumbar Puncture
Kalpesh Patel, MD
Dept. of Pediatric Emergency
Medicine
December 6, 2006
Objectives
 To learn the indications and contraindications for
performing lumbar puncture
 To learn lateral decubitus and sitting procedure for
lumbar puncture
 To learn the median and paramedian approach
 To review complications that can occur with lumbar
puncture, their precautions and treatments
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History
 CSF first examined in 19th century using primitive
techniques (sharpened bird quills)
 Modern technique first performed by Quincke in
1890 on a small child and has changed little since
then
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Indications
 To obtain CSF for the diagnosis of:
• Meningitis
• Meningoencephalitis
• Subarachnoid hemorrhage
• Malignancy – diagnosis and treatment
• Pseudotumor Cerebri
• Other neurologic syndromes
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Contraindications
 Unstable patient with cardiovascular or respiratory
instability
 Localized skin/soft tissue infection over puncture
site
 Evidence of unstable bleeding disorder
• Platelets < 50,000 or clotting factor deficiency
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Contraindications
 Increased intracranial pressure
• Head CT before study if focal neurologic findings
present to rule out impending cerebral mass
herniation
• Normal CT does not preclude intracranial HTN
• Do not delay antibiotics to obtain imaging studies
when bacterial meningitis is strongly suspected
 Neurologic deterioration can occur if LP is done
below the level of a complete spinal subarachnoid
block
 Caution in patients with Chiari malformations
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Equipment
 Most CSF trays come with:
• Anesthetic such as:
 Topical - EMLA, Elamax, Zylocaine
cream
 Lidocaine 1% with 25 gauge needle
and syringe
• Povidone-iodine solution & sponge wand
• Drapes, gauze, and bandages
• Manometer, stopcock and tubing in noninfant kits
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Equipment
 Spinal needle, usually
22 gauge
• 1.5 in for < 1 yr
• 2.5 in for 1 year to
middle childhood
• 3.5 in for older
children and
adolescents
• Larger for large
adolescents
 Atraumatic needles,
less spinal headaches
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Lateral Decubitus Position
 Apply topical anesthetic 30-45 min prior to procedure
 Spinal cord ends at L1-L2, so sites for puncture are
located at L3-L4 or L4-L5
 Restrain patient in lateral decubitus position
• Maximally flex spine without compromising airway
• Keep alignment of feet, knees and hips
• Position head to left if right handed or vice versa
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Procedure
 Cleanse skin with povidone iodine from puncture
site radially out to 10 cm and ALLOW TO DRY
 Drape below patient and around site with
fenestrated drape
 Anesthetize with lidocaine if topical not used by:
• Intradermally raising a wheal at needle insertion
site
• Advance needle through wheal to desired
interspace
 Careful not to inject into a blood vessel or
spinal canal
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Procedure
 Insert spinal needle with stylet with bevel up to
keep cutting edge parallel with nerve and ligament
fibers
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Procedure
 Aim towards umbilicus directing
needle slightly cephalad
 Hold needle firmly
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Procedure
 A “pop” of sudden
decrease in resistance
indicates that
ligamentum flavum and
dura are punctured
 Remove stylet and
check for flow of spinal
fluid
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Procedure
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 If no fluid, then:
• Rotate needle 90°
• Reinsert stylet and advance needle slowly
checking frequently for CSF
 Jugular vein compression can increase CSF
pressure in low flow situations
 If bony resistance is felt immediately then you are
not in the spinal interspace
 If bony resistance is felt deeply, then withdraw
needle to the skin surface and redirect more
cephalad and increase patient flexion
 If bloody fluid that does not clear or that clots
results, then withdraw needle and reattempt at a
different interspace
Manometry
 When CSF flows, attach manometer to obtain
opening pressure if desired
 Pressure can only be accurately measured in
lateral decubitus position and in the relaxed patient
 Attach manometer with a 3-way stopcock when free
flow of CSF is obtained
 Read column when highest level is achieved and
respiratory variation is noted
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Procedure
 Collect 1ml of CSF in each of 3 vials for:
• Tube 1: culture & gram stain
• Tube 2: glucose, protein
• Tube 3: cell count & differential
• and extra CSF if desired for other lab tests
 Check closing pressure with manometer, if desired
 Reinsert stylet and remove needle in one quick
motion
 Cleanse back and cover puncture site
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LP The Movie
Sitting Position
 Restrain infant in the seated position
with maximal spinal flexion
• Hold infant’s hands between
flexed legs with one hand and flex
head with the other hand
 Drape patient below buttocks and
fenestrated drape opening over
puncture site
 Insert needle so bevel is parallel to
spinal cord (Bevel left or right)
 Cannot measure pressure accurately
in this position
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Paramedian (Lateral) Approach
 Use for patients who
have calcifications from
repeated LPs or
anatomic abnormalities
 Needle passes through
erector spinae muscles,
and ligamentum flavum
• Bypasses
supraspinal and
interspinal ligaments
 Less incidence of
spinal headache
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Complications
 Headache
• Uncommon in < 10 y/o
 Apnea (central or obstructive)
 Back pain
• Occasionally with short-lived referred limp
• Disc herniation if needle advanced too far
 Bleeding or fluid leak around spinal cord
 Infection, pain, hematoma
 Subarachnoid epidermal cyst
 Ocular muscle palsy (transient)
 Nerve Trauma
 Brainstem herniation
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Spinal Headache
 Most common complication
 Risk factors: female, age 18-30, lower BMI, hx of
HA, prior spinal HA
 Bilateral HA, improves when supine
 Can last hours to weeks
 Supine position for at least 2 hours
 Hydration
 Caffeine either PO or IV
 Epidural blood patch
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Spinal Headache Prevention
 Can avoid by:
• Passing needle bevel parallel to longitudinal
fibers of dura
• Replacing stylet before removing needle
• Using small diameter needles
• Using atraumatic needles
 Bed rest or PO intake after LP does not reduce
incidence of headache
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Nerve Root Trauma/Irritation
 Can feel electric shocks or dysesthesias
 Back pain can persist for months
• Consider disc herniation
 Rarely permanent
 Withdraw needle immediately
 If pain or motor weakness persists, start
corticosteroids
 Electromyogram/nerve conduction velocity studies
should be scheduled if pain persists
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Herniation
 Manifests initially as altered mental status, followed
by cranial nerve abnormalities and Cushing triad
 May be rapidly fatal.
 Immediately remove needle and raise the head of
bed to 30-45° improve venous return from the brain.
 Mannitol or 3% Saline
 Intubate patient and hyperventilate
 Emergent neurosurgical consult
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Epidermal Inclusion Cyst
 Very rare due to use of stylet
 Occurs when a core of skin is driven into spinal or
paraspinal space with hollow needle
 Do not remove stylet until through the skin
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Failure of Procedure
 If sample of CSF is critical several
alternatives are available:
• Have someone else try
 Anesthesia
 Neurology
• Bedside ultrasound for difficult
LPs
• Radiographic guided
procedure
 Fluoroscopy
 Ultrasound
 CT
• Cisterna Magna tap
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Questions?
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