Lumbar Puncture

Cognitive Content

Skill Title :

Lumbar Puncture   Status :  O

Learning Objectives :

  1. Definition and Indications for Lumbar Puncture (K)
  2. Anatomy of Lumbar Spine and spinal cord with coverings
  3. Equipment required and Choosing appropriate needle:
  4. Complications / Risks associated with lumbar puncture (K)
  5. Explanation to Patient of entire procedure
  6. Aseptic precautions during procedure and their impact
  7. Demonstrate correct method of of lumbar Puncture with strict aseptic technique in mannequin.

Definition and Indications for Lumbar Puncture (K):: Short term / Long Term

Diagnostic Lumbar Puncture is one of the most commonly performed invasive tests in clinical medicine. Serious complications are rare, and correct technique and skill acquired will minimise diagnostic error and ensure patient comfort.

Indications for procedure :

  • To exclude subarachnoid haemorrhage
  • In acute severe headache
  • To investigate or exclude meningitis
  • To investigate neurological disorders like Multiple Sclerosis,Sarcoidosis, Guillian Barre,
  • To demonstrate and manage disorders of Intracranial Pressure like Idiopathic Intracranial Hypertension
  • To administer therapeutic or diagnostic agents like in Spinal anaesthesia, Intrathecal chemotherapy, Intrathecal antibiotics
  • Injection of Contrast media in myelography or cisternography

Anatomy of Lumbar Spine and spinal cord with covering (K)

The Lumbar Puncture needle pierces in order: skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space containing the internal vertebral venous plexus, dura, arachnoid, and finally the subarachnoid space.

Equipment required and Choosing an appropriate needle:

Equipment needed for Lumbar Puncture

  • Cleaning and draping material
  • CSF Specimen Bottles
  • Syringe for local anaesthetic
  • Introducer for spinal needle (not always required)
  • 19G and 25G hypodermic needles to draw up and inject anaesthetic
  • Whitacre 22G spinal needle (atraumatic needle)
  • Manometer with 3-way tap if CSF pressure measurement is desired.

Currently use of atraumatic needles are recommended. The recommended needle is a 22 gauge atraumatic needle. As an atraumatic needle will not pierce the epidermis, Options include using the introducer needle provided to pierce the skin, or using Puncture site local anaesthetic .

Needles of smaller diameter have been preferred and that is No.18 . Large bore atraumatic needles allow adequate pressure measurement and collection of sufficient CSF.

Simulation Equipment for Lumbar Puncture :

   Add Pictures of Catheters

  • Patient sex
  • The size of the patient’s urethral canal
  • The expected duration of catheterization (e.g. intermittent or indwelling)
  • Knowledge of any allergies to latex or plastic and cleansing solutions.

What is French Scale / English Scale ?

Commonly used range is from 12 to 16 Fr The higher the number the larger the diameter of the catheter. 3Fr. = 1mm (i.e. a 24fr. catheter is 8mm in diameter)

Simulation Equipment for demonstration :

Lumbar puncture acquires a sample of cerebrospinal fluid (CSF) for testing to confirm or exclude diagnosis of infection (bacterial, viral or fungal). TruBaby X facilitates lumbar puncture training with: Ability to maneuver the baby into the required lateral decubitus position or sit upright Palpable vertebrae landmarks including the iliac crest Insertion sites include L3-L4 and L4-L5 spine locations Accurate needle placement allows for positive response and collection of simulated cerebrospinal fluid (CSF) Fluid is isolated and can be quickly refilled for a unique training experience Insert can last for 100+ needle penetrations using a 22g needle and is fully interchangeable

dual-purpose simulator represents a 12-month-old infant in the left lateral decubitus position with neck and knees flexed. Features include embedded iliac crest for exceptional realism, removable spine, tactilely correct spinal canal, and two soft skin pads – one transparent for preliminary anatomic study, and one opaque for more advanced hands-on training. Fluid flow provides immediate feedback on proper needle placement for either procedure. Students will appreciate the opportunity to practice these two important procedures on a single simulator that is both appealing and anatomically accurate

Explanation to Patient of entire procedure

Aseptic precautions during procedure and their impact

Demonstration correct method of  lumbar Puncture with strict aseptic technique in mannequin

PATIENT POSITIONING

  • A right-handed practitioner should position the patient in the left lateral decubitus position, with the vertebrae in line in the horizontal plane and the head in a neutral position and the knees flexed.
  • Always ensure that the patient is comfortable, and that the bed height is appropriate for the operator, as the practitioner risks compromising aseptic technique if the patient has to be re-positioned
  • Lumbar Puncture can also be performed in the seating position like in spinal anaesthesia. There are occasions when pressure measurement is sacrificed in order to obtain a CSF sample.

Procedure :

  • Aseptic technique is required, and a pre-prepared epidural pack contains all the equipment needed other than your needle, lidocaine and manometer .
  • The manometer should be prepared prior to commencing the spinal injection
  • Once skin is sterile, local anaesthetic can be administered. A small amount of lidocaine can be infiltrated into deeper tissues, but care must be taken not to distort local anatomy .
  • The Lumbar Puncture needle should be inserted at an angle that will allow it to pass between the spinous processes . The most common problem encountered by operators is their needle impacting on a bony structure like spinous process. If this happens, Withdraw the needle and adjust the trajectory, gradually proceeding until a “give” is felt on passing through the ligamentum flavum
  • The stylet should be in place when the needle insertion commences
  • Once the needle is sufficiently advanced, withdraw the stylet slowly and wait about 5 seconds to see if CSF emerges. If it does not, replace the stylet and advance the needle another 2 or 3 mm and check again for CSF.
  • Once CSF is obtained, connect the manometer if pressure is required to be measured .
  • Samples should be taken either using sterile bottles .
  • Aspiration of CSF is not recommended, as it may cause spinal cord injury.

The patient can mobilise as soon as it is comfortable to do so.

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