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BackTable / VI / Topic / Procedure
Lumbar Puncture
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Pre-Procedure Prep
Indications
• Meningitis
• Occult subarachnoid hemorrhage
• CSF analysis
• CSF pressure measurements - normal adult pressure between 6-25 cm H2O
• Intrathecal administration of medications such as chemotherapy or antibiotics
Contraindications
• Risk for cerebral herniation from space-occupying lesion with mass effect
• Thrombocytopenia, anticoagulation or bleeding diathesis: if possible attempt to correct platelet counts <50,000 and INR >1.4. Hold anticoagulants when possible (do not need to hold aspirin)
• Local skin infection at skin entry site or epidural abscess at intrathecal entry site
Risk Factors for Post-Lumbar Puncture Complications
• Young
• Females <40 years old
• History of headaches
• Fear of post procedural complications
SIR Periprocedural Coagulation Parameters
• INR, aPTT, platelets labs not routinely recommended
• INR: correct to 2.0 - 3.0
• Platelets: < 50,000/µl recommend transfusion (AABB recommendation - conservative). Also reasonable to use < 20,000/µl
Lumbar Puncture Podcasts
Listen to leading physicians discuss lumbar puncture on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Procedure Steps
Positioning is Key
• Preferred position is LAO, particularly if fluoro unit is stationary
• Patient's right leg is bent
• Back is obliqued towards the operator
Use metallic device and marker to approximate skin entry site with fluoroscopy
Tight collimation can be helpful to reduce parallax and beam exposure to operator's hands
Typical Access Levels are L2-L3 and L3-L4
• Shorter distance from skin to thecal sac
• Thecal sac can narrow close to sacrum
Preferable to prep skin with betadine
Anesthetize skin and subcutaneous tissue with lidocaine using 25-g needle
Standard Needle is 3.5" 22 g Spinal Needle
• Evidence suggests that atraumatic needle tip may reduce post-dural puncture headache (aka: spinal headache)
• Atraumatic needles: Whitacre, Sprotte, Gertie Marx, and others
• Often need longer needles for larger patients
Advance Needle via Paramedian Approach into Thecal Sac
Should feel loss of resistance as needle penetrates thecal sac
Attempt to orient bevel of needle parallel to longitudinal fibers of the interspinous ligaments
Remove inner stylet and evaluate for CSF flow
• Helpful to have a goose neck lamp for improved visualization of CSF
• Connect connection tubing with 3 way stopcock on back
Ideally, CSF should flow freely into tubing. If slow flow, many options for troubleshooting
• Rotate bevel of needle - will try bevel cranial and caudal first followed by both lateral positions
• Elevate head of bed to increase CSF flow - careful to not dislodge needle, can be difficult in obese patients
• Gentle aspiration with 10 ml syringe can be safe when used cautiously
If obtaining opening pressure, microbore connection tubing can be helpful
• Need connection tubing to bring 3-way stopcock to expected location of heart
• Usually cumbersome to reposition patient in decubitus position after intrathecal access is obtained
• Normal opening pressure 10-24 cm H2O
Volume of CSF to Obtain
• Depends on tests being requested
• Many places obtain 3 cc in first 3 tubes and 5 cc in the 4th tube
• High-volume lumbar puncture for idiopathic intracranial hypertension: removing >30 ml of CSF. Often times opening and closing pressure is requested. Helpful to use 20-g spinal needle for increased CSF flow.
• After CSF removed, replace stylet and remove needle.
Recommendations to Reduce Post-Procedural Complications
• Smaller gauge needle - can use 25g
• Minimize number of lumbar puncture attempts
• Passive removal of CSF
• Safe to collect up to 30 mL of CSF
• Bedrest not shown to reduce post lumbar puncture complaints
Post-Procedure
Complications
• Post-dural puncture headache - refractory headaches can be treated with epidural blood patch
• Infection
• Bleeding
• Cerebral herniation
• Nerve injury with radiculopathy or numbness
• Back pain
Post-Operative Care
• Varies widely with institution
• Some discharge patients immediately
• Some require bed rest: between 1-4 hours
• Encourage hydration for remainder of day
• No driving day of procedure
Post-Dural Puncture Headache
• AKA: spinal headache
• Conservative treatment: recumbent position and caffeine
• Epidural blood patch
Lumbar Puncture Demos
Watch video walkthroughs of lumbar puncture on the BackTable VI expanded content network.
References
[1] Özütemiz C, Rykken JB. Lumbar puncture under fluoroscopy guidance: a technical review for radiologists. Diagn Interv Radiol. 2019;25(2):144‐156. doi:10.5152/dir.2019.18291
[2] Johnson KS, Sexton DJ. (2018) Lumbar puncture: Technique, indications, contraindications, and complications in adults. UptoDate. Available from: https://www.uptodate.com/contents/lumbar-puncture-technique-indications-contraindications-and-complications-in-adults
[3] Engelborghs S, Niemantsverdriet E, Struyfs H, et al. Consensus guidelines for lumbar puncture in patients with neurological diseases. Alzheimers Dement (Amst). 2017;8:111‐126. Published 2017 May 18. doi:10.1016/j.dadm.2017.04.007
[4] Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, et al. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev. 2017;4(4):CD010807. Published 2017 Apr 7. doi:10.1002/14651858.CD010807.pub2
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