LUMBAR PUNCTURE

By:- firoz qureshiDept. psychiatric nursing

INTRODUCTION

A Lumbar puncture (or LP, and known as a spinal tap) is a diagnostic and at times therapeutic medical procedure. Diagnostically it is used to collect cerebrospinal fluid (CSF) to confirm or exclude conditions such as meningitis and subarachnoid haemorrhage and it may be used in diagnosis of other conditions.

ANATOMY OF SPINE:

The cervical area consists of seven vertebrae in the neck. TThe spinal column is made up of 33 vertebrae that are separated by

spongy disks and classified into distinct areas: he thoracic area consists of 12 vertebrae in the chest area. The lumbar area consists of five vertebrae in the lower back area. The sacrum has five, small fused vertebrae. The four coccygeal vertebrae fuse to form one bone, called the coccyx

or tailbone. The spinal cord, a major part of the central nervous system, is located in

the vertebral canal and reaches from the base of the skull to the upper part of the lower back. The bones of the spine and a sac containing cerebrospinal fluid surround it. The spinal cord carries sense and movement signals to and from the brain and controls many reflexes.

SPINAL CORD

DEFINITION:

Lumbar puncture (spinal tap) is performed in your lower back, in the lumbar region. During lumbar puncture, a needle is inserted between two lumbar bones (vertebrae) to remove a sample of cerebrospinal fluid — the fluid that surrounds your brain and spinal cord to protect them from injury.

A lumbar puncture can help diagnose serious infections, such as meningitis; other disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis; or cancers of the brain or spinal cord. Sometimes doctors use lumbar puncture to inject anesthetic medications or chemotherapy drugs into the cerebrospinal fluid.

INDICATIONS:

1. Lumbar puncture may be done to: Collect cerebrospinal fluid for laboratory analysis Measure the pressure of your cerebrospinal fluid Inject spinal anesthetics, chemotherapy drugs or other

medications Inject dye (myelography) or radioactive substances into

cerebrospinal fluid to make diagnostic images of the fluid's flow 2.To obtain CSF for the diagnosis of: Meningitis Meningoencephalitis Subarachnoid hemorrhage Malignancy – diagnosis and treatment

LUMBAR PUNCTURE HELP TO DIAGNOSE:

Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis

Bleeding around the brain (subarachnoid hemorrhage) Certain cancers involving the brain or spinal cord Certain inflammatory conditions of the nervous system, such

as multiple sclerosis and Guillain-Barre syndrome.

RISK FACTORS:

A small amount of CSF can leak from the needle insertion site. This can cause headaches after the procedure. If there is a persistent leak the headache can be severe.

There is a slight risk of infection because the needle breaks the skin’s surface, providing a possible portal of entry for bacteria.

A temporary pain or numbness to the legs or lower back pain may be experienced.

There is a risk of bleeding in the spinal canal.

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 Age >65 Reduced GCS Recent history of seizure Focal neurological signs Abnormal respiratory pattern Hypertension with bradycardia and deteriorating

consciousness

EQUIPMENTS:

Most CSF trays come with: Anesthetic such as:

Topical - Zylocaine cream Lidocaine 1% with 25 gauge needle and syringe

Povidine-iodine solution & sponge wand Drapes, gauze, and bandages Manometer 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

 

NEEDLES GAUGES:

PREPARATION OF PATIENT:

Preparing for your lumbar puncture is easy provider will probably order several blood tests to be sure that you don't have any unusual bleeding or clotting.

Some patients will be asked to have a brain scan (CT or MRI) performed prior to the procedure if you have never had one before.

If you take a blood thinner, make sure you ask your provider when you should stop this medication. If you take Ibuprofen or aspirin frequently, you should stop taking them a few days before your spinal tap.

CONT….. Plan to spend at least two hours at the hospital on

the day of your procedure. Although the actual spinal tap takes only a few minutes, numbing and cleaning the area and preparation can take about 30 minutes.

You will want to wear loose fitting clothing to increase your comfort following your procedure.

You will also need to lie flat following the spinal tap for a minimum of thirty minutes to promote clotting at the site of the puncture

PROCEDURE: Assess the general condition of the patient and check all

the laboratory investigations.preapare all the articles Wash hands Wear the gloves and maintain sterile field Performed with the patient in the lateral recumbent

position. Spinal needles entering the subarachnoid space at this

point are well below the termination of the spinal cord. Apply topical anesthetic 30-45 min prior to procedure

PROCEDURE CONT.. 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 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

PROCEDURE CONT.. Careful not to inject into a blood vessel or spinal canal Insert spinal needle with stylet with bevel up to keep cutting

edge parallel with nerve and ligament fibers Hold needle firmly A “pop” of sudden decrease in resistance indicates that

ligamentum flavum and dura are punctured Remove stylet and check for flow of spinal fluid 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

PROCEDURE CONT..

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

POSITION FOR LUMBAR PUNCTURE

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

IMAGES OF MANOMETRY

PROCEDURE CONT..

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

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

AFTER CARE: Once the needle is removed, a small bandage is placed over

the hole in your skin and you will be asked to remain flat on the exam table for a minimum of 30 minutes to help prevent any leakage of spinal fluid after the procedure.

You will be encouraged to drink extra fluid while you recover and for the next two to three days.

A headache following spinal tap occurs in up to 20 percent of patients. It typically occurs upon standing and is relieved by lying down.

You should lie flat on your back or stomach (but not your side) for as long as you can the first 24 hours after the procedure or if you have a headache.

AFTER CARE CONT.. Also, to minimize complications, it is recommended that

patients avoid bending and heavy lifting for two to three days following the procedure.

Even lifting a small child following this procedure can cause the clot formation to become dislodged, resulting in a headache.

Your provider will tell you when it is safe to return to work. Most people can generally return to work in one to two days.

Wash hands Recording and reporting. 

COMPLICATIONS

Headache Apnea (central or obstructive) Back pain Bleeding or fluid leak around spinal cord Infection, pain, hematoma Subarachnoid epidermal cyst Ocular muscle palsy (transient) Nerve Trauma

SUMMARY

So today we have discuss the topic lumbar puncture under this we have discussed:

Introduction, Anatomy of spine, Definition, Indications, Risk factors, Contraindications, Preparation of patient, Procedure, After care of patient.

CONCLUSION

Lumbar puncture is the process of insertion of a needle into lumbar region of the spine so that the cerebrospinal fluid can be withdrawn for laboratory investigations to diagnose the disease. It is a common procedure in order to detect any bacterial, viral infection causes the disease.

 

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