NEUROLOGY + NEUROSURGERY
LUMBAR PUNCTURE
PromptIndications for LP
ResponseDiagnostic - analyse CSF and pressure
Theraputic - Remove CSF in idiopathic intracranial hypertension
Intrathecal medications
Theraputic - Remove CSF in idiopathic intracranial hypertension
Intrathecal medications
PromptCONTRAIndications for Lumbar Puncture
ResponseSuspected raised ICP - altered conscious state, unilateral dilated pupil, papilloedema, hypertension + bradycardia
Focal neurologic signs
Coagulopathy - Low platelets, raised INR, purpuric rash
Seizures
Abnormality at LP site - infection, spinal fusion, spina bifida
Previous complication of LP
Patient adgitation/compliance
Patient refusal
Other infection to explain symptoms (may not be required)
Focal neurologic signs
Coagulopathy - Low platelets, raised INR, purpuric rash
Seizures
Abnormality at LP site - infection, spinal fusion, spina bifida
Previous complication of LP
Patient adgitation/compliance
Patient refusal
Other infection to explain symptoms (may not be required)
PromptComplications of lumbar puncture
ResponseSpinal cord/nerve injury - Use spinal needle, enter below cord (L1 in adults)
Infection - aseptic technique
Pain, radicular pain - Local anaesthetic to skin to interspinous ligament
Post LP/Low pressure headache/CSF leak - small needle + gentle technique
Bleeding - fix coagulopathy prior to puncture
Spinal haematoma
False positive/non diagnostic sample
Haemorrhage
Failed procedure
Infection - aseptic technique
Pain, radicular pain - Local anaesthetic to skin to interspinous ligament
Post LP/Low pressure headache/CSF leak - small needle + gentle technique
Bleeding - fix coagulopathy prior to puncture
Spinal haematoma
False positive/non diagnostic sample
Haemorrhage
Failed procedure
PromptDescribe in a stepwise fashion how to do a lumbar puncture
ResponseConsent, consider sedation
Landmarks - superior aspect of iliac crest
Equipment - LP tray, 2 needles, anaesthetic 1-2% lignocaine, chlorhex, sterile gloves/gown/mask/drape, numbered tubes
Positioning - Seated vs L lateral foetal position
22-25 ga spinal needle midline, bevel sideways, 20-30 degrees cephalid. Insert for double “pop”. Remove stylette
Layers: Skin > S/C tissue > Supraspinous ligament > Ligamentum Flavum > Epidural space > Dura > subarachnoid space > Arachnoid Mater > Subarachnoid space (The goal!)
ICP measurement if indicated
10 drops x 3 tubes
Replace stylet, withdraw needle
Dressing
Send specimens to lab
Landmarks - superior aspect of iliac crest
Equipment - LP tray, 2 needles, anaesthetic 1-2% lignocaine, chlorhex, sterile gloves/gown/mask/drape, numbered tubes
Positioning - Seated vs L lateral foetal position
22-25 ga spinal needle midline, bevel sideways, 20-30 degrees cephalid. Insert for double “pop”. Remove stylette
Layers: Skin > S/C tissue > Supraspinous ligament > Ligamentum Flavum > Epidural space > Dura > subarachnoid space > Arachnoid Mater > Subarachnoid space (The goal!)
ICP measurement if indicated
10 drops x 3 tubes
Replace stylet, withdraw needle
Dressing
Send specimens to lab
Prompt3 strategies to minimise post LP headache
ResponseAtraumatic needle (Sprotte/whitacre)
Small needle calibre
Early mobilisation
Replace stylet before removal of the needle
Small needle calibre
Early mobilisation
Replace stylet before removal of the needle