Lumbar Puncture (Training Physician)

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Evaluation for meningitis
  • Evaluation for subarachnoid blood
  • Diagnosis and therapeutic removal of CSF in idiopathic intracranial hypertension
  • Diagnosis of other neurologic conditions
  • Infusion of chemotherapeutic agents or contrast media for spinal cord imaging
CONTRAINDICATIONS
  • Suspected tumor, mass lesion, or increase in intracranial pressure
  • Skin infection at site of puncture
  • Bleeding disorder
EQUIPMENT
  • Face mask and sterile gloves **UNIVERSAL PRECAUTIONS** **STERILE TECHNIQUE**
  • Antiseptic solution, sterile gauze, sterile drapes **STERILE TECHNIQUE**
  • 1%-2% lidocaine without epinephrine, 3-mL syringe, 25-gauge needles
  • Topical anesthetic (e.g., EMLA) cream for pediatric patients (see Local Anesthesia for further details)
  • 22-gauge spinal needle
    • For patients younger than 2 years, a 1.5-inch needle is recommended.
    • For patients 2-12 years old, a 2.5-inch needle is recommended.
    • For patients older than 12 years, a 3.5-inch needle is recommended.
    • Obese patients may require a longer needle.
    • Traumatic or atraumatic needles may be used.
  • 3-way stop cock
  • Manometer
  • Four plastic tubes with caps, numbered 1 to 4
  • Bandage
ANATOMY
  • In adults, the spinal cord ends at L1; the cauda equina extends distally.
  • Puncture at the L3-L4 or the L4-L5 interspace is preferred.
  • The L4 spinous process is at the level of the posterior-superior iliac crests.
  • The needle traverses the supraspinal ligament, the interspinous ligament, the ligamentum flavum, and finally, the dura and arachnoid mater.
  • The spinous processes are angled caudally.
  • The space between spinous processes can be increased by flexing the lower back and hips.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • There is no need to have the patient lie supine.
  • Patients with coagulopathies or those who experienced traumatic taps should be observed for several hours.
  • Treatment of specific conditions revealed by CSF analysis should be undertaken in a timely manner.
COMPLICATIONS
  • Post-dural puncture headache
  • Cerebral herniation
  • Hemorrhagic complications
  • Local nerve root trauma and back pain
  • Infection
  • Epidermoid tumor
RESULT ANALYSIS
  • Normal opening pressure is 7-18 cm H2O.
  • Normal CSF contains less than 5 WBC/mm3.
  • Normal CSF contains less than 10 RBC/mm3.
  • Xanthochromia results from bleeding in the CSF that may be up to 12 hours old.
  • Normal CSF glucose levels are 50-80 mg/dL.
  • Normal CSF protein levels are 14-45 mg/dL.
  • Gram stain is positive in 60% to 80% of untreated cases of bacterial meningitis and 40% to 60% of partially treated cases of bacterial meningitis.
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