LUMBAR PUNCTURE

Indications

Diagnostic
Therapeutic Anaesthetic Radiological

Diagnostic
Suspected intracranial infections-meningitis and encephalitis. Suspected subarachnoid haemorrhage (SAH) (sometimes) CSF pressure measurement- eg: idiopathic intracranial hypertension. For carcinomatous meningitis Demyelinating diseases like Multiple sclerosis and Guillian Barre syndrome, neurosyphilis , sarcoidosis.

Therapeutic
Recurrent LPs to remove CSF are useful in the treatment of Idiopathic Intracranial Hypertension ( pseudotumour cerebri) Intrathecal injections/drugs (eg: Inj.Methotrexate in acute lymphoblastic leukemia) Inj hydrocortisone 50-100mg in TB meningitis Inj CP in pyogenic meningitis.

Anaesthetic
LP is a part of spinal anaesthesia

Radiological
To do a myelogram

To scan or Not to scan?

LP should be performed only after a thorough Neurological examination. In a suspected case of meningitis with no signs of raised ICP , LP can be done without prior CT. If there are raised signs of ICP ( fluctuating levels of consciousness, focal neurological signs , papilloedema) then a CT scan is a must. Never delay potentially life saving interventions such as antibiotics in patients with suspected meningitis.

Contraindications
1. Suspicion of a mass lesion in the brain or spinal cord ( coning can occur). 2. Raised intracranial pressure 3. Local infection near the LP site 4. Bleeding disorders (prolongedPT/aPTT or low platelets < 40,000/microlitre ) 5. Gross spinal lesion in the lumbar region like meningomyelocele

Site
Space between L3 L4 is located by palpating the posterior superior iliac crests and moving medially towards the spine. Children -L4 L5 interspace. Position lateral recumbent or sitting posture . Always obtain signed informed consent. Ensure patients are hydrated before LP.

Anatomical layers punctured during LP

Skin Subcutaneous tissue Supraspinatous ligament Interspinous ligament Ligamentum flavum Extradural fat/ Epidural space Duramater Subdural space Arachnoid mater

Equipment
Lumbar puncture needle
20 or 22 gauge beveled needle QUINCKE Needle Newer atraumatic /Pencil tip needles are available.

Needle to be inserted in cephaloid direction towards the umblicus.

Site of puncture

Site of puncture

CSF investigations

CSF specimens are collected in 3 sterile bottles & 1 sample for CSF glucose along with a simultaneous blood glucose sample. Record CSF naked-eye appearance clear, cloudy, red or yellow ( xanthochromic). Cells (RBC, WBC and differential) Protein Glucose Gram stain Culture AFB India ink stain

CSF picture- Physiological Appearance- colourless Pressure- 60 to 150 mm of CSF Cell count- 0-5 cells/c.mm. Mononuclear only. Protein- 0.2 to 0.4 g/L Glucose- 60% of Blood Glucose IgG-- < 15% of the total CSF protein Oligoclonal bands- absent

CSF picture- Pathological Raised PMN cells & decreased glucose in CSF = Pyogenic meningitis Raised Lymphocytes in CSF = TB or Viral meningitis Very high protein levels in = TB Meningitis & spinal block. Xanthochromia = yellowish colour seen due to RBC hemolysis detected on centifuged supernatent CSF. Seen in SAH. Oligoclonal bands [ Ig G ] = seen in Multiple sclerosis Traumatic / Bloody tap = can mimic CSF with SAH.

Post-spinal headache-most common side-effect , Bloody Tap Dry Tap Infection Trauma to blood vessels, spinal cord & intervertebral disc Root pain due to puncture of nerve root Transtentorial herniation or coning

Complications

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