lumbar spinal puncture (LP, Quincke puncture, spinal tap, rachicentesis, rachiocentesis)
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Indications
- CNS infection/meningitis: bacterial, fungal, viral
- Subarachnoid hemorrhage
- carcinomatous meningitis:
- inflammatory conditions:
- miscellaneous conditions:
- pseudo tumor cerebri, normal pressure hydrocephalus
- introduction of diagnostic & therapeutic agents
Contraindications
- evidence of increased intracranial pressure
- papilledema
- focal neurologic signs
- CT suggests increased intracranial pressure*
- infected skin or tissue overlying puncture site
- anticoagulated state
- increased prothrombin time
- reverse anticoagulation 1 hr prior to LP
- thrombocytopenia
- no serious complications in 100 patients receiving dual antiplatelet therapy with clopidogrel + aspirin[7]
Procedure
- a 20-22 gauge needle with stylet inserted is inserted using sterile technique into the lumbar cistern of the spinal cord for diagnostic or therapeutic purposes
- atraumatic needles diminish incidence of headache after lumbar puncture (RR=0.4) compared with standard needles[6]*
- the spinal cord ends at L1-L2 in adults, L3 in children
- the needle is inserted into the L4-L5 or the L3-L4 interspace
- the L2-L3 space may be used in adults
- the superior aspects of the iliac crests marks the level of the L4-L5 interspace
- local anesthesia with lidocaine is standard procedure & narcotic analgesia is usually greatly appreciated
- opening pressure of the CSF may be measured with a manometer
- normal pressures are 10-20 cm of H2O
- opening pressure > 25 cm H2O with viral meningitis
- opening pressure > 20-50 cm H2O with bacterial meningitis[5]
- 1-2 mL of CSF is collected in tubes 1-3 & 4 mL of fluid is collected in tube for special studies
- simulation-based education may improve LP skills[3]
- ultrasound guidance reduces frequency of failed attempts[4]
* conventional needles have their collection port integrated into the point, which cuts through tissue
* atraumatic needles have a closed, pencil-like point, which tends to separate & dilate dural fibers
- non-cutting collection port of atraumatic needle is further up the shaft
- atraumatic needles diminish leakage of CSF after puncture[6]
Radiology
- head CT prior to LP is indicated, except:
- if clinically suspected meningitis, & low risk of abnormal CT[2]
- indications for head CT prior to LP[5][9]
- suspected mass lesion
- immunosuppression
- history of CNS disease
- new-onset seizures
- altered level of consciousness
- focal neurologic deficit[9]
- papilledema
- performance of a head CT prior to LP delays administration of antibiotics by about 1 hour
Complications
- headache occurs 10-20% of the time
- hydration, supine position & small gauge needle are most useful measures
- autologous epidural blood patch for headache due to CSF leakage[5]
- infection
- bleeding
- spinal hematoma (0.2% not significantly affected by anti-platelet agent or anticoagulant use)[8]
- backache
- epidermal transplant: stylet is used to prevent epidermal transplant into the spinal canal
- paresthesias: use stylet, do not aspirate CSF or nerve roots
- herniation:*
- avoid LP if mass lesion or acutely elevated intracranial pressure is suspected
- CT of head prior to LP to identify mass lesions
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1065-67
- ↑ Jump up to: 2.0 2.1 Journal Watch 22(2):17, 2002 Hasbun R et al Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 345:1727, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11742046
- ↑ Jump up to: 3.0 3.1 Barsuk JH et al. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology 2012 Jun 6; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22675080 <Internet> http://neurology.jwatch.org/cgi/content/full/2012/619/2
- ↑ Jump up to: 4.0 4.1 Shaikh F et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: Systematic review and meta-analysis. BMJ 2013 Mar 26; 346:f1720. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23532866
- ↑ Jump up to: 5.0 5.1 5.2 5.3 Medical Knowledge Self Assessment Program (MKSAP) 16, 18. American College of Physicians, Philadelphia 2012, 2018.
- ↑ Jump up to: 6.0 6.1 6.2 Nath S, Koziarz A, Badhiwala JH et al Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. Dec 6, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29223694 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32451-0/fulltext
van de Beek D, Brouwer MC Atraumatic lumbar puncture needles: practice needs to change. Lancet. Dec 6, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29223693 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32480-7/fulltext - ↑ Jump up to: 7.0 7.1 Carabenciov ID et al. Safety of lumbar puncture performed on dual antiplatelet therapy. Mayo Clin Proc 2018 May; 93:627 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29573815 https://www.mayoclinicproceedings.org/article/S0025-6196(18)30102-2/fulltext
- ↑ Jump up to: 8.0 8.1 Bodilsen J et al. Association of lumbar puncture with spinal hematoma in patients with and without coagulopathy. JAMA 2020 Oct 13; 324:1419 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33048155 https://jamanetwork.com/journals/jama/article-abstract/2771609
- ↑ Jump up to: 9.0 9.1 9.2 NEJM Knowledge+ Question of the Week. Dec 22, 2020 https://knowledgeplus.nejm.org/question-of-week/5036/