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Updated: Dec 31 2021

Lumbar Puncture

  • Snapshot
    • A 25-year-old woman presents to the emergency department with left upper extremity weakness and urinary retention. The patient was admitted due to suspicion of multiple sclerosis and a lumbar puncture was performed. Cerebrospinal fluid demonstrated oligoclonal bands and an elevated IgG index. The patient subsequently developed a headache that is worse when sitting or standing and improves when lying flat in bed. (Positional orthostatic headaches from a cerebrospinal fluid leak caused by lumbar puncture).
  • Introduction
    • Lumbar puncture (LP) is a procedure where a spinal needle is advanced into the subarachnoid space in order to collect cerebral spinal fluid (CSF)
      • the LP can allow the physician to determine
        • the etiology of meningitis
        • if the patient has a subarachnoid hemorrhage in the setting of a normal non-contrast head CT
        • the presence of a malignancy affecting the central nervous system (e.g., leptomeningeal carcinomatosis)
        • the presence of a demyelinating disease (e.g., multiple sclerosis)
        • if the patient has symptoms concerning for Guillain-Barre syndrome
        • elevated opening pressure in patients with idiopathic intracranial hypertension (pseudotumor cerebri)
      • caution should be taken in performing the LP in patients with
        • increased intracranial pressure from a space-occupying lesion
          • the patient runs the risk of brain herniation
        • thrombocytopenia or other bleeeding diathesis
        • signs and symptoms concerning for a spinal epidural abscess
    • Cerebrospinal Fluid Analysis
      Opening pressure
      • ≤ 20 cm H
      • normal or slightly ↑
      • Clear
      • Cloudy
      • Clear
      • Cloudy
      Cell count
      • 0-5 cells/µL
      • ↑ (PMN)
      • ↑ (Lymphocytes)
      • ↑ (Lymphocytes)
      • < 45 mg/dL
      • Slighty ↑
      CSF:Serum glucose
      • > 0.6
      • Normal
  • Technique
    • Patient position
      • lateral recumbent position
        • preferred for accurate opening pressure measurement
      • prone position
        • better for fluoroscopy guided LP
      • sitting upright
    • Needle entry
      • into the subarachnoid space at L3-4 or L4-5 interspace
        • remember that the spinal cord ends in L1-2
          • thus there should not be any trauma to the spinal cord if properly performed
    • In cases where there are unsuccessful attempts in obtaining CSF, imaging guidance can be used such as
      • fluoroscopy
      • ultrasound
  • Complications
    • Post-LP headache
    • Infection
    • Bleeding
    • Cerebral herniation
    • Traumatic lumbar puncture
      • absence of xanthchromia
      • declining red blood cell count in successive CSF collection tubes
      • cerebrospinal fluid white -to-red blood cell ratio of 1:750-1000
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Private Note

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