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A procedure in which a thin, hollow needle is inserted into the lower part of the spine to gather a sample of cerebrospinal fluid. The needle is placed between two bones in the spine and into the subarachnoid space

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A set of practices used to eliminate all microorganisms from an area, preventing infection during surgical and other invasive procedures

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The process of cleaning and disinfecting a patient's skin, typically before a surgical procedure or other invasive intervention

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Skin preparation before procedures like surgery or injections is crucial for preventing infections

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It aids in diagnose infections like meningitis, multiple sclerosis, and other conditions affecting the central nervous system.

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Skin preparation involves cleaning the area where the needle will be inserted with antiseptic solutions to minimize the risk of infection.

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Draping refers to covering the patient wi sterile drapes during the procedure to maintain a sterile environment and prevent contamination

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1. Preparation

2. Needle Insertion

3. Post-Procedure

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Various methods are employed to sterilize surgical instruments and environments:

• Steam Under Pressure

• Dry Heat

• Chemical Sterilization

• Ethylene Oxide (Gas): A gas used for sterilizing sensitive equipment

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The procedure is primarily used for diagnosing conditions such as meningitis, multiple sclerosis, and other neurological disorders by analyzing the collected cerebrospinal fluid.

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To eliminate all microorganisms from an area or object to prevent infection during surgical procedures and other invasive interventions

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Meticulous hand hygiene, use of personal protective equipment (PPE), sterile supplies, and maintaining a sterile field

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Biopsies Screening and Diagnostics Neurology Radiology

A lumbar puncture (LP) or spinal tap may be done to diagnose or treat a condition. For this procedure, your healthcare provider inserts a hollow needle into the space surrounding the spinal column (subarachnoid space) in the lower back to withdraw some cerebrospinal fluid (CSF) or inject medicine.

CSF is a clear fluid that bathes and cushions the brain and spinal cord. It is continuously made and reabsorbed in the brain. CSF is made up of cells, water, proteins, sugars, and other substances that are essential to maintain balance in the nervous system.

Why might I need a lumbar puncture?

A lumbar puncture may be done for various reasons. The most common reason is to remove a small amount of CSF for testing. This can help in the diagnosis of various disorders. The fluid is tested for red and white blood cells, protein, and glucose (sugar). The clarity and color of the fluid are also checked and it is tested to see whether bacteria, viruses, or abnormal cells are present. Excess CSF may also be removed in people who have an overproduction or decreased absorption of the fluid.

A lumbar puncture procedure may be helpful in diagnosing many diseases and disorders, including:

Meningitis. An inflammation of the membrane covering the brain and spinal cord. The inflammation is usually the result of a viral, bacterial, or fungal infection.

Encephalitis. An inflammation of the brain that is usually caused by a virus.

Certain cancers involving the brain and spinal cord

Bleeding in the area between the brain and the tissues that cover it (subarachnoid space)

Reye syndrome. A sometimes fatal disease that causes severe problems with the brain and other organs. Although the exact cause of the disease is not known, it has been linked to giving aspirin to children. It is now advised not to give aspirin to children during illnesses, unless prescribed by your child's healthcare provider.

Myelitis. An inflammation of the spinal cord or bone marrow.

Neurosyphilis. A stage of syphilis during which the bacteria invades the central nervous system.

Guillain-Barré syndrome. A disorder in which the body's immune system attacks part of the nervous system.

Demyelinating diseases. Diseases that attack the protective coating that surrounds certain nerve fibers - for example, multiple sclerosis or acute demyelination polyneuropathy.

Headaches of unknown cause. After evaluation and head imaging if necessary, a lumbar puncture may be done to diagnose certain inflammatory conditions that can result in a headache.

Pseudotumor cerebri (also called idiopathic intracranial hypertension, or IIH). In this condition,pressure within the subarachnoid space is elevated for reasons that are not clear. A lumbar puncture is only done in this condition after evaluation and head imaging.

Normal pressure hydrocephalus. A rare condition affecting mainly older people in which there is a triad of loss of urinary control, memory problems, and an unsteady gait. A lumbar puncture is done to see if the pressure of the CSF is elevated or not.

In addition, a lumbar puncture may be used to measure the pressure of the CSF. The healthcare provider uses a special tube (called a manometer) to measure s the pressure during a lumbar puncture.

Finally, a lumbar puncture may be done to inject medicine directly into the spinal cord. These include:

Spinal anesthetics before a surgical procedure

Contrast dye for X-ray studies - for example, myelography

Chemotherapy drugs used to treat cancer

Your healthcare provider may have other reasons to recommend a lumbar puncture.

Pseudotumor Cerebri | Ashley's Story

What are the risks of a lumbar puncture?

Because this procedure involves the spinal cord and brain, the following complications may occur:

A small amount of CSF can leak from the needle insertion site. This can cause headaches after the procedure. If the leak continues, your headache can be severe.

You may have a slight risk of infection because the needle breaks the skin's surface, providing a possible way for bacteria to enter the body.

Short-term numbness of the legs or lower back pain may be experienced.

here is a risk of bleeding in the spinal canal.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I prepare for a lumbar puncture?

I f you are having a lumbar puncture at Johns Hopkins Hospital or Bayview Medical Center, a neuroradiologist or radiology nurse will contact you by phone two or three days prior to your lumbar puncture to discuss the procedure and answer any questions you may have.

Please inform the neuroradiology physician if:

You are on antibiotics - you may need to wait to do the procedure if currently on antibiotics for an in infection in your blood. If you have an active infection or fever, your procedure may need to be rescheduled.

You are allergic to any local anesthetics (lidocaine)

There is any chance that you could be pregnant

You are on anticoagulant therapy (blood thinners)

PRECAUTIONS : If you are pregnant or think you might be pregnant, please check with your doctor before scheduling the exam. Other options should be discussed with you and your doctor.

: Youmay be asked to change into a gown. A gown will be provided for you. However, the procedure may also be done while you remain in your clothes from home. For this reason, try to wear non-restrictive, comfortable clothing and slip on shoes if possible. Please remove all piercings and leave all jewelry and valuables at home

: Try to increase your fluid intake (such as water and juice) for the two days leading up to your procedure unless a medical condition does not allow you to safely do so. If you are not sure if it is safe for you, contact your primary care provider or referring provider.

However, on the day of the procedure, do not eat for three hours before the procedure. You may have liquids and can take your usual medications unless previously advised to hold certain medications in preparation for the lumbar puncture.

MEDICATION : All patients can take their prescribed medications as usual unless instructed to hold certain medications such as blood thinners. Please bring a current list of your medications and allergies with you.

: You must have an adult driver accompany you so they can drive you home after the procedure. This is for your safety and comfort.

Arrive one hour prior to the scheduled procedure time for check-in and to be prepped for the procedure.

Please note: You will be unable to drive for 24 hours after the procedure. If you are taking a cab or using public transportation, you need to bring a friend or family member to accompany you after the procedure to your home or hotel. A cab or public transportation driver is not considered an escort.

What happens during a lumbar puncture?

A lumbar puncture procedure may be done on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices. Some healthcare providers may prefer to do this procedure at the bedside or may opt to have it done using a type of live X-ray called fluoroscopic guidance.

Generally, a lumbar puncture follows this process

You will remove any clothing, jewelry, or other objects that may interfere with the procedure

You will be given a gown to wear.

You will be reminded to empty your bladder prior to the start of the procedure.

During the lumbar puncture you may lie on the exam table on your side with your chin tucked to your chest and knees tucked to your abdomen. Or, you may sit on the edge of an exam table with your arms draped over a table positioned in front of you. In either position the back is arched, which helps to widen the spaces between your vertebrae.

Therefore, your back will be cleansed with an antiseptic solution and draped with sterile towels. The healthcare provider will wear sterile gloves during the procedure.

The provider will numb the skin by injecting a local anesthetic. This injection may sting for a few seconds, but makes the lumbar puncture less painful.

The hollow needle will be inserted through the numbed skin and into the space where the CSF is located. You will feel some pressure while the needle is inserted. You must remain absolutely still during the insertion of the needle.

The CSF will begin to drip out of the needle and a small amount, about one tablespoon, will be collected into test tubes.

If the provider needs to inject medicine into the spinal canal, it will be given through the same needle after the CSF is collected.

When the procedure is done, the needle will be removed and a bandage will be placed over the injection site. The test tubes will be taken to the lab for testing

Tell the healthcare provider if you feel any numbness, tingling, headache, or light-headedness during the procedure.

You may have discomfort during a lumbar puncture. Your healthcare providers will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.

What happens after a lumbar puncture?

This helps reduce the incidence of a headache. You will be allowed to roll from side to side as long as your head is not elevated. If you need to urinate, you may need to do so in a bedpan or urinal during the time that you need to stay flat.

You will be asked to drink extra fluids to rehydrate after the procedure. This replaces the CSF that was withdrawn during the spinal tap and reduces the chance of developing a headache.

After recovery, you may be taken to your hospital room or discharged to your home. If you go home, usually your healthcare provider will advise you to rest for the remainder of the day

Once you are at home, notify your provider of any abnormalities, such as:

Numbness and tingling of the legs

Drainage of blood or pain at the injection site

Inability to urinate

If the headaches persist for more than a few hours after the procedure, or when you change positions, contact the neuroradiology team with the phone number provided on your discharge instructions.

You may be instructed to limit your activity for 24 hours following the procedure.

Your healthcare provider may give you other specific instructions about what you should do after a lumbar puncture.

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Biopsies Screening and Diagnostics Neurology Radiology A lumbar puncture (LP) or spinal tap may be done to diagnose or treat a condition. For this procedure, your healthcare provider inserts a hollow needle into the space surrounding the spinal column (subarachnoid space) in the lower back to withdraw some cerebrospinal fluid (CSF) or inject medicine.

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When it is difficult to palpate landmarks (eg, because of obesity), lumbar puncture can be done by a radiologist using fluoroscopic guidance. Ultrasound can also be used to identify landmarks and, less commonly, to guide needle placement in real time if equipment and personnel are available. However, ultrasound is still not commonly used outside of teaching centers.

Diagnostic indications*

Suspected central nervous system (CNS) infection ( , viral meningitis, , )

Suspected CNS inflammatory conditions, including (or other CNS demyelinating conditions such as NMO or MOGAD), autoimmune encephalitis (eg, anti-NMDAR encephalitis), and

Suspected spontaneous not diagnosed on neuroimaging or if immediate neuroimaging is not available

Suspected intracranial hypotension

Other CNS conditions, including , leptomeningeal metastases (carcinomatous meningitis), genetic metabolic encephalopathies

To give a radiopaque contrast agent for myelography

* Decide in advance what information you need from the lumbar puncture and what tests you need to order. Confirm requirements for any unusual tests with the clinical laboratory before starting the procedure.
Therapeutic indications

Reduction of intracranial pressure in idiopathic intracranial hypertension

Administration of intrathecal medications (eg, spinal or epidural anesthesia, intrathecal chemotherapy)

Absolute contraindications

Suspected infection (eg, cellulitis, abscess) at or near the site of needle insertion: If possible, use an alternate, uninfected site. This involves a suboccipital (cisternal) or cervical (C1-C2) approach and is always done under fluoroscopic guidance.

Relative contraindications

Suspicion of increased intracranial pressure due to an intracranial mass (eg, tumor, brain abscess, or blood, especially if in the infratentorial space) that could precipitate transtentorial or cerebellar * following lumbar puncture. If there are suggestive findings (eg, focal neurologic deficits, altered mental status, papilledema, ), do CT or MRI before lumbar puncture. (However, risk of herniation cannot always be predicted by CT or MRI.)

(eg, international normalized ratio [INR] 1.5, including therapeutic anticoagulation; thrombocytopenia [< 50,000/mcL, 50 × 10 /L], or pathologically increased activated partial thromboplastin time), which can lead to spinal hematoma from lumbar puncture: Consider correcting prior to procedure.†

Cardiopulmonary insufficiency or respiratory distress, which can be exacerbated by recumbent positioning during lumbar puncture

Anatomic abnormalities at the insertion site (eg, spinal fusion, laminectomy, congenital anomalies)

Bacteremia has not been shown to predispose to meningitis after lumbar puncture and thus is not a contraindication.

* When lumbar puncture is deferred, begin treatment of suspected or immediately. For meningitis, also do blood cultures immediately.

† Therapeutic anticoagulation (eg, for pulmonary embolism) increases the risk of bleeding with lumbar puncture, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. If time permits, discuss any contemplated reversal with the clinician managing the patient's anticoagulation.

Bleeding into the epidural space (spinal hematoma)

Lower back discomfort or pain that may radiate to the posterior legs (self-limited)

Epidermoid tumor, which occurs years after lumbar puncture; risk is increased if the spinal needle is inserted or withdrawn with the stylet absent (very rare)

Cortical blindness (rare)

Cervical spinal cord infarction (rare)

Transient or permanent deafness (rare)

Iatrogenic infection (rare)

Transient nausea and/or tinnitus

Intracranial hypotension due to CSF leak (rare)

Headache develops after lumbar puncture in about 10% of patients, usually hours to a day or two afterward, and can be severe. Younger patients with a small body mass are at greatest risk. Using narrower, cutting (beveled-tip), or noncutting (pencil-point tip) needles reduces risk. Neither the amount of CSF removed nor a period of recumbency after lumbar puncture affects incidence.

In many centers, prepackaged lumbar puncture kits are available. If not, necessary equipment includes the following:

Sterile gloves, gown, face mask, and cap

Sterile drapes and/or towels

Antiseptic solution (eg, chlorhexidine , povidone-iodine , alcohol wipes) Antiseptic solution (eg, chlorhexidine, povidone-iodine, alcohol wipes)

Sterile gauze (eg, 10 cm × 10 cm [4" × 4"] squares)

Local anesthetic (eg, 1 or 2% without epinephrine , 25- and 20-gauge needles, 10-mL syringe) Local anesthetic (eg, 1 or 2% lidocaine without epinephrine, 25- and 20-gauge needles, 10-mL syringe)

Topical anesthetic (standard for children): Needle-free gas-injection device, - epinephrine - tetracaine (LET) gel or - prilocaine cream Topical anesthetic (standard for children): Needle-free lidocaine gas-injection device, lidocaine-epinephrine-tetracaine (LET) gel or lidocaine-prilocaine cream

Spinal needle with stylet: Cutting needle (beveled-tip) or noncutting (atraumatic) needle* (pencil-point tip); 20 or 22* gauge; 9-cm-long for adults, 6 cm for children, 4 cm for infants

4 CSF collection tubes (labeled 1 through 4) for laboratory studies; additional tubes if large-volume CSF collection is needed (eg, 30 to 40 mL) or additional special tests are needed. Large volumes of 30 to 40 mL of CSF may need to be collected when (eg, or ) or carcinomatous meningitis is suspected. Additional tubes (enough to contain 30 to 40 mL of CSF) may also be needed if a high-volume LP is planned for diagnosis of normal pressure hydrocephalus.

Manometer and stopcock; optionally, short extension tubing

* Use of noncutting (pencil-point tip) needles, cutting (beveled-tip) needles, and smaller caliber (ie, 22-gauge) needle reduces risk of post-lumbar puncture headache.

For ultrasonographic guidance:

If needed, draw blood for blood glucose to compare with CSF glucose; blood for oligoclonal bands can be collected at the same time.

Short-term sedation (eg, with or and/or ) may be needed for children and anxious adults. Short-term sedation (eg, with propofol or fentanyl and/or midazolam) may be needed for children and anxious adults.

Although ultrasonographic guidance can increase success rates and decrease complication rates in certain settings ( ), routine use of ultrasound in emergency medicine to localize anatomical landmarks has not been shown to have these benefits ( ).

The desired insertion point of the needle is the L3-L4 or L4-L5 interspace; thus, the needle is inserted below the level of the spinal cord.

The spinous process of L4 lies along an imaginary line between the top of the posterior superior iliac crests.

Because the spinal cord ends at approximately T12-L1, the LP can theoretically be done as high up as L2 without risk of spinal cord injury.

In a midline insertion (most common approach), the spinal needle first traverses the supraspinous and interspinous ligaments between the vertebral spinous processes, before reaching the ligamentum flavum.

A lateral insertion (eg, 1 cm both lateral and caudad to the midline skin insertion point) bypasses the midline ligaments and may facilitate lumbar puncture in older patients whose ligaments are calcified and sclerotic.

The ligamentum flavum is thick connective tissue, and a distinct pop may (or may not) be palpable when the needle traverses it.

The needle then passes through epidural space (fat tissue and internal vertebral venous plexus) and then may palpably pop-again-through the dura mater (and simultaneously through the adjacent subarachnoid membrane) to enter the subarachnoid space (CSF space). Note that in many cases, no "pop" can be appreciated.

In children or infants, whose fibrous tissue offers little resistance to penetration, a pop may not be palpable as the needle passes the ligamentum flavum or dura.

The goal is to flex the lumbar spine to expand the intervertebral spaces. The patient may either lie in the lateral decubitus position or be seated. The lateral decubitus position is generally preferred and should be used if CSF manometry is desired. The sitting position may be helpful for patients in whom physical landmarks are difficult to palpate in a lying position (eg, those with obesity); it is the preferred position for infants.

Lateral decubitus position: The patient lies on the side in a fetal position, with the hips flexed as much as is tolerable. Ensure the pelvis, back, and shoulders are perpendicular to the bed. Place a pillow under the head to align the head with the spine and between the knees for comfort if needed. An assistant can help the patient curl up as much as possible. Before beginning, assume a comfortable position close to the patient.

Sitting position: The patient sits at the edge of the bed with their feet on a stool or chair to flex the hips, and leans forward with the head and shoulders resting on a bedside table.

For an infant, an assistant holds the arms and legs from the front, maintaining the infant in a sitting fetal position on the bed. The head is also supported to prevent asphyxiation due to neck flexion.

Bedrest after lumbar puncture is unnecessary and does not reduce the incidence of post-lumbar puncture headache; however, recumbency remains helpful in treating post-lumbar puncture headache.

Increased oral intake of fluids has been suggested to treat post-procedural headache but has not been effective in controlled trials. may help prevent post-procedural headache, but, because of its diuretic effect, is another reason to increase fluid intake. Increased oral intake of fluids has been suggested to treat post-procedural headache but has not been effective in controlled trials. Caffeine may help prevent post-procedural headache, but, because of its diuretic effect, is another reason to increase fluid intake.

Instruct the patient to be vigilant for persistent or worsening back pain, which may occur up to several days after the lumbar puncture and requires prompt evaluation to exclude hematoma.

Be sure to keep the patient's hips, back, and shoulders precisely perpendicular to the bed.

When using the lateral decubitus position, maintain the patient's tightly curled fetal position.

Be sure to direct the needle toward the midline (not angled to one side) and slightly cephalad.

These errors make it difficult to enter the spinal canal. In addition,

Do not withdraw the needle without reinserting the stylet.

If the spinal canal is not entered, do not try to reposition the needle by moving the tip to one side or another; this can damage tissue. Instead, withdraw the needle nearly to the skin surface (ie, outside of the spinal ligament) before changing the angle and direction of insertion.

Seat yourself comfortably close to the patient before doing the procedure in the lateral decubitus position.

Consider holding the needle with both hands to obtain better control.

Avoid inserting the lumbar puncture needle through a skin infection or tattooed skin because of risk that infection could be introduced or the theoretical possibility that tattoo ink could be introduced into the CSF and cause irritation or toxicity. If necessary, either use an adjacent interspace or make a small stab incision through the tattooed epidermis with a scalpel and then introduce the needle through the incision.

After the needle is through the skin and into the spinous ligament, recheck the patient's alignment (hips perpendicular to bed) and direction of the needle (perpendicular to spine) before inserting further.

CSF flow may be facilitated by turning the fully inserted needle 90° (so that the bevel faces cephalad). If this is done, rotate the needle back to the parallel position before removing the needle to avoid tearing dural fibers.

Draw blood to measure glucose level before (eg, by up to 30 minutes) lumbar puncture so that level can be accurately compared with the CSF glucose level. With this timing, serum and CSF oligoclonal bands can be compared also.

If lumbar puncture is unsuccessful in the decubitus position, try the sitting position, which may be successful because of increased spinal flexion and intervertebral space opening.

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How To Do Lumbar Puncture - Neurologic Disorders - Merck Manual Professional Edition

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How To Do Lumbar Puncture - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the Merck Manuals - Medical Professional Version.

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https://med.libretexts.org/Bookshelves/Nursing/Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/01%3A_Infection_Control/1.05%3A_Surgical_Asepsis_and_the_Principles_of_Sterile_Technique#:~:text=Sterile%20technique%20may%20include%20the,the%20principles%20of%20sterile%20technique.

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1.5: Surgical Asepsis and the Principles of Sterile Technique