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© Springer Science+Business Media New York 2016
L. Ganti (ed.), Atlas of Emergency Medicine Procedures , DOI 10.1007/978-1-4939-2507-0_41
L umbar Puncture in Adults K evin T ench ,L .C onnor N ickels ,and R ohit P ravin P atel 41.1I ndications • D iagnostic
– E valuation for the possibility of a central nervous sys-tem (CNS) infection: viral, bacterial, and fungal men-ingitis and encephalitis –E valuation for infl ammatory process: multiple scle-rosis, Guillain-Barré syndrome – E valuation for spontaneous subarachnoid hemorrhage (SAH) – S uspicion of CNS dias: oncological and metabolic process • T herapeutic – T herapeutic reduction of cerebrospinal fl uid (CSF) pressure – P rocedures requiring lower body analgesia or anesthesia – I ntrathecal antibiotic administration for some types of meningitis – C hemotherapy and methotrexate for some forms of leukemia and lymphomas 41.2C ontraindications • P rence of infection in tissues at or around puncture site. • I ncread intracranial pressure (ICP) from a space- occupying lesion; patients with signs of cerebral hernia-tion or with potential of incread ICP and focal neurological signs. • B leeding diathesis (thrombocytopenia, anticoagulant therapy, hemophilia); may increa risk
of spinal hema-toma, but level of coagulopathy that increas risk is unclear. • P atients with cardiorespiratory compromi may worn owing to position. P atients with prior history of lumbar surgery, osteoarthri-tis, ankylosing spondylitis, kyphoscoliosis, or degenerative disk dia might have more success if lumbar puncture is performed by an interventional radiologist using imaging techniques and should be considered. 41.3M aterials and Medications (See Fig. 123.1)• S pinal needle(s) with stylet – A dults: 3.5-in. 20-gauge needle; obe may require
5.0-in. 22- to 24-gauge needle – C hildren: 2.5-in. 22-gauge needle
多捞啊什么意思–I nfants: 1.5-in. 22-gauge needle • T hree-way stopcock (optional: drainage catheter)
• M anometer (optional: extension tube for higher opening pressures) • S pecimen tubes (# may vary, but in general labeled 1–4,金字塔有多高
important to obtain from 1, 2, 3, 4 owing to cell count obtained from tubes 1 and 3)
• L ocal anesthetic (lidocaine 1 or 2 %), 5- to 10-mL syringe and needle (25-gauge) for local anesthesia
• S terile drapes and gauze
• M ask, sterile gown, sterile gloves
• A ntiptic solution for skin preparation (Chloroprep or iodine) K . T ench ,M D D epartment of Emergency Medicine , B anner Boswell Medical
小夫子授课
Center ,S un City ,A Z ,U SA L . C . N ickels ,M D, RDMS ( ) • R . P . P atel ,M D D epartment of Emergency Medicine , U niversity of Florida Health
Shands Hospital ,G ainesville ,F L ,U SA e -mail: cnickels@ufl
.edu ; rohitpatel@ufl .edu
41
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41.4P rocedure
1. P ositioning
• D etermined by practitioner preference or patient capability.
• O ptions: lateral recumbent position, upright sitting position (Fig. 41.1).
• L ateral recumbent position is preferred to obtain accu-rate opening pressure and to reduce the risk of post-
puncture headache.
• B oth positions require the patient to arch the lower back toward the practitioner in order to open up the
intervertebral spaces (obtain the “fetal position” or
arch “like a cat”).
• S houlders and hips should remain aligned during process.
2. L andmarks
• D etermined by palpation.
• D raw a visual line between the superior aspects of the iliac crests that intercts the midline at the
L4 inter-
space. The L3–4 and L4–5 spaces are preferred
becau the points are below the termination of the
spinal cord.
• P alpate the posterosuperior iliac crests with the mid-point of a visual line that connects the two crests rep-
renting the L4 spinous process.
• P alpate the space between the L3–4 or the L4–5 spi-nous process and mark where the needle will be
placed.
3. U ltrasound guidance (optional)
• H elpful in obe patients, patients with previous surgi-cal scarring, or anyone in whom palpation of
the spi-
nous process is not easily done.
• S onographic measurement of the dura mater strongly correlates with needle depth needed to
obtain CSF.
• I dentify the spinal process in the short and long axis to determine the midline and the interspinous space.
• I dentify the interspinous ligament for estimation of the depth of needle inrtion.
C ommonly only the spinous process are well
visualized, and the interspinous ligament, ligamentum
麦卢卡蜂蜜功效fl avum, and subarachnoid space are less clearly en.
• H igh-frequency (5–10 MHz) linear probe to best eval-uate anatomy.
• A marking pen can be ud to create a cross-hair-type fi gure (Fig. 41.1).
• A fter placing the patient as described, locate the mid-line at the lumbar spine in transver and longitudinal
orientations.
• B right echogenic structures with shadowing posteri-orly identify the spinous process.
• T ransver probe positioning to identify midline (Fig. 41.2), and then longitudinal probe positioning to
identify interspinous space (Fig. 41.3).
建水古城游玩攻略4. S terile preparation
• A fter positioning and palpating the appropriate land-marks, the practitioner should then dress in the appro-
priate protective gear: mask, gown, and sterile gloves.
• A fter dressing, the practitioner can then sterilely pre-pare the patient.
–M ake sure the patient’s back is completely expod.
–C lean the patient’s back with an antiptic solution (Chloroprep should be scrubbed in an up/down and
side/side fashion; iodine in a circular motion starting
from the center of the anticipated inrtion point).
–A pply sterile drapes with the puncture site expod.
T his is an optimal time to make sure all equipment in
a standard lumbar puncture tray connects properly and
that the stopcock for opening pressure measurement is
asmbled. Make sure the stopcock is clod away from
the patient so that CSF can fl ow from the patient to the
manometer. If the asmbly is done, it will decrea the
amount of CSF lost after the puncture.
• L ocal anesthesia
–1 % Lidocaine or anesthetic cream topically before preparing skin
–F or injection, form a skin wheal over the inrtion site.
arp防火墙–I nject into the deep tissues below the wheal in all directions while only breaking the skin once.
–S ystemic datives and analgesics may also be ud. 5. N eedle inrtion
• N eedle should be inrted in the midline between the L3–4 or the L4–5 spinous process, and the stylet
should be fi rmly in place.
• I nitially parallel to the bed, but once into the subcuta-neous tissue, the needle should be angled toward the
umbilicus (slightly cephalad, 15°) with the bevel fac-
ing upward (Fig. 41.4). This sagittal plane orientation
spreads rather than cuts the fibers of the dural sac,
which run parallel to the spinal axis.
• I f properly positioned, the needle pass through the skin;
subcutaneous tissue; supraspinous ligament; interspinous
ligament between the spinous process; ligamentum fl a-
vum; epidural space including the internal vertebral
venous plexus, dura, and arachnoid; into the subarachnoid
space and between the nerve roots of the cauda equina.
• I n most cas, a “pop” will be felt when the needle pen-etrates the ligamentum fl avum, entering into the sub-
arachnoid space; then intermittent withdrawal should
be done in 2-mm intervals to asss for CSF fl ow.
• I f bone is encountered during inrtion, the needle should be withdrawn partially without exiting the skin
and readjusted to a different angle more cephalad.
K. Tench et al.
249• I f the tap is traumatic, CSF may be blood tinged but
should clear as more is collected. If it does not clear, it
may indicate intracranial hemorrhage or subarachnoid blood. Also in traumatic patients, clotting will be en in the tubes; clotting does not occur in SAH owing to defi brinated blood being prent in the CSF. Blood- tinged CSF can also be en in herpes simplex virus (HSV) encephalitis.
• A dry tap is usually due to incorrect positioning and misdirection of needle, often due to a superior direc-tion of the needle with obstruction by the lamina or
spinous process of the superior or inferior vertebra. If
the needle is too lateral, an inferior or superior articu-
lar process may be hit.
I f fl ow slows down, rotate the needle 90° becau a
nerve root may be obstructing the opening.
6. O pening pressure measurement
• M ust be performed in the lateral recumbent position.
Although there are some conversion formulas from
the sitting position, the are not standard of care.
a b
F ig. 41.1 S itting position ( a) left lateral decubitus position, ( b) with general areas of inrtion of needle
F ig. 41.2 T ransver view, w hite arrow indicates spinous process. Place in middle of ultrasound vie
w to locate appropriate midline access point
F ig. 41.3 L ongitudinal view of lumbar spine. T hick white arrows indi-cate vertebral shadows; t hin white arrow indicates supraspinous liga-ment. R ed arrow indicates trajectory of needle
41 Lumbar Puncture in Adults
250
• O nce the needle is in the subarachnoid space and CSF is flowing from the needle, the three-way stopcock
should be attached to the needle and the manometer
工程合同管理should be attached to the stopcock to take a measure-
ment. U the fl exible tube to connect the manometer
to the hub of the needle.
• N ote the height of fl uid in the manometer after it stops rising (normal opening pressure, <20 cm Hg); it may
be possible to e pulsations from cardiac or respira-
tory motion.
–E levated CSF pressure is en with meningeal inflammation, hydrocephalus, pudotumor cere-
bri, SAH, and CHF.
–D ecread CSF pressure is en in leakage of CSF and vere dehydration.
7. C ollecting CSF fl uid
• C ollect at least 1–2 mL of CSF fluid in each tube, going from 1 to 4 and never aspirate becau this can
cau hemorrhage.
• A fter collecting the fl uid, replace the stylet and remove the needle, clean the skin, and place a bandage over the
puncture site.
• G eneral recommendations
–T ube 1: gluco, protein, protein electrophoresis
–T ube 2: Gram stain, bacterial and viral cultures
–T ube 3: cell count and differential
• W hen ruling out SAH, cell count should be performed in tubes 1 and 3 or 1 and 4 to differentiate between
SAH and traumatic tap.
–T ube 4: Any special tests: myelin basic proteins, lactate, pyruvate, and smear on cell concentrates all
depend on suspicion. 41.5C omplications
• I mplantation of epidermoid tumors: from introducing skin plug into the subarachnoid space and can be avoided by using stylet when advancing.
• P ostlumbar puncture headache: most common, occurring in 36.5 % of patients within 48 h
• C SF leak: caus headache when CSF leak through punc-ture site exceeds rate of production
• B leeding: most common in patients with bleeding diathe-sis; may result in spinal cord compression
• E pidural hematoma
• I nfection: local cellulitis, abscess (local or epidural), or meningitis
• H erniation syndromes: high risk can be identifi ed by computed tomography but may not completel
y identify all patients with incread ICP
• B ackache: local or referred pain
• C ardiorespiratory compromi
41.6 P earls and Pitfalls
• P earls
–P ositioning the patient is key to a successful procedure.
–I n adults the spinal cord may terminate higher than previously thought and it may be okay to go one inter-
space higher than recommended; but in infants owing
to the differential in longitudinal growth of the spinal
canal and cord, the spinal cord usually ends in L3. So
in children the tap must go L4–5 or L5–S1.
–A lways keep the stylet in place until after the skin bar-rier is penetrated becau this will avoid introduction
of epidermoid tissue.
• P itfalls
–P ostspinal headaches can be avoided with smaller nee-dles and intravenous (IV) fl uids.
• H aving the patient lie on the back for 1 h after the procedure has no change in incidence of headache.
• T reatment consists of IV fl uids initially, then caf-feine, and, ultimately, if the headache persists, a
blood patch.
S elected Reading
B oon JM, Abrahams PH, Meiring JH, Welch T. Lumbar puncture: ana-
tomical review of a clinical skill. Clin Anat. 2004;17:544–53.
E llenby MS, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medi-
cine. Lumbar puncture. N Engl J Med. 2006;355:e12.
F erre RM, Sweeney TW, Strout TD. Ultrasound identifi cation of land-
marks preceding lumbar puncture: a pilot study. Emerg Med J. 2009;26:276–7.
P eterson MA, Abele J. Bedside ultrasound for diffi cult lumbar punc-ture. J Emerg Med. 2005;28:197–200.
F ig. 41.4 A ngle of inrtion of needle, cephalad with bevel up
K. Tench et al.
