Lumbar Puncture

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Lumbar Puncture

• 8/8/07 HVA
• 8/9/07 LUMC

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This Is A Spinal Tap
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The Lumbar Puncture

• History
• Heinrich Irenaus Quincke
• Quinckes most notable contribution, however,
  was his introduction of the lumbar puncture as a
  diagnostic and therapeutic technique. He arrived
  at this in an interesting and local fashion.
  Following his earlier work on the physiology of
  the cerebrospinal fluid he reasoned that infants
  with hydrocephalus might be benefited by the
  removal of some of the spinal fluid and thus
  break the over-production and/or under-absorption
  of liquor caused by compression of the pachonian
  granulations. As Friedrich Theodor von Frerichs'
  (1819-1885) assistant, he had studied in 1872 the
  anatomy and physiology related to the
  cerebrospinal fluid in dogs by injecting red
  sulphide of mercury into the spinal subarachnoid
  space. The knowledge gained thereby encouraged
  him to insert a fine needle with a stylet into
  the lumbar interspace of an infant, a procedure
  which he thought might cause slight injury to a
  root fibre of the cauda but would not cause
  paralysis.From the first he recognized its
  diagnostic potential (1891) and took accurate
  pressure measurements at the beginning and the
  end of the procedure. He also measured protein
  and sugar values and described the low sugar
  occurring in the CSF in purulent meningitis. He
  diagnosed tuberculous meningitis by demonstrating
  tubercle bacilli in the CSF and was the first
  person to puncture the lateral ventricle to
  obtain CSF in infants with hydrocephalus. When he
  first reported the technique at the Wiesbaden
  Congress in 1891 it excited little comment.
  However, over the years he had the satisfaction
  of seeing it become the premier diagnostic
  approach in neurological disorders.
• www.whonamedit.com
• James Leonard Corning
• Walter Essex Winter

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Indications

• Diagnostic
• Infectious
• Meningitis
• Encephalitis
• Inflammatory
• Multiple Sclerosis
• Gullain-Barre syndrome
• Oncologic
• Metabolic

• Therapeutic
• Analgesia
• Anesthesia
• Antibiotics
• Antineoplastics

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Contraindications

• Increased intracranial pressure
• Cerebral herniation
• Impending herniation
• Possible increased ICP and focal neuro signs
• Coagulopathy
• Prior lumbar surgery
• Severe vertebral osteoarthritis or degenerative
  disc disease
• Significant cardiorespiratory compromise

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Technique Tips

• Raise the bed
• Prepare your tray (i.e. the tubes)
• Use your landmarks
• Sytlet in with insertion, in with removal
• Unless you hand them to a runner yourself, carry
  the specimens to the lab

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Lab Studies

• Protein
• Glucose
• Cell count with differential
• Gram stain and culture
• PCR
• Myelin basic protein
• Smear
• Lactate
• Pyruvate

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Complications

• Herniation
• Cardiorespiratory compromise
• Pain
• Headache (36.5)
• Bleeding
• Infection
• Subarachnoid epidermal cyst
• CSF leakage

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Results

• Typical Cerebrospinal Fluid Findings in Various
  Types of Meningitis
• Test Bacterial Viral Fungal Tubercular
• Opening pressure Elevated Usually normal
  Variable Variable
• White blood cell count 1,000 per mm3 lt100 per
  mm3 Variable Variable
• Cell differential Predominance of Predominance
  of Predominance Predominance
• PMNs lymphocytes of lymphocytes of
  lymphocytes
• Protein Mild to marked Normal to elevated
  Elevated Elevated
• elevation
• CSF-to-serum glucose Normal to marked Usually
  normal Low Low
• ratio decrease

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