PERFORMING LUMBER PUNCTURE (INDICATIONS, PROCEDURE, COMPLICATIONS)
Indications: diagnostic-r/o meningitis, sub-arachnoid hemorrhage, demyelinating disorders
Therapeutic-ex cryptococcal meningitis
Symptoms: patient presents with 2 or more of the following; fever(t>38.0), headache, altered mental
status (GCS<14), neck stiffness (kerning/ Brudzinski’s signs). Fever with headache alone are indications
for LP if malaria is negative.
Contraindications for performing LP: skin infection over puncture site, increase intracranial pressure due
to a mass (papilledema, CT scan with mass), bleeding disorders
PROCEDURE:
Position the patient in either the lateral decubitus or upright sitting position. In both positions
the patient’s spine should be straight and as flexed as possible with forehead bent towards the
knees. Positioning is very important for LP
Identify the puncture site. Palpate the top of the iliac crest and the vertebral interspace located
at the same level(l4-l5). Palpate L3-L4, L4-L5 and L5-S1 and mark the interspace that is most
open. Conus medullaris is at L1-L2
Sterilize the puncture site around your mark.
Using a sterile 20g needle or spinal needle and sterile gloves, enter at the middle of the
interspace. Advance the needle slowly towards the umbilicus and parallel to the ground.
Once CSF is obtained, estimate the opening pressure based on the flow rate. Collect fluid in at
least 3 separate tubes/bottles. Only the 2 nd bottle needs to be sterile to be sent for microbiology.
Describe the color and appearance of fluid in each bottle/tube
Place some drops of CSF on a urine dipstick and record results.
Send the 1st tube to chemistry(1ml) for total protein and glucose. Send the 2 nd bottle (5 ml) to
microbiology for gram stain, culture and sensitivity and AFB. Send the 3 rd bottle to hematology
for cell count and differentials.
Complications; post LP headache-common, nerve root injury (shooting pains, transient), tonsillar
herniation/spinal hemorrhage (severe but rare).
REFERENCES
Lecture notes- Weill Bugando school of medicine
Eddleston M, Davidson R, Brent A, Wilkinson R. Oxford Handbook of tropical medicine. 3rd ed. New York,
NY: Oxford university press USA; 2008.
Indications: diagnostic-r/o meningitis, sub-arachnoid hemorrhage, demyelinating disorders
Therapeutic-ex cryptococcal meningitis
Symptoms: patient presents with 2 or more of the following; fever(t>38.0), headache, altered mental
status (GCS<14), neck stiffness (kerning/ Brudzinski’s signs). Fever with headache alone are indications
for LP if malaria is negative.
Contraindications for performing LP: skin infection over puncture site, increase intracranial pressure due
to a mass (papilledema, CT scan with mass), bleeding disorders
PROCEDURE:
Position the patient in either the lateral decubitus or upright sitting position. In both positions
the patient’s spine should be straight and as flexed as possible with forehead bent towards the
knees. Positioning is very important for LP
Identify the puncture site. Palpate the top of the iliac crest and the vertebral interspace located
at the same level(l4-l5). Palpate L3-L4, L4-L5 and L5-S1 and mark the interspace that is most
open. Conus medullaris is at L1-L2
Sterilize the puncture site around your mark.
Using a sterile 20g needle or spinal needle and sterile gloves, enter at the middle of the
interspace. Advance the needle slowly towards the umbilicus and parallel to the ground.
Once CSF is obtained, estimate the opening pressure based on the flow rate. Collect fluid in at
least 3 separate tubes/bottles. Only the 2 nd bottle needs to be sterile to be sent for microbiology.
Describe the color and appearance of fluid in each bottle/tube
Place some drops of CSF on a urine dipstick and record results.
Send the 1st tube to chemistry(1ml) for total protein and glucose. Send the 2 nd bottle (5 ml) to
microbiology for gram stain, culture and sensitivity and AFB. Send the 3 rd bottle to hematology
for cell count and differentials.
Complications; post LP headache-common, nerve root injury (shooting pains, transient), tonsillar
herniation/spinal hemorrhage (severe but rare).
REFERENCES
Lecture notes- Weill Bugando school of medicine
Eddleston M, Davidson R, Brent A, Wilkinson R. Oxford Handbook of tropical medicine. 3rd ed. New York,
NY: Oxford university press USA; 2008.
