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Updated: Jul 13 2017

Lumbar Puncture

  • Overview
  • Snapshot
    • A 59-year-old man presents to the emergency department with altered mental status. The patient is accompanied by his wife who says that the patient had a fever and headache for the past few days. On physical exam the patient is oriented to person but not place or time. Photophobia and neck stiffness is present. A lumbar puncture is performed for CSF analysis and shows a lymphocytic pleocytosis with normal glucose and protein. A PCR of the CSF is positive for HSV-1, and he is started on intravenous acyclovir. (Viral meningitis caused by HSV-1)
  • 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
      • caution should be taken in performing the LP in patients with
        • increased intracranial pressure
          • the patient runs the risk of brain herniation
        • thrombocytopenia or other bleeeding diathesis
        • signs and symptoms concerning for a spinal epidural abscess
    • Complications
      • post-LP headache
      • infection
      • bleeding
      • cerebral herniation
      • Cerebrospinal Fluid Analysis
      • Test
      • Normal
      • Bacterial
      • Viral
      • Fungal/TB
      • Opening pressure
      • ≤ 20 cm H2O
      • normal or slightly ↑
      • Color
      • Clear
      • Cloudy
      • Clear
      • Cloudy
      • Cell count
      • 0-5 cells/µL
      • ↑ (PMN)
      • ↑ (Lymphocytes)
      • ↑ (Lymphocytes)
      • Protein
      • < 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
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