Lumbar Puncture

Video Guide: https://www.youtube.com/watch?v=xnH9gECy_wU

 

Absolute Contraindications

  • Increased intracranial pressure from space occupying lesions
  • Infection over puncture side or epidural abscess
  • Trauma to mass or lumbar vertebrae

 

Relative Contraindications

  • intracranial pressure, thrombocytopenia, bleeding diatheses, anticoagulation

 

Pre-procedure considerations:

  • Consider sending to fluoro-guided if: Attempts without imaging are unsuccessful, morbidly obese pts with no palpable anatomy, severe scoliosis, prior spine surgery, borderline low Plts and multiple sticks might be needed, or pt requires heavy sedation
  • IR guidelines require Plavix to be off 5 days; ASA alone is OK
  • Full dose LMWH must be off 24h, ppx LMWH off 12h, ppx heparin off 8h, hep gtt off 4-8hrs with repeat lab demonstrating normalized PT
  • P2Y12 inhibitors should be held for 7 days to avoid bleeding risks
  • Labs: cell count w/diff, BF culture, glucose, protein; if infectious or neurological labs are needed, consider consult first Try to freeze sample for future labs (order in epic).
  • Ensure lateral decubitus position for open pressure with glass pressure manometer

 

Procedural considerations

  • US Probe: Linear (can use curvilinear in obese pts) in transverse axis to establish midline & in sagittal axis to identify spinous processes
  • Volume removal for studies: Basic only 2mL per tube in 1-4. Many studies ordered: 3mL per tube (*consider calling lab to confirm). Cytology desired: call lab to confirm amount needed (rule of thumb 2/2/6/2mL); Tube 4 is sent for micro to reduce contamination. Therapeutic high volume: 30mL max
  • Anesthetic use: Lidocaine 1-2% (likely need more than what is provided in kit; consider empiric anesthetization of 2 spaces +/- Pain-Ease spray.
  • Increased number of attempts = increased success rates
  • Higher rate of success if stylet is removed before entering subarachnoid space to better observe flow of CSF once in the subarachnoid space. Stylet should be replaced prior to LP needle removal
  • Aspiration of CSF = increase risk of bleeding. Dont do that!

 

Post-procedural considerations

  • Post-LP headache (~10%): encourage pt to lay flat to reduce the intensity of symptoms (but does not prevent it); if prolonged, consider blood patch (c/s Anesthesia)
  • Neuro changes OR bleeding complications: STAT non-contrast MRI lumbar spine for epidural hematoma, q1 neuro-checks x4hrs then q2 for 24-48hrs & consult NSGY
  • Sample cannot be tubed; someone must walk fluid to the lab
  • Resuming anticoagulation: 1h UFH, 4h LMWH, 4-6h rivaroxaban/apixaban, 6h dabigatran/fondaparinux. Longer periods should be considered after traumatic tap, and post-procedure monitoring of neurological function is recommended for all pts