DEFINATION

Lumber puncture is the insertion of a needle into the subarachnoid space of the spinal canal to with draw cerebrospinal fluid.

PURPOSE

To test the pressure of CSF. To relive pressure by removing CSF. To remove fluid such as CSF, blood, pus etc. Contained in the subarachnoid

space, thereby reduce the intracranial pressure. To remove a sample of CSF for laboratory examination in order to diagnose

disease. To inject a spinal anaesthetic, dye or air into the spinal cord. To detect spinal subarachnoid block. To introduce medication into the spinal fluid in treating neurological illness,

e.g. meningitis.

INDICATIONS

Diagnostic: to obtain pressure, suspected intracranial infection, suspected subarachnoid hemorrhage, peripheral vascular diseases.

Therapeutic: intrathecal drug administration’s-inj. Hydrocortisone 50-100 mg in spinal arachnoiditis,

Anaesthetic: inj. Lignocaine 50 mg and inj. Bupivacaine i percent in spinal anaesthesia.

Radiological: to do a myelogram/myelography/myodil dye injection.

CONTRAINDICATIONS

1. Gross spinal tension with obvious neurological damage because of danger of complete transverse lesion.

2. Sepsis in skin at or near the proposed puncture site or ostemyelitis.3. Papilledema or other signs of raised intracranial pressure or focal

neurological signs, until intracranial mass is ruled out.4. Bleeding diathesis or anticoagulant therapy.

GENERAL INSTRUCTIONS

1. Site used for lumber puncture is between 3rd and 4th or between 4th and 5th lumbar vertebrae in adults and still lower in children.

2. Strict aseptic techniques are to be followed. Since any infection introduced into the spinal cavity would be fatal for the patient.

3. The position used is side lying position with the knees drawn to the chin or a sitting position with the head and neck flexed is maintained during the procedure.

4. The patient should be placed near the edge of the bed or table for the convenience of doctor.

5. The lumber puncture needles should be sharp, small in size and not curved.

6. The pressure reading of CSF is taken when the patient is relaxed and fluid level remains fairly constant in the manometer.

7. The flow of CSF varies in different conditions when the intracranial pressure is high the fluid may spurt out jets, when the tension is low as in case of dehydration.

8. The patient’s vital sign should be checked frequently during and after the procedure to detect the early signs of complications.

9. Drug to inject must be warmed to body temperature and it should be injected very slowly.

10.The amount of CSF withdrawn is equal to the volume of fluid to be introduced or is sufficient for the laboratory investigations planned.

11.If a ‘queckenstedt’s test’ is to be carried out during the procedure. The nurse is asked to compress the jugular vein first on one side, then on the other side and finally on both sides at the same time.

12.When ‘queckenstedt’s test’ is normal, there is a sharp rise in the pressure followed by a full as the compression is released. If the test is negative, one must conclude, that a block exists between the ventricles of the brian and spinal canal which might be caused by spinal tumor, dislocation or fracture of the vertebrae, etc.

13.‘queckenstedt’s test’ is control indicated in the presence of intracranial disease particularly in the presence of intracranial pressure and intra cranial haemorrhage.

14. At the end of the procedure, the puncture site is sealed to prevent leakage of fluid from the spinal cavity and infection, entering into the spinal cavity.

15.After the lumber puncture, the patient should lie flat on the bed.

CSF ANALYSIS DONE TO DETECT

1. Physical findings: colour and appearance- normally the CSF is crystal clear. Turbulence indicates infection. Blood indicates haemorrhage.

2. Cell count: normally there is no RBC found in CSF. Presence of RBC indicates haemorrhage in the CNS. Increased number of WBC indicates infection somewhere in the CNS.

3. Sugar count: bacterial infections such as tuberculosis meningitis often lower the sugar content from the normal level of 40 to 60 mg per 100ml.

4. Chloride level: Bacterial infections also reduce the chloride level from the normal 720 to 750mg per 100ml.

5. Protein level: in the presence of degenerative diseases and brain tumours, the protein content is increased from the normal level of 30 to 50 mg per 100 ml.

6. Serological test: serological test for syphilis may be positive in the CSF even when the blood serology is negative.

PRELIMINARY ASSESSMENT

CHECK

1. The doctor’s order for specific instructions.2. General condition and diagnosis of the patient.3. Self care ability of the patient.4. Mental status to follow directions or instructions.5. Specimen bottles available to collect sample.6. Equipment available in the unit.

PREPARATION OF THE PATIENT AND ENVIRONMENT

1. Explain the sequences of the procedure.2. Provide privacy.3. Warn the patient that any movement.4. Monitor the vital signs before the procedure.5. Prepare the skin as for as a surgical procedure.6. Arrange the articles that are necessary for lumbar puncture at the bed

site.7. Protect bed with mackintosh and towel.

8. The nurse should stand near the patient throughout the procedure observing the general condition and helping him to maintain the desired position.

9. Provide a stool for a doctor to sit comfortably during the procedure.

EQUIPMENT

An unsterile tray containing:

Mackintosh drapes and towel Cleaning articles, tincture, iodine, spirit. Local anesthetic 2% xylocaine Tincture benzion Mask, apron. Kidney tray Monometers, specimen container, lab requisition forms.

A sterile tray containing

LP needles- 2 sizes with their stiletto Sponge holding forceps Syringe 5ml with needles to give local anesthesia Small bowl to take cleaning lotion Specimen bottles Cotton balls, gauze pieces and cotton pads Gloves gown and masks Dressing towels or slit The 3 way adapter, manometer and tubing to measure the pressure of

CSF.

POST-PROCEDURE CARE

1. Instruct the patient to lie in supine position for 6to 24 hours2. Maintain every half hourly pulse and respiration for 4to 5 hours till

stable.3. Encourage liberal fluid intake4. Label specimens and send to lab with investigation slip5. Wash hands6. Replace the articles after cleaning.7. Record the procedure in the nurse’s record sheet.8. Observe for any complication.9. Check the puncture site frequently for CSF leak.

COMPLICATIONS

1. Injury to the spinal cord and spinal nerves.2. Infection introduced into the spinal cavity which may rise to meningitis3. Leakage of CSF through the puncture site and lowering the intracranial

pressure and cause post puncture headaches4. Damage to intervertebral discs5. Pain radiating to the things due to tumour of the spinal nerves.6. Herniation of the brain structures into the foramen magnum due to

sudden reduction in the intracranial pressure.7. Temperature elevation.8. Local pain, oedema and hematoma at the puncture site.9. Sixth cranial nerve palsy caused by removal of large volume of CSF with

traction on the sixth nerve.