Lumbar Puncture Periprocedural Care

  • Author: Gil Z Shlamovitz, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: May 8, 2012
 

Equipment

A spinal or lumbar puncture tray (see the image below) should include the following items:

  • Sterile dressing
  • Sterile gloves
  • Sterile drape
  • Antiseptic solution with skin swabs
  • Lidocaine 1% without epinephrine
  • Syringe, 3 mL
  • Needles, 20 and 25 gauge
  • Spinal needles, 20 and 22 gauge
  • Three-way stopcock
  • Manometer
  • Four plastic test tubes, numbered 1-4, with caps
  • Syringe, 10 mL (optional)Lumbar puncture disposable tray. Image courtesy ofLumbar puncture disposable tray. Image courtesy of Gil Z Shlamovitz, MD.
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Patient Preparation

Local anesthesia is employed for lumbar puncture (see Technique and Local Anesthetic Agents, Infiltrative Administration).

The patient is placed in the lateral recumbent position (see the image below) with the hips, knees, and chin flexed toward the chest so as to open the interlaminar spaces. A pillow may be used to support the head. In a single-center prospective study, performance of lumbar puncture in the extended rather than the flexed lateral recumbent position yielded a statistically significant decrease in the cerebrospinal fluid (CSF) opening pressure, but the difference (mean, 0.6 ± 2.2 cm water) was small and of doubtful clinical significance.

Lumbar puncture lateral recumbent position. Image Lumbar puncture lateral recumbent position. Image courtesy of Gil Z Shlamovitz, MD.

The sitting position (see the image below) may be a helpful alternative, especially in obese patients, because it makes it easier to confirm the midline. In order to open the interlaminar spaces, the patient should lean forward and be supported by a Mayo stand with a pillow on it, by the back of a stool, or by another person.

Lumbar puncture sitting position. Image courtesy oLumbar puncture sitting position. Image courtesy of Gil Z Shlamovitz, MD.

If the procedure is performed with the patient in the sitting position and an opening pressure is required (as in the case of pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent position. There are no data suggesting that a position change will increase the risk of spinal headache or transection of the spinal nerves. Take care, however, not to change the orientation of the spinal needle during this maneuver.

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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD  Assistant Professor, Section of Emergency Medicine, Baylor College of Medicine; Director of Medical Informatics, Emergency Center, Ben Taub General Hospital

Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Nirav R Shah, MD, MPH  Commissioner, New York State Department of Health

Nirav R Shah, MD, MPH is a member of the following medical societies: American College of Physicians, New York Academy of Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

Additional Contributors

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

References

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  2. Reichman E, Simon RR. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.

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  13. Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth. Jan-Feb 1997;22(1):66-72. [Medline].

  14. [Best Evidence] Lavi R, Yarnitsky D, Yernitzky D, Rowe JM, Weissman A, Segal D. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. Oct 24 2006;67(8):1492-4. [Medline].

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  16. Tung CE, So YT, Lansberg MG. Cost comparison between the atraumatic and cutting lumbar puncture needles. Neurology. Jan 10 2012;78(2):109-13. Epub 2011 Dec 28.

  17. Spriggs DA, Burn DJ, French J, et al. Is bed rest useful after diagnostic lumbar puncture?. Postgrad Med J. Jul 1992;68(801):581-3. [Medline].

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  22. Lenelle L, Lahaye-Goffart B, Dewandre PY, Brichant JF. [Post-dural puncture headache: treatment and prevention]. Rev Med Liege. Nov 2011;66(11):575-80. [Article in French].

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  24. Aronson PL, Zonfrillo MR. Epidural cerebrospinal fluid collection after lumbar puncture. Pediatr Emerg Care. Jul 2009;25(7):467-8. [Medline].

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  26. Avery RA, Mistry RD, Shah SS, Boswinkel J, Huh JW, Ruppe MD, et al. Patient Position During Lumbar Puncture has no Meaningful Effect on Cerebrospinal Opening Pressure in Children. J Child Neurol. Feb 22 2010;[Medline].

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  28. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.

  29. Tintinalli J, Stapczynski J. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2010.

 
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Lumbar puncture disposable tray. Image courtesy of Gil Z Shlamovitz, MD.
Lumbar puncture lateral recumbent position. Image courtesy of Gil Z Shlamovitz, MD.
Lumbar puncture sitting position. Image courtesy of Gil Z Shlamovitz, MD.
L3-L4 interspace palpation. Image courtesy of Gil Z Shlamovitz, MD.
CSF collection tubes. Image courtesy of Gil Z Shlamovitz, MD.
Skin preparation. Video courtesy of Gil Z Shlamovitz, MD.
Drape application. Video courtesy of Gil Z Shlamovitz, MD.
Local anesthesia. Video courtesy of Gil Z Shlamovitz, MD.
Spinal needle insertion. Video courtesy of Gil Z Shlamovitz, MD.
Spinal needle removal. Video courtesy of Gil Z Shlamovitz, MD.
Opening pressure measurement. Video courtesy of Gil Z Shlamovitz, MD.
 
 
 
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