Equipment
A spinal or lumbar puncture tray (see the image below) should include the following items:
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Sterile dressing
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Sterile gloves
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Sterile drape
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Antiseptic solution with skin swabs
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Lidocaine 1% without epinephrine
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Syringe, 3 mL
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Needles, 20 and 25 gauge
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Spinal needles, 20 and 22 gauge
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Three-way stopcock
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Manometer
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Four plastic test tubes, numbered 1-4, with caps
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Syringe, 10 mL (optional)
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 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.
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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Lumbar puncture disposable tray. Image courtesy of Gil Z Shlamovitz, MD.
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Lumbar puncture lateral recumbent position. Image courtesy of Gil Z Shlamovitz, MD.
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Lumbar puncture sitting position. Image courtesy of Gil Z Shlamovitz, MD.
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L3-L4 interspace palpation. Image courtesy of Gil Z Shlamovitz, MD.
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CSF collection tubes. Image courtesy of Gil Z Shlamovitz, MD.
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Skin preparation. Video courtesy of Gil Z Shlamovitz, MD.
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Drape application. Video courtesy of Gil Z Shlamovitz, MD.
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Local anesthesia. Video courtesy of Gil Z Shlamovitz, MD.
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Spinal needle insertion. Video courtesy of Gil Z Shlamovitz, MD.
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Spinal needle removal. Video courtesy of Gil Z Shlamovitz, MD.
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Opening pressure measurement. Video courtesy of Gil Z Shlamovitz, MD.
