Before we begin, it is important to address that every case is different and for every procedure pros and cons must be discussed along with the patient and his/her relatives as no medical procedure is exempt of complications. 🚨🚨
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What is a lumbar puncture?
A lumbar puncture (LP) is an invasive technique that accesses the restricted compartment of the subarachnoid space in order to sample CSF.
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A lumbar puncture (LP) is an invasive technique that accesses the restricted compartment of the subarachnoid space in order to sample CSF.
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How is it performed?
Two positions
1.- Left lateral recumbent position
2.- Sitting position: this one is not suitable for measuring pressure.
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Two positions
1.- Left lateral recumbent position
2.- Sitting position: this one is not suitable for measuring pressure.
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Tips:
1⃣Lay the patient with the head on the same side as your dominant hand.
2⃣L3/L4 space is usually the easiest to access
3⃣Remember, spinal cord ends between L1/L2 in adults
4⃣Difficult cases may require to use the seated position
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1⃣Lay the patient with the head on the same side as your dominant hand.
2⃣L3/L4 space is usually the easiest to access
3⃣Remember, spinal cord ends between L1/L2 in adults
4⃣Difficult cases may require to use the seated position
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Most frequent indications 👨⚕️👨⚕️👨⚕️🩺
1⃣Confirm or rule out CNS infections
2⃣Study CSF looking for inflammatory disorders (MS, NMDA, etc)
3⃣Therapeutic/diagnostic (IHH, NPH)
4⃣Test for biomarkers of many neurological disorders
5⃣Drug delivery
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1⃣Confirm or rule out CNS infections
2⃣Study CSF looking for inflammatory disorders (MS, NMDA, etc)
3⃣Therapeutic/diagnostic (IHH, NPH)
4⃣Test for biomarkers of many neurological disorders
5⃣Drug delivery
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Common contraindications 🚫
1⃣ Low platelet count* or INR >1.5
2⃣Local skin infection
3⃣Local developmental abnormality, e.g. myelomeningocele
4⃣Suspected Raised intracranial pressure + herniation predictors on CT/MRI
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1⃣ Low platelet count* or INR >1.5
2⃣Local skin infection
3⃣Local developmental abnormality, e.g. myelomeningocele
4⃣Suspected Raised intracranial pressure + herniation predictors on CT/MRI
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CT scan before lumbar puncture?
Older patients (>60 y/o) 🧓
Immunocompromised state 🛡️
History of CNS disease 🧠
Any neurological findings on the exam 🧪
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Older patients (>60 y/o) 🧓
Immunocompromised state 🛡️
History of CNS disease 🧠
Any neurological findings on the exam 🧪
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What do we measure?
1⃣ Pressure
2⃣ Glucose (always measure finger prick glucose to obtain CSF-to-Blood ratio)
3⃣ Protein level
4⃣ # of cells and predominant cell type
5⃣Extra tests according to every case (OCB, NMDA, Culture, Lactate, etc).
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1⃣ Pressure
2⃣ Glucose (always measure finger prick glucose to obtain CSF-to-Blood ratio)
3⃣ Protein level
4⃣ # of cells and predominant cell type
5⃣Extra tests according to every case (OCB, NMDA, Culture, Lactate, etc).
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Most Fx complication?
Headache 🤕🤕🤯🤯
Treatment, risk factors and preventive measures of Post-LP-Headache is topic for another thread.
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Headache 🤕🤕🤯🤯
Treatment, risk factors and preventive measures of Post-LP-Headache is topic for another thread.
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Remember, in medicine there are no two exact same cases and no absolute rules (or truths) exist in our science.
Always individualize situations and remember "Primum non nocere".
Always individualize situations and remember "Primum non nocere".
Sources:
1.- J Neurol. 2012 Aug;259(8):1530-45.
doi: 10.1007/s00415-012-6413-x
2.- CONTINUUM (MINNEAP MINN) 2018;24(5, NEUROINFECTIOUS DISEASE):1264–1283.
doi: 10.1212/CON.0000000000000660.
3.- N Engl J Med. 2001 Dec 13;345(24):1727-33.
doi: 10.1056/NEJMoa010399.
1.- J Neurol. 2012 Aug;259(8):1530-45.
doi: 10.1007/s00415-012-6413-x
2.- CONTINUUM (MINNEAP MINN) 2018;24(5, NEUROINFECTIOUS DISEASE):1264–1283.
doi: 10.1212/CON.0000000000000660.
3.- N Engl J Med. 2001 Dec 13;345(24):1727-33.
doi: 10.1056/NEJMoa010399.
4.- Infect Dis (Lond). 2018 Jul;50(7):514-521.
doi: 10.1080/23744235.2018.1441539
doi: 10.1080/23744235.2018.1441539
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