Lumbar puncture and CSF Analysis

Lumbar puncture and CSF Analysis

1. Lumbar Puncture & CSF Analysis Presenter: Shruti Shirke Evaluator : Mr. L Anand M.Sc (N) Neuroscience Asso . Professor CON AIIMS BBSR 02/9/2020

2. Introduction The procedure is carried out by the doctor, who will insert the needle in the space between the third and fourth lumbar vertebrae Insertion any higher up the spine would risk injury to the spinal cord. The level is found by imagining a line drawn from one iliac crest to the other, and noting where this line crosses the vertebrae.

3. Definition A lumbar puncture is the insertion of a hollow tube needle under local anesthetic into the subarachnoid space of the spinal canal to obtain a sample of cerebrospinal fluid (CSF) for clinical investigations or to inject medication (therapeutic & diagnostic)

4. Anatomy The three coverings of the brain and spinal cord (meninges), are separated by small spaces. The outer membrane, the dura mater, is in two layers, with a space between containing fluid, blood vessels and venous sinuses. Beneath the dura mater is a small subdural space, followed by the arachnoid mater, which has a spider’s weblike structure. Below this, the subarachnoid space is filled with CSF. The innermost layer, the pia mater, rests on the brain and cord surface.

5. Purpose of lumbar puncture Lumbar puncture is done for one of three reasons: To acquire a sample of CSF for analysis. To measure and relieve the CSF pressure To introduce drugs into the spinal canal (called an intrathecal injection).

6. Purpose of lumbar puncture Cont.. Lumbar puncture may also be carried out to introduce a contrast radio-opaque medium (one that shows up on X-ray), to provide radiographic images of the spinal canal that do not show on ordinary X-rays. This type of X-ray is called a myelogram and is used for two purposes - the diagnosis of spinal lesions and to help plan surgery by isolating the level of the lesion and selecting the most suitable spinal segment for operation.

7. Indications Suspicion of meningitis. Suspicion of subarachnoid hemorrhage (SAH) Suspicion of nervous system diseases such as Guillain-Barré syndrome and carcinomatous meningitis. Therapeutic relief of pseudotumor cerebri .

8. Contraindications Absolute contraindications for lumbar puncture are the presence of infected skin over the needle entry site and the presence of unequal pressures between the supratentorial and infratentorial compartments . i.e. Midline shift Loss of suprachiasmatic and basilar cisterns Posterior fossa mass Loss of the superior cerebellar cistern Loss of the quadrigeminal plate cistern

9. Contraindications cont.. Relative contraindications for lumbar puncture include the following: Increased intracranial pressure (ICP ) Coagulopathy Brain abscess

10. Pre-procedure care – Equipment 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)

11. Patient preparation The patient is placed in the lateral recumbent position 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. The sitting position 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.

12. Patient preparation cont.. 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 .

13. Procedure

14. Samples of CSF are taken for: Taking cell counts (a tiny number of white cells may normally be present) Measuring glucose and protein (also present in small quantities) Cytology , i.e. looking for abnormal cells Immunoglobulin (antibody) studies Bacterial or viral tests Biochemical analysis.

15. Complications Post–spinal puncture headache Bloody tap Dry tap Infection Hemorrhage Dysesthesia (abnormal sensation of pain, itching , burning.) Post– dural puncture cerebral herniation

16. Complication prevention Explain the procedure, benefits, risks, complications, and alternative options to the patient or the patient’s representative, and obtain a signed informed consent. Before performing the lumbar puncture, ensure that patients are hydrated so as to avoid a dry tap. Never allow a lumbar puncture or a pre–lumbar puncture CT scan to delay administration of intravenous (IV) antibiotics; meningitis can usually be inferred from the cell count, antigen detection, or both .

17. Complication prevention cont.. Avoid lumbar puncture in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation ( ie , deteriorating level of consciousness and brainstem signs that include pupillary changes, posturing, irregular respirations, and very recent seizure)

18. Research evidence The smaller the needle used for the lumbar puncture, the lower the risk that the patient will experience a post–lumbar puncture headache. Data suggest an inverse linear relation between needle gauge and headache incidence, and some authors recommend using a 22-gauge needle regardless of what size needle is supplied with the kit . Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth . 1997 Jan-Feb. 22(1):66-72. [Medline].

19. Research evidence cont.. The use of atraumatic needles has been shown to significantly reduce the incidence of post–lumbar puncture headache (3%) when compared to the use of standard spinal needles (approximately 30 %). In addition, it may lead to cost savings. However , obtaining pressures can be more difficult with atraumatic needles. 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. 2006 Oct 24. 67(8):1492-4. [Medline].

20. CSF Analysis

21. Normal results in adults Appearance: Clear Opening pressure: 10-20 cm H2 O WBC count: 0-5 cells/µL (< 2 polymorphonucleocytes [PMN]); normal cell counts do not rule out meningitis or any other pathology Glucose level: >60% of serum glucose Protein level: < 45 mg/ dL

22. Bacterial meningitis Appearance: Clear, cloudy, or purulent Opening pressure: Elevated (>25 cm H2 O) WBC count: >100 cells/µL (>90% PMN); partially treated cases may have as low as 1 WBC/ µL Glucose level: Low (< 40% of serum glucose) Protein level: Elevated (>50 mg/ dL ) Consider additional tests: CSF Gram stain and cultures, blood cultures, CSF bacterial antigens, CSF polymerase chain reaction (PCR), others depending on clinical findings

23. Aseptic (viral) meningitis Appearance: Clear Opening pressure: Normal or elevated WBC count: 10-1000 cells/µL (lymph but PMN early) Glucose level: >60% serum glucose (may be low in HSV infection) Protein level: Elevated (>50 mg/ dL ) Consider additional tests: CSF Gram stain and cultures, blood cultures, CSF bacterial antigens, CSF PCR ( eg , herpes simplex virus [HSV], varicella-zoster virus [VZV]), others depending on clinical findings

24. Fungal meningitis Appearance: Clear or cloudy Opening pressure: Elevated WBC count: 10-500 cells/µL Glucose level: Low Protein level: Elevated Consider additional tests: CSF Gram stain and cultures, blood cultures, CSF bacterial antigens, CSF PCR, CSF India ink, others depending on clinical findings.

25. Tubercular meningitis Appearance: Clear or opaque Opening pressure: Elevated WBC count: 50-500 cells/µL (early PMN then lymph ) Glucose level: Low Protein level: Elevated Consider additional tests: CSF Gram stain and cultures, blood cultures, CSF bacterial antigens, CSF PCR, CSF tuberculosis culture/stain, others depending on clinical findings.

26. Subarachnoid hemorrhage Appearance: Xanthochromia , bloody, or clear Opening pressure: Elevated WBC count: (1 additional WBC per 1000 RBCs is considered normal correction) Glucose level: Normal Protein level: Elevated Consider additional tests: CSF Gram stain and cultures, others depending on clinical findings

27. Multiple sclerosis Appearance: Clear Opening pressure: Normal WBC count: 0-20 cells/µL (lymph) Glucose level: Normal Protein level: Mildly elevated (45-75 mg/ dL ) Consider additional tests: Oligoclonal band analysis (serum and CSF), others depending on clinical findings.

28. Guillian barre syndrome Appearance: Clear or xanthochromia Opening pressure: Normal or elevated WBC count: Normal or elevated Glucose level: Normal Protein level: Elevated Consider additional tests: Others depending on clinical findings

29. Nursing considerations Lumbar puncture is a strict aseptic technique requiring full sterile procedures. Positioned the patient carefully, laying on one side in a curled up position with the lumbar spine exposed (knees drawn up to the chest). Moving the patient’s back closer to the edge of the bed will make access to the lumbar spine easier. Support the patient in this position throughout the procedure .

30. Nursing consideration cont.. Encourage patients to drink well before and after the procedure . A small local sterile dressing is applied to the spinal site after removal of the needle. Headache is a common complaint following lumbar puncture. The patient should lay flat for 6-12 hours afterwards, as sitting up may make any headache worse.

31. Nursing consideration cont.. In myelograms, the patient’s head should be kept raised for up to 24 hours afterwards to prevent contrast medium in the spinal canal from entering the skull. This may caused seizures if it passes around the brain .

32. Conclusion

33. T h a n k y o u