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Lumbar Puncture (Spinal Tap)
Lumbar puncture is used to do the following:
Evaluate intracranial pressure and CSF composition (see Table: Cerebrospinal Fluid Abnormalities in Various Disorders)
Therapeutically reduce intracranial pressure (eg, idiopathic intracranial hypertension)
Administer intrathecal drugs or a radiopaque contrast agent for myelography
Cerebrospinal Fluid Abnormalities in Various Disorders
Relative contraindications include
If papilledema or focal neurologic deficits are present, CT or MRI should be done before lumbar puncture to rule out presence of a mass that could precipitate transtentorial or cerebellar herniation (see Figure: Brain herniation.).
For the procedure, the patient is typically in the left lateral decubitus position. A cooperative patient is asked to hug the knees and curl up as tightly as possible. Assistants may have to hold patients who cannot maintain this position, or the spine may be flexed better by having patients, particularly obese patients, sit on the side of the bed and lean over a bedside tray table.
An area 20 cm in diameter is washed with iodine, then wiped with alcohol to remove the iodine and prevent its introduction into the subarachnoid space. A lumbar puncture needle with stylet is inserted into the L3-to-L4 or L4-to-L5 interspace (the L4 spinous process is typically on a line between the posterior-superior iliac crests); the needle is aimed rostrally toward the patient’s umbilicus and always kept parallel to the floor. Entrance into the subarachnoid space is often accompanied by a discernible pop; the stylet is withdrawn to allow CSF to flow out.
Opening pressure is measured with a manometer; 4 tubes are each filled with about 2 to 10 mL of CSF for testing. The puncture site is then covered with a sterile adhesive strip.
A post–lumbar puncture headache occurs in about 10% of patients.
Normal CSF is clear and colorless; ≥ 300 cells/μL produces cloudiness or turbidity.
Bloody fluid may indicate a traumatic puncture (pushing the needle in too far, into the venous plexus along the anterior spinal canal) or subarachnoid hemorrhage. A traumatic puncture is distinguished by
With intrinsic subarachnoid hemorrhage, the CSF remains uniformly bloody throughout collection; xanthochromia is often present if several hours have passed after ictus; and RBCs are usually older and crenated. Faintly yellow fluid may also be due to senile chromogens, severe jaundice, or increased protein (> 100 mg/dL).
Cell count and differential and glucose and protein levels aid in the diagnosis of many neurologic disorders (see Table: Cerebrospinal Fluid Abnormalities in Various Disorders).
Normally, CSF:blood glucose ratio is about 0.6, and except in severe hypoglycemia, CSF glucose is typically > 50 mg/dL (> 2.78 mmol/L).
Increased CSF protein (> 50 mg/dL) is a sensitive but nonspecific index of disease; protein increases to > 500 mg/dL in purulent meningitis, advanced TB meningitis, complete block by spinal cord tumor, or a bloody puncture. Special examinations for globulin (normally < 15%), oligoclonal banding, and myelin basic protein aid in diagnosis of a demyelinating disorder.
If infection is suspected, the centrifuged CSF sediment is stained for bacteria (Gram stain), for TB (acid-fast stain or immunofluorescence), and for Cryptococcus sp (India ink). Larger amounts of fluid (10 mL) improve the chances of detecting the pathogen, particularly acid-fast bacilli and certain fungi, in stains and cultures. In early meningococcal meningitis or severe leukopenia, CSF protein may be too low for bacterial adherence to the glass slide during Gram staining, producing a false-negative result. Mixing a drop of aseptic serum with CSF sediment prevents this problem. When hemorrhagic meningoencephalitis is suspected, a wet mount is used to search for amebas. Latex particle agglutination and coagglutination tests may allow rapid bacterial identification, especially when stains and cultures are negative (eg, in partially treated meningitis). CSF should be cultured aerobically and anaerobically and for acid-fast bacilli and fungi.
Except for enteroviruses, viruses are seldom isolated from the CSF. Viral antibody panels are available.
Venereal Disease Research Laboratories (VDRL) testing and cryptococcal antigen testing are often routinely done. PCR tests for herpes simplex virus and other CNS pathogens are increasingly available.
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