Lumbar Puncture And Lumbar Drain Placement

Indications

A lumbar puncture (LP) is indicated for both diagnostic and therapeutic purposes. It is used to sample the cerebrospinal fluid (CSF) to aid in the diagnosis of infectious, inflammatory, hemorrhagic, and oncologic conditions. An urgent LP is indicated to aid in the diagnosis of meningitis/encephalitis and of suspected subarachnoid hemorrhage in a patient with a negative head computed tomography (CT) scan. Therapeutic indications include the removal of CSF and the intrathecal administration of medications. Finally, an LP can be used to measure intracranial pressure (ICP).

Extended CSF sampling and/or external drainage can be achieved with the temporary placement of a lumbar drain (LD). It is used to manage disorders of increased ICP, assess symptom responsiveness to CSF diversion (e.g. idiopathic intracranial hypertension, normal pressure hydrocephalus), facilitate healing of a cranial or spinal CSF leak, and promote spinal cord perfusion during aortic surgery. An LD is also used to decompress CSF spaces, enabling brain relaxation during intracranial and transsphenoidal surgery when access to the subarachnoid cisterns is not readily achievable.

Contraindications

Suspected or known infection along the skin and soft tissue along the needle entry point and planned tract is an absolute contraindication to lumbar cisternal CSF access and drainage. An LP or LD is avoided in patients with obstructive hydrocephalus or signs of cerebral herniation from increased ICP. If there is concern for an intracranial lesion causing mass effect and/or increased ICP, head imaging can be obtained prior to the procedure to assess for obstructive hydrocephalus and midline shift. If necessary, the absolute minimum CSF volume (<3 mL) is sampled for diagnostic testing. Inherited or acquired coagulopathy presents a relative contraindication to LP or LD because of an increased risk of spinal hematoma. Recommended thresholds include a platelet count >50,000 per mL and an INR <1.4. ^, Finally, congenital spine or spinal cord abnormalities (e.g. tethered cord) may be a contraindication depending on the anatomy.

Stepwise Procedure ( Video 80.1 )

An LP and placement of an LD are performed using sterile technique at the patient’s bedside or in the operating room. Many of the initial steps are shared between the two procedures; the similarities and important differences are highlighted.