Lumbar Puncture in Adults- Standard Operating Procedure
|Next review: 06/12/2023|
|Standard Operating Procedure|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2020|
This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.
Standard Operating Procedure: Lumbar Puncture in adults
To standardise and optimise lumbar puncture sampling.
A Lumbar puncture (LP) is a procedure which involves collecting a sample of cerebrospinal fluid for diagnostic or therapeutic indications.
A lumbar puncture can be performed:
- To aid in diagnosis of suspected central nervous system (CNS) infection
- To aid in diagnosis of sub-arachnoid haemorrhage
- To aid in diagnosis of other neurological conditions
- To relieve intracranial pressure
- To administer medications
The number of definite indications for LP has reduced with advances in neuroradiology, however an LP can be performed without a CT brain, in the absence of immunocompromise, focal neurology or deranged clotting.
A lumbar puncture is a relatively safe procedure but when consenting a patient for this procedure they should be aware of these complications and their frequency: backache (25%), headache (22%), severe radicular pain (15%) and paraparesis (in less traumatic procedures) (0.1) 1,2. Death due to coning is a rare complication.3 Severe pain occurs in 6.7% of procedures. Post LP headache can occur between 10 and 30% of cases. 4,5
Contraindications include coagulopathy and suspected spinal abscess. To reduce the risk of bleeding; platelets should be above 40x103 uL, and the INR <1.5. Detailed guidance with regards to antithrombotics and Lumbar Puncture is to be found in the Association British Neurologists guideline on this topic.Full text available via https://pn.bmj.com/content/18/6/436.6
A relative contraindication is raised intracranial pressure. Fundoscopy should be performed and documented before attempting a lumbar puncture
To perform this procedure safely and effectively all the following steps must be followed.
Appropriately qualified and trained staff should undertake this procedure.
If you have any questions about the technique, the indication, or consent process please contact the on-call Medical or Neurology Specialist trainee via switchboard.
Where appropriate to the clinical setting, provide the patient with the LTHT patient information leaflet (available through the Print Unit LN004770)
- Wash hands with soap and water, then dry hands in accordance with LTHT Hand Hygiene Policy and put on disposable apron.
- Identify the correct patient e.g. check name band and verbally confirm identity where possible, explain the procedure and obtain written consent. This should include the benefits of the procedure in terms of possible diagnoses and potential complications using risk data in “background” section.
- The most important part of the procedure is the position of the patient; the procedure can be performed with the patient sitting or lying on the side (left or right) in the foetal position to maximize flexion of the spine. For diagnostic procedures opening and/or closing pressures are required. The lateral recumbent position is the best position to obtain pressure readings. If pressure readings are not required the procedure can be done, by an experienced operator,with the patient in the sitting position.
- Ensure that the plane of the back is exactly at 90° to the bed (ie not leaning towards or away from you). Make sure the hips and shoulders are in line and the patient is as comfortable and relaxed as possible.
- Draw an imaginary line between the tops of the iliac crests. This intersects the spine at approximately the L3-4 interspace (mark this if necessary using a skin marker pen). The conus medullaris finishes near L3 at birth, but at L1-2 by adulthood. Aim for the L3-4 or L4-5 interspace.
PREPARE TROLLEY AND ASSEMBLE EQUIPMENT
- Perform hand hygiene again, in accordance with LTHT Hand Hygiene Policy.
- Prepare all the equipment you will require. An assistant will also be required to help with the procedure, and to handle non-sterile equipment and non-sterile sample pots
- Sterile gloves
- Face mask
- Skin Preparation - containing 0.5% chlorhexidine in 70% isopropyl alcohol (2% is not recommended for this procedure)
- Dressing pack
- Local anaesthetic lignocaine; 2ml syringe, 25G needle, 21G needle
- Spinal Needles - 22G pencil point (blunt) spinal needle with stylet to reduce the risk of headache in adults, unless specific indication for traditional spinal needle. Eg Idiopathic Intracranial Hypertension, failure to get CSF with pencil point. (24G, 25G, 27G Sprotte needles also used. NB the risk of post procedure headache is reduced with a smaller needle)
- Spinal manometer – for measuring opening and closing CSF pressures.
- Swabs/cotton wool
- Specimen bottles - 2x Fluoride/Oxalate (grey), 3x universal tubes labeled 1-3 (a 4th is required if testing for xanthochromia which should be placed in an envelope following sampling) Please check which sample bottles are required if also sending samples for PCR.
- Open a dressing pack carefully ensuring only the corners are touched with your ungloved hands to create a sterile field on the trolley. Carefully open supplementary equipment and drop onto the sterile field.
- Put on apron,2 and face mask, wash hands and put on sterile gloves aseptically.
- Clean the skin with soap and water first, if it is visibly soiled Disinfect the skin at the LP site using a 0.5% chlorhexidine in 70% isopropyl alcohol wipe. Apply the disinfectant by pressing the swab in the centre of chosen site and working out from the centre. Always allow the preparation to dry before puncturing the skin.
- Place a sterile drape below the patient and a fenestrated drape on the patient, to allow access to the spine for the procedure.
- Infiltrate the skin and deeper tissues with up to 5mL 1% lignocaine using a 25G needle. Aspirating the syringe after each repositioning of the needle to ensure the tip is not in a vessel.
- If using an introducer remove it from the spinal needle. Assemble the manometer with the 3-way stopcock. Loosen the three way tap and ensure it is open in the right direction to allow CSF to rise up the column once attached to the spinal needle.
- Pierce the skin with the introducer and then insert the spinal needle through the introducer, ensuring the bevel of the needle is directed laterally and angled slightly towards the head.
- Advance the needle into the spinous ligament (increased resistance). Continue to advance the needle within the ligament until there is a fall in resistance. (4-6cm in average adult)
- Remove the stylet. If CSF is not obtained, replace the stylet and advance the needle in increments then re-check for CSF.
- If blood stained fluid is obtained collect some for culture*. If it clears it can be used for a cell count. If it fails to clear another attempt, at a different level may be required.
NB: Call for assistance early +/- abandon procedure if requiring multiple attempts.
- If CSF is flowing, collect into 3 numbered sample tubes; 1,2,3.
- 5-10 drops in each is usually adequate for microbiological investigation, glucose and cell analysis
- A 4th tube is required for xanthochromia. 1mL is required and the labelled sample tube should be placed immediately into a dark envelope.
- 10ml is required for mycobacterial examination (TB)7 and more will be required for specialist tests eg oligoclonal bands
- fluoride oxalate bottle for glucose sampling.
- A maximum of 15ml CSF can be sampled in adults.8
- Replace the stylet (this may reduce risk of headache) handling only the “handle”, not the shaft of the needle, and remove the needle and stylet from the patient, together.
- Apply a sterile swab to the puncture site and apply pressure for 30 to 60 seconds. Then apply an occlusive dressing.
- Write patient details and clinical information on all sample bottles according to Trust policy. Arrange transport of the sample to the laboratory.
- Send specimens urgently to the lab for microscopy and culture and protein and glucose measurement. Contact the microbiology lab on 23499 and the biochemistry lab on. SJUH 65551/ LGI 23285 to inform them of the samples.
- Discard needle and syringe into a sharps bin. Discard other waste into clinical waste bin.
- Wash hands with soap and water, then dry hands.
- Document procedure in the notes including the consent and asepsis.
- Ask the patient to drink lots of water following the procedure where clinically appropriate. This as well as caffeine intake can help with the symptoms of post-lumbar puncture headache. There is no convincing evidence that lying flat post procedure is helpful
- Ensure that sampling details and any subsequent positive results communicated by the laboratories via the results server +/- telephone, are accurately documented in the patient’s notes and advice is acted on within one hour.
NB: CSF glucose SHOULD be sent with a simultaneous serum glucose sample.* and if xanthochromia is required serum samples for bilirubin and protein should also be sent. The collection tubes are not sterile. The assistant should handle the sample tubes and ensure the tubes are filled in the correct order ie 1,2,3, glucose.9
- If a bloody tap doesn’t run clear, assume this is venous and re-try.
- The non-sterile apron is to protect your clothing it does not contribute to the maintenance of an aseptic environment. If you touch the apron with gloved hands, asepsis is broken.
To standardise and optimise lumbar puncture sampling
|Target patient group:||Adults|
|Target professional group(s):||Allied Health Professionals
Secondary Care Nurses
Secondary Care Doctors
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
- Standard vs Atraumatic Whitacre Needle for diagnostic lumbar puncture: a randomised trial. Lavi R, Yarnitsky D, Yernitzky D, Rowe JM, Weissman A, Segal D.
Neurology 2006: 67(8): 1492-4
- Post lumbar puncture headache: diagnosis and management. Ahmed SV, Jayawarna C, Jude E Postgrad Med J. 2006;82(973):713
- Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma.
Oliver WJ, Shope TC, Kuhns LR. Pediatrics. 2003 112(3 Pt 1):e174-6.
- Lumbar puncture headache: a review. Raskin NH. Headache. 1990;30(4):197.
- Headaches associated with low spinal fluid pressure.
Fernández E. Headache. 1990;30(3):122.
- Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Dodd KC, Emsley HCA, Desborough MJR, et al. Pract Neurol 2018;18:436–446
- Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. Thoennissen J, Herkner H, Lang W, Domanovits H, Laggner AN, Müllner M CMAJ. 2001;165(10):1311.
- British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J; British Infection Society. J Infect. 2009;59:167-87.
- The Royal Marsden Hospital Manual of Clinical Nursing Procedures, Eighth edition.
The Royal Marsden NHS Foundation Trust. Wiley-Blackwell. 2011.
Trust Clinical Guidelines Group
LHP version 2.0
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