الرحيم الرحمن الله بسم

• ترینرمتخصص : شیف نظر تحتحبیب صاحب

• ترینرمتخصصصاحب : رهنما استادمحمدی

• توکلی : بصیراحمد داکتر کننده تهیه

History• Lumbar puncture, early 20th century.• The first technique for accessing the dural space was described by the

London physician Walter Essex Wynter In 1889. • He developed a crude cut down with cannulation in four patients with

tuberculosis meningitis.• The main purpose was the treatment of raised intracranial pressure

rather than for diagnosis.• The technique for needle lumbar puncture was then introduced by the

German physician Heinrich Quincke,

• A lumbar puncture (LP), often called a spinal tap, is a common medical test that involves taking a small sample of cerebrospinal fluid (CSF) for examination.

• Myelography

Diagnostic

• The chief diagnostic indications of lumbar puncture is for collection of cerebrospinal fluid (CSF) and its evaluation to exclude infectious,

inflammatory and neoplastic diseases affecting the central nervous system.

Therapeutic

• Lumbar punctures may also be done to inject medications into the cerebrospinal fluid particularly for

spinal anesthesia or chemotherapy

Contraindications

1- Suspected Increase in ICP2- Suspected Spinal Cord Compression3- Infection at the Site of an LP4- Coagulopathy5- Space occupying surgery6- Prior lumbar surgery

LUMBAR PUNCTURE [Complications]

Post lumbar puncture headache occurs in 10% to 30% of patients within 1 to 3 days and lasts 2 to 7 days.

The pain is relieved by lying flat. Treatment consists of bed rest and fluid with simple analgesics. Continued leakage of cerebrospinal fluid . Low pressure Hematoma. Cerebral herniation. Infections. Neural injury. LBP.

Instrument for LUMBAR PUNCTURE

1. Material for sterile technique [gloves and mask are necessary]2. Spinal Needle, 20 and 22-gauge3. Manometer4. Three-way stopcock5. Sterile drapes6. 1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles7. Material for skin sterilization8. Adhesive dressing9. Sponges - 10 X 10 cm

LUMBAR PUNCTURE position• Place the patient in the lateral decubitus position lying on the

edge of the bed and facing away from operator. • Place the patient in a knee-chest position with the neck flexed. • The patient's head should rest on a pillow, so that the entire

cranio-spinal axis is parallel to the bed. • Sitting position is the second choice because there may be a

greater risk of herniation and CSF pressure cannot be measured

• Find the posterior iliac crest and palpate the L4 spinous process, and mark the spot with a fingernail.

• Prepare the skin by starting at the puncture site.

• Insert in the midline with the needle parallel to the floor and the point directed toward the patient's umbilicus.

CEREBROSPINAL FLUIDThe cerebrospinal Fluid [CSF] is a clear,

colorless transparent, tissue fluid present in

the cerebral ventricles, spinal canal, and

subarachnoid spaces.

CIRCULATION OF CSF

Lateral ventricle

Foramen of Monro [Interventricular foramen]

Third ventricle:

Subarachnoid space of Brain and Spinal cord

Fourth ventricle:

Cerebral aqueduct

Foramen of megendie and formen of luschka

COMPOSITION OF CSF

• Proteins= 20-40 mg/100 ml• Glucose = 50-65 mg/100 ml• Cholesterol = 0.2 mg/100 ml• Na+ = 147 meq/Kg H2O• Ca+ = 2.3 meq/kg H2O• Urea = 12.0 mg/100 ml• Creatinine = 1.5 mg/100 ml• Lactic acid = 18.0 mg/100 ml

Laboratory tests on CSF

• Sent the sample to lab to be examined under the microscope to look for bacteria.

• It is also 'cultured' for any bacterial growth • The fluid can also be tested for protein, sugar

and other chemicals if necessary. • Sometimes also measure the pressure of the

fluid.

Lumbar Puncture needles

Lumbar Puncture needles

Thanks 4 you

Reference

Hand book of head and vertebral column trauma.Principle of Neurosurgery.Internet(medscape_medline plus_wikipedia ).