LUMBAR PUNCTURE

Definition: Lumbar puncture is the introduction of a hollow needle into the subarachnoid
space of the spinal cannal and usually in the lumbar region.
Purposes:1 To withdraw cerebro spinal fluid to relieve pressure.
2 To secure specimens of C. S. F. for diagnostic purpose.
3 To inject sera or drug in the treatment of the diseases.
4 To inject spinal anaesthetic.
5 To introduce an opaque liquid or air or oxygen before taking an X-ray for diagnosis
of cord and brain lesions.
6 To test the pressure of the spinal fluid under different conditions.
When opaque substances are injected and X-ray pictures are taken, it is known
as MYELOGRAM. When air or oxygen is injected the procedure is called
Pneumoencephalogr am.
Preparation of the patient:The lumbar region should be washed well with soap and water (shaved if
necessary) wiped and dried. Then apply some antiseptics as Tr: iodine or spirit, and
covered with sterile towel and fix with binder. L. P. is done between the 2nd and 3 rd or
4th and 5th intervertebral space because the spinal cord ends at the level of the 1 st
lumbar vertebra.
Position of the Patient:Put the patient in right or left lateral position near the edge of the bed
(according to the convenience of the physician). Have his back arched so that his
head is almost touching his knees, instruct the patient to draw his knees up towards
the chest. In any way, tru back should be arched to widen the intervertebral space.
Nurse should help him to lie in the proper position.
1

The treatment can be done in sitting position also. A table or chair must be
provided for the patient to lean on, so as to arch his back and the nurse should
support by standing in front of the patient.
Requisites:A Screen to provide privacy.
Unsterile tray containing:
1)
2)
3)
4)
5)
6)

Small mackintosh and towel to protect the bed,

Bottles of Tr: iodine and spirit, or any antiseptic to clean the skin, Tr. Benzoin
Bottles of local anaesthetic as novacaine 1 percent.
Bottle of drug or serum in case of introduction into the spinal column.
Kidney tray.
Sterile normal saline in a bottle.

Sterile tray containing:1) Sterile towels 2 (one to wipe hands of the Doctor and one fene started towel for
the patient)
2) Small bowls 2 (one for local anaesthetic, and one for cotton swabs)
3) 2cc syringe and needles for giving local anaesthetic (if necessary)
4) Spinal needles 2 (of different sizes) with fitting stiletto
5) Sponege holding forceps.
6) Manometer (in case pressure is to be noted)
7) Three way adaptor -1
8) Sterile dressings to apply over puncture
9) sterile bottles with cork (to obtain specimens) or test tubes.
10)
Sterile gloves and mask.
11)
One syringe and needle in case drug has to be introduced.

Procedure:Explain the procedure to the patient.

Provide privacy.
2

Assemble the equipment to the bedside.

Protect the bed with mackintosh and towel.
Put the patient in position as explained before, at the edge of the bed. Fold the
clothing down to the hip so that the back is free from clothes. Cover chest with a
small blanket or towel. Explain that there will be certain amount of pain which is
unavoidable. He should keep himself without shaking.
If the patient is in a sagging bed a board is placed under the bed to get firmness
and to get the correct spinal curvature. Doctor gets ready (washing his hands
thoroughly and dressed in sterile gloves and mask). Provide a stool to sit if necessary.
The skin area at the lumbar region is cleaned and painted with Tr: iodine using
forceps, and the forceps is discarded in the kidney tray.
After the skin is prepared, cover the part with a' sterile towel or a Fenestrated
sheet (a sheet with a hole in the middle). Local anaesthetic is given sometimes with 2
cc syringe and needle by injecting novocaine 1 percent.
Then the lumbar region is punctured with the spinal needle usually done at the
lumbar intervertebral space.
If specimen is to be collected it should be taken as soon as begins to drop-from
the needle, without touching the needle. If pressure is to be noted, Manometer is
attached to the needle, to note the pressure. When a serum or any drug is to-be
injected, the same quantity of
drug

spinal fluid is withdrawn and an equal quantity of

is injected. Usually 20 to 50 cc of serum is injected.

After

the removal of fluid or

introduction of therapuetic drug

the

needle is

closed with the stilette (sometimes doctors use their gloved hand to close the needle)
3

and

then

the needle

Throughout
The

colour,

the procedure

it is

the nurse's duty to watch the patient carefully.

pulse and respiration should be watched.

patient made such

surgeon. After

is withdrawn and sterile dressing applied over the wound.

Anycomplaint that the

as headache or nausea, should be reported immediately to the

the treatment, the patient usually is put in the recumbent

with the foot raised

particularly if a serum

position

or drug is introduced or otherwise

ordered by the physician. The patient should stay in bed at least 24 hours after
a lumbar puncture.
Any specimen taken should be labelled properly and send for examination.
Record the treatment, date, time, amount, character of spinal fluid withdrawn,
its colour (cloudy or bloody) whether it is drawn with pressure and discomfort shown
by the patient. Any drug or serum injected into the spinal column, its quantity and
nature, whether the specimen has been sent to the laboratory for examination and by
whom it was done.
N.B. If the patient is child or an infant it should be

restrained to prevent it

from moving its limbs at the time of the procedure. Sometimes the patient's B. P is to
be checked at frequent intervals.
Normal C. S. F is clear, colourless. Usually 1 or 2 drops per second flows from
the needle. But under high pressure it may spurt out. Pressure at the jugular veins
causes increase in pressure. Sometimes the first fluid flows from the needle may the
blood stained. In inflammation of the meninges, the C. S. F. may show an increase in
pressure. Normal pressure of spinal fluid is 100 to 130 mm of water and sp: gravity
is 1006 (Encyclopedia).
4

In acute infections, the fluid may be cloudy or yellow in colour or turbid

because of the presence of pus. Blood usually dark in colour may indicate injury to
the spinal cord above the site of puncture.
Cisternal Puncture
Definition: Is the introduction of a needle into the cistern magna (enlargement
of the subarachnoid space just below the cerebellum) and it is similar in nature of
lumbar puncture except for the area of injection.
Purposes:To diagnose spinal block.
1)
2)
3)

To introduce serum in inflammation.

To introduce drugs directly into the meningeal space.
To inject air or opaque drug before making an encephalogram to discover the
location of brain lesions.

Position of Patient: Same as for lumbar puncture, but the head must rest on a small sand pillow or
sand bag. Patient is told to tilt his head forward, to draw his legs up and fold his
arms over the chest.
Cisternal puncture is same as lumbar puncture but the only difference is that
the physician inserts the needle between the first and second cervical vertebrae. The
preparation of patient and equipments are all same as lumbar puncture.

BIBLIOGRAPHY

1) Theresamma. CP., 2006 Fundamentals of Nursing Procedure manual for

5

General nursing & Midwifery Course. 1st Edition, Jaypee Brothers, Medical
Publishers (p) Ltd., New Delhi.p:243-246.
2) Nancy Sr., 2002, Principles & Practice of Nursing & Nursing arts procedures,
5th edition published & Printed by N.R. Publishers, House, Indore.p:360-368.
3) LC Gupta US, Sahu, Priya Gupta, 2007 Practical Nursing Procedure. 3 rd
Edition, Printed at Para Offset Pvt. Ltd. New Delhi; p: 322-327.
4) Sagunthala Sharma Birpuri 1997 Principles and Practice of Nursing 1 st
edition Printed at Lordson Publishers (P) ltd., New Delhi. p. 401-403.
5) Brunner & Siddarths, 2001, Text book of Medical- surgical Nursing- 12 th
edition, volume2, published by Wolters Kluwer (India) pvt. Ltd New Delhi, Page
No: 333-336
6) Lewis, collier, Heitkemper, 1996 Medicalsurgical Nursing, 4 th Edition, Mosby
year book- Inc USA, Page no: 471-478