• Central nervous system (CNS) infection (viral,
fungal, or bacterial) or malignancy.
• Intracranial pressure or pseudotumor.
• Metabolic studies.
• Neurotransmitter disorders.
• Demyelinating disease (eg, multiple sclerosis).
• Spinal needle: 0.5 inch for neonate, 22 gauge.
• Sterile collection tubes (sufficient number for studies).
• 3-way stopcock.
• Flexible tubing.
• Placing the patient with the sacral plane vertical
• The head of the patient should be on your nondominant side. (Left-handed
physicians should place the patient in the left lateral decubitus
• Use your nondominant thumb to palpate the spinous process of
L4 and put your index finger on the iliac crest.
• Use your dominant hand to manipulate the needle.
• If positioning is felt to be correct, try rotating the needle 90
• If cerebrospinal fluid (CSF) flows slowly, be patient.
• Sterile technique.
• Povidone-iodine preparation.
• Sterile drape with fenestration over midlumbar spine.
• Sedation, if needed.
• Connect 3-way stopcock to flexible tubing and manometer at 90
degrees from each other.
• Free end of tubing will connect to hub of needle.
• Lateral decubitus position.
• Back arched in extreme lordosis.
• Spine should be as perfectly horizontal as possible.
• Sacral plane should be as vertical as possible (Figure
Lateral decubitus position.
• Spinous process of L4 is on line drawn between
• Cauda equina is in midlumbar region.
• Spinous processes are angled inferiorly (caudally).
• Place lumbar puncture needle between interspaces
• Angle the needle tip approximately 15–30 degrees from perpendicular
to plane of back in rostral direction, aiming toward umbilicus (Figure 34–3).
• Needle remains fixed in horizontal plane to back.
• Advance needle slowly until light resistance (a pop) is felt.
• Remove stylet and check for CSF flow.
• If no CSF flows, continue to advance the needle slowly.
• If CSF flows, connect flexible tubing to hub of lumbar puncture
• Allow CSF to flow through tubing into manometer.
• Hold base of manometer and stopcock at level of heart.
• Straighten the patient’s back and legs.
• When CSF stops advancing along manometer, measure opening pressure
• Collect CSF for studies.
• Measure closing pressure, ...
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