Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + • Central nervous system (CNS) infection (viral, fungal, or bacterial) or malignancy.• Intracranial pressure or pseudotumor.• Metabolic studies.• Aminoacidopathies.• Neurotransmitter disorders.• Undiagnosed movement disorders.• Undiagnosed infantile or pediatric epilepsy.• Demyelinating disease (eg, multiple sclerosis). +++ Absolute + • CNS herniation.• Unilateral mass lesion with edema or mass effect. +++ Relative + • Suspected focal mass lesion. + • Spinal needle: 0.5 inch for neonate, 22 gauge.• Manometer.• Sterile collection tubes (sufficient number for studies).• 3-way stopcock.• Flexible tubing. + • Herniation (extremely rare) is associated with focal structural lesions causing increased intracranial pressure.• Infection (extremely rare).• Headache (rare).• Back pain. + • Placing the patient with the sacral plane vertical is key.• The head of the patient should be on your nondominant side. (Left-handed physicians should place the patient in the left lateral decubitus position.)• 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 degrees.• 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 34–1). ++Figure 34–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Lateral decubitus position. + • Spinous process of L4 is on line drawn between iliac crests.• Cauda equina is in midlumbar region.• Spinous processes are angled inferiorly (caudally). + • Palpate for L4 spinous process using iliac crests as landmarks (Figure 34–2). + • Place lumbar puncture needle between interspaces L4–5.• 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 needle.• 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 at meniscus.• Collect CSF for studies.• Measure closing pressure, if ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth