31/10/21 11:52 Procedure: How to Do a Lumbar Puncture

Contraindications
Presences of increased intracranial pressure (ICP), regardless of cause, can increase risk of
cerebral or cerebellar brainstem herniation at the level of the foramen magnum.
Use of anticoagulants (e.g., warfarin, enoxaparin, etc) due to increased risk of developing an
epidural hematoma.
Evidence of cellulitis or abscess over the area where LP would be performed due to risk of
introducing infection into the subarachnoid space.
Significant degenerative joint disease or prior back surgeries where hardware maybe in
place (Note: many of these patients may require an LP under fluoroscopy)

Complications
The following are in order of most concerning to the least:
Herniation of the brainstem
Accidental puncture of the aorta or vena cava leading to retroperitoneal hematoma
Accidental puncture of the spinal cord from being in wrong location
Infection being introduced into the subarachnoid space
Pain over the LP site
Headache from CSF leak

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31/10/21 11:52 Procedure: How to Do a Lumbar Puncture

Can worsen with sitting up or standing, and if lasting longer than 1-2 days may require
a blood patch in the area of the LP puncture site

Before the Procedure

Verify that no contraindications exist.

This may include doing a CT head to rule out active bleeding, midline shift, space-
occupying lesions or signs of brain swelling.
EBM Topic: Who needs a head CT prior to LP when evaluating for the presence of
meningitis ...click here (/articles/lumbar-punture-lp-risk-factors-brain-stem-
herniation)
Explain the procedure to the patient and answer all questions
Obtain informed consent with appropriate documentation
Do a baseline neurologic exam with special notation on the strength, sensation and ability to
move extremities
Place the necessary orders so that the CSF tubes can be labeled after the procedure is
completed
Wash hands, open the lumbar puncture tray without compromising sterility and consider
any extra supplies (i.e., spinal needles or extra tubes)

During the Procedure

Position the patient either in lateral decubitus / fetal position, or sitting upright leaning
forward over a small table
Opening pressures cannot be obtained accurately if the patient is upright.
If opening pressures are indicated, the patient will need to straighten out after
insertion of the needle to accurately measure the opening and closing pressure,
because they can be falsely increased with the pressure applied to the abdomen in a
fetal position
Locate the L3/L4 space by locating the superior iliac crests and placing your thumbs
midline to the spine. Palpate above and below to determine the widest space and attempt to
mark location with the nail of your thumb or create a small indentation with an object like
pen or needle cap
Aseptically clean the skin using chlorhexidine skin prep
Some clinicians will do this using the skin prep provided in the LP tray once they have
their sterile gloves on
EBM Focused Topic: Chlorhexidine vs. povidone-iodine (Betadine) in invasive
procedures ... click here (/articles/skin-preparation-surgery-chlorhexidine-chloraprep-
povidone-iodine)
Put on sterile gloves, facemask, and protective gear per institutional policy
Finish setting the LP tray including opening the CSF tubes in preparation to be easily
accessed, and apply the sterile drapes to the patient
Draw up and inject 10 mL of 1% or 2% lidocaine (preservative free; without epinephrine) to
the area
Consider injecting some anesthetic a level above or below this area in case an
adjustment is needed

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31/10/21 11:52 Procedure: How to Do a Lumbar Puncture

Insert the spinal needle directed at a slight cephalad angle (imagine aiming towards the
umbilicus) and with the bevel of the needle oriented to the longitudinal fibers in attempt to
separate the fibers instead of cutting them
If the patient is lying in lateral decubitus position the bevel should be oriented up
If the patient is sitting upright and leaning forward the bevel should be oriented to the
left or right
The entry into the subarachnoid space is commonly described as feeling a "pop" sensation,
the needle insert (obturator) is then removed and CSF should begin to drip out
Have the patient slowly stretch out legs (if lying in lateral decubitus)
Attach the sterile manometer to the end of the spinal needle to measure the opening
pressure
Normal opening pressures: < 20 cm H2O
Measuring opening pressure is very important for evaluation for cryptococcal
meningitis or pseudotumor cerebri
If blockage of CSF flow to the spinal subarachnoid space is suspected, the clinician may
perform a Queckenstedt-Stookey test
Empty the manometer into CSF tube #1 and about 10 drops of CSF into tubes #2 - 4 (note:
some institutions use only 3 tubes)
Measure the closing pressure (if indicated)
Reinsert the needle insert (obturator) and withdraw the spinal needle and immediately
apply pressure and an adhesive bandage over the insertion site

After the Procedure

While the traditional teaching is to have the patient remain lying flat after a procedure,
there is no evidence that it has any effect on the development of post-LP headache. At the
same time, there is no harm in having the patient lie flat if they desire to do so.
Despite the lack of evidence, some clinicians will have the patient lay prone with a
pillow under the abdomen to increase the pressure on the tissues around the area of
the LP in the thought that it might prevent CSF leaking.
While based on expert opinion only, some clinicians will encourage and counsel the patient
to drink extra fluids to help replace the CSF drained off and prevent a headache (or give the
patient IV fluids if warranted)
Immediately label the CSF tubes have the tubes hand carried/delivered to the lab for
analysis
If meningitis is suspected, initiate empiric antibiotics with or without steroids based on the
clinical scenario
Repeat neurologic assessment to evaluate for any changes post-LP
Document the procedure, number of attempts, opening and closing pressure (if applicable),
total amount of CSF drained

Counseling Points
Before the procedure, no fasting needed
During the procedure, encourage the patient to not move and try to remain calm

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31/10/21 11:52 Procedure: How to Do a Lumbar Puncture

After the procedure, encourage fluid intake to prevent headache and consider resting and
lying flat for first 12 hours to help prevent possible headaches while things heal

Related Content
To see other related content please click or tap on an item:
EBM Focused Topic: Risk Factors for Brain Stem Herniation When Doing a Lumbar
Puncture (/articles/lumbar-punture-lp-risk-factors-brain-stem-herniation)
EBM Focused Topic: Chlorhexidine vs. Povidone-Iodine for Prevent Post-Procedure and
Surgical Infections (/articles/skin-preparation-surgery-chlorhexidine-chloraprep-povidone-
iodine)
EBM Focused Topic: Nimodipine Use for Subarachnoid Hemorrhage
(/articles/nimodipine-subarachnoid-hemorrhage)
Anatomy: Cavernous Sinus (/articles/anatomy-cavernous-sinus)
Anatomy: Homunculus (Motor & Sensory) (/articles/homunculus-sensory-motor-cortex)
Anatomy & Pathology: Subdural vs. Epidural Hematoma (/articles/anatomy-epidural-
subdural-hematoma)

Editors & Reviewers

Editors:
Anthony J. Busti, MD, PharmD, FNLA, FAHA
Dylan Kellogg, MD
Last Reviewed: August 2015

Copyright EBM Consult, LLC

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