Lumbar Puncture for Diagnostics and Intrathecal Administration of ChemotherapyMedical editor Harald Holte MD
- A diagnostic tool for suspicion of disease in the brain or meninges.
- Intrathecal chemotherapy treatment, either as prophylaxis or for treatment of disease.
- Diagnose disease in spinal fluid.
- Treat or prevent disease and/or CNS affection.
If possible, a lumbar puncture should be avoided in cases of:
- Thrombocyte values < 30,000 (give thrombocyte transfusion first).
- For INR values > 1.8. Give Octaplas® or Konakion® first, but weigh this with risk of raised anticoagulation. The effect of Konakion® appears first the day after administration.
- Heparin combined with an antiplatelet agent such as Albyl-E®, Plavix®, Tielid®, ReoPro®, Aggrastat®. Confer with an hematologist.
- Disseminated intravascular coagulation.
- In cases where a patient is undergoing fibrinolytic treatment or where similar treatment concluded less than 2 days prior.
- Hemophilia C – confer with an hematologist.
- Full heparinization.
- Sterile care kit
- Lumbar needle
- Introducer needle
- Sterile gloves
- Broad-spectrum antiseptic
- Local anesthetic
- 2 ml syringe with cannula
- Two sterile 10 ml specimen containers (more as needed) if samples of spinal fluid are taken.
Inform the patient about why and how the examination will be carried out.
Examine the patient with ophthalmoscopy before the lumbar puncture if there is a suspicion of increased intracranial pressure.
Check the chemotherapy immediately before puncture.
- The patient lies on their side in full flexion or sits on the edge of a bed bending forward. In this position, the ligamenta flava is accessible.
- Help the patient to remain in this postion during the entire procedure.
- Wash the area with chlorhexidine.
- Draw a line between the highest points of the hip bones. This line crosses the spine right over L4.
- Mark the area with a pen.
- As needed, administer local anesthetic.
- To avoid dura leakage, use a thin needle (25 G, or 0.5 mm or thinner).
- Insert the lumbar needle between L3 and L4 (or L4 and L5). Precise identification of the injection point is difficult.
- The needle is inserted at the midline, or sideways, and angled horizontally and sagittally, enough to go through the ligamenta flava or very close to the midline.
- Reasonable constant resistance is noticed from the tissue until meeting the ligamenta flava, which gives greater resistance.
- When the needle enters the epidural space, there is less resistance (like a small "give") . The distance between the skin and the dura mater is usually 40–50 mm.
- Push carefully through the dura-arachnoid mater.
- Carefully pull out the mandrin and check if spinal fluid comes out. This should be performed sterile such that it can be repeated if positioning is uncertain.
- The drop rate of spinal fluid coming out rarely surpasses 1 drop/second.
- The first drops can drop freely as they might contain blood from the puncture.
- After the desired amount of spinal fluid is tapped for a specimen, chemotherapy can be injected.
- The needle is removed and a bandage is applied.
- The patient is helped back to the supine position.
Cell counting and testing for protein and glucose
- 1 tube (without additive) with minimum of 20 drops (1 ml) marked "spinal fluid for glucose, protein, and cells"
- 1 tube with minimum of 60 drops (3 ml) for cytology and flow cytometry
Follow-upThe patient should lie flat with their upper body lowered 20° for 2 hours after intrathecal chemotherapy is administered. Thereafter, the patient should lie flat to avoid a headache.
- Lie flat until the headache goes away.
- Drink a copious amount of fluid.
- Paracetamol for pain (unless contraindicated).
- Up to 500 mg caffeine in 1000 ml fluid over 4 hours.
- If headache lasts more than 2–4 days and is associated with tight dura leakage with epidural "blood patch" then contact an anesthesiologist
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