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Lumbar Puncture for Diagnostics and Intrathecal Administration of Chemotherapy


Medical editor Harald Holte MD
Oncologist
Rikshospitalet HF

General

Indications

  • A diagnostic tool for suspicion of disease in the brain or meninges.
  • Intrathecal chemotherapy treatment, either as prophylaxis or for treatment of disease.

Goal 

  • 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.

Equipment

  • Sterile care kit
  • Lumbar needle
  • Introducer needle
  • Bandages
  • 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.
  • Drape

Preparation

  • 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.

Implementation

  • 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-up

The 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.

For 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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