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INDEX 48 history of LP 50 normal CSF

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abnormal CSF 58 lumbar puncture & indication

62 conterindication 63 procedure

70 complication 72 purpose

74 cross examination & microscopic examination 77- culture

78 latex agglutination 78- PCR 79-LDH

83- after care &risks 85- LP& BRIEF OF THE GUID LINE-

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History of lumbar puncture

The first technique for

accessing the Dural

space was described by

the London physician

Dr Walter Essex

Wynter. In 1889, he

developed a crude cut down with cannulation in 4 patients with

tuberculous meningitis. The main purpose was the treatment of raised

intracranial pressure rather than for diagnosis. The tecnique for needle

lumbar puncture was then introduced by the German physician Heinrich

Quincke, who credits Wynter with the earlier discovery; he first reported

his experiences at an internal medicine conference in Wiesbaden in 1891.

He subsequently published a book on the subject.

The lumbar puncture procedure was taken to the United States by Arthur

H. Wentworth M.D., an assistant professor at the Harvard Medical

School, based at Children's Hospital. In 1893, he published a long paper

on diagnosing cerebro-spinal meningitis by examining spinal fluid. His

career took a nosedive, however, when anti vivisectionists prosecuted

him for having obtained spinal fluid from children. He was acquitted, but

he was disinvited from the then forming Johns Hopkins Medical School

where he would have been the first professor of pediatrics.

THE NORMAL CSF

The cerebrospinal fluid (CSF)

is produced from arterial

blood by the choroid plexuses

of the lateral and fourth

ventricles by a combined

process of diffusion, pinocytosis and active transfer. by ependymal cells.

The choroid plexus A small amount is also produced consists of tufts of

capillaries with thin fenestrated endothelial cells. These are covered by

modified ependymal cells with bulbous microvilli. The total volume of

CSF in the adult is about 140 ml. The volume of the ventricles is about 25

mi. CSF is produced at a rate of 0.2 - 0.7 ml per minute or 600-700 ml per

day. The circulation of CSF is aided by the pulsations of the choroid

plexus and by the motion of the cilia of ependymal cells. CSF is absorbed

across the arachnoid villi into the venous circulation. The arachnoid villi

act as one-way valves between the subarachnoid space and the dural

sinuses. The rate of absorption correlates with the CSF pressure. CSF acts

as a cushion that protects the brain from shocks and supports the venous

sinuses. It also plays an important role in the homeostasis and metabolism

of the central nervous system

CSF from the lumbar region contains 15 to 45 mg/dl protein (lower in

childen) and 50-80 mg/dl glucose (two-thirds of blood gluCose). Protein

concentration in cisternal and ventricular CSF is lower. Normal CSF

contains 0-5 mononuclear cells. The CSF pressure, measured at lumbar

puncture (LP), is 100-180 mm of H20 (8-15 mm Hg) with the patient

lying on the side and 200-300 mm with the patient sitting up.

Unlike other organs and tissues, brain capillaries show no fenestrations or

pinocytotic (transportation) vesicles and have tight junctions that almost

fuse adjacent cells. This anatomy creates the blood-brain barrier (BBB).

Astrocytic foot processes surround brain capillaries and, during

development, induce brain endothelial cells to develop in this special

leak-proof fashion.

The BBB separates plasma from the interstitial space of the CNS and

affects in a critical fashion the traffic of molecules in and out of the brain.

The ability to exclude certain substances from brain interstitial space has

to do not only with the vascular anatomy, but also with lipid solubility

and selective transcellular transport by endothelial cells. Lipophilic

compounds cross the BBB easier than hydrophilic ones do, and small

lipophilic molecules such as 02 and C02 diffuse freely. Some hydrophilic

compounds, including glucose and amino acids, enter the brain with the

help of transporters, and larger molecules enter via receptor-mediated

endocytosis. The BBB protects the brain from toxic substances but

impedes also the entry of drugs. Hypertonic stimuli and chemical

substances including glutamate and certain cytokines can open the BBB.

HIE and inflammatory mediators produced in sepsis disrupt the BBB.

Blood vessels in GBM and other malignant brain tumors do not have tight

junctions, explaining the fluid leakage and cerebral edema that

accompanies these tumors. The interstitial space of the brain is separated

from the ventricular CSF by the ependymal lining and from the

subarachnoid CSF by the glia limitans. The glia limitans is a thick layer

of interdigitating astrocytic processes with an overlying basement

membrane. This layer seals the surface of the CNS and dips into brain

tissue along the perivascular space (see below). External to it is the pia

matter, a thin layer of connective tissue cells with a small amount of

collagen. The ependymal barrier is far more permeable than the BBB.

The major cerebral arteries and veins traverse the subarachnoid space and

penetrate into the brain, where they branch into smaller vessels and

eventually capillaries. Capillaries are in contact with astrocytic processes.

Vessels larger than capillaries are separated from the surrounding brain

tissue by a space (the perivascular or Virchow-Robin space), which is

an extension of the subarachnoid space. The outer surface of this

perivascular space (PVS) is formed by the glia limitans. The inner surface

is the vascular basement membrane. Postcapillary venules are also

surrounded by a PVS. The BBB is important for regulating transport of

molecules in and out of the brain. The PVS that surrounds postcapillary

venules is the portal of entry of leukocytes into the brain in the normal

state and during inflammation . Circulating monocytes and lymphocytes

normally traverse postcapillary venules and enter the PVS. In the course

of inflammation, such as MS, this entry is increased because of leukocyte

interactions with inflamed endothelial cells. Furthermore, leukocytes

penetrate the glia limitans and enter into the CNS. The latter move is

facilitated by matrix metalloproteinases (MMPs) produced by crophages,

hich loosen the glia limitans.

ABNORMALITIES OF CSF

Blood: Blood may be spilled into the CSF by accidental puncture of a

leptomeningeal vein during entry of the LP needle. Such blood stains the

fluid that is drawn initially and clears gradually. If it does not clear, blood

indicates subarachnoid hemorrhage. Erythrocytes from subarachnoid

hemorrhage are cleared in 3 to 7 days. A few neutrophils and

mononuclear cells may also be present as a result of meningeal irritation.

Xanthochromia (blonde color) of the CSF following subarachnoid

hemorrhage is due to oxyhemoglobin which appears in 4 to 6 hours and

bilirubin which appears in two days. Xanthochromia may also be seen

with hemorrhagic infarcts, brain tumors, and jaundice.

Increased inflammatory cells (pleocytosis) may be caused by infectious

and noninfectious processes. Polymorphonuclear pleocytosis indicates

acute suppurative meningitis. Mononuclear cells are seen in viral

infections (meningoencephalitis, aseptic meningitis), syphilis,

neuroborreliosis, tuberculous meningitis, multiple sclerosis, brain abscess

and brain tumors.

Tumor cells indicate dissemination of metastatic or primary brain tumors

in the subarachnoid space. The most common among the latter is

medulloblastoma. They can be best detected by cytological examination.

A mononuclear inflammatory reaction is often seen in addition to the

tumor cells.

Increased protein: In bacterial meningitis, CSF protein may rise to 500

mg/dl. A more moderate increase (150-200 mg/dl) occurs in

inflammatory diseases of meninges (meningitis, encephalitis), intracranial

tumors, subarachnoid hemorrhage, and cerebral infarction. A more severe

increase occurs in the Guillain-Barre syndrome and acoustic and spinal

schwannoma. In multiple sclerosis, CSF protein is normal or mildly

increased, but there is often an elevation of IgG in CSF, but not in serum,

expressed as an elevation of the CSF IgG/albumin index (normally 10: 1).

In addition, 90% of MS patients have oligoclonal IgG bands in the CSF.

Oligoclonal bands are also seen occasionally in some chronic CNS

infections. The type of oligoclonal bands is constant for each MS patient

throughout the course of the disease. Oligoclonal bands occur in the CSF

only (not in the serum). These quantitative and qualitative CSF changes

indicate that in MS, there is intrathecal immunoglobulin production. In

addition, the CSF in MS often contains myelin fragments and myelin

basic protein (MBP). MBP can be detected by radioimmunoassay. MBP

is not specific for MS. It can appear in any condition causing brain

necrosis, including infarcts.

Low glucose in CSF is seen in suppurative, tuberculous and fungal

infections, sarcoidosis, and meningeal dissemination of tumors. Glucose

is consumed by leukocytes and tumor cells. Lumbar puncture is a very

safe procedure. It is routinely performed without complication. Before the

test you will have been carefully assessed by your doctor. Basic blood

tests and often a brain scan will have been reviewed. In these

circumstances no serious complications are likely. Headache after

lumbar puncture does occur in a small proportion of cases and its

occurrence appears to be unrelated to how easily the procedure was

performed. It is very rare for this headache to be severe (reported in less

than 5 in 100 procedures in good units) and even rarer for the headache to

be sufficiently prolonged to require readmission to hospital (necessary in

less than 1 in 100 procedures). If this is necessary then you may be given

an infusion of caffeine or the anaesthesist may be asked to perform a

blood patch. (A blood patch is a very simple procedure during which the

anaesthesist will ask you to lie on your side and then inject a small

amount of your own blood into your lower back to seal any site of spinal

fluid leak.) Other complications are usually mild and uncommon. Back

pain may occur but will usually settle. It is extraordinarily unlikely for the

test to cause infection within the nervous system but this is theoretically

possible.

We advise the following:

Lie down flat for at least half an hour (you are in hospital for this time).

Before leaving hospital, get up and walk around to ensure that you are

ready for your journey home. Inform your nurse when you intend to

leave.

Do not drive for the next 24 hours.

Over the next 48 hours, try to drink 3 liters of fluid a day. This helps

replace fluid taken in the procedure.

Lumbar puncture

In medicine, a lumbar puncture (colloquially known as a spinal tap) is

a diagnostic and at times therapeutic procedure that is performed in order

to collect a sample of cerebrospinal fluid (CSF) for biochemical,

microbiological, and cytological analysis, or very rarely as a treatment

("therapeutic lumbar puncture") to relieve increased intracranial pressure.

Lumbar puncture is indicated for both diagnostic and therapeutic reasons.

Knowledge of the contraindications, the pertinent anatomy, and the

methods to minimize the risk of complications are necessary for the safe

and efficient performance of the procedure. Risks although rare, can be

substantial and even potentially life-threatening. The risks can be

minimized with an appropriate understanding of the indications,

contraindications, and procedural techniques.

INDICATIONS

Lumbar puncture is used to obtain a sample of cerebrospinal fluid (CSF)

to aid in the diagnosis of infectious, inflammatory, oncologic, and

metabolic processes (Table 1). Therapeutic indications include the

delivery of chemotherapy, antibiotics, and anesthetic agents.

Table 1. Indications and Uses for Lumbar Puncture.

Variable

Diagnostic indications

Infectious disease

Viral. bacterial. or fungal

meningitis

Encephalitis

Inflammatory process

Multiple sclerosis

Guillan-Barre syndrome

Variety of oncologic procedures

Variety of metabolic processes

Therapeutic indications

Numerous procedures requiring

lower-body analgesia

Anesthesia

Narcotics

Bupivacaine

Ventriculitis and some types of

meningitis

Antibiotic administration

Vancomycin

Tests performed on CSF

Cell count, differential count,

measurement of glucose

and protein, cultures

Measurement of myelin basic

proteins, cell counts, cultures

Cell counts. smear on cell

concentrate

Measurement oflactate. pyruvate,

glucose. Protein

Gentamicin

Some leukemias and

lymphomas

Chemotherapy

Methotrexate

Indications

The most common purpose for a lumbar puncture is to collect

cerebrospinal fluid in a case of suspected meningitis, since there is no

other reliable tool with which meningitis, a life-threatening but highly

treatable condition, can be excluded. Young infants commonly require

lumbar puncture as a part of the routine workup for fever without a

source, as they have a much higher risk of meningitis than older persons

and do not reliably show signs of menangeal irritation (meningismus). In

any age group, subarachnoid hemorrhage, hydrocephalus, benign

intracranial hypertension and many other diagnoses may be supported or

excluded with this test.

Lumbar punctures may also be done to inject medications into the

cerebrospinal fluid ("intrathecaly"), particularly for spinal anesthesia or

chemotherapy. It may also be used to detect the presence of malignant

cells in the CSF, as in carcinomatous meningitis or medulloblastoma.

Contraindications

Lumbar puncture should not be performed in the following situations

* Idiopathic (unidentified cause) increased intracranial pressure (ICP)

* Rationale: lumbar puncture in the presence of increased ICP may cause

oncal herniation

* Exception: therapeutic use of lumbar puncture to reduce ICP

* Precaution

* CT brain is advocated by some, especially in the following situations

* Age >65

* Reduced GCS or conscious state

* Recent history of seizure

* Focal neurological signs

* Ophthalmoscopy for papiloedema

* Bleeding diathesis

* Coagulopathy

* Decreased platelet count «50 x 1 09/L)

* Infections

Skin infection at puncture site

* Sepsis

* Abnormal respiratory pattern . . .

* Hypertension with bradycardia and deteriorating consciousness.

* Vertebral deformities (scoliosis or kyphosis),

Procedure

In performing a lumbar puncture, first the patient is usually placed in a

left (or right) lateral position with his/her neck bent in full flexion and

knees bent in full flexion up to his/her chest, approximating a fetal

position as much as possible. It is also possible to have the patient sit on a

stool and bend his/her head and shoulders forward. The area around the

lower back is prepared using aseptic technique. Once the appropriate

location is palpated, local anaesthesia is infiltrated under the skin and

then injected along the intended path of the spinal needle. A spinal needle

is inserted between the lumbar vertebrae L3/L4 or L4/L5 and pushed in

until there is a "give" that indicates the needle is past the dura mater. The

needle is again pushed until there is a second 'give' that indicates the

needle is now past the arachnoid mater, and in the subarachnoid space.

The style from the spinal needle is then withdrawn and drops of

cerebrospinal fluid are collected. The opening pressure of the

cerebrospinal fluid may be taken during this collection by using a simple

column manometer. The procedure is ended by withdrawing the needle

while placing pressure on the puncture site. In the past, the patient would

often be asked to lie on his/her back for at least six hours and be

monitored for signs of neurological problems, though there is no

scientific evidence that this provides any benefit. The technique described

is almost identical to that used in spinal anesthesia, except that spinal

anesthesia is more often done with the patient in a sitting position.

The upright seated position is advantageous in that there is less distortion

of spinal anatomy which allows for easier withdrawal of fluid. It is

preferred by some practitioners when a lumbar puncture is performed on

an obese patient where having them lie on their side would cause a

scoliosis and unreliable anatomical landmarks. On the other hand,

opening pressures are notoriously unreliable when measured on a seated

patient and therefore the left or right lateral (lying down) position is

preferred if an opening pressure needs to be measured.

Patient anxiety during the procedure can lead to increased CSF pressure,

especially if the person holds their breath, tenses their muscles or flexes

their knees too tightly against their chest. Diagnostic analysis of changes

in fluid pressure during lumbar puncture procedures requires attention

both to the patient's condition during the procedure and to their medical

history.

blockage resulting in a large pool of CSF, or hydrocephalus associated

with large volumes of CSF. Lumbar puncture for the purpose of reducing

pressure is performed in some patients with idiopathic intracranial

hypertension (also called pseudotumor cerebri.)

The presence of white blood cells in cerebrospinal fluid is called

pleocytosis. A small number of monocytes can be normal; the presence of

granulocytes is always an abnormal finding. A large number of

granulocytes often heralds bacterial meningitis. White cells can also

indicate reaction to repeated lumbar punctures, reactions to prior

injections of medicines or dyes, central nervous system hemorrhage,

leukemia, recent epileptic seizure, or a metastatic tumor. When peripheral

blood contaminates the withdrawn CSF, a common procedural

complication, white blood cells will be present along with erythrocytes,

and their ratio will be the same as that in the peripheral blood.

The finding of erythrophagocytosis where phagocytosed erythrocytes is

observed, signifies haemorrhage into the CSF that preceded the lumbar

puncture. Therefore, when erythrocytes are detected in the CSF sample,

erythrophagocytosis suggests causes other than a traumatic tap, such as

intracranial haemorrhage and haemorrhagic herpetic encephalitis. In

which case, further investigations are warranted, including imaging and

viral culture.

Several substances found in cerebrospinal fluid are available for

diagnostic measurement.

* Measurement of chloride levels may aid in detecting the presence of

tuberculous meningitis.

*

that in the peripheral circulation. A fingerstick or venipuncture at the time

of lumbar puncture may therefore be performed to assess peripheral

glucose levels in order to determine a predicted CSF glucose value.

Decreased glucose levels can indicate fungal, tuberculous or pyogenic

infections; lymphomas; leukemia spreading to the meninges;

meningoencephalitis mumps; or hypoglycemia. A glucose level of less

than one third of blood glucose levels in association with low CSF lactate

levels is typical in hereditary CSF glucose transporter deficiency also

known as De Vivo disease.

* Increased glucose levels in the fluid can indicate diabetes, although the

60% rule still applies.

* Increased levels of glutamine are often involved with hepatic

encephalopathies, Reye's syndrome, hepatic coma, cirrhosis and

hypercapnia.

* Increased levels of lactate can occur the presence of cancer of the

CNS, multiple sclerosis, heritable mitochondrial disease, low blood

pressure, low serum phosphorus, respiratory alkalosis, idiopathic

seizures, traumatic brain injury, cerebral ischemia, brain abscess,

hydrocephalus, . hypocapnia or bacterial meningitis.

* The enzyme lactate dehydrogenase can be measured to help

distinguish meningitides of bacterial origin, which are often associated

with high levels of the enzyme, from those of viral origin in which the

enzyme is low or absent. .

* Changes in total protein content of cerebrospinal fluid can result from

pathologically increased permeability of the blood-cerebrospinal fluid

barrier, obstructions of CSF circulation, meningitis, neurosyphilis, brain

abscesses, subarachnoid hemorrhage, polio, collagen disease or

GuillanBarre syndrome, leakage of CSF, increases in intracranial pressure

or hyperthyroidism. Very high levels of protein may indicate tuberculous

meningitis or spinal block.

* IgG synthetic rate is calculated from measured IgG and total protein

levels; it is elevated in immune disorders such as multiple sclerosis,

transverse myelitis, and neuromyelitis optica of Disc.

* Numerous antibody-mediated tests for CSF are available in some

countries: these include rapid tests for antigens of common bacterial

pathogens, treponemal titers for the diagnosis of neurosyphilis and Lyme

disease, Coccidioides antibody, and others. Reinsertion of the style may

decrease the rate of post lumbar puncture headaches Risks

Post spinal headache with nausea is-the most common complication; it

often responds to analgesics and infusion of fluids. It was long taught that

this complication can often be prevented by strict maintenance of a

supine posture for two hours after the successful puncture; this has not

been borne out in modern studies involving large numbers of patients.

Merritt's Neurology (10th edition), in the section on lumbar puncture,

notes that intravenous caffeine injection is often quite effective in

aborting these so-called "spinal headaches." Contact between the side of

the lumbar puncture needle and a spinal nerve root can result in

anomalous sensations (paresthesia) in a leg during the procedure; this is

harmless and patients can be warned about it in advance to minimize their

anxiety if it should occur. A headache that is persistent despite a long

period of bedrest and occurs only when sitting up may be indicative of a

CSF leak from the lumbar puncture site. It can be treated by more

bedrest, or by an epidural blood patch, where the patient's own blood is

injected back into the site of leakage to cause a clot to form and seal off

the leak.

Serious complications of a properly performed lumbar puncture are

extremely They include spinal or epidural bleeding, and trauma to the

spinal cord or spinal nerve roots resulting in weakness or loss of

sensation, or even paraplegia. The latter is exceedingly rare, since the

level at which the spinal cord ends (normally the inferior border of L 1,

although it is slightly lower in infants) is several vertebral spaces above

the proper location for a lumbar puncture (L3/L4). There are case reports

of lumbar puncture resulting in perforation of abnormal dural arterio-

venous malformations, resulting in catastrophic epidural hemorrhage; this

is exceedingly rare.

The procedure is not recommended when epidural infection is present or

suspected, when topical infections or dermatological conditions pose a

risk of infection at the puncture site or in patients with severe psychosis

or neurosis with back pain. Some authorities believe that withdrawal of

fluid when initial pressures are abnormal could result in spinal cord

compression or cerebral herniation; others believe that such events are

merely coincidental in time, occuring independently as a result of the

same pathology that the lumbar puncture was performed to diagnose. In

any case, computed tomography of the brain is often performed prior to

lumbar puncture if an intracranial mass is suspected.

Removal of cerebrospinal fluid resulting in reduced fluid pressure has

been shown to corelate with greater reduction of cerebral blood flow

among patients with Alzheimer's disease. Its clinical significance is

uncertain.

Diagnostics:

Increased CSF pressure can indicate congestive heart failure, cerebral

edema, subaracnoid hemorrhage, hypo-osmolality resulting from

hemodialysis, meningeal inflanmation, purulent meningitis or tuberculous

meningitis, hydrocephalus, or pseudotumor cerebri.

Decreased CSF pressure can indicate complete subarachnoid blockage,

leakage of spinal fluid, severe dehydration, hyperosmolality, or

circulatory collapse. Significant changes in pressure during the procedure

can indicate tumors or spinal

COMPLICATIONS:

Obese patients may represent a challenge because of difficulty in

identifying landmarks. Osteoarthritis, ankylosing spondylitis,

kyphoscoliosis, previous lumbar surgery, and degenerative disk disease

may make the procedure more difficult. In patients with such conditions,

consultation with an anesthesiologist or interventional radiologist may be

necessary for lumbar puncture to be successful.

Complications from lumbar puncture include herniation cardiorespiratory

compromise, local or referred pain, headache, bleeding, infection,

subarachnoid epidermal cyst, and leakage of CSF. The most common

complication is headache, occurring in up to 36.5% of patients within 48

hours after the procedure. Headaches can be caused by the leakage of

CSF through the puncture site at a rate that exceeds the rate of CSF

production. The incidence increases in relation to the size of the spinal

needles The most serious complication is herniation, which may result

when a large pressure gradient exists between the cranial and lumbar

compartments. This gradient can be increased during a lumbar puncture,

resulting in brain-stem herniation. Patients at high risk for herniation can

be identified by a thorough history- taking and neurologic examination. If

there is still concern about the procedure, CT may be helpful, with the

caveat that these images may not identify pressure elevations. However,

CT is not necessary for all patients, because it could delay diagnosis and

treatment. Bleeding is most likely to occur in a patient with a bleeding

diathesis. The resulting hemorrhage may cause spinal cord compression.

No absolute criteria exist regarding the degree of coagulopathy and the

risk of bleeding, so clinical judgment is necessary. Subarachnoid

epidermal cysts can develop as a consequence of introducing a skin plug

into the subarachnoid space and can be avoided through the use of a

needle with a styll.

Cerebrospinal fluid (CSF) analysis:

Cerebrospinal fluid (CSF) analysis is a set of laboratory tests that

examine a sample of the fluid surrounding the brain and spinal cord. This

fluid is an ultrafiltrate of plasma. It is clear and colorless. It contains

glucose, electrolytes, amino acids, and other small molecules found in

plasma, but has very little protein and few cells. CSF protects the central

nervous system from injury, cushions it from the surrounding bone

structure, provides it with nutrients, and removes waste products by

returning them to the blood. CSF is withdrawn from the subarachnoid

space through a needle by a procedure called a lumbar puncture or spinal

tap. CSF analysis includes tests in clinical chemistry, hematology,

immunology, and microbiology. Usually three or four tubes are collected.

The first tube is used for chemical and/ or serological analysis and the last

two tubes are used for hematology and microbiology tests. This reduces

the chances of a falsely elevated white cell count caused by a traumatic

tap (bleeding into the subarachnoid space at the puncture site), and

contamination of the bacterial culture by skin germs or flora.

Purpose:

The purpose of a CSF analysis is to diagnose medical disorders that affect

the central nervous system. Some of these conditions are:

* meningitis and encephalitis, which may be viral, bacterial, fungal, or

parasitic infections

* metastatic tumors (e.g., leukemia) and central nervous system tumors

that shed cells into the CSF

* syphilis, a sexually transmitted bacterial disease

* bleeding (hemorrhaging) in the brain and spinal cord

* multiple sclerosis, a degenerative nerve disease that results in the loss

of the myelin coating of the nerve fibers of the brain and spinal cord

* Guillan-Barre syndrome, a demyelinating disease involving peripheral

sensory and motor nerves.

Routine examination of CSF includes visual observation of color and

clarity and tests for glucose, protein, lactate, lactate dehydrogenase, red

blood cell count, white blood cell count with differential, syphilis

serology (testing for antibodies indicative of syphilis), Gram stain, and

bacterial culture. Further tests may need 1>0 be performed depending

upon the results of initial tests and the presumptive diagnosis. For

example, an abnormally high total protein seen in a patient suspected of

having a demyelinating disease such as multiple sclerosis dictates CSF

protein electrophoresis and measurement of immunoglobulin levels and

myelin basic protein.

GROSS EXAMINATION:. Color and clarity are important diagnostic

characteristics of CSF. Straw, pink, yellow, or amber pigments

(xanthochromia) are abnormal and indicate the presence of bilirubin,

hemoglobin, red blood cells, or increased protein. Turbidity (suspended

particles) indicates an increased number of cells. Gross examination is an

important aid to differentiating a subarachnoid hemorrhage from a

traumatic tap. The latter is often associated with sequential clearing of

CSF as it is collected; streaks of blood in an otherwise clear fluid; or a

sample that clots.

Microscopic Examination:

Gram stain is positive in 60 to 80 percent of untreated cases of bacterial

meningitis and in 40 to 60 percent of partially treated cases. The

sensitivity according to the causative organism ranges from 90 percent in

pneumococcal or staphylococcal meningitis to less than 50 percent in

Listeria meningitis. Hyphae can occasionally be seen in Candida or other

fungal meningitis cases.

Several factors influence the sensitivity of Gram stain. Laboratory

techniques used to concentrate and stain CSF can greatly influence

reliability. Cytocentrifugation increases the ability to detect bacteria.

Greater numbers of colony-farming units (CFU) per mm' of CSF increase

the likelihood of a positive result. Staining will be positive in 25 percent

of cases if fewer than 1,000 CFU per mm' are present, and

in 75 percent of cases if more than 100,000 CFU per mm' are present.'

Lastly, the experience of laboratory personnel is very important. Up to 10

percent of initial Gram stains are misread."

Acid-fast staining should be done if tuberculosis is clinically suspected.

Only 37 percent of initial smears will be positive for acid-fast bacilli.

This result can be increased to 87 percent if four smears are done."

Sensitivity also can be increased by examining the CSF sediment."

Other stains should be performed if indicated by the situation.

Cryptococcus may be identified up to 50 percent of the time on an India

ink preparation. A tap-water control should always be done to ensure that

the India ink is not contaminated.

Toxoplasmosis can be diagnosed With Wright or Giemsa stain. A simple

wet preparation of CSF under a cover slip can yield positive results in a

variety of protozoan and helminthic infections.

GLUCOSE.: CSF glucose is normally approximately two-thirds of the

fasting plasma glucose. A glucose level below 40 mg/ dL is significant

and occurs in bacterial and fungal meningitis and in malignancy.

PROTEIN.: Total protein levels in CSF are normally very low, and

albumin makes up approximately twothirds of the total. High levels are

seen in many conditions including bacterial and fungal meningitis,

multiple sclerosis, tumors, subarachnoid hemorrhage, and please refer to

page 18

Glucose Level:

A true normal range cannot be given for CSF glucose. As a general rule,

CSF glucose is about two thirds of the serum glucose measured during

the preceding two to four hours in a normal adult. This ratio decreases

with increasing serum glucose levels. CSF glucose levels generally do not

go above 300 mg

Glucose in the CSF of neonates varies much more than in adults, and the

CSF-to-serum ratio is generally higher than in adults.

CNS infections can cause lowered CSF glucose levels, although glucose

levels are usually normal in viral infections Normal glucose levels do not

rule out infection, because up to 50 percent of patients who have bacterial

meningitis will have normal CSF glucose levels.

Chemical meningitis, inflammatory conditions, subarachnoid

hemorrhage, and hypoglycemia also cause hypoglycorrhachia (low

glucose level in CSF). Elevated levels of glucose in the blood is the only

cause of having an elevated CSF glucose level. There is no pathologic

process that causes CSF glucose levels to be elevated

.

Culture:

Cultures done on 5 percent sheep blood agar and enriched chocolate agar

remain the gold standards for diagnosing bacterial meningitis. Antibiotic

treatment prior to lumbar puncture can decrease the sensitivity of culture,

especially when given intravenously or intramuscularly.

Enterovirus, the leading cause of viral meningitis, can be recovered ill 40

to 80 percent of cases. Culture for herpes simplex virus is 80 to 90

percent sensitive but can take five to seven days to become positive.

Results of viral cultures rarely change the initial management of

meningitis.

Mycobacterium tuberculosis is best grown using multiple large volume

samples of CSF. At least 15 mL and preferably 40 to 50 mL of CSF are

recommended. Culture is positive 56 percent of the time on the first

sample, and improved to 83 percent of the time if four separate samples

are cultured. These cultures often take up to six weeks for positive

identification.

Fungal cultures are positive in more than 95 percent of cryptococcus

neoformans cases and in 66 percent of candidal meningitis cases. Other

fungi are less likely to be culture positive. Similar to tuberculous

meningitis, culture yield in fungal meningitis can be increased by

obtaining large volumes of CSF via repeated lumbar punctures.

Latex Agglutination:

Latex agglutination (LA) allows rapid detection of bacterial antigens in

CSF. Sensitivity varies greatly between bacteria. LA for Haemophilus

illfluenzae has a sensitivity of 60 to 100 percent, but is much lower for

other bacterial. The specificity for LA is very low. However, LA can be

useful in partially treated meningitis cases where cultures may not yield

an organism. Because false positives lead to unnecessary treatment, LA is

not routinely used today. Some experts suggest using LA in cases of

suspected bacterial meningitis if the initial Gram stain and bacterial

culture are negative after 48 hours.

Polymerase Chain Reaction:

Polymerase chain reaction (PCR) has been a great advance in the

diagnosis of meningitis. PCR has high sensitivity and specificity for

many infections of the CNS, is fast, and can be done with small volumes

of CSF. Although testing is expensive, there is a potential for cost savings

by decreasing overall diagnostic testing and intervention.

PCR has been especially useful in the diagnosis of viral meningitis. PCR

of the CSF has a sensitivity of 95 to 100 percent, and a sensitivity of 100

percent for herpes simplex virus type I, Epstein-Barevirus, and

enterovirus. PCR is faster and more sensitive than culture for enterovirus

meningitis. When PCR is positive for enterovirus, it allows earlier

hospital discharge and less intervention.

PCR is the most sensitive means of diagnosing CMV infections of the

CNS, and it has been suggested that PCR should replace brain biopsy as

the gold standard for herpes encephalitis.

PCR has a sensitivity of 54 to 100 percent and a specificity of 94 to 100

percent for tuberculous meningitis, and could replace acid-fast bacillus

smear and culture as the test of choice. PCR is sensitive for acute

neurosyphilis but not for more chronic frms. PCR also is being studied as

a diagnostic tool for bacterial meningitis and other infections of the CNS.

LACTATE:. The CSF lactate is used mainly to help differentiate

bacterial and fungal meningitis, which cause increased lactate, from viral

meningitis, which does not.

LACTATE DEHYDROGENASE:. This enzyme is elevated in bacterial

and fungal meningitis, malignancy, and subarachnoid hemorrhage.

WHITE BLOOD CELL (WBC) COUNT.: The number of white blood

cells in CSF is very low, usually necessitating a manual WBC count. An

increase in WBCs may occur in many conditions including infection

(viral, bacterial, fungal, and parasitic), allergy, leukemia, multiple

sclerosis, hemorrhage, traumatic tap, encephalitis, and Guillain-Barre

syndrome. The WBC differential helps to distinguish many of these

causes. For example, viral infection is usually associated with an increase

in lymphocytes, while bacterial and fungal infections are associated with

an increase in polymorphonuclear leukocytes (neutrophils). The

differential may also reveal eosinophils associated with allergy and

ventricular shunts; macrophages with ingested bacteria (indicating

meningitis), RBCs (indicating hemorrhage), or lipids (indicating possible

cerebral infarction); blasts (immature cells) that indicate leukemia; and

malignant cells characteristic of the tissue of origin. About 50% of

metastatic cancers that infiltrate the central nervous system and about

10% of central nervous system tumors will shed cells into the CSF.

RED BLOOD CELL (RBC) COUNT.: While not normally found in

CSF, RBCs will appear whenever bleeding has occurred. Red cells in

CSF signal subarachnoid hemorrhage, stroke, or traumatic tap. Since

white cells may enter the CSF in response to local infection,

inflammation, or bleeding, the RBC count is used to correct the WBC

count so that it reflects conditions other than hemorrhage or a traumatic

tap. This is accomplished by counting RBCs and WBCs in both blood

and CSF. The ratio of RBCs in CSF to blood is multiplied by the blood

WBC count. This value is subtracted from the CSF WBC count to

eliminate WBCs derived from hemorrhage or traumatic tap.

GRAM STAIN.: The Gram stain is performed on a sediment of the CSF

and is positive in at least 60% of cases of bacterial meningitis. Culture is

performed for both aerobic and anaerobic bacteria. In addition, other

stains (e.g. the acid-fast stain for Mycobacterium tuberculosis, fungal

culture, and rapid identification tests [tests for bacterial and fungal

antigens]) may be performed routinely.

SYPHILIS SEROLOGY.: This involves testing for antibodies that

indicate neurosyphilis. The fluorescent treponemal antibody-absorption

(FTA-ABS) test is often used and is positive in persons with active and

treated syphilis. The test is used in conjunction with the VDRL test for

nontreponemal antibodies, which is positive in most persons with active

syphilis, but negative in treated cases.

Precautions:

In some circumstances, a lumbar puncture to withdraw a small amount of

CSF for analysis may lead to serious complications. Lumbar punctures

should be performed only with extreme caution, and only if the benefits

are thought to outweigh the risks. In people who have bleeding disorders,

lumbar puncture can cause hemorrhage that can compress the spinal cord.

If there is increased spinal column pressure, as may occur with a brain

tumor and other conditions, removal of CSF can cause the brain to

herniate, compressing the brain stem and other vital structures and

leading to irreversible brain damage or death. Bacteria introduced during

the puncture may cause meningitis. For this reason, aseptic technique

must be followed strictly, and a lumbar puncture should never be

performed at the site of a localized skin lesion.

Specimens should be handled with caution to avoid contamination with

skin flora. They should be refrigerated if analysis cannot be performed

immediately.

Description:

Lumbar puncture is performed by inserting the needle between the fourth

and fifth lumbar vertebrae (L4-L5). This location is used because the

spinal cord stops near L2, and a needle introduced below this level will

miss the cord. In rare instances, such as a spinal fluid blockage in the

middle of the back, a physician may perform a spinal tap in the cervical

spine.

Aftercare:

After the procedure, the site of the puncture is covered with a sterile

bandage. The patient should remain lying down for four to six hours after

the lumbar puncture. Vital signs should be monitored every 15 minutes

for four hours, then every 30 minutes for another four hours. The

puncture site should be observed for signs of weeping or swelling for 24

hours. The neurological status of the patient should also be evaluated for

such symptoms as numbness and/ or tingling in the lower extremities.

Aftercare:

After the procedure, the site of the puncture is covered with a sterile

bandage. The patient should remain lying down for four to six hours after

the lumbar puncture. Vital signs should be monitored every 15 minutes

for four hours, then every 30 minutes for another four hours. The

puncture site should be observed for signs of weeping or swelling for 24

hours. The neurological status of the patient should also be evaluated for

such symptoms as numbness and/ or tingling in the lower extremities.

Risks:

The most common side effect after the removal of CSF is a headache.

This occurs in 10-30% of adult patients and in up to 40% of children. It is

caused by a decreased CSF pressure related to a small leak of CSF

through the puncture site. These headaches usually are a dull pain,

although some people report a throbbing sensation. A stiff neck and

nausea may accompany the headache. Lumbar puncture headaches

typically begin within two days after the procedure and persist from a few

days to several weeks or months.

Normal results:

Gross appearance: Normal CSF is clear and colorless.

CSF opening pressure: 50-175 mm H 2 0.

Specific gravity: 1.006-1.009.

Glucose: 40-80 mg/ dL.

Total protein: 15-45 mg/ dL.

LD: 1/10 of serum level.

Lactate: less than 35 mg/ dL.

Leukocytes (white blood cells): 0-

30/microL (newborns).

Differential: 60-

macrophages; other cells 2% or less. Monocytes and macrophages are

somewhat higher in neonates.

Gram stain: negative.

Culture: sterile.

Syphilis serology: negative.

Red blood cell count: Normally, there are no red blood cells in the CSF

unless the needle passes through a blood vessel on route to the CSF.

Lumbar Puncture (LP)brief of the guide line

Indications:*

1. Diagnostic aid (infection, hemorrhage, leptomeningeal carcinomatosis,

multiple sclerosis, Guillain-Barre .syndrome, inflammatory conditions, to test for

therapeutic response in NPH, normal pressure hydrocephalus, before shunting)

2. Therapy for idiopathic intracranial hypertension

3. Infusion of anaesthetic ("spinal"), chemotherapy, or agents (contrast myelography

Contraindications:

- INR > 1.4 or other coagulopathy

- platelets < 50

- infection at desired puncture site

- obstructive / non-communicating hydrocephalus

- intracranial mass

- high intracranial pressure (ICP) / papilledema (relative contraindication

, depends on etiology, especially with intracranial mass lesion secondary

to the increased risk of tran stentorial or cerebellar herniation)

- focal neurological symptoms/signs, decreased level of consciousness

- partial/complete spinal block

- acute spinal trauma

Complications:

Relatively common

1) Post LP headache (rates vary from 1-70%, probably <5% for persistent

troublesome headache, "low pressure headache" i.e. headache increases

when upright and diminishes when supine, occasionally associated with

nausea, vomiting and tinnitus, onset within 1-3 days and usually lasts

<5d)

2) Post LP back pain «1/3 of patients, due to local soft tissue truma

Rare

3) Infection e.g. spinal abcess, meningjtis (estimated at 0.2%)

4) Spinal subdural/epidural hematoma (predominantly in patients with a

coagulopathy)

5) Nerve root or spinal cord injury (transient nerve root irritation much

more common than persistent injury)

6) Epidermoid tumor implantation (very low risk if needle advanced only

with stylet in place)

7) Transtentorial or cerebellar herniation (risk 0-5% in patients known to

have an intracranial mass and high ICP)

8) Complications secondary to low intracranial pressure

a) Hearing loss, CNV1 paresis

b) Intracranial subdural hygroma 1 hematoma

10) Complete spinal block (in patients willl partial spinal block)

11) Pachymeningeal enhancement may be seen on gadolinium-enhanced

MRI of head or spine after a lumbar puncture (may be related to low

pressure) CT scanning of the head before LP in suspected meningitis:

- The most worrisome contraindication to lumbar puncture is the

suspicion of increased ICP due to a cerebral mass lesion. Performing a

lumbar puncture in these patients may lead to either trans-tentorial or

uncal herniation and acute neurological deterioration.

- The absence of allthese features makes a significant lesion precluding

LP very unlikely

1) Age> 60 yrs

2) Immuno-compromised state

3) History of CNS disease (eg. grand mal seizures, brain tumour,

hydrocephalus, multiple sclerosis)

4) Seizure within one week of presentation

5) Abnormal LOC

6) Unable to answer two questions correctly or follow two commands

7) Abnormal neurological examination

. An LP may safely be performed without first doing a CT head in a

young previously healthy patient with no history of seizures, a normal

level of consciousness and a normal neurological exam.

Anatomy - Spinal cord usually terminates at L 1 or L 1/L2 in adults (-

95% of adults)

- Thecal sac terminates at -S2

- Intercristal line is an imaginary line that connects the superior border of

the iliac crests

- L4/5 interspace is the first interspace caudal to the intercristal line

Materials:

- sterile gloves and mask

- LP kit (contains: syringe, 25 and 22G needles, 1 % lidocaine, sterile

drapes, sponges and gauze, 22G LP needle, stopcock and manometer, 4

collection tubes and band-aid)

- sterilization solution (chlorhexidine or proviodine) -,

- extra spinal needle, 20 or 22-gauge

- extra sterile sponges - 2x2s or 4x4s

*** If collecting for cytology, get appropriate container with cytofixative

ready beforehand

Technique:

1. Obtain patient consent. Describe reason for procedure, procedure itself

and potential complications.

2. Position the patient. There are 2 recommended positions:

a. Lateral decubitus - Place patient in lateral decubitus position (right or

left)

- Lumbosacral area should be as close to edge of bed as possible

- Pillow under head and between legs

- Head flexed and legs curled up towards chest ("fetal" position)

- Shoulders and hips must be perpendicular to bed / floor

b. $itting up

- patient sitsup and leans over a table, resting head and arms on a pillow

- the back of the patient's legs should be resting against the edge of the

bed

- torso / spinal column should be perpendicular to the bed / floor

- ask patient to bulge out lumbosacral spine

3. Landmark. Identify intercristal line and the L4/L5 interspace. Mark this

interspace by making an impression on the patient's skin with the tip of a

pen.

4. Carefully open LP kit and put cleaning solution in reservoir.

5. Put on mask and sterile gloves.

6. Sterilize the field using the sterilizing solution and sponges provided.

Clean a 6 inch area around the desired entry site, proceeding outward in

concentric circles. Do this 3 separate times. Place sterile drape over the

field.

7. Ensure all items in LP tray are ready for use. Eg. 1 % or 2% lidocaine

loaded into syringe, collection tubes open, test to see that the stylet slides

in/out of LP needle easily, stopcock and manometer for opening pressure

measurement ready.

8. Local anaesthesia. Using a 25G needle, inject 1 % or 2% lidocaine

under the skin at the desired entry site. A small bleb under the skin is

sufficient. Switch the needle tip to the 22G needle and anaesthetize

deeper structures by inserting the needle further, injecting lidocaine while

proceeding forward.

9. Insert LP needle. The bevel should be parallel to the spinal column.

Always advance the needle with the stylet in place. Aim needle in the

midline, slightly cephalad, towards the patient's umbilicus. Advance

needle slowly until it is inserted 2-3 cm, then withdraw the stylet to check

for CSF return. Continue to advance the needle,

periodically checking for CSF return. Often a "pop" is appreciated as the

needle pierces the dural membrane. If the needle meets bone or if blood

returns (hitting the venous plexus anterior or posterior to the spinal

canal), withdraw the needle to the skin and redirect the needle

10. Once CSF flow is obtained, measure the opening pressure by

attaching first the stopcock to the LP needle and then the manometer to

the stopcock CSF pressure measured in this way is only accurate with

patient in lateral decubitus position and relaxed (Neck not flexed, legs

extended, no valsalva).

11. Collect CSF fluid into sequential tubes ·1-2 ml in each tube is

sufficient for basic investigations. More fluid will need to be collected for

special tests e.g. viral PCR, cytology etc. 12. Reinsert stylt. Withdraw

needle Place'band-aid over insertion site.

Tips:

1. Position, position, position

2. Try one level above or below (adults)

3. Try 20G needle

4. Ask someone else to try

5. If you can't get it .. abort and order LP under fluoroscopy

Post-LP mobilization and dural puncture headache

- A. period of bed rest along willl supplementary fluids has traditionally been

recommended post-LP to decrease the risk of post-dural puncture headache

- There is no good evidence that either of these recommendations alters the risk

of post-dura1 puncture headache

What to order:

The basics

Tube #1 Cell count and differential

Tube #2 Chemistry (protein, glucose)

Tube #3 Culture and Gram stain

Tube #4 Cell count and differential

Other tests to consider:

- Will need to collect extra fluid for these tests in tube #3 or #4.

India ink and I or Cryptococcal Ag (for Cryptococcus neoformans)

AFB and or PCR for TB

Viral PCR (includes HSV, CMV, EBV)

arbovirus WNV, echovirus

VDRL

fungal culture

viral culture

PCR and or antibody titers for Lyme ds.

oligoclonal banding (3-4 ml)

IgG index, IgG :albumin ratio

cytology (must be collected in cytology fixative) (8-10ml)

flow cytometry (3-4 Inl) (NOT in fixative)

How much CSF to withdraw?

- CSF is produced at a rate of 0.3 ml/min in adults or 450 ml/24t1

- CSF volume is approximately 150 ml in an adult

- For basic investigations, only require 4-8 ml

- May require more volume for special tests (see above). Maximum to be

removed at one time should probably not exceed 20 Ill!.

- 20-30 ml can be removed in case of NPH "tap test" to gauge response.

Normal values:

- Opening pressure 5-20 cm water (oilly valid in lateral decubitus

position)

- Appearance: clear, colorless

- Nucleated cells. <5 per µl

- RBC: <5 per µl.

- WBCRBC ratio. 1 :700 (. For every additional 700 RBCs seen due to

presumed traumatic tap, one WBC is expected)

- Glucose: 2/3 serum value - Protein: 200-450 mg/L

CSF Findings:

Traumatic tap (TT) VS. SAH?

Supernatant:Clear in TT In SAH, expect to see xanthochromia (yellowish

discolouration). NOTE: Xanthocromia takes time to develop. Seen in%

70 by 6h , 90% by12h after SAH.

- RBC count: Declines as CSF drains in TT, therefore compare tube #1 to

tube #4. Does not decline in SAH

- WBC.RBC ratio.' Similar to peripheral blood in TT (. 1 :700). SAH

usually promotes a leukocytosis.

Cloting of fluid May clot in TT if RBC count high. Usually does not clot

in SAH, since there are no clotting factors in CSF.

- Protein.' In TT, increase of approx. 1 mg per 100 RBC. Levels are

greater than this in SAH.

- Opening pressure Usually normal in TT and usually elevated in SAH

- Repeat LP' Usually clear in TT and still bloody xanthochromic in SAH

(CSF taken at a different spinal level)

DDx of CSF hypoglycacrnia

Infectious - Bacterial meningitis TB, Fungal, Cysticercosis, Amoebic,

Syphilis, Trichinosis, Mumps (25%), HSV, VZV

Inflammatory

Sarcoidosis

neoplastic LM carcinomatos and

VASCULAR-SAH(4-8days post bleed and metabolic du to

hypoglycemia

Refrence 1-laviR,yarnitskyD,ROWEJM,weissmanA,segal D.standard vsatramatic Whitacre needle for diagnostic lumbar puncture :arandomized trial .neurology .Oct24 2006:67(8):1492-4 2joffeAR. Lumbar puncture and brain herniation in acute bacterial minangitis:areview.j intencsive care med.jul-aug2007:22(4):194-207 2-roosKL(march 2003)lumbar puncture,semin neural23(1):105-14. 3- how do I perform alumbar puncture and analysis the result to diagnose bacterial meningitis JAMA296(16):2012-22 (OCTOBER2006) 4-leeLC,sennetM erikson JM.prevention and management of post lumber puncture head ache in pediatric oncology pation .jpediate oncol nurs .jul-aug 2007:24(4):200 5- ahmedSV, jayawarena c,judeE.post lumber puncture head ache:diagnos and management .post grade medj.NOV 2006:82(973):713-6 6-springgs DA.BURNDJ.frenchJ, etal .is bed rest useful after diacnostic lumbar puncture post grade med j .jul1992:68(801):581-3 7-aronsonPL ,zonfrilloMR .epidural cerebrospinal fluid collection after lumbar puncture pediater emerging care.jul2009:25 (7):467

-schmidex&sweet operation neurosurgical techniques indication methods and result copyright 2000 by w.b. sanders company page 1103 -2269

-merritt,s neurology twwefth edition page 310-317 10-principal neurology adam,s and victor,s 8 th 2005page 11-12 147-54211- cerospinal fluid j neuro neurosurgerypsychiatry 59-349 .1995

LUMBAR PUNCTURE

By : Dr . M . Besharat

SBMU

IDTMRC Loghman Hospital

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