GuidelinesPEML (Paeds Hospital STG)
Lumbar Puncture
Lumbar Puncture
Contraindictions to lumbar puncture
CONTRAINDICATIONS TO LUMBAR PUNCTURE
- Focal neurological signs and depressed level of consciousness.
- Clinical signs of raised intracranial pressure, or impending cerebral herniation:
- deep coma, i.e. GCS < 9, or sudden deterioration of level of consciousness,
- decerebrate or decorticate posturing,
- neurogenic hyperventilation,
- unequal dilated or poorly reactive pupils,
- absent doll’s eye reflex,
- papilloedema.
- Haemodynamic/respiratory unstable patients.
- Clinical meningococcaemia (septicaemia) with petechiae/purpura. (Confirm with skin scrape, Gram stain and blood culture).
- Skin sepsis or abnormalities over the lumbar puncture site.
- Coagulopathy.
- Spinal anatomic abnormality.
- Acute paraplegia.
- Status epilepticus.
PROCEDURE
- Positioning and restraint are vital in determining the success of the procedure.
- The ability of the assistant in restraining is as important as the skill of the ‘operator’.
- Preparation entails not only positioning, but attention to sedation/analgesia, ‘patient comfort’ and safety, as well as factors such as adequate lighting.
- Resuscitation equipment must be available at bed side.
- Pay attention to the sterility of the operating field.
- Local analgesia with/without sedation may be required. See: Pain Control, Management of pain.
- Ensure that all necessary equipment, e.g. needles, manometers and specimen tubes are close at hand.
- Only the interspaces below L3 (L3/L4 or L4/L5) are used in order to avoid damaging the conus medullaris.
- With the patient in the lateral recumbent position, the L3/L4 interspace is found at the level of the line joining the highest points of the two iliac crests.
- Turn the bevel of the needle (with stylet) to face the patient’s side to avoid cutting the longitudinal dural fibres.
- As the needle is advanced, the first ‘give’ or loss of resistance is encountered with the piercing of the ligamentum flavum. A slight ‘popping’ sensation is felt as the needle penetrates the dura. Remove the stylet to allow CSF to drain out passively. If no fluid appears, then rotate the needle a quarter turn (90°). If this does not help, replace the stylet and advance the needle a few millimetres and then check for fluid as before.
- Measure the opening pressure using a manometer, with the child relaxed in the lateral decubitus position. In a young relaxed child, the opening pressure is in the range of 6–18 cm H2O.
- At the end of the procedure, re-insert the stylet before removing the needle completely.
Note:
If intracranial infection is suspected, do a blood culture and initiate antimicrobial treatment immediately.
See: Infective/Infectious Diseases, Meningitis, acute bacterial.
Remember to catch a few drops of CSF on a labstick to check the glucose and for the presence of white cells which may give an indication of an infection.
Click here to access NEMLC Report.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Paediatric Hospital Level_Updated May 2025
Chapter 13: The Nervous System_13.11 Lumbar Puncture