2/20/2023 0 Comments Lumbar puncture position![]() As a drop of CSF is hanging from the needle, touch the drop with the inner surface of the collection tube.Asking the patient to gently straighten their legs.Once CSF is encountered, you may be able to increase flow by:.Up to 40 ml of CSF can safely be removed at a time, but large volumes will likely cause a temporary headache.About 2 cc/tube is needed for basic LP labs (glucose, protein, cell count + diff, bacterial Cx, and HSV PCR).Sitting with the feet supported on a chair and the patient maximally curled forward leaning on pillows in their lap.This position maximally increases the space between spinous processes.This position may increase the success of the LP.Get the knees as close to the chest as possible Maximal flexion of the neck, back, and knees maximally widens the space between the spinous processes.Placing a pillow under the head and between the knees is helpful Make sure the spine is perpendicular to the hips and shoulders (see image below).Have the patient move as close to you at the edge of the bed as safely possible.Lateral DecubitusThis is the preferred position to measure opening pressure, and if the patient cannot sit upright due to weakness, altered mental status, etc.Adjust the height of the bed so your elbows are bent at 90 degrees while performing the procedure.If blood ever comes out of the hub of needle, or if no CSF is found after several needle passes, remove the needle and flush it with saline.Often after encountering bone several times, a small amount of bleeding occurs which can clot and clog the needle.Consider moving up or down to another interspinous space.Re-palpate and re-ultrasound the landmarks.If no CSF is encountered after 3- needle passess.Trying angling the needle the opposite direction. On your new needle pass, if you encounter bone at a shallower depth you have angled the wrong direction.You may be able to “walk down” the spinous process into the CSF Pull back into the subcu, then take a slightly steeper angle in the same direction. If you encounter bone, but your needle traveled deeper than before, you are headed in the right direction.When re-advancing the needle take note how deep the needle travels.It is impossible to re-adjust the angle when the needle is anchored in the dense spinous ligaments.Once you determine which direction to wish to re-angle your needle, slowly withdraw the needle tip into the subcutaneous tissue, then adjust your angle.Palpate or use ultrasound to see if the needle is too close to one of the spinous processes.US can help confirm that you are in the midline. Check if the needle is angled too far to the right or left.When bone is encounter, leave the needle in place, and carefully assess the alignment of the needle.It’s common to encounter bone while looking for a path to the CSF.Lumbar Puncture Tips and Tricks If Bone is Encountered
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