Lumbar Puncture Pearls On obese patients, it can be easier to obtain a lumbar puncture with the patient in the sitted position. If you require an opening pressure (eg, pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent position
If the CSF flow is too slow, ask the patient to cough or bear down as in the Valsalva maneuver, or intermittently press on the patient s abdomen to increase the flow. The needle can also be rotated 90 degrees such that the bevel faces cephalad.
In children, a recent study has shown that performing an LP can be more successful by using adequate analgesia and advancing the needle through the dura without the stylet.
In adults with suspected meningitis, a CT scan of the head does NOT need to be done prior to the lumbar puncture unless the patient has one of the following
- Immunocompromised state: HIV infection or AIDS, receiving immunosuppressive therapy, or after transplantation
- History of CNS disease: Mass lesion, stroke, or focal infection
- New onset seizure: Within 1 week of presentation;
- Papilledema: Presence of venous pulsations suggests absence of increased intracranial pressure
- Abnormal level of consciousness...
- Focal neurologic deficit
Nigrovic LE et al. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007 Jun; 49:762-71.
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267 84.