 Performed to obtain information about the

cerebrospinal fluid (CSF)

 Diagnostic and therapeutic purposes

 Should be performed only AFTER a neurologic

examination but should never delay potential life
saving interventions (e.g antibiotics, steroids)
A. Obtaining cerebrospinal fluid (CSF) for the diagnosis
of central nervous system (CNS) disorders:
 Meningitis
 Encephalitis
 Idiopathic intracranial hypertension
 Other neurologic syndromes
B. Aid in the diagnosis of intracranial hemorrhage.
C. Diagnose an inborn error of metabolism.
D. Draining CSF in communicating hydrocephalus
associated with intraventricular hemorrhage.
E. Administration of intrathecal medications.
F. Monitoring efficacy of antibiotics used to treat CNS
infections by examining CSF fluid.
G. Diagnose CNS involvement with leukemia.
H. For the initial sepsis workup (controversial).
 Increased intracranial pressure
 risk of CNS herniation
 obtain a computed tomography (CT) or magnetic resonance
imaging (MRI) of the head
 Uncorrected bleeding abnormality
 Severe bleeding diathesis
 Infection near puncture site
 Severe cardiorespiratory instability
 Lumbosacral abnormalities
 Suspected mass lesion of brain
 Suspected mass lesion of spinal cord
 Symptoms and signs of impending herniation
in a child with probable meningitis
▪ Alterations of respiratory pattern
▪ Abnormalities of pupil size and reactivity
▪ Loss of brainstem reflexes
▪ Decorticate and decerebrate posturing
 Most CSF trays come with:
 Three/Four sterile specimen tubes
 Sterile drapes, gauze, and bandages
 Anesthetic such as:
▪ Topical - EMLA, Elamax, Zylocaine cream
▪ Lidocaine 1% with 25 gauge needle and
syringe
 Povidone-iodine solution & sponge
wand
 Manometer, stopcock and tubing in
non-infant kits
 Spinal needle, usually
25- to 27-gauge needle
 1.5 in for < 1 yr
 2.5 in for 1 year to
middle childhood
 3.5 in for older children
and adolescents
 Larger for large
adolescents
 Atraumatic needles,
less spinal headaches
Pain management
 Topical anesthetics
 EMLA or other topical agents - applied 30 minutes before the
procedure
 Lidocaine
 0.5–1% in a 1-mL syringe with a 25- or 27-gauge needle can
be injected subcutaneously
 Systemic therapy
 sedation with a slow IV opiate bolus if the infant is intubated
 if not intubated, a bolus of midazolam in a term infant can be
used
Position
Lateral Decubitus Position

 Maximally flex spine without

compromising airway
 Keep alignment of feet, knees
and hips
 Position head to left if right
handed or vice versa
Position
Sitting Position
 Restrain infant in the seated
position with maximal spinal
flexion
 Hold infant’s hands between
flexed legs with one hand and
flex head with the other hand
 Once the infant is in
position, check for
landmarks.
 Palpate the iliac crest and
slide your finger down to
the L4 vertebral body.
 use the L4-L5
interspace
 Make a nail imprint at the
exact location to mark the
site.
 Prepare the materials.
 Put gloves on and clean the lumbar area with
antiseptic solution, starting at the interspace
selected.
 Drape the area with one towel under the infant
and one towel covering everything but the
selected interspace.
 Insert the needle in the midline with steady pressure aimed
toward the umbilicus.
 Guidelines for spinal needle depth.
▪ 1–1.5 cm in term infant, <1 cm in a preterm,
 Advance the needle slowly and then remove the stylet to check for
appearance of fluid

 Remove the stylet frequently to keep from going too far and getting a bloody
specimen.
 Early stylet removal improves the success rate.
  A “pop” of sudden decrease in
resistance indicates that
ligamentum flavum and dura are
punctured

 Remove stylet and check for flow of spinal

fluid
 If no fluid, then:
 Rotate needle 90°
 Reinsert stylet and advance needle
slowly checking frequently for CSF
 When CSF flows, attach manometer to obtain opening
pressure if desired
 Pressure can only be accurately measured in lateral
decubitus position and in the relaxed patient
 Attach manometer with a 3-way stopcock when free flow of
CSF is obtained
 Read column when highest level is achieved and
respiratory variation is noted
 Collect 0.5–1 mL of CSF in each of the 4 sterile
specimen tubes
 Tube 1. Gram stain, bacterial culture, and sensitivity testing.
 Tube 2. Glucose and protein levels. Others if metabolic
disease suspected.
 Tube 3. Cell count and differential.
 Tube 4. Optional and can be sent for rapid antigen tests for
specific pathogens (eg, group B Streptococcus) or PCR
(polymerase chain reaction; eg, herpes).

 CSF white blood cell (WBC) and glucose values

can decrease over time (>2 hours)
 For the treatment of communicating
hydrocephalus with intraventricular
hemorrhage.
 Remove 10–15 mL/kg of CSF
 Replace the stylet before removing the needle to
prevent trapping the spinal nerve roots.
 Withdraw the needle. Maintain temporary
pressure and clean and bandage on the site.
 A repeat tap in 24 to 48 hours is recommended.
If a bloody specimen is obtained in the first tube:

1. Observe for clearing in the second and third tubes.

 RB count: If the last tube has fewer RBCs than the first  traumatic

2. If blood does not clear but forms clots.

 blood vessel has probably been punctured

3. If blood does not clear and does not clot and there are equal
numbers of RBCs in the first and last tubes
 infant probably has intracranial bleeding.
A. Contamination of CSF specimen with blood.
B. Infection
 Bacteremia
 Meningitis
 Abscess (spinal and epidural)
 Vertebral osteomyelitis
C. Intraspinal epidermoid tumor
D. Herniation of cerebral tissue through the foramen
magnum.
E. Spinal cord and nerve damage
F. Intramedullary hemorrhage resulting in paraplegia.
G. Bleeding/hematoma.
 Spinal epidural hematoma, intracranial or spinal subdural hematoma,
and intracranial or spinal subarachnoid
H. Cerebrospinal fluid leakage.
I. Apnea and bradycardia.
J. Hypoxia
K. Cardiopulmonary arrest