Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Sampling

16

Lumbar Puncture

  1. Lee Woods
  2. Indications (1,2)
  3. To diagnose central nervous system (CNS) infections (meningitis, encephalitis), including congenital infections (TORCH—toxoplasmosis, other infections [usually implying syphilis], rubella, cytomegalovirus, and herpes simplex—infections) as well as bacterial and fungal infections

Routine inclusion of lumbar puncture (LP) in the initial sepsis evaluation of newborn infants (in the first 7 days of life) is controversial (3,4,5,67 and 8). Meningitis occurs less frequently in this population than in older newborns, and the majority of cases of meningitis occur in infants with positive blood cultures. The procedure may be poorly tolerated by newborns with cardiorespiratory compromise (910,11). An LP is indicated if early bacteremia is documented or if signs of CNS involvement are present (seizures, coma, focal neurologic abnormality). An LP is also indicated in the evaluation for acquired infection in the later neonatal period, when the incidence of meningitis is significant. In a recent review (8), as many as one third of very low-birthweight infants who had late-onset meningitis (after 3 days of life) did so in the absence of positive blood culture.

  1. To monitor efficacy of antimicrobial therapy in the presence of CNS infection by examining cerebrospinal fluid (CSF) cell count, microbiology, and drug levels (12)
  2. To drain CSF in communicating hydrocephalus associated with intraventricular hemorrhage (1,2,13)

For effective treatment of posthemorrhagic hydrocephalus by this means, there must be communication between the lateral ventricles and the lumbar subarachnoid space, and an adequate volume of CSF (10 to 15 mL/kg) must be obtained. Communication is demonstrated by an immediate decrease in ventricular size or change in anterior fontanelle or head circumference following LP. Efficacy and safety of serial LPs in the temporary amelioration or long-term improvement of posthemorrhagic hydrocephalus are controversial (14,15,16,17 and 18). Potential risks of repeated LPs must be weighed against possible benefits.

  1. To aid in the diagnosis of metabolic disease (1,2,19)
  2. To diagnose intracranial hemorrhage

The finding of increased red blood cells and protein content in the CSF or xanthochromia of centrifuged fluid suggests intracranial hemorrhage. The definitive diagnosis and determination of the site of hemorrhage (subdural, subarachnoid, intraparenchymal, intraventricular) are best made by neuroimaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI).

  1. To diagnose CNS involvement with leukemia
  2. To inject chemotherapeutic agents
  3. To instill contrast material for myelography
  4. Contraindications (1,2,20,21)
  5. Increased intracranial pressure (ICP)

Increased ICP may occur with bacterial meningitis or intracranial mass lesions. In the neonate with open cranial sutures, this rarely results in signs of transtentorial or cerebellar herniation. However, herniation can occur after LP in the presence of elevated ICP, even when the sutures are open. If signs of significant increased ICP exist (rapidly declining or severely depressed level of consciousness, abnormal posturing, cranial nerve palsies, tense anterior fontanelle, abnormalities in heart rate, respirations, or blood pressure without other cause), CT or MRI should be performed before LP. Papilledema is a late sign and is rarely present in the neonate, regardless of the degree of increased ICP.

  1. Uncorrected thrombocytopenia or bleeding diathesis
  2. Infection in the skin or underlying tissue at or near the puncture site
  3. Lumbosacral anomalies
  4. Cardiorespiratory instability, which may be exacerbated by the procedure
  5. Equipment

All equipment must be sterile, except facemask. Prepackaged lumbar puncture kits are available.

  1. Gloves and mask
  2. Cup with iodophor antiseptic solution
  3. Gauze swabs

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  1. Towels or transparent aperture drape
  2. Spinal needle with short bevel and stylet, 20 or 22 gauge x 1½ in
  3. Three or more specimen tubes with caps
  4. Adhesive bandage
  5. Precautions
  6. Monitor vital signs and oxygen saturation. Preoxygenation and increased supplemental oxygen during the procedure can prevent hypoxemia (22). Airway compromise can be reduced by avoiding the fully flexed lateral decubitus position and direct flexion of the neck (9,10 and 11). Flexing the hips to only 90 degrees avoids abdominal compression and the potential for aspiration.
  7. Use strict aseptic technique as for a major procedure (see Chapter 4).
  8. Always use a needle with stylet to avoid development of intraspinal epidermoid tumor (23).

Incidence of traumatic LP is not reduced by use of a needle without stylet (24).

  1. To prevent traumatic tap caused by overpenetration, insert the needle slowly while removing the stylet at frequent intervals to detect CSF as soon as the subdural space is entered.
  2. Never aspirate CSF with a syringe. Even a small amount of negative pressure can increase the risk of subdural hemorrhage or herniation.
  3. Palpate landmarks accurately to prevent puncture above the L2–L3 interspace (lower interspace should be used for preterm infants; see discussion under E.2).
 

FIG. 16.1. Restraining infant for lumbar puncture in the lateral recumbent position. Neck should not be flexed.

  1. Technique (20,21,25,26 and 27)
  2. Have an assistant restrain the infant in the lateral decubitus or sitting position, with spine flexed (Figs. 16.1 and 16.2). Avoid flexion of the neck, as this increases the chance of airway compromise.
  3. Palpate the interspace that falls immediately above or below an imaginary line drawn between the iliac crests (L3–L4 and L4–L5 interspaces, preferred sites for LP) (Fig. 16.3).

The termination of the spinal cord relative to the spine changes during fetal development and early infancy (28,29). The normal adult termination, between the middle of T12 and the lower portion of L3 vertebrae (28,30), is not achieved until 2 months postterm (28). Between 25 and 40 weeks' gestation, the cord termination gradually ascends from L4 to L2 (28). This should be taken into account and the lower L4–L5 interspace used for lumbar puncture in significantly preterm infants to avoid possible cord penetration (29).

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  1. Prepare as for major procedure (see Chapter 4). Wash hands thoroughly. Put on mask and sterile gloves.
  2. Clean the lumbar area three times with antiseptic.
  3. Begin at the desired interspace and wash in enlarging circles to include the iliac crests.
  4. Allow antiseptic to dry or blot excess with sterile gauze.
  5. Drape, leaving the puncture site and infant's face exposed. A transparent aperture drape is recommended because it does not obstruct the view of the patient.

Local anesthesia is generally not used for LP in neonates. Use of local anesthetic cream prior to cleaning the area may be helpful in reducing pain during LP (31,32 and 33). Use of lidocaine injection does not reduce physiologic instability but may reduce struggling by the infant during the procedure (34,35).

  1. Insert the needle in the midline into the desired interspace.
  2. Aim slightly cephalad (on a plane with the umbilicus) to avoid the vertebral bodies (Fig. 16.4).
  3. If resistance is met, withdraw the needle slightly and redirect more cephalad.
  4. Hold a finger on the vertebral process above the interspace to aid in locating the puncture site if the infant moves.
 

FIG. 16.2. Restraining infant for lumbar puncture in the sitting position.

 

FIG. 16.3. A: Externally palpable anatomic landmarks. B: Vertebral bodies removed to show anatomy of spinal cord in lumbosacral area in relation to external landmarks.

  1. Advance the needle slowly to a depth of approximately 1 to 1.5 cm in a term infant, less in a preterm infant, until the epidermis and dermis are traversed.
  2. As the needle is further advanced, remove the stylet frequently to check for fluid. Replace the stylet before advancing the needle.
  3. A change in resistance can often be felt as the needle passes through the ligamentum flavum and

P.102


dura (Fig. 16.5). This may be more difficult to appreciate in a young infant than in an older child.

  1. Wait for fluid after removing the stylet, as the flow may be slow.
  2. If no fluid is obtained, rotate the needle to reorient the bevel. If no fluid is obtained, replace the stylet, remove the needle, and try one interspace above or below, using a new needle for each attempt.
  3. Collect CSF for diagnostic studies. Allow CSF to flow passively into the collection tubes; never aspirate with a syringe. Accurate opening pressure measurement is possible in a quiet infant.
  4. Collect 1 mL of CSF in each of three to four tubes.
  5. Send first sample for bacterial culture.
  6. Send last sample for cell count, unless fluid becomes visibly more bloody during the tap.
  7. Send the remainder for desired chemical and microbiologic studies.
  8. Look for clearing of fluid in successive collections in the event of a traumatic tap.
  9. For myelography or instillation of chemotherapeutic agents, it is not necessary to remove CSF.
  10. For treatment of hydrocephalus, remove 10 to 15 mL/kg of CSF, or collect until CSF flow ceases (up to 10 minutes).
  11. Replace the stylet before removing the needle to prevent entrapment of spinal nerve roots in the extradural space. Remove the needle, and place an adhesive bandage over the puncture site.
 

FIG. 16.4. Inserting spinal needle in slightly cephalad direction to avoid vertebral bodies.

 

FIG. 16.5. Needle has penetrated the dura, and stylet has been removed to allow free flow of spinal fluid.

  1. Complications (1,2,36)

In older children and adults, headache is the most common complication following LP, occurring in up to 40% of patients (36). There is no clear evidence that headache occurs in infants. In neonates, the most common complication is transient hypoxemia from positioning for the procedure (9,10 and 11). In some reports, this is seen in a majority of cases and depends on the method of positioning used. Also common, occurring in up to 36% of LPs in neonates (27), is contamination of the CSF sample with blood from puncture of the epidural venous plexus on the posterior surface of the vertebral body (traumatic tap). All other potential complications listed below are rare, occurring in about 0.3% of LPs (36).

  1. Hypoxemia from knee–chest position (9,10 and 11)
  2. Contamination of CSF sample with blood (traumatic tap) (27)
  3. Aspiration
  4. Cardiopulmonary arrest
  5. Sudden intracranial decompression with cerebral herniation (37,38)
  6. Infection
  7. Meningitis from LP performed during bacteremia (incidence about 0.2%) (39,40 and 41)
  8. Discitis (42)
  9. Spinal cord abscess (43)
  10. Epidural abscess (43,44)
  11. Vertebral osteomyelitis (44)
  12. Bleeding
  13. Spinal epidural hematoma (45)
  14. Spinal or intracranial subdural hematoma (46,47 and 48)
  15. Spinal or intracranial subarachnoid hematoma (48,49)
  16. Rupture of intracranial aneurysm (48)

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  1. Intraspinal epidermoid tumor from epithelial tissue introduced into the spinal canal (23)
  2. Spinal cord puncture and nerve damage if puncture site is above the level of cord termination (see discussion in E.2 concerning cord termination in preterm infants) (29)
  3. Sixth-nerve palsy caused by removal of excessive CSF with resulting traction on the nerve (50)
  4. Deformity of the lumbar spine secondary to acute spondylitis (51)

References

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  5. Bergman I, Wald ER, Meyer JD, et al. Epidural abscess and vertebral osteomyelitis following serial lumbar punctures. Pediatrics.1983;72:476.
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