Lumbar Puncture
Anatomy
“Some Spanish Students Ingest Lime-Flavored Drinks And Sip”
S: Skin
S: Subcutaneous tissue (superficial&deep fascia)
S: Supraspinous ligament
I: Interspinous ligament
L: Ligamentum flavum
F: (Epi)Fural space → remember this is the epidural space
D: Dura mater
A: Arachnoid mater
S: Subarachnoid space
Landmarks
-“Pop” = ligamentum flavum
-CSF after dura + arachnoid
Before LP
- Do neuroimaging (CT/MRI) before LP
>Neuroimaging/LP should not delay therapy
Needle types
-Atraumatic (pencil-point): Whitacre, Autocan, Eldor, Greene→ Lower PDPH
-Cutting needle: Quincke→ Higher PDPH risk
-Epidural needles: Tuohy, Crawford→ Do NOT enter subarachnoid space intentionally
Contraindications
Absolute
-⬆️ICP 2/2 mass
-VZV at lumbar site
-Coagulopathy (Plat < 50K, INR > 1.5, PTT > 45s)
-Suspect epidural abscess
Relative
-IC mass without inc ICP
-Coagulopathy that can be reversed (give Plat)
Regarding anti-thrombotics/ thromboprophylaxis
-Non-urgent vs urgent LPs
Interesting
- Clopidogrel→ no correlation P2Y12 & LP safety, still time should be used