tips for lumbar puncture-how to hold the needle

  1. Hello, I was wondering if any of you could share what is the best way to hold a spinal needle when doing an LP on a patient who is sitting upright? I have just started doing LPs with intrathecal chemotherapy administration and have read differing opinions: hold it by the hub only...to hold it along the needle length with both hands to steady the needle...and seen it done both ways.

    What are your thoughts/tips?
    Do you give local anesthesia? If so, how much and how?
    Oh, and what location do you prefer to do the LP and why?

    Thanks so much.
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  2. 22 Comments

  3. by   TexasCRNA
    I hold the introducer needle with my left hand to stablize and advance the spinal needle with my right (at the hub)till I feel the pop and rotate a little then back and pull out the inner needle stylet. It is not as easy as it sounds however I feel epidural placement is a little more technical.

    As far as the different meds given, it depends on the procedure to be done and length of case. You can also place a cath in the space and give a intermittent boluses with out having to give repeated spinals. However these can only be left in place for a limited amount of time. Be aware that there are risk involved with doing this and make sure you know the pts hx. coag profile and exc... You also need to know what meds you injecting and what they do to the body. As a nurse you would never give a med that you did not know so know you're meds, pharmokinetics, pharmodynamics, duration, half-life and what to do if you get into a bind.

    I am also surprised that as a nurse that you are doing this type of procedures on patients. This is something that should be reserved for advanced practitioners and those trained specifically in regional skills. It is not something to take lightly for with it comes great responsibility. It may really fall outside your scope of practice so make sure that you are covered and recieve the proper training and education. If you are an advanced practice nurse then good luck to you and I would suggest finding a CRNA to follow to get some help on technique. A pain clinic would be a great place to go to get more exposure.

    I have about 75 spinals under my belt and still do not feel proficient because every patient presents a unique challenge. I will say that about 70% of success depends on positioning of the patient and a good back.



    Lee
    Last edit by TexasCRNA on Nov 13, '02
  4. by   Roland
    first son was born she received a "bad" epidural. According to her description the resident went to far (beyond the epidural space) into and through the dural matter, arachnoid, pia mater, funiculus, gray matter and finally central canal. She says that she went into respiratory arrest and had to be revived (somehow the baby was unharmed). The resident blaimed the incident on her "weird" anatomy. How common is something like this and how do you minimize its occurance? I would think that a Lumbar puncture would be just as tricky or even more so (doesn't it proceed deeper within the spinal cord layers than an Epidural injection?)
  5. by   globalRN
    Thank you for your helpful advice Gowkout.
    I am a hematology/oncology NP and am doing these LPs under medical supervision. We give CNS prophylaxis to ALL patients
    and this often involves giving methotrexate or cytarabine intrathecally. Once I am in and the CSF is collected for specimens,
    I inject the drug IT. I know there is a lot of expertise on this board and that the CRNAs here are very generous in sharing their knowledge... There seem to be a variety of approaches to LPs....some give local anaesthesia....experts may choose not to etc. I have seen L3-L4, L4-L5 recommended or even L5-S1.
    Others will say not to go down as far d/t possibility of stenosis in older patients. Another recommendation is to look at spinal xrays if available to avoid difficult sites right from the word go...
    Thank you for all replies and contributions.
  6. by   kmchugh
    Tip for holding the needle in a lumbar puncture: Pointy end towards the patient.

    Kevin McHugh, CRNA
  7. by   Tenesma
    roland,

    some edumacation:
    1) lumbar puncture goes within the intra=thecal space to collect CSF... It is done at the lumbar level mainly to avoid hitting the spinal cord (the cord itself usually terminates at L1 to L3 depending on patient size/age/anatomy), the only nervous structure left within the dural sac are the nerve cords running down, and these often roll away from the needle.

    2) spinal: same idea as a lumbar puncture, except instead of collecting fluid - you are administering fluid into the CSF - and the site of entry can be anywhere along the spinal cord (cervical to sacral - except most people don't do cervical anymore )

    3) epidural: the needle never enters the dural sac (or at least it isn't supposed to), it is done with a loss of resistance technique (read about that) and the catheter is threaded into the epidural space. as far as the purported story you gave of the epidural needle, it doesn't make much sense... if the cord had been hit by the needle the patient would have experienced other neurologic events (paresthesias, pain, etc). The most likely reason the patient went into respiratory arrest is more likely due to the level of anesthesia/analgesia obtained via the catheter. For example, if an epidural drug is hypobaric/overdosed and ascends along the cord to cervical then patients can stop breathing... very different from "entering the central canal"... trust me, if the central canal were entered then true neurologic damage would have occured at least causing horrible extremity pains, hyperreflexia and most likely ending in catastrophic para/quadriplegia (depending on height of lesion)...

    lumbar puncture is way easier than non-lumbar spinals (ie: thoracic/sacral) and is way easier than epidurals...

    for GLOBALRN, the argument that some use for not using local anesthesia is that the needle used for most spinals is small to begin with (22 to 27 gauge) - but there are numerous layers to penetrate, and it isn't uncommon to strike bone while searching for the dural sac.... this is painful, and i think as a "patient advocate" patients prefer local anesthesia. you can use pretty much anything (mainly as long as it is preservative free in case of accidental intra-thecal injection) - i like 1% lidocaine (also known as xylocaine), and i often use my topical anesthetic needle as the finder-syringe: meaning i create a wheal at the skin surface then enter in the intended direction and attempt to anesthetize the planned tract of the LP/spinal/epidural.

    tenesmus
  8. by   smiling_ru
    There is also some debate as to wether or not to infiltrate local anesthetic beyond the skin wheal, as there are not supposed to be any pain fibers beyond it.
  9. by   Brenna's Dad
    "...except most people don't do cervical anymore."

    LOL.
  10. by   canoehead
    So to increase the level of anesthesia (L1 to T12 )you infuse a greater concentration of the drug. To increase the numbness in the legs/abd you infuse a larger volume?
  11. by   Tenesma
    smiling_ru.... it would be false to assume there aren't any pain fibers beyond the skin layer (except within the calvarium). When doing a spinal/epidural the needle can hit/traverse the following (not always on purpose): back muscles, ligaments and bone and thus create a pain response - however fatty layers and the dural sac do not have a pain response per se...

    i am glad people enjoyed my cervical comment... however, in the past people did do cisternal taps before and that is with a needle through the cervical spine up into the skull (yikes!)

    canoehead... there is a big difference between a greater concentration and a larger volume!!! a greater concentration will tend to be more hyperbaric and therfore settle with gravity along the curvature of the spine/and depending on patient positioning (ie: you want to mainly numb the left leg you can do a hyperbaric concentration with the patient in left lateral decub).... you can use hyperbaric/hypobaric solutions depending on where you want the maximum drug effect based on where the solution is originally introduced... as far as increasing the numbness, that is a difficult question! once something is numb, how can you make it more numb??? but larger volumes do tend last a big longer (if that answers your question) - but also remember that everything you give eventually enters systemically so you don't want to overdose either
  12. by   globalRN
    Thank you
    Last edit by globalRN on Nov 15, '02
  13. by   globalRN
    Thank you for your advice Tenesma.
    I agree with you that most patients would definitely want local anesthesia, myself included.

    I put my hands on the top of the patient's iliac crests with my thumbs meeting at the back. I choose the space caudal to where the thumbs meet for my LP site.
    I mark the site with my nail to create a small impression first then disinfect the skin.
    I use a 25gauge needle to create a small skin wheal with the 1% local. Then I use a 22g - 1.5 inch to site the correct placement and inject about 2 ccs of local as I withdraw. If all goes well, I use the same site to place the spinal needle.
    I posed the question because there are often many ways to skin a cat and I just wanted to 'ask the experts'.

    I read an online statement from one university professor who felt that LPs are so easy that medical students need not see one to attempt their first LP. Any thoughts on this?



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    11-15-2002 09:35 PM
  14. by   Tenesma
    Lumbar punctures are really not that easy... And I think it would be wrong for anybody to shove a needle into somebody's spine without at least having seen 1 or 2, then assisted in 1 or 2 and then doing their own under supervision for the next 20 to30 (i think that is the number of LPs to perform in order to reach 95% of learning curve)... In theory it is straightforward - but then again so is a nephrectomy

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