tips for lumbar puncture-how to hold the needle

Specialties CRNA

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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.

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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Originally posted 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 :)

Thanks again, that gives me a number to work with...20-30 LPs before I am on my own. I suspect that I may be on my own before I get to the 95th percentile..

Do medical residents and students get supervised until their LP skills approach that level of confidence?

Or is it the anesthetist students we are referring to?

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as a medical student i did about 12 or so, then as a medical intern i did another 40 or so ... i am talking purely about CSF collection via Lumbar puncture. that was even before i started anesthesia residency (now i stopped counting how many times i have shoved sharp pointy objects into peoples backs)...

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Specializes in Nurse Anesthetist.

I have had all the lectures on spinals and epidurals and in 2 weeks I start clinicals. It was great to read Tenesma's descriptions and it also gave me an idea of how much supervision to expect from my preceptors. Above all, I want to do no harm, while at the same time learn A LOT!

I realize there may be some CRNAs and MDAs that don't like to precept, but I am praying for some that are willing to teach and to be patient. I am a very compenent and skilled PICU nurse, but we are in a whole different realm.

I like reading about procedures with this much detail. It assures me that I was taught correct procedures. Ten.. your description was exactly like I was taught, including the lidocaine in deeper and infuse as withdrawing. Thanks!

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Originally posted by Tenesma

[...

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. [/b]

Is this "loss of resistance" the famous "pop" much like when puncturing a vein?

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I could be wrong but I thought the loss of resistance was referring to the pressure lost on the syringe as your needle enters the epidural space which is a potential space.

As the needle enters this potential space the fluid from the syringe can "puddle" in the epidural space. I wonder if it feels the same as trying to flush a clotted off heploc as compared to flushing a good IV.

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All these "pops" are MUCH more subtle than the books lead you to believe. Also that LOR technique can steer you wrong if you miss the epiduraql space altogether and end up in a paraspinous muscle. The syringe goes woosh but the catheter won't thread. No alternative to LOR, just not a guarentee.

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In answer to my own question:

I use my left hand to help guide in the spinal needle initially then use a two handed approach with both forefingers and thumbs to insert further. Worked well. I did my LP and gave the chemotherapy all within 15-20 minutes of opening my tray. The patient was fine.

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Specializes in Nurse Anesthetist.

I started clinical this week and have already done 3 spinals. Whew! (One was a spotty block) I think I allowed the needle to push further in after I got a swiral. The patients so far have been: 1 lady partsl hysterectomy, 1 abd hysterectomy and 1 knee. I am left handed, so my technique is nothing to mimick! I did not realize that putting the needle in was so "firm, tough" I thread with 2 hands moving together. 2 of the above pts were under 30, tho.

I have yet to feel any pop. But I do have good CSF return. Who knows? Besides, I've only done 3.

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Originally posted by Qwiigley

I did not realize that putting the needle in was so "firm, tough" I thread with 2 hands moving together.

I have yet to feel any pop. But I do have good CSF return.

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Yes, I agree with both points. Any comments from those more experienced?

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Specializes in Nurse Anesthetist.

Now 5!! :)

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