Alternative Names: Spinal tap; Ventricular puncture; Lumbar puncture; Cisternal puncture; Cerebral spinal fluid culture

How the test is performed:

There are different ways to get a sample of spinal fluid. Lumbar puncture, commonly called a spinal tap,�is the most common method. The test is usually performed in the following manner:

• The patient must lay on his or her side, with the knees pulled up�toward the chest, and the chin tucked downward. Sometimes the test is done�with the person sitting up, but bent over.�
• After the�back is cleaned, the health care provider will inject� a local numbing medicine (anesthetic) into the lower spine.
• A spinal needle is inserted,�usually between the 3rd and 4th lumbar vertebrae.
• Once the needle is properly positioned, spinal fluid pressure is measured, and fluid is collected.
• The needle is removed, the area is cleaned, and a bandage is placed over the needle site.�The patient�will need�to remain flat for 20 minutes to 1 hour after the test.

Lumbar puncture with fluid collection may also be part of other procedures, particularly a myelogram (x-ray or CT scan after dye has been inserted into the CSF).

Alternative methods of�CSF collection are rarely used, but may be�necessary in in the event of a back deformity or infection.

Cisternal puncture uses a needle�placed below the occipital bone (back of the skull). It can be�dangerous because it is so�close to the brain stem.

Ventricular puncture is even more rare, but may be recommended in people with possible� brain herniation. This test is usually done in the operating room. A hole is drilled in the skull, and a needle is inserted directly into one of brain's ventricles.

How to prepare for the test:

The patient (or guardian) must sign a consent for. The patient must�remain in the hospital for at least several hours after the test for observation.

How the test will feel:

The position may be uncomfortable, but it is imperative that the patient stays�in the bended position to avoid moving the needle and possibly injuring the spinal cord.

The anesthetic will sting or burn when first injected. There will be a hard pressure sensation when the needle is inserted, and there is usually some brief pain when the needle goes through the tissue surrounding the spinal cord (meninges). This pain should stop in a few seconds.

Overall, discomfort is minimal to moderate. The entire procedure usually takes about 30 minutes, but it may take longer. The actual pressure measurements and fluid collection only take a few minutes.

Why the test is performed:

This test is done to measure pressures within the cerebrospinal fluid and to collect� a sample of the fluid for further testing.�CSF can be used to diagnose�certain neurologic disorders, particularly infections (such as menigitis)�and brain or spinal cord damage.

See also:

• CSF coccidioides complement fixation
• CSF oligoclonal banding�
• CSF smear
• CSF VDRL test

Normal Values:

• Pressure: 50 - 180 mm H20
• Appearance: clear, colorless
• CSF total protein: 15 - 45 mg/100 ml
• Gamma globulin: 3 - 12% of the total protein
• CSF glucose: 50 - 80 mg/100 ml (or approximately 2/3 of serum glucose level)
• CSF cell count: 0 - 5 white blood cells (WBC), no red blood cells (RBC)
• Chloride: 110 - 125 mEq per liter

Note: mg/ml = milligrams per milliliter; mEq/L = milliequivalent per liter

What abnormal results mean:

• Pressure, increased: increased intracranial pressure (pressure within the skull) from trauma or infection
• Pressure, decreased: obstruction to the flow of CSF above the puncture site (spinal cord tumor), shock, fainting, diabetic coma
• Appearance
  • Cloudy: infection, white blood cells in the CSF, protein in the CSF, microorganisms
  • Bloody or reddish colored: bleeding within the brain or subarachnoid space, spinal cord obstruction, traumatic lumbar puncture (first specimen bloody, rest clear)
  • Brown, orange, yellow color: elevated protein in the CSF, old (greater than 3 days) blood in the CSF
• Protein, increased: blood in the CSF, diabetes, polyneuritis, tumors, trauma, any inflammatory or infectious condition
• Protein, decreased: rapid CSF production
• Gamma globulin, increased: demyelinating disease such as multiple sclerosis, neurosyphilis, Guillain-Barre syndrome
• Glucose, increased: systemic hyperglycemia (elevated blood sugar)
• Glucose, decreased: systemic hypoglycemia (low blood sugar), bacterial or fungal infection (such as meningitis), tuberculosis, carcinomatous meningitis
• WBC, increased: active meningitis, acute infection, beginning of a chronic illness, tumor, abscess, brain infarction (stroke), demyelinating disease (such as multiple sclerosis)
• RBC: bleeding into the spinal fluid, traumatic lumbar puncture

Additional conditions under which the test may be performed:

• Chronic inflammatory polyneuropathy
• Dementia due to metabolic causes
• Encephalitis
• Epilepsy
• Febrile seizure (children)
• Generalized tonic-clonic seizure
• Hydrocephalus
• Inhalation anthrax
• Normal pressure hydrocephalus (NPH)
• Pituitary tumor
• Reye's syndrome

What the risks are:

• Risks of lumbar puncture include:
  • Hypersensitivity (allergic) reaction to the anesthetic.
  • Discomfort during the test.
  • Headache after the test.
  • Bleeding into the spinal canal.
• Brain herniation (if performed on a person with increased intracranial pressure), and resulting in brain damage or death.
• Damage to the spinal cord (particularly if the person moves during the test).
• Cisternal puncture or ventricular puncture carry additional risk of damage to the brainstem or brain tissue and risk of bleeding within the brain; resulting in incapacitation or death.

Special considerations:

This test should not be performed on people who may have increased intracranial pressure.

References:

Nathan, BR. Cerebrospinal Fluid and Intracranial Pressure. In: Goetz, CG, ed. Textbook of Clinical Neurology, 2nd ed. Philadelphia, Pa:WB Saunders Company; 2003:511-524.