Lp; Prosedur Dan Analisis

PUNGSI LUMBAL: PROSEDUR DAN ANALISISI WAYAN TUNJUNG, dr. Sp.SBAGIAN NEUROLOGIRSU KOTA MATARAM

PREFACECEREBROSPINAL FLUIDA colourless fluid.Around and inside thebrain andspinal cord in thesubarachnoid space and theventricular system. Produced in the choroid plexus.Mechanical and immunological protection to the brain. Composed of about 99% water.

Lumbar PunctureAn invasive procedure for obtaining CSF. insertion of a needle into the subarachnoid space of the lumbar (lower back) region. for Dx. or Tx. purposes.The lumbar region is most often used.

HISTORYFirst reports of CSF is in Edwin-Smith Surgical Papyrus written 3700 yrs ago.Hippocrates reported CSF presence in brain cavities, 4 centuries B.C.Galen described ventricular cavities 2 centuries A.C.In 1891 Heinrich Quincke, of Kiel, Germany, introduced this procedure as we know it today. In 1901: Widal introduced CSF cytological studies.

Lumbar Puncture

INDICATIONS:Suspicion ofmeningitisSuspicion ofsubarachnoid hemorrhageSuspicion of central nervous system diseases such asGuillain-Barr syndrome and carcinomatous meningitisTherapeutic relief ofpseudotumor cerebriInjection of drugs and anesthetics

Lumbar Puncture Indications:LP for DxInfections, e.g. meningitis.Demyelinating diseases, e.g., GBS.High ICP, e.g., pseudotumor cerebri.Bleeding, e.g., SAH.Introducing contrast agent for Dx., e.g. MyelographyLP for Tx.Infections, e.g. meningitis.High ICP, e.g., pseudotumor cerebri.Malignancies, e.g., leukemia.AnesthesiaOthers, e.g., CSF leakage.

Lumbar PunctureContraindicationsInfection or wound at the site of LPBleeding tendency.Intracranial or intraspinal mass lesions.

CONTRA INDICATIONS:Increased intracranial pressure (ICP) of and unidentified origin - Can cause cerebral herniation - Exception: therapeutic use of lumbar puncture to reduce ICPInfections - Skin infections at puncture site may cause sepsisAbnormal respiratory pattern - Hypertension with bradycardia and deteriorating consciousness - Vertebral deformities (scoliosis orkyphosis), in hands of an inexperienced physician.Bleeding diathesis-Coagulopathy-Decreasedplatelet count (

PROSEDUR

Lumbar PunctureQuinke needlesSprotte needleTouhy needle

Lumbar Puncture

Indications for CT prior to LP (in suspicion of meningitis)Patients who are older than 60 yearsPatients who are immunocompromisedPatients with known central nervous system (CNS) lesionsPatients who have had a seizure within 1 week of presentationPatients with an abnormal level of consciousnessPatients with focal findings on neurologic examinationPatients with papilledema seen on physical examination, with clinical suspicion of an elevated ICP

Lumbar punctureThe patient is placed in a lateral position with the knees bent in full flexion up to the chest (fetal position) (sit and bend position also possible)Introduction of 1% lidocain into the subcutaneous spaceInsertion of a spinal needle into the subarachnoid space at the L3-L4 or L4-L5 spaces. Removal of the stylet of the needle in order to collect the fluid

Lumbar PunctureProcedure: Sitting Lying downL2/L3 level downwardsNeedle between 2 spinal processes30* cephalad directionBeveled tip direction depends to the aim of LP

Lumbar puncture

Alternative TechniquesSitting PositionRadiological GuidanceCisternal TapCervical TapLP Technique in Neonates and Infants

Lumbar Puncture

2005-5-17Medicine School of Shandong University

INTERPRETASI

CSF analysis - ColourCrystal clear- normal finding, viral meningitisTurbid- indicates the presence of >200WBCs or >400 RBCs, bacterial meningitisXantochromia- yellow, orange or pink discoloration (in more than 90% subarachnoid hemorrhages), physiologic in newbornsYellow: RBCs breakdown, high bilirrubin levels, high protein levels >150mg/dL , tubercular and fungal meningitis (viscous)Pink: RBCs breakdownOrange: RBCs breakdown; high carotenoid intakeGreen: hyperbiliruminemia, purulent CSF, (bacterial meningitis)Brown: meningeal melanomatosis

CSF analysis - PressureMeasured with a column manometer (fetal position is optimal)Increased pressure: congestive heart failure,cerebral edema,subarachnoid hemorrhage, hypo-osmolality resulting fromhemodialysis, purulent or tuberculous meningitis,hydrocephalus, orpseudotumor cerebri.Decreased pressure: complete subarachnoid blockage, leakage of spinal fluid, severedehydration, hyperosmolality, orcirculatory collapse

Opening PressureNormal opening pressure: in adults is 90 - 180mmH2O, in children 10 - 100mmH2O.

2005-5-17Medicine School of Shandong UniversityELEVATED PRESSURECongestive heart failureMeningitisSuperior vena cava syndromeCerebral edemaMass lesion

Medicine School of Shandong University

DECREASED PRESSURESpinal-subarachnoid blockDehydrationCirculatory collapseCSF leakage

CSF analysis- cell countNormal cell count: < 5 WBCs/mm in adults and < 20 WBCs/mm in newborns (70% lymphocytes, 30% monocytes).99% of patients with bacterial meningitis have >100 WBCs/mm (less than that is only common for viral meningitis)Viral meningitis: predominance of lymphocytes TBacterial meningitis: predominance of PMNsFungal and tubercular meningitis: predominance of lymphocytes and high content of proteins, decrased glucoseRBCs: abnormal finding(be careful with traumatic taps, 3 samples are needed)

Total cell count & DCThe normal leukocyte cell count in adults is 0~5 cells/ul.Increased neutrophils: Bacterial Meningitis cerebral abscess subdural empyema CNS hemorrhage CNS infarct

2005-5-17Medicine School of Shandong UniversityIncrease Lymphocytes: Viral meningitisMultiple sclerosis


2005-5-17Medicine School of Shandong UniversityGLUCOSEThe normal Glucose is about 60% compared to serum level.Normal 50~80mg/dlElevated Glucose: Diabetes mellitusDecreased Glucose: Bacterial Meningitis


2005-5-17Medicine School of Shandong University TOTAL PROTEINOver 80% of CSF protein content is derived from the plasma.An increased CSF protein serves as a useful but nonspecific indicator of disease.Normal level 15 45 mg/dl.


2005-5-17Medicine School of Shandong UniversityELEVATED CSF PROTEINReasonIncreased permeability of the blood-brain barrier.Decreased resorption Mechanical obstruction of CSF flow


2005-5-17Medicine School of Shandong UniversityELEVATED CSF PROTEINArachnoiditisMeningitisHemorrhageEndocrine/Metabolic disorders


Lumbal Pungsi

Perbedaan Interpretasi Cairan Serebrospinal (Saharso, 2006)

TesMeningitis BakterialMeningitis VirusMeningitis TBCTekanan

Warna

sel

Jenis sel

Protein

GlukosaMeningkat

Keruh

> 1000/ml

Predominan PMN

Sedikit meningkat

Normal/menurunBiasanya normal

Jernih

< 100/ml

Predominan MN

Normal/meningkat

Biasanya normalBervariasi

Xanthochrom

Bervariasi

Predominan MN

Meningkat

Rendah

CSF analysis other testsPresent compouds : -cl: tuberculous meningitis - lactate: cancer, MS, etc. -LD: bacterial meningitis -Glucose (60% of serum glucose): inflammations, lymphomas -proteins (18-58mg/dL normal range): infections, MS, Guillain Barr sy, malignancies, some medications, etc. -IgG: multiple sclerosis, transverse myelitis, and neuromyelitis optica of Devic. -Glutamine: hepatic encephalopathies,Reye's syndrome, hepatic coma,cirrhosisand hypercapnia.India Ink test (cryptococcus neoformans)PCRMicrobioloy: Gram stain, Acid fast

Complications1. Headache (Post LP Headache)2. Painful Paresthesias3. Persistent Pain or Paresthesias4. Spinal Hematoma5. Spinal Infection6. Herniation7. CSF leak

8. CSF Leak

Bloody Tap

TERIMA KASIH

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Lp; Prosedur Dan Analisis