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Lumbar puncture, also called cerebrospinal fluid puncture, is used to obtain cerebrospinal fluid (nervous fluid), which is then analyzed in the laboratory for diseases in the brain and spinal cord. Lumbar punctures are used not only in diagnostics, but also in therapeutic areas. More about the reason for a lumbar puncture, how it is performed, the risks and possible pain can be found here in the overview.
What is a lumbar puncture?
A lumbar puncture is the removal of nerve fluid with a thin puncture needle from the spinal canal in the area of the lumbar spine. The corresponding vertebrae are called lumbar vertebrae, which is why the procedure is also called lumbar puncture. The nerve fluid is also called cerebrospinal fluid and provides an insight into the patient’s state of health. If the nerve fluid is reddish in color, it indicates a fresh hemorrhage. A yellowish discoloration, in turn, indicates an older hemorrhage. In the case of inflammation, the nerve fluid may also be cloudy. For a more detailed analysis of the constituents of the nerve fluid, examination in the laboratory is necessary. Puncture is practiced to diagnose various diseases of the brain and spinal cord and is additionally used in therapy and for injections of anesthetics.
For which diseases is a lumbar puncture performed?
A lumbar puncture is performed in cases of suspected inflammation of the brain and meninges, i.e. encephalitis and meningitis, because the germs responsible for these diseases may be found in the cerebrospinal fluid. In addition, a lumbar puncture is performed in the case of multiple sclerosis, since an accumulation of certain proteins and inflammatory cells can be found in the cerebrospinal fluid. A lumbar puncture is also performed in cases of cancer of the meninges. However, lumbar puncture can be used not only for disease investigation, but can also be used in the treatment of diseases. Among other things, in the administration of medication, because the spinal cord is easier to reach and can therefore be used, for example, in chemotherapy and thus the treatment of tumors. In addition, lumbar puncture can be used to relieve pain during surgical procedures as lumbar anesthesia or spinal anesthesia – for example, during hip surgery or a C-section. In addition, lumbar puncture is also used therapeutically, for example, for excruciating headaches.
Lumbar puncture – contraindications
Lumbar puncture is not performed if the patient has an increased tendency to bleed or has taken substances that inhibit blood clotting. In these cases, there is a high risk of bleeding due to the puncture. Lumbar puncture is also not performed if there is inflammation of the skin or tissue near the puncture site. Another contraindicator is increased pressure in the brain, as the extracted neural fluid may cause entrapment of the elongated spinal cord at the junction of the skull and the spine.
Lumbar puncture – preparation
Before a lumbar puncture is performed, the patient should be informed about the puncture more than 24h before the procedure. In emergencies, of course, this rule does not apply. In this information the patient should be informed about the following points:
- Benefits of the examination and comparison to other procedures
- Consequences and risks if an examination is not performed
- Explanation of the puncture procedure, ideally with a diagram
- Side effects
- Risks of such an examination.
In addition to the explanation of the procedure, the patient must give written consent. As described above, the patient should not have previously taken any medication that leads to the inhibition of blood clotting. In rare cases, signs of increased intracranial pressure are also examined.
Lumbar puncture – procedure
Usually, a lumbar puncture is performed in a clinic, but some neurology practices also offer outpatient procedures. During a lumbar puncture, the patient’s posture is essential. The patient should make a round back, or even a cat hump, and during the procedure can either be seated bent forward on the examination couch, or lie in the fetal position – the patient lies on his side, pulls his legs and arms and rests his chin on his chest. The patient is supported in this position by pillows. Due to the strong flexion of the spine, there is enough space between the vertebrae to be able to insert the needle. First, the skin is disinfected and the skin site is covered with a sterile cloth. The patient receives a local anesthetic through a syringe. This takes effect after about two minutes and the doctor inserts a puncture needle between two lumbar vertebrae, usually in the intervertebral space of the third and fifth lumbar vertebrae. There is no spinal cord left here, so there is no chance of injury from the puncture needle. The physician punctures through the skin and muscles, and as soon as the spinal canal is reached by the needle, the nerve fluid drips out of it. During this process, a standpipe can also be used to determine the nerve water pressure. When the physician has collected enough nerve water for laboratory testing, usually 10 to 15 milliliters, the needle is withdrawn and the puncture site is dressed with some pressure and covered with a wound patch. 
The patient is placed in a lying position, the puncture site is located between the 3rd and 5th lumbar vertebrae, and 10 to 15 milliliters of nerve fluid are collected. The number of cells in the cerebrospinal fluid or the composition of components (proteins, glucose and lactate) of the cerebrospinal fluid is then analyzed in the laboratory. In addition, the cerebrospinal fluid is examined for bacteria that can cause meningitis and for proteins that can indicate dementia.
How long does a lumbar puncture take?
The lumbar puncture itself takes about 15 minutes. However, it is important that the patient rest and lie down for at least an hour after the procedure. The patient should also rest for the next 24 hours. A few hours after the procedure, a doctor checks the puncture site for bruising and whether the patient can move his or her legs. As a rule, a patient stays in the clinic or practice for at least one hour, but usually up to four hours.
What should be done afterwards?
A patient is advised to rest after a lumbar puncture, stay on their stomach and drink plenty of fluids. After a puncture, the patient should be on bed rest for at least one hour to prevent circulatory problems. The following 24h, the patient should continue to rest and drink plenty of fluids.
How painful is a lumbar puncture?
In general, many patients describe the procedure as uncomfortable because the meninges are irritated when the puncture needle is inserted. During the puncture itself, and if the needle touches a nerve root, there may be brief pain. This pain radiates “electrifyingly” into one of the two legs, but quickly subsides. Often, a lumbar puncture is equated to a blood draw in terms of the pain felt. However, a lumbar puncture can also be performed under local anesthesia.
Lumbar puncture risks – How dangerous is a lumbar puncture?
A lumbar puncture carries certain risks, about which the patient must be informed by his or her physician beforehand. Serious consequences, such as bleeding or infection, occur after a lumbar puncture in extremely rare cases. The occurrence of post-puncture headaches also happens only in the rarest of cases, but is favored by the following factors:
- young age
- female gender
- frequent headaches in everyday life.
Consequently, lumbar puncture is very low risk and there is no danger of damaging spinal cord. Moreover, in patients suffering from seizure disorders, such as epilepsy or migraine, a seizure can be triggered.
Lumbar puncture – side effects
Shortly after the procedure, patients may experience dizziness and nausea. A side effect may be post-puncture headache. The headaches already mentioned above occur rarely and usually in an upright posture. The headache subsides considerably in a recumbent position. This pain may last a few days and in some cases a few weeks. The headache itself cannot be treated with painkillers, but caffeine and theophylline can help to a small extent. If other symptoms, such as dizziness, nausea, neck stiffness, photophobia, and ringing in the ears, are also present, the patient is suffering from neural hydrocephalus syndrome. In addition, there may also be pain at the puncture site that spreads to the hip region, as well as nausea, a high pulse and low blood pressure. However, these pains and after-effects are temporary.
Back pain
After a lumbar puncture, there may be pain at the puncture site that spreads to the entire hip region. This pain disappears, usually, after a few days.
Permanent damage?
In the rarest cases, inflammation, bleeding or other complications can occur after a lumbar puncture. These must be treated in the clinic.
Lumbar puncture – costs
In general, the costs for a lumbar puncture are covered by the statutory health insurance, provided that there is a medical indication. In some rare cases, the costs may only be partially covered. If a lumbar puncture is performed without a doctor’s order, i.e. at the patient’s request, the patient must bear the costs of the examination, anesthesia, and possible hospital stay himself. All NetDoktor.de content is reviewed by medical journalists. A Lumbar puncture (CSF puncture) refers to the removal of a nerve fluid sample from the spinal canal. It is used to diagnose various diseases and is also used for therapeutic purposes or to insert local anesthetics. Read here everything about lumbar puncture, the areas of application and what risks it entails. Article overview Lumbar puncture
- What is a lumbar puncture?
- When is a lumbar puncture performed?
- What is done during a lumbar puncture?
- What are the risks of a lumbar puncture?
- What do I have to consider after a lumbar puncture?
What is a lumbar puncture?
During a lumbar puncture, cerebrospinal fluid (CSF) is taken. To do this, the doctor uses a thin puncture needle that he inserts into the spinal canal at the level of the lumbar spine. From this, the cerebrospinal fluid drips into a sample vessel. During the CSF examination, the physician examines the nerve fluid (hence the term cerebrospinal fluid examination is also used) for the presence of various cells, for example blood or inflammatory cells.
When is a lumbar puncture performed?
Lumbar puncture is used for both diagnostic (CSF diagnostics) and therapeutic purposes.
Lumbar puncture as a diagnostic tool
Cerebrospinal fluid puncture is used to detect or exclude various diseases:
- Brain and spinal cord tumors
- cancerous lesions of the meninges, for example lymphoma
- inflammatory diseases of the brain (encephalitis) or the meninges (meningitis)
- Infectious diseases (Lyme disease, neurosyphilis and others)
- Subarachnoid hemorrhage
- multiple sclerosis
In addition, the physician can measure the pressure inside the skull as part of the CSF diagnostics in order to detect an expansion of the so-called CSF spaces (hydrocephalus).
Lumbar puncture for therapy
Medications can be introduced into the spinal canal through the puncture needle. These include, for example, local anesthetics or chemotherapeutic agents. If a patient has normal pressure hydrocephalus, i.e. a widening of the cerebrospinal fluid spaces without an increase in pressure, lumbar puncture can be used to relieve the fluid spaces by draining nerve fluid.
When should a lumbar puncture not be performed?
Before the CSF is removed, the patient’s tendency to bleed is ruled out. If necessary, blood-thinning medications must be discontinued. Patients suffering from thrombocytopenia, which is associated with platelet deficiency and thus an increased bleeding tendency, can be supplied with platelets (thrombocytes) if the lumbar puncture is urgently necessary. Lumbar puncture is not possible if there is increased intracranial pressure or inflammation of the skin, subcutaneous tissue or muscles at the puncture site.
What is done during a lumbar puncture?
Whether the lumbar puncture is performed on an outpatient or inpatient basis is always decided individually depending on the patient’s general health. The brain and spinal cord are surrounded by three skins. On the outside is the hard meninges, and on the inside is the soft meninges. Between them is a narrow gap, the so-called subarachnoid space, in which the cerebrospinal fluid is located.
Lumbar puncture: Procedure
For lumbar puncture, the patient either sits relaxed on a patient couch with a curved back or lies on his side, pulls his legs and arms together and rests his chin on his chest. These positions allow the vertebral body processes to move far apart and provide good access to the intervertebral spaces through which the lumbar puncture is performed. The physician usually punctures the space between the third and fourth or fourth and fifth lumbar vertebrae after marking and disinfecting the puncture site. If desired, the patient is given an injection of a local anesthetic. If CSF collection in the lumbar region is not possible, the puncture can be made below the occiput (suboccipital puncture). The physician carefully punctures the skin and muscles with a hollow needle and pushes it between the vertebrae into the spinal canal. The cerebrospinal fluid now drips through the hollow needle into a sample vessel. Once sufficient cerebrospinal fluid has been obtained, the physician withdraws the needle and dresses the wound. CSF diagnostics are then performed in a laboratory.
What are the risks of a lumbar puncture?
Risks that exist and about which the patient must be informed include:
- Bleeding and bruising
- Infections and inflammations
- Circulatory and consciousness disorders (syncope)
- Temporary nerve loss with numbness or paralysis.
In patients suffering from seizure disorders such as epilepsy or migraine, a seizure can be triggered by the lumbar puncture. Another risk is the so-called cerebrospinal fluid hypotension syndrome, in which the patient suffers from headaches, neck stiffness, ringing in the ears (tinnitus), nausea and sensitivity to light. It can occur after a CSF puncture when the patient sits up or stands up from a lying position. Administration of certain medications such as theophylline or injection of the patient’s own blood into the epidural cleft (blood patch) can relieve the discomfort. The use of the thinnest possible puncture needle and a correct angle of insertion reduces the risk of CSF hypotension syndrome occurring.
Is a lumbar puncture painful?
Lumbar puncture can be performed under local anesthesia if desired. However, patients sometimes find the procedure uncomfortable because the meninges are irritated when the puncture needle is inserted.
What should I pay attention to after a lumbar puncture?
After the lumbar puncture, you should lie on your stomach for about half an hour to a full hour to prevent the reflux of neural fluid. You should also largely remain on bed rest for the first few hours after the puncture. However, you may go to the bathroom independently or sit up for meals.
Lumbar puncture: side effects
Your doctor will inform you about possible side effects that may occur in the days following the procedure before the lumbar puncture:
- Headache, back pain
- nausea, vomiting
- localized pain at the puncture site
Nausea and headache after lumbar puncture are the most common side effects. However, the discomfort is rarely severe and usually resolves itself within a few days – sometimes only after a few weeks. Drink enough water after the Lumbar puncture; You can often relieve pain in the head and back this way. If the symptoms do not disappear or become more severe, you should consult a doctor. If the side effects are particularly severe, you may also need to be admitted as an inpatient or your hospital stay may be prolonged.
Author & source information
Scientific Standards: This text complies with the requirements of medical literature, medical guidelines, and current studies and has been reviewed by medical professionals. Template:Peter Borlinghaus, MD Author: 
- Aumüller, G. et al: Duale Reihe Anatomie, Georg Thieme Verlag, 3rd edition, 2014.
- Diener, H.-G.: Kopfschmerzen, Georg Thieme Verlag, 1st ed. Edition, 2003
- Guideline of the German Society of Neurology: Lumbar puncture and cerebrospinal fluid diagnostics, as of July 2019.
- Masuhr, K. F. et al: Duale Reihe Neurologie, Georg Thieme Verlag, 7th edition, 2013.
- Mattle, H. & Mumenthaler, M.: Neurology, Georg Thieme Verlag, 13th edition, 2012.
Negative pressure headache may result from a reduction in CSF volume and pressure due to lumbar puncture or spontaneous or traumatic CSF leak. The removal of CSF during lumbar puncture (LP), as well as spontaneous or traumatic CSF leaks, reduces CSF volume and pressure. Headaches after lumbar puncture are common. They usually occur hours to 1-2 days after puncture and can be severe. Younger, slender patients are most affected. The use of thinner, nontraumatic puncture needles decreases the risk. The amount of CSF removed and the duration of bed rest after puncture do not affect the occurrence. Spontaneous CSF leaks can occur when an arachnoid diverticulum or cyst of the nerve root ruptures along the spinal canal. Coughing or sneezing can trigger the rupture. CSF may leak after certain head or facial injuries (e.g., basilar skull fractures). The headache occurs when the painful basal meninges are stretched while the head is elevated while sitting or standing. The headache is severe, positional and often accompanied by neck pain, meningismus and vomiting. The headache subsides only when the patient lies flat.
- Clinical evaluation
Postpuncture headache is clinically obvious, and further investigation is rarely needed; other low-pressure headaches may require brain imaging. MRI with gadolinium contrast enhancement often shows diffuse enhancement of pachymeninges and, in severe cases, deep sacculation of the brain. CSF pressure is usually low or not measurable if patients have been in the upright position for some time.
- Fluid administration and caffeine
- Usually epidural blood patch.
First-line therapy for post-LP headache is.
- “Recumbency”
- Hydration
- An elastic abdominal bandage
- Caffeine
- Analgesics as needed
However, if the postpuncture headache persists after one day on this therapy, an epidural blood patch (a few milliliters of the patient’s clotted venous blood injected into the lumbar epidural space) is usually effective. A blood patch may also be effective for spontaneous or traumatic CSF leaks that rarely require surgical closure. The blood patch is thought to increase pressure in the epidural space, thereby decreasing the rate of CSF leakage, regardless of where the CSF leak is located. When normal CSF production exceeds the leak rate, symptoms subside. NOTE: This is the issue for medical professionals. LAYMAN: VIEW PATIENT EDITION 
Copyright © 2022 Merck & Co, Inc, Rahway, NJ, USA and its affiliates. All rights reserved.
Lumbar puncture – briefly explained
The name lumbar puncture means that the doctor uses a hollow needle to remove neural fluid from the spinal canal in the lumbar spine. This is examined as part of the CSF diagnosis: the mere sight of the nerve fluid provides the trained eye with initial indications. In a healthy person, the cerebrospinal fluid is clear. A reddish discoloration indicates fresh bleeding, a yellowish discoloration indicates older bleeding. In addition, the nerve fluid may be cloudy in the case of inflammation. A laboratory is then responsible for the exact analysis of the contents.
When is a CSF examination necessary?
Changes in the composition of the cerebrospinal fluid occur in numerous diseases of the brain and spinal cord. CSF diagnostics helps in the diagnosis of the following clinical pictures:
- Inflammations of the brain and meninges (encephalitis and meningitis) – here, the responsible germs may be detectable under certain circumstances.
- Multiple sclerosis – in this long-lasting, inflammatory disease, which is caused by an overreaction of the patient’s own immune system, certain proteins and inflammatory cells accumulate in the cerebrospinal fluid.
- cancerous lesions of the meninges
- Hemorrhages in the neighborhood of the cerebrospinal fluid, especially subarachnoid hemorrhages
What is the procedure for a lumbar puncture?
First, the doctor checks to make sure there is nothing contraindicating the puncture. For example, a contraindication could be an increased risk of bleeding. In addition, the patient must be informed about the procedure beforehand and give his or her written consent.
In what posture is the lumbar puncture performed?
The patient should make as round a back as possible (like a “cat hump”). Either he sits bent forward on the examination couch, or he assumes the fetal position while lying on his side, so that his elbows and knees touch. The patient should be supported with pillows so that the head is at the same level as the subsequent puncture site in the lower back. It is also important that the patient’s shoulders are vertical in this horizontal position so that the spine does not twist. The strong flexion of the spine ensures that there is enough space between the vertebrae for the needle to be inserted. The puncture should only be performed or instructed by a very experienced physician who is confident in this technique. The procedure is performed under “sterile conditions”, which means that the skin is thoroughly disinfected and the skin site is covered with a sterile cloth. Then a local anesthetic is applied by injection. When this anesthetic has taken full effect after about two minutes, the doctor inserts the puncture needle between two lumbar vertebrae. Normally, it selects an intervertebral space between the third and fifth lumbar vertebrae. At this level and further down, there is no longer any spinal cord, so there is no risk of injury from the puncture needle. When the spinal canal is reached, nerve fluid begins to drip from the needle. A so-called riser tube can also be used to determine the nerve water pressure during this process. When the doctor has collected enough nerve fluid for laboratory testing, he withdraws the needle and the small puncture site is dressed with a wound patch. 
What are the risks?
More serious consequences such as bleeding or even infections are extremely rare after a lumbar puncture. If the puncture is performed according to all the rules of medical art with the use of atraumatic needles and a special procedure during the puncture, there is only a small risk of about one percent for a so-called postpuncture headache. However, some factors favor it
- young age
- female gender
- frequent headaches in everyday life
The transient post-puncture headache occurs only when the patient is in an upright position. It subsides when lying down. This pain can last a few days, very rarely even weeks. If other symptoms are also present, it is called neural hydrocephalus syndrome. These include:
- Dizziness
- Nausea
- Neck stiffness
- Photophobia
- Ringing in the ears
Painkillers do not help with postpuncture headache; caffeine and theophylline are slightly effective. The most effective method to stop postpuncture headache within half an hour is the so-called blood patch. In this method, the physician uses at least 20 milliliters of the patient’s own blood to seal the cerebrospinal fluid leak created by the puncture. Blood patch treatment immediately following the lumbar puncture to prevent a headache from occurring in the first place has been found to be ineffective. In addition, there are sometimes transient pain sensations around the site of the puncture with radiation to the hip region.
Contraindications: When should lumbar puncture not be performed?
- If there is a bleeding tendency: If there is a greatly increased tendency to bleed, or the patient has taken substances that inhibit blood clotting. Then there is too great a risk of bleeding from the puncture.
- In case of inflammation: If the skin or surrounding tissue near the puncture site is inflamed, puncture is generally not performed.
- In the case of increased pressure in the brain: In this case, too, a lumbar puncture must be avoided. Otherwise, there is a risk of entrapment of the extended spinal cord at the transition of the skull to the spinal column due to the tapped nerve fluid. If symptoms are present, a computer tomography or magnetic resonance imaging of the head can clarify whether increased intracranial pressure is present.
Is the lumbar puncture also used for treatment?
Sometimes the lumbar puncture is used not only for examination, but also for treatment:
- Drug administration: in this way, the spinal cord is reached much more directly than via the blood. This is due to the so-called blood-brain barrier, which certain drugs have difficulty crossing. One example is chemotherapeutic agents used to treat tumors.
- Pain relief during surgical procedures: Lumbar puncture is useful in the form of lumbar anesthesia (also: spinal anesthesia), for example, during a Caesarean section or hip surgery.
- Therapy for excruciating headaches: Even in the case of a so-called spontaneous cerebrospinal fluid hypotension syndrome with very severe headaches in an upright position, the physician can provide relieving relief by performing a lumbar puncture with an injection of at least 20 milliliters of the patient’s own blood directly in front of the cerebrospinal fluid space.
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