Lumbar Puncture Needle

Once the boundary marker is identified again, a needle with a needle core is inserted at the midline, at the upper edge of the next spinous process. The needle is facing the head at about 15 degrees, seemingly in the direction of the patient's umbilical cord. Recent data suggest that the use of "pencil-tip" needles may reduce the risk of post-puncture headache caused by leakage of CSF because they disperse the fibers of the dural sac rather than cutting them. If the more commonly used bevel needle is used, the bevel of the needle should be located in the sagittal plane, which also allows the fibers parallel to the spinal axis to be scattered without cutting them.

If inserted correctly, the needle should pass through the skin, subcutaneous tissue, the supraspinal ligament, the interspinous ligament between spinous processes, the ligamentum flavum, the epidural space (which includes the internal vertebral plexus, the dura mater, and the arachnoid membrane), into the subarachnoid space, and between the cauda equina nerve roots. When the needle passes through the ligamentum flavum, the physician may feel a sense of breakthrough. At this point, the needle core should be pulled out 2 mm to observe whether there is cerebrospinal fluid outflow. If the puncture is unsuccessful and touches bone, withdraw the needle to the subcutaneous tissue, but do not withdraw from the skin. Adjust the direction and insert the needle again. Once the needle enters the subarachnoid space, CSF exits. If there is trauma from the puncture, the CSF may be slightly sanguine. The CSF should be clear and bloodless at the time of collection, unless subarachnoid hemorrhage is present. If cerebrospinal fluid is not flowing freely, rotate the needle 90 degrees as the opening of the needle may become blocked by nerve roots.

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