{"id":799,"date":"2023-05-24T13:35:00","date_gmt":"2023-05-24T13:35:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=799"},"modified":"2025-10-01T11:39:36","modified_gmt":"2025-10-01T19:39:36","slug":"usmle-step-2-question-of-the-day-lumbar-puncture","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Lumbar puncture"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#D_D\" >D. &nbsp;D<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#A_A\" >A. &nbsp;A<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#B_B\" >B. &nbsp;B<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#C_C\" >C. &nbsp;C<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#E_E\" >E. &nbsp;E<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>This week, we are sharing another USMLE\u00ae Step 2-style practice question to test your knowledge of medical topics.&nbsp;<\/em><\/strong><strong><em>Today&#8217;s case focuses on a 56-year-old man that has an occipital headache that progressed and is now associated with nausea, vomiting, and fever. The patient has a past medical history of diabetes, hypertension, and kidney transplant, for which he takes tacrolimus daily. Physical examination is notable for photophobia, nuchal rigidity, and scattered petechiae over the upper and lower extremities. Based on the image below, which of the following is the most appropriate anatomical location to perform the procedure to diagnose this patient\u2019s clinical condition?&nbsp;<\/em><\/strong><strong><em>Can you figure it out?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 56-year-old man presents for evaluation of a headache. The patient was in his usual state of health until several days ago, when he noted an occipital headache that has progressed and is now associated with nausea, vomiting, and fever. The patient has a past medical history of diabetes, hypertension, and kidney transplant, for which he takes tacrolimus daily. Temperature is 38.0 \u00b0C (100.4 \u00b0F), pulse is 105\/min, respirations are 17\/min, and blood pressure is 90\/65 mmHg. Physical examination is notable for photophobia, nuchal rigidity, and scattered petechiae over the upper and lower extremities. Based on the image below, which of the following is the most appropriate anatomical location to perform the procedure to diagnose this patient\u2019s clinical condition?<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"844\" height=\"878\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/structure-abdominal-skeletal-region.png\" alt=\"illustration of the abdominal skeletal region\" class=\"wp-image-800\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/structure-abdominal-skeletal-region.png 844w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/structure-abdominal-skeletal-region.png?resize=288,300 288w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/structure-abdominal-skeletal-region.png?resize=768,799 768w\" sizes=\"auto, (max-width: 844px) 100vw, 844px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. &nbsp;A<br><br>B. &nbsp;B<br><br>C. &nbsp;C<br><br>D. &nbsp;D<\/strong><br><strong><br>E. &nbsp;E<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down to find the answer!<em>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_D\"><\/span>D. &nbsp;D<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The incorrect answers to today&#8217;s USMLE\u00ae Step 2 Question is&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_A\"><\/span>A. &nbsp;A<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Choice A represents the thoracic spinal vertebral interspace, which is too high to perform this procedure safely. Lumbar puncture at this interspace risks damage to the thoracic spinal cord.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_B\"><\/span>B. &nbsp;B<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Choice B represents the thoracic interspace between ribs 9 and 10. This area may be appropriate for performing a thoracentesis, not a lumbar puncture.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_C\"><\/span>C. &nbsp;C<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Choice C represents the L2 interspace, which is too high to perform a lumbar puncture safely. Performance of this procedure at this interspace risks direct injury to the spinal cord.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_E\"><\/span>E. &nbsp;E<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Choice E represents the sacrum, which does not have an interspace for the performance of a lumbar puncture.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png?w=700\" alt=\"Osmosis ad\" class=\"wp-image-513\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/08\/79.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span><strong>Main Explanation<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This immunocompromised patient with headache, fever, and associated nuchal rigidity and photophobia most likely has meningitis. The most appropriate test to diagnose this condition is a lumbar puncture performed at the&nbsp;<strong>L4\/L5 intervertebral space<\/strong>, denoted by choice D in the diagram above.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Indications for the performance of a&nbsp;<strong>lumbar puncture (LP)<\/strong>&nbsp;are many, namely the evaluation of infection in the central nervous system, subarachnoid hemorrhage, central nervous system malignancies, and demyelinating disorders such as Guillain Barre syndrome. LP is generally safe; however, it is contraindicated in patients with increased intracranial pressure, bleeding diathesis, or suspected spinal epidural abscess.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Performance of the procedure requires sterile technique and positioning the patient in either a lateral decubitus position or sitting upright. In an average adult, the spinal cord tapers and ends at the level between the L1 and L2 vertebrae. In neonates, it ends at L3, so the procedure is safely performed via needle insertion at the L4\/L5 interspace in both populations. This space is most easily identified via&nbsp;<strong>direct palpation of the superior iliac crests<\/strong>&nbsp;and tracing an imaginary line from this point to the lumbar spine. Palpation of the lumbar spine at this location will reveal the L4\/L5 spinous processes, and the area for needle insertion is between the two.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The insertion sequence includes skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, and finally, the&nbsp;<strong>subarachnoid space<\/strong>. Once in this space, removal of the stylet will reveal the flow of cerebrospinal fluid through the proximal end of the needle.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"844\" height=\"474\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/illustration-lumbar-puncture.png?w=844\" alt=\"illustration of lumbar punctures\" class=\"wp-image-802\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/illustration-lumbar-puncture.png 844w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/illustration-lumbar-puncture.png?resize=300,168 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/illustration-lumbar-puncture.png?resize=768,431 768w\" sizes=\"auto, (max-width: 844px) 100vw, 844px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span><strong>Major Takeaway<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A<strong>&nbsp;lumbar puncture (LP)<\/strong>&nbsp;is most safely performed at the L4\/L5 intervertebral space level, which is best identified via direct palpation of the superior iliac crests and tracing an imaginary line from this point to the lumbar spine. The insertion sequence includes skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, and finally, the&nbsp;<strong>subarachnoid space<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Doherty CM, Forbes RB. Diagnostic Lumbar Puncture. Ulster Med J. 2014;83(2):93-102.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Sternbach G. Lumbar puncture. J Emerg Med 1985; 2:199.<br><em><strong>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;_________________________<\/strong><br><br><strong>Want more USMLE\u00ae Step 2 practice questions? Try Osmosis today! Access your&nbsp;<em><strong><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/strong><\/em>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>This week, we are sharing another USMLE\u00ae Step 2-style practice question to test your knowledge of medical topics.&nbsp;Today&#8217;s case focuses on a 56-year-old man that has an occipital headache that progressed and is now associated with nausea, vomiting, and fever. The patient has a past medical history of diabetes, hypertension, and kidney transplant, for which [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":801,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,20,1370,45],"tags":[],"class_list":["post-799","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Lumbar puncture - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Lumbar puncture - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"This week, we are sharing another USMLE\u00ae Step 2-style practice question to test your knowledge of medical topics.&nbsp;Today&#8217;s case focuses on a 56-year-old man that has an occipital headache that progressed and is now associated with nausea, vomiting, and fever. The patient has a past medical history of diabetes, hypertension, and kidney transplant, for which [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2023-05-24T13:35:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:39:36+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/lumbar-puncture.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1081\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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