Lumbar puncture: Indications, contraindications, technique, and complications in children
- Rebecca K Fastle, MD
Rebecca K Fastle, MD
- Assistant Professor of Emergency Medicine
- University of New Mexico School of Medicine
- Pediatric Emergency Medicine Fellowship Director
- Joan Bothner, MD
Joan Bothner, MD
- Professor of Pediatrics and Emergency Medicine
- University of Colorado School of Medicine
- Section Editor
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Examination of the cerebrospinal fluid (CSF) provides essential diagnostic information in many clinical situations. The indications, contraindications, and procedure for performing a lumbar puncture in children are presented here.
Lumbar puncture in adults, the physiology and utility of examination of CSF, and the diagnosis, prevention, and treatment of postspinal headache are discussed separately. (See "Lumbar puncture: Technique, indications, contraindications, and complications in adults" and "Cerebrospinal fluid: Physiology and utility of an examination in disease states" and "Post-lumbar puncture headache".)
Suspected CNS infection — For most children, the indication for an emergent lumbar puncture (LP) is to obtain cerebrospinal fluid (CSF) for the evaluation of possible central nervous system (CNS) infection. (See "Viral meningitis: Clinical features and diagnosis in children", section on 'CSF studies' and "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation'.)
Delay in the administration of appropriate antibiotics can have deleterious effects on outcome for patients with bacterial meningitis. Empiric antimicrobial treatment is recommended when the diagnosis of bacterial meningitis or herpes encephalitis is strongly suspected, as early treatment improves prognosis of these conditions (see "Treatment and prognosis of coma in children"). Treatment may impair the diagnostic sensitivity of CSF cultures but should not affect other tests (such as CSF white blood cell count, gram stain, or polymerase chain reaction). Blood cultures should be obtained prior to antibiotic administration, as they are positive at least a 50 percent of the time in patients with bacterial meningitis . (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation'.)
- Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- The diagnostic spinal tap. Health and Public Policy Committee, American College of Physicians. Ann Intern Med 1986; 104:880.
- Marton KI, Gean AD. The spinal tap: a new look at an old test. Ann Intern Med 1986; 104:840.
- Sternbach G. Lumbar puncture. J Emerg Med 1985; 2:199.
- Cronin KM, Wiley JF. Lumbar puncture. In: Textbook of Pediatric Emergency Medicine Procedures, Henretig FM, King C. (Eds), Lippincott Williams & Wilkins, Philadelphia 1997. p.541.
- Kooiker JC. Spinal puncture and cerebrospinal fluid examination. In: Clinical Procedures in Emergency Medicine, 4th ed, Roberts JR, Hedges JR (Eds), WB Saunders, Philadelphia 2004.
- Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222.
- Silverman R, Kwiatkowski T, Bernstein S, et al. Safety of lumbar puncture in patients with hemophilia. Ann Emerg Med 1993; 22:1739.
- Kneen R, Michael BD, Menson E, et al. Management of suspected viral encephalitis in children - Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines. J Infect 2012; 64:449.
- Pinheiro JM, Furdon S, Ochoa LF. Role of local anesthesia during lumbar puncture in neonates. Pediatrics 1993; 91:379.
- Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003; 157:1065.
- Carraccio C, Feinberg P, Hart LS, et al. Lidocaine for lumbar punctures. A help not a hindrance. Arch Pediatr Adolesc Med 1996; 150:1044.
- Baxter AL, Fisher RG, Burke BL, et al. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success. Pediatrics 2006; 117:876.
- Nigrovic LE, Kuppermann N, Neuman MI. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007; 49:762.
- Abo A, Chen L, Johnston P, Santucci K. Positioning for lumbar puncture in children evaluated by bedside ultrasound. Pediatrics 2010; 125:e1149.
- Gleason CA, Martin RJ, Anderson JV, et al. Optimal position for a spinal tap in preterm infants. Pediatrics 1983; 71:31.
- Weisman LE, Merenstein GB, Steenbarger JR. The effect of lumbar puncture position in sick neonates. Am J Dis Child 1983; 137:1077.
- Kempen PM, Mocek CK. Bevel direction, dura geometry, and hole size in membrane puncture: laboratory report. Reg Anesth 1997; 22:267.
- Bruccoleri RE, Chen L. Needle-entry angle for lumbar puncture in children as determined by using ultrasonography. Pediatrics 2011; 127:e921.
- Baxter AL, Welch JC, Burke BL, Isaacman DJ. Pain, position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians. Pediatr Emerg Care 2004; 20:816.
- Ellis R 3rd. Lumbar cerebrospinal fluid opening pressure measured in a flexed lateral decubitus position in children. Pediatrics 1994; 93:622.
- Avery RA, Shah SS, Licht DJ, et al. Reference range for cerebrospinal fluid opening pressure in children. N Engl J Med 2010; 363:891.
- Gorn M, Kunkov S, Crain EF. Prospective Investigation of a Novel Ultrasound-assisted Lumbar Puncture Technique on Infants in the Pediatric Emergency Department. Acad Emerg Med 2017; 24:6.
- Coley BD, Murakami JW, Koch BL, et al. Diagnostic and interventional ultrasound of the pediatric spine. Pediatr Radiol 2001; 31:775.
- Coley BD, Shiels WE 2nd, Hogan MJ. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture. Pediatr Radiol 2001; 31:399.
- Özdamar E, Özkaya AK, Güler E, et al. Ultrasound-Assisted Lumbar Puncture in Pediatric Emergency Department. Pediatr Emerg Care 2015.
- Fisher A, Lupu L, Gurevitz B, et al. Hip flexion and lumbar puncture: a radiological study. Anaesthesia 2001; 56:262.
- Ramamoorthy C, Geiduschek JM, Bratton SL, et al. Postdural puncture headache in pediatric oncology patients. Clin Pediatr (Phila) 1998; 37:247.
- Tobias JD. Postdural puncture headache in children. Etiology and treatment. Clin Pediatr (Phila) 1994; 33:110.
- Kokki H, Salonvaara M, Herrgård E, Onen P. Postdural puncture headache is not an age-related symptom in children: a prospective, open-randomized, parallel group study comparing a22-gauge Quincke with a 22-gauge Whitacre needle. Paediatr Anaesth 1999; 9:429.
- Janssens E, Aerssens P, Alliët P, et al. Post-dural puncture headaches in children. A literature review. Eur J Pediatr 2003; 162:117.
- Ebinger F, Kosel C, Pietz J, Rating D. Headache and backache after lumbar puncture in children and adolescents: a prospective study. Pediatrics 2004; 113:1588.
- Crock C, Orsini F, Lee KJ, Phillips RJ. Headache after lumbar puncture: randomised crossover trial of 22-gauge versus 25-gauge needles. Arch Dis Child 2014; 99:203.
- Ebinger F, Kosel C, Pietz J, Rating D. Strict bed rest following lumbar puncture in children and adolescents is of no benefit. Neurology 2004; 62:1003.
- Potgieter S, Dimin S, Lagae L, et al. Epidermoid tumours associated with lumbar punctures performed in early neonatal life. Dev Med Child Neurol 1998; 40:266.
- Halcrow SJ, Crawford PJ, Craft AW. Epidermoid spinal cord tumour after lumbar puncture. Arch Dis Child 1985; 60:978.
- Ziv ET, Gordon McComb J, Krieger MD, Skaggs DL. Iatrogenic intraspinal epidermoid tumor: two cases and a review of the literature. Spine (Phila Pa 1976) 2004; 29:E15.
- Jeong IH, Lee JK, Moon KS, et al. Iatrogenic intraspinal epidermoid tumor: case report. Pediatr Neurosurg 2006; 42:395.
- McDonald JV, Klump TE. Intraspinal epidermoid tumors caused by lumbar puncture. Arch Neurol 1986; 43:936.
- Batnitzky S, Keucher TR, Mealey J Jr, Campbell RL. Iatrogenic intraspinal epidermoid tumors. JAMA 1977; 237:148.
- Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System, WB Saunders, Philadelphia 1980.
- DRIPPS RD, VANDAM LD. Hazards of lumbar puncture. J Am Med Assoc 1951; 147:1118.
- Findlay L, Kemp FH. Osteomyelitis of the spine following lumbar puncture. Arch Dis Child 1943; 18:102.
- Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitis following lumbar puncture: case report and review. Clin Infect Dis 1995; 21:694.
- Rennick G, Shann F, de Campo J. Cerebral herniation during bacterial meningitis in children. BMJ 1993; 306:953.
- Shetty AK, Desselle BC, Craver RD, Steele RW. Fatal cerebral herniation after lumbar puncture in a patient with a normal computed tomography scan. Pediatrics 1999; 103:1284.
- Adler MD, Comi AE, Walker AR. Acute hemorrhagic complication of diagnostic lumbar puncture. Pediatr Emerg Care 2001; 17:184.
- Suspected CNS infection
- Suspected subarachnoid hemorrhage
- Patient counseling
- Analgesia and sedation
- - Lateral recumbent
- - Sitting
- - Sterile preparation
- - Local anesthesia
- - Technique
- - Use of manometer
- - Ultrasound guidance
- - Fluid collection
- Bony resistance
- Poor flow
- Traumatic puncture
- Lateral approach
- Postspinal headache
- Epidermoid tumor
- Cerebral herniation
- Spinal hematoma
- FOLLOW-UP CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS