Disclosures: Kimberly S Johnson, MD Nothing to disclose. Daniel J Sexton, MD Grant/Research/Clinical Trail Support: Cubist [C. difficile infection (Fidaxomicin)]. Consultant/Advisory Boards: Johnson & Johnson [Pelvic mesh-related infection]; Sterilis [Medical waste disposal systems]; Magnolia Medical Technologies [Intravenous devices]. Other Financial Interest: National Football League [Infection control program]. Equity Ownership/Stock Options: Magnolia Medical Technologies [Intravenous devices]. Michael J Aminoff, MD, DSc Equity Ownership/Stock Options: Trust, which is independently managed by a financial company. The portfolio may include medical or drug companies. Janet L Wilterdink, MD Nothing to disclose.
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INTRODUCTION — Quincke performed the first lumbar puncture (LP) in 1891 to relieve increased intracranial pressure in children with tuberculous meningitis . This technique subsequently became important in the diagnosis of a variety of infectious and noninfectious neurologic conditions. However, its relative value for diagnosing central nervous system (CNS) conditions other than infection has diminished as new testing methods, especially imaging techniques, have appeared.
The indications, contraindications, and complications of LP will be reviewed here. With a few exceptions, the results of an LP are rarely diagnostic. As a result, analysis of the cerebrospinal fluid (CSF) has to be correlated with the history, physical findings, and other laboratory tests in order to be maximally useful. (See "Cerebrospinal fluid: Physiology and utility of an examination in disease states".)
Preparation — An LP can be performed with the patient in the lateral recumbent or prone positions or sitting upright. The lateral recumbent or prone positions are preferred over the upright position because they allow more accurate measurement of the opening pressure. The prone position is generally used for LPs performed under fluoroscopic guidance. (See 'Imaging guidance' below.)
The choice of needle type (cutting versus atraumatic) and bore size can influence the risk of a post-LP headache, but also may increase the technical difficulty of the procedure. This is discussed in detail separately. (See "Post-lumbar puncture headache", section on 'Prevention'.)
The correct level of entry of the spinal needle is most easily determined with the patient sitting upright or standing. The highest points of the iliac crests should be identified visually and confirmed by palpation; a direct line joining these is a guide to the fourth lumbar vertebral body. However, this line may intersect the spine at points ranging from L1-L2 to L4-L5 , and tends to point to a higher spinal level in women and in obese patients . The lumbar spinous processes of L3, L4, and L5, and the interspaces between can usually be directly identified by palpation. The spinal needle can be safely inserted into the subarachnoid space at the L3/4 or L4/5 interspace, since this is well below the termination of the spinal cord.
Correct patient positioning is an important determinant of success in obtaining CSF. The patient is instructed to remain in the fetal position with the neck, back, and limbs held in flexion. The lower lumbar spine should be flexed with the back perfectly perpendicular to the edge of a bed or examining table. The hips and legs should be parallel to each other and perpendicular to the table. Pillows placed under the head and between the knees may improve patient comfort.
The overlying skin should be cleaned with alcohol and a disinfectant such as povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent); the antiseptic should be allowed to dry before the procedure is begun. Many product inserts of chlorhexidine-containing solutions warn against use of chlorhexidine prior to lumbar puncture because of a concern that it can cause arachnoiditis. The evidence that it does so is very limited, and many experts believe that chlorhexidine has an advantage over povidone-iodine because of its onset, efficacy, and potency [4-8]. Due to specific labeling prohibiting use, a formal institutional policy to support such use may be indicated. After the skin is cleaned and allowed to dry, a sterile drape with an opening over the lumbar spine is placed on the patient. Local anesthesia (eg, lidocaine) is infiltrated into the previously identified lumbar intervertebral space and a 20 or 22 gauge spinal needle containing a stylet is inserted into the lumbar intervertebral space.
Procedure technique — The spinal needle may be advanced slowly, angling slightly toward the head, as if aiming towards the umbilicus. The flat surface of the bevel of the needle should be positioned to face the patient's flanks to allow the needle to spread rather than cut the dural sac (the fibers of which run parallel to the spinal axis). The approximate distance of the epidural space from the skin is 45 to 55 mm . Many physicians choose to advance the needle incrementally, removing the stylet periodically to check for CSF flow, then reinserting the stylet until the subarachnoid space is entered . However, others report a higher rate of successful LP when the stylet is removed, just after the skin is punctured and before it is passed into the subarachnoid space in order to better observe the flow of CSF upon entry of the subarachnoid space [10,11].
Once CSF appears and begins to flow through the needle, the patient should be instructed to slowly straighten or extend the legs to allow free flow of CSF within the subarachnoid space. While the pressure measurement is affected by the position of the legs, the available evidence suggests that the effect is likely to be small. In one review, pressures were elevated by only 1 to 2 cm H2O in four of five studies studying this effect; however, in one study, changing position from a straight to a fully flexed position resulted in an increase in pressure of 6.4 mm Hg (approximately 8.7 cm H2O) . Opening pressure does not appear to be significantly different if measured in the prone or lateral recumbent position . A manometer should then be placed over the hub of the needle and the opening pressure should be measured (figure 1). Fluid is then serially collected in sterile plastic tubes. A total of 8 to 15 mL of CSF is typically removed during routine LP. However, when special studies are required, such as cytology or cultures for organisms that grow less readily (eg, fungi or mycobacteria), 40 mL of fluid can safely be removed. Aspiration of CSF should not be attempted as it may increase the risk of bleeding . The stylet should be replaced before the spinal needle is removed, as this can reduce the risk of post-lumbar puncture headache. (See "Post-lumbar puncture headache", section on 'Reinsertion of the stylet'.)
No trials have shown that bed rest following LP significantly decreases the risk of post LP headache compared with immediate mobilization [14,15]. (See "Post-lumbar puncture headache", section on 'Bedrest'.)
The Queckenstedt maneuver can be used to demonstrate that there is free flow of fluid from the ventricles to the lumbar space. This maneuver is performed by measuring the CSF pressure and then observing the change in pressure after manual compression of both jugular veins. However, this test is rarely useful in modern practice, since newer techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) readily identify most obstructing spinal or basilar lesions.
Fluoroscopy — Fluoroscopic guidance for LP may be required if attempts without imaging are unsuccessful. This is also suggested for patients who are obese or have difficult anatomy because of prior spine surgery or other reasons. Most neuroradiologists perform fluoroscopically guided LPs in the L2-L3 or L3-L4 intervertebral space with the patient in the prone position and rotate the patient to their side for measurement of opening pressure . In addition to improving success rates, fluoroscopic guidance may reduce the incidence of traumatic LP .
Ultrasound — Imaging guidance may also be obtained with ultrasound . A meta-analysis of 14 randomized trials (1334 patients) that compared LPs and epidural catheterizations performed with ultrasound to those performed without imaging found that ultrasound guidance reduced the risk of failed and traumatic procedures (RR = 21 and 0.27 respectively), as well as the number of needle insertions and redirections . A subsequently published randomized trial involving 100 adult patients found no significant difference in outcomes with ultrasound guidance .
INDICATIONS — LP is essential or extremely useful in the diagnosis of bacterial, fungal, mycobacterial, and viral CNS infections and, in certain settings, for help in the diagnosis of subarachnoid hemorrhage, CNS malignancies, demyelinating diseases, and Guillain-Barré syndrome.
Urgent — The number of definite indications for LP has decreased with the advent of better neuroimaging procedures including CT scans and MRI, but urgent LP is still indicated to diagnose two serious conditions [21,22]:
●Suspected CNS infection (with the exception of brain abscess or a parameningeal process).
●Suspected subarachnoid hemorrhage (SAH) in a patient with a negative CT scan . The use of CSF examination in the evaluation of a patient with suspected SAH is discussed in detail separately. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage", section on 'Lumbar puncture'.)
The most common use of the LP is to diagnose or exclude meningitis in patients presenting with some combination of fever, altered mental status, headache, or meningeal signs. Examination of the CSF has a high sensitivity and specificity for determining the presence of bacterial and fungal meningitis.
The findings on CSF analysis also may help distinguish bacterial meningitis from viral infections of the central nervous system. However, there is often substantial overlap. (See "Viral encephalitis in adults", section on 'Cerebrospinal fluid findings'.)
Nonurgent — A nonurgent LP is indicated in the diagnosis of the following conditions. The findings are discussed in the appropriate topic reviews:
●Idiopathic intracranial hypertension (pseudotumor cerebri)
●Normal pressure hydrocephalus
Conditions in which LP is rarely diagnostic but still useful include:
LP is also required as a therapeutic or diagnostic maneuver in the following situations [21,22,24,25]:
●Intrathecal administration of chemotherapy
●Intrathecal administration of antibiotics
●Injection of contrast media for myelography or for cisternography
CONTRAINDICATIONS — Although there are no absolute contraindications to performing the procedure, caution should be used in patients with:
●Possible raised intracranial pressure
●Thrombocytopenia or other bleeding diathesis (including ongoing anticoagulant therapy)
●Suspected spinal epidural abscess
These are discussed in detail in relation to the complications with which they are associated. (See 'Complications' below.)
COMPLICATIONS — LP is a relatively safe procedure, but minor and major complications can occur even when standard infection control measures and good technique are used. These complications include:
●Minor neurologic symptoms such as radicular pain or numbness
●Late onset of epidermoid tumors of the thecal sac
The risk of complications was studied in a cohort of 376 patients who underwent LP for evaluation of acute cerebrovascular disease . The following frequency of complications was noted: backache (25 percent), headache (22 percent), headache and backache (12 percent), severe radicular pain (15 percent), and paraparesis (1.5 percent). Severe pain or paraparesis occurred in 6.7 percent of patients receiving anticoagulants following the procedure and in none of the 34 patients who did not receive anticoagulants.
Post LP headache — Headache, which occurs in 10 to 30 percent of patients, is one of the most common complications following LP. Post-LP headache is caused by leakage of CSF from the dura and traction on pain-sensitive structures. Patients characteristically present with frontal or occipital headache within 24 to 48 hours of the procedure, which is exacerbated in an upright position and improved in the supine position. Associated symptoms may include nausea, vomiting, dizziness, tinnitus, and visual changes.
This risk factors, prevention, and treatment of post-LP headache are discussed separately. (See "Post-lumbar puncture headache".)
Meningitis — Meningitis is an uncommon complication of LP. In a review of 179 cases of post-LP meningitis reported in the medical literature between 1952 and 2005, half of all cases occurred after spinal anesthesia; only 9 percent occurred after diagnostic LP. The most commonly isolated causative organisms were streptococcus salivarius (30 percent), streptococcus viridans (29 percent), alpha-hemolytic strep (11 percent), staphylococcus aureus (9 percent), and pseudomonas aeruginosa (8 percent) .
While some cases of post-LP meningitis due to staphylococci, pseudomonas, and other gram-negative bacilli have been attributed to contaminated instruments or solutions or poor technique , other studies have suggested that post-LP meningitis could arise from aerosolized oropharyngeal secretions from personnel present during the procedure especially since many of the causative organisms are found in the mouth and upper airway [27,29-31].
Based upon these observations, some authors have recommended the routine use of face masks during LP and neuroradiologic imaging procedures involving LP [32-34]. Others have questioned the practicality and necessity of the use of face masks since there is no proof that face masks prevent such infections [30,35]. In 2005 the Healthcare Infection Control Advisory Committee recommended that face masks be used by individuals who place a catheter or inject material into the spinal canal, and in 2007 the CDC endorsed this recommendation . These guidelines do not require use of a face mask for routine diagnostic LP. However, we believe a face mask can reasonably be used for diagnostic procedures especially if the procedure is likely to be prolonged or difficult, or if the person carrying out the procedure has an upper respiratory tract infection. (See "General principles of infection control".)
Because meningitis can be caused in animals by performing an LP after first inducing a bacteremia [37,38], several authors have speculated that an LP in a bacteremic patient without preexisting meningitis might actually cause meningitis . However, this phenomenon is rare, if it occurs at all. In a retrospective study of 1089 bacteremic infants, the incidence of spontaneous meningitis in children who underwent LP and subsequently developed meningitis was not statistically different from those who did not undergo LP (2.1 versus 0.8 percent) . We agree with other authors that theoretical concerns about inducing meningitis in patients with bacteremia should not be used as the basis to forego LP if meningitis is suspected .
An LP through a spinal epidural abscess can result in the spread of bacteria into the subarachnoid space. Because an LP is not needed for diagnosis, the procedure should NOT be performed in most patients with suspected epidural abscess in the lumbar region . (See "Spinal epidural abscess".)
Other infections — There are rare anecdotal case reports of discitis and vertebral osteomyelitis following LP. Most cases were due to normal skin flora such as Propionibacterium species and coagulase negative staphylococci [42-44]. These complications presumably result from direct inoculation of bacteria into the vertebral bone.
Bleeding — The CSF is normally acellular, although up to five red blood cells (RBCs) are considered normal after LP due to incidental trauma to a capillary or venule. A higher number of RBCs is seen in some patients in whom calculation of the white blood cell (WBC) to RBC ratio and the presence or absence of xanthochromia may differentiate LP-induced from true CNS bleeding. (See "Cerebrospinal fluid: Physiology and utility of an examination in disease states", section on 'Cells'.)
At risk patients — Serious bleeding that results in spinal cord compromise is rare in the absence of bleeding risk . Patients who have thrombocytopenia or other bleeding disorders or in those who received anticoagulant therapy prior to or immediately after undergoing LP have an increased risk of bleeding. In one series, spinal hematoma developed in 7 of 342 patients (2 percent) who received anticoagulant therapy after undergoing LP; five of these patients developed paraparesis . In one literature review, 47 percent of 21 published cases of spinal hematoma following lumbar puncture occurred in patients with a coagulopathy . Thus, a high index of suspicion of spinal hematoma should be maintained in all patients who develop neurologic symptoms after a lumbar puncture, including those with no known coagulopathy. In rare cases, intraventricular, intracerebral, and subarachnoid hemorrhage have also been reported as complications of lumbar puncture [47,48].
We are unaware of any study that examined the risk of bleeding following LP based upon the degree of thrombocytopenia or clotting study abnormalities. Thus, at present the only guidepost is "clinical judgment." We generally advise NOT performing an LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet counts <50,000 to 80,000/µL), or an INR >1.4, without correcting the underlying abnormalities [49,50]. When an LP is considered urgent and essential in a patient with an abnormal INR or platelet count in whom the cause is not obvious, consultation with a hematologist may provide the best advice for safe correction of the coagulopathy prior to performing the LP. (See "Approach to the adult with unexplained thrombocytopenia", section on 'General management principles' and "Clinical and laboratory aspects of platelet transfusion therapy", section on 'Preparation for an invasive procedure'.)
For elective procedures in a patient receiving systemic anticoagulation, observational studies and expert opinion have suggested stopping unfractionated intravenous heparin drips two to four hours, stopping low-molecular-weight heparin 12 to 24 hours, stopping dabigatran one to two days, and stopping warfarin five to seven days before spinal anesthesia or LP [51,52]. This presumes that the underlying indications for anticoagulation therapy allow a temporary suspension of treatment. While the optimal timing of restarting anticoagulation after LP is not known, the incidence of spinal hematoma in the above-mentioned series was much lower when anticoagulation was started at least one hour after the LP . Subcutaneous heparin administration is not believed to pose a substantial risk for bleeding after LP if the total daily dose is less than 10,000 units.
Aspirin has not been shown to increase the risk of serious bleeding following LP. In a prospective study of 924 patients who underwent orthopedic procedures with spinal or epidural anesthesia, 386 patients were taking antiplatelet therapy prior to surgery; 193 were taking aspirin . Neither aspirin nor any other antiplatelet agents were associated with an increased risk of bleeding. However, none of these patients was taking clopidogrel, ticlopidine, or a GP IIb/IIIa receptor antagonist. Female gender, increased age, a history of excessive bruising/bleeding, hip surgery, continuous catheter anesthetic technique, large needle gauge, multiple needle passes, and moderate or difficult needle placement were all significant risk factors for minor bleeding at the site of catheter placement . Given the unknown risk of bleeding with thienopyridine derivatives (clopidogrel, ticlopidine) it may be reasonable to suspend treatment with these agents, when possible, for one to two weeks prior to an elective LP, while pharmacologic data suggests that for GP IIb/IIIa receptor antagonists, a shorter period of treatment cessation (8 hours for tirofiban and eptifibatide and 24 to 48 hours for abciximab) may be indicated .
In all cases, the relative risk of performing an LP has to be weighed against the potential benefit (eg, diagnosing meningitis due to an unusual or difficult to treat pathogen). In cases in which LP is considered necessary but the risk of bleeding is considered to be high, it may be useful to perform the procedure under fluoroscopy to reduce the chance of accidental injury to small blood vessels.
Management — The diagnosis of spinal hematoma is complicated by the concealed nature of the bleeding; thus, a high index of suspicion must be maintained. Patients who have persistent back pain or neurologic findings (eg, weakness, decreased sensation, or incontinence) after undergoing LP require urgent evaluation (usually spinal magnetic resonance imaging (MRI)) for possible spinal hematoma .
The appropriate treatment for patients with significant or progressing neurologic deficits is prompt surgical intervention, usually a laminectomy, and evacuation of the blood. Timely decompression of the hematoma is essential to avoid permanent loss of neurologic function [55,56]. Patients with mild symptoms or early signs of recovery may be managed conservatively with vigilant monitoring; dexamethasone may be administered to mitigate against neurologic injury [46,47]. (See "Disorders affecting the spinal cord", section on 'Spinal epidural hematoma'.)
Cerebral herniation — The most serious complication of LP is cerebral herniation. Suspected increased intracranial pressure (ICP) is a relative contraindication to performance of an LP and also requires independent assessment and treatment. The magnitude of the risk was evaluated in a report of 129 patients with increased ICP: 15 patients (12 percent) had an unfavorable outcome within 48 hours of LP . Similar findings were noted in a series of 55 patients with subarachnoid hemorrhage: seven patients (13 percent) experienced neurologic deterioration during or soon after an LP, six of whom had evidence of cerebral dislocation . Cardiorespiratory collapse, loss of consciousness, and death may follow. (See "Evaluation and management of elevated intracranial pressure in adults".)
A 1969 study of 30 patients with increased ICP who deteriorated after LP attempted to identify the clinical features of patients who were at greatest risk for this complication . The following findings were noted: 73 percent had focal findings on neurologic examination (including dysphagia, hemiparesis, and cranial nerve palsies); 30 percent had documented papilledema prior to the LP; and 30 percent had evidence of increased ICP on plain skull films (erosion of the posterior clinoid processes). Deterioration occurred immediately in one-half of the patients, with the remainder declining within 12 hours.
The concern about this serious complication has resulted in routine CT scanning prior to LP being the standard of care in many emergency departments. At one institution, for example, 78 percent of patients with suspected meningitis underwent CT scanning before the LP was performed . However, this practice, when applied to patients with suspected bacterial meningitis, delays the performance of LP, which in turn may delay treatment or limit the diagnostic power of CSF analysis when performed after antibiotic administration. Moreover, CT scanning is not necessary in all patients prior to LP and may not be adequate to exclude elevated ICP in others [61,62]. Some studies suggest that high-risk patients can be identified, allowing the majority of patients to safely undergo LP without screening CT [60,63]. This was best illustrated in a prospective study of 301 adults with suspected meningitis . The following findings were noted:
●Among the 235 (78 percent) who underwent CT scan before LP, 24 percent had an abnormal finding but only 5 percent (11 patients) had a mass effect.
●The risk of an abnormal CT scan was associated with specific clinical features (presence of impaired cellular immunity, history of previous central nervous system disease, or a seizure within the previous week), as well as certain findings on neurologic examination (reduced level of consciousness, and focal motor or cranial abnormalities).
●Among 96 patients with none of these abnormalities, only three had an abnormal CT scan; one of the three misclassified patients had a mild mass effect but all three underwent LP without herniation.
●Compared to patients who did not undergo CT scan before LP, those who underwent CT scan before LP had an average of a two-hour delay in diagnosis and a one-hour delay in therapy.
Based upon these observations, we do NOT perform a CT scan before an LP in patients with suspected bacterial meningitis unless one or more risk factors is present:
●Focal neurologic signs
●Seizure within the previous week
●Impaired cellular immunity
Patients with these clinical risk factors should have a CT scan to identify possible mass lesion and other causes of increased ICP. Mass lesions causing elevated ICP are usually easily identified on CT scan. However, the CT scan should also be scrutinized for more subtle signs including diffuse brain swelling as manifest by loss of differentiation between gray and white matter and effacement of sulci, as well as ventricular enlargement and effacement of the basal cisterns .
Independent of the decision to perform LP, patients with possible elevated ICP based upon the above clinical features may require urgent life-saving interventions to lower ICP that may include head elevation, hyperventilation to a PCO2 of 26 to 30 mmHg, and intravenous mannitol (1 to 1.5 g/kg). When indicated, these should NOT await CT scan. The evaluation and management of patients with elevated ICP is discussed in detail separately. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'Urgent situations'.)
When the LP is delayed or deferred in the setting of suspected bacterial meningitis, it is important to obtain blood cultures (which reveal the pathogen in more than half of patients) and promptly institute antibiotic therapy. Urgent evaluation and treatment of increased intracranial pressure, along with the administration of antibiotics and steroids, should be instituted promptly when this is suspected. Specific treatments are discussed separately. (See "Initial therapy and prognosis of bacterial meningitis in adults", section on 'Avoidance of delay'.)
Epidermoid tumor — The formation of an epidermoid spinal cord tumor is a rare complication of LP that may become evident years after the procedure is performed [65-67]. Most reported cases are children ages 5 to 12 years who had a LP in infancy; however this has also been described in adults [68-70]. It may be caused by epidermoid tissue that is transplanted into the spinal canal during LP without a stylet, or with one that is poorly fitting. This complication probably can be avoided by using spinal needles with tight-fitting stylets during LP [71,72].
Abducens palsy — Both unilateral and bilateral abducens palsy are reported complications of LP [73-75]. This is believed to result from intracranial hypotension and is generally accompanied by other clinical features of post LP headache. Most patients recover completely within days to weeks. Other cranial nerve palsies are rarely reported .
Radicular symptoms and low back pain — It is not uncommon (13 percent in one series) for patients to experience transient electrical-type pain in one leg during the procedure . However, more sustained radicular symptoms or radicular injury appear to be rare .
Up to one-third of patients complain of localized back pain after LP; this may persist for several days, but rarely beyond .
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient information: Lumbar puncture (spinal tap) (The Basics)")
SUMMARY AND RECOMMENDATIONS — Lumbar puncture (LP) is essential or extremely useful in the diagnosis of bacterial, fungal, mycobacterial, and viral CNS infections and, in certain settings, for help in the diagnosis of subarachnoid hemorrhage, CNS malignancies, demyelinating diseases, and Guillain-Barré syndrome.
●LP is a relatively safe procedure, but minor and major complications can occur, including headache, infection, bleeding, cerebral herniation, as well as minor neurologic symptoms such as radicular pain or numbness.
●Meningitis is a relatively rare complication of LP. (See 'Meningitis' above.)
•LP is contraindicated in patients with a suspected spinal epidural abscess.
•Suspected bacteremia is NOT a contraindication to LP.
•We suggest the use of a face mask for diagnostic LP if the procedure is expected to be prolonged or difficult or if the operator has an upper respiratory tract infection.
●Bleeding in the epidural or subdural space following LP may occur in up to 2 percent of patients, primarily in those patients with thrombocytopenia or other bleeding disorders or in those who have received anticoagulant therapy. (See 'Bleeding' above.)
•Antiplatelet therapy with aspirin and nonsteroidal anti-inflammatory agents is NOT clearly associated with an increased risk of bleeding after LP. The bleeding risk associated with thienopyridine derivatives or GP IIb/IIIa-receptor antagonists is unknown. It is reasonable to suspend therapy, when possible, prior to elective LP.
•Anticoagulation therapy is generally suspended, when possible, prior to elective LP.
•We recommend NOT performing an LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet counts <50,000 to 80,000/µL), or an INR >1.4, without correcting the underlying abnormalities.
•When an LP is considered essential in this setting, consultation with a hematologist may provide the best advice for safe correction of the coagulopathy prior to LP.
●Cerebral herniation is a rare, but usually fatal, complication of an LP performed in an individual with increased intracranial pressure (ICP). While routine neuroimaging, usually brain computed tomography (CT), before LP is not indicated in all patients, those with suspected increased intracranial pressure (altered mentation, focal neurologic signs, papilledema, recent seizure, and impaired cellular immunity) should have a CT scan to rule out possible mass lesion and other causes of increased intracranial pressure. (See 'Cerebral herniation' above.)
•Independent of a decision to perform LP, patients with suspected elevated ICP may require urgent interventions to lower ICP. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'Urgent situations'.)
•When the LP is delayed or deferred in a patient with suspected meningitis, it is important to obtain blood cultures and promptly institute antibiotic therapy. (See "Initial therapy and prognosis of bacterial meningitis in adults", section on 'Avoidance of delay'.)
- Quincke HI. Lumbar puncture. In: Diseases of the nervous system, Church A. (Ed), Appleton, New York 1909. p.223.
- Margarido CB, Mikhael R, Arzola C, et al. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Can J Anaesth 2011; 58:262.
- Chakraverty R, Pynsent P, Isaacs K. Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines? J Anat 2007; 210:232.
- Scott M, Stones J, Payne N. Antiseptic solutions for central neuraxial blockade: which concentration of chlorhexidine in alcohol should we use? Br J Anaesth 2009; 103:456; author reply 456.
- Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006; 31:311.
- Arendt KW, Segal S. Present and emerging strategies for reducing anesthesia-related maternal morbidity and mortality. Curr Opin Anaesthesiol 2009; 22:330.
- Greenberg BM, Williams MA. Infectious complications of temporary spinal catheter insertion for diagnosis of adult hydrocephalus and idiopathic intracranial hypertension. Neurosurgery 2008; 62:431.
- Sakuragi T, Yanagisawa K, Dan K. Bactericidal activity of skin disinfectants on methicillin-resistant Staphylococcus aureus. Anesth Analg 1995; 81:555.
- Ellenby MS, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Lumbar puncture. N Engl J Med 2006; 355:e12.
- Agrawal D. Lumbar puncture. N Engl J Med 2007; 356:424; author reply 425.
- Baxter AL, Fisher RG, Burke BL, et al. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success. Pediatrics 2006; 117:876.
- Rajagopal V, Lumsden DE. Best BETs from the Manchester Royal Infirmary. BET 4: does leg position alter cerebrospinal fluid opening pressure during lumbar puncture? Emerg Med J 2013; 30:771.
- Abel AS, Brace JR, McKinney AM, et al. Effect of patient positioning on cerebrospinal fluid opening pressure. J Neuroophthalmol 2014; 34:218.
- Thoennissen J, Herkner H, Lang W, et al. Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. CMAJ 2001; 165:1311.
- Arevalo-Rodriguez I, Ciapponi A, Munoz L, et al. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 2013; 7:CD009199.
- Abel AS, Brace JR, McKinney AM, et al. Practice patterns and opening pressure measurements using fluoroscopically guided lumbar puncture. AJNR Am J Neuroradiol 2012; 33:823.
- Eskey CJ, Ogilvy CS. Fluoroscopy-guided lumbar puncture: decreased frequency of traumatic tap and implications for the assessment of CT-negative acute subarachnoid hemorrhage. AJNR Am J Neuroradiol 2001; 22:571.
- Conroy PH, Luyet C, McCartney CJ, McHardy PG. Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach. Anesthesiol Res Pract 2013; 2013:525818.
- Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ 2013; 346:f1720.
- Peterson MA, Pisupati D, Heyming TW, et al. Ultrasound for routine lumbar puncture. Acad Emerg Med 2014; 21:130.
- Gorelick PB, Biller J. Lumbar puncture. Technique, indications, and complications. Postgrad Med 1986; 79:257.
- The diagnostic spinal tap. Health and Public Policy Committee, American College of Physicians. Ann Intern Med 1986; 104:880.
- Vermeulen M, van Gijn J. The diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990; 53:365.
- 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.
- Ruff RL, Dougherty JH Jr. Complications of lumbar puncture followed by anticoagulation. Stroke 1981; 12:879.
- Baer ET. Post-dural puncture bacterial meningitis. Anesthesiology 2006; 105:381.
- SWARTZ MN, DODGE PR. BACTERIAL MENINGITIS--A REVIEW OF SELECTED ASPECTS. I. GENERAL CLINICAL FEATURES, SPECIAL PROBLEMS AND UNUSUAL MENINGEAL REACTIONS MIMICKING BACTERIAL MENINGITIS. N Engl J Med 1965; 272:898.
- Domingo P, Mancebo J, Blanch L, et al. Iatrogenic streptococcal meningitis. Clin Infect Dis 1994; 19:356.
- Gelfand MS, Abolnik IZ. Streptococcal meningitis complicating diagnostic myelography: three cases and review. Clin Infect Dis 1995; 20:582.
- Rubin L, Sprecher H, Kabaha A, et al. Meningitis following spinal anesthesia: 6 cases in 5 years. Infect Control Hosp Epidemiol 2007; 28:1187.
- Schlesinger JJ, Salit IE, McCormack G. Streptococcal meningitis after myelography. Arch Neurol 1982; 39:576.
- de Jong J, Barrs AC. Lumbar myelography followed by meningitis. Infect Control Hosp Epidemiol 1992; 13:74.
- Schelkun SR, Wagner KF, Blanks JA, Reinert CM. Bacterial meningitis following Pantopaque myelography. A case report and literature review. Orthopedics 1985; 8:73.
- Williams J, Lye DC, Umapathi T. Diagnostic lumbar puncture: minimizing complications. Intern Med J 2008; 38:587.
- Siegel JD, Rhinehart E, Jackson M et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings June 2007 http; ://www.cdc.gove/ncidod/dhap/pdf/isolatons2007.pdf.
- PETERSDORF RG, SWARNER DR, GARCIA M. Studies on the pathogenesis of meningitis. II. Development of meningitis during pneumococcal bacteremia. J Clin Invest 1962; 41:320.
- Austrian, CR. Experimental meningococcal meningitis. Bull Johns Hopkins Hosp 1919; 29:183.
- Pray, LG. Lumbar puncture as a factor in the pathogenesis of meningitis. Am J Dis Child 1941; 62:295.
- Eng RH, Seligman SJ. Lumbar puncture-induced meningitis. JAMA 1981; 245:1456.
- Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175.
- Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitis following lumbar puncture: case report and review. Clin Infect Dis 1995; 21:694.
- Findlay L, Kemp FH. Osteomyelitis of the spine following lumbar puncture. Arch Dis Child 1943; 18:102.
- Wald ER. Risk factors for osteomyelitis. Am J Med 1985; 78:206.
- Pitkänen MT, Aromaa U, Cozanitis DA, Förster JG. Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiol Scand 2013; 57:553.
- Sinclair AJ, Carroll C, Davies B. Cauda equina syndrome following a lumbar puncture. J Clin Neurosci 2009; 16:714.
- Adler MD, Comi AE, Walker AR. Acute hemorrhagic complication of diagnostic lumbar puncture. Pediatr Emerg Care 2001; 17:184.
- Lee SJ, Lin YY, Hsu CW, et al. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci 2009; 337:143.
- Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg 2009; 109:648.
- van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010; 148:15.
- Horlocker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res 2001; 101:V141.
- Layton KF, Kallmes DF, Horlocker TT. Recommendations for anticoagulated patients undergoing image-guided spinal procedures. AJNR Am J Neuroradiol 2006; 27:468.
- Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995; 80:303.
- Braun P, Kazmi K, Nogués-Meléndez P, et al. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol 2007; 64:119.
- Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79:1165.
- Lawton MT, Porter RW, Heiserman JE, et al. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995; 83:1.
- KOREIN J, CRAVIOTO H, LEICACH M. Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension. Neurology 1959; 9:290.
- Duffy GP. Lumbar puncture in spontaneous subarachnoid haemorrhage. Br Med J (Clin Res Ed) 1982; 285:1163.
- Duffy GP. Lumbar puncture in the presence of raised intracranial pressure. Br Med J 1969; 1:407.
- Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001; 345:1727.
- 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.
- Joffe AR. Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med 2007; 22:194.
- Gopal AK, Whitehouse JD, Simel DL, Corey GR. Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med 1999; 159:2681.
- van Crevel H, Hijdra A, de Gans J. Lumbar puncture and the risk of herniation: when should we first perform CT? J Neurol 2002; 249:129.
- 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.
- 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.
- Miyake S, Kobayashi N, Murai N, et al. Acquired lumbar epidermoid cyst in an adult. Neurol Med Chir (Tokyo) 2005; 45:277.
- Prat Acín R, Galeano I. Giant occipital intradiploic epidermoid cyst associated with iatrogenic puncture. Acta Neurochir (Wien) 2008; 150:413.
- Park JC, Chung CK, Kim HJ. Iatrogenic spinal epidermoid tumor. A complication of spinal puncture in an adult. Clin Neurol Neurosurg 2003; 105:281.
- 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.
- Béchard P, Perron G, Larochelle D, et al. Case report: epidural blood patch in the treatment of abducens palsy after a dural puncture. Can J Anaesth 2007; 54:146.
- Anwar S, Nalla S, Fernando DJ. Abducens nerve palsy as a complication of lumbar puncture. Eur J Intern Med 2008; 19:636.
- Kose KC, Cebesoy O, Karadeniz E, Bilgin S. Eye problem following foot surgery--abducens palsy as a complication of spinal anesthesia. MedGenMed 2005; 7:15.
- Follens I, Godts D, Evens PA, Tassignon MJ. Combined fourth and sixth cranial nerve palsy after lumbar puncture: a rare complication. A case report. Bull Soc Belge Ophtalmol 2001; :29.
- Evans RW. Complications of lumbar puncture. Neurol Clin 1998; 16:83.
- Hasegawa K, Yamamoto N. Nerve root herniation secondary to lumbar puncture in the patient with lumbar canal stenosis. A case report. Spine (Phila Pa 1976) 1999; 24:915.