eMedicine Specialties > Clinical Procedures > Neurologic Procedures

Lumbar Puncture

Author: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Coauthor(s): Nirav R Shah, MD, MPH, Assistant Professor, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research and Rural Advocacy, Geisinger Health; Senior Analyst, LifeTech Research, Inc
Contributor Information and Disclosures

Updated: Dec 13, 2007

Introduction

Lumbar puncture is a procedure that is often performed in the emergency department to obtain information about the cerebrospinal fluid (CSF).1 Although usually used for diagnostic purposes to rule out potential life-threatening conditions such as bacterial meningitis or subarachnoid hemorrhage, lumbar puncture is also sometimes performed for therapeutic reasons, such as the treatment of pseudotumor cerebri. CSF fluid analysis can also aid in the diagnosis of various other conditions, such as demyelinating diseases and carcinomatous meningitis. Lumbar puncture should be performed only after a neurological examination and should never delay potentially lifesaving interventions such as the administration of antibiotics and steroids to patients with suspected bacterial meningitis.2 Formoreinformation, please see Lumbar Puncture (CSF Examination).

For more information on bacterial meningitis, see the Medscape CME activity New Recommendations for Evaluating and Treating Adult Bacterial Meningitis.

Indications


Contraindications

  • Absolute contraindications to lumbar puncture are as follows:

    • Unequal pressures between the supratentorial and infratentorial compartments, usually inferred by characteristic findings on the brain CT scan:
      • Midline shift
      • Loss of suprachiasmatic and basilar cisterns
      • Posterior fossa mass
      • Loss of the superior cerebellar cistern
      • Loss of the quadrigeminal plate cistern
    • Infected skin over the needle entry site
  •  Relative contraindications to lumbar puncture are as follows:
    • Increased intracranial pressure (ICP)
    • Coagulopathy
    • Brain abscess
  • Indications for brain CT scan prior to lumbar puncture include the following:3
    • Patients who are older than 60 years
    • Patients who are immunocompromised
    • Patients with known CNS lesions
    • Patients who have had a seizure within 1 week of presentation
    • Patients with abnormal level of consciousness
    • Patients with focal findings on neurological examination
    • Patients with papilledema seen on physical examination with clinical suspicion of elevated ICP

More on Lumbar Puncture

Overview: Lumbar Puncture
Treatment & Medication: Lumbar Puncture
Multimedia: Lumbar Puncture
References
Further Reading
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References

  1. Farley A, McLafferty E. Lumbar puncture. Nurs Stand. Feb 6-12 2008;22(22):46-8. [Medline].

  2. de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. Nov 14 2002;347(20):1549-56. [Medline]. [Full Text].

  3. 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. Dec 13 2001;345(24):1727-33. [Medline]. [Full Text].

  4. Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth. Jan-Feb 1997;22(1):66-72. [Medline].

  5. Lavi R, Yarnitsky D, Yernitzky D, Rowe JM, Weissman A, Segal D. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. Oct 24 2006;67(8):1492-4. [Medline].

  6. Lavi R, Rowe JM, Avivi I. Traumatic vs. atraumatic 22 G needle for therapeutic and diagnostic lumbar puncture in the hematologic patient: a prospective clinical trial. Haematologica. Jul 2007;92(7):1007-8. [Medline].

  7. Spriggs DA, Burn DJ, French J, et al. Is bed rest useful after diagnostic lumbar puncture?. Postgrad Med J. Jul 1992;68(801):581-3. [Medline].

  8. Ebinger F, Kosel C, Pietz J, Rating D. Strict bed rest following lumbar puncture in children and adolescents is of no benefit. Neurology. Mar 23 2004;62(6):1003-5. [Medline].

  9. Teece S, Crawford I. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bed rest after lumbar puncture. Emerg Med J. Sep 2002;19(5):432-3. [Medline].

  10. Lee LC, Sennett M, Erickson JM. Prevention and management of post-lumbar puncture headache in pediatric oncology patients. J Pediatr Oncol Nurs. Jul-Aug 2007;24(4):200-7. [Medline].

  11. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. Nov 2006;82(973):713-6. [Medline].

  12. Reichman E, Simon RR. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.

  13. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th. Philadelphia, PA: Saunders; 2004.

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Further Reading

MedlinePlus: CSF Collection

Queen's University technical skills module: Lumbar Puncture

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Keywords

lumbar puncture, LP, spinal tap, lumbar puncture procedure, lumbar puncture headache, spinal puncture, lumbar puncture pain, cerebrospinal fluid culture, cerebral spinal fluid, CSF, cerebrospinal fluid, bacterial meningitis, subarachnoid hemorrhage, pseudotumor cerebri, CNS diseases, interlaminar spaces, longitudinal dural fibers, opening pressure, post–spinal puncture headache, post–lumbar puncture headache, epidural blood patch, bloody tap, dry tap, dysesthesias, postdural puncture cerebral herniation, increased intracranial pressure

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Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Nirav R Shah, MD, MPH, Assistant Professor, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research and Rural Advocacy, Geisinger Health; Senior Analyst, LifeTech Research, Inc
Nirav R Shah, MD, MPH is a member of the following medical societies: American College of Physicians, New York Academy of Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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