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 and Associate Director for Research, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research, Geisinger Health
Contributor Information and Disclosures

Updated: Jul 20, 2009

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

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:4
    • 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. Petzold A, Brettschneider J, Jin K, et al. CSF protein biomarkers for proximal axonal damage improve prognostic accuracy in the acute phase of Guillain-Barré syndrome. Muscle Nerve. Jul 2009;40(1):42-9. [Medline].

  4. 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].

  5. 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].

  6. [Best Evidence] 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

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

  13. Kim HJ, Cho YJ, Cho JY, Lee DH, Hong KS. Acute subdural hematoma following spinal cerebrospinal fluid drainage in a patient with freezing of gait. J Clin Neurol. Jun 2009;5(2):95-6. [Medline].

  14. Aronson PL, Zonfrillo MR. Epidural cerebrospinal fluid collection after lumbar puncture. Pediatr Emerg Care. Jul 2009;25(7):467-8. [Medline].

  15. Hatfield MK, Handrich SJ, Willis JA, Beres RA, Zaleski GX. Blood patch rates after lumbar puncture with Whitacre versus Quincke 22- and 20-gauge spinal needles. AJR Am J Roentgenol. Jun 2008;190(6):1686-9. [Medline].

  16. Joffe AR. Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med. Jul-Aug 2007;22(4):194-207. [Medline].

  17. Oliver WJ, Shope TC, Kuhns LR. Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma. Pediatrics. Sep 2003;112(3 Pt 1):e174-6. [Medline].

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

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

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Further Reading

MedlinePlus: CSF Collection

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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 and Associate Director for Research, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research, Geisinger Health
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 financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate 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, 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

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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