Lumbar Puncture 

  • Author: Gil Z Shlamovitz, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Feb 1, 2012
 

Background

Lumbar puncture is a procedure that is often performed in the emergency department to obtain information about the cerebrospinal fluid (CSF).[1, 2, 3, 4] Although usually used for diagnostic purposes to rule out potential life-threatening conditions (eg, bacterial meningitis or subarachnoid hemorrhage), it is also sometimes used for therapeutic purposes (eg, treatment of pseudotumor cerebri). CSF fluid analysis can also aid in the diagnosis of various other conditions (eg, demyelinating diseases and carcinomatous meningitis).

Lumbar puncture should be performed only after a neurologic examination but should never delay potentially life-saving interventions, such as the administration of antibiotics and steroids to patients with suspected bacterial meningitis.[5]

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Indications

Lumbar puncture should be performed for the following indications:

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Contraindications

Absolute contraindications for lumbar puncture are the presence of infected skin over the needle entry site and the presence of unequal pressures between the supratentorial and infratentorial compartments. The latter is usually inferred from the following characteristic findings on computed tomography (CT) of the brain:

  • Midline shift
  • Loss of suprachiasmatic and basilar cisterns
  • Posterior fossa mass
  • Loss of the superior cerebellar cistern
  • Loss of the quadrigeminal plate cistern

Relative contraindications for lumbar puncture include the following:

  • Increased intracranial pressure (ICP)
  • Coagulopathy
  • Brain abscess

Indications for performing brain CT scanning before lumbar puncture in patients with suspected meningitis include the following[8] :

  • 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 an abnormal level of consciousness
  • Patients with focal findings on neurologic examination
  • Patients with papilledema seen on physical examination, with clinical suspicion of an elevated ICP

Cranial CT scanning should be obtained before lumbar puncture in all patients with suspected SAH in order to diagnose obvious intracranial bleeding or any significant intracranial mass effect that might be present in awake and alert SAH patients with a normal neurologic examination.[9, 10]

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Technical Considerations

Complication prevention

The following measures should be taken to help minimize complications of lumbar puncture:

  • Explain the procedure, benefits, risks, complications, and alternative options to the patient or the patient’s representative, and obtain a signed informed consent
  • Before performing the lumbar puncture, ensure that patients are hydrated so as to avoid a dry tap
  • Never allow a lumbar puncture or a pre–lumbar puncture CT scan to delay administration of intravenous (IV) antibiotics; meningitis can usually be inferred from the cell count, antigen detection, or both
  • Avoid lumbar puncture in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation (ie, deteriorating level of consciousness and brainstem signs that include pupillary changes, posturing, irregular respirations, and very recent seizure)[11, 12]

The smaller the needle used for the lumbar puncture, the lower the risk that the patient will experience a post–lumbar puncture headache. Data suggest an inverse linear relation between needle gauge and headache incidence, and some authors recommend using a 22-gauge needle regardless of what size needle is supplied with the kit.[13]

The use of atraumatic needles has been shown to significantly reduce the incidence of post–lumbar puncture headache (3%) when compared to the use of standard spinal needles (approximately 30%).[14, 15] In addition, it may lead to cost savings.[16] However, obtaining pressures can be more difficult with atraumatic needles.

Prophylactic bed rest after lumbar puncture has not been shown to be of benefit and should not be recommended.[17, 18, 19]

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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD  Assistant Professor, Section of Emergency Medicine, Baylor College of Medicine; Director of Medical Informatics, Emergency Center, Ben Taub General Hospital

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  Commissioner, New York State Department of 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.

Chief Editor

Helmi L Lutsep, MD  Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; 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; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

Additional Contributors

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.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; 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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

References

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

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

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

  4. Cooper N. Lumbar puncture. Acute Med. 2011;10(4):188-93.

  5. 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].

  6. 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].

  7. Chern JJ, Tubbs RS, Gordon AS, Donnithorne KJ, Oakes WJ. Management of pediatric patients with pseudotumor cerebri. Childs Nerv Syst. Jan 19 2012;[Epub ahead of print].

  8. 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].

  9. Baraff LJ, Byyny RL, Probst MA, Salamon N, Linetsky M, Mower WR. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med. Apr 2010;17(4):423-8. [Medline].

  10. Boesiger BM, Shiber JR. Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: are fifth generation CT scanners better at identifying subarachnoid hemorrhage?. J Emerg Med. Jul 2005;29(1):23-7. [Medline].

  11. 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].

  12. 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].

  13. 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].

  14. [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].

  15. 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].

  16. Tung CE, So YT, Lansberg MG. Cost comparison between the atraumatic and cutting lumbar puncture needles. Neurology. Jan 10 2012;78(2):109-13. Epub 2011 Dec 28.

  17. 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].

  18. 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].

  19. 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].

  20. Avery RA, Mistry RD, Shah SS, Boswinkel J, Huh JW, Ruppe MD, et al. Patient Position During Lumbar Puncture has no Meaningful Effect on Cerebrospinal Opening Pressure in Children. J Child Neurol. Feb 22 2010;[Medline].

  21. 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].

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

  23. 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].

  24. Lenelle L, Lahaye-Goffart B, Dewandre PY, Brichant JF. [Post-dural puncture headache: treatment and prevention]. Rev Med Liege. Nov 2011;66(11):575-80. [Article in French].

  25. Majd SA, Pourfarzam S, Ghasemi H, Yarmohammadi ME, Davati A, Jaberian M. Evaluation of pre lumbar puncture position on post lumbar puncture headache. J Res Med Sci. Mar 2011;16(3):282-6.

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

  27. 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].

 
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Lumbar puncture disposable tray. Image courtesy of Gil Z Shlamovitz, MD.
Lumbar puncture lateral recumbent position. Image courtesy of Gil Z Shlamovitz, MD.
Lumbar puncture sitting position. Image courtesy of Gil Z Shlamovitz, MD.
L3-L4 interspace palpation. Image courtesy of Gil Z Shlamovitz, MD.
CSF collection tubes. Image courtesy of Gil Z Shlamovitz, MD.
Skin preparation. Video courtesy of Gil Z Shlamovitz, MD.
Drape application. Video courtesy of Gil Z Shlamovitz, MD.
Local anesthesia. Video courtesy of Gil Z Shlamovitz, MD.
Spinal needle insertion. Video courtesy of Gil Z Shlamovitz, MD.
Spinal needle removal. Video courtesy of Gil Z Shlamovitz, MD.
Opening pressure measurement. Video courtesy of Gil Z Shlamovitz, MD.
 
 
 
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