Lumbar Puncture Indications and Contraindications

Indications

Urgent

Meningitis 1

  • It is very difficult to clinically rule out meningitis with out an LP. Fever, neck stiffness, altered mental status, and headache are the most common symptoms.
  • Only 2 effective ways to rule out meningitis
    • Jolt Acceleration
      • Sensitivity 97%   Specificity 60%
      • Patient turns their head horizontally 2 rotations a second for several seconds. If this does not worsen their headache, then you can rule out meningitis.
    • Absence of fever, headache, AND altered mental status
      • Sensitivity 99%
      • If any one of these three are present you cannot rule out meningitis

Subarachnoid Hemorrhage

  • For a thunderclap headache and a negative head CT, an LP should be performed to look for xanthochromia

Non-urgent

  • Wide variety of indications including suspicion for multiple sclerosis, guillain barre, paraneoplastic antibodies, leptomeningeal carcinomatosis, normal pressure hydrocephalus, pseudotumor cerebri

Contraindications

Increased Intracranial Pressure

  • IDSA recommends head CT prior to LP if2
    • Immunosuppressed
    • History of stroke or CNS mass
    • New onset seizure
    • Altered mental status
    • Focal neurologic deficits
    • Papilledema

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  • If suspecting bacterial meningitis but need a CT, work up the patient in this order
    • Blood cultures ->  Antibiotics + Dexamethasone -> CT -> LP
    • Meningococcal CSF cultures are often (-) 1 hour after antibiotics, but strep pneumonia CSF will remain (+) 4 hours after antibiotics 3
  • Concerning CT findings include4
    • Midline shift
    • Loss of normal cisterns and ventricles
      • Ask yourself: are there any black fluid filled spaces in the brain that are missing on this CT?

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Hyper-dense subdural hematoma causing midline shift and compression of the lateral ventricle.

 

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Risk of bleeding

  •  Goal platelets > 50,000 5
    • No risk of bleeding has been seen with aspirin
    • Plavix and other anti-platelet medications have not been studied
  • Goal INR < 1.5 6
    • Therapeutic anticoagulation increases the incidence of spinal hematoma and paraparesis to an absolute risk of 2%
    • Therapeutic anticoagulation should be avoided
    • Delay non-urgent LP’s 12-24 hours after prophylactic anticoagulation

Cardiorespiratory Compromise

  • Consider how patient positioning could jeopardize the patients breathing or volume status

Infection at the site of needle insertion

  • Cellulitis
  • Epidural abscess

Next Page: Complications

References

1. Attia, J., Hatala, R., Cook, D.J. & Wong, J.G. DOes this adult patient have acute meningitis? JAMA 282, 175-181 (1999).

2. Tunkel, A.R. et al. Practice Guidelines for the Management of Bacterial Meningitis. Clinical Infectious Diseases 39, 1267-1284 (2004).

3. Kanegaye, J.T., Soliemanzadeh, P. & Bradley, J.S. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics 108, 1169-74 (2001).

4. Joffe, A.R. Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med 22, 194-207 (2007).

5. Vavricka, S.R., Walter, R.B., Irani, S., Halter, J. & Schanz, U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 82, 570-3 (2003).

6. Ruff, R.L. & Dougherty, J.H., Jr. Complications of lumbar puncture followed by anticoagulation. Stroke 12, 879-81 (1981).