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Lumbar puncture: Technique, indications, contraindications, and

complications in adults

TECHNIQUE

PreparationAn LP can be performed with the patient in the lateral recumbent position or

sitting upright. The lateral recumbent position is preferred because it allows

accurate measurement of the opening pressure.

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 thepatient 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.

The 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 orchlorhexidine(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 [2-6].

Due to specific labeling prohibiting use, a formal institutional policy to support
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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). Many

physicians choose to advance the needle incrementally, removing the stylet

periodically to check for CSF flow, then reinserting the stylet until thesubarachnoid space is entered 7. 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 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. 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.

No trials have shown that bed rest following LP significantly decreases the risk of

post LP headache compared with immediate mobilization

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.
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Imaging guidance

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 neuroradiologistsperform 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 [12]. In addition to improving success rates,

fluoroscopic guidance may reduce the incidence of traumatic LP [13].

Imaging guidance may also be obtained with ultrasound [14]. A meta-analysis of

14 randomized trials 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 0.27respectively), as well as the number of needle insertions and redirections

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-Barr 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

Suspected CNS infection (with the exception of brain abscess or aparameningeal process).

Suspected subarachnoid hemorrhage (SAH) in a patient with a negative CTscan [18]. The use of CSF examination in the evaluation of a patient with

suspected SAH is discussed in detail separately. (See"Etiology, clinical

manifestations, and diagnosis of aneurysmal subarachnoid hemorrhage", section

on 'Lumbar puncture'.)
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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 meningitisfrom 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) Carcinomatous meningitis Tuberculous meningitis Normal pressure hydrocephalus CNS syphilis CNS vasculitis

Conditions in which LP is rarely diagnostic but still useful include:

Multiple sclerosis Guillain-Barr syndrome Paraneoplastic syndromes

LP is also required as a therapeutic or diagnostic maneuver in the following

situations

Spinal anesthesia 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)
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Suspected spinal epidural abscessThese are discussed in detail in relation to the complications with which they are

associated.

COMPLICATIONSLP 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:

Post-LP headache Infection Bleeding Cerebral herniation Minor neurologic symptoms such as radicular pain or numbness Late onset of epidermoid tumors of the thecal sac Back pain

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.

Infection


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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 werestreptococcus 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 inthe mouth and upper airway

Based upon these observations, some authors have recommended the routine

use of face masks during LP and neuroradiologic imaging procedures involving LP

Others have questioned the practicality and necessity of the use of face masks since

there is no proof that face masks prevent such infections [25,30]. 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 [31]. 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.

Because meningitis can be caused in animals by performing an LP after first

inducing a bacteremia several authors have speculated that an LP in a bacteremic

patient without preexisting meningitis might actually cause meningitis [34].

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) [35]. 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
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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 [36]. (See"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 [37-39]. These complications

presumably result from direct inoculation of bacteria into the vertebral bone.

Bleeding

Incidence and managementThe 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.

Serious bleeding that results in spinal cord compromise has occurred in up to

1 to 2 percent of patients in some case series [21,40]. 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 Patients with mild symptoms or early signs of recovery may be managed

conservatively with vigilant monitoring;dexamethasonemay be administered to

mitigate against neurologic injury

At risk patients
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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 a series cited above, spinal hematoma

developed in 7 of 342 patients (2 percent) who received anticoagulant therapy after

undergoing LP; five of these patients developed paraparesis [21]. In one literaturereview, 47 percent of 21 published cases of spinal hematoma following lumbar

puncture occurred in patients with a coagulopathy [44]. 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 [45,46].

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 1.4, without correcting the underlying abnormalities

[47,48]. 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.

For elective procedures in a patient receiving systemic anticoagulation,

observational studies and expert opinion have suggested stopping unfractionated

intravenousheparindrips two to four hours, stopping low-molecular-weight

heparin 12 to 24 hours, stoppingdabigatranone to two days, and

stoppingwarfarinfive to seven days before spinal anesthesia or LP [49,50]. 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 [21]. 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.

Aspirinhas not been shown to increase the risk of serious bleeding

following LP. In a prospective study of 924 patients who underwent orthopedic
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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 [55]. 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 [56,57]. Some studies suggest that high-risk patients

can be identified, allowing the majority of patients to safely undergo LP withoutscreening CT [55,58]. This was best illustrated in a prospective study of 301 adults

with suspected meningitis [55]. The following findings were noted:

Among the 235 (78 percent) who underwent CT scan before LP, 24 percenthad an abnormal finding but only 5 percent (11 patients) had a mass effect.

The risk of an abnormal CT scan was associated with specific clinicalfeatures (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 anabnormal 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 whounderwent 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:

Altered mentation Focal neurologic signs Papilledema Seizure within the previous week
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Impaired cellular immunityPatients 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 asmanifest by loss of differentiation between gray and white matter and effacement

of sulci, as well as ventricular enlargement and effacement of the basal cisterns

[59].

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 intravenousmannitol(1 to 1.5 g/kg). When

indicated, these should NOT await CT scan. The evaluation and management ofpatients with elevated ICP is discussed in detail separately.

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..

Others

Epidermis 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 .Most reported

cases are children ages 5 to 12 years who had a LP in infancy; however this has

also been described in adults 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

Abducens palsy

Both unilateral and bilateral abducens palsy are reported complications of

LP . This is believed to result from intracranial hypotension and is generally
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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 experiencetransient 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 keyquestions 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 10 th 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

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-Barr syndrome.

LP is a relatively safe procedure, but minor and major complications canoccur, 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.)
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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 withaspirinand nonsteroidal anti-inflammatoryagents 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 suspendtherapy, when possible, prior to elective LP.

Anticoagulation therapy is generally suspended, when possible, prior toelective LP.

We recommend NOT performing an LP in patients with coagulationdefects who are actively bleeding, have severe thrombocytopenia (eg,

platelet counts 1.4, without correcting

the underlying abnormalities.

When an LP is considered essential in this setting, consultation with ahematologist 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 LPperformed 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.

Independent of a decision to perform LP, patients with suspected elevatedICP may require urgent interventions to lower ICP.

When the LP is delayed or deferred in a patient with suspectedmeningitis, it is important to obtain blood cultures and promptly institute

antibiotic therapy.
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