Lumbar Puncture Complications

Traumatic Tap

  • Blood contamination in the CSF from traumatic taps can be reduced with ultrasound guidance1
  • A clue to a traumatic tap is that the RBC count falls from tube 1 to tube 4
  • To figure out if there is active inflammation in the CSF following a traumatic tap, subtract 1 WBC for every 700 RBC in the CSF2

Post-LP Headache

  • Occurs in up to 40% of patients3
  • Symptoms4
    • Frontal or occipital headache within 6 to 48 hours of the procedure
    • Exacerbated by being upright and improved while supine
    • Can be severe and can last up to 2 weeks
    • Rarely associated with nausea, vomiting, dizziness, tinnitus and visual changes
  • Reduced by
    • Horizontal needle insertion parallel to the spinal cord in the sagittal plane4
    • When finished collecting CSF, reinsert the stylet before removing the needle5
    • Smaller needles with a rounded tip

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Keeping the needle bevel in the sagittal plane parallel to the spinal cord to spread the dural fibers instead of cutting them

  • Headaches are NOT prevented by laying flat after the procedure6
  • Treatment
    • Bed rest and analgesics
    • If symptoms are severe and persistent, an epidural blood patch is very effective at stopping the CSF leak and resolving the headache7

Back Pain 3

  • Localized pain over the needle track occurs in up to 40%

Radicular Symptoms3

  • Occurs in 10% of patients during the procedure when the needle is too lateral and encounters a nerve route
  • Immediately withdraw the needle, re-identify landmarks, and re-insert in the proper midline
  • Pain should resolve quickly with needle re-direction

Spinal Epidural Hematoma

  • Suspect if radicular pain fails to resolve quickly or if other neurologic symptoms occur
  • Requires emergent MRI and neurosurgery consult
  • Do not perform LP if patient is receiving therapeutic anticoagulation

Brain Herniation8

  • CT prior to LP if the patient meets the IDSA criteria on previous page
    • Look for compression and loss of ventricles and cisterns on CT
  • Closely monitor for herniation if opening pressure > 25 cm H2O
  • 50% of patients with herniation decompensate immediately during the LP, but some herniations can be delayed up to 12 hours

Iatrogenic CNS Infection

  • Adhere to sterile technique and avoid passing the needle through areas cellulitis or known epidural abscess

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References

  1. Shaikh, F. et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ 346, f1720 (2013).
  2. Conly, J.M. & Ronald, A.R. Cerebrospinal fluid as a diagnostic body fluid. The American Journal of Medicine 75, 102-108 (1983).
  3. Flaatten, H., Krakenes, J. & Vedeler, C. Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia. Acta Neurol Scand 98, 445-51 (1998).
  4. Amorim, J.A., Gomes de Barros, M.V. & Valenca, M.M. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 32, 916-23 (2012).
  5. Strupp, M., Brandt, T. & Muller, A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J Neurol 245, 589-92 (1998).
  6. Arevalo-Rodriguez, I., Ciapponi, A., Munoz, L., Roque i Figuls, M. & Bonfill Cosp, X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 7, CD009199 (2013).
  7. Boonmak, P. & Boonmak, S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev, CD001791 (2010).
  8. Joffe, A.R. Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med 22, 194-207 (2007).