Lumbar Puncture - Curbside
Lumbar Puncture
Editors: Dan Imler, MD, Nat Wharton
Inclusion Criteria  (Any one criteria present)
  • Clinical need for lumbar puncture
Exclusion Criteria
  • Clinically unstable patient
  • Patients at risk of decreased venous return to heart from LP positioning
  • Soft tissue infection over puncture site
  • Anatomical issues (obesity, orthopedic issues, etc.) making LP very difficult
Consider delaying LP or consulting interventional radiology for fluoroscopic guidance

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Evidence
Total Notes: 15
Evidence

1 Lumbar Puncture

The lumbar puncture is a common and safe procedure for multiple diagnostic and therapeutic interventions. Patients who are clinically unstable may have their LPs deferred until such time as they can safely be performed. In the case of presumed bacterial meningitis, if the LP cannot be performed quickly or the patient is acutely ill, giving antibiotics prior to LP may be warranted.

Certain patients with cardiopulmonary disease (including newborns with congenital heart disease) may be at increased risk of cardiovascular compromise if they are placed in the sitting or lateral recumbent position for LP. It is rare that these patients cannot still undergo an LP with attenuated positioning to ensure venous return.

The provider should evaluate all patients for anatomical issues which may make LP more difficult. Severe obesity, orthopedic complications, spine surgery and other issues may prompt the provider to consult with intervential radiology for fluoroscopic guidance for LP.



References:
  1. The spinal tap: a new look at an old test.
    Marton KI, Gean AD
    Ann Intern Med. 1986;104(6):840.
  2. Lumbar puncture.
    Sternbach G
    J Emerg Med. 1985;2(3):199.

2 Increased intracranial pressure

The most feared complication of a lumbar puncture is the risk of cerebral herniation secondary to the effect on the brain anatomy from an occupying mass or other cause in increased intracranial pressure. Multiple studies have tried to identify patients who are at high risk of herniation. Classically bacterial meningitis was a concern, however more recent studies have shown that meningitis is of little risk and that lumbar puncture can be safely preformed in these patients without the need of antecedent brain imaging.

Any patient with altered mental status, papilledema, seizures in the past week, impaired cellular immunity, history of intracranial pathology or other focal neurologic signs of increased intracranial pressure should undergo brain imaging (CT or MRI) prior to LP.

It should be noted that a normal CT does not completely remove the risk of herniation and that providers should proceed with caution in high risk patients.



References:
  1. Lumbar puncture in spontaneous subarachnoid haemorrhage.
    Duffy GP
    Br Med J (Clin Res Ed). 1982;285(6349):1163.
  2. Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension.
    Korein J, Cravioto H, Leicach M
    Neurology. 1959 Apr;9(4):290-7.
  3. Lumbar puncture in the presence of raised intracranial pressure.
    Duffy GP
    Br Med J. 1969;1(5641):407.
  4. Computed tomography of the head before lumbar puncture in adults with suspected meningitis.
    Hasbun R, Abrahams J, Jekel J, Quagliarello VJ
    N Engl J Med. 2001;345(24):1727.
  5. Fatal cerebral herniation after lumbar puncture in a patient with a normal computed tomography scan.
    Shetty AK, Desselle BC, Craver RD, Steele RW
    Pediatrics. 1999;103(6 Pt 1):1284.
  6. Lumbar puncture and brain herniation in acute bacterial meningitis: a review.
    Joffe AR
    J Intensive Care Med. 2007;22(4):194.
  7. Cranial computed tomography before lumbar puncture: a prospective clinical evaluation.
    Gopal AK, Whitehouse JD, Simel DL, Corey GR
    Arch Intern Med. 1999;159(22):2681.
  8. Lumbar puncture and the risk of herniation: when should we first perform CT?
    van Crevel H, Hijdra A, de Gans J
    J Neurol. 2002;249(2):129.
  9. Cerebral herniation during bacterial meningitis in children.
    Rennick G, Shann F, de Campo J
    BMJ. 1993;306(6883):953.

3 Bleeding diathesis

In a large study of greater than 5,000 ALL patients of which 941 patients had platelet counts less than 50k and 29 patients had platelet counts less than 10k there were no significant complications from LP (of note, this is only a small number of patients less than 10k platelets and is difficult to interoperate). Also, in a study looking at hemophilia patients who received factor replacement prior to LP there were no major complications. However, patients with uncorrected bleeding risks, LP should only be undergone after a complete review of the risks and may be further clarified by consultation with a hematologist.

Anticoagulation has also been associated with an increased risk of spinal hematoma and bleeding complications, especially with INR greater than 4. Aspirin has not been associated with these risks. In any patient considered at risk of bleeding the provider should make a throughout risk assessment prior to proceeding. Spinal hematomas should be high on the differential of any patient with a bleeding diathesis and prompt intervention should proceed given the risk of neurologic compromise.



References:
  1. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia.
    Howard SC, Gajjar A, Ribeiro RC, Rivera GK, Rubnitz JE, Sandlund JT, Harrison PL, de Armendi A, Dahl GV, Pui CH
    JAMA. 2000;284(17):2222.
  2. Safety of lumbar puncture in patients with hemophilia.
    Silverman R, Kwiatkowski T, Bernstein S, Sanders N, Hilgartner M, Cahill-Bordas M, Jackson K, Lipton R
    Ann Emerg Med. 1993;22(11):1739.
  3. Personal practice: how we manage the risk of bleeding and thrombosis in children and young adults with acute lymphoblastic leukaemia.
    Astwood E, Vora A
    Br J Haematol. 2011 Mar;152(5):505-11.
  4. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion.
    Vavricka SR, Walter RB, Irani S, Halter J, Schanz U
    Ann Hematol. 2003;82(9):570.
  5. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals.
    van Veen JJ, Nokes TJ, Makris M
    Br J Haematol. 2010;148(1):15.
  6. Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009.
    Pitkänen MT, Aromaa U, Cozanitis DA, Förster JG
    Acta Anaesthesiol Scand. 2013 May;57(5):553-64.
  7. Cauda equina syndrome following a lumbar puncture.
    Sinclair AJ, Carroll C, Davies B
    J Clin Neurosci. 2009 May;16(5):714-6.
  8. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses.
    Choi S, Brull R
    Anesth Analg. 2009;109(2):648.
  9. Recommendations for anticoagulated patients undergoing image-guided spinal procedures.
    Layton KF, Kallmes DF, Horlocker TT
    AJNR Am J Neuroradiol. 2006;27(3):468.

4 Topical anesthetics

Topical anesthetics can provide pain relief for the skin puncture associated with lumbar puncture and should be used in most cases where time allows and there are no contraindications.

ELMA should only be placed on intact skin as it can be absorbed systemically through wounded tissue. It also carries the risk of methemoglobinemia in patients with underlying risk factors. The key to efficacy in use of EMLA appears to be length of time the medication is left on intact skin. Anesthesia measured by needle insertion was 3 mm one hour and 5 mm after 1.5 to 2 hours.

Liposomal lidocaine (ELA-max) has shown efficacy vs. placebo and in some cases vs. EMLA (although there are contradicting studies). It does have a faster onset of action than EMLA.

Similar to EMLA and Liposomal lidocaine, the self-heating lidocaine and tetracaine patch (Synera) has shown improvement over placebo. It has the shortest onset of action of the three.



References:
  1. Topical skin anesthesia for venous, subcutaneous drug reservoir and lumbar punctures in children.
    Halperin DL, Koren G, Attias D, Pellegrini E, Greenberg ML, Wyss M.
    Pediatrics. 1989;84(2):281.
  2. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream.
    Bjerring P, Arendt-Nielsen L
    Br J Anaesth. 1990;64(2):173.
  3. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children.
    Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB
    Pediatrics. 2002;109(6):1093.
  4. Topical anesthetics for intravenous insertion in children: a randomized equivalency study.
    Kleiber C, Sorenson M, Whiteside K, Gronstal BA, Tannous R
    Pediatrics. 2002;110(4):758.
  5. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion.
    Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T
    Paediatr Anaesth. 2004;14(12):977.
  6. A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates.
    Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G.
    Pediatrics. 1998 Feb;101(2):E1.
  7. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns.
    Kaur G, Gupta P, Kumar A.
    Arch Pediatr Adolesc Med. 2003 Nov;157(11):1065-70.

5 Procedural sedation

Sedation has been shown to improve provider’s ability to adequately preform procedures in patients who otherwise would not be able to tolerate the procedure. There are no hard and fast indications for the use of procedural sedation. The providers should assess the patient's level of anxiety, behavioral status and ability to tolerate the procedure and weight this against the risks inherent in sedation.



References:
  1. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;Lancet. 2006;
  2. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.
    American Academy of Pediatrics, American Academy of Pediatric Dentistry, CotéCJ, Wilson S, Work Group on Sedation
    Pediatrics. 2006;118(6):2587.
  3. Relief of pain and anxiety in pediatric patients in emergency medical systems.
    Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
    Pediatrics. 2004;114(5):1348.

6 Anxiolysis

Lumbar puncture can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.

Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrious oxide.

Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).



References:
  1. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.
    Annequin D, Carbajal R, Chauvin P, Gall O, Tourniaire B, Murat I.
    Pediatrics. 2000 Apr;105(4):E47.
  2. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.
    Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM
    Ann Emerg Med. 2001;37(1):20.
  3. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents.
    Ekbom K, Kalman S, Jakobsson J, Marcus C
    Arch Pediatr Adolesc Med. 2011;165(9):785.
  4. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases.
    Zier JL, Liu M
    Pediatr Emerg Care. 2011 Dec;27(12):1107-12.
  5. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation.
    Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN
    Pediatrics. 2008 Mar;121(3):e528-32.
  6. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.

7 Oral sucrose

Oral sucrose (and other sweet tasting liquids) has been shown to have an anesthetic effect on infants up to 3 months of age (including preterm infants). Studies noted: reduced crying, reduced changes in physiologic responses (HR, O2sat, and vagal tone), low pain score from facial expression and improved composite pain scores. Sucrose likely works by activating the infant’s opioid receptors and non-opioid systems. Naloxone has been shown to block the effects of giving sucrose as well.

Therefore, for mildly painful procedures sucrose is likely a helpful adjunct to other anesthetics or used on its own.



References:
  1. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise.
    Harrison D, Bueno M, Yamada J, Adams-Webber T, Stevens B
    Pediatrics. 2010;126(5):894.
  2. Sucrose for analgesia in newborn infants undergoing painful procedures.
    Stevens B, Yamada J, Ohlsson A
    Cochrane Database Syst Rev. 2010;1:CD001069
  3. Oral sucrose and facilitated tucking for repeated pain relief in preterms: a randomized controlled trial.
    Cignacco EL, Sellam G, Stoffel L, Gerull R, Nelle M, Anand KJ, Engberg S
    Pediatrics. 2012;129(2):299.
  4. Pain-reducing properties of sucrose in human newborns.
    Blass EM, Shah A
    Chem Senses. 1995;20(1):29.
  5. The role of endogenous opioids in mediating pain reduction by orally administered glucose among newborns.
    Gradin M, Schollin J
    Pediatrics. 2005;115(4):1004.
  6. Beta-endorphin concentration after administration of sucrose in preterm infants.
    Taddio A, Shah V, Shah P, Katz J
    Arch Pediatr Adolesc Med. 2003;157(11):1071.
  7. Efficacy of sucrose to reduce pain in premature infants during eye examinations for retinopathy of prematurity.
    Gal P, Kissling GE, Young WO, Dunaway KK, Marsh VA, Jones SM, Shockley DH, Weaver NL, Carlos RQ, Ransom JL
    Ann Pharmacother. 2005;39(6):1029.
  8. Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial.
    Boyle EM, Freer Y, Khan-Orakzai Z, Watkinson M, Wright E, Ainsworth JR, McIntosh N
    Arch Dis Child Fetal Neonatal Ed. 2006;91(3):F166.
  9. Pain management during eye examinations for retinopathy of prematurity in preterm infants: a systematic review.
    Sun X, Lemyre B, Barrowman N, O'Connor M
    Acta Paediatr. 2010;99(3):329.
  10. Analgesia in preterm newborns: the comparative effects of sucrose and glucose.
    Okan F, Coban A, Ince Z, Yapici Z, Can G
    Eur J Pediatr. 2007;166(10):1017.

8 Patient positioning

The patient may be placed in the lateral recumbent or sitting position for lumbar puncture. The sitting position may be useful for ill patients or those with respiratory distress. It is often easier to monitor patients in this position and may not cause as much respiratory compromise as there is less neck hyperflexion. The lateral recumbent position is necessary for opening pressure measurement. However, an ultrasound study has shown that hyperflexion of the neck in lateral recumbent positioning did not increase the interspinous spaces an may not be useful (unless the child is uncooperative).



References:
  1. Optimal position for a spinal tap in preterm infants.
    Gleason CA, Martin RJ, Anderson JV, Carlo WA, Sanniti KJ, Fanaroff AA
    Pediatrics. 1983;71(1):31.
  2. The effect of lumbar puncture position in sick neonates.
    Weisman LE, Merenstein GB, Steenbarger JR
    Am J Dis Child. 1983;137(11):1077.
  3. Positioning for lumbar puncture in children evaluated by bedside ultrasound.
    Abo A, Chen L, Johnston P, Santucci K
    Pediatrics. 2010;125(5):e1149.

9 Puncture site

In order to safely perform a lumbar puncture the needle must enter the subarachnoid space below the terminating level of the spinal cord within the cauda equina. One should note that the level of spinal cord termination changes with age. At birth the tip is at the L3 vertebral body and as the child grows to adulthood the vertebral column grows faster than the cord so that by adulthood the tip is at the inferior border of the L1 vertebral body. Therefore in children less than 1 year the LP must be performed below the L2-L3 interspace.

To locate the L4 vertebral body the provider can follow a perpendicular line between the iliac crests. Ultrasound guidance has been shown helpful in identifying the correct lumbar interspaces and positioning for spinal needle insertion.



References:
  1. Textbook of Pediatric Emergency Medicine Procedures
    Cronin KM, Wiley JF.
    Lippincott Williams & Wilkins, Philadelphia 1997.p.541.
  2. Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach.
    Conroy PH, Luyet C, McCartney CJ, McHardy PG
    Anesthesiol Res Pract. 2013;2013:525818.
  3. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis.
    Shaikh F, Brzezinski J, Alexander S, Arzola C, Carvalho JC, Beyene J, Sung L
    BMJ. 2013;346:f1720.

10 Local anesthetic infiltration

The use of local anesthetic (1% lidocaine) has been shown to decrease pain in children and adults and may improve the likelihood of successful procedure. Even in young children the use of local anesthetic should be used unless there are contraindications to administration.



References:
  1. Role of local anesthesia during lumbar puncture in neonates.
    Pinheiro JM, Furdon S, Ochoa LF
    Pediatrics. 1993;91(2):379.
  2. Lidocaine for lumbar punctures. A help not a hindrance.
    Carraccio C, Feinberg P, Hart LS, Quinn M, King J, Lichenstein R
    Arch Pediatr Adolesc Med. 1996;150(10):1044.
  3. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success.
    Baxter AL, Fisher RG, Burke BL, Goldblatt SS, Isaacman DJ, Lawson ML
    Pediatrics. 2006;117(3):876.
  4. Risk factors for traumatic or unsuccessful lumbar punctures in children.
    Nigrovic LE, Kuppermann N, Neuman MI
    Ann Emerg Med. 2007;49(6):762.

11 Needle positioning

The angle of the needle should be with the bevel parallel to the fibers of the ligamentum flavum (upwards in the lateral decubitus - sideways for sitting). This spreads the fibers of the ligamentum flavum instead of cutting them and may lead to a decreased incidence of post-LP headache.

Using higher gauge needles also has decreased the incidence of post-LP headaches as has the use of spinal (atraumatic) needles vs. conventional (cutting) needles.



References:

12 Stylet removal

A rare complication of lumbar puncture is the transfer of epidermal tissue into the spinal column causing an epidermal tumor. The lack of a stylet or loose stylet can catch epidermal tissue as it goes through the skin. Therefore a stylet should always be used during the skin puncture. However, once through the skin the stylet can be removed. Several studies have shown improved rates for successful and nontraumatic lumbar punctures with the removal of the stylet as it allows the provider to immediately know when CSF is obtained through visualization of fluid at the hub. After fluid is collected and the needle is to be removed, the stylet should always be reinserted into the needle as this decreases leakage through the dura and the incidence of post-LP headache.



References:
  1. Epidermoid tumours associated with lumbar punctures performed in early neonatal life.
    Potgieter S, Dimin S, Lagae L, Van Calenbergh F, Plets C, Demaerel P, Casaer P
    Dev Med Child Neurol. 1998;40(4):266.
  2. Epidermoid spinal cord tumour after lumbar puncture.
    Halcrow SJ, Crawford PJ, Craft AW
    Arch Dis Child. 1985;60(10):978.
  3. Iatrogenic intraspinal epidermoid tumor: two cases and a review of the literature.
    Ziv ET, Gordon McComb J, Krieger MD, Skaggs DL
    Spine (Phila Pa 1976). 2004;29(1):E15.
  4. Iatrogenic intraspinal epidermoid tumor: case report.
    Jeong IH, Lee JK, Moon KS, Kwak HJ, Joo SP, Kim TS, Kim JH, Kim SH
    Pediatr Neurosurg. 2006;42(6):395.
  5. Intraspinal epidermoid tumors caused by lumbar puncture.
    McDonald JV, Klump TE
    Arch Neurol. 1986;43(9):936.
  6. Iatrogenic intraspinal epidermoid tumors.
    Batnitzky S, Keucher TR, Mealey J Jr, Campbell RL
    JAMA. 1977;237(2):148.
  7. Pain, position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians.
    Baxter AL, Welch JC, Burke BL, Isaacman DJ
    Pediatr Emerg Care. 2004;20(12):816.
  8. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success.
    Baxter AL, Fisher RG, Burke BL, Goldblatt SS, Isaacman DJ, Lawson ML
    Pediatrics. 2006;117(3):876.
  9. Risk factors for traumatic or unsuccessful lumbar punctures in children.
    Nigrovic LE, Kuppermann N, Neuman MI
    Ann Emerg Med. 2007;49(6):762.
  10. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?
    Straus SE, Thorpe KE, Holroyd-Leduc J
    JAMA. 2006;296(16):2012.
  11. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients.
    Strupp M, Brandt T, Müller A
    J Neurol. 1998 Sep;245(9):589-92.

13 Needle angle

Even with flexion of the lumbar spine, the needle often will need to be angled cephelad to transverse the interspinous space. Classically the provider was instructed to direct the needle towards the patient's umbilicus. In a study by Bruccoleri et al using ultrasound measurements the angle was more acute in infants less than one year than older children and using this angle may theoretically improve the provider’s success rate.



References:
  1. Needle-entry angle for lumbar puncture in children as determined by using ultrasonography.
    Bruccoleri RE, Chen L
    Pediatrics. 2011;127(4):e921.

14 Opening pressure

Normal opening pressure 50 - 200 mmH20 in relaxed patient & 100 - 280 mmH20 in patients with neck and legs flexed. Opening pressures are only valid if patient in the lateral recumbent position.



References:
  1. Lumbar cerebrospinal fluid opening pressure measured in a flexed lateral decubitus position in children.
    Ellis R 3rd
    Pediatrics. 1994;93(4):622.
  2. Reference range for cerebrospinal fluid opening pressure in children.
    Avery RA, Shah SS, Licht DJ, Seiden JA, Huh JW, Boswinkel J, Ruppe MD, Chew A, Mistry RD, Liu GT
    N Engl J Med. 2010;363(9):891.

15 Collection and after care

Previously patients were told to lay flat after a lumbar puncture to prevent post-LP headaches. However, there is no evidence that this helps and is not necessary for this procedure.



References: