What are the indications and contraindications for performing a Lumbar Puncture (LP) on a patient?

From the Guidelines

Lumbar puncture (LP) should be performed in patients with suspected meningitis or other conditions requiring cerebrospinal fluid analysis, but only after carefully evaluating for contraindications such as signs of increased intracranial pressure, infection at the puncture site, or coagulopathy, as outlined in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1. The indications for LP include diagnosing conditions like meningitis, encephalitis, subarachnoid hemorrhage, multiple sclerosis, or Guillain-Barré syndrome, as well as measuring CSF pressure in conditions like idiopathic intracranial hypertension.

• Key indications for LP:
  • Diagnosing infectious or inflammatory conditions affecting the central nervous system
  • Measuring CSF pressure in conditions like idiopathic intracranial hypertension
  • Administering intrathecal medications or chemotherapy
• Contraindications for LP, as recommended by the guideline 1, include:
  • Signs of severe sepsis or rapidly evolving rash
  • Respiratory or cardiac compromise
  • Anticoagulant therapy or known thrombocytopenia
  • Infection at the site of LP
  • Focal neurological signs, presence of papilloedema, or continuous or uncontrolled seizures, which require neuroimaging before LP
  • Glasgow Coma Scale (GCS) score ≤12, although LP may be safe at lower levels of consciousness The guideline also provides recommendations for managing coagulopathy in patients undergoing LP, including delaying the procedure in patients on anticoagulant therapy or with known thrombocytopenia, and considering the risks and benefits of reversing anticoagulation in patients on warfarin or other anticoagulants 1.
• Management of coagulopathy:
  • Delay LP in patients on anticoagulant therapy or with known thrombocytopenia
  • Consider the risks and benefits of reversing anticoagulation in patients on warfarin or other anticoagulants
  • Use platelet transfusion or other measures to manage thrombocytopenia, if necessary In summary, LP is a valuable diagnostic and therapeutic procedure, but it requires careful evaluation of indications and contraindications, as well as management of coagulopathy and other potential complications, to ensure safe and effective performance.

From the Research

Indications for Lumbar Puncture (LP)

• Acute central nervous system (CNS) infections, such as meningitis and encephalitis, are indications for LP, as analysis of the cerebrospinal fluid (CSF) is pivotal to establishing the diagnosis and guiding management 2
• Suspected CNS infections, where LP can help identify the pathogen and guide treatment 3
• Diagnosis of multiple sclerosis (MS), although the usefulness of LP in this context is debated 4
• Other neurological syndromes, such as optic neuropathy and unspecified demyelinating disease, where LP can help analyze CSF oligoclonal bands (OCBs) 5

Contraindications for Lumbar Puncture (LP)

• Increased intracranial pressure, as LP can worsen this condition 6
• Traumatic LP, which can entail infrequent risks and represents unnecessary expense 4
• Patients with suspected CNS infections who have undergone cranial imaging, as this may not be associated with treatment delays, but can still be a contraindication in certain cases 3
• Patients with MS, where LP is not recommended by the 2010 McDonald criteria and CSF analysis is not useful for diagnosis 4

Special Considerations

• Repeated LP for OCBs analysis may not yield a practical benefit, as the conversion rate of OCBs status is low and may not lead to a change in diagnosis or clinical management 5
• The presence of oligoclonal bands in CSF analysis may not represent a surrogate marker for individual prognostic outcomes 4