From the Guidelines
Lumbar puncture is contraindicated in patients with increased intracranial pressure, infection at the puncture site, coagulopathy or anticoagulant therapy, and cardiorespiratory instability. The decision to perform a lumbar puncture should be based on a thorough clinical assessment, taking into account the potential risks and benefits of the procedure.
Key Contraindications
- Increased intracranial pressure, which can lead to brain herniation
- Infection at the puncture site, which could introduce pathogens into the CSF
- Coagulopathy or anticoagulant therapy, which can increase the risk of bleeding complications
- Cardiorespiratory instability, which can compromise the patient's ability to tolerate the procedure
Relative Contraindications
- Immunocompromised status, which may increase the risk of complications
- Previous lumbar surgery, which can complicate needle placement
- Uncooperative patients, who may require sedation or other measures to ensure safe completion of the procedure
Precautions
Before performing a lumbar puncture, clinicians should obtain neuroimaging (preferably MRI or CT) if there are signs of increased intracranial pressure, such as papilledema, focal neurological deficits, altered consciousness, or recent seizures 1. Patients on anticoagulants should have their medication held when possible, with specific timing depending on the agent (warfarin for 5-7 days, DOACs for 2-3 days, heparin for 4-6 hours) 1. If lumbar puncture is urgently needed despite coagulopathy, correction with appropriate products (fresh frozen plasma, platelet transfusion, or specific reversal agents) should be considered 1. These precautions are necessary because lumbar puncture can precipitate brain herniation in patients with increased intracranial pressure or cause epidural hematoma in those with bleeding disorders.
From the Research
Contraindications to Lumbar Puncture (LP)
The following are contraindications to lumbar puncture:
- Soft-tissue infection adjacent to the puncture site 2
- Findings of increased intracranial pressure due to a mass lesion 2, 3, 4, 5
- Coagulopathy, as performance in this setting may be hazardous 2
- Presence of an intracranial space-occupying lesion, as it may precipitate neurologic deterioration 4
- Idiopathic intracranial hypertension, as lumbar puncture is classically contraindicated in this setting 6
Rationale for Contraindications
The rationale for these contraindications is to prevent serious complications, such as:
- Cerebral herniation, which is the most serious potential complication of lumbar puncture 2
- Brain herniation, which can result from increased intracranial pressure 5
- Neurologic deterioration, which can be precipitated by lumbar puncture in the presence of an intracranial space-occupying lesion 4
- Cerebellar tonsillar herniation, which can occur following lumbar puncture in idiopathic intracranial hypertension 6