Lumbar Puncture Counselling: Key Components
When counselling patients for lumbar puncture, you must discuss the specific complications with quantified risks, emphasize that atraumatic needles will be used to minimize these risks, and explain the procedure's purpose and technique. 1
Essential Discussion Points for Patient Counselling
Complications That Must Be Discussed
Despite using optimal technique, complications cannot be eliminated entirely and patients must understand the following risks: 1
Post-Dural Puncture Headache (Most Common)
- With atraumatic needles: 39 per 1000 procedures 1
- With conventional needles: 98 per 1000 procedures (for comparison) 1
- This represents a 60% reduction in risk when atraumatic needles are used 1
- Younger patients face higher risk, while those >65 years have 32% lower risk 2
- Headache typically worsens when upright and improves when lying flat 3
Other Complications to Discuss
- Epidural blood patch requirement: 12 per 1000 with atraumatic needles (vs. 24 per 1000 with conventional) 1
- Hearing disturbance: 13 per 1000 with atraumatic needles (vs. 53 per 1000 with conventional) 1
- Nerve root irritation: 89 per 1000 with atraumatic needles (vs. 126 per 1000 with conventional) 1
- Hospital readmission for IV fluids/analgesia: 17 per 1000 with atraumatic needles (vs. 39 per 1000 with conventional) 1
- Back pain: No significant difference between needle types (approximately 160 per 1000) 1
- Failed procedure: 33 per 1000 with atraumatic needles (no important difference from conventional) 1
Serious But Rare Complications
- Cerebral or spinal herniation (in setting of mass lesion with elevated intracranial pressure) 4, 5
- Spinal hematoma (particularly with coagulopathy) 5, 6
- Infection/meningitis 4, 5
- Cranial neuropathies (particularly diplopia) 4, 5
Contraindications to Screen For
You must evaluate and discuss these contraindications before proceeding: 2
- Deteriorated level of consciousness or focal neurological signs suggesting mass lesion 2
- Coagulopathy: Platelet count <50 × 10⁹/L is a contraindication for elective diagnostic lumbar puncture 2
- Soft-tissue infection at puncture site 5, 6
- Evidence of increased intracranial pressure from mass lesion 5, 6
Technique Details to Explain
Inform patients that the following evidence-based techniques will be used to minimize complications: 2
- Atraumatic (pencil-point) needles ≥22 gauge, preferably ≥24 gauge will be used, as these dramatically reduce post-dural puncture headache risk 2, 1
- Lateral decubitus positioning to ensure accurate opening pressure measurement 2
- Proper bevel orientation: If atraumatic needles are used, orientation is less critical; if cutting needles must be used, bevel parallel to spine's long axis 7
What Will Be Analyzed
Explain that cerebrospinal fluid analysis will include: 2
- Cell count with differential 2, 8
- Glucose determination 2, 8
- Protein concentration 2, 8
- Additional studies based on diagnostic suspicion (Gram stain, cultures, specific markers) 2, 8
Special Considerations to Mention
In certain clinical scenarios, patients should know: 2
- If herpes simplex encephalitis is suspected, 5-10% may have initially normal cerebrospinal fluid, potentially requiring repeat lumbar puncture if clinical suspicion persists 2
- The procedure has been used safely for nearly a century and is considered safe in expert hands when proper technique and indications are followed 6, 8
Common Pitfalls in Counselling
- Failing to quantify risks: Patients need actual numbers, not vague statements about "possible complications" 1
- Not emphasizing needle type matters: The 60% reduction in headache risk with atraumatic needles is a major quality-of-life benefit that should be highlighted 1
- Omitting age-related risk stratification: Younger patients need to know they face higher complication risks 2
- Not explaining that complications cannot be eliminated: Even with optimal technique, risks remain 1