From the Guidelines
Lumbar puncture (LP) is indicated in adults with muscle fasciculations when there is a suspicion of neurological disorders such as Guillain-Barré syndrome, multiple sclerosis, or spinal cord compression.
Indications for LP
- Diagnosis of neurological disorders, such as Guillain-Barré syndrome, multiple sclerosis, or spinal cord compression
- Investigation of suspected central nervous system infections, such as meningitis or encephalitis
- Evaluation of cerebrospinal fluid (CSF) biomarkers for neurodegenerative diseases, such as Alzheimer's disease
Contraindications for LP
- Local skin sepsis at the site of puncture
- Clinically unstable patient
- Clinical suspicion of spinal cord compression
- Coagulopathy or bleeding disorders
- Platelet count less than 100 x 10^9/L
- Use of anticoagulant medication, such as warfarin or novel oral anticoagulants (NOACs)
Procedure and Technique
- Use of atraumatic needles (e.g., 24 G) to reduce the risk of post-LP headache
- Needle diameter and length should be chosen based on patient characteristics, such as obesity
- LP can be performed with the patient in either a lateral recumbent (supine) or sitting position
- Active withdrawal of CSF through a syringe is not recommended, as it increases the risk of post-LP headache
- Gravity flow removal is preferred, and the volume of CSF withdrawn should be limited to 5-12 mL
Adverse Events
- Post-LP headache is the most common adverse event, occurring in up to 9% of patients
- Back pain, nausea, vomiting, and dizziness are also possible adverse events
- Severe complications, such as infection, cerebral or spinal hemorrhage, and cerebral venous thrombosis, are rare but potentially disabling or fatal As stated by 1, the management of suspected viral encephalitis in adults includes LP as a diagnostic tool, and the procedure should be performed with caution in patients with coagulopathy or bleeding disorders. Additionally, 1 highlights the importance of using atraumatic needles and proper technique to reduce the risk of post-LP headache and other adverse events.
From the Research
Indications for Lumbar Puncture
The indications for lumbar puncture (LP) in an adult with muscle fasciculations, a symptom of potential neurological disorders, include:
- Infectious diseases affecting the central nervous system (CNS) 2, 3
- Inflammatory diseases affecting the CNS 2, 3
- Neoplastic diseases affecting the CNS 2
- Acute severe headache 4
- Encephalopathy 4
- Guillain-Barré syndromes 3
- Subarachnoid hemorrhages (SAH) 3
- Carcinomatous meningitis 3
Diagnostic Efficiency
The diagnostic efficiency of LP varies by indication, with the highest yield of abnormal results seen in cases of acute severe headache and encephalopathy 4. The efficiency of LP is modest, but it is an important tool in the diagnosis of neurological diseases, particularly in cases where the suspected diagnosis is serious 3.
Complications
The complications of LP are infrequent, but can be severe 2. The most common complication is post-dural puncture headache (PDPH), which is mild and self-limiting in most cases 3, 4. Other complications include low back pain 2 and traumatic LP 3. Serious complications are rare, and correct technique can minimize diagnostic error and maximize patient comfort 5.