From the Guidelines
Lumbar puncture is contraindicated in patients with increased intracranial pressure due to space-occupying lesions, infection at the puncture site, coagulopathy, or therapeutic anticoagulation, as these conditions can lead to serious complications such as brain herniation, spinal hematoma formation, or introduction of infection into the cerebrospinal fluid. The contraindications for lumbar puncture can be categorized into absolute and relative contraindications. Absolute contraindications include:
- Increased intracranial pressure due to space-occupying lesions (tumors, abscesses, hematomas) 1
- Infection at the puncture site, which can introduce pathogens into the central nervous system 1
- Coagulopathy (INR >1.5, platelets <50,000/μL) or therapeutic anticoagulation, which increases bleeding risk and should be corrected before the procedure 1 Relative contraindications include:
- Severe thrombocytopenia
- Hemodynamic instability
- Respiratory insufficiency requiring mechanical ventilation
- Suspected spinal epidural abscess In patients with suspected increased intracranial pressure, neuroimaging (preferably CT or MRI) should be performed before lumbar puncture to rule out mass lesions 1. Patients with immunosuppression or cardiopulmonary disease require careful consideration of risks versus benefits. The most recent and highest quality study 1 recommends evaluating potential contraindications, identifying patient-related risk factors, and using an atraumatic narrow-bore (≥22-gauge) needle to reduce the risk of adverse events after lumbar puncture.
From the Research
Contraindications for Lumbar Puncture
The following are contraindications for lumbar puncture:
- Increased intracranial pressure, especially when a mass lesion is present 2, 3, 4
- Space-occupying intracranial lesions 3
- Elevated intracranial pressure or space-occupying intracranial lesions, as drainage of lumbar cerebrospinal fluid can increase the pressure gradient between the spinal, supratentorial, and infratentorial compartments, resulting in rapid herniation of the brain stem or occluding hydrocephalus 3
- Presence of raised intracranial pressure, as lumbar puncture can worsen the condition and cause clinical deterioration 4
Considerations for Lumbar Puncture
When considering lumbar puncture, the following should be taken into account:
- The risks of performing a lumbar puncture, including mild adverse effects and infrequently more serious ones, such as psychological distress 5
- The difficulty of obtaining a lumbar puncture in some healthcare settings, which may require inpatient admission 5
- The importance of weighing the benefits and risks of lumbar puncture, especially in patients with mild presumed idiopathic intracranial hypertension 5