From the Guidelines
Lumbar puncture is contraindicated in patients with increased intracranial pressure, infection at the puncture site, severe thrombocytopenia, coagulopathy, or those on anticoagulant therapy without proper reversal or normalization of coagulation status. The contraindications for lumbar puncture can be categorized into absolute and relative contraindications. Absolute contraindications include conditions that pose a significant risk of serious complications, such as brain herniation or introduction of infection into the central nervous system. These conditions include:
- Increased intracranial pressure due to space-occupying lesions (tumors, abscesses, hematomas) 1
- Infection at the puncture site, which presents a risk of introducing pathogens into the central nervous system 1
- Severe thrombocytopenia (platelet count below 50,000/μL) or coagulopathy, which increases bleeding risk 1
- Patients on anticoagulant therapy without proper reversal or normalization of coagulation status 1
Relative contraindications include mild coagulation abnormalities, immunocompromised status, and certain spinal deformities that make the procedure technically difficult. Papilledema, a sign of increased intracranial pressure, requires neuroimaging before lumbar puncture to rule out mass lesions. In patients with suspected meningitis but signs of increased intracranial pressure, empiric antibiotics should be started before neuroimaging and potential lumbar puncture. These contraindications exist because lumbar puncture can lead to serious complications including brain herniation, spinal hematoma, or introduction of infection in high-risk patients.
Some key points to consider:
- Clinical assessment and not cranial CT should be used to determine if it is safe to perform a lumbar puncture, unless there is a clinical contraindication indicating possible raised intracranial pressure due to or causing brain shift 1
- If an immediate CT is not indicated, imaging (CT or, preferably, MRI) should be performed as soon as possible after the lumbar puncture 1
- In anticoagulated patients, adequate reversal is mandatory before lumbar puncture, and in patients with bleeding disorders, replacement therapy is indicated 1
- The decision to perform a lumbar puncture should be made on a case-by-case basis, considering the potential benefits and risks of the procedure 1
From the Research
Contraindications of Lumbar Puncture
The contraindications of a lumbar puncture include:
- Increased intracranial pressure due to space-occupying lesions, as it can lead to brain herniation 2
- Thrombocytopenia, as it increases the risk of bleeding complications, although the evidence is not conclusive 3, 4
- Use of anticoagulants and antiplatelet agents, as it increases the risk of bleeding complications 5
- Infection at the site of the puncture, as it can lead to the spread of infection to the central nervous system 2
Relative Contraindications
Relative contraindications of lumbar puncture include:
- Severe thrombocytopenia, as it increases the risk of traumatic tap, especially when performed by less experienced operators 4
- Presence of other bleeding risk factors, although the evidence is not conclusive 4
Important Considerations
It is essential to note that the decision to perform a lumbar puncture should be individualized, taking into account the patient's underlying condition, the urgency of the procedure, and the potential risks and benefits 5, 6. Effective communication between the healthcare team and careful monitoring of the patient after the procedure are crucial to minimize potential complications 5.