Lumbar puncture: Indications, contraindications, technique

Lumbar puncture: Indications, contraindications,technique, and complications in childrenAuthors: Rebecca K Fastle, MD, Joan Bothner, MDSection Editor: Anne M Stack, MDDeputy Editor: James F Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2020. | This topic last updated: Mar 25, 2019.

INTRODUCTION

Examination of the cerebrospinal fluid (CSF) provides essential diagnostic information inmany clinical situations. The indications, contraindications, and procedure for performing alumbar puncture in children are presented here.

Lumbar puncture in adults, the physiology and utility of examination of CSF, and thediagnosis, prevention, and treatment of postspinal headache are discussed separately.(See "Lumbar puncture: Technique, indications, contraindications, and complications inadults" and "Cerebrospinal fluid: Physiology and utility of an examination in disease states"and "Post dural puncture headache".)

INDICATIONS

Suspected CNS infection — For most children, the indication for an emergent lumbarpuncture (LP) is to obtain cerebrospinal fluid (CSF) for the evaluation of possible central

Official reprint from UpToDate www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

®

https://www-uptodate-com.uml.idm.oclc.org/contents/lumb…ult&selectedTitle=1~150&usage_type=default&display_rank=1 2020-02-21, 12:35 PMPage 1 of 37

nervous system (CNS) infection. (See "Viral meningitis: Clinical features and diagnosis inchildren", section on 'CSF studies' and "Bacterial meningitis in children older than onemonth: Clinical features and diagnosis", section on 'Evaluation'.)

Delay in the administration of appropriate antibiotics can have deleterious effects onoutcome for patients with bacterial meningitis. Empiric antimicrobial treatment isrecommended when the diagnosis of bacterial meningitis or herpes encephalitis is stronglysuspected, as early treatment improves prognosis of these conditions (see "Treatment andprognosis of coma in children"). Treatment may impair the diagnostic sensitivity of CSFcultures but should not affect other tests (such as CSF white blood cell count, gram stain,or polymerase chain reaction). Blood cultures should be obtained prior to antibioticadministration, as they are positive at least a 50 percent of the time in patients withbacterial meningitis [1]. (See "Bacterial meningitis in children older than one month: Clinicalfeatures and diagnosis", section on 'Evaluation'.)

An algorithmic approach to the child with suspected meningitis should be considered tominimize delay in the initiation of antimicrobial therapy (table 1) [2].

Suspected subarachnoid hemorrhage — Evaluation for spontaneous subarachnoidhemorrhage (SAH) is an emergent indication for LP. A computed tomography (CT) scanshould be performed initially for all children with suspected SAH, followed by LP when adiagnosis is not evident on the scan. (See "Aneurysmal subarachnoid hemorrhage: Clinicalmanifestations and diagnosis", section on 'Evaluation and diagnosis'.)

Other — Other indications for LP include the instillation of chemotherapy or contrast mediafor spinal cord imaging, the evaluation of various neurologic conditions (eg, normalpressure hydrocephalus, Guillain-Barré syndrome), and the removal of CSF in thetreatment of idiopathic intracranial hypertension (pseudotumor cerebri) [3-5]. (See"Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features anddiagnosis".)

CONTRAINDICATIONS

Contraindications to lumbar puncture (LP) can be absolute or relative. Increased


intracranial pressure (ICP) is an absolute contraindication.

For patients with a bleeding diathesis or cardiopulmonary instability, the contraindicationsare relative to the importance of cerebrospinal fluid (CSF) results for immediatemanagement decisions. As an example, an unstable patient who may have bacterialmeningitis should receive a blood culture and antibiotics. LP can be performed when thechild's condition stabilizes.

Specific contraindications are as follows:

Nevertheless, because of the risk of subdural or epidural hematoma formation, wegenerally do not advise performing LP in patients with coagulation defects who are actively

Increased intracranial pressure (ICP) – Children with elevated ICP are at risk forcerebral herniation when LP is performed [6,7]. Consequently, CT of the head shouldbe obtained before LP for all patients with clinical suspicion for increased ICP,including those at risk for brain abscess (immunocompromise or congenital heartdisease with a right-to-left shunt). (See "Elevated intracranial pressure (ICP) inchildren: Clinical manifestations and diagnosis", section on 'Clinical manifestations'and 'Evaluation' below.)

●

Bleeding diathesis – Evidence regarding the safety of performing LP in patients withthrombocytopenia or coagulation factor deficiency is limited.

●

The safety of performing LP in children with thrombocytopenia at the time ofdiagnosis or during treatment for acute lymphoblastic leukemia was reported in aretrospective series describing 5223 LPs, of which 941 were performed in childrenwith a platelet count less than 50,000/microL [8]. No serious hemorrhagiccomplications occurred. However, only 29 children had a platelet count less than10,000/microL, making the safety of performing LP without giving a platelettransfusion uncertain at these low levels.

•

No serious complications were reported in a small retrospective series describingchildren and adults with hemophilia who received LP following replacement of thedeficient factor [9].

•


bleeding, have severe thrombocytopenia (eg, platelet counts <50,000/microL), or an INR>1.4, without correcting the underlying abnormalities. When LP is considered essential fora patient with an abnormal INR or platelet count in whom the cause is not obvious, wesuggest consultation with a hematologist to provide the best advice for safe correction ofthe coagulopathy prior to performing the LP. (See "Approach to the adult with unexplainedthrombocytopenia", section on 'General management principles' and "Clinical andlaboratory aspects of platelet transfusion therapy", section on 'Preparation for an invasiveprocedure'.)

In all cases, the relative risk of performing LP has to be weighed against the potentialbenefit (eg, diagnosing meningitis due to an unusual or difficult-to-treat pathogen). In casesin which LP is considered necessary but the risk of bleeding is considered to be high, itmay be useful to perform the procedure under fluoroscopy to reduce the chance ofaccidental injury to small blood vessels.

National guidelines from the United Kingdom have suggested contraindications for lumbarpuncture in pediatric patients with possible viral encephalitis [10].

Cardiopulmonary instability – The position in which the patient must be placed in orderto perform LP may result in further cardiopulmonary compromise. Administration ofantibiotics must not be delayed for the child with suspected meningitis who cannottolerate an LP (table 1).

●

Soft tissue infection at the puncture site (see 'Infection' below)●

Clinical contraindications to lumbar puncture without neuroimaging:●

Moderate to severe impairment of consciousness with reduced or fluctuatingGlasgow coma scale total score <13 or fall in score >2

•

Focal neurological signs such as unequal, dilated, or poorly responsive pupils(see "Elevated intracranial pressure (ICP) in children: Clinical manifestations anddiagnosis", section on 'Clinical manifestations' and "Elevated intracranial pressure(ICP) in children: Clinical manifestations and diagnosis", section on 'Subacutely orchronically elevated ICP' and "Elevated intracranial pressure (ICP) in children:

•


PREPARATION

Evaluation — Circumstances that should be identified in preparation for lumbar puncture(LP) include the following:

Clinical manifestations and diagnosis", section on 'Acutely elevated ICP')

Abnormal posture or posturing (ie, decorticate or decerebrate posturing)•

Papilledema•

After seizures until stabilized•

Relative bradycardia with hypertension•

Abnormal "doll's eye" movements•

Immunocompromise•

Cardiovascular shock•

Coagulation abnormalities with platelet count <100 x 10 /L or the patient is onanticoagulant therapy

• 9

Local infection at the proposed lumbar puncture site•

Respiratory insufficiency•

Suspected meningococcal septicemia•

Imaging (after CT scan) contraindications to lumbar puncture:●

The decision to carry out a lumbar puncture is assessed case by case.•Normal CT scan does not absolutely exclude the presence of elevated ICP or thatelevated ICP will not develop in the later hours. However, lumbar puncture can beconsidered within six hours of a normal CT scan and no other contraindications.

•

Children with the following conditions may have increased intracranial pressure (ICP)●


Those with suspected bacterial meningitis should have a blood culture drawn andantibiotics administered prior to CT (table 1).

In addition, a topical transdermal anesthetic cream (such as EMLA) may be applied overthe puncture site approximately 30 to 60 minutes, depending upon the specific anestheticused, before the procedure if the LP does not need to be performed emergently. (See"Clinical use of topical anesthetics in children", section on 'Lidocaine-prilocaine' and'Analgesia and sedation' below and "Clinical use of topical anesthetics in children", sectionon 'Agents for intact skin'.)

Patient counseling — Although LP is a relatively simple and safe procedure to perform, itis frightening for most children and their families. A clear explanation of the urgentindications for the procedure, as well as the details of the procedure itself, is usuallyreassuring and should routinely be provided. In addition, it may be helpful for older childrenand adolescents to "practice" the position that they will assume for the procedure.

and should have a CT performed before LP [2]:

Altered mental status•Focal neurologic signs•Papilledema•Focal seizure•Risk for brain abscess (immunocompromise or congenital heart disease with aright-to-left shunt)

•

Critically ill children require monitoring of oxygen saturation, respirations, and heartrate during the procedure.

●

Children in respiratory distress, particularly infants and small children, may tolerate theprocedure better when performed in the sitting position. (See 'Sitting' below.)

●

Patients with spinal abnormalities (such as spina bifida or severe scoliosis) should beidentified. An alternative approach for obtaining CSF (such as performing theprocedure under fluoroscopy) may be required for such patients [6].

●

Children who may require sedation for the procedure should be identified.●


In the emergency setting, LP is performed primarily to identify central nervous system(CNS) infection or subarachnoid hemorrhage (SAH), conditions that must be urgentlydiagnosed and treated (see 'Indications' above). Consequently, the benefit of earlydiagnosis far outweighs the risks of the procedure for patients who have been carefullyscreened for contraindications. (See 'Contraindications' above.)

Materials — Commercial trays are available for performing LP and typically contain all ofthe necessary equipment except povidone-iodine solution, sterile gloves, and manometers.The following equipment is needed if a commercial tray is not available:

Lidocaine 1 percent without epinephrine and topical anesthetic cream (such asliposomal lidocaine or eutectic mixture of lidocaine 2.5 percent and prilocaine 2.5percent)

●

Sterile 3 mL syringe with 25-gauge needle for lidocaine injection●

Four sterile collecting tubes●

Sterile gloves●

Sterile drapes●

Povidone-iodine solution●

Sterile sponges or 4 x 4s for preparing puncture site●

Manometer (typically used in patients older than two years of age)●

22-gauge styletted spinal needle. The following guidelines for the appropriate lengthneedle are based on the child's age (although a longer needle may be necessary forchildren who are large for their age, particularly for those closer to 12 years):

●

Under two years, 1.5 inches (3.75 cm)•Between 2 and 12 years, 2.5 inches (6.25 cm)•Over 12 years, 3.5 inches (8.75 cm)•

Resuscitation equipment should be immediately available for all patients.●


ANATOMY

During lumbar puncture (LP), a styletted needle is passed between the interspinousprocesses of the lumbar vertebrae and through the supraspinal and intraspinal ligaments,ligamentum flavum, dura mater, and arachnoid mater into the subarachnoid space.Cerebrospinal fluid (CSF) is then removed for sample.

LP should be performed distal to the spinal cord, at the level of the cauda equina. At birth,the inferior tip of the spinal cord is located opposite the body of L3. The vertebral columngrows more rapidly than the spinal cord. As a result, by adulthood, the tip of the spinal cordis at the inferior border of the body of L1. In older children, LP can be performed from theL2-L3 interspace to the L5-S1 interspace because these interspaces are below thetermination of the spinal cord. LP in children younger than 12 months must be performedbelow the L2-L3 interspace [6].

An imaginary line that connects the two posterior-superior iliac crests intersects the spineat approximately the fourth lumbar vertebra (figure 1). This landmark helps to locate theL3-L4 and L4-L5 interspaces.

PROCEDURE

Analgesia and sedation — Local anesthesia should be provided whenever possible whenperforming lumbar puncture (LP) in infants and children. Available options includeinfiltration with lidocaine and/or topical preparations (such as EMLA or LMX) (see"Subcutaneous infiltration of local anesthetics" and "Clinical use of topical anesthetics inchildren"). Each has its advantages and disadvantages:

Infiltration with lidocaine provides immediate analgesia but may obscure bonylandmarks in neonates and young infants, making the procedure more difficult toperform.

●

Topical anesthetics anesthetize the skin (but not the subcutaneous tissues) withoutaltering landmarks, but require 30 to 60 minutes to be effective, depending on the

●


Evidence from randomized trials in neonates demonstrates that both infiltrative and topicalanesthesia reduce the pain associated with LP [11,12]. The use of an infiltrative anestheticdoes not appear to interfere with obtaining CSF in infants and small children [11-13].Furthermore, observational evidence suggests that using a local anesthetic increases thelikelihood of a successful procedure:

These findings suggest that local anesthesia should be provided for all children wheneverpossible. We suggest topical anesthesia for all neonates and young infants for whom theprocedure can safely be delayed until the medication has had an effect. When there is notenough time for topical anesthesia, an infiltrative anesthetic is suggested for most; theavailable data do not support the notion that infiltrative anesthetics interfere with theprocedure, even in this young age group.

For older infants and children, ideal local anesthesia is provided by the combination of atopical and infiltrative anesthetic. The latter can be used alone when the LP must beperformed emergently.

Some older infants and young children may be apprehensive and unable to tolerate beingpositioned and restrained for the procedure. They should receive procedural sedation.(See "Procedural sedation in children outside of the operating room".)

Oral sucrose offered to infants on a pacifier is safe and effective when used to reduceprocedural pain for minor skin breaking procedures in neonates (eg, venipuncture,

preparation.

Among 297 infants ≤3 months of age receiving lumbar punctures in an emergencydepartment, LPs performed with a local anesthetic were twice as likely to besuccessful as those performed without local anesthesia (odds ratio [OR] 2.2, 95% CI1.04-4.6) [14].

●

In a prospective series describing 1459 children receiving lumbar punctures in anemergency department, procedures performed without local anesthetic were morelikely to be traumatic or unsuccessful than those performed with local anesthesia (OR1.6, 95% CI 1.1-2.2) [15].

●


heelstick) and has attenuated pain in infants up to six months of age undergoingintramuscular injections. The influence of factors such as age, type of painful procedure,location in which the procedure is performed, and intercurrent illness on the analgesiceffect of sucrose is uncertain.

Nevertheless, sucrose appears to be safe and is easy to administer. Thus, offering sucroseto infants less than six months of age undergoing LP who are not restricted from oral intakein addition to local anesthesia is an option (table 2). (See "Pharmacologic agents forpediatric procedural sedation outside of the operating room", section on 'Analgesic agents'and "Prevention and treatment of neonatal pain", section on 'Oral sucrose or glucose'.)

Position — Careful positioning is required in order to accurately identify landmarks andsuccessfully perform the LP. An assistant must be available to hold the child in an optimalposition. Children should be observed for adequate respiratory function throughout theprocedure because positioning may compromise respiratory status.

The lateral recumbent or the sitting position can be used.

Lateral recumbent — The lateral recumbent position is used most frequently (figure 1).The child is positioned near the edge of the examining table. Classically, the child has theneck flexed and knees drawn upward by the assistant. This position can be accomplishedif the assistant places one arm around the posterior aspect of the child's neck and theother arm under the child's knees. The assistant can maintain adequate restraint byholding onto his or her own wrists.

However, a small observational study of 28 children with a median age of five years foundthat neck flexion in the lateral recumbent position did not significantly change theinterspinous space as determined by ultrasound (US) measurement [16]. Thus, neckflexion may be omitted in the cooperative child, although neck flexion is still oftennecessary to prevent movement in the infant or young child.

Satisfactory positioning requires the following:

The child's hips and shoulders should be kept perpendicular to the examining table inorder to maintain spinal alignment without rotation.

●


Sitting — The sitting position may be preferred in children who have the potential fordeveloping respiratory compromise because of hyperflexion of the neck in the lateralrecumbent position (figure 2) [17,18]. In addition, this position may improve flow of CSF invery small infants (less than two weeks of age). The sitting position does not permitaccurate measurement of opening pressure. (See 'Use of manometer' below.)

Infants can be held in the sitting position by an assistant who grasps one of the infant'sarms and one of the legs in each hand, while supporting the head to prevent excessiveflexion at the neck.

Older children should be asked to sit with their legs hanging over the edge of theexamining table. They can then be flexed over a pillow with the elbows resting on theknees. An assistant should maintain alignment throughout the procedure, even in acooperative child.

Method

Sterile preparation — LP should be performed with universal precautions and steriletechnique. The procedure is as follows:

Local anesthesia

The gluteal crease must be aligned with the spinous processes.●

The puncture site is cleansed with povidone-iodine solution or other appropriate sitepreparation solution, such as 2 percent chlorhexidine gluconate 70 percent isopropylalcohol after sterile gloves have been donned. The area cleansed should be large,including the posterior superior iliac spine, which may be palpated as a landmarkduring the procedure. The solution may be removed with alcohol.

●

Sterile drapes are placed around the puncture site.●

For children receiving infiltrative anesthesia, the skin and subcutaneous tissues areanesthetized with 1 percent lidocaine using a 25-gauge needle to raise a wheal overthe interspace and then to infiltrate the deeper subcutaneous tissue. In order toadequately infiltrate the deeper tissues for larger children, the 25-gauge needle should

●


Technique

be replaced with a longer needle once the skin is anesthetized.

The spinal needle is checked to ensure that the stylet is firmly in place.●

The spinal needle can be held with one or both hands, depending upon clinicianpreference and experience. With the two-handed approach, the needle is supportedbetween the index fingers, and the hub is stabilized with the thumbs. In the single-hand approach, alignment can be ensured by using the free thumb tip as a guide byholding it on the spinous process above or below the desired interspace entry site(figure 3).

●

The spinal needle is positioned in the midline with the bevel parallel to the direction ofthe fibers of the ligamentum flavum (eg, bevel facing up for the patient in the lateraldecubitus position and sideways for the patient in the sitting position). This positioningof the needle is thought to decrease CSF leak after the procedure is completedbecause the needle separates, rather than cuts, the fibers of the dura [19].

●

The needle is advanced slowly through the spinous ligaments aiming cephalad towardthe umbilicus. Based upon US measurements, the angle of entry in children in thelateral recumbent position is approximately 45 degrees from perpendicular in infantsunder 12 months of age and about 30 degrees from perpendicular in children over 12months of age [20].

●

Since penetration of the dura is not always obvious and the depth to which the needlemust be inserted varies depending on the size of the patient and body habitus, thestylet can be cautiously removed from time to time as the needle is advanced to lookfor CSF. A "pop" often is perceived as the needle penetrates the dura and enters thesubarachnoid space. At this point, the stylet can be removed. CSF should be seen atthe hub and flow freely.

●

Some clinicians advocate removing the stylet once the skin has been punctured andadvancing the needle into the subarachnoid space without the stylet to enhance thelikelihood of obtaining cerebrospinal fluid (CSF), particularly for small infants [21]. In

●


Use of manometer — The opening pressure should be measured with manometrywhenever possible. Opening pressure measurement may be deferred in a struggling oruncooperative patient, or if the LP is performed with the patient in the sitting position,because the measurement may be unreliable.

Ultrasound guidance — Prior to performing an LP in children and whenever properlytrained providers are available, we suggest that static bedside US be used to identify thebest site and safest depth (picture 1 and image 1). In a meta-analysis of 12 randomizedtrials of static bedside US guidance for LP in a total of 956 pediatric and adult patients,

observational reports, rates for successful and nontraumatic lumbar punctures wereimproved using this technique [14,15]. The safety of stylet removal with regard to thecomplication of epidermoid tumors is uncertain. (See 'Epidermoid tumor' below.)

Once CSF has been collected, the stylet should be replaced and the needle removed.The area should be cleansed of povidone iodine solution and a sterile dressing appliedto the puncture site.

●

The manometer is attached to the spinal needle hub with a three-way stop-cock (figure4).

●

CSF is permitted to enter the manometer; opening pressure is recorded at the highestlevel attained by the CSF in the manometer column, ideally with the legs in extension.The CSF level fluctuates slightly with respiratory and cardiac cycles. The presence ofthese fluctuations confirms placement of the spinal needle in the subarachnoid space.The absence of fluctuations may indicate that the needle is partially occluded by duraor a nerve root and the reading may be inaccurate.

●

Normal opening pressures range from 5 to 20 cmH2O in a relaxed patient in the lateralrecumbent position with the neck and legs extended. The range can increase to 10 to28 cmH2O in patients in the lateral recumbent position with the neck and legs flexed[22,23].

●

After the opening pressure has been measured, the stop-cock can be used to transferfluid from the manometer column to sterile tubes.

●


first-pass success rate was more likely when US guidance was used compared with alandmark-based technique (risk difference 9 percent, 95% CI 1-17 percent) [24].Furthermore, US guidance significantly decreased the number of needle passes ortraumatic taps and reduced reported pain. Subgroup analysis of the six pediatric studies(456 children) found that the first-pass success rate was higher when US guidance wasused, but the result was not significant (risk difference 12 percent, 95% CI -10 to 34percent); fewer traumatic taps occurred when US guidance was used in children (riskdifference -21 percent, 95% CI -38 to -4 percent). Risk of bias was low for most of theincluded studies, but there was significant heterogeneity seen in the meta-analyses.

Thus, when performed by an experienced provider, static US is a useful tool in obtainingCSF in children. For infants, the technique of static US to mark the best site and determinethe needle depth prior to LP is described in the reference [25]. LP in adults is discussedseparately. (See "Lumbar puncture: Technique, indications, contraindications, andcomplications in adults", section on 'Ultrasound'.)

Fluid collection — The CSF should be collected in three to four sterile tubes.Approximately 1 mL of CSF per tube is needed for standard studies. The first tube shouldbe sent for Gram stain and bacterial culture, the second for CSF glucose and protein, andthe third for CSF cell count and differential. Additional tubes may be saved for futurestudies or used for viral culture, fungal culture, cell pathology, or special chemistries. Ifsubarachnoid hemorrhage (SAH) is suspected, four tubes should be collected and the firstand fourth tubes sent for cell count. (See "Cerebrospinal fluid: Physiology and utility of anexamination in disease states".)

TROUBLESHOOTING

Bony resistance — Bony resistance occasionally is felt during attempted lumbar puncture(LP). Immediate bony resistance is probably due to puncture over the posterior spinousprocess; it can be overcome by withdrawing the needle to the subcutaneous tissue,confirming that the position of the spine is not rotated, and palpating again to make surethat the puncture site is in the midline. Bony resistance also may be caused by the inferiorspinous process; this resistance can be overcome by repositioning the child to ensure the


presence of adequate flexion, particularly at the hips, to open the interlaminar space andby redirecting the spinal needle more sharply cephalad [26].

Poor flow — The following techniques can be attempted to improve the flow of CSF:

Traumatic puncture — A traumatic puncture occurs when the spinal needle strikes thevenous plexus that encircles the spinal cord as it advances into the subarachnoid space.The CSF typically clears as it is collected if the spinal needle is in the subarachnoid space.The spinal needle should be removed if the bloody fluid clots in the hub or does not clear;these events are indications that the needle is in an improper position. The LP should bereattempted, with a new needle, at a different site.

Trauma from the LP can cause small amounts of bleeding into the CSF that can interferewith interpretation of the CSF cell count. How to account for this possibility is discussedelsewhere. (See "Cerebrospinal fluid: Physiology and utility of an examination in diseasestates", section on 'Predicted WBC count after traumatic tap'.)

Lateral approach — The midline approach usually is preferred in pediatrics. However, alateral or paramedian approach is acceptable (figure 5). In the lateral approach, the needleis inserted lateral to the upper border of the L3 or L4 spinous process. The needle is thendirected slightly medially and cephalad.

The lateral approach bypasses the supraspinal ligament (which can be calcified in olderpatients, causing deflection of the needle) and penetrates the ligamentum flavum, passingthrough the dura into the subarachnoid space.

COMPLICATIONS

Rotating the spinal needle by 90 degrees●

Replacing the stylet and advancing the needle slightly●

Pulling the needle back to the subcutaneous tissue and redirecting●

Removing the spinal needle and attempting the procedure at a different site; a newneedle should be used for each additional attempt, if the needle has been removedcompletely

●


Postspinal headache — Postspinal headache is one of the most common complicationsof lumbar puncture (LP). Limited evidence suggests that the frequency of postspinalheadaches in children is approximately 5 to 15 percent [27-32].

Various techniques such as using the smallest possible needle, use of atraumatic needles,and placing the bevel of the needle parallel to the long axis of the spine have been shownto prevent or lessen postspinal headache in adults. (See "Post dural puncture headache",section on 'Procedural risk factors'.)

However, the efficacy of using smaller LP needles in children is not proven. As anexample, in a blinded crossover trial of 341 LPs in 93 children, the frequency of postspinalheadache was not significantly different between smaller (25 gauge) or larger (22 gauge)needles (5 versus 7 percent, respectively, p = 0.3) [32]. Thus, use of a 22 gauge needle isreasonable and may be preferred by some clinicians because it shortens the duration ofthe procedure and is easier to place without bending. In adults, larger needles (eg, 20gauge) have clearly been associated with a higher frequency of postspinal headaches,data in children is limited but we advise against the use of an LP needle that is larger than22 gauge. (See "Post dural puncture headache", section on 'Procedural risk factors'.)

Bed rest does not appear to prevent headache in children. As an example, in onerandomized trial comparing bed rest for 24 hours with free mobility following LP in 111children Those who were kept on bed rest experienced significantly more headaches thanthose who were not (15 versus 2 percent positional headaches, respectively) [33].

The treatment of postspinal headache is discussed in detail separately. (See "Post duralpuncture headache", section on 'Treatment'.)

Epidermoid tumor — The formation of an epidermoid spinal cord tumor is a rarecomplication of LP that may become evident years after the procedure is performed [34-37]. It may be caused by epidermoid tissue that is transplanted into the spinal canal duringLP without a stylet, or with one that is poorly fitting. This complication probably can beavoided by using spinal needles with tight-fitting stylets during LP [38,39]. (See 'Technique'above.)

Infection — Meningitis can be induced if the LP is performed through cellulitis or soft


tissue infection at the site of puncture. For this reason, local infection at the puncture site isa contraindication to performing LP [40]. The risk of causing meningitis, epidural abscess,or osteomyelitis is extremely low in the absence of soft tissue infection at the puncture site[41-43].

Cerebral herniation — The most serious complication of LP is cerebral herniation. Thiscan occur when LP is performed in a patient with increased intracranial pressure (ICP).

Computed tomography (CT) of the head should be performed before LP for children whoare at increased likelihood of elevated ICP. Signs of increased risk include alteredmentation, papilledema, and focal neurologic findings. (See "Elevated intracranial pressure(ICP) in children: Clinical manifestations and diagnosis" and 'Evaluation' above.)

For children, concern regarding herniation following LP arises most frequently for thosewith suspected bacterial meningitis. In one retrospective review of 445 childrenhospitalized with bacterial meningitis, cerebral herniation occurred in 19 (4.3 percent); 12of the episodes occurred within the first 12 hours after LP was performed [44]. However, areview of the literature found that herniation was unlikely in children with bacterialmeningitis unless they had focal neurologic findings or coma; furthermore, a normal CTdoes not absolutely exclude subsequent herniation [45].

Spinal hematoma — Spinal hematoma is a complication after LP that usually occurs inpatients with uncorrected bleeding disorders, but it has also been reported in those with noapparent risk factors for bleeding [46]. (See 'Contraindications' above.)

The diagnosis of spinal hematoma is complicated by the concealed nature of the bleeding;thus, a high index of suspicion must be maintained. Patients who have back pain that isassociated with neurologic findings (eg, weakness, decreased sensation, or incontinence)after undergoing LP require emergent evaluation for possible spinal hematoma.

The appropriate treatment for the symptomatic patient is prompt surgical intervention,usually a laminectomy, and evacuation of the blood. Timely decompression of thehematoma is essential to avoiding permanent loss of neurologic function.


FOLLOW-UP CARE

No specific follow-up care is required for children who have had a lumbar puncture (LP).Bed rest is of no apparent benefit. (See 'Postspinal headache' above.)

Patients may receive analgesia with acetaminophen or ibuprofen. They should seekmedical attention for worsening headache or back pain or for leg pain, paresthesias, orweakness.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regionsaround the world are provided separately. (See "Society guideline links: Post duralpuncture headache".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond theBasics." The Basics patient education pieces are written in plain language, at the 5 to 6grade reading level, and they answer the four or five key questions a patient might haveabout a given condition. These articles are best for patients who want a general overviewand who prefer short, easy-to-read materials. Beyond the Basics patient education piecesare longer, more sophisticated, and more detailed. These articles are written at the 10 to12 grade reading level and are best for patients who want in-depth information and arecomfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you toprint or e-mail these topics to your patients. (You can also locate patient education articleson a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

th th

th

th

Basics topic (see "Patient education: Lumbar puncture (spinal tap) (The Basics)")●


SUMMARY AND RECOMMENDATIONS

Primary indications for lumbar puncture (LP) are to diagnose central nervous system(CNS) infection or subarachnoid hemorrhage (SAH). (See 'Indications' above.) Theprocedure should not be performed in patients with elevated intracranial pressure(ICP). (See 'Contraindications' above.)

●

Children with the following conditions should have computed tomography (CT) of thehead performed before LP:

●

Altered mental status•Focal neurologic signs•Papilledema•Focal seizure•Risk for brain abscess (immunocompromise or congenital heart disease with aright-to-left shunt)

•

Children with suspected bacterial meningitis should have a blood culture drawn andantibiotics administered prior to CT (table 1). (See 'Evaluation' above.)

●

Children who are critically ill should have cardiorespiratory monitoring during LP. (See'Evaluation' above.)

●

Infants and children should receive local anesthesia for LP.●

We suggest topical anesthesia for neonates and young infants for whom LP cansafely be delayed until the medication has had an effect. In addition, we suggestthat most neonates and small infants receive infiltrative anesthetics. (See'Analgesia and sedation' above and "Clinical use of topical anesthetics inchildren".)

•

We suggest that older infants and children receive combination of a topical andinfiltrative anesthetic. The latter can be used alone when the LP must beperformed emergently.

•


Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteralantibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art.Rev Infect Dis 1988; 10:365.

2. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management ofbacterial meningitis. Clin Infect Dis 2004; 39:1267.

3. The diagnostic spinal tap. Health and Public Policy Committee, American College ofPhysicians. Ann Intern Med 1986; 104:880.

4. Marton KI, Gean AD. The spinal tap: a new look at an old test. Ann Intern Med 1986;104:840.

5. Sternbach G. Lumbar puncture. J Emerg Med 1985; 2:199.

We suggest offering sucrose for analgesia to infants younger than six months of agewho are not restricted from oral intake (table 2). (See "Pharmacologic agents forpediatric procedural sedation outside of the operating room", section on 'Analgesicagents'.)

●

The procedure for performing LP includes carefully positioning the patient and usingsterile technique. (See 'Procedure' above.)

●

Prior to performing a lumbar puncture (LP) in children and whenever properly trainedproviders are available, we suggest that static bedside US be used to identify the bestsite and safest depth (picture 1 and image 1) (Grade 2B). (See 'Ultrasound guidance'above.)

●

Complications following LP are unusual in children. Headache occurs most commonly.(See 'Complications' above.)

●


6. Cronin KM, Wiley JF. Lumbar puncture. In: Textbook of Pediatric Emergency Medicine Procedures, Henretig FM, King C (Eds), Lippincott Williams & Wilkins, Philadelphia 1997. p.541.

7. Kooiker JC. Spinal puncture and cerebrospinal fluid examination. In: Clinical Procedures in Emergency Medicine, 4th ed, Roberts JR, Hedges JR (Eds), WB Saunders, Philadelphia 2004.

8. Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children withacute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222.

9. Silverman R, Kwiatkowski T, Bernstein S, et al. Safety of lumbar puncture in patientswith hemophilia. Ann Emerg Med 1993; 22:1739.

10. Kneen R, Michael BD, Menson E, et al. Management of suspected viral encephalitisin children - Association of British Neurologists and British Paediatric Allergy,Immunology and Infection Group national guidelines. J Infect 2012; 64:449.

11. Pinheiro JM, Furdon S, Ochoa LF. Role of local anesthesia during lumbar puncture inneonates. Pediatrics 1993; 91:379.

12. Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anestheticsduring lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003; 157:1065.

13. Carraccio C, Feinberg P, Hart LS, et al. Lidocaine for lumbar punctures. A help not ahindrance. Arch Pediatr Adolesc Med 1996; 150:1044.

14. Baxter AL, Fisher RG, Burke BL, et al. Local anesthetic and stylet styles: factorsassociated with resident lumbar puncture success. Pediatrics 2006; 117:876.

15. Nigrovic LE, Kuppermann N, Neuman MI. Risk factors for traumatic or unsuccessfullumbar punctures in children. Ann Emerg Med 2007; 49:762.

16. Abo A, Chen L, Johnston P, Santucci K. Positioning for lumbar puncture in childrenevaluated by bedside ultrasound. Pediatrics 2010; 125:e1149.

17. Gleason CA, Martin RJ, Anderson JV, et al. Optimal position for a spinal tap in


preterm infants. Pediatrics 1983; 71:31.

18. Weisman LE, Merenstein GB, Steenbarger JR. The effect of lumbar puncture positionin sick neonates. Am J Dis Child 1983; 137:1077.

19. Kempen PM, Mocek CK. Bevel direction, dura geometry, and hole size in membranepuncture: laboratory report. Reg Anesth 1997; 22:267.

20. Bruccoleri RE, Chen L. Needle-entry angle for lumbar puncture in children asdetermined by using ultrasonography. Pediatrics 2011; 127:e921.

21. Baxter AL, Welch JC, Burke BL, Isaacman DJ. Pain, position, and stylet styles: infantlumbar puncture practices of pediatric emergency attending physicians. PediatrEmerg Care 2004; 20:816.

22. Ellis R 3rd. Lumbar cerebrospinal fluid opening pressure measured in a flexed lateraldecubitus position in children. Pediatrics 1994; 93:622.

23. Avery RA, Shah SS, Licht DJ, et al. Reference range for cerebrospinal fluid openingpressure in children. N Engl J Med 2010; 363:891.

24. Gottlieb M, Holladay D, Peksa GD. Ultrasound-assisted Lumbar Punctures: ASystematic Review and Meta-Analysis. Acad Emerg Med 2019; 26:85.

25. Gorn M, Kunkov S, Crain EF. Prospective Investigation of a Novel Ultrasound-assisted Lumbar Puncture Technique on Infants in the Pediatric EmergencyDepartment. Acad Emerg Med 2017; 24:6.

26. Fisher A, Lupu L, Gurevitz B, et al. Hip flexion and lumbar puncture: a radiologicalstudy. Anaesthesia 2001; 56:262.

27. Ramamoorthy C, Geiduschek JM, Bratton SL, et al. Postdural puncture headache inpediatric oncology patients. Clin Pediatr (Phila) 1998; 37:247.

28. Tobias JD. Postdural puncture headache in children. Etiology and treatment. ClinPediatr (Phila) 1994; 33:110.


29. Kokki H, Salonvaara M, Herrgård E, Onen P. Postdural puncture headache is not anage-related symptom in children: a prospective, open-randomized, parallel groupstudy comparing a22-gauge Quincke with a 22-gauge Whitacre needle. PaediatrAnaesth 1999; 9:429.

30. Janssens E, Aerssens P, Alliët P, et al. Post-dural puncture headaches in children. Aliterature review. Eur J Pediatr 2003; 162:117.

31. Ebinger F, Kosel C, Pietz J, Rating D. Headache and backache after lumbar puncturein children and adolescents: a prospective study. Pediatrics 2004; 113:1588.

32. Crock C, Orsini F, Lee KJ, Phillips RJ. Headache after lumbar puncture: randomisedcrossover trial of 22-gauge versus 25-gauge needles. Arch Dis Child 2014; 99:203.

33. Ebinger F, Kosel C, Pietz J, Rating D. Strict bed rest following lumbar puncture inchildren and adolescents is of no benefit. Neurology 2004; 62:1003.

34. Potgieter S, Dimin S, Lagae L, et al. Epidermoid tumours associated with lumbarpunctures performed in early neonatal life. Dev Med Child Neurol 1998; 40:266.

35. Halcrow SJ, Crawford PJ, Craft AW. Epidermoid spinal cord tumour after lumbarpuncture. Arch Dis Child 1985; 60:978.

36. Ziv ET, Gordon McComb J, Krieger MD, Skaggs DL. Iatrogenic intraspinal epidermoidtumor: two cases and a review of the literature. Spine (Phila Pa 1976) 2004; 29:E15.

37. Jeong IH, Lee JK, Moon KS, et al. Iatrogenic intraspinal epidermoid tumor: casereport. Pediatr Neurosurg 2006; 42:395.

38. McDonald JV, Klump TE. Intraspinal epidermoid tumors caused by lumbar puncture.Arch Neurol 1986; 43:936.

39. Batnitzky S, Keucher TR, Mealey J Jr, Campbell RL. Iatrogenic intraspinalepidermoid tumors. JAMA 1977; 237:148.

40. Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System, WB Saunders,Philadelphia 1980.


41. DRIPPS RD, VANDAM LD. Hazards of lumbar puncture. J Am Med Assoc 1951;147:1118.

42. Findlay L, Kemp FH. Osteomyelitis of the spine following lumbar puncture. Arch DisChild 1943; 18:102.

43. Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitisfollowing lumbar puncture: case report and review. Clin Infect Dis 1995; 21:694.

44. Rennick G, Shann F, de Campo J. Cerebral herniation during bacterial meningitis inchildren. BMJ 1993; 306:953.

45. Shetty AK, Desselle BC, Craver RD, Steele RW. Fatal cerebral herniation afterlumbar puncture in a patient with a normal computed tomography scan. Pediatrics1999; 103:1284.

46. Adler MD, Comi AE, Walker AR. Acute hemorrhagic complication of diagnosticlumbar puncture. Pediatr Emerg Care 2001; 17:184.

Topic 6325 Version 31.0


GRAPHICS

Rapid overview: Emergency management of infants (≥1 month) and childrenwith suspected bacterial meningitis

Clinical findings

Infants: Fever, hypothermia, bulging fontanel, lethargy, irritability, seizures, respiratory distress, poorfeeding, vomiting.

Older children: Fever, headache, photophobia, meningismus, nausea/vomiting, confusion, lethargy,irritability.

Evaluation

Laboratory testing – Initial laboratory testing should include (STAT):

Blood cultures (two sets).

CBC with differential and platelet count.

Serum electrolytes, BUN, creatinine, glucose.

PT, INR, and PTT.

Lumbar puncture:LP should be performed in all children with suspected meningitis unless there is a specificcontraindication to LP.

Contraindications to LP include: Cardiopulmonary compromise, clinical signs of increasedintracranial pressure, papilledema, focal neurologic signs, and skin infection over the site for LP.If there is a contraindication to or inability to perform an LP, or if the LP is delayed by the needfor cranial imaging, antimicrobial therapy should not be delayed. Blood cultures should beobtained and empiric antibiotics administered as soon as is possible.

CSF should be sent for the following (STAT): Cell count and differential, glucose and proteinconcentration, Gram stain, and culture.

Neuroimaging (eg, head CT):

In children who require neuroimaging before LP, blood cultures should be obtained andempiric antibiotics administered before imaging. LP should be performed as soon aspossible after neuroimaging is completed, provided that the imaging has not revealed anycontraindications.

Indications for neuroimaging before LP include: Severely depressed mental status (coma),papilledema, focal neurologic deficit (with the exception of cranial nerve VI or VII palsy), historyof hydrocephalus and/or presence of a CSF shunt, recent history of CNS trauma orneurosurgery.

Management

Supportive care:Ensure adequate oxygenation, ventilation, and circulation.

Obtain venous access and initiate cardiorespiratory monitoring while obtaining laboratorystudies.

Keep the head of bed elevated at 15 to 20 degrees.

Treat hypoglycemia, acidosis, and coagulopathy, if present.

Antimicrobial therapy – Antibiotic therapy should be initiated immediately following the LP if theclinical suspicion for meningitis is high:

Administer first dose of empiric antimicrobial therapy:


Vancomycin (15 mg/kg IV), plusCeftriaxone (50 mg/kg IV) or cefotaxime (100 mg/kg IV; where available).

Consider dexamethasone therapy* (0.15 mg/kg IV) in patients with certain risk factors (eg,unimmunized patients, young children [age ≥6 weeks to ≤5 years], children with sickle celldisease, asplenic patients) or if there is known or suspected Haemophilus influenzae infection(eg, based on Gram stain results).

If dexamethasone is given, it should be administered before, or immediately after, the first doseof antimicrobial therapy.

STAT: intervention should be performed emergently; CBC: complete blood count; BUN: blood urea nitrogen;PT: prothrombin time; INR: international normalized ratio; PTT: partial thromboplastin time; LP: lumbarpuncture; CSF: cerebrospinal fluid; CT: computed tomography; CNS: central nervous system; IV: intravenous.* Decisions regarding the administration of dexamethasone should be individualized. The use ofdexamethasone in children with suspected meningitis is controversial, and the opinions of UpToDate authorsregarding this issue differ. One UpToDate author would administer dexamethasone only to children who areknown or highly suspected to have H. influenzae (Hib) at the time the LP is performed (a fairly uncommonscenario), whereas another UpToDate author would administer dexamethasone to all young children (age ≥6weeks to ≤5 years old) with community-acquired meningitis and to children with sickle cell disease or aspleniawith suspected bacterial meningitis. The 2015 Red Book statement on dexamethasone use in pneumococcalmeningitis also acknowledges that expert opinion differs on this issue. Evidence supporting the efficacy ofdexamethasone in reducing the risk of hearing loss in children with meningitis is most clearly established forinfections caused by Hib. For other bacterial pathogens (eg, pneumococcus, meningococcus), the efficacy ofdexamethasone is uncertain. For further details, refer to UpToDate topics on bacterial meningitis in children,pneumococcal meningitis in children, and the use of dexamethasone and other measures to preventneurologic complications of pediatric bacterial meningitis.

Graphic 74865 Version 10.0


Lateral recumbant position

The child is positioned near the edge of the examining table. The assistantplaces one arm around the posterior aspect of the child's neck and the otherarm under the child's knees to hold the child in optimal position. The child'ships and shoulders should be kept perpendicular to the table in order tomaintain spinal alignment without rotation. The assistant can maintainadequate restraint by holding onto his or her own wrists.

Adapted from Cronan, KM, Wiley, JF. Lumbar puncture. In: Henretig, FM, King, C,(Eds), Textbook of Pediatric Emergency Procedures, Williams and Wilkins,Baltimore, 1997.



Procedure for sucrose analgesia

Indications

1. Painful procedure such as venipuncture or lumbar puncture

2. Age < 6 months

Contraindications

Infant is restricted from oral intake

Procedure

1. Use a 25 percent sucrose solution

2. Administer 2 mL, perferably by allowing the infant to suck on a pacifier, or with a syringe, 1 mL ineach cheek

3. Administer no more than 2 minutes before beginning painful procedure

4. May repeat the dose but not to exceed two doses in one hour



Sitting position for lumbar puncture in an infant

The assistant grasps one of the infant's arms and one of the legs in eachhand while supporting the head to prevent excessive flexion at the neck.Older children should be asked to sit with their legs hanging over the edge ofthe examining table. They can be flexed over a pillow with the elbows restingon the knees. An assistant may be helpful, even in a cooperative child, inmaintaining alignment throughout the procedure.

Adapted from Cronan, KM, Wiley, JF. Lumbar puncture. In: Henretig, FM, King, C,(Eds), Textbook of Pediatric Emergency Procedures, Williams and Wilkins,Baltimore, 1997.



Spinal needle placement using one or two hands



Cerebrospinal fluid (CSF) manometry

Midsagittal section through lumbar spinal column showing positioning formeasurement of CSF opening pressure. The manometer is attached to the spinalneedle hub with a three-way stop-cock. CSF is permitted to enter themanometer; opening pressure is recorded at the highest level attained by theCSF in the manometer column. Pressure measurements should be taken with thepatient recumbent.

Adapted from Dieckmann RA, Fiser DH, Selbst SM, (Eds). Illustrated Textbook ofPediatric Emergency and Critical Care Procedures. Mosby, St. Louis, 1997.



Ultrasound technique for identifying landmarks prior to lumbar puncture in infants

Pre-LP evaluation of the spinal landmarks. Ultrasonographic findings and probe orientation in longitudinal (panel A and C) andtransverse (panel B and D) views of the lower spine. Posterior dural border (arrow); anterior dural border (dashed arrow).(A) Subcutaneous tissue.(B) Spinous process with bone shadowing.(C) Epidural space.(D) CSF in the dural sac.(E) Cauda equina nerves.(F) Vertebral body.

CSF: cerebrospinal fluid; LP: lumbar puncture.

From: Gorn M, Kunkov S, Crain EF. Prospective investigation of a novel ultrasound-assisted lumbar puncture technique on infants in thepediatric emergency department. Acad Emerg Med 2017; 24:6. http://onlinelibrary.wiley.com/wol1/doi/10.1111/acem.13099/abstractCopyright © 2017 Society for Academic Emergency Medicine. Reproduced with permission of John Wiley & Sons Inc. This image has beenprovided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed.Please contact Wiley's permissions department either via email: [email protected] or use the RightsLink service by clicking on the


'Request Permission' link accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).



Ultrasound technique for determining the safe needle depth during lumbarpuncture in young infants

Measurements performed on patients in the UALP group.(A) The conus medullaris at the T12–L2 spinal level is identified.(B) The probe is advanced caudally, and a measurement of the maximum safe depth is taken from


the skin to the anterior border of the dural sac at the L3–4 interspace.(C) The maximum safe depth is marked on a spinal needle with a caliper.

From: Gorn M, Kunkov S, Crain EF. Prospective investigation of a novel ultrasound-assisted lumbarpuncture technique on infants in the pediatric emergency department. Acad Emerg Med 2017; 24:6.http://onlinelibrary.wiley.com/wol1/doi/10.1111/acem.13099/abstract. Copyright © 2017 Society forAcademic Emergency Medicine. Reproduced with permission of John Wiley & Sons Inc. This image has beenprovided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint,printed, shared or emailed. Please contact Wiley's permissions department either via email:[email protected] or use the RightsLink service by clicking on the 'Request Permission' linkaccompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).



Spinal needle access into the subarachnoid space by the median orlateral approach

In the lateral approach, the needle is inserted lateral to the upper border of the L3 or L4spinous process. The needle is then directed slightly medially and cephalad. The lateralapproach bypasses the supraspinal ligament (which can be calcified in older patients,causing deflection of the needle) and penetrates the ligamentum flavum, passing throughthe dura into the subarachnoid space.



Contributor DisclosuresRebecca K Fastle, MD Nothing to disclose Joan Bothner, MD Nothing to disclose Anne M Stack,

MD Nothing to disclose James F Wiley, II, MD, MPH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, theseare addressed by vetting through a multi-level review process, and through requirements for referencesto be provided to support the content. Appropriately referenced content is required of all authors andmust conform to UpToDate standards of evidence.

Conflict of interest policy


Documents

Lumbar puncture: Indications, contraindications, technique