CONTRAINDICATIONS FOR SPINAL PUNCTURE
Spinal puncture is absolutely contraindicated in the presence of infection in the tissues near the puncture site.[39][130] Spinal puncture is relatively contraindicated in the presence of increased ICP from a space-occupying lesion. Caution is particularly advised when lateralizing signs (hemiparesis) or signs of uncal herniation (unilateral third nerve palsy with altered level of consciousness) are present. In such cases, a tentorial or cerebellar pressure cone may be precipitated or aggravated by the spinal puncture. Cardiorespiratory collapse, stupor, seizures, and sudden death may occur when pressure is reduced in the spinal canal.[26]
The risk of herniation seems to be particularly pronounced in patients with brain abscess.[13][107] Brain abscesses frequently occur as expanding intracranial lesions with headache, mental disturbances, and focal neurologic signs rather than as infectious processes with signs of meningeal irritation. In 75% of cases, a primary source of chronic suppuration is present. Common predisposing causes of brain abscess include craniofacial trauma, craniocerebral trauma, penetrating injuries with bone fragments in brain, transmitted foreign objects or large animal bites of infant skulls, postneurosurgical procedures, cardiovascular disorders with right to left shunts, bacterial endocarditis, gram-negative sepsis in neonates, dental infections, chronic sinusitis, otitis, mastoiditis, chronic abdominal pulmonary or pelvic infections, bacterial meningitis, and immunosuppression. Infarcted brain tissue may develop abscesses in the presence of sepsis because of a compromised blood-brain barrier.[114] Although the CSF is usually abnormal (elevated pressure, elevated white blood cell count, and elevated protein concentration), spinal puncture in patients with a known, or highly probable, abscess is contraindicated in most cases. In one study by Samson and Clark, 5 of 22 patients exhibited signs of midbrain compression within 2 hours of lumbar puncture.[107] Evidence of herniation markedly reduces the patient's chances for survival.
Brain abscess may spontaneously rupture into the ventricular system producing ventriculitis and meningitis. If the history suggests possible brain abscess, CT can rapidly diagnose and localize the lesion.[144] Because the appearance of brain abscesses on CT is similar to that of neoplastic and vascular lesions, false-positive reports of brain abscess may be encountered.[102]
Lumbar puncture can cause trauma to the dural or arachnoid vessels, which may result in minor hemorrhage into the CSF. This generally is of little consequence. However, the number of patients with hemophilia and human immunodeficiency virus (HIV) infection who require lumbar puncture has increased in the past decade. Spinal epidural hematomas may occur in some subpopulations of patients undergoing lumbar puncture. Individuals most at risk are those with some sort of bleeding diathesis, including those on anticoagulant therapy or those with abnormal clotting mechanisms, especially thrombocytopenia. Edelson and colleagues reviewed more than 100 cases of spinal epidural hematoma; approximately one third were associated with anticoagulant therapy.[29] Most articles describe isolated cases.[29][71][104][112] Spinal subdural hematomas after lumbar puncture are even more rare than epidural hematomas.[25][30]
When a patient is anticoagulated or has a coagulopathy, the tap should be performed by experienced clinicians, who are less likely to traumatize the dura. The patient should be carefully followed for progressive back pain, lower extremity motor and sensory deficits, and sphincter impairment after the procedure. Complaints of motor weakness, sensory loss, or incontinence after lumbar puncture should be thoroughly investigated. Lumbar puncture may be performed in the presence of a coagulation defect if the procedure is expected to provide essential information, such as in the diagnosis of meningitis. In cases of severe thrombocytopenia, the infusion of platelets before the lumbar puncture may be desirable.
The infusion of clotting factors in the hemophiliac patient and normalization of the prothrombin time with fresh frozen plasma in the anticoagulated patient are desirable if the clinical situation permits such delay before performing a lumbar puncture. Because as many as 90% of patients with severe hemophilia are seropositive for HIV, the issue of performing a lumbar puncture in patients with coagulopathies is an increasingly common phenomenon. Silverman and colleagues have demonstrated the safety of lumbar puncture in patients with hemophilia A or B who had their deficit clotting factor replaced before the procedure. In their series of 33 patients (30 with <1% normal factor level) who underwent a total of 52 spinal taps after specific factor replacement, no serious procedure-related complications were identified.[120] Their protocol was to attain an immediate postinfusion factor level between 5% and 100%. Use of additional factor replacement after lumbar puncture is of unknown value.
Howard and colleagues reported on 5223 lumbar punctures done in 958 children with newly diagnosed acute lymphoblastic leukemia.[56] Of these lumbar punctures, 29 were performed with platelet counts of 10 × 109/L or less, 170 with platelet counts of 11 - 20 × 109/L, and 742 with platelet counts of 21 - 50 × 109/L. No serious complications were reported. The overall rate of traumatic taps was 10.5%, but these were not associated with adverse sequelae. They concluded that in children with acute lymphoblastic leukemia, prophylactic platelet transfusion for lumbar puncture is not required if the platelet count is greater than 10 × 109/L. The number of patients with platelet counts of 10 × 109/L or less was too small to reach any conclusion about this group of patients.
If the history and physical examination suggest a treatable illness, such as meningitis or subarachnoid hemorrhage, the clinician may perform a spinal puncture after careful consideration of the entire clinical picture. In all cases, the study should be undertaken after careful thought regarding how the results will assist in patient evaluation and treatment. It is unlikely that the spinal puncture will beneficially alter management in the presence of a neoplasm, a cranial hematoma, an abscess, a completed nonembolic infarction, or cranial trauma.
References
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26. Duffy GP: Lumbar puncture in the presence of raised intracranial pressure. Br Med J 1969; 1:407.
29. Edelson RN, Chernik NL, Posner JB: Spinal subdural hematomas complicating lumbar puncture. Arch Neurol 1974; 31:134.
30. Egede LE, Moses H, Wang H: Spinal subdural hematoma: A rare complication of lumbar puncture. MD Med J 1999; 48:15.
39. Fishman RA: Cerebrospinal Fluid in diseases of the nervous system, Philadelphia, WB Saunders, 1980.
56. Howard SC, Gajjar A, Ribeiro RC, et al: Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222.
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114. Seydoux C, Francioli P: Bacterial brain abscesses: Factors influencing mortality and sequelae. Clin Infect Dis 1992; 15:394
120. Silverman R, Kwiatkowski T, Bernstein S, et al: Safety of lumbar puncture in patients with hemophilia. Ann Emerg Med 1993; 22:1739.
130. Tourtellotte WW, Shorr RJ: Cerebrospinal fluid. In: Youmans JP, ed. Neurological Surgery, vol 1. Philadelphia: WB Saunders; 1982:423.
144. Zimmerman RA, Bilaniuk LT, Shipkin PM, et al: Evolution of cerebral abscess: Correlation of clinical features with computed tomography: A case report. Neurology 1977; 27:14.
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