Contraindications for Lumbar Puncture
Lumbar puncture has several essential contraindications.
The following are the absolute contraindications:
- Non-communicating obstructive hydrocephalus.21
- Cerebral mass lesion causing brain shift.22
- Spinal cord compression23
- Skin infection near the site of the lumbar puncture (e.g., Suspected
spinal epidural abscess).24
- Congenital anomalies like Arnold Chiari malformation, tethered spinal
cord, myelomeningocele.25
Van de Beek et al. drafted the ESCMID guidelines for the diagnosis and
treatment of bacterial meningitis in 2015,26 and
strongly recommended performing imaging of brain before lumbar puncture
in patients presenting with:
- Focal neurologic deficits (excluding cranial nerve palsies)
- Recent Seizures
- Impaired Consciousness (evident as Glasgow Coma Scale score of less
than 10)
- Known Immunocompromised state
There is still controversy as to the lowest platelet count at which LP
can be done safely to avoid causing spinal or epidural hematoma. As such
it constitutes a relative contraindication. Consensus guidelines propose
that, a recent platelet count of higher than 40 × 10⁹ cells/L in adults,
before an elective spinal tap (based on level 3
evidence),25 is safe.
Patients on antiplatelets and anticoagulants also constitute a relative
contraindication. Most of the antithrombotic drugs, except argatroban,
have renal clearance and therefore their serum concentrations may be
higher in patients with impaired renal function.27
The European Society of Anesthesiology27 has proposed
the following intervals of stoppage of antiplatelet and anticoagulant
medications {Figure 2} before a spinal tap to mitigate the
risk of hemorrhagic complications (e.g., epidural hematoma), considering
the patients have normal renal function.
To address this issue further, Lee et al. did a study on 665 patients
who were on single or dual antiplatelet and underwent lumbar puncture.
They divided these patients into 3 groups depending on the time interval
of discontinuation of antiplatelet medication to lumbar puncture viz
>4 weeks , 1-4 weeks, <1 week.28 Spinal hematoma occurred in only 0.7% of patients.
They also evaluated the risk of traumatic spinal tap. The incidence of
traumatic and bloody tap, in those who had stopped taking antiplatelet
for 1 week were 4% and 3% respectively, compared to those who had
stopped it for more than 4 weeks at 5% for both traumatic and bloody
tap. So there was no significant rise in the risk of hemorrhagic
complications in patients currently taking aspirin and/or clopidogrel,
also regardless of the time interval the antiplatelet drug was stopped
prior to the procedure.28