Lumber Puncture

Lumbar puncture is a procedure that is often performed in the emergency department to obtain information about the cerebrospinal fluid (CSF).

Although usually used for diagnostic purposes to rule out potential life-threatening conditions (eg. bacterial meningitis or subarachnoid hemorrhage), it is also sometimes used for therapeutic purposes (eg. treatment of pseudotumor cerebri). CSF fluid analysis can also aid in the diagnosis of various other conditions (eg. demyelinating diseases and carcinomatous meningitis).

Lumbar puncture should be performed only after a neurologic examination but should never delay potentially life-saving interventions, such as the administration of antibiotics and steroids to patients with suspected bacterial meningitis.


Cranial CT scanning should be obtained before lumbar puncture in all patients with suspected SAH in order to diagnose obvious intracranial bleeding or any significant intracranial mass effect that might be present in awake and alert SAH patients with a normal neurologic examination.

Lumbar Puncture (LP) Interpretation of Cerebrospinal Fluid

The following measures should be taken to help minimize complications of lumbar puncture:

  • Explain the procedure, benefits, risks, complications, and alternative options to the patient or the patient’s representative, and obtain a signed informed consent
  • Before performing the lumbar puncture, ensure that patients are hydrated so as to avoid a dry tap
  • Never allow a lumbar puncture or a pre–lumbar puncture CT scan to delay administration of intravenous (IV) antibiotics; meningitis can usually be inferred from the cell count, antigen detection, or both
  • Prophylactic bed rest after lumbar puncture has not been shown to be of benefit and should not be recommended.
  • The overall risk of post dural puncture headache (PDPH) does not appear to be influenced by opening pressure, closing pressure, and volume of cerebrospinal fluid removed in instances of high-volume removal.
  • Local anesthesia is employed for lumbar puncture (see Technique and Local Anesthetic Agents, Infiltrative Administration).
  • The sitting position may be a helpful alternative, especially in obese patients, because it makes it easier to confirm the midline. In order to open the interlaminar spaces, the patient should lean forward and be supported by a Mayo stand with a pillow on it, by the back of a stool, or by another person.

Possible lumbar puncture–related complications include the following

  • Post–spinal puncture headache
  • Bloody tap
  • Dry tap
  • Infection
  • Hemorrhage
  • Dysesthesia
  • Post–dural puncture cerebral herniation

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