Elsevier

Neurologic Clinics

Volume 16, Issue 1, 1 February 1998, Pages 83-105
Neurologic Clinics

COMPLICATIONS OF LUMBAR PUNCTURE

https://doi.org/10.1016/S0733-8619(05)70368-6Get rights and content

Although neurologists often evaluate the surgical complications of other physicians, they are responsible for complications of the lumbar puncture, the quintessential neurologic procedure. Headache is the most common complication, usually lasting 1 week or less, occurring in up to 40 % of patients after lumbar puncture. Other complications, including headaches lasting from 8 days to 1 year, cranial neuropathies, prolonged backache, nerve root injury, and meningitis, are rare, following perhaps 0.3 % of lumbar punctures.136 The prospect of a lumbar puncture, however, seems to cause an inordinate amount of fear and anxiety in patients. This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, post–dural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet-associated problems, infectious complications, and bleeding complications (Table 1).

Section snippets

Fluid or Ether?

Before the lumbar puncture procedure could be developed, an understanding of the cerebrospinal fluid (CSF) circulation was necessary. The first written record of the CSF, in the Edwin Smith Surgical Papyrus, is in association with head injury from about seventeenth century B.C. Egypt. In the fifth century B.C. Hippocrates reported the presence of fluid around the brain, which he believed was pathologic. Galen (129–199 A.D.) described the cerebral ventricles, which he concluded were filled with

Brain Masses

Even in the presence of a brain neoplasm, abscess, or hematoma, uncal or tonsillar herniation leading to neurologic deterioration or death is quite uncommon. When a complication occurs, it can be difficult to determine whether the lumbar puncture was responsible if deterioration is not immediate or if the procedure is performed on an obtunded or comatose patient who might have gotten worse or died in a short time anyway.

Lubic and Marotta72 reported a total of 447 lumbar punctures performed on

Characteristics

Post–lumbar puncture headache, which is more precisely termed PDPH, is the most common complication of lumbar puncture, occurring in up to 40 % of patients after diagnostic lumbar puncture.28 The headache begins within 48 hours in about 80 % and within 72 hours in about 90 % of patients.66, 75 The onset can be immediately after the lumbar puncture81 or delayed for as long as 14 days.127 The duration of the headache is less than 5 days in about 80 %,75 although the headache can persist for 12

CRANIAL NEUROPATHIES

Dysfunction of cranial nerves III, IV, V, VI, VII, and VIII have been reported after lumbar puncture.45, 125 The cranial neuropathies, which are usually transient, are presumably due to intracranial hypotension leading to traction on the nerves. In a large series of patients who had spinal anesthetics, 0.4 % reported visual symptoms (including diplopia, blurred vision, spots before the eyes, photophobia, and scintillation), and 0.4 % had auditory complaints (including dizziness, tinnitus,

NERVE ROOT IRRITATION AND LOW BACK PAIN

During lumbar puncture, contact with the sensory roots causing transient electric shocks or dysesthesias is common, reported by 13 % of patients in one series.32 Permanent sensory and motor loss can rarely occur.24 If the procedure is performed at the improper level, the spinal cord may be injured by the needle. Two cases of reflex sympathetic dystrophy after lumbar myelograms have been reported.86

Patients frequently complain of backache (35 % in one study1) for several days after a lumbar

COMPLICATIONS OF USING OR NOT USING THE STYLET

The stylet should always be used on insertion through the skin and the sub cutaneous tissue. Rarely a needle without a stylet may implant a plug of skin, which can grow into an intraspinal epidermoid tumor.80, 103

There are rare reports of nerve complications with both reinserting and not reinserting the stylet before removing the needle. Because a nerve root can rarely herniate through the dura owing to aspiration by the needle during rapid with drawal, the argument can be made that the stylet

INFECTIONS

Lumbar puncture can cause infectious complications as a result of the following: using a contaminated needle (i.e., contamination owing to respiratory drop lets), disseminating skin flora without adequate disinfection of the skin, performing a lumbar puncture when an infection in present in the area (i.e., cellulitis, furunculosis, or epidural abscess), and introducing blood in the subarachnoid space in the presence of bacteremia.40, 45 In patients with CSF leaks, lumbar puncture can reverse

BLEEDING COMPLICATIONS

A variety of bleeding complications may occur after lumbar puncture. Locations include intracranial and spinal subdural hematoma, intracranial and spinal subarachnoid hemorrhage, and spinal epidural hematoma.

SUMMARY

Before the first lumbar puncture, knowledge of the cerebrospinal fluid path ways was essential. Galen's concept that pneuma, a gaseous substance, filled the ventricles was widely believed for 16 centuries until disproven by Cotugno in 1764 and Magendie in 1825. Wynter performed the first lumbar puncture via an incision of the skin and theca in February 1889. Quincke performed the first per cutaneous lumbar puncture in December 1890. Death as a result of lumbar puncture performed on patients

ACKNOWLEDGMENTS

I am grateful to Barbara Leighton, MD, for reviewing the manuscript and her suggestions. I also thank Thomas Brandt, MD, Harvey Carp, MD, Andreas Engelhardt, MD, Michael Serpell, MB BCH, and Wallace Tourtellotte, MD, for discussing their studies with me, and Charles Manner, MD, for discussing laboratory studies for bleeding disorders.

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    Address reprint requests to Randolph W. Evans, MD 1200 Binz #1370 Houston, TX 77004

    *

    From the Department of Neurology, University of Texas at Houston Medical School; and Neurology Section, Park Plaza Hospital, Houston, Texas

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