Consensus guidelines for lumbar puncture in patients with neurological diseases

Sebastiaan Engelborghs, Ellis Niemantsverdriet, Hanne Struyfs, Kaj Blennow, Raf Brouns, Manuel Comabella, Irena Dujmovic, Wiesje van der Flier, Lutz Frölich, Daniela Galimberti, Sharmilee Gnanapavan, Bernhard Hemmer, Erik Hoff, Jakub Hort, Ellen Iacobaeus, Martin Ingelsson, Frank Jan de Jong, Michael Jonsson, Michael Khalil, Jens Kuhle, Alberto Lleó, Alexandre de Mendonça, José Luis Molinuevo, Guy Nagels, Claire Paquet, Lucilla Parnetti, Gerwin Roks, Pedro Rosa-Neto, Philip Scheltens, Constance Skårsgard, Erik Stomrud, Hayrettin Tumani, Pieter Jelle Visser, Anders Wallin, Bengt Winblad, Henrik Zetterberg, Flora Duits, Charlotte E Teunissen, Sebastiaan Engelborghs, Ellis Niemantsverdriet, Hanne Struyfs, Kaj Blennow, Raf Brouns, Manuel Comabella, Irena Dujmovic, Wiesje van der Flier, Lutz Frölich, Daniela Galimberti, Sharmilee Gnanapavan, Bernhard Hemmer, Erik Hoff, Jakub Hort, Ellen Iacobaeus, Martin Ingelsson, Frank Jan de Jong, Michael Jonsson, Michael Khalil, Jens Kuhle, Alberto Lleó, Alexandre de Mendonça, José Luis Molinuevo, Guy Nagels, Claire Paquet, Lucilla Parnetti, Gerwin Roks, Pedro Rosa-Neto, Philip Scheltens, Constance Skårsgard, Erik Stomrud, Hayrettin Tumani, Pieter Jelle Visser, Anders Wallin, Bengt Winblad, Henrik Zetterberg, Flora Duits, Charlotte E Teunissen

Abstract

Introduction: Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.

Methods: We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III).

Results: Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications.

Discussion: When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.

Keywords: Back pain; Cerebrospinal fluid; Consensus guidelines; Evidence-based guidelines; Headache; Lumbar puncture; Post-LP complications.

Figures

Fig. 1
Fig. 1
Risk factors for PLPH (A) and nonspecific headache (B) ranked by magnitude (defined by odds ratio) as reported by the multicenter LP feasibility study . Abbreviations: CI, confidence interval; LP, lumbar puncture; OR, odds ratio; PLPH, post-LP headache.
Fig. 2
Fig. 2
Risk factors for back pain ranked by magnitude (defined by odds ratio) as reported by the multicenter LP feasibility study . Abbreviations: CI, confidence interval; LP, lumbar puncture; OR, odds ratio.
Fig. 3
Fig. 3
Lumbar puncture procedure and position of the needle during a lumbar puncture. The procedure involves introducing a needle or its respective introducer at the superior aspect of the inferior spinal process into the subarachnoid space of the lumbar sac, at the L4/L5 level or other level safely (L3/L4) below the spinal cord. The technique is for both atraumatic and cutting bevel needles the same, but when using an atraumatic needle, an introducer is inserted into the interspinal ligament first, after which the smaller atraumatic needle is inserted through the introducer. The introducer should be inserted no more than 2/3 – 1/4 of the total length, depending on the adipose tissue availability. During the procedure, the needle stylet is removed every 2-mm interval to check for flow of CSF. In case a nonrecommended cutting bevel needle is used, it is preferred to hold the bevel in the sagittal plane as this diminishes injury to the dura mater by separating its longitudinal fibers rather than cutting through them and reduces the risk of leakage of CSF after the LP. Abbreviations: CSF, cerebrospinal fluid; LP, lumbar puncture.
Fig. 4
Fig. 4
Schematic representative of lateral (A) and superior (B) aspects of the tips of spinal needles: 1, standard large-bore beveled needle; 2, standard small-bore beveled needle; and 3, atraumatic small-bore needle.

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