Lumbar Puncture Evidence

Our practice should be driven by evidence and where that is limited by a "safe consensus" or eminence. There has been, over the years, a number of landmark papers regarding the procedure of Lumbar Puncture. Anna Holdgate and Karyn Cuthbert's 2001 paper 'Perils and pitfalls of lumbar puncture in the emergency department' (Emerg Med 2001 Sep;13(3):351-8) represents a clear review of evidence as it stood at the time. Interestingly, a number of the practice points such as use of pencil point needles and keeping needle size to a minimum are slow to enter practice across the board. 

Rod Bishop, at the 2013 Terrigal EM in Review Conference, looked at evidence to date. This presentation is available in the three videos below with an accompanying written summary for each:

There are a number of significant practice points but the key message in lumbar puncture for suspected meningitis is "just do it" and do it safely with a small pencil point needle. The key message for SAH is after a CT scan (done within 6 hours of onset of headache and reported as normal by a radiologist) do we need to do an LP looking for Xanthochromia. In our current practicing environment we should involve a transparent discussion with the patient and share decision making based on that discussion. I suggest you watch the movies and read the evidence for yourself as this may change your current practice.

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