Spinal epidural haematoma complicating diagnostic lumbar puncture

Risk stratification for CNS infection: A potential tool to avoid unwarranted lumbar punctures - An observational study

OBJECTIVE

Central nervous system (CNS) infection poses a diagnostic challenge especially in elderly patients who frequently exhibit atypical symptoms. Our study aimed to identify patients with a low risk of CNS infection, in whom lumbar puncture (LP) could be avoided.

METHODS

Observational study of consecutive adult patients who underwent a LP in the emergency room (ER) of Hospital Universitari Vall d'Hebron between January 2017 and December 2021. We performed a univariate and multivariate analysis to identify factors associated with non-CNS infection. These factors were used to create a combined variable, and its diagnostic positive predictive value and specificity to detect patients without CNS infections were calculated.

RESULTS

We included 489 patients of which 77 (15.7%) were diagnosed with CNS infection. Median age was 62 years (IQR 41-78) and 240 (49.1%) were male. In the multivariate analysis, variables associated with non-CNS infection were female sex (OR 1.89; 95% CI 1.12-3.20), age older than 80 years (OR 3.14; 95% CI 1.20-8.19), previous cognitive impairment (OR 3.91; 95% CI 1.18-13.01), and clinical presentation without meningitis triad (fever, headache and neck stiffness) (OR 4.12; 95% CI 1.72-9.85). A composite variable encompassing age older than 80, cognitive impairment, and the absence of the meningitis triad was used as a diagnostic tool to identify patients with non-CNS infection, exhibiting a 98% positive predictive value and 99% specificity.

CONCLUSIONS

This study identifies factors associated with a low risk of CNS infection. Thus, a more precise clinical approach could help clinicians to detect patients who would not benefit from a LP.

Safety of bedside lumbar puncture in adult patients with thrombocytopenia

The risk of lumbar puncture (LP) hemorrhagic complications is believed to be exacerbated by thrombocytopenia, yet evaluations in clinical practice are lacking. We conducted a retrospective cohort study to examine the risk of traumatic tap (TT) and significant hemorrhagic complications in thrombocytopenic patients undergoing bedside LP. Two hundred sixty-two adult patients undergoing initial bedside LP were analyzed. Overall, we observed 37 TTs (14.1%, 95% CI 10.0 to 18.3%). TTs occurred in 11 of 78 LPs performed on patients with thrombocytopenia, compared with 26 of 184 LPs among patients with a normal platelet count (14.1% vs 14.1%; p > 0.99) and 6 of 19 LPs among patients with severe thrombocytopenia compared with 31 of 243 among those without (31.6% vs 12.8%; p = 0.04). For patients with severe thrombocytopenia, the relative risk of TT was 2.5 (95% CI 1.2 to 5.2; p = 0.02). Stratifying this group by operator experience, a higher incidence of TTs was observed in LPs performed by trainees (57.1% vs 15.8%; p = 0.02), an effect which did not reach significance in LPs performed by dedicated procedural operators (16.7% vs 10.8%; p = 0.63). The presence of other bleeding risk factors was not found to be statistically associated with the incidence of TT. There were no significant hemorrhagic complications. TTs occurred significantly more frequently among patients with severe thrombocytopenia, an effect modulated by operator experience. For patients in this higher risk group, LPs should be performed by the most skilled operators available.

Iatrogenic spinal hematoma as a complication of lumbar puncture: What is the risk and best management plan?

Background:

Lumbar puncture (LP) rarely results in complications such as spinal hematomas. However, it remains unclear if certain variables increase likelihood of these events, or if surgical intervention improves outcome.

Methods:

In addition to two clinical vignettes, we evaluated the post-1974 literature for cases of spinal hematoma and subsequent intervention. Based on our compilation of data, we evaluated outcome relative to numerous distinct variables.

Results:

Based on 35 LP-related spinal hematoma cases in the post-1974 literature and our encounters, we found 28.6% of patients presenting with preexisting coagulopathy had poor outcomes regardless of intervention, relative to 14.3% of patients without coagulopathy; a highly significant difference (P = 0.02). Once diagnosed, 21 patients were treated surgically and 14 nonsurgically. Of the 60% surgical patients, 57.1% had good outcomes, and 42.9% had poor outcomes within 12 months. Of 40% nonsurgical patients, 57.1% had good outcomes and 42.9% had poor outcomes. Results in these groups were not statistically different.

Conclusions:

We found a significant correlation between preexisting coagulopathy and poor neurological outcome irrespective of intervention. However, outcomes for these patients may be confounded by comorbidities including underlying conditions contributing to their coagulopathy. No significant correlation between type of surgical intervention and good outcome was found, possibly attributable to the paucity of details in existing case reports and the difficulty defining the degree of spinal cord compromise from a given lesion. Despite our findings, emergent neurosurgical intervention may be beneficial for the management of complications such as cauda equina syndrome secondary to intrathecal spinal hematoma.

Lumbar puncture complicated by spinal epidural hematoma in a child with leukemia

We report a case of spinal epidural hematoma (SEH) preceded by diagnostic lumbar puncture (LP) in a 5-year-old boy with acute lymphoblastic leukemia. MRI confirmed the presence of SEH between T7 and L5 levels, but the patient showed fast recovery during the next hours and conservative management was elected.

Spinal epidural hematoma after pain control procedure

Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.

Lumbar punctures: use and diagnostic efficiency in emergency medical departments

Background

Lumbar punctures (LP) are regularly and effortlessly used in the emergency medical departments (EMD). LP use and efficiency have not been fully explored in the published literature.

Aims

The goal of this study was to assess in a French EMD, the frequency of use and the diagnostic efficiency of LP, the final diagnoses, and related medical practices.

Methods

We retrospectively studied all patients who underwent an LP after admission to our adult EMD in 2004 and 2005. Patients’ medical files were reviewed to collect clinical and paraclinical features. We defined efficient LP as abnormal LP, which confirmed a suspected diagnosis in an emergency setting.

Results

A total of 247 patients, representing 0.5% of all admissions, underwent an LP. LP were efficient in fewer than 15% of cases and confirmed aseptic meningitis (8.5%), bacterial meningitis (2.4%), Guillain-Barré syndromes (1.6%), subarachnoid hemorrhages (SAH, 0.4%), and carcinomatous meningitis (0.4%). The principal differential diagnoses were infections outside the central nervous system (CNS, 30%), noninfectious neurological disorders (28.7%), and benign headaches (14.2%). The main assumed LP indications were to search for CNS infection (62%) and for SAH (25%). LP efficiency decreased dramatically according to patients’ age. Brain imaging was performed in 90% of patients prior to LP. Excessive use of polymerase chain reaction to detect herpes simplex in cerebrospinal fluid was observed. The only LP complications found were postdural puncture headaches (6.1% of cases). The rate of traumatic LP was 17%.

Conclusions

Our results are in accordance with the few published surveys on this topic. LP efficiency is modest but must be considered in light of the seriousness of suspected diagnoses. However, the search for differential diagnoses should not be neglected.

Symptomatic spinal epidural collections after lumbar puncture in children

BACKGROUND AND PURPOSE

Complications from lumbar puncture (LP) include headache; mild puncture-site pain; and, rarely, subdural, epidural, or subarachnoid hemorrhage. In infants, asymptomatic leakage of CSF documented with ultrasound is common. We report the MR imaging findings and clinical course of 25 symptomatic patients with spinal epidural collections after LP.

MATERIALS AND METHODS

MR imaging and clinical records of 25 children with new symptoms following LP were retrospectively reviewed.

RESULTS

All patients had abnormal dorsal spinal epidural collections. Signal-intensity characteristics of the collections were most commonly isointense to CSF on all pulse sequences. Significant anterior displacement of the dura with effacement of the subarachnoid space was frequently noted. All patients had fluid surrounding small foci of epidural fat, elevating them from their native interspinous fossa, resulting in a "floating" appearance. Eighteen collections involved the thoracic and lumbar spine; 4 involved the thoracic, lumbar, and sacral spine; 2 extended from the lumbar to the cervical level; and 1 was isolated to the lumbar spine. Five patients had follow-up MR imaging showing complete resolution of collections. The size of the collections was not directly related to the number of puncture attempts. Clinical symptoms resolved with time in all patients with conservative management.

CONCLUSION

Symptomatic epidural fluid collections after LP are often extensive and may compromise the thecal sac. These collections are not usually the result of a difficult LP and have signal intensity characteristics most consistent with CSF leak rather than hemorrhage. Signs and symptoms typically resolve with time, without treatment and with no serious sequelae.

Spinal epidural hematoma complicating thrombolytic therapy with tissue plasminogen activator--a case report

Patients who receive thrombolytic therapy are at risk of central nervous system (CNS) hemorrhage, and this diagnosis must be sought in any patient who develops neurologic complaints after thrombolysis and anticoagulation. Early imaging and neurosurgical consultation are essential to improve outcome after hemorrhage occurs. We describe a patient who developed spinal epidural hematoma (SEH) after thrombolysis and anticoagulation for acute myocardial infarction. Delay in diagnosis and management may have contributed to a poor outcome. The literature on SEH is reviewed, and approaches to improve the prognosis of patients suffering CNS hemorrhage after thrombolysis are discussed.

Epidural hematoma after epidural block: implications for its use in pain management

BACKGROUND

Spinal epidural hematoma after spinal puncture such as for injection of steroids for pain management may result in a rare complication of a spinal epidural hematoma causing acute myelopathy. Although this complication is well known with epidural anesthesia, where it is usually seen with impaired hemostasis, there are surprisingly few case reports of epidural hematoma after an epidural steroid block.

CASE DESCRIPTION

A healthy 34-year-old man with no evidence of coagulopathy and not taking antiplatelet medication suddenly had onset of acute cervical myelopathy from a large cervical epidural hematoma 8 days after a cervical epidural steroid block. Following prompt surgical evacuation of the clot, the patient made a near complete recovery.

CONCLUSION

Spinal epidural hematoma after spinal puncture is usually associated with impaired hemostasis. This case illustrates that it may occur in the absence of known risk factors. The delayed onset and the absence of risk factors have implications for the use of this procedure in chronic pain management.

Acute hemorrhagic complication of diagnostic lumbar puncture

OBJECTIVE

To present a case of an epidural hematoma after lumbar puncture in a pediatric patient without known risk factors for such a complication and to review the literature regarding this complication.

DESIGN

Case report, review of the literature, and discussion.

DATA SOURCES

A review of MEDLINE (1966-1998) for keywords "lumbar puncture" and "hemorrhage" or "hematoma" was conducted, and each bibliography was reviewed for other sources extending to 1911. Articles describing a case of spinal hematoma after a lumbar puncture for any procedure were included.

RESULTS

A 5-year-old boy underwent a lumbar puncture for evaluation of lethargy and fever, and subsequently developed marked back pain and severe pain on flexion of his legs. Magnetic resonance imaging revealed an epidural blood collection. The patient's symptoms resolved over the next few days in association with steroid administration. Multiple reports of epidural and subdural hematomas were found on literature review, most occurring in the setting of coagulation abnormalities. These reports involve lumbar puncture in anesthetic, interventional, and diagnostic settings.

CONCLUSION

Lumbar puncture is a frequently employed procedure. Known complications include epidural, subdural, and subarachnoid hemorrhage, usually in the setting of abnormal coagulation. The case presented is unusual in that the patient is a child and lacks any known risk factors for a hemorrhagic complication. Such a complication appears to be rare; only five of the 64 cases discovered in the literature review occurred following this diagnostic procedure in patients without known risk factors.

Complications of lumbar puncture

This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.