Lumbar Puncture in Pediatric Age

Lumbar Puncture Introduction Indications Contraindications Equipment Procedure Complications Interpretation of Results Special Considerations

Introduction to Lumbar Puncture in Pediatrics

Lumbar puncture (LP) is a crucial diagnostic and therapeutic procedure in pediatric medicine. It involves the insertion of a needle into the subarachnoid space of the lumbar spine to collect cerebrospinal fluid (CSF) or to administer medications. In pediatrics, LP is particularly important for diagnosing central nervous system infections, subarachnoid hemorrhage, and certain oncological conditions.

The procedure requires special considerations in children due to anatomical differences, varying levels of cooperation, and the need for appropriate pain management. Proper technique and understanding of the procedure are essential for successful outcomes and minimizing complications.

Indications for Lumbar Puncture in Pediatrics

• Suspected meningitis or encephalitis
• Evaluation of subarachnoid hemorrhage
• Diagnosis and monitoring of central nervous system malignancies
• Evaluation of idiopathic intracranial hypertension
• Administration of intrathecal medications (e.g., chemotherapy, antibiotics)
• Diagnosis of Guillain-Barré syndrome
• Evaluation of demyelinating disorders (e.g., multiple sclerosis)
• Diagnosis of neurodegenerative disorders
• Therapeutic drainage in pseudotumor cerebri

The decision to perform an LP should be based on the clinical presentation, age of the patient, and potential risks and benefits.

Contraindications for Lumbar Puncture in Pediatrics

Absolute Contraindications:

• Increased intracranial pressure with risk of herniation
• Infection at the puncture site
• Severe thrombocytopenia or coagulopathy
• Spinal cord compression

Relative Contraindications:

• Cardiorespiratory instability
• Presence of a brain abscess
• Ongoing seizures
• Severe immunosuppression

In cases of suspected increased intracranial pressure, neuroimaging should be performed before the LP to assess the risk of herniation.

Equipment for Pediatric Lumbar Puncture

• Sterile gloves and drapes
• Antiseptic solution (e.g., chlorhexidine, povidone-iodine)
• Local anesthetic (e.g., 1% lidocaine without epinephrine)
• Spinal needles:
  • 22-25 gauge for infants
  • 20-22 gauge for older children
• Manometer for measuring opening pressure
• Collection tubes (usually 4) for CSF analysis
• Sterile gauze and adhesive bandage
• Age-appropriate immobilization devices

The choice of needle size and type (e.g., Quincke vs. Sprotte) depends on the patient's age, size, and the procedure's purpose.

Procedure for Pediatric Lumbar Puncture

1. Preparation:
   • Obtain informed consent from parents or guardians
   • Position the patient: lateral decubitus position with knees flexed to chest, or sitting position for older children
   • Identify the L3-L4 or L4-L5 interspace
   • Apply topical anesthetic cream 30-60 minutes before the procedure if possible
2. Sterilization: Clean the area with antiseptic solution in a circular motion
3. Local Anesthesia: Infiltrate the skin and deeper tissues with lidocaine
4. Needle Insertion:
   • Insert the spinal needle with the bevel parallel to the longitudinal dural fibers
   • Advance slowly, feeling for the characteristic "pop" as the needle enters the subarachnoid space
5. CSF Collection:
   • Measure opening pressure if indicated
   • Collect CSF into numbered tubes (typically 4 tubes, 0.5-1 mL each)
6. Completion:
   • Remove the needle and apply pressure to the site
   • Clean the area and apply a sterile dressing

Throughout the procedure, maintain sterile technique and monitor the patient's comfort and vital signs.

Complications of Pediatric Lumbar Puncture

• Post-LP headache: More common in older children and adolescents
• Bleeding: Usually minor and self-limiting
• Infection: Rare with proper sterile technique
• Cerebral herniation: In cases of undiagnosed increased intracranial pressure
• Abducens nerve palsy: Temporary, due to intracranial hypotension
• Epidermoid tumors: Rare, from epidermal cell implantation
• Radicular pain or paresthesia: From nerve root irritation
• CSF leak: May require epidural blood patch in severe cases

Proper patient selection, technique, and post-procedure care can minimize these complications.

Interpretation of Lumbar Puncture Results in Pediatrics

Normal CSF Values (approximate):

• Opening pressure: 10-20 cm H2O
• WBC count: <5 cells/μL
• RBC count: 0
• Protein: 15-45 mg/dL
• Glucose: 50-80 mg/dL (or 2/3 of serum glucose)

Common Abnormal Findings:

• Bacterial meningitis: Elevated WBC (neutrophil predominance), high protein, low glucose
• Viral meningitis: Mild to moderate WBC elevation (lymphocyte predominance), normal to slightly elevated protein, normal glucose
• Subarachnoid hemorrhage: RBCs in all tubes, xanthochromia in supernatant
• CNS malignancy: Elevated protein, possible malignant cells on cytology
• Guillain-Barré syndrome: Elevated protein with normal cell count (albuminocytologic dissociation)

Always interpret CSF results in conjunction with clinical presentation and other laboratory findings.

Special Considerations for Pediatric Lumbar Puncture

• Age-specific approaches:
  • Neonates: Consider using a sitting position with neck flexion
  • Infants: Use of pacifier with sucrose solution for comfort
  • Toddlers and young children: May require sedation or child life specialist assistance
• Pain management: Use of topical anesthetics, local infiltration, and non-pharmacological methods (distraction, comfort positioning)
• Traumatic tap: Common in pediatrics, may require correction formulas for cell count interpretation
• Fluid replacement: Not routinely required in children unless large volumes are removed
• Post-procedure care: Monitor for headache, provide age-appropriate instructions for activity and hydration
• Failed attempts: Consider ultrasound guidance for difficult cases

Pediatric lumbar punctures require a combination of technical skill, patience, and child-specific considerations to ensure success and minimize distress.

Lumbar Puncture in Pediatric Age

1. Question: What is the most common position for performing a lumbar puncture in infants? Answer: Lateral recumbent position
2. Question: Which intervertebral space is typically used for lumbar puncture in pediatric patients? Answer: L3-L4 or L4-L5
3. Question: What is the recommended needle size for lumbar puncture in newborns? Answer: 22-gauge
4. Question: Which anatomical landmark is used to identify the correct level for lumbar puncture? Answer: Iliac crest (Tuffier's line)
5. Question: What is the maximum amount of CSF that should be collected during a diagnostic lumbar puncture in infants? Answer: 3-4 mL
6. Question: Which complication of lumbar puncture is more common in pediatric patients compared to adults? Answer: Traumatic tap (bloody tap)
7. Question: What is the recommended duration of bed rest after lumbar puncture in children? Answer: No bed rest required
8. Question: Which condition is an absolute contraindication for lumbar puncture in pediatric patients? Answer: Increased intracranial pressure with risk of herniation
9. Question: What is the most common reason for a failed lumbar puncture attempt in infants? Answer: Inadequate flexion of the spine
10. Question: Which local anesthetic is commonly used for lumbar puncture in older children? Answer: 1% lidocaine
11. Question: What is the recommended angle of needle insertion for lumbar puncture in infants? Answer: 10-15 degrees cephalad
12. Question: Which medication can be used to reduce anxiety in children undergoing lumbar puncture? Answer: Midazolam
13. Question: What is the most common complication of lumbar puncture in pediatric patients? Answer: Post-lumbar puncture headache
14. Question: Which imaging study is recommended before lumbar puncture if increased intracranial pressure is suspected? Answer: CT scan or MRI of the brain
15. Question: What is the recommended needle type for atraumatic lumbar puncture in children? Answer: Sprotte or Whitacre needle
16. Question: Which technique can be used to reduce pain during lumbar puncture in infants? Answer: Sucrose solution administration
17. Question: What is the normal range for CSF opening pressure in children during lumbar puncture? Answer: 10-20 cm H₂O
18. Question: Which condition may cause a "dry tap" during lumbar puncture? Answer: Severe dehydration
19. Question: What is the recommended time interval between lumbar puncture attempts in pediatric patients? Answer: At least 5 minutes
20. Question: Which maneuver can help open the interlaminar space during lumbar puncture in infants? Answer: Flexing the hips and knees towards the abdomen
21. Question: What is the maximum number of lumbar puncture attempts recommended before considering alternative methods? Answer: 3 attempts
22. Question: Which imaging modality can be used to guide difficult lumbar punctures in pediatric patients? Answer: Ultrasound
23. Question: What is the recommended observation time after lumbar puncture in outpatient settings for children? Answer: 30-60 minutes
24. Question: Which factor increases the risk of post-lumbar puncture headache in children? Answer: Use of large-bore needles
25. Question: What is the appropriate management for a post-lumbar puncture headache in children? Answer: Conservative measures (hydration, caffeine, analgesics)
26. Question: Which technique can be used to reduce the risk of a traumatic tap in infants? Answer: Removing the stylet frequently during needle advancement
27. Question: What is the recommended position for lumbar puncture in older children and adolescents? Answer: Sitting position
28. Question: Which complication of lumbar puncture requires immediate neurosurgical consultation? Answer: Epidural hematoma
29. Question: What is the recommended approach if CSF flow is not observed after needle placement? Answer: Rotate the needle 90 degrees
30. Question: Which medication can be used for procedural sedation during lumbar puncture in children? Answer: Ketamine