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Risk factors for traumatic or unsuccessful lumbar punctures in children
Lise E Nigrovic1, Nathan Kuppermann, Mark I Neuman
1Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA. lise.nigrovic@childrens.harvard.edu <lise.nigrovic@childrens.harvard.edu>
Insights
Traumatic or unsuccessful lumbar punctures in children are common. Modifiable procedural factors like needle advancement with stylet in place and no local anesthetic increase risk.
Area of Science:
- Pediatric Emergency Medicine
- Neurosurgery
- Clinical Procedures
Background:
- Traumatic and unsuccessful lumbar punctures (LPs) complicate pediatric care, leading to diagnostic uncertainty and increased healthcare utilization.
- Limited research exists on risk factors for traumatic or unsuccessful LPs in children.
Purpose of the Study:
- To identify patient, physician, and procedural factors associated with traumatic or unsuccessful lumbar punctures in a pediatric emergency department.
Main Methods:
- Prospective cohort study of children undergoing LPs between July 2003 and January 2005.
- Defined traumatic LP by cerebrospinal fluid RBC counts ≥10,000 cells/mm³ and unsuccessful LP by failure to obtain fluid for cell counts.
- Used multiple logistic regression to determine independent predictors of poor LP outcomes.
Main Results:
- 35% of 1,459 LPs were traumatic or unsuccessful on the first attempt.
- Increased risk associated with less physician experience, no local anesthetic, advancing the needle with stylet in place, and increased patient movement.
- Adjusted odds ratios: lack of local anesthetic (1.6), needle advancement with stylet (1.3), increased patient movement (2.1).
Conclusions:
- Advancing the spinal needle with the stylet in place and lack of local anesthetic use are the most significant modifiable factors.
- Targeting these procedural elements may reduce the incidence of traumatic or unsuccessful LPs in pediatric patients.
Study Objective:
Traumatic and unsuccessful lumbar punctures can cause substantial diagnostic ambiguity that may lead to unnecessary antibiotic use and hospitalization, in addition to patient discomfort. Risk factors for obtaining traumatic and unsuccessful lumbar punctures have been studied in a limited fashion only. We sought to determine patient, physician, and procedural factors associated with traumatic and unsuccessful lumbar punctures in children.
Methods:
The study included a prospective cohort of all children undergoing lumbar punctures in a single emergency department between July 2003 and January 2005. Our main outcome was either a traumatic lumbar puncture (cerebrospinal fluid RBC counts > or = 10,000 cells/mm3) or unsuccessful lumbar puncture (failure of the procedure to yield fluid for cell counts) after the first lumbar puncture attempt. We performed multiple logistic regression analyses to identify independent predictors of traumatic or unsuccessful lumbar punctures.
Results:
Of the 1,474 eligible lumbar punctures, 1,459 (99%) were included in the analysis. Of these, 513 (35%) were traumatic or unsuccessful on the first attempt. After adjustment for patient characteristics, physician and procedural factors associated with an increased risk of a traumatic or unsuccessful lumbar puncture included less physician experience (adjusted odds ratio for an ordinal decrease in experience 1.08; 95% confidence interval [CI] 1.01 to 1.15), lack of local anesthetic use (adjusted odds ratio 1.6; 95% CI 1.1 to 2.2), advancement of the spinal needle with stylet in place versus stylet removed (adjusted odds ratio 1.3; 95% CI 1.04 to 1.7), and increased patient movement (adjusted odds ratio 2.1; 95% CI 1.6 to 2.6).
Conclusion:
Of the factors associated with traumatic or unsuccessful lumbar punctures in children, advancement of the spinal needle with the stylet in place and lack of local anesthetic use are the most modifiable. Modification of these procedural factors may reduce the risk of traumatic or unsuccessful lumbar punctures in children.
