Rethinking lumbar puncture safety: pathophysiology, diagnostic uncertainty, and research gaps in herniation risk

Area of Science:

• Neurology
• Neurosurgery
• Radiology

Background:

• Lumbar puncture (LP) is a vital diagnostic and therapeutic procedure.
• Concerns exist regarding LP-induced brain herniation, particularly with elevated intracranial pressure (ICP).
• Risk factors and mechanisms of LP-related herniation require further clarification.

Purpose of the Study:

• To systematically review the risk of cerebellar and paradoxical brain herniation after LP.
• To evaluate the incidence of LP-related herniation.
• To discuss clinical implications and research gaps.

Main Methods:

• Systematic literature review following PRISMA guidelines.
• Searched PubMed (MEDLINE) database for studies from 1990-2024.
• Included studies on bacterial meningitis, idiopathic intracranial hypertension, and post-surgical states with elevated ICP.

Main Results:

• LP-related herniation occurred in various clinical scenarios, notably cerebellar herniation in bacterial meningitis and IIH.
• Herniation onset ranged from minutes to days post-LP.
• Cranial CT's predictive accuracy for herniation risk is debated.

Conclusions:

• LP is relatively safe, but herniation risk is context-specific.
• Clinical, radiological, and pathophysiological factors must guide decision-making.
• Further research is needed for predictive models and guidelines for high-risk patients.