ALiEM - By DeLaney M, White C and Wang H - June 27th, 2016
"The lumbar puncture (LP) procedure is commonly performed in the Emergency Department (ED). While minor complications of LP such as post-procedure headache or back pain occur somewhat regularly, significant complications such as post-procedural spinal hematomas, are rare. Despite their low incidence, these spinal hematomas are associated with a significant amount of morbidity for the patient and increased medicolegal risk for the provider...
THE BOTTOM LINE
The exact risk of significant bleeding in anticoagulated patients undergoing an emergent LP is unknown and there is not sufficient evidence to suggest that LP should not be performed in the anticoagulated patient. While the overall rate of significant complication is low, there is a high rate of morbidity in patients who develop post-LP bleeding. Given this risk, providers should make the decision to perform an LP on an anticoagulated patient based on factors such as:
- Age
- Comorbidities
- Spinal pathology
- Reason for anticoagulation
- Feasibility of reversing anticoagulation
- Clinical gestalt of the presenting illness
In addition, the overall utility of the test should be balanced with other considerations such as the possibility of empiric treatment or alternative, non-invasive diagnostic tests.
Providers should involve patients in the medical decision making process both before performing a LP in an anticoagulated patient and when determining the appropriate disposition. While some patients with a high post-procedural risk of bleeding may need to be admitted for further monitoring, other patients with a lower risk may be reasonably discharged with a plan for followup, and specific return instructions."