Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy

Abstract

IMPORTANCE Coagulopathy may deter physicians from performing a lumbar puncture.OBJECTIVE To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy.DESIGN, SETTING, AND PARTICIPANTS Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 10 9 /L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.EXPOSURES Coagulopathy at the time of lumbar puncture.MAIN OUTCOMES AND MEASURES Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 10 6 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.RESULTS A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%). CONCLUSIONS AND RELEVANCEIn this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for ...

Characterization of the Blood and Cerebrospinal Fluid Microbiome in Children with Bacterial Meningitis and Its Potential Correlation with Inflammation

“…The most reliable way to diagnose meningitis is to obtain a cerebrospinal fluid (CSF) specimen by lumbar puncture (LP) for analysis ( 52 ). However, some patients such as preterm infants are not suitable for lumbar puncture because of the risk of spinal hematoma and herniation ( 53 – 55 ). If blood can replace cerebrospinal fluid as the main carrier of disease diagnosis and treatment monitoring for some patients, even a minority of patients, our studies could contribute to reducing the risk of further clinical deterioration.…”

Early Coagulation Disorder Is Associated With an Increased Risk of Atrial Fibrillation in Septic Patients

“…Additive PLT, INR, and APTT scores were used to define early coagulation disorder with reference to SIC and coagulopathy ( Table 2 ) ( 12 , 14 ). Propensity score matching (PSM) minimized the imbalance of AF and non-AF groups with age, gender, ICU type, ethnicity, and marital status.…”

“…The patients accompanied with AF were older than that of patients without AF (70, 63-76 vs. 58, 48-69; P < 0.001). Furthermore, stroke (0.76 vs. 3.30%; P < 0.001), CHF (16.23 vs. 41.43%; P < 0.001), hypertension (43.90 vs. 56.48%; P < 0.001), diabetes (24.47 vs. 35.32%; P < 0.001), ECI (11,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) vs. 17.12-22; P < 0.001), APS III (49, 37-63 vs. 53, 42-67; P < 0.001), INR (1.3, 1.2-1.7 vs. 1.5, 1.2-2.2; P < 0.001), and APTT (32.7, 27.7-43.9, vs. 34.6, 29-46.1; P < 0.001) were significantly different in patients between the AF and non-AF groups. Among septic patients, the AF group had higher in-hospital mortality and 90-day mortality (19.71 vs. 13.79%, P < 0.001; 59.21 vs. 56.04%, P = 0.001).…”

Clinical Progress Note: Consolidated Guidelines on Management of Coagulopathy and Antithrombotic Agents for Common Bedside Procedures

“…In one retrospective review of more than 49,000 patients without coagulopathy who underwent LP, the risk for developing a spinal hematoma by 30 days post procedure was 0.20%. 16 Certain techniques may help to mitigate serious bleeding, including the use of image guidance in patients with large body habitus or those with difficult anatomy. Compared with paracentesis and thoracentesis, guideline recommendations for safe INR and platelet thresholds in patients undergoing LP are based on a more limited body of evidence.…”