Risk Factors for Traumatic or Unsuccessful Lumbar Punctures in Children
Received 5 April 2006; received in revised form 25 July 2006 and 5 October 2006; accepted 20 October 2006. published online 06 March 2007.
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 ≥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.
aDivision of Emergency Medicine, Children’s Hospital and Harvard Medical School, Boston, MA
bDepartments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Davis, CA.
Address for correspondence: Lise E. Nigrovic, MD, MPH, Division of Emergency Medicine, 300 Longwood Avenue, Children’s Hospital, Boston, Boston, MA 02115; 617-355-6624, fax 617-730-0335
Funding and support: This work was supported by the National Research Service Award grand T32 HD40128-01 (Research Training Grant in Pediatric Emergency Medicine).
Supervising editor: Kathy N. Shaw, MD, MSCE
Author contributions: LEN and MIN conceived the study, designed the trial, and collected the data. LEN, NK, and MIN conducted the data analysis and drafted and revised the article. LEN takes responsibility for the paper as a whole.
Publication dates: Available online February 23, 2007.
ABSTRACT