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Leading article
The role of lumbar puncture in suspected CNS infection—a disappearing skill?
  1. R Kneen,
  2. T Solomon,
  3. R Appleton
  1. The Roald Dahl EEG Unit, Department of Neurology, Royal Liverpool Children’s Hospital (Alder Hey), Liverpool L12 2AP, UK
  1. Correspondence to:
    Dr Appleton;
    Richard.Appleton{at}RLCH-TR.NWEST.NHS.UK

https://doi.org/10.1136/adc.87.3.181

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    Declining use of lumbar puncture may be detrimental to patient care

    Introduced by Quincke in 1891 to diagnose and treat tuberculous meningitis, lumbar puncture (LP), has since been used extensively in the investigation of many neurological conditions.1 Cerebrospinal fluid (CSF) analysis and culture is the definitive method of diagnosing central nervous system (CNS) infections and, until the late 1970s, all or most patients admitted with suspected CNS infection in Western countries underwent LP.2 In many developing countries this remains the practice. However, in the West the use of LP has declined over the last 20 years, primarily because of increasing anxiety that the procedure may precipitate cerebral herniation. In this paper we review the reasons for the declining use of LP and examine whether its usage is now so infrequent that it may be detrimental to patient care.

    RAISED INTRACRANIAL PRESSURE IN CNS INFECTION

    It has been recognised since the early 1960s that raised intracranial pressure (ICP) is a serious complication of acute bacterial meningitis.3 Causes are thought to include occlusion of the arachnoid granulations, cerebritis, generalised brain oedema, inappropriate antidiuretic hormone secretion, subdural effusions or abscesses, seizures, and an increase in CSF production.4 Raised ICP in itself does not cause brainstem herniation—patients with idiopathic (benign) intracranial hypertension may have very high pressures without causing herniation or death. In other CNS infections, including cerebral malaria, high opening pressures are often found, but herniation is rare.5

    Herniation can result when raised ICP leads to differences in pressure between different brain compartments.6 The uncus of the temporal lobe may herniate through the tentorial opening, or the cerebellar tonsils may herniate through the foramen magnum. These processes damage the brainstem either directly or indirectly, by compromising its blood supply resulting in ischaemia and haemorrhage. By careful examination, it is possible to recognise the …

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