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No increased risk of spinal hematoma with lumbar puncture in adults with coagulopathy
Question clinique
Is the risk of spinal hematoma after lumbar puncture increased in patients with coagulopathy?
L’Essentiel
This study found no significant difference in the risk of spinal hematoma following lumbar puncture among patients (aged 0 to 81 years) with or without coagulopathy. 2b
Référence
Plan de l'etude: Cohort (retrospective)
Financement: Self-funded or unfunded
Cadre: Population-based
Sommaire
The risk of a spinal hematoma following lumbar puncture in patients with coagulopathy is concerning and may affect clinical decision-making. These investigators analyzed data obtained from multiple national registries in Denmark from January 1, 2008, through December 31, 2018, including medical records, laboratory results, hospitalizations, and causes of death. The primary outcome was 30-day risk of first-time spinal hematoma in patients with and without coagulopathy at the time of lumbar puncture. Coagulopathy was defined as platelets lower than 150 x 10(9)/L, an international normalized ratio greater than 1.4, or activated partial thromboplastin time greater than 39 seconds. Multiple adjusted analyses occurred for age groups, sex, and co-morbidity index. A total of 83,711 individual lumbar punctures occurred among 64,730 study participants (aged 0 to 81 years). Complete follow-up occurred for more than 99% of participants. No significant differences occurred in the rate of spinal hematoma following lumbar puncture in patients without coagulopathy (0.17%; 95% CI 0.14% - 0.20%), with coagulopathy (0.23%; 0.15% - 0.34%), and without relevant blood samples within 5 days of the procedure (0.08%; 0.05% - 0.13%). The risk of spinal hematoma was significantly greater with increasing age and male sex. However, there was no association of risk with type and severity of coagulopathy, cumulative number of lumbar punctures in each individual, or medical indications including pediatrics.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Commentaires
spinal hematoma
That will make spinal anaesthesia easier.
Definition of coagulopathy
I believe the definition of coagulopathy is too generous. I would like to see a definition which is in keeping with modern day surgical practice-platelets less than 60,000, INR greater than 1.6
Risk of spinal hematoma from LP in patients with a coagulopa
Interesting but controversial. Problem is the potential outcome of a spinal hematoma is catastrophic. While the results of the study are very intriguing, they are observational. However no one is going to do an RCT around this issue. I don't consider the reviewed article to be practice changing but I don't see a way out to sort through the dilemma it now poses about the risk/safety of an LP in patients with a coagulopathy. Does poor evidence of absence of harm equate to evidence of safety? I'm not ready to make that leap.
Muscle Cramps in general
On patient on warfarin we stope it for seven day and on patient with inr above 1.4 we try to correct that epidural block done by Toey needle it a large bore needle, I have not epidural myself but I been consulted at least in one to two symptomatic post epidural hematoma with symptoms and signs although they improved without intervention but left with some deficit I am not criticizing since I have read all article which I will try to find and read it , But I will not discourage the protocol to be changed because of this study
I would like to add that there should be answer that "no I will not change my practice as a result of this article.
No increased risk of spinal hematoma with lumbar puncture in
The definition of coagulopathy was too broad. I wonder if there would be an increased risk of spinal hematoma if the coagulopathy were defined as INR > 2, PTT > 60, or platelet count < 50.
no
no