Lumbar Puncture in Leukemia Patient Causes Fatal Hematoma

This case involves a nine-year-old female patient with a medical history significant for leukemia and was undergoing chemotherapy with methotrexate. The patient underwent a lumbar puncture that was met with several complications including a subdural hematoma with compression of the cauda equina and severe spinal hemorrhage. The patient had the lumbar puncture despite her coagulopathic status and was given platelets as the only precaution. A few hours after the LP, the patient could not move her lower extremities and she became incontinent. The patient was then rushed to the OR for an emergency decompression, but a poor prognosis was discussed with the parents given the patient’s refractory leukemia, coagulopathy status, and spinal instability. The patient survived the procedure but suffered from complications for four months before passing away.

Question(s) For Expert Witness

1. What are the contraindications for performing a LP and should this test have been placed on hold until the patient's condition improved clinically?

Expert Witness Response E-000042

Absolute contraindications for lumbar puncture are the presence of infected skin over the needle entry site and the presence of unequal pressures between the supratentorial and infratentorial compartments. The latter is usually inferred from specific characteristic findings on computed tomography (CT) of the brain. Relative contraindications for lumbar puncture include any coagulopathy disorders, which would be the case in this patient with leukemia and a low platelet count. This is really a judgment call on the part of the treating team given that the patient would benefit from confirming the type of leukemia with the LP and starting prompt chemotherapy treatment.