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Lumbar Puncture

Should LP be obtained?

Author, date, country, and industry of funding

Patient Group

Strength of Evidence (GRADE)

Research design

Significant results

Limitations

(Landau, Waisman, & Shuper, 2010)

Israel

85 subjects average age 7.5 y (range 0-18 y) who made 104 visits to the ED

Excluded febrile seizure or other primary diagnosis

Very Low- inconsistent includes subjects that do not apply to this guideline

Retrospective chart review

Laboratory tests were obtained in 84% of visits. Eight percent provided useful information and < 5% were helpful in diagnosis and management.

Only one lumbar puncture was performed.

Eight percent of visits had electrocardiography performed and all were normal

Seven percent of visit had electroencephalography performed and was consistently useful and was always performed along with a neurology consultation

Mix of children with first seizure and those already on medication for seizure. Only 30 (35% )subjects presented with first seizure

(Lateef et al., 2008)

 

USA

Children 1- 6 months with new onset seizures

N= 141

Very Low  Cohort study, small number of subjects, not all had results of HSV or enteroviral infection

Prospective cohort

Diagnostic standards of infected CSF

WBC > 6 mm3

Protein elevation > 50 mg/dl

Positive bacterial culture

Herpes simplex virus (HSV) PCR

 

76/141 (54%) underwent LP.

Age was the greatest factor in obtaining an LP. Subjects aged 1-2 mo 70% LP whereas aged 5-6 mo 33 % LP

There was no relationship between presence of CSF abnormalities and the final diagnosis of seizure. At the time of discharge, 53% of those who had an abnormal CSF were thought to have a seizure, while the remaining 47% were thought to have a non-seizure event.

LP is only performed on subjects whom the attending provider deems necessary

Small population

 

(Chan et al., 2010)

Singapore

Children aged 1 month to 15 years with first  afebrile seizure

108 with ≥ 2 afebrile seizure and 103 with first afebrile seizure

Very Low

Population Survey

 

1st SZ

Epilepsy≥ 2 SZ

P value

Develop- mental exam (normal)

93%

87%

P=0.046

Neuro exam (normal)

98%

92%

P=0.016

EEG (abnl)

36.9%

75%

P≤0.005

CT/MRI (abnl)

33%

20.3%

NR

 

 

Population based study that looked at the epidemiology of afebrile seizure.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.