ORIGINAL ARTICLE Safety of bedside lumbar puncture in adult patients with thrombocytopenia Andrew Jay Portuguese 1 & Alessandra Rothberg 1 & Matthew Gorgone 2 & Myla Strawderman 3 & Chris Jacob 1 Received: 21 May 2020 /Accepted: 14 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020 Abstract The risk of lumbar puncture (LP) hemorrhagic complications is believed to be exacerbated by thrombocytopenia, yet evaluations in clinical practice are lacking. We conducted a retrospective cohort study to examine the risk of traumatic tap (TT) and significant hemorrhagic complications in thrombocytopenic patients undergoing bedside LP. Two hundred sixty-two adult patients undergoing initial bedside LP were analyzed. Overall, we observed 37 TTs (14.1%, 95% CI 10.0 to 18.3%). TTs occurred in 11 of 78 LPs performed on patients with thrombocytopenia, compared with 26 of 184 LPs among patients with a normal platelet count (14.1% vs 14.1%; p > 0.99) and 6 of 19 LPs among patients with severe thrombocytopenia compared with 31 of 243 among those without (31.6% vs 12.8%; p = 0.04). For patients with severe thrombocytopenia, the relative risk of TT was 2.5 (95% CI 1.2 to 5.2; p = 0.02). Stratifying this group by operator experience, a higher incidence of TTs was observed in LPs performed by trainees (57.1% vs 15.8%; p = 0.02), an effect which did not reach significance in LPs performed by dedicated procedural operators (16.7% vs 10.8%; p = 0.63). The presence of other bleeding risk factors was not found to be statistically associated with the incidence of TT. There were no significant hemorrhagic complications. TTs occurred significantly more frequently among patients with severe thrombocytopenia, an effect modulated by operator experience. For patients in this higher risk group, LPs should be performed by the most skilled operators available. Keywords Lumbar puncture . Thrombocytopenia . Traumatic tap . Platelet transfusion . Hemostasis Introduction Lumbar puncture (LP) is a common bedside procedure used to assess for central nervous system pathology and to instill in- trathecal chemotherapy. LP is considered safe in the absence of raised intracranial pressure and bleeding risk factors. Nevertheless, serious hemorrhagic complications do rarely occur [1–3]. Although the incidence of spinal hematoma is low (1:3600 to 1:200,000) [ 4], it is the most feared hemorrhagic complication, as it can result in death or perma- nent neurological damage [5, 6]. The risk of hemorrhagic complications is believed to be exacerbated by thrombocytopenia. Thrombocytopenia can re- sult from lack of production, consumption, or destruction of platelets, which may occur in hematologic malignancies [7], disseminated intravascular coagulation [8], and immune thrombocytopenia [9], respectively. However, several studies have failed to detect an increase in hemorrhagic complications at low platelet counts [10–15]. Given that significant hemor- rhagic complications are rare, it has proved infeasible to ob- serve an association between incidence of spinal hematoma and degree of thrombocytopenia. Traumatic tap (TT) is often used as a proxy for hemorrhag- ic risk, as its occurrence has been linked to a dramatic increase in the frequency of major bleeding complications [16, 17]. In adults, the reported frequency of TT is approximately 14–15% using generally accepted definitions [12, 18]. The intrinsic harms of a TT are not entirely clear. There is a theoretical risk of introducing blood into the cerebrospinal fluid (CSF), po- tentially seeding the central nervous system (CNS) with * Andrew Jay Portuguese aportugu@gmail.com 1 Department of Medicine, University of Rochester Medical Center, Box MED, 601 Elmwood Ave., Rochester, NY 14642, USA 2 Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, USA 3 Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14642, USA Annals of Hematology https://doi.org/10.1007/s00277-020-04148-6