Lumbar Puncture in Leukemia Patient Causes Fatal Hematoma

Case Overview

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.

Questions to the Pediatrics expert and their responses

What are the contraindications for performing a LP?

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.

Should this test have been placed on hold until the patient's condition improved clinically?

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.

About the expert

This highly qualified expert has 30 years of experience as a pediatric oncologist. She earned her BS from the University of Massachusetts and her MD from Tufts University. She went on to complete her residency in pediatrics at Albany Medical Center Hospital and her fellowship in pediatric hematology and oncology at the Children's Hospital of Philadelphia. She is board certified in pediatrics and pediatric hematology and oncology and is an active member of the American Society of Pediatric Hematology/Oncology and the Children's Oncology Group. This expert formerly served as an associate professor of pediatrics at Albany Medical School and as the co-director of the Center for Childhood Cancer and Blood Disorders at Albany Medical College. Currently, she serves as the director of pediatric palliative care and as a professor of pediatrics at a medical school in New York, as well as the associate chief of pediatric hematology and oncology at a children's hospital in New York.

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Specialties:

Pediatrics

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