The risk of traumatic lumbar punctures in children with acute lymphoblastic leukaemia

Published:March 21, 2014DOI:



      Traumatic lumbar punctures with blasts (TLP+) in children with acute lymphoblastic leukaemia (ALL) obscure central nervous system status and are associated with a poorer event-free survival (EFS).


      We conducted a retrospective cohort study of all lumbar punctures (LPs) for children with ALL diagnosed at our institution from 2005 to 2009. We utilised random-effects and fixed-effects repeated-measures logistic regression analyses to identify risk factors for TLPs. Fixed-effects models use each patient as his or her own control. We used survival analysis to describe outcomes after a TLP+.


      264 children underwent 5267 evaluable lumbar punctures (LPs), of which 944 (17.9%) were traumatic. In the multivariable random-effects model, variables significantly associated with TLPs were age <1 year (odds ratio (OR) 3.46, 95% confidence interval (CI) 2.06–5.81) or age ⩾10 years (OR 2.00, CI 1.66–2.40); body mass index percentile ⩾95 (OR 1.44, CI 1.19–1.75); platelet count <100 × 103/μL (OR 1.49, CI 1.08–20.7); fewer days since previous LP (OR 5.13, CI 2.34–11.25 for ⩾16 days versus 0–3 days); and a preceding TLP (OR 1.43, CI 1.19–1.73). In the fixed-effects model, image-guidance reduced the odds of TLP (OR 0.55, CI 0.32–0.95). The 5-year EFS (±SE) for children with TLP+ (77 ± 8%) was significantly lower than for children with CNS1 status (93 ± 2%; p = 0.002).


      The frequency of TLP remains high. Consistent with previous studies, a TLP+ at diagnosis was associated with a poorer EFS. These risk factors can allow identifying interventions to reduce TLPs and directing interventions to those at highest risk.


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        • Pui C.-H.
        • Thiel E.
        Central nervous system disease in hematologic malignancies: historical perspective and practical applications.
        Semin Oncol. 2009; 36: S2-S16
        • Gajjar A.
        • Harrison P.L.
        • Sandlund J.T.
        • Rivera G.K.
        • Ribeiro R.C.
        • Rubnitz J.E.
        • et al.
        Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia.
        Pediatr Blood Cancer. 2000; 96: 3381-3384
        • Burger B.
        • Zimmermann M.
        • Mann G.
        • Kuhl J.
        • Loning L.
        • Riehm H.
        • et al.
        Diagnostic cerebrospinal fluid examination in children with acute lymphoblastic leukemia: significance of low leukocyte counts with blasts or traumatic lumbar puncture.
        J Clin Oncol. 2003; 21: 184-188
        • te Loo D.M.W.M.
        • Kamps W.A.
        • van der Does-van den Berg A.
        • van Wering E.R.
        • de Graaf S.S.
        Prognostic significance of blasts in the cerebrospinal fluid without pleocytosis or a traumatic lumbar puncture in children with acute lymphoblastic leukemia: experience of the Dutch Childhood Oncology Group.
        J Clin Oncol. 2006; 24: 2332-2336
        • Larson S.
        • Schall G.
        • Di Chrio G.
        The influence of previous lumbar puncture and pneumoencephalography on the incidence of unsuccessful radioisotope cisternography.
        J Nucl Med. 1971; 12: 555-557
        • Ebinger F.
        • Kosel C.
        • Pietz J.
        • Rating D.
        Headache and backache after lumbar puncture in children and adolescents: a prospective study.
        Pediatrics. 2004; 113: 1588-1592
        • Eskey C.J.
        • Ogilvy C.S.
        Fluoroscopy-guided lumbar puncture: decreased frequency of traumatic tap and implications for the assessment of CT-negative acute subarachnoid hemorrhage.
        Am J Neuroradiol. 2001; 22: 571-576
        • Miksys N.
        • Gordon C.L.
        • Thomas K.
        • Connolly B.L.
        Estimating effective dose to pediatric patients undergoing interventional radiology procedures using anthropomorphic phantoms and MOSFET dosimeters.
        Am J Roentgenol. 2010; 194: 1315-1322
        • Howard S.C.
        • Gajjar A.J.
        • Cheng C.
        • Kritchevsky S.B.
        • Somes G.W.
        • Harrison P.L.
        • et al.
        Risk factors for traumatic and bloody lumbar puncture in children with acute lymphoblastic leukemia.
        JAMA. 2002; 288: 2001-2007
        • Howard S.C.
        • Gajjar A.
        • Ribeiro R.C.
        • Rivera G.K.
        • Rubnitz J.E.
        • Sandlund J.T.
        • et al.
        Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia.
        JAMA. 2000; 284: 2222-2224
        • Barlow S.E.
        Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
        Pediatrics. 2007; 120: S164-S192
        • Glatstein M.M.
        • Zucker-Toledano M.
        • Arik A.
        • Scolnik D.
        • Oren A.
        • Reif S.
        Incidence of traumatic lumbar puncture: experience of a large, tertiary care pediatric hospital.
        Clin Pediatr. 2011; 50: 1005-1009
      1. A SAS Program for the CDC Growth Charts. [Web Page] Atlanta, GA: Centers for Disease Control and Prevention; 2011 [March 2012]. Available from:

        • Allison P.D.
        Fixed effects regression methods for longitudinal data: using SAS.
        SAS Institute Inc, Cary, NC2005
        • Fitzmaurice G.M.
        • Laird N.M.
        • Ware J.H.
        Applied longitudinal analysis.
        Wiley, New Jersey2011
        • Gardiner J.C.
        • Luo Z.
        • Roman L.A.
        Fixed effects, random effects and GEE: what are the differences?.
        Stat Med. 2009; 28: 221-239
      2. Guideline for platelet transfusion thresholds for pediatric hematology/oncology patients: Complete reference guide. Edmonton, AB: The C17 Guidelines Committee; 2010 [updated March 2011March 2011]. Available from:

        • Chong A.L.
        • Grant R.
        • Ahmed B.
        • Thomas K.
        • Connolly B.L.
        • Greenberg M.
        Imaging in pediatric patients: time to think again about surveillance.
        Pediatr Blood Cancer. 2010; 55: 407-413
        • Shaikh F.
        • Brzezinski J.
        • Alexander S.
        • Arzola C.
        • Carvalho J.C.A.
        • Beyene J.
        • et al.
        Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis.
        BMJ. 2013; 346: f1720
        • Caruso V.
        • Iacoviello L.
        • Di Castelnuovo A.
        • Storti S.
        • Mariani G.
        • de Gaetano G.
        • et al.
        Thrombotic complications in childhood acute lymphoblastic leukemia: a meta-analysis of 17 prospective studies comprising 1752 pediatric patients.
        Pediatr Blood Cancer. 2006; 108: 2216-2222