Lumbar Puncture Consent Form

Lumbar Puncture
(Affix Patient Label)

What is a lumbar puncture?
A lumbar puncture is the insertion of a needle into the fluid space within the spinal canal. It is termed a
lumbar puncture because the needle goes into the lower back called the lumbar area.
Why is this done?
A lumbar puncture is most commonly done for diagnostic purposes, namely to obtain a sample of the
fluid in the spinal canal (cerebrospinal fluid) for tests to detect infection and/ or presence of cancer cells.
How is this procedure performed?
You will most commonly be lying down sideways for the procedure. After local anaesthesia is injected
into the lumber area, a needle is inserted in between the bony blocks (vertebrae) into the spinal canal.
The needle is usually placed between the 3
rd
and 4
th
lumbar vertebrae. The spinal fluid pressure can
then be measured. Cerebrospinal fluid is then removed for tests.
What are the risks of a lumbar puncture?
As with any medical procedure, complications may occur. Some of the most common and important
complications following lumbar puncture are:
Backache
Headache
Bleeding
Infection
Neurological deterioration
Backache
The doctor will numb the skin of your lower back before insertion of the needle. However, mild lower
back discomfort, generally lasting one or two days, might still occur. This is easily treated with simple
pain medications.
Headache
Occasionally, a headache follows lumbar puncture. This is the most common complication following a
lumbar puncture, but occurs in less than one of ten procedures. The headache can occur from hours up
to a day or so after the procedure. Remaining recumbent and avoiding walking until six hours after the
procedure may reduce the likelihood of headache. Drinking adequate water may also help reduce the
incidence or severity of headaches. Pain medications can usually relieve the headache.
Bleeding
As with any procedure involving puncture with a needle, bleeding may occur at the procedure site.
Bleeding is usually minimal in lumbar puncture, except when disorders of the blood clotting system are
present. Occasionally a blood clot that has formed under the skin at the site of the procedure called a
haematoma may cause prolonged pain. The risk of this happening can be reduced by lying flat for six
hours after the procedure.

Infection
Rarely, an infection may develop at the procedure site. In order to reduce the chances of infection, the
skin of your lower back will be cleaned with a sterilizing agent. However, it is possible that infection may
still occur.

To be continued on the next page
Neurological deterioration
In very rare situations, neurological deterioration may follow lumbar puncture. This only occurs if the
cerebrospinal fluid pressure is high and becomes reduced during the procedure, causing a part of the
brain to sink into an area of the skull resulting in coma and possible life-threatening event. The chance of
any such adverse change developing can be assessed by clinical examination and/ or radiological
procedures performed prior to the lumbar puncture.
Others (to be filled by Medical Practitioner)
Acknowledgement Section
Part I To Be Filled by Patient
I have read and understood the potential complication(s) that can arise from the surgery.
I acknowledge that the complication(s) listed are not intended to be exhaustive. I have had an
opportunity to ask for more information about any of the above-mentioned complications, as well as the
risks in general, or any specific condition of concern to me.

Part II To Be Filled by Medical Practitioner
I confirm that I have explained the reason for and the nature of potential complication(s) that may arise
from the procedure to the patient and the above-named witness.

Part III To Be Filled by Interpreter (if applicable)
I, _____________________________confirm that I have explained to the patient the reason for and the
nature of potential complication(s) that may arise from the procedure in _______________________.

* Please delete accordingly
(*Signature/Thumbprint(*Right/Left) of
*Patient/ Parent/ Guardian/ Next of kin)
(Name & NRIC of *Patient/Parent/
Guardian/Next of kin)
(Designation of Witness) (Name of Witness)
(Date of Signing) (Signature of Witness)
(Name & Signature of Medical Practitioner) (Date of Signing)
(Name of Interpreter)
(*Language / Dialect)
(Date of Signing) (Signature of Interpreter)

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Lumbar Puncture Consent Form

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Lumbar Puncture

(Affix Patient Label)

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