When should I consider referring a patient for a lumbar puncture versus managing them in primary care?

Consider referring a patient for lumbar puncture when there is suspicion of serious central nervous system infection such as bacterial meningitis or meningococcal disease, or when clinical features suggest subarachnoid haemorrhage. In primary care, patients with symptoms like fever, neck stiffness, altered consciousness, new focal neurological signs, seizures, or a rapidly deteriorating level of consciousness should be urgently referred for hospital assessment and lumbar puncture, rather than managed solely in primary care.

Do not perform lumbar puncture in primary care. It requires hospital facilities for safe performance, appropriate investigations, and management of potential complications.

Before lumbar puncture, ensure the patient is stable and does not have contraindications such as signs of raised intracranial pressure (e.g., Glasgow Coma Scale ≤9, abnormal pupillary reactions, new focal neurological signs), extensive purpura, infection at the puncture site, or risk factors for space-occupying lesions. If these are present, urgent neuroimaging and specialist assessment are required before lumbar puncture.

Start antibiotics promptly if bacterial meningitis is suspected, ideally after blood cultures but do not delay antibiotics to perform lumbar puncture if unsafe or delayed. Lumbar puncture should be performed as soon as safely possible after starting antibiotics.

In summary, manage suspected meningitis or subarachnoid haemorrhage patients in secondary care with lumbar puncture performed by specialists; primary care role is early recognition and urgent referral.

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