COMMON MISCONCEPTIONS OF LUMBAR PUNCTURE COMPLICATIONS AMONG PARENTS IN THE EASTERN REGION OF THE KINGDOM OF SAUDI ARABIA

Saleh Abdulrahim Alnajim 1 , Zainab Mohammed Al Sulaiman 2 , Sama Mohammed Al Sulaiman 3 , Fay Ali Al Otaibi 3 , Harith Own Alsahfy 1 , Sarah Saeed Alawami 3 , Nora Mohammed Almarri 1 and Munirah Abdulrahman Sattam 3 . 1. Imam Abdulrahman Bin Faisal University, Dammam, KSA. 2. Gulf Medical University, Ajman, UAE. 3. King Abdulaziz University, Jeddah, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

1258 cerebrospinal fluid (CSF) that can be used for diagnosis of a variety of infectious and noninfectious neurologic conditions. Therapeutic LP involves administration of drugs, including antibiotics or chemotherapeutic agents, into the CSF (Estcourt et al., 2016).
Lumbar Puncture was first reported in the late 19th Century by Heinrich IraneusQuincke, whose patient with meningitis survived 3 procedures, and around the same time Walter Essex Wynter reported the death of 4 patients undergoing Lumbar Puncture. The procedure had a poor reputation as it was associated with high mortality due to lack of imaging techniques at this time (Doherty and Forbes, 2014).
Although it is a relatively safe procedure, LP may be associated with a number of complications such as headache, infection, and bleeding. The presence of red blood cells in the CSF may point to minor bleeding. Patients with bleeding diathesis are at greater risk of spinal hematoma (Lawton et al., 1995).
Indications for LP are many including measurements of intracranial pressure. Obtaining CSF for analysis may be the only way to confirm subarachnoid hemorrhage, meningitis and neuro-inflammatory diseases (Ragauskas et al., 2012).
Informed consent of patients undergoing LP should include the risk of post-LP headache, localized bruising, bleeding and local discomfort at the injection site, in addition to rare complications such as meningitis and nerve root injury (Fishman, 1992).
Lumbar puncture is an aseptic procedure that can be carried out in the ward setting or in an operating theatre. Standard bedside aseptic procedures apply with no-touch technique, sterile drapes and use of chlorhexidine or an equivalent antiseptic. Hand-washing and wearing of masks may be associated with reduced bacterial transfer (Sellors et al., 2002).
Needle selection for LP is a critical issue. The American Academy of Neurology recommended atraumatic needles as means of reducing the risk of post-LP headache. Atraumatic needles have even been shown to be more costeffective than classic cutting needles as patients with post-LP headache can require in-patient care (Doherty and Forbes, 2014).
A right-handed practitioner should position the patient in the left lateral decubitus position, with the vertebrae in line in the horizontal plane and the head in a neutral position and the knees flexed. Lumbar Puncture can also be performed in the seated position. If the procedure is to be performed in the upright position, seated with the chin down and the feet supported, a table and pillow will improve comfort and optimize positioning (Sandoval et al., 2004).
The most common complication of LP is post-LP headache. It has a postural component, where the patient reports worsening of headache within a few minutes of adopting upright posture and rapid improvement when lying flat. It is most probably due to loss of compliance of the spinal compartment, rather than due to loss of CSF from a continuous CSF leak. The pain is usually diffuse and accompanied by nausea, tinnitus, photophobia or neck stiffness (Thömke et al., 2000;Levine and Rapalino, 2001).
Needle selection and the use of a 22G atraumatic needle is now recommended as the most important maneuver in reducing the risk of post-LP headache (Armon and Evans, 2005). Administration of oral or intravenous fluids, the use of analgesics and antiemetics, besides maintaining a supine posture are first steps conservative management of post-LP headache, but epidural blood patching is the definitive treatment if conservative management fails (Bezov et al., 2010). Complications such as cortical vein thrombosis and reversible cerebral vasoconstriction syndrome have rarely been reported. These may present with worsening headache following LP and require additional neuroimaging to confirm their presence (Doherty and Forbes, 2014).
The aim of this study was to assess the misconceptions regarding lumbar puncture complications and the practices that could prevent or reduce these complications among parents in the eastern region of the Kingdom of Saudi Arabia.

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Methodology:-Ethical considerations:-This study was conducted after approval of the institutional review board of the responsible authorities. All candidates received a detailed explanation that included the study's purpose and methods, and a written informed consent was taken from each participant. Confidentiality of the data was maintained by making code numbers for each patient.

Study design:-
The current study had a cross-sectional design, and it was carried out among the general population in the Eastern Region of Saudi Arabia during the period from September, 2017 to October, 2017 to assess awareness of a sample of Saudi parents (both males and females aged more than 18 years old) regarding LP.
A self-administered questionnaire was distributed to participants by the researchers through direct contact with them. Data were confirmed then coded and entered to a personal computer. Thanks and appreciations were used to inspire the participants to be involved in the study.
Statistical analysis:-All statistical analyses were done using SPSS v20. Qualitative data were represented as numbers and percentages in brackets. Fisher's Exact test was used to examine associations between two variables. Significance was adopted at p < 0.05 for interpretation of results of tests.

Results:-
This study was carried out on 402 Saudi parents who completed the self-administered questionnaires during the study period. There were 312 (77.6%) mothers and 90 (22.4%) fathers. Their ages ranged from 18 to more than 45 and the younger age groups (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) were the most frequent. The level of education of the study participants was mostly (65.7%) high, while only 15 (3.7%) had PhD degree as shown in table 1. Table 2 shows knowledge of the study participants. The majority them did not know the reason for performing LP, whereas only few numbers answered that this procedure is done for diagnosis of suspected meningitis (20.4%) or for diagnostic and/or therapeutic purposes of headache (23.6% and 18.2 respectively). When asked about CT or MRI as alternative diagnostic tools for LP, about half (50.2%) of them did not know, while only 29.1% answered that CT and MRI cannot be used instead of LP. In addition, 11.9% of the respondents were misunderstanding that experienced physicians don't need LP for diagnosis, while 38.6% disagree with them, and nearly half (49.5%) of them did not have that information. As regards knowledge about LP procedure 43.5% stated that performing LP requires specific training, while higher proportion (46.0%) did not know. The majority of the parents recognize that LP done under a septic technique and did not require general anesthesia (64.2% and 46.5% respectively). However, lower percent (44.0%) did not have knowledge about the type anesthesia under which LP is performed. Whether CT scan should be carried out before LP or not was not known by 59.0% of respondents. The level of knowledge was statistically higher (p<.05) among those with post high-school education than their counterparts in most of the studied parameters.
Most of the enrolled subjects regarded LP as painful procedure that could cause severe back pain (47.5% and 53.2% respectively). But, more than half of them did not know if doctors can use analgesics to reduce this pain. Deep knowledge about presence of special needles that can be used to decrease post LP headache was low (18.2%). More than half (56.7%) of the parents did not know about safety of LP and whether it causes severe complications or not but, only 18.7% recognized it unsafe. The majority of the study participants did not have an idea about possible complications of LP. The recorded beliefs of the parents about complications of LP were as follow; induce paralysis (16.4%), cause meningitis (13.2%), infertility (4.0%), and urine incontinence (12.2%) and /or aggravate the course of poliomyelitis (12.2%) as shown in table 3.
Attitudes of the participating parents towards lumbar puncture were illustrated in tables 4 & 5. The majority of the study population settled that LP should be performed at a hospital and an informed consent should be obtained from patients or their relatives before the procedure (75.6% and 70% respectively). Majority of the parents (72.3%) approved that consultants and senior doctors should perform this procedure while lower percentage (38.0%) stated that resident doctor is capable of performing LP. Moreover, 47.8% totally disagree that medical students could 1260 perform LP. Out of the surveyed parents, 97(24.2%) stated that LP is not acceptable in the society. Higher proportion (55.5%) was not sure about the attitude of people towards LP. More than half (58.2%) agreed that people don't know the importance of LP as a diagnostic method and most of them (75.3%) recorded that people are in need for more health education. 45.5% of the parents showed positive attitude and disagreed to ask for discharge if physician requested permission for LP. On the other hand, 44.0% of them could not give decision. Moreover, high percent (80.9%) expressed their needs for more discussion and information given by physicians. Statistically higher percentages of highly educated people agreed that medical students are incapable of performing LP and appreciated the need for more discussions about LP procedure with the treating physician. Otherwise, there was no statistically significant difference in attitudes of the parents between the three studied levels of education.

Discussion:-
Lumbar puncture is an important and relatively safe procedure to diagnose underlying central nervous system problems in children, mainly meningitis (Sadek et al., 2016). Different studies in developing countries have recorded rising prevalence of parents' refusal to give consent to LP for their children. This was attributed to false cultural beliefs, perceptions and fears among parents regarding this procedure (Deng et al., 1994;Ling and Boey, 2000;Farag et al., 2009;Narchi et al., 2013). So, this study was undertaken to assess the level of knowledge and attitude of Saudi parents towards LP, so that common misconceptions about LP could be explored. This will be helpful in developing solutions to enhance acceptance among parents.
An important factor that affects parent's decision is their knowledge. In this study, there was considerable lack of information regarding the reasons for which LP was performed and whether CT or MRI could be good alternatives. In addition, some respondents falsely believed that experienced physicians don't need LP for diagnosis. Detailed information about LP technique and its requirements also showed great defects among the studied parents. Similarly, A Malaysian study among staff in a public university revealed high frequency (74%) of poorly informed subjects about LP (W.A. Wan Sulaiman, et al., University Putra Malaysia, article in press).
The current study revealed increased fears from LP, where most of the enrolled subjects felt LP as painful procedure that could cause severe back pain. Moreover, more than half of them did not know that this pain could be reduced by using analgesics or special types of needles. Knowledge about the safety of this procedure was assessed. The majority of the parents in our study did not have an idea about possible complications of LP. Some parents thought that LP will result in paralysis of the child, meningitis, infertility, urine incontinence and /or aggravate the course of poliomyelitis. Similar fears of complications and particularly paralysis were recorded by parents in similar regional studies in Kuwait and United Arab Emirates (Farag et al., 2009 andNarchi et al., 2013).
In addition, a study by Wong et al. (2010) showed that fear of paralysis (48%) and mental retardation (6%) was the main reason of LP dissatisfaction by parents. The same fears were recorded in Iranian population by Khakshour et al. (2013). An earlier Asian study, which interviewed Malays, Indians and Chinese mothers revealed similar fears of pain, paralysis or death of their children with LP (Deng et al., 1994).
Most of parents in this survey showed positive attitude and disagreed to ask for discharge if physician requested permission for LP. Moreover, high percent of them expressed their needs for more discussion and information about the procedure. Wan Sulaiman et al. (2017) also reported highly frequent (72%) moderate attitude score towards LP among their Malaysian participants. This constitutes a favorable finding but, this might be limited by its theoretical situation. Further studies to assess the parent's attitudes towards acceptance or refusal of LP in a true situation where their children are in need of LP and the study of the associated factors with refusal are recommended.
Out of the surveyed parents, 24.2% stated that LP is not acceptable in the society. More than half (58.2%) agreed that people don't know the importance of LP as a diagnostic method and most of them (75.3%) recorded that people are in need for more health education. These parents' views accentuate the importance of successful education of the public through mass media or health campaigns. It is important that the treating physician informs parents with simple, clear and precise information about the requested procedure. Using of diagrammatic or visual aids could be helpful.

Conclusion:-
There is considerable lack in Saudi parent's information about LP with some beliefs and fears that could affect their acceptance and compliance with LP. So, it is crucial to educate parents and the public to increase their knowledge through mass media or health campaigns.