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Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1920 (Published 22 May 2018) Cite this as: BMJ 2018;361:k1920

Population

Patients with any indication for lumbar puncture Diagnosis Anaesthesia Myelography Not applicable to patients only undergoing epidural puncture

Comparison 1

or Conventional needle Atraumatic needle Lumbar puncture with any atraumatic (pencil point) needle Lumbar puncture with any conventional needle Conventional needle Atraumatic needle

We recommend the use of atraumatic over conventional needles Click fordetails Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours conventional needle Favours atraumatic needle Evidence quality Events per 1000 people No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

59 fewer Postdural puncture headache High More 39 98

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles decreases the risk of postdural puncture headache Within five days of lumbar puncture

Need for epidural blood patch High More 24 12 fewer 12

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles decreases the probability of returning to hospital to receive an epidural blood patch

7 fewer Backache High More 159 166 No important difference

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles has little or no effect on the risk of backache Maximal follow up 2 days – 3 weeks

40 fewer Hearing disturbance High More 13 53

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles decreases the risk of hearing disturbance Maximal follow up 2 days – 3 weeks

37 fewer Nerve root irritation Moderate More 89 126

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles decreases the risk of nerve root irritation Maximal follow up 2 days – 3 weeks

22 fewer Hospital for fluids or analgesia High More 17 39

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles decreases the probability of returning to hospital for intravenous fluids or controlled analgesia Maximal follow up 2 days – 3 weeks

Failed lumbar puncture High More 33 38 No important difference

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Use of atraumatic needles has little or no impact on the risk of failed lumbar puncture Immediate
See all outcomes
The panel believes patients will put a high value attributed to the large reduction in symptoms that they may suffer following the procedure. Given the lack of harms from atraumatic needles, most patients are likely to choose this option Preferences and values While atraumatic and conventional needles are reported to be similar to use, some learning may be required for clinicians to use the new types of needle Training and use Subgroups There are no differences in the effects of atraumatic versus conventional needles between subgroups defined by: Key practical issues Patient age Prescription or use of prophylactic measures Position of the patient during the lumbar puncture Clinical specialty of the individual performing procedure The indication for the procedure Use of bed rest after the procedure Patient sex Needle gauge Atraumatic needles do not eliminate the risk of complications entirely and clinicians should continue to discuss potential adverse consequences of the lumbar puncture with their patients

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  • Postdural puncture headache after intentional or unintentional dural punctures: time to think about risk reduction and acknowledge the burden of sequelae
  • Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group
  • Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index
  • A nudge towards better lumbar puncture practice
  • Atraumatic lumbar puncture needles are associated with fewer complications than conventional needles
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