Atraumatic LP needles: what you need to know

This week's BMJ has a rapid recommendation piece on the advantages of using atraumatic needles in routine clinical practice. Let's hope this will now drive the necessary changes we have been arguing for, for several years. Our aim is to get neurologists and MSers to rethink CSF analysis for monitoring MS.

Rochwerg et al. Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline. BMJ 2018;361:k1920

What you need to know:
  1. Post-dural-puncture headache is a common complication after lumbar puncture, affecting up to 35% of patients
  2. This headache results from sustained leakage of cerebrospinal fluid from a dural tear; it can be debilitating and require return to hospital for narcotics or invasive therapy
  3. We issue a strong recommendation for use of atraumatic needles in all patients (adults and children) undergoing lumbar puncture because they decrease complications and are no less likely to work than conventional needles
  4. Atraumatic needles are more expensive, but evidence suggests that they reduce costs overall compared with conventional needles

Why is this paper so important? 

We have known about post-LP headaches being much more common with traumatic or cutting LP needles, but despite this many NHS hospitals continue to purchase these needles because they are cheaper. The people in charge of procurement have to stay in budget this year and hence don't really care about the downstream costs of treating the complications of LPs nor the misery caused to thousands of patients every year suffering from the complications of LPs. We started our #AtraumaticNeedle campaign several years ago as part of our public engagement programme in the run-up to our PROXIMUS trial.  The following are our three papers on the subject and our #ClinicSpeak LP Web App

What have your LP experiences being like; good, bad or indifferent? 

Barts-MS paper 1

Davis et al. Atraumatic needles for lumbar puncture: why haven't neurologists changed? Pract Neurol. 2016 Feb;16(1):18-22.

Diagnostic lumbar puncture is a key procedure in neurology; however, it is commonly complicated by post-lumbar puncture headache. Atraumatic needle systems can dramatically reduce the incidence of this iatrogenic complication. However, only a minority of neurologists use such needles. In this paper, we discuss possible reasons why neurologists have not switched to new technology, looking more at diffusion of innovation rather than lack of evidence. We suggest ways to overcome this failure to adopt change, ranging from local interventions to patient empowerment.

Barts-MS paper 2

Davis et al. Change practice now! Using atraumatic needles to prevent post-lumbar puncture headache. Eur J Neurol. 2014 Feb;21(2):305-11.

BACKGROUND AND PURPOSE: Lumbar puncture (LP) is a key diagnostic procedure in medicine. Post-lumbar puncture headache (PLPHA) is a well-recognized complication of LP. Evidence suggests that using atraumatic needles for diagnostic LP (ATNLP) reduces the risk of PLPHA. However, clinicians in Europe and the USA routinely use traumatic needles for diagnostic LP (TNLP). The occurrence of PLPHA following ATNLP and TNLP was compared in a clinical setting. Further, a survey was performed exploring use of ATNLP amongst UK neurologists.

METHODS: Service development study. Patients were followed up 2 and 7 days after LP using blinded telephone assessment. A questionnaire was developed to assess the use of ATNLP amongst UK neurologists. Frequency, onset, duration and severity of PLPHA were recorded as were use of analgesia, general practitioner consultations, hospital readmissions, days off work due to PLPHA and cost. Neurologists were asked about their familiarity with, and use of, ATNLP.

RESULTS: One hundred and nine participants attending the Royal London Hospital were included, and 74 attendees of the Association of British Neurologists 2012 conference completed an on-site questionnaire. ATNLP reduced the rate of PLPHA (27.1% vs. 60.4%; P < 0.01). In those participants who developed PLPHA symptoms were short-lived (mean 50 h vs. 94 h, P = 0.02) and less severe after ATNLP. Use of ATNLP led to significant cost savings. Only one in five UK neurologists regularly use ATNLP stating lack of training and availability of atraumatic needles as main reasons.

CONCLUSIONS: ATNLP significantly reduces the risk of PLPHA. Training is required 3 to facilitate a change from TNLP to ATNLP amongst clinicians.

Barts-MS paper 3

Gafson et al. Towards the incorporation of lumbar puncture into clinical trials for multiple sclerosis. Mult Scler. 2012 Oct;18(10):1509-11.


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