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Atraumatic needles for lumbar
puncture: why haven’t neurologists
changed?
A Davis,
1,2
R Dobson,
1,3
S Kaninia,
4
G Giovannoni,
1,2
K Schmierer
1,2
1
Department of Neurosciences,
Blizard Institute, Barts and The
London School of Medicine and
Dentistry, Queen Mary
University, London, UK
2
The Royal London Hospital,
CAG Neuroscience, Barts Health
NHS Trust, London, UK
3
Hurstwood Park Neurosciences
Centre, Brighton and Sussex
University Hospital Trust,
Haywards Heath, West Sussex,
UK
4
The National Hospital for
Neurology and Neurosurgery,
UCLH NHS Foundation Trust,
London, UK
Correspondence to
Dr Angharad Grace Davis,
Blizard Institute, Barts and The
London School of Medicine and
Dentistry, Queen Mary
University, 4 Newark Street,
London E1 2AT, UK;
angharadgracedavis@gmail.com
Accepted 5 August 2015
To cite: Davis A, Dobson R,
Kaninia S, et al. Pract Neurol
Published Online First: [please
include Day Month Year]
doi:10.1136/practneurol-
2014-001055
ABSTRACT
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.
THE CASE FOR ATRAUMATIC
DIAGNOSTIC LUMBAR PUNCTURE
Diagnostic lumbar puncture is a key pro-
cedure in neurology as well as other
medical disciplines. Quincke carried out
the first lumbar puncture in 1891.
1
It is
generally safe but a common complica-
tion is post-lumbar puncture headache
syndrome
2
caused by the iatrogenic cere-
brospinal fluid (CSF)
3
leak. The occur-
rence the headache syndrome depends
largely on the type of needle used.
Numerous studies have shown that fre-
quency and severity of post-lumbar punc-
ture headache syndrome can be
dramatically reduced by replacing trau-
matic needles with atraumatic systems
4
(figures 1 and 2). Using the MeSH
(medical subject headings) terms ‘lumbar
puncture’, ‘headache’, ‘atraumatic’ and
‘spinal needle’, we identified 11 studies
that compared the incidence of post-
lumbar puncture headache following
diagnostic lumbar puncture when using
atraumatic versus traumatic spinal
needles. All studies showed a lower inci-
dence from using atraumatic spinal
needles (table 1).
5–13
A meta-analysis of 38 studies across a
wider population confirms a significantly
lower rate of post-lumbar puncture head-
ache. A subgroup analysis in the same
study showed an even lower inciden ce of
headache following atraumatic lumbar
puncture in people undergoing the pro-
cedure for diagnosis rather than for
anaesthesia.
4
Earlier suggestions that
atraumatic needles would have lower
CSF flow rates and would impair pres-
sure measurements have been invali-
dated.
15
Finally, recent evidence
confirmed the clinical effectiveness and
the cost-effectiveness of switching to
atraumatic spinal needles for diagnostic
lumbar puncture.
16
However, despite the overwhelming
evidence favouring atraumatic (rather
than traumatic) lumbar puncture, and
practice guidelines from the American
Academy of Neurology,
17
neurologists
around the world continue to dither
about adopting this over 60-year-old
‘innovation’.
18 19
For example, a recent
survey of UK neurologists showed that
while 74% knew that atraumatic needles
can significantly reduce the risk of post-
lumbar puncture headache syndrome,
only 16% were actually using them.
5
By
contrast, anaesthetists consider the use of
atraumatic needles to be the norm and
continued use of traumatic needles to be
ethically unacceptable.
20
The question therefore arises: why are
neurologists so reluctant to adopt atrau-
matic needles? We argue that the ‘failure
to switch’ from one needle type to
another has very little to do with the evi-
dence, which is strikingly favours atrau-
matic needles. The explanation is more
likely in the way that this innovation has
been communicated—‘diffused’ as
Everett Rogers
21
calls it—among neurolo-
gists. We explore this hypothesis and
propose suggestions on how to overcome
this innovation deadlock.
REVIEW
Davis A, et al. Pract Neurol 2015;0:1–5. doi:10.1136/practneurol-2014-001055 1
RECOGNISING THE BENEFITS OF ATRAUMATIC
LUMBAR PUNCTURE
According to Rogers, for an innovation to be adopted,
there must be a recognisable benefit.
21
The non-
adoption of atraumatic needle suggests a lack of aware-
ness of the morbidity associated with post-lumbar
puncture headache. The qualitative data support this
impression, indicating that most UK neurologists
believe that post-lumbar puncture headache occurs
‘rarely’. This is also reflected in the wealth of patient
information sheets that describe post-lumbar puncture
headache as a rare and mild complication, despite the
overwhelming evidence to the contrary.
22–24
We
propose a root cause of the discrepancy between evi-
dence and awareness is the disconnect between those
colleagues performing lumbar punctures and those
who subsequently review patients with their post-
procedure headache; the investigation is often per-
formed in an outpatient or day-case setting, with
patients leaving hospital soon afterwards. By the time
they develop post-lumbar puncture headache, most
have returned home and so present to their general
practitioner rather than the hospital.
MYTH-BUSTING: THE ‘COMPLEXITY’ OF
ATRAUMATIC LUMBAR PUNCTURE
The complexity of an innovation affects the likelihood
of its adoption.
21
There is a common perception
among neurologists that using atraumatic lumbar
puncture systems is more complex than using trau-
matic needles.
5
However, the evidence suggests that
the learning curve between atraumatic and traumatic
lumbar puncture is no different.
11
After completing a
training session using a simulator, 92% of neurology
residents indicated that they would use atraumatic
needles again in their first lumbar puncture in a
patient.
25
Our group has shown no difference in the
number of attempts using either needle system
between two operators, one of whom had previously
used only traumatic needles, while the other had used
atraumatic needles from the outset.
5
AUSTERITY AND MULTI-PROFESSIONALISM IN
PUBLIC HEALTHCARE AS BARRIERS TO CHANGE
Financial pressures in public healthcare encourage us
all to identify potential savings. Atraumatic needle
systems cost three times as much as standard trau-
matic needles (in the UK, £9.47 vs £3.42). However,
analysis of the total financial burden of diagnostic
lumbar puncture—including the management of post-
lumbar puncture headache syndrome—shows that
atraumatic systems are clearly more cost-effective.
516
Doctors performing lumbar punctures may not know
of the medical problems they may be causing, but
commissioners should be more aware of the respect-
ive cost implications. However, with one needle type
costing three times as much as the other, and with
savings on the total cost of the procedure either not
assessed or not obvious, a narrow hospital-focussed
financial view continues to determine which needle
type to purchase. The result is the oft-quoted
‘unavailability’ of atraumatic needles on hospital
wards and in clinics.
5
BOUNDARIES BETWEEN CLINICAL COMMUNITIES
AS BARRIERS TO CHANGE
We also need to consider how the evidence for atrau-
matic needles is communicated among neurologists,
particularly compared with anaesthetists, where their
use is standard. It was an anaesthetist who published
the first study in Anaesthesiology in 1949, showing a
reduction incidence of headache following use of
atraumatic needles.
26
There has since been a wealth
of evidence in both neurological and anaesthetic jour-
nals.
2–13 26–31
Rogers describes how ‘heterophilous
communities’ (eg, neurologists and anaesthetists),
show slower rates of adoption than those where
innovators and early adopters share the same role as
those they subsequently influence.
21
This may
Figure 1 Overview of spinal needle types showing the
atraumatic ‘pinpoint’ spinal needle (middle) with introducer
(top), and traumatic ‘cutting’ spinal needle (bottom).
Figure 2 The needle tip in the atraumatic ‘pinpoint’ needle
(left) and traumatic ‘cutting’ needle (right).
REVIEW
2 Davis A, et al. Pract Neurol 2015; 0:1–5. doi:10.1136/practneurol-2014-001055
explain the difference between speciali ties. Even
when excluding the interspeciality lag between anaes-
thetists and neurologists, the adoption rate of atrau-
matic needles still appears to be much slower among
neurologists.
51832–34
DIFFERENCES IN MEDICAL PRACTICE AND
TRAINING AS BARRIERS TO CHANGE
The dissemination of evidence to underpin changes in
clinical practice does not rely on peer-reviewed publi-
cations and on communication and training among
colleagues within a speciality. The procedure-based
nature of anaesthetics with its emphasis on
‘elbow-to-elbow’ training may well have facilitated the
diffusion and adoption of atraumatic needles. Rogers
suggests the rate of adoption within a community
follows a bell-shaped curve. If the cumulative number
of adopters is plotted, the result is an S-shaped curve.
This S-shaped curve rises slowly at first, when there
are only a few adopters in each time period, but then
accelerates before eventually levelling out to a ‘tipping
point’ in adoption. Rogers outlines adopter categories
and describes progression along the curve as depend-
ing on dissemination of information and practice
across these categories, within which individuals
possess a different threshold for innovation.
21
Others
have argued that dissemination within healthcare
systems takes less of a linear format.
35
Are anaesthe-
tists more venturesome than neurologists, or does the
nature of the speciality where procedural proficiency
forms a critical part of training account for this
difference?
MAKING DIAGNOSTIC LUM BAR PUNCTURES
FINALLY ATRAUMATIC: SUGGESTIONS TO
OVERCOME BARRIERS
The common denominator of the barriers to switch
from traumatic to atraumatic diagnostic lumbar punc-
ture as standard in neurology is a distinct lack of com-
munication. Doctors need to know the evidence and
act on it. To act they need to be trained in atraumatic
lumbar puncture, and pass their knowledge and skill
on to trainees, and perhaps to some seniors too.
Commissioners need to be aware of the real cost of
lumbar puncture, and neurologists should actively
engage in translating the evidence in favour of atrau-
matic needles. Where traumatic needles are still used,
Table 1 Studies comparing incidence of post-lumbar puncture headache when using atraumatic and traumatic needles
Reference Patient group Study type
Incidence of post-lumbar
puncture headache
Braune and Huffman
6
n=75 Prospective, double-blind clinical trial Traumatic needle 36%
atraumatic needle 4%
Kleyweg et al
7
n=99 traumatic needle=50
atraumatic needle=49
Double-blind randomised trial Traumatic needle 32%
atraumatic needle 6%, p=0.001
Strupp et al
8
n=230 traumatic needle=115
atraumatic needle=115
Prospective, randomised, double-blind study Traumatic needle 24.4%
atraumatic needle 12.2%, p<0.05
Torbati et al
9
n=317 traumatic needle=54.6%
atraumatic needle=45.4%
Retrospective review Traumatic needle 11.32%
atraumatic needle 4.48%, p=0.017
Luostarinen et al
10
n=78 traumatic needle=39
atraumatic needle=39
Prospective, randomised study Traumatic needle 49%
atraumatic needle=36%, not significant
Vakharia and Lote
11
n=52 traumatic needle=24
atraumatic needle=36
Retrospective (traumatic needle) and
prospective (atraumatic needle)
Traumatic needle 10%
atraumatic needle 8%, p<0.01
Jager et al
12
Atraumatic needle=600 Prospective Atraumatic needle 3.6%
Hammond et al
13
n=187 traumatic needle=130
atraumatic needle=57
Prospective Traumatic needle 32%
atraumatic needle 19%
Thomas et al
14
n=97 traumatic needle=48
atraumatic needle=49
Double-blind randomised trial Risk of headache with atraumatic needle
reduced by 26% (95% CI 6% to 45%)
Lavi et al
2
n=55 traumatic needle=26
atraumatic needle=29
Prospective, randomised trial Traumatic needle 36%
atraumatic needle 3%, p=0.002
Davis et al
5
n=96 traumatic needle=48
atraumatic needle=48
Prospective observational study Traumatic needle 50%
atraumatic needle 20.9%, p=0.01
This excludes studies of children and patients undergoing either therapeutic lumbar puncture or epidural anaesthesia.
Figure 3 Patient information cards with the ClinicSpeak
weblink, for patients awaiting diagnostic lumbar puncture.
We can provide a sample pack of these cards on request.
REVIEW
Davis A, et al. Pract Neurol 2015; 0:1– 5. doi:10.1136/practneurol-2014-001055 3
and commissioners need ‘local’ evidence to convince
them, audits comparing the two needle systems can
provide the required information.
Finally, patients should be encouraged to seek infor-
mation and to choose the needle type for their
lumbar puncture. The ‘clean hands campaign’ of the
National Patient Safety Agency tried to reassure
patients; ‘it’s OK to ask’ clinicians to wash their
hands.
36
This could serve as a model for patients to
request an atraumatic needle for their lumbar punc-
ture. We have developed a simple web-based tool for
patients to read before their lumbar puncture, includ-
ing information about the benefits of atraumatic
needle for their lumbar puncture: http://www.
clinicspeak.com/LumbarPuncture/ (figure 3).
Key points
▸ There is overwhelming evidence to support the use
of atraumatic needles to reduce complications in
diagnostic lumbar puncture; despite this, few neurol-
ogists have adopted this 60-year-old ‘innovation’.
▸ Potential barriers to adoption include the communi-
cation of the evidence to commissioners who may
not appreciate the overall cost savings; clinicians
have a responsibility to ensure that those who
procure our medical equipment know the evidence
surrounding it.
▸ Lack of training opportunities may account for the
perceived technical difficulties oft-quoted by neurolo-
gists resisting ‘making the switch’; sharing good
practice and communicating between neurology and
anaesthetics—where atraumatic needles are standard
—should help training and adoption.
▸ The patient champion has a role in influ encing
change of practice; a web-based information reso urce
http://www.clinicspeak.com/LumbarPuncture/
encourages patients to ask about spinal needle type.
Twitter Follow Klaus Schmierer at @KlausSchmierer
Acknowledgements Images courtesy of ‘Agency of Design’.
Contributors AD and SK performed the literature review
described in the review. AD drafted the manuscript, which was
subsequently edited by RD, GG and KS. All authors agreed on
the final submitted manuscript.
Competing interests GG has received research grant support
from Bayer-Schering Healthcare, Biogen-Idec, GW Pharma,
Merck Serono, Merz, Novartis, Teva and Sanofi-Aventis. GG
has received personal compensation for participating on
Advisory Boards in relation to clinical trial design, trial steering
committees and data and safety monitoring committees from
Bayer-Schering Healthcare, Biogen-Idec, Eisai, Elan, Fiveprime,
Genzyme, Genentech, GlaxoSmithKline, Ironwood,
Merck-Serono, Novartis, Pfizer, Roche, Sanofi-Aventis, Synthon
BV, Teva, UCB Pharma and Vertex Pharmaceuticals. KS is a
principal investigator of trials sponsored by Novartis and
Roche. He has received speaking honoraria from, and served on
advisory boards for, Novartis, Merck-Serono and Merck Inc.
Provenance and peer review Not commissioned; externally
peer reviewed. This paper was reviewed by Brendan McLean,
Truro, UK.
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