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Lancet. 2018 Mar 24;391(10126):1197-1204. doi: 10.1016/S0140-6736(17)32451-0. Epub 2017 Dec 7.

Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis.

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Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Division of Neurosurgery, University of Toronto, Toronto, ON, Canada.
Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Health Sciences Library, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Department of Biochemistry and Biomedical Sciences, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Department of Hygiene and Dietetics, Jagiellonian University, Krakow, Poland.
Department of Internal Medicine, United Arab Emirates University, Al Ain, United Arab Emirates.
Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark.
Evidence based Insurance Medicine, University Hospital of Basel, Basel, Switzerland.
Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan.
Department of Neurosurgery, Yale University, New Haven, CT, USA.
Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Department of Anaesthesia and Intensive Care, St George's Hospital, University of London, London, UK.
Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. Electronic address:



Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles.


In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546.


We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation.


Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.



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