How to perform a lumbar puncture

In collaboration with Prof. Claire Paquet (Neurologist, Center for Cognitive Neurology, Lariboisière Fernand Widal Hospital - APHP - Paris Diderot University, France) we have produced a short, pocket-sized leaflet that explains the basics of how to perform a lumbar puncture.

Download the Practical guide for lumbar puncture here.

We also recommend you watch this video tutorial created with Prof. Claire Paquet:
 

How to prevent side effects

Post-lumbar puncture headache (PLPH) is best explained by spinal fluid leakage due to delayed closure of a dural defect but there is no link between the quantity of collected CSF and the risk of PLPH.

The use of an Atraumatic Sprotte needle reduces the incidence of post-lumbar puncture headaches.

Different needle designs are available. Cutting bevel needles (standard Quincke and Yale) are the standard needles with a medium cutting bevel and an orifice at the needle tip. Atraucan, Pecan, Sprotte, and Whitacre needles are noncutting, pencil-point, and atraumatic needles.

Among patients who had lumbar puncture, atraumatic needles are 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 (Lancet.2017, Systematic review & meta-analysis).

Conventional needles

Medium (23G-24G) cutting bevel needles are most frequently used in clinical practice. Different hubs with size marking and cannulas of varying diameters and lengths can be used for different patients’ needs (e.g. for overweight patients).

Needle characteristics based on needle length, size, and design

(systematic literature review 2016; consensus guidelines 2017)

History of atraumatic needle

1890 H.I. Quincke invented the Quincke cannula - lumbar puncture has become an established
part of neurological diagnosis since then. In 1979 Market launch of the first atraumatic cannula developed by Prof. Sprotte.

Atraumatic needles allow better fluid flow while at the same time reducing the incidence of post-lumbar puncture headaches, therefore, they decrease post-puncture morbidity and improve the efficiency of diagnosis.

The closed, ogive-shaped cannula tip displaces tissue during puncture rather than cutting it (compared to the cutting tip of the traumatic cannula). The lateral eye has rounded edges, and is sealed precisely by the stylet during puncture. After the retraction of the cannula, the multi-layered texture of the dura of collagen and elastic fibers closes again.

The surfaces of the atraumatic cannula are polished and free from burrs. This enables the atraumatic cannula to be positioned very accurately, while the smooth inner surface of the cannula optimises fluid reflux.

Since 2005 the American Academy of Neurology (AAN) recommends the use of atraumatic needles (level A recommendation) for spinal anesthesia as well as for diagnostic lumbar puncture since there is firm scientific evidence of the benefits of atraumatic puncture of the fluid space.

A study from 2012 involving direct comparison between traumatic and atraumatic cannula, confirms the superiority of the atraumatic cannula. Post-lumbar puncture headache was much less common in patients treated with an atraumatic cannula.

Bibliography

  • Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis.
    Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Côté E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Lancet. 2017 Dec 6. pii: S0140-6736(17)32451-0. doi: 10.1016/S0140-6736(17)32451-0
  • Consensus guidelines for lumbar puncture in patients with neurological diseases.
    Engelborghs S, Niemantsverdriet E, Struyfs H, Blennow K, Brouns R, Comabella M, Dujmovic I, van der Flier W, Frölich L, Galimberti D, Gnanapavan S, Hemmer B, Hoff E, Hort J, Iacobaeus E, Ingelsson M, Jan de Jong F, Jonsson M, Khalil M, Kuhle J, Lleó A, de Mendonça A, Molinuevo JL, Nagels G, Paquet C, Parnetti L, Roks G, Rosa-Neto P, Scheltens P, Skårsgard C, Stomrud E, Tumani H, Visser PJ, Wallin A, Winblad B, Zetterberg H, Duits F, Teunissen CE. Alzheimers Dement (Amst). 2017 May 18;8:111-126
  • Lumbar puncture in patients with neurologic conditions.
    Babapour Mofrad R, Bouwman FH, Slot RER, Timmers T, van der Flier WM, Scheltens P, Teunissen CE. Alzheimers Dement (Amst). 2017 May 18;8:108-110
  • Introduction of Sprotte needles to a single-centre acute neurology service: before and after study.
    Vakharia VN, Lote H. JRSM Short Rep. 2012 Dec;3(12):82.
  • Lumbar Puncture: It Is Time to Change the Needle?
    Lavi R., Rowe J. M., Avivi I. Eur. Neurol. 2010; 64: 108-11
  • Assessment: prevention of post-lumbar puncture headaches. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurol. Evans R.W., Armon C., Frohman E.M., Goodin D.S.  Neurol. 2000; 55(7):909-914. Addendum / Neurol. 2005;65:510–512
  • Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial.
    Lavi R, Yarnitsky D, Rowe JM, Weissman A, Segal D, Avivi I. Neurology. 2006 Oct 24;67(8):1492-4.