Lumbar punction: comparison between an atraumatic and a traumatic punction needle 1
ProfessionaL articLe
1 University 
Rehabilitation Institute, 
Republic of Slovenia - 
Soča, Ljubljana, Slovenia
2 Department of Vascular 
Neurology and Intensive 
Therapy, Division of 
Neurology, University 
Medical Centre Ljubljana, 
Slovenia
Korespondenca/
Correspondence:
tina Bregant,  
e: tina.bregant@siol.net
Ključne besede:
igla; popunkcijski 
glavobol (PPG); glavobol 
po punkciji dure
Key words:
needle; post-lumbar 
puncture headache; post-
dural puncture headache 
(PDPH)
Citirajte kot/Cite as:
Zdrav Vestn. 2017;  
86(1–2):53–64
received: 23. 8. 2016 
accepted: 3. 1. 2017
Professional article neurobiologyZdrav Vestn | januar – februar 2017 | Letnik 86
Lumbar punction: comparison between an 
atraumatic and a traumatic punction needle
Lumbalna punkcija: primerjava netravmatske 
in travmatske punkcijske igle
tina Bregant,1 Uroš rot,1 Leja Dolenc Grošelj2
Abstract
Background: Lumbar puncture is a standardized, routine diagnostic procedure in the diagnosis of 
neurological diseases. Post-dural puncture headache (PDPH) is a common complication which oc-
curs in 10 to 30 % of patients. Although the incidence of PDPH is much lower with the use of small, 
non-cutting needles, neurologists in Slovenia routinely use the classical traumatic spinal needles.
Methods: In the article we provide an overview of a research concerned with the use of traumatic 
and atraumatic needles in the procedure with the emphasis on complications of the lumbar punc-
ture. We present American and European recommendations for lumbar puncture procedure.
Conclusions: International recommendations for neurologists advise the use of atraumatic spinal 
needles for lumbar puncture. We recommend to Slovenian neurologists to start using the atraumatic 
needles for elective lumbar punctures and hence provide neurological patients with better quality 
and cheaper long-term care.
Izvleček
Uvod: Lumbalna punkcija je standardni, rutinski postopek pri diagnosticiranju nevroloških bole-
zni. Pogost zaplet lumbalne punkcije je popunkcijski glavobol (PPG), ki se pojavlja v povprečju pri 
10–30 % punktiranih. Na nevroloških oddelkih v Sloveniji zaenkrat rutinsko uporabljamo klasične 
travmatske punkcijske igle, medtem ko je bilo z več raziskavami dokazano, da incidenco PPG zmanj-
šamo z uporabo netravmatskih punkcijskih igel.
Metode: V prispevku je opisan pregled do sedaj opravljenih raziskav o uporabi travmatske in ne-
travmatske igle pri lumbalni punkciji s poudarkom na primerjavi zmanjšanja zapletov. Predstavimo 
ameriške in evropske smernice ter priporočila pri izvedbi lumbalne punkcije s poudarkom na upo-
rabi različnih vrst igel. Pregledamo možnosti, ki jih imamo pri nas za izvedbo lumbalne punkcije.
Zaključki: Mednarodne smernice priporočajo nevrologom uporabo netravmatskih punkcijskih igel. 
Na podlagi do sedaj opravljenh mednarodnih študij predlagamo uvedbo netravmatskih igel za neur-
gentne lumbalne punkcije tudi pri nas, saj bomo tako nevrološkim bolnikom omogočili bolj kakovo-
stno in na dolgi rok cenejšo oskrbo.
1. Introduction
Modern international guidelines sup-
port the use of atraumatic needles for 
lumbar puncture. As the diagnostic lum-
bar puncture in neurological patients is 
a frequent routine investigation, which 
is in our settings still performed with 
2 Zdrav Vestn | januar – februar 2017 | Letnik 86
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traumatic needles, we hereby present 
a review of the literature on the use of 
traumatic and atraumatic needles along 
with the American and European guide-
lines and recommendations for the per-
formance of this investigation.
2. Lumbar puncture
Lumbar puncture is a standard, routine 
diagnostic procedure in patients with neu-
rological symptoms and signs. The physi-
cian, in aseptic conditions, using a special 
needle intended for this purpose, punc-
tures the spinal channel – subarachnoid 
space, most frequently at the level of the 
3rd and 4th lumbar vertebrae, and collects 
a sample of the cerebrospinal fluid (1). The 
purpose of lumbar puncture is to diagnose 
possible infection, inflammation, CNS 
disorder or a subarachnoid haemorrhage 
by cerebrospinal fluid examination. In the 
event of idiopathic intracranial hyper-
tension, the puncture may be performed 
with therapeutic intent. Lumbar puncture 
is also used for intrathecal administration 
of various agents, such as antibiotics, an-
aesthetics, chemotherapeutic agents or 
radiopaque contrast media.
2.1 Historical aspects 
of lumbar puncture
The first lumbar puncture was per-
formed by Walter Essex Wynter in 1889 in 
London, with an intent to relieve/decom-
press intracranial pressure in four patients 
with tubercular meningitis. The article 
was published in the first issue of the Lan-
cet. Only two years after this first attempt 
in which all four patients died, in 1891 at 
a conference in Wiesbaden, Dr Heinrich 
Quincke presented a new technique of 
lumbar puncture  (3,4) in a patient with 
meningitis, who had undergone three 
repetitions of the procedure and survived. 
Even today, the Quincke’s traumatic nee-
dle is the most frequently used lumbar 
puncture needle and the procedure is also 
similar, the only difference being in that it 
is performed in aseptic conditions.
2.2 Complications and 
contraindications
Despite the fact that nowadays lum-
bar puncture represents a routine and 
relatively safe procedure, complications 
may not be fully avoided (5,6). The risk 
of complications is particularly high in 
patients with an increased intracranial 
pressure due to brain neoplasm, an in-
creased risk of bleeding due to coagu-
lation disorder: thrombocytopenia with 
a platelet level below 50,000–80,000/
µL  (7), active haemorrhage or INR 
>1.4 (8) or an epidural spinal abscess (9). 
In these patients lumbar puncture is 
contraindicated. By means of vigilant 
clinical examination, imaging diagnos-
tics (CAT scan of the head or MR scan 
of the spine in the case of a spinal epi-
dural abscess) and laboratory tests (hae-
mogramme, INR) the risk of lumbar 
puncture-associated complications can 
be reduced, and conditions in which 
lumbar puncture is contraindicated can 
be detected. Whenever in doubt, we con-
sult a radiologist or a haematologist (10).
A relevant factor that affects the prob-
ability of complications in lumbar punc-
ture is the quality of the procedure, where 
the technique and skills of the physician 
performing it are of great importance. 
But nevertheless, complications may 
occur even when the procedure is per-
formed with due diligence in adequately 
selected patients by a skilled physician. 
Among the most frequent ones are lum-
bago and headache, a combination of 
both and severe radicular pain  (11). In-
fections, haemorrhage or spinal haema-
toma, herniation or intradural epider-
moid cyst occur less frequently (10).
Lumbar punction: comparison between an atraumatic and a traumatic punction needle 3
ProfessionaL articLe
2.3 Post-lumbar puncture 
headache – PLPH
Some subjects, particularly younger 
ones, may develop a post-dural-puncture 
headache (PDPH) (12). Other CNS-relat-
ed complications, such as complaints of 
double vision, tinitus and transient deaf-
ness, are considerably less frequent (13). 
The mechanisms of these complications 
have not been fully explained yet; most 
probably they are attributable to a de-
crease in the intracranial pressure as a 
result of cerebrospinal fluid withdrawal 
and leakage (12,14). This causes traction 
to the intracranial structures, such as 
the meninges, blood vessels and crani-
al nerves, and the associated feeling of 
pain. A possible compensatory reaction 
to intracranial hypotension is dilatation 
of the cerebral veins, which also may 
cause a headache (14).
In the International Classification of 
Headaches-II (ICHD-II) PDPH is de-
fined as a postural headache that occurs 
within five days of the puncture. It is 
exacerbated with upright position, lasts 
at least 15  minutes and resolves after 15 
minutes. In order to meet the diagnos-
tic criteria, at least one more additional 
symptom, such as e.g. stiff neck, nau-
sea, tinitus, hypoacusis or photophobia 
should be present (15).
The incidence of PDPH ranges be-
tween <1 % and 70 %. It depends on the 
procedure-related factors. PDPH inci-
dence is influenced to the greatest ex-
tent by the type and diameter (gauge) of 
the puncture needle  (16-21). The use of 
an atraumatic needle (e.g. Whitacre or 
Sprotte type) in comparison with a trau-
matic needle (Quincke type) significant-
ly reduces the occurrence of PDPH (22). 
More PDPH cases are observed among 
younger people  (17,23,24), women  (17), 
persons with a low BMI, and those 
who already suffer from chronic head-
aches (17,25). Less frequently are report-
ed problems in children and the elder-
ly  (10). According to the investigation 
reports, lumbar puncture with a trau-
matic needle in older people is deemed 
to be safe and associated with less pain 
and lower risk of PDPH occurrence 
than in younger people  (26). The inci-
dence of PDPH is the lowest in the age 
group 60+, in persons with Alzheimer’s 
disease and mild cognitive disorder (27). 
A comparably low incidence with an 
even lower occurrence of PDPH at <2 % 
is reported in patients with Alzheimer’s 
disease, who underwent puncture with 
Figure 1: a Quincke type traumatic needle for lumbar puncture (top to bottom): 22-gauge with black hub, 
short, 38 mm; 20-gauge with yellow hub, medium, 75 mm; 22-gauge with black hub, 90 mm (standard), 
and in the bottom, sprotte type atraumatic needle: 25-gauge with orange hub, long, 120 mm. the 
Quincke needle has a sharp bevel that advances easily through tissue planes. source: Bregant t.
4 Zdrav Vestn | januar – februar 2017 | Letnik 86
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Figure 2: the tip of the traumatic Quincke type spinal needle is triangular 
sharpened, which enables a quick and easy penetration of the skin while the 
tip of the atraumatic sprotte type needle is blunt with a side aperture. source: 
Bregant t.
a 24-gauge Sprotte’s atraumatic nee-
dle (28).
The use of thinner atraumatic punc-
ture needles reduces the frequency of 
PDPH in all subjects with a spinal tap. 
There are different and not fully ex-
plained reasons why the standard thicker 
traumatic needles are still in use (25,29). 
In 1998, more than 70 % of neurology 
departments in Great Britain were still 
using traumatic needles while in only 
two out of 48 units they were also using 
thinner needles with a diameter of less 
than 22-gauge (30). In 2001, only 2 % of 
neurologists in the U.S.A. used thinner, 
atraumatic puncture needles (29). At the 
Mayo Clinic Department of Neurology 
in Arizona the use of atraumatic needles 
for lumbar puncture was introduced in 
2002. Until 2008, their use increased 
from 0 % to 37 % (25). In 2005, the Amer-
ican Academy for Neurology (AAN) ad-
opted recommendations for the use of 
atraumatic puncture needles, as the use 
of atraumatic, thinner needles was found 
to prevent PDPH by first-order proof, 
consistent with an A-level recommenda-
tion (31).
2.4 Frequency of investigation
With advanced imaging techniques, 
which allow identification of patients in 
whom lumbar puncture is contraindi-
cated, the lumbar puncture has become 
a safe, routine and standard procedure. 
According to the data for England for 
the period 2011/12, as many as 55,427 
in-hospital stays also included a diagnos-
tic lumbar puncture, which – calculated 
per individual institution with 75,000 
in-hospital stays annually – makes 1 
lumbar puncture daily (32). In the same 
year, 0.53 % of hospital consultations in 
England consisted of a clinical examina-
tion combined with a diagnostic lumbar 
puncture (33).
The laboratory for cerebrospinal flu-
id diagnostics of the University Depart-
ment of Neurology in Ljubljana per-
forms between 800–900 CSF analyses 
yearly, while during on-call times a few 
CSF samples are additionally sent to the 
emergency laboratory. The data for the 
last five years show that there were 810 
basic CSF investigations performed in 
the year 2013, 828 in 2014, 794 in 2015 and 
465 in the first half of 2016 (34).
2.5 Puncture needles
For lumbar puncture neurologists 
use special atraumatic as well as trau-
matic puncture needles, which differ 
from each other according to the shape 
of the needle tip. The use of atraumatic 
needles statistically significantly reduces 
the incidence of PDPH while also reduc-
ing the costs of treatment. According to 
the international guidelines, which are 
presented below, neurologists are rec-
ommended to use atraumatic needles 
as a method of choice, while also using 
traumatic needles, which are consid-
ered more suitable for use in emergency 
wards.
Lumbar punction: comparison between an atraumatic and a traumatic punction needle 5
ProfessionaL articLe
Table 1: Larger studies comparing post-dural puncture headache (PDPH) incidence when using traumatic and atraumatic needles for 
routine diagnostic lumbar puncture.
Study
(reference 
number)
Pub-
lished 
year
Study type Patient group 
(number of 
patients, 
special 
descriptors)
Incidence of PDPH when using 
traumatic and
atraumatic needles
Suggested use 
of atraumatic 
needles for LP
Braune, 
Huffman (42).
1992 Prospective, 
double-blind
75 36 % and 4 % yes
Davis et al (38). 2014 Prospective, 
observational
96 50 % and 21 % yes; p=0.01
Duits et al (43). 2016 Multicentric, 
prospective
3868; patients 
at memory 
clinics (MMse 
= 25 ± 5)
total 9 % yes
Hammond et 
al (18).
2011 Prospective 187; 
neurological 
outpatients
32 % and 19 % yes
Jager et al (44). 1993 Prospective 600 atraumatic needle: 3.6 % yes
Kleyweg et 
al (45).
1998 Double-blind, 
randomised
99 32 % and 6 % yes; p=0.001
Lavi et al (17). 2006 Prospective, 
randomised
55 36 % and 3 % yes; p=0.002
Luostarinen et 
al (46).
2005 Prospective, 
randomised
78 49 % and 36 % no statistically 
significant 
difference
Peskind et 
al (28).
2009 Prospective, 
multicentric
63 patients 
with 
alzheimer’s 
dementia
<2 % for atraumatic needle yes
straus et al (41). 2006 Meta-analysis of 
15 randomised 
controlled trials 
(rcts)
587 absolute reduction of risk for 
PDPH by 12.3 % with atraumatic 
needle. More, but not statistically 
significantly more LP insertion trials 
with atraumatic needle.
yes, with further 
research backup
strupp et al (16). 2001 Prospective, 
double-blind, 
randomised
230 24 % and 12 % yes; p<0.05
thomas et 
al (20).
2000 Double-blind, 
randomised
97 reduction of risk for PDPH by 26 % 
with atraumatic needle.
yes
torbati et 
al (47).
2009 retrospective 317; 
neurological 
emergency 
patients
11 % and 4 % yes; p=0.017
Vakharia, 
Lote (37).
2009 combined retro/
prospective
52; acute 
neurological 
patients
10 % and 8 % yes; p<0.01
PDPH = post-dural puncture headache, LP = lumbar puncture.
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2.5.1 Traumatic needles
Classic or standard lumbar puncture 
needle is a Quincke type spinal traumat-
ic needle of a 22-gauge diameter and a 
length of 90 mm (Figure 1). The needle 
is marked with black colour. The tip is 
triangular tapered, which allows quick 
and easy piercing of the skin (Figure 2). 
However, it also makes a triangular cut 
in the dura, thus causing greater cere-
brospinal fluid leak than that caused by 
an atraumatic needle, which leads to the 
onset of PDPH (Figure 3).
2.5.2 Atraumatic needles
Atraumatic needles are routinely used 
by anaesthesiologists in spinal anaesthe-
sia (spinal block) and increasingly often 
also by neurologists in diagnostic lumbar 
puncture (35). The tip of these needles is 
blunt, oval-shaped, with either one or 
two side apertures, which allows the dura 
to be entered gently by pushing aside its 
fibres rather than being cut. Despite the 
overwhelming evidence of the advan-
tages of these needles, their use has not 
been spread widely enough to be used 
routinely (25). Most frequently, neurolo-
gists abroad use 22-gauge Whitacre type 
atraumatic needles for lumbar puncture 
or even thinner 25-gauge and 27-gauge 
Whitacre type, and Sprotte needles (16-
20,33,36-38).
2.5.3 Comparison of traumatic 
and atraumatic needles
Lumbar puncture can be successfully 
performed with 20- or 22-gauge atrau-
matic needles (39). A standard atraumat-
ic needle with a diameter of 26-gauge 
considerably decreases the occurrence 
of PDPH in comparison with a 22-gauge 
needle (40). Further investigations sum-
marised in Table 1 show that the use of 
atraumatic needles decreases the occur-
rence of PDPH (16-18,20,28,38,41-47).
The investigation that stands out 
among them is a meta analysis of the use of 
traumatic and atraumatic needles, which 
has confirmed the safety and reliability of 
atraumatic needles of various diameters, 
their use being associated with a consid-
erable decrease in PDPH occurrence (41). 
At the same time, the authors pointed out 
that the use of thin atraumatic needles was 
associated with more frequent unsuccess-
ful punctures, however, the association 
was not statistically significant (41). Simi-
lar observations were reported by authors 
of an older investigation, which – apart 
from statistically insignificant increase 
in the number of repeated punctures – 
also showed a decrease in the occurrence 
of PDPH from 54 % to 29 % respectively 
when 20-gauge atraumatic needles were 
used as compared to traumatic ones (20). 
Probably this may also explain why the 
use of atraumatic needles has not become 
more widely accepted among neurolo-
gists and emergency physicians, as it is ex-
tremely important that puncture for CSF 
retrieval in these settings is performed 
quickly and efficiently.
Table 1 summarises the results of 
studies on the use of traumatic and at-
raumatic needles for lumbar puncture in 
neurological patients. Investigations in 
patients who had puncture performed 
outside the routine diagnostic proce-
dures under epidural anaesthesia and all 
investigations in children were excluded.
2.6 Deficiencies and special 
features of atraumatic needles
In the studies, several factors were as-
sessed regarding the use of atraumatic 
needles: possibly longer duration of (sam-
ple) retrieval, greater number of attempts 
/puncture repetitions, inconvenient use 
of a pressure gauge, price and the reluc-
tance of the staff to use these needles.
Lumbar punction: comparison between an atraumatic and a traumatic punction needle 7
ProfessionaL articLe
Slika 3: travmatska igla tipa Quincke naredi trikoten rez v duro, zaradi česar je iztekanje likvorja večje 
kot pri atravmatski igli, kar vodi v nastanek PPG. Vir: strupp M, schueler o, straube a, Von stuckrad-
Barre s, Brandt t. atraumatic sprotte needle reduces the incidence of post-lumbar puncture headaches. 
neurology 2001; 57  (12): 2310–2. slika je objavljena s pisnim dovoljenjem glavnega avtorja.
2.6.1 Cerebrospinal fluid collection
With an atraumatic needle of less 
than 22-gauge diameter CSF collection 
takes longer  (39,41). However, since the 
quantities needed for diagnostic exam-
inations are small (3–12 ml, most often 
10 ml) this should not represent a major 
problem (33).
Recent studies do not report higher 
number of puncture repetitions with at-
raumatic needles  (18,33) Moreover, the 
number of puncture repetitions with 
the use of thinner atraumatic needles is 
even statistically significantly lower (33). 
A larger, more recent study compar-
ing 20- and 22-gauge traumatic needles 
with 22-gauge atraumatic needles has 
confirmed the safety and applicability 
of atraumatic needles, as the probabil-
ity of PDPH occurrence with the latter 
decreased by 69 % while the number of 
puncture repetitions did not differ be-
tween the two studied needle types (18). 
This observation is consistent with a 
larger and older anaesthesiological data 
meta-analysis confirming that the use 
of atraumatic spinal needles in patients 
at high risk of PDPH is appropriate 
and safe, and not associated with an in-
creased risk of puncture failure (48).
CSF withdrawal requires dura pen-
etration. The onset of PDPH is signifi-
cantly influenced by CSF leak through 
cut dura  (49). With an atraumatic nee-
dle dura fibres are only separated while 
with a traumatic needle the dura is cut. 
Therefore the technique using traumatic 
needle should require bevel to be aligned 
parallel to the longitudinal axis of the spi-
nal cord, without rotating the needle at 
the end of the investigation. In atraumat-
ic needle it is recommended to replace 
the stylet when removing the needle in 
order to avoid also withdrawing arach-
noid fibres. In 21-gauge Sprotte type nee-
dle, the stylet replacement additionally 
reduced the occurrence of PDPH from 
previous 16 % to 5 % (16). Figure 3 shows 
the difference in the puncture wound 
caused by a traumatic vs. an atraumatic 
spinal needle when entering the dura.
Figure 3: Dural puncture hole made 
with a Quincke type traumatic nee-
dle is triangular and larger than when 
made with a atraumatic needle. The 
subsequent loss of CSF is larger, which 
results in a higher incidence of PDPH 
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(post-dural puncture headache. Source: 
Strupp M, Schueler O, Straube A, Von 
Stuckrad-Barre S, Brandt T. Atraumatic 
Sprotte needle reduces the incidence of 
post-lumbar puncture headaches. Neu-
rology 2001; 57  (12): 2310–2. The photo 
was approved for reproduction by the 
first author.
The fear that CSF withdrawal with 
an atraumatic needle would take longer 
has not been confirmed in experimen-
tal conditions. The flow rates of both 
needles with equal diameters were test-
ed with physiological saline solution as 
well as with a thicker, protein-saturated 
solution (50). The flow rate between both 
needles differed by 10 % in physiological 
saline solution and slightly less in pro-
tein-saturated mixture, in favour of the 
traumatic needle. In taking pressure 
measurements, the subjects were even 
slightly faster when using atraumat-
ic needles and a manometer with pro-
tein-saturated mixture (50).
2.6.2 Needle prices and the 
cost of patient treatment
Although traumatic needles are con-
siderably cheaper than atraumatic ones, 
the overall costs of patient care after 
the lumbar puncture performed with 
an atraumatic needle are much lower. A 
comparison between 22-gauge traumat-
ic (Quincke type) needles and 22-gauge 
atraumatic (Whitacre type) needles has 
shown that the use of atraumatic needles 
of the same diameter reduced the patient 
care costs on the account of a consider-
ably lower occurrence of PDPH. The rate 
of complications in terms of puncture 
repetition or failure to withdraw CSF 
with both needles were comparable (36).
In Europe, the price of traumatic 
needles is around 1 Euro while the price 
of atraumatic needles ranges between 
5–10 Euros  (35). In the U.S.A. the ratio 
between these prices is about the same, 
i.e. slightly less than 2 USD for traumatic 
needles and 15 USD for atraumatic nee-
dles. However, a routinely performed 
lumbar puncture with a traumatic nee-
dle is more expensive as compared to 
the same performed with an atraumat-
ic needle, i.e. USD 192.15 vs. USD 166.08 
respectively, which means that the latter 
costs USD 26.07 less (51). If needle prices 
were the same, the saved amount would 
be even higher, i.e. USD 41.87. Taking 
into account the current prices, by using 
atraumatic needles, the whole healthcare 
system in the U.S.A. could save as much 
as USD 10.4 million. A similar study 
carried out in the U.S.A. has indicated 
comparable savings, though the cost of 
their procedure with traumatic needle 
amounting to USD 239 is higher, while 
the cost of the procedure with atraumatic 
needle amounting to USD 187, is compa-
rable to that in Europe (24,33). The anal-
yses for Europe show even greater sav-
ings, i.e. USD 142 when lumbar puncture 
is performed with a 25-gauge atraumatic 
needle (33). The great savings in Europe 
are attributable to shorter absence from 
work – fewer sick leaves and fewer social 
transfers. It is interesting to note that the 
patients who require lumbar puncture 
irrespective of their diagnosis are absent 
from work 175 days if the puncture is 
performed with a traumatic needle, but 
only 55 days if an atraumatic needle is 
used (33).
Table 2 presents the advantages and 
disadvantages of the use of traumat-
ic and atraumatic needles for lumbar 
puncture.
2.7 International guidelines and 
clinical recommendations
In 2005, the American Academy of 
Neurology (ANN) published recom-
mendations for the use of atraumatic 
puncture needles. The use of atraumat-
Lumbar punction: comparison between an atraumatic and a traumatic punction needle 9
ProfessionaL articLe
ic, thinner needles was found to prevent 
PDPH by first-order proof, consistent 
with an A-level recommendation  (31). 
Despite the recommendations, they 
found that the use of atraumatic needles 
at neurology departments was not wide-
ly accepted, and therefore in 2009 they 
reaffirmed their position that the use of 
atraumatic needles in diagnostic lum-
bar punctures should become the gold 
standard (25). Further studies have con-
firmed that the use of atraumatic needles 
facilitates cheaper, safer and more reli-
able investigations (49,51).
In the U.S.A. too, in the theory and 
practice of emergency and general med-
icine, they still use 20- and 22-gauge 
traumatic needles, while pointing out 
that the probability of PDPH occurrence 
with spinal traumatic needles of greater 
diameter is higher  (52,53). The reason 
should be sought in the specific organ-
isation of emergency medicine and the 
need that lumbar puncture be performed 
efficiently and as quickly as possible.
Likewise, poor compliance of spe-
cialists, with the exception of anaesthe-
siologists who have been routinely using 
atraumatic needles for spinal analgesia 
for years, is also noted in Europe. Prac-
tical recommendations are clear: for 
lumbar puncture atraumatic needles 
with 22-gauge or smaller outer diameter 
should be used (54).
Similar situation is observed in the 
United Kingdom. A study at an emer-
Table 2: characteristics of traumatic and atraumatic needle use in lumbar puncture.
Needle type Traumatic Atraumatic
Skin puncture easy Harder
skin can be punctured first prior to insertion of 
the LP-atraumatic needle by using the 18G or 
green 19G local anaesthetic needle
Puncture of the 
ligamentum 
flavum and dura
a “give” (or »plop«) is 
felt on passing through 
the ligamentum 
flavum and dura
Dural puncture is not felt
Dural puncture hole triangular, larger no cutting of dural fibers
Use of local 
anaesthethics
not mandatory yes
Obtaining CSF reliable, fast reliable, can be slower
Several LP-attempts Usually not Usually not; the first attempts of LP are more 
successful with atraumatic needle
PDPH incidence High Low
Duration of 
hospitalisation
Prolonged shortened
Routine use yes no
Needle costs eur 0.89 eur 5.34–10.1
Overall (total) costs of 
patient care with LP
Higher due to 
complications, esp. 
PDPH
Lower; immediate discharge after procedure
CSF = cerebrospinal fluid, LP = lumbar puncture, PDPH = post-dural puncture headache.
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gency department of neurology in Lon-
don has proven a statistically significant 
decrease of traumatic punctures and the 
ability of the staff to learn the technique 
fast, so they reiterated their recommen-
dation that atraumatic 22-gauge Sprotte 
type needles for lumbar puncture should 
be used at all neurology departments, 
including the emergency units  (37). In 
Ulster, Northern Ireland, atraumatic 
22-gauge Whitacre type needles were in-
troduced for routine use after a compar-
ative study.
Repeated appeals and studies in Eu-
rope and the U.S.A. certainly call for the 
use of atraumatic needles in diagnostic 
lumbar punctures, while pointing out 
the need for additional training to en-
sure that the transition from the use of 
traumatic to atraumatic needles would 
be as smooth and uneventful as possi-
ble (38).
3. Discussion
At the University Department of 
Neurology in Ljubljana, we use trau-
matic needles for lumbar puncture. 
Emergency punctures are generally per-
formed by specialists-neurologists at the 
emergency outpatient clinic of the Uni-
versity Department of Neurology, Uni-
versity Medical Centre Ljubljana, with 
traumatic needles, which applies to both, 
in-hospital and outpatient procedures.
For lumbar puncture, likewise oth-
er physicians but not also anaesthesi-
ologists, neurologists use classic spi-
nal traumatic needles, most frequently 
Quincke type, with a 22-gauge diameter 
and a length of 90 mm. These needles 
are marked with black hub and have 
sharp bevel. Rare cases require the use 
of a thicker and/or longer needle with 
a 20-gauge diameter and/or a length 
of 150 mm. These needles are marked 
with yellow hub. The thickest 18-gauge 
needles is 90 mm long and is marked 
with pink hub. Generally, a manome-
ter is also used with puncture in adults. 
The same 22-gauge Quincke type nee-
dles are used in toddlers and babies, but 
these needles are shorter, measuring 38 
or 63 mm in length. Anaesthesiologists 
use atraumatic needles particularly for 
spinal analgesia (spinal block). These 
needles can be used for spinal anaes-
thesia as well as for diagnostic lumbar 
punctures and cytological diagno-
sis. Our anaesthesiologists generally 
use atraumatic needles with a 25- and 
27-gauge diameter.
Differences regarding the experience 
in the use of traumatic and atraumatic 
needles for lumbar puncture between 
different specialists in different insti-
tutions are associated with a variety of 
factors. A few-fold difference in price, 
which is apparent at first glance, may 
certainly affect the accessibility in larg-
er orders. However, the use of cheaper 
traumatic needles entails considerably 
higher hidden costs associated particu-
larly with the occurrence of PDPH and 
longer post-puncture care, as shown in 
Table 2.
In comparison with a stiffer, thicker 
needle of a 22-gauge type, handling of 
an atraumatic thinner needle, such as 
e.g. 27-gauge needle, is slightly different 
as the needle may bend. This requires 
stable and comfortable positioning of 
the patient on a harder surface, which is 
generally not provided by hospital beds. 
As with thinner needles the time to CSF 
sample retrieval is slightly longer, in the 
fear that the procedure would take too 
long, we use a slightly thicker atraumatic 
25- or 22-gauge needle.
In our settings too the specific organ-
isation of work in emergency medicine 
requires that lumbar puncture should be 
carried out quickly and efficiently, which 
considerably restricts the opportunities 
Lumbar punction: comparison between an atraumatic and a traumatic punction needle 11
ProfessionaL articLe
for learning new diagnostic techniques 
through regular work. Therefore it would 
be necessary that the introduction of a 
new lumbar puncture technique with 
atraumatic needles should be accom-
panied with additional training, which, 
however, calls for additional efforts from 
the side of the management as well as the 
staff.
The transition from traumatic to at-
raumatic needles and the learning of 
new technique should not pose a partic-
ular problem, as some of our colleagues, 
and in particular anaesthesiologists, 
learn how to use them already during 
their residence training. Considering 
the material that is already available in 
the UMC Ljubljana, it would be rea-
sonable to start using atraumatic 22- or 
25-gauge needles of Sprotte type. When 
introducing the use of these needles, it 
would make sense to organise a practi-
cal workshop for interested physicians 
beforehand.
The use of atraumatic needles for 
lumbar puncture is reasonable in elec-
tive diagnostic lumbar punctures and 
in patients that are prone to developing 
PDPH, i.e. in young people, women, tall 
persons and those with a low BMI. Thus 
we could reduce the duration of in-hos-
pital stays, as currently the patients after 
lumbar puncture generally stay in the 
hospital whole day, or in the case that 
the procedure is performed on an out-
patient basis, two hours. The compari-
son of both techniques would allow for 
justified change of the needles and stay-
ing abreast of the modern international 
guidelines with faster and better patient 
care.
The change of traumatic needles for 
atraumatic ones seems reasonable par-
ticularly in neurology departments, 
whereas in emergency departments, due 
to the specifics of their work, lumbar 
puncture with a classic 22-gauge trau-
matic needle of Quincke type remains 
the gold standard.
4. Conclusion
Review of the literature and guidelines 
on the performance of lumbar puncture 
indicates that it would be reasonable to 
use atraumatic puncture needles also in 
the Slovenian neurology departments. 
Neurologists are recommended to start 
using atraumatic needles for elective 
lumbar punctures. In this way we will be 
able to provide a higher quality patient 
care, which will be consistent with inter-
national guidelines.
Acknowledgement
The authors thank medical director 
of the University Department of Neu-
rology of the UMC Ljubljana David B. 
Vodušek, MD, PhD, for his expert guid-
ance and advice.
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