Lumbar puncture: technique and goals for collecting cerebrospinal fluid. Spinal puncture - is the risk justified? Protocol of lumbar puncture in the medical history

Spinal puncture is an important step in the diagnosis of neurological pathologies and infectious diseases, as well as one of the methods of drug administration and anesthesia.

Often this procedure is called a lumbar puncture, lumbar puncture.

Thanks to computed tomography and magnetic resonance therapy, the number of punctures performed has significantly decreased.

However, they cannot completely replace the capabilities of this procedure.

Spinal puncture

About the puncture technique

There is a puncture technique that is not allowed to be violated and is the grossest mistake of the surgeon. According to the correct one, such an event should be referred to as a puncture of the subarachnoid space or, more simply, a spinal puncture.

Liquor is located under the meninges, in the ventricular system. Thus, nerve fibers are fed, brain protection is created.

When a disorder occurs due to a disease, the cerebrospinal fluid can increase, causing increased pressure in the skull. If an infectious process joins, then the cellular composition undergoes changes and, in case of hemorrhages, blood appears.

The lumbar region is pierced not only for medicinal purposes to administer the drug, but also to diagnose or confirm the alleged diagnosis. It is also a popular method of anesthesia for surgical intervention on the organs of the peritoneum and small pelvis.

Be sure to study the indications and contraindications when deciding on spinal cord puncture. It is not allowed to ignore this clear list, otherwise the safety of the patient is violated. Of course, without reasons, such an intervention is not prescribed by a doctor.

Who can appoint a puncture?

The indications for such a manipulation are as follows:

• alleged infection of the brain and its membranes - these are diseases such as syphilis, meningitis, encephalitis and others;
• diagnostic measures in the formation of hemorrhages and the appearance of formations. It is used for information impotence of CT and MRI;
• the task is to determine the cerebrospinal fluid pressure;
• coma and other disorders of consciousness;
• when it is necessary to inject a drug in the form of cytostatics and antibiotics directly under the membranes of the brain;
• x-ray with the introduction of a contrast agent;
• the need to reduce intracranial pressure and remove excess fluid;
• processes in the form of multiple sclerosis, polyneuroradiculoneuritis, systemic lupus erythematosus;
• unreasonable increase in body temperature;
• spinal anesthesia.

Absolute indications - tumors, neuroinfections, hemorrhages, hydrocephalus.

Sclerosis, lupus, incomprehensible fever - do not oblige to be investigated in this way.

The procedure is necessary in case of an infectious lesion, since it is important not only to diagnose the diagnosis, but also to understand what kind of treatment is required, to determine the sensitivity of microbes to antibiotics.

A puncture is also used to remove excess fluid with high intracranial pressure.

If we talk about therapeutic properties, then in this way it is possible to act directly on the focus of neoplastic growth. This will allow to have an active effect on tumor cells without an elephantine dose of drugs.

That is, the cerebrospinal fluid performs many functions - it detects pathogens, is a carrier of information about the cellular composition, blood impurities, detects tumor cells and tells about the pressure of the cerebrospinal fluid.

Important! Be sure to exclude possible pathologies, contraindications and risks before the puncture. Failure to do so can lead to the death of the patient.

When a spinal tap cannot be performed

Sometimes this diagnostic and treatment procedure can cause more harm and can even be life-threatening.

The main contraindications for which the puncture is not performed:

Puncture procedure

How is the preparation for the procedure going?

Preparation depends on the indications and nuances during the spinal puncture. Any invasive procedure requires diagnostic measures consisting of:

1. blood and urine tests;
2. diagnostics of blood properties, in particular, clotting indicators;

Important! The doctor must be informed about the medications taken, allergies and pathologies.

Be sure to stop taking all anticoagulants and angioplatelets a week before the planned puncture so as not to provoke bleeding. It is also not recommended to use anti-inflammatory drugs.

Women before x-rays with contrast should make sure that at the time of the puncture, there is no pregnancy. Otherwise, the procedure may adversely affect the fetus.

If the puncture is performed on an outpatient basis

Then the patient himself can come to the study. If he is being treated in a hospital, then he is brought from the department by medical personnel.

With self-arrival and departure, it is worth considering returning home. After the puncture, dizziness, weakness are possible, it would be good to use the help of someone.

No food or liquid should be consumed for 12 hours prior to the procedure.

The puncture can be assigned to children

The indications are similar in adulthood. However, infections and suspicions of malignant tumors account for the majority.

Without parents, the puncture is not performed, especially when the baby is scared. A lot depends on the parents. They are obliged to explain to the child why the procedure is performed, to inform about the pain, that it is tolerable and to calm.

As a rule, a lumbar puncture does not involve the introduction of anesthesia. Local anesthetics are used. This is done for better portability of the procedure. But, in case of an allergy to novocaine, you can completely refuse anesthesia.

When puncturing, when there is a risk of cerebral edema, it makes sense to administer furosemide 30 minutes before the needle is inserted.

The process of taking a puncture

The procedure begins with the patient taking the correct position. There are two options:

1. Lying. The person is placed on a hard table on the right side. At the same time, the legs are pulled up to the stomach and clasped with hands.
2. sitting, for example, on a chair. It is important in this position to bend your back as much as possible. However, this position is used less frequently.

The puncture is made in adults above the second lumbar vertebra, usually between 3 and 4. In children, 4 and 5 to minimize damage to the spinal tissue.

The technique of the procedure is not complicated if the specialist has been trained and, moreover, has experience. Compliance with the rules allows you to avoid terrible consequences.

Stages

The puncture procedure consists of several stages:

Training

The medical staff prepares the necessary tools and materials - a sterile needle with a mandrel (a rod for closing the lumen of the needle), a container for cerebrospinal fluid, and sterile gloves.

The patient takes the necessary position, the medical staff helps to further bend the spine and fix the position of the body.

The injection site is lubricated with iodine solution and then several times with alcohol.

The surgeon finds the right place, the iliac crest, and draws an imaginary perpendicular line to the spine. It is the right places that are recognized as the safest due to the absence of spinal cord substance.

Anesthesia stage

They are used to choose from - lidocaine, novocaine, procaine, ultracaine. It is introduced first superficially, then deeper.

Introduction

After anesthesia, a needle is inserted into the intended place with a cut up at an angle of 90 degrees relative to the skin. Then, with a slight inclination towards the head of the subject, the needle is very slowly inserted deep into.

On the way, the doctor will feel three needle failures:

1. skin puncture;
2. intervertebral ligaments;
3. sheath of the spinal cord.

After passing through all the dips, the needle has reached the intrathecal space, which means that the mandrin should be removed.

If the cerebrospinal fluid does not appear, then the needle should penetrate further, but this must be done with extreme caution due to the proximity of the vessels and to avoid bleeding.

When the needle is in the canal of the spinal cord, a special device - a manometer, determines the CSF pressure. An experienced doctor can determine the indicator visually - up to 60 drops per minute is considered the norm.

The puncture is taken in 2 containers - one sterile in the amount of 2 ml, necessary for bacteriological examination and the second - for the cerebrospinal fluid, which is examined to determine the level of protein, sugar, cellular composition, etc.

Completion

When the material is taken, the needle is removed, and the puncture site is sealed with a sterile napkin and adhesive tape.

The given technique for performing the procedure is mandatory and does not depend on age and indications. The accuracy of the doctor and the correctness of actions affect the risk of complications.

In total, the amount of fluid obtained during the puncture is no more than 120 ml. If the purpose of the procedure is diagnostics, then 3 ml is enough.

If the patient has a special sensitivity to pain, it is recommended to use sedatives in addition to anesthesia.

Important! During the entire procedure, the patient's mobility is not allowed, so the assistance of medical staff is required. If the puncture is performed on children, then the parent helps.

Some patients are afraid of puncture because of the pain. But, in reality, the puncture itself is tolerable and not terrible. Pain occurs when the needle passes through the skin. However, when the tissues are soaked with an anesthetic, the pain subsides and the area becomes numb.

In the case when the needle touches the nerve root, the pain is sharp, as with sciatica. But, this rarely happens and even refers more to complications.

When the cerebrospinal fluid is removed, a patient diagnosed with intracranial hypertension experiences a clear feeling of relief and relief from headache.

Recovery period

As soon as the needle is removed, the patient does not get up, but remains in a supine position for at least 2 hours on the stomach without a pillow. Children under 1 year old, on the contrary, are laid on their backs, but pillows are placed under the buttocks and legs.

The first hours after the procedure, the doctor observes the patient every 15 minutes with a condition control, because the cerebrospinal fluid can run out of the hole from the needle for up to 6 hours.

As soon as there are signs of swelling and dislocation of the brain sections, help is urgently provided

After the puncture procedure, bed rest must be observed. It is allowed to get up after 2 days at normal rates. If there are unusual changes, then the period may increase up to 14 days.

There may be headaches caused by a decrease in fluid volume and a decrease in pressure. In this case, analgesics are prescribed.

Complications

A lumbar puncture is always associated with risks. They increase if the algorithm of actions is violated, there is not enough information about the patient, in case of a serious state of health.

Possible but rare complications are:

If the procedure is carried out in compliance with all conditions, then undesirable consequences almost do not appear.

The stage of studying liquor

Cytological analysis is performed immediately on the same day as the lumbar puncture. When bacteriological culture and sensitivity assessment to antibiotics is necessary, the process is delayed for 1 week. This is the time to multiply the cells and evaluate the response to the drugs.

The material is collected in 3 tubes - for general analysis, biochemical and microbiological.

normal color cerebrospinal fluid clear and colorless, without erythrocytes. Protein is contained and the indicator should not exceed 330 mg per liter.

There is sugar in a small amount and red blood cells - in adults, no more than 10 cells per μl, in children a higher rate is allowed. The normal density of cerebrospinal fluid is 1.005 to 1.008, pH is from 7.35-7.8.

If blood is observed in the received material, this means that either the vessel was injured, or there was a hemorrhage under the membranes of the brain. To clarify the cause, 3 test tubes are collected and examined. If the cause is a hemorrhage, then the blood will be scarlet.

An important indicator is the density of cerebrospinal fluid which changes with disease. If there is inflammation, then it rises, if hydrocephalus - decreases. If at the same time the pH level dropped, then most likely the diagnosis is meningitis or encephalitis, if it increased - brain damage with syphilis, epilepsy.

dark liquid speaks of jaundice or melanoma metastasis.

Cloudy cerebrospinal fluid is a bad sign indicating bacterial leukocytosis.

If protein is increased, then most likely we will talk about inflammation, tumors, hydrocephalus, brain infections.

Lumbar puncture is one of the types of invasive (penetrating into tissues) diagnostics of the body, or to be more precise, of the spinal cord. The technique is carried out for taking cerebrospinal fluid and its subsequent analysis in the laboratory.

Often, during a lumbar puncture (namely, at this level, the spinal cord fluid is taken), the patient feels quite severe pain. The solution is to perform anesthesia, which, unfortunately, can also have long-term consequences (complications in the form of allergies, nausea, vomiting).

1 What is a spinal tap and why is it done?

A lumbar puncture (also known as spinal tap or lumbar puncture) is a diagnostic procedure that is performed to collect cerebrospinal fluid for analysis.

The technique of the procedure involves the introduction of a special needle into the subarachnoid space of the spinal cord exclusively at the level of the lumbar spine. In some cases, manipulation is carried out not for diagnosis, but for therapeutic or anesthetic purposes.

But what exactly is it made for? Why is it needed and what does it show? As a rule, a lumbar puncture is required in cases where severe diseases of the central nervous system must be ruled out. For example, meningitis, encephalitis, or even cancer.

1.1 Indications for a lumbar puncture

It is necessary to distinguish between indications for lumbar puncture, dividing them into diagnostic and therapeutic/manipulative (in the latter case, we are talking about the introduction of painkillers).

Diagnostic indications include:

1. In order to detect meningitis (viral, bacterial).
2. In order to detect neurosyphilis, encephalitis (of any etiology).
3. Confirmation or refutation of the presence of bleeding in the patient in the central nervous system.
4. In order to identify demyelinating pathologies (for example, multiple sclerosis).
5. In order to detect malignant primary neoplasms of the central nervous system or metastases of secondary tumors.

Treatment/manipulation indications include:

• for medicinal purposes - for the introduction of antimicrobial drugs or chemotherapeutic drugs;
• for manipulation purposes - to reduce increased intracranial pressure of various etiologies;
• for analgesic purposes - for the administration of painkillers/painkillers.

1.2 Are there any contraindications?

There are a number of absolute and relative contraindications to lumbar puncture. Relative contraindications vary from patient to patient, that is, there is no exact list (list) of them.

Absolute contraindications include:

1. Extremely high intracranial pressure (greater than 220 millimeters H2O).
2. Septic lesions (generalized infection, infection with pathogenic blood flora).
3. Local infectious processes in the injection area.
4. Massive bleeding of any organs of the body (including the central nervous system).
5. The presence of pronounced deformities of the spinal column (, pathological kyphosis or, spinal adhesions).
6. The patient has intracranial expansive processes.

1.3 What can be determined by spinal tap

The diseases described in the previous paragraph can be confirmed by a thorough analysis of the CSF (cerebrospinal fluid) taken during the procedure. But how are the results analyzed after the procedure?

With the help of special tools (a set of reagents, microbiological equipment), cerebrospinal fluid evaluated according to the following criteria:

• the pressure of the cerebrospinal fluid is measured (directly during the procedure);
• cerebrospinal fluid is assessed by a macroscopic method;
• the amount of proteins and sugar in the cerebrospinal fluid is analyzed;
• the cellular morphology of the obtained cerebrospinal fluid is analyzed.

After all the described manipulations, the final verdict is put: norm or pathology. However, diagnosticians do not make a diagnosis, they only state the norm or deviation according to the results. The diagnosis is made by the attending physician.

1.4 Norm and deviations

Whether the CSF is normal is judged by several criteria, including its color. Liquor can have four different colors:

1. Blood color - there are hemorrhagic pathological processes (most often an early stage subarachnoid hemorrhage).
2. Yellowish color - a late stage of hemorrhagic pathological processes (for example, carcinomatosis, blockade of the cerebrospinal fluid circulation, chronic hematomas).
3. Grayish-green color - in most cases indicates the presence of malignant neoplasms of the brain.
4. Transparency is the absolute norm.

The biochemical parameters of the cerebrospinal fluid are also evaluated. The norm for this is:

• color: transparent;
• amount of protein: 150-450 milligrams per liter;
• the amount of glucose (sugar): from 60% in the blood;
• atypical cells: absent;
• leukocytes: no more than 5 mm 3;
• neutrophils: absent;
• erythrocytes: absent;
• CSF pressure is within 150-200 water column or 1.5-1.9 kPa.

2 Preparing for a lumbar puncture

In most cases, preparation for a lumbar puncture, especially if it is performed for urgent (urgent) indications, is not required. But the minimum program is still available, but it is general, and is used for any invasive diagnostics, not only lumbar puncture.

For example, if possible, you should take a shower a few hours before the manipulation. It is highly recommended to eat a little, but you should not eat up “to satiety”, as patients often feel sick after the procedure, and this can lead to unwanted vomiting.

Drugs used for health reasons should not be canceled either before or after the procedure. As for minor drugs (pills for headaches, heartburn, skin dermatitis), they can be used, but it is recommended to cancel the intake the day before the procedure until it is carried out.

There is no other way to prepare for a lumbar puncture.

2.1 Lumbar puncture instrument kit

In some cases, the patient needs to independently purchase a set for a lumbar puncture, which is especially important for state provincial clinics. What is included in this surgical kit?

The lumbar puncture kit includes:

1. A pair of sterile gloves.
2. Korntsang (sterile).
3. Salicylic alcohol (70%) for skin treatment or alcohol solution on chlorhexidine 0.5%.
4. Sterile balls, skin adhesive plaster (not to be confused with the one needed to attach droppers).
5. Syringes with a volume of 5 milliliters and needles to it.
6. A half-percent or 0.25% solution of novocaine for local anesthesia (since the patient often hurts from the procedure, and the pain is especially relevant in children).
7. Trimecaine solution (1-2%).
8. Sterile mandrin needles 12 centimeters long (they are also "Beer's needles").
9. Sterile tubes for collecting cerebrospinal fluid.

2.2 How is the procedure carried out?

What is the algorithm for performing a lumbar puncture? The whole procedure is carried out in stages and very rarely its duration exceeds 60 minutes.

Algorithm for performing a lumbar puncture:

1. The specialist finds a zone for puncture (between 3-4 or 4-5 vertebrae of the lumbar spine).
2. The puncture area and adjacent tissues are treated with a disinfectant (iodine or ethyl alcohol). Processing is carried out from the center to the periphery.
3. According to indications, anesthesia is performed (usually novocaine is used, no more than 6 milliliters).
4. Between the spinous processes, a puncture is made with a Beer needle (at a slight inclination).
5. The needle is inserted exactly into the subarachnoid region (at a depth of about five centimeters, it feels a sharp drop in the needle).
6. Then the mander is removed, after which the liquor expires on its own. Approximately 120 milliliters of cerebrospinal fluid is sufficient for diagnosis.

2.3 Description of the procedure and performing a lumbar puncture (video)

2.4 After care

The first step after the lumbar puncture is to lay the patient on the couch and measure blood pressure. It is mandatory to re-disinfect the puncture site with the capture of nearby tissues (even if extensive antiseptic treatment was carried out before).

Care after the procedure also implies the imposition of a sterile bandage on the postoperative puncture site. The patient is prescribed absolute rest for the next day. It is desirable for the patient to be in a horizontal position most of this time, not to lift weights and avoid stressful situations.

If you get up often or completely neglect the prescription of rest, then you should expect severe headaches. it most common complication of lumbar puncture in the event that postoperative care is not fully provided.

2.5 Possible complications after the procedure

Any invasive diagnostic technique is bad because it has non-zero chances to give side effects. This also applies to lumbar puncture, which also has postoperative complications, from barely noticeable to extremely severe.

Possible consequences of a lumbar puncture:

1. Headaches of varying intensity (often very severe) due to changes in intracranial pressure (post-puncture syndrome).
2. Paresthesia (tingling sensation, goosebumps, impaired sensitivity) in the lower extremities.
3. Swelling and soreness at the puncture site.
4. Bleeding from the puncture site (massive bleeding is relatively rare).
5. Disorders of consciousness, deprivation, migraine.
6. Nausea, in some cases vomiting is possible.
7. Urination disorders, pulling pains in the peritoneum.

2.6 Where is it made and what is the price?

Where is a lumbar puncture done? This procedure is carried out both in public medical institutions and in private clinics. Is there a big difference in the quality of service, price and number of postoperative complications depending on the type of medical institution?

In fact, the difference is minimal, except perhaps for the cost. In state medical institutions, the price of this procedure is approximately 50% lower than in private ones. And for a number of patients, this procedure is completely free ( but often in order).

The price of a lumbar puncture directly depends on where exactly you will carry it out. In public hospitals, for a procedure out of turn, you need to pay on average 6000 rubles. In private clinics, prices are much higher. So, for example, in Moscow in private clinics the cost of a lumbar puncture on average is 12500 rubles.

Lumbar puncture is a method of collecting cerebrospinal fluid from the spinal canal. The human brain produces cerebrospinal fluid (CSF). Its content changes with many pathological processes in the body. CSF analysis obtained by lumbar puncture is an important factor for the final diagnosis and the appointment of the correct treatment for the disease.

LP was first described by Quincke over 100 years ago. This method provides indispensable information for diagnosing diseases of both the central nervous system and a number of other systemic diseases.

INDICATIONS FOR DIAGNOSTIC LUMBAL PUNCTURE

• Suspicion of neuroinfection (meningitis, encephalitis) of various etiologies: 1) bacterial, 2) neurosyphilis, 3) tuberculosis, 4) fungal, 5) viral, 6) cysticircosis, toxoplasmosis, 7) amoebic, 8) borreliosis.
• Suspicion of aseptic meningitis.
• Suspicion of subarachnoid hemorrhage, in cases where there is no computed or magnetic resonance imaging.
• Suspicion of oncopathology of the membranes of the brain and spinal cord (leptomeningeal metastases, carcinomatosis, neuroleukemia).
• Primary diagnosis of hemoblastosis (leukemia, lymphoma). Cellular characterization is important (the appearance of blast blood cells and an increase in protein levels).
• Diagnosis of various forms of liquorodynamic disorders, including conditions with intracranial hyper- and hypotension, including the administration of radiopharmaceuticals, but excluding occlusive forms of hydrocephalus.
• Diagnosis of normotensive hydrocephalus.
• Diagnosis of liquorrhea, detection of cerebrospinal fluid fistulas, using the introduction of various contrast agents (dyes, fluorescent, radiopaque substances) into the subarachnoid space.

RELATIVE

• Septic vascular embolism.
• Demyelinating processes.
• Inflammatory polyneuropathy.
• paraneoplastic syndromes.
• Systemic lupus erythematosus.
• Hepatic (bilirubin) encephalopathy.

NB! Due to the advent of computed tomography and magnetic resonance imaging, LP as a diagnostic procedure is not indicated for tumors of the brain and spinal cord.

INDICATIONS FOR THERAPEUTIC LUMBAL PUNCTION

• The absence of positive dynamics after 72 hours from the start of treatment or the presence of ventriculitis requires endolumbar administration of antibiotics for bacterial meningitis.
• Fungal meningitis (candidiasis, coccidioidomycosis, cryptococcal, histoplasmoid) require endolumbar administration of amphorecin B.
• Chemotherapy for neuroleukemia, leptomeningeal lymphoma.
• Chemotherapy of meningeal carcinomatosis, malignant tumors of the central nervous system, including cancer metastases.
• At present, indications for LP in the following situations remain controversial and require further study:
• With arachnoiditis, radiculopathy, liquorrhea with the introduction of air, ozone or oxygen.
• With subarachnoid hemorrhage for sanitation of the cerebrospinal fluid.
• In inflammatory diseases such as multiple sclerosis, sciatica, arachnoiditis with the introduction of various pharmacological preparations.
• In spastic conditions in the muscles of the limbs with the introduction of baclofen.
• With pain postoperative syndrome with the introduction of morphine.
• With intracranial hypertension, it can be reduced by removing part of the cerebrospinal fluid and thereby achieve temporary relief of the condition (this is permissible only if intracranial volumetric processes, volumetric processes of the spinal canal that cause impaired CSF circulation, as well as occlusive hydrocephalus) are excluded.

• LP is contraindicated if there are signs or threat of axial dislocation of the brain in the presence of an intracranial volumetric process of any etiology. The absence of congestion in the fundus is not a sign that allows the production of LP. In such cases, one should be guided by the data of computer and magnetic resonance imaging.
• Occlusive form of hydrocephalus.
• Pathology of the spinal cord and spinal canal with impaired CSF circulation.
• The presence of infection in the lumbar region, including the skin, subcutaneous tissues, bones and epidural space.
• Long-term use of anticoagulants, the presence of hemorrhagic diathesis with severe disorders of the blood coagulation system. It should be remembered that cytostatics also affect the blood coagulation system.

NB! In the case of neuroinfection, contraindications lose their force, since the identification of the pathogen and the determination of sensitivity to antibiotics determine the prognosis for the patient's life.

TECHNIQUE OF PERFORMANCE

POSITION OF THE PATIENT

1. Lying on your side. This position is more commonly used and most comfortable. The legs are bent and brought to the stomach, the chin to the chest, the back is arched, the stomach is retracted. A lumbar puncture is performed in the presence of a nurse. After insertion of the needle, the position of the patient can be changed.

2. Sitting position. The patient sits on a gurney, holding on to it with his hands. The assistant holds the patient and monitors his condition, taking into account the autonomic reaction. It is used during pneumoencephalon and pneumoencephalography.

At the intersection of the line of the spine with a conditional line connecting the wings of the ilium, they find the gap L4 - L5 (Jacobi line). Be sure to immediately palpate the spaces L3 - L4, as well as the underlying L5 - S1.

Field processing: 3% solution of iodine, 70% solution of ethyl alcohol, from the center to the periphery.

Anesthesia. Enough 4 - 6 milliliters of a 2% solution of novocaine or other anesthetic, which is injected during the proposed puncture (preferably lidocaine). Local anesthesia is also performed in patients with a pronounced deficit of consciousness, since a slight pain can cause an inadequate motor response. Before puncturing, once again orient yourself and check the condition of the needle, especially if it is reusable. Make sure that the mandrin can be easily removed and that it fits this needle. The puncture needle is held in the position of a writing pen. The direction is perpendicular to the dotted plane for young children. And in adults, taking into account the overhanging of the spinous vertebrae, with a slight slope. When passing through the dura there is a feeling of "failure", which indicates the correct position of the needle. The sensation of failure may not appear if disposable sharp needles are used. In this case, you can check the position of the needle by the appearance of cerebrospinal fluid, periodically removing the mandrin. But do not take out the mandrin immediately to its full length.

REASONS FOR Lack of CSF

The direction of the puncture was chosen incorrectly and you did not enter the spinal canal. Once again palpate the spinous processes and check how correctly the patient lies. Dot again, you can change the level.

The needle rested against the body of the vertebra. Pull the needle 0.5 - 1.0 cm.

The lumen of the needle is covered by the root of the spinal cord. Slightly turn the needle around its axis and pull 2-3 mm.

You are sure that you hit the sac, but the patient has severe CSF hypotension. Ask the patient to cough or have an assistant press on the abdomen (similar to the Stukey test). If this does not help, then raise the head end of the gurney or seat the patient. All these actions increase the cerebrospinal fluid pressure in sake.

In repeatedly punctured patients, especially when chemotherapy drugs were administered, an adhesive process may develop at the puncture site. In such cases, patience is required from the patient and the doctor. You have to change the direction of the needle and the level of the puncture, using both the L5-S1, L4-L5, L3-L4, and L2-L3 level. To reduce the adhesive process, after endolumbar administration of chemotherapy drugs, 20-30 mg is administered. prednisolone.

An extremely rare cause is a tumor of the spinal canal at this level. It is impossible to get liquor. This is the mistake of a doctor who did not evaluate the symptoms.

Far advanced purulent process. The liquor does not reach the sac, and the pus is of such a consistency that it does not enter the thin puncture needle. In such cases, a thicker needle can be chosen and, in infants, the lateral ventricle can be punctured through the large fontanel.

CAUSES OF BLOOD IN THE NEEDLE

When you try to puncture, you did not reach the sac, you damaged the vessel and only blood enters the needle. Change the direction of the puncture or select a different level.

You hit the sak and damaged a small vessel. In this case, along with the liquor, you will receive an admixture of travel blood. This is a scarlet streak in the liquor stream, the admixture of traveling blood quickly decreases, sometimes until it disappears completely after 4-5 ml flows out. liquor. Change the tube and collect CSF without blood impurities.

The patient has subarachnoid hemorrhage. The first portions of the CSF may also be more intensely colored, but there will be no significant difference. With repeated punctures, changes in the CSF will be preserved. A sign of CSF sanitation is the change of red and pink color to yellow (xanthochromia). A small subarachnoid hemorrhage can be difficult to visually distinguish from inflammatory changes. You should wait for the results of the laboratory test.

We should not forget that purulent contents may resemble blood clots. If a neuroinfection is suspected, always send the contents for culture.

After receiving the CSF, measure the CSF pressure. To do this, the needle is connected to a glass column with a diameter of 1 - 2 mm. Approximately, the pressure can be estimated by the rate of outflow of cerebrospinal fluid. 60 drops per minute conditionally corresponds to normal pressure. Remember that in a sitting position, the pressure is 2 to 2.5 times higher. Then take 2 ml of cerebrospinal fluid for examination and, if necessary, for culture. Remove the needle. For a minute, press the ball with alcohol to the puncture site, and then attach the dry sterile ball with a plaster for 1 day.

AFTER MODE LUMBAL PUNCTION

Some researchers believe that bed rest does not prevent the development of post-puncture syndrome, and therefore, you can walk immediately after LP. However, most authors conclude that bed rest is necessary, and its duration and the position of the patient are discussed. at the Institute of Neurosurgery. acad. N.N. Burdenko adopted a technique in which bed rest is maintained for 3-4 hours. The patient is in a horizontal position prone (lying on his stomach). It is appropriate to recall the intracranial hypotension here. It is more often observed in the elderly and in patients with prolonged intoxication. General cerebral symptoms are characteristic (headache, nausea, vomiting, dizziness, noise in the head), in combination with an autonomic reaction, they have a characteristic feature - worsening when trying to get up. It is important to create peace, lower the head end, give a plentiful warm drink and (or) inject plasma substitutes intravenously.

What is a puncture? And what could be the consequences?

A puncture is when an organ or vessel is pierced for the purpose of diagnosis or treatment.

Health, life, hobbies, relationships

Puncture for stroke

A lumbar puncture is the insertion of a needle into the subarachnoid space of the spinal cord for therapeutic or diagnostic purposes. As a diagnostic measure, a lumbar puncture should be performed during laboratory tests of cerebrospinal fluid in order to measure pressure and also to determine the patency of the subarachnoid space of the spinal cord. Spinal puncture allows you to accurately diagnose the intensity and the subarachnoid hemorrhage itself, identify inflammation of the meninges, and clarify the nature of the stroke. Increased pressure in the subarachnoid space is presumably indicative of intracranial pressure.

Spinal puncture for therapeutic purposes is used to extract purulent or bloody cerebrospinal fluid (up to ten to twenty ml), as well as to administer antiseptics, antibiotics and other drugs, mainly for purulent-inflammatory diseases of the spinal cord and brain. Most often, a lumbar puncture is performed when the patient lies on his side with bent legs, which are brought to the stomach. The puncture is usually taken in the intervals between the processes of LIV-LV or LIII-LIV. In this case, they are guided by the spinous process LIV, which can be felt in the middle of the line connecting the iliac crests. Asepsis rules should be strictly observed: first, the skin is treated with iodine, after which it is wiped with alcohol. In the place where the puncture is made, anesthesia is performed, introducing it intradermally with a thin needle, and then subcutaneously - three to five ml of a two percent solution of novocaine. A special needle with a mandrel (its length is ten centimeters and a thickness of up to one millimeter) for spinal puncture is directed inward in the sagittal plane and slightly upward, then the skin, subcutaneous tissue is overcome, the interaxial yellow ligament, epidural fatty tissue, arachnoid or dura mater are pierced. After the sensation appears that the needle has failed, the mandrin is removed from it and it is made sure that cerebrospinal fluid enters through the needle channel. An L-shaped glass tube is attached to the pavilion of the needle in order to measure the pressure of the cerebrospinal fluid. The cerebrospinal fluid is then taken for analysis. It is withdrawn slowly, the rate of expiration is regulated with the help of a mandrin, which is inserted into the lumen of the needle. If an intracranial volumetric process is suspected, only one to two ml of cerebrospinal fluid is removed. When all precautions are taken, a lumbar puncture is an almost painless procedure. After the puncture, bed rest is prescribed for two days. The first two hours the patient should lie without a pillow.

Indications for lumbar puncture: meningitis, spontaneous subarachnoid hemorrhage caused by rupture of arteriovenous and arterial aneurysms, myelitis, cysticercosis, craniocerebral injury, diseases of the central nervous system.

Indications:

1. taking cerebrospinal fluid for research (blood, protein, cytosis);

2. taking cerebrospinal fluid to reduce intracranial pressure;

3. the introduction of medicinal substances and anesthetic solutions;

4. introduction of air into the subarachnoid space during pneumoencephalography.

Equipment:

1.clean manipulation table especially for aseptic procedures;

2. sterile styling with a set of necessary tools to perform the procedure;

3. packaging (bix) with sterile dressing material,

5.sterile styling with gripping tools (tweezers, forceps);

6.disinfectants approved for use in Russia in the manner prescribed by law;

7. drugs depending on the purpose of the study;

8. mask, gloves;

9.sterile cotton balls, sterile wipe;

10.5% iodine solution, syringe, 2% novocaine solution;

11.adhesive plaster;

12.needle with mandrin, for spinal puncture;

13.2 test tubes (one is sterile for bacterial culture of spinal punctures, the other is clean - for general analysis);

14.forms-directions.

Mandatory conditions:

Before performing this manipulation, the nurse should:

1.Wash your hands in the standard way;

2.treat with an alcohol-containing antiseptic;

3. put on a sterile gown, gloves;

4. cover the sterile table or tray in accordance with the algorithm;

5. The procedure is performed on an empty stomach.

Compilation of a set of instruments for lumbar puncture

Check the appearance of the styling for the procedure - tightness, integrity, dryness.

Pay attention to the date of sterilization on the tag or packaging.

Open the outer package of the sterile kit, take out its contents in the inner sterile package and place it on a sterile diaper on the top shelf of the table.

Do not allow the outer packaging to come into contact with the surface of the sterile part of the table.

Using sterile tweezers, lay out the instruments on the table:

3 syringes with a capacity of 5 ml with needles;

2-3 needles for spinal puncture with mandrin;

Glass tube with pressure gauge;

Gauze balls, napkins.

Place on the non-sterile part of the table:

0.25% novocaine solution;

70% alcohol solution;

2 sterile tubes in a rack;

Cleol (adhesive plaster).

I. Preparing the patient for a lumbar puncture

Mandatory conditions:

1. the procedure is performed on an empty stomach;

2. make sure that the patient is not allergic to novocaine solution, skin diseases in the puncture area, acute conditions requiring immediate intensive treatment.

Preparation for the procedure.

Explain to the patient (relatives) the purpose and course of the procedure, obtain consent.

Clarify with the attending physician the time, place of the puncture (ward, treatment room, special department), the position of the patient (on the side, sitting) and the method of transportation.

Accompany the patient to the examination room.

Note:

according to the doctor's prescription, transport the patient on a gurney with a hard surface.

1. Identify complaints from the patient; measure heart rate, respiratory rate, blood pressure; if necessary, partially cover the patient with a blanket and adjust the pillows.

2. Inform the doctor about the readiness for the puncture and the data of the visual control of the patient's condition.

Note: during the manipulation by the doctor, be nearby and follow the orders of the doctor.

Lay the patient on his side, the head is bent to the chest, the legs are bent at the knees and pressed to the stomach as much as possible (if the patient is conscious, he makes a lock with his hands under his knees).

With a cotton swab moistened with iodine, a line is drawn connecting the iliac crests.

II. Carrying out the procedure.

medical manipulation.