What is a puncture of the cerebrospinal fluid used for? Spinal puncture: indications, contraindications, technique. Contraindications for the procedure

A puncture of the cerebrospinal fluid in medical terminology is designated as a lumbar puncture, and the fluid itself is called cerebrospinal fluid. Lumbar puncture is one of the most complex methods that pursues diagnostic, anesthetic and therapeutic purposes. The procedure is the introduction of a special sterile needle (length up to 6 cm) between the 3rd and 4th vertebrae under the arachnoid membrane of the spinal cord, and the brain itself is not affected at all, and then the extraction of a certain dose of CSF. It is this liquid that allows you to obtain accurate and useful information. In the laboratory, it is examined for the content of cells and various microorganisms to detect proteins, various infections, and glucose. The doctor also evaluates the transparency of the cerebrospinal fluid.

Indications for spinal cord puncture

A lumbar puncture is most often used when infections of the central nervous system are suspected, causing diseases such as meningitis and encephalitis. Multiple sclerosis is very difficult to diagnose, so a lumbar puncture is indispensable. As a result of the puncture, the cerebrospinal fluid is examined for the presence of antibodies. If antibodies are present in the body, the diagnosis of multiple sclerosis is practically established. Puncture is used to differentiate stroke and identify the nature of its occurrence. Liquor is collected in 3 test tubes, later comparing the blood admixture.

With the use of a lumbar puncture, diagnostics helps to detect inflammation of the brain, subarachnoid bleeding, or to identify a herniated disc by injecting a contrast agent, as well as to measure the pressure of the spinal cord fluid. In addition to collecting liquid for research, experts also pay attention to the outflow rate, i.e. if one transparent drop appears in one second, the patient has no problems in this area. In medical practice spinal cord puncture, consequences which can sometimes be very serious, is prescribed in order to remove excess cerebrospinal fluid and thereby reduce intracranial pressure in benign hypertension, is carried out for the administration of drugs for various diseases, for example, chronic normotensive hydrocephalus.

Contraindications for lumbar puncture

The use of lumbar puncture is contraindicated for injuries, diseases, formations and some processes in the body:

edema, volumetric formations of the brain;

intracranial hematoma;

Dropsy with mass formation in the temporal or frontal lobe;

Infringement of the brain stem;

Bedsores of the lumbosacral zone;

Profuse bleeding;

Skin and subcutaneous infections in the lumbar region;

Thrombocytopenia;

Extremely serious condition of the patient.

In any case, the doctor first conducts a series of tests to make sure that the appointment is urgently needed. puncture of the spinal cord. Effects it, as already noted, can be very, very serious, since the procedure is risky, and it is associated with certain risks.

Spinal puncture and its consequences

The first few hours (2-3 hours) after the procedure, in no case should you get up, you should lie on a flat surface on your stomach (without a pillow), later you can lie on your side, within 3-5 days you should observe strict bed rest and do not take standing or sitting position to avoid various complications. Some patients experience weakness, nausea, spinal pain, and headache after a lumbar puncture. A doctor can prescribe medications (anti-inflammatory and painkillers) to relieve or reduce symptoms. Complications after a lumbar puncture may occur due to incorrect procedure. Here is a list of possible complications as a result of incorrect actions:

trauma of varying degrees of complexity of the spinal nerve;

Various pathologies of the brain;

The formation of epidermoid tumors in the spinal canal;

Damage to the intervertebral discs;

Increased intracranial pressure in oncology;

Infection.

If the procedure was performed by a qualified specialist, all the necessary rules were strictly observed, and the patient follows the recommendations of the doctor, then its consequences are minimized. Contact our medical center, where only experienced doctors work, do not risk your health!

Shoshina Vera Nikolaevna

Therapist, education: Northern Medical University. Work experience 10 years.

Articles written

For many, brain puncture is subconsciously considered dangerous, but in fact it is not. If it is carried out by an experienced doctor, then it is absolutely safe. It is thanks to her that it is possible to detect abscesses in the brain tissues, determine the contents of neoplasms and the state of other pathologies.

But there are also a number of dangers that can be encountered with this procedure. Let's figure it out.

The puncture is carried out with a special needle, which, penetrating into the brain tissue, can draw fluid from it. To make the puncture safe, you need to follow a number of rules:

1. The area of ​​the head where the puncture will be made must be thoroughly disinfected. First, it is treated with hydrogen peroxide, and then liberally lubricated with iodine.
2. For the procedure, you can not use an ordinary needle, only a special, puncture, which has a blunt end. It is produced wide enough and equipped with a mandrin.
3. There should be 2 needles available, one of which will be spare if the first is blocked by brain tissue.
4. The puncture should be made to a depth of no more than 4 cm. This is the only way to ensure the safety of the fence and prevent the penetration of a purulent secret into.
5. Before the procedure, the patient must defecate.
6. Complete immobility of the patient is required, so it can be fixed with special devices.

Areas of conduct, indications, contraindications

Such a study is carried out in areas where there is a suspicion of the formation of pus, most often it is:

• the lower part of the frontal lobe;
• the lower part of the temporal lobe;
• drum space;
• near the mastoid process.

A puncture is taken to diagnose brain pathologies, such as:

• infectious lesion of the central nervous system;
• inflammatory process in the central nervous system;
• bacterial, viral, fungal diseases;
• infection of brain tissue with tuberculosis or syphilis;
• bleeding;
• multiple sclerosis;
• neoplasms of any type;
• neuralgic pathology;
• swelling of the brain tissue;
• problems with the vascular system.

Important! Before the procedure, the patient in a special questionnaire must indicate the list of drugs that he is currently taking, whether he is allergic to anesthetics or drugs, and whether he has problems with blood clotting.

The procedure is prohibited if:

• the patient is at any stage of pregnancy;
• he is in a state of traumatic shock;
• lost a lot of blood;
• there are intracranial hematomas;
• a brain abscess was diagnosed;
• abundant present;
• diagnosed with hypertension
• on the back there are abundant infectious and purulent lesions;
• have lumbar bedsores;
• brain is injured.

How is the procedure carried out

Why do the procedure determined, now you need to figure out the methods of its implementation. They are different and directly depend on the area where the fluid is taken.

Anterior horn of the lateral ventricle

The ventricular procedure of this area is carried out as follows:

1. The patient lies on his back when a tumor in the brain is to be detected. Usually the patient lies on the healthy side, so that it is more convenient for the doctor to puncture from the affected side.
2. The head is slightly tilted towards the chest.
3. The puncture site is thoroughly disinfected and smeared twice with iodine.
4. A puncture line is drawn, which should pass with a focus on the swept seam, passing the Kocher point. It is covered with a layer of brilliant green solution.
5. The head is covered with a sterile sheet.
6. Any local anesthetic, to which the patient is not allergic, anesthetizes the puncture area, most often it is Novocain.
7. Using a scalpel, an incision is made along the intended line.
8. They make a cut of a trepanation window on a bare skull.
9. The neurosurgeon makes a cruciform incision on the dura mater. Rub wax or produce electrocoagulation. What for? To stop bleeding, the latter being the most effective.
10. The cannula is inserted into the brain tissue to a depth of no more than 5-6 cm so that it runs parallel to the incision line. When the wall of the lateral ventricle is punctured, the doctor will feel a small dip.
11. Through the immersed cannula, yellowish cerebrospinal fluid will begin to flow. Having penetrated into the cavity of the ventricle, the doctor fixes the needle and, using a mandrel, regulates the volume and speed of the fluid being withdrawn.

Often there is high pressure in the cavity of the ventricle, and if it is not controlled, then the fluid will come out with a jet. This will lead to the fact that the patient will begin neuralgic problems.

The allowable volume of fluid intake is in the range of 3-5 ml. It is important to note that in parallel with the preparation of the room for the puncture, the operating room is also prepared, since there is a high risk that air can enter the area under study, or the puncture depth will be excessive, which can cause injury to the blood vessel. In these cases, the patient will be urgently operated on.

In cases of puncture, children use the CSF sampling methods according to Dogliotti and Geimanovic:

1. In the first case, the puncture is carried out through the orbit.
2. In the second - through the lower part of the temporal bone.

Both of these options have a significant difference from the traditional procedure - they can be repeated as much as needed. For infants, this procedure is carried out through an open fontanel, simply by cutting the skin over it. In this case, there is a serious danger that the baby will develop a fistula.

Posterior horn of the brain

The technology for taking cerebrospinal fluid from the area is carried out in the following order:

1. The patient lies on his stomach. His head is tightly fixed in such a way that the sagittal suture falls strictly in the median cavity.
2. The preparatory process is identical to the above procedure.
3. The incision of the tissues of the skull is carried out parallel to the sagittal suture, but in such a way that it passes along the Dandy point, which should be strictly in its middle.
4. Take a number 18 needle, which is used strictly for this kind of puncture.
5. It is inserted at an angle, directing the tip of the needle to the outer upper edge of the orbit to a depth of no more than 7 cm. If the procedure is performed on a child, then the puncture depth should not exceed 3 cm.

lower horn of the brain

The principle of the procedure is similar to the previous two:

• the patient should lie on his side, since the lateral part of the head and the auricle will be the operating field;
• the incision line will go 3.5 cm from the external auditory meatus and 3 cm above it;
• part of the bone in this area will be removed;
• make an incision in the dura mater;
• introduce a 4 cm puncture needle, directing it to the top of the auricle;
• will carry out the collection of liquor.

Clinical picture after the procedure

Of course, the symptoms after puncture sampling are different for everyone, but it can be combined into a general clinical picture:

1. Pain in the head of varying intensity and duration.
2. Prolonged nausea and vomiting.
3. Convulsions and fainting.
4. Failure of the cardiovascular system.
5. Violation of respiratory function, in rare cases, the patient may need artificial ventilation.
6. neuralgic problems.

It directly depends on the experience of the neurosurgeon and his skills whether the patient will have the above symptoms. The procedure must be performed strictly according to medical instructions, which can guarantee the absence of complications after the puncture.

It is important not only to fix the patient correctly, but also to accurately determine the puncture zone. Treatment of the affected area is important both at the stage of preparation for the procedure and after it. Upon completion of the fence, a sterile bandage is necessarily applied.

It is important that the patient at the time of the puncture does not feel any discomfort, and pain even more so.

Due to the fact that the procedure is most often prescribed for the diagnosis of pathologies, it, like any other diagnostic measure, should be painless. The patient will be conscious all the time, so he should immediately inform the doctor about the discomfort that has arisen. This will help avoid a number of complications. The doctor will change the technology or completely interrupt the procedure.

A puncture is an important procedure in medicine, and the collection of cerebrospinal fluid from the brain is even more so. Before it is carried out, the patient will undergo a series of studies that will help identify possible contraindications. Do not worry, a brain puncture is trusted to be carried out only by experienced specialists who know their business.

Everyone remembers how often the phrase “lumbar puncture” (LP) appears in the series “House Doctor”, let's see what kind of diagnostic method it is.

In 1890, the German general practitioner and surgeon Heinrich Ireneus Quincke was the first to perform this procedure. His research became the basis for the creation of a method of spinal anesthesia. A breakthrough in the development of the method occurred in the middle of the 20th century. In that period, manipulation was performed in virtually every suspicion of a neurological pathology. The introduction of neuroimaging techniques (MRI, CT) has minimized the number of diagnostic punctures.

What is a lumbar puncture - why is it done

Lumbar puncture - the placement of a needle into the cavity between the pia and arachnoid membranes of the spinal cord to collect cerebrospinal fluid (CSF). Carried out for the purpose of diagnosis and therapy. Puncture of the spinal cord provides important information for establishing the nature of lesions of the central nervous system (CNS). Its results confirm the diagnosis of polyradiculoneuropathy, multiple sclerosis, neuroinfection, and suspected meningitis.

How is a spinal cord puncture taken? During the procedure, the patient lies or sits. The area L3-L4 is punctured, finding a place for a puncture by palpation. The spinal cord usually ends at the level of L1, so punctures are allowed above or below this area, in the L2-L3 or L4-L5 segments.

Indications and contraindications

With a therapeutic purpose, spinal cord puncture is carried out to remove CSF and reduce pressure in benign intracranial hypertension, in hydrocephalus with normal intracranial pressure, and for endolumbar drug administration. In this way, antibiotics are administered for meningitis. Therapeutic puncture is indicated in the absence of a positive result within 72 hours after the start of parenteral administration of antibacterial drugs. Its implementation is justified for meningitis of a bacterial nature, for chemotherapy of malignant processes of the central nervous system, including metastases.

There are absolute and relative indications for diagnostic lumbar puncture.

1. Absolute indications - suspicion of a neurogenic infection. We are talking about meningitis and encephalitis of bacterial, borreliosis, viral, neurosyphilis, fungal origin.
2. Relative indications include destruction of the myelin of the white matter of the nervous system, inflammatory polyneuropathy, portosystemic encephalopathy, Liebmann-Sachs disease, septic vascular embolism.

With intracranial hemorrhage, puncture is advisable if CT is not possible or it gives negative results.

• local inflammation (pressure sores);
• occlusive hydrocephalus;
• pathology of the spinal cavity with impaired CSF circulation;
• suspicion of an intracranial mass process with increasing intracranial hypertension, progressive focal symptoms, edema of the optic nerve head.

In the latter case, before the procedure, it is necessary to conduct EchoES, MRI, check the fundus.

Borderline contraindications include motor neuron disease, inflammatory disease of the spine with curvature (spondylitis), syringomyelia with bulbar phenomena, Erb-Goldflam disease. Patients with Graves' disease and severe psychoneurosis do not tolerate manipulation well. If the study does not add anything new to the diagnosis, it is better not to injure such patients.

Training

A lumbar puncture does not require any special physical preparation, unless the doctor indicates otherwise. But the psychological readiness of the patient for the upcoming procedure is one of the important conditions for its implementation. Inattention to the preparatory stage contributes to the occurrence of complications. Physical or mental trauma, which was provoked by spinal puncture, in emotionally labile people can cause headache, dizziness, local pain in the area of ​​medical intervention.

The task of a specialist is a comprehensive influence on the patient's psyche, minimizing preoperative time, and conducting a painless procedure.

Technique and algorithm for puncture

Puncture is carried out in accordance with the rules of asepsis. To take CSF during spinal cord puncture, lumbar needles up to 10 cm long are used. Before the procedure, the patient is laid on his side, asked to take the fetal position. He should tilt his head to the limit, bend the lower limbs at the knee and hip joints. A pillow is placed under the torso to prevent lateral arching of the spine. Performing the LP is permissible in a sitting position with an inclination forward.

Spinal puncture algorithm:

1. Palpation of the segment L3-L
2. Treatment of the skin with iodine from the center according to the type of concentric circles.
3. Treatment with alcohol, surrounding the puncture site with a sterile sheet.
4. Conducting local anesthesia with a 0.5% solution of novocaine.
5. Leading the Beer puncture needle with mandrin in the anteroposterior direction at an angle of 70-80°. When punctured during a puncture of the spinal cord, they pass through the skin, subcutaneous tissue, and then penetrate into the hard and arachnoid membranes of the brain. In adult patients, the needle deepens by 5-7 cm, in children - by 2-5 cm. Its penetration into the subarachnoid region is felt by the performer as a failure. Manipulation is carried out very slowly.
6. Removing the mandrin, attaching the Waldmann apparatus to determine intracavitary pressure.
7. Registration of CSF pressure in millimeters of water column. In the prone position, it is 40-120 mm. water. Art., in a sitting position - up to 400 mm. water. Art.
8. Disconnecting the machine.
9. Collection of cerebrospinal fluid into sterile tubes. The amount of CSF depends on the purpose of the puncture and the patient's condition.
10. Extraction of the needle, treatment of the surgical field with iodine.
11. Applying a sterile napkin.

The duration of the LP is 1-5 minutes. After the manipulation, the patient should lie on his stomach without a pillow, without raising his head for 3-4 hours, then on his side for 12-24 hours.

Results – Cerebrospinal Fluid Examination

Liquor cells are sensitive to thermal and chemical effects. At room temperature, leukocytes disintegrate, after half an hour their number is halved. Therefore, the study of CSF is carried out within 30 minutes after the puncture.

Normally, cerebrospinal fluid is a colorless liquid with a relative density of 1005-1009 and a pH reaction of 7.31 - 7.33.

It contains:

• total protein in the amount of 0.16-0.33 g/l;
• glucose - 2.78-3.89 mmol / l;
• chloride ions - 120-128 mmol / l.

Cytosis (number of cells) in CSF according to the standard does not exceed 3-4 in 1 µl. These are elements of the meninges, ependymocytes of the ventricles of the brain, lymphocytes, monocytes.

Puncture of the spinal cord makes it possible to determine:

• color, transparency, the presence of blood in the cerebrospinal fluid during macroscopic examination;
• number and type of cells (microscopic examination).

An increase in cells in the CSF (pleocytosis) is noted in inflammatory diseases of the central nervous system.

Protein coefficient has an important diagnostic value. According to the results of lumbar puncture, an increased number of protein cells in the cerebrospinal fluid (hyperproteinorachia) is noted with hemorrhage into the subarachnoid space. It is caused by the admixture of blood to the CSF. With hemorrhagic strokes, the amount of protein can reach 6-8 g / l. Its increase to 20-49 g / l is diagnosed with a massive breakthrough of blood into the ventricles of the brain. Exacerbation of chronic inflammatory processes in the central nervous system is accompanied by a rise in protein levels up to 1-2 g/l.

A decrease in glucose and chlorides in the CSF occurs in acute meningitis of various etiologies. An increase - with the phenomenon of irritation of the membranes of the brain.

In children of the first years of life, only according to the results of a lumbar puncture with the detection of antigen, antibodies, DNA or RNA in the cerebrospinal fluid, the diagnosis of congenital CNS infections is carried out. The study of cerebrospinal fluid allows you to confirm the origin of congenital encephalitis.

Why spinal cord puncture is dangerous - complications

Due to the specifics of the examination, patients ask doctors a lot of questions. Many people are worried about whether it is dangerous to take a spinal cord puncture and what complications can be.

Some experts allow you to move immediately. But after the procedure, the appearance of cerebral symptoms when trying to get up is not ruled out. Vomiting, headache, unsteadiness during movements may occur.

More often the consequences of spinal cord puncture are manifested:

• through the fault of the doctor as a result of a violation of asepsis, non-compliance with all technical aspects and the lack of instructions to the patient on how to behave during and after manipulation;
• due to the fault of the patient;
• due to patient intolerance to the procedure.

Complications after lumbar puncture include post-puncture syndrome, direct trauma, teratogenic factor, changes in CSF. The clinic with post-puncture syndrome is caused by a violation of the dura mater with a needle. The leakage of CSF into the epidural space causes pain in the occipital and frontal region, which does not go away for several days, rarely more.

Puncture of the spinal cord is dangerous with hemorrhagic complications. These include spinal subarachnoid, chronic and acute intracranial subdural hematoma. Injury to the vessels provokes bleeding in people with poor blood clotting or thrombocytopenia.

When a needle is inserted into the subarachnoid space, puncture of the spine is fraught with damage to the roots, trauma to the IVD, and complications in violation of sterility. Due to the ingress of skin fragments into the brain canal, tumors can form, which manifest themselves years after the intervention with increasing pain in the spine and limbs, impaired posture and gait.

Does it hurt

Any surgical intervention in the area of ​​the spinal canal causes a natural fear. Before the upcoming procedure, patients often think about the pain of manipulation.

Common questions:

1. Does it hurt during a spinal cord puncture?
2. How long does the back hurt after a spinal cord puncture?

Different people have different feelings. Some people may experience an uncomfortable posture during the examination. The procedure itself is practically painless.

Spinal puncture begins with preliminary anesthesia with novocaine solution or other anesthetic. An important factor that significantly affects the quality of anesthesia is the dose of the anesthetic drug. With its introduction, numbness or bursting is felt, as during dental procedures. Sometimes, after the insertion of the needle, a sharp, short pain appears - evidence that the nerve is affected.

After spinal cord puncture, mild stiffness of the neck muscles may be present, which accompanies post-puncture headache. In some people, radicular pain persists for several days.

Spinal cord puncture is a neurosurgical diagnostic method based on the introduction of a special medical needle into the central spinal canal in order to obtain fluid circulating in the subarachnoid space. In some cases, the procedure is used for therapeutic and prophylactic purposes for the local administration of drugs (for example, after neurosurgical operations on the spine). Thanks to the extensive experience in carrying out such manipulations, today it is possible to significantly reduce the risks of severe consequences, but there is still a small likelihood of complications after puncture of the subarachnoid space of the spinal cord. To prevent possible pathologies, it is necessary to follow all the instructions of the doctor and his assistants during the procedure itself, and also follow the recommendations regarding the regimen for at least three days after the lumbar puncture.

The main purpose of puncturing the subarachnoid space is to obtain CSF (cerebrospinal fluid) for further assessment of microbiological and biochemical parameters. CSF is a clear, colorless liquid that fills the CSF pathways, protects the brain from mechanical stress and maintains normal intracranial pressure. In patients suffering from elevated ICP, a subarachnoid puncture is indicated to remove excess fluid and is performed as an emergency medical treatment for the prevention of strokes and hydrocephalus, which is also called dropsy of the brain.

Indications for use

Absolute indications for puncture of the subarachnoid space are the presence of clinical symptoms of infectious and inflammatory diseases of the spinal membranes, as well as various autoimmune and metabolic disorders of the central nervous system. An assessment of the chemical composition and rheological properties of the fluid produced in the ependymal cells is necessary for patients with leukodystrophy, a severe hereditary disease that affects the white matter of the brain (an accumulation of long cylindrical processes of nerve cells covered with a myelin sheath). For some types of neuropathies, the doctor may also suggest a lumbar puncture to clarify the etiological and pathogenetic picture of CNS damage.

The procedure can also be indicated in the presence of the following conditions and pathologies:

• the presence of signs that may indicate a hemorrhage in the subarachnoid space (acute headache, pulsation in the occipital and temporal part of the head, convulsions, impaired consciousness, repeated vomiting, etc.);
• the need to introduce contrasts for other diagnostic methods;
• the need for an emergency reduction in ICP;
• malignant tumors of the spine, spinal cord, bone marrow and other organs and tissues, in which the study of cerebrospinal fluid will provide a more accurate picture of the disease and determine the tactics of further management of a cancer patient;
• septic blockage of blood vessels;
• some systemic pathologies of fibrous connective tissue (Libman-Sachs disease).

Spinal cord puncture can be used for endolumbar administration of drugs, such as antibiotics and antiseptics for CNS infections, or cytostatics (antineoplastic drugs) for the treatment of various neoplasms. In the same way, anesthetics (lidocaine and novocaine) are administered to perform local anesthesia.

In children under 2 years of age, emergency puncture of the subarachnoid space can be used for febrile syndrome of unspecified origin, provided there is no effect on therapy with antibiotics, glucocorticoids and other first-line drugs used to treat various inflammatory diseases.

Important! Most neuroimaging diagnostic methods completely replace the lumbar puncture, but in some diseases, such as neuroleukemia, a complete clinical and pathogenetic picture can be achieved by studying the composition and properties of cerebrospinal fluid.

Contraindications

An absolute and categorical contraindication for performing subarachnoid puncture is the displacement of some segments of the brain relative to its other structures, since the introduction of instruments into the subarachnoid space in this case leads to a difference between the cerebrospinal pressure in different areas and can cause sudden death of the patient right on the operating table .

All possible risks and their correlation with the expected benefits are carefully weighed and evaluated in the presence of the following contraindications, which are considered relative:

• infectious and pustular skin diseases in the lumbar region (furunculosis, carbunculosis, fungal diseases, etc.);
• congenital anomalies, malformations and defects of the spinal tube, central spinal canal and spinal cord;
• violation of blood clotting ability;
• previous blockade of the subarachnoid space.

In the presence of these contraindications, which most neurosurgeons and neurologists consider conditional, the procedure is postponed until the existing restrictions and diseases are eliminated. If this is not possible, and the diagnosis must be carried out urgently, it is important to consider all possible risks. For example, in the case of infectious diseases of the skin at the puncture site after puncture, the patient is prescribed antibiotics and broad-spectrum antimicrobial agents to prevent infection of the internal tissues of the body and the development of inflammatory reactions.

Risks of axial herniation during the procedure

Axial (cerebellar-tentorial) herniation is the descent of the brain into the foramen magnum, which is a natural opening of the skull bones. Clinically, the pathology is manifested by the onset of coma, stiff neck muscles, sudden respiratory arrest. In the absence of emergency assistance, acute ischemia and hypoxia of the brain tissue occurs, and the person dies. To prevent wedging syndrome during the procedure, the doctor uses the thinnest possible needle and draws the minimum amount of fluid required to prevent sudden changes in cerebrospinal pressure.

The maximum risks of axial herniation are observed in the presence of the following pathologies:

• hydrocephalus 3-4 degrees;
• large neoplasms;
• greatly increased ICP (difference between CSF pressure and atmospheric pressure);
• violation of the patency of the liquor-conducting pathways.

In the presence of these four factors, the risk of sudden herniation of the brain is maximum, so these pathologies in most cases are absolute contraindications for lumbar puncture.

How is the procedure?

The fear experienced by patients who are about to undergo a lumbar puncture procedure may arise against the background of a patient's lack of awareness about the features of lumbar puncture and a misconception about the procedure for its implementation.

Where is a lumbar puncture done?

A lumbar puncture is a medical procedure that requires strict adherence to asepsis rules. For this reason, such manipulations are carried out in the operating room, and the patient is hospitalized for one day in a neurological hospital in the neurosurgery department. It is permissible to perform a puncture in a day hospital: in the absence of complications, the patient is allowed to go home 2-4 hours after puncture.

Training

Before undergoing the procedure, the patient must sign an informed consent for medical manipulations, as well as undergo the necessary examination. The list of mandatory diagnostic minimum before performing a lumbar function includes:

• examination of the fundus (to identify possible symptoms of increased intracranial pressure);
• computed tomography of the brain and spinal cord to exclude tumor formations and hydrocephalus;
• complete blood count (if platelet insufficiency is detected, drug correction is required).

If the patient is taking drugs from the group of anticoagulants (thinning the blood and increasing its fluidity), the treatment must be canceled 72 hours before the scheduled procedure.

Pose for puncturing

The classic and most effective position for a lumbar puncture is when a person lies on the edge of the operating table (on his side), pressing his legs bent at the hip and knee joints to his stomach. The head should also be tilted forward (the chin stretches towards the knees). This position provides maximum expansion of the interspinous spaces between the vertebrae and facilitates the passage of the needle into the spinal canal.

In some cases, for example, with a large amount of fat in the back, inserting a needle in a supine position is difficult. In such situations, manipulations are carried out in a sitting position: the patient sits on the edge of a table or couch, puts his feet on a special stand, crosses his arms in the chest area and lowers his head on them.

Needle insertion technique

To perform a puncture, a special Beer needle with a rigid rod is used to close holes in tubular instruments (mandrin). It is introduced into the space between the spinous processes at the level of L3-L4 or L4-L5. In children, the spinal cord is located slightly lower than in adults, so children are punctured strictly at the level of L4-L5. The criterion that the needle has reached the subarachnoid space is the sensation of "failure" (the instrument is lowered into an empty cavity). If everything was done correctly, a clear liquid, cerebrospinal fluid, begins to drain from the needle.

Prior to puncture, the skin within a radius of 15-25 cm from the puncture site is treated with an alcohol solution of iodine. Subarachnoid puncture does not require general anesthesia and is performed under local anesthesia, for which, while advancing the needle, a local anesthetic is injected at regular intervals (most often it is a 0.25% novocaine solution).

For research, from 1-2 ml to 10 ml of cerebrospinal fluid is usually taken, which is immediately placed in three test tubes, after which its chemical composition, rheological properties, and microbiological parameters are examined.

Risks associated with a lumbar puncture

After sampling the cerebrospinal fluid, the puncture site is treated with a 4% solution of colloxylin, diluted in a mixture of ethanol and diethyl ether, and sealed with sterile cotton. Within 2 hours, the patient should be in a supine position (strictly face down) under the supervision of the doctor who performed the puncture. The patient is forbidden to get up from the table or couch, roll over onto his back, raise his upper body, hang his legs. In some institutions, bed rest is prescribed for 24 hours, but in European clinics this approach is considered inappropriate and unjustified, and the patient is allowed to go home within 3-4 hours after the puncture.

What are the possible side effects?

Normal side effects that do not indicate a violation of the puncture technique or any complications are:

• headache;
• increased weakness;
• dizziness;
• nausea and vomiting;
• pain in the puncture area and other parts of the back;
• difficulty urinating and defecation.

Such symptoms are included in the complex of post-puncture syndrome, can persist for 7-15 hours (less often - up to 1-3 days) and are the result of irritation of the membranes of the spinal cord. Such side effects are most pronounced in people with an unstable nervous system and neurological pathologies.

Important! If headaches and other alarming signs that appear immediately after the lumbar puncture do not go away within 72 hours or worsen a day after the puncture, you should immediately go to the hospital and exclude possible complications.

Risk of Complications

Complications after puncture of the spinal cord, although rare, do occur. These include:

• epidural hematoma;
• paresis, paresthesia and paralysis of the lower extremities;
• hemorrhage in the subarachnoid space;
• damage to the periosteum of the vertebrae or the musculoskeletal apparatus of the spine;
• acute osteomyelitis (purulent inflammation) of the lumbar vertebrae, which is the result of a violation of the rules of asepsis;
• bleeding;
• epidermoid cyst.

There are known cases of intervertebral hernias as a result of damage to the intervertebral discs during the advancement of the needle, therefore, it is advisable to use only thin needles up to 8.7 cm long and a mandrel no more than 22 G to perform the procedure.

To reduce the risk of complications, it is necessary to behave correctly during the procedure: do not move, try to relax your back muscles as much as possible and follow other recommendations of the medical staff. After the puncture, it is important to observe a sparing regimen, avoid increased physical exertion, do not bend over, do not make sudden movements and do not lift weights. Alcoholic drinks, especially with manifestations of post-puncture syndrome, it is important to completely exclude until the state of health stabilizes.

Deciphering the results

Normally, cerebrospinal fluid has a moderate viscosity, a transparent and colorless structure. Even before the analysis, the doctor evaluates the appearance of the cerebrospinal fluid, the presence of impurities in it (for example, blood), the consistency of the liquid and the rate of its outflow. Normally, CSF should be released at a rate of 20 to 60 drops per minute. Deviation from these indicators may indicate inflammatory processes, neoplastic diseases, or metabolic disorders (eg, leukodystrophy).

Normal values ​​of cerebrospinal fluid and possible deviations

Turbidity of the cerebrospinal fluid indicates an increased infiltration of leukocyte cells, and a dark yellow color indicates possible metastases in skin cancer.

Video - Spinal Puncture

Puncture of the spinal cord is an effective therapeutic and diagnostic neurosurgical procedure that has a high degree of reliability and information content in case of suspected various diseases of the central nervous system. To date, sufficient practical experience has been accumulated in carrying out such manipulations, and the risk of possible complications is minimized, so you should not be afraid of a lumbar puncture. All actions are performed under local anesthesia, and the patient does not feel pain during the procedure, with the exception of the initial discomfort from the injection itself.

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Spinal puncture (lumbar or lumbar puncture), as a diagnostic or therapeutic procedure, has been used by doctors for a long time. In connection with the introduction of new diagnostic methods (CT, MRI, etc.) into medical practice, the frequency of this intervention has noticeably decreased, however, it still remains relevant.

Anatomical details

In humans, it is located in the bone canal formed by the vertebrae. At the top, it directly passes into the medulla oblongata, and at the bottom it ends with a sharpening, having a conical shape, at the level of the second lumbar vertebra.

The spinal cord is covered by three outer membranes: hard, arachnoid (arachnoid) and soft. Between the arachnoid and soft membranes is the so-called subarachnoid space, which is filled with cerebrospinal fluid (CSF). The average volume of cerebrospinal fluid in an adult is 120-270 ml and continuously communicates with the fluid of the subarachnoid space of the brain and cerebral ventricles. The spinal membranes end at the level of the first sacral vertebrae, that is, much lower than the location of the spinal cord itself.

Strictly speaking, the term "spinal cord puncture" is not entirely correct, since during this manipulation, a puncture of the subarachnoid space is performed at a level where spinal structures are absent.

Characteristics of the cerebrospinal fluid

Liquor is normally completely transparent and colorless. It is practically possible to estimate the pressure by the rate of flow of CSF from the lumen of the needle: approximately 1 drop per 1 second corresponds to the norm.

If the cerebrospinal fluid is taken for the purpose of further laboratory analysis, then the following indicators are determined:

If an infectious lesion of the membranes of the spinal cord and / or brain is suspected, a bacterioscopic and bacteriological examination of the cerebrospinal fluid is also performed to identify the pathogen.

Methodology

Puncture of the spinal cord should be performed exclusively in a hospital by a specialist who thoroughly knows this technique.

Manipulation is performed in the position of the patient sitting or lying down. The most preferred position is lying on the side with the knees strongly pressed to the chest, the head lowered as much as possible and the back bent. In this position, the intervertebral spaces increase, as a result of which the risk of unpleasant consequences during the manipulation is reduced. It is important to remain still throughout the procedure.

The spine is punctured at the level between the third and fourth lumbar vertebrae. In children, a lumbar puncture is performed between the fourth and fifth lumbar vertebrae (taking into account the age-related anatomical features of the spinal structures and spine).

The sequence of actions of the doctor:

1. The skin is treated with any antiseptic solution (for example, iodine and alcohol).
2. Spend local anesthesia (for example, novocaine solution) of the puncture site.
3. The puncture is performed at a certain angle between the spinous processes of the lumbar vertebrae. For this, a special needle with a translucent mandrel is used.
4. The appearance of liquor indicates a correctly performed procedure.
5. Further actions are determined by the purpose of the manipulation: cerebrospinal fluid is taken for analysis (in a volume of approximately 10 ml), drugs are injected into the subarachnoid space, etc.
6. The needle is removed, the puncture site is sealed with a sterile bandage.

After the end of the procedure, the patient turns over on his stomach and stays in this position for at least two hours. This is carried out in order to prevent such consequences as post-puncture syndrome associated with the outflow of fluid through a defect in the hard shell.

It is important to know that, despite the ongoing anesthesia, the moment of the puncture may be accompanied by discomfort.

Why do a lumbar puncture?

Spinal cord puncture is performed for various purposes. The main ones include:

• Collection of cerebrospinal fluid for its subsequent analysis.
• Assessment of cerebrospinal fluid pressure, study of the patency of the subarachnoid space using special compression tests.
• The introduction of drugs into the spinal canal, such as antibiotics or cytostatics.
• Removal of excess amount of cerebrospinal fluid in certain diseases.

Most often, spinal cord puncture is used for diagnostic purposes. In what cases is it used:

• Subarachnoid bleeding in the brain and spinal cord (for example, or injuries).
• Some infectious diseases - meningitis, encephalitis, ventriculitis, neurosyphilis and others.
• Malignant lesion of the membranes of the spinal cord and/or brain.
• Suspicion of liquorrhea or the presence of cerebrospinal fluid fistulas (using dyes or contrast agents).
• Normotensive.

Also, a spinal cord puncture is sometimes done for fever of unclear etiology in early childhood (up to two years), demyelinating processes, paraneoplastic syndrome, and some other pathologies.

Contraindications

There are also contraindications for this procedure. These include:

• Conditions in which there is a high risk of axial herniation - severe cerebral edema and intracranial hypertension, occlusive hydrocephalus, some brain tumors, etc.
• Infectious and inflammatory processes in the lumbar region.
• Serious violations of the coagulation system, the use of drugs that affect blood coagulation.

In any case, indications and contraindications for such a procedure are established exclusively by a doctor.

Complications

Like any invasive procedure, lumbar puncture has its complications. Their frequency averages up to 0.5%.

The most common consequences of a lumbar puncture include:

• Axial herniation with the development of dislocation (displacement of structures) of the brain. This complication often develops after a sharp decrease in the pressure of the cerebrospinal fluid, as a result of which the structures of the brain (more often the medulla oblongata and part of the cerebellum) are "wedged" into the foramen magnum.
• The development of infectious complications.
• The occurrence of headaches, which are usually stopped in the supine position.
• Radicular syndrome (the occurrence of persistent pain as a result of damage to the spinal roots).
• Meningeal manifestations. Especially often they develop with the introduction of drugs or contrast agents into the subarachnoid space.
• The formation of an intervertebral hernia as a result of damage to the cartilage tissue of the disc.
• Bleeding and other hemorrhagic complications.

When a spinal puncture is performed by an experienced specialist with an assessment of all indications and contraindications for this procedure, as well as strict adherence by the patient to the instructions of the attending physician, the risk of complications is extremely low.