Lumbar (spinal) puncture. Lumbar puncture: technique and purposes of collecting cerebrospinal fluid Complications during puncture of the spinal cord and brain

Spinal cord puncture. Such a terrible phrase can often be heard at a doctor’s appointment, and it becomes even scarier when this procedure concerns you specifically. Why do doctors puncture the spinal cord? Is such manipulation dangerous? What information can be obtained from this study?

The first thing you need to understand when it comes to spinal cord puncture (which is what patients most often call this procedure), it does not mean a puncture of the tissue of the central nervous system organ itself, but only the collection of a small amount of cerebrospinal fluid, which washes the spinal cord and brain . Such manipulation in medicine is called a spinal, or lumbar, puncture.

Why is a spinal cord puncture performed? There can be three purposes for such manipulation: diagnostic, analgesic and therapeutic. In most cases, a lumbar puncture of the spine is done to determine the composition of the cerebrospinal fluid and the pressure inside the spinal canal, which indirectly reflects the pathological processes occurring in the brain and spinal cord. But specialists can perform a spinal cord puncture for therapeutic purposes, for example, to administer medications into the subarachnoid space to quickly reduce spinal pressure. Also, one should not forget about such an anesthesia method as spinal anesthesia, when anesthetics are injected into the spinal canal. This makes it possible to perform a large number of surgical interventions without the use of general anesthesia.

Considering that in most cases, spinal cord puncture is prescribed for diagnostic purposes, this type of research will be discussed in this article.

Why is a puncture taken?

A lumbar puncture is taken to examine the cerebrospinal fluid, which can help diagnose some diseases of the brain and spinal cord. Most often, such manipulation is prescribed for suspected:

• infections of the central nervous system (meningitis, encephalitis, myelitis, arachnoiditis) of a viral, bacterial or fungal nature;
• syphilitic, tuberculous lesions of the brain and spinal cord;
• subarachnoid bleeding;
• abscess of the central nervous system;
• ischemic, hemorrhagic stroke;
• traumatic brain injury;
• demyelinating lesions of the nervous system, such as multiple sclerosis;
• benign and malignant tumors of the brain and spinal cord, their membranes;
• other neurological diseases.

Examination of cerebrospinal fluid makes it possible to quickly diagnose severe diseases of the brain and spinal cord

Contraindications

It is prohibited to take a lumbar puncture for space-occupying formations of the posterior cranial fossa or temporal lobe of the brain. In such situations, taking even a small amount of cerebrospinal fluid can cause dislocation of brain structures and cause strangulation of the brain stem in the foramen magnum, which entails immediate death.

It is also prohibited to perform a lumbar puncture if the patient has purulent-inflammatory lesions of the skin, soft tissues, or spine at the puncture site.

Relative contraindications are severe spinal deformities (scoliosis, kyphoscoliosis, etc.), since this increases the risk of complications.

With caution, puncture is prescribed to patients with bleeding disorders, those who take drugs that affect blood rheology (anticoagulants, antiplatelet agents, non-steroidal anti-inflammatory drugs).

In case of brain tumors, lumbar puncture can be performed only for health reasons, since there is a high risk of developing dislocation of brain structures

Preparation stage

The lumbar puncture procedure requires preliminary preparation. First of all, the patient is prescribed general clinical and biochemical blood and urine tests, and the state of the blood coagulation system is necessarily determined. The lumbar spine is examined and palpated. To identify possible deformations that may interfere with the puncture.

You need to tell your doctor about all the medications you are currently taking or have recently taken. Particular attention should be paid to drugs that affect blood clotting (aspirin, warfarin, clopidogrel, heparin and other antiplatelet agents and anticoagulants, non-steroidal anti-inflammatory drugs).

You also need to inform the doctor about possible allergies to medications, including anesthetics and contrast agents, recent acute illnesses, or the presence of chronic illnesses, as some of them may be a contraindication to the study. All women of childbearing age should tell their doctor if they may be pregnant.

Before performing a spinal cord puncture, the patient must consult a doctor.

It is forbidden to eat for 12 hours before the procedure and drink for 4 hours before the puncture.

Puncture technique

The procedure is performed with the patient lying on his side. In this case, you need to bend your legs as much as possible at the knee and hip joints, bringing them to the stomach. The head should be bent forward as much as possible and close to the chest. It is in this position that the intervertebral spaces widen well and it will be easier for the specialist to get the needle into the right place. In some cases, the puncture is performed with the patient sitting with the back as rounded as possible.

The specialist selects the puncture site by palpating the spine so as not to damage the nerve tissue. The spinal cord in an adult ends at the level of the 2nd lumbar vertebra, but in short people, as well as in children (including newborns), it is slightly longer. Therefore, the needle is inserted into the intervertebral space between the 3rd and 4th lumbar vertebrae or between the 4th and 5th. This reduces the risk of complications after puncture.

After treating the skin with antiseptic solutions, local infiltration anesthesia of soft tissues is carried out with a solution of novocaine or lidocaine using a regular syringe with a needle. After this, a lumbar puncture is performed directly with a special large needle with a mandrel.

This is what a spinal puncture needle looks like

The puncture is made at the selected point, the doctor directs the needle sagittally and slightly upward. At approximately a depth of 5 cm, resistance is felt, after which a peculiar dip of the needle follows. This means that the end of the needle has entered the subarachnoid space and you can begin collecting cerebrospinal fluid. To do this, the doctor removes the mandrin (the inner part that makes the instrument airtight) from the needle and cerebrospinal fluid begins to drip from it. If this does not happen, you need to make sure that the puncture is performed correctly and that the needle enters the subarachnoid space.

After collecting the cerebrospinal fluid into a sterile tube, the needle is carefully removed and the puncture site is sealed with a sterile bandage. For 3-4 hours after the puncture, the patient should lie on his back or side.

The puncture is performed between the 3rd and 4th or 4th and 5th lumbar vertebrae

The first step in cerebrospinal fluid analysis is to assess its pressure. Normal values ​​in a sitting position are 300 mm. water Art., in a lying position – 100-200 mm. water Art. As a rule, pressure is assessed indirectly - by the number of drops per minute. 60 drops per minute corresponds to the normal value of cerebrospinal fluid pressure in the spinal canal. Pressure increases during inflammatory processes of the central nervous system, with tumor formations, with venous stagnation, hydrocephalus and other diseases.

Next, the cerebrospinal fluid is collected into two 5 ml tubes. They are then used to carry out the necessary list of studies - physicochemical, bacterioscopic, bacteriological, immunological, PCR diagnostics, etc.

Depending on the results of the cerebrospinal fluid study, the doctor can recognize the disease and prescribe appropriate treatment

Consequences and possible complications

In the vast majority of cases, the procedure takes place without any consequences. Naturally, the puncture itself is painful, but pain is present only at the stage of inserting the needle.

Some patients may develop the following complications.

Post-puncture headache

It is generally accepted that after a puncture a certain amount of cerebrospinal fluid flows out of the hole, as a result of which intracranial pressure decreases and a headache occurs. This pain resembles a tension headache, has a constant aching or squeezing character, and decreases after rest and sleep. It can be observed for 1 week after the puncture; if cephalgia persists after 7 days, this is a reason to consult a doctor.

Traumatic complications

Sometimes traumatic complications of puncture can occur, when the needle can damage spinal nerve roots and intervertebral discs. This is manifested by back pain, which does not occur after a correctly performed puncture.

Hemorrhagic complications

If large blood vessels are damaged during the puncture, bleeding and hematoma formation may occur. This is a dangerous complication that requires active medical intervention.

Dislocation complications

Occurs when there is a sharp drop in cerebrospinal fluid pressure. This is possible in the presence of space-occupying formations in the posterior cranial fossa. To avoid such a risk, before taking a puncture, it is necessary to perform a study for signs of dislocation of the midline structures of the brain (EEG, REG).

Infectious complications

They may occur due to violation of the rules of asepsis and antisepsis during puncture. The patient may develop inflammation of the meninges and even form abscesses. Such consequences of puncture are life-threatening and require the prescription of powerful antibacterial therapy.

Thus, spinal cord puncture is a very informative technique for diagnosing a large number of diseases of the brain and spinal cord. Naturally, complications during and after the manipulation are possible, but they are very rare, and the benefits of the puncture far outweigh the risk of developing negative consequences.

A spinal tap, or lumbar puncture, is a minimally invasive, image-guided diagnostic procedure that removes a small amount of cerebrospinal fluid surrounding the spinal cord and brain or injects drugs or other substances into the lumbar spinal canal.

Cerebrospinal fluid (CSF) is a clear, colorless fluid that cushions the spinal cord and brain and delivers nutrients to them.

Why is a spinal tap performed?

A spinal tap is performed for the following purposes:

• Taking a small sample of cerebrospinal fluid for subsequent laboratory analysis
• Measurement of cerebrospinal fluid pressure in the spinal canal
• Removal of cerebrospinal fluid in case of excess amount
• Introduction of chemotherapy drugs and other drugs into the spinal canal

A spinal tap is used to diagnose the following conditions:

• Bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis
• Subarachnoid hemorrhage (bleeding around the brain)
• Malignant tumors of the brain and spinal cord
• Inflammatory conditions of the nervous system, including Guillain-Barré syndrome and multiple sclerosis

How should you prepare for research?

As a rule, before the procedure, a series of blood tests are performed to assess the function of the liver and kidneys, as well as the functioning of the blood coagulation system.

Often, a spinal tap reveals signs of increased intracranial pressure, for example, with hydrocephalus. Therefore, the patient may be given a CT scan before the study, which helps detect swelling of the brain or fluid accumulation around it.

It is very important to inform the doctor about all medications the patient is taking, including those of herbal origin, as well as any allergies, especially to local anesthetics, anesthesia drugs, or iodinated contrast materials. Some time before the procedure, you should stop taking aspirin or other blood thinners, as well as non-steroidal anti-inflammatory drugs.

It is important for the doctor to know about taking blood thinning drugs such as warfarin, heparin, clopidogrel, etc., as well as painkillers and anti-inflammatory drugs: aspirin, ibuprofen, naproxen, etc.

You should also tell your doctor if you have any recent illnesses or other conditions.

In addition, you should stop eating and drinking 12 hours before the procedure.

You should check with your doctor about what medications you can take in the morning.

It is advisable to come to the hospital with a relative or friend who will help the patient get home.

You must wear a special hospital gown during the procedure.

Women should always inform their doctor and radiologist of any possibility of pregnancy. As a rule, studies using x-rays are not carried out during pregnancy to avoid negative effects on the fetus. If x-rays are necessary, every effort should be made to minimize the effects of radiation on the developing child.

During a spinal puncture, a child is allowed to stay with one of the parents in the treatment room with prior agreement with the doctor.

What does the diagnostic equipment look like?

A spinal tap typically uses an X-ray tube, a patient table, and a monitor located in the radiologist's office. To monitor the process and control the doctor’s actions, a fluoroscope is used, which converts X-ray radiation into a video image. To improve image quality, a special amplifier is used, suspended above the patient's table.

The procedure also uses a long, hollow needle, the length and diameter of which varies.

In addition, other devices and equipment are used during the procedure, such as an intravenous infusion system and machines to monitor blood pressure and heart rate.

What is the basis for the research?

X-rays are similar to other forms of radiation such as light or radio waves. It has the ability to pass through most objects, including the human body. When used for diagnostic purposes, an X-ray machine produces a small beam of radiation that passes through the body and creates an image on photographic film or a special matrix for obtaining digital images.

X-rays are absorbed differently by different organs and parts of the body. Dense structures, such as bones, absorb radiation strongly, while soft tissue structures (muscles, fatty tissue and internal organs) transmit X-rays to a greater extent. As a result, on an x-ray, bone tissue appears white, air and air spaces appear black, and soft formations appear various shades of gray.

Until recently, X-ray images were stored as copies on film, similar to photographic negatives. Nowadays, most images are available as digital files that are stored electronically. Such images are readily available and are used for comparison with the results of subsequent examinations to assess the effectiveness of treatment.

In fluoroscopy, radiation is produced continuously or in pulses, which produces a sequence of images projected on a monitor screen. In addition, you can take a snapshot of the image, which will be stored either on film or in the computer's memory.

How is the research conducted?

Typically, a spinal tap is performed on an outpatient basis.

The nurse is setting up an intravenous infusion line that will be used to administer sedatives to a client. In other cases, general anesthesia is possible.

The patient lies on the treatment table on his stomach, face down.

Devices that are connected to the patient's body are used to monitor heartbeat, pulse and blood pressure during the procedure.

The skin at the site of needle insertion is thoroughly cleaned of hair, disinfected and covered with a surgical drape.

The doctor numbs the skin using a local anesthetic.

Under real-time X-ray guidance (fluoroscopy, or fluoroscopy), the doctor inserts a needle into the spinal canal through the skin between two lumbar vertebrae. After inserting the needle, the doctor may ask the patient to slightly change his body position, which is necessary to measure the pressure of the cerebrospinal fluid.

Subsequent measures depend on the reason for the spinal tap:

• A needle is used to extract a small amount of cerebrospinal fluid for laboratory analysis.
• Cerebrospinal fluid is removed to reduce pressure in the spinal canal
• Painkillers or other drugs are injected into the spinal canal

After this, the needle is removed, the bleeding is stopped, and a pressure bandage is applied to the skin. No stitches are required. The nurse then removes the IV line.

For several hours after the procedure, the patient should lie on his back or side.

As a rule, the duration of a spinal tap is no more than 45 minutes.

What should you expect during and after the procedure?

When setting up an intravenous infusion system, as well as when administering a local anesthetic, you may feel a slight prick.

During the procedure, you should remain as still as possible. The child is held during a spinal tap by a nurse or one of the parents. In addition, children are often prescribed a sedative, which ensures peace of mind for both the child and the doctor.

After the procedure, you should lie on your back or side for several hours and rest for the rest of the day.

Some patients experience headaches for several hours or days after a spinal tap, which may be accompanied by nausea, vomiting, and dizziness. The duration of headaches ranges from several hours to a week or more. In addition, there may be increased sensitivity of the skin in the lower back and pain that spreads along the back of the thigh.

Painkillers in tablets can help relieve headaches or back pain. However, if pain is severe, you should contact your doctor.

Who reviews the results of a spinal tap and where can they be obtained?

The results of a spinal tap can be obtained from your doctor. After completion of the procedure or other treatment, the doctor may recommend that the patient undergo a follow-up examination, which includes a physical examination, blood tests or other tests, and instrumental examination. During this consultation, the patient can discuss with the doctor any changes or side effects that have appeared after the treatment.

What are the benefits and risks of a spinal tap?

Advantages:

• After completion of the examination, no radiation remains in the patient’s body.
• When used for diagnostic purposes, X-rays do not cause any side effects.

Risks:

• Any procedure that involves violating the integrity of the skin carries a risk of developing infection. However, in this case, the chance of developing an infection that requires antibiotic treatment is less than 1 in 1000 cases.
• After a spinal puncture, bleeding with the formation of an epidural hematoma or subarachnoid hemorrhage is possible.
• In rare cases, a spinal tap is accompanied by compression of the spinal cord stem, caused by increased intracranial pressure, a brain tumor, or other lesion. The presence of high blood pressure can be determined by CT or MRI performed before the spinal puncture.
• With excessive exposure to X-ray radiation on the body, there is always an extremely small risk of developing malignant tumors. However, the benefits of accurate diagnosis significantly outweigh this risk.
• A woman should always tell her doctor or radiologist about the possibility of pregnancy.

A few words about reducing the impact of radiation on the body

During an X-ray examination, the doctor takes special measures to minimize radiation exposure to the body while trying to obtain the best quality image possible. Experts from international radiological safety councils regularly review radiology standards and produce new technical recommendations for radiologists.

Spinal cord puncture (lumbar puncture) is a type of diagnosis that is quite complex. The procedure removes a small amount of cerebrospinal fluid or injects drugs and other substances into the lumbar spinal canal. In this process, the spinal cord is not directly affected. The risk that arises during puncture contributes to the rare use of the method exclusively in a hospital setting.

Purpose of a spinal tap

Spinal cord puncture is performed for:

Performing a spinal tap

• collecting a small amount of cerebrospinal fluid (CSF). Subsequently, their histology is carried out;
• measuring the pressure of cerebrospinal fluid in the spinal canal;
• removal of excess cerebrospinal fluid;
• administration of drugs into the spinal canal;
• relief of difficult labor in order to prevent painful shock, as well as as anesthesia before surgery;
• determining the nature of the stroke;
• isolation of tumor markers;
• performing cisternography and myelography.

Using a spinal tap, the following diseases are diagnosed:

• bacterial, fungal and viral infections (meningitis, encephalitis, syphilis, arachnoiditis);
• subarachnoid bleeding (bleeding in the brain);
• malignant tumors of the brain and spinal cord;
• inflammatory conditions of the nervous system (Guillain-Barré syndrome, multiple sclerosis);
• autoimmune and dystrophic processes.

Often a spinal tap is equated with a bone marrow biopsy, but this statement is not entirely correct. During a biopsy, a tissue sample is taken for further research. Access to the bone marrow is achieved through a puncture of the sternum. This method allows you to identify bone marrow pathologies, some blood diseases (anemia, leukocytosis and others), as well as metastases in the bone marrow. In some cases, a biopsy can be performed during the puncture process.

To prevent and treat JOINT DISEASES, our regular reader uses the increasingly popular NON-SURGERY treatment method recommended by leading German and Israeli orthopedists. After carefully reviewing it, we decided to offer it to your attention.

Indications for spinal cord puncture

Spinal cord puncture is mandatory for infectious diseases, hemorrhages, and malignant neoplasms.

Inflammatory polyneuropathy

A puncture is taken in some cases for relative indications:

• inflammatory polyneuropathy;
• fever of unknown pathogenesis;
• demyelinating diseases (multiple sclerosis);
• systemic connective tissue diseases.

Preparatory stage

Before the procedure, medical workers explain to the patient why the puncture is being performed, how to behave during the procedure, how to prepare for it, as well as possible risks and complications.

Spinal cord puncture requires the following preparation:

1. Registration of written consent for the manipulation.
2. Taking blood tests to evaluate blood clotting, as well as the functioning of the kidneys and liver.
3. Hydrocephalus and some other diseases require computed tomography and MRI of the brain.
4. Collection of information on the medical history, recent and chronic pathological processes.

The specialist must be informed about the medications the patient is taking, especially those that thin the blood (Warfarin, Heparin), relieve pain, or have an anti-inflammatory effect (Aspirin, Ibuprofen). The doctor should be aware of existing allergic reactions caused by local anesthetics, anesthesia drugs, iodine-containing agents (Novocaine, Lidocaine, iodine, alcohol), as well as contrast agents.

It is necessary to stop taking blood thinning drugs, as well as analgesics and non-steroidal anti-inflammatory drugs in advance.

Before the procedure, water and food are not consumed for 12 hours.

Women must provide information about their suspected pregnancy. This information is necessary due to the expected x-ray examination during the procedure and the use of anesthetics, which may have an undesirable effect on the unborn child.

Your doctor may prescribe a medication to take before the procedure.

The presence of a person who will be next to the patient is mandatory. A child is allowed to undergo a spinal puncture in the presence of his mother or father.

Technique of the procedure

A spinal cord puncture is performed in a hospital ward or treatment room. Before the procedure, the patient empties his bladder and changes into hospital clothes.

Spinal cord puncture

The patient lies on his side, bends his legs and presses them to his stomach. The neck should also be in a bent position, with the chin pressed to the chest. In some cases, spinal puncture is performed with the patient sitting. The back should be as motionless as possible.

The skin in the puncture area is cleaned of hair, disinfected and covered with a sterile napkin.

The specialist may use general anesthesia or use a local anesthetic. In some cases, a drug with a sedative effect may be used. Also during the procedure, heartbeat, pulse and blood pressure are monitored.

The histological structure of the spinal cord provides for the safest needle insertion between the 3rd and 4th or 4th and 5th lumbar vertebrae. Fluoroscopy allows you to display a video image on a monitor and monitor the manipulation process.

Next, the specialist collects cerebrospinal fluid for further research, removes excess cerebrospinal fluid or injects the necessary drug. The liquid is released without outside help and fills the test tube drop by drop. Next, the needle is removed and the skin is covered with a bandage.

CSF samples are sent for laboratory testing, where histology occurs directly.

Spinal cord cerebrospinal fluid

The doctor begins to draw conclusions based on the nature of the fluid coming out and its appearance. In its normal state, the cerebrospinal fluid is transparent and flows out one drop per second.

At the end of the procedure you must:

• adherence to bed rest for 3 to 5 days as recommended by a doctor;
• keeping the body in a horizontal position for at least three hours;
• getting rid of physical activity.

When the puncture site is very painful, you can resort to painkillers.

Risks

Adverse consequences after spinal cord puncture occur in 1–5 cases out of 1000. There is a risk of:

Intervertebral hernia

• axial wedging;
• meningism (symptoms of meningitis occur in the absence of an inflammatory process);
• infectious diseases of the central nervous system;
• severe headache, nausea, vomiting, dizziness. Your head may hurt for several days;
• damage to the spinal cord roots;
• bleeding;
• intervertebral hernia;
• epidermoid cyst;
• meningeal reaction.

If the consequences of the puncture are expressed in chills, numbness, fever, a feeling of tightness in the neck, or discharge at the puncture site, you should immediately consult a doctor.

There is an opinion that during a spinal tap the spinal cord can be damaged. It is erroneous, since the spinal cord is located higher than the lumbar spine, where the puncture is directly made.

Contraindications to spinal cord puncture

Spinal cord puncture, like many research methods, has contraindications. Puncture is prohibited in case of sharply increased intracranial pressure, dropsy or cerebral edema, or the presence of various formations in the brain.

It is not recommended to take a puncture if there are pustular rashes in the lumbar region, pregnancy, impaired blood clotting, taking blood thinning drugs, or ruptured aneurysms of the brain or spinal cord.

In each individual case, the doctor must analyze in detail the risk of the manipulation and its consequences for the life and health of the patient.

It is advisable to contact an experienced doctor who will not only explain in detail why it is necessary to perform a spinal cord puncture, but will also carry out the procedure with minimal risk to the patient’s health.

A lumbar puncture is a procedure in which cerebrospinal fluid is removed from the spinal canal for further examination.

The action is used mainly to confirm or exclude inflammatory diseases of the central nervous system, spinal cord and spinal membrane. The procedure is also used in the diagnosis of bleeding in the brain.

A spinal tap is performed in the lumbar region, in a place where the spinal cord no longer reaches. There is therefore no risk of injury or damage.

The procedure is followed by 24 hours of bed rest as a preventive measure aimed at preventing headaches.

From the history of spinal puncture

Historically, the first documented sampling of cerebrospinal fluid dates back to the end of the 19th century. A qualitative breakthrough in the development of this method occurred in the 50s of the 20th century, when lumbar puncture was performed in almost every suspected neurological disease.

Currently, the procedure is one of the most frequently performed minimally invasive ones. We can say that in the diagnosis of some diseases it is a necessary condition (bleeding into the spinal canal,).

Scope of application

All indications for performing lumbar puncture are divided into absolute and relative.

Absolute readings

Based on the medical history and clinical picture (symptoms), as well as the results of the examinations, the doctor - neurologist, surgeon or therapist - will recommend or perform a spinal puncture.

The method is used primarily to diagnose inflammatory or degenerative diseases of the brain, spinal cord membrane, medulla itself and nerve roots, detect bleeding in the spinal canal, confirm or exclude the presence of cancer cells in the cerebrospinal fluid.

Cerebrospinal fluid puncture can also be performed for therapeutic (medicinal) purposes, due to its ability to reduce high pressure in the meninges by withdrawing fluid or injecting drugs into the cerebrospinal fluid.

Repeat sampling is used to monitor disease progression or treatment effectiveness.

So, lumbar puncture is used for the following purposes:

• diagnostics ( , );
• confirmation or exclusion of bleeding in the central nervous system;
• diagnosis of demyelinating diseases ();
• determination of primary CNS tumors and metastases.

Relative readings

Less common indications for lumbar puncture include diagnosing dementia (,), assessing the extent of CNS tissue damage and determining prognosis after post-global hypoxic injury (eg, after cardiopulmonary resuscitation), and.

When is the procedure contraindicated?

Contraindications to fluid collection:

• high intracranial pressure (more than 220 mm H2O);
• confirmed intracranial expansive processes;
• infection at the injection site;
• sepsis;
• bleeding;
• vertebral deformities (scoliosis, kyphosis, spinal adhesions).

Preparation and technique for lumbar puncture

During a spinal tap, the patient does not need any preparation. The procedure takes only a few minutes. After the examination

Spinal puncture needle

24 hours of strict bed rest are required to prevent complications after dural puncture.

If we are talking about an outpatient examination, subsequent hospitalization should be taken into account. More often, however, lumbar puncture is performed in the context of hospitalization.

A spinal puncture is performed on an outpatient basis, but if necessary, the specialist will only need the patient’s hospital bed. The procedure does not require any special equipment, however, it is necessary that all equipment is sterile!

The doctor uses a special puncture needle, which is hollow, but when inserted into the patient’s body, it contains a so-called metal mandrel, which is a thin fiber. After inserting the needle into the intended place, the fiber is removed, creating space for the selected fluid or administration of the drug.

The patient sits or lies with his back to the doctor; the back is bent, causing the vertebrae to separate from each other. This is necessary so that the needle can easily enter the spinal canal.

The collection occurs in the lumbar region, namely in the midline between the spinous processes of the 3rd and 4th lumbar vertebrae or the 4th and 5th vertebrae.

First of all, the injection site is determined, then it is disinfected and anesthetized. The actual injection is usually painless, but may be a little uncomfortable and the patient will usually feel pressure.

After correct insertion of the needle, the mandrel is removed and the pressure of the cerebrospinal fluid in the spinal canal is measured. The doctor then collects the fluid into a laboratory tube; it flows mostly on its own. Already at this stage, a specialist can evaluate the visual aspect of the liquor, especially its color and impurities.

After collection, the pressure is measured again using a pressure gauge and the needle is removed. The injection site is then closed and the patient assumes a horizontal position in bed.

The cerebrospinal fluid sample is sent to a laboratory where it undergoes biochemical, microbiological and immunological analysis.

The first hours after the procedure

After the procedure, the patient must remain absolutely at rest for 24 hours, being in a horizontal position and remembering to consume a sufficient amount of fluid.

You should lie down all day, even without raising your head, because this is the only way to prevent very severe headaches that arise as a result of the intervention.

CSF examination

Statin tests:

• assessment of the appearance of CSF before and after centrifugation;
• determination of the number of nucleated cells and red blood cells in a volumetric unit;
• screening tests for protein and hemoglobin;
• total protein – quantitatively;
• glucose and lactate;
• spectrometry for suspected bleeding into the cerebrospinal fluid tract.

Basic immunochemical tests:

• albumin, IgG, IgM (quantitative);
• oligoclonal IgG.

CSF and serum are always examined at the same time!

Special examination

An additional basic immunological panel of IgA (quantitatively), free light chain (quantitatively and/or electrophoretically), or other plasma proteins (components C3, C4, transthyretin, transferrin and many others, the value of which in the diagnosis of neurological diseases has not yet been fully proven) are examined.

Triggers of CNS tissue damage (partially specific to a particular type of damage at the level of individual cell populations):

Auxiliary Value Research:

• Cl, Na, K ions;
• enzymes: LD and isoenzymes LD, CK, CK-BB;
• classical electrophoresis of cerebrospinal fluid protein.

Diagnosis of liquorrhea

CSF leak = leakage of cerebrospinal fluid in the meninges, usually after neurosurgery or trauma; (cerebrospinal fluid leakage from the nose = rhinorrhea; liquorrhea from the ears = otorrhea):

• beta2-transferrin (asialotransferrin, i.e. transferrin in which there are no sialic acid residues) - electrophoretic map; it is also necessary to examine the serum;
• beta trace protein (prostaglandin D synthase - quantitative);
• indicative (unreliable) statin tests: glucose, potassium, total protein.

What does blood in the cerebrospinal fluid mean?

Pink or red color of the cerebrospinal fluid indicates the presence of blood impurities originating from damaged blood vessels or caused by bleeding from subcutaneous blood vessels in the injection area (= artificial bleeding). In this case, a test of 3 test tubes is carried out - the liquid is collected in 3 test tubes and in the 3rd it should be transparent and colorless.

If even in the 3rd test tube there is a bloody admixture in the liquid, we can talk about.

What should a patient expect after the procedure?

Complications after lumbar puncture are rare, but they can still be:

• headache due to changes in pressure (so-called post-puncture syndrome);
• paresthesia of the lower extremities;
• swelling at the injection site;
• bleeding from the injection site;
• disorders of consciousness;
• migraine;
• nausea;
• urination disorder.

I. Indications for lumbar puncture

Suspicion of meningitis, meningoencephalitis.

Convulsive syndrome of unknown origin.

Coma of unknown etiology.

Fever (38 – 40 0) of unknown origin in young children.

The presence of acute flaccid paralysis or paresis.

Contraindications for lumbar puncture

Picture of infectious-toxic shock.

Brain swelling.

Dislocation and herniation of the brain.

The presence of bright focal symptoms (puncture is done after an examination of the fundus, CT, MRI if a space-occupying process such as a tumor, hematoma, abscess is excluded).

II. Technique for performing a spinal (lumbar) puncture

Prepare for puncture a sterile needle with a mandrel, two test tubes, one of them must be sterile and have a stopper.

The patient is placed on the manipulation table on his right side.

The doctor performing the puncture washes his hands thoroughly, puts on sterile gloves, and treats them with alcohol.

Before performing a puncture, the nurse treats the skin over the lumbar spine, starting from the site of the intended puncture and further, in diverging circles, first 2 times with iodine, and then 3 times with alcohol to completely remove any remaining iodine. In addition, the skin over the iliac crest is treated.

The assistant fixing the patient bends him as much as possible to increase the space between the spinous processes of the vertebrae.

The doctor determines the site of insertion of the puncture needle. He feels the iliac crest and lowers a perpendicular from it to the spine, the intersection point corresponds to the space between the 3rd and 4th lumbar vertebrae. The puncture can be performed in this gap or up one vertebrae; at these levels there is no brain matter, so the puncture is safe.

Before the puncture, you can anesthetize the puncture site with lidocaine or procaine: 0.1 - 0.2 ml of anesthetic is injected intradermally, forming a “lemon peel”, then 0.2 - 0.5 ml of anesthetic is injected into the deeper layers of the skin. More often, the puncture is performed without prior anesthesia.

A needle with a mandrel cut upward is inserted perpendicular to the skin into the center of the intervertebral space, then the needle is advanced slowly, slightly deflecting the needle tip (by 10 - 15 0) towards the head end. When advancing the needle, the doctor feels three failures: after puncture of the skin, intervertebral ligament and dura mater.

After the third failure, remove the mandrin and see if any cerebrospinal fluid is released from the puncture needle. If there is no fluid, then the needle is advanced until cerebrospinal fluid appears, and the mandrel is periodically (every 2–3 mm) removed. Care must be taken not to push the needle too far and puncture the anterior venous plexus of the spinal canal - this is the most common complication of lumbar puncture.

When the needle has reached the spinal canal, it is necessary to measure the pressure of the cerebrospinal fluid: the mandrel is removed from the needle, a locking device and a pressure gauge are attached to the needle, and the pressure is determined by the height of the cerebrospinal fluid column in the manometer. In the absence of a manometer, cerebrospinal fluid pressure is estimated approximately by the rate of cerebrospinal fluid flow from the needle. In a healthy person, cerebrospinal fluid flows out in rare drops - 40-60 drops per minute.

After turning off the pressure gauge, cerebrospinal fluid is collected into two test tubes: a) 2 ml is taken into a sterile test tube. for bacterioscopic, bacteriological research and latex agglutination reaction (RLA); b) into the second test tube - to determine the cellular composition, protein concentration, glucose (1 ml.) It is necessary to prevent the rapid flow of cerebrospinal fluid by regulating the rate of its removal with a mandrel.

After collecting the cerebrospinal fluid, the needle is removed without fully inserting the mandrel, since the spinal roots may be pinched and subsequently torn off when the needle is removed, which will cause the appearance of pain and motor disorders.

A dry sterile cotton swab is placed on the skin in the area of ​​the puncture hole and secured with a bandage.

After the puncture, the patient is transported in a horizontal position to the bed and placed on his stomach for 2 hours without a pillow under his head. Children in the first year of life are placed on their backs with a pillow under their buttocks and legs. The horizontal position of the patient with the head end slightly lowered allows one to avoid complications of spinal puncture - dislocation of the brain and its wedging into the foramen magnum.

For 3–4 hours after the puncture (every 15 minutes), the patient’s condition is monitored in order to promptly recognize brain dislocation and provide emergency assistance, because Through the puncture hole in the dura mater, cerebrospinal fluid leaks out for another 4–6 hours.

After a lumbar puncture, the patient must observe strict bed rest: for 2–3 days if normal cerebrospinal fluid values ​​are obtained, and up to 14 days if pathological changes in the cerebrospinal fluid are detected.