Puncture of the spinal cord: indications, consequences and complications

Spinal puncture: indications, contraindications, technique of carrying out

Spinal puncture is the introduction of a special needle into the subarachnoid space of the spinal cord in order to take a cerebrospinal fluid for research or for a therapeutic purpose.

This manipulation has many synonyms: lumbar puncture, lumbar puncture, lumbar puncture, puncture of the subarachnoid space of the spinal cord.

In this article we will talk about the indications and contraindications to this procedure, the technique of its conduct and possible complications.

Indications for lumbar puncture

As mentioned above, lumbar puncture can be performed with a diagnostic or therapeutic purpose.

As a diagnostic manipulation, a puncture is performed if it is necessary to examine the composition of cerebrospinal fluid, to determine the presence of infection in it, to measure fluvial pressure and permeability of the subarachnoid space of the dorsal the brain.

If it is necessary to remove the excess of CSF from the spinal canal, introduce antibacterial drugs or chemotherapy, also perform lumbar puncture, but already as a method treatment.

Absolute indications for spinal puncture:

1. infectious diseases of the central nervous system (encephalitis, meningitis and others);
2. malignant neoplasms in the area of ​​the membranes and structures of the brain;
3. diagnostics of cerebrospinal fluid (discharge of cerebrospinal fluid) by introducing radiopaque substances or dyes into the spinal canal;
4. hemorrhage under the arachnoid membrane of the brain.

Relative indications:

• multiple sclerosis and other demyelinating diseases;
• polyneuropathy of inflammatory nature;
• septic embolism of vessels;
• fever of unknown nature in young children (up to 2 years);
• systemic lupus erythematosus and some other systemic connective tissue diseases.

Contraindications to lumbar puncture

In some cases, carrying out this diagnostic treatment can lead a patient more harm than good, and can even be dangerous for the patient's life - this is contraindication. The main ones are listed below:

1. marked swelling of the brain;
2. sharply increased intracranial pressure;
3. the presence of volume education in the brain;
4. occlusive hydrocephalus.

These 4 syndromes, when carrying out spinal puncture, can lead to axial cuffing - a life-threatening condition when part of the brain falls into the large occipital foramen - the functioning of the vital centers located in it is disturbed and the patient can to perish. The probability of wedging increases when using a thick needle and removing a large amount of liquor from the spinal canal.

If the puncture is necessary, output should be the minimum possible amount of cerebrospinal fluid fluid, and in case of signs of wedging, urgently enter through the puncture needle the right amount of fluid from the outside.

Other contraindications are:

• pustular eruptions in the lumbar region;
• diseases of the blood coagulation system;
• taking medications that dilute the blood (antiaggregants, anticoagulants);
• hemorrhage from an aneurysm of the vascular of the brain or spinal cord;
• blockade of the subarachnoid space of the spinal cord;
• pregnancy.

These 5 contraindications are relative - in situations where the lumbar puncture is vital, it is performed with them, they simply take into account the risk of developing certain complications.

Technique of puncture

During the given manipulation the patient, as a rule, is in a position lying on the side with the head tilted to the chest and pressed to the stomach, knees bent at the feet.

It is in this position that the puncture site becomes as accessible to the physician as possible. Sometimes the patient is in a position not lying, and sitting on a chair, while he leans forward and puts his hands on the table, and his head in his hands.

However, this provision has been used more and more rarely.

Children puncture is performed in the interval between the spinous processes of 4 and 5 lumbar vertebrae, and adults a little higher - between 3 and 4 lumbar vertebrae.

Some patients are afraid to perform a puncture, because they believe that the spinal cord may be touched while carrying it, however it is not! The spinal cord of an adult ends at about 1-2 lumbar vertebrae.

Below it simply does not exist.

The skin in the puncture area is treated with solutions of alcohol and iodine alternately, after which an analgesic drug is administered (novocaine, lidocaine, ultracaine) first intradermally, until the formation of the so-called lemon peel, then subcutaneously and deeper, along the way puncture.

Puncture (puncture) is performed by a special needle with a mandrel (this is the rod for closing the lumen of the needle) in the plane from the front back, but not perpendicular to the lower back, and at a slight angle - from the bottom up (along the course of the spinous processes of the vertebrae, between them).

When the needle deviates from the median line, it usually rests against the bone.

When the needle passes through all the structures and enters the spinal canal, the specialist who conducts the puncture feels like a failure; if such a the sensation is absent, but when the mandrene is removed through the needle, the cerebrospinal fluid passes, this is a sign that the goal is reached and the needle is in channel. If the needle is inserted correctly, but the spinal fluid does not flow out, the doctor asks the patient to cough or lift the head end of it to increase the pressure of the cerebrospinal fluid.

When as a result of numerous punctures appear spikes, to achieve the appearance of cerebrospinal fluid can be very difficult. In this case, the doctor will try to perform the puncture on another, above or below the standard level.

To measure the pressure in the subarachnoid space, a special plastic tube is attached to the needle. In a healthy person, the CSF pressure ranges from 100 to 200 mm Hg.

To obtain accurate data, the doctor will ask the patient to relax as much as possible. The level of pressure can be estimated approximately: 60 drops of liquor per minute correspond to normal pressure.

In inflammatory processes in the brain or other conditions that contribute to an increase in the volume of the cerebrospinal fluid, the pressure increases.

The pressure during the sample increases by 10-20 mm of water column, and 10 seconds after the restoration of blood flow is normalized. Stool sample: in the navel area, press down with your fist for 10 seconds, as a result of which the pressure also rises.

Blood in liquor

There are 2 reasons for the admixture of blood in the cerebrospinal fluid: bleeding under the arachnoid membrane and damage to the vessel during the puncture.

To differentiate them from each other, the liquor is collected in 3 test tubes. If the admixture of blood is a hemorrhage, the liquid will be uniformly colored in a scarlet color.

If, however, the liquor from the 1st to the 3rd test tube becomes purer, it is likely that the blood appeared as a result of injury to the vessel when puncturing.

If the hemorrhage is small, staining the cerebrospinal fluid in a scarlet color may be barely noticeable or not noticeable at all. In this case, changes will necessarily be revealed in the laboratory study.

Investigation of CSF

As a rule, cerebrospinal fluid is collected in 3 test tubes: for general analysis, biochemical and microbiological examination.

When carrying out a general analysis, the lab worker evaluates the density, pH, color, fluid transparency, counts cytosis (the number of cells in 1 μl), determines the protein content. If necessary, identify other cells: tumor cells, epidermal cells, arachnoendothelium and others.

The density of cerebrospinal fluid is normal, 05 08; It increases with inflammation, decreases - with excess fluid.

The normal value of pH 5 it rises in the case of paralysis, neurosyphilis, epilepsy; decreases with meningitis and encephalitis.

Muddy liquor becomes with an increased content of leukocytes (above 200-300 in 1 μl). In bacterial infection, neutrophilic cytosis is determined, in the case of a viral infection, a lymphocytic parasitosis - eosinophilic, with a hemorrhage, an increased content in the cerebrospinal fluid erythrocytes.

The protein should normally not be more than 5 g / L, but with inflammatory processes in the brain, neoplasms, hydrocephalus, neurosyphilis and other diseases, its level is significantly increased.

In the biochemical study of cerebrospinal fluid, the level of many indicators is determined, among which the most important are the following:

• glucose (its level is approximately 40-60% of the blood level and is equal to, mmol / l, decreases with meningitis, rises - with strokes);
• lactate (norm for adults, mmol / l; increases with meningitis of bacterial nature, brain abscesses, hydrocephalus, cerebral ischemia, decreases with viral meningitis);
• chlorides (normal - 118-132 mol / l, increased concentration in tumors and abscesses of the brain, as well as echinococcosis, decreased - with meningitis, brucellosis, neurosyphilis).

Microbiological examination is carried out by staining a smear of cerebrospinal fluid according to one of the possible methods (depending on the suspected pathogen), carrying out the seeding of the liquid on a nutrient medium. Thus, the causative agent of the disease and its sensitivity to antibacterial drugs.

How to behave to a patient after spinal puncture

To prevent possible outflow of liquor through the puncture hole, the patient should be kept bed resting, being in a horizontal position, for 2-3 hours after the puncture. To prevent the development of complications of the operation or facilitate their condition in the case of their appearance, bed rest should be extended to several days. Exclude weight lifting.

Complications of spinal puncture

Complications of this procedure develop in 1-5 patients out of 1000. These are:

• axial wedging (acute - with increased intracranial pressure, chronic - with repeated punctures);
• meningism (the appearance of symptoms of meningitis in the absence of inflammation as such, is the result of irritation of the meninges);
• infectious diseases of the central nervous system due to violation of asepsis rules during puncture;
• severe headaches;
• damage to the roots of the spinal cord (there are persistent pains);
• bleeding (if there was a clotting disorder or a patient taking drugs that diluted the blood);
• intervertebral hernia, resulting from damage to the disc;
• epidermoid cyst;
• meningeal reaction (a sharp increase in the cytosis and protein level with the glucose content within the norm and the absence of microorganisms in the crop, resulting from the introduction into the spinal canal antibiotics, chemotherapy, analgesics and radiopaque substances; as a rule, quickly and without a trace regress, but in some cases becomes the cause of myelitis, radiculitis or arachnoiditis).

So, spinal puncture is the most important, very informative medical and diagnostic procedure to which there are both indications and contraindications.

The expediency of conducting it is determined by the doctor, and he also assesses possible risks.

The overwhelming number of punctures is tolerated by patients well, but complications sometimes develop, in the case of which the examinee should immediately tell about it to the treating doctor.

A source: https://doctor-neurologist.ru/spinnomozgovaya-punkciya-pokazaniya-protivopokazaniya-texnika-provedeniya

Complications after spinal cord puncture

The puncture of cerebrospinal fluid in medical terminology is indicated as a lumbar puncture, and the fluid itself is called the cerebrospinal fluid. Lumbar puncture is one of the most complex methods that pursues diagnostic, anesthesia and therapeutic goals.

The procedure is the introduction of a special sterile needle (the length is up to 6 cm) between the 3rd, and also the 4th vertebra under spider web of the spinal cord, moreover, the brain itself is not affected at all, and then extraction of a certain dose cerebrospinal fluid. 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 for the detection of proteins, various infections, glucose. The doctor also evaluates the transparency of the cerebrospinal fluid.

Spinal puncture is most often used for suspected central nervous system infections that cause diseases such as meningitis and encephalitis. Multiple sclerosis is very difficult to diagnose, so without lumbar puncture can not do.

As a result of the puncture, the cerebrospinal fluid is examined for the presence of antibodies. If antibodies in the body are present, the diagnosis of multiple sclerosis is practically established. Puncture is used to differentiate the stroke and to identify the nature of its occurrence.

Liquor is collected in 3 test tubes, later comparing the blood admixture.

With the use of lumbar puncture, the diagnosis helps to identify the inflammation of the brain, subarachnoidal bleeding or determine the hernia of intervertebral discs by the introduction of contrast medium, and also measure the pressure of the fluid of the dorsal the brain.

In addition to collecting fluid for research, specialists pay attention to the rate of leakage, i.e. if one transparent drop appears in one second, the patient does not have problems in this area.

In medical practicespinal cord puncture, consequenceswhich can sometimes be very serious, is prescribed in order to remove excess liquor and thereby reduce intracranial pressure when benign hypertension, is used to administer drugs for various diseases, for example, chronic normotensive hydrocephalus.

Contraindications to lumbar puncture

The use of lumbar puncture is contraindicated in traumas, diseases, formations and certain processes in the body:

In either case, the physician first conducts a series of tests to ascertain the urgency of the appointmentpuncture of the spinal cord. Effectsit, as already noted, can be very, very serious, because the procedure is risky, and it entails certain risks.

Puncture of the spinal cord and its consequences

The first few hours (2-3 hours) after the procedure, in no case can not get up, it is necessary to lie on a flat surface on the abdomen (without a pillow), later you can lie on your side, for 3-5 days you should observe strict bed rest and not take a standing or sitting position to avoid different complications.

Some patients after lumbar puncture experience weakness, nausea, pain in the spine and headache. A physician can take medicines (anti-inflammatory and pain-relieving) to relieve or reduce symptoms. Complications after lumbar puncture may appear due to incorrect procedure. Here is a list of possible complications resulting from incorrect actions:

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, its consequences are minimized. Contact our medical center, where only experienced doctors work, do not risk your health!

Puncture of the spinal cord (lumbar puncture) is a form of diagnosis that is complex enough.

In this process, the spinal cord itself is not affected. The risk that arises during the puncture, contributes to the rare use of the method exclusively in a hospital.

Purpose of spinal puncture

Puncture of the spinal cord is carried out for:

Spinal puncture

collection of a small amount of cerebrospinal fluid (spinal fluid).

Further their histologists are conducted; Measuring the pressure of cerebrospinal fluid in the spinal canal; excess of cerebrospinal fluid liquid; management of drugs in the spinal canal; relief of seriously passing childbirth in order to prevent pain and shock, and as anesthesia before surgery; character impairment stroke; oncomarkero; cysterography and myelography.

With the help of spinal puncture, the following diseases are diagnosed:

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

Often spinal puncture is identified with bone marrow biopsy, but this statement is not entirely correct. When a biopsy is taken a sample of tissues for further research.

Access to the bone marrow is through a sternum puncture. This method allows to reveal pathologies of the bone marrow, some blood diseases (anemia, leukocytosis and others), as well as metastases in the bone marrow.

In some cases, a biopsy can be performed while taking a puncture.

Indications for spinal cord puncture

A mandatory puncture of the spinal cord is carried out with infectious diseases, hemorrhages, malignant neoplasms.

Inflammatory polyneuropathy

Take a puncture in some cases with relative indications:

inflammatory polyneuropathy; a fever of unknown pathogenesis; emilyeniziruyuschih diseases (multiple sclerosis), systemic diseases of connective tissue.

Preparatory stage

Before the procedure, the medical workers explain to the patient: what the puncture is doing, how to behave during the manipulation, how to prepare for it, and also the possible risks and complications.

Puncture of the spinal cord provides the following training:

Registration of written consent for manipulation. The delivery of blood tests, with the help of which its coagulability is evaluated, as well as the work of the kidneys and liver.

Hydrocephalus and some other diseases suggest a CT scan and brain MRI.

The specialist should be informed about the medicines being taken by the patient, especially those that are dilute blood (Warfarin, Heparin), anesthetize, or have an anti-inflammatory effect (Aspirin, Ibuprofen). The physician should be aware of the present allergic reaction caused by local anesthetics, drugs for anesthesia, iodine-containing drugs (Novocaine, lidocaine, iodine, alcohol), as well as contrasting substances.

Beforehand it is necessary to stop taking drugs that dilute the blood, as well as analgesics and non-steroidal anti-inflammatory drugs.

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

Women need to be provided with information about the alleged pregnancy. This information is necessary due to an anticipated X-ray examination during the procedure and the use of anesthetics, which may have an undesirable effect on the child's future.

A doctor may prescribe a medication that must be taken before the procedure.

It is mandatory to have a person who will be near the patient. The child can be spinal punctured in the presence of the mother or father.

Technique of the procedure

Do a puncture of the spinal cord in a hospital room or treatment room. Before the procedure, the patient empties the bladder and changes into hospital clothes.

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

Skin covers in the area of ​​the puncture are cleared from the hair, disinfected and covered with a sterile tissue.

The histological structure of the spinal cord provides for the most safe insertion of the needle between 3 and 4 or 4 and 5 lumbar vertebrae. X-rays reveal video on the monitor and monitor the manipulation process.

Next, the specialist spans the cerebrospinal fluid for further research, removes surplus liquor or injects the necessary drug. The liquid is excreted unaided and fills the test tube by drop. Then the needle is removed, the skin is covered with a bandage.

Samples of cerebrospinal fluid are sent to a laboratory study, where histology occurs directly.

Spinal cord ligament

The doctor begins to draw conclusions on the nature of the fluid outlet and its appearance. In the normal state, the cerebrospinal fluid is clear and follows one drop per second.

At the end of the procedure it is necessary:

compliance with bed rest for 3 to 5 days on the recommendation of a doctor; The movement of the body in a horizontal position for at least three hours; Zbavlenie from physical exertion.

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

Risks

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

• Intervertebral hernia
• axial wedge;
• meningism (there are symptoms of meningitis in the absence of an inflammatory process);
• infectious diseases of the central nervous system;
• severe headache, nausea, vomiting, dizziness.
• The head can ache for several days;
• damage to the roots of the spinal cord;
• bleeding; hernial hernia;
• the epidermoid cyst;
• meningeal reaction.

If the effects of puncture are expressed in chills, numbness, fever, a feeling of tightness in the neck region, secretions at the puncture site, you should urgently consult a doctor.

Contraindications to spinal cord puncture

Puncture of the spinal cord, like many methods of research, has contraindications. Puncture is prohibited with sharply increased intracranial pressure, edema or edema of the brain, the presence of various formations in the brain.

It is not recommended to take a puncture for pustular eruptions in the lumbar region, pregnancy, impaired blood coagulability, the use of blood-thinning drugs, rupture of aneurysms of the brain or spinal cord.

It is advisable to contact an experienced doctor who will not only explain in detail why the spinal cord should be punctured, but will also perform the procedure with minimal risk to the patient's health.

A source: http://lechim-nogi.ru/2017/10/18/oslozhneniya-posle-punkcii-spinnogo-mozga/

Lumbar puncture: goals, technique, consequences and complications

Surgical interventions

A lumbar puncture, also called lumbar or spinal, is a common procedure in modern medicine. Most often it is used in neurological practice and in leukemia.

Such a simple procedure still causes fears in patients and is surrounded by a lot of myths. Therefore, it is necessary to know about the indications and contraindications to it, about the purpose and technique of its conduct, and also about possible consequences.

In addition, sometimes the needle is inserted into the spinal cord to establish anesthesia.

With therapeutic purposes, spinal puncture is not used very often, the most common is the diagnostic procedure for obtaining cerebrospinal fluid.

The obtained biological substance for the study is sent to the laboratory diagnostician, who counts the number of different cells in it, determines the level of protein content, glucose and some other indicators, on the basis of what is confirmed or refuted the presence disease.

With the advent of MRI in a broad medical practice and equipping hospitals with computer tomographs, the need to obtain CSF significantly decreased, but this procedure continues to be used regularly to diagnose and treat some states.

Absolute are the indications that do not leave other options for diagnosis or treatment of patients. For diagnostic purposes, lumbar puncture is unconditionally indicated when:

• infectious diseases of the central nervous system;
• tumors of the brain and its membranes;
• cerebrospinal fluid (discharge of cerebrospinal fluid);
• craniocerebral trauma or stroke with suspected subarachnoid hemorrhage.

Relative, that is, optional indications for the diagnostic procedure, are:

1. increased intracranial pressure (for its direct measurement);
2. demyelinating diseases (multiple sclerosis, amyotrophic lateral sclerosis, etc.);
3. inflammatory polyneuropathies;
4. septic embolism of vessels feeding the brain and spinal cord;
5. severe fever of unknown etiology in newborns and children up to two years;
6. diffuse connective tissue diseases (systemic lupus erythematosus, systemic scleroderma, etc.).

For medical purposes, a puncture is prescribed for:

• reduction of pressure inside the spinal canal and the cranial cavity;
• administration of drugs (antibiotics, chemotherapeutic agents);
• pneumatization of the spinal canal (a rare way to treat severe forms of epilepsy).

Puncture is done in the position of the patient sitting or lying on its side. The head of the examinee is tilted to the chest, legs are bent at the knees and close to the stomach, the back is arched to the doctor. To prevent bending of the spine under the lower back, put a small hard pillow.

Previously, the skin of the back is treated with an antiseptic.The puncture site is determined by carrying out an imaginary line at the level of the upper edge of the ileal bones forming the pelvis.

This axis, called the intergranular line, passes between the III and IV lumbar vertebrae. You can perform a puncture either at this point, or on one intervertebral gap above or below.

This is not so, because this vital structure in an adult ends at the level I of the lumbar vertebra, that is, much higher than the puncture level.

Landmarks for puncturing the skin with iodine. Carry out local anesthesia,% solution of novocaine, which is first injected intradermally, and then 3 - 4 cm deep in the course of the future puncture.

The main stage of the algorithm of this procedure is the introduction of a puncture needle closed with a mandrel (a special core). With cautious, but strong movement, the doctor enters the instrument at a predetermined point.

When the needle hits the subarachnoid space, it senses its "failure".

After that, the liquor is collected for analysis (usually take 2 - 3 ml), the needle is removed from the cavity, the puncture site is processed and sealed with an aseptic bandage.

After the procedure, the patient needs rest. It is recommended to comply with bed rest at least 2 - 3 hours. In some cases, the doctor orders to spend a few days in bed. In the first days after puncture, emotional overstrain and weight lifting should be avoided.

Inflammation of the medulla oblongata

Sometimes a lumbar puncture should be abandoned, despite its diagnostic and therapeutic value. Contraindications, like the testimony, are divided into absolute and relative. The absolute (radical) are:

• severe cerebral edema;
• sharply increased pressure inside the cranial cavity;
• volume formation of the brain of large sizes;
• occlusive hydrocephalus.

These pathological situations suggest refusal of a puncture of cerebrospinal membranes, because with a sharp decrease in the volume of CSF and a drop in pressure in the canal of the spinal cord may occur axial wedging - a severe condition, when the medulla oblongata is lowered into the large occipital opening skull.Most often this leads to the death of the patient, because the medulla oblongata is a very delicate structure that can perish from such gross effects. Since in this department of the brain are the oldest centers of vital activity of the organism, it is almost impossible to survive after the wedging.

Other, less dangerous (relative) contraindications to spinal puncture, do with:

1. furunculosis and other purulent skin diseases in the projection of the puncture;
2. disorders of blood clotting and taking drugs that affect it (dezagregantov, anticoagulants);
3. rupture of the aneurysm of the vessel of the brain or spinal cord;
4. blockade of the subarachnoid space of the spinal cord;
5. pregnancy.

The unfavorable consequences of this widespread procedure are developing in 1 to 5 patients out of 1000. The following side effects are possible:

• dislocation of brain structures and axial wedging (acute or chronic);
• the appearance of meningeal symptoms without infectious damage to the meninges (meningism);
• infection of cerebrospinal fluid and cerebral membranes;
• Strong headache ;
• trauma of roots of spinal nerves (back pain);
• bleeding;
• trauma of the spinal disc and the subsequent occurrence of a hernia;
• epidermoid cyst;
• meningeal reaction (change in the composition of the cerebrospinal fluid in response to stimulation of the membranes of the brain or the administration of drugs and subsequent incorrect results of the analysis).

Lumbar puncture is the most important diagnostic procedure of high informativeness. Its appropriateness and possible risks are assessed by the doctor.

The vast majority of patients endure the procedure without complications and any consequences and quickly comes back to normal after spinal puncture.

Most of the adverse reactions occur due to unaccounted contraindications or violation of the regime after the puncture.

A source: http://spina-health.ru/lyumbalnaya-punkciya/