dural pathway

(1) Transsacral hiatus puncture method: the patient is placed in a prone position, the skin is routinely disinfected, and after local anesthesia, a 16-gauge epidural needle is used to penetrate the sacrococcygeal ligament at a 45-degree angle to the trunk, and then slowly penetrate into the sacral canal at a 25-degree angle. Since the subarachnoid space terminates at the second sacral level, the puncture needle should not exceed this plane to ensure that it will not penetrate into the subarachnoid space, pull out the needle core, observe whether there is cerebrospinal fluid leakage, and insert the epidural anesthesia catheter into Exit the needle into the lumbosacral epidural space and then examine the large site to collect. Before the injection of contrast agent, 80-120ml of 0.5% procaine can be injected to observe whether there is spinal anesthesia to rule out dural penetration injury. After confirming that there is no dural damage, the contrast agent can be injected. (2) Translumbar puncture postdural angiography: the patient is placed in a lateral decubitus position with the affected side down and the head slightly elevated. The method was the same as epidural anesthesia, puncture was performed from the lumbar 3 and lumbar 4 spaces. After confirming that the needle tip is located in the epidural space, slowly inject the contrast medium, then remove the puncture needle and take X-rays. (3) Predural angiography via lumbar puncture: the patient is placed in the lateral decubitus position, and a 22-gauge puncture needle is inserted through the interspinous space between the 4th and 5th lumbar spines. When the needle tip breaks through the posterior wall of the arachnoid and enters the subarachnoid space, cerebrospinal fluid flows out, and the puncture continues forward. When the needle tip penetrates the predural space, there is no cerebrospinal fluid outflow. Take the X-ray film to confirm that the needle tip is at the posterior edge of the vertebral body, inject 2ml of 0.5% procaine, if there is no resistance, inject 2ml of contrast agent, then take the X-ray film to confirm that no contrast agent overflows into the subarachnoid space, then inject the contrast agent. The dose is 4ml, the puncture needle is pulled out, and it is completed. Epidural imaging can show the size of the spinal canal, disc herniation beyond the confines of the dural sac. It has a high accuracy for the diagnosis of lumbar disc herniation, but because of the variable amount of fat, loose connective tissue and venous plexus in the epidural space of the spinal canal, the display of the spinal canal contour image is affected. When reading the film, it is necessary to combine the positive and lateral analysis.

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