Extradural puncture needle technique and determination method

Three common puncture methods are judged: disappearance of gas injection resistance, capillary negative pressure, hand feeling (change in resistance), and a combination of three puncture methods: a. Push the needle bar with three fingers of the left hand and the other two fingers touch the patient’s skin to cushion the force, and continue to push the syringe with the right hand to test the pressure. Change; b Connect the capillary tube to see the pressure change; c Push the needle with both hands, feel the resistance change, and test the pressure of the syringe intermittently. The first method to find that the needle enters the epidural space is the first method, but it is also the easiest method for novices to penetrate, because it is easy for a hand to lose control of the strength and the cushioning is not good. The second method often inserts the needle too deep, unless it feels good, and it is still very troublesome to switch between the capillary and the syringe. It is a safe way for chest puncture and novices. The third is the most casual. I like it better. It is the most stable to hold the needle and the most stable to enter the needle, but you need to try the pressure change from time to time, especially when the expected depth is reached. This method requires evaluation of the patient before the puncture, the estimated depth, and also Clearly distinguish whether the needle tip enters the ligamentum flavum, because there can be very low resistance under the skin, under the supraspinous ligament, and next to the interspinous ligament, which brings obstacles to the judgment. It is best to be proficient in the first type, and to play the third type, and you can use the second type when it is time to use it.

(Neck, thoracic and even lower thoracic sections, the indicator for judging whether the puncture needle enters the epidural space is not the "bubble wave method", not "bulging sensation", not "smooth placement of the tube", and "water overflow" is important Indicators. If there is no overflow of water injection and only the above-mentioned characteristics, it can be concluded that almost failed. If there are the above-mentioned characteristics, plus water injection overflow, the effect is almost good. In addition, the above-mentioned puncture site only needs to clearly enter the epidural space. The effect is basically accurate, and the lumbar segment, although it clearly enters the epidural space, the anesthesia effect needs to be combined with other factors.)

4 Epidural puncture angle. Before mentioning the angle, let’s first mention the anatomy of the spine and the evaluation of the skeletal development of the patient’s spine. The former can be learned through atlas, but the latter can only be felt through clinical observation and memory. Observe the patient's spine, not just confined to the puncture site, let alone thinking about piercing, piercing, or piercing. There must be an overall concept. The entire observation of the patient's bone development, ligament development, and multiple spines in the puncture gap Processes, their gaps, the size, width and narrowness of the spinous processes are all important points for assessing the development, size, and gap of the bones. They are very helpful in estimating the three-dimensional position of the spinal canal.

a For puncture in the gap below T10, the included angle of the anamorphic surface is not the main one (mostly vertical), even for the lumbar-epidural joint operation of the non-central approach, the coronal angle is not the main one, the main thing is that it can be correct Through the gap between the two vertebrae closed by the ligamentum flavum (fish mouth). It is not a bad thing to pin the needle on the bone, because you can correct the positioning with the bone quality, and it is more troublesome if you can't distinguish which position the bone is. The most common is to press on the vertebral arch near the upper and lower joints. At this time, the needle is completely retracted and the cross-sectional angle is adjusted. There will be improvement. If the needle is not retracted, it is incorrect to force the direction to change depending on the hardness of the needle. Purpose, the correct puncture route, the significance must be far greater than reducing the damage of the needle track.

b. It is necessary to pay attention to the local anatomical changes of the spine lumbar process, which will change the dislocation angle of the upper and lower 2-3 gaps of L3, and no longer be vertical, especially for patients with short fat, thick bones, and poor waist flexibility.

c Unless the patient's flexion position cannot be coordinated, or the supraspinal and interspinous ligaments are severely calcified, the lateral approach does not have more advantages than the median approach for low puncture. The biggest advantage is that you can familiarize yourself with the lateral approach in a safer position. The basic operation.

d. The needle insertion angle in the middle of the thoracic segment depends to a large extent on the needle feel, because there is no too much gap in itself, and it will go wherever resistance is small. Therefore, it makes more sense to enter laterally, and you need to firmly believe that there is no need to work hard in a gap. I prefer the paraspinous process as a puncture point. The needle can be directed perpendicularly to the midline. The inside should be the vertebral arch, so that you can get the basic The depth of the positioning, and then the needle tail gradually oblique to the tail, you can find the upper gap. Estimating the angle between the spinous process and the vertebral body has a certain meaning, which can prevent the needle body from being too tilted and going to a farther gap.

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