Puncture method of lumbar puncture

Intervertebral puncture is usually performed from lumbar 2 to sac1 (mainly from lumbar 3-4) in the stooped lateral decubitus position. After routine local disinfection and anesthesia, wear rubber gloves and use no. 20 puncture needle (no. 21-22 for children) to penetrate slowly along the direction of the spinous process. When the tip of the needle meets the bone in the process of puncture, the needle should be withdrawn to the subcutaneous Angle to be corrected before puncture. When the adult needle is inserted about 4-6cm (about 3-4cm in children), the dural membrane can be punctured and the subarachnoid space can be reached. The needle core can be extracted and the cerebrospinal fluid can be drained. After pressure measurement and slow drainage (no more than 2-3ml), the needle core can be inserted and the needle can be pulled out. The puncture point was slightly pressurized to stop bleeding, and sterile gauze was applied and fixed with adhesive tape. Postoperative supine 4-6 hours. If the initial pressure exceeds 2.94kpa (300mm water column), it is not suitable to discharge fluid, only take the cerebrospinal fluid in the pressure tube to send cell count and protein quantification.

1. Patients were asked to lie on the side of a hard bed, the back and the bed surface vertical, the head forward chest flexion, hands holding knees close to the abdomen, so that the trunk was a bow; Or by the assistant in the opposite side of the surgeon with one hand hold the patient's head, the other hand hold the popliteal fossa of both lower limbs and hold tightly, so that the spine as far as possible kyphosis to widen the vertebral space, easy to enter the needle.

2. The puncture point is determined at the intersection of the iliac crest line and the posterior midline. Generally, the space between the spinous process of the third to fourth lumbar spine is taken, and sometimes it can also be carried out in the upper or lower lumbar spine space.

3. After routine skin disinfection, sterile gloves and hole patch were worn, and local infiltration anesthesia was performed layer by layer with 2% lidocaine from the skin to the intervertebral ligament.

4. The surgeon uses the left hand to fix the skin at the puncture site, and the right hand holds the puncture needle and slowly penetrates it vertically to the back. The depth of the insertion is about 4-6cm for adults and 2-4cm for children. When the needle passes through the ligament and dura, there is a sudden loss of resistance and a sense of frustration. At this point, the needle core can be pulled out slowly (to prevent cerebrospinal fluid rapidly outflow, causing cerebral hernia), that is, visible cerebrospinal fluid outflow.

5. Connect the pressure tube to measure the pressure before discharge. Normal lateral decubitus cerebrospinal fluid pressure is 0.69-1.764kPa or 40-50 drops /min. If the subarachnoid space is known to be obstructed, the Queckenstedt test may be performed. That is, after the determination of initial pressure, the assistant pressed one jugular vein for about 10s, then the other side, and finally pressed both jugular veins at the same time; When the jugular vein is normally compressed, the cerebrospinal fluid pressure immediately increases rapidly to about double, 10-20s after lifting the compression, and rapidly drops to the original level, which is called negative obstruction test, indicating the subarachnoid space is unobblocked. If cerebrospinal fluid pressure cannot be increased after jugular vein compression, the obstruction test is positive, indicating complete subarachnoid space obstruction. If the pressure rises slowly after pressure is applied and then decreases slowly after relaxation, there is incomplete obstruction. This test should not be performed in patients with increased intracranial pressure.

6. The pressure tube was removed and 2-5ml of cerebrospinal fluid was collected for examination; If culture is required, the specimen should be kept in aseptic operation.

7. After the operation, insert the needle core, pull out the needle together, cover it with sterile gauze, and fix it with adhesive tape.

8. After surgery, patients went to the pillow prone (or supine if difficult) for 4-6h, so as not to cause postoperative headache with low cranial pressure

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