Where is the puncture for the patient's cerebrospinal fluid? Why? What structure does the needle go through when it penetrates the terminal cistern from shallow to deep

lumbar puncture

The lumbar puncture kit includes the necessary equipment for lumbar puncture: a lumbar puncture needle with a needle core, skin disinfectant, surgical towel, collection tube and a manometer. The 22-gauge puncture needle is preferred because the small puncture hole reduces the risk of CSF leakage. Generally speaking, babies use 1.5-inch (3.8 cm) needles, children use 2.5-inch (6.3 cm) needles, and adults use 3.5-inch (8.9 cm) needles.

Draw a line between the upper edges of the iliac ridges on both sides and intersect the midline passing through the L4 spinous process. Insert the needle in the gap between L3 and L4 or L4 and L5 because these points are located below the terminal segment of the spinal cord. Physicians should find out the landmarks before disinfecting the skin and injecting local anesthetics, because these operations may obscure the landmarks. Use the skin marker to mark the correct position.

If the needle position is correct, the puncture needle should pass through the skin, subcutaneous tissue, supraspinous ligament, interspinous interspinous ligament, ligamentum flavum, and epidural space (including the internal vertebral venous plexus, dura mater, and arachnoid) , Into the subarachnoid space, and located between the cauda equina nerve roots. When the puncture needle passes through the ligamentum flavum, the physician can feel a sense of breakthrough. At this time, the needle core should be pulled out 2 mm to observe whether there is cerebrospinal fluid outflow. If the puncture is unsuccessful and the bone is touched, retract the puncture needle to the subcutaneous tissue, but do not withdraw from the skin, adjust the direction and insert the needle again. Once the needle enters the subarachnoid space, CSF flows out. If there is trauma during the puncture, the CSF may be slightly bloody. When collecting CSF, CSF should be clear and bloodless, unless there is subarachnoid hemorrhage. If the cerebrospinal fluid does not flow out smoothly, the needle can be rotated 90 degrees because the opening of the needle may be blocked by the nerve root.

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