Koks yra juosmens punkcijos procesas?

Position The patient should be in a lateral or sitting position. To obtain accurate opening pressure and reduce the risk of post-puncture headache, the lateral position is preferred. Not all patients can receive a lumbar puncture in any position, so physicians learn to perform the procedure with the patient lying on the left, right, and upright positions. Once the patient's basic position is established, the physician should instruct the patient to adopt a fetal position or to arch the waist "like a cat" to increase the space between the spinous processes. When the patient is in a sitting position, the lumbar spine should be perpendicular to the tabletop, and when the patient is in a lateral position, the lumbar spine should be parallel to the tabletop. Landmarks Draw a line between the superior borders of the iliac crests on both sides, intersecting the midline passing through the L4 spinous process. Insert the needle in the space between L3 and L4 or L4 and L5, as these points are located below the terminal segment of the spinal cord. Physicians should look for landmarks before sterilizing the skin and injecting local anesthetic, as these operations have the potential to obscure the landmarks. Use a skin marker to mark the correct location. Preparation before puncture After the physician puts on sterile gloves, disinfect the skin with an appropriate disinfectant (povidone-iodine or chlorhexidine-containing solution), starting from the center and expanding outward in circles. Then cover with a disinfectant wipe. Pain relief and sedation A lumbar puncture can cause pain and discomfort, and a minimal dose of local anesthetic is appropriate. If time permits, physicians may apply topical anesthetic cream to patients before disinfecting their skin. After the skin is disinfected and covered with a drape, local anesthetics can be injected subcutaneously, and systemic sedatives and pain relievers can also be used. Lumbar puncture After finding out the landmarks again, the physician inserts a puncture needle with a core at the midline position and the upper edge of the next spinous process, with the needle facing the head at about 15 degrees, which seems to be in the direction of the patient's umbilicus. CSF leakage can cause post-puncture headaches, and recent data suggest that the use of "pencil-like" needles may reduce the risk of headaches because they allow the fibers of the dural sac to loosen without severing them. If the more commonly used beveled needles are used, the bevel of the needle should be in the sagittal plane, which also allows the fibers parallel to the spinal axis to spread out without severing them. If the needle is inserted in the correct position, the needle should be passed through the skin, subcutaneous tissue, supraspinous ligament, interspinous ligament between spinous processes, ligamentum flavum, and epidural space (including the internal vertebral venous plexus, dura mater, and arachnoid) in order. , enters the subarachnoid space and is located between the roots of the cauda equina. As the 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 touches the bone, withdraw 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, there is CSF outflow. If there is trauma during the puncture, the CSF may be slightly bloody. When the CSF is collected, the CSF should be clear and bloodless, unless there is subarachnoid hemorrhage. If the flow of CSF is poor, the needle may be rotated 90 degrees because the opening of the needle may be blocked by a nerve root. Opening pressure Open pressure can only be measured on patients in the lateral decubitus position. Connect the manometer to the needle hub of the puncture needle with a flexible tube. This should be done before any samples are collected. When the liquid column no longer rises, read the measured value. It is possible that you will see a pulsation of the fluid level caused by the movement of the heart or breathing. Sample collection CSF should be dripped into the collection tube and should not be aspirated because even a small negative pressure can easily cause bleeding. The volume of fluid collected should be limited to the minimum required, usually 3 to 4 ml. If the patient is undergoing open manometry, the physician should turn the rotary valve toward the patient to allow CSF from the manometer to flow into the collection tube for CSF sample collection. After collecting enough sample, insert the needle core and withdraw the puncture needle.

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