Meningitis indicator 500, is a repeat puncture necessary? How to take a puncture for meningitis: features of the procedure

Taking a sample of cerebrospinal fluid - cerebrospinal fluid- allows you to accurately identify the nature of the disease (bacterial or viral) and, accordingly, draw up a diagram effective treatment.

The procedure has not only diagnostic utility. By removing a small amount of cerebrospinal fluid, increased intracranial pressure, which causes painful headaches, is reduced.

How is puncture performed for meningitis?

The patient is placed on his side, asked to pull his legs to his chest and lie still. The doctor's assistant monitors the maintenance of the desired posture.

The target area in the lumbar region is disinfected. Then, at its level, a puncture of the spinal canal is made with a special needle. The needle is inserted into the subarachnoid space.

The patient experiences far from the most pleasant sensations, but against the backdrop of the general serious condition they are not perceived as a big shock.

The procedure takes place quickly - within just seven to ten minutes.

In some forms of meningitis, punctures are done not to establish a diagnosis or to reduce pressure, but primarily to directly administer an antibiotic. For example, repeated endolumbar administration of streptomycin is the main therapeutic measure with tuberculous inflammation of the spinal cord membranes.

Is a spinal tap dangerous?

There is a popular opinion that this procedure often makes a person disabled - they say, the doctor can awkwardly touch the nerve endings, and the legs will be paralyzed.

Such statements should not be believed. The puncture is performed in an area that is poorly innervated. A complication such as paralysis is extremely unlikely. In the worst case, complications will include meningeal meningeal symptoms:

A puncture can lead to undesirable consequences unless there are contraindications for its implementation. The latter include: axial displacement of the brain, occlusive hydrocephalus, blood coagulation pathologies.

Multiple punctures (as with the above tuberculous meningitis) can subsequently lead to the development of implantation cholesteatomas of the spinal canal. But this complication is still better than death as a result of progressive inflammation of the spinal cord membranes.

The insertion of a special needle into the subarachnoid space into the spinal cord is a spinal puncture. It is used to diagnose and treat a number of diseases.

Where and how is a spinal cord puncture performed?

Spinal cord puncture for meningitis is carried out only in special laboratories. There the pressure of the cerebrospinal fluid is measured, the patency of the spaces is determined of this body. Using a puncture, you can promptly diagnose the presence of meningitis and other diseases.

For example, to diagnose the nature of the stroke, the intensity of the hemorrhage, identify inflammation in the meninges, etc. Based on the volume of the cerebrospinal fluid, a conclusion is drawn about the state of the fluid in the brain.

Spinal cord puncture for meningitis is used to administer radiopaque and medicinal substances. When performing pneumoencephalography, cisternography, myelography, air is introduced.

The puncture has the following indications:

Spontaneous hemorrhages.
Meningitis.
Meningoencephalitis.
Myelitis.
Arachnomeilitis.
Neurosyphilis.
Liquororrhea.
Uysticercosis.
Echinococcosis.
Traumatic brain injury.

Spinal cord puncture for meningitis

This procedure is used to introduce antibiotics into the spinal cord for purulent meningoencephalitis, meningitis, including tuberculosis.

This method of treatment is done with extreme caution, since when the pressure decreases, the tumor may become pinched in the tectorial or occipital foramen. There are other complications of puncture: headache, vomiting, pain in the lower back. The needle hole may remain open for a long time, leading to hypotension.

Repeated spinal puncture during meningitis can lead to implantation cholestasis in the spine.

The most dangerous complication is considered to be infringement of the brain stem. Such a puncture of the spinal cord most often leads to death; unfortunately, there are quite a few such cases. Only bone marrow puncture is inferior in terms of the number of complications, after which serious diseases can develop, such as anemia, osteomyelitis.

When performing such serious operations, doctors follow all the rules of technique and caution. Only highly qualified doctors perform puncture diagnostics.

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Meningitis is an infectious disease in which the lining of the brain becomes inflamed. This disease can be either primary or secondary. In the first case, the disease develops due to infection.

Spinal cord puncture for meningitis

Meningitis is an acute infectious disease accompanied by overproduction of cerebrospinal fluid - brain fluid, which can cause compression of the brain substance, dilation of the ventricles of the brain, increased intracranial pressure, and is accompanied by specific symptoms.

For diagnostic and therapeutic purposes for meningitis, a lumbar (or spinal) puncture is performed.

How is a spinal cord puncture performed for meningitis?

Its principle is that cerebrospinal fluid and brain fluid communicate with each other, and with the outflow of excess cerebrospinal fluid, its volume in the subarachnoid space and ventricles of the brain decreases, which helps to normalize intracranial pressure and improve the patient’s condition. Also, the cerebrospinal fluid is sent for analysis to determine the causative agent of the disease, its sensitivity to antibiotics, as well as to determine the presence or absence of inflammation and differential diagnosis.

Contraindications to lumbar puncture are brain tumors with increased intracranial pressure, inflammatory and infectious processes in the lumbosacral region, blood clotting disorders, taking anticoagulants and antiplatelet agents.

During the manipulation, the cerebrospinal fluid pressure is measured and the patency of the cerebrospinal fluid tract is examined. Also lumbar puncture for meningitis, it is carried out with the aim of administering antibiotics and other drugs.

Lumbar puncture is performed under sterile conditions, observing the rules of asepsis and antisepsis. The patient lies on his side with his legs bent, and the doctor, standing from the patient’s back, with preliminary local anesthesia, inserts a long needle between the lumbar vertebrae, into the subarachnoid space of the spinal cord, at a level where there is no longer a spinal cord trunk, and the spinal cord roots are free float in the cerebrospinal fluid.

After inserting a needle into the subarachnoid space, excess cerebrospinal fluid is removed. After removing a sufficient amount of cerebrospinal fluid, as determined by the doctor, and carrying out all the necessary manipulations, the needle is removed and the wound is treated with antiseptics and a bandage is applied.

After a lumbar puncture, it is necessary to maintain a horizontal position for 2-3 hours, as there is a danger of cerebrospinal fluid leaking from the puncture hole. If you experience dizziness, loss of consciousness, headache or back pain during and after the puncture, you must immediately inform your doctor.

Spinal cord puncture for meningitis: consequences

Complications of lumbar puncture statistically occur with a frequency of less than 1 percent. This is an axial herniation with loss of consciousness, the phenomenon of meningism or irritation of the meninges, infectious complications, headaches, mainly in the supine position, hemorrhagic complications, epidermoid cysts, damage intervertebral disc with the subsequent formation of a disc herniation, damage to the roots with the subsequent formation of persistent pain.

When choosing a lumbar puncture, the doctor is guided by the ratio of the benefits and necessity of this manipulation and the possibility probable harm for the patient.

Puncture for meningitis

The diagnosis of acute pyogenic meningitis is confirmed by examination of the CSF, in typical cases by the presence of microorganisms (on Gram staining and culture), neutrophilic pleocytosis, increased protein levels and decreased glucose concentrations. If bacterial meningitis is suspected, a lumbar puncture (LP) is necessary.

Contraindications for emergency lumbar puncture (LP) include:

1) signs of increased ICP (except for a bulging fontanel), for example, signs of damage to the third or sixth cranial nerves in combination with a decreased level of consciousness, or hypertension and bradycardia in combination with respiratory disorders;

2) severe cardiopulmonary impairment requiring resuscitation to treat shock or risk of worsening cardiopulmonary impairment in the position required for LA;

3) infectious skin lesion in the area of lumbar puncture (LP). Thrombocytopenia - relative contraindication for LP. If it is delayed, empirical antibiotic therapy is necessary. Treatment should not be delayed until the results of a CT scan (ordered to detect a brain abscess or signs of increased ICP) are available. In these cases, LP can be performed after relief intracranial hypertension and exclusion of brain abscess.

Blood cultures should be performed in all patients with suspected meningitis and can identify the bacteria that cause meningitis in% of cases.

Lumbar puncture for meningitis

Lumbar puncture (LP) is usually performed with the patient lying on his side in a flexed position. A needle with a mandrel is inserted into the intervertebral space at the level LIII-LIV or LIV-LV. Once the needle has entered the subarachnoid space, the degree of dorsal flexion is reduced to measure ICP, although crying baby The measurement result may not be accurate. In case high pressure it is necessary to limit the collection of a small volume of CSF to avoid sharp decline ICP.

The content of leukocytes in the CSF usually exceeds 1000 per 1 μl; in typical cases, neutrophils predominate (75-95%). Turbid CSF indicates that the white blood cell count is greater than/µL. Healthy newborns can normally have up to 30 leukocytes per μl, but in older children who do not suffer from viral or bacterial meningitis, the number of leukocytes in the CSF does not exceed 5/μl. Both children age groups Normally, lymphocytes or monocytes dominate in the cerebrospinal fluid.

In approximately 20% of patients with acute bacterial meningitis, the level of leukocytes in the CSF does not exceed 250 per 1 μl; pleocytosis may be absent in patients with a combination of severe sepsis and meningitis, which serves as an unfavorable prognostic sign. Pleocytosis with a predominance of lymphocytes is possible at the early stage of acute bacterial meningitis conversely, neutrophilic pleocytosis can be detected in the early stages of acute viral meningitis.

A shift towards the lymphocyte-monocyte link inevitably occurs 8-24 hours after the first lumbar puncture (LP). Gram stain gives positive result in the majority (70-90%) of patients with bacterial meningitis.

Traumatic lumbar puncture (LP) complicates the diagnosis of meningitis. With repeated lumbar puncture (LP) in the intervertebral space for more high level The CSF may be less hemorrhagic but usually still contains red blood cells. Traumatic LA may influence the interpretation of CSF leukocyte and protein levels, but Gram stain, culture results, and CSF glucose levels may not change.

Although methods are proposed for correcting the results of CSF analysis in the case of the content of red blood cells in the cerebrospinal fluid, it is more reliable to rely on the results of bacteriological analysis rather than drawing conclusions based on the content of protein and leukocytes in the cerebrospinal fluid obtained from a traumatic LA.

Lumbar puncture as an integral part of the diagnosis of meningitis

Lumbar puncture is a manipulation in which a needle is inserted into the subarachnoid space for diagnostic or therapeutic purposes. More often this technique performed for a disease such as meningitis (inflammation of the meninges). With this disease this manipulation is one of the key stages in diagnosis, as it allows you to confirm or exclude the presence of the diagnosis itself, as well as clarify the pathogen that caused this or that type of meningitis.

The patient in the lying and sitting position during lumbar puncture

When most patients hear the word “lumbar puncture,” they imagine a dangerous and quite painful procedure. However, it must be said that if the personnel performing this procedure have sufficient skills and the patient himself follows the rules of preparing for the puncture and following a gentle regimen after it, then usually the lumbar puncture takes place quite quickly, with less pain. And the consequences of puncture on meningitis with such correct behavior of the patient and medical staff are either absent or minimal.

General information

Meningitis is a fairly serious disease that can lead to subsequent irreversible changes, disability and even death. The basis of this disease is inflammation of the membranes of the brain, as well as the spinal cord. During the inflammatory process, the production of excess cerebrospinal fluid is triggered, with damage to the brain matter, as well as a decrease in blood circulation in the microvascular bed. All this can lead to a serious complication - cerebral edema, which is already an emergency condition and requires intensive measures. In addition, meningitis is accompanied by neurological disorders, which in the future can seriously affect later life person.

If meningitis is suspected, the patient should be hospitalized as soon as possible

Meningitis itself may have various factors, triggering its development. Usually there are purulent and aseptic varieties. The purulent form of meningitis appears due to the action of bacteria (pneumococci, meningococci and Staphylococcus aureus, as a consequence surgical interventions). The aseptic type of meningitis is caused by viruses. Aseptic meningitis can be triggered by the action of herpes viruses, enteroviruses, and choriomeningitis viruses.

Such features require specific treatment, since the therapy for bacterial or viral meningitis is different. But in order to determine the treatment method and the causative agent, a special microbiological study of the cerebrospinal fluid is necessary, which is what a lumbar puncture allows.

The puncture mechanism itself is based on the following principle. Cerebrospinal fluid (or cerebrospinal fluid) is formed in special areas of the brain - the ventricles. It is produced choroid plexuses, which are located at the bottom of the ventricles. After this, the cerebrospinal fluid circulates through the ventricular system and exits into the subarachnoid space of the spinal cord and brain. The functions of cerebrospinal fluid are that it maintains constant levels of intracranial pressure, absorbs head impacts, and also performs various trophic (nutritional) functions for brain tissue. Since the cerebrospinal fluid also washes the membranes, it is a kind of reservoir for bacteria and viruses during meningitis.

Taking cerebrospinal fluid for examination

Therefore, a lumbar puncture, which allows penetration into the subarachnoid space, makes it possible to take samples of cerebrospinal fluid and examine them for the presence of an infectious or viral agent.

Indications for manipulation

Lumbar puncture should be performed in the following situations:

Suspicion of a neuroinfection. A striking example of these diseases is meningitis. It can also be encephalitis,
Suspicion of hemorrhage in the subarachnoid space.
The need to confirm or exclude oncological and metastatic processes in the structures of the brain (meninges).
Diagnosis of conditions such as liquorrhea.
The need to diagnose liquor fistulas. In this case, the introduction of a special x-ray is also added to the lumbar puncture contrast agent.
Prevention and exclusion of neuroleukemia in hematological oncology patients.

These indications are called absolute, that is, those in which a puncture is necessary and is key. There are also relative indications - those in which lumbar puncture is either not a fundamental or an additional method. Usually this is:

Various processes accompanied by demyelinating processes.
Inflammatory polyneuropathy.
Unexplained fever.

Contraindications

There are a number of contraindications to performing a lumbar puncture

However, in addition to the indications for puncture, there are also conditions whose presence requires abandoning this manipulation.

Brain swelling. In this condition, lumbar puncture will lead to changes in intracranial pressure, which, in turn, can lead to herniation of the cerebellum into the foramen magnum and death. This is the most important and first contraindication to lumbar puncture.
Any large-scale processes in the structures of the brain.
Conditions with low blood clotting ability.
Inflammatory conditions at the puncture site.

Methodology

Lumbar puncture is performed as follows. The patient on the operating table is asked to take a characteristic position: lying on his side, his knees should be brought to his chest, and his head should be tilted forward. This position is necessary to widen the intervertebral spaces, which provides the doctor performing the procedure with greater comfort. The puncture can also be performed while sitting (especially in obese patients).

The puncture site itself is located at the level of the 3-4 lumbar vertebrae. A convenient guide for identifying the 4th vertebra is a line that can be visually drawn connecting the ridges iliac bones. The skin at the site of manipulation is treated with some kind of antiseptic, and then local anesthesia is started. For this, an anesthetic is used, which is administered in 3 ways sequentially: intradermal, subcutaneous and during the puncture. A needle with a mandrel is inserted parallel to the spinous processes and carefully moved forward until a feeling of failure is felt, which will mean that the needle has passed through the ligaments and hard shell, after which a test sample of liquor fluid is taken in order to confirm the correct placement of the needle. After that, a clean test tube is inserted into which the liquid is collected.

The appearance and color of the liquid, as well as the nature of its flow into the test tube, are carefully assessed.

If the fluid does not flow in the form of rare drops, but often and quickly, this indicates possible intracranial hypertension. It is also necessary to check for the presence of red coloration of the liquid, which may indicate injury to the vessel during manipulation or hemorrhage into the subarachnoid space.

Consequences

Only a specially trained doctor with the necessary tools can take a puncture correctly.

As mentioned above, if the patient correctly follows all the recommendations prescribed to him and the medical staff is competent, complications after the puncture are minimal. However, there are still some situations that can appear even with competent manipulation. They make up a small percentage in the overall summary of all cases, but you should not forget about them:

Herniation of brain structures or dislocation of midline structures.
Pain syndrome due to damage to nerve roots.
Headaches.
Hematomas that develop as a result of damage to small vessels along the puncture needle.

Also, a separate group of complications are complications of puncture when performed in pregnant women. Such patients, especially in the first trimester, may be at risk for miscarriages in response to puncture.

Patients with heart disease and a spinal puncture require close attention, since when vasovagal reactions are triggered, the consequences can be catastrophic, as breathing or cardiac activity may stop.

Features of cerebrospinal fluid in meningitis

Each meningitis is determined by the type of its pathogen, resulting in changes in the cerebrospinal fluid for each of them.

Therefore, knowing certain visual features of the cerebrospinal fluid and its microbiological characteristics, it is possible to make a correct differential diagnosis of the types of meningitis and begin the correct treatment.

CSF examination confirms the diagnosis of meningitis

The bacterial type of meningitis is characterized by next view cerebrospinal fluid:

Opaque color of the liquor.
The predominance of the percentage of leukocytes over lymphocytes.
The number of neutrophils and segmented cells is over 1000 per 1 cubic millimeter.
Presence of a positive bacterial culture.
Low glucose levels.

Aseptic or viral meningitis is characterized by the following cerebrospinal fluid:

Tuberculous meningitis has certain diagnostic features of the cerebrospinal fluid:

Opalescent, cloudy appearance of cerebrospinal fluid in a test tube.
The number of lymphocytes is over 100 per cubic millimeter.
Low glucose levels.
Bacteria that can be identified by staining.

Microbiological examination of cerebrospinal fluid

Such features of tuberculous meningitis indicate that it is impossible to make a correct diagnosis only based on visual data of the cerebrospinal fluid, since without knowing microbiological research, you can make a diagnostic error.

Confirmation of the diagnosis is always based on a combination of the visual qualities of the cerebrospinal fluid and its microbiological properties.

Treatment control

Approximately by the third week of treatment, it is necessary to assess how meningitis regresses under the influence of drugs. To do this, repeat puncture is used. It is used to analyze changes cellular composition, as well as the absence of a bacterial culture in the cerebrospinal fluid, which is a sign of clinical recovery.

Taking a puncture for meningitis

Meningitis is an acute infectious disease that is accompanied by inflammation of the meninges. Lumbar puncture for suspected meningitis is the main diagnostic method that allows you to reliably determine the presence of infection in the body. The manipulation involves inserting a needle into the subarachnoid space and taking a sample of cerebrospinal fluid. This way it is possible to install a virus or bacterial nature infection, and also indicate treatment tactics.

General information about the disease

Meningitis is a dangerous disease that can cause serious consequences. The pathology is characterized by inflammation of the lining of the brain, in which it begins to form large number cerebrospinal fluid (CSF), is damaged medulla, blood microcirculation in the vascular bed deteriorates.

The consequences of such inflammation are neurological changes that negatively affect the life and health of the patient, as well as cerebral edema - an emergency condition requiring immediate medical attention.

Factors causing development meningitis are divided into aseptic and purulent subtypes. The aseptic type is characterized viral nature infections: enterovirus, herpes and choriomeningitis viruses. The purulent type of infection is caused by the intervention of bacteria: meningococcal, pneumococcal, staphylococcal - or external surgical influence.

For meningitis, depending on the nature of the infection, special treatment is required. To diagnose the causative agent of the disease and determine the method of therapy, specific research spinal cerebrospinal fluid - puncture for meningitis.

Excess cerebrospinal fluid (cerebrospinal fluid) is produced in the cerebral ventricles. At the bottom of these areas of the brain there are plexuses of blood vessels responsible for the production of fluid. The cerebrospinal fluid passes through the ventricles and penetrates the subarachnoid space of the brain and spinal cord. Liquor is necessary to maintain an optimal level of intracranial pressure, provide shock absorption during shock and injury, and nourish brain tissue and cells. Liquor washes the lining of the brain and therefore represents a certain container for the accumulation of viruses and bacterial microorganisms during illness.

Insertion of a special needle into the subarachnoid space - lumbar puncture - is a modern and accurate method for diagnosing the causative agent of infectious meningitis using spinal cord fluid analysis.

Features of the procedure

A puncture for meningitis is carried out as follows. The manipulation is carried out on the operating table, where the patient is positioned lying on his side with his legs pulled up to his chest. The head is tilted forward. The specific position of the body ensures expansion of the intervertebral spaces, which facilitates needle insertion and reduces painful sensations patient. In some cases, the procedure is performed while sitting (with overweight in the patient).

The target area from which material for analysis is taken is at the level of the 3rd - 4th lumbar vertebrae. For quick and precise definition 4th vertebra is used next method: when connecting the iliac crests, a conditional line is drawn, which is located at the level of the desired vertebra.

The procedure is carried out under sterile conditions. The puncture site is treated disinfectant. After which the patient is injected with a drug for local anesthesia. The anesthetic is administered three times: intradermally, subcutaneously and additionally during manipulation.

The needle with the mandrel is inserted parallel to the spinous processes and slowly moved forward until it enters the cavity (feeling of failure). This means that the instrument has passed through the dura and ligaments and entered the subarachnoid space. An initial collection of cerebrospinal fluid is then performed to verify correct needle placement. After this, the material for research is collected into a clean test tube.

When assessing the result of the manipulation, the nature of the flow of cerebrospinal fluid into the test tube, the color and type of brain fluid are taken into account.

Normally, cerebrospinal fluid should flow out in the form of rare drops. With frequent and rapid flow, a significant increase in intracranial pressure is likely. The red tint of the secreted fluid indicates a possible hemorrhage in the subarachnoid space or damage to the vessel during puncture.

The duration of the procedure is about 7 – 10 minutes. In this case, the patient may experience quite unpleasant sensations. At the end of the manipulation, the needle is removed and the insertion site is treated antiseptic and apply a bandage. The patient must remain motionless for 2 to 3 hours after the puncture to eliminate the risk of cerebrospinal fluid leaking out of the hole.

A cerebrospinal fluid puncture can be taken not only to establish an accurate diagnosis and the causes of meningitis infection. The procedure is prescribed to eliminate intracranial hypertension through the direct administration of antibiotics. Also, during the manipulation, the pressure of the cerebrospinal fluid is measured and the patency of the cerebrospinal fluid tract is examined.

Analysis results

Each type of meningitis is characterized a certain type pathogen that will describe changes in the spinal fluid.

Viral meningitis is characterized by certain changes in the cerebrospinal fluid:

the predominance of the concentration of lymphocytes over the content of leukocytes in percentage terms;
absence of bacterial microorganisms in the sown material;
clear color of cerebrospinal fluid.

Bacterial meningitis is accompanied by the following changes in the cerebrospinal fluid:

increase in the number of neutrophils (above 1000 per 1 mm3);
the predominance of the concentration of leukocytes over the number of lymphocytes in percentage terms;
opaque color of cerebrospinal fluid;
low glucose levels;
the presence of a bacterial focus of infection;
positive reaction on Gram stain.

In typical types of the disease, the level of neutrophils reaches 75–95%. The leukocyte norm for newborns is up to 30/mm3. At an older age, the concentration should not exceed 5 leukocytes per 1 mm3. In healthy children who do not suffer from viral or bacterial meningitis, monocytes and lymphocytes predominate in the cerebrospinal fluid.

Tuberculous meningitis is characterized by specific symptoms:

the lymphocyte content reaches 100/mm3;
low glucose;
bacterial foci determined by staining of the cerebrospinal fluid;
cloudy liquid.

Indications and contraindications for the procedure

Lumbar puncture is prescribed in the following cases:

signs of neuroinfection (encephalitis, meningitis and others);
risk of hemorrhage in the subarachnoid space;
clarification of the diagnosis of liquorrhea;
diagnostics oncological processes and metastasis in the lining of the brain;
diagnosis of cerebrospinal fluid fistulas using cerebrospinal fluid puncture and injection of contrast agent;
diagnosis and prevention of neuroleukemia in patients with hematological oncology.

If there are such indications, taking a puncture of the cerebrospinal fluid is the only and key diagnostic method. In some cases, the procedure is used as an additional examination method:

diseases accompanied by destruction of the membrane of neurons of the central nervous system and PNS (demyelinating processes);
inflammatory polyneuropathy;
attacks of fever in the absence of other symptoms.

Contraindications for puncture

Pathological processes in the structural elements of the brain.
Inflammatory lesions at the site of manipulation.
Brain swelling. If you take a puncture in this condition, then a sharp drop in intracranial pressure is possible, which can provoke wedging of the cerebellum into the foramen magnum. This process is fatal.
Blood clotting disorder.

Risks and consequences of a spinal tap

Complications after puncture occur primarily when the rules of manipulation are not followed and doctors make mistakes. In other cases, the following consequences may occur:

wedging of individual structural elements brain;
dislocation of midbrain structures;
damage to nerve endings causing pain in the patient;
headaches, nausea, vomiting;
hematomas at the site of needle insertion when small capillaries are damaged.

When taking cerebrospinal fluid material from pregnant women, the risk of spontaneous abortion increases, especially in the first third. Patients suffering from cardiovascular diseases also represent a risk group during manipulation. In particularly serious cases, the launch of vasovagal processes can provoke cardiac and respiratory arrest.

Contrary to popular belief that puncture can lead to paralysis, this complication is unlikely. The needle is inserted into the part of the spine that is most poorly innervated and the risk of damage to nerve endings is very low. The incidence of complications after puncture in patients does not exceed 1%.

After two weeks of intensive treatment, the patient’s health condition and the effectiveness of the chosen therapy method are assessed. To do this, repeat manipulation is performed with the collection of spinal fluid material for research. Based on the results of the puncture, changes in the cellular composition are analyzed and the presence or absence of a bacterial culture in the contents is determined. Positive dynamics indicate the patient’s clinical recovery.

Meningitis is serious illness, which requires an accurate identification of the causative agent of the infection and the appointment of competent treatment. Cerebrospinal fluid puncture is the only and reliable method for diagnosing the disease.

All materials on the site were prepared by specialists in the field of surgery, anatomy and related disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Spinal puncture is the most important diagnostic method for a number of neurological and infectious diseases, as well as one of the routes for administering drugs and anesthesia. Usage modern methods studies such as CT and MRI have reduced the number of punctures performed, but specialists cannot yet completely abandon it.

Patients sometimes mistakenly call the procedure for collecting cerebrospinal fluid a spinal cord puncture, although the nerve tissue should in no case be damaged or get into the puncture needle. If this happens, then we are talking about a violation of technique and a gross mistake by the surgeon. That's why more correct procedure called puncture of the subarachnoid space of the spinal cord, or spinal puncture.

Liquor, or cerebrospinal fluid, circulates under the meninges and in the ventricular system, providing trophism nerve tissue, support and protection of the brain and spinal cord. With pathology, its quantity can increase, provoking an increase in pressure in the skull; infections are accompanied by changes in cellular composition; in case of hemorrhages, blood is found in it.

A puncture in the lumbar region can be of a purely diagnostic nature, when the doctor prescribes a puncture for confirmation or staging correct diagnosis, and therapeutic, if medications are injected into the subarachnoid space. Increasingly, puncture is used to provide anesthesia for operations on the abdominal and pelvic organs.

Like any invasive intervention, spinal puncture has a clear list of indications and contraindications, without which it is impossible to ensure the patient’s safety during and after the procedure. Such an intervention is not prescribed just like that, but there is also no need to panic prematurely if the doctor considers it necessary.

When is it possible and why not to do a spinal tap?

Indications for spinal puncture are:

Possible infection of the brain and its membranes - syphilis, meningitis, encephalitis, tuberculosis, brucellosis, typhus, etc.;
Diagnosis of intracranial hemorrhages and neoplasms, when other methods (CT, MRI) do not provide the required amount of information;
Determination of liquor pressure;
Coma and other types of disorders of consciousness without signs of dislocation and herniation of stem structures;
The need to administer cytostatics, antibacterial agents directly under the membranes of the brain or spinal cord;
Administration of contrast during radiography;
Removal of excess cerebrospinal fluid and reduction of intracranial pressure in hydrocephalus;
Demyelinating, immunopathological processes in nervous tissue (multiple sclerosis, polyneuroradiculoneuritis), systemic lupus erythematosus;
Unexplained fever, when pathology of other internal organs is excluded;
Conducting spinal anesthesia.

Tumors, neuroinfections, hemorrhages, hydrocephalus can be considered absolute indications to a “spinal cord” puncture, while in case of multiple sclerosis, lupus, unexplained fever, it is not always necessary and can be abandoned.

In case of infectious damage to the brain tissue and its membranes, a spinal puncture is not only important diagnostic value to determine the type of pathogen. It makes it possible to determine the nature of subsequent treatment, the sensitivity of microbes to specific antibiotics, which is important in the process of fighting infection.

When intracranial pressure increases, spinal cord puncture is considered perhaps the only way to remove excess fluid and relieve the patient from many unpleasant symptoms and complications.

Introduction antitumor drugs directly under the membranes of the brain significantly increases their concentration in the focus of neoplastic growth, which makes it possible not only to more active influence on tumor cells, but also applications higher dosage medicines.

Thus, cerebrospinal fluid is taken to determine its cellular composition, the presence of pathogens, blood admixtures, and tumor cells and measuring the pressure of the cerebrospinal fluid in its circulation pathways, and the puncture itself is carried out when administering drugs or anesthetics.

In case of a certain pathology, a puncture can cause significant harm and even cause the death of the patient, therefore, before prescribing it, possible obstacles and risks must be eliminated.

Contraindications to spinal tap include:

Signs or suspicion of dislocation of brain structures due to swelling, neoplasm, hemorrhage - a decrease in cerebrospinal fluid pressure will accelerate the herniation of brain stem sections and can cause the death of the patient directly during the procedure;
Hydrocephalus caused by mechanical obstacles to the movement of cerebrospinal fluid (adhesions after infections, operations, congenital defects);
Bleeding disorders;
Purulent and inflammatory processes of the skin at the puncture site;
Pregnancy (relative contraindication);
Aneurysm rupture with ongoing bleeding.

Preparing for a spinal tap

Features of the conduct and indications for spinal puncture determine the nature preoperative preparation. Just like before any invasive procedure, the patient will have to undergo blood and urine tests, undergo a blood coagulation test, CT scan, and MRI.

It is extremely important to tell your doctor about any medications you are taking, any allergies you have had in the past, concomitant pathology. All anticoagulants and angioplatelet agents are canceled at least a week in advance due to the risk of bleeding, as well as anti-inflammatory drugs.

Women who are scheduled for cerebrospinal fluid puncture and, especially, during X-ray contrast studies, must be sure that there is no pregnancy in order to exclude a negative effect on the fetus.

The patient either comes for the study himself if the puncture is planned in outpatient setting, or he is taken to the treatment room from the department where he is undergoing treatment. In the first case, it is worth thinking in advance about how and with whom you will have to get home, since weakness and dizziness are possible after the manipulation. Before the puncture, experts recommend not eating or drinking for at least 12 hours.

In children, the reason for a spinal puncture can be the same diseases as in adults, but most often these are infections or suspected malignant tumor. Required condition The presence of one of the parents is considered to be present during the operation, especially if the child is small, scared and confused. Mom or dad should try to reassure the baby and tell him that the pain will be quite bearable, and the study is necessary for recovery.

Typically, a spinal puncture does not require general anesthesia; local anesthetics are sufficient to make the patient comfortable. In more rare cases (allergy to novocaine, for example), puncture without anesthesia is allowed, and the patient is warned about possible pain. If there is a risk of cerebral edema and dislocation during a spinal puncture, then it is advisable to administer furosemide half an hour before the procedure.

Spinal puncture technique

To perform cerebrospinal fluid puncture, the subject is placed on a hard table on right side, lower limbs raised to the abdominal wall and clasped by the arms. It is possible to perform the puncture in a sitting position, but at the same time, the back should also be bent as much as possible. In adults, punctures are allowed below the second lumbar vertebra, in children, due to the risk of damage to spinal tissue, no higher than the third.

The technique of spinal puncture does not present any difficulties for a trained and experienced specialist, and its careful adherence helps to avoid serious complications. Puncture of cerebrospinal fluid includes several successive stages:

The specified algorithm of actions is mandatory regardless of the indications and age of the patient. The risk of dangerous complications depends on the accuracy of the doctor’s actions, and in the case spinal anesthesia- degree and duration of pain relief.

The volume of liquid obtained during puncture is up to 120 ml, but 2-3 ml is sufficient for diagnosis, used for further cytological and bacteriological analyses. During the puncture, pain at the puncture site is possible, so especially sensitive patients are advised to undergo pain relief and the administration of sedatives.

During the entire manipulation, it is important to maintain maximum stillness, so adults are held in the desired position a doctor's assistant, and the child is one of the parents, who also helps the baby calm down. In children, anesthesia is mandatory and helps ensure peace of mind for the patient, and gives the doctor the opportunity to act carefully and slowly.

Many patients are afraid of puncture, because they are sure that it hurts. In reality the puncture is quite tolerable, and the pain is felt at the moment the needle penetrates the skin. As soft fabrics“impregnated” with the anesthetic, the pain goes away, a feeling of numbness or bloating appears, and then all negative sensations disappear altogether.

If during the puncture the nerve root, then it is inevitable sharp pain, similar to the one that accompanies radiculitis, however, these cases are attributed more to complications than to normal sensations during a puncture. In the case of a spinal puncture with an increased amount of cerebrospinal fluid and intracranial hypertension, as excess fluid is removed, the patient will notice relief, a gradual disappearance of the feeling of pressure and pain in the head.

Postoperative period and possible complications

After taking the cerebrospinal fluid, the patient is not lifted, but is taken in a supine position to the ward, where he lies on his stomach for at least two hours without a pillow under his head. Babies up to one year old are placed on their backs with a pillow under their buttocks and legs. In some cases, the head end of the bed is lowered, which reduces the risk of dislocation of brain structures.

The first few hours the patient is under careful medical supervision, every quarter of an hour specialists monitor his condition, since the flow of cerebrospinal fluid from the puncture hole can continue for up to 6 hours. When signs of swelling and dislocation appear brain regions there are urgent measures.

After a spinal tap, strict bed rest is required. If the cerebrospinal fluid levels are normal, then after 2-3 days you can get up. In case of abnormal changes in the punctate, the patient remains on bed rest for up to two weeks.

A decrease in fluid volume and a slight decrease in intracranial pressure after a spinal tap can trigger headache attacks that can last about a week. It can be relieved with analgesics, but in any case, if you experience such a symptom, you should talk to your doctor.

Collecting cerebrospinal fluid for research may be associated with certain risks, and if the puncture algorithm is violated, the indications and contraindications are not carefully assessed, or the patient’s general condition is severe, the likelihood of complications increases. The most likely, although rare, complications of a spinal puncture are:

Displacement of the brain due to the outflow of a large volume of cerebrospinal fluid with dislocation and wedging of the brainstem and cerebellum into the occipital foramen of the skull;
Pain in the lower back, legs, sensory disturbances due to spinal cord root injury;
Post-puncture cholesteatoma, when epithelial cells enter the spinal cord canal (using low-quality instruments, lack of a mandrel in the needles);
Hemorrhage due to injury venous plexus, including subarachnoid;
Infection followed by inflammation of the soft membranes of the spinal cord or brain;
When entering the intrathecal space antibacterial drugs or radiopaque agents- symptoms of meningism with severe headache, nausea, vomiting.

Consequences after a properly performed spinal tap are rare. This procedure makes it possible to diagnose and effectively treat, and in case of hydrocephalus it is itself one of the stages in the fight against pathology. Danger during puncture may be associated with a puncture, which can lead to infection, damage to blood vessels and bleeding, as well as dysfunction of the brain or spinal cord. Thus, spinal puncture cannot be considered harmful or dangerous if the indications and risks are correctly assessed and the procedure algorithm is followed.

Evaluation of the result of spinal puncture

Result cytological analysis The cerebrospinal fluid is ready on the day of the study, and if bacteriological culture and assessment of the sensitivity of microbes to antibiotics is necessary, the wait for an answer can last up to a week. This time is necessary for microbial cells to begin to multiply in nutrient media and show their response to specific drugs.

Normal cerebrospinal fluid is colorless, transparent, and does not contain red blood cells. The permissible amount of protein in it is no more than 330 mg per liter, the sugar level is approximately half of that in the patient’s blood. It is possible to find leukocytes in the cerebrospinal fluid, but in adults the norm is considered to be up to 10 cells per µl, in children it is slightly higher depending on age. Density is 1.005-1.008, pH - 7.35-7.8.

An admixture of blood in the cerebrospinal fluid indicates hemorrhage under the membranes of the brain or injury to the vessel during the procedure. To distinguish between these two reasons, the liquid is taken into three containers: in case of hemorrhage, it is colored homogeneously red in all three samples, and in case of damage to the vessel, it becomes lighter from the 1st to the 3rd tube.

The density of cerebrospinal fluid also changes with pathology. Thus, in the case of an inflammatory reaction, it increases due to cellularity and protein component, and with excess fluid (hydrocephalus) it decreases. Paralysis, brain damage from syphilis, and epilepsy are accompanied by an increase in pH, and with meningitis and encephalitis it falls.

The cerebrospinal fluid may darken with jaundice or metastases of melanoma, it turns yellow with an increase in the content of protein and bilirubin, after a previous hemorrhage under the membranes of the brain.

The biochemical composition of the cerebrospinal fluid also indicates pathology. Sugar levels decrease with meningitis and increase with strokes; lactic acid and its derivatives increase in the case of meningococcal lesions, abscesses of brain tissue, ischemic changes, A viral inflammation, on the contrary, leads to a decrease in lactate. Chlorides increase with neoplasms and abscess formation, and decrease with meningitis and syphilis.

According to reviews from patients who have undergone a spinal puncture, the procedure does not cause significant discomfort, especially if it is performed by a highly qualified specialist. Negative consequences are extremely rare, and patients experience the main concern at the stage of preparation for the procedure, while the puncture itself, performed under local anesthesia, is painless. After a month after the diagnostic puncture, the patient can return to his usual lifestyle, unless the result of the study requires otherwise.

Video: spinal tap

As practice shows, puncture for meningitis, when the inflammatory process affects the spinal cord and brain, is prescribed to patients in almost all cases. Identify the pathogen pathological process without resorting to similar procedure, the doctor will only be able to do so when a characteristic rash appears on the patient’s skin.

Spinal cord puncture for meningitis is the only way to absolutely accurately determine the nature of the pathological process, which can be viral or bacterial in nature, and based on the results, choose the most effective scheme therapy. In the first case, we are talking about serous meningitis. If the disease is of a bacterial nature, then they talk about the development of cerebrospinal meningitis, which is more common in children.

In the opinion of the vast majority of patients, lumbar puncture is very dangerous and painful procedure. However, in practice this is not always and not entirely true. Provided that the medical personnel performing such a manipulation are sufficiently qualified, and the patient follows all the recommendations regarding preparation for the procedure, the process itself does not take very much time, and the patient experiences minimal pain. In this way, it is possible to avoid or minimize the consequences of the manipulations performed.

At the same time, taking a sample of cerebrospinal fluid is not only diagnostic purpose, but also helps reduce high intracranial pressure, which causes painful headaches.

As for young patients, with meningitis in children, an accurate diagnosis and timely therapy can save lives. It is also necessary and very important for children to have a puncture.

However, before a child is subjected to such manipulation, he must be carefully examined. This is due to the fact that young patients have much more contraindications than adults, since their body is not yet strong enough and continues to grow. After the puncture is performed, the child must be provided with bed rest for 3 days.

The mechanism of puncture is based on the following principle. Cerebrospinal fluid is formed in special areas of the brain. The choroid plexuses, which are localized at the bottom of the ventricles, are responsible for its production. After this, the fluid begins to circulate through the ventricular system and ends up in the subarachnoid space of the brain and spinal cord. In turn, cerebrospinal fluid is responsible for maintaining a constant level of intracranial pressure, serves as a kind of shock absorber in the event of a head impact, and also nourishes brain tissue. Since this fluid also washes the meninges, it is a reservoir for viruses and bacteria in the event of meningitis.

A spinal tap is performed as follows. The patient lies down on operating table and takes the corresponding position, i.e. lies on his side, bringing his knees to his chest and tilting his head forward. This position is necessary in order to achieve widening of the spaces between the vertebrae, which will create convenience for the doctor who will perform the puncture. The procedure can also be performed in a sitting position, especially when it comes to obese patients.

The skin in the area where the needle will be inserted is treated with an antiseptic, after which it is done local anesthesia. To do this, the anesthetic is administered intradermally, subcutaneously and during the procedure. After this, a puncture is made at the appropriate level of the lumbar vertebrae with a needle, which is inserted until a feeling of failure occurs. Only after this is a test sample of cerebrospinal fluid performed, which is necessary to confirm the adequate placement of the inserted needle. After the test collection, a clean test tube is placed into which the liquid is collected.

Frequent and rapid flow of cerebrospinal fluid is a possible sign of increased intracranial pressure. At the same time, the doctor should pay attention to the red tint of the resulting composition. This may be a sign of a vessel injured during the procedure or hemorrhage into the subarachnoid space.

As for children, if chills or discomfort in the cervical region, as well as feelings of tightness after little patient They took cerebrospinal fluid, the situation requires immediate contact with your doctor. The same should be done by parents of those children who have any discharge or a feeling of numbness in the puncture area on the back.

Existing indications and contraindications for the procedure

Doctors perform a lumbar puncture under the following circumstances:

In case of suspected neuroinfection. A striking example of such an infection is cerebrospinal meningitis. In some cases, it may also be encephalitis.
If there is a suspicion of hemorrhage in the subarachnoid space.
If there is a need to confirm or exclude oncological diseases and the presence of metastases in brain tissue.
When is it necessary to diagnose liquorrhea?
To prevent and exclude neuroleukemia in cancer patients.

The listed indications are considered absolute for carrying out the indicated manipulation. IN medical practice There are also relative indications when lumbar puncture is additional diagnostic method. These include:

unexplained fever;
inflammatory polyneuropathy;
conditions accompanied by demyenilizing processes.

It is impossible to take cerebrospinal fluid in a situation where:

Swelling of the brain developed. The procedure is fraught with death for the patient.
The development of volumetric processes in brain tissues is underway.
The patient has low clotting blood.
An inflammatory process developed in the area of the procedure.

Possible complications

Complications from the manipulation of cerebrospinal fluid sampling to diagnose the patient’s condition with meningitis can only occur in a situation where the rules of the procedure or qualifications were violated medical workers was not high enough.

However, there are cases when even a properly carried out procedure has undesirable consequences. Their share in medical practice is not so high, but you should still not forget about them:

the procedure performed may have a negative impact and lead to wedging of brain structures or changes in the position of central structures;
pain syndrome develops due to damage to the nerve roots;
headaches occur;
hematomas appear.

A separate group includes complications that occur after the procedure in pregnant women. It is worth remembering that manipulation, especially during the first trimester of pregnancy, can result in a miscarriage for the expectant mother.

Patients suffering from cardiac pathologies require special attention. A puncture for such patients may result in cessation of breathing or cardiac muscle function.

And finally, rerun future procedures may lead to the formation of so-called implantation cholesteatomas in the spinal canal. But such a complication is not so terrible in comparison with the death resulting from the development of meningitis.

There is a widespread belief among patients that the manipulation performed can lead to the development of paralysis. However, the probability similar complication very small and amounts to approximately 1%.

After a 2-week course of intensive therapy, the patient’s health condition is assessed, for which a repeat puncture is performed. The results of cerebrospinal fluid studies allow us to judge the patient’s recovery.

Meningitis is a serious and very dangerous disease, to eliminate which it is necessary to accurately determine the catalyst of the infection. And only possible method The study in this case is a lumbar puncture. This is the only way the patient can avoid death and hope for recovery. A existing risks Compared to the possibilities provided by the procedure, they are negligible.

Puncture of cerebrospinal fluid into medical terminology is designated as a lumbar puncture, and the fluid itself is called cerebrospinal fluid. Lumbar puncture is one of the most complex methods that has diagnostic, anesthetic and medicinal purposes. The procedure involves the insertion of a special sterile needle (length up to 6 cm) between the 3rd and 4th vertebrae under arachnoid membrane the spinal cord, and the brain itself is not affected at all, and then extracting a certain dose of cerebrospinal fluid. It is this liquid that allows you to obtain accurate and useful information. IN laboratory conditions it is examined for the content of cells and various microorganisms to identify proteins, various kinds infections, glucose. The doctor also evaluates the transparency of the cerebrospinal fluid.

A lumbar puncture is most often used when a central infection is suspected. nervous system, causing diseases such as meningitis and encephalitis. Multiple sclerosis is very difficult to diagnose, so a lumbar puncture is indispensable. As a result of the puncture, the cerebrospinal fluid is examined for the presence of antibodies. If antibodies are present in the body, the diagnosis is multiple sclerosis practically installed. The puncture is used to differentiate a stroke and identify the nature of its occurrence. The cerebrospinal fluid is collected into 3 test tubes, and later the blood mixture is compared.

With the use of lumbar puncture, diagnosis helps to detect inflammation of the brain, subarachnoid bleeding or detect herniated intervertebral discs by injecting a contrast agent, as well as measure the pressure of the spinal cord fluid. In addition to collecting liquid for research, specialists also pay attention to the flow rate, i.e. if one clear drop appears in one second, the patient has no problems in that area. In medical practice spinal puncture, consequences which can sometimes be very serious, is prescribed in order to remove excess cerebrospinal fluid and thereby reduce intracranial pressure in benign hypertension, and is carried out to administer medications for various diseases, for example, chronic normotensive hydrocephalus.

Contraindications to lumbar puncture

The use of lumbar puncture is contraindicated for injuries, diseases, formations and certain processes in the body:

Edema, space-occupying formations of the brain;
Intracranial hematoma;

Dropsy with extensive education in the temporal or frontal lobe;

Brain stem entrapment;

Bedsores of the lumbosacral area;

Heavy bleeding;

Skin and subcutaneous infections in the lumbar region;

Thrombocytopenia;

Extremely serious condition sick.

In any case, the doctor first conducts a series of tests to ensure that the prescription is urgently needed. spinal puncture. Consequences it, as already noted, can be very, very serious, since the procedure is risky, and it is associated with certain risks.

Spinal cord puncture and its consequences

The first few hours (2-3 hours) after the procedure should not get up under any circumstances, you must lie on a flat surface on your stomach (without a pillow), later you can lie on your side, for 3-5 days you should observe strict bed rest and do not take standing or sitting position to avoid various complications. Some patients experience weakness, nausea, pain in the spine and headache. The doctor may prescribe medications (anti-inflammatory and painkillers) to relieve or reduce symptoms. Complications after lumbar puncture may occur due to incorrect procedure. Here is the list possible complications as a result of incorrect actions:

Injury to varying degrees spinal nerve complications;
Various brain pathologies;

Formation of epidermoid tumors in the spinal canal;

Damage to intervertebral discs;

Increased intracranial pressure in oncology;

Infection.

If the procedure was performed by a qualified professional, all procedures were strictly followed. necessary rules, and the patient follows the doctor’s recommendations, then its consequences are minimized. Contact our medical center, where only experienced doctors work, do not risk your health!

Spinal cord puncture (lumbar puncture) is a type of diagnosis that is quite complex. The procedure removes a small amount of cerebrospinal fluid or injects drugs and other substances into the lumbar spinal canal. In this process, the spinal cord is not directly affected. The risk that arises during puncture contributes to the rare use of the method exclusively in a hospital setting.

Purpose of a spinal tap

Spinal cord puncture is performed for:

Performing a spinal tap

collecting a small amount of cerebrospinal fluid (CSF). Subsequently, their histology is carried out; measuring the pressure of cerebrospinal fluid in the spinal canal; removing excess cerebrospinal fluid; introducing drugs into the spinal canal; facilitating difficult labor in order to prevent pain shock, as well as as anesthesia before surgery; determining the nature of a stroke; isolating tumor markers; performing cisternography and myelography.

Using a spinal tap, the following diseases are diagnosed:

bacterial, fungal and viral infections (meningitis, encephalitis, syphilis, arachnoiditis); subarachnoid bleeding (hemorrhages in the brain); malignant tumors of the brain and spinal cord; inflammatory conditions of the nervous system (Guillain-Barré syndrome, multiple sclerosis); autoimmune and dystrophic processes.

Often a spinal tap is equated with a bone marrow biopsy, but this statement is not entirely correct. During a biopsy, a tissue sample is taken for further research. Access to the bone marrow is achieved through a puncture of the sternum. This method allows you to identify bone marrow pathologies, some blood diseases (anemia, leukocytosis and others), as well as metastases in the bone marrow. In some cases, a biopsy can be performed during the puncture process.

To prevent and treat JOINT DISEASES, our regular reader uses the increasingly popular NON-SURGERY treatment method recommended by leading German and Israeli orthopedists. After carefully reviewing it, we decided to offer it to your attention.

Indications for spinal cord puncture

It is mandatory to perform a spinal cord puncture when infectious diseases, hemorrhages, malignant neoplasms.

Inflammatory polyneuropathy

A puncture is taken in some cases for relative indications:

inflammatory polyneuropathy; fever of unknown pathogenesis; demyelinating diseases (multiple sclerosis); systemic connective tissue diseases.

Preparatory stage

Before the procedure, medical workers explain to the patient why the puncture is being performed, how to behave during the procedure, how to prepare for it, as well as possible risks and complications.

Spinal cord puncture requires the following preparation:

Registration of written consent for the manipulation. Submission of blood tests, which evaluate its coagulability, as well as the functioning of the kidneys and liver. Hydrocephalus and some other diseases require computed tomography and MRI of the brain. Collection of information on the history of the disease, recent and chronic pathological processes.

The specialist must be informed about the medications the patient is taking, especially those that thin the blood (Warfarin, Heparin), relieve pain, or have an anti-inflammatory effect (Aspirin, Ibuprofen). The doctor must be aware of the existing allergic reaction caused by local anesthetics, anesthetic drugs, iodine-containing agents (Novocaine, Lidocaine, iodine, alcohol), as well as contrast agents.

It is necessary to stop taking blood thinning drugs, as well as analgesics and non-steroidal anti-inflammatory drugs in advance.

Before the procedure, water and food are not consumed for 12 hours.

Women must provide information about their suspected pregnancy. This information is necessary due to the expected x-ray examination during the procedure and the use of anesthetics, which may have undesirable effect for the unborn child.

The doctor may prescribe medicinal product, which must be taken before the procedure.

The presence of a person who will be next to the patient is mandatory. A child is allowed to undergo a spinal puncture in the presence of his mother or father.

Technique of the procedure

A spinal cord puncture is performed in a hospital ward or treatment room. Before the procedure, the patient empties bladder and changes into hospital clothes.

Spinal cord puncture

The patient lies on his side, bends his legs and presses them to his stomach. The neck should also be in a bent position, with the chin pressed to the chest. In some cases, spinal cord puncture is performed with the patient sitting. The back should be as motionless as possible.

The skin in the puncture area is cleaned of hair, disinfected and covered with a sterile napkin.

The specialist may use general anesthesia or use a drug local anesthesia. In some cases, a drug with a sedative effect may be used. Also during the procedure, heartbeat, pulse and blood pressure are monitored.

The histological structure of the spinal cord provides for the safest needle insertion between the 3rd and 4th or 4th and 5th lumbar vertebrae. Fluoroscopy allows you to display a video image on a monitor and monitor the manipulation process.

Next, the specialist takes cerebrospinal fluid for further research, removes excess cerebrospinal fluid or injects necessary drug. Liquid is released without outside help and fills the test tube drop by drop. Next, the needle is removed skin covered with a bandage.

CSF samples are sent to laboratory test, where the histology itself takes place.

Spinal cord cerebrospinal fluid

The doctor begins to draw conclusions on the nature of the fluid exit and its appearance. In its normal state, the cerebrospinal fluid is transparent and flows out one drop per second.

At the end of the procedure you must:

compliance with bed rest for 3 to 5 days as recommended by a doctor; keeping the body in horizontal position at least three hours; avoidance of physical activity.

When the puncture site is very painful, you can resort to painkillers.

Risks

Adverse consequences after spinal cord puncture occur in 1–5 cases out of 1000. There is a risk of:

Intervertebral hernia

axial herniation; meningism (symptoms of meningitis occur in the absence of an inflammatory process); infectious diseases of the central nervous system; severe headache, nausea, vomiting, dizziness. The head may hurt for several days; damage to the roots of the spinal cord; bleeding; intervertebral hernia; epidermoid cyst; meningeal reaction.

If the consequences of the puncture are expressed in chills, numbness, fever, a feeling of tightness in the neck, or discharge at the puncture site, you should immediately consult a doctor.

There is an opinion that during a spinal tap the spinal cord can be damaged. It is erroneous, since the spinal cord is located higher than the lumbar spine, where the puncture is directly made.

Contraindications to spinal cord puncture

Spinal cord puncture, like many research methods, has contraindications. Puncture is prohibited in case of sharply increased intracranial pressure, dropsy or cerebral edema, or the presence of various formations in the brain.

It is not recommended to take a puncture if there are pustular rashes in the lumbar region, pregnancy, impaired blood clotting, taking blood-thinning drugs, or ruptured aneurysms of the brain or spinal cord.

In each individual case, the doctor must analyze in detail the risk of the manipulation and its consequences for the life and health of the patient.

It is advisable to contact an experienced doctor who will not only explain in detail why it is necessary to perform a spinal cord puncture, but will also carry out the procedure with minimal risk for the patient's health.

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Meningitis

A.Etiology. Meningitis is a complication of bacteremia. In children over 2 years of age, the causative agents of acute bacterial meningitis are most often Haemophilus influenzae type B (60-65%), meningococci and pneumococci. Less common are streptococci, Staphylococcus aureus, and gram-negative enterobacteriaceae. With the introduction of vaccination against Haemophilus influenzae type B, the incidence of meningitis caused by this organism has decreased sharply.

b.Survey

1) In infants, the first manifestations of meningitis are nonspecific - severe crying, irritability, anorexia, vomiting, drowsiness, bulging fontanelles. Meningeal symptoms are rare and there may be no fever. Particular attention is paid to disturbances of consciousness. One of the first symptoms of meningitis may be seizures, so in combination with fever they serve as an indication for CSF examination.

2) In children over 1 year of age meningeal symptoms with meningitis they are more common. The indication for lumbar puncture is Brudzinski's symptom (when the neck is flexed while lying on the back, involuntary flexion of the legs in the hip joints is observed).

3) Meningitis must be excluded in case of bacteremia.

4) If meningitis is suspected, a lumbar puncture is performed. Plasma glucose is preliminarily determined for comparison with the glucose level in the CSF.

5) Relative contraindication to lumbar puncture is disc swelling optic nerve. Before performing a puncture, a consultation with a neurosurgeon is necessary. This symptom is not typical for acute bacterial meningitis, so other diseases, such as a brain abscess, should be excluded.

6) Conduct tuberculin test, culture of blood, feces, urine, joint fluid, abscess contents, discharge from the middle ear, etc.; bacterioscopy of smears and culture from all foci of infection. The levels of BUN, electrolytes and osmolarity of plasma and urine are determined, and radiography is performed chest. For infants, head circumference is measured.

V.Diagnosis meningitis is diagnosed only on the basis of the results of a lumbar puncture.

1) In bacterial meningitis, the CSF is turbid, its pressure is increased, the number of leukocytes is more than 100 μl -1, neutrophils predominate, the protein level is increased, the glucose level is less than half its level in plasma. Bacterioscopy of a Gram-stained CSF smear reveals the pathogen. All of these signs are not always present, therefore, with any of them, especially if neutrophils predominate in the CSF, meningitis should be suspected. CSF culture is indicated to confirm the diagnosis.

2) Determination of capsular polysaccharide antigens allows you to quickly identify the pathogen in some bacterial meningitis.

G.Treatment. Immediately after taking material for culture, IV antibiotics are prescribed. The choice of antibiotic is determined by the results of bacterioscopy of Gram-stained CSF smears and the age of the child. If gram-negative bacilli are detected, children over 2 months of age are prescribed dexamethasone, as it prevents hearing loss due to meningitis caused by Haemophilus influenzae type B.

1) If in children older than 2 months there is no reason to suspect a rare pathogen, choose any of two treatment regimens: ampicillin (300-400 mg/kg/day IV, the dose is divided and administered every 6 hours) in combination with chloramphenicol (100 mg/kg /day intravenously, the dose is divided and administered every 6 hours); or cefotaxime (150 mg/kg/day IV, divided dose and administered every 8 hours) or ceftriaxone (75-100 mg/kg/day IV, divided dose and administered every 12-24 hours). If the pathogen is Haemophilus influenzae, sensitive in vitro to ampicillin, ampicillin is additionally prescribed. For meningitis caused by Pseudomonas aeruginosa, the drug of choice is ceftazidime. For meningococcal or pneumococcal meningitis, the drug of choice is benzylpenicillin, and third-generation cephalosporins are used as a reserve drug. We prefer the combination of ampicillin and chloramphenicol because it is the most effective and safe.

2) The duration of treatment is determined individually. Standard courses of antibiotic therapy: meningitis caused by Haemophilus influenzae - 7-10 days, meningitis caused by meningococci - 5-7 days, meningitis caused by pneumococci - 10-14 days.

3) Dexamethasone, 0.6 mg/kg/day IV (dose divided and administered every 6 hours), is prescribed during the first 4 days of antimicrobial therapy. The drug is administered simultaneously with the antibiotic or immediately after it.

4) It is necessary to identify in time arterial hypotension, bleeding and ADH hypersecretion syndrome. The latter occurs in the first 72 hours of treatment, and until it is excluded, fluid intake is limited to 3/4 of the minimum water requirement. At the same time, in most cases, patients with meningitis are admitted to the hospital 12-24 hours after the onset of the disease, when they are already developing dehydration. Therefore, before limiting fluid intake, it is necessary to restore BCC. Maintaining normal blood pressure and blood supply to the brain is more important than preventing ADH hypersecretion syndrome.

5) During the treatment period, monitor heart rate, blood pressure, respiratory rate and body temperature. Conducted daily neurological examination and diaphanoscopy (with an open fontanel), measure the head circumference.

6) In severe cases or with unsuccessful therapy, lumbar puncture is repeated every 24-48 hours. An indicator of the effectiveness of treatment is the disappearance of the pathogen from the CSF 24-48 hours after the start of therapy.

7) The persistence of fever is most often due to phlebitis, a reaction to drugs, a hospital infection, concomitant viral infection or subdural effusion. The latter occurs in the acute period of the disease in 50% of children and is often asymptomatic. Prolonged (more than 7 days) or recurrent fever is an indication for lumbar puncture. In this case, it is necessary to exclude foci of infection in the subdural space, bones, joints, pericardium and pleural cavity. In some cases, CT scanning is indicated to confirm subdural effusion.

8) At the end of antimicrobial therapy, we do not repeat the lumbar puncture because recurrence of bacterial meningitis after stopping antibiotics is rare. For uncomplicated meningitis, at the final stage of treatment, you can switch to intramuscular administration (ceftriaxone, 50-75 mg/kg intramuscularly 1 time per day) or oral administration (chloramphenicol in the same doses as for intravenous administration). In the latter case, monitor the level of the drug in the blood.

9) Persons who have close contact at home or in day care with a patient with meningitis caused by Haemophilus influenzae type B or Neisseria meningitidis are indicated for examination and preventive treatment. If the causative agent is Haemophilus influenzae type B, the risk of meningitis for family members under 6 years of age is 0.5%, if the causative agent is Neisseria meningitidis, the risk for all ages is 0.5%.

10) All children with Haemophilus influenzae type B infections are recommended to be treated with rifampicin to eliminate nasopharyngeal carriage. The drug is prescribed at a dose of 20 mg/kg (maximum 600 mg) once a day for 4 days (Red Book, American Academy of Pediatrics, 1991).

J. Gref (ed.) "Pediatrics", Moscow, "Practice", 1997