Lumbar puncture

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Lumbar puncture in a sitting position after skin disinfection
Typical needle for lumbar puncture; the lower needle in the picture fills the cavity of the actual cannula when it is pierced and is then pulled out so that the liquor can run out.
Historical illustration of a lumbar puncture with subsequent administration of antisera, early 20th century.

A lumbar puncture ( Latin lumbus , loin) is a puncture of the dural sac in the area of ​​the lumbar vertebrae . A hollow needle is inserted into the lumbar canal at the level of the loin and nerve fluid ( cerebrospinal fluid ) is removed. The lumbar puncture is the most common form of CSF extraction . The puncture site is between the spinous processes of the second to fifth lumbar vertebrae, i.e. significantly lower than the lower end of the spinal cord .

If a lumbar puncture is not possible - for example in the case of tumors of the spine - nerve fluid can be obtained through a suboccipital puncture (also cistern puncture; puncture of the cerebellomedullary cistern ; puncture between the occipital bone and the first cervical vertebra ) or a ventricular puncture (puncture of the brain ventricle ).

The first lumbar punctures were performed by Heinrich Irenaeus Quincke in Kiel in 1891 and by Walter Essex Wynter in the same year . From 1898, beginning with August Bier , spinal anesthesia with 0.5 percent cocaine solution was carried out via this access route to the spinal canal.

Diagnostic application

If inflammatory and malignant diseases of the meninges or the brain ( meningitis , encephalitis , neurolues , multiple sclerosis , meningiosis carcinomatosa, etc.) or other diseases are suspected, important markers can be determined in this way. Examples are the detection of bacteria, tumor cells, leukocytes (increased with inflammation / infections), glucose (decreased with bacterial infections), lactate , blood or free hemoglobin (after bleeding), detection of disorders of the blood-brain barrier (see Reiber- Scheme ) and oligoclonal immunoglobulins (for example in multiple sclerosis). Depending on the question, the samples are sent to the laboratory, pathology and / or microbiology .

A lot can be read off macroscopically. A normal CSF is clear as water, inflammatory CSF is more or less cloudy, a red or red-tinged CSF can be observed in fresh real (for example subarachnoid hemorrhage ) or artificial (caused by the puncture itself) bleeding, while after older bleeding there may be one yellow discoloration can be seen.

A liquor pressure measurement can also be carried out. For this purpose, a sterile hose system is connected to the puncture cannula and the hydrostatic pressure in cmH 2 O (centimeter water column) is read off using a ruler .

Before the invention of newer imaging diagnostics, especially computed tomography and magnetic resonance tomography , lumbar punctures were also performed for pneumoencephalography , in which air was passed into the liquor space in order to be able to depict brain structures by means of an X-ray examination. This investigation method is obsolete today.

Therapeutic use

Between the brain and the peripheral bloodstream there is a barrier ( blood-brain barrier ) that is not permeable to some drugs in healthy people. Therefore, in rare cases, drugs (for example chemotherapeutic agents ) are administered via the spinal cord fluid. Due to the direction of the CSF flow, these act primarily in the area of ​​the spinal cord.

A CSF puncture can also be used for short-term relief in the case of increased CSF pressure, for example in the case of hydrocephalus malresorptivus after subarachnoid hemorrhage .

Modified application in anesthesia

The spinal anesthesia or spinal anesthesia is a form of regional anesthesia , in which through a puncture of the subarachnoid space a means of a guide cannula spinal needle is introduced and this local anesthetic can be injected. This causes a temporary, reversible function inhibition of selected nerve segments . It leads (in the order mentioned) to sympathicolysis , freedom from pain, insensibility and inhibition of active mobility in parts of the body. As an anesthetic procedure, it can be used for operations on the lower half of the body, such as caesarean sections or hip joint operations, and it replaces anesthesia .

Contraindications and Complications

Do not puncture patients suspected of having increased intracranial pressure . A lumbar puncture is also contraindicated in patients with a blood clotting disorder (for example, due to the use of medication that inhibits blood clotting) . The puncture process itself is usually only slightly painful. Local anesthesia is therefore often not used. The most common undesirable side effect of lumbar puncture is post- puncture headache , which is less common when atraumatic puncture cannulas are used. It occurs in about 3–10% of patients. It is characteristic that it loses weight in a lying position. Prophylactic bed rest is not effective. The post-puncture headache subsides on its own after a few days. Temporary pain over the puncture site and radiating pain in the area of ​​the buttocks and hips are also common. Serious complications such as infection and bleeding are extremely rare. In individual cases, the duration of the post-puncture headache can last up to 3–4 weeks. In addition, nausea and dizziness can be accompanying aftereffects.

literature

Individual evidence

  1. ^ Heinrich Irenaeus Quincke: The lumbar puncture of the hydrocephalus . In: Berlin Medical Weekly . tape 28 , 1891, p. 929-933 .
  2. ^ Walter Essex Wynter: Four cases of rubercular meningitis in which paracentesis was performed for the relief of fluid pressure . In: Lancet . tape 1 , 1891, p. 981-982 .
  3. ^ JM Pearce: Walter Essex Wynter, Quincke, and lumbar puncture . In: Journal of Neurology, Neurosurgery, and Psychiatry . tape 57 , no. 2 , February 1994, ISSN  0022-3050 , pp. 179 , PMID 8126500 , PMC 1072445 (free full text).
  4. ↑ Michael Heck, Michael Fresenius: Repetitorium Anaesthesiologie. Preparation for the anesthesiological specialist examination and the European diploma in anesthesiology. 3rd, completely revised edition. Springer, Berlin / Heidelberg / New York et al. 2001, ISBN 3-540-67331-8 , p. 803.
  5. ^ Eckhard Thiel, Beate Gleissner: Meningeosis neoplastica . In: Deutsches Ärzteblatt . tape 103 , no. 39 , September 29, 2006, pp. A2559 – A2565 / B2216 / C2137 ( online ).
  6. ↑ F. Gerheuser, D. Craß: spinal anesthesia . In: The anesthesiologist . tape 54 , no. December 12 , 2005, ISSN  0003-2417 , p. 1245-1267 , doi : 10.1007 / s00101-005-0947-6 , PMID 16317479 (review).
  7. ^ CSF negative pressure syndrome, postpuncture and spontaneous: Diagnostics and Therapy ( Memento from February 28, 2016 in the Internet Archive ) DGN guideline, last viewed on February 28, 2016.