Lumbar puncture is the procedure of inserting a needle into the subarachnoid space of the spinal cord at the lumbar level. It is performed to determine spinal pressure, obtain cerebrospinal fluid to study the composition of the cerebrospinal fluid and for anesthesia. Lumbar puncture in Moscow is performed at the Yusupov Hospital. Neurologists perform spinal taps for both diagnostic and therapeutic purposes. The neurology clinic has all the conditions for treating patients:
- rooms of varying comfort levels are equipped with air conditioning;
- patients are provided with individual personal hygiene products and dietary nutrition;
- Doctors use modern diagnostic equipment from leading companies in the world to examine patients;
- medical staff is attentive to the wishes of patients and their relatives.
The Yusupov Hospital employs candidates and doctors of medical sciences, doctors of the highest category. They are fluent in the technique of performing lumbar puncture. Lumbar puncture is performed for stroke and traumatic brain injury. Lumbar puncture for multiple sclerosis is necessary to obtain cerebrospinal fluid for laboratory testing. The detection of a large number of immunoglobulins (antibodies) in the cerebrospinal fluid, as well as oligoclonal bands (a special arrangement of immunoglobulins during a more specific test) or the determination of proteins - products of myelin breakdown, gives doctors reason to assume a diagnosis of multiple sclerosis. The lumbar puncture protocol is recorded in the medical history.
Indications and contraindications
Lumbar puncture is necessary in the following cases:
- if you suspect infectious diseases of the central nervous system (encephalitis or meningitis);
- in case of suspected subarachnoid or intracerebral hemorrhage, if computed tomography cannot be performed or the study gives negative results;
- patients with high intracranial pressure due to hypertensive hydrocephalus, subarachnoid hemorrhage or benign intracranial hypertension;
- for administering medications into the spinal canal (antibiotics for meningitis).
A lumbar puncture of the spine is performed to exclude or confirm the diagnosis of neuroleukemia.
Contraindications to performing a lumbar puncture are infectious skin diseases at the site of the intended puncture, suspicion of the presence of a brain space-occupying lesion (abscess, tumor, subdural hematoma), especially in the posterior cranial fossa, and a marked decrease in the number of platelets in the blood. Repeated lumbar puncture, if indicated, is performed after 5-7 days. Despite the presence of contraindications, lumbar puncture is performed in cases of papilledema (when purulent meningitis is suspected) and in patients with benign intracranial hypertension.
Preparation for follicle puncture
Usually, before starting treatment, future parents undergo a comprehensive diagnosis, during which conditions that can complicate any of the stages of treatment are excluded. Proper preparation for the program minimizes the risk of problems arising during its implementation. Contraindications to puncture can be determined in advance by general clinical tests, incl. microscopy of a smear from the genital tract, and instrumental studies (ECG, ultrasound, etc.).
Preparation for puncture of follicles during IVF implies strict adherence to the instructions of the reproductologist at the stimulation stage. It is important to take prescribed medications on time, perform injections, and perform folliculometry according to the schedule. A special stage is the stimulation of ovulation. You need to give the injection strictly at the recommended time, as well as come for the puncture.
Recommendations before puncture of follicles during IVF are as follows:
- sexual abstinence for 3-5 days;
- refusal of thermal procedures, hardening and swimming in reservoirs;
- discussion with the doctor about taking any medications outside the treatment regimen (painkillers, dietary supplements, etc.);
- diet against flatulence 2-3 days before the procedure (exclude bread, sweets, milk, legumes, fresh vegetables, fruits and berries);
- cleansing the intestines on the eve of manipulation (using an osmotic laxative or enema);
- hygienic shower and hair removal in the groin before surgery;
- refusal to eat 12 hours before the intervention;
- refusal to drink 4 hours before.
With proper preparation, the procedure is easily tolerated, and the patient recovers quickly.
Algorithm
Neurologists at the Yusupov Hospital perform a lumbar puncture according to the procedure algorithm. The nurse prepares a lumbar puncture kit:
- sterile gloves;
- sterile forceps;
- alcohol (70%) or 0.5% alcohol solution of chlorhexidine for skin treatment;
- adhesive plaster and sterile beads, adhesive plaster;
- 5 syringes with a capacity of 5 ml and needles for them;
- 0.25% or 0.5% solution of novocaine for anesthesia of the puncture site;
- 1-2% trimecaine solution for administration into the subdural and epidural space;
- sterile needles with a mandrel 10-12 cm long (Bier needle for lumbar puncture);
- sterile tubes for collecting cerebrospinal fluid.
The patient is psychologically prepared for lumbar puncture according to the algorithm. Successful spinal puncture largely depends on the correct position of the patient. Immediately before the puncture, the patient is given a fetal position - laid on his side, head tilted as much as possible, legs bent at the hip and knee joints.
At the level of the line that connects the superior posterior iliac spines, the doctor determines the gap between the spinous processes of the third and fourth lumbar vertebrae. Before puncture, the skin is treated with iodine. After this, the iodine is carefully removed with alcohol so that it does not enter the subarachnoid space. The spinal puncture site is surrounded with a sterile drape.
The site of the intended puncture is anesthetized with a 0.5% novocaine solution. A mandrel is inserted into the needle for lumbar puncture, the skin is pierced, and the direction of the needle is specified. As the needle is inserted, the doctor sequentially overcomes the resistance of the ligamentum flavum and dura mater. After puncture of the dura mater, the spinal puncture needle is inserted very slowly. From time to time, the mandrel is removed to check whether cerebrospinal fluid is leaking. When the needle enters the subarachnoid space, a sinking sensation occurs. When cerebrospinal fluid appears, the needle is advanced another 1–2 mm.
The patient is then asked to relax and carefully straighten his legs and head. The doctor removes the mandrin, preventing the cerebrospinal fluid from leaking. A pressure gauge is attached to the needle and the cerebrospinal fluid pressure is measured. It is normally 100–150 mm of water column. The flow of cerebrospinal fluid, if necessary, is increased by coughing, pressing the jugular veins or abdomen, or the jugular veins.
Cerebrospinal fluid is collected in at least 3 sterile tubes:
- firstly, to determine the concentration of glucose and protein;
- in the second - for serological research and determination of the cellular composition of the cerebrospinal fluid;
- in the third - for bacteriological examination of cerebrospinal fluid.
If doctors suspect tuberculous meningitis in a patient, collect cerebrospinal fluid in a fourth tube to identify the fibrin film. After collecting the cerebrospinal fluid, the mandrin is removed and the needle is removed. When a lumbar puncture is performed, the technique used in children has its own peculiarities. In children, the needle is placed perpendicular to the line of the spine, and in adults - slightly at an angle, open in the direction of the horse's tail.
How is the procedure done?
Follicle puncture during IVF is done on an outpatient basis. In most cases, the procedure is performed under general anesthesia, which increases the accuracy of the manipulations and eliminates the occurrence of discomfort. The exception is cases when 1-3 follicles are subject to puncture. In such situations, going into medicated sleep may not be advisable.
You should arrive at the clinic 30-40 minutes before your scheduled time. Before surgery, you will need to fill out forms, change clothes, and empty your bladder. Lateness is highly undesirable, since the time of the procedure is determined taking into account the injection of the ovulation trigger.
Puncture of follicles during IVF takes place within 20-30 minutes. Upon completion, the patient is transferred to the recovery room for observation. If you feel well, after 2-3 hours the woman can go home.
Complications
The most serious consequence of lumbar puncture is herniation. It can develop in patients with a volumetric process of the brain against the background of intracranial hypertension. With a sudden drop in pressure in the spinal canal, the uncus of the hippocampus becomes wedged into the notch of the tentorium of the cerebellum or the cerebellar tonsils into the foramen magnum or. If the cerebrospinal fluid pressure turns out to be high, only a minimal amount of cerebrospinal fluid is removed for examination, mannitol and glucocorticoids are prescribed, and the patient is monitored. If there is a high risk of herniation or deterioration of the patient’s condition during lumbar puncture, the needle with the inserted mandrin is left in place, mannitol and high doses of corticosteroids are administered intravenously, after which the needle is removed. Complete or partial blockade of the subarachnoid space, caused by compression of the spinal cord, can cause herniation of the spinal cord with rapidly increasing focal symptoms.
Headaches after lumbar puncture occur in 10-30% of patients. They are associated with prolonged leakage of cerebrospinal fluid through a hole in the dura mater, which leads to a decrease in intracranial pressure. The pain is most often localized in the occipital and frontal region and occurs in the first three days after the puncture. How many days do you have a headache after a lumbar puncture? The headache usually lasts 2-5 days, but sometimes lasts for several weeks.
Back pain after lumbar puncture is associated with damage to the spinal cord roots. Sometimes there is a transient lesion of the abducens nerve, accompanied by the appearance of paralytic convergent strabismus and double vision. If the needle passes through infected tissue, meningitis may develop. Local complications of lumbar puncture in the form of redness at the puncture site are rare and do not require treatment.
Doctors at the Neurology Clinic will perform a lumbar puncture. Get a consultation with a neurologist by first making an appointment by phone at the Yusupov Hospital.
Stages of follicle puncture
- Preparation. The doctor takes the patient to the operating room and helps her take the correct position in the gynecological chair. The anesthesiologist administers anesthesia drugs. The genitals are treated with an antiseptic solution. The gynecologist prepares the equipment (transvaginal ultrasound probe and needle manipulator).
- Egg retrieval. Puncture of the ovaries during IVF is done through the vaginal wall under ultrasound guidance. The doctor pierces each follicle and evacuates its contents. Follicular fluid is sent into test tubes. The procedure takes about 10 minutes.
- Completing the operation. The genitals are re-treated, after which the intervention is considered completed. The patient is transferred to the postoperative observation room. The resulting material is transferred to the embryology laboratory for processing and subsequent fertilization.
Answers to popular questions
What is done after follicle puncture during IVF?
After 4-6 days, the woman undergoes an embryo implantation procedure. One or two viable blastocysts are transferred into the uterine cavity using a catheter. The effectiveness of IVF is assessed after 2 weeks using laboratory tests. After another 1-2 weeks, an ultrasound is performed to assess the location of the ovum and exclude ectopic pregnancy.
Is it possible to eat on the day of the puncture?
If the procedure is planned to be performed under general anesthesia, you should not eat food. The last meal should take place the night before.
Is it possible to perform a puncture without anesthesia?
The use of anesthesia is advisable, even if follicle puncture occurs during IVF in a natural cycle. In this case, it is necessary to obtain an aspirate from 2-3 follicles. The manipulation takes a few minutes and is accompanied by minor discomfort. The reason for refusing anesthesia may be the patient’s allergy to drugs.
At the SM-Clinic Reproductive Health Center, all types of procedures are performed as part of the IVF program in accordance with advanced protocols. Contact the Center's reproductive specialists to realize your dream of motherhood!
Postoperative period and recovery
After emerging from medicated sleep, a woman may feel dizzy, weak, drowsy and somewhat distracted. These symptoms are considered normal and disappear within an hour and a half.
After puncture of the follicles during IVF, a control ultrasound is performed, after which the patient is discharged. It is better to get home accompanied by a loved one. Symptoms associated with anesthesia disappear within 24 hours. Driving and professional activities can be resumed the next day.
After puncture of the ovaries, a woman may be bothered by a pulling sensation in the lower abdomen and scanty bleeding from the genital tract. All this is normal. In consultation with the doctor, it is possible to use painkillers or antispasmodics. In case of acute pain, bleeding or sudden deterioration of the condition, you should seek medical help.
Recommendations after follicle puncture during IVF are as follows:
- abstinence from sexual intercourse;
- eliminating thermal effects on the body (swimming in a hot bath, visiting a sauna, bathhouse, etc.);
- refusal to swim in ponds and pools;
- exclusion of physical activity.
On the day of the puncture, it is recommended to rest. It is advisable to spend the time after visiting the clinic in a quiet home environment. On the second or third day, you can return to your usual activities.
When is the puncture performed?
Surgical intervention to puncture the follicles is carried out on days 12-22 of the cycle. The determining factor in this case is ultrasound, which monitors the growth of follicles. Ultrasound scans help determine ovulation, which is usually difficult to do. When the follicles reach a diameter of 14-16 mm, the woman is injected with synthetic human chorionic gonadotropin, a hormone necessary for the final maturation of the eggs. The puncture is performed 34-36 hours after the injection. If the ovaries are punctured too early, the likelihood of receiving immature oocytes increases.
A delay of 2-3 hours is fraught with spontaneous ovulation, the release of oocytes into the abdominal cavity.
Before puncture of the ovaries, a control ultrasound scan of the pelvic organs is performed. Its goal is to find out the size, number and location of mature follicles. A puncture is prescribed when three or more follicles with a diameter of about two centimeters are found in the ovary. In general, the number of mature eggs varies between different in vitro fertilization protocols. There is also a dependence on the ovarian reserve.
In patients over 35 years of age, with various ovarian diseases, the number of retrieved oocytes is lower than in young women with tubal factor infertility. Sometimes the number of extracted germ cells does not exceed 5-7, or it is not possible to obtain eggs at all.
Receiving eggs
Rules of conduct after puncture
It is recommended to lie on your stomach for 3 hours after a lumbar puncture. It is also prohibited to lift heavy objects or subject yourself to physical stress. If these rules are followed, the patient will be able to avoid leakage of cerebrospinal fluid from the hole.
If medications are administered into the subarachnoid space, the patient must remain in bed for at least 3 days.
Carefully. If there is an increase in temperature, numbness or fluid discharge from the hole after the puncture, you should visit a doctor.
Basic information
Spinal cord puncture is a therapeutic and diagnostic procedure during which cerebrospinal fluid is extracted from the subarachnoid space through a special needle.
There is an opinion that lumbar puncture is dangerous, since during it the spinal cord can be damaged. To understand that this is not so, you need to delve a little deeper into embryology.
During fetal development, the central nervous system, which consists of the brain and spinal cord, develops from the fetal neural tube. All components of the nervous system (neurons, peripheral nerves, subarachnoid cisterns, cerebrospinal fluid, etc.) have the same origin. Therefore, by the composition of cerebrospinal fluid from the caudal region of the back, the condition of the entire nervous system can be assessed.
The spinal cord ends at the level of the 2nd lumbar vertebra
During fetal development, vertebrae grow faster than nerve tissue. For this reason, the spinal cord ends at the level of the 2nd lumbar vertebra with the conus medullaris. Further, thin threads extend to the junction with the sacrum.
Thanks to this structure, it is safe to puncture the spinal canal in this place. According to doctors, the phrase “spinal cord puncture” is incorrect, since there is no spinal cord at the puncture site, only its membranes and cerebrospinal fluid are located here.
Reference. The volume of cerebrospinal fluid in an adult is approximately 120 ml. It is updated after 5 days.
Not all people understand why they take a spinal cord puncture. Lumbar puncture is done to achieve the following goals:
- Study of biological material in laboratory conditions for glucose, certain cells, proteins and other components.
- Determination of cerebrospinal fluid pressure.
- Removing excess cerebrospinal fluid.
- Introduction of drugs into the nervous system.
Now you know why a cerebrospinal fluid puncture is taken.
Feelings during the procedure
Many patients are interested in the question of whether it is painful to perform a lumbar puncture. If the procedure is performed correctly, the patient does not feel any significant discomfort or pain. He can feel the needle passing through the hard membranes, but there is no painful reaction. Unpleasant symptoms do not appear, since the doctor administers an anesthetic solution before the puncture.
You may feel an electric shock if the needle hits a spinal nerve. Some patients experience headaches during the procedure.