How to diagnose meningitis in children: necessary studies and tests. Spinal puncture: when performed, procedure, interpretation, consequences

Study cerebrospinal fluid(CSF) is the only reliable method for quickly diagnosing meningitis.

If no inflammatory changes are detected in the cerebrospinal fluid, this completely excludes the diagnosis of meningitis.

The study of CSF makes it possible to differentiate between serous and purulent meningitis, identify the causative agent of the disease, determine the severity of the intoxication syndrome, and monitor the effectiveness of treatment.

CSF in purulent meningitis

According to the etiological structure, purulent bacterial meningitis is heterogeneous. About 90% of all bacteriologically confirmed cases of purulent meningitis are caused by three main agents that are responsible for the etiology of purulent bacterial meningitis: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus.

Pleocytosis is the most important feature of CSF changes in meningitis, which makes it possible to differentiate purulent meningitis from serous meningitis. With purulent meningitis, the number of cells increases and is more than 0.6·10 9 /l. In this case, a CSF examination should be carried out no later than 1 hour after its collection.

A CSF sample with purulent meningitis has a cloudy consistency - from milky to densely green, sometimes xanthochromic. Neutrophils predominate, the number of formed elements varies widely. In some cases, already on the first day of the disease, cytosis is 12..30·10 9 /l.

The severity of the inflammatory process in the membranes of the brain is judged by pleocytosis and its nature. A decrease in the relative number of neutrophils and an increase in the relative number of lymphocytes in the CSF indicates a favorable course of the disease. However, a clear correlation between the severity of pleocytosis and the severity of purulent meningitis may not be observed. There are cases with a typical clinical picture and relatively minor pleocytosis, which is most likely due to a partial blockade of the subarachnoid space.

Protein in purulent meningitis is increased and ranges from 0.6 to 10 g/l; as the cerebrospinal fluid is sanitized, it decreases. As a rule, a high concentration of protein is observed in severe forms of the disease, which occurs with ependymitis syndrome. If high concentration protein is detected during the recovery period, this indicates an intracranial complication. A particularly unfavorable prognostic sign is the combination of low pleocytosis and high protein.

With purulent meningitis, the biochemical parameters of the CSF are significantly changed - glucose is reduced below 3 mmol/l, the ratio of glucose level in the CSF to the blood glucose level in 70% of patients is less than 0.31. A favorable prognostic sign is an increase in glucose content in the CSF.

CSF in tuberculous meningitis

Bacterioscopic examination of CSF in tuberculous meningitis can give negative result. The more thoroughly the studies are carried out, the higher the percentage of detection of tuberculosis bacillus in the cerebrospinal fluid. For the tuberculous form of meningitis, it is typical for a sample of CSF to precipitate within 12..24 hours while standing. The sediment is a delicate fibrin web-like mesh in the form of an overturned Christmas tree, sometimes it can be coarse flakes. In 80% of cases, Mycobacterium tuberculosis is found in the precipitate. Mycobacterium tuberculosis may not be detected in lumbar puncture when present in the cisternal CSF.

In tuberculous meningitis, the CSF is transparent, colorless, pleocytosis varies in a wide range of 0.05..3.0·109/l and depends on the stage of the disease, amounting to 0.1..0.3·109/l by the end of the week. l. If etiotropic treatment is not carried out, the number of cells in the CSF constantly increases throughout the disease. After a repeat lumbar puncture, which is performed one day after the first puncture, a decrease in cells in the CSF may be observed.

In most cases, lymphocytes predominate in pleocytosis, but there are cases when at the onset of the disease pleocytosis is lymphocytic-neutrophilic in nature, which is typical for milliary tuberculosis with seeding of the meninges. An unfavorable prognostic sign is the presence of a large number of monocytes and macrophages in the CSF.

A characteristic feature of tuberculous meningitis is the “variegation” of the cellular composition of the CSF, when, along with big amount Lymphocytes include neutrophils, monocytes, macrophages, and giant lymphocytes.

Protein in tuberculous meningitis is always increased to 2..3 g/l. The protein increases even before the appearance of pleocytosis, and decreases only after its significant decrease.

Biochemical studies In CSF with tuberculous meningitis, a decrease in glucose levels to 0.83..1.67 mmol/l is detected early, and in some patients there is a decrease in the concentration of chlorides in the CSF.

CSF in meningococcal meningitis

Due to the characteristic morphology of meningococci and pneumococci, bacterioscopic examination of CSF is a simple and accurate express method that gives a positive result at the first lumbar puncture 1.5 times more often than culture growth.

Simultaneous bacterioscopic examination of CSF and blood on a microscope gives 90% positive results for meningococcal meningitis, if the patient was examined on the first day of hospitalization. By the third day, the percentage decreases to 60% (in children) and to 0% (in adults).

With meningococcal meningitis, the disease occurs in several stages:

• rises first intracranial pressure;
• then mild neutrophilic cytosis is detected in the cerebrospinal fluid;
• later changes characteristic of purulent meningitis are noted.

Therefore, in approximately every fourth case, the CSF examined in the first hours of the disease does not differ from the norm. In case of inadequate therapy, a purulent appearance of the CSF, high neutrophilic pleocytosis, increased protein(1-16 g/l), the concentration of which in the CSF reflects the severity of the disease. With adequate treatment, neutrophilic pleocytosis decreases and is replaced by lymphocytic.

CSF in serous meningitis

At serous meningitis viral etiology The CSF is transparent, with slight lymphocytic pleocytosis. In some cases, the initial stage of the disease is accompanied by neutrophilic pleocytosis, which indicates a more severe course of the disease and has a less favorable prognosis. The protein content in serous meningitis is within normal limits or moderately increased (0.6..1.6 g/l). In some patients, protein concentration is reduced due to overproduction of cerebrospinal fluid.

ATTENTION! The information provided on this site is for reference only. Only a specialist doctor in a specific field can make a diagnosis and prescribe treatment.

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. Most often, this technique is 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 that trigger its development. Usually there are purulent and aseptic varieties. Purulent appearance meningitis occurs due to the action of bacteria (pneumococci, meningococci and Staphylococcus aureus, as a consequence of 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 by the 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. Functions 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 injection of a special X-ray contrast agent is also added to the lumbar puncture.
• 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:

• 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. At this state A 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 iliac crests. 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 the liquor fluid is taken in order to confirm the correct location 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 midline structures.
• Pain syndrome due to damage to nerve roots.
• Headache.
• Hematomas developing as a result of damage 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 carry out the correct differential diagnosis types of meningitis and begin the right 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:

• Clear-looking liquor.
• The predominance of the percentage of lymphocytes over leukocytes.
• No inoculated bacterial culture.

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 diagnose only based on visual data of the cerebrospinal fluid. correct diagnosis, since without knowing the microbiological test, 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 in cellular composition, as well as the absence of a bacterial culture in the cerebrospinal fluid, which serves as a sign of clinical recovery.

Spinal puncture: indications, contraindications, technique

A spinal puncture is the insertion of a special needle into the subarachnoid space of the spinal cord to remove cerebrospinal fluid for research or for therapeutic purposes. This manipulation has many synonyms: lumbar puncture, lumbar puncture, lumbar puncture, puncture of the subarachnoid space of the spinal cord. In our article we will talk about indications and contraindications for this procedure, the technique of its implementation and possible complications.

Indications for lumbar puncture

As mentioned above, a lumbar puncture can be performed for diagnostic or therapeutic purposes.

As a diagnostic procedure, a puncture is performed if it is necessary to examine the composition of the cerebrospinal fluid, determine the presence of infection in it, measure the cerebrospinal fluid pressure and patency of the subarachnoid space of the spinal cord.

If it is necessary to remove excess cerebrospinal fluid from the spinal canal, introduce antibacterial drugs or chemotherapy into it, a lumbar puncture is also performed, but as a method of treatment.

Indications for this manipulation are divided into absolute (that is, in these conditions, puncture is mandatory) and relative (the doctor decides at his own discretion whether to perform a puncture or not).

Absolute indications for spinal puncture:

• infectious diseases of the central nervous system(encephalitis, meningitis and others);
• malignant neoplasms in the area of ​​the membranes and structures of the brain;
• diagnosis of liquorrhea (leakage of cerebrospinal fluid) by injecting radiopaque substances or dyes into the spinal canal;
• hemorrhage under the arachnoid membrane of the brain.

• multiple sclerosis and other demyelinating diseases;
• polyneuropathy of inflammatory nature;
• septic vascular embolism;
• fever of unknown origin in children early age(up to 2 years);
• systemic lupus erythematosus and some others systemic diseases connective tissue.

Contraindications for lumbar puncture

In some cases, carrying out this therapeutic and diagnostic manipulation can lead to the patient more harm than good, and can even be dangerous for the patient’s life - these are contraindications. The main ones are listed below:

• severe cerebral edema;
• sharply increased intracranial pressure;
• the presence of a space-occupying formation in the brain;
• occlusive hydrocephalus.

These 4 syndromes during a spinal puncture can lead to axial herniation - a life-threatening condition when part of the brain descends into the foramen magnum - the functioning of the vital centers located in it is disrupted, and the patient may die. The likelihood of herniation increases when using a thick needle and removing a large amount of cerebrospinal fluid from the spinal canal.

If puncture is necessary, the minimum possible amount of cerebrospinal fluid should be withdrawn, and if signs of herniation appear, the required amount of fluid from the outside should be urgently injected through the puncture needle.

Other contraindications are:

• pustular rashes in the lumbar region;
• diseases of the blood coagulation system;
• taking blood thinning medications (antiplatelet agents, anticoagulants);
• hemorrhage from a ruptured aneurysm of a vessel in the brain or spinal cord;
• blockade of the subarachnoid space of the spinal cord;
• pregnancy.

These 5 contraindications are relative - in situations where performing a lumbar puncture is vital, it is performed in them as well, simply taking into account the risk of developing certain complications.

Puncture technique

During this manipulation, the patient, as a rule, is in a position lying on his side with his head tilted to his chest and his legs pressed to his stomach, his knees bent. It is in this position that the puncture site becomes as accessible as possible to the doctor. Sometimes the patient is not in a lying position, but sitting on a chair, while he leans forward and puts his hands on the table and his head in his hands. However, this provision has recently been used less and less.

For children, the puncture is performed in the interval between the spinous processes of the 4th and 5th lumbar vertebrae, and for adults a little higher - between the 3rd and 4th lumbar vertebrae. Some patients are afraid to perform a puncture because they believe that the spinal cord may be damaged during the procedure, but this is not the case! The spinal cord of an adult ends at approximately the level of 1-2 lumbar vertebrae. It simply isn't there below.

The skin in the puncture area is treated with solutions of alcohol and iodine alternately, after which an anesthetic drug (novocaine, lidocaine, ultracaine) is injected, first intradermally, until the so-called lemon peel forms, then subcutaneously and deeper, along the puncture.

The puncture (puncture) is performed with a special needle with a mandrel (this is a rod for closing the lumen of the needle) in the plane from front to back, but not perpendicular to the lower back, but at a slight angle - from bottom to top (along the spinous processes of the vertebrae, between them). When the needle deviates from the midline, it usually rests on the bone. When the needle passes through all the structures and enters the spinal canal, the specialist performing the puncture feels a kind of failure; if there is no such sensation, but when the mandrel is removed, cerebrospinal fluid passes through the needle, this is a sign that the goal has been achieved and the needle is in the canal. If the needle is inserted correctly, but the cerebrospinal fluid does not flow out, the doctor asks the patient to cough or lifts the head end to increase the pressure of the cerebrospinal fluid.

When adhesions appear as a result of numerous punctures, it can be very difficult to achieve the appearance of cerebrospinal fluid. In this case, the doctor will try to perform a puncture at a different level, higher or lower than the standard one.

To measure the pressure in the subarachnoid space, a special plastic tube is attached to the needle. U healthy person cerebrospinal fluid pressure ranges from 100 to 200 mm Hg. To obtain accurate data, the doctor will ask the patient to relax as much as possible. The pressure level can be estimated approximately: 60 drops of liquor per minute corresponds to normal pressure. During inflammatory processes in the brain or other conditions that contribute to an increase in the volume of cerebrospinal fluid, the pressure increases.

To assess the permeability of the subarachnoid space, special tests are carried out: Stukey and Queckenstedt. The Queckenstedt test is carried out as follows: determine the initial pressure, then compress for a maximum of 10 seconds jugular veins subject. The pressure during the test increases by 10-20 mm of water column, and 10 seconds after the restoration of blood flow it returns to normal. Stukey's test: press in the navel area with a fist for 10 seconds, as a result of which the pressure also increases.

Blood in the cerebrospinal fluid

There are 2 reasons for blood in the cerebrospinal fluid: hemorrhage under the arachnoid membrane and damage to the vessel during the puncture. To differentiate them from each other, the cerebrospinal fluid is collected in 3 tubes. If the blood admixture is hemorrhage, the liquid will be uniformly colored scarlet. If the cerebrospinal fluid becomes cleaner from the 1st to the 3rd tube, the blood probably resulted from injury to the vessel during puncturing. If the hemorrhage is small, the scarlet discoloration of the cerebrospinal fluid may be barely noticeable or not noticeable at all. In this case, changes will definitely be detected during laboratory testing.

CSF examination

As a rule, cerebrospinal fluid is collected in 3 tubes: for general analysis, biochemical and microbiological examination.

When conducting a general analysis, the laboratory assistant evaluates the density, pH, color, transparency of the liquid, counts cytosis (the number of cells in 1 μl), and determines the protein content. If necessary, other cells are also determined: tumor cells, epidermal cells, arachnoendothelium and others.

The density of the cerebrospinal fluid is normally 1.005-1.008; it increases with inflammation, decreases with excess fluid.

Normal pH value is 7.35-7.8; it increases in the case of paralysis, neurosyphilis, epilepsy; decreases with meningitis and encephalitis.

Healthy cerebrospinal fluid is colorless and transparent. Dark color it indicates jaundice or melanoma metastases, yellow is a sign of an increased level of protein or bilirubin, as well as hemorrhage in the subarachnoid space.

Protein should normally be no more than 0.45 g/l, but with inflammatory processes in the brain, neoplasms, hydrocephalus, neurosyphilis and other diseases, its level increases significantly.

In a biochemical study of cerebrospinal fluid, the level of many indicators is determined, among which the most important are the following:

• glucose (its level is approximately 40-60% of the level in the blood and is equal to 2.2-3.9 mmol/l; decreases with meningitis, increases with strokes);
• lactate (the norm for adults is 1.1-2.4 mmol/l; increases with bacterial meningitis, brain abscesses, hydrocephalus, cerebral ischemia; decreases with viral meningitis);
• chlorides (normally - 118-132 mol/l; increased concentration in case of brain tumors and abscesses, as well as echinococcosis; decreased - in case of meningitis, brucellosis, neurosyphilis).

Microbiological examination is carried out by staining a smear of cerebrospinal fluid according to one of possible methods(depending on the suspected pathogen), inoculating the liquid onto a nutrient medium. In this way, the causative agent of the disease and its sensitivity to antibacterial drugs.

How to behave as a patient after a spinal puncture

To prevent possible leakage of cerebrospinal fluid through the puncture hole, the patient should remain in bed while in bed. horizontal position, within 2-3 hours after puncture. To prevent the development of complications of the operation or to alleviate your condition if they occur, bed rest should be extended to several days. Avoid heavy lifting.

Complications of spinal tap

Complications of this procedure develop in 1-5 patients out of 1000. These are:

• axial herniation (acute - with increased intracranial pressure; chronic - with repeated punctures);
• meningism (the appearance of symptoms of meningitis in the absence of inflammation as such; is the result of irritation of the meninges);
• infectious diseases of the central nervous system due to violation of aseptic rules during puncture;
• severe headaches;
• damage to the spinal cord roots (persistent pain occurs);
• bleeding (if there were blood clotting disorders or the patient was taking blood thinning medications);
• intervertebral hernia resulting from disc damage;
• epidermoid cyst;
• meningeal reaction ( sharp increase cytosis and protein level with glucose levels within normal limits and the absence of microorganisms in the culture, resulting from the introduction of antibiotics, chemotherapy, painkillers and radiocontrast agents into the spinal canal; As a rule, it quickly and completely regresses, but in some cases it becomes the cause of myelitis, radiculitis or arachnoiditis).

So, spinal puncture is the most important, very informative therapeutic and diagnostic procedure, for which there are both indications and contraindications. The feasibility of carrying out it is determined by the doctor, and the possible risks are assessed by him. The overwhelming majority of punctures are well tolerated by patients, but sometimes complications develop, in the event of which the patient should immediately tell the attending physician about them.

Educational program in neurology, lecture on the topic “Lumbar puncture”:

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. In this way, it is possible to establish the viral or bacterial nature of the infection, as well as to designate 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 a large amount of cerebrospinal fluid (CSF) begins to form, the medulla is damaged, and 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 - emergency requiring immediate medical attention.

Factors causing the development of meningitis are divided into aseptic and purulent subtypes. The aseptic type is characterized by the viral nature of infection: 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, a specific study of the spinal cerebrospinal fluid is performed - a 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.

The introduction of a special needle into the subarachnoid space - lumbar puncture - is modern and precise method Diagnosis of 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 (if the patient is overweight).

The target area from which material for analysis is taken is at the level of the 3rd – 4th lumbar vertebrae. To quickly and accurately determine the 4th vertebra, the following method is used: 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;
• diagnosis of oncological processes and metastases 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 method diagnostics 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

1. Pathological processes in the structural elements of the brain.
2. Inflammatory lesions at the site of manipulation.
3. 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.
4. 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 of the brain;
• dislocation of midbrain structures;
• damage 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 intensive treatment assess the patient's health status and the effectiveness of the chosen therapy method. 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.

An acute infectious disease that occurs when microorganisms penetrate the membranes of the brain and develop an inflammatory process in the central nervous system is called meningitis. When a patient with suspected meningitis is admitted to the Yusupov Hospital, doctors conduct a neurological examination and perform a spinal tap. Only the results of a study of cerebrospinal fluid make it possible to establish an accurate diagnosis, identify the causative agent of infection, determine its sensitivity to antibacterial drugs, and select adequate antimicrobial therapy.

A blood test for meningitis reveals acute inflammatory changes. Meningococci (bacteria that cause meningitis) are found in a smear from the mucous membranes of the nasopharynx. In order to clarify the nature of the disease and determine the severity of the pathological process, patients undergo the following tests:

• polymerase chain reaction;
• determination of glucose in blood serum;
• general clinical examination of stool (coprogram);
• determination of creatinine, ALT, AST, total bilirubin, lactate and procalcitonin in blood serum.

If viral meningitis is suspected, immunoglobulins M to viruses are determined herpes simplex types 1 and 2 (HSV-I, II) in blood serum, Ig M to the early antigen of Epstein-Barr virus (HSV-IV) and to cytomegalovirus (HSV-V) in blood serum by immunochemiluminescence.

Patients undergo an electrocardiogram, an electroencephalogram, computed tomography and magnetic resonance imaging. All instrumental studies carried out using the latest equipment from leading global manufacturers.

After the diagnosis is established, complex therapy for meningitis begins according to Russian, European and American recommendations. When drawing up an individual treatment regimen for patients, doctors take into account the serotype of the pathogen, its sensitivity to antibacterial drugs, the severity of the disease, and the severity of symptoms. For bacterial meningitis, antibiotics begin to be administered no later than 60 minutes after the initial examination of the patient.

If the results of laboratory tests do not correspond to the clinical picture of the disease, the patient’s management tactics are discussed at a meeting of the expert council. It includes candidates and doctors medical sciences, doctors of the highest category. They are traveling specialists in the diagnosis and treatment of infectious diseases of the central nervous system.

Cerebrospinal fluid examination for meningitis

The only reliable method quick installation The diagnosis of meningitis is a study of cerebrospinal fluid. By analyzing changes in the cerebrospinal fluid and the results of other studies, doctors make a differential diagnosis for serous and purulent meningitis, identify the causative agent of the disease, determine the severity of the intoxication syndrome, and monitor the effectiveness and treatment.

The first study of cerebrospinal fluid is carried out upon admission of the patient to the neurology clinic. Analysis results can be ready 2 hours after taking cerebrospinal fluid samples. The presence of a large number of neutrophils in the cerebrospinal fluid in most cases indicates the bacterial nature of the disease. After 8-12 hours, the analysis is repeated and checked to see if a lymphocytic shift has appeared. If bacteria are detected in the cerebrospinal fluid samples, the test is repeated several times. The need to perform a lumbar puncture disappears when the clinical signs of the disease reverse, the number of cells, protein and sugar in the cerebrospinal fluid normalizes, and microorganisms disappear from the cerebrospinal fluid.

According to the cause that caused the disease, purulent bacterial meningitis is heterogeneous. In 90% of cases, the disease is caused by Neisseria meningitis, streptococcus pneumoniae and Haemophilus influenzae. The most important feature of changes in cerebrospinal fluid during meningitis is pleocytosis. With purulent meningitis, the number of cells in the cerebrospinal fluid is more than 0.6 × 109/l. In this case, the study of cerebrospinal fluid is carried out no later than 1 hour after its collection.

With purulent meningitis, the cerebrospinal fluid is cloudy, whitish or Green colour. It is dominated by neutrophils. The number of formed elements varies widely. In some cases, already in the first samples of cerebrospinal fluid, cytosis is 12 – 30 × 109/l. The severity of the inflammatory process in the membranes of the brain is judged by the nature of pleocytosis. A decrease in the relative number of neutrophils and an increase in the relative number of lymphocytes in the cerebrospinal fluid indicates a favorable course of the disease. At partial blockade subarachnoid space there may be a typical clinical picture meningitis with relatively little pleocytosis.

With purulent meningitis, the level of protein in the cerebrospinal fluid increases. It varies between 0.6-10 g/l. As the cerebrospinal fluid is freed from microorganisms, it decreases. Higher protein concentrations are observed when severe form meningitis. If a high level of protein is detected during the recovery period, this indicates an intracranial complication. A particularly unfavorable prognostic sign for meningitis is the combination of low pleocytosis and high protein. The amount of glucose in the cerebrospinal fluid during purulent meningitis is below 3 mmol/l. The ratio of cerebrospinal fluid glucose to blood glucose levels in 70% of patients is less than 0.31. A favorable prognostic sign is an increase in glucose content in the cerebrospinal fluid.

In case of tuberculous meningitis, bacterioscopic examination of the cerebrospinal fluid may give a negative result. A characteristic feature tuberculous meningitis is the precipitation of a taken sample of cerebrospinal fluid during standing within 12-24 hours. The sediment is a delicate fibrin cobweb-like mesh in the form of an overturned Christmas tree. Sometimes it can be rough flakes. In most cases, tuberculosis bacilli are found in the sediment.

With tuberculous meningitis, the cerebrospinal fluid is transparent and has no color. Pleocytosis can vary over a wide range - from 0.05. Up to 3.0×109/l. If treatment is not carried out aimed at destroying Mycobacterium tuberculosis, then the number of cells in the cerebrospinal fluid constantly increases throughout the disease. A day after the first lumbar puncture, a second procedure is usually performed. CSF samples obtained during repeat lumbar puncture often show a decrease in cells.

In most cases, lymphocytes predominate in the cerebrospinal fluid during tuberculous meningitis. There are cases when, at the onset of the disease, pleocytosis is lymphocytic-neutrophilic in nature. An unfavorable prognostic sign is the presence of a large number of monocytes and macrophages in the cerebrospinal fluid. The protein concentration in tuberculous meningitis is always increased to 2-3 g/l. Its level increases before the onset of pleocytosis and decreases after a significant decrease. Biochemical studies of cerebrospinal fluid in tuberculous meningitis early reveal a decrease in glucose levels to 0.83-1.67 mmol/l. Some patients experience a decrease in chloride concentrations in the cerebrospinal fluid.

Meningococci and pneumococci have a characteristic structure, due to which they are identified using the express method during bacterioscopic examination of the cerebrospinal fluid, which is obtained during the first lumbar puncture. If the patient is examined within the first day after hospitalization, simultaneous bacterioscopic examination of the blood cerebrospinal fluid under a microscope gives 90% positive results.

With meningococcal meningitis, intracranial pressure first increases, then mild neutrophilic cytosis is detected in the cerebrospinal fluid, then changes characteristic of purulent meningitis are determined. In this regard, in every fourth case, the cerebrospinal fluid examined in the first hours of the disease does not differ from the norm. In case of inadequate therapy, the cerebrospinal fluid may be purulent, there is a high neutrophilic pleocytosis, an increased level of protein, the concentration of which in the cerebrospinal fluid reflects the severity of the disease. With adequate therapy, neutrophilic pleocytosis decreases and is replaced by lymphocytic.

In serous meningitis of a viral nature, the cerebrospinal fluid is transparent, and slight lymphocytic pleocytosis is noted. In some cases in initial stages disease, an increased content of neutrophils is determined in the cerebrospinal fluid. This indicates a more severe course of the disease and has a less favorable prognosis. With serous meningitis, protein levels may be within normal limits or moderately elevated. In some patients, protein concentrations are reduced due to excess cerebrospinal fluid production.

Serodiagnosis of viral meningitis

Unlike bacteria, viruses are very difficult to detect in biological fluids. Often the diagnosis viral infection placed on the basis of the difference in the results of serological studies in acute period illness and recovery. The antibody titer can be determined in the cerebrospinal fluid. This method is used to clarify the nature of the disease. In most viral meningitis, antibodies to the virus are produced in the cerebrospinal fluid, therefore the ratio of specific antibodies in the cerebrospinal fluid and blood serum increases. If the ISCT is greater than or equal to 1.5, this indicates a higher relative content of specific immunoglobulins in the cerebrospinal fluid than in the serum, and thus - on infectious nature meningitis.

Oligoclonal immunoglobulins are detected by agarose gel electrophoresis or isoelectric focusing of cerebrospinal fluid gamma globulins. These immunoglobulins appear in meningitis caused by the human immunodeficiency virus, human T-lymphotropic virus type 1, Varicella Zoster virus, mumps. Identification of oligoclonal immunoglobulins helps doctors make a differential diagnosis of infectious meningitis caused by enteroviruses, arboviruses, and herpes simplex virus, in which they are usually absent.

Other studies for meningitis

In patients with symptoms of meningitis, it is necessary to identify or exclude the enteroviral nature of the disease. For this purpose, laboratory assistants at the Yusupov Hospital perform a polymerase chain reaction. The results of the study are received within a few hours. To determine the pathogen, the semi-nested polymerase chain reaction technique is often used to parallel definition meningococci, Haemophilus influenzae and streptococci.

Methods instrumental diagnostics for meningitis used for neuroimaging and functional assessment state of brain structures and blood flow, timely diagnosis of intracranial complications, sensorineural hearing loss. All patients with suspected meningitis upon admission to the neurology clinic undergo ophthalmoscopy with assessment of the condition of the fundus. Young children with an open large fontanelle undergo neurosonography.

If the blood supply is stable, computed tomography or magnetic resonance imaging is performed. Neuroimaging methods are necessary to carry out differential diagnosis with other diseases of the central nervous system in the presence of focal neurological symptoms. Absence pathological changes in the brain during tomography early stages meningitis does not eliminate the risk of further development. All patients with meningitis in the early stages of the disease undergo recording of short-latency auditory evoked potentials to exclude or early detect sensorineural hearing loss. In order to get tested for meningitis, call the Yusupov Hospital.

Bibliography

• ICD-10 (International Classification of Diseases)
• Yusupov Hospital
• "Diagnostics". - Brief Medical Encyclopedia. - M.: Soviet Encyclopedia, 1989.
• « Clinical assessment laboratory research results”//G. I. Nazarenko, A. A. Kishkun. Moscow, 2005
• Clinical laboratory analytics. Fundamentals of clinical laboratory analysis V.V. Menshikov, 2002.

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*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, defined by the provisions of Art. 437 Civil Code of the Russian Federation. For accurate information, please contact the clinic staff or visit our clinic.

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 causative agent of the 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, and, based on the results, select the most effective treatment regimen. In the first case we're talking about 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.

Lumbar puncture, in the minds of the vast majority of patients, is a 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.

However, taking a sample of cerebrospinal fluid has not only a diagnostic purpose, but also helps to reduce high intracranial pressure, which is the cause of 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 child has a puncture, he 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 the operating table and takes the appropriate 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 location 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 possible sign 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 a feeling of tightness after cerebrospinal fluid was taken from a small patient, the situation requires immediate appeal to the attending physician. 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:

1. In case of suspected neuroinfection. A striking example of such an infection is precisely cerebrospinal meningitis. In some cases, it may also be encephalitis.
2. If there is a suspicion of hemorrhage in the subarachnoid space.
3. If there is a need to confirm or exclude oncological diseases and the presence of metastases in brain tissue.
4. When is it necessary to diagnose liquorrhea?
5. 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:

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

Possible complications

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

Nevertheless, there are cases when even a competently performed 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;
• develops pain syndrome due to damage to nerve roots;
• headaches occur;
• hematomas appear.

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

Patients suffering from cardiac pathologies require special attention. For such patients, a puncture may result in respiratory arrest or cardiac arrest.

Finally, repeating the procedure in the future can 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 of such a complication is very small and is approximately 1%.

After a 2 week course intensive care The patient's health status 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 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. And the existing risks compared to the opportunities provided by the procedure are negligible.

Spinal cord puncture. Such a terrible phrase can often be heard at a doctor’s appointment, and it becomes even scarier when this procedure concerns you specifically. Why do doctors puncture the spinal cord? Is such manipulation dangerous? What information can be obtained from this study?

The first thing you need to understand when it comes to spinal cord puncture (namely, this procedure most often referred to by patients), this does not imply a puncture of the tissue of the central nervous system organ itself, but only the collection of a small amount of cerebrospinal fluid, which washes the spinal cord and brain. Such manipulation in medicine is called a spinal, or lumbar, puncture.

Why is a spinal cord puncture performed? There can be three purposes for such manipulation: diagnostic, analgesic and therapeutic. In most cases, a lumbar puncture of the spine is done to determine the composition of the cerebrospinal fluid and the pressure inside the spinal canal, which indirectly reflects pathological processes occurring in the brain and spinal cord. But specialists can perform a spinal cord puncture for therapeutic purposes, for example, to introduce medicines into the subarachnoid space, for rapid decline spinal pressure. Also, one should not forget about this method of pain relief, such as when anesthetics are injected into the spinal canal. This makes it possible to perform a large number of surgical interventions without the use of general anesthesia.

Considering that in most cases, spinal cord puncture is prescribed specifically for diagnostic purposes, it is this type of study that is discussed we'll talk In this article.

Why is a puncture taken?

A lumbar puncture is taken to examine the cerebrospinal fluid, which can help diagnose some diseases of the brain and spinal cord. Most often, such manipulation is prescribed for suspected:

• infections of the central nervous system (meningitis, encephalitis, myelitis, arachnoiditis) of a viral, bacterial or fungal nature;
• syphilitic, tuberculous lesions of the brain and spinal cord;
• subarachnoid bleeding;
• abscess of the central nervous system;
• ischemic, hemorrhagic stroke;
• traumatic brain injury;
• demyelinating lesions of the nervous system, such as multiple sclerosis;
• benign and malignant tumors brain and spinal cord, their membranes;
• other neurological diseases.

Cerebrospinal fluid examination makes it possible to quickly diagnose serious illnesses brain and spinal cord

Contraindications

It is prohibited to take a lumbar puncture for space-occupying formations of the posterior cranial fossa or temporal lobe of the brain. In such situations, taking even a small amount of cerebrospinal fluid can cause dislocation of brain structures and cause strangulation of the brain stem in the foramen magnum, which entails immediate death.

It is also prohibited to perform a lumbar puncture if the patient has purulent-inflammatory lesions of the skin, soft tissues, or spine at the puncture site.

Relative contraindications are severe spinal deformities (scoliosis, kyphoscoliosis, etc.), since this increases the risk of complications.

With caution, puncture is prescribed to patients with bleeding disorders, those who take drugs that affect blood rheology (anticoagulants, antiplatelet agents, non-steroidal anti-inflammatory drugs).

In case of brain tumors, lumbar puncture can be performed only for health reasons, since there is a high risk of developing dislocation of brain structures

Preparation stage

The lumbar puncture procedure requires preliminary preparation. First of all, the patient is prescribed general clinical and biochemical tests blood and urine, the state of the blood coagulation system is necessarily determined. Carry out inspection and palpation lumbar region spine. To identify possible deformations that may interfere with the puncture.

You need to tell your doctor about all the medications you are currently taking or have recently taken. Special attention should be given to drugs that affect blood clotting (aspirin, warfarin, clopidogrel, heparin and other antiplatelet agents and anticoagulants, non-steroidal anti-inflammatory drugs).

You should also tell your doctor about possible allergies to medications, including anesthetics and contrast agents, about recently transferred acute diseases, about availability chronic illnesses, since some of them may be a contraindication to the study. All women of childbearing age should tell their doctor if they may be pregnant.

Before performing a spinal cord puncture, the patient must consult a doctor.

It is forbidden to eat for 12 hours before the procedure and drink for 4 hours before the puncture.

Puncture technique

The procedure is performed with the patient lying on his side. In this case, you need to bend your legs as much as possible at the knees and hip joints, bring them to the stomach. The head should be bent forward as much as possible and close to chest. It is in this position that the intervertebral spaces expand well and it will be easier for a specialist to get a needle into Right place. In some cases, the puncture is performed with the patient sitting with the back as rounded as possible.

The specialist selects the puncture site by palpating the spine so as not to damage the nerve tissue. ends at the level of the 2nd lumbar vertebra, but in short people, as well as in children (including newborns), it is slightly longer. Therefore, the needle is inserted into the intervertebral space between the 3rd and 4th lumbar vertebrae or between the 4th and 5th. This reduces the risk of complications after puncture.

After skin treatment antiseptic solutions local infiltration anesthesia of soft tissues is performed with a solution of novocaine or lidocaine using a regular syringe with a needle. After this, a lumbar puncture is performed directly with a special large needle with a mandrel.

This is what a spinal puncture needle looks like

The puncture is made at the selected point, the doctor directs the needle sagittally and slightly upward. At approximately a depth of 5 cm, resistance is felt, after which a peculiar dip of the needle follows. This means that the end of the needle has entered the subarachnoid space and you can begin collecting cerebrospinal fluid. To do this, the doctor removes the mandrin (the inner part that makes the instrument airtight) from the needle and cerebrospinal fluid begins to drip from it. If this does not happen, you need to make sure that the puncture is performed correctly and that the needle enters the subarachnoid space.

After collecting the cerebrospinal fluid into a sterile tube, the needle is carefully removed and the puncture site is sealed with a sterile bandage. For 3-4 hours after the puncture, the patient should lie on his back or side.

The puncture is performed between the 3rd and 4th or 4th and 5th lumbar vertebrae

The first step in cerebrospinal fluid analysis is to assess its pressure. Normal indicators in a sitting position – 300 mm. water Art., in a lying position – 100-200 mm. water Art. As a rule, pressure is assessed indirectly - by the number of drops per minute. 60 drops per minute corresponds to the normal value of cerebrospinal fluid pressure in the spinal canal. Pressure increases during inflammatory processes of the central nervous system, with tumor formations, with venous stagnation, hydrocephalus and other diseases.

Next, the cerebrospinal fluid is collected into two 5 ml tubes. They are then used to carry out necessary list research – physicochemical, bacterioscopic, bacteriological, immunological, PCR diagnostics, etc.

Depending on the results of the cerebrospinal fluid study, the doctor can recognize the disease and prescribe appropriate treatment

Consequences and possible complications

In the vast majority of cases, the procedure takes place without any consequences. Naturally, the puncture itself is painful, but pain is present only at the stage of inserting the needle.

Some patients may develop the following complications.

Post-puncture headache

It is generally accepted that after a puncture a certain amount of cerebrospinal fluid flows out of the hole, as a result of which intracranial pressure decreases and a headache occurs. This kind of pain reminds headache tension, has a constant aching or squeezing nature, decreases after rest and sleep. It can be observed for 1 week after the puncture; if cephalgia persists after 7 days, this is a reason to consult a doctor.

Traumatic complications

Sometimes traumatic complications of puncture may occur, when the needle can damage the spinal cord. nerve roots, intervertebral discs. This is manifested by back pain, which does not occur after a correctly performed puncture.

Hemorrhagic complications

If large blood vessels are damaged during the puncture, bleeding and hematoma formation may occur. This is a dangerous complication that requires active medical intervention.

Dislocation complications

Occurs when there is a sharp drop in cerebrospinal fluid pressure. This is possible in the presence of space-occupying formations in the posterior cranial fossa. To avoid such a risk, before taking a puncture, it is necessary to perform a study for signs of dislocation of the midline structures of the brain (EEG, REG).

Infectious complications

They may occur due to violation of the rules of asepsis and antisepsis during puncture. The patient may develop inflammation of the meninges and even form abscesses. Such consequences of puncture are life-threatening and require the prescription of powerful antibacterial therapy.

Thus, spinal cord puncture is a very informative technique for diagnosing a large number of diseases of the brain and spinal cord. Naturally, complications during and after the manipulation are possible, but they are very rare, and the benefits of the puncture far outweigh the risk of developing negative consequences.

Inflammation of the membranes and tissues of the brain - infectious pathology posing a threat to human life and health. Puncture for meningitis allows you to timely diagnose the disease and prescribe adequate treatment. The further course of the inflammatory process and the occurrence of dangerous complications.

Lumbar puncture is an opportunity to penetrate into the subarachnoid space to take samples of cerebrospinal fluid and further examine it for the presence or absence of a viral or infectious agent.

Cerebrospinal fluid is taken from patients in the following cases:

1. Suspicion of neuroinfections: encephalitis, meningitis.
2. The presence of bleeding in the subarachnoid cavity.
3. Exclusion or confirmation of malignant formations, metastases in the membranes " gray matter».
4. Diagnosis of liquorrhea.
5. Detection of cerebrospinal fluid fistulas, in addition to puncture, a contrast agent is administered.
6. Exclusion and prevention of neuroleukemia in patients with oncohematological pathologies.

If there are absolute indications, a puncture is prescribed without fail. As an additional examination, cerebrospinal fluid sampling is carried out in the following conditions:

• processes occurring in conjunction with demyelinating inflammation;
• inflammatory polyneuropathy;
• febrile state of unknown origin.

The puncture allows you to establish the etiology of the disease (viral or bacterial) and draw up a plan for complex therapy. The procedure is prescribed not only for diagnostic purposes, but also to collect a small amount of cerebrospinal fluid to lower VD and eliminate headaches.

Suspicion of meningitis

Contraindications to lumbar puncture

In some situations, the procedure may cause Negative consequences for the patient. The main contraindications to the procedure are considered to be:

1. Severe swelling of the “gray matter”.
2. Sudden increase in pressure.
3. Large neoplasms in the brain cavity.
4. Occlusive hydrocephalus.

Such conditions during the procedure can cause axial herniation, which poses a real threat to the patient. When part of the “gray matter” descends into the occipital large cavity, the performance of key centers is disrupted, and the patient may die.

Other contraindications to cerebrospinal fluid collection for meningitis include:

• ulcers in the lumbar region;
• poor blood plasma clotting;
• bleeding from an aneurysm of a spinal cord or brain vessel;
• use of medications that have a thinning effect on the blood: anticoagulants, antiplatelet agents;
• bearing a child;
• blockade of the subarachnoid cavity spinal substance.

These conditions are relative contraindications - in cases where cerebrospinal fluid was taken from the patient, doctors took into account possible complications and risks. If the procedure is vitally necessary, it is carried out in any situation, but only under the strict supervision of specialists.

One of the contraindications to collecting cerebrospinal fluid for meningitis is ulcers in the lumbar region

Features of lumbar puncture

The procedure is performed in a hospital setting only by experienced medical professionals. For a painless and quick collection of cerebrospinal fluid, the patient needs to relax as much as possible.

The correct posture that the patient should take is:

1. The patient lies on his side.
2. The lower limbs are drawn as close as possible to the chest.
3. The head is lowered down, the chin is pressed tightly to the body.

It is this position that will prevent possible negative consequences after puncture. For heavyweight patients with meningitis, the procedure is performed while sitting.

The puncture is made between the 4th and 3rd vertebrae of the lumbar spinal column. The guideline for finding the injection point is a (visual) line located across the back from the base of one bone to the ridge of the other.

Before performing a puncture, the patient’s skin in the lumbar region is disinfected with an antiseptic, then the patient is given anesthesia. The anesthetic drug is administered intradermally, subcutaneously and during the procedure.

To collect the cerebrospinal fluid, a needle with a mandrel is inserted into the indicated place, then it is carefully and very slowly pushed inward until it feels like it is in an empty space.

Resistance disappears when the tool has passed through hard shells and ligaments. First, a test withdrawal of cerebrospinal fluid is performed, which is necessary to confirm the correct insertion of the needle with the mandrel. If the procedure is done correctly, doctors collect cerebrospinal fluid for further analysis for meningitis.

Results of the study for the presence of the agent

Meningitis happens different types, each of which causes a specific type of pathogen. A disease of viral origin is characterized by specific changes in the composition of the cerebrospinal fluid:

• predominance of lymphocytes over leukocytes;
• absence of pathogenic microorganisms;
• transparent structure of the cerebrospinal fluid.

The bacterial type of infection is accompanied by other changes in the composition of the cerebrospinal fluid. Among the main violations are:

1. A significant number of neutrophils: more than 1 thousand per 1 mm3.
2. Predominance of leukocytes over lymphocytes.
3. Opaque structure of the liquor.
4. Fairly low amount of glucose.
5. Presence of a bacterial epicenter of infection.
6. Positive Gram stain test.

Different types of meningitis are caused by certain types of pathogens

At typical forms meningitis, the number of neutrophils reaches 75-95%. The leukocyte norm for infants is up to 30/mm3. In older children, this indicator should not be higher than 5 leukocytes per mm3.

In healthy children who do not suffer from bacterial or viral meningitis, lymphocytes and monocytes predominate in the cerebrospinal fluid.

The tuberculosis form of the disease has special characteristics:

• the number of lymphocytes reaches 100 per 1 mm3;
• insignificant concentration of glucose;
• bacterial epicenters identified by the shade of the liquid;
• cloudy structure of the liquor.

Ideally, the cerebrospinal fluid should be transparent and yellowish in color and should be collected in small drops into the test tube. Various disorders are the first sign of increased VD; vascular injury during puncture or the presence of blood in the subarachnoid space is indicated by the red color of the cerebrospinal fluid.

Possible consequences after the procedure

Puncture for meningitis can lead to various complications, but only if during the manipulations the rules for collecting cerebrospinal fluid were violated or if the medical personnel had insufficient qualifications and experience.

But sometimes you can encounter situations where even a correctly performed manipulation causes unpleasant consequences. The number of cases is small, but they should not be forgotten:

1. Axial violation: acute - with high internal pressure, chronic - with systematic procedures.
2. Meningism: the formation of symptoms of meningitis in the absence of an inflammatory process, is the result of irritation of the membranes of the “gray matter”.
3. Pathologies of the central nervous system of infectious origin due to neglect of the rules of asepsis when performing manipulation;
4. The most common complication after puncture is severe migraine attacks.
5. Injury to the roots of the spinal substance: constant discomfort appears.
6. Bleeding: in case of plasma coagulation disorders or if the patient has taken medications to thin the blood.
7. A herniation between the vertebrae resulting from a disc injury.
8. Cystic formation of epidermoid nature.
9. Meningeal reaction: sudden increase in cytosis, amount of protein with normal level glucose, absence of pathogenic organisms when painkillers and antibiotics are introduced into the canal.

The most common complication after puncture is severe migraine attacks.

To prevent the possible escape of cerebrospinal fluid through the hole, the patient must adhere to bed rest, remain completely at rest, remaining in a horizontal position, for several hours after the procedure.

To prevent the occurrence of various consequences or alleviate the patient’s condition when they occur, the patient should rest after the procedure for 2-3 days without getting out of bed. Lifting heavy objects is strictly prohibited.

Lumbar puncture is quite informative and important procedure, used to make an accurate diagnosis if meningitis is suspected, as well as to determine the infection that provoked inflammation of the brain. But before manipulation, you need to make sure there are no contraindications.

The expediency of prescribing a puncture is determined by a specialist, as well as possible risks. A large number of Patients tolerate punctures well, but sometimes complications may arise; if unpleasant discomfort occurs, it is necessary to urgently tell the attending doctor about this, who should take action. emergency measures to eliminate them.