The space around the cord is the epidural space. Back to epidurals and spinals: The main difference is the placement. With an epidural, anesthesia is injected into the epidural space.
With a spinal, the anesthesia is injected into the dural sac that contains cerebrospinal fluid. The direct access means that a spinal gives immediate relief. The following lists give you the other differences. Whereas a spinal gives you pain relief for an hour or two, an epidural offers you the option of pain relief for a longer period of time.
Learn more about the pros and cons of epidurals. There are births where a spinal has advantages over an epidural. If you experience any complications during birth or are having a cesarean delivery, also known as a C-section, your OB may advise you to opt for a spinal.
In these cases, you want immediate relief. In addition, by injecting anesthetics directly into the dural sac that contains cerebrospinal fluid, lower doses of medication can be used. Both epidurals and spinals share the same amount of risk. Your medical team will monitor you closely, as the anesthetics that you receive also affect the central nervous system CNS , cardiovascular system, and respiratory system. Together, you make an informed decision.
Just know that plans can change. You've seen the movies and heard the stories, but you want to know the details. Insert the needle all the way to the hub, aspirate to confirm that the needle is not in a blood vessel, and then inject a small amount as the needle is withdrawn a few centimeters. Continue this process above, below, and to the sides very slightly using the same puncture site. Next, stabilize the or gauge needle with the index fingers, and advance it through the skin wheal using the thumbs.
Orient the bevel parallel to the longitudinal dural fibers to increase the chances that the needle will separate the fibers rather than cut them; in the lateral recumbent position, the bevel should face up, and in the sitting position, it should face to 1 side or the other. An alternative variation of the technique involves removing the stylet once the needle is in the ligament and advancing very slowly without stylet, watching for CSF to flow back.
Using this technique, unintentional entry past the subarachnoid space is avoided. For measurement of the opening pressure, the patient must be in the lateral recumbent position. After fluid is returned from the needle, attach the manometer through the stopcock, and note the height of the fluid column.
Give time for the pressure to stabilize. The needle should be passed slowly towards the dura. There is a particular feel to the passage of the spinal needle through the ligamentum flavum. The appearance of CSF at the hub of the needle always confirms the correct placement of the spinal needle. Although placing a needle into the CSF space of a slim individual is easy, placing a spinal needle in the correct place when faced with obese, pregnant, elderly or uncooperative patients consistently takes skill and considerable experience.
More than anything the success of a lumbar puncture depends on the correct position of the patient. Collect at least a cc of cerebrospinal fluid in each of the 4 plastic tubes, starting with tube 1. If the CSF flow is too slow, changing the needle position might enhance the flow. At the end of collecting the CSF, replace the stylet, and remove the needle.
After applying brief pressure at the puncture site, clean the area, apply a sterile dressing, and place the patient in the supine position. Post procedure varies between hospitals and outpatient clinics.
Lying flat in bed with rest for 1 to 4 hours is generally the rule. However, there is no clear evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of postprocedural headache Peralta and colleagues looked at the utility of a single prophylactic intrathecal morphine to decrease the incidence or severity of postdural puncture headache and did not find any meaningful benefit At times, bedside lumbar puncture could prove difficult for even the most experienced, confident operator.
Under these circumstances one should not shy away from asking another qualified person to do the procedure or consider doing the procedure under fluoroscopy. Paramedic approach to lumbar puncture. Prehospital providers EMTs and paramedics may become involved with this phase of patient management, particularly in a setting when patients present with acute meningitis or encephalitis and have rapidly progressing symptoms.
High index of suspicion for meningitis is warranted, especially when the patient has had a sore neck and altered mental status. Paramedics on scene should collect a detailed history from all concerned and relay this to the ER staff for an early diagnosis.
When indicated, contact precautions and respiratory isolation should be established. Care providers in this scenario should wear masks and gloves, and where indicated patient can wear a surgical mask.
The main aim will be to stabilize the patient regarding airways, breathing, and cardiac function. In the acute phase of care, intravenous access should ideally be established, with fluid therapy to establish euvolemia.
Seizure precautions should be established, and seizures, should they occur, should be managed according to established protocols. At the time of this writing lumbar puncture is a procedure exclusive to physicians, and a paramedic should not perform the procedure, though a paramedic might assist in holding the patient in the proper position.
An informed consent should be obtained after explaining and discussing with the patient all options as well as risks and benefits of the procedure. At this time, a decision should be made on the type of technique to be used, either a single-shot continuous catheter or intermittent bolus technique. Although Crawford needle is appropriate for a 1-shot technique, a Tuohy needle is usually the choice for epidural catheter insertion.
To identify the epidural space, one must choose to use the loss of resistance versus the hanging drop technique. As with lumbar puncture, the success of an epidural injection also depends on the correct position of the patient. Three positions are routinely used for the administration of epidural anesthesia: lateral decubitus, sitting, and prone. Lateral decubitus. The patient is positioned with their back parallel with the side of the operating room table in a fetal position with the thighs flexed up, and the neck is flexed forward.
This position is often used for caudal approach, especially in children, as this allows for the maintenance of a patent airway because the caudal technique is often performed under general anesthesia in pediatric patients. In this position, the provider often has less dependence on an assistant for positioning.
The provider also has the ability to administer more sedation. The patient should place their feet on a stool and sit up straight, head flexed, arms hugging a pillow, or on a table in front of them.
In adults, in the lumbar area, skin to ligamentum flavum depth ranges from 3. The average thickness of the ligamentum flavum is 5 to 6 mm. One must be extra cautious in the dorsal thoracic area to avoid dural puncture and spinal cord injury, as the spinal canal is narrowest here. After a sterile preparation, place a skin wheal at the determined site of insertion using a local anesthetic, followed by anesthetizing the deeper tissues. Anatomical structures transverse before reaching the epidural space include skin, subcutaneous tissue, supraspinous ligament, and interspinous ligament.
Identifying the midline helps immensely to locate the epidural space. The general concept of epidural anesthesia or analgesia is to provide local administration of the anesthetic or analgesic agent into the epidural space. The level of segmental block depends on the distance that the drug diffuses in the rostral or caudal directions as well as volume, concentration, and potency of the drug.
Typically, an gauge needle is used to penetrate through the skin and ligamentum flavum into the epidural space. As the needle is advanced through the ligamentum flavum, resistance to injection of air or saline is continuously or frequently checked. When the tip of the needle is within the ligamentum flavum, air or saline cannot be readily injected. Immediately past the ligamentum flavum, there is a loss of resistance, and air or saline can be injected; this indicates that the needle tip has entered the epidural space.
Loss of resistance technique. Once the needle is placed into the ligamentum flavum, remove the stylet. Attach a glass syringe with 2 to 3 ml of preservative-free normal saline and a small 0. The needle is held steady by the non-dominant hand, and the dominant hand holds the syringe. Steady pressure is applied to the plunger to compress the air bubble. Slowly and steadily advance the needle until loss of resistance is noted and the air bubble and saline get sucked in.
Hanging drop technique. Place the needle into the ligamentum flavum. Next, apply a drop of preservative-free normal saline to the hub of the needle. Apply slow, steady pressure to the needle until the hanging drop gets sucked in as the epidural space contains subatmospheric pressure.
In addition to localization of the needle tip within the epidural space, injection of air or saline pushes the dura away from the needle tip, thus, reducing the risk of puncturing or entering the subarachnoid space. A flexible catheter is then inserted through the needle bore and passed approximately 2 to 3 cm into the epidural space.
To prevent migration of the catheter out of the epidural space during labor and delivery in obstetric patients, the catheter can be inserted 4 to 5 cm. The needle is withdrawn, and the catheter immobilized so that multiple injections of medications into the epidural space can be performed Aspiration of the catheter for CSF is attempted to determine if the catheter tip is within the subarachnoid space.
Test doses small volumes of an anesthetic and epinephrine are routinely injected to determine if the catheter tip is in the subarachnoid space leading to unexpected spinal block or intravenous vessel causing tachycardia from the epinephrine.
A test dose consists of 3 ml of 1. Aspiration of the catheter for CSF and the injection of test doses should be performed before each injection of medication to ensure that the catheter tip has not migrated through the dura into the subarachnoid space. Mahajan and coworkers recommend that the catheter should be inserted 1 to 2 hours preoperatively in an awake patient This provides ample time to place the catheter and accurately assess the level of sensory analgesia with local anesthetic drug before surgery begins.
Accurate positioning of the catheter is only confirmed by bilateral sensory block. Anything other than an effective bilateral block suggests that the catheter may not be correctly positioned, with pleural puncture as one of the possibilities Among the various methods epidural anesthesia providers use to identify the epidural space, some use air, some use fluid, and others use a combination of air and fluid during the loss of resistance technique.
It has long been speculated that loss of resistance to air results in a lesser quality of analgesia compared with loss of resistance to only fluid. In a study that also included a systematic review with meta-analysis of 4 older studies, Sanford and colleagues found inconclusive evidence in determining whether a difference in analgesia quality results from the use of air or fluid during the loss of resistance technique Instrumentation for epidural injection has included a novel spring-loaded syringe, which is a potentially useful loss of resistance syringe that provides a reliable, objective endpoint for identification of the epidural space.
It is an optimal pressure, loss of resistance device for identifying the epidural space. In addition to offering good Tuohy needle control, Epidrum also helps in performing epidural anesthesia quickly compared to the loss of resistance or hanging drop technique. Vital signs, pulse oximetry, level of consciousness, block progression, and signs and symptoms of toxicity should be monitored continuously.
Numbness of the arms and hands, problems with breathing, and altered level of consciousness might suggest block progression. Postoperative care should include assessment of block regression, followed by full return of baseline motor and sensory functions. In the likely event of hypotension, patient should be treated with a Trendelenburg position, additional intravenous fluids, oxygen, and vasopressors as needed. If urinary retention occurs, it should be dealt with appropriately.
Lumbar puncture is indicated in the diagnosis of bacterial, fungal, mycobacterial, and viral CNS infections as follows and, in certain settings, for help in the diagnosis of subarachnoid hemorrhage, with a normal CT scan of the brain. Lumbar puncture is also needed as a therapeutic or diagnostic maneuver in the following situations 35 ; 11 ; 22 :.
Lumbar epidural anesthesia or analgesia. Lumbar epidural anesthesia or analgesia is indicated for regional anesthesia of the lumbosacral segments during obstetric, gynecologic, urologic, orthopedic, and general surgical procedures and for postoperative pain control.
It is often performed in conjunction with general anesthesia to permit lighter, general anesthesia followed by postoperative analgesia. Lumbar epidural analgesia has also been used in patients with severe pain in the lumbosacral segments, such as from cancer or reflex sympathetic dystrophy.
Based on their study, Choi and colleagues concluded that it is possible to offer regional block to women with inherited bleeding disorders provided their coagulation defects have normalized, either spontaneously during pregnancy or following adequate hemostatic cover Lumbar puncture should not be performed in the following situations:.
In the hands of an inexperienced physician, this might require lumbar puncture under fluoroscopy Ross ; Lumbar puncture and intracranial hypertension. The risk of holding or postponing a spinal tap because of concern of the risk of brain herniation is small.
In these patients antibiotics should be started immediately along with a mannitol infusion, with other interventions to control increased intracranial pressure, including attention to airway, breathing, and circulation.
This should be immediately followed by a brain CT and not a spinal tap. Hence, a detailed neurologic examination is essential before deciding on a lumbar puncture. Hence, a normal CT scan in acute bacterial meningitis does not equate to a safe lumbar puncture. With the evidence available, lumbar puncture is temporally strongly associated with brain herniation and is also considered causative in precipitating the same.
Current international guidelines recommend cerebral CT before lumbar puncture in many adults with suspected acute bacterial meningitis, due to concern about lumbar puncture-induced cerebral herniation. Still the guideline emphasis is on early treatment based on symptoms. Glimaker and colleagues argue that performing CT prior to lumbar puncture implies a risk of delayed acute bacterial meningitis treatment, which may be associated with a fatal outcome They further feel that firm evidence for lumbar puncture-induced herniation in adult acute bacterial meningitis is absent and brain CT cannot discard herniation.
Lumbar puncture with coagulopathy. Foerster and colleagues in their studies found that even in thrombocytopenic patients, an epidural hematoma would be a relatively rare complication following lumbar puncture Only meager published data are available regarding the provision and safety of neuraxial techniques in patients with common bleeding diatheses.
The minimum "safe" factor levels and platelet count for neuraxial techniques remain undefined in both the obstetric and general populations. Based on the available information, evidence-based recommendations in the setting of hemophilia, von Willebrand disease, or idiopathic thrombocytopenic purpura cannot be offered Lumbar puncture. It's carried out in hospital by a doctor or specialist nurse. When a lumbar puncture may be needed A lumbar puncture may be used to: take a sample of fluid from your spinal cord cerebrospinal fluid or measure the fluid's pressure — to help diagnose a condition inject medicine — such as painkillers, antibiotics or chemotherapy inject a spinal anaesthetic epidural — to numb the lower part of your body before an operation remove some fluid to reduce pressure in the skull or spine Before having a lumbar puncture Your doctor or nurse should explain what's going to happen and why you need a lumbar puncture.
A few days or weeks before the test: you may have a CT scan or MRI scan — to make sure you need the lumbar puncture and it's safe to have one let the hospital know if you're taking blood-thinning medicine anticoagulants — such as warfarin On the day: you can eat, drink and take medicine as normal you'll be asked to sign a consent form you'll usually need to undress and change into a hospital gown before the procedure — you might also want to use the toilet What happens during a lumbar puncture You normally lie on your side, with your legs pulled up and your chin tucked in Credit:.
Do drink plenty of fluids take painkillers, such as paracetamol lie down instead of sitting upright try drinks containing caffeine, such as coffee, tea or cola — some people find this helps to relieve the headaches remove the dressing or plaster yourself the next day. Non-urgent advice: Contact the hospital team or a GP if:.
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