From Big Medical Encyclopedia

SUBOKTSIPITALNY PUNCTURE (Latin the sub-prefix under + occipitium a nape; puncture; synonym: cisternal puncture, puncture of the big occipital tank, suboktsipitalny puncture) — introduction of a needle to the big occipital tank with the diagnostic or medical purpose.

For the purpose of S.'s diagnosis items make for comparative study of composition of cerebrospinal liquid (see) in the big occipital tank and in lumbar department of the spinal channel, for administration of radiopaque substances at specification of localization patol. the center in a spinal cord (see. Miyelografiya ). Pages of the item apply also at pnevmotsisterno-and a pneumoencephalography when it is impossible spinal puncture (see).

With the medical purpose C. of the item use for introduction to subarachnoid (subarachnoid) space of antibiotics, antiseptic agents, serums.

To page of the item it is contraindicated at suspicion of a tumor of a back cranial pole, verkhnesheyny or srednesheyny departments of a spinal cord. S. by the item at patients with ventrally the located craniospinal tumor since the myelencephalon displaced in such cases of a kzada directly prilezhit to a firm meninx is especially dangerous and can be easily damaged by a needle. Extreme care it is necessary to observe at S. the item at children of younger age in connection with various options of development of a back cranial pole.

At S. items use the same tools, as at a spinal puncture (see. Neurosurgical tools). The puncture is carried out in the operating room or specially equipped dressing room with strict observance of rules of an asepsis.

Pages of the item make in position of the patient sitting or lying. More often than S. items carry out in position of the patient lying because of difficulty of fixing of the head of sick and negative pressure of cerebrospinal liquid in the big occipital tank in a sitting position. In position of the patient lying cerebrospinal liquid expires spontaneously that prevents need of dangerous aspiration it from the tank the syringe.

the Diagrammatic representation of the main stages of a suboktsipitalny puncture on a sagittal section of the head: 1 and 2 — initial provisions of a needle, 3 — the needle is entered into the big occipital tank.

The patient is stacked sideways, under the head enclose the roller. For the best designation of the centerline and increase in space between a handle of Skh of a vertebra and the rear edge of a big occipital opening the head of the patient is inclined by kpered. Previously shaved skin in cervicooccipital area is carefully disinfected. After local anesthesia of 2% or 0,5% solution of novocaine (3 — 4 ml) stick a needle over an acantha of the Joint venture of a vertebra and direct it strictly on the centerline at an angle in 45 — 60 ° in relation to the frontal plane to feeling of a bone (fig., 1). Then, without taking out a needle, bringing up her back, change a tilt angle and again enter to feeling of a bone (fig., 2). Advancing a needle thus on scales of an occipital bone, pass edge of a big occipital opening. When resistance of a bone is not felt, the careful movement the needle is advanced on 1,5 — 2 cm deep into, puncture a suboktsipitalny membrane and get to the big occipital tank (fig., 3). At a puncture of a membrane characteristic resistance is felt. If the puncture is made correctly, from a needle after removal of mandrin cerebrospinal liquid is emitted. Receipt from a needle of blood can be caused by finding of a needle in soft tissues of a neck. In these cases it is necessary to advance it on 2 — 3 mm deep into and to puncture a suboktsipitalny membrane and a firm meninx. Usually the needle is entered on depth of 5 — 6 cm. For control of depth in Coca put on a sterile rubber tag a needle or do semi-centimetric notches.

Not to damage large veniplexes of deep muscles of a neck, it is necessary to adhere strictly to the centerline and not to displace a needle in the parties. It is impossible to press with a force on a bone since the tip of a needle can be kryuchkoobrazno deformed and at its extraction to injure the zadnenizhnemozzhechkovy arteries which are freely passing in the tank.

At observance of indications and the correct equipment of complications usually it is not observed. Only nek-ry patients at a puncture of a suboktsipitalny membrane can have passing pains in a face and in extremities. In rare instances in the first days after S. the item note a headache, nausea, vomiting, a hyperthermia.

Small impurity of a venous blood in cerebrospinal liquid at S. the item can be caused by wound of the venous vessels located in the big occipital tank or damage of the lowered almond of a cerebellum. Injury of a zadnenizhnemozzhechkovy artery by a needle, an injury of arterial vessels of the tumor filling the big occipital tank can be the cause of plentiful arterial bleeding. One of dangerous complications — injury of a medulla, a cut is shown by disturbance of breath, cordial activity, cyanosis, nausea, vomiting, a nystagmus, etc. In these cases of S. of the item stop and hold the events directed to a stop of bleeding, elimination of disturbances of breath and cordial activity.

Bibliography: Zograbyan S. G. Diagnostic operations at diseases of a head and spinal cord, page 58, M., 1955; And r of e r I. M. Neyrokhirurgiya, page 15, etc., M., 1982; Fundamentals of neurosurgery of children's age, under the editorship of A. A. Arendt and S. I. Nersesyants, page 107, M., 1968; Fundamentals of practical neurosurgery, under the editorship of A. JI. Polenova and I. S. Babchin, page 442, JI., 1954; Ugryumov V. M., Baskin I. S. and Abrakov JI. B. Operational neurosurgery, D., 1959; Surgery of the central nervous system, under the editorship of V. M. Ugryumov, p.1 — 2, JI., 1969; Grote W. Neurochirurgie, S. 55, 91, Stuttgart, 1975; M err em G. Lehrbuch der Neurochirurgie, S. 96, B., 1964.

A. F. Sokolov