anaesthetise the skin and subcutaneous tissues with 1% lignocaine at the chosen site
place the spinal needle in the interspace with the bevel uppermost and advance it towards the umbilicus keeping it parallel to the ground
when advancing the needle consider:
when there is an increase in resistance as you go into the tough ligamentum flavum and a marked reduction of resistance when the needle passes through. When through the ligamentum flavum, the dura is very close (1-2mm away) and the needle should be slowly advanced and the stylet withdrawn after each step
when the dura is reached there should be a free flow of cerebrospinal fluid (CSF)
measure the opening pressure with a manometer - if greater than 40 cm of water, remove needle immediately to avoid brain stem herniation. Normal pressure is 6-20 cm of water
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