【有奖翻译】腰穿《新英格兰杂志》-（欢迎认领）

蓝鱼o_0

【腰穿】
第一部分
Lumbar puncture is indicated for both diagnostic and therapeutic reasons. Knowledge of the contraindications, the pertinent anatomy, and the methods to minimize the risk of complications are necessary for the safe and efficient performance of the procedure. Risks, although rare, can be substantial and even potentially life-threatening. The risks can be minimized with an appropriate understanding of the indications, contraindications, and procedural techniques.
腰椎穿刺被用来诊断和治疗。医护人员需要了解禁忌症、相关解剖知识和具体操作方法，继而安全和高效的进行腰穿操作，以最小化并发症的发病风险。危险虽然较为罕见，然而一旦发生危害是巨大，甚至可能危及生命。充分了解腰穿适应症、相关并发症及操作技巧可以将风险降至最低。



翻译比较仓促，若有不到之处，请专业人士点评指证！

蓝鱼o_0

【腰穿】【第二部分】
Indications
Lumbar puncture is used to obtain a sample of cerebrospinal fluid (CSF) to aid in the diagnosis of infectious, inflammatory, oncologic, and metabolic processes (Table 1). Therapeutic indications include the delivery of chemotherapy, antibiotics, and anesthetic agents.
腰椎穿刺是用于获取脑脊液（CSF）的样本，以辅助感染，炎症，肿瘤和代谢过程的诊断（见表1）。其治疗适应症包括化疗药物，抗生素和麻醉剂的释放。

蓝鱼o_0

【腰穿】【第三部分】【已认领，蓝鱼】
Contraindications
Cardiorespiratory compromise may occur because of the position patients must assume to undergo lumbar puncture; patients with some degree of cardiorespiratory compromise should avoid lumbar puncture.1 The procedure should also be avoided in patients with signs of cerebral herniation, patients with incipient herniation from increased intracranial pressure, and those with potentially increased intracranial pressure and focal neurologic signs. If there are concerns, cranial computed tomography (CT) should be performed before lumbar puncture, with the caveat that CT may not definitively reveal signs of increased intracranial pressure.2 Coagulopathy will increase the risk of a spinal hematoma, although the level of coagulopathy that increases risk is unclear. For patients who have previously undergone lumbar surgery, the likelihood of successful lumbar puncture may be increased if the procedure is
performed by an interventional radiologist using imaging techniques. Equipment Commercially available trays contain the necessary supplies, including a spinal needle with a stylet, skin-cleansing agents, drapes, collection tubes, and a manometer. A 22-gauge needle is preferred, because the smaller hole will decrease the risk of CSF leakage. In general, a needle measuring 1.5 in. (3.8 cm) is used in infants, 2.5 in. (6.3 cm) in children, and 3.5 in. (8.9 cm) in adults.

蓝鱼o_0

【腰穿】【第四部分】
Positioning
The patient should assume either the lateral recumbent position or a sitting position. The lateral recumbent position is preferred, to obtain an accurate opening pressure and to reduce the risk of post-puncture headache. Since not all patients can be put in any position, it is reasonable to learn to perform the procedure in both left and right decubitus, as well as the upright, position. Once situated, the patient should be instructed to adopt the fetal position or arch “like a cat” with his or her back flexed, to widen the gap between the spinous processes. The lumbar spine should be perpendicular to the table with the patient in the sitting position and parallel to the table with the patient in the lateral recumbent position.
Landmarks Draw a line visually between the superior aspects of the iliac crests that intersects the midline at the L4 spinous process. Insert the needle in the interspace between L3 and L4 or L4 and L5, because these points are below the termination of the spinal cord. You should palpate the landmarks before preparing the skin and applying local anesthesia, since these procedures may obscure the landmarks. Use a skin-marking pen to indicate the proper position. Preparation After donning sterile gloves, clean the overlying skin with an appropriate disinfectant, either povidone–iodine or a chlorhexidine-based solution. Apply the disinfectant in widening concentric circles. Cover the area with sterile drapes.

翻译部分见16楼（认领人：mickeypank ）

蓝鱼o_0

【第五部分】
Analgesia and Sedation
Lumbar puncture is a painful and anxiety-provoking procedure. At a minimum,
local anesthesia is appropriate. If time allows, you can apply anesthetic cream
topically before preparing the skin. After the skin has been clean and draped, local
anesthetic can be infiltrated subcutaneously. Systemic sedatives and analgesics may
also be used.
Lumbar Puncture
After once again palpating the landmarks, insert the needle, with stylet firmly in
place, at the superior aspect of the inferior spinous process, in the midline, approximately
15 degrees cephalad, as if aiming at the patient’s umbilicus. Recent data suggest
that the use of a “pencil-tipped” needle can decrease the risk of postdural puncture
headache3 owing to CSF leakage by spreading rather than cutting the fibers of
the dural sac. If the more commonly used bevel needle is used, the bevel of the needle
should be in the sagittal plane, so as to spread rather than cut the fibers of the
dural sac, which run parallel to the spinal axis.
If properly positioned, the needle should pass through, in order, the skin, subcutaneous
tissue, supraspinous ligament, interspinous ligament between the spinous
processes, ligamentum flavum, epidural space including the internal vertebral
venous plexus, dura, and arachnoid, into the subarachnoid space and between the
nerve roots of the cauda equina. As the needle passes through the ligamentum flavum,
you may feel a popping sensation. After this point, withdraw the stylet in 2-mm
intervals to assess for CSF flow.4 If the attempt is unsuccessful and bone is encountered,
withdraw the needle to the subcutaneous tissue, without exiting the skin,
and redirect the needle. CSF will flow once the subarachnoid space has been entered.
If the tap was traumatic, the CSF may be tinged with blood. The blood should
clear as additional CSF is collected, unless the source of the blood is a subarachnoid
hemorrhage. If flow is poor, you may rotate the needle 90 degrees, since a nerve
root may be obstructing the opening.

翻译部分见11楼（认领人：Adler007 ）

蓝鱼o_0

【第六部分】
Opening Pressure
An opening pressure can be obtained only from patients in the lateral recumbent
position. Use a flexible tube to connect a manometer to the hub of the needle. This
should be done before you obtain any samples. A measurement can be made after
the column of fluid stops rising. It may be possible to see pulsations from cardiac
or respiratory motion.
Specimen Collection
CSF will drip into the collection tubes; it should never be aspirated because even
a small amount of negative pressure can precipitate a hemorrhage. The amount of
fluid collected should be limited to the smallest volume necessary — typically, 3 to
4 ml. Fluid should be collected from the manometer if an opening pressure was measured
by turning the stopcock toward the patient and draining the fluid into a tube.
After collecting an adequate specimen, replace the stylet and remove the needle.
Follow-up
The site should be cleaned, and a bandage applied. Despite the widely held belief,
bed rest does not decrease the incidence of headaches after lumbar puncture.

complications
Obese patients may represent a challenge because of difficulty in identifying landmarks.
Osteoarthritis, ankylosing spondylitis, kyphoscoliosis, previous lumbar surgery,
and degenerative disk disease may make the procedure more difficult. In patients
with such conditions, consultation with an anesthesiologist or interventional
radiologist may be necessary for lumbar puncture to be successful.
Complications from lumbar puncture include herniation, cardiorespiratory compromise,
local or referred pain, headache, bleeding, infection, subarachnoid epider-mal cyst, and leakage of CSF. The most common complication is headache, occurring
in up to 36.5% of patients within 48 hours after the procedure. Headaches
can be caused by the leakage of CSF through the puncture site at a rate that exceeds
the rate of CSF production. The incidence increases in relation to the size of the
spinal needle.5 The most serious complication is herniation, which may result when
a large pressure gradient exists between the cranial and lumbar compartments.
This gradient can be increased during a lumbar puncture, resulting in brain-stem
herniation. Patients at high risk for herniation can be identified by a thorough history-
taking and neurologic examination. If there is still concern about the procedure,
CT may be helpful, with the caveat that these images may not identify pressure
elevations. However, CT is not necessary for all patients, because it could delay
diagnosis and treatment. Bleeding is most likely to occur in a patient with a bleeding
diathesis. The resulting hemorrhage may cause spinal cord compression. No
absolute criteria exist regarding the degree of coagulopathy and the risk of bleeding,
so clinical judgment is necessary. Subarachnoid epidermal cysts can develop as
a consequence of introducing a skin plug into the subarachnoid space and can be
avoided through the use of a needle with a stylet.

翻译部分见12楼（认领人：Adler007 ）

绿茵场

辛苦 蓝鱼o_0  了！
为您喝彩！

蓝鱼o_0

回复 7# 绿茵场

谢谢你哦，你的信任和鼓励是我的动力！

米奇朋克

【腰穿】【第四部分】
Positioning
The patient should assume either the lateral recumbent position o ...
蓝鱼o_0 发表于 2011-4-25 12:44

                               
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第四部分，我来认领，试试翻翻看。

Adler007

【第五部分】我认领了
【第五部分】Analgesia and Sedation

Adler007

【第五部分】Analgesia and Sedation

止痛和镇静
腰椎穿刺是一个使人疼痛和令人焦虑的过程。最低剂量的局部麻醉是必须的，如果时间允许，在准备清洁皮肤前，你可以申请麻醉乳膏，在清洁消毒皮肤并铺上消毒巾后，局部麻醉剂已经透过皮下组织，也可以使用全身镇静剂和止痛剂。

腰椎穿刺

　再次摸清界标后，在中线位置、下一个棘突的上缘插入带针芯的穿刺针，针头朝向头部，约呈15度，似乎是向着患者脐部的方向。脑脊液（CSF）漏可引起穿刺后头痛，最新数据表明，采用“铅笔头样”针头可降低头痛的发生危险，因为这种针头可使硬脊膜囊的纤维散开，而不会将其切断。如果使用较常用的斜面针头，针头的斜面应位于矢状面，这样也可以使与脊柱轴平行的纤维散开，而不会将其切断。

　　如果进针位置正确，穿刺针应依次通过皮肤、皮下组织、棘上韧带、棘突间的棘间韧带、黄韧带、硬膜外隙（其中包括内椎静脉丛、硬脊膜和蛛网膜），进入蛛网膜下腔，并位于马尾神经根之间。当穿刺针通过黄韧带时，可感觉到一种突破感。此时，应将针芯拔出2 mm，观察是否有脑脊液流出。如果穿刺不成功，并碰到骨，将穿刺针退至皮下组织，但不要退出皮肤，调整好方向后再次进针。针头一旦进入蛛网膜下腔，就有CSF流出。如果穿刺时有创伤，CSF可能略带血。收集CSF时，CSF应清澈无血，除非存在蛛网膜下腔出血。如果脑脊液流出不畅，可将针头旋转90度，因为针头开口处可能被神经根堵塞。

Adler007

Opening Pressure
An opening pressure can be obtained only from patients in the lateral recumbentposition. Use a flexible tube to connect a manometer to the hub of the needle. Thisshould be done before you obtain any samples. A measurement can be made afterthe column of fluid stops rising. It may be possible to see pulsations from cardiacor respiratory motion.

开放压

测量开放压时患者须侧卧位。用一根软管将测压计与穿刺针的中心（hub）相连。这项操作应在收集任何样本前完成。当测压计液柱不再上升时，读出测量值。您有可能看到因心脏或呼吸运动引起的液面浮动。

Specimen Collection
CSF will drip into the collection tubes; it should never be aspirated because evena small amount of negative pressure can precipitate a hemorrhage. The amount offluid collected should be limited to the smallest volume necessary — typically, 3 to4 ml. Fluid should be collected from the manometer if an opening pressure was measuredby turning the stopcock toward the patient and draining the fluid into a tube.After collecting an adequate specimen, replace the stylet and remove the needle.

样本收集

　　脑脊液（CSF）应滴入收集管内；不应该进行抽吸，因为甚至是很小的一点负压，也会导致出血。收集的液量应限制在最小需要量，一般是3～4 ml。如果患者要进行开放压的测量，要将旋转阀转向患者，让测压计内的CSF流入收集管内。收集足量样本后、插入针芯、拔出穿刺针。

Follow-up
The site should be cleaned, and a bandage applied. Despite the widely held belief, bed rest does not decrease the incidence of headaches after lumbar puncture.
随访

穿刺部位应清洁消毒，并用纱布覆盖。腰椎穿刺后尽管普遍认为卧床休息可降低腰穿后头痛发生率，但事实并非如此。
complications
Obese patients may represent a challenge because of difficulty in identifying landmarks.
Osteoarthritis, ankylosing spondylitis, kyphoscoliosis, previous lumbar surgery,and degenerative disk disease may make the procedure more difficult. In patients with such conditions, consultation with an anesthesiologist or interventionalradiologist may be necessary for lumbar puncture to be successful.
Complications from lumbar puncture include herniation, cardiorespiratory compromise,
local or referred pain, headache, bleeding, infection, subarachnoid epider-mal cyst, and leakage of CSF. The most common complication is headache, occurring
in up to 36.5% of patients within 48 hours after the procedure. Headachescan be caused by the leakage of CSF through the puncture site at a rate that exceedsthe rate of CSF production. The incidence increases in relation to the size of thespinal needle.5 The most serious complication is herniation, which may result whena large pressure gradient exists between the cranial and lumbar compartments.This gradient can be increased during a lumbar puncture, resulting in brain-stemherniation. Patients at high risk for herniation can be identified by a thorough history-
taking and neurologic examination. If there is still concern about the procedure,CT may be helpful, with the caveat that these images may not identify pressureelevations. However, CT is not necessary for all patients, because it could delaydiagnosis and treatment. Bleeding is most likely to occur in a patient with a bleedingdiathesis. The resulting hemorrhage may cause spinal cord compression. Noabsolute criteria exist regarding the degree of coagulopathy and the risk of bleeding,so clinical judgment is necessary. Subarachnoid epidermal cysts can develop asa consequence of introducing a skin plug into the subarachnoid space and can beavoided through the use of a needle with a stylet.

并发症

　　肥胖患者的界标很难确定，这是一种挑战。骨关节炎、强制性脊柱炎、腰部手术史、退行性椎间盘疾病可能使得腰椎穿刺较难完成。对于此类患者，可能需要请麻醉科医师或介入放射科医师会诊，以提高腰椎穿刺的成功率。腰椎穿刺的并发症包括脑疝、心肺功能受损、局部或牵涉痛、头痛、出血、感染、蛛网膜下皮囊肿和脑脊液漏。最常见的并发症是头痛，其在腰穿后48小时内的发生率高达36.5%。头痛的原因是CSF从穿刺部位渗漏的速度超过CSF的生成速度。头痛发生率的增加与所用腰穿针的粗细有关。最严重的并发症是脑疝，如果颅腔与脊髓腔之间的压力差大，就有可能导致脑疝。在腰椎穿刺过程中，这种压力差可导致脑疝形成。医师通过详细询问病史和神经系统体检，可以发现脑疝的高危患者。如果医师对进行腰椎穿刺仍有顾虑，CT可能有帮助，但颅内压升高不一定都能被影像学检查发现。但是，CT对所有患者可能都不是必须的，因为它可耽搁诊断和治疗。有出血体质的患者非常容易发生出血，出血可导致脊髓受压。关于凝血障碍程度与出血危险的关系，尚无绝对标准，所以必须根据临床情况进行判断。采用有针芯的穿刺针可避免其发生因皮肤栓子进入蛛网膜下腔引起的蛛网膜下囊肿。

蓝鱼o_0

回复 7# 绿茵场


热心的网友。我本来计划把腰穿部分全部翻译的，却有人捷足先登了。
感谢他们！

认领最好以整篇文档，不要一部分一部分的认领！
比如我认领腰穿SOP，我就负责所有部分的翻译整理。这样也不会乱.

蓝鱼o_0

回复 9# mickeypank

欢迎认领！

Adler007

大家一起共同进步，Thank you for your hard work !

米奇朋克

回复 14# 蓝鱼o_0

定位
腰穿病人应呈侧卧位或坐位，但是侧卧位首选，因为可以获得精确的开启压力并且可以减少腰穿后头痛风险。但是并不是所有病人都能采取任何体位进行穿刺，所以学习演练左右侧卧位及直立体位的穿刺步骤是合情合理的。一旦体位确定，应要求患者采取胎儿体位或者将身体拱成像猫一样的拱形，以使背部屈曲，这样可以增加脊柱棘突间隙的宽度。采取坐位的患者其腰椎应与检查台平面成直角，采取侧卧位的应与检查台平面平行。标记，即在两髂棘上方的地方划一条可见的连线并且与人体的正中线相交于第四腰椎棘突；然后将穿刺针刺入第三和第四腰椎或第四和第五腰椎的间隙里，因为这些穿刺点正好位于脊髓末端的下方。操作人员应在皮肤准备和局部麻醉前用手触摸标记，因为这些操作可能会使标记模糊不清。使用皮肤标记笔来标示合适的穿刺点。先套上无菌手套，然后用恰当的消毒剂消毒穿刺将要覆盖的皮肤，既可以选用聚维酮碘也可以选以洗必泰为主要成份的消毒剂。消毒时应按照同心圆从中心向外扩大。手术区域应铺无菌单。

绿茵场

回复 13# 蓝鱼o_0
分部分认领的话，可以大大提高参与度。
整篇整篇领的话，估计会让很多人望而却步，我想主要原因是时间问题！

蓝鱼o_0

回复 3# 蓝鱼o_0

【腰穿】第三部分
禁忌
腰椎穿刺的病患有潜在心肺损伤的可能。因此，具有某种程度的心肺功能障碍的患者应避免腰刺。1具有脑疝症状，初期颅内压增高和潜在的颅内压增高或者局部神经系统症状的患者应该避免腰穿。如果存在疑虑，腰穿前必须进行头颅CT扫描，CT可以显示是否有颅内压增高的现象；2凝血障碍可以增加脊柱血肿的风险，但是其机制尚不清楚。对于有腰椎手术史的患者，介入治疗放射医生通过成像技术，腰椎穿刺成功率可能增加。商业售卖的穿刺器材盘装，内含一些必要用品，包括有钢丝，皮肤清洁剂，批盖，收集管，针头和一个压力计。22号针头是首选，因为较小的孔将减少脑脊液漏的风险。一般来说，1.5英寸（3.8厘米）测量针用于婴幼儿，2.5英寸（6.3厘米）用于儿童，成年人则用3.5英寸（8.9厘米）。

蓝鱼o_0

回复 7# 绿茵场

【腰穿】新英格兰医学SOP，已经下载好了，请验收！

蓝鱼o_0

回复 17# 绿茵场

为了便于网友阅读，我已经完成了编辑。将英文和中文串联起来了。
请下载！

腰穿.doc (134.5 KB, 下载次数: 50)

2011-5-1 15:48 上传

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