The safest procedure to obtain cerebrospinal fluid is lumbar
puncture. However, there are situations where lumbar puncture is
either contraindicated or technically not feasible. This includes infections
in the lumbar area, obesity, previous spinal surgery, previous spinal
fusion, previous arachnoiditis, and the previous injection of chemotherapeutics.
The usual and safe alternative method is a lateral cervical puncture
under such circumstances. Cisternal puncture describes the suboccipital
access to cisterna magna, a cerebral spinal fluid (CSF) containing
space. It is a less frequently used procedure due to the high incidence
of complications. As a result, cisternal puncture should be performed
by a Neurological Surgeon for patients whose CSF cannot be accessed by
lumbar puncture or lateral cervical puncture.1
Dr. Mullan introduced a method for performing a percutaneous
cordotomy using a lateral cervical puncture in the early 1960s.2 He
introduced a strontium-90 needle through the C1-C2 interspace and
entered the subarachnoid space under fluoroscopic guidance. He then
directed the needle anteriorly towards the anterior dura mater to
interrupt the spinal thalamic fibers in an attempt to control intractable
pain. The lateral cervical puncture is a direct derivative of this
Lateral cervical puncture involves the placement of a spinal
needle into the C1-C2 interspace, posterior and inferior to the
vertebral artery. The vertebral artery ascends through the foramina
in the transverse processes of the cervical vertebrae beginning
at the sixth cervical vertebra. It winds behind the lateral mass
of the atlas (C1) to enter the skull through the foramen magnum
(Figure 98-1). Inserting the needle 1 cm inferior to the tip of
the mastoid process and 1 cm posterior from that point will avoid
puncturing the vertebral artery (Figure 98-2).
The course of the vertebral artery at the level of C1-C2. A. Posterior view. B.
Anatomic landmarks for cisternal puncture. The site
for insertion of the needle is represented by an ⊗.
The spinal canal is formed by sequential vertebral foramina and
is triangular in shape. Its lateral width is greater than the anteroposterior
width. The spinal canal is more spacious in the upper cervical spine
allowing for safe placement of a needle into the C1-C2 interspace.
The sagittal diameter of the spinal canal is approximately 23 mm
at C1 and 20 mm at C2. The cross-sectional area of the cervical
spinal canal is greatest at C2 and progressively decreases. It is
smallest at the level of C7. The vertebral canal is narrower in
women than in men. The spinal canal at the level of C1-C2 can be
divided into three parts. The anterior third is occupied by the
odontoid process. The middle third is occupied by the spinal cord
itself. The posterior third is occupied by ...