CLINICAL ARTICLE J Neurosurg 129:146–152, 2018 A new method of subarachnoid puncture for clinical diagnosis and treatment: lateral atlanto-occipital space puncture Dianrong Gong, BS, Haiyan Yu, MS, and Xiaoling Yuan, MD Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong, China OBJECTIVE Lumbar puncture may not be suitable for some patients needing subarachnoid puncture, while lateral C1–2 puncture and cisterna magna puncture have safety concerns. This study investigated lateral atlanto-occipital space puncture (also called lateral cisterna magna puncture) in patients who needed subarachnoid puncture for clinical diagnosis or treatment. The purpose of the study was to provide information on the complications and feasibility of this technique and its potential advantages over traditional subarachnoid puncture techniques. METHODS In total, 1008 lateral atlanto-occipital space puncture procedures performed in 667 patients were retrospec- tively analyzed. The success rate and complications were also analyzed. All patients were followed up for 1 week after puncture. RESULTS Of 1008 lateral atlanto-occipital space punctures, 991 succeeded and 17 failed (1.7%). Fifteen patients (2.25%) reported pain in the ipsilateral external auditory canal or deep soft tissue, 32 patients (4.80%) had a transient increase in blood pressure, and 1 patient (0.15%) had intracranial hypotension after the puncture. These complications resolved fully in all cases. There were no serious complications. CONCLUSIONS Lateral atlanto-occipital space puncture is a feasible technique of subarachnoid puncture for clinical diagnosis and treatment. It is associated with a lower rate of complications than lateral C1–2 puncture or traditional (sub- occipital) cisterna magna puncture. It may have potential in the neurological diagnostic and treatment fields. https://thejns.org/doi/abs/10.3171/2017.1.JNS161089 KEY WORDS lateral atlanto-occipital space puncture; lateral cisterna magna puncture; spinal puncture; treatment outcome; diagnostic technique; adverse effects UBARACHNOID puncture is a routine technique in both To find a safe and convenient method that may be a suit- the basic neurosciences and clinical practice, which able alternative to LP, Professor Dianrong Gong has, since despite the development of advanced imaging mo- 1990, steadfastly studied the anatomical characteristics of Sdalities, such as CT, has not been entirely replaced.15 The the atlanto-occipital space and cisterna magna and spe- most common method of subarachnoid puncture is lumbar cific puncture sites and has performed repeated simulated puncture (LP), and this is generally considered to be safe procedures in specimens in the Department of Neurology, with few complications.22 Nevertheless, LP has some con- Liaocheng People’s Hospital. After she had mastered the traindications, such as in patients with increased intracra- main points and methods of the puncture procedure, the nial pressure or lesions in the puncture site. Also, LP may technique of lateral atlanto-occipital space puncture was not be feasible in patients who are unable to maintain the applied in the clinic beginning in 1995. As of this writing, required position, either seated or lying on their side.8,21 we have conducted 1008 lateral atlanto-occipital space Other methods for subarachnoid puncture such as lateral punctures for clinical diagnosis and treatment. Since July C1–2 puncture and suboccipital cisterna magna puncture 2011, 229 patients with refractory neurological disease are seldom used because of anatomical issues and risks of have received 340 human umbilical cord blood mono- major complications.13,16 nuclear cell transplantations via lateral atlanto-occipital ABBREVIATIONS LP = lumbar puncture. SUBMITTED April 26, 2016. ACCEPTED January 5, 2017. INCLUDE WHEN CITING Published online July 28, 2017; DOI: 10.3171/2017.1.JNS161089. 146 J Neurosurg Volume 129 • July 2018 ©AANS 2018, except where prohibited by US copyright law Unauthenticated | Downloaded 09/30/21 06:03 PM UTC Lateral atlanto-occipital space puncture space puncture, and there have been no cases of iatrogenic TABLE 1. Baseline characteristics of the patients who underwent injury. lateral atlanto-occipital space puncture We present a retrospective analysis of a large case se- Characteristic Value ries of patients who underwent lateral atlanto-occipital space puncture in our clinic. Our goal is to provide details Age in yrs on the procedure as well as the success and safety of the Mean ± SD 56.78 ± 18.13 method in the hope that this information may assist other Median 59 clinicians who require an alternative to LP for subarach- Range 5–88 noid puncture. Sex, no. of pts (%) Male 389 (58.32) Methods Female 278 (41.68) Patient Group Reason for puncture, no. of punctures (%) From March 1995 to March 2015, 667 patients hos- Diagnosis 196 (19.44) pitalized in the Department of Neurology, Liaocheng Treatment 812 (80.56) People’s Hospital, received 1008 lateral atlanto-occipital space puncture procedures for clinical diagnosis or treat- Disease, no. of pts/punctures ment (Table 1). The method was approved by the medical Subarachnoid hemorrhage 250/309 ethics committee of the hospital. Of the 667 patients, 389 CNS infection 121/186 (58.32%) were male and 278 (41.68%) were female. Their Guillain-Barré syndrome 19/19 ages ranged from 5 to 88 years (median 59 years, mean Coma of unknown cause 15/15 ± [ SD] 56.78 ± 18.13 years). Two hundred twenty-nine of Intrathecal injection of drugs for delayed encepha- 8/20 the patients had refractory neurological diseases and were lopathy after acute CO poisoning undergoing treatment with human umbilical cord blood mononuclear cell transplantation; these patients were Dredge treatment when the lateral ventricle drain- 17/17 treated between July 2011 and March 2015. age tube was not free The indications for lateral atlanto-occipital space punc- Whiplash injury syndrome 1/1 ture were as follows:3,21 1) inflammation of the CNS; 2) Cerebellar tonsillar hernia after LP 1/1 diagnosis of subarachnoid hemorrhage in patients with Chemotherapy w/ intrathecal injection 6/20 negative brain CT or difficult differential diagnosis of Umbilical cord blood stem cell therapy 229/420 meningitis; 3) CSF replacement or intrathecal drug ther- apy; 4) stem cell transplantation; 5) diagnosis and differ- Pts = patients. ential diagnosis of demyelinating disease; 6) treatment of ventricular hemorrhage; 7) alternative to difficult LP; 8) rescue of patients with brain herniation of varying causes; The procedure is as follows. The patient is placed in a or 9) need for CSF specimen or intrathecal treatment in supine position with any pillow removed (although a pil- critically ill patients who were not suitable candidates for low could be placed under the shoulders of an obese pa- LP or radiographic investigation. tient to facilitate the procedure if necessary). The patient Lateral atlanto-occipital puncture was not performed is required to keep the head and neck straight and in the in patients who could not cooperate because of tension or midline position. The highest point of the mastoid is lo- those with any of the following contraindications:3,21 1) lo- cated, and the puncture site is identified as 1 cm inferior cal infection of the puncture site; 2) allergic reaction to and 1 cm posterior to that point (between the lower edge local anesthetic; 3) critical clinical condition, such as se- of the occipital bone and atlas). After local sterilization vere cardiopulmonary dysfunction; 4) intracranial space- and induction of local anesthesia by infiltration of 2.5–3 occupying lesions; or 5) severe coagulation disorders. ml of a solution containing 400 mg lidocaine per 20 ml, Data Collection a 20-gauge needle (0.9-mm outer diameter, Shanghai SA Medical & Plastic Instruments Co.) is used to pierce the The baseline characteristics of the patients were col- skin. (The puncture needle consists of 2 parts: one part lected from their medical records. These data included is the needle with a hollow structure; the other part is the their age and sex as well as the reason for the puncture needle core.) The puncture direction is perpendicular to procedure and the clinical diagnosis. The success of the the neck, parallel to the imaginary line of both sides of procedure was noted and any reasons for unsuccessful the external auditory canal, and just below the occipital puncture recorded. bone. Viewed from the side, the needle passes through the rear of the atlanto-occipital joint (the vertebral arteries run The Lateral Atlanto-Occipital Space Puncture Procedure on both sides of the atlanto-occipital joints), posterior and Diagrams presenting the location of the puncture site external to the spinal canal, and between the spinal cord are presented in Figs. 1–3, and a video clip demonstrating and posterior arch. Viewed from the front, the needle is the procedure is shown in Video 1. located above the odontoid and lateral mass (the vertebral VIDEO 1. Video clip showing the procedure for lateral atlanto- artery runs behind the lateral mass). Radiographs of a suc- occipital space puncture. Copyright Dianrong Gong. Published with cessful puncture are shown in Fig. 4. No important blood permission. Click here to view. vessels or nerves run very close to the puncture route, so J Neurosurg Volume 129 • July 2018 147 Unauthenticated | Downloaded 09/30/21 06:03 PM UTC D. Gong, H. Yu, and X. Yuan FIG. 1. Sagittal section showing the correct angle of the needle for lateral atlanto-occipital space puncture. A. = arteria. From Guo Guangwen and Wang Xu: Color Atlas of Human Anatomy[M], 2001, page 8. Beijing: People’s Medical Publishing House. Published with permission from the authors of the work. Figure is available in color online only. there is a good safety margin that reduces the risks of the either obtain or replace CSF or inject the necessary drugs. procedure. The needle core is then removed, and pressure is applied Generally, 2 points of membrane breakage can be felt to the puncture point for 1 minute.