The technique for lateral cervical puncture.

The theoretical risk of injuring the vertebral artery or anomalous vessels at lateral cervical puncture is assessed. In just less than 30% of vertebral arteries the vessel overlies the lateral aspect of the spinal canal between the first and second cervical vertebrae, usually the antero-inferior quadrant. Directing the spinal needle to the posterior third of the canal virtually eliminates the possibility of injuring this and most anomalous arteries traversing the region. The likelihood of inducing subarachnoid haemorrhage by injuring these vessels would appear to be considerably less in lateral cervical than in cisternal puncture.

An acute subdural hematoma dissecting into the posterior cranial fossa and resulting in death is reported. The patient had undergone spinal puncture by the lateral cervical technique prior to development of the hematoma. Autopsy demonstrated that the source of hemorrhage was an anomalous intraspinal vertebral artery.

Two patients with altered hemostatic mechanisms developed spinal subarachnoid hemorrhage after difficult lumbar punctures. One patient had received anticoagulation therapy soon after lumbar puncture and the other had a low platelet count (63,000/mm3) at the time of lumbar puncture. In both patients a hematoma evolved, producing blockage of cerebrospinal fluid flow. Clinical manifestations consisted of severe back and radicular pain with sphincteric disturbances followed by rapidly developing severe paraparesis. Of the methods of radiographic evaluation that were used, including computed tomography (CT) without contrast enhancement, myelography, CT with intrathecally administered contrast medium, and magnetic resonance imaging, we found the best study to be myelography via lateral cervical puncture followed by CT. Unfortunately, diagnosis was delayed, and surgical evacuation of the hematomas did not substantially improve the patients' conditions. The salient clinical and radiographic features of this disorder and its pathophysiology are reviewed. Prompt recognition of these lesions is necessary so that surgical intervention may maximize chances of recovery.

Sampling of the cerebrospinal fluid is an extremely important procedure, since it is essentially the only neurodiagnostic technique that permits physicians to evaluate the biochemical and metabolic aspects of central nervous system functioning. However, it is imperative that the sample be properly collected and processed in order for the maximum information to be obtained. Before attempting to obtain cerebrospinal fluid, the physician should be aware of what information is desired from the study and how much cerebrospinal fluid is required for each laboratory test to be performed in order to collect and process the specimens properly. This chapter deals with the proper techniques used to sample cerebrospinal fluid and the techniques for subsequently handling the collected fluid. Cerebrospinal fluid may be collected by lumbar puncture, cisternal puncture, or lateral cervical puncture, or through ventricular cannulas (or shunts).

Ultrasound-Guided Anterograde Cervical Thoracic Duct Puncture Facilitating Retrograde Cannulation: An Access Route for Thoracic Duct Endoluminal Interventions.