Suboccipital Puncture

SUBOCCIPITAL PUNCTURE was proposed in 1916 by Westenhofer and developed in 1917 by Anton and Schmieden. From the operation proposed by these authors (an incision 2 cm below the external occipital protuberance to the spinous process of C1 followed by creating a window in the atlanto-occipital membrane), at present the majority have transitioned to the actual puncture. The technique of S. p. was thoroughly developed by Wegeforth, Ayer, Eskuchen, Hartwich and others. At present S. p. or puncture of the posterior cerebral cistern has become widespread, especially among neurologists, surgeons, pediatricians and others. For S. p., ordinary lumbar puncture needles are used, as well as thin Brown or Quincke needles with a thickness of 0.7-2 mm. To determine the depth of needle passage during puncture, it is better to place guards on the needles at a distance of 5-6 cm from the tip or to make notches on the needle to orient in the distance passed by the needle. Guards are used in the form of plugs (Forster, Nonne) or metal sleeves on a screw (Frid, Osann). S. p. is performed after the usual thorough aseptic preparation of hands, instruments, and the skin of the patient's occiput. The position of the patient during S. p. can be sitting or lying (on the side). Most authors perform diagnostic punctures in the sitting position. In severely ill patients (meningitis) and in children, S. p. should be performed with the patient lying down. When performing S. p. in the sitting position, the patient sits on a stool with their back to the doctor. An assistant standing in front holds the head with both hands from the sides. The patient slightly bends the head forward, without bending the back, but on the contrary, straightening it. The bending of the head downward should be slight to avoid excessive tension of the nuchal ligament and to allow palpation of the cervical vertebrae (spinous process of the axis). When performing puncture in the lying position, the patient lies on the right or left side. A roll is placed under the head so that the occipital protuberance and cervical vertebrae are in a straight line with the entire spine. The skin of the occipital region, where S. p. is performed, is thick. Along the midline from the external occipital crest, the posterior tubercle of the atlas, and the apices of the cervical spinous processes, the triangular-shaped ligamentum nuchae extends. The latter connects with the lig. interspinalia and the occipital fascia. The muscles of the occiput have several layers: 1) m. trapezius, 2) mm. splenius, levator scapulae, rhomboideus and serratus post, sup., 3) mm. longissimus cervicis and capitis, ilio-costalis and semi-spinalis capitis. The atlanto-occipital membrane passes on the sides into the articular ligaments. Between the medulla oblongata and the cerebellum is the cisterna cerebello-medullaris, a space filled with cerebrospinal fluid. Its length from the cerebellum to the spinal cord is 5-6 cm. The depth of the cisterna cerebello-medullaris is on average 1.5 cm (Nonne, Eskuchen, Hartwich and others). The space between the posterior edge of the occipital bone and the posterior arch of the atlas is the site of S. p. The reference points for palpation should be: the occipital protuberance, the posterior tubercle of the atlas, and the spinous process of the axis. However, during palpation it is difficult to determine the spinous processes of the cervical vertebrae (especially the posterior tubercle of the atlas), especially in well-nourished people. The reference points for S. p., according to Eskuchen, are the occipital protuberance and the posterior tubercle of the atlas (or the spinous process of the axis), between which the skin is punctured. Further, the needle is directed upward and forward to the occipital bone, under which the needle is brought to the posterior edge of the foramen magnum and the atlanto-occipital membrane is punctured. According to Ayer, the skin is punctured over the spinous process of the axis, the needle is directed along the line of the external auditory canal and glabella until the atlanto-occipital membrane is felt to be punctured. It is better to combine Ayer's and Eskuchen's technique, as Wartenberg did, since the posterior tubercle of the atlas is difficult to palpate. In S. p. technique according to Wartenberg, the following are used as punctum fixum: 1) the spinous process of the axis and 2) the lower edge of the occipital bone. Wartenberg advises puncturing the skin over the spinous process of the axis and, during further advancement of the needle, using the lower edge of the occipital bone, puncturing the membrane and meninges under the control of the latter. In addition, Wartenberg adds a third point for directing the needle: a point located 2-3 cm above the eyebrows. An important moment when performing S. p. is determining the depth of puncture from the skin to the atlanto-occipital membrane. This distance varies depending on the shape of the neck, the fatty layer and musculature, the circumference of the neck, the sagittal diameter, the 'constitution' of the neck, as well as the height of the puncture and even the shape of the skull (in dolichocephalics it is greater, in brachycephalics it is less) and others. According to the authors, this depth varies from 3 to 8 cm, on average 5 cm (Nonne), 4-5 cm (Hartwich), 4.5-5.5 cm (Eskuchen), 6 cm (Ayer, Pfister) and others. After puncturing the skin and soft tissues, according to most authors, a sensation is obtained when passing through the atlanto-occipital membrane as overcoming the resistance of a taut film, which sometimes gives a distinct perception, facilitated by the fact that the dura mater is often fused with the membrane. This sensation is identical to the sensation when performing a lumbar puncture. Following the puncture of the membrane, cerebrospinal fluid appears through the needle. In the sitting position of the patient, fluid can sometimes only be obtained by aspiration with a syringe, since the pressure in the cistern is either zero or negative. Aspiration of fluid with a syringe is unphysiological and sometimes does not provide the required amount of fluid (encephalography). Therefore, other techniques are used to increase intracranial pressure. Queckenstedt's method: after puncturing the atlanto-occipital membrane with a needle, the neck is compressed in the region of the jugular veins, after which fluid begins to flow in frequent drops. The 'straining' method, proposed by Emdin and Garkavi, consists in the fact that after puncturing the membrane, the patient is instructed to strain. At this time, he takes a deep breath, holds the exhalation, and contracts the abdominal press, thoracic, and laryngeal muscles. This maneuver increases intracranial pressure and provides the required amount of fluid. Rarely, S. p. does not allow fluid to be obtained. The presence of blood in S. p. is less frequent than in lumbar puncture, since in the region of the cistern the dura mater is tightly adjacent to the atlanto-occipital membrane. After S. p., headaches, numbness and paresthesias in the upper extremities, and radicular pains are observed. Cases of meningitis have been observed. Individual cases of injury to the medulla oblongata, hemorrhage, cessation of breathing, and a number of fatal outcomes have been described. Puncture of the posterior cistern is used as a diagnostic tool in neurosyphilis, although there is no significant difference between S. p. and lumbar puncture (the RW is equally expressed in both the upper and lower fluid). Some difference is obtained in spinal forms of neurosyphilis. In the presence of cerebral luetic processes, Gennerich proposed the introduction of neosalvarsan by the cisternal route, as it gives more effect and fewer complications. According to Gennerich, the brain tolerates larger doses of neosalvarsan than the spinal cord with the endolumbar method. In meningitis, S. p. is an addition to lumbar puncture in treatment, especially in cerebrospinal meningitis. Combined treatment in such cases improves the outcome of the disease, but S. p. cannot completely replace the lumbar puncture. In combined treatment of cerebrospinal meningitis, fluid is simultaneously released through two needles (cisternal-lumbar therapy). The introduction of therapeutic fluids (urotropin, antimeningococcal serum) by the lumbar route in cerebrospinal meningitis hardly achieves the goal, since the distance from the puncture site obviously does not allow the medicinal fluid to rise to the subarachnoid spaces of the brain, and in a positive case - only in significant dilution. In this case, the cisternal route for introducing therapeutic fluids is better, and as a last resort, direct puncture of the ventricles remains. S. p. is used in the study of cerebrospinal fluid in patients with brain tumors. In addition to ventriculography methods according to Dandy (introduction of air through puncture of the lateral ventricles) and lumbar puncture according to Bingel, encephalography is also performed through puncture of the posterior cerebral cistern (Nonne). Sometimes the cisternal route is used for myelography by introducing 40% lipiodol or 25% iodipin. For encephalography purposes, up to 20 cm³ of fluid is released by S. p. with replacement by air (Nonne) or 30-40 cm³ without the introduction of air (Emdin). Encephalograms in such cases give good images of the ventricles.