Suboccipital Puncture

Suboccipital puncture is a procedure that was developed at the beginning of the last century. It was designed to obtain cerebrospinal fluid (CSF) for diagnostic and therapeutic purposes as an alternative to lumbar puncture. It was performed through a midline puncture below the occipital bone. Many years later, the puncture was modified, and it was performed as a lateral C1-C2 cervical puncture. Recently, suboccipital puncture has been popularized using a lateral trajectory. In 1908, Obregia performed the first in vivo midline suboccipital puncture. His idea was used in 1919 by Ionescu to administer general anesthesia. Wegeforth, Ayer, and Essick also used it during 1919-1920, which they called a cisterna magna puncture. In its early years, the suboccipital puncture had numerous indications, but most are now outdated. Nevertheless, it can be used when a lumbar puncture cannot be performed or is contraindicated. It is still currently used for animal experiments to obtain CSF or to inject drugs. A lateral C1-C2 cervical puncture technique for percutaneous cervical cordotomy was developed by Mullan et al. in 1962 and by Rosomof et al. in 1965. The technique was later used in 1975 by Skalpe and Amundsen for myelography and in 1979 by Rice and Bathia. With its safer CSF collection and the ability to perform cervical myelography, it has largely supplanted suboccipital puncture. Cervical myelography led to the widespread use of the lateral cervical puncture in appropriate cases. Several years later, a controversy arose, arguing that a cervical injection was unnecessary for cervical myelography, noting that if sufficient contrast were injected into the lumbar spine via lumbar puncture, adequate visualization of the entire spine would be achieved, making lateral cervical or suboccipital puncture unnecessary. Therefore, the procedure was also abandoned and was used only in cases where lumbar access was unavailable or contraindicated. Although lateral C1–C2 puncture was previously preferred for cervical myelography, most radiologists now prefer a lumbar puncture approach. In 2009, a survey showed that over 85% of neuroradiologists still performed C1-C2 lateral punctures and that over 95% still consider it to be the standard of care for cervical myelography. In 2017, Gong et al described a lateral atlantooccipital space puncture (also called lateral cisterna magna puncture), in which they performed 1008 procedures in 667 patients. This procedure is similar to the original midline suboccipital puncture but is performed via a lateral approach. The method avoids midline suboccipital puncture and the risks associated with medulla oblongata puncture. This technique will probably revive the use of the suboccipital puncture. Both techniques are described in this review: the suboccipital puncture and the cervical C1-C2 puncture. Both should be well known, and on some occasions, one procedure can be used as an alternative to the other.