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, the suboccipital puncture was popularized but using a lateral trajectory. In 1908, Obregia performed the first in vivo midline suboccipital puncture. His idea was utilized in 1919 by Ionescu to inject general anesthetics. It was also used by Wegeforth, Ayer, and Essick during 1919-1920, which they called a cisterna magna puncture. On its origins, the suboccipital puncture had many indications, but most of them are out of date. Still, it can be used when the lumbar puncture can not be performed or is contraindicated. It still is currently used for animal experiments to obtain CSF or inject drugs. A lateral C1-C2 cervical puncture technique was developed to do percutaneous cervical cordotomy by Mullan et al. in 1962, and by Rosomof et al. in 1965. The technique was later used in 1975 by Skalpe and Amundsen to perform myelography, and in 1979 by Rice and Bathia. With its safer use to obtain CSF and the capacity to perform cervical myelogram, it almost replaced the use of the suboccipital puncture. Cervical myelography led to the widespread use of the lateral cervical puncture in appropriate cases. Several years later, a controversy was commenced arguing that a cervical injection was not needed to perform a cervical myelogram recognizing that if enough contrast were injected in the lumbar spine by a lumbar puncture, there would be adequate visualization of the entire spine making a lateral cervical puncture or a suboccipital puncture unnecessary. Therefore, the procedure was also forgotten and only used for those cases where there was no lumbar access, or there were contraindications. 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), where he performed 1008  procedures in 667 patients. This procedure is similar to the original midline suboccipital puncture, but it is executed using a lateral approach. The method avoids the midline suboccipital puncture and the risks of 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.