Lateral cervical puncture for myelography. Technical note

C1 Posterior Arch Flare Point: A Useful Landmark for Fluoroscopically Guided C1-2 Puncture

BACKGROUND AND PURPOSE

The C1-2 intrathecal puncture is routinely performed when lumbar puncture is not feasible. Usage has steadily decreased in part because of the perceived high risk of injury to the cervical cord. Up to this point, vague fluoroscopic guidelines have been used, creating uncertainty about the actual needle location relative to the spinal cord. We present a novel osseous landmark to aid in C1-2 intrathecal puncture, corresponding to the posterior spinal cord margin on lateral fluoroscopic views. This landmark, which we have termed the "flare point," represents the triangular "flaring" of the posterior C1 arch at its junction with the anterior arch.

MATERIALS AND METHODS

Cervical spine CT myelograms were reviewed. High-resolution axial images were reformatted into the sagittal plane, and maximum-intensity-projection images were created to simulate a lateral fluoroscopic view. Tangential lines were drawn along the superior cortices of the anterior and posterior C1 arches, with the point of intersection used to approximate the flare point. Chart review was performed for all C1-2 punctures using the flare point technique in the past 3 years.

RESULTS

Forty-two cervical myelograms were reviewed. The average flare point was 0.2 ± 0.5 mm posterior to the dorsal spinal cord margin. In 37/42 subjects, the flare point was localized posterior to the spinal cord. Targeting by means of the flare point was used in 16 C1-2 punctures without complications.

CONCLUSIONS

The C1 posterior arch flare point accurately approximates the dorsal spinal cord margin on myelography. Targeting between the flare point and the spinolaminar line, at the mid-C1-2 interspace, allows safe and optimal needle positioning.

Cervical subarachnoid catheter placement for continuous cerebrospinal fluid drainage: a safe and efficacious alternative to the classic lumbar cistern drain

BACKGROUND

Cerebrospinal fluid (CSF) drainage serves an important role in the management of patients with established or potential CSF fistulae. Classically, a lumbar CSF drain has been used for this purpose and has been shown to be safe and effective. In certain cases, such as extensive previous lumbar surgery, a lumbar drain cannot be used. In such instances, a cervical CSF drain can be inserted via a lateral C1-2 puncture and provides an excellent and safe alternative.

OBJECTIVE

To describe the technique, safety, and effectiveness of placing a cervical drain for CSF drainage. Pitfalls and possible complications and their avoidance are also discussed.

METHODS

Twenty-seven cervical drains were placed in 24 patients with a mean age of 56.1 years (range, 19-82 years). There were 13 women and 11 men. All cervical drains were placed via a lateral C1-2 puncture under direct fluoroscopic vision. A standard Hermetic closed-tip lumbar catheter was used in all cases. The drains were in place for an average of 5.96 days (range, 3-11 days). CSF surveillance was performed on the day of placement as well as every 48 hours that the drain was in place.

RESULTS

Cervical drain placement was achieved in all cases, allowing for continuous CSF drainage. No permanent procedural complications occurred. There were no instances of meningitis.

CONCLUSIONS

Placement of a cervical intrathecal catheter for CSF drainage is a safe and effective alternative when lumbar access is contraindicated or not achievable.

Subarachnoid hematoma, hydrocephalus, and aseptic meningitis resulting from a high cervical myelogram

Despite its reduced use since the advent of magnetic resonance imaging, the high cervical myelogram remains a common diagnostic test in the evaluation of patients whose symptoms suggest cervical stenosis. We report a case of subarachnoid hematoma, hydrocephalus, and aseptic meningitis after a high cervical myelogram. A 52-year-old woman presented with headache, slurred speech, worsened neck pain and stiffness, and diffuse extremity weakness leading to gait instability beginning several hours after a cervical myelogram. Computed tomography (CT) scan revealed a C1-C2 hematoma below the dura, blood in the fourth and lateral ventricles, and hydrocephalus. An external ventricular drain was placed, and cerebrospinal fluid profile was consistent with aseptic meningitis. A suboccipital craniectomy and C1-C2 laminectomies were performed, followed by a C1-C2 durotomy, which revealed a large subarachnoid blood clot in the region of the cisterna magna extending down to the upper aspect of C2, which was evacuated by incising the arachnoid. In the midline at C1, an active source of intramedullary arterial bleeding on the dorsal surface of the spinal cord was coagulated. Spinal subarachnoid hematoma is a rare complication of high cervical myelogram. The extension of blood into the ventricular system with associated hydrocephalus has never been previously reported after myelography. Thus, severe persistent pain after cervical myelography should be evaluated by CT scans of the brain and cervical spine.

Intramedullary injection of contrast into the cervical spinal cord during cervical myelography: a case report

STUDY DESIGN

A case of iatrogenic intramedullary contrast injection during a C1-C2 cervical myelography is reported.

OBJECTIVE

To investigate the occurrence of iatrogenic intramedullary contrast injection during a current C1-C2 cervical myelography.

SUMMARY OF BACKGROUND DATA

Intramedullary injection of contrast is a rare but serious complication of C1-C2 cervical myelography that has not been reported since the widespread use of magnetic resonance imaging and the NASCIS III study protocol.

METHODS

A 39-year-old woman received an iatrogenic intramedullary contrast injection during a C1-C2 cervical myelography.

RESULTS

During the procedure the patient reported right-side face, neck, and arm pain and parethesias. After the procedure, right arm weakness and diffuse hyperreflexia developed. Postmyelography imaging demonstrated intramedullary contrast and cord swelling. High-dose methylprednisolone was administered intravenously and the patient's symptoms improved. The literature and management of this rare complication are reviewed.

CONCLUSIONS

Intramedullary cord injection is a rare complication of cervical myelography. The mechanism of spinal cord injury appears to involve a combination of physical compression from the injected liquid and neurotoxicity of the contrast material. Iohexol rather than metrizamide should be used when C1-C2 myelography is indicated in patients who are unable to undergo magnetic resonance imaging, or those whose pathology is inadequately demonstrated magnetic resonance imaging alone. In the event of contrast injection into the spinal cord, administration of high-dose methylprednisolone is recommended.

[Lateral cervical puncture for myelography and cerebrospinal fluid collection: technical note]

The lateral cervical puncture for myelography or cerebrospinal fluid collection is a modification of the technique of percutaneous cervical cordotomy. It may be performed at the atlanto-axial or atlanto-occipital interspace. It is simple to perform, and appears to be safer and more easily mastered than suboccipital puncture, with no more discomfort to the patient than that associated with lumbar puncture.

Ketoconazole treatment of coccidioidal meningitis

Fifteen patients with coccidioidal meningitis were treated with high doses of ketoconazole for up to 4 years. Five patients were treated with ketoconazole alone. One clinically failed, one developed hepatotoxicity, and three achieved remission of meningitis. One patient received intrathecal AMB in addition to ketoconazole for only 2 weeks before continuing on ketoconazole alone. He improved, but discontinued ketoconazole because of nausea and vomiting, and suffered a lethal relapse. Nine patients received ketoconazole in combination with prolonged courses of intrathecal AMB. Two patients were failures from nausea and vomiting, and the remaining seven either improved or experienced remission. The clinical responses appeared to be similar in patients receiving high-dose ketoconazole, either alone or combined with AMB, suggesting that there is no clinically significant antagonism of the drugs. Nausea and vomiting are significant limitations of high-dose ketoconazole. Ketoconazole alone is effective in some patients with coccidioidomycotic meningitis.

Symptomatic duplication of the vertebral artery

A case is presented of extracranial duplication of the vertebral artery in a patient who had spinal cord symptoms for 26 years. Vertebral angiograms and computed tomography with metrizamide enhancement demonstrated a bypass artery of the duplication compresing the upper cervical spinal cord intradurally at the level of the atlas; this finding was verified at operation. The symptomatology and clinical significance of this rare case are discussed.

Vascular anatomy in the suboccipital region and 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.

Cervical and lumbar routes for metrizamide cervical examination

The C1-C2 lateral spinal puncture for metrizamide injection is compared to decubitus lumbar puncture for cervical myelography. By lumbar route, the contrast medium was taken into the cervical region with the patient prone. The instances when the lumbar route could not be used include cervical spinal trauma, spinal deformity, and lumbar epidural infection. Routine metrizamide cervical myelography by the C1-C2 route has better film quality and probably fewer short-term adverse reactions than use of the lumbar route of injection.

Selective anterior cervical gas myelography by the lateral approach

In order to observe pathological changes in the anterior cervical subarachnoid space with the least disturbance to the patient by gas myelography, needle puncture into the cervical spinal subarchnoid space was performed between the arch of C1 and the lamina of C2 with the patient in a horizontal supine position, gas was introduced selectively into the anterior cervical spinal subarachnoid space.

Discography and myelography in acute injuries of the cervical spine

✓ Nineteen patients who suffered trauma to the cervical spine that resulted in moderate to severe neurological deficit were studied by discography. In 15 cases, myelography was also performed. When both tests were done there was good correlation of results. In the four cases where only discography was performed, the lesion was accurately localized. The danger of myelography in acute cervical fracture dislocation is emphasized and the relative safety, ease, and value of discography stressed.

Continuous simultaneous monitoring of intraventricular and cervical subarachnoid cerebrospinal fluid pressure to indicate development of cerebral or tonsillar herniation

✓ A simultaneous continuous recording of intraventricular and cervical subarachnoid cerebrospinal fluid pressures was made in each of 20 patients who were comatose or decerebrate. All patients with a pressure gradient greater than 10 mm Hg died and at autopsy were found to have evidence of severe transtentorial and/or tonsillar herniation.