Chapter IV: Percutaneous Puncture of Spinal Cord Cysts

Acta Radiologica: Diagnosis ISSN: 0567-8056 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iard19 Chapter IV: Percutaneous Puncture of Spinal Cord Cysts To cite this article: (1966) Chapter IV: Percutaneous Puncture of Spinal Cord Cysts, Acta Radiologica: Diagnosis, 4:sup252, 51-62 To link to this article: https://doi.org/10.1080/05678066609169976 Published online: 04 Jan 2010. Submit your article to this journal Article views: 9 View related articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=iard19 Download by: [37.44.193.70] Date: 23 December 2017, At: 18:17

CHAPTER IV PERCUTANEOUS PUNCTURE OF SPINAL CORD CYSTS Downloaded by [37.44.193.70] at 18:17 23 December 2017 After it had been found that cysts can be diagnosed by gas myelography it seemed logical to consider the possibility of puncturing them percutaneoudy. Percutaneous puncture of spinal cord cysts has not been previously reported. The technical equipment used for the procedure has been described in Chapter 11, p. 20. Nine pecataneous cyst punctures have been performed and these will be discussed in chronological order. Puncture 1. (Sept. 2, 1964). Case 17. Gas myelography (Figs 16, p. 26 and 22, p. 31). Immediately after a repeat gas myelography the patient was placed on the table in the supine position with the head lowered and the feet elevated. The movements in the greatly dilated cervical cord were followed on the television screen. Fluctuations in the cyst were observed with movements of the patient s head. The puncture needle was inserted in a straight line from the back, between the vertebral arches of C3 and C4. The midline position of the needle was checked in a frontal projection just before the spinal cord was punctured. The patient experienced slight transient pain in the right arm when the needle pierced the cyst wall, but had no further discomfort. A roentgen film revealed that the cervical cord had collapsed after 12 ml of fluid had been aspirated from the cyst (Fig. 28, b, c). Puncture 2. (Nov. 28, 1964). Case 16. The puncture was performed in the same way as in the preceding case, the needle being inserted between the vertebral arches of C3 and C4. Ten ml of clear fluid were aspirated from the cyst and 3 ml of gas were injected. The thin cyst wall was seen between the gas in the cyst and the gas in the subarachnoid space (Fig. 29). Puncture 3. (Jan. 29, 1965). Case 19. The puncture was performed in the same way as in the two preceding cases, with the needle between the vertebral arches of C3 and C4. Ten ml of clear cyst fluid were aspirated. Puncture 4. (April 6, 1965). Case 18. Gas myelography (Figs 14, 17 and 18, pp. 24, 27 and 28,). The puncture was made at the level of the upper part of the vertebral body of C3, and 10 ml of fluid were aspirated. Three ml of gas were 51

Fig. 28. Puncture 1. Case 17. Hydromyelia. Puncture during gas myelography. Before (a) and after (b) percutaneous puncture of cyst with aspiration of its contents. c) Tomography after aspiration. Cyst empty. 52

\ Fig. 29. Puncture 2. Case 16. Hydromyelia. Gas in both subarachnoid space and cyst shows thickness of cyst wall. \/* Fig. 30. Puncture 4. Case 18. Hydromyelia. Gas present only in upper, peaked portion of cyst. Head of patient was raised approx. 41'. 53

a t b Fig. 31. Puncture 1. Case 24. Cystic tumor. a) Gas in cyst only; patient in sitting position. Upper pole rounded at level of C3-C4. b) Cyst superimposed on gas myelogram. injected into the cyst. The head of the table was then raised about 45" (Fig. 30). No communication with the fourth ventricle was observed. In puncture interventions 2, 3 and 4 only a small amount of air was injected, and no attempt was made to demonstrate the caudal limit of the cyst. The patients were all selected from the group with considerable fluctuations in the entire lesion. Puncture 5. (May 6, 1965). Case 24, p. 46. (This patient was from Group 3, with only slight fluctuations.) Gas myelography (Fig. 25, p. 47). The needle was inserted between the vertebral arches of C5 and C6; 15 ml of yellow, cloudy cyst fluid were aspirated and coagulated spontaneously. The impression gained at the puncture was that the pressure in the cyst was increased, since the drip rate was fairly rapid at first. Four ml of gas were injected into the cyst, 54

a Fig. 32. Intramedullary tumor. a) Axial tomography at level of foramen magnum. Intramedullary growth. b) Lateral projection. Tumor extends above foramen magnum. whose upper and lower limits were determined with the patient in the high and low pelvic and in the sitting position (Fig. 31). Following the cyst puncture, the patient s symptoms gradually subsided, and nine months later she was almost asymptomatic and returned to work. Puncture 6. (Aug. 8, 1965). A 39-year-old woman with rapidly progressing walking difficulties, leg weakness, spasms, and incontinence. Paresthesia and numbness in the left hand. At a gas myelography (Fig. 32) no films were taken with variation in the patient s position. An axial tomographic view of the upper cervical cord revealed an intramedullary expanding process extending up beyond the foramen magnum (Fig. 33). A markedly swollen, spindle-shaped cervical cord filling up the entire dural sac was found at operation. Puncture yielded a

-J 3 I b \ Fig. 33. Puncture 6. Same case as in fig. 32. Irregular cyst. a) Upper pole. b) Lower pole. yellowish, viscous fluid. An incision made in the midline revealed no macroscopic tumor tissue. Following slight improvement, spastic paraplegia with con- 56

.- Fig. 34. Puncture 7. Case 16. Hydromyelia. Same case as in fig. 29. Pressure curve during cyst puncture. Absence of pulsations at section between arrows indicates that needle lay against the cyst wall. Pulsations in subarachnoid space (left) and in cyst (right). Downloaded by [37.44.193.70] at 18:17 23 December 2017 a l Fig. 31. Puncture 7. Case 16. Hydromyelia. a) Upper part of cyst. Patient in sitting position. b) Upper part of cyst superimposed on gas myelogram. b tractures developed. The patient was re-admitted, a complete invalid, three years later. As it was already known from the previous operation that a cyst was present in the cervical region percutaneous Puncture was undertaken in an attempt to prevent further progression. This patient was examined without gas in the subarachnoid space. Fifteen ml of yellowish viscous fluid were aspirated, and 4 ml of gas were injected. The cyst extended from the level of C1 to Th3 (Fig. 33). 57

' \ Fig. 36. Puncture 7. Case 16. Hydromyelia. Same case as in fig. 35. Central canal widens at ventriculus terminalis. l'unctures 1 to 5 were performed in conjunction with gas myelography. For the sixth puncture, the latter procedure could not be performed for technical reasons. The cyst was purposely punctured without using gas myelography in the following three cyst punctures, to measure the pressure inside and outside the cyst under as normal conditions as possible. Puncture 7. (Aug. 11, 1965). Case 16 (same case as in Puncture 2). The punciuring technique was the same, and the pressure was measured with the equipment 58

Fig. 37. Puncture 8. Case 17. Same case as in figs 16 and 39. Hydromyelia. Upper part of cyst superimposed on gas myelogram. described in Chapter 11, p. 20. The curve obtained (Fig. 34) proved that the pressure in the cyst was practically the same as in the subarachnoid fluid. When the needle reached the cyst wall the pulsations disappeared and the pressure fell. When the cyst wall was pierced the pulsations returned and a rise in pressure was recorded. After the pressure recordings were terminated 7 ml of gas were injecte d into the cyst and roentgen films were taken with the patient sitting (Fig. 35 a) and in the high pelvic position (Fig. 36). The films revealed hydromyelia, with gas filling of the central canal and the ventriculus terminalis. In Fig. 35 b, the upper part of the cyst has been superimposed on the view obtained at the earlier gas myelography. Puncture 8. (Aug. 12, 1965). Case 17 (same as in Puncture 1). The procedure was the same at both punctures, and 10 ml of cyst fluid were aspirated and 8 ml of air injected. The upper (Fig. 39 a) and lower limits (Fig. 38) of the hydromyelia agreed with the findings at gas myelography (Figs 16 and 22). Puncture 9. (Sept. 22, 1965). Case 20. Gas myelography. The site of the puncture was between the vertebral arches of C3 and C4 and approximately 15 ml of cyst fluid were aspirated. After withdrawal of fluid the needle position in relation to the cyst was uncertain. For this reason no more gas was injected. The pressure curves in the last three punctures were similar. 59

Fig. 38. Puncture 8. Case 17. Hydromyelia. Caudal end of cyst terminates a few centimeters above the cauda. (Cf. fig. 22, p. 31.) Comments. In two patients (Punctures 7 and 8) an investigation was carried out to ascertain how the gas in the cyst was resorbed. The patients were ambulant, and were examined in the sitting position. The results obtained are shown in Fig. 39. These results have been discussed in connection with GARDNER S theory @. 40). When the puncture is being performed, an increased resistance, which suddenly ceases, is experienced as the needle pierces the dura. On the other hand, no resistance is felt as the cyst wall itself is pierced. It might be expected that when the subarachnoid space is filled with gas it should be possible to observe the needle tip passing through the dorsal cyst wall. However, this was not possible, since the posterior wall of the cyst is at first lifted up slightly by the needle tip. Image amplification with television monitors is essential to allow continuous observation of the puncturing procedure. The ability to check the midline position of the needle is equally important. 60

a l b f c I Fig. 39. Puncture 8. Case 17. Hydromyelia. Gas in cyst only. Films taken immediately after puncture (a), after 24 hours (b) and after 6 days (c). Gradual decrease in sagittal diameter. Discussion All punctures except no. 5 were carried out without general anesthesia. General anesthesia was used in this patient because she was very nervous and could not cooperate. The procedures caused no discomfort except in one patient who noted transient mild pain radiating to one arm. The injection of the air also caused no difficulty. No neurologic or other complications arose, either during or after the cyst puncture. The patient described under Puncture 5 (Case 25), who had a cystic tumor, was markedly improved both subjectively and objectively. In the patient with paraplegia (Puncture 6), no improvement could be expected, but the spasticity decreased slightly. In the other patients, all of whom had hydromyelia, no objective improvement in the clinical status was noted. Slight subjective improvement was reported, however, by 2 patients. None of the patients became worse as a result of the puncture. The presence of an intramedullary expanding process showing fluctuations in shape should be established with complete certainty by roentgenography prior 61

to attempted cyst puncture. There are, of course, cases where some uncertainty is felt as to whether the process is cystic or not. If there is a suspicion that the lesion is an inflammatory process puncture should not be attempted. Conclusions Both hydromyelia and tumor cysts may be punctured percutaneously for diagnostic as well as for therapeutic purposes. 62