CT-guided thoracic cerebrospinal fluid puncture as an alternative approach when conventional approaches fail.

Abstract

Lumbar puncture (LP) is the most common approach for cerebrospinal fluid (CSF) access, but anatomical abnormalities may prevent this safe procedure. We describe the use of CT-guided thoracic puncture in a patient whom conventional lumbar and cervical approaches were unsafe and discuss procedural safety considerations. A patient with history of meningomyelocele and Chiari malformation presented with suspected meningitis requiring CSF analysis. Standard LP and cervical puncture were considered unsafe due to patient's complex anatomy. Therefore, a CT-guided thoracic puncture was performed to obtain CSF. Procedural planning, imaging guidance and safety measures were utilized to minimize the risk of spinal cord injury and other complications. CT-guided thoracic puncture was successfully performed using a carefully planned oblique approach, allowing acquisition of adequate CSF for diagnostic evaluation. The procedure was completed without immediate or delayed complications. Although thoracic puncture is generally considered a high-risk procedure, it may represent an effective alternative in selected patients with contraindications to lumbar or cervical puncture. However, the absence of complications in this single case does not establish the safety of this approach and this procedure should be performed by experienced physicians after careful assessment of patient's anatomy.