Myelography

 Myelography is an imaging examination that

involves the introduction of a spinal needle into the
spinal canal and the injection of contrast
material within in the subarachnoid space around
the spinal cord and nerve roots typically under
fluoroscopy guidance.
 Its frequency has declined in recent years as MRI
has gained widespread acceptance for most spinal
studies.
 Used when CT and MRI are not available or when
MRI is contraindicated or unacceptable to patient.
 Typically done by performing a lumbar puncture
under fluoroscopic guidance followed by the
fluoroscopically monitored introduction of a
nonionic water soluble iodinated contrast medium
into the subarachnoid space.

 Alternatively, when the lumbar approach is

contraindicated or less advantageous, the contrast
medium may be introduced into the thecal sac via a
lateral C1 / C2 puncture (cervical puncture).
 Cervical puncture is indicated:

1. Where there is severe lumbar disease – making

lumbar puncture difficult or restricting flow of
contrast media.
2. When there is thoracic spinal stenosis
3. For demonstration of upper end of spinal block

 Cervical puncture is contraindicated in cases :

1. Suspected high cervical or craniocervical pathology

2. Where normal bony land mark are distorted
 Contrast medium
 Ideal contrast medium for myelography:

- Water soluble, non-ionic, iso-osmolar with CSF

- Highly hydrophilic
- Minimal brain penetrance
- Minimal neurotoxicity and meningeal toxicity
- Rapid excretion from body
- Optimum radio-opacity and viscosity
- Easy delivery
- Acceptable price
 Ionic contrast media must never be injected
into subarachnoid space.

 Currently Iohexol, Iopamidol and Iotrolan are

used in thecal sac.
 Indications:
 Largely been superseded by CT and MRI.
 However, there remain the following indications :

1. Suspected spinal cord or conus medullaris lesions, nerve

root or cauda equina compression and spinal stenosis in
patients in whom CT is inconclusive and who are unable
or unwilling to undergo MRI
2. Demonstration of the site of a CSF leak (postlumbar
puncture headache, postspinal surgery headache,
rhinorrhea, or otorrhea).
3. Surgical planning, especially in regard to the nerve roots.
4. Radiation therapy planning
5. Diagnostic evaluation of spinal or basal cisternal
disease.
6. Nondiagnostic MRI studies of the spine or skull base.
7. Poor correlation of physical findings with MRI studies.
8. Use of MRI precluded because of:
a. Claustrophobia
b. Safety reasons, e.g., pacemaker
c. Surgical hardware
d. Technical issues, e.g., patient size
 Contraindications:
 Absolute:

1. Skin sepsis over the spinal puncture site

2. Infection of subarachnoid space or meninges

 Relative:

1. Known significant intracranial process with

increased intracranial pressure (ICP).
2. Historical or laboratory evidence of bleeding disorder or
coagulopathy.
 3. Recent myelography / lumbar puncture performed
within 1 week.
4. Previous surgical procedure in anticipated puncture site
(can choose alternative puncture site).
5. Generalized septicemia.
6. H/O significant adverse reaction to iodinated contrast
media.
7. History of seizures (patient may be premedicated).
8. Grossly bloody spinal tap .
9. Pregnancy (risk Vs benefit).
10. Medications known to decrease seizure threshold, (e.g.,
phenothiazines, tricyclic antidepressants, monoamine oxidase
inhibitors, SSRI medications) should be discontinued for at least 24
to 72 hours prior to myelography.
 Equipments:
A. Myelographic Facility: The minimum requirements for the facility
are:

1. High-quality radiographic/fluoroscopic imaging equipment with

facility for film or digital records of the examination, and a tilt table
(capable of –30 degrees of tilt in the head downward direction ) . A
proper support device for securing the patient on the tilt table should
be available.

2. An adequate selection of spinal needles and appropriate nonionic

contrast media approved for intrathecal use.

3. Appropriate facilities and equipment for treating adverse reactions

(e.g., seizure, vasovagal reactions, and/or cardiorespiratory collapse).
4. Appropriately trained personnel to provide proper patient
care and operation of the equipment.

5. A CT scanner to perform postmyelogram CT studies.

Multiplanar reconstruction capability for CT is highly desirable.

B. Surgical and Emergency Support:

- Although serious complications of myelography

are infrequent, there should be prompt access to surgical and
interventional management of complications.
 Preprocedural Patient Care/ Preparation:
1. Prior to myelography, review of previous CT &/ or MRI should
be done - should include evaluation for the position of the
conus, as well as lumbar stenosis or any other potential
hazard prior to choosing the level for LP or myelogram.

2. The patient should be asked specific questions about

relevant medications, prior seizures, prior allergic reactions,
and clotting ability.

3. Patients who are taking anticoagulants for prophylaxis of

myocardial or cerebral ischemia should discontinue this drug
for at least 5 days prior to undergoing myelography.
4. For patients with hematologic disorders or other conditions
affecting blood coagulation, a platelet count, PT, INR and aPTT
values within one week of the procedure should be available.

5. Informed consent should be obtained and documented. The patient

should be informed of the risks and the benefits of the procedure.

6. The patient should be adequately hydrated, but no food or drink

allowed for previous 3 hours.

7. Sedatives may be used in anxious patients.

 Procedure : lumbar myelography
 Preliminary film: AP and lateral view of the region under study.
 Patient position: lateral decubitus, sitting or prone.
 Aseptic precaution.
 Typically L2/L3 or L3/L4 interlaminar or interspinous space is
localized under fluoroscopy.
 Subcutaneous and intramuscular local anesthetic is
administered
 A styletted spinal needle (22G) is introduced through the
anesthetized region with bevel facing laterally.
 When the subarachnoid space is reached the stylet is slowly
removed to check for CSF return. CSF must flow freely and CSF
may be slowly withdrawn for laboratory studies if requested.
 Contrast medium is slowly administered (over 30 – 60 sec)
intrathecally through the lumbar needle under fluoroscopic control.

 Generally, the total amount of the contrast agent used for lumbar
myelography is 2000 – 3000 mg of iodine (should not exceed 3.0 gm),
which can be injected either as 10 – 15 ml of 200mgI/ml or 7- 10 ml of
300mgI/ml strength.

 Prior to removing the needle from the back, an anteroposterior

fluoroscopic “spot” image may be obtained.

 Then LP needle is withdrawn and skin puncture sealed with sterile

dressing.

 X-ray table tilted 20 degrees foot down and patient kept in prone
position.
 Radiographic Projections:
 Using intermittent fluoroscopy, table tilting, and
patient rotation, anteroposterior, oblique, and cross-
table lateral images of the region in question are
documented on film or digital media.
 First radiograph: patient prone and foot end of table
tilted 45 degrees down. (frontal)
 Prone oblique radiographs: patient rotating in own
long axis, right and left side about 15 – 25 degrees
 Lateral views
 Accessory radiographic projections:
- Lateral decubitus
- Tomography
- Erect lateral

 To show lower dorsal subarachnoid space – head

down tilt of about 5 – 10 degrees under
fluoroscopic guidance; then frontal, oblique and
lateral radiographs taken
 For cervical myelography, and in some
instances thoracic myelography : the head is
hyperextended on the neck - the table is then
gradually and slowly tilted head downward
until the opacified cerebrospinal fluid “column”
flows through the area of interest.

 Anteroposterior, oblique and cross-table

lateral images are obtained
 Postprocedural Care:

1. The patient is encouraged to remain in sitting or semi

recumbent position for about 6 hours
2. The patient should be adequately hydrated.
3. The patient should be observed following the examination.
4. If the myelogram is performed on an outpatient basis, the
patient should be properly instructed regarding limitations
following the procedure (e.g., driving).
5. Instructions regarding warning signs of adverse reactions
and the possibility of persistent headaches, including a
recommendation that the patient should be in the company
of a responsible adult for 12 hours following the procedure.
6. A physician should be available to answer questions and
provide patient management following the procedure
 Complications:
1. Headache ( d/t CSF leak), nausea, vomiting and
dizziness.
2. Lower back pain
3. Epileptic fits
4. Mental reaction: Confusion, disorientation,
confusion
5. Adhesive arachnoiditis: rare with recent contrast
agents
6. Subdural and epidural injection of contrast medium
7. Intramedullary injection of contrast medium
 CT myelography
 Involves a lumbar or cervical spine puncture
with contrast injected into the spinal canal,
followed by CT
 Should be delayed for up to 4 hours – allows
dilution of contrast.
 Turning patient few times prior to CT – even
distribution and reduces layering effect of
contrast.
 Contrast - high in attenuation and therefore
bright on CT – allowing for detailed imaging of
the spinal canal.

Indications:
• Spinal stenosis, nerve root compression
• CSF leak
• MRI inadequate or contraindicated
Advantages:
 Defines extent of subarachnoid space,
identifies spinal block

Disadvantages:
 Invasive, complications (CSF leak, headache,
contrast reaction, etc.)
 Ionizing radiation and iodinated contrast
Magnetic Resonance Myelography
 Relatively new imaging sequence which produces
myelogram like images of the thecal sac by MR imaging.

Advantages:
1. Non invasive
2. No side effect from intrathecal contrast
3. No exposure to ionizing radiataion
4. Short imaging time
5. Both the superior and inferior extent of the spinal
block are shown.
 Single shot TSE, TR 8000ms, TE 1000ms, TSE
factor 256, acquisition time 3:36

 MR myelographic images are automatically

reconstructed as maximum intensity
projections and presented as 9 consecutive
images at 22.5 degrees interval, extending
from right lateral to left lateral projection.
 Evaluation of patient with low back pain
 Assess the degree of pressure on the thecal sac and the level
of maximum pressure
 Shows focal deformity of thecal sac margin due to disc
herniation
 Helps in the better detection of foraminal disease
 Useful adjunct in the investigation of cervical spondylotic
radiculopathy (Nerve root compression)
 Evaluation of disc migration
 Facet joint hypertrophy, ligamentum flavum hypertrophy
 Evaluation of spinal stenosis – disc, facet joint , ligamentum
flavum
 Spondylolesthesis
 Post operative spine – epidural scar compressing thecal
sac.
 Thecal sac compression by tumor
 Evaluation of spinal cysts
 Diagnosis of arachnoid adhesions
 Dural vascular malformation
 Spinal infections, trauma – compression of thecal sac
 Congenital malformations – Meningocele,
Meningomyelocele, diastometamyelia, Chiari
malformations