Myelography

What is Myelography
An x-ray exam of the spinal cord and the
fluid-filled space surrounding it.
X-ray film is taken after injecting a contrast
medium through a needle into the
subarachnoid space surrounding the cord.
A myelogram may be used to find a variety
of different problems.
 A Myelogram may find...
Blockages in the spinal canal that may be
caused by a tumor or by a ruptured spinal disc
Inflammation of a membrane covering the
brain and spinal cord
Difficulties in blood supply to the spinal cord
Abnormalities of the spinal cord and the nerves
that branch off from it
 Myelography
By defining the level
and extent of
abnormalities,
myelography is an
important method of
diagnosis for physicians,
particularly
neurosurgeons who need
to locate pathologies for
surgical treatment.
Most often a myelogram
will be performed in
conjunction with a
computed tomography
scan or a magnetic
resonance imaging scan
to provide the most
adequate information
possible.
 Indications
A patient experiencing pain or numbness-
may be an indicator of a lesion within the
spinal canal or protruding into the spinal
canal.
These lesions could be both benign and
malignant tumors, cysts, herniated nucleus
pulposus, and extradural masses or bone
fragments caused by trauma.
 Commonly...

Most myelograms are performed in the

cervical and lumbar regions because the
greatest amount of pathology and trauma occur
here.
A herniated nucleus pulposus is the most
common pathologic finding of myelography.
Symptoms include numbness, pain , or a
burning sensation in particular areas of the
body, especially in the extremities.
 Contraindications
Sensitivity to iodine or
contrast media
Arachnoiditis
The presence of blood in
the cerebral spinal fluid
Abnormal intracranial
pressure
A spinal puncture
performed within two
weeks of the myelogram
Furthermore, bleeding
abnormalities, such as
elevated prothrombin and
partial thromboplastin
times, decreased platelet
count, or patients on
anticoagulation therapies
should also abstain from
a myelogram.
 Preprocedural Care
Thorough explanation of the procedure by
the performing physician.
Signed informed consent by the patient.
The patient will then be asked to do several
things before the exam
 Patient is asked to
Stop smoking the day Have a clear liquid
before the exam and breakfast two hours
on the day of the before the procedure
exam. (tea, apple juice, broth,
Drink 4-8 ounces of etc.).
fluid every hours Empty bladder just
while awake starting at prior to procedure.
noon the day before
the exam.
 DRUGS
Since most patients exhibit apprehension,
fear and anxiety of the exam, a sedative or
muscle relaxant is prescribed 1 hour prior to
starting the procedure.
A common drug and dosage used is 10 mg
of diazepam (Valium) given
intramuscularly.
 Equipment
Sterile tray includes:
Radiographic- contrast medium, anti-
fluoroscopic room septic solution, sterile
90-degree two-way tilt gloves, basins, three prep-
table with footrest, sponges, band-aid, towels,
ankle boots, and gauze sponges, fenestrated
shoulder supports drape, 5 and 20 ml syringe,
Prep razor 18, 22, and 25 g needles,
Lab requisitions 18 g spinal needle,
extension tubing, local
Positioning sponges
anesthetic, and test tubing.
 Injection Procedure
Most common puncture sites are the lumbar and
basal cistern regions. Lumbar is safest.
Radiologist uses fluoro to locate the best
placement for the needle.
Puncture site is shaved and cleaned with Betadine
and the fenestrated drape is centered on the
puncture site.
The skin and underlying tissue are injected with a
local anesthetic.
 Injection Procedure
Patient is positioned lying on one side with knees
drawn up and chin tucked into the chest while the
spinal needle is inserted.
This position allows the spaces between the
vertebrae to open up.
The spinal cord ends at the interspace between L-1
and L-2, so commonly the needle is inserted well
above, at L-3, L-4.
Radiologist uses fluoro to guide the needle into the
subarachnoid space.
An indication that the needle is in the correct place is
a backflow of CSF through the needle.
 Injection Procedure
Once the needle is in place, CSF will be collected
and sent to the lab for analysis.
The physician will then slowly injected the
iodinated contrast agent, watching with fluoro for
abnormalities within the spinal canal.
After contrast is administered, the needle is
removed and the radiographer is ready to position
the patient to take images of the contrast filled
subarachnoid space.
 Contrast Media
An ideal contrast The 3 most common
medium: types used in
Mixes well with CSF myelography are:
Is readily absorbed by Air or gas
the body
Oil-based
Is nonreactive with
body substances or to Water-soluble
the patient
Provides good
radiopacity.
 Air or gas contrast
Rare
Sometimes employed when the patient has a
sensitivity to iodine
Causes no known patient reactions
Inadequate radiopacity under fluoroscopy
Difficult to move in the spinal canal
 Oil-based contrast
Used in mid1940s till early 1980s
Good radiopacity but poor visualization of
nerve roots
Major drawback: the contrast had to be
removed from the spinal canal after the
exam because it was not readily absorbed or
excreted by the body
Frequently associated with arachnoiditis
 Water-soluble contrast
Widely preferred today because: low
viscosity, excellent visualization of nerve
roots, and it is rapidly absorbed and
excreted by the body within 48 hours
Only drawback is that the filming
procedures must be performed immediately
because the contrast is absorbed so quickly.
 Filming and Positioning
Under fluoro, the table
and patient are tilted
from upright to
trendelenburg to
facilitate flow of contrast
to area of interest
In trendelenburg,
patients chin must
remain hyperextended to
prevent contrast from
entering the head.
Once spot filming is
completed, routine
radiographs are taken by
the radiographer
Positioning is dictated by
the area of interest
Radiologist tilts the table
to pool the contrast at the
appropriate level for
routing filming
AP and Lateral view of the
lumbar spine
 Post Procedural Care
Once the spinal needle is removed, the puncture
site should be bandaged
Patient should maintain a semi-erect position of
15-30 degrees for the first 8 hours following the
procedure
Fluids and foods are encouraged to help eliminate
contrast from the body and prevent headaches
Patient is asked not to engage in strenuous
physical activity or bend over for one or two days
 Complications
Headaches are the most
common complication. They
are caused by the passage of
air through the subarachnoid
space into the ventricles of
the brain.
A totally erect position
should be avoided during and
after the procedure.
Rest and increased fluid
intake will usually relieve a
mild headache.
Other rare complications may
include: nausea, obscured
visualization due to the
contrast injected into the
wrong space, and irritated
nerve tissue.
Rare contrast media reactions
include: headache, nausea,
vomiting, chest pains,
abnormal heart rates, changes
in blood pressure, seizures,
aseptic meningitis, allergic
symptoms, and central
nervous system abnormalities.
 Conclusion
Myelography may be done in either a
hospital x-ray department or an outpatient
radiology unit.
For patients who cannot have an MRI,
myelography will usually be performed.
A CT scan is almost always performed
immediately after the exam while the
contrast is still present in the spinal canal.
This combination of imaging studies is
known as CT myelography.
 Conclusion
Myelography usually takes about 30 to 60
minutes to complete and a CT scan can add
another 30 to 60 minutes to the total examination
time.
Myelography is more expensive than CT and
MRI done alone because of the likelihood of the
extra expense of the hospital stay for patient
observation.
In some cases, myelography will show the cause
of pain and other spinal symptoms even when a
CT scan and MRI is negative.