Myelography

9/30/10 online ed.

 Central nervous system

2 basic parts- What

are they?

Brain

Spinal Cord
 The Brain
Composed of outer
portion of gray
matter called?

Cortex

Inner portion- white

matter
 The Brain
► Forebrain-largest part of
brain known as?
 Cerebrum
 Divided into lobes and
lobules by sulci

► Midbrain
 Connects cerebrum to
pons and cerebellum
 Hindbrain

Cerebellum-
largest part of
hind brain

Pons

Medulla
oblongata
 Spinal Cord
► Continuouswith
medulla oblongata

► Extendsfrom brain to
approximately L2

► Connected to 31 pairs
of spinal nerves
 The Meninges
► Layered coverings of brain and
spinal cord

► Pia mater- inner sheath

 Highly vascular
► Arachnoid- central sheath
 Separated from pia mater by
subarachnoid space
► Dura mater- outer sheath
 Outermost, protective layer
 Ventricles-
4 fluid-filled cavities within the brain
What is that fluid?

Cerebral spinal fluid (CSF)

Two upper pair are identical, known as

left and right lateral ventricals

3rd Ventrical- just inferior to body of

lateral ventricals

4th Ventrical located in hindbrain

All ventricles communicate with each
other through special connecting
channels known as interventricular
foramina
 Pneumoencephalography
► Introduced in 1919

► Performed extensively throughout late

20th century

► Cerebrospinal fluid -a small amount

drained from around brain and replaced
with air, oxygen, or helium as contrast
to allow the structure of brain to show
up more clearly on an X-ray

► Derived from cerebral

ventriculography- air is injected
through holes drilled in skull

► Pt turned upside down in special chair

that can rotate vertically 360 degrees to
get air to fill ventricals
 Pneumoencephalography cont’d

► Extremely painful, very dangerous

► Test was generally not well tolerated by pts-

headaches and severe vomiting common side effects

► Replacement of spinal fluid was by natural

generation- took as long as 2-3 months

► MRI and CT have largely replaced

Pneumoencephalography.
 Myelography-
Radiographic exam of spinal cord
X-ray examination performed
by radiologist to detect
abnormalities of the spine,
spinal cord, or surrounding
structures
Contrast material is injected
into the fluid-filled space
around spinal cord
X-rays are taken
 Myelogram cont’d

► Air used for early myelograms

 Injected via lumbar puncture

► In 1922, iodized poppy seed oil was used

 Accidentally discovered with no apparent side effects

► Nonionic, water-soluble compounds now used

 Demonstrates a low neurotoxicity

► CT and MRI now chiefly used to image nervous

system
 Myelography
► Injections can be given at:

 Cistern (below occipital bone -can be

hazardous because the needle is inserted
close to brain stem)

 Cervical spine

 Thoracic spine

 lumbar region (most

common)

► Injection is in subarachnoid
space –which is?

 (space between arachnoid and pia

mater)
 Myelography Indications

► Intraspinal abnormalities

► Nerve root abnormalities

► Disk prolapse (slipped disk), herniation

► Spondylosis- degenerative arthritis of spinal vertebra and related tissue

► Spondylolisthesis

► Spinal stenosis (spinal canal narrows and compresses spinal cord and nerves)

► Tumors

► Metastases
 Myelography Contraindications
► Central aneurysms-(balloon-like bulge in an artery caused
by weakening of artery wall)

► Arterio-venous malformations

► lumbar puncture within one week

► Previous reaction to contrast

 Preliminary Radiographs
► Purpose
 Determine accurate bony
anatomy

 To exclude pathologies that

wouldn’t need myelography

 Distinguish congenital
abnormalities

 For correlation with

myelography, MRI and CT
images when reporting
 Preliminary Radiographs
 AP

 Lateral

 Both anterior oblique views to

demonstrate pars interarticularis (neck of
Scotty dog)

 Lateral L5-S1
 Contrast Media

► Iohexol – Nonionic, water-soluble contrast

► Iotrolan (Isovist) – More recent contrast agent

 Less toxic than Iohexol
 Procedure Sequence
► Prepare room, sterile trays, and contrast

► Pt placed prone on table

► Area to be punctured is cleaned and prepped with

sterile towels

► Local anesthetic injected in area of puncture

 Procedure Sequence (cont’d)

► Lumbar puncture
needle inserted
under fluoroscopic
guidance until fluid
appears

► CSF may be taken

for analysis
 Procedure Sequence (cont’d)

► Contrast material injected

► Flow monitored
fluoroscopically

Pt. tilted into trendelenberg

and reverse-trendelenberg
to control flow of contrast
during spot films
Overheads
 Radiographs taken during exam:

Generally, cross table

lateral and PA

Why not routine views?

Pt has needle in spine

Don’t want to change
contrast position by rotating
pt
Lumbar Myelogram

PA Lateral
 Myelography accuracy rate

When compared with surgical findings:

MRI – 96%
Myelography – 81%
CT – 57%

CT and Myelography together - 84%

Cervical
Myelogram
Set-Up for Lateral Cervical Film
 Cervical Radiographs

► Overheads
 PA
 PA Oblique projections
 Cross-table lateral films
 Alternative Radiographs
► Lateral flexion/extension

Demonstrates:

►Stenosis

►spinal instablility

►deg. of movement of disk protrusion

 Patient Care Concerns

► Maintainhead in acute extension during

examination!

► Bedrest 8 – 24 hours after procedure with head

elevated

► Encourage hydration
Possible Post-Procedure Complications

 Headache

 Hypotension- which is?

Low blood pressure

 Convulsions

 Confusion/hallucinations!
Advanced Imaging Techniques
 Diskography
► Radiographic exam of
intervertebral disks

► Contrast is injected
directly into disk
 Determines disk
morphology
 Reproduces pain caused
by disk disease itself
Diskogram Films
 CT Brain Scan

► Often 1st to evaluate head

and spine trauma
► Very accurate
diagnosis of acute
intracranial injuries
 Contusions
 Hemorrhage
 Fracture evaluation
 MRI (Magnetic Resonance Imaging)

► In brain for assessing:

 Middle and posterior cranial

fossa abnormalities
 Acoustic neuromas
 Pituitary tumors
 Primary and metastatic
neoplasms
 Hydrocephalus
 AVMs
 Brain atrophy
 MRI
► In spine-for assessing:
 Demyelinating disease-
(any condition resulting in damage
to the protective covering (myelin
sheath) that surrounds nerves in
brain and spinal cord)
 Spinal cord compression
 Paraspinal masses
 Postradiation therapy
changes in spinal cord
tumors
 Metastatic disease
 Herniated disks
 Congenital anomalies