Lumbar myelography with amipaque.

In lumbar myelography, early side effects occur in about half the patients examined with modern water-soluble contrast media. At myelography with Amipaque (metrizamide) these reactions are usually minor, and serious adverse reactions are rare. In our own series of 650 consecutive lumbar myelographies with Amipaque there were no serious adverse effects. Minor adverse reactions occurred in 56% of the patients. Transient electroencephalogram (eeg) changes were seen in 14% of the patients, with only 5 patients showing paroxysmal spike activity. Adhesive arachnoiditis following lumbar myelography occurs significantly less often with Amipaque than with any other contrast medium. The properties of Amipaque provide excellent possibilities for detailed studies of all parts of the spinal subarachnoid space, and the medium constitutes a new and interesting aid for these investigations.     

Outpatient lumbar myelography. Analysis of complications after myelography comparing outpatients with inpatients

Over a 2-year period, 92 patients were submitted as outpatients to lumbar myelography using lopamidol, a new nonionic water-soluble contrast medium. The incidence and severity of adverse reactions associated with myelography in these cases were compared with those in 116 patients who underwent lopamidol myelography as inpatients. The hospitalized patients received 10 ml, and the outpatients 8 or 10 ml of contrast medium (300 mg l/ml). The severity of complications was graded as very mild, mild, moderate, or severe. The complication rate was 37% in the hospitalized patients and 40% in the outpatients. Adverse reactions, mostly in the form of headache, were very mild in approximately two thirds of cases in each group, and moderate or severe in 15% of the inpatients and 24% of the outpatients presenting complications. The incidence of moderate or severe reactions was lower in the outpatients receiving 8 ml of contrast medium compared with those given 10 ml. lopamidol lumbar myelography performed on an outpatient basis is a safe procedure. The outpatient regimen considerably reduces the cost of myelography and indirectly increases the availability of beds in orthopaedic and neurologic units.     

Magnetic resonance myelography (MRM) as a spinal examination technique

Summary Purpose: Conventional myelography involves side effects and complications due to puncture of CSF space and injection of contrast medium. On the other hand, MR-myelography (MRM) is a new noninvasive method requiring neither puncture nor contrast medium and causing no side effects. The diagnostic value and accuracy of MRM was evaluated in comparison with conventional myelography. Materials and methods: In this prospective comparative study, 41 patients (17 male, 24 female, mean age 42 years) with radicular symptoms underwent conventional lumbar myelography and were also submitted to MRM. Evaluation was performed in a blind manner by two independent examiners. Results: The specificity and sensitivity of the methods are identical. MRM shows 35 cases of thecal indentation with amputation of a nerve root sheath and 6 cases of spinal stenosis. The results of conventional myelography and MRM were surgically confirmed in 38 patients. Conclusions: Both methods have the same diagnostic accuracy, but MRM requires neither puncture nor contrast medium nor x-rays.     

Experiences with the contrast medium metrizamid in lumbar and thoracolumbar myelographies (author's transl)]

At the orthopaedic clinic in Ratingen we investigated between November 1976 and May 1977 60 patients who were suffering from low back pain by means of myelography in order to verify the type of pathology. As contrast medium we used Metrizamid. All X-rays showed a clear outline of the spinal canal and the roof sheat. In 39 cases out of 60 a prolapsed disk was found. In 9 cases the result was uncertain and the rest was negative. Operation was carried out on 42 patients and the findings in 37 cases were conclusive. No severe side effects were found which were due to the contrast medium.     

Metrizamide myelography in patients with iodine allergy or previous adverse reactions to iodinated contrast media

Twenty-seven metrizamide myelographies were performed in 26 patients who had a history of iodine allergy or adverse reactions to iodinated contrast media. Three of the patients had had adverse reactions from a previous myelography procedure. All patients received atropine, diazepam, and metoclopramide as premedication. In ten examinations corticosteroids were also given. No patient, during or after myelography, had any reaction that could be related to hypersensitivity to the contrast medium. The incidence of headache, the most frequent side effect, was almost the same in patients who had corticosteroids in their premedication (30%) as in patients without (35%). These observations indicate that metrizamide myelography may be performed despite previous adverse reactions to contrast media.     

Diagnosis of a cystic lesion in the spinal cord--studies on delayed CT myelography and MRI

The collection of contrast medium within the spinal cord on delayed CT myelography generally indicates the presence of syringomyelia. We report the cases of cystic myelopathy with intramedullary contrast accumulation on delayed CT myelography. The purpose of this report is to compare MRI with delayed CT myelogram and to discuss the pathogenesis of the intramedullary contrast accumulation on delayed CT myelography. Methods and Materials: Thirty patients with intramedullary contrast accumulation on delayed CT myelography were studied with High Resolution Computed Tomography (Siemens Somatom II) and Magnetic Resonance Imaging (MRI) (0.15T imager, Toshiba MRT 15A). MRI were routinely obtained in both axial plane and sagittal plane. Short spin-echo sequences (30 msec TE, 500 msec TR) were used. This series included 6 cases of cervical disc disease, 5 cases of Chiari malformation, 4 cases of lipomeningocele, 4 cases of adhesive arachnoiditis, 2 cases of thoracolumbar spondylosis, 2 cases of trauma, one case of spinal arachnoid cyst, one case of spinal epidural cyst, and 5 cases of idiopathic type. Results: 1) In 17 out of the 30 patients (57%), the region corresponding to the region of contrast medium collection, which was visualized on delayed CT myelography, was seen as an area of the low signal intensity on MRI. In 11 cases out of 17, the syrinx cavity was confirmed at surgery. 2) In 13 cases, delayed CT myelogram showed collection of intramedullary contrast medium, but MRI failed to reveal an area of low signal intensity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myelography with a water-soluble contrast medium: a revision of technique and a review of results

Experience with Dimer-X myelography in 3000 patients provides some indication of the scope of examination of the lumbar, thoracic and cervical segments of the spinal canal with a water-soluble contrast medium. Myelography with any contrast medium should only be applied for serious indications, and never as an outpatient procedure, for the patient requires careful after-treatment. However, the routine use of myelography may offer the best insurance against the disappointment and embarrassment of surgery by trial and error. The application of a careful, standardized technique makes it possible to obtain accurate information about the whole spinal canal and to avoid the danger of the false results to which examination with oily media are liable at all levels. The development of ever safer contrast media may help to limit the problem of spinal fibrosis, which is not a rare complication of myelography and spinal surgery.     

Spinal imaging: will MRI replace myelography?

A retrospective study on the value of magnetic resonance imaging (MRI) in replacing contrast studies of the lumbar spine has been undertaken. Studying pre- and postoperative conditions, the authors attempted to answer the question, Will MRI replace myelography? In this retrospective study, comparison is made in 20 patients between MRI and myelography and with 12 intra-operative findings. The overall impression was that MRI is equally sensitive as the invasive myelogram in diagnosing both protruded lumbar discs and postoperative fibrosis. The practical conclusion was an almost complete abandonment of myelography.     

The value of spinal computed tomography in diagnosis of herniated lumbar discs

Summary In this study the diagnostic value and topographical accuracy of spinal computed tomography (CT) in the preoperative diagnosis of lumbar disc herniations were tested in 36 patients with surgically proven herniated discs. All patients also underwent metrizamide myelography. CT findings and myelograms were compared and correlated with the surgical observations. Especially in demonstrating exact diagnosis (lateral or more medial protrusion), and in showing the extent of upward or downward displacement of free disc material, CT provides valuable preoperative information. As a non-invasive diagnostic procedure, spinal CT scan may replace lumbar myelography in many patients with radicular lumbar pain.     

CTM观察正常臂丛神经根的初步报告

目的 探讨脊髓造影ＣＴ薄层扫描（ｃｏｍｐｕｔｅｄ ｔｏｍｏｇｒａｐｈｙ ｍｙｅｌｏｇｒａｐｈｙ,ＣＴＭ）诊断臂丛神经根损伤的可行性。方法 对１９９６年１０月至１９９９年５月,因其它疾病做颈脊髓造影ＣＴ薄层扫描的５３例患者,观察ＣＴ片臂丛神经根的结构及造影后的副作用。结果 脊髓造影ＣＴ薄层扫描片上,能清晰地显示神经根,经腰穿注入第三代非离子造影剂后不良反应少而轻。结论 脊髓造影ＣＴ薄层扫描有助于手术前正确诊断臂丛椎管内神经根的损伤。     

Iopamidol for myelography--practical implications

Iopamidol (Jopamiron 200) is a new water-soluble, non-ionic contrast medium for myelography, which recommends itself for reasons of safety, diagnostic effectiveness, economy and convenience. It has been used in a small series of 185 patients in doses of 10-15 ml and found to be highly satisfactory for myelography of the lumbosacral, thoracic and cervical regions.     

Dynamic computed tomography myelography for the investigation of cervical degenerative disease

Dynamic computed tomography (CT) myelography was conducted in 15 patients with cervical degenerative disease to assess the lesions responsible for their symptoms. CT myelography was performed using a multi-detector row helical CT system in dynamic positions (flexion or extension or both) in addition to the neutral position. Fine sagittal reconstructed images could be obtained in addition to axial images. This method provided static information including cervical vertebral body deformities, and good contrast images of the spinal cord, nerve roots, and cerebrospinal fluid space. In addition, laterality of the offending lesion and changes exaggerated by cervical motion were clearly shown in both axial and sagittal images. Ten of 15 patients demonstrated dynamic changes including dynamic canal stenosis or spinal cord impingement. The operative strategies were changed based on dynamic CT myelography findings in three of the 15 patients. Dynamic CT myelography can provide the axial and sagittal images required for flexion-extension studies, and in combination with conventional imaging modalities, provides valuable information for determining treatment strategies and objectives.     

Fundamental and clinical studies on CT gas myelography of the cervical spine

We applied CT gas myelography at the cervical spinal region and investigated the clinical value of CT gas myelography as a supplementary diagnostic method for the spinal cord and vertebral diseases. Fundamental studies of the conditions of window width and window height and the permitted limit of the angle of incidence were made with phantoms of human neck to establish proper conditions of these factors. In clinical studies, 23 adult persons, who had no abnormality in the cervical spine and in the cervical spinal cord were observed to have normal CT gas myelograms of the cervical region, whereas 37, of clinical cases including 18 of cervical spondylosis, 10 of OPLL, 2 of cervical discopathy, 3 of fracture and dislocation of the cervical spine, 2 of cervical vertebral tumor and 2 of CYL, were found to show clear pathologic findings in the cross sections of the vertebral foramen, subarachnoidal space and spinal cord on the CT gas myelograms. The representative cases of these diseases were presented. The gas myelograms were morphologically classified and investigated in relation to the clinical findings. From the result of these investigations, CT gas myelography appears to be highly useful as a supplementary diagnostic method for diseases of the cervical spine and the cervical spinal cord. Furthermore, we compared the effect of this method with that of CT myelography using metrizamide, a recently developed water-soluble contrast medium.     

Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management

Two patients with altered hemostatic mechanisms developed spinal subarachnoid hemorrhage after difficult lumbar punctures. One patient had received anticoagulation therapy soon after lumbar puncture and the other had a low platelet count (63,000/mm3) at the time of lumbar puncture. In both patients a hematoma evolved, producing blockage of cerebrospinal fluid flow. Clinical manifestations consisted of severe back and radicular pain with sphincteric disturbances followed by rapidly developing severe paraparesis. Of the methods of radiographic evaluation that were used, including computed tomography (CT) without contrast enhancement, myelography, CT with intrathecally administered contrast medium, and magnetic resonance imaging, we found the best study to be myelography via lateral cervical puncture followed by CT. Unfortunately, diagnosis was delayed, and surgical evacuation of the hematomas did not substantially improve the patients' conditions. The salient clinical and radiographic features of this disorder and its pathophysiology are reviewed. Prompt recognition of these lesions is necessary so that surgical intervention may maximize chances of recovery.     

Diagnostic value of CT in spinal cord neurinomas

The computed tomography (CT) in examination of the spine and spinal cord has rapidly advanced and its diagnostic value has been well documented. It is widely accepted that CT is very useful for the diagnosis of the spinal neurinomas, especially of dumb-bell tumors. In the last two years we have experienced with 11 cases of spinal neurinomas. These include 1 accessory neurinoma, 7 cervical neurinomas of dumb-bell type, 2 thoracic dumb-bell neurinomas, 1 intradural neurinoma in the conus medullaris and multiple neurofibromas in the cauda equina in one patient. The age distributed from 24 to 52 years, with an average of 41.5. In all of these patients except one, metrizamide CT was performed following a total myelography. In most of the cases, CT with and without an intravenous contrast medium injection was also carried out. The conventional radiologic examinations including plain radiography, tomography and angiography were done in most of the patients. Comparing with the results of those examinations, we reached the following conclusions: (1) metrizamide CT can disclose the superior border of the tumor which is often not visualized by conventional ascending myelography. The reconstruction CT clearly outlines the whole extent of the tumor. (2) The bony changes associated with a dumb-bell neurinoma, for example, the widening of the intervertebral foramen, can be found by plain CT in much earlier stage than by the plain roentgenogram. The findings can be more clearly using a "ReView" software program. (3) The extraspinal part of the dumb-bell tumor is shown in CT by an intravenous enhancement as a slightly high-dense, homogeneous mass with CT-number of approximately 70 HU. The capsule of the tumor is a little more enhanced in the most cases. (4) It is recommended to do a metrizamide CT with "ReView" technique when a tumor in the cauda equina is suspected on conventional myelography. (5) A tumor near the foramen magnum or in the upper cervical region is often overlOoked on metrizamide myelography. When a tumor in these regions is highly suspected on neurological examinations, it is also recommended to perform a metrizamide CT about 3 hours after conventional myelography.     

Reoperation after treatment of a disk hernia. Comparison between radiology and surgical findings in 18 cases

Eighteen patients with recurrent sciatica after lumbar disc surgery were investigated by both, myelography and computed tomography (CT) before reoperation. The radiological diagnosis according to the original x-ray report was correlated with the surgical findings at reoperation. Myelography reports describe morphological changes but often contain no definite diagnosis. CT reports usually contain detailed tissue diagnosis, but correlation with surgical findings is generally poor. Review of the original x-ray films leads to the following conclusions: At present, myelography is always indicated, except in suspected extreme lateral disc herniation. CT should be reserved for particular clinical or myelographic problems.     

The superior facet syndrome--report of three cases and a review of the literature (author's transl)]

Within the past 6 months we paid special attention to the superior facet syndrome on examining the patients with lumbar pain at the outpatient clinic. Out of 264 patients who complained of lumbago or sciatica, this syndrome was suspected in three patients and verified in all of them by operation. Neurologically it was difficult to differentiate this syndrome from disc protrusion or other related conditions. On the other hand, plain roentgenographic examinations were valuable: horizontal portion of the superior facet was larger and thicker than normal so that the a-p view of the lumbar spine showed a large bulbous processes joining in the frontal plane, and a narrowing of the interlaminal spaces was seen in some case. A differential diagnosis between this syndrome and the major type of lumbar canal stenosis can be made by means of dynamic myelography. Although the myelography with watersoluble contrast medium reveals nerve roots better than Myodil myelography, identification of the nerve roots at the lateral recesses is not necessarily easy, and the final diagnosis has to be made at operation.     

Myelographic versus clinical diagnostics in lumbar disc disease

The series consisted of 200 patients on whom lumbar myelography was performed for sciatica. After myelography, a disc operation was carried out on 95 patients. The episode of sciatica was the first for 90 patients. Objective neurologic signs were present in 185 patients, while 15 had only subjective symptoms. Definite or possible disc herniation was revealed by myelography in 66%. Most positive findings were located at the L4-L5 interspace. The clinical diagnostic accuracy rate was assessed from the patients' histories. As confirmed by operation, the accuracy of the clinical diagnostics was 52%, and the accuracy rate of myelography was 90%. The rate of false positive findings in myelography was 4%, that of false negative findings 6%. When the clinical or myelographic diagnosis was definitive, a disc herniation or protrusion was always found at operation. Almost one fourth of the clinically diagnosed definite herniations were not treated surgically because myelography proved negative. One fifth of those patients in whom myelography revealed an unequivocal disc herniation were not operated on because these patients had clinically improved before being admitted to myelography. The results of this study justify the following conclusions: the clinical level diagnostics of a disc herniation is rather unreliable, and myelography is therefore always indicated before operation; myelography should only be performed in those cases in which there is a clear clinical indication for surgery; myelography ought to be performed within 1 week; an unequivocal positive finding in myelography predicts a good operative result.     

Discography: an element of decision. Surgery versus chemonucleolysis

It is a well known fact that both surgery and chemonucleolysis can cure a patient suffering from root pain due to a prolapsed intervertebral disc. However, the failure rate after intradiscal injection of chymopapain remains important. Analysis of the cases operated after unsuccessful chemonucleolysis show that about two thirds are due to a remaining discal fragment. Considering the possibility of a bad penetration of the enzyme in the herniated area, neither computed tomography (CT) scan nor myelography, but only discography, can demonstrate invasion of the prolapsed area. On a series of 165 patients injected with chymopapain in only one disc, discographic data were correlated with the result of the treatment on the root pain. Three items were analyzed: the size of the protruding area located at the back of the disc (closely related to operative findings, as shown on a previous study), the density of the contrast medium filling the protruding area, and the pain response during the injection. A large, well-filled protruding area characterizes a "good" image and correlated with 76% of good results. Likewise when the pain response is lateralized (in the buttock or the affected lower limb), it correlates with 42% of success and 13% of failures. In 24.8% of the cases a combination of good images and lateralized pain correlates with 97.5% of good results. Therefore discography should be an element of decision between surgery and chemonucleolysis, and should be considered as a preoperative examination.     

Arachnoiditis from experimental myelography with aqueous contrast media.

Myelography was performed on 80 monkeys to study postmyelographic arachnoiditis. Metrizamide myelography caused arachnoiditis when high concentrations were used, but not with the usual clinical concentrations. Arachnoiditis resulted after myelography with meglumine iocarmate; however, the risk of arachnoiditis was reduced by diluting the contrast medium. Prophylactic intrathecal methylprednisolone was not effective in preventing arachnoiditis. Blood in the cerebrospinal fluid did not affect the degree of arachnoiditis.