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Fifty-seven patients with a strong clinical suspicion of cervical myelopathy were studied with body coil magnetic resonance (MR) and conventional myelography or CT myelography. Eight patients were believed to have normal studies with both modalities. There were six patients with syringomyelia; four with an intramedullary tumor; one with an arteriovenous malformation; 19 with cervical spondylosis at multiple levels; eight with cervical spondylosis at a single level; four with extensive rheumatoid arthritis; four with extradural neoplasm; two with trauma; and one patient with an epidural abscess. In this study, body coil MR was the superior examination for the evaluation of an intramedullary process. It was as diagnostic as myelography in one case of an extramedullary intradural lesion. In patients with extradural disease, body coil MR was the superior study in 45%, equivalent to myelography in 37%, and, although still diagnostic, inferior to myelography in 17%. In 8% of the cases, body coil MR was at best equivocal, whereas myelography was diagnostic. It appears that in technically adequate studies, MR is at least equivalent to myelography in its ability to delineate disease. A superior MR study provides a better appraisal of the size and character of the spinal cord as well as the degree of both anterior and posterior defects on the subarachnoid space and neural structures. In addition, MR is as good as conventional myelography for the identification of extrinsic cervical cord lesions producing cervical myelopathy. Finally, an additional small group of 30 patients were studied with a prototype surface coil to determine its advantages relative to body coil imaging. Each patient had correlative myelography. As with body coil MR, imaging with the surface coil was believed to be more informative than conventional myelography in four patients with intramedullary lesions. The remaining 26 patients suffered from cervical spondylosis. Surface coil MR was believed to be more informative than myelography in six cases (23%), equivalent to myelography in 19 (73%), and less diagnostic than myelography in one (4%). The improved spatial resolution with the use of the surface coil was believed to increase the accuracy of MR.
PURPOSE: To determine the diagnostic accuracy of three-dimensional MR myelography in the evaluation of traumatic injuries of the brachial plexus. METHODS: Twenty patients with clinical and electromyographic evidence of traumatic brachial plexopathy were examined with three-dimensional MR myelography, conventional cervical myelography, and CT myelography 1 to 9 months after trauma. Three-dimensional MR myelography was performed on a 1.5-T MR unit with a constructive interference in steady state (CISS) technique. For each patient, maximum intensity myelographic projections and multiplanar reconstruction reformatted 1-mm axial sections were obtained from the same 3-D data set. Three-dimensional MR myelographic findings were compared with findings at cervical myelography and CT myelography. Surgical findings were available for comparison in 13 patients. RESULTS: Three-dimensional MR myelography enabled detection of meningoceles with avulsed or intact nerve roots, partial or complete radicular avulsions without disruption of the thecal sac, dural sleeve abnormalities, and dural scars. Assuming cervical myelography and CT myelography as the standards of reference, 3-D MR myelography showed 89% sensitivity, 95% specificity, and 92% diagnostic accuracy in the evaluation of nerve root integrity. CONCLUSION: Three-dimensional MR myelography can show the majority of traumatic lesions that involve the proximal portion of the brachial plexus in a single rapid examination. On the basis of our findings, we propose this technique as a screening examination for patients with traumatic brachial plexus palsy.
This study was conducted to determine whether prescribed ambulation in post-myelography patients injected with metrizamide would significantly decrease the incidence of post-myelography headache. Eighty patients undergoing metrizamide lumbar myelography were assigned to two groups of 40 patients each. The control group was restricted to complete bedrest for the immediate 24-hour period following myelography. The experimental group participated in a prescribed regimen of ambulation every four hours following myelography. Data were collected during the immediate 24 hours post-myelography. Subjects were assessed as to the presence or absence of headache at four-hour intervals during data collection. At the end of the 24-hour period post-myelography, the Visual Analogue Pain Intensity Scale was administered to subjects with documented subjective complaints of headache pain. The nonambulatory group had a 62.5% incidence of headache while the ambulatory group revealed only a 42.5% incidence of post-myelography headache. The z test was used to test the first research hypothesis that there would be a higher incidence of post-myelography headache in the nonambulatory group than in the ambulatory group. The calculated z = 1.79, p less than .05; therefore, it was possible to conclude that the number of nonambulatory patients with headache was significantly higher than the number of ambulatory patients with headache. The second research hypothesis, that the severity of post-myelography headache would be greater in the nonambulatory group than in the ambulatory group, was tested using the Student's t test. The calculated t = .6492, p greater than .05. The subjects' self-perception of the severity of headache was not significantly different in the nonambulatory than in the ambulatory subjects.
Myelography and CT myelography (CTM) were reviewed in 18 cases of birth palsy with clinically suspected avulsion injury. Root-somatosensory evoked potential (root-SEP) was also reviewed for myelographic evaluation of the nerve root avulsion in birth palsy. Root-SEP is not induced in case of avulsed nerve roots, but is induced in case of both normal and incompletely avulsed roots. Myelography demonstrated 58 abnormal nerve roots in 18 cases (19 limbs); 45 (78%) complete and 13 (22%) incomplete nerve root avulsions. Each of complete and incomplete avulsions was defined as total absence and partial presence of rootlets on myelography, respectively. Traumatic meningoceles were detected at 46 roots (79%) on myelography and/or CTM; 35 roots on myelography and 45 roots on CTM. CTM could not detect only a very small meningocele at one root. At 11 roots CTM was superior to myelography in delineating a meningocele because CTM is sensitive to a poorly enhanced meningocele. CTM, however, could not diagnose nerve root avulsions so accurately as myelography, since myelography detected 12 (7 completely and 5 incompletely) avulsed roots without meningocele, whereas CTM could not delineate the nerve roots clearly. Thus, myelography is indispensable to evaluate nerve root avulsions without meningocele. Root-SEP was examined in 9 patients who underwent brachial plexus exploration. SEP was negative at 22/25 roots with complete avulsion and was positive at 7/7 roots with myelographically incomplete avulsion, regardless of presence or absence of any traumatic meningocele.(ABSTRACT TRUNCATED AT 250 WORDS)
Metrizamide, a non-ionic water soluble contrast medium, is used in myelography for detecting spinal cord lesions. Because it is an injection in the subarachnoid space, the effects on the central nervous system following metrizamide myelography should be studied. Electroencephalography can offer a non-invasive and objective method for evaluating the functions of the central nervous system. From September to December 1986, 30 cases which had received cervical or lumbar metrizamide myelography were collected. After myelography, in addition to a history review and neurologic examination, electro-encephalography was carried out within 24 hours. If the EEG record revealed abnormal, a series of EEG follow-ups were conducted until recordings were normal. The incidence of clinical adverse effects following Metrizamide myelography was 53.3% and 66.6% respectively in cervical and lumbar injections. No significant difference was found between the two groups. Secondly, the abnormal rate of the EEG record was 40.0% and 60.0% following cervical and lumbar myelography. The difference was also not significant. Lastly, the relation between clinical adverse effects and an abnormal EEG records was poor in cervical metrizamide myelography but good in lumbar myelography. The conclusions suggested by this research that the clinical adverse effects and the abnormal EEG record after metrizamide myelography are transient and are reversible changes. The mechanism of complications following cervical and lumbar metrizamide are different. Although complications may occur following cervical and lumbar metrizamide myelography, it remains a practical method in detecting spinal cord lesions.
Our objective was to analyse the usefulness of single-slice MR-myelography images as a complementary test to conventional MR of the spine in patients with clinically suspected degenerative spine disease. A prospective analysis of 1022 consecutive patients studied with conventional MR and MR-myelography (four acquisitions: one coronal plane, one sagittal plane, and two oblique lateral, right and left planes) examinations was performed. Conventional MR and MR-myelography studies were classified as positive when morphological or structural alterations were noted. Positive MR-myelography information was also categorized as relevant if findings were considered important and radiologically significative to the final diagnosis (either by increasing the radiologists confidence in the diagnosis or because the findings were not observed in the conventional study). Other positive findings were considered non- relevant. There were 62% cases considered positive in the MR-myelography examination. Of them, 3% revealed no alterations on the conventional MR examination. Of the negative MR-myelography studies, 75% had a positive conventional MR examination. Considered as diagnostic techniques, their Kappa concordance was poor. However, MR-myelography complemented the information obtained with the conventional MR examination of the spine, this information being relevant to the final MR diagnosis in 22% of the total number of cases. The contribution of MR-myelography was not different in the three spinal levels. In conclusion, MR-myelography complements the information obtained with conventional MR in a large number of cases.
We used magnetic resonance (MR) myelography in ten patients with injuries to the brachial plexus and compared the findings with those obtained by conventional myelography and postmyelographic CT (CTM). In the presence of complete nerve-root avulsion (seven cases), a post-traumatic meningocele was detected by MR myelography. In injuries to the upper roots (three cases) MR myelography showed abnormal findings with a high signal intensity in the nerve root, obliteration of the damaged nerve root, or enlargement and obliteration of the root sleeve. No pseudomeningoceles were detected in these upper-root injuries by MR myelography and CTM. The overall accuracy of detection of damaged nerve roots or root sleeves was better with MR myelography than with conventional myelography and was similar to that of CTM. MR myelography is non-invasive, relatively quick, requires no contrast medium, provides imaging in multiple projections, and is comparable in diagnostic ability to the more invasive, time-consuming techniques of conventional myelography and CTM.
PURPOSE: To report that iopamidol myelography can induce status epilepticus (SE) in patients carrying the diagnosis of symptomatic epilepsy and to estimate the incidence of seizures in patients undergoing iopamidol myelography. METHODS: We retrospectively identified all patients with seizures/SE associated with 1350 iopamidol myelographies during the last 5 years at our institution. The impact of cervical versus lumbar myelography was analysed. RESULTS: Induced by iopamidol myelography two non-epileptic patients suffered from first generalised tonic-clonic seizures and a 67-year-old women with symptomatic epilepsy after a remote ischemic stroke developed a generalised tonic-clonic seizure evolving into a dialeptic and right nystagmus SE (i.e. complex focal status) of 5-hour duration. The incidence of seizures in non-epileptic patients was 0.15%. The incidence of seizure induction for lumbar myelography was lower than for myelographies that included the cervical subarachnoid space. CONCLUSIONS: Iopamidol myelography (especially if cervical) is associated with a risk of seizures in non-epileptic individuals and can induce SE in patients with epilepsy. Patients should be informed about the risk of seizure induction.
A consecutive series of 397 myelograms performed in 385 patients over a six month period at the Mersey Regional Neurosciences Unit is reported. The reasons for performing the myelogram were to identify the cause of a radicular lesion in 54% of patients, a chronic spinal cord lesion in 30%, an acute cord lesion in 9%, suspected disease at the level of the foramen magnum 6%, and for a variety of other conditions in 8%. For the 385 patients undergoing a myelogram in the study period, the median interval from admission to request, request to myelography and from myelography to discharge was nought, one and three days respectively. The proportion of patients submitted to myelography by individual consultants ranged from 7% to 28%. There was a two-fold variation in the delays in the time to requesting and performing myelograms. There was room for improvement in the clinical information supplied on the myelography request form. The role of ancillary investigations and their effect on myelography was unclear. Only 16 of the patients with suspected cord disease had visual evoked responses performed before myelography. Five of them had myelography after an abnormal result. The estimated annual direct cost of myelography in the unit was at least 486,000 pounds. Reorganisation might have yielded hypothetical "savings" of between 30,000 pounds (6%) and 155,000 pounds (32%), though in practical terms these "savings" represented resources which might have been freed for use in other higher priority clinical problems within the unit, rather than true reductions in monetary cost.
Computer-assisted myelography (CAM) is a technique in which computed tomography (CT) is combined with the intrathecal administration of metrizamide to demonstrate the spinal cord and surrounding structures. This retrospective study of 139 CAMs performed at Emory University Hospital included 125 CAMs that were preceded by routine metrizamide myelography (secondary CAM). The remaining 14 CAMs were primary studies without concomitant myelography. These CAMs and conventional myelograms were reviewed to provide indications for the use of CAM as a replacement for other radiodiagnostic studies or as an adjunct to radiological diagnosis. Eighty-one CAMs (58%) were positive for some pathological process. Of the 69 secondary CAMs demonstrating a pathological condition, 46 (67%) revealed some aspect of the lesion not apparent on routine metrizamide myelography. In no case with positive myelography was CAM negative. However, conventional myelography often added valuable diagnostic information. Although high resolution CT has allowed limited visualization of the spinal cord, CAM is often indicated for cases in which diagnosis requires more definition of cervicomedullary, extradural, intradural, extramedullary, and intramedullary lesions. Our clinical review found CAM to be extremely useful in the diagnostic evaluation of pathological conditions involving the spine and spinal cord and suggests clinical indications for the use of CAM based upon selected illustrative cases. Furthermore, CAM seemed to be superior to other radiological procedures in certain instances, such as in cases of spinal dysraphism and in the evaluation of lesions at the foramen magnum. Until more experience is obtained using spinal CT and CAM, CAM should not replace myelography altogether. The present study indicates that, rather than replacing conventional CT and myelography, CAM should be used as a primary study in situations where it has been shown to be superior and as a complementary study when other neurodiagnostic examinations are equivocal or nondiagnostic.
Sixty patients with suspected lumbar herniated disk and/or canal stenosis were studied prospectively with surface coil MRI, CT, and/or myelography, and the results were compared with the surgically confirmed abnormality. Forty-eight patients had lumbar surgery at 62 levels. There were no negative explorations. Thirty-nine patients had a myelogram and CT. Thirty of the CTs were performed following the injection of metrizamide for myelography. Nine patients had a CT without intrathecal contrast material 1 to several days before the myelogram. Six patients had myelography only, and three patients had CT only. All studies were evaluated for the location and type of disease in a forced choice fashion. Independent of the surgically correlated levels, there was 86.8% agreement between the MR and CT studies in all patients at 151 levels and 87.2% agreement between MR and myelography at 218 levels. At the operative levels, there was 82.6% agreement between MR and surgical findings for both type and location of disease; 83% agreement between CT and surgical findings; and 71.8% agreement between myelography and surgical findings. There was 92.5% agreement when MR and CT were used jointly, and 89.4% agreement when CT and myelography were used jointly. The results of this study indicate that a technically adequate MR examination was equivalent to CT and myelography in the diagnosis of lumbar canal stenosis and herniated disk disease. CT and MR can be complementary studies, and surface coil MR can be viewed as an alternative to myelography.
The results of lumbar myelography and computed tomography (CT) were compared in 51 consecutive patients with clinically suggested lumbar disc herniation. A total of 100 intervertebral levels were examined. At 62 levels, either L4/L5 or L5/S1, myelography was normal. CT showed no pathologic changes at 55 levels. The results concurred between myelography and CT in 89 per cent of the patients with normal findings. Four cases of disc herniation and one bulging disc, which had been missed at myelography because of a large epidural space at L5/S1, were picked up by CT. Two of these were verified by surgery and two were treated conservatively. There was one possible false negative case with CT as well. Abnormalities were shown at 38 intervertebral levels, 22 in the bulging and 16 in the herniated disc group. The pathologic changes concurred in 84 per cent between the two investigations. For intervertebral disc herniation the true negative rate was, for myelography 88 per cent and for CT 97 per cent. The treatment strategy could have been based on CT alone at 37 out of 38 levels (97%), and on myelography alone at 34 out of 38 levels (89%). Furthermore, at CT the imaging of soft tissues and intervertebral joints was superior to that at myelography. It is concluded that CT should be the primary examination method of imaging for lumbar disc herniation. Myelography is, however, to be preferred where the level of the lesion is clinically unclear or when the entire lumbar region and thoraco-lumbar junction are to be examined.
Clinical reports have suggested that myelography and laminectomy may produce more arachnoiditis than myelography alone. The effect of experimental lumbar myelography and laminectomy on arachnoiditis in monkeys was studied. Arachnoiditis was as severe after myelography alone as after myelography and laminectomy. Minimal arachnoiditis was found myelographically and histologically after myelography with metrizamide 300 mg l/ml, and severe arachnoiditis was found after myelography with iophendylate whether or not laminectomy was performed. Laminectomy alone produced insignificant arachnoid changes. Experimental myelography preceding laminectomy did not increase the risk of arachnoiditis.
PURPOSE: To determine the sensitivity of contrast MR versus myelography followed by CT in the detection of cerebrospinal fluid metastases in children with primary central nervous system tumors. METHODS: Thirty-three patients who had primary central nervous system malignancies had spinal MR with gadolinium within 2 weeks of a myelogram followed by CT. MR technique included T1-weighted image sequences of the entire spine with and without gadolinium. CT scans were routinely performed at T-12 to L-2, L-4 to S-1, and foramen magnum to C-2. All studies were reviewed blindly; the number, character, and location of all metastases was recorded and the results of the two studies compared. Cerebrospinal fluid cytologic findings were recorded for each patient, and compared with the results of the imaging studies. RESULTS: Seven of the 33 patients had metastases detected; metastases were seen on both MR and myelography followed by CT. However, MR showed 24 lesions and myelography followed by CT showed only 15. When a lesion was seen on both MR and myelography followed by CT, the MR was usually more convincing. Superficial lesions seen on MR sometimes would be missed on myelography followed by CT. Both MR and myelography followed by CT were quite sensitive in the detection of small lesions (2 to 3 mm) when present on spinal nerve roots. Whereas MR showed multiple lesions not seen on myelography followed by CT, CT failed to show any metastases not seen on MR. Imaging studies showed metastases in 3 patients who had normal cytologic findings. CONCLUSIONS: MR shows significantly more cerebrospinal fluid metastases than myelography followed by CT.
Three-dimensional (3D) MR Myelography is a new technique using constructive interference steady-state (CISS) sequences, which are characterized by a symmetric flow compensation enhancing CSF signal intensity compared with neural and extradural structures. 3D myelographic projections with different rotation angles are obtained from the 3D dataset with a mathematical algorithm called maximum intensity projection (MIP). Myelographic projections yield a global view of subarachnoid spaces and of root sleeves with no intrathecal contrast agent injection. This study was aimed at assessing the feasibility, the clinical value and the diagnostic accuracy of 3D MR Myelography in comparison with conventional myelography. From September 1992 to January 1994, thirty-five myelograms were performed. The study population consisted of 10 volunteers, 8 patients with traumatic brachial plexus lesions, 7 with herniated disks (4 lumbar and 3 cervical disks), 4 with sacral radicular cysts, 2 with spinal vascular malformations, 3 with extramedullary intradural neoplasms (2 cervical neuromas and 1 cervical meningioma) and 1 with an intramedullary tumor (a conus medullaris ependymoma). All patients underwent SE MRI and conventional myelography (22 lumbar injections, 3 cervical injections of nonionic iodinated contrast agent) followed by CT (CT myelography). This trial demonstrates the feasibility of 3D MR myelography in the study of the cervical and lumbar spine: its results are comparable to those obtained with conventional myelography also in some specific indications like traumatic brachial plexus injuries, where invasive conventional myelography is usually thought to be essential.