Arachnoiditis

Definition

Myelography is an x-ray examination of the spinal canal. A contrast agent is injected through a needle into the space around the spinal cord to display the spinal cord, spinal canal, and nerve roots on an x ray.

Purpose

The purpose of a myelogram is to evaluate the spinal cord and/or nerve roots for suspected compression. Pressure on these delicate structures causes pain or other symptoms. A myelogram is performed when precise detail about the spinal cord is needed to make a definitive diagnosis. In most cases, myelography is used after other studies, such as magnetic resonance imaging (MRI) or a computed tomography scan (CT scan), have not yielded enough information to be sure of the disease process. Sometimes myelography followed by CT scan is an alternative for patients who cannot have an MRI scan, because they have a pacemaker or other implanted metallic device.

A herniated or ruptured intervertebral disc, popularly known as a slipped disc, is one of the most common causes for pressure on the spinal cord or nerve roots. Discs are pads of fiber and cartilage that contain rubbery tissue. They lie between the vertebrae, or individual bones, which make up the spine. Discs act as cushions, accommodating strains, shocks, and position changes. A disc may rupture suddenly, due to injury, or a sudden straining with the spine in an unnatural position. In other cases, the problem may come on gradually as a result of progressive deterioration of the discs with aging. The lower back is the most common area for this problem, but it sometimes occurs in the neck, and rarely in the upper back. A myelogram can help accurately locate the disc or discs involved.

Myelography may be used when a tumor is suspected. Tumors can originate in the spinal cord, or in tissues surrounding the cord. Cancers that have started in other parts of the body may spread or metastasize in the spine. It is important to precisely locate the mass causing pressure, so effective treatment can be undertaken. Patients with known cancer who develop back pain may require a myelogram for evaluation.

Other conditions that may be diagnosed using myelography include arthritic bony growths, known as spurs, narrowing of the spinal canal, called spinal stenosis, or malformations of the spine.

Precautions

Patients who are unable to lie still or cooperate with positioning should not have this examination. Severe congenital spinal abnormalities may make the examination technically difficult to carry out. Patients with a history of severe allergic reaction to contrast material (x-ray dye) should report this to their physician. Pretreatment with medications to minimize the risk of severe reaction may be recommended.

Description

Myelograms can be performed in a hospital x-ray department or in an outpatient radiology facility. The patient lies on the x-ray table on his or her stomach. The radiologist first looks at the spine under fluoroscopy, where the images appear on a monitor screen. This is done to find the best location to position the needle. The skin is cleaned, then numbed with local anesthetic. The needle is inserted. Occasionally, a small amount of cerebrospinal fluid, the clear fluid which surrounds the spinal cord and brain, may be withdrawn through the needle and sent for laboratory studies. Then contrast material is injected. The contrast material (dye) is a liquid that shows up on x rays.

The x-ray table is tilted slowly. This allows the contrast material to reach different levels in the spinal canal. The flow is observed under fluoroscopy, then x rays are taken with the table tilted at various angles. A footrest and shoulder straps or supports will keep the patient from sliding.

In many instances, a CT scan of the spine will be performed immediately after a myelogram, while the contrast material is still in the spinal canal. This helps outline internal structures most clearly.

A myelogram takes approximately 30-60 minutes. A CT scan adds about another hour to the examination. If the procedure is done as an outpatient exam, some facilities prefer the patient to stay in a recovery area for up to four hours.

Preparation

Patients should be well hydrated at the time of a myelogram. Increasing fluids the day before the study is usually recommended. All food and fluid intake should be stopped approximately four hours before the myelogram.

Certain medications may need to be stopped for one to two days before myelography is performed. These include some antipsychotics, antidepressants, blood thinners, and diabetic medications. Patients should consult with their physician and/or the facility where the study is to be done.

Patients who smoke may be asked to stop the day before the test. This helps decrease the chance of nausea or headaches after the myelogram. Immediately before the examination, patients should empty their bowels and bladder.

Aftercare

After the examination is completed, the patient usually rests for several hours, with the head elevated. Extra fluids are encouraged, to help eliminate the contrast material and prevent headaches. A regular diet and routine medications may be resumed. Strenuous physical activity, especially any which involve bending over, may be discouraged for one or two days. The doctor should be notified if a fever, excessive nausea and vomiting, severe headache, or stiff neck develops.

Risks

Headache is a common complication of myelography. It may begin several hours to several days after the examination. The cause is thought to be changes in cerebrospinal fluid pressure, not a reaction to the dye. The headache may be mild and easily alleviated with rest and increased fluids. Sometimes, nonprescription medicine are recommended. In some instances, the headache may be more severe and require stronger medication or other measures for relief. Many factors influence whether the patient develops this problem. These include the type of needle used and the age and sex of the patient. Patients with a history of chronic or recurrent headache are more likely to develop a headache after a myelogram.

The chance of reaction to the contrast material is a very small, but potentially significant risk with myelography. It is estimated that only 5-10% of patients experience any effect from contrast exposure. The vast majority of reactions are mild, such as sneezing, nausea, or anxiety. These usually resolve by themselves. A moderate reaction, like wheezing or hives, may be treated with medication, but is not considered life threatening. Severe reactions, such as heart or respiratory failure, happen very infrequently. These require emergency medical treatment.

Rare complications of myelography include injury to the nerve roots from the needle, or from bleeding into the spaces around the roots. Inflammation of the delicate covering of the spinal cord, called arachnoiditis, or infections, can also occur. Seizures are another very uncommon complication reported after myelography.

Normal results

A normal myelogram would show a spinal canal of normal width, with no areas of constriction or obstruction.

Abnormal results

A myelogram may reveal a herniated disk, tumor, bone spurs, or narrowing of the spinal canal (spinal stenosis).

Key Terms

Contrast agent

Also called a contrast medium, this is usually a barium or iodine dye that is injected into the area under investigation. The dye makes the interior body parts more visible on an x-ray film.

Further Reading

For Your Information

Books

• Daffner, Richard. Clinical Radiology, The Essentials. Baltimore: Williams and Wilkins, 1993.
• Pagana, Kathleen and Timothy Pagana. Mosby's Diagnostic and Laboratory Test Reference. St. Louis: Mosby-Year Book, 1997.
• Torres, Lillian. Basic Medical Techniques and Patient Care in Imaging Technology. Philadelphia: Lippincott, 1997.

  Organizations

• The Spine Center. 1911 Arch St., Philadelphia, PA 19103. (215) 665-8300. http://thespinecenter.org.

Gale Encyclopedia of Medicine. Gale Research, 1999.