Myelography Techniques: Agents, Uses & Interpretation Myelography is the radiographic examination of the spinal cord and emerging

nerve roots following injection of contrast medium into the subarachnoid space. Diagnosis of spinal disease is based on history, physical and neurologic examination findings and imaging. Radiography is one of the most important diagnostic aids for localization of spinal injuries. Plain radiography, though, reveals fractures and luxations in spine, yet, usually fail to suggest any compression and other soft tissue disorders. Myelography not only diagnose the existence but also the location of spinal lesions. In veterinary science, it is very important to identify the location of a spinal lesion because determination of the clinical lesion is difficult by neurological examination alone. Indications Myelography is indicated when focal spinal cord lesion is suspected and no inflammatory response is seen on CSF analysis. The contrast media mixes with CSF that surrounds the spinal cord and demonstrates focal spinal cord compression or expansion. Myelography is performed in following conditions: 1. Intervertebral disc protrusion: Unless intervertebral discs are mineralized, they are not visible when viewing plain radiographic images. Therefore, myelography may be useful to diagnose spinal cord compression from a herniated disc. 2. Intraspinal lesions that do not result in a disruption of the osseous vertebral architecture such as tumors and granulomas. 3. Vertebral canal haemorrhage 4. Spinal cord edema Contraindications 1. Meningitis 2. Myelitis 3. Myelomalacia 4. History of recent myelography Contrast Agents

The selection of contrast agent has a crucial role in myelographic examination. The ideal contrast preparation should be minimal neurotoxic, should be pharmacologically inert, nonirritating miscible with CSF and radio opaque at an isotonic concentration. A number of contrast agents have been recommended for myelography which include ionic and non-ionic monomers of benzoic acid. Various contrast agents are: 1. Non-ionic water-soluble contrast agents: They are metrizamide, iohexol and iopamidol. Metrizamide, the first low osmolarity (470 mEq/L) contrast medium produced by Nyegaard is the agent of choice being non-irritating and also visualized for a longer time. It is available under trade name of Amipaque having iodine content of 300 mg/ml and its dose is 0.4 ml/kg in dogs and 0.3-0.4 ml/kg in neonatal calves. Newer much cheaper agents such as iohexol and iopamidol possess lower neurotoxicity and better patient tolerance than metrizamide. 2. Oil based contrast agents: Pentoplaque, thorotrast, neo-ipex (75%), idochlorol, skiodon (20%), lipidal and diodrast (35%) are various type agents. Disadvantages of oil-based contrast agents are poor diagnostic quality, poor flow characteristics, tendency to globulate and post myelographic arachnoiditis. Because of these disadvantages, they are no longer used. Techniques For myelography, the animal should be kept on general anaesthesia and all aseptic precautions should be taken to inject contrast medium. A) Cervical/Cisternal Myelography i) Control the animal in lateral or sternal recumbency with the head in a hyper-flexed position. ii) Introduce 19 G spinal needle with a stylet into subarachnoid space through the foramen magnum. iii) With help of syringe attached to spinal needle, aspirate CSF in equal quantity to that of volume of contrast material to be injected. iv) v) Slowly inject contrast material @ 1ml/min and withdraw the needle. Raise the head to an angle of 250 from horizontal plane to prevent cranial flow.

vi)

Obtain lateral radiograph as early as possible if using water soluble agents and then at 5 and 10 min. In case of oily agents, obtain radiograph at 10, 15 and 30 min.

vii) viii)

If convulsions occur, anaesthetise the animal further. After obtaining radiographs, raise the head of animal to reduce risk of convulsions.

Advantages 1. It provides an easy access to subarachnoid space allowing collection of requisite amount of CSF with minimum chances of blood contamination. 2. Needle insertion is technically easier. 3. Less contrast medium is required for evaluation of cervical lesions. Disadvantages 1. Subdural injection is most common complication observed during cisternal injection of contrast medium. 2. Post-procedural seizures are common. 3. Slight risk of needle puncture into medulla oblongata or cervical spinal cord is there. B) Lumbar Myelography i) Control the animal in lateral recumbency and bring hind limb cranially to open the inter-arcuate space. ii) Introduce spinal needle in the midline just anterior to L6 through 5th lumbar space. iii) Remove CSF and inject contrast agent. iv) Obtain first radiograph without withdrawing the needle and subsequent radiographs be obtained at 5, 10 and 15 min. Advantages 1. It is safer than cisternal puncture. 2. It is useful for compressive lesions of thoracolumbar region. 3. It is more useful in cases with acute disc prolapse.

Disadvantages

1. Technically, it is more difficult than cisternal myelography. 2. It has been reported various side effects of lumbar myelography as spinal cord edema, cystic necrosis, myelomalacia, axonal necrosis and hydromelia. C) Lumbosacral Myelography Similar to lumbar myelography except needle is inserted through lumbosacral space. Advantages 1. Spinal cord terminates at caudal lumbar, so there is minimal risk for cord injury. 2. Lumbosacral myelography is less difficult because of large space. 3. Puncture site is easily palpable. 4. No neurological signs including seizures are observed after myelography. Complications Complications from radiographic contrast media depend on variety of factors including the route of administration, chemical composition of the agent and the patients underlying condition and needle placement. There has been mentioned side effects like fasciculation, seizures, bradycardia, vomition, fatal cardiopulmonary arrest, death due to acute subdural hemorrhage involving brain stem and cranial cervical spinal cord caused by wrong needle placement.

References Paithanpagare, Y.M., Tank, P.H., Mankad, M.Y., Shirodkar, K. and Derashri H.J. (2008).

Myelography in dogs. Veterinary World, 1(5):152-154. Singh, A.P. and Singh, J. (1994). Veterinary Radiology: Basic principles and radiographic positioning. CBS Publishers & Distributers Pvt. Ltd. Whittington, J.K. and Bennett, R.A. (2011). Clinical Technique: Myelography in Rabbits. Journal of Exotic Pet Medicine, 20(3): 217221.