myelography and cns exams using mri & ct
DESCRIPTION
MYELOGRAPHY and CNS Exams using MRI & CT. Spring 2009 (DRAFT). Meninges. Membranes that enclose the brain and spinal cord Dura Mater- outer layer Arachnoid = middle layer Pia mater = innermost layer - PowerPoint PPT PresentationTRANSCRIPT
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MYELOGRAPHY and
CNS Exams using MRI & CT
Spring 2009(DRAFT)
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Meninges Membranes that enclose the brain
and spinal cord
Dura Mater- outer layer
Arachnoid = middle layer
Pia mater = innermost layer
Subarachnoid space = wide space between arachnoid and pia mater
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Subarachnoid space Wide space between arachnoid and pia mater
Filled with CSF Bathes brain & spinal cord with nutrients Cushions against shocks and blows Where contrast is injected for myelograms
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CSF Information Total adult CSF volume is 150 ml
50% intracranial 50% spinal
Adult opening pressure is normally 7-15 cm fluid >18 abnormal Young adults slightly higher <18-20
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Spinal Cord Diameter AP diameter is 7mm through C7 C7 to conus medullaris is 6mm At conus it is 7mm
Cord size is considered abnormal if it is over 8mm or under 6mm
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Myelography
General term applied to the radiologic examination of the CNS structures situated in the vertebral canal
Requires contrast introduction into the subarachnoid space by spinal puncture
Puncture made at L2-L3 or L3-L4 space May also be introduced into cisterna magna at C1 and
occipital bone
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Myelography
Contrast is generally water-soluble, nonionic, iodinated medium
OMNIPAQUE
ISOVUE
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Contrast Precautions Verify it is the correct contrast
Non-ionic iodinated contrast Omnipaque or Isovue
Correct concentration 180 and 300 common
Check expiration date
Keep contrast vial in room until procedure is complete
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Puncture made at L2-L3 or L3-L4 space
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Spinal needle injection
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MYELOGRAM WITH CONTRAST
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Room should be prepared by RT before patient arrival
Table and equipment cleaned
Footboard and shoulder supports attached
Radiographic equipment checked
Image intensifier locked to prevent accidental contact with sterile field or spinal needle
Tray setup
FOOTBOARD
SHOULDERPADS
Hand grips
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MYELOGRAM TRAY
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Additional items Blankets Sterile towels Sodium bicarbonate (if not in tray) Non-ionic iodinated contrast media Sterile gloves for DR Shields for PT, DR, anyone else in room, and
yourself Varying sizes of spinal needles and needles Extra syringes and tubing Cleaning liquid
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Syringes and Spinal Needles
Syringes
Spinal Needles(covered)
More Spinal Needles (uncovered)
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PRE- Procedure :Myelography Premedication rarely needed
Patient should be well hydrated
Check orders, obtain history, labs results (if necessary), and previous exams
Informed consent: Risks, benefits alternatives
Procedural details, including table movement and sensations should be explained, and get pt into a gown
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Contraindications and Considerations PT < 15.0 seconds
Preferable to reschedule exam if below 15 Platelets >100,000
If below 50,000 a platelet transfusion may be indicated before procedure
Heparin stopped 4 hours before Can be restarted 2 hrs after procedure Usually given as IP
Coumadin stopped 3-4 days before Usually OP Labs usually indicated
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Radiation Safety
Have shields for PT’s, DR and yourself
Question LMP and the possibility of being pregnant
Use cardinal rules Time Distance Shielding
ALARA Use pulse if possible Save the last image on screen when possible
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Prone & Lateral Flexion Prone
Pillow under abdomen for flexion of spine
Lateral flexion is not commonly used Widens interspace for
easier introduction of needle
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Scout Images
Cross table lateral With grid Closely collimated
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Myelography
Local anesthesia given at puncture site Lidocaine and sodium bicarbonate
Spinal needle inserted (pressure obtained)
CSF usually withdrawn and sent to laboratory
Contrast injected and needle removed 9-12 ml
Table angle and gravity used to move contrast under fluoroscopy
Spot images taken as needed
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Spot Films
Central ray vertical or horizontal using CR or film screen cassettes
Images are taken at Site of blockage Level of distortion
If conus medullaris is area of concern: Lay pt supine Central ray at T12- L1 Use 10x12 cassette and collimate tightly
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Myelogram overview
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Myelography
If contrast is moved into cervical area, head is positioned in acute extension to prevent contrast from entering ventricular system
Acute extension compresses cisterna magna and is the only position that will prevent contrast from entering ventricles
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Myelography
Usually performed as outpatient basis
Common for CT myelography (CTM) to be used with conventional Myelogram
MRI often used instead
Myelography and CTM still used for patients with contraindications for MRI Pacemakers and metal fusion rods
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Post procedure: Myelography Monitoring required
Head and shoulders elevated 30 to 45 degrees
Bed rest for several hours
Fluid encouraged
Puncture site checked before release
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Possible Complications from Myelography Vomiting
Vertigo
Neck Pain
Spinal Headache
Due to loss of CSF during puncture
Increased severity upright
Decreased pain when recumbent.
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More Severe Complications
Nerve root damage Meningitis Epidural abscess Contrast reaction (anaphylactic shock) CSF leak Hemorrhage
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Treatment for Spinal Headache Initial treatment
Tylenol
Horizontal position
Forced fluids
Caffeine
Persistent headache If a fever occurs,
contact MD May be indicative of
meningitis
Beyond 48 hrs w/o fever (24 hrs if severe) Blood patch
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Blood Patch Sterily injecting a small
amount of patient’s blood into the epidural space Clot will occur over hole Usually will stop
headache immediately 1st patch is 70% effective 2nd patch is 95% effective
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Myelogram radiographs
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Myelograms Images
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CTM
Performed after intrathecal injection
Can be performed at any level of vertebral column
Multiple slices taken (1.5 – 3mm) Gantry is tilted
Windowing allows for density and contrast changes
Can obtain images with small amounts of contrast Can be done 4 hours after initial injection
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CTM
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MRI of Spinal Cord and CSF flow
Non-invasive
Provides anatomic detail of brain, spinal cord, intravertebral disc spaces, and CSF within subarachnoid space
Does not require intrathecal injection
Does not have bone artifacts
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MRI basics T1 & T2 images can be taken
Head coil for brain Body coil and surface coil form spine
IV contrast can be used to enhance tumor Gadolinium
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Contraindications to MRI Pacemakers Ferromagnetic aneurysm clips Metallic spinal fusion rods
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Myelography Using MRI and Conventional methods
MYELOGRAM
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Preference of MRI MRI is the preferred modality for middle and
posterior cranial fossa of brain. In CT these structures are obscured by bone
artifacts Spinal cord
Allows direct visualization of spinal cord, nerve roots, and surrounding CSF
Can be done in various planes Aid in diagnosis and treatment of neurodisorders
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Usefulness of MRI Assessing
demyelinating disease Such as MS
Spinal cord compression
Postradiation therapy changes of spinal cord tumors
Herniated disks
Congenital abnormalities of vertebral column
Metastatic disease
Paraspinal masses
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MRI and Brain imaging Middle and posterior fossa abnormalities Acoustic neuromas Pituitary Tumors Primary and metastatic neoplasms Hydrocephalus AVM’s Brain atrophy
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Not valuable for diagnosing: Osseous bone abnormalities of skull
Intracerebral hematomas
Subarachnoid Hemorrhage
CT preferred for these 3 illnesses
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CT of Brain basics Useful for demonstrating size, location and
configuration of mass lesions and surrounding edema
Assessing cerebral ventricle or cortical sulcus enlargement
Shifting of midline structures caused by mass lesions, cerebral edema, or hematoma
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Indications for Pre and Post contrast Imaging using CT
Suspected Neoplasms Suspected metastatic disease Arteriovenous malformation (AVM) Demyelinating disease (MS) Seizure disorder Bilateral isodense hematomas
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Indications for Brain scans without Contrast media Dementia
Craniocerebral trauma
Hydrocephalus
Acute infarcts
Post evacuation follow up of hematomas
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CT Brain imaging Most often Axial orientation Gantry 20-25 degrees to OML
Allows lowest slice to provide an image of both the upper cervical, foramen magnum, and roof of orbit
12-14 slices 8-10 mm slices 3-5 mm slices through post fossa Depending of PT size Slice thickness
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CT Brain imaging (cont) Coronal imaging
Helpful in evaluation of Pituitary gland Sella turcica Facial bones Sinuses
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CT: Modality of choice Modality of choice for
the following”
Hematomas Suspected aneurysms Ischemic or
hemorrhagic strokes Acute infarcts
Used as initial diagnostic modality for:
Craniocerebral trauma
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CT of Spine Useful in diagnosis of vertebral column
hemangiomas and lumbar spine stenosis Often used post-trauma to assess Axis and
Atlas fractures and for better demonstration of C7-T1
Clearly demonstrates size, number and locations of fracture fragments of C, T and L spine.
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Surgery Applications of CT imaging Greatly assists surgeons in distinguishing
neural compression by soft tissue from compression by bone
Post-op Useful in assessing outcome of surgical
procedure
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MRI vs. CT
MRi superior to CT for imaging of posterior fossa CT has artifacts from bone MRI is free from bone artifacts
MRI has inability to image calcified structures. CT is superior for calcifications
MRI can detect cerebral infarction earlier than CT.
Both modalities provide similar information on subacute and chronic strokes
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Diskography and Nucleography Radiologic exam of individual intervertebral
disks Small amount of water soluble iodinated contrast
injected into center of disk double needle entry Pt’s given local anesthetic
So pt is alert and communicate with DR about pain when needle and contrast are inserted
Used to investigate disk lesions Ruptured nucleus pulpous
Has been largely replaced by CTM and MRI
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Diskograms
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Lumbar Diskograms
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Vertebroplasty Interventional radiology procedure to treat
compression fractures or other pathologies in the vertebral bodies
Used when conservative treatment does not work
Used when severe pain does not improve over a number of weeks of treatment
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Percutaneous Vertebroplasty Done in specials or OR Trocar needle is advanced through pedicle into the
vertebral body under fluoro Non-ionic contrast media is used to confirm needle
placement Bone cement ( polymethyl methacrylate) is injected
into vertebral body using fluoro AP & LAT images taken post procedure
CT sometimes done as well
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Vertebroplasty under Fluoro
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Post Vertebroplasty
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Percutaneous Kyphoplasty Trocar needle advanced
Through pedicle, avoiding spinal canal Biopsies can be taken Balloon catheter used to expand the compressed
vertebral body to near its original height before injection of bone cement
Trocar needle is considered the “working cannula”
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Kyphoplasty Outline
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Pre and Post Kyphoplasty radiographs
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Kyphoplasty Short clip http://images.google.com/imgres?imgurl=http://
www.beverlyhillsspinesurgery.com/images/icon-video-kyphoplasty.jpg&imgrefurl=http://www.beverlyhillsspinesurgery.com/spine-surgery-lumbar-los-angeles.htm&usg=__Ev4umMv-foN7fMgacwWnVMuVF9A=&h=121&w=146&sz=6&hl=en&start=30&tbnid=B96VZbmx2Ojy4M:&tbnh=79&tbnw=95&prev=/images%3Fq%3Dkyphoplasty%26start%3D20%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DN
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Complications of Vertebroplasty and Kyphoplasty Most common: leakage of cement
Less common: pulmonary embolism Death
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Success of Vertebroplasty and Kyphoplasty Success is measured by the pt’s pain
reduction and quality of life improvement
Can help reduce hunchback and restore normal curvature
With Kyphoplasty there is a 80-90% success rate
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Vertebroplasty and Kyphoplasty clips http://www.unikron.com/tools/play/play_displ
ay.cgi?speed=hi&id=good_samaritan2
http://www.or-live.com/StJoseph/1319/
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Pain Management Epidural Injection
Facet Injection
Spinal Cord stimulation
Radiofrequency Neurolysis
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Considerations of Pain Management Interventional Procedures Stop NSAID 3 days prior to procedures
With Facet injections no pain relievers 4 hours prior to procedure
Takes 3- 10 days for full results to manifest
Done when conventional treatment has not helped
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Epidural Used to treat pain as a result of and injured disk affecting
spinal nerves Decreased inflammation & swelling
Done under fluoroscopy with PT awake Takes 10- 15 minutes Recovery short Sterile procedure
Complications Spinal headache (most common Infection Epidural Hematoma
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Epidural Can be done at any
level of the spine Place a needle (often
with catheter) into epidural space
Small amount of contrast injected to verify placement
Corticosteroid & anesthetic injected ( Cortisone Lidocaine
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Epidural with Catheters
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Facet Injections
Indications: Diagnosis Therapy
Causes of pain include: Inflammation, swelling,
or arthritis
Awake under fluoro Takes 20-40 minutes Sterile procedure
Complications Pain at site Bleeding Infection Increase in pain
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Facet Injections Inject needle into facet
joint
Inject contrast to verify needle placement
Inject lidocaine or bupivivaine (anesthetic) & corticsteroid (anti-inflammatory)
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Side effects of Steroids Fluid retention
Weight gain
Mood swings
Increase in blood pressure
Usually temporary
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Spinal Cord Stimulation Delivers low voltage electrical stimulation to
the spinal cord Delivered through 1-2 wires which are carefully
placed in epidural space Electrical signals replace sensation of pain with a
tingling sensation Done in two stages
Trial Permanent placement
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SCS Radiographs
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Trial and Permanent Placement Done in OR
Local anesthetic & intravenous sedation
Wires placed in epidural space
PT goes home with wires in place for 1 week to test and see if it helps
If trial period helps permanent generator is placed under skin in OR
Contains generator with battery (some are rechargeable) Periodically battery is
replaced
Others have transmitters & generators
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Generators only vs. Generators with Transmitters
SCS with generators inside the body must be replaced in OR Some are one time use Those that are
rechargeable allow for more time in between battery replacement
SCS with transmitters can also be one time use or rechargeable PT can adjust settings
according to different programs Set by DR according to
PT’s pain patterns
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SCS With Generator and Transmitter
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SCS Indications, Benefits & Risks
Indications: Chronic pain associated
with: Neuropathic pain Failed back surgery
syndrome Arachnoiditis Certain vascular disease
Benefits Reduces rather than
eliminates pain Reduces pain by 50% Reduces narcotic use
Risks Infection & bleeding Paint at insertion site Nerve injury Dural puncture or tear Migration or breakage of
wire
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Radiofrequency Neurolysis Uses high frequency radio waves to produce a
heat lesion Lesion ablates or inactivates nerves responsible
for transmitting pain Usually done in L and C spine Pain can be caused from whiplash or arthritis
Done under fluoro in OR
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Radiofrequency Neurolysis Helps for 6-24 months
70% of PT’s get relief
Takes about 45-60 minutes
Can be repeated if pain returns
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Radiofrequency Neurolysis PT is awake and mildly sedated Local anesthetic injected
Stimulation test is done to verify needle placement PT is questioned for tingling or buzzing feeling (as
when hitting your funny bone) Once PT confirms this , they are sedated more
Radio waves are transmitted ablating the nerve Muscles may spasm or “jump”
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RF Risks Infection
Bleeding Blood vessel damage
Soreness for a few days