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Objective: We compared traditional bevel-tip end-hole spinal needles and pencil-point-tip side-hole needles for the incidence, severity, and duration of spinal headaches in subjects who had myelograms. Age, sex, and myelographic findings were examined., Subjects and Methods: We studied 138 subjects referred for myelograms. For 108 procedures, we randomly used 22-gauge Quinke bevel-tip end-hole needles or 22-gauge Sprotte pencil-point-tip needles. The 30 additional subjects were examined with Gertie Marx pencil-point-tip needles. All myelograms were performed by one of two neuroradiologists using recommended doses of iohexol. The myelograms were examined by an independent neuroradiologist for quality of image and presence of extraarachnoid contrast material. Five to 14 days after myelography, subjects were telephoned by an independent observer and asked about the presence, severity, duration, and positional quality of headache. Spinal headache is defined by positional quality and increases in severity when the subject moves from horizontal to sitting or standing., Results: We found that four (8%) of 52 subjects who had myelograms with Sprotte needles had spinal headaches. Likewise, 14 (25%) of 56 subjects who had myelograms with Quinke needles had spinal headaches. We calculated a statistically significant difference in the incidence of spinal headaches using chi-square analysis (p = .02). The average grade and duration of the spinal headaches did not differ significantly, although they were less marked in the Sprotte group. Spinal headaches occurred more frequently in young and middle-aged subjects than in older subjects. We found one definite extraarachnoid injection in each group. For the Gertie Marx needles, two (7%) of 30 subjects had spinal headaches. The average grade of postmyelogram headache was 2.5, and the mean duration was 1 day. There were no mixed injections., Conclusion: We found a significant reduction in spinal headaches after myelograms when we used the pencil-point-tip side-hole needle. These results support the routine use of these needles for myelography in young and middle-aged patients.

Purpose: To compare the postdural puncture headache (PDPH) rates after myelography with use of 22-gauge Whitacre (blunt tip) versus standard 22-gauge Quincke (bevel-tip) spinal needles., Materials and Methods: At myelography, 340 patients were randomly assigned to one of two groups in which either the Whitacre (167 patients) or the Quincke (173 patients) needle was used. Follow-up was at 48 hours and at 4 days after the procedure. Crude and adjusted Whitacre/PDPH odds ratios and risk ratios were calculated., Results: The crude Whitacre needle PDPH risk was 9.6%, and the crude Quincke needle PDPH risk was 15.6%. The absolute risk difference was 6.0% with a 95% confidence interval of -0.98% and 13.04%. The adjusted Whitacre/PDPH odds ratio was 0.492 with a 95% confidence interval of 0.241 and 1.003. The Whitacre needle group had a statistically significantly lower PDPH severity grade (P = .0151), similar PDPH duration, and more technical difficulty with the needle., Conclusion: The Whitacre needle is associated with an equal or lower PDPH risk; the lack of statistical significance is most likely related to sample size. Further study is necessary to determine whether the decreased PDPH rate justifies the added difficulty associated with use of the Whitacre needle.

The author reviews the topic of postdural puncture headache (PDPH) so radiologists can better understand, prevent, and treat this common complication of myelography. PDPH, a postural headache relieved by lying supine, occurs after 36.0%-58.2% of myelographic procedures performed with 22-gauge Quincke needles. It begins within 3 days and lasts 3-5 days. Thin, young women are more likely to develop PDPH. Smaller gauge needles, blunt-tip needles, a paramedian approach, and parallel orientation of a bevel needle are associated with lower PDPH rates. Intravenous hydration, no removal of cerebrospinal fluid, experience of the myelographer, and inpatient status have been inconsistently associated with lower PDPH rates. Treatment is supportive with bed rest. Oral or intravenous methylxanthine agents may be given for more severe PDPH. An epidural blood patch, although rarely needed, is very effective.

109 patients who had undergone Myodil myelography on at least one occasion were identified. The patterns of lumbar nerve root distribution in this group were examined using magnetic resonance imaging. The relationship between these patterns and the presence of spinal stenosis or previous surgery was investigated. Chronic adhesive arachnoiditic nerve root patterns were seen in 68 patients and were classified into three groups according to Delemarter et al. Central clumping of nerve roots (type 1) and complete opacification of the thecal sac (type 3), extending over at least one vertebral level, were significantly related to spinal stenosis at an adjacent level (p < 0.0001). Peripheral adhesion of nerve roots to the theca (type 2) was significantly related to previous surgery at the level of abnormality (p < 0.00005). Only a single case of arachnoiditic nerve root patterns was seen in the absence of stenosis or previous surgery. We conclude that chronic adhesive arachnoiditis is significantly related to previous Myodil myelography in the presence of spinal stenosis or previous surgery but that Myodil alone rarely produces these changes.

Few cases of radiation injury related to lengthy interventional neuroradiologic procedures have been reported, although concern has been heightened, as evidence by a 1994 FDA Public Health Advisory. We report a case of radiation-induced dermatitis in a patient undergoing multiple diagnostic and embolization procedures for treatment of a spinal arteriovenous malformation.

A case of pontine haemorrhage following lumbar myelography using iohexol is described. Stress, inducing transient hypertension during the procedure, with superimposed neurotoxicity from contrast medium (iohexol) is suggested as a possible mechanism. No brain stem lesion was seen on the initial brain CT scan, possibly because of the high attenuation of the contrast medium in the subarachnoid space. A delayed CT brain scan demonstrated the pontine haemorrhage and was necessary to confirm the diagnosis.

In a prospective study lumbar iohexol myelography was performed in 107 consecutive patients, randomised for lumbar puncture with a Quincke or Whitacre spinal needle. All patients answered a questionnaire about possible side effects. Data from 100 patients (58 men, 42 women) were evaluated. In the Quincke group (n = 53), 23 (43%) reported no side effects. In the 30 patients who reported various side effects, post-dural puncture headache (PDPH) occurred in 22 (42%), of whom 9 had mild, 6 moderate and 7 (13%) severe cephalalgia, 18 (34%) reported increased low back pain/sciatica, 5 nausea and 7 dizziness. In the Whitacre group (n = 47), 33 (70%) had no side effects. PDPH was reported by 9 patients (19%), of whom 2 had mild, 6 moderate and only 1 (2%) severe cephalalgia, 4 (9%) reported increased low back pain/sciatica, 5 nausea and 4 dizziness. The conclusion drawn from this study is that lumbar myelography performed with the Whitacre spinal needle reduces postspinal side effects.

Purpose: Two cases illustrate the symptoms, signs, etiologies, and treatment of ocular neuromyotonia (ONM)., Methods: The histories, neuroradiologic tests, and/or biopsy revealed the etiologies of ONM in both patients. Clinical observations, videotaping, and electronic eye movement recordings documented the eye movements., Results: A 72-year-old man with chronic arachnoiditis following myelography with thorium dioxide (Thorotrast) developed intermittent diplopia and a partial right third nerve palsy. Left gaze induced spasm of the right medial rectus. Right gaze produced right lateral rectus spasm. A 66-year-old woman, who had radiation treatment for a pituitary tumor and acromegaly, had intermittent spasm of the left medial rectus muscle and left esotropia. The episodes occurred spontaneously and were induced by right gaze. A left internuclear ophthalmoplegia was also found. Carbamazepine (Tegretol) abolished the ONM in both patients., Conclusions: Although ONM is an unusual cause of intermittent diplopia and strabismus, its distinctive clinical features identify it. Injury to the peripheral cranial nerves probably leads to segmental demyelination, axonal hyperexcitability, and a self-perpetuating, reverberating circuit, which causes spasms of the extraocular muscles.

Bacterial meningitis is a rare complication of myelography. Most reported cases of bacterial meningitis are caused by a wide variety of streptococcal species, but the source of these organisms is uncertain. We recently participated in the defense of two legal cases arising from this complication. We discuss the medicolegal aspects of streptococcal meningitis that is a complication of myelography.

Prolonged cerebrospinal fluid leakage from the dural puncture site is considered the most important factor in the development of post-myelography headache. Incidences of post-myelography headache and post dural puncture headache vary a lot--possible reasons are discussed. The statement that patients with a low substance P level in cerebrospinal fluid are prone to developing a post dural puncture headache seems especially interesting. Articles considering clinical as well as experimental studies are reviewed.

Lumbar myelography is still frequently used in cases of suspected lumbar radiculopathy. Since 1984, iohexol has been the contrast medium of choice in myelography, and so far only a few cases of chemical meningitis have been reported. Bacterial meningitis cannot be distinguished from chemical meningitis on the basis of clinical findings. A cerebrospinal fluid Gram stain and culture are the only truly reliable tests in deciding the etiology of the meningitis. We describe two patients who developed meningitis following myelography with iohexol. In one of the patients, the cerebrospinal fluid culture was positive with subsequent identification of Flavobacterium meningosepticum, a species not previously reported as an infectious agent in meningitis after myelography.

Our goal was to determine if evidence of cerebrospinal fluid (CSF) leakage on routine postmyelogram computed tomography (CT) of the lumbar spine was useful in predicting subsequent development of moderate or severe headaches in patients having outpatient myelography. We reviewed postmyelogram CT studies of the lower lumbar region of 89 patients for radiographic indication of CSF leakage. These patients had outpatient lumbar myelography. We conducted telephone interviews to determine whether a postmyelographic headache occurred. Correlation of CT-verifiable contrast leakage with subsequent development of postmyelogram headache was statistically significant. The early radiographic identification of such patients affords the opportunity for additional measures, such as extended bed confinement, to decrease the morbidity of myelography. Additionally, statistical correlation of such findings should provide an objective method of evaluating the effectiveness of alterations in myelographic technique.

Complications following myelography do not usually cause serious disability. However, we report a case of sixth nerve palsy where the disability lasted a few months. We also discuss the possible pathogeneses.

Bacterial meningitis is a rare complication of myelography. Most reported cases are due to miscellaneous streptococci, but the source of these organisms is uncertain. The differential diagnosis of chemical meningitis caused by the contrast material vs. bacterial meningitis may be difficult. We recently treated three patients with streptococcal meningitis following myelography performed with the contrast medium iopamidol. We discuss the diagnostic and therapeutic approach to postmyelography meningitis.

We report a case of aseptic meningoencephalitis complicating iohexol myelography and compare this case with previous reports of neurotoxicity from intrathecal contrast media.

Auditory threshold and auditory brainstem response studies were conducted in 50 patients before and after myelography. Analysis of amplitudes and latencies of auditory brainstem measurements demonstrated significant disorders of function of the cochlea and auditory pathway. The Jewett I wave showed a prolongation of latency from 1.92 to 1.98 ms using an average of all repetition rates. The Jewett III wave showed prolongation from 4.01 to 4.14 ms and the Jewett V wave prolongation from 6.01 to 6.16 ms. At the same time average amplitudes for Jewett III and V decreased. In most of the patients these disorders of function were found to be subclinical. However, 12 patients had changes ranging from a subjectively slight hearing loss to an audiometrically defined acute hearing loss. The reasons for these disorders could not be clarified. An open cochlear aqueduct through which perilymph can enter the subarachnoid space, leading to secondary endolymphatic hydrops, was suggested as the cause for the losses found. Changes in brainstem audiometry were also explained by changes in osmolality of inner ear fluids, leading to the development of an endolymphatic hydrops.

We report a case of acute intracranial subdural haematoma after lumbar myelography with Iopamidol. The haematoma was successfully treated by emergency craniotomy. The bleeding came from cortical bridging veins as confirmed by surgery. This rare complication should be suspected in patients who complain of prolonged headache or develop a neurological deficit after myelography.

An attempt was made to assess the usefulness of using animal models to predict the neural tolerability in man of iodinated contrast media (CM) in general, and of the new nonionic dimer iodixanol in particular. For this purpose, the results from 6 animal experiments evaluating excitative and depressive effects of subarachnoidally injected CM in nonanesthetized rabbits were compared with the results from 22 randomized double-blind clinical trials dealing with post-myelographic adverse reactions. Comparisons were made as regards the nonionic monomers metrizamide, iohexol, and iopamidol, and the dimer iotrolan. The results seem to justify the conclusion that the convulsive effects of CM can be reliably predicted from animal experiments. The animal model cannot be used to predict specific types of nonconclusive adverse reactions in man, but reflects well the differences in frequencies of minor reactions following clinical myelography with different nonionic CM. In general, the neural tolerability of iodixanol may be expected to be better than that of the nonionic monomers and approximately equal to that of iotrolan.

The objective of this study was to assess the etiology of lateral rectus palsies in patients undergoing lumbar myelograms with Iopamidol (Isovue; ER Squibb and Sons, Princeton, NJ, USA; Niopam, E Merc, UK.). An audit of the departmental orthoptic record revealed two patients who had suffered abducens palsies after myelograms. A further search revealed three additional patients who had suffered similar complications. The incidence of abducens palsy in patients undergoing myelography with the contrast agent Iopamidol was found to be 1 in 500 in around 2,500 myelograms performed under standard conditions. It would appear that lateral rectus palsy in myelography is the result of the lumbar puncture, the neurotoxic effect of the contrast agent, or a combination of the two in patients with an already compromised neurophysiologic state. This is the first series to associate this problem with Iopamidol. Although usually a serious neurologic symptom, when associated with contrast myelography using Iopamidol it is important to appreciate that such symptoms usually resolve of their own accord.

Summary of Background Data: The authors report a 46-year-old female patient who was referred to this unit for assessment of chronic postsurgical back pain. She reported severe burning pain in the lumbar region accompanied by burning pain and loss of sensation in the lower limbs. She had previously undergone lumbar spinal surgery on three occasions preceded by myelography., Methods: Examination revealed generalized weakness and hypertonicity of both lower limbs with loss of all sensory modalities below D7., Results: The MRI scanning of the thoracic spine showed an extensive complex syrinx within the thoracic cord., Conclusions: She underwent syringopleural shunting, and her condition has remained stable.

Out-patient lumbar myelography was carried out on 74 consecutive patients, and adverse reactions were registered by the patients themselves. Twenty-four percent experienced moderate or severe headache; 62% experienced increasing back pain of a moderate or severe degree; 40% experienced increasing leg pain of a moderate or severe degree; 15% experienced nausea/general symptoms to a moderate or severe degree. Twenty-nine percent experienced the myelography as unpleasant in a moderate or severe degree. Fourty-seven percent had some kind of adverse reaction for > or = four days. Eleven patients (16%) were admitted to hospital because of severe adverse reactions, mostly headache, and nine of them were treated with a blood patch. Twenty-five percent were referred for operation for their back disease. Generally, out-patient lumbar myelography is well tolerated, but a large proportion of the patients experience temporary adverse reactions to a moderate or severe degree, perhaps in part because of immobilisation in connection with photographing procedures.

Study Design: The adverse effects of lumbar myelography in 400 patients were analyzed., Objectives: To determine whether adverse effects of lumbar myelography occur less frequently when using the fine needle technique., Summary of Background Data: Lumbar myelography can be performed safely on an outpatient basis. The side effects may be reduced by using the fine needle technique., Methods: Four hundred patients were studied; 200 with a 25 gauge needle and 200 with a 22 gauge needle. Each was given a questionnaire and instructed to report details of post-myelogram adverse effects., Results: Transient worsening of back or leg symptoms, headache, and nausea and vomiting, the most frequent complaints, were reduced in the 200 patients studied with a 25 gauge needle rather than a 22 gauge needle. Regardless of the needle, patients with normal myelograms reported more adverse effects., Conclusions: A lower frequency of adverse effects can be achieved when fine needle is used for lumbar myelography. More adverse effects are reported by patients with normal myelograms.

The aim of this study was to investigate whether the incidence of headaches following myelography could be reduced by using a needle with an atraumatic tip. 107 patients were studied in a trial of 22 gauge atraumatic versus 22 gauge bevel tipped needles. In the first 3 days after myelography, there was a significant reduction in the incidence of headaches in patients in whom an atraumatic needle had been used.

Thirty patients presenting with post-dural puncture headache (PDPH) were prospectively studied to determine the influence of the duration of the decubitus position after epidural blood patch on the efficacy of treatment. All patients received 12 ml of autologous blood. They were randomly distributed into three groups of ten patients. Patients in Group 1 were maintained in a decubitus position for 30 min after the epidural injection of autologous blood in the epidural space. Patients in Group 2 were maintained for 60 min in decubitus and patients in Group 3 for 120 min. Post-dural puncture headache was evaluated using a visual analogue scale before the epidural blood patch, at the time of initially adopting a standing position after the blood patch, and 24 hr later. The severity of PDPH in the three groups was reduced at the time of initially adopting a standing position and after 24 hr, in comparison with preblood patch VAS (P < 0.001). Patients in Group 3 presented less severe PDPH than patients in Group 1 at the time of initially standing up and 24 hr later (P < 0.05). We conclude that epidural blood patch was effective in treating PDPH but that the maintenance of a decubitus position for at least one hour and preferably for two hours after the blood patch was more effective than maintenance for 30 min.

Rationale and Objectives: The accuracy and safety of nonionic myelography, unenhanced computed tomography (CT), and magnetic resonance (MR) in the diagnosis of lumbar disc herniation are reviewed. The comparative costs of these tests are also considered., Methods: The accuracy of imaging tests that diagnose disc herniations was established by conducting a Medline search between 1985 and 1992. The morbidity associated with these tests are less formally established from selected articles. Finally, the mediocre reimbursement rates of these tests are reviewed., Results and Conclusions: The evolution of nonionic contrast media from the first to the second generation has been accompanied by a notable decrease in adverse reactions. Although nonionic myelograms are now better tolerated by patients, noninvasive imaging with CT and MR imaging has become as accurate as or more accurate than lumbar myelography, and should replace it as a screening test. Computed tomography may have advantages over MR imaging when issues of availability and cost are considered. In contrast to lumbar myelography, CT myelography may continue to be a useful method for clarifying ambiguous results of noninvasive tests. The morbidity associated with CT myelography can be minimized by using low doses of a nonionic agent, keeping the patient well hydrated, and using a small lumbar puncture needle. The incidence of adverse reactions can be expected to decrease further as new nonionic dimers become clinically available.

This prospective investigation was conducted to evaluate the efficacy of different volumes of epidural blood patch (EBP) for treatment of postdural puncture headache (PDPH) in 81 consecutive patients. In the first part of the investigation (Study part I), 10 ml of blood was injected for EBP in 28 patients. In the second randomized part of the investigation (Study part II), the patients were allocated to receive for EBP either 10 ml (27 patients) or 10-15 ml (26 patients), according to the height of the patient. The procedure was considered initially successful if PDPH disappeared completely during the 2-h recovery room follow-up. To evaluate the long-term success, a questionnaire was mailed to all patients. The EBP performed 3.7 +/- 2.9 days following the dural puncture was initially successful in 88-96% of the patients in the different study groups. In the questionnaire, only 50-68% of the patients reported that PDPH had disappeared immediately without recurrence. In 16-36% of the patients the PDPH returned at lesser intensity and in 14-17% PDPH was reported to have continued, disappearing gradually in all patients. Despite this, 87% of all patients were satisfied with the EBP treatment. There were no statistically significant differences between the groups. The results indicate that a larger, height-adjusted volume of blood for EBP in adults does not produce a better effect on PDPH compared to a standard 10-ml volume. Despite the excellent initial effect (91%) seen in our patients, a permanent effect of the blood patch was only achieved in 61%.

The authors report the adverse reactions to myelography in two groups of patients. The only difference was the spinal needle size: 20 G (0.9 mm) in the first group versus 26 G (0.45 mm) in the second one. In the second group the adverse reactions appear 3 to 10 less frequent and 3 to 5 less lasting.

This study aimed to test the hypothesis that the use of fine rather than larger calibre needles for myelography reduces the incidence of post-procedural headache. 160 patients were randomized in a prospective controlled trial of 22 gauge versus 26 gauge needles. The incidence and overall severity of headache as measured at 1, 4 and 21 days after myelography was not significantly different in the two groups.

Only a few case reports have been published about hearing impairment following lumbar puncture, and not all were thoroughly documented by audiograms. We present nine cases of hearing loss following myelography, lumbar puncture, and spinal anesthesia. We speculate that this rare complication arises only in persons with a wholly or partially patent cochlear aqueduct, and occurs via the release of perilymphatic fluid in the cerebrospinal space. Hearing loss was seen in eight of the nine patients in the lower frequencies, and in six of the nine patients on both sides. Recovery to normal hearing was noticed in six of the nine patients. Transient hearing loss may occur more often than it is generally assumed, and the symptom can remain unnoticed. Since not all of these hearing losses proved to be fully reversible, we suggest informing patients about this complication for medicolegal reasons.

Medical records of 66 dogs that had undergone myelography, using iohexol (240 mg of iodine/ml, 0.3 to 0.5 ml/kg of body weight) during a 2-year period, were reviewed. In 3 dogs, myelography was performed twice during different anesthetic procedures. Neurologic abnormalities were more pronounced the day after myelography in dogs with caudal cervical spondylomyelopathy (P less than 0.01), meningitis (P less than 0.01), or extradural tumors (P less than 0.05). Neither anesthetic regimen nor duration of anesthesia significantly affected the frequency of complications. Seizures occurred after myelography in 6 dogs, and 1 dog had seizures after each of 2 myelographic procedures. The frequency of seizures was significantly greater in male Doberman Pinschers afflicted with caudal cervical spondylomyelopathy. Male dogs (P less than 0.01) and Doberman Pinschers (P less than 0.001) had higher prevalence of seizures. Caudal cervical spondylomyelopathy was associated with higher prevalence of seizures, compared with all other diagnoses (P less than 0.001). Seizures were significantly more prevalent when body weight was greater than or equal to 29 kg (P less than 0.001), when greater than or equal to 2 injections of contrast medium were administered (P less than 0.016), or when 2 injections of contrast medium were given at the cisterna magna (P less than 0.015). The 10% prevalence of seizures after myelography with iohexol in the study reported here is greater than in previous reports, but is lower than that reported after myelography using metrizamide.

We report an unusual case of an acute encephalopathy following injection of iohexol for myelographic study, which was reversible after a treatment with water restriction and glucocorticoids. The pathophysiologic mechanism appears to be related with hyponatremia. We conclude that drinking of large amounts of fluids must be not recommendable in order to avoid the developing of encephalopathy.

One hundred three patients with different diseases of the vertebral or spinal column were studied with hydrosoluble myelography. In fifty-three patients spinal puncture was carried out with a 25 G needle (fine) and in the remaining 50 patients a 22 G needle (thick) was used. Post myelographic control by means of a scale which we designed permitted the clear establishment of the responsibility of needle diameter in the incidence of complications, fundamentally cephaleas with 11.3% with the 25 G needle vs 66% with the 22 G needle. Following the therapies herein suggested, only rarely was there a complication of little significance thereby encouraging the use of this method when non invasive procedures are insufficient for clarifying diagnostic doubts.

Two cases of vestibular disturbance caused by residual oily contrast medium in the internal auditory canals after myelography are reported. Nystagmus towards the affected side and normal caloric responses were observed; therefore, contrast media are considered to act as irritants to the vestibular nerve.

A randomized prospective trial of 26 G versus 22 G spinal needles was performed in 284 consecutive patients referred for myelography, during which contrast medium was introduced by lumbar puncture. Use of the fine (26 G) gauge needle resulted in a significant decrease in moderately or severely painful needle placements and moderate, severe or postural headaches following myelography. The incidence of other side effects was not significantly influenced by needle size. The incidence of headaches and other side effects was significantly higher in female patients. Back pain, the commonest side effect, was significantly more common in patients who had normal lumbar myelograms than in those in whom lumbar root compression was demonstrated. The incidence of neck stiffness was significantly higher following cervicothoracic myelograms than lumbar myelograms but there was no significant difference in the incidence of other side effects. The use of 4.5 g instead of 3.0 g of iodine resulted in no increase in symptoms. The experience of the operator had no significant effect on the incidence of side effects. Some side effects of myelography appear to be due mainly to cerebrospinal fluid leakage at the site of puncture and are strongly influenced by psychological factors.