RadteraMyelogram (Lumbar)
Fluoro+ ContrastNeuroverify
Indications
- Spinal canal/nerve root compression when MRI contraindicated (pacemaker, hardware artifact) or inconclusive
- CSF leak localization (often with CT myelogram)
- Evaluation of arachnoiditis, spinal stenosis, disc herniation
- Surgical planning, especially with extensive instrumentation
- Assessment of nerve root avulsion
Patient prep
- Review coagulation status; hold anticoagulants/antiplatelets per guidelines
- Screen for contrast allergy and seizure-lowering meds (avoid drugs lowering seizure threshold)
- Hydration before/after; consent
- Check prior imaging; confirm level
Contrast
AgentNonionic water-soluble iodinated contrast approved for INTRATHECAL use ONLY (e.g., iohexol/Omnipaque intrathecal concentrations such as 180/240/300 labeled for myelography)
Routeintrathecal (subarachnoid) via lumbar puncture
DosePer label for lumbar myelography (typically ~10-15 mL of appropriate concentration; do not exceed labeled intrathecal dose)
TimingInject under fluoroscopy after confirming subarachnoid position; image immediately, then CT myelogram often follows
Technique
- Position prone or lateral; sterile prep
- Fluoroscopically guided lumbar puncture (commonly L2-L3 or L3-L4, below conus)
- Confirm subarachnoid placement with free CSF return and a small test of contrast flowing freely in the thecal sac (not epidural/subdural)
- Inject intrathecal contrast under fluoroscopy
- Tilt table to distribute contrast to region of interest; obtain AP, lateral, and oblique spot films
- Proceed to CT myelogram (post-myelography CT) for cross-sectional detail
Series / Sequences
| # | Series / Sequence | Plane | Notes |
|---|---|---|---|
| 1 | Needle placement / test injection | Lateral fluoro | Confirm intrathecal (free contrast in thecal sac) |
| 2 | AP lumbar | AP | Nerve root sleeves, filling defects |
| 3 | Lateral lumbar | Lateral | Canal stenosis, disc impressions |
| 4 | Oblique | RPO/LPO | Nerve root cutoff, lateral recess |
| 5 | Post-myelogram CT | Axial CT | Cross-sectional detail, recommended adjunct |
Key points
- ONLY use contrast specifically labeled for intrathecal administration — inadvertent intrathecal injection of non-approved/ionic contrast can cause seizures, neurotoxicity, and death
- Confirm subarachnoid (not subdural/epidural) placement before full injection
- Keep head of bed elevated after procedure; avoid stooping; this reduces upward migration of contrast and post-procedure headache/seizure risk
- Avoid drugs that lower seizure threshold (e.g., phenothiazines) periprocedurally
- Watch for post-dural-puncture headache; hydration and rest
- Contraindications: coagulopathy, infection at puncture site, raised ICP / posterior fossa mass (herniation risk)
References
• ACR–ASNR–SPR Practice Parameter for the Performance of Myelography and Cisternography (gravitas.acr.org/PPTS, DocId 64)
• ASNR Practice Guideline: Myelography — link
• Omnipaque (iohexol) intrathecal prescribing information (GE Healthcare)
• Radiopaedia: Myelography
• ASNR Practice Guideline: Myelography — link
• Omnipaque (iohexol) intrathecal prescribing information (GE Healthcare)
• Radiopaedia: Myelography
Source: Researched — verify against your institution
Reference template — verify and adapt to your scanner, vendor and institution before clinical use. Not a substitute for clinical judgment.