MAGNETIC RESONANCE MYELOGRAPHY

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1 MAGNETIC RESONANCE MYELOGRAPHY HUMERA AHSAN, M.D. F.C.P.S. DEPARTMENT OF RADIOLOGY & IMAGING AGA KHAN UNIVERSITY HOSPITAL Presentation material is for education purposes only. All rights reserved URMC Radiology Page 1 of 64

2 Magnetic Resonance Myelography is a relatively new imaging sequence which produces myelogram like images of the thecal sac by MR imaging. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 2 of 64

3 Advantages It is totally non invasive and patient friendly. Has no side effects from intra-thecal contrast. No exposure to ionizing radiation. Short imaging time. Both the superior and inferior extent of spinal block are shown. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 3 of 64

4 Technique Single shot TSE, TR 8000 ms, TE 1000 ms, TSE factor 256, acquisition time 3:36. MR myelographic images are automatically reconstructed as maximum intensity projections and presented as 9 consecutive images at 22.5 intervals, extending from a right lateral to a left lateral projection. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 4 of 64

5 Why MR Myelogram? The main indication of MR myelography is in the evaluation of low back pain The methods which are currently available for the imaging of spine include CT, CT mylography, conventional myelography and MRI. It has been shown that the accuracy of the diagnosis in discogenic disease is higher when a combination of two imaging modality is used. Cont. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 5 of 64

6 There was 92.5% agreement between the surgery and the findings when CT and MR were used jointly used. Modiac MT, Masaryk T et al 1986 AJNR 7 : Presentation material is for education purposes only. All rights reserved URMC Radiology Page 6 of 64

7 Presurgical evaluation MRI has become the single most useful imaging test for evaluation of patients with back pain and is accepted as the gold standard, however myelography is needed in cases where the exact topograhic correlation of the spinal nerve roots to the bony or discogenic structures has to be verified preoperatively. Myelography is also needed to assess the degree of pressure on the thecal sac and the level of maximum pressure. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 7 of 64

8 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 8 of 64

9 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 9 of 64

10 Disk Herniations MR myelography shows focal deformity of thecal sac margin due to disk herniation. Oblique MR myelography reveals extrinsic deformity of lateral recess of the thecal sac margin due to posterolateral disk herniation. Far lateral disk herniation, which does not affect the thecal sac, cannot be detected on MR myelography. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 10 of 64

11 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 11 of 64

12 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 12 of 64

13 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 13 of 64

14 The sensitivity for detecting and localizing CSF root sheath / nerve root in patients with nerve root compression is higher using 3 D MRM (90.6%) compared to conventional myelography (81.4%) K.E.W Eberhardt et. al 3 D MRM of lumbar spine. Eur Radiol 7, (1997) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 14 of 64

15 Nerve root compression Although MRI provides superior diagnostic information regarding the spinal cord and spinal canal, results are sub optimal in delineation of foraminal pathology in cervical spine MR myelography helps in the detection of foraminal disease in two ways. First, the heavily T 2 weighted nature of the technique results in high contrast between the CSF and all other soft tissue structures, including disk material, this allows the demonstration of foraminal disk protrusions that would otherwise are less easily detected on conventional axial T 2 weighted images. Second, any possible abnormality seen on MR myelography prompts a re-evaluation of the relevant axial and sagittal sequences and produces an increased rate of detection of foraminal compression as a result of this review process. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 15 of 64

16 Although MRM did not significantly improve the diagnostic accuracy of MRI, it allowed a better overall view of the dural sac and root sleeves, therefore making it easier to diagnose spinal stenosis and disc herniation in a minority of cases Pui M.H.; Husen Y.A. Australasian Radiology August 2000, vol. 44, no. 3, pp (4) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 16 of 64

17 Nerve root Compression MR myelography may be a useful adjunct to conventional axial and sagittal imaging in the investigation of cervical spondylotic radiculopathy. The use of MR myelography increased the number of compressive foraminal stenoses positively identified and it has the potential to reduce the need for subsequent CT myelographic examination British Journal of Radiology (2003) 76, Presentation material is for education purposes only. All rights reserved URMC Radiology Page 17 of 64

18 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 18 of 64

19 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 19 of 64

20 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 20 of 64

21 Disc Migration The herniated disc may affect the nerve root above it if there is lateral and upward migration of a free fragment into the neural foramen. This will be seen as filling defect at the origin of nerve root sleeve or obliteration of nerve root sleeve. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 21 of 64

22 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 22 of 64

23 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 23 of 64

24 Facet arthrosis syndrome. Facet joint hypertrophy can cause pressure on the thecal sac which can be appreciated by MR myelogram. Pressure caused by hypertrophy of ligamentum flavum can also be seen on MR myelograms. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 24 of 64

25 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 25 of 64

26 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 26 of 64

27 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 27 of 64

28 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 28 of 64

29 Spinal Stenosis The thecal sac is effaced anteriorly by the buldging discs and posterolateraly by the ligamentum flavum and hypertrophied facets resulting in an hourglass configuration with progressive stenosis.the amount of CSF progressively diminishes and the nerve roots become crowded together. As a result of epidural compression prominent enhancement of retrovertebral venous plexus is common and is very well seen on MR myelograms. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 29 of 64

30 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 30 of 64

31 The sensitivity of patients with canal stenosis is higher using 3D MRM (92.5%)than conventional X-ray myelography (82.5%) - K. E. W Eberhardt et. al Eur. Radiol 7, Presentation material is for education purposes only. All rights reserved URMC Radiology Page 31 of 64

32 Assessment of Severity of Canal Stenosis In cases of spinal stenosis at multiple levels MRM can assess the severity of stenosis at a certain level. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 32 of 64

33 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 33 of 64

34 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 34 of 64

35 Spondylolisthesis In isthmic type (pars defect) the spinal canal elongates in its AP dimension. In degenerative spondylolisthesis (close arch type) the spinal canal is narrowed and pressure on the thecal sac due to hypertrophied facet can be appreciated on MR myelogram. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 35 of 64

36 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 36 of 64

37 Post operative spine The pressure caused on the thecal sac by epidural scar can be appreciated on MR myelogram, however contrast enhancement is needed to differentiate recurrent disc from the scar tissue. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 37 of 64

38 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 38 of 64

39 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 39 of 64

40 Scar tissue Presentation material is for education purposes only. All rights reserved URMC Radiology Page 40 of 64

41 Tumors of the Spine ( Extra spinal and Extradural) The pressure caused by the presence of tumors on the thecal sac and the extension of tumors in the spinal canal can be accurately depicted by MR myelography. In case of metastatic disease at multiple levels MR myelography may help the surgeon to decide the level of maximum compromise of the spinal canal. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 41 of 64

42 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 42 of 64

43 Arachnoid Cyst Presentation material is for education purposes only. All rights reserved URMC Radiology Page 43 of 64

44 Intradural Extra Medullary tumors (Neurofibroma and Meningioma) The typical appearances of an intradural extramedullary mass is seen on myelogram. Widening of the subarachnoid space above and below and displacement of the cord is seen. Sometimes a small intramedullary intradural mass may only be picked up on MR myelogram as a filling defect. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 44 of 64

45 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 45 of 64

46 Intra-medullary Tumors Cord expansion with narrowing of the surrounding subarachnoid space is appreciated in cases of intra-medullary tumors. The length of expansion can be identified. Cystic degeneration within the tumors can be seen both on MR myelogram images. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 46 of 64

47 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 47 of 64

48 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 48 of 64

49 Intra-medullary Cysts The focal intramedullary cysts associated with ependymoma or astrocytoma, septated syrinx or simple syrinx can be identified. Postoperative assessment of syrinx can also be done. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 49 of 64

50 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 50 of 64

51 Arachnoid Adhesions Fibrous septas within the subarachnoid space, displacement, compression and retraction of neural elements can be clearly seen on MR myelogram suggesting the diagnosis. MRM clearly depicts the arachnoid adhesions which are not adequately seen on conventional MR imaging and could avert the need for intra-thecal contrast myelography Taher EL Gammal et.al AJR : 164 January 1995 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 51 of 64

52 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 52 of 64

53 Dural Vascular Malformations Serpentine filling defects and large draining veins within the subarachnoid space can be easily identified. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 53 of 64

54 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 54 of 64

55 Spinal Infection (Tuberculosis) The degree of compression by gibbous formation or epidural mass can be evaluated. Extent of Para-vertebral and epidural mass can also be studied on MR myelogram. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 55 of 64

56 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 56 of 64

57 Spinal Trauma. Pressure on the thecal sac, traumatic disc herniation and filling defect due to presence of bony fragments can be seen. Traumatic meningiocoele Post traumatic cord cysts can be seen on MRM. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 57 of 64

58 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 58 of 64

59 Congenital Anomalies Meningiocoele and myelomeningiocoele. Diastometamyelia. Chiari Malformation. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 59 of 64

60 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 60 of 64

61 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 61 of 64

62 Pitfalls in Imaging. Excessive extension of cervical spine may over-estimate the thecal pressure. If the maximum intensity projection of the thecal sac ends at L5 level, then a protruding disk at L5S1 may not be seen on MR myelogram images. Disk protrusions seen on MRI may not be seen on MR myelogram if they only displace the epidural fat but not the thecal sac. (M.J Thronton et al. Eur. Radiol 9, (1999) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 62 of 64

63 Incidental Findings Presentation material is for education purposes only. All rights reserved URMC Radiology Page 63 of 64

64 Conclusion MR myelography is a new, non invasive method that produces images comparable to conventional myelography. It is patient friendly, has no risk of side effects and because of its brief measurement time can be added routine imaging sequences. When used with MRI it can provide accurate diagnosis in evaluation of the majority of spinal pathologies. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 64 of 64

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