The use of water-soluble intrathecal contrast medium has markedly decreased over the past 10 to 15 years with the introduction of CT and, more recently, MRI. Before these more advanced imaging tools, water-soluble myelography was the gold standard in evaluating patients with back pain and had the ability to evaluate spinal stenosis, disc bulges and herniations, other extradural impressions on the thecal sac, spinal cord enlargement, and various inflammatory conditions. However, intrathecal contrast medium enhancement still lacked sensitivity in evaluating lateral disc herniations and the specificity in determining the exact cause for extradural impressions on the thecal sac and cord enlargement. With the use of CT and MRI, it is now possible to further define the factors contributing to spinal stenosis and to offer a much more exact and detailed differential diagnosis for the etiology of intramedullary lesions. With this added preciseness has come the general acceptance of these imaging modalities over myelography by other physicians not formally trained in radiological sciences.
Certain situations still warrant the use of water-soluble myelography. In extremely obese patients, in whom image resolution is significantly degraded on both CT and MRI studies, myelography in conjunction with postmyelography CT of abnormal levels still plays an important role in the diagnosis of spinal disease. Likewise, in patients with marked claustrophobia, in patients in whom MRI is contraindicated (e.g., those patients with intracerebral aneurysm clips, pacemakers, transcutaneous electrical nerve stimulation units, orbital metallic foreign bodies), or in patients with postoperative metallic internal fixation devices, myelography and postmyelography CT are the imaging studies of choice. In our experience, myelography, in conjunction with postmyelography CT, is as sensitive in the evaluation of subtle cases of arachnoiditis as MRI.
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