Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls.

D.K Kim,W Brinjikji,J.K Cutsforth-Gregory,R.I Farb,F.E Diehn,J.T Verdoorn,P.P Morris,G.B Liebo,V.T Lehman,J.C Benson,C.M Carr,J.M Morris

doi:10.3174/ajnr.a6368

Abstract

Digital subtraction myelography is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate appropriate diagnosis and treatment of spontaneous spinal CSF leaks. Digital subtraction myelography is an excellent diagnostic tool for assessment of various types of CSF leaks, and lateral decubitus digital subtraction myelography is increasingly being used to diagnose CSF-venous fistulas. Lateral decubitus digital subtraction myelography differs from typical CT and fluoroscopy-guided myelograms in many ways, including equipment, supplies, and injection and image-acquisition techniques. Operators should be familiar with techniques, common pitfalls, and artifacts to improve diagnostic yield and prevent nondiagnostic examinations.

Highlights

Digital subtraction myelography (DSM) is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate definitive treatment with surgery or targeted blood patch
Prone DSM has been used for several years to identify the exact focus of a CSF leak in patients with suspected fast ventral leaks in the setting of spinal extradural fluid collections,[2] the technique of lateral decubitus positioning has been introduced more recently to detect subtle CSF-venous fistulas and different types of leaks.[3,4]
At Mayo Clinic, we implemented this technique into our practice in 2018, and the advantages of DSM to identify CSFvenous fistulas compared with other techniques such as conventional, dynamic CT and positive pressure MR myelograms quickly became apparent, with continuously increasing demand

Summary

Introduction

Patients need to be in as perfect a lateral decubitus position as possible to ensure that the neural foramina and nerve sheath diverticula have maximal exposure to the iodinated contrast and to increase the likelihood of optimally imaging potentially very subtle CSF-venous fistulas. The proceduralist should start injecting the contrast first, wait about 2 seconds, have the patient breath-hold while starting the digital subtraction image acquisition.

Results

Conclusion