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Meningeal reactions seen with myodil myelography
Clin. RadioL (1974) 25, 361-365 MENINGEAL
REACTIONS
SEEN
WITH
MYODIL
MYELOGRAPHY
A. J. K E O G H *
From the Regional Neurosurgical Unit, Brook General Hospital, London. F o u r cases o f a m e n i n g e a l r e a c t i o n g i v i n g a c h a r a c t e r i s t i c r a d i o g r a p h i c a p p e a r a n c e w i t h i o p h e n d y l a t e i n j e c t i o n B.P. ( M y o d i l ) m y e l o g r a p h y are r e p o r t e d . S t e r o i d s s e e m to h a v e h e l p e d in t w o o f these cases. M e n t i o n is m a d e o f a r e v i e w o f s y m p t o m s in a f u r t h e r 111 cases. T h e m o r b i d i t y a s s o c i a t e d w i t h M y o d i l m a y be h i g h e r t h a n h a s p r e v i o u s l y b e e n appreciated.
IODINATED lipoids h a v e b e e n e x t e n s i v e l y u s e d f o r m y e l o g r a p h y f o r s o m e years. T a v e r a s a n d W o o d (1964) r e p o r t e d t h a t t h e side effects f o l l o w i n g t h e i r use are few, b u t Sinclair a n d R i t c h i e (1972) c o n c l u d e d t h a t m y e l o g r a p h y (using E t h i o d i a n ) causes a significant p o s t - e x a m i n a t i o n m o r b i d i t y . Case 1.~E. H., aged 51, was subjected to lumbar myelography in November 1971. Almost immediately after the procedure he experienced an aching sensation in the "tail", becoming very severe within the next few hours. The following day he experienced sharp, searing pain in both lower limbs, extending upwards to his buttocks and lingering for a few seconds to minutes, particularly when moving and coughing. For about the next six weeks he had intense pain in the sacral region radiating down both legs, aggravated by a change of position. He was re-screened on 29th December 1971 but all the Myodil was noted to be fixed (Fig. 1A & B) despite vigorous retiring. In view of the lumbar cerebro-spinal fluid (C.S.F.) findings on the 30th December, 1971 (Table 1) he was given a course of prednisolone 5 nag. 6 hourly for 1 week. There was some subjective improvement, which seemed to be associated with improvement in the lumbar C.S.F. findings of 4th January 1972 (Table 1). His severe symptoms returned and this was reflected in further C.S.F. changes noted on 17th January, 1972. He was started on 10mg. prednisolone 6 hourly, again with some subjective improvement. The steroids were discontinued one week later in view of dyspeptic symptoms. Over the next few weeks his symptoms subsided. Plain radiographs of his lumbar spine in January 1972 showed some absorption of the Myodil. Case 2.--ln October 1972 A. W., aged 62, had a repeat myelogram: one year before a prolapsed lumbar disc had been removed after his first myelogram, there being insufficient remaining for a satisfactory examination. Over the next two to three days he had terrible headaches with some vomiting. As his headaches subsided he became aware of severe pain in the sacrum and described it as if he had been kicked. This persisted for a month, was associated with an aching pain in the back of the left thigh and occasionally in
the right, with his only relief being obtained by walking. Further lumbar exploration was performed but he continued to experience aching pain in the sacral region and buttocks; he could neither sit nor lie with comfort, coughing and sneezing aggravated the pain, and standing was his only bearable position. Re-screening with extensive tilting on 28th December 1971 revealed that the Myodil was fixed (Fig. 2A and B). In view of the severity of his symptoms and the findings in the lumbar C.S.F. on 31st December 1971 (Table 2) he was given prednisolone 10 rag. 6 hourly for one week. After starting the steroid course he claimed some improvement hut was also receiving a regular analgesic. No C.S.F. could be obtained on a further L.P. attempted on 4.1"72, but a cisternal puncture showed no gross abnormality (Table 2). Case 3.--P. C., a man of 51, underwent myelography in March 1972; for 2 days afterwards he had pain in both legs and in his lower back, constantly present, without obvious relieving or aggravating factors and quite different from his original pain. Following an operation for a prolapsed lumbar disc he continued to have severe low back pain which spread to his thighs, buttocks and over the sacrum. Sitting aggravated the pain - such that he was forced, during his meals, to get up between courses and walk around to gain some relief. Re-screening was performed, when it was found most of the Myodil was fixed (Fig. 3A and n). Over the next few days his symptoms settled spontaneously. No lumbar punctures were attempted after his operation, nor were his symptoms felt to be severe enough to warrant a course of steroids. Case 4.--In January 1972 Myodil myelography was carried out on W. C., a man aged 60. This revealed an almost complete block at the L4/5 level, which at operation was felt to be due to arachnoiditis. After operation he continued to complain of pain in his back and down the left leg. On 16th February 1972 rescreening was performed and this revealed that the Myodil was fixed (Fig 4A and B). His pain gradually settled spontaneously after three to four weeks. During this period, two cisternal punctures were performed and both revealed normal C. S. F. No lumbar punctures were attempted and no steroids were given.
DISCUSSION *Present address: Department of Neurological Surgery, Royal Infirmary, Sheffield.
R a d i o g r a p h s in t h e f o u r cases a b o v e reveal a similar picture, viz. M y o d i l b r e a k i n g u p i n t o 361
362
CLINICAL
RADIOLOGY
TABLE 1 C.S.F. RESULTS. CASE 1
Lymphocytes
Date
Proem
G~bulin
30.12.71
1175
Heavy
t
320
4.01.72
320
Sfight
]"
160
* 4.01.72
134
Slight
1"
17.01.72
460
Heavy
1"
28.01.72
45
Slight
'["
Polymorphs
R.B.C.
Glucose
205
40
45
29
30
60
--
35
75
225
69
55
--
128
14
390
30
* F r o m cisternal puncture.
FIG. 1, Case 1. Re-screening with vigorous tilting showed Myodil to be fixed. FIG. 1A AP. FIG. la. Lateral
FIG. 2. Case 2. Similar findings to Case 1. FIG. 2A. AP. FIG. 2B. Lateral
MENINGEAL
REACTIONS
SEEN W I T H
FIG. 3. Case 3. Re-screening revealed m o s t o f the Myodil to be fixed. FIG. 3A. AP.
MYODIL
MYELOGRAPHY
FIG. 3B. Lateral.
363
364
CLINICAL
RADIOLOGY
TABLE 2 C.S.F. RESULTS. CASE 2
Date
Protein
Globulin
Lymphocytes
Polymorphs
R.B.C.
Glucose
21.10.70
76.5
No
~
0
0
1600
--
13.10.71
71
Slight
'~
7
0
38
--
31,12.71
1175
Heavy
'~
9
420
30
--
* 4.01.72
30
Slight
]'
0
0
36
65
* F r o m cistcrnal puncture.
FIG. 4A. AP.
FIG. 4B. Lateral. Fro. 4. Case 4. Similar findings to Cases 1 a n d 2.
streaky columns, becoming rapidly fixed and slowly absorbing as the symptoms resolve. These features seem to be characteristic of a meningeal reaction. Lumbar puncture should probably not be performed to establish a diagnosis of arachnoiditis in these cases where Myodil reveals this characteristic picture, in view of the risk of bleeding into the C.S.F., thereby aggravating the position (De Jong Sugar, 1972; Howland and Curry, 1964). A questionnaire review was completed on personal interview at varying times after lumbar myelography on a further 111 cases. These were all adults thought to have 'mechanical' lumbar pathology, in which approximately 6 ml. of Myodil had been introduced into the cerebro-spinal fluid by lumbar puncture. This revealed fourteen patients (12.6~) who complained of similar symptoms to the cases detailed above. The symptoms were of severe aching pains over the sacrum and in the buttocks persisting for periods of two to three days to several weeks. Four of these patients spontaneously described these pains as if they had been 'kicked in the tail'. All experienced these symptoms within a few hours, and certainly by the following day. These pains were quite different in character from their original complaints. It was also noted in the review that twelve patients (10.8~o) other than the ones noted above complained of severe incapacitating headaches, usually altering with position, and were presumed to be related directly to the lumbar puncture. Sinclair and Ritchie (1972) in their series of 100 cases
MENINGEAL REACTIONS SEEN WITH MYODIL MYELOGRAPHY r e m o v e d as m u c h as possible o f the m e d i u m (Ethiodian) i m m e d i a t e l y after the procedure. T h e y f o u n d a definite relationship between the presence o f persistent b a c k a c h e a n d leg p a i n a n d the volume o f the m e d i u m left behind. This review tends to confirm the findings o f Sinclair a n d Ritchie (1972) that a higher m o r b i d i t y is associated with m y e l o g r a p h y t h a n has previously been appreciated. M y o d i l has been used for m a n y years a n d the r e p o r t e d incidence o f serious arachnoiditis has been low. M y o d i l at least w o u l d seem to d e m o n s t r a t e a severe meningeal reaction, even if it c a n n o t be directly i n c r i m i n a t e d in the aetiology.
Aeknowledgements.--I would like to thank Mr. G. B. Northcroft, Consultant Neurosurgeon to the S.E. Metro-
365
politan Regional Hospital Board and Dr. R. G. Grainger, Consultant Radiologist, United Sheffield Hospitals for their helpful criticism and advice in the preparation of this paper.
REFERENCES DE JONG SUGAR, R. N. (1972). Year Book of Neurology and Neurosurgery. Year Book Medical Publishers, Chicago. p. 306. HOWLAND, W. J. & CURRY, J. L. (1966). Experimental Studies of Pantopaque Arachnoiditis, Radiology, 87, 253-261. SINCLAIR,D. J. • RITCmE, G. W. (1972). Morbidity in postmyelogram patients - a survey of 100 patients. The Journal of the Canadian Association of Radiologists, 23, 278-283. TAVERAS,J. M. & WOOD, t~. H. (1964). Diagnostic Neuroradiology. The Williams and Wilkins Company, Baltimore, 842-844.
REACTIONS
SEEN
WITH
MYODIL
MYELOGRAPHY
A. J. K E O G H *
From the Regional Neurosurgical Unit, Brook General Hospital, London. F o u r cases o f a m e n i n g e a l r e a c t i o n g i v i n g a c h a r a c t e r i s t i c r a d i o g r a p h i c a p p e a r a n c e w i t h i o p h e n d y l a t e i n j e c t i o n B.P. ( M y o d i l ) m y e l o g r a p h y are r e p o r t e d . S t e r o i d s s e e m to h a v e h e l p e d in t w o o f these cases. M e n t i o n is m a d e o f a r e v i e w o f s y m p t o m s in a f u r t h e r 111 cases. T h e m o r b i d i t y a s s o c i a t e d w i t h M y o d i l m a y be h i g h e r t h a n h a s p r e v i o u s l y b e e n appreciated.
IODINATED lipoids h a v e b e e n e x t e n s i v e l y u s e d f o r m y e l o g r a p h y f o r s o m e years. T a v e r a s a n d W o o d (1964) r e p o r t e d t h a t t h e side effects f o l l o w i n g t h e i r use are few, b u t Sinclair a n d R i t c h i e (1972) c o n c l u d e d t h a t m y e l o g r a p h y (using E t h i o d i a n ) causes a significant p o s t - e x a m i n a t i o n m o r b i d i t y . Case 1.~E. H., aged 51, was subjected to lumbar myelography in November 1971. Almost immediately after the procedure he experienced an aching sensation in the "tail", becoming very severe within the next few hours. The following day he experienced sharp, searing pain in both lower limbs, extending upwards to his buttocks and lingering for a few seconds to minutes, particularly when moving and coughing. For about the next six weeks he had intense pain in the sacral region radiating down both legs, aggravated by a change of position. He was re-screened on 29th December 1971 but all the Myodil was noted to be fixed (Fig. 1A & B) despite vigorous retiring. In view of the lumbar cerebro-spinal fluid (C.S.F.) findings on the 30th December, 1971 (Table 1) he was given a course of prednisolone 5 nag. 6 hourly for 1 week. There was some subjective improvement, which seemed to be associated with improvement in the lumbar C.S.F. findings of 4th January 1972 (Table 1). His severe symptoms returned and this was reflected in further C.S.F. changes noted on 17th January, 1972. He was started on 10mg. prednisolone 6 hourly, again with some subjective improvement. The steroids were discontinued one week later in view of dyspeptic symptoms. Over the next few weeks his symptoms subsided. Plain radiographs of his lumbar spine in January 1972 showed some absorption of the Myodil. Case 2.--ln October 1972 A. W., aged 62, had a repeat myelogram: one year before a prolapsed lumbar disc had been removed after his first myelogram, there being insufficient remaining for a satisfactory examination. Over the next two to three days he had terrible headaches with some vomiting. As his headaches subsided he became aware of severe pain in the sacrum and described it as if he had been kicked. This persisted for a month, was associated with an aching pain in the back of the left thigh and occasionally in
the right, with his only relief being obtained by walking. Further lumbar exploration was performed but he continued to experience aching pain in the sacral region and buttocks; he could neither sit nor lie with comfort, coughing and sneezing aggravated the pain, and standing was his only bearable position. Re-screening with extensive tilting on 28th December 1971 revealed that the Myodil was fixed (Fig. 2A and B). In view of the severity of his symptoms and the findings in the lumbar C.S.F. on 31st December 1971 (Table 2) he was given prednisolone 10 rag. 6 hourly for one week. After starting the steroid course he claimed some improvement hut was also receiving a regular analgesic. No C.S.F. could be obtained on a further L.P. attempted on 4.1"72, but a cisternal puncture showed no gross abnormality (Table 2). Case 3.--P. C., a man of 51, underwent myelography in March 1972; for 2 days afterwards he had pain in both legs and in his lower back, constantly present, without obvious relieving or aggravating factors and quite different from his original pain. Following an operation for a prolapsed lumbar disc he continued to have severe low back pain which spread to his thighs, buttocks and over the sacrum. Sitting aggravated the pain - such that he was forced, during his meals, to get up between courses and walk around to gain some relief. Re-screening was performed, when it was found most of the Myodil was fixed (Fig. 3A and n). Over the next few days his symptoms settled spontaneously. No lumbar punctures were attempted after his operation, nor were his symptoms felt to be severe enough to warrant a course of steroids. Case 4.--In January 1972 Myodil myelography was carried out on W. C., a man aged 60. This revealed an almost complete block at the L4/5 level, which at operation was felt to be due to arachnoiditis. After operation he continued to complain of pain in his back and down the left leg. On 16th February 1972 rescreening was performed and this revealed that the Myodil was fixed (Fig 4A and B). His pain gradually settled spontaneously after three to four weeks. During this period, two cisternal punctures were performed and both revealed normal C. S. F. No lumbar punctures were attempted and no steroids were given.
DISCUSSION *Present address: Department of Neurological Surgery, Royal Infirmary, Sheffield.
R a d i o g r a p h s in t h e f o u r cases a b o v e reveal a similar picture, viz. M y o d i l b r e a k i n g u p i n t o 361
362
CLINICAL
RADIOLOGY
TABLE 1 C.S.F. RESULTS. CASE 1
Lymphocytes
Date
Proem
G~bulin
30.12.71
1175
Heavy
t
320
4.01.72
320
Sfight
]"
160
* 4.01.72
134
Slight
1"
17.01.72
460
Heavy
1"
28.01.72
45
Slight
'["
Polymorphs
R.B.C.
Glucose
205
40
45
29
30
60
--
35
75
225
69
55
--
128
14
390
30
* F r o m cisternal puncture.
FIG. 1, Case 1. Re-screening with vigorous tilting showed Myodil to be fixed. FIG. 1A AP. FIG. la. Lateral
FIG. 2. Case 2. Similar findings to Case 1. FIG. 2A. AP. FIG. 2B. Lateral
MENINGEAL
REACTIONS
SEEN W I T H
FIG. 3. Case 3. Re-screening revealed m o s t o f the Myodil to be fixed. FIG. 3A. AP.
MYODIL
MYELOGRAPHY
FIG. 3B. Lateral.
363
364
CLINICAL
RADIOLOGY
TABLE 2 C.S.F. RESULTS. CASE 2
Date
Protein
Globulin
Lymphocytes
Polymorphs
R.B.C.
Glucose
21.10.70
76.5
No
~
0
0
1600
--
13.10.71
71
Slight
'~
7
0
38
--
31,12.71
1175
Heavy
'~
9
420
30
--
* 4.01.72
30
Slight
]'
0
0
36
65
* F r o m cistcrnal puncture.
FIG. 4A. AP.
FIG. 4B. Lateral. Fro. 4. Case 4. Similar findings to Cases 1 a n d 2.
streaky columns, becoming rapidly fixed and slowly absorbing as the symptoms resolve. These features seem to be characteristic of a meningeal reaction. Lumbar puncture should probably not be performed to establish a diagnosis of arachnoiditis in these cases where Myodil reveals this characteristic picture, in view of the risk of bleeding into the C.S.F., thereby aggravating the position (De Jong Sugar, 1972; Howland and Curry, 1964). A questionnaire review was completed on personal interview at varying times after lumbar myelography on a further 111 cases. These were all adults thought to have 'mechanical' lumbar pathology, in which approximately 6 ml. of Myodil had been introduced into the cerebro-spinal fluid by lumbar puncture. This revealed fourteen patients (12.6~) who complained of similar symptoms to the cases detailed above. The symptoms were of severe aching pains over the sacrum and in the buttocks persisting for periods of two to three days to several weeks. Four of these patients spontaneously described these pains as if they had been 'kicked in the tail'. All experienced these symptoms within a few hours, and certainly by the following day. These pains were quite different in character from their original complaints. It was also noted in the review that twelve patients (10.8~o) other than the ones noted above complained of severe incapacitating headaches, usually altering with position, and were presumed to be related directly to the lumbar puncture. Sinclair and Ritchie (1972) in their series of 100 cases
MENINGEAL REACTIONS SEEN WITH MYODIL MYELOGRAPHY r e m o v e d as m u c h as possible o f the m e d i u m (Ethiodian) i m m e d i a t e l y after the procedure. T h e y f o u n d a definite relationship between the presence o f persistent b a c k a c h e a n d leg p a i n a n d the volume o f the m e d i u m left behind. This review tends to confirm the findings o f Sinclair a n d Ritchie (1972) that a higher m o r b i d i t y is associated with m y e l o g r a p h y t h a n has previously been appreciated. M y o d i l has been used for m a n y years a n d the r e p o r t e d incidence o f serious arachnoiditis has been low. M y o d i l at least w o u l d seem to d e m o n s t r a t e a severe meningeal reaction, even if it c a n n o t be directly i n c r i m i n a t e d in the aetiology.
Aeknowledgements.--I would like to thank Mr. G. B. Northcroft, Consultant Neurosurgeon to the S.E. Metro-
365
politan Regional Hospital Board and Dr. R. G. Grainger, Consultant Radiologist, United Sheffield Hospitals for their helpful criticism and advice in the preparation of this paper.
REFERENCES DE JONG SUGAR, R. N. (1972). Year Book of Neurology and Neurosurgery. Year Book Medical Publishers, Chicago. p. 306. HOWLAND, W. J. & CURRY, J. L. (1966). Experimental Studies of Pantopaque Arachnoiditis, Radiology, 87, 253-261. SINCLAIR,D. J. • RITCmE, G. W. (1972). Morbidity in postmyelogram patients - a survey of 100 patients. The Journal of the Canadian Association of Radiologists, 23, 278-283. TAVERAS,J. M. & WOOD, t~. H. (1964). Diagnostic Neuroradiology. The Williams and Wilkins Company, Baltimore, 842-844.