Landes Bioscience Musculoskeletal Procedures Diagnostic and Therapeutic Jun 2003 PDF

LANDES LANDES
BIOSCIENCE V ad e me c u m BIOSCIENCE V ad e me c u m
Table of contents
1. Shoulder Arthrography 13. Bone Biopsies
Musculoskeletal
2. Elbow Arthrography
3. Wrist Arthrography
14. Percutaneous Treatment
of Osteoid Osteoma
15. Vertebroplasty
Procedures:
4. Hip Arthrography
5. Knee Arthrography
16. Ultrasound Diagnostic and Therapeutic
Appendix
6. Ankle Arthrography
7. MR Arthrography
8. Myelography
9. Discography
10. Percutaneous Blocks
11. Epidural Blocks
12. Tenography
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I SBN 1- 57059- 600- X Jacqueline C. Hodge
www.landesbioscience.com 9 781570 596001
v a d e m e c u m
Musculoskeletal Procedures:
Diagnostic and Therapeutic
Jacqueline C. Hodge, M.D.

Lenox Hill Hospital
Department of Diagnostic Radiology
New York, New York
LANDES
BIOSCIENCE
GEORGETOWN, TEXAS
U.S.A.
VADEMECUM
Musculoskeletal Procedures: Diagnostic and Therapeutic
LANDES BIOSCIENCE
Georgetown, Texas U.S.A.
Copyright ©2003 Landes Bioscience

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Dedication
To my mother
Contents
Foreword .......................................................................... xi
1. Shoulder Arthrography ..................................................... 1
Wilfred C.G. Peh and Jacqueline C. Hodge
Introduction ............................................................................................... 1
Indications .................................................................................................. 1
Contraindications ....................................................................................... 1
Equipment .................................................................................................. 2
Preliminary Radiographs ............................................................................. 2
Technique ................................................................................................... 2
Contrast Agents .......................................................................................... 4
Post-Puncture Protocol ............................................................................... 5
Complications ............................................................................................ 7
Normal Arthrogram .................................................................................... 7
Abnormal Arthrogram ................................................................................ 9
Acromio-Clavicular Arthrography ............................................................. 16
Summary .................................................................................................. 16
2. Elbow Arthrography ....................................................... 20
Clara G.C. Ooi and Wilfred C.G. Peh
Introduction ............................................................................................. 20
Normal Arthrogram .................................................................................. 25
Abnormal Arthrogram .............................................................................. 26
MR Arthrography ..................................................................................... 28
3. Wrist Arthrography ......................................................... 32
Isabelle Pigeau, Philippe Valenti, C. Sokolow, Stephane Romano
and Philippe Saffar
Introduction ............................................................................................. 32
Pre-Procedure Protocol ............................................................................. 33
Post-Procedure Protocol ............................................................................ 35
Pitfalls of Arthrography-CT ...................................................................... 38
Complications .......................................................................................... 38
Pathological Aspects .................................................................................. 38
4. Hip Arthrography ........................................................... 47
Laurent Sarazin, Alain Chevrot and Jacqueline C. Hodge
Indications ................................................................................................ 47
Prearthrogram Preparation ........................................................................ 47
Technique ................................................................................................. 47
Postarthrogram Protocol ........................................................................... 50
Complications .......................................................................................... 50
The Normal Arthrogram .......................................................................... 50
Pathology .................................................................................................. 53
5. Knee Arthrography ......................................................... 62
Jacqueline C. Hodge
Introduction ............................................................................................. 62
Indications ................................................................................................ 63
Contraindications ..................................................................................... 63
Equipment ................................................................................................ 63
Pre-Arthrography Protocol ........................................................................ 63
Technique ................................................................................................. 63
Normal Anatomy ...................................................................................... 65
Post-Procedure Protocol ............................................................................ 67
Complications .......................................................................................... 70
Pathology .................................................................................................. 70
6. Ankle Arthrography ........................................................ 78
Mary-Josee Berthiaume and Jacqueline C. Hodge
Introduction ............................................................................................. 78
Prearthrogram Evaluation ......................................................................... 78
Indications ................................................................................................ 79
Equipment ................................................................................................ 79
Contrast Agents ........................................................................................ 79
Technique ................................................................................................. 79
Postarthrographic Recommendations ........................................................ 80
Complications .......................................................................................... 81
The Normal Ankle Arthrogram ................................................................ 81
Pathologic Conditions .............................................................................. 81
7. MR Arthrography ........................................................... 94
David R. Marcantonio, Robert D. Boutin and Donald Resnick
Introduction ............................................................................................. 94
General Information ................................................................................. 94
Specific Joint Pathology ............................................................................ 96
Summary ................................................................................................ 103
8. Myelography ................................................................. 105
Jacqueline C. Hodge
Introduction ........................................................................................... 105
Pre-Myelogram Preparation .................................................................... 105
Lumbar Puncture .................................................................................... 106
Cervical Puncture ................................................................................... 108
Contrast Agents ...................................................................................... 110
Post-Puncture Protocol ........................................................................... 111
Post-Procedure Protocol .......................................................................... 115
Complications ........................................................................................ 118
Pathology ................................................................................................ 118
9. Discography .................................................................. 124
Jacqueline C. Hodge
Introduction ........................................................................................... 124
Lumbar Discography .............................................................................. 125
Thoracic Discography ............................................................................. 134
Cervical Discography .............................................................................. 134
Post-Procedure Care ................................................................................ 137
Interpretation ......................................................................................... 137
10. Percutaneous Blocks ..................................................... 140
Jacqueline Hodge
Facet Blocks ............................................................................................ 140
Synovial Cysts ......................................................................................... 145
Sacroiliac Joint Block .............................................................................. 146
Interspinous Ligament Blocks ................................................................. 148
C1-2 Block ............................................................................................. 148
Miscellaneous Blocks .............................................................................. 149
11. Epidural Blocks ............................................................. 152
Jim Sloan
Introduction ........................................................................................... 152
Epidural Injections .................................................................................. 152
Nerve Blocks ........................................................................................... 155
12. Tenography ................................................................... 163
Jacqueline C. Hodge
Introduction ........................................................................................... 163
Patient Management ............................................................................... 168
Pathology ................................................................................................ 169
13. Bone Biopsies ................................................................ 175
Jacqueline C. Hodge
Introduction ........................................................................................... 175
Biopsy Instruments ................................................................................. 179
Pre-Biopsy Considerations ...................................................................... 183
Post-Biopsy Care ..................................................................................... 183
Specimen Handling ................................................................................ 185
Complications ........................................................................................ 185
Additional Considerations ...................................................................... 185
MR-Guided Intervention ........................................................................ 186
14. Percutaneous Treatment of Osteoid Osteoma ............... 189
Jacqueline C. Hodge
Introduction ........................................................................................... 189
Percutaneous Drill Resection .................................................................. 189
Percutaneous Radio-Frequency Ablation ................................................. 190
Post-Procedure Care ................................................................................ 190
15. Vertebroplasty ............................................................... 193
Jacqueline C. Hodge
Introduction ........................................................................................... 193
Methyl Methacrylate ............................................................................... 194
Pre-Procedure Protocol ........................................................................... 194
Post-Procedure Protocol .......................................................................... 201
Assessing Your Intervention .................................................................... 201
Common Side Effects ............................................................................. 202
Complications ........................................................................................ 202
Future Developments in Vertebroplasty .................................................. 203
16. Ultrasound .................................................................... 204
Patrice-Etienne Cardinal and Rethy Chhem
Introduction ........................................................................................... 204
Pre-procedure Preparation ....................................................................... 204
Pathological Conditions .......................................................................... 205
Appendix ....................................................................... 211
Contrast Reactions .................................................................................. 211
Prophylaxis for Contrast Reactions ......................................................... 213
Selecting a Contrast Medium .................................................................. 213
Index ............................................................................. 217
Editor
Jacqueline C. Hodge, M.D.
Lenox Hill Hospital
Department of Diagnostic Radiology
New York, New York
JHodge@LENOXHILL.net
Chapters 1, 4-6, 8-10, 12-15
Contributors
Mary-Josée Berthiaume Maryse Guerin
Département de Radiologie Montreal General Hospital
Hôpital Notre Dame Montreal, Quebec, Canada
Université de Montréal Foreword
Montréal, Québec, Canada
email: mjb3gb@sympatica.ca David R. Marcantonio
Chapter 6 Division of Musculoskeletal Radiology
University of Texas Southwestern Medical
Robert D. Boutin Center
University of California, San Francisco Dallas, Texas, U.S.A.
San Mateo, California, U.S.A. email: dmarca@mednet.swmed.edu
email: rboutin@stanfordalumni.org Chapter 7
Chapter 7
G. Clara Ooi
Patrice-Etienne Cardinal Department of Diagnostic Radiology
Département de Radiologie Queen Mary Hospital
Hôpital Saint-Luc The University of Hong Kong
Université de Montréal Hong Kong
Montréal, Québec, Canada email: cgcooi@hkucc.hku.hk
email: etienne.cardinal@videotron.ca Chapter 2
Chapter 16
Wilfred C G Peh
Alain Chevrot Department of Radiology
Groupe Hospitalier Cochin Singapore General Hospital
Service de Radiologie B Queen Mary Hospital
Paris, France Singapore
email: alain.chevrot@cch.ap-hop-paris.fr email: gdrpcg@sgh.gov.sg
Chapter 4 Chapters 1, 2
Rethy Chhem Isabelle Pigeau
Diagnostic Radiology Department Département de Radiologie
National University Hospital Clinique Des Lilas–CEPIM
National University of Singapore Les Lilas, France
Singapore Chapter 3
email: dnrckr@nus.edu.sg
Chapter 16
Donald Resnick Jim Sloan
Department of Diagnostic Radiology McGill University
University of California, San Diego Department of Anaesthesia
Department of Veterans Affairs The Royal Victoria Hospital
Medical Center Montreal, Quebec, Canada
San Diego, California, U.S.A. Chapter 11
email: asuptuesat@hotmail.com
Chapter 7 C. Sokolow
Institut Français de Chirurgie de la Main
Stephane Romano Clinique du Trocadero
Institut Français de Chirurgie de la Main Paris, France
Clinique du Trocadero Chapter 3
Paris, France
Chapter 3 Philippe Valenti
Clinique Jouvenet
Philippe Saffar c/o Clinique du Trocadero
Institut Français de Chirurgie de la Main Paris, France
Clinique du Trocadero Chapter 3
Paris, France
Chapter 3
Laurent Sarazin
Groupe Hospitalier Cochin
Service re Radiologie B
Paris, France
email: laurent.sarazin@cch.ap-hop-paris.fr
Chapter 4
Foreword
In times of overburdened daily practice, we are all looking for concise,
practical books; books that are easy to consult and in which we rapidly find
clear answers to specific problems or suddenly arising queries. Musculoskeletal
Procedures: Diagnostic and Therapeutic belongs to this category of books.
With the valuable collaboration of a select group of young dedicated
musculoskeletal radiologists, the editor has revisited all of the chapters of her
previous book, Musculoskeletal Imaging: Diagnostic and Therapeutic Procedures,
with the fixed purpose of assisting residents in radiology, orthopaedics, and
neurosurgery in their diagnostic and therapeutic procedures. In addition,
this book offers the general radiologist a gamut of practical step-by-step
techniques now currently in demand. This is a true vademecum book.
Maryse Guerin, M.D.

Assistant Professor of Neuroradiology
Montreal General Hospital
Montreal, Quebec, Canada
CHAPTER 1
CHAPTER 1
Shoulder Arthrography
Wilfred C.G. Peh and Jacqueline C. Hodge
Introduction
Arthrography is a long-established technique for evaluating internal structures
of the shoulder joint not otherwise visualized by conventional radiographic and
computed tomography (CT) techniques. Shoulder abnormalities such as rotator
cuff tear, damage from previous dislocation, articular disease, capsular abnormality
and long head of biceps tendon lesions can be demonstrated arthrographically.
Although arthrographic findings are considered reliable, the introduction of newer
diagnostic methods, such as magnetic resonance (MR) imaging,1-5 arthroscopy6-8
and ultrasound,9-13 have led to modifications of previous indications for arthrography.
As with arthrography of other joints, successful shoulder arthrography depends on
precise needle placement under fluoroscopy, high quality radiography supplemented
by advanced imaging techniques, and accurate interpretation of arthrographic
findings.
Patient Preparation
No special preparation is required for shoulder arthrography. Like other needling
procedures, informed consent and careful questioning for possible allergic history
should be obtained. For adults, shoulder arthrography is usually performed as an
outpatient procedure, while for children, sedation or even general anesthetic may be
required. As the patient may experience discomfort following the procedure, it may
be advisable to ask the patient to be accompanied on departure from the radiology
department, particularly if bilateral shoulder arthrography is performed.
Indications
• Rotator cuff tear
• Recurrent or previous dislocation
• Synovitis
• Adhesive capsulitis
• Loose bodies
• Long head of biceps tendon abnormality
• Evaluation of painful shoulder
Contraindications
• Local sepsis
• General contraindications to MR imaging
Musculoskeletal Procedures: Diagnostic and Therapeutic, edited by

Jacqueline C. Hodge. ©2003 Landes Bioscience.
2 Musculoskeletal Procedures: Diagnostic and Therapeutic
Equipment
• Radiographic unit, ideally with a small focal spot
1 • Fluoroscopic unit, ideally with an overcouch X-ray tube
• Sterile trolley
• 22-gauge short-bevelled 9 cm lumbar puncture needle
• Syringes (1-10 ml) and needles (18- to 23-gauge) of various sizes
• Short plastic connecting tube
• Sterile drapes
• Skin cleansing solutions
• Local anesthetic (1% lidocaine hydrochloride)
• 1:1000 adrenalin
• Nonionic contrast medium
• Gadopentetate dimeglumine (for MR arthrography)
• Normal saline (for MR arthrography)
Preliminary Radiographs
• Antero-posterior (AP) supine in internal rotation (bone exposure)
• AP supine in external rotation (bone exposure)
• AP erect with 20º caudal tilt (subacromial view) (soft tissue exposure)
Technique
The patient lies supine, with the arm and hand of the shoulder of interest placed
next to the body. The patient’s palm should be in contact with the upper thigh. The
skin over the shoulder region is cleansed and draped using strictly aseptic technique.
The shoulder of interest is briefly screened fluoroscopically and positioned such that
the field-of-view is centered over the intended puncture site, which is the gleno-
humeral joint at the junction of the superior 2/3 and inferior 1/3 of the glenoid
labrum (Fig. 1.1A). Maximum collimation is applied to minimize radiation and
the area of interest is magnified. Fluoroscopic positioning up to this point can be
performed by an assistant or alternatively by the radiologist prior to the start of the
procedure. Subsequent fluoroscopic screening should ideally be controlled by
the radiologist, using a footswitch. The articular surface of the glenoid should face
slightly forwards. If not, that is if the glenohumeral articulation is in profile, the
needle may damage the anterior cartilaginous labrum during its insertion. Slight
adjustments to shoulder position may be made by placing of pads under the shoulder
to ensure appropriate orientation of the glenoid (Figs. 1.1A and B).
Under screening, the needle tip of the syringe containing the local anesthetic is
placed over the intended puncture site. The syringe is held at a shallow angle in
relation to the skin surface such that the radiologist’s hand is outside the radiation
field. When the ideal position is located, the skin and subcutaneous tissue overlying
the intended puncture site is anesthetized. At the end of the local anesthetic injection,
my practice is to unscrew the syringe from the 23-gauge needle, leaving the needle
embedded in the subcutaneous tissue/muscle. A quick fluoroscopic screening is then
performed to check the position of the needle. Ideally, it should be seen end-on, that
is vertically orientated, directly over the intended joint space target site (Fig. 1.1A).
Shoulder Arthrography 3
Fig. 1.1. A) Shoulder arthrography puncture technique. The position of the needle
entry point (cross) is marked over the glenohumeral joint on the frontal view. B)
Needle pathway is illustrated on the cross-sectional image.
Keeping a mental picture of the orientation of the 23-gauge needle, this needle is
quickly withdrawn and replaced, using the same puncture point, with a 22-gauge
lumbar puncture needle. If the skin puncture site does not overlie the glenohumeral
joint space, I would recommend choosing a more ideal skin puncture site, even if it
means re-infiltrating local anesthetic. The needle should be advanced vertically, under
intermittent screening to ensure that it does not deviate from its proper path, until
mild resistance is felt. If it is in the glenohumeral joint, the tip of the needle may be
seen to curve slightly, conforming to the joint articulation. The patient may experience
slight discomfort at this point.
The needle should be withdrawn, using a gentle rotating action, by about 1 mm
to free its tip. My practice is then to inject a few drops of local anesthetic, using very
gentle pressure, through the lumbar puncture needle. If there is no resistance to the
flow of local anesthetic, it is very likely that the needle is within the joint space (Fig.
1.1B). If there is much resistance, the needle tip may still be embedded in the articu-
lar cartilage and I would then withdraw the needle a further 1 mm and repeat the
injection of local anesthetic. If resistance persists, then it may be worthwhile
rescreening the joint before further injection of the contrast medium. Another
advantage of injecting a small (0.5-1 ml) amount of local anesthetic is that it provides
the patient with some relief from any discomfort associated with the procedure or
pre-existing shoulder pain.
The syringe containing the contrast medium is attached to the lumbar puncture
needle using a short connecting tube. The contrast medium is then injected slowly
under continuous screening to verify that the needle tip is within the joint. The
contrast medium should flow away from the needle tip, outlining the humeral head
articular surface or typically collecting at the subscapularis recess or the axillary pouch
(Fig. 1.2). If the contrast medium collects in a patch around the needle tip, its
position is extra-articular. If this patch becomes increasingly dense or if parallel streaks
1 indicating intramuscular injection are seen, the contrast injection should be
terminated immediately. It is important to fluoroscopically view the contrast flow
continuously during injection, especially if a rotator cuff tear is suspected clinically
(Fig. 1.3).
In my institution, a nonionic contrast medium (Omnipaque 300) is routinely
used. The amount of the contrast medium to be injected depends on whether a
single or double-contrast arthrogram is required and whether the examination is to
be followed by a CT or MR scan. Almost all the shoulder arthrograms currently
performed in my institution are MR arthrograms, with the exception of the occasional
CT arthrogram. 1:1000 adrenalin is usually pre-mixed with the contrast medium
prior to injection with the advantages of: (1) decreased resorption of contrast; (2)
decreased development of intra-articular effusion; (3) maintenance of longer coating
and local contact of contrast with articular cartilage.14 In many institutions the
fluoroscopic screening room is remote from the CT and MR suites, hence there is
usually a delay between contrast injection and start of scanning. With adrenalin
mixed with contrast, a good quality CT or MR arthrogram should still be achievable
even after a 45-60 minute delay. I use a 1 ml tuberculin syringe for drawing precise
amounts of adrenalin, a rule-of-thumb is to add 0.1 ml of 1:1000 adrenalin for each
ml of the nonionic contrast medium to be injected.14
Contrast Agents
Single Contrast Shoulder Arthrography
12-15 ml of nonionic contrast medium is injected. In adhesive capsulitis, pain
development during injection may limit the total volume of contrast medium being
introduced. Addition of a small amount of local anesthetic may allow more
comfortable postprocedural manipulation. The single contrast technique is seldom
used nowadays except for distention arthrography in patients with the frozen shoulder.
In such cases, a painful shoulder may sometime be effectively treated using this
technique.14-16
Double Contrast Shoulder Arthrography
Two 4 ml volumes of nonionic contrast medium is injected, followed by 8-12 ml
of air. The amount of air, which provides the negative contrast, to be introduced into
the joint depends on the size of the patient. In modern practice, the double contrast
study is usually part of the CT arthrographic examination.16-18
MR Shoulder Arthrography
Up to 2 ml of nonionic contrast medium, containing up to 0.3 ml of 1:1000
adrenalin, is injected for the purpose of delineating the shoulder joint. This is
followed by a 9 ml mixture of a 2 mmol/L solution of gadopentetate dimeglumine
(Magnevist) diluted in normal saline. This solution is prepared prior to the whole
procedure and although 9 ml is routinely injected in my institution, the total amount
(up to 25 ml) to be injected depends on the joint capacity and body size of the
patient. At present, the use of intra-articular gadolinium is yet to be approved by the
Fig. 1.2. Double contrast

shoulder arthrogram. Extra-
vasation of contrast and air
(white arrowheads) from the
1
subscapularis recess (S),
occurring during injection. The
joint capacity is small, consistent
with adhesive capsulitis.
Smooth humeral head articular
cartilage is outlined by the
contrast medium (black arrow-
heads). (B = biceps tendon
sheath, A = axillary pouch).
Fig. 1.3. Double contrast

shoulder arthrogram showing
rotator cuff tear. Leakage of
contrast through a gap in the
rotator cuff (white arrows) is
demonstrated during contrast
injection. (S = subscapularis
recess).
Food and Drug Administration (FDA) or the Health Protection Branch (HPB) and
institutional review board permission is required. An alternative contrast agent is
normal saline, but it suffers from the disadvantage of being indistinguishable from
bursal fluid on MR imaging. Intravenous MR arthrography, though avoiding shoul-
der joint puncture, produces inferior quality images compared with intra-articular
arthrography and fails to distend the joint capsule adequately.
Post-Puncture Protocol
Following needle removal for each of the above-mentioned types of shoulder
arthrography, the joint is gently manipulated to distribute the contrast medium evenly
within the capsule. If a rotator cuff tear is strongly suspected clinically, more vigorous
shoulder exercise may be employed to demonstrate the site of tear, especially if a
small one is present.
Single Contrast Shoulder Arthrography
Radiographs
• AP supine in internal rotation (bone exposure)
• AP erect (subacromial view) (soft tissue exposure)
Double Contrast Shoulder Arthrography

1 Radiographs
• AP supine in internal rotation (bone exposure)
• AP erect in neutral (soft tissue exposure)
• AP erect (subacromial views) (soft tissue exposure)
CT Shoulder Arthrography
• Radiographs as for double contrast shoulder arthrography
• CT technique
a) Patient is supine with arms in the neutral position (palms placed against
the side of the upper thighs).
b) 18 cm field-of-view (FOV), centered upon the glenohumeral joint.
c) 3 mm-thick contiguous axial scans from upper acromio-clavicular joint
to the inferior axillary pouch of the joint.
d) Prospectively-obtained scans using bone algorithm (Window level 300-
400 HU, window width 1500-2000 HU), with retrospectively
reconstructed scans using soft tissue algorithm (Window level
80-100 HU, window width 450-500 HU).
e) In spiral scanners, 1.0 mm or 1.5 mm overlapping bone images are
retrospectively reconstructed, followed by sagittal, coronal and oblique
reformatted images.
• Radiographs as for single contrast shoulder arthrography
• MR technique
a) Ensure that there are no contraindications to MR examination.
b) Patient is supine, with palms placed against the sides of the upper
thighs.
c) The shoulder coil is positioned and secured around the shoulder of
interest.
d) Axial localizer (24 cm FOV; 5 mm thickness, 1 mm gap; 256 x 128
matrix; 0.75 number of excitations (NEX)
e) Oblique coronal images (parallel to the plane of the supraspinatus
muscle)
- spin-echo (SE) T1 (14 cm FOV; 3 mm, 0 mm gap; 256 x 192; 2
NEX)
- SE T1 fat saturation (sat) (14 cm FOV; 3 mm, 0 mm gap; 256 x
160; 1.5 NEX)
- Fast SE T2 fat sat (14 cm FOV; 3 mm, 0 mm gap; 256 x 224; 2
NEX)
f ) Oblique sagittal images (perpendicular to the supraspinatus muscle
plane)
- SE T1 (14 cm FOV; 4 mm, 0.5 mm gap; 256 x 192; 2 NEX)
- SE T1 fat sat (14 cm FOV; 4 mm, 0.5 mm gap; 256 x 160; 2 NEX)
g) Axial (from the acromio-clavicular joint to the inferior axillary pouch)
- SE T1 (14 cm FOV; 3 mm, 0.5 mm gap; 256 x 160; 2 NEX) 1
Complications
After the procedure, the patient should be warned to expect some joint discomfort
lasting up to one day. Complications are otherwise generally rare and are related to
either needle placement or contrast reaction. Faulty needle placement may result in
injection of contrast into the surrounding soft tissues, into the subacromial bursa or the
biceps tendon sheath. These inadvertent injections are preventable by meticulous
positioning of the needle tip.19
A rare complication is painful swelling of the joint developing within hours
following the arthrogram due to irritation of the synovium by contrast medium. This
chemical synovitis usually subsides after 1-2 days and may be treated by the aspiration
of joint effusion. Infection is an extremely rare and a largely preventable complica-
tion.20 Vasovagal syncope occurs infrequently. A minor allergic reaction in the form
of urticaria affects 1 per 1000 patients, while serious allergic reaction or death from
shoulder arthrography has yet to be reported.19 Morbidity from this procedure can
be reduced by using nonionic contrast media and/or double contrast instead of single
contrast examinations.21,22
Normal Arthrogram
Conventional Shoulder Arthrography
The glenohumeral space is initially visible as a curvilinear opacity between the
humeral head and the glenoid surface. The axillary pouch, adjacent to the humeral
neck, is best seen with the shoulder externally rotated while the subscapular recess,
overlying the glenoid and lateral subscapular region, is best appreciated on the internal
rotation view. The long head of biceps tendon is a tubular-shaped filling defect within
the contrast-filled biceps tendon sheath which extends into the bicipital groove in the
upper humeral metaphysis (Figs. 1.2 and 1.3). Sometimes, the biceps tendon can be
seen running across the superior aspect of the humeral head. Before CT arthrography
became commonly performed, axillary views were important in delineating the
glenoid labra and the articular surfaces of the glenohumeral joint.15-17,19
CT Shoulder Arthrography
The pouches and recesses of the shoulder joint seen on conventional
arthrography are precisely delineated on CT. The relationship of the joint capsule to
the surrounding muscles and the capsular insertion sites are well demonstrated. Using
spiral CT, coronal and sagittal reformatted images are able to show the muscles of the
rotator cuff in relation to the adjacent contrast- and air-filled joint capsule and bony
structures.
The contour and outline of the cartilaginous glenoid labra are clearly demonstrated
on CT arthrography. The anterior labrum is usually triangular in shape compared to
the more rounded posterior labrum, although normal variations in appearances of
these structures exist (Fig. 1.4). Other intra-articular structures which may be depicted
are the three glenohumeral ligaments and the long head of biceps tendon. In my
Fig. 1.4. Normal CT shoulder arthrogram at mid-glenoid level. The triangular-shaped

anterior glenoid labrum (straight arrow) and more rounded posterior labrum (curved
arrow) are seen. The long head of the biceps tendon (arrowheads) is present within
its tendon sheath in the bicipital groove. The anterior and posterior joint capsular
attachments are delineated by air and contrast.
experience, the superior glenohumeral ligament, which arises from the superior
labrum and runs anteriorly and parallel to the coracoid process, is most constantly
seen as it is the thickest of the three ligaments. The origin of the middle gleno-
humeral ligament is from the superior labrum and it courses adjacent to the superior
subcapularis tendon, often merging with and strengthening the anterior capsule.
The inferior glenohumeral ligament consists of two bands—superoanterior and
inferoposterior—which attach the inferior half of the labrum to the humerus. The
middle and inferior glenohumeral ligaments are better seen on MR than on CT
arthrography.18
The long head of the biceps tendon originates from the supraglenoid tubercle
and superior glenoid labrum, takes an intra-articular course over the humeral head,
and runs through the bicipital groove, before merging with the short head of the
biceps in the distal third of the arm and inserting into the proximal forearm bones.
On CT arthrography, this tendon is best appreciated in cross-section as a rounded
filling defect within its air and contrast-filled sheath in the bicipital groove of the
upper humerus (Fig. 1.4). Its origin from the superior glenoid can often be seen on
axial or coronal reformatted images. Its path over the humeral head is however
visualized with difficulty, due to partial volume averaging.
Besides intra-articular structures, the surrounding bones such as the
humeral head, bony glenoid, acromium, and the acromio-clavicular joint are nicely
demonstrated on CT. The shape of the acromial arch can be determined using
oblique sagittal reformatted images.23
MR arthrography combines the advantages of visualizing intra-articular structures,
made possible by capsule distention, with the inherent multiplanar capability of MR 1
and superior delineation of soft tissue structures. The rotator cuff and other muscles
and tendons are exquisitely demonstrated on T1-weighted images (WI). The bone
marrow, intra- and inter-muscular fat and subcutaneous fat are also well seen with
this sequence. T2-WI are useful for detection of soft tissue edema or other lesions,
bone edema, contusion or other lesions, and fluid in the subacromial bursa and
acromio-clavicular joint. Fat-suppression sequences improve visualization of fluid
on T2-WI and of the rotator cuff by nulling the adjacent bright subacromial-
subdeltoid peribursal fat on T1-WI.24-32
Besides demonstrating intra-articular structures such as the glenoid labra, long
head of biceps tendon and loose bodies, the middle and inferior glenohumeral
ligaments are visualized, particularly on the oblique sagittal images. Extra-articular
structures forming the coracoacromial arch such as the coracoacromial ligament can
also be seen (Figs. 1.5 and 1.6).24-32 The shape of the acromial arch, important in the
impingement syndrome and suspected rotator cuff lesions, is best appreciated on
oblique sagittal images.33
Abnormal Arthrogram
Rotator Cuff Tears
Plain radiographic clues to impingement and rotator cuff disease include
narrowing of the acromio-humeral space, sclerosis of the greater tuberosity, inferior
acromio-clavicular joint osteophytes and subacromial soft tissue calcification (Fig. 1.7).
Fig. 1.5. Normal MR shoulder arthrogram—oblique coronal sections. A) Spin-echo

(SE) T1-weighted image (WI) shows the supraspinatus muscle (large arrowheads)
and tendon (small arrowheads), and normal marrow signal within the humeral head,
glenoid and distal end of the clavicle (*). The supraspinatus fossa is marked with a
star. B) Fat-saturated SE T1-WI shows the contrast-filled joint capsule, inferior gleno-
humeral ligament (white arrows), and the superior (black arrowheads) and inferior
(black arrows) glenoid labra more clearly. Normal sublabral sulcus is arrowed (small
white arrows).
Fig. 1.6. Normal MR shoulder arthro-

gram—Oblique sagittal T1-WI, at A) mid-
and B) medial humeral head levels, show
1 the muscles and tendons comprising the
rotator cuff, namely: subscapularis (small
white arrows), supraspinatus (black arrows),
infraspinatus (open arrows) and teres minor
(white arrowhead). The inferior gleno-
humeral (long black arrows) and cora
coacromial (black arrowheads) ligaments,
as well as the intra-capsular course of the
long head of biceps tendon (short black
thick arrows), are also seen. (A =
acromium, * = coracoid process). C) Axial
T1-WI at the level of the coracoid process
shows normal anterior (black
arrowheads) and posterior (black arrows)
glenoid labra, part of the middle gleno-
humeral ligament (white arrow), long head
of biceps tendon (white arrowhead) and
the deltoid muscles (short black thick
arrows). (* = coracoid process).
These radiographic signs are however unreliable, particularly for acute tears of the
rotator cuff, and double contrast shoulder arthrography has long been recognized as
the standard technique for diagnosis of full-thickness rotator cuff tears.19 This type
of tear is demonstrated arthrographically as abnormal communication between the
glenohumeral joint space and the subacromial-subdeltoid bursa (Fig. 1.8). Partial
tears, especially superior surface tears, are difficult to diagnose arthrographically.
Undersurface tears are seen as small focal or linear areas of opacification, usually at
the musculotendinous junction, or critical zone, of the affected tendon.19 Reformat-
ted coronal and sagittal CT images provide an improved display of the cuff tears
(Fig. 1.9).18
Fig. 1.7. Radiograph showing

calcification of the subacro-
mial soft tissue. 1
Fig. 1.8. Full- thickness rota-

tor cuff tear. Double contrast
arthrogram shows air and
contrast outlining the sub-
acromial-subdeltoid bursa
(arrowheads).
The location and size of a full-thickness rotator cuff tear, the degree of retraction
and state of the remnant muscle can be demonstrated by conventional MR imaging,
particularly in the presence of pre-existing joint effusion. In partial tears however, as
tendon morphology is usually normal, the diagnosis relies heavily on changes in
tendon signal intensity. Normal variations in signal intensity of supraspinatus tendons
exist and hence may simulate lesions.34,35 MR arthrography has been shown to be
superior to conventional MR imaging in depiction of partial tears, in distinguishing
between partial and small full-thickness tears, particularly if fat-suppression is
employed (Fig. 1.10).36,37 Recently, the usefulness of MR arthrography in detection of
postero-superior glenoid impingement in throwing athletes,38 and the effectiveness of
positioning the arm in abduction and external rotation (ABER position) during
MR arthrography,39 have been described.
Labral-Ligamentous Complex Abnormalities
Although the bony Bankart and Hill-Sachs deformities may be visible radio-
graphically, and labral and capsular abnormalities may be seen following double
contrast shoulder arthrography,17,19 CT arthrography has been the standard method
of evaluating the labral-ligamentous complex since the early 1980s. Besides showing
bony lesions, CT arthrography depicts tears of the cartilaginous labra and stripping
Fig. 1.9. CT arthrography showing

a full-thickness supraspinatus
tear. A) Axial section at level of
1 the coracoid process shows air
and contrast within the subdeltoid
bursa (arrowheads). B) Oblique
coronal reformatted image
depicts air and contrast in the
supraspinatus tear gap (arrow-
heads), and contrast media in the
subacromial bursa (white arrows;
* = acromial arch). C) Oblique
sagittal reformatted image also
demonstrates the full-thickness
supraspinatus tear (black arrow-
heads) and contrast media in the
subdeltoid bursa (white arrow-
heads; * = acromial arch).
of the joint capsule attachments, structures which have been accepted, in the past,
to contribute to shoulder instability (Figs. 1.11, 1.12, 1.13).18,40-42
MR arthrography has been shown to be more sensitive than conventional MR
imaging and CT arthrography in detecting labral tears, and distinguishing between
labral detachment and degeneration (Figs. 1.14).43 MR arthrography is particularly
useful in detecting abnormalities of the labral-ligamentous complex, particularly if
there is no joint effusion. The superior, middle and inferior glenohumeral ligaments
are nicely shown during MR arthrography. Together with the long head of the biceps
tendon, these three ligaments attach to the glenoid labrum. Hence labral tears may
result in ligamentous instability, especially of the inferior glenohumeral ligament.29-
31
Palmer and Caslowitz, in their recent analysis of 121 MR arthrograms, concluded
that inferior labral-ligamentous instability was closely associated with anterior
glenohumeral instability and that capsular insertion sites had no role in the evaluation
of shoulder instability.44
Adhesive Capsulitis45
Adhesive capsulitis may be both diagnosed and treated during single contrast
arthrography. Relatively high resistance to the injection of contrast, overall decreased
Fig. 1.10. MR arthrography

showing a full-thickness su-
praspinatus tear. Fat-satu-
rated oblique coronal SE
1
T1-WI shows a large full-
thickness tear (arrows) pro-
viding communication be-
tween the glenohumeral
joint and the subacromial-
subdeltoid bursa (arrow-
heads). Note mild retrac-
tion of the supraspinatus
muscle.
Fig. 1.11. Anterior Bankart

lesion after anterior shoul-
der dislocation. CT arthro-
gram shows a mildly dis-
placed osteocartilaginous
glenoid fracture (arrow).
volume of contrast within the joint, and/or irregularity of the joint capsule all
suggest the presence of “frozen shoulder”. Patients are often referred with the diag-
nosis, in which case the radiologist requires only 1-2cc’s of contrast or air to confirm
that the needle is indeed intra-articular. Once this has been established Depomedrol
40 mg and 10 cc’s of 1% Bupivocaine are instilled into the joint capsule. The patient
is shown a series of stretching exercises that he/she must perform until his second
appointment.46,47 In total the patient has three shoulder injections , as described above,
separated by a seven to ten day interval. This treatment regimen may be supple-
mented by physiotherapy.
Calcific Tendinitis
Calcific tendinitis is a relatively common condition in the soft tissues of the
shoulders and hips. Nonsteroidal anti-inflammatory agents constitute the first line
of treatment. In those patients who are unresponsive, extra-corporeal shock wave
therapy may be the next step.48,49 Alternatively, blind injections of corticosteroids is
often attempted. A small group of patients will still have persistent symptoms,
either because the injection was not administered directly into the calcifications or
because of resistance to percutaneous and medical therapy.50 In these cases, fluoro-
scopic, CT, or ultrasound-guided percutaneous corticosteroid administration, and/
or aspiration of soft tissue calcifications, is recommended.51,52
Fig. 1.12. Severe changes following recurrent anterior shoulder dislocation. CT

arthrogram at (a) mid- and (b) distal humeral head levels show a truncated anterior
bony glenoid (thick arrow), with the resulting detached osteocartilaginous fracture
fragment (arrows) located in the anterior axillary pouch. Note flattening of the
posterior humeral head (arrowheads) consistent with a Hill-Sachs deformity, as
well as a capacious anterior capsule.
Fig. 1.13. Moderate changes following recurrent anterior shoulder dislocation. CT

arthrogram at (a) coracoid process and (b) mid-glenoid levels show a Hill-Sachs
defect (black arrow), attenuation of the anterior cartilaginous labrum (white ar-
row), and medial stripping of the anterior joint capsular attachment (arrowhead).
For fluoroscopic or ultrasound guidance, you should localize the calcifications in

two planes that are essentially perpendicular to one another. Then proceed with
needle placement, using aseptic technique.
With CT, the calcifications are easily identified. Depending on the site of soft
tissue calcifications, and the adjacent neurovascular structures, the patient is placed
in the prone, supine, or decubitus position. Using aseptic technique, a 22g 3-1/2”
spinal needle is placed into the calcifications and corticosteroids are administered
(Fig. 1.15). If you are planning to aspirate the calcifications, an 18 or 20g 3-1/2”
spinal needle should be utilized for the procedure.
Fig. 1.14. MR arthrography show-

ing recurrent anterior shoulder
dislocation. Axial SE T1-WI at
A) upper level head shows a notch-
1
like Hill-Sachs defect (open arrow).
B) Axial SE T1-WI at mid-humeral
head level shows deficiency of the
anterior cartilaginous glenoid
labrum (arrowheads). A normal
long head of biceps tendon is seen
(curved arrow). C) An oval loose
body, representing the detached
cartilaginous labral fragment, is
demonstrated in the axillary pouch
(arrowheads) on the oblique
coronal SE T1. D) The oval loose
body is also well seen on fat-
saturated oblique sagittal SE T1-WI.
Fig. 1.15. A) CT localization of calcification in the shoulder. B) Needle placement

for aspiration of calcifications.
The risks of this procedure are extremely low, especially if you avoid the neu-
rovascular structures. It is also important to avoid intratendinous
administration of corticosteroids as this predisposes the patient to subsequent tendon
rupture. Utilisation of aseptic technique minimizes the incidence of infection.
Acromio-Clavicular Arthrography
Acromio-clavicular joint injection is rarely indicated. Possible applications for
this technique include acromio-clavicular joint dislocation and assessment of the
degree of synovial, cartilaginous and bony involvement in patients with rheumatoid
arthritis. In trauma, leakage of the contrast medium around and away from the joint
may give an indication of the severity of ligamentous injury.16
The acromio-clavicular joint is palpated and usually punctured using a superior
approach (Fig. 1.16). An alternative approach is from the anterior aspect of the
joint. A 21-gauge short-bevelled 3.85 cm needle is used; 1 ml of contrast medium
often suffices for joint delineation. The acromio-clavicular joint cavity is L-shaped
with the horizontal component extending inferior to the distal end of the clavicle.16,53
Summary
Although MR arthrography has recently emerged as a valuable tool in the evalu-
ation of shoulder disorders, its role in various conditions continues to evolve. It is
likely that MR arthrography would eventually be utilized in a problem-solving ca-
pacity, supplementing rather than replacing conventional MR imaging of the shoul-
der. CT arthrography is still useful where there is limited access to MR imaging and
in disorders predominantly involving bony structures. Ultrasonic guidance of needle
placement for shoulder MR arthrography has recently been described. This tech-
nique avoids exposure to ionizing radiation and obviates the need for the procedure
to be performed in a fluoroscopic screening room.54
Fig. 1.16. Acromio-clavicular

arthrography puncture tech-
nique. Needle pathway is shown
in the frontal view.
1
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CHAPTER 2
Elbow Arthrography
Clara G.C. Ooi and Wilfred C.G. Peh
Introduction
Elbow arthrography is a procedure not commonly performed in many general
radiology departments, but is occasionally required to evaluate dysfunctional and
painful elbows. This imaging technique is safe and relatively painless when properly
executed. Depending on the indications, contrast media, with or without the addition
of air, is injected into the joint after careful patient preparation and positioning.
Single contrast examinations using contrast media alone are useful to assess synovial1
and capsular integrity,1,2 to delineate synovial cysts,1,2 and to opacify the elbow joint
after diagnostic joint lavage.3 Loose bodies, as well as cartilaginous and osseous defects,
are better demonstrated with double contrast studies using air and contrast media.1-4
Joint effusion should be routinely aspirated to exclude joint infection, prior to the
injection of contrast media. Computed tomography (CT) is often used in conjunction
with arthrography.
Indications
• Intra-articular loose bodies
• Recurrent dislocation
• Cartilaginous abnormalities
• Synovial abnormalities
• Capsular and ligamentous injuries
• Osseous defects
• Diagnostic aspiration
Contraindications
Local sepsis
Equipment
An elbow arthrographic tray should include a 22- or 23-gauge short-bevelled
3.85 cm needle for intra-articular injection, local anesthetic (1% Lidocaine hydro-
chloride), sterile drapes, water-soluble contrast medium, and 5 ml and 10 ml syringes
for the contrast medium and air, respectively. In our institution, a nonionic contrast
medium such as Omnipaque 300 (Iohexol 300 mgI/ml) is used. If an ionic contrast
medium is utilized, meglumine salts are preferred to sodium salts as they cause less
pain.5 An image-amplified fluoroscopy unit with a fractional millimeter focal spot
for spot filming, although not essential, is desirable.3,5 However, to be able to per-
form the procedure comfortably with sufficient space to maneuver, it would be ideal
to have the use of an overcouch X-ray tube with an undercouch image intensifier.
After intra-articular injection of contrast under fluoroscopy, “spot” arthrographic
Elbow Arthrography 21
films are obtained, followed by films taken with an overhead tube for superior image
detail. Availability of conventional tomography facilitates visualization of loose bodies,
osteochondritis dessicans and the articular surfaces of the trochlea and ulna.6,7
Technique
Prior to the procedure, preliminary antero-posterior (AP) and lateral 2
radiographs of the elbow should be routinely reviewed for joint abnormalities, bony
fragments and soft tissue calcifications. The patient is seated next to, or lying prone
on, the fluoroscopic table. The elbow is flexed to 90˚, with its lateral aspect being
uppermost. This position may be maintained with the support of sand bags or sponge
pads. The radio-capitellar joint is located fluoroscopically and a lead marker placed
over the point of skin entry, either before or after skin preparation (Fig. 2.1). If
preferred, the point of entry can be marked with indelible ink. Using an aseptic
technique, the skin and soft tissues under the marked point are infiltrated with local
anesthetic. The 22- or 23-gauge needle is then inserted vertically into the radio-
capitellar joint under intermittent fluoroscopy. If the needle strays from its intended
path, it should be withdrawn and reinserted. The needle is advanced slowly until
resistance is felt just prior to penetration of the fibrous joint capsule.
Occasionally one feels a “give” when the needle perforates the capsule and enters the
joint space.
To confirm the intra-articular position of the needle, a small amount (about
0.5 ml) of the contrast medium is injected slowly. If the needle is correctly sited, the
contrast medium should flow away freely from its tip (Fig. 2.2B). Should there be
puddling of the contrast medium around the needle tip, the needle should be
repositioned. Once the intra-articular position of the needle tip is verified, the rest
of the contrast medium is given (Fig. 2.2C). Normally, 6-10 ml is injected for a
single contrast study, with the actual amount instilled depending on the size of the
joint. For a double contrast arthrogram, 0.5-2 ml of contrast medium and 6-12 ml
of air are injected (Fig. 2.3).1,3 In patients with previous severe reaction to contrast
media, 8-12 ml of air alone may be given as an alternative. The use of air alone
produces a negative contrast effect; as a result, the intra-articular surfaces may not be as
well seen compared to a single or double contrast arthrogram. There should not be
any resistance to contrast injection if the needle is properly positioned.
Contrast medium can be injected either by direct attachment of the syringe to
the needle or via a length of plastic tubing between the syringe and needle. The
former method is favored by some authors as it is easier to judge the injection pressure.3
We prefer the latter method as the flow of contrast can be fluoroscopically observed
during the injection (Fig. 2.2B,C). Using this “dynamic” method, inadvertent contrast
extravasation can also be detected immediately, with the appropriate action taken to
terminate the injection. After injection of contrast media, the needle is withdrawn
and the elbow joint passively moved to distribute the contrast evenly within the
joint. Rigorous movements are not recommended as the joint capsule may be ruptured
or in cases where air has been injected, air bubbles produced may give a confusing
appearance. To delay resorption of contrast media and to ensure adequate quality of
articular cartilage coating, a small amount (0.1-0.3 ml) of 1:1000 adrenalin is added
to the contrast medium prior to injection. This is indicated in studies where arthro-
tomography prolongs the examination, where there may be an expected delay in
Fig. 2.1. Elbow arthrography puncture technique. A) The position of the needle
entry point (cross) is marked over the radio-capitellar joint on the lateral view. B)
The pathway of the needle, perpendicular to the skin and joint, is indicated on the
frontal view.
transporting the patient to the CT suite, or in inflamed joints where rapid absorption
of the contrast medium is anticipated.
The usual radiographic projections obtained are AP, lateral, internal and external
45˚ oblique radiographs. These can be supplemented by conventional tomography or
CT, both of which are useful to evaluate the integrity of articular surfaces, extent of
transchondral fractures and the presence of bony fragments.1,2,8 Conventional
arthrotomography is best performed with the elbow in the lateral projection. In CT
arthrography, the patient is usually positioned lying prone with the elbow in full
extension; 3 mm-thick contiguous axial sections are then performed through the
humerus, radius and ulna (Fig. 2.4). Coronal views of the ulna and radius can also be
obtained with the patient lying either prone or supine, with the arm stretched above
the head and the elbow flexed at a 90° angle (Fig. 2.2D).9 In these sections, the
humerus remains imaged in the axial plane, while the radio-capitellar and ulna-
trochlear joints are in the coronal plane (Fig. 2.2E). If soft tissue abnormalities are
present, reconstruction of images using a standard algorithm is useful. We use 1500
HU window width and 400-450 HU window level for bone target images, and 400-
500 HU window width and 70-100 HU window level for soft tissue target images. If
a spiral CT scanner is utilized, overlapping thin-section (1.0-1.5 mm) reconstruc-
tion of images in the sagittal, coronal and oblique planes is recommended to im-
prove orientation of abnormalities to normal anatomical landmarks.
Complications
After the procedure, the patient should be warned to expect some discomfort in
the joint lasting about 1-2 days. Complications are uncommon but can occur due
Fig. 2.2. Osseous subchondral defect. A) An area of lucency in the subchondral

area of the trochlea, suggestive of an osteochondral defect, is seen on the plain
radiograph. Lateral arthrograms in the (B) early and (C) late phases of contrast in-
jection with the needle in-situ, show contrast filling of the coronoid (arrows) and
periradial (arrowheads) recesses. D) CT scout view showing scanning plane with
the elbow flexed at 90˚. E) Direct coronal CT of the radius and ulna demonstrate an
osseous subchondral defect (arrows) in the trochlea, with intact overlying articular
cartilage. The radio-capitellar joint is not involved.
Fig. 2.3. Normal double contrast

elbow arthrogram. (A) Lateral
view shows the coronoid and
epiradial recesses filled with air
and contrast. (B) Frontal projection
2 shows that the articular cartilage
of the radio-capitellar and ulna-
trochlear joints are of uniform
thickness and have smooth
outlines.
either to the contrast medium or to the technique. Allergic reaction and chemical
synovitis are typical examples of the former type of complication. In a patient with
previous reaction to contrast medium, air alone should be used as negative
contrast. With respect to technique-related complications, peri-articular and
intra-articular infection can be introduced if a strictly aseptic technique is not
adhered to. Other complications include pain, capsular rupture, and injury to
neighboring structures such as nerves and blood vessels.
Fig. 2.4. Normal CT arthrogram with scanning of the elbow in full extension. (A)
Axial scan at the level of the olecranon fossa demonstrates distension of the anterior
(coronoid) (arrows) and posterior (arrowheads) recesses. B) More distal axial scan
through the epicondyles of the distal humerus shows normal articular cartilage
(arrows) and part of the posterior recess around the olecranon process and fossa
(arrowheads). C) Axial scan performed through the proximal radio-ulnar joint shows
normal articular cartilage surrounding the radial head (black arrows). D) Axial scan
performed through the proximal radio-ulnar joint shows the peri-radial recess (white
arrows).
Normal Arthrogram
The elbow joint consists of three joint articulations, enclosed by the joint capsule
which is in turn lined by synovial membrane. The three articulations are the radio-
ulnar, radio-capitellar and ulna-trochlear joints. Tomograms in the lateral position
depicts the radio-capitellar and ulna-trochlear articulations clearly, while the external
oblique projection best demonstrates the radial head and the radio-ulnar joint.
Outpouchings of the joint capsule give rise to three recesses. The anterior (coronoid),
posterior and annular (peri-radial) joint recesses, when distended with the contrast
medium and/or air, are clearly visible arthrographically (Fig. 2.2C and Fig. 2.3A).
The anterior or coronoid recess is located anterior to the capitellum and trochlea of
the distal humerus, and lies posterior to the anterior fat pad which is elevated when
intra-articular contrast fills this recess. The posterior recess extends over the posterior
aspect of the distal humerus, enclosing the condyles, posterior capitellum and the
olecranon fossa. Contrast within this recess elevates the posterior fat pad. This recess
is not easily evaluated on routine arthrographic views and is best assessed with
2 conventional or computed tomography (Figs. 2.4A-B).3 The most distal extent of
the synovial cavity of the elbow is the annular or peri-radial recess which encircles
the radial head and neck, and bulges under the annular ligament (Fig. 2.2C and
Fig. 2.4D). A normal infolding of synovium may be seen as a triangular opacity
just proximal to the radial head on the lateral view, particularly when the cap-
sule is relaxed with the elbow in the flexed position. This structure should not be
mistaken for a loose body. The articular cartilage of the humerus, radius and ulna
have smooth and regular surfaces of uniform thickness (Fig. 2.3B and Fig. 2.4C),
except for the midportion of the ulnar notch which normally has an area of
cartilaginous and subchondral cortical deficiency. Normal synovium should be
sharply and smoothly outlined by contrast.
Abnormal Arthrogram
Synovial Disorders
In inflammatory conditions, the synovium becomes edematous and thickened,
with increased reabsorption of the contrast medium. This results in an ill-defined
and fuzzy appearance of the synovial lining. In disorders such as rheumatoid arthritis,
juvenile chronic arthritis, neuropathic arthropathy and septic arthritis, hypertrophy
and villous transformation of the inflamed synovium can occur, producing an irregular
and nodular contrast outline. Similar appearances may also be seen with pigmented
villonodular synovitis (PVNS) and synovial osteochondromatosis.1,3 The arthrographic
appearances of these conditions are however not specific and diagnosis cannot be made
solely on arthrography.3 In current practice, PVNS is better assessed by magnetic
resonance (MR) imaging while synovial osteochondromatosis should be evaluated
by radiographs and if indicated, CT.
Synovial Cysts
Synovial cysts are seen mainly in rheumatoid arthritis, although they may be
associated with other arthritic conditions.3 The most common site is the antecubital
fossa, with the olecranon being another recognized location. Synovial cysts usually
communicate with the joint and a larger-than-usual amount of contrast media is
often required to fill them adequately. Occasionally, repeat radiographs after
vigorous exercise may be required to optimize cyst filling. Direct injection of
these cysts are sometimes performed in an attempt to demonstrate direct
communication with the joint.
Intra-Articular Loose Bodies
A loose body is demonstrated arthrographically as a mobile intra-articular opacity
that is completely coated by contrast media (Fig. 2.5 and Figs. 2.6A-B). 3 In cases
where overlying bony structures obscure suspected loose bodies, tomograms
are helpful in confirming the presence and multiplicity of loose bodies. CT
Fig. 2.5. Elbow arthrogram

(frontal projection) shows an
intra-articular loose body (arrow)
located just superior to the
lateral aspect of the radial head.
2
arthrography is another excellent method of determining whether an opacity

is intra-articular or whether it lies extrinsic to the joint capsule (Figs. 2.7A-B).
Osteochondral Abnormalities
The integrity of articular cartilage in suspected osteochondral lesions can be
assessed at arthrography (Figs. 2.2B-C). Subtle subchondral defects are, however,
better demonstrated with conventional or computed arthrotomography (Fig. 2.2E).
In the later stages of osteochondritis dessicans, the osteocartilaginous fragment is
delineated by the contrast medium leaking through the chondral fracture and
surrounding the fragment. When this fragment becomes completely separated from
its bed, it can be seen as a loose body within the joint cavity. Occasionally, an
osteochondral fracture fragment may be extruded outside the joint cavity. In the
traumatized elbow, cartilage infractions can be visualized by tracking of the contrast
medium along the fracture lines. This is particularly true in children where injuries
to the unossified cartilage and intra-articular chondral bodies may not be detectable
on plain radiography. Condylar injuries, particularly those involving the epiphysis,
are often misdiagnosed or missed clinically and radiographically. Previous studies
Fig. 2.6. Intra-articular loose bodies. A) Lateral plain radiograph shows two calcified
opacities posterior to and another opacity anterior to the distal humerus. B) Elbow
arthrogram confirms that two of these opacities are intra-articular in position (black
arrows), while the third is located outside the anterior joint capsule (white arrow).
have demonstrated the superiority of elbow arthrography over plain radiographs in

accurately diagnosing and hence influencing the management of these injuries
(Figs. 2.8A-C).10,11
Capsular Abnormalities
Adhesive capsulitis, capsular tears and rupture, abnormal laxity of the
capsuloligamentous complex and dissection of neuropathic joints (Figs. 2.9A-B),13
can be demonstrated by arthrography. Redundancy of the joint recesses results from
laxity of the capsular attachments which are associated with recurrent dislocations.12
Pooling of contrast media lateral to the radial head indicates laxity of the lateral
capsuloligamentous complex. Similarly, ballooning of the coronoid recesses on either
side of the joint, with extension of contrast media lateral and medial to the respective
lateral and medial humeral epicondyles, are associated with laxity of the collateral
ligaments which normally prevent expansion of the capsule. Anatomic capsular
alterations after insertion of a joint prosthesis can also be confirmed by arthrography
(Figs. 2.10A-C).
MR Arthrography
MR imaging has, since its advent, replaced arthrography for many indications,
being particularly useful in imaging of periarticular soft tissue masses. The advantages
of MR imaging over arthrography include its multiplanar imaging capability, increased
soft tissue contrast and definition, and avoidance of ionizing radiation. A recent
article by Schwartz et al14 has described the role of MR elbow arthrography, using
normal saline, in demonstrating tears of the ulnar collateral ligament. MR
arthrography is potentially useful as a problem-solving tool in selected clinical
situations.
Fig. 2.7. Extra-articular loose body. A) Frontal radiograph shows a bony fragment
located adjacent to the lateral epicondyle (arrowhead). B) CT arthrogram confirms
that the fragment is extra-articular in position (arrowhead).
Fig. 2.8. Young child with previous elbow trauma. A) Frontal radiograph shows a
bony fragment adjacent to the medial epicondyle, which itself has an irregular
appearance. B) Elbow arthrogram confirms that the fragment (arrows) is not attached
to the epicondyle. C) Single contrast CT arthrogram demonstrates an osteochondral
defect at the medial epicondyle. The bony fragment has a large cartilaginous com-
ponent, consistent with a non-united osteochondral avulsion fracture.
Fig. 2.9. Dissecting neuropathic joint. A) Left elbow radiograph of a neuropathic

joint shows irregular destruction of the ulna-trochlear joint. Calcific densities are
seen in the soft tissues adjacent to the elbow extending into the medial upper
forearm. (Reprinted with permission from: Peh WCG, Brockwell J, Chau MT et al.
Imaging features of dissecting neuropathic joints. Australasian Radiology 1995;
39:249-253. ©1995 Blackwell Scientific Publications.) B) Arthrogram confirms
dissection of the neuropathic joint with contrast tracking from the elbow joint into
the soft tissues of the medial upper forearm, with small filling defects. Extravasated
extracapsular contrast is also present on the lateral aspect of the joint at the puncture
site. (Reprinted with permission from: Peh WCG, Brockwell J, Chau MT et al.
Imaging features of dissecting neuropathic joints. Australasian Radiology 1995;
39:249-253. ©1995 Blackwell Scientific Publications.)
Fig. 2.10. Arthrogram of a dislocated prosthetic joint. A) Initial puncture of the

radiocapitellar joint shows filling of the periradial recess only. B) Injection of con-
trast through a second needle (arrows), placed just distal to the lower end of the
humeral prosthesis, shows filling of the anterior and posterior recesses. C) The frontal
projection, with both needles removed, provides an overview of the dislocated
prosthesis and the separate joint recesses, which are probably a consequence of
extensive scar formation.
References
1. Resnick D. Arthrography, tenography, and bursography. In: Resnick D, ed. Diag-
nosis of Bone and Joint Disorders. 3rd ed. Philadephia: WB Saunders Co.,
1995:277-409.
2. Teng MM, Murphy WA, Gilula LA et al. Elbow arthrography: a reassessment of
the technique. Radiology 1984; 153:611-613. 2
3. Hudson T. The elbow. In: Freiberger RH, Kaye JJ, eds. Arthrography. New York:
Appleton- Century- Crofts, 1979:261-276.
4. Chapman S, Nakielny R. Elbow Arthrography. In: A Guide to Radiological Proce-
dures. 3rd ed. London: Bailliere Tindall, 1993:315-316.
5. Pavlov H, Ghelman B, Warren RF. Double-contrast arthrography of the elbow.
Radiology 1979; 130:87-95.
6. Eto RT, Anderson PW, Harley JD. Elbow arthrography with the application of
tomography. Radiology 1975; 115:283-288.
7. Roebuck EJ. Elbow Arthrography. In: Whitehouse GH, Worthington BS, eds.
Techniques in Diagnostic Radiology. Oxford: Blackwell Scientific Publications,
1983:305-313.
8. Roback DL. Elbow arthrography: brief technical considerations. Clin Radiol 1979;
30:311-312.
9. Gilula LA. Conventional arthrography : general aspects. In: Resnick D, Pettersson
H, eds. Skeletal Radiology. London: Merit Communications, 1992:9-35.
10. Yates C, Sullivan JA. Arthrographic diagnosis of elbow injuries in children. J Pediatr
Orthop 1987; 7:54-60.
11. Akbarnia BA, Silberstein MJ, Rende RJ et al. Arthrography in the diagnosis of
fractures of the distal end of the humerus in infants. J Bone Joint Surg 1986;
68A:599-602.
12. Mink JH, Eckardt JJ, Grant TT. Arthrography in recurrent dislocation of the el-
bow. Am J Roentgenol 1981; 136:1242-1244.
13. Peh WCG, Brockwell J, Chau MT et al. Imaging features of dissecting neuro-
pathic joints. Australas Radiol 1995; 39:249-253.
14. Schwartz ML, Al-Zahrani S, Morwessel RM et al. Ulnar collateral ligament injury
in the throwing athlete: evaluation with saline-enhanced MR arthrography. Radi-
ology 1995; 197:297-299.
CHAPTER 3
Wrist Arthrography
Isabelle Pigeau, Philippe Valenti, C. Sokolow, Stephane Romano
and Philippe Saffar
Introduction
Although this section is entitled wrist arthrography, it will illustrate the use of
arthrography-CT. We feel that arthrography-CT is the examination of choice for
evaluation of the wrist ligaments and cartilage due to its ability to perform millimetric
contiguous slices in three planes without overlapping areas of contrast.1,communications
Correlation between arthrography-CT and surgical findings are very good.
Arthrography-CT has demonstrated significant advantages over conventional
arthrography. Although arthrography can identify an abnormal communication of
contrast between adjacent compartments, called a communicating defect (CD),
during injection or in the post-exercise period, it can not adequately assess the
extent of the CD. A CD, via a ligament or the triangular fibrocartilage (TFC), can
easily by diagnosed by conventional arthrography. However, smaller associated CDs
or cartilage abnormalities may be obscured once the arthrogram injection is complete
because overlapping articular recesses may mask the pathologic area.2-5 Lastly,
arthrography-CT, unlike conventional arthrography, allows visualization of the entire
ligament. This is important because the proximal part of the scapholunate (SL)
ligament, the area that has no important biomechanical role, is the only area visualized
on conventional arthrogram.6
Having alluded to the most common indications for wrist arthrography, it is
important to state that there is no correlation between the site of patient symptoms
and CDs.7 Similarly, there is no correlation between the site of patient symptoms
and non communicating defects (NCD).8 Furthermore, there was no clinical utility
in assessing the direction of the CD—i.e., unidirectional versus bidirectional.7
Nonetheless, arthrography and arthrography-CT remain the most important methods
by which to assess ligament, and cartilage, integrity.
Although much has been written about MRI of the wrist, it is less sensitive than
conventional arthrography and arthrography-CT for ligament and cartilage
evaluation.9-14 This decreased sensitivity is due to the inconsistent visualization and
variable appearance of the ligaments, especially the lunotriquetral (LT) ligament.
Intermediate signal intensity is identified in a significant percentage of SL and LT
ligaments and TFC in asymptomatic patients. MRI, however, does offer the advantage
of direct visualization of some of the extrinsic ligaments.15
Indications
• suspected intercarpal ligament, TFC or capsular defect
• abnormal instability series

Wrist Arthrography 33
• detect cartilage abnormalities

• demonstrate the origin of a synovial cyst
• localize joint bodies
• adhesive capsulitis1
• aspiration1
• administration of anesthesia and/or steroids1
Contraindications 3
There are no absolute and relatively few contraindications to wrist arthrography.
Relative contraindications include prior contrast reaction, bleeding diatheses and
cellulitis at the site of proposed injection.
Equipment
25 g 1" needle, 25 g 5/8" needle, 18 g 1-1/2" needle, connecting tubing, 5 cc
syringe for local anesthetic, 10 and 20 cc syringes for contrast, sterile drape, gauze,
epinephrine 1:1000, 1% Xylocaine, contrast medium, saline.
Pre-Procedure Protocol
Standard four view examination of the wrist—including posteroanterior (PA),
semi-supination and semi-pronation obliques and lateral radiographs—is suggested.
If SL diastasis, dorsal intercalated segment instability (DISI), volar intercalated
segment instability (VISI) or other evidence of carpal malalignment is identified
you may want to perform an instability series, a bilateral dynamic fluoroscopic
evaluation of the intrinsic and extrinsic wrist ligaments, before proceeding to wrist
arthrography. If the clinical history warrants—for example, a history of capitolunate
instability pattern (CLIP), proceed to an instability series.
Examine the patient to determine the site of maximal tenderness which will
determine the site at which you perform your injections. Also note the presence of
soft tissue mass(es), such as a potential synovial cyst, or surgical scar which heralds
the possibility of postoperative fibrosis. Obtain adequate patient history to determine
if the patient has locking or clicking (indicators of joint bodies or abnormal bony
motion), dynamic or rest pain, chronic or acute pain. Inquire about their occupation
which may also be helpful in determining the suspected origin of the patient’s
symptoms.
Technique
Wrist arthrography should include evaluation of all three compartments:
radiocarpal (RCJ), midcarpal (MCJ), and distal radioulnar joints (DRUJ). This
necessitates three injections, unless a CD allows filling of two or all three contiguous
compartments during a single injection. Three compartment arthrography has a
relatively high sensitivity of detecting CDs, as compared with subtotal arthrography.16
The most common sequence of injection is MCJ, DRUJ and RCJ. Injection should
be performed contralateral to the painful site—i.e., patients presenting with
radial-sided wrist pain should undergo ulnar-sided injection. This avoids later
confusion on interpretation of arthrograms (extravasation at the injection site versus
defect related to patient symptoms).
1 Arthrogram is sufficient. Arthrography-CT is need not be performed.
Yin et al have suggested injection of the contralateral asymptomatic MCJ, and

RCJ, respectively, to exclude matching defects of the intercarpal ligaments and TFC,
respectively in those with abnormal arthrogram on the symptomatic side.17 The
presence of bilateral symmetric CD and NCD are felt by many authors to represent
age-related changes which are much less likely to be the source of the patient’s pain.17-18
Arthrography is performed under sterile conditions. With fluoroscopic guidance,
the needle site is selected and 1% Xylocaine is administered as local anesthetic.
3 Using fluoroscopic guidance, injections are performed at the following sites.
MCJ Injection
In patients with radial-sided pain, injection may be performed at the articulation
between the capitate, hamate, lunate and triquetrum. If the patient presents with
ulnar-sided symptoms, the needle is advanced into the MCJ at the articulation
between the scaphoid, trapezium and trapezoid. At both of these sites, the needle is
directed into the joint perpendicular to the skin surface.
RCJ Injection
Radial-sided injection is performed at the radioscaphoid joint. It is best to avoid
the ulnar third of the articular surface of the scaphoid as the SL ligament has a
variable attachment site along the scaphoid. The needle is introduced into the skin
over the proximal surface of the scaphoid and directed towards the elbow (angle of
45-60˚). Ulnar-sided injection is performed along the proximal articular surface of
the central portion of the triquetrum. Again, try to avoid injection at the radial side
of the lunate to prevent iatrogenic LT injury and/or filling of the MCJ (false positive
arthrogram).
DRUJ Injection
Regardless of patient symptoms, the DRUJ injection is performed at the same
site. With the hand and wrist in the prone position, rotate the wrist and hand slightly
until the DRUJ joint is profiled. Then advance the needle straight down into the
joint until you hit cartilage. At the site perform a test injection of 1% Xylocaine.
Once the needle is intra-articular, inject dilute contrast and epinephrine 1:1000
(0.1 cc/1 cc of contrast) into the compartment of interest. We prefer to use nonionic
contrast diluted with saline or 1% Xylocaine in a ratio of 3:1. Although ionic contrast
media may be used as well, patient discomfort and the risk of synovitis are higher
with ionic contrast media. Whether you choose to use nonionic or ionic contrast
media, it is important to dilute the contrast media to minimize contrast-related
artifacts at CT. Mix the contrast/saline (1% Xylocaine) in a 20 cc syringe. However,
perform the intra-articular injection with a 10 cc syringe and connecting tubing.
This allows you to feel the resistance to injection, important information in adhesive
capsulitis and in determining the endpoint of your injection at arthrography
Typically, three to four cc of fluid should be injected into the MCJ and RCJ.
However, increasing resistance in some patients will preclude injection of the full 3 cc
of fluid into the compartment. In other patients, especially those with a defect, the
joint can easily accomodate more than 4 cc. It is important to adequately distend
the joint. With inadequate distention some defects will not be demonstrated at
arthrography. Conversely, overdistention of a compartment may result in

extraarticular contrast extravasation and pain.
Post-Procedure Protocol
Dynamic examination of the wrist should be performed under fluoroscopic
guidance. This is essential since arthrography-CT is a static examination. As a
minimum, fluoroscopic spot films should be performed in posteroanterior (PA) and
anteroposterior (AP) projection with the wrist in neutral, radial and ulnar deviation 3
and a lateral view should be obtained. Ideally, fluoroscopic spot films with the SL
and LT joints in profile, should be taken during the injection of contrast into a
given compartment to demonstrate small defects of these ligaments. Fluoroscopic
spots performed at the end of the injection only may mask subtle pathology, including
small intra-articular joint bodies.
At the completion of each injection, the patient is instructed to perform mild
exercise of the wrist. Post-exercise fluoroscopic spots or four view wrist examination
is then repeated.
Subsequently, arthrography-CT is performed in the coronal plane. Contiguous
one mm slices are performed. Additional series—sagittal, sagittal oblique, and/or
axial—are performed as needed, based on the findings of the coronal series,
arthrogram, and clinical history. To ensure a high quality examination, the delay
between arthrography and arthrography-CT should not exceed 20 minutes. Beyond
this time interval, contrast begins to diffuse into articular cartilage increasing the
chance of a false—positive study. This is particularly true in postoperative patients
or in those patients with reflex sympathetic dystrophy or synovitis. The
administrataion of intra-articular epinephrine reduces this dilutional effect.
Coronal Series
The patient lies prone with the elbow in flexion and the wrist above the head
(Fig. 3.1A). The ulnar surface of the wrist lies against the table. The wrist is flexed to
avoid tangential artifacts from the elbow. The dorsal surface of the wrist is immobilized
against a splint. A sagittal scout view is performed.
The coronal series allows analysis of the SL and LT ligaments and the TFC.
Reviewing the images from ventral to dorsal, the anterior, proximal and posterior
parts of the SL and LT ligaments and anterior, middle and posterior parts of the
joint surfaces, including articular cartilage, are depicted.
Sagittal Series
The patient lies prone with the elbow in flexion and the wrist above the head
(Fig. 3.1B-E). The palm of the hand lies flat against the table. The wrist should be in
radial deviation. A coronal scout view is performed. The sagittal series allows
evaluation of the TFC, distal ulna, radiolunate, radiotriquetral, lunocapitate,
triquetrohamate, scaphotrapezial and scaphotrapezoid cartilages.
Sagittal Oblique Series
The patient should be prone with the wrist above the head and with the wrist in
45˚ of supination relative to the table top (Fig. 3.1F and G). (This positioning
corresponds to that described by Stewart and Gilula for the oblique
Fig. 3.1. (A-C) Arthrogram—CT. Normal anatomy. A) Mid coronal section with
contrast within the distal radioulnar, radiocarpal, and midcarpal compart-
ments. The contrast outlines the radioscaphoid, radiolunate, scaphocapitate,
lunocapitate, triquetrohamate and distal radioulnar joint articular cartilage. The
scapholunate and lunotriquetral ligaments, and the Y-shaped triangular fibrocarti-
lage are also visualized. Only one of the three normal recesses around the wrist,
the dorsoscaphoid recess represented by a contrast collection adjacent to the
radial side of the scaphoid, is identified. The ventral radial recess, which overlies
the distal radius, and prestyloid recess, which lies distal to the ulnar styloid process,
are not visualized. B) Coronal scout view for sagittal sections. C) Sagittal section
through the lateral aspect of the wrist demonstrating the ulnar, lunate, and capitate.
The lunocapitate cartilage is normal.
scaphotrapezialtrapezoidal CT plane).19 The wrist is placed in ulnar deviation to

elongate the scaphoid. Scans are performed parallel to the long axis of the scaphoid
and/or perpendicular to the scaphoid fossa. This series optimizes visualisation of
the scaphoid, scaphoid fossa and radioscaphoid joint.
Transaxial Series
The patient lays prone on the table with the arm extended above the head and
the palmar aspect of the hand on the table top (Fig. 3.1H and I). This series allows
visualisation of the DRUJ, distal ulna and extensor carpi ulnaris (ECU) tendon.
Fig. 3.1 (D-F). D) Sagittal section through the radial aspect of the wrist. The distal
radius, scaphoid, trapezium, trapezoid, and base of the second metacarpal bones
are visualized. The scaphotrapezial and scaphotrapezoidal cartilage is normal. E)
Mid-sagittal section demonstrating the distal radius, lunate, capitate, and base of
the third metacarpal. The radiolunate and lunocapitate cartilage is normal. F) Coronal
scout view for sagittal oblique slices. Sections are performed perpendicular to the
radioscaphoid joint.
Fig. 3.1 (G-I). G) Mid-sagittal oblique scan demonstrating the distal radius, scaphoid
and capitate. The radioscaphoid cartilage is normal. H) Transaxial section through
the proximal aspect of the anterior and posterior scapholunate ligament. I) Transaxial
section through the distal radioulnar joint. The extensor carpi ulnaris tendon sits
along the dorsum of the ulna, within the groove formed by the ulnar styloid process
and head of the ulna.
Dynamic study, with maximum supination and pronation of the wrist, as well as
imaging of the contralateral wrist is often necessary for evaluation of the position of
the distal ulna and ECU.
Pitfalls of Arthrography-CT
• limited wrist motion may result in beam hardening artifact on the coronal
and sagittal scans as the wrist and elbow will be in the same plane during
3 scanning,
• if during sagittal imaging slices are obtained at an oblique angle to the
lunate, this can cause the false appearance of a DISI,
• the medullary space of the osseous structures often appears dense; however,
this does not always correlate with avascular necrosis,
• arthrography-CT is a static examination; dynamic fluoroscopic
examination should be performed as a complimentary exam,
• long delays between arthrography and arthrography-CT may result in
false-positive studies due to the diffusion of contrast into articular cartilage.
Complications
• iatrogenic ligament perforation
• contrast—induced synovitis
• sepsis
Pathological Aspects
The wrist is a complex joint composed of 8 carpal bones and a myriad of ligaments,
both intrinsic and extrinsic.20-24 The intrinsic ligaments incude the SL and LT
ligaments. The extrinsic ligaments are composed of the stronger ventral and weaker
dorsal capsular ligaments. Disruption of either the intrinsic or extrinsic ligaments or
fracture of the distal radius or scaphoid may result in carpal instability. Left untreated,
the consequence of these injuries is osteoarthritis secondary to altered bony motion.25
Arthrography-CT aims to provide a complete assessment of the ligaments and
cartilage so that a satisfactory treatment approach (surgical versus conservative) can
be determined. In those cases in which surgery is indicated, arthrography-CT results
can be utilized to plan approach to the pathologic site as well as treatment method—
i.e., primary or secondary ligament re-attachment, capsulodesis and/or extent of
carpal arthrodesis.17
The normal arthrogram-CT allows visualisation of the SL and LT ligaments,
from RCJ or MCJ injection, and of the TFC from RCJ or DRUJ injection. The SL
and LT ligaments appear as areas of soft tissue density running along the proximal
articular surface of the scaphoid and lunate, and lunate and triquetral bones,
respectively. Each of these ligaments has three components: anterior, posterior and
proximal parts. Whereas the anterior and posterior parts are of biomechanical
significance, the proximal component has no biomechanical function.6 Yet it is
primarily the proximal part of the SL and LT ligaments that is visualized on
conventional arthrography.
The ligaments may be perforated, in which case contrast traverses between

contiguous compartments via the CD within the ligament. Arthrography-CT
determines the exact site of ligament disruption and determines whether the
perforation is complete or partial (Fig. 3.2 and 3.3). Ligaments may also be stretched
in which case the distance between the osseous attachments of the ligaments is
widened but no contrast leaks through the ligament (Fig. 3.4). Unfortunately, the
distance between the osseous attachments of the ligaments may be normal on the
static radiograph and may only be seen with dynamic radiography—such as an 3
instability series. Arthrography-CT is not a dynamic examination and can not detect
ligamentous laxity.
The TFC appears as a triangular-shaped soft tissue density that sits between the
DRUJ and proximal surfaces of the lunate and triquetrum. It may be perforated,
detected when contrast flows between the RCJ and DRUJ. Arthrography-CT
determines whether the CD is complete or partial (Fig. 3.5 and 3.6).
The contour of the joint capsule should be evaluated. It should be smooth.
Contour abnormalities may indicate the presence of synovitis, or a NCD (contrast
exits the joint via a capsular perforation and remains confined to the surrounding
soft tissues). The opacity of the joint capsule should be homogenous excluding the
presence of intra-articular joint bodies.
Systematic evaluation of cartilage should be performed in the appropriate planes.
In general, scans obtained perpendicular to the articular cartilage of interest are
necessary to evaluate that segment of cartilage. Scans performed in the plane parallel
to the articular surface of interest are of limited value. The thickness of articular
cartilage should be uniform with contrast confined to the articular surface of the
cartilage. Diffuse or focal cartilage thinning or thickening or fissuring of articular
cartilage is abnormal (Fig. 3.7, 3.8 and 3.9).
Intra-tendon and peri-tendinous pathology is best depicted on MRI. However,
tendon position is best evaluated by CT where the tendon position can be evaluated
with the anatomic part of interest in two or more varying positions. Within the
wrist, the extensor carpi ulnaris tendon position is ideally evaluated with transaxial
CT images in supination and pronation (Fig. 3.10). These two positions can also be
utilized to evaluate the relationship between the ulna and radius at the DRUJ, such
as in cases of suspected dislocation or subluxation.
Occasionally a synovial cyst will fill upon the injection of a compartment. As
these cysts are often associated with ligament perforation, especially involving the
SL ligament, careful evaluation should be performed to exclude ligamentous
perforation (Fig. 3.11). Determine the size of the cyst and the status of the adjacent
cartilage.
In the subacute setting, arthrography-CT may be requested to assess the status
of the ligaments and articular cartilage in the setting of carpal bone and distal radial
fractures and avascular necrosis (Fig. 3.12 and 3.13).
Acknowledgment
Thanks to Jacqueline C. Hodge for her contribution to this Chapter.
Fig. 3.2. Coronal arthrogram—

CT. A) Anterior coronal scan
demonstrates a communicating
defect between the radiocarpal
and midcarpal joints at the site
of the anterior proximal part of
the scapholunate ligament. B)
Posterior coronal scan. There is
3 no communication between the
radiocarpal and midcarpal joints
indicating that the posterior part
of the scapholunate ligament is
intact. As well, the lunotriquetral
ligament, triangular fibrocartilage
and articular cartilage are intact.
Fig. 3.3. Coronal arthrogram—

CT. A communicating defect
between the radiocarpal and
midcarpal compartments is
present at the proximal part
of the scapholunate and
lunotriquetral ligaments. Addi-
tional CT images (not shown)
demonstrated that the anterior
and posterior parts of the liga-
ments were preserved.
Fig. 3.4. Anterior coronal arthro-

gram—CT. The anterior part of the
scapholunate ligament measures
7 mm. No communication is
present between the radiocarpal
and midcarpal compartments.
This is consistent with scarring and
post-traumatic fibrosis.
3
Fig. 3.5. Coronal arthrogram—CT. A) Mid-coronal section demonstrates a tiny com-

municating defect between the distal radioulnar joint and radiocarpal compartments
along the radial side of the triangular fibrocartilage. The scapholunate and lunotriquetral
ligaments and articular cartilage are intact. B) Lateral sagittal section. The defect ap-
pears larger.
Fig. 3.6. Arthrogram—CT. Ulnar impaction syndrome secondary to ulnar positive

variance. A) Anterior coronal scan. A 3 mm communicating defect is present within
the central portion of the triangular fibrocartilage. There is a focal area of cartilage
erosion involving the lunate—contrast abuts the subchondral surface of the lunate.
The scapholunate ligament is thinned. The lunotriquetral ligament, radioscaphoid
and capitolunate articular cartilage is preserved. A cystic lesion is identified within
the capitate. B) Lateral sagittal scan. The communicating defect within the triangu-
lar fibrocartilage is larger than previously suspected measuring 5 mm.
Fig. 3.7. Arthrogram—CT. Coronal

scan. Three weeks after a distal
radial intra-articular fracture, treated
by cast, this patient presents with
persistent pain. Bony union is noted
at the fracture site. The scapholunate
ligament is intact. A 2 mm area of
cartilage erosion is identified oppo-
site the fracture site involving the
radial and scaphoid cartilage.
Fig. 3.8. Arthrogram—CT. Coro-

nal scan. Contrast is present
between the proximal and distal
poles of the scaphoid consistent
with scaphoid nonunion. Severe
cartilage erosion is identified at
the articulation between the
radial styloid process and the
scaphoid. The scapholunate and 3
lunotriquetral ligaments and the
triangular fibrocartilage are intact.
Fig. 3.9. Arthrogram—CT. Lateral

sagittal scan. There is impaction
between the posterior horn of the
lunate and the capitate head
resulting in a 3 mm area of carti-
lage erosion at the capitolunate
joint. This is consistent with
scapholunate advanced collapse
and has resulted from long-
standing dorsal intercalated seg-
ment instability.
Fig. 3.10. Arthrogram—CT.

Transaxial scan through the distal
radioulnar joint. There is ulnar
subluxation of the extensor carpi
ulnaris tendon.
Fig. 3.11. Arthrogram—CT. Coro-

nal scan . A round collection of
contrast, representing a synovial
cyst, fills from the midcarpal
compartment. The scapholunate
ligament and cartilage are intact.
Fig. 3.12. Arthrogram—CT. a.

Coronal scan. Collapse and con-
densation of the lunate is consis-
tent with Kienböck disease. The
scapholunate and lunotriquetral
ligaments and the triangular fi-
brocartilage are intact. The
radiolunate and lunocapitate ar-
ticular cartilage appears intact. B)
There is a vertical fissure in the
capitolunate cartilage consistent
with cartilage wear.
Fig. 3.13. Arthrogram—CT. Coronal

scan. Osteosynthetic material has not
degraded the quality of the examina-
tion. The scapholunate, lunotriquetral
ligaments and the triangular fibrocar-
tilage are intact. Articular cartilage is
preserved within the radiocarpal and
midcarpal joints.
3
References
1. Quinn SF, Belsole RS, Greene TL et al. Work in progress: Postarthrography com-
puted tomography of the wrist: Evaluation of the triangular fibracartilage complex.
Skeletal Radiol 1989; 17:565-9.
2. Gilula LA, Hardy DC, Totty WB et al. Fluoroscopic identification of torn intercar-
pal ligaments after injection of contrast material. Am J Roentgenol 1987; 149:761-4.
3. Quinn SF, Pittman C, Belsole R, et al. Digital subtraction wrist arthrography:
Evaluation of the multiple compartment technique. Am J Roentgenol 1988;
151:1173-4.
4. Metz VM, Mann FA, Gilula LA. Three-compartment wrist arthrography: Correla-
tion of pain site with location of uni- and bidirectional communications. Am J
Roentgenol 1993; 160:819-22.
5. Saffar P, Sokolow C, Mathoulin C et al. Cinearthrography of the wrist in carpal
instability. In: Brunelli G, Saffar P, eds. Wrist imaging. Paris:Springer-Verlag.
1992:109-13.
6. Berger RA, Blair WF, Crowninshield et al. The scapholunate ligament. J Hand
Surg 1982; 7A:87-91.
7. Metz VM, Mann FA, Gilula LA. Three-compartment wrist arthrography: Correla-
tion of pain site with location of uni- and bidirectional communications. Am J
Roentgenol 1993; 160:819-22.
8. Metz VM, Mann FA, Gilula LA. Lack of correlation between site of wrist pain and
location of noncommunicating defects shown by three-compartment wrist
arthrography. Am J Roentgenol 1993; 160:1239-43.
9. Smith DK. Scapholunate interosseous ligament of the wrist: MR appearances in
asymptomatic volunteers and arthrographically normal wrists. Radiology 1994;
192:217-21.
10. Smith DK. Lunotriquetral interosseous ligament of the wrist: MR appearances in

asymptomatic volunteers and arthrographically normal wrists. Radiology 1994;
191:199-202.
11. Sugimoto H, Shinozaki T, Ohsawa T. Triangular fibrocartilage in asymptomatic
subjects: Investigation of abnormal MR signal intensity. Radiology 1994; 191:193-7.
12. Zlatkin MB, Chao PC, Osterman AL et al. Chronic wrist pain: Evaluation with
high-resolution MR imaging. Radiology 1989; 173:723-9.
13. Gundry CR, Kursunoglu-Brahme S, Schwaighofer B. Is MR better than arthrog-
3 raphy for evaluating the ligaments of the wrist? In vitro study. Am J Roentgenol
1990; 154:337-41.
14. Pigeau I, Frija G, Seeman I, et al. Advantages of MRI in the study of the wrist
ligaments. In: Brunelli G, Saffar P, eds. Wrist imaging. Paris:Springer-Verlag.
1992:173-82.
15. Totterman SM, Miller R, Wasserman B et al. Intrinsic and extrinsic carpal liga-
ments: Evaluation by three-dimensional Fourier transform MR imaging. Am J
Roentgenol 1993; 160:117-23.
16. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: Value of the
three-compartment injection method. Radiology 1991; 179:231-9.
17. Yin YM, Evanoff B, Gilula LA et al. Evaluation of selective wrist arthrography of
contralateral asymptomatic wrists for symmetric ligamentous defects. Am J
Roentgenol 1996; 166:1067-73.
18. Cantor RM, Stern PJ, Wyrick JD et al. The relevance of ligament tears of perfora-
tions in the diagnosis of wrist pain: An arthrographic study. J Hand Surg 1994;
19A:945-53.
19. Stewart NR, Gilula LA. CT of the wrist: A tailored approach. Radiology 1992;
183:13-20.
20. Taleisnick J. The ligaments of the wrist. J Hand Surg 1976; 2A:110-8.
21. Mayfield JK. Mechanism of carpal injuries. Clin Orthop 1980; 149:45-54.
22. Johnson RP. The acutely injured wrist and its residuals. Clin Orthop 1980;
149:33-44.
23. Mayfield JK, Johnson R, Kilcoyn R. Carpal dislocations: Pathomechanics and pro-
gressive perilunar instability. J Hand Surg 1980; 5A;226-41.
24. Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid
waist fractures. J Hand Surg 1978; 3A:142-8.
25. Saffar P. Les traumatismes du carpe. Anatomie, radiologie et traitment actuel.
Paris:Springer-Verlag, 1989.
Communications
a. Pigeau I, Sokolow C, Saffar P et al Apport de l’arthroscanner dans les lésions
ligamentaires du poignet (ligaments interosseux et triangulaire). Comparison avec
l’arthrographie conventionelle. 1er congrès européen de chirurgie de la main.
Bruxelles, 1993; 26-30 mai. Communication avec acte.
b. Pigeau I, Sokolow C, Saffar P et al. Apport de l’arthroscanner dans le bilan
préchirurgical des lésions ligamentaires du poignet. GEM, Paris, 1993;8-11
décembre.
c. Pigeau I, Sokolow C, Saffar P et al. Apport de l’arthroscanner dans le bilan
préchirurgical des lésions cartilagineuses du poignet. GEM, Paris, 1993;8-11
décembre.
CHAPTER 1
CHAPTER 4
Hip Arthrography
Laurent Sarazin, Alain Chevrot and Jacqueline C. Hodge
Indications
Hip arthrography (HA) provides valuable information regarding the articular
cartilage, acetabular labrum, synovium, and intra-articular loose bodies.1-3 However,
due to the risk of introduced infection, it should only be performed if other imaging
techniques, such as computerized tomography (CT), magnetic resonance imaging
(MRI), and bone scan, are insufficient in establishing the final diagnosis. MR
arthrography, more so than conventional MRI, occasionally plays a role in the
evaluation of the acetabular labrum, cartilage, and in the assessment of joint bodies
because of the presence of joint fluid. However, by nature, MR arthrography is
invasive. Furthermore, limited experience with and the relatively high cost of MR
arthrography, makes it difficult to compete with CT/arthrography.
Additional indications for HA include diagnosis and treatment of adhesive
capsulitis, localization and potential treatment of hip pain, assessment of synovial
fluid for crystals or infection, and assessment for prosthetic loosening. HA is essential
for establishing the diagnosis and/or for therapeutic intervention in these first three
entities. With regard to prosthetic loosening, the core question is septic versus aseptic
loosening which again is most reliably answered with HA. Therefore, HA remains
the procedure of choice for diagnosis of these entities.
Prearthrogram Preparation
Before performing HA, pertinent radiological examinations should be carefully
reviewed and the indications for HA discussed with the referring physician. Screening
laboratories should be checked to exclude those patients with blood dyscrasias.2
Inquire about medication and contrast allergies. In those patients with known contrast
allergies, hydroxyzine 100 mg should be given orally on the day of and the day
before HA.4 In those patients with previous severe allergic reactions, the indications
for HA must be reconsidered. If possible, alternative imaging modalities should be
performed.
Preliminary radiographs for HA include an AP view of the pelvis, and AP view
of the hip, a “frog” lateral view of the hip, and a 65˚ lateral view (Fig 4.1).3
Technique
To minimize the risk of infection, it is important to perform as few manipulations
of the hip as possible during the puncture. Additional maneuvers, such as changing
syringes, injection of Xylocaine through the puncture needle, etc. should be avoided.
Ideally, the puncture needle should be directly connected to a contrast-filled syringe.3
As direct puncture of the joint space is impossible, HA is generally performed by

Fig. 4.1. Position for 65˚ lateral view. A) The hip of interest rests on the table while
the contralateral hip is elevated 65˚. B) The distance between the two femoral
heads should be equal to the width of the femoral head.
puncture of the articular recesses. The four main articular recesses are the superior
and inferior articular recesses, and the superior and inferior recesses colli.
Several approaches have been proposed for HA (Fig. 4.2).5-9 Regardless of the
technique, all of these approaches require fluoroscopic guidance. Of the three
approaches illustrated in this article, superior, inferior, and anterolateral, we prefer
the latter. We feel that this approach is safer since it avoids the femoral neurovascular
bundle.3 Additionally, a lateral approach for HA has been described. With this
approach, the needle is advanced into the hip, parallel to the table top, beginning at
the level of the greater trochanter and angling slightly cephalad. This approach may
be limited in obese patients or in those with heterotopic ossification.
Single contrast arthrography with a water-soluble contrast agent such as
meglumine sodium ioxaglate (Hexabrix 320 mg iodine/ml) is the rule.3 Epinephrine
(0.5 cc of 1:1000 solution) should be mixed with contrast medium if
post-arthrography CT is contemplated to prolong the duration of contrast within
the joint space.10-12 Epinephrine should be utilized only in the absence of cardiac
contraindications.
The patient should be in the supine position with the extremity of interest in
mild external rotation to enlarge the inferior recess colli to facilitate the puncture. A
large area of skin is prepped with iodinated alcohol and a sterile drape placed over
the hip. 0.5% Xylocaine is administered as local anesthetic. (Local anesthetic is not
mandatory with experienced operators.) A low concentration of Xylocaine is preferred
to decrease the risk of allergic reaction.3
A 10 cm 22 gauge spinal needle should be connected to a 20 ml contrast-filled
syringe in preparation for hip puncture. The 22 gauge needle should pierce the skin
at the level of the intertrochanteric line, at the level of the inferior aspect of the
femoral neck. The needle is advanced until it makes contact with the femoral neck.
Hip Arthrography 49
Fig. 4.2. Approaches for hip

arthrography. Superior (super-
olateral arrow), inferior (small
medial arrow), and anterolateral
(large arrow) approach.
At this point, aspiration of synovial fluid is attempted. If successful, synovial fluid is

identified within the syringe and contrast administered intra-articularly. Often,
however, aspiration is difficult even when an effusion is present and the needle is
intra-articular. If aspiration is mandatory, such as in a case of septic arthritis, a larger
spinal needle (an 18 gauge) is recommended.13 If attempts to aspirate synovial fluid
are still unsuccessful, 10 cc of nonbacteriostatic sterile saline should be injected into
the joint and reaspirated for analysis.13 Typically, most of the saline solution will not
be reaspirated and it may dilute the contrast that will subsequently be placed into
the joint. If the dilutional effect is too great, the quality of the arthrogram will be
compromised.
If attempts at aspiration have been unsuccessful, a test injection is performed
with a few drops of contrast medium. If the needle is intra-articular, contrast will
flow freely away from the needle tip. If the needle is extra-articular, contrast will
collect at the needle tip (Fig. 4.3). In the latter situation, avoid excess contrast
administration as contrast is an irritant to the extra-articular soft tissues.
Once the intra-articular position of the needle has been ascertained, instill contrast
freely. Ideally, inject 6 to 8 ml of contrast into the joint. This avoids reflux into the
soft tissues. As well, this prevents obscuration of fine synovial detail.3-13 The exception
are those cases in which you are trying to demonstrate a connection between the hip
joint and an adjacent bursa or sinus tract or to assess for loosening of a prosthetic
component. Without adequate distention of the hip joint, you are unlikely to fill
the communicating collection. Depending on the indication for HA, steroids and/
or local anesthetic can be injected into the joint before removing the needle.
Fig. 4.3. Extraarticular injection. A) Contrast pools around the needle tip. B) Adequate
repositioning of the needle must be achieved before continuing the injection.
Postarthrogram Protocol
During contrast injection, fluoroscopic spot radiographs are obtained after the
instillation of 2 cc, 3 cc, 4 cc, and 5 cc to demonstrate possible small loose bodies.3
Once the needle is removed, the hip is exercised to improve delineation of articular
cartilage. 14 Following exercise, obtain AP neutral/internal/external rotation
radiographs, AP adduction/abduction radiographs, “frog” lateral radiograph , and a
65˚ lateral radiograph. If necessary, CT with multiplanar reformatting is performed
to detect articular cartilage defects and/or loose bodies.12-19
Complications
Mild pain and discomfort may be encountered during HA. Pre-existing synovial
inflammation may be exacerbated by contrast administration for HA.15,16 Vasovagal
responses may occur, although they usually resolve relatively promptly. 14
Hypersensitivity reactions are rarely observed. Their occurence can be reduced with
premedication in the appropriate setting.15,16 However, the radiologist should be
prepared to treat a hypersensitivity reaction.
Gas bubbles may be inadvertently introduced into the joint during HA and may
be difficult to distinguish from a loose body.3 The risk of introducing gas into the
joint is reduced if syringe changing is minimized once the needle is intra-articular.
The most serious complication of HA is septic arthritis.18 This risk is negligible
if aseptic technique is strictly adhered to.
The Normal Arthrogram
The normal hip joint cavity appears as two homogenous opaque bundles. The
more cephalad articular recesses are separated from the more caudad recess colli by a
circumferential lucent band, the zona orbicularis, composed of thickened ligamentous
fibers (Fig. 4.4).20,21 The appearance of the recesses varies with hip motion (Fig.
4.5). In internal rotation and/or adduction, the articular recess is larger due to filling
of its posterior aspect which is prominent in comparison to its anterior one. In
external rotation and/or abduction the recess colli is larger due to filling of its anterior
aspect which is larger than its posterior one. The inferior articular recess forms a
Hip Arthrography 51
Fig. 4.4. Normal hip arthrogram. A) AP view. B) “Frog” lateral view. 1. acetabular
roof, 2. acetabular labrum, 3. transverse ligament, 4. articular recesses, 5. zona
orbicularis, 6. recess colli.
Fig. 4.5. Normal hip arthro-

gram. A) AP view during in-
jection of contrast. B) AP
view, hip in internal rota-
tion. The articular recesses
are dilated. C) AP view, hip
in external rotation. Note
the dilatation of the recess
colli. D) AP view, hip in ab-
duction. The recess colli are
dilated. E) AP view, hip in
adduction. The articular re-
cesses are dilated. F) “Frog”
lateral view. G) 65˚ lateral
view of the hip. The joint
space is demonstrated along
its anteroposterior axis.
pouch at the base of the femoral head limited medially by the transverse ligament.
The superior articular recess extends around the acetabular labrum, a triangular
radiolucent area adjacent to the superolateral aspect of the acetabulum (Fig. 4.6).
A thin line of contrast delineates the acetabular and femoral cartilages. Usually,
the femoral cartilage is thicker than the acetabular cartilage.22,23 The femoral cartilage
is thicker at its superomedial aspect than at its superolateral aspect (approximately
1.5 mm versus 0.5 mm). The acetabular cartilage demonstrates the reverse pattern,
such that it is thicker laterally than medially (1.0 mm versus 0.5 mm). The line of
contrast outlining the articular cartilages should be smooth and regular. Medially,
the cartilages are interrupted by the ligamentum teres as it enters the fovea centralis
4 of the femoral head. The ligamentum teres is not visualized in normal hips.13-22
A normal communication occurs between the hip joint and the iliopsoas bursa
in 15-20% of individuals (Fig. 4.7).22,24-26 Extrinsic compression of the posteroinferior
aspect of the capsule is also possible due to the obturator externus tendon (Fig.
4.8).3 At its distal aspect, the capsule insertion can be irregular forming small
diverticula secondary to synovial folds, a finding which must not be mistaken for
synovitis (Fig. 4.9).13-27
Fig. 4.6. Normal acetabular labrum.

Note that there is no interruption
between the acetabular cartilage
and articular labral surface.
Fig. 4.7. Iliopsoas bursa opacification

during hip arthrography (arrow). This has
no significance.
Hip Arthrography 53
Fig. 4.8. Extrinsic compression of the capsule by the obturator externus muscle
tendon. A) Schematic. B) Arthrogram (arrowheads).
Fig. 4.9. Synovial diverticula

representing a normal structure
(arrowhead). This should not be
mistaken for synovitis.
Pathology
Osteoarthritis
The diagnosis of osteoarthritis (OA) is usually made on plain films. However,
HA may provide additional information in some cases. In advanced OA associated
with hip dysplasia, HA may help determine surgical management (Fig. 4.10).3 If
cartilage and/or labral destruction is prominent, a prosthesis may be proposed rather
than an osteotomy. In early OA, HA may be the only modality capable of establishing
the diagnosis. The joint cavity, usually normal in size, may contain multiple small
filling defects due to fibrous or cartilaginous debris (Fig. 4.11). Additionally, femoral
and acetabular cartilage may appear thinned or irregular. Early diagnosis of OA is
important in young patients with hip dysplasia or excessive stress in order to propose
conservative treatment (Fig. 4.12).
Fig. 4.10. Advanced osteoarthritis in hip dysplasia. A) Plain radiograph demonstrating

an ossific fragment superolaterally and mild joint space narrowing. B) Arthrography
demonstrating the intra-articular position of the ossific density, as well as labral
destruction, femoral and acetabular cartilage thinning.
Fig. 4.11. Hip arthrogram, during

contrast instillation, demonstrat-
ing intra-articular cartilaginous
bodies (arrow).
HA may also be useful in the etiology and evaluation of subchondral cysts.3 A

large subchondral cyst may be an isolated sign of OA while more classic signs (cartilage
loss, osteophytosis, and subchondral sclerosis) are very subtle (Fig. 4.13). HA can
demonstrate that these cysts are of degenerative origin, rather than representing
pigmented villonodular synovitis or giant cell tumor, by simultaneously detecting
associated cartilage abnormalities. Additionally, HA may demonstrate opacification
of these cysts, indicating fissuring of the articular cartilage. Post-arthrography CT is
often necessary to detect these changes as the findings can be quite subtle on HA.
Hip Arthrography 55
Fig. 4.12. Early stages of osteoarthritis. A) 65˚ lateral radiograph demonstrating 4

cartilage erosion at the superior aspect of the femoral head (arrow). B) Sagittal, and
C) Coronal reformatted images from helical CT confirming erosion of femoral head
cartilage (arrowheads).
Fig. 4.13. Cystic osteoarthritis. A) AP pelvis radiograph demonstrates a large sub-

chondral cyst of the acetabular roof (arrow). B) Arthrography demonstrating con-
trast within the cyst (arrow), as well as thinning of acetabular and femoral cartilage
(arrowhead). Cartilage loss confirms the degenerative origin of the cyst.
Arthritides
HA allows the early diagnosis of septic arthritis via aspiration. Opacification of
the joint may demonstrate associated abscess cavities or sinus tracts (Fig. 4.14). In
inflammatory arthritis, HA indicates the severity of cartilage loss and synovitis.
Cartilage thinning, enlargement and/or irregularity of the articular cavity, diverticulae,
synovial cysts, or iliopsoas bursa opacification may be present (Fig. 4.15).26-28
Lymphatic filling, consistent with chronic inflammation, is a frequent finding but is
not specific.22-29 Aspiration and subsequent analysis of synovial fluid may also be of
interest.
Loose Bodies
HA is useful in the identification of intra-articular loose bodies. Whether osseous
or cartilaginous, HA demonstrates the location and presence of joint bodies (Fig.
Fig. 4.14. Septic arthritis. Hip arthrogram. A) AP view, and B) Cross-table lateral view
demonstrating diffuse thinning of acetabular cartilage. Two abscess cavities are also
identified—a large anterior one (arrow) and a smaller posterior one (arrowhead).
Fig. 4.15. Rheumatoid arthritis.

Hip arthrogram. Widespread syn-
ovial irregularity, a small diver-
ticula (arrow), diffuse severe car-
tilage thinning, and associated
erosion of the femoral head
(arrowhead). Note the absence of
osteophytes.
4.16). Most frequently, OA is the cause of intra-articular loose bodies.17 However,

loose bodies may occur as a consequence of Legg-Perthes-Calvé disease,
osteochondritis dissecans, osteonecrosis or trauma.13-30
Synovial osteochondromatosis, a disorder of synovial metaplasia, may also result
in loose bodies.17 This mono-articular condition, primarily affecting males in their
fifth decade, involves the hip in 10% of cases. When loose bodies are ossified, plain
radiographs demonstrate them in two-thirds of cases. Erosions of the femoral neck,
joint space widening secondary to loose body incarceration or secondary OA may
be present.
Ossific loose bodies are apparent on plain radiographs, although their exact
location is not known. However, HA is essential to the detection of chondral joint
bodies. Chondral bodies appear as small filling defects within the contrast, particularly
Hip Arthrography 57
Fig. 4.16. Synovial osteochondromatosis. A) AP radiograph demonstrating multiple

ossific bodies. B) AP radiograph, post-arthrography demonstrating multiple filling de-
fects within the capsule proving the intra-articular location of these ossific bodies.
well demonstrated during filling of the joint (Fig. 4.17). When only a few joint
bodies are present, they usually lie in the inferior articular recess. Additionally, it is
very important to examine the acetabular fossa because removal of loose bodies in
this location requires surgical hip dislocation. CT/arthrography is the best modality
to demonstrate this finding (Fig. 4.18).12
Pigmented Villonodular Synovitis
HA may demonstrate an enlarged joint cavity with subtle granular changes of
the synovium.17-31 A bloody joint effusion is very suggestive of this diagnosis.13-17
Adhesive Capsulitis
Adhesive capsulitis refers to capsular constriction that may occur after trauma or
surgery or that may be idiopathic.32-34 Plain films are unremarkable. HA demonstrates
low joint capacity (< 5 cc), and, commonly, reflux of contrast into the adjacent soft
tissues (Fig. 4.19).3-33 HA is often painful in this population.
Acetabular Labrum Pathology
Evaluation of the acetabular labrum may be an indication for HA (Fig. 4.20).13
Pain and clicking of the hip are suggestive of labral pathology.35 HA may demonstrate
perforation or detachment of the labrum. Although helical CT with reformatted
coronal images, as compared with conventional HA, has a much improved sensitivity
for detecting labral pathology, MR/arthrography is superior to both of these imaging
modalities.13-19, 36-38 In fact, MR/arthrography has been proven to be the study of
choice in imaging labral pathology. MR/arthrography may demonstrate labral
blunting, absence of the labrum, displacement of the labrum, intrasubstance contrast
material within the labrum, and labral detachment (contrast material at the
acetabular-labral junction), all manifestations of labral tears. In addition, MR/
arthrography may also be helpful in establishing the presence of intra-articular loose
bodies and influencing the treatment of osteochondral fractures. (Fig. 4.21).
Fig. 4.17. Synovial osteochondromatosis. A) AP radiograph demonstrating multiple

erosions of the femoral head and neck. Note the absence of ossific densities. B) AP
radiograph, post-arthrography demonstrating multiple tiny filling defects within the
capsule consistent with numerous small cartilaginous loose bodies. Note also thinning
of the acetabular cartilage.
Fig. 4.18. Synovial osteochondromatosis. A) “Frog” lateral radiograph, post-arthrography

demonstrating loose bodies within the acetabular fossa (arrow). B) Transaxial image,
helical CT confirming the position of these loose bodies.
HA in Joint Replacement
Preliminary plain radiographs, including the entire prosthetic components, are
essential. They provide a reference point for comparison with post HA radiographs
to assess for loosening of the components.39 Additionally, they provide information
regarding cement and/or component fracture, subsidence, change in component
position, or particulate synovitis (the histiocytic response to intra-articular metal
debris).40
On HA, one should expect to find a pseudocapsule, an irregular collection of
contrast that replaces the native joint capsule. Contrast should not be present at the
bone-cement or bone-prosthesis interface. Contrast medium encircling the entire
Hip Arthrography 59
Fig. 4.19. Adhesive capsulitis fol-

lowing septic arthritis. Note the
small volume of the joint cavity
and non opacification of the re-
cess colli. Lymphatic filling is
noted in keeping with a chronic
inflammatory process (arrow).
Fig. 4.20. “Frog” lateral radio-

graph, post-arthrography showing
an acetabular labral tear
(arrow).
acetabular component, of a width of more than 1 cm, has a significant correlation

with the presence of loosening. Criteria are less stringent for the femoral component,
requiring that contrast media penetrate the bone-cement or bone-prosthesis interface
to at least the level of the intertrochanteric line. Occasionally, an abscess cavity, the
greater trochanteric bursa or rarely the ischiotrochanteric bursa will be identified on
HA. Whether evaluating for loosening or a communicating soft tissue collection, it
is important that sufficient contrast be instilled into the hip joint. Gross loosening
can be missed with the administration of too little contrast into the joint. Conversely,
extravasation of contrast, which has a feathery appearance, may result from overfilling
of the joint.
Fig. 4.21. A) Transaxial CT, post-arthrography. A cartilagenous fragment, its rim

coated with contrast, is identified within the medial aspect of the left hip joint.B)
Transaxial fat-suppressed T1-weighted spin echo MR image, post-arthrography. This
image is comparable to the CT image in 4.21A. Intra-articular contrast is identified
surrounding the periphery of the cartilagenous fragment.
References
1. Barnett JC, Arcomano JP. Hip arthrography with renografin. Radiology 1958; 73:245-9.
2. Gelman M. Arthrography of the adult hip. In: Dalinka MK, ed. Arthrography.
New York: Springer-Verlag, 1980:127-134.
3. Pallardy G, Chevrot A, Gires F et al. Hanche. In: Pallardy G, ed. Arthrographies
opaques. 2ieme ed. Paris: Masson, 1992:1-40.
4. Greenberger PA, Patterson R, Simon R et al. Pretreatment of high risk patients
requiring radiographic contrast media studies. J Allerg Clin Immun 1981; 67:185-7.
5. Heublein GW, Greene GS, Conforti VP. Hip joint arthrography. Am J Roentgenol
1952; 68:736-48.
6. Kenin A, Levine J. A technique for hip arthrography of the hip. Am J Roentgenol
1952; 68:107.
7. Mitchell GP. Arthrography in congenital displacement of the hip. J Bone Joint
Surg 1963; 45B:88.
8. Goldman AM. Hip arthrography. In: Goldman AM, ed. Procedures in skeletal
radiology. Orlando:Grune & Stratton, 1984:1-49.
9. Kilcoyne RF, Kaplan P. The lateral approach for hip arthrography. Skel Radiol
1992; 21:239.
10. Hall F. Epinephrine-enhanced knee arthrography. Radiology 1974; 111:215-7.
11. Spataro RF. Epinephrine-enhanced knee arthrography. Invest Radiol 1978;
13:286-90.
12. Chevrot A et al. Hanche. In: Chevrot A, ed. Arthro-scanners. Paris:Masson,
1992:1-8.
13. Berquist TH. Hip arthrography in the adult. In: Berquist TH, ed. Imaging of
orthopaedic trauma surgery. Philadelphia:WB Saunders, 1986:253-60.
14. Resnick D. Arthrography, tenography and bursography. In: Resnick D, Niwayama
G, eds. Diagnosis of bone and joint disorders. Philadelphia: WB Saunders,
1995:278-409.
15. Hall FM, Rosenthal DI, Goldberg RP et al. Morbidity from shoulder arthrogra-
phy: Etiology, incidence and prevention. Am J Roentgenol 1981; 136:59-62.
Hip Arthrography 61
16. Hall FM, Goldberg RP, Wyshak G et al. Shoulder arthrography: Comparison of
morbidity after use of various contrast media. Radiology 1985; 154:339-41.
17. Ghelman B, Freiberger RH. The adult hip. In: Freiberger RH, Kaye JJ, eds. Ar-
thrography. New York: Appleton-Century-Crofts, 1979:189-216.
18. Newberg AH, Muhn CS, Robbins AH. Complications of arthrography. Radiology
1985; 155:605-6.
19. Langer-Cherbit A. Hanche. In: Chevrot A, ed. Scanner spiralé et pathologie
ostéoarticulaire. Paris: Masson, 1995:14-28.
20. Razzano CD, Nelson CL, Wilds AH. Arthrography of the adult hip. Clin Orthop
1974; 99:86-94.
21. Guerra J Jr, Armbuster TG, Resnick D et al. The adult hip: An anatomic study.
Part II. The soft tissue landmarks. Radiology 1978; 128:11-20. 4
22. Goldman AB. Arthrography of the hip joint. CRC Crit Rev Diag Imaging 1980;
13:111-171.
23. Chevrot A, Adamsbaum C, Gailly G et al. Le bourrelet cotyloïdien. A propos de
121 arthrographies de la hanche de l’adulte. J Radiol 1988; 69:711-20.
24. Staple TW. Arthrographic demonstration of the iliopsoas bursa. Radiology 1972;
102:515-6.
25. Warren R, Kaye JJ, Salvati EA. Arthrographic demonstration of an enlarged iliop-
soas bursa complicating osteoarthritis of the hip. J Bone Joint Surg, 1975;
57A:413-5.
26. Kataoka M, Torisu T, Nakamura M et al. Iliopsoas bursa of the rheumatoid hip
joint. A case report and review of the literature. Clin Rheum 1995; 14:358-64.
27. Hélénon C, Bergevin H, Aubert JD et al. Le repli synovial supra-cervical de la
hanche. J Radiol 1986; 67:737-40.
28. Savy JM. Synovial cysts and bursitis of the hip. Ann Radiol 1993; 36:52-57.
29. Coren GS, Curtis J, Dalinka M. Lymphatic visualization during hip arthrography.
Radiology 1975; 115:621-3.
30. Goldman AB, Hallel T, Salvati EM et al. Osteochondritis dissecans complicating
Legg-Calvé-Perthes disease. Radiology 1976; 121:561-6.
31. Murphy WA, Siegel MJ, Gilula LA. Arthrography in the diagnosis of unexplained
chronic hip pain with regional osteopenia. Am J Roentgenol 1977; 129:283-7.
32. Lequesne M, Becker J, Bard M et al. Capsular constriction of the hip: Arthrographic
and clinical consideration. Skeletal Radiol 1981; 6:1-10.
33. Goldman AB. Hip arthrography. Evaluation of disorders of children, adolescents
and adults without prostheses. Radiol Clin North Am 1981; 19:329-48.
34. Lequesne M. Capsular retraction of the hip. Ann Radiol 1993; 36:70-3.
35. Fitzgerald RH Jr. Acetabular labral tears. Diagnosis and treatment. Clin Orthop
Rel Research 1995; 311:60-8.
36. Petersilge CA, Haque MA, Petersilge WJ et al. Acetabular labral tears: Evaluation
with MR arthrography. Radiology 1996; 200:231-5.
37. Czerny C, Hofmann S, Neuhold A et al. Lesions of the acetabular labrum: Accu-
racy of MR imaging and MR arthrography in detection and staging. Radiology
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38. Leunig M, Werlen S, Ungersbock A et al. Evaluation of the acetabular labrum by
MR arthrography. J Bone & Joint Surg 1997; 79B:230-4.
39. Berquist TH, Coventry MB. The pelvis and hips. Berquist TH, ed. Imaging of
Orthopaedic trauma. New York:Raven Press 1992; 207-310.
40. Quale JL, Murphey MD, Huntrakoon M et al. Titanium-induced arthropathy
associated with polyethylene-metal separation after total joint replacement. Radi-
ology 1992; 182:855-8.
CHAPTER 5
Knee Arthrography
Jacqueline C. Hodge
Introduction
Knee arthrography has essentially been replaced by magnetic resonance imaging
(MRI) in the past decade.1,2 MRI, unlike arthrography, is noninvasive, requires no
ionizing radiation, and allows examination of the knee in multiple planes without
patient repositioning. MRI of the knee can be routinely performed in the presence
of an effusion. Additionally, the articular and nonarticular surfaces of the
fibrocartilaginous structures—including the menisci, and the cruciate and collateral
ligaments—can be evaluated. Furthermore, MRI examination allows evaluation of
the intra- and extra-articular soft tissues simultaneously, precluding arthrography
for evaluation of the joint and computerized tomography (CT) for evaluation of the
soft tissues. In some cases, MRI may even be diagnostic of soft tissue masses, for
example lipomas or pigmented villonodular synovitis.
Although the indications for arthrography are significantly reduced, there are
still occasions where arthrography is indicated. Patients exceeding the weight limit
of the MRI table, claustrophobic patients, or patients containing devices that preclude
evaluation with MRI will still require arthrography for diagnosis of intra-articular
pathology. In cases of suspected infection, particularly in patients with prostheses,
aspiration and arthrography, to assess for prosthetic loosening, may be requested.
Both arthrography and MRI of the knee, as compared with the gold standard of
arthroscopy, have established themselves as highly accurate and sensitive imaging
modalities for evaluation of the menisci.3-5 MRI, however, has surpassed arthrography
in accuracy with regards to evaluation of the cruciate ligaments, particularly the
posterior cruciate ligament. This is at least partly related to the relatively long learning
curve of arthrography as compared with that for MRI.
There are a few areas where MRI has not definitively declared itself superior to
other imaging modalities. Depending on the size of meniscal resection, it remains
difficult to distinguish the normal postoperative meniscus from the postoperative
meniscus with a recurrent tear.6 MR arthrography plays a role in this setting
potentially, but this is an invasive, time-consuming, and expensive procedure, more
so than either conventional MRI or arthrography.7 Furthermore, MR arthrography
requires close proximity of a fluoroscopy suite and an MRI scanner.
Additionally, subtle abnormalities of hyaline cartilage are not routinely detected
on conventional MRI sequences.8,9 Although sensitivity is improved with MR
arthrography, this is an invasive and more costly procedure than CT arthrography
with relatively little increase in sensitivity relative to CT/arthrography.9 Thus, there
is still a role for CT/arthrography in the diagnosis of chondromalacia patellae.

Knee Arthrography 63
Indications
• patients unable to undergo MRI
• aspiration for suspected infection
• to assess for loosening of prosthetic components
• injection of steroids and/or lidocaine for suspected knee pain (diagnostic)
• injection of steroids and/or lidocaine for knee pain due to osteoarthritis
(therapeutic)
• assess synovial plicae/chondromalacia patellae
• equivocal MRI for assessing the location of osteocartilaginous densities
(intra- vs extra-articular)
• equivocal MRI in assessing the overlying articular cartilage in osteochondral
fractures 5
Contraindications
There are no absolute contraindications to knee arthrography. Air may be
substituted for contrast in those patients with contrast allergies. Arthrography should
be postponed, if possible, if a joint effusion is present. Joint fluid interferes with
coating of the articular surfaces.10
Equipment
18g 1-1/2" needle, 22g 1-1/2" needle, 5cc and 20cc syringes, epinephrine 1:1000,
stabilizing device for knee, bracket permanently attached to the fluoroscopy table
(stabilizing device for the knee is attached to the bracket during the exam), small
sponge to place under the knee, pillow to evaluate the anterior cruciate ligament
(ACL), sterile drape
Pre-Arthrography Protocol
Obtain four radiographs of the affected knee: an AP standing film, an AP film
with the knee flexed (tunnel view), a routine lateral radiograph, and a sunrise view.
Careful evaluation of the osseous and soft tissues often helps direct your search
during arthrography. For instance, the presence of a Segond fracture should make
you highly suspicious for an ACL injury.11 A widened lateral femorotibial joint space,
in the absence of medial compartment osteoarthritis, should make you suspicious
for a discoid meniscus and a possible meniscal tear.5
Similarly, obtain a good history prior to arthrography. This too can help direct
your search during arthrography. Anterior knee pain or pain accentuated with
climbing stairs and/or running in young patients raises the possibility of
chondromalacia. These patients will require CT examination following arthrography.
A history of a positive anterior or posterior drawer sign suggests the presence of ACL
and posterior cruciate ligament (PCL) injury, respectively. Locking and/or clicking
may be attributed to a joint body, such as a meniscal fragment, a fragment of articular
cartilage, or an osseous fragment. CT may be necessary to detect the intra-articular
fragment.
Technique10
Most often medial or lateral approach is utilized to enter the patellofemoral joint.
The exception is in those patients who have had previous patellectomy. In this setting,
the anterior approach is the most direct method of entering the knee joint. With the
patient’s knee flexed, a needle is advanced into the joint along either side of the
patellar tendon.5 Although the anterior approach to knee arthography is usually
reserved for those patients who have undergone patellectomy, it may also be used in
those patients who have retained their patellae (Fig. 5.1A-D).
In all other patients, place the patient supine with his/her knee flexed between
20˚ and 40˚. Place a small sponge under the knee to maintain flexion. Palpate the
medial or lateral margin of the patellofemoral joint by having the patient flex and
extend the knee a few times. (Fluoroscopy is not necessary unless the patient is
extremely obese and the joint can not be palpated.) Decide whether you will use a
medial or lateral approach to the patellofemoral joint. The medial soft tissues are
almost always more abundant than the lateral soft tissues. Thus, in an average-sized
5 patient, using the medial approach, you will have to insert more than one half of the
Fig. 5.1. With the patient in the supine position and the knee in slight flexion and
external rotation, locate the inferomedial border of the patella. Place the needle at
this site and advance it towards the intercondular notch until you abut bone. Inject
contrast media and/or air to verify the intra-articular position of the needle. (Courtesy
of Vincent Bergeron, M.D., FRCPC, Centre Hospitalier de L’Universitie de Quebec,
Sainte Foy, QC.)
needle length before entering the patellofemoral joint. Utilizing a lateral approach
in the same patient, you will enter the joint space when approximately one third of
the needle length is within the soft tissues. With increasing obesity this difference is
exaggerated. To minimize the depth of subcutaneous tissues that the needle must
traverse and to ensure that the 1 1/2" needle will enter the patellofemoral joint
space, I recommend using the lateral approach in obese patients. Additionally, in
the presence of skin changes suggestive of infection (cellulitis, puncture wound,
draining sinus tract), approach the patellofemoral joint from the side contralateral
to the site of skin changes to avoid contamination of the joint.
Cleanse the skin with Betadine (Poviodone-Iodine, Purdue Frederick) or
Stanhexidine (Chlorohexidine Gluconate, Stanley Pharmaceuticals). Local anesthetic
is optional in this exam. Because this is a very straightforward procedure, usually
requiring one puncture, I do not subject the patient to a second needle for the 5
administration of local anesthetic. Using aseptic technique, advance the 22g needle,
approximately parallel to the table top, until you hit cartilage or until you have
return of viscous yellow synovial fluid. If you do not aspirate synovial fluid
(intra-articular needle position) or blood (intravascular needle position), check the
needle position by injecting a few ccs of lidocaine. If there is no resistance to the
injection of lidocaine, the needle may be intra-articular. Next, perform a test injection
of contrast under fluoroscopic guidance. If there is resistance during the injection of
lidocaine, the needle is almost certainly extra-articular. The needle is repositioned
before repeating the lidocaine test. The advantage of performing a test injection
with lidocaine, rather than with air or contrast, is that lidocaine is not radiopaque
and therefore will not interfere with the subsequent interpretation of the arthrogram.
Additionally, it does not irritate the extra-articular soft tissues.
Before injecting the full volume of contrast, remove any residual joint fluid to
optimize coating of the articular cartilage. Studies have shown that it is typical to
have fluid within the knee joint.12 Instill 4.5cc contrast, 0.5cc Epinephrine (1:1000),
and 35cc of air into the joint. It is preferable to use meglumine salt rather than
sodium salt because the latter causes more pain if extravasated.10 Epinephrine is
essential in knee arthrography, with or without CT, because of the lengthy protocol
that is required for examination for the menisci and cruciate ligaments.13 Place the
patient prone, then flex and extend the knee a few times to coat the entire joint
surface. Do not exercise the joint vigorously because this will accelerate the absorption
of contrast agent.
Normal Anatomy
The cruciate ligaments, ACL and PCL, are linear-shaped fibrous structures. They
are intra-articular and extrasynovial (Fig. 5.2).
• ACL: originates from the posterior aspect of the lateral femoral condyle
inserts in the anterior tibial intercondylar region
• PCL: originates from the anterior aspect of the medial femoral condyle
inserts in the posterior tibial intercondylar region
• The menisci, medial (MM) and lateral (LM), are intra-articular
fibrocartilaginous structures consisting of an anterior horn, posterior horn,
and body. In the axial plane, the menisci have a curvilinear shape. However,
Fig. 5.2. Double-contrast knee

arthrogram, horizontal beam
lateral radiograph of the knee
taken during simulation of the
anterior drawer test. Contrast
outlines the synovial reflections
of the ACL and PCL (arrows).
The normal posterior recess of
the knee joint is identified.
(Courtesy of Marie-Josée
Berthiaume, MD, FRCP, Hôpital
Notre-Dame, Montréal, QC.)
Fig. 5.3. Double contrast knee arthrogram, fluoroscopic spot views of the menisci. A)
Medial meniscus . B) Lateral meniscus. The popliteus tendon (arrowhead), and struts
contribute to the difficulty in evaluating the posterior horn of the lateral meniscus.
in the sagittal and coronal planes, the anterior and posterior meniscal
horns appear as triangular-shaped soft tissue structures. Their surfaces are
coated by contrast (Fig. 5.3A and B).
– MM: the posterior horn is much larger than the anterior horn medial
tibial plateau is concave relative to the joint space.
– LM: the anterior and posterior horns are essentially equal in size. The
lateral tibial plateau is flat relative to the joint surface. The popliteus
tendon is a normal anatomic structure seen in this region (Fig. 5.2B)
• The collateral ligaments include the medial collateral ligament (MCL)
and lateral collateral ligament (LCL). The MCL, or tibial collateral
ligament, has superficial and deep layers, the latter of which is part of the
knee capsule. The LCL, or fibular collateral ligament, is an extracapsular
structure which originates from the lateral femoral condyle. It shares a
common insertion, called the conjoined tendon, with the biceps femoris
tendon. The MCL and LCL originate from the medial and lateral femoral
condyles, respectively. The MCL inserts on the proximal tibia whereas
the LCL inserts on the fibular head.
• Several cysts and bursae are present around the knee joint.14 However, the
only collection that consistently communicates with the joint is the
meniscal cyst. The most frequently encountered collections around the
knee are described below.
– Popliteal cyst—a posteromedial fluid collection of the
gastrocnemiosemi-membranosus bursa that communicates with the
knee joint, in 35-55% of cadavers, through a defect in the joint capsule
(Fig. 5.4).
– Meniscal cyst—an extension of joint fluid through a meniscal tear 5
(Fig. 5.5).
– Intra-articular ganglion—usually arises near the cruciate ligaments and
does not communicate with the joint.
– Prepatellar bursa—a fluid collection sitting between the patella and
the overlying skin surface (Fig. 5.6).
– Superficial infrapatellar bursa—a fluid collection sitting between the
tibial tubercle and the subcutaneous tissues
– Deep infrapatellar bursa—a fluid collection sitting between the
posterior margin of the patellar tendon and the tibia
– Iliotibial bursa—a laterally located collection that sits between the
iliotibial band and tibia
– Tibial collateral ligament bursa—a collection sitting between the
superficial and deep layers of the medial collateral ligament
Before obtaining fluoroscopic spot views, make sure that the technicians have set
the radiographic tube to the small focal spot. For best results use 0.3mm or 0.6mm.
These settings will give you the highest quality radiographs.5 Obtaining a test
fluoroscopic spot film allows the technician to adjust the kV and mAS before the
exam begins.
ACL
To evaluate the cruciate ligaments, it is necessary to simulate the anterior and
posterior drawer tests. The anterior drawer test refers to anterior translation of the
tibia relative to the femur. It is a test of ACL integrity. Ask the patient to sit up and
place his/her legs over the edge of the fluoroscopy table. With the affected knee
flexed approximately 60˚, place a large sponge between the patient’s calf and the
edge of the table. Place a sling around the ipsilateral ankle and pull the ankle back
towards the table. Have the technician place a grid between the two knees and take
an overhead radiograph of the affected knee with a horizontal beam. Technical factors
are beyond the scope of this chapter. However, you should request a dark,
overpenetrated radiograph of the affected knee.10 This will highlight the interface
between the radiolucent ACL and the dense contrast coating its surface.

arthrogram, lateral overhead ra-
diograph, in a 61 year old male
with chronic knee pain. Two
oval-shaped ossific densities are
identifed within a posterior
air-filled collection. This collec-
tion communicates with the
joint. A frontal view demon-
strates that this collection is me-
dially situated (not shown).
These findings are consistent
with a popliteal cyst that con-
5 tains two ossific bodies (arrow).
Incidentally, a synovial fold (ar-
rowhead), representing a plicae,
is identified within the supra-
patellar bursa. (Courtesy of
Marie-Josée Berthiaume, MD,
FRCP, Hôpital Notre-Dame,
Fig. 5.5. MRI was requested to exclude a medial meniscal tear in this 52 year old
male with right knee pain. A) Sagittal proton density weighted spin echo image (TR
672 msec, TE 18 msec) demonstrates a well-circumscribed 0.8mm diameter round
lesion in the posterior horn of the medial meniscus. The lesion has high signal
intensity suggesting that it contains fluid. B) Sagittal proton density weighted spin
echo image (TR 672 msec, TE 18 msec). Linear intrameniscal high signal intensity
is seen in the posterior horn of the medial meniscus on three contiguous images,
one of which is shown here. C) Double-contrast knee arthrogram, fluoroscopic
spot view of the posterior horn of the medial meniscus. An air-filled collection,
coated with contrast, is identified within the meniscus. This air-filled cyst remains
intrameniscal on several images. The meniscal tear seen in conjunction with this
lesion on MRI is identified during arthrography. Arthroscopists confirmed the pres-
ence of a posterior central meniscal cyst with an associated meniscal tear. (Cour-
tesy of Marie-Josée Berthiaume, MD, FRCP, Hôpital Notre-Dame, Montréal, QC.)
Next, examine the ACL using fluoroscopy.10 Place the patient in the lateral position
with the affected knee against the table. Maintain the knee in approximately 60˚ of
flexion. Place a sling below the affected knee. Attach the bracket to the side of the
Fig. 5.6. A) Lateral radiograph, soft tissue technique, demonstrating thickened soft
tissues anterior to the patella. B) Bursogram, performed by placing a needle into 5
the midline soft tissues, at the level of the patella. Air and contrast distend the
prepatellar bursa. There is no communication of the prepatellar bursa with the
knee joint.
table that is farthest from you. Attach the sling to the bracket. Pull the ipsilateral
ankle posteriorly towards you. As in the preceding paragraph, you are now performing
the anterior drawer test. Before taking 4:1 fluoroscopic spot films of the ACL, make
sure that the knee is in a true lateral position—i.e., the femoral condyles overlap.
PCL
Without altering the patient’s position described in the preceding paragraph,
move the sling above the affected knee. Again, pull the ipsilateral ankle posteriorly.
You are now performing the posterior draw test. Obtain 4:1 fluoroscopic spot films
of the PCL while maintaining the knee in the true lateral position.
Menisci
With the patient prone, place the sling above the affected knee. To evaluate the
medial meniscus, attach the sling to the bracket that is closest to the lateral side of
the affected knee joint. During fluoroscopic visualization and exposures, pull the
ankle laterally. These two maneuvers will distract the medial side of the knee, allowing
air to outline the medial meniscus. Repeat this maneuver at 20˚ increments while
the patient turns 180˚. Using a 4:1 fluoroscopic spot film, make nine exposures. Be
sure to include the femoral condyles on your spot films for orientation (Fig. 5.3).
To evaluate the lateral meniscus, leave the sling above the knee. Attach the sling
to the bracket that is closest to the medial aspect of the affected knee. While obtaining
fluoroscopic spot films, pull the ankle medially. This will distract the lateral side of
the knee joint.
CT/Arthrography
The sensitivity of CT/arthrography is much better than that of either CT or
arthrography alone. Indications for CT/arthrography include: detection of subtle
cartilage disease (chondromalacia), detection of intra-articular joint bodies, and
evaluation of articular cartilage. This latter task may require coronal and/or sagittal
reconstruction images.
CT/arthrography is performed with the patient prone, and the knee flexed
approximately 30˚. Place a small wedge-shaped sponge beneath the knee to maintain
the knee in flexion. Scan through the knee joint at 3mm slice thickness and 3mm
intervals.
MR/Arthrography
For the evaluation of osseous and cartilagenous bodies, studies have shown that
MR/arthrography is clearly more accurate than either CT/arthrography or
conventional MRI.15 Additional indications for MR/arthrography include the
evaluation of osteochondral fractures and the post-operative meniscus.16
As in other joints, gadolinium 0.5 to 1.0 cc is diluted in a 50cc bag of saline.
Using the fluoroscopic technique outlined in previous paragraphs, 40 cc’s of the
5 gadolinium/saline solution is instilled into the knee joint. MRI is performed as per
routine in the sagittal, coronal, and axial planes.
Complications
It is normal for the patient to have swelling, crepitus, and discomfort of the
injected joint for 48-72 hours. The patient may take pain medication to relieve his
discomfort. Actual complications of knee arthrography are rare. The following list
includes those that have been reported in the literature.
• venous air emboli17
• infection
• contrast reaction
Pathology
Evaluate the capacity and contour of the joint capsule, as well as the resistance
during injection. The knee joint holds approximately 40 cc of fluid. There is little or
no resistance to the instillation of fluid as long as the joint capacity is not exceeded.
The contour of the joint capsule should be smooth. Altered joint capacity, irregularity
of the joint capsule, and/or increased resistance during contrast injection is indicative
of a synovitis. Inflammation, hemorrhage, arthritis, or trauma may result in synovitis.
In addition, patients may develop detritic synovitis in response to a prosthesis, or
other intra-articular foreign bodies.18 Extracapsular soft tissue masses may also
deform the contour of the joint capsule.
Apparently diminished joint capacity is rarely attributed to a complete synovial
plicae. Plicae, embryologic remnants of synovial tissue within the knee joint, may
be complete or incomplete (Fig. 5.7). A complete plicae creates two distinct
compartments, within the same joint, that do not communicate with one another.
Incomplete plicae are often insignificant but have been associated with
chondromalacia of the patellae (Fig. 5.8).19,20
The contrast should appear homogenous within the joint. Radiolucencies or
radiodensities within the contrast may indicate the presence of intracapsular
pathology, osseous or soft tissue. Joint bodies are probably the most common
intra-articular densities (Fig. 5.4). Whether osseous or cartilaginous, they are usually
secondary to trauma. Occasionally, however, joint bodies will be primary in origin,
due to synovial metaplasia (synovial osteochondromatosis). Meniscal ossicles, a
rare ossific density, is located within the meniscus, most often the posterior horn of
Fig. 5.7. Double-contrast CT/ar-

thrography of the knee. Transaxial
CT images, soft tissue technique,
obtained with the knee in 30˚ of
flexion. An incomplete thickened
synovial plica is present (arrow).
The cartilage covering the adja-
cent lateral and distant medial
patellar facets is normal. The car-
tilage covering the trochlear
groove of the femur is normal.
Fig. 5.8. Double-contrast CT/arthrography of the knee in a two different patients.

Transaxial CT images, soft tissue technique, were obtained through the
patellofemoral joint with the knee in approximately 30˚ of flexion. Contrast out-
lines the patellar and femoral articular cartilage. A) Intravasation, or imbibition, of
contrast into the articular cartilage that covers the lateral patellar facet (arrow-
head). This is an early stage of chondromalacia patellae. B) Nodularity of the sur-
face of the patellar articular cartilage, confirmed at arthroscopy. This is within the
spectrum of chondromalacia patellae. (Taken from Hodge JC, Ghelman B. Stan-
dard Radiologic Analysis of the Normal and Abnormal Knee. In: Scott WN, ed. The
Knee. St. Louis: Mosby, 1993:123-58.)
the medial meniscus. Intracapsular soft tissue lesions, in decreasing order of

frequency, include pigmented villonodular synovitis, synovial hemangiomas,
and lipoma arborescens.
The menisci should appear as triangular-shaped soft tissue structures. Contrast

should be present at the periphery of the menisci only. Elongation of the meniscus
may indicate the presence of a discoid meniscus (Fig. 5.9). The discoid meniscus
has an incidence of less than 3%, typically occurring in adolescents and young adults.
It is much more common on the lateral than on the medial side of the knee. Contrast
within the meniscus indicates the presence of a meniscal tear. Three basic types of
meniscal tears occur: those that are perpendicular to the free edge of the meniscus
(radial), those that are parallel to the long axis of the meniscus (longitudinal), and
oblique (Fig. 5.10). Meniscal tears are most common in the posterior horn of the
medial meniscus. In addition, meniscal tears are frequently associated with discoid
menisci.21 The posterior horn of the lateral meniscus is difficult to evaluate because
of the complex anatomy, including the popliteus tendon.
5 The postoperative meniscus is usually a remnant of meniscal tissue that is one
third to one half the size of the original meniscus.5 Complete menisectomy is not

arthrogram, fluoroscopic spot
view of the medial meniscus, in
a 21 year old male. The medial
meniscus is extremely long. This
was observed on all of the fluo-
roscopic spot views. These find-
ings are consistent with a discoid
meniscus. There is no evidence
for meniscal tear. (Courtesy of
Montréal, QC.)
Fig. 5.10. This middle-aged man pre-

sented with locking of his left knee.
Double-contrast knee arthrogram,
medial meniscus, fluoroscopic spot
view. Blunting of the meniscal apex,
and a linear band of intravasated con-
trast are seen within the residual por-
tion of the meniscus (2 arrowheads).
A separate contrast-coated meniscal
fragment is present within the inter-
condylar notch (3 arrowheads). These
findings are consistent with a bucket-
handle (longitudinal) tear of the me-
niscus. The central meniscal fragment
now sits in the notch of the knee. The
linear area of intrameniscal contrast
represents a second component to
the meniscal tear. (Courtesy of Marie-
Josée Berthiaume, MD, FRCP,
Hôpital Notre-Dame, Montréal, QC.)
typically performed, except in cases of extremely severe meniscal pathology, because

of the important role that the meniscus serves in protecting the osseous structures of
the knee from the stresses of daily activities. Meniscal tissue typically regenerates
after three months. The regenerated meniscus develops smooth margins and a
relatively small triangular-like shape. At arthrography, contrast outlines the peripheral
margin of the postoperative meniscus. Contrast or air within the meniscal fragment
indicates the presence of a recurrent meniscal tear.
The cruciate ligaments are linear soft tissue structures whose surfaces are coated
by contrast. The normal ACL should have a “ruler-straight” anterior synovial surface.
ACL injury should be suspected if the ACL is not visualized, appears wavy, is acutely
angulated, its inferior attachment is irregular, if contrast pools in the typical location
of the ligament, or if the infrapatellar synovial fold is visualized.22 (This latter structure
is normally confused with the ACL).23 The credence of these findings is strengthened 5
if the PCL is visualized, implying that the technical qualities of the study are adequate.
To my knowledge, no firm criteria have been published for distinguishing the normal
from the injured PCL on arthrography.
Excluding MRI, collateral ligament injuries are most reliably detected with stress
radiography. Widening of the medial joint space with valgus stress of the knee joint
indicates injury to the MCL (Fig. 5.11). Conversely, widening of the lateral joint
space with varus stress indicates LCL injury. The sine qua non of MCL disruption
on arthrography is contrast extravasation into the medial soft tissues. However, after
48 hours, a negative arthrogram, as regards the MCL, is unreliable. Fibrosis may
conceal a chronic MCL injury. Similarly, fibrosis may mask chronic meniscal and
cruciate ligament injury. Fortunately, there are ancillary signs for the detection of
ACL and meniscal injury so it is not necessary to rely solely on the presence of
contrast extravasation. Arthrography is even more unreliable in detecting LCL injury,
acute or chronic, because of the soft tissue space that exists between the joint capsule
and LCL.
On the normal arthrogram, contrast is confined to the surface of hyaline cartilage.
If, in the presence of an osteochondral fracture, contrast enters or crosses the articular
cartilage, the articular cartilage is fractured. An osteochondral fracture that is
completely surrounded by contrast on arthrography or CT/arthrography is called a
loose fragment. The integrity of the overlying articular cartilage is important in
determining patient management. Surgical intervention is often indicated in those
patients with a loose fragment whereas conservative management is often adequate
in those with intact articular cartilage (Fig. 5.12).
The normal joint capsule contains a suprapatellar bursa and a posterior recess. If
contrast is seen beyond the expected margins of the joint, exclude a popliteal cyst,
meniscal cyst, or abscess (Fig. 5.13). The other fluid collections mentioned above do
not usually communicate with the knee joint.
If a prosthesis is present, evaluate for loosening of the components (Fig. 5.14).
The components of the prosthesis may be either cemented or porous. Loosening is
more common at the bone-cement interface and may involve either component of a
total knee arthroplasty, but is more common at the tibial component. Contrast at
the bone-cement or bone-prosthesis interface indicates loosening. Digital subtraction
may be helpful in detecting subtle cases of loosening. It is important to remember

arthrogram performed to assess for
meniscal tear. Top. Fluoroscopic
spot film of the knee with varus
stress, patient prone. The lateral
compartment is of normal height.
Bottom. Fluoroscopic spot film of
the knee with valgus stress, patient
prone. There is marked widening
of the medial compartment of the
knee joint, consistent with an MCL
tear (arrows). The absence of con-
trast extravasation within the me-
5 dial soft tissues suggests that the
MCL injury is not acute. (Taken
from Hodge JC, Ghelman B. Stan-
dard Radiologic Analysis of the
Normal and Abnormal Knee. In:
Scott WN, ed. The Knee. St. Louis:
Mosby, 1993:123-58.)
Fig. 5.12. A) Sunrise radiograph

of the left knee. There is a fracture
involving the lateral patellar facet.
B) CT/arthrography, performed
after double-contrast knee
arthrography, demonstrates that
the overlying patellar cartilage is
intact. No contrast has intra-
vasated into the patellar cartilage.
Fig. 5.13. This 30 year old female

with thrombophlebitis. AP and
lateral radiographs of the left calf
following knee arthrography. Air
and contrast outline a popliteal
cyst which has dissected into the
posteromedial soft tissue planes
of the calf. (Courtesy of
Montréal, QC.)
Fig. 5.14. Knee arthrography was requested to assess for loosening. Following the
insertion of a 22 g needle, fluid was aspirated and sent for culture. A) Preliminary
lateral overhead radiograph demonstrates a three-component cemented total knee
arthroplasty. The radiolucency adjacent to the femoral component is suspicious for loos-
ening. B) Lateral overhead radiograph of the same knee following arthrography. Con-
trast is present at the bone-cement interface of the femoral and tibial components.
Additionally, contrast extravasates from a sinus tract along the anterior aspect of the
proximal calf.
that a negative arthrogram does not exclude loosening, especially if contrast selectively
fills bursae around the knee. The intracapsular pressure must be sufficiently high
before contrast will extravasate to the periprosthetic region.
References
1. Kaye JJ. Magnetic resonance imaging of the knee. A senior musculoskeletal
radiologist’s perspective. Magnetic resonance imaging. Clinics of North America
1994; 2:497-500.
2. Langer JE, Meyer SJ, Dalinka MK. Imaging of the knee. Radiologic Clinics of
North America 1990; 28:975-90.
3. DeSmet AA, Norris MA, Yandow DR et al. Diagnosis of meniscal tears of the knee
with MR imaging: Effect of observer variation and sample size on sensitivity and
specificity. AJR 1993; 160:555-9.
5 4. Dumas JM, Edde DJ. Meniscal abnormalities: Prospective correlation of
double-contrast arthrography and arthroscopy. Radiology 1986; 160:453-6.
5. Resnick D. Arthrography, tenography, and bursography. In: Resnick D, Niwayama
G (Editor) Diagnosis of bone and joint disorders, Philadelphia, WB Saunders
Comp., Chapter 12, 1988:374-412.
6. Applegate GR, Flannigan BD, Tolin BS et al. MR diagnosis of recurrent tears in
the knee: Value of intra-articular contrast material. AJR 1993; 161:821-5.
7. Tuite MJ, Desmet AA. MR of the postoperative knee. Topics in magnetic reso-
nance imaging 1996; 8:2-14.
8. Conway WF, Hayes CW, Loughran T, et al. Cross-sectional imaging of the
patello-femoral joint and surrounding structures. Radiographics 1991; 11:195-217.
9. Gagliardi JA, Chung EM, Chandnani VP, et al. Detection and staging of chondro-
malacia patellae: Relative efficacies of conventional MR imaging, MR arthrogra-
phy, and CT arthrography.
10. Freiberger RH, Pavlov H. Knee arthrography. Radiology 1988; 166:489-92.
11. Wood GW, Stanley RF, Tullos HS. Lateral capsular sign: X-ray clue to a significant
knee instability. Am J Sports Med 1979; 7:27-33.
12. de Carvalho A, Jurik AG. Joint fluid after aspiration. A disturbing factor in knee
arthrography. Acta Radiologica: Diagnosis 1985; 26:715-7.
13. Ng YY, Khaw KT, Halpin S, et al. A comparative study to evaluate the role of
intra-articular adrenaline in double-contrast knee arthrography. Clin Radiol 1989;
40:598-601.
14. Jantzen DL, Peterfy CG, Forbes JR, et al. Cystic lesions around the knee joint: MR
imaging findings. AJR 1994; 163:155-161.
15. Brossmann J, Preidler KW, Daenen B et al. Imaging of osseous and cartilagenous
intra-articular bodies in the knee: Comparison of MR imaging and MR arthrogra-
phy with CT and CT arthrography in cadavers. Radiology 1996; 200:509-17.
16. Palmer WE. MR arthrography: Is it worthwhile? Topics in Magnetic Resonance
Imaging 1996; 8:24-43.
17. Kobayashi S, Takei T. Venous air embolism during knee arthrography. A case
report. Arch of Orthop & Trauma Surg 1991; 110:311-3.
18. Karl LA, Sundstrom WR. Prosthesis-induced synovitis simulating villonodular syno-
vitis. Wisconsin Med J 1991;90:165-8.
19. Laissy JP, Schouman-Claeys E, Lacombe P et al. Value and limits of arthrography
in the study of pathological plicae of the knee; a comparison with arthroscopy. Eur
J Radiol 1990; 11:93-7.
20. Hodge JC, Ghelman B, O’Brien SJ. Synovial plicae and chondromalacia patellae:
Correlation of results of CT arthrography with results of arthroscopy. Rad 1993;
186:827-31.
21. Berson BL, Hermann G. Torn discoid menisci of the knee in adults. Four case
reports. J Bone Joint Surg 1979; 61A:303-4.
22. Pavlov H, Warren RF, Sherman MF et al. The accuracy of double-contrast
arthrographic evaluation of the anterior cruciate ligament. A retrospective review
of one hundred and sixty-three knees with surgical confirmation. J Bone Joint
Surg 1983; 65A:175-83.
23. Brody GA, Pavlov H, Warren RF et al. Plica synovialis infrapatellaris: Arthrographic
sign of anterior cruciate ligament disruption. AJR 1983; 140:767-9.
5
CHAPTER 6
Ankle Arthrography
Mary-Josee Berthiaume and Jacqueline C. Hodge
Introduction
Arthrography is an ancillary technique by which a joint is studied with the use of
intra-articular contrast. In the ever evolving era of magnetic resonance imaging (MRI),
one might question the relevance of such a technique. In reality, arthrography remains
a widely accepted and utilized technique for diagnostic and/or therapeutic purposes
either alone or in conjunction with conventional tomography, computerized
tomography (CT), or MRI.1-4 Furthermore, inasmuch as an imaging modality like
MRI can provide noninvasive objective information, MRI is often incapable of
answering questions relative to chronic instability, joint motion restriction,
intra-articular bodies, or cartilage abnormalities. Thus, arthrography remains the
procedure of choice for:
• synovial fluid assessment (microbacteriology, crystal, and arthropathy
profile);
• determination of joint capacity for diagnosis and treatment of adhesive
capsulitis;
• therapeutic procedures, such as radioactive synovectomy in pigmented
villonodular synovitis and rheumatoid arthritis, etc.;
• those cases where MRI is contraindicated; and
• those cases in which MRI is non diagnostic (chronic instability, cartilage
abnormalities, communication between the joint and soft tissues [cysts]
or communication between the joint and adjacent bone [geodes,
intraosseous ganglion]).
This chapter will emphasize ankle arthrography either alone or in conjunction
with other imaging modalities. It will address, more precisely, the study of the subtalar
joint and other joints of the foot. One must remember that arthrography requires a
knowledge of proper technique as well as a thorough understanding of the regional
anatomy and anatomical variants.
Prearthrogram Evaluation
Simple rules should be followed:
• a proper history covering the topics of contrast allergy, local anesthetic
adverse reactions, and blood dyscrasias should be obtained from the patient
since in most cases these are not specifically addressed by the referring
physician.5 In patients with known contrast allergies steroid coverage
consisting of 50 mg of prednisone, orally, should be prescribed for lunch,
dinner, and bedtime on the day before the exam, and on the morning of
the exam. Furthermore, one must bear in mind that allergic reactions
Ankle Arthrography 79
may be delayed due to a relatively slower absorption of contrast by the

synovium as compared with that from intravenous administration of
contrast. Although one might argue that blood dyscrasia is not of significant
concern because of the small size of the needle utilized for ankle
arthrography and the superficial structures involved, remember that the
distal portion of the anterior tibial artery is very close to the recommended
site of puncture for ankle arthrography. Having considered that, blood
dyscrasias are of lesser concern than contrast allergy.
• relevant clinical history findings are valuable for selecting the appropriate
arthrographic technique (i.e., single or double contrast examination).4,6
• routine films (AP, lateral, and mortise views) done during the previous
2-3 months should be reviewed in the setting of a chronic problem whereas
more recent films are mandatory in the setting of recent trauma.
• stress films of the ankle should be part of the prearthrogram evaluation in
order to assess gross ankle instability.7,8 6
Indications
Arthrography remains a reliable, valuable, and relatively low cost method for the
evaluation of ligamentous, capsular, and articular problems, as well as some congenital
conditions.1,3,4,9-13 Table 6.1 lists current indications and the appropriate arthrographic
technique for each.
Equipment
A standard tray includes: one 22 g 1-1/2" needle, two 18g 1-1/2" needles, one
25g needle for local anesthesia, one 5cc syringe, one 10cc syringe, connecting tubing,
sterile tubes for potential joint aspiration, sterile drapes, and gauze.
Contrast Agents
Either ionic or nonionic contrast agents can be used for joint arthrography.
However, it is my experience that nonionic contrast agents are less inclined to provoke
a reactive synovitis.
Technique
After informed consent has been obtained, the patient is invited to assume a
lateral decubitus position, facing the examiner, and lying on the side of the painful
ankle. The foot should be held in plantar flexion to open the anterior aspect of the
ankle mortise. The opposite leg, knee flexed, should be moved out of the way.
Under fluoroscopic control, position the patient so that the optimal lateral view
of the talar dome is achieved. Locate the dorsalis pedis artery and extensor hallucis
longus tendon.3,4,14,15 Under fluoroscopic guidance, a lead marker (the letter “O”) is
placed on the skin anteromedially in relation to the previously identified dorsalis
pedis artery and extensor hallucis longus tendon at the level of the joint space. This
chosen spot is then marked with indelible ink. After standard aseptic preparation,
local anesthetic is administered with the 25g needle. Next, the 22g needle is advanced
into the anteromedial aspect of the tibiotalar joint. A trial aspiration of joint fluid is
performed in order to confirm the intra-articular position of the needle and/or to
Table 6.1.
Indications Technique
Traumatic
ligament/soft tissue injury single or double contrast
cartilage: loose bodies mainly double contrast
osteochondral fractures
subtalar lucencies
Arthritis
septic aspiration/analysis
crystal induced aspiration/analysis
synovial evaluation single or double contrast
32
radioactive synovectomy P injection
Synovitis
6 Adhesive Capsulitis single contrast/anesthetic/steroid
Congenital Conditions
Trevor’s disease single contrast
tarsal coalition single contrast
obtain joint fluid for analysis. Often you will be unable to aspirate fluid from the
joint. In these instances, perform a Xylocaine or contrast test. With the administration
of Xylocaine, you will feel a change in the resistance to injection once the joint space
is entered. As for contrast, one is able to visualize fluoroscopically its normal
intra-articular distribution—dye will be seen flowing away from the needle tip
outlining the contour of the articular cartilage and synovium.
If single contrast arthrography is planned, draw up 6 to 10cc of contrast into the
10cc syringe. Three cc will remain in the connecting tubing to insure a wet-to-wet
connection with the arthrogram needle. Inject the remaining 3 to 6 cc into the ankle
joint. If complementary studies are scheduled, such as CT/arthrography, 0.1cc of
1:1000 epinephrine per 1 cc of contrast should be added to the contrast mixture to
slow the rate of contrast resorption and reduce the “blurring effect”.3,4,8,16 If double
contrast arthrography is scheduled, 1cc of contrast and 5cc of room air are injected
into the joint. In either case, the injection of contrast and air should be monitored
under fluoroscopy in order to assess the pattern of distribution of contrast before
total joint opacification is obtained since some abnormalities are better detected
during this phase of the examination. Spot films may even be necessary during the
injection of contrast/air.
Following arthrography, AP, lateral, and bilateral oblique films should be obtained
after passive motion. If these are normal, this series of radiographs should be repeated
after active motion and fluoroscopic positioning.
Postarthrographic Recommendations
The patient must understand that arthrography is usually performed for diagnostic
purposes. Patients should be told to avoid all stressful activity (such as sports) for
two days following the exam. The patient should be told to expect decreasing
discomfort and a pressure sensation during the days following the exam. Instruct
the patient to apply ice or cold clean towels on the ankle for as long as 24 hours
following the study.
Complications
During and following any arthrogram the patient should be evaluated for possible
vasovagal reaction, inadvertent puncture of vascular or neurological structures,
immediate or delayed allergic reaction, reactive synovitis or infection. The risk of
infection under normal aseptic conditions is extremely low. On the other hand, the
risk of reactive synovitis may be significant, and sometimes necessitating joint
aspiration of contrast and the newly formed effusion and treatment with nonsteroidal
anti-inflammatory agents for two days.5 The risk of minor complications, including
vasovagal reactions, is about 0.1%.5
The Normal Ankle Arthrogram
On the lateral view, contrast delineates the normal articular cartilage as well as 6
the anterior and posterior recesses (Fig. 6.1). The posterior recess is variable in size
and shape. On the AP view, contrast should not trespass the tips of the
malleoli.3,4,7,9,11,15,17,18 Proximally, on the AP view, there is an outpouching between
the distal tibia and fibula called the syndesmotic recess. This recess should be less
than 2.5 cm cephalad to the joint space.3,4,15,18 A communication with the posterior
subtalar joint occurs in 10% of the asymptomatic population (Fig. 6.2) and with
the tarsal tunnel tendon sheaths (posterior tibialis, flexor digitorum longus, flexor
hallucis longus) in 20% of the asymptomatic population (Fig. 6.3).3,4,18
Pathologic Conditions
Trauma
The role of arthrography in the investigation of ankle instability is still debated
in the literature.1,4,18-20 Acute tears are usually depicted by arthrography within the
first 48 hours following the incident. However, studies performed beyond 48 hours
may not demonstrate the tear because it may be sealed off by blood clots, scarring or
granulation tissue, resulting in a false negative exam.3,4,8,9,17 Nevertheless, arthrography
remains a valuable tool for predicting surgical indications in cases of chronic ankle
instability and recurrent ankle sprains.1,3 False positive results have rarely been reported
(e.g., normal filling of the peroneal tendon sheath with full distention of the joint
capsule).
Instability
• three major groups of ligaments are part of the lateral ligamentous complex:
• the anterior talofibular ligament (ATF) which is intimately associated with
the anterior lateral capsule;
• the calcaneofibular ligament (CF); and
• the posterior talofibular ligament (PTF).1,3,4,7,18
Fig. 6.1. Normal arthrogram.

Lateral radiograph of the ankle
following contrast injection
demonstrating the normal
anatomy and puncture site
(broad arrow). Anterior (short
arrow) and posterior recesses
(long arrow) are opacified.
Fig. 6.2. Normal communication

between the ankle and posterior
subtalar (open arrows) joints.
Fig. 6.3. A) AP radiograph, and B) Lateral radiograph of a double contrast arthrogram

demonstrating normal filling of the tarsal tunnel tendon sheaths (arrows).
Pertinent Arthrographic Abnormalities

Lateral-sided abnormalities are secondary to inversion injuries. The ATF ligament
is the most frequently torn. The capsule is also usually torn allowing contrast to
extravasate laterally and anteriorly to the distal fibula.11 This is best seen on oblique
views (Fig. 6.4).
An isolated tear of the CF ligament is rare. Filling of the peroneal tendon sheath
is classic in cases of CF ligament tears, but is most often associated with the tear of
the ATF capsular complex (Fig. 6.5).3,4,19,21 If the CF ligament tear is not associated
with contrast filling of the peroneal tendon sheath, one must consider an associated
sealed CF ligament tear with at least an ATF-capsular complex injury. Anterolateral
synovial irregularities are usually noticeable as diverticulae indicating an old ATF
injury. CF ligamentous tears may be difficult to demonstrate, especially if an
ATF-capsular complex tear is coexisting with CF ligament tear since contrast will
take the path of least resistance and constantly decompress the joint during contrast
injection thereby preventing the filling of the peroneal tendon sheath.3,4,11,22 Massive
extravasation of contrast anterolaterally suggests a tear of both the ATF-capsular
complex and the CF ligament.15 Direct filling of the peroneal tendon sheath
(tenography) probably provides the most accurate method of diagnosis for a CF
ligament tear.4,21,23
The medial ligamentous complex is composed of the very strong deltoid
ligament.3,4,11,18 Medial-sided injuries are less common and usually involve both the
deltoid ligament and distal talofibular syndesmosis. Single or double contrast
arthrography demonstrates contrast extravasation around the medial malleolar process
and leakage of contrast proximal to the syndesmotic recess (i.e., > 2.5 cm cephalad
Fig. 6.4. A) Lateral radiograph, and B) External oblique radiograph of the ankle
demonstrating anterolateral contrast leakage (arrows). This suggests at least an
ATF-capsular complex tear.
Fig. 6.5. Lateral instability. A)

Varus stress radiograph demon-
strates 23˚ of talar tilt, a sign of
a hypermobile ankle. B) Lateral
radiograph, and C) Mortise view
from a double contrast arthro-
gram demonstrating filling of the
peroneal tendon sheath (arrow).
Again talar tilt is observed. D)
Coronal CT arthrogram of the
same patient illustrating extrava-
sation through the proximal
(straight arrow) and distal
(curved arrow) attachments of
the calcaneofibular ligament
consistent with a tear.
to the joint space) or some irregularity of this recess. Rupture of the ATF ligament is
also sometimes associated with syndesmotic tears. A small leak around the medial
malleolus may be obscured by the normal opacification of the tarsal tunnel tendon
sheaths (Fig. 6.6).
Cartilaginous Lesions
Osteochondritis dissecans (OCD) is a term that was coined before there was a
known association with inversion type injuries. Osteochondral lesion might be more
appropriate.24 The diagnosis is often delayed since OCD may be radiographically
occult initially. Its exact prevalence is therefore unknown, although some authors
have suggested that OCD comprises 4-5% of all ankle instabilities. Berndt and
Harty suggested a four stage classification based on x-ray findings.25 This classification
allows the determination of the prognosis and the appropriate treatment. There are
some discrepancies between x-ray and arthrographic findings, mainly because the
articular cartilage is better depicted on arthrography. Dipaolo et al. have proposed a
classification that includes MRI and arthroscopic findings.26 Articular cartilage 6
abnormalities can be very small and may not be detectable by MRI which has limited
spatial resolution. Thus CT/arthrography and arthroscopy are often superior to MRI
in this setting.
Double contrast arthrography with epinephrine is performed followed by 2 to 3
mm thick coronal slices through the entire contrast-filled region. (Coronal ankle
CT is performed with the knees flexed and the feet flat on the table.) Cartilaginous
fissures, osteochondral defects, and loose bodies can be depicted (Fig. 6.7).
Fig. 6.6. Chronic medial instability syndrome. A) Coronal FLASH MRI showing
significant thickening of the deltoid ligament (curved arrow) and irregularity of the tip
of the medial malleolar process (open arrow). B and C) Coronal CT arthrogram of the
same patient confirming the bony irregularities of the medial malleolar process
(arrows) with adjacent faint reactive bone formation, not appreciated on MRI but slightly
visible on recent plain radiographs (not shown) in retrospect. No abnormal contrast
extravasation is depicted.
Fig. 6.7. Osteochondritis dissecans. A) Coronal CT arthrogram of the ankle demon-

strating depression of the medial talar dome cartilage as well as linear oblique impreg-
nation of contrast into the cartilage denoting a fissure of the cartilage (arrow). B) A
subchondral cystic lesion, either degenerative or post-traumatic, does not fill with
either contrast or air (arrow).
Arthritis
Arthrographic technique can be used for diagnostic purposes such as joint
aspiration (culture, crystal deposition, immunochemistry analysis) or biopsy (Fig.
6.8). Alternatively, arthrography may be utilized for anesthetic administration with
or without steroid injection—either for therapeutic purposes or as a predictor of
success of arthrodesis. For therapeutic injections, a long-acting anesthetic, such as
Bupivacaine, is preferable to Xylocaine. Steroids should not be administered if septic
arthritis is suspected.
Adhesive Capsulitis
Clinically, frozen ankle is defined by a decreased range of motion secondary to
ankle trauma. This diagnosis is considered once other etiologies have been excluded.
Single contrast arthrogram findings include:
• increased resistance during contrast injection,
• decreased joint capacity (< 6cc),
Fig. 6.8. Chronic septic arthritis of the ankle. A) AP radiograph, and B) Lateral
radiograph demonstrating severe joint space narrowing (open arrows) and either
synovitis of a joint effusion (closed arrow). C) AP radiograph, and D) Lateral radio-
graph performed after single contrast arthrography. Marked cartilage thinning (open
arrows), multiple radiolucencies within the joint consistent with synovitis (small
arrows), and contrast extravasation adjacent to the lateral malleolus representing a
sinus tract (curved arrow) are identified. Synovial fluid analysis identified Staphy-
lococcus aureus as the responsible agent.
• contrast extravasation along the puncture site during or after •

obliteration of the normal anterior, posterior, and/or lateral recesses,
• rapid filling of lymphatics.
Reflecting the favorable results from distention arthrography for frozen shoulder
syndrome, a trial of three consecutive distention arthrograms is proposed for adhesive
capsulitis of the ankle. Once a standard arthrographic ankle joint puncture has been
performed, one drop of contrast is injected to ensure proper intra-articular needle
position, documented with a spot film. Next a mixture of 5-6 cc of 1% Xylocaine
and 10-20 mg of triamcinolone acetonide (Kenalog) is slowly injected and the
connecting tubing, with the syringe still connected, clamped for ten minutes.
Afterwards, the tubing is unclamped and re-expansion of the syringe is observed. If
the syringe re-expansion occurs rapidly, the injection-clamping sequence is repeated
two or three times. The radiologists can usually infer an increase in joint capacity by
decreasing or slow re-expansion of the syringe once unclamped.27
6 Arthrography in Congenital Diseases
Dysplasia epiphysealis hemimel is a developmental epiphyseal growth disorder,
commonly involving the ankle and the knee and resulting in osteocartilaginous
proliferation on one side of the epiphysis. The result is an intra-articular
osteochondroma-like lesion. In asymptomatic cases where the epiphysis and abnormal
cartilaginous mass are not yet ossified, more precise diagnostic information
about its extent and the articular surface is obtained from a double contrast
arthrogram, that is:
• articular surface involvement,
• configuration of the mass in relation to the articular surface
• extent of the lesion,
• adjacent anatomy, such as that of the epiphyseal plate.
Nowadays, MRI demonstrates significant capacity in replacing ankle arthrography
in this setting.12
Arthrography of the Subtalar and Other Joints of the Foot
These procedures are rarely used but can still be useful. The posterior subtalar
joint can be entered either medially or laterally unlike the other tarsal, tarsometatarsal,
and metatarsophalangeal joints which must be approached dorsally.4,6,28 Because these
joints are relatively small, single contrast arthrograms are preferred. With the patient
lying in the lateral decubitus position, fluoroscopy is used to obtain a perfectly tangent
view of the posterior talocalcaneal facet. If a medial approach is planned, the posterior
tibial artery is located. After standard preparation, a 22g 1-1/2" needle is advanced
vertically into the joint under fluoroscopic guidance. Single contrast arthrography is
performed by injecting 2-4 cc of contrast. Tomography or CT may be obtained if
greater articular detail is warranted.
Probably the most common indication for subtalar joint arthrography is to
administer 1% Lidocaine for diagnostic purposes. In the post-traumatic setting,
posterior subtalar joint injection may be performed as part of the preoperative
assessment for subtalar arthrodesis. If pain can be localized to this joint, subtalar
arthrodesis will be performed (Fig. 6.9). Alternatively, intra-articular steroid
administration may be performed for therapeutic purposes in patients with arthritic
Fig. 6.9. Twenty-year old male with mild left clubfoot deformity, and persistent pain 6
years status post posteromedial release procedure. Left foot CT demonstrated posterior
subtalar joint arthritis. Posterior subtalar joint injection with 1% Xylocaine was re-
quested for diagnostic purposes. If the patient experienced pain relief following the
injection of 1% Xylocaine, he would undergo a subtalar arthrodesis. A) Preliminary
scout radiographs include subtalar views. The foot is internally rotated 45˚; a series of
four radiographs are obtained with the x-ray tube angled cephalad at 10˚, 20˚, 30˚, and
40˚, respectively. This radiograph, obtained with 30˚ cephalad angulation, demon-
strates mild osteoarthritic change of the posterior subtalar joint. B) Lateral fluoroscopic
spot film of the hindfoot. Via a lateral approach, Conray 60 outlines the subtalar joint.
C) Lateral fluoroscopic spot film of the hindfoot. At a later phase during the injection of
Conray 60, contrast enters one of the neighboring tendon sheaths. D) AP fluoroscopic
spot film of the hindfoot. There is contrast within a Y-shaped tendon sheath on the
medial side of the ankle (the common flexor tendon sheath), most likely related to the
prior surgery.
Fig. 6.10. Contrast opacification of the sec-

ond metatarsophalangeal joint following
joint aspiration.
joint involvement, most often rheumatoid arthritis. In the past, the diagnosis of
sinus tarsi syndrome, post-traumatic fibrosis of the soft tissues within the sinus tarsi,
was established with posterior subtalar arthrography. The obliteration of the posterior
recess on arthrography was considered diagnostic. Today, this diagnosis is easily made
noninvasively with MRI.
The capacity of the posterior subtalar joint is 2-3cc.31 In the lateral projection,
the normal subtalar joint should contain a linear band of contrast material running
parallel to the bony margins of the joint and a posterior contrast-filled recess. In
10-20% of posterior subtalar arthrograms, there will be a communication with the
ankle joint.30
Midfoot and forefoot arthrography are even simpler. Utilizing a 25g 1-1/2" needle,
up to 2 cc of contrast is injected into the joint of interest under fluoroscopy. A series
of films are obtained (Fig. 6.10). Complementary tomography or CT are rarely
necessary. Indications are limited but include
• prearthrodesis evaluation,
• joint fluid aspiration for analysis,
• synovial lining evaluation (such as in post-traumatic synovitis),
• congenital abnormalities (for example nonosseous tarsal coalition, clubfoot
deformity), and
• evaluation of the joint with soft tissue cystic masses or sinus tracts (Fig.
6.11). In the presence of a sinus tract a sinogram may be performed.
However, since midfoot and forefoot joints are small, it is often difficult
to build up enough pressure to demonstrate the communication with the
joint from sinography. In this setting, arthrography is preferred to
demonstrate filling of the sinogram (Fig. 6.12).4,29
6
Fig. 6.11. Talocalcaneonavicular arthrography. A) Lateral view of the ankle, under
fluoroscopy, demonstrating the dorsal medial approach to this joint space (arrow).
B) Lateral radiograph of the ankle, post-arthrography. Intra-articular contrast fills
the talonavicular and subtalar joints, excluding subtalar coalition. An abnormal
collection of contrast along the plantar aspect of the foot represents a synovial cyst
(open arrow) that was clinically palpable.
References
1. Ala-Ketola L, Puranen J, Koivisto E, et al. Arthrography in the diagnosis of liga-
ment injuries and classification of ankle injuries. Radiology 1977; 125:63.
2. Chandnani VP, Harper MT, Ficke JR, et al. Chronic ankle instability: Evaluation
with MR arthrography, MR imaging, and stress radiography. Radiology 1994;
192:189-94.
3. Freiberger RH, Kaye JJ, eds. Arthrography. New York: Appleton-Century-Crofts,
1977.
4. Morrey BF, Cass JF, et al. The foot and ankle. In: Berquist TH, ed. Imaging of
orthopaedic trauma and surgery. Philadelphia:WB Saunders Co., 1986:407-98.
5. Newberg AH. Contrast reactions in arthrography. ACR categorical course, Balti-
more, Sept 1986.
6. Berquist TM. Interventional orthopaedic techniques. In: Berquist TM, ed. Radi-
ology of the foot and ankle. New York: Raven Press Ltd., 1989:81-97.
7. Edeiken J, Colter JM. Ankle injury: The need for stress films. JAMA 1978;
240:1182-4.
8. Hudson TM. Joint fluoroscopy before arthrography: Detection and evaluation of
loose bodies. Skeletal Radiol 1984; 12:199-203.
9. Chee SG, Khoo TK, Chong BK, et al. Early local experience of ankle arthrography
and its influence on management of patients with ankle injury. Singapore Med J
1991; 32:130-3.
10. Broström L. Sprained ankles: A pathologic, arthrographic, and clinical study. Diss
Karolinska Inst., Stockholm, 1966.
11. Goergen TG, Resnick D. Ankle arthrography. In: Dalinka M, ed. Arthrography.
New York: Springer-Verlag Inc., 1981.
Fig. 6.12. Septic arthritis of the first metatarsophalangeal (MTP) joint secondary to
a diabetic ulcer. A) AP radiograph, and B) Lateral radiograph of the forefoot dem-
onstrating a soft tissue ulcer (small arrows) on the plantar aspect of the first MTP
and early erosive changes of the first metatarsal head (large arrow). C) Oblique
radiograph, and D) Lateral radiograph of the forefoot following arthrography dem-
onstrating the communication between the MTP joint and the deep plantar ulcer
(small arrows). The arthrogram was performed via a dorsal approach (open arrow).
A sinogram would have been impossible with such a wide-mouth ulcer. (This was
previously Fig. 6.10)
12. Ho AMW, Blane CE, Kling TF. The role of arthrography in the management of
dysplasia epiphysealis hemimelica. Skeletal Radiol 1986; 15:224-7.
13. Hjelmstedt EA,Sahlstedt B. Arthrography as a guide in treatment of congenital
clubfoot. Acta Orthop Scand 1980; 51:321-4.
14. Lundholmer E, Anderson A, Anderson SB, et al. Arthrography of the ankle. Value
in diagnosis of rupture of the calcaneofibular ligament. Acta Radiol Diagn 1983;
24:217-223.
15. Olson RW. Ankle arthrography. Radiol Clin North Am 1981; 19:255-68.
16. Tehranzedek J, Galrieli OF. Intra-articular calcified bodies: Detection by com-
puted arthromography. South Med J, 1984; 77:703-10.
17. Dory MA. Arthrography of the ankle joint in chronic instability. Skeletal Radiol
1986; 15:291-4.
18. Kaye JJ, Bohne WHO. A radiographic study of the ligamentous anatomy of the
ankle. Radiology 1977; 125:659-67.
19. Cass JR, Morrey BF. Ankle instability: Current concepts, diagnosis, and treatment.
Mayo Clin Proc 1984; 59:165-70.
20. Parisien JS, Vangsness T. Operative arthroscopy of the ankle: Three year experi-
ence. Clin Orthop 1985; 199:46-53.
21. Black HM, Brand RL, Eichelberger MR. An improved technique for the evalua-
tion of ligamentous injury in severe ankle sprains. Am J Sports Med 1978; 6:276-82.
22. Spiegel PK, Staples OS. Arthrography of the ankle joint: Problems in diagnosis of
acute lateral ligament injuries. Radiology 1975;114:587-90.
23. Johannsen A. Radiology of lateral ligament lesion of the ankle. Acta Orthop Scand
1978; 49:295-301.
24. Crim JR. Injuries of the foot. In: Crim JR, ed. Imaging of the foot and ankle. New
York: Lippincott-Raven, 1996:54-62.
25. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the
talus. J Bone Joint Surg 1959; 41A:988-1020.
26. Dipaola JD, Nelson DW, Colville MR. Characterizing osteochondral lesions by
magnetic resonance imaging. J Arthroscopy Rel Surg 1991; 7:101-4.
27. Goldman AB, Katz MC, Freiberger RH. Posttraumatic adhesive capsulitis of the
ankle: Arthrographic diagnosis. Am J Roentgenol 1976;127:585-8.
28. Pavlov H. Ankle and subtalar arthrography. Clin Sports Med 1982;1:47-69. 6
29. Goldman F, Manzi J, Carver A et al. Sinography in the diagnosis of foot infections.
J Am Podiatry Assoc 1981; 71:497-502.
30. Resnick D. Radiology of the talocalcaneal articulations. Anatomic considerations
and arthrography. Radiology 1974; 111:581-6.
31. Weston WJ. Traumatic effusions of the ankle and posterior subtaloid joints. Brit J
Radiol 1958; 31:445-7.
CHAPTER 7
MR Arthrography
David R. Marcantonio, Robert D. Boutin and Donald Resnick
Introduction
Magnetic resonance (MR) imaging has rapidly become the primary imaging
method for assessment of many musculoskeletal abnormalities. With few exceptions,
MR imaging is now the standard for evaluation of internal joint derangements, and
it has replaced conventional arthrography for all but a few indications. Although
MR imaging allows diagnosis of many internal joint derangements with a high degree
of sensitivity and specificity, in certain situations conventional MR imaging alone
may be inconclusive.
In situations in which conventional MR imaging is not adequate for diagnosis,
many radiologists have advocated the use of MR arthrography to enhance diagnostic
accuracy. Intra-articular fluid serves as a contrast agent, and it also acts in a mechanical
fashion to separate closely apposed structures. With joint distention, elevated intra-
articular pressure may cause fluid to fill potential spaces within the joint, both normal
and abnormal. For example, fluid may be driven into meniscal tears, may be forced
into partial-thickness or through small full-thickness rotator cuff tears, and may
enter the junctional zone between the parent bone and an unstable osteochondral
fragment. To date, the glenohumeral and knee joints have been studied most often
with MR arthrography.
While MR arthrography offers advantages over conventional MR imaging in
certain situations, it also has disadvantages. First, MR arthrography converts a
noninvasive examination into a more complicated and invasive procedure. Second,
logistical and scheduling difficulties must be considered, as fluoroscopic assistance
is often required for intra-articular contrast injection. Third, if gadolinium compounds
are used, radiologists generally must apply for investigational review board approval
at their hospital. Although intra-articular injection of gadolinium compounds has
not been approved by the U.S. Food and Drug Administration, no untoward systemic
or local effects have been identified.1
General Information
Indications for MR Arthrography
MR arthrography is usually performed when conventional MR imaging has failed
to adequately answer a specific clinical question. However, for some indications,
MR arthrography may be the initial imaging study employed. Common indications
for performing MR arthrography include: in the shoulder, evaluation of small
complete and partial rotator cuff tendon tears, and evaluation of glenohumeral joint
instability; in the knee, differentiation of postoperative changes from recurrent
meniscal tears after meniscal surgery; and, in general, evaluation of osteochondral

MR Arthrography 95
lesions and articular cartilage surface integrity. Indications as they pertain to evaluation
of specific joints will be discussed in more detail later in this chapter.
Indications for conventional arthrography have changed dramatically since the
advent of MR imaging; the reader is referred to the chapter on conventional
arthrography for its current indications. CT arthrography is primarily employed in
two specific settings: the evaluation of glenohumeral joint instability and the detection
of intra-articular bodies. While CT arthrography currently is used more frequently
in the detection of intra-articular bodies, MR arthrography also has been used.2
When conventional and CT arthrography are nondiagnostic or are not suited to
answer the clinical question, MR arthrography may be chosen.
Contraindications to MR Arthrography
Contraindications to MR arthrography are few in number. Most importantly, it
must be remembered that any contraindication to conventional MR imaging (e.g.,
cardiac pacemaker, intra-ocular foreign body) is a contraindication to MR
arthrography. A past medical history of adverse reaction to either iodinated contrast
agents or gadolinium compounds should be considered a relative contraindication.
7
Technique, Contrast Agents and Imaging Sequences
Once the decision to perform MR arthrography is made, the type of contrast
agent must be chosen. Options include saline, iodinated contrast agents, and
gadolinium compounds.
When saline or iodinated contrast agents are used, T2-weighted imaging sequences
are mandatory. This has the relative disadvantage of an increased imaging time and
a decreased signal to noise ratio. Furthermore, high T2-weighted signal intensity
may be related to native fluid or the contrast agent, or both. For example, high
signal intensity seen within the subacromial-subdeltoid bursa on T2-weighted images
following intra-articular saline or iodinated contrast injection may be related to native
bursal fluid with an intact rotator cuff, but also may represent intra-articular contrast
agent which has passed through a rotator cuff tendon tear. Therefore, high signal
intensity seen on T2-weighted images may be nonspecific and can lead to diagnostic
difficulty. An advantage of using iodinated contrast material is that MR arthrography
may be performed following a conventional arthrogram.
In contrast, MR arthrography with intra-articular gadolinium compounds takes
advantage of T1-weighted imaging sequences. T1-weighted sequences provide
improved signal to noise ratio and shorter examination times, thereby providing
better anatomic detail with decreased motion artifact. Fat suppression also will
improve diagnostic accuracy. For example, in evaluating rotator cuff pathology,
Palmer et al compared T1-weighted images with and without fat suppression and
showed improved diagnostic accuracy in differentiating partial from full-thickness
tears, as well as improved diagnostic accuracy for small articular-sided partial tears
when fat suppression was used.3 At our institution, we prefer intra-articular
gadolinium administration coupled with fat-suppressed T1-weighted images in
conventional orthogonal planes. Additional sequences, imaging planes, and patient
positions are employed on a case by case basis.
Intra-articular contrast injection often requires fluoroscopic assistance, which
may limit the availability of MR arthrography in certain settings. If fluoroscopy is to
be used, adequate time should be incorporated into scheduling and planning of the
MR examination. Regardless of the type of intra-articular contrast agent used, the
technique of intra-articular injection is similar to that of conventional arthrography.
Informed consent for intra-articular contrast injection should be obtained. After
percutaneous needle placement, intra-articular location of the needle tip may be
confirmed with a small amount of iodinated contrast agent. The full volume of
contrast material may then be injected.
When using gadolinium-containing compounds, the amount of iodinated
contrast agent used to confirm intra-articular position should be minimized. The
influence of iodinated contrast agents on the signal intensity of gadolinium
compounds, as well as untoward effects related to mixing of these contrast agents
has not been rigorously studied. Gadolinium agents must be diluted prior to intra-
articular injection. However, the optimal concentration for intra-articular injection
of diluted gadolinium compounds has not been determined. Various concentrations
have been reported in the literature, ranging from 2-10 mmol/L. At our institution,
gadolinium dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ, USA) is
diluted in normal saline (1:250), for a concentration of 2 mmol/L.
7 The total volume of injected fluid should approximate that for conventional
arthrography for the joint under examination. Adequate distention of the joint should
be achieved, without rupture of the joint capsule. It is crucial that air not be injected
into the joint during the procedure, as this will cause magnetic susceptibility artifact.
Immediate MR imaging should follow intra-articular gadolinium administration as
excessive time delay will allow diffusion and imbibition of contrast material, thereby
decreasing image quality. Saline and iodinated contrast agents have less stringent
time constraints.
Specific Joint Pathology
Shoulder
Rotator Cuff Tendon Tears
MR arthrography, with direct opacification of the glenohumeral joint space, has
been performed with the hope of improving diagnostic accuracy in cases of rotator
cuff tendon tears.3,4 With joint distention, intra-articular contrast material will be
driven into an articular-sided partial tear and through a full-thickness tear of the
rotator cuff tendons. With full-thickness tears, contrast material enters the
subacromial-subdeltoid bursa. MR arthrography provides no added benefit in the
diagnosis of intrasubstance and bursal-sided partial tears, as these tears do not
communicate with the glenohumeral joint space.
When conventional MR imaging is diagnostic of a full-thickness rotator cuff
tendon tear, MR arthrography is not indicated. In a study comparing MR
arthrography with conventional MR imaging, Hodler and associates showed no
improvement with MR arthrography over conventional MR imaging in diagnostic
accuracy in cases of full-thickness rotator cuff tears.4 However, in cases with a strong
clinical suspicion for rotator cuff tear and a negative conventional MR imaging
examination, MR arthrography occasionally may document a small full-thickness
tear (Fig. 7.1). MR arthrography also may distinguish between partial and small
MR Arthrography 97
7
Fig. 7.1. Small full-thickness rotator cuff tear seen only with MR arthrography. A)
Coronal oblique T2-weighted (TR/TE 3000/108) fast spin echo MR image. The su-
praspinatus muscle and tendon are intact (arrows). No focal defects are identified.
Normal high signal peribursal fat is seen deep to the deltoid muscle (arrowhead). B)
Coronal oblique fat-suppressed T1-weighted (TR/TE 800/20) spin echo MR image ob-
tained following the intra-articular administration of a gadolinium compound. High-
signal gadolinium contrast agent is identified within the subacromial-subdeltoid bursa
(arrow), documenting a small full-thickness tear which was occult on the conventional
MR imaging examination (A). The tear is located at the junction of the supraspinatus
and infraspinatus tendons (not shown).
full-thickness rotator cuff tears, and may better define the size of a complete tear
and status of the torn tendon edges.
Accurate diagnosis of partial thickness rotator cuff tendon tears has become more
meaningful now that arthroscopic repair of some partial tears is possible. In some
studies, conventional MR imaging has been shown to be insufficient for confident
diagnosis.5,6 Compared with conventional MR imaging, MR arthrography can
provide improved diagnostic accuracy for evaluation of articular-sided partial-
thickness tears of the tendons of the rotator cuff.4 Recently a new patient position
during MR arthrography has been described, which may improve detection of
articular-sided partial-thickness tears.7 The arm is positioned in abduction and
external rotation (ABER position) during MR imaging. Abduction of the arm allows
intra-articular contrast material to more easily pass into the space between the humeral
head and the articular surface of the rotator cuff tendons. Thus, undersurface lesions
of the rotator cuff are more clearly depicted.
Glenohumeral Joint Instability

Assessment of shoulder instability includes evaluation of the rotator cuff, glenoid
labrum, joint capsule, and glenohumeral ligaments, the last representing focal
thickening of the anterior joint capsule. Together, the labrum and glenohumeral
ligaments are referred to as the labral-ligamentous complex, and their importance in

providing passive anterior shoulder stability has been emphasized.8-11
Accurate evaluation of the labral-ligamentous complex using conventional MR
imaging has been inconsistent. Contributing factors include the wide variability in
appearance of the labrum and anterior capsule seen on MR imaging in asymptomatic
persons,12,13 as well as the lack of joint distention in the absence of a joint effusion.
Advantages of MR arthrography over conventional MR imaging in the evaluation
of the labral-ligamentous complex of the shoulder are well documented.8,14-15 For
example, in the nondistended joint, the middle and inferior glenohumeral ligaments
are often closely apposed to the anterior labrum and may simulate labral tears.13
Joint distention during MR arthrography will separate these structures and may
avoid false positive diagnosis of labral tears.
With MR arthrography, the labrum, glenohumeral ligaments and anterior capsular
insertion site are consistently identified. MR arthrography also is able to differentiate
true labral detachment from normal variation caused by hyaline cartilage undercutting
the labrum. On fat-suppressed T1-weighted axial images, gadolinium compounds
will have higher signal intensity than hyaline cartilage, and will be seen passing into
7 the space between the detached labrum and glenoid surface. Partial and complete
labral detachment can be identified.
Tears of the superior labrum at the site of attachment of the tendon of the long
head of the biceps brachii muscle are well documented, and are referred to as SLAP
lesions (superior labrum anterior and posterior).16 Evaluation of these lesions using
conventional MR imaging has yielded conflicting results.17,18 MR arthrography will
demonstrate intra-articular contrast agent passing between the displaced labral
fragment and the glenoid and also may outline the torn biceps anchor. A normal
superior sublabral sulcus may occur at the labral-bicipital junction and may be
confused with a labral tear. While a superior sublabral sulcus will show contrast
agent at the labral-bicipital junction, a displaced labral fragment will not be present.8,14
Bankart tears of the anteroinferior labrum also may be detected with MR
arthrography.
The anterosuperior labrum lies between the origin of the middle glenohumeral
ligament and the midportion of the anterior glenoid rim and can be an area of
diagnostic difficulty. Both normal anatomic variants and pathologic lesions may
occur at this site. Regarded as normal variants, the anterosuperior labrum may be
absent, or a segment of the anterosuperior labrum may be separated from the glenoid
rim.19 Absence of the anterosuperior labrum, associated with cord-like thickening of
the middle glenohumeral ligament, has been referred to as the Buford complex. MR
arthrographic imaging features of the Buford complex have been described.20 Isolated
separation of the anterosuperior labrum has been referred to as a sublabral hole,
sublabral foramen, or sublabral recess. Both the superior and anteroinferior labrum
should appear normal on imaging studies of these normal variants. Therefore, when
the anterosuperior labrum appears abnormal, differentiation between these normal
variants and an anterosuperior labral tear relies on evaluation of the superior
and anteroinferior labrum. Extension of either a superior (SLAP) or
anteroinferior (Bankart) labral tear into the region of the anterosuperior labrum
should be excluded before diagnosing one of these normal variants; isolated
MR Arthrography 99
tears of the anterosuperior labrum are rare. MR arthrography may be useful in

this assessment (Fig. 7.2).
Other recently described pathologic lesions of the labral-ligamentous complex
have been reported in the arthroscopy literature. These include the glenolabral
articular disruption (GLAD), anterior labroligamentous periosteal sleeve avulsion
(ALPSA), and humeral avulsion of the glenohumeral ligament (HAGL).21-23
Familiarity with these lesions will improve diagnostic accuracy in the evaluation of
anterior shoulder instability and MR arthrography may be helpful in identification
and characterization of these lesions.
Elbow
Osteochondral Injuries and Osteonecrosis
MR arthrography is useful for evaluation of osteochondral injuries and
osteonecrosis about the elbow, allowing assessment of articular surface integrity, the
viability of the separate fragment, and the presence of intra-articular bodies. On fat-
suppressed T1-weighted images, gadolinium contrast will be of high signal intensity
and will outline the chondral surface, which will be of lower signal intensity. Injected 7
intra-articular fluid under increased pressure also may be forced between an
osteochondral fragment and the parent bone, which is believed to represent evidence
of an unstable lesion. This is best appreciated on fat-suppressed T1-weighted images
following intra-articular injection of gadolinium compounds, in which high signal
intensity fluid is identified at the junction of the fragment and the parent bone
(Fig. 7.3). Conventional MR imaging cannot differentiate between granulation tissue
Fig. 7.2. Normal anterosuperior sublabral hole, confirmed at arthroscopy, simulat-

ing a SLAP lesion. A) Coronal oblique fat-suppressed T1-weighted (TR/TE 700/14)
spin echo MR image obtained following the intra-articular administration of a ga-
dolinium compound. High-signal intensity gadolinium contrast agent is identified
deep to the anterosuperior labrum (thin arrow). The biceps anchor remains at-
tached to the superior labrum (thick arrow). B) Transaxial fat-suppressed T1-weighted
(TR/TE 500/12) spin echo MR image postintra-articular contrast. At arthroscopy, a
sublabral hole was confirmed, and no labral tear was identified.
Fig. 7.3. Osteonecrosis of the

capitellum with an unstable
osteochondral fragment. Sagittal
fat-suppressed T1-weighted (TR/
TE 800/20) spin echo MR image
obtained following the intra-
articular administration of a
gadolinium compound. A non-
viable osteochondral fragment of
low signal intensity is identified.
High signal intensity gadolinium
contrast agent is present in the
junctional zone (arrows), indicat-
ing an unstable osteochondral
fragment. A nonspecific cystic
area is identified in the capitellum
(open arrow), but does not com-
municate with the joint space.
There is extensive cartilage loss
7 over the capitellum.
and joint fluid at this junction, as both are of high signal intensity on T2-weighted
images. Intra-articular bodies are sometimes seen as filling defects after intra-articular
contrast injection.
Ligamentous Injuries
Collateral ligament injuries of the elbow, both partial and complete, can be
identified using MR arthrography. MR arthrography has been shown to be useful
for demonstration of subtle ulnar collateral ligament abnormalities, and accurate
depiction of these injuries may have treatment implications, especially in throwing
athletes.24
Wrist
MR arthrography has been applied to the wrist. While tears of the triangular
fibrocartilage complex (TFCC) and interosseous ligaments may be seen more clearly
with MR arthrography than with conventional MR imaging, the invasive nature
and added imaging time have not resulted in a clear diagnostic advantage of the
former method.
Hip
MR arthrography has been utilized in evaluation of the hip, with particular
attention to the acetabular labrum.25-29 Distention of the hip joint helps separate the
labrum from the joint capsule. Contrast material of high signal intensity can be seen
entering the labral tear, which usually occurs at the labral base (Fig. 7.4). However,
in one study MR arthrography did not improve the specificity for diagnosis of
intrasubstance labral degeneration.29
MR Arthrography 101
Fig. 7.4. A) Acetabular labral tear. Coronal fat-suppressed T1-weighted (TR/TE 600/10)
spin echo MR image. A tear at the base of the left acetabular labrum is identified, with
high signal intensity gadolinium contrast agent noted within the labral tear (long ar-
row). B) Sagittal fat-suppressed T1-weighted (TR/TE 650/11) spin echo MR image fol-
lowing the intra-articular administration of a gadolinium compound. A left acetabular
cystic structure without joint space communication also is identified, most likely repre-
7
senting an intraosseous ganglion (short arrow). Shallow bilateral acetabuli with mild
lateral subluxation of the left femoral head are suggestive of bilateral developmental
dysplasia of the hip.
Knee
Meniscal Tears
The value of MR imaging in evaluation of internal derangements of the knee is
not questioned. However, in the setting of partial meniscectomy or meniscal repair,
evaluation for recurrent meniscal tear can be difficult. The postoperative appearance
of the meniscus can be highly variable, and abnormal increased intrameniscal signal
on proton density and T2-weighted images may not indicate a recurrent meniscal
tear, but instead may represent granulation tissue at sites of previous surgery. If this
abnormal signal intensity increases further with increasing echo time, then recurrent
tear may be more likely than granulation tissue, but confident differentiation
ultimately may be difficult.
MR arthrography has been shown to have improved sensitivity over conventional
MR imaging for detection of recurrent meniscal tears in the postoperative knee.30
Advantages of MR arthrography over conventional MR imaging are greater as the
extent of meniscal resection increases. In differentiating recurrent tear from
postoperative granulation tissue, extension of the abnormal intrameniscal signal
intensity to the free edge of the meniscus is critical for the diagnosis of recurrent or
new meniscal tear. With MR arthrography, distention of the joint is accomplished,
and fluid may enter a meniscal tear if one is present. The tear then appears as a
region of increased signal intensity on T1-weighted images when intra-articular
gadolinium administration is used (Fig. 7.5).
Fig. 7.5. Recurrent tear of the posterior horn of the medial meniscus in a patient status
post partial meniscectomy: Value of MR arthrography. A) Sagittal fat-suppressed T1-
weighted (TR/TE 700/16) spin echo MR image. Abnormal intra-meniscal signal inten-
sity is identified and reaches the inferior free edge of the meniscal remnant (white
7 arrow). However, communication with the joint space cannot be established, and dif-
ferentiation between recurrent meniscal tear and postoperative granulation tissue is
not possible. B) Sagittal fat-suppressed T1-weighted (TR/TE 750/16) spin echo MR im-
age following the intra-articular administration of a gadolinium compound. Abnormal
intrameniscal signal within the meniscal remnant now demonstrates high signal inten-
sity equivalent to that of intra-articular gadolinium contrast agent, and establishes com-
munication with the joint space (black arrow). This is diagnostic of a recurrent tear of
the meniscal remnant.
Osteochondral Injuries and Osteonecrosis

As discussed previously, MR arthrography offers advantages over conventional
MR imaging in the evaluation of osteochondral injuries and osteonecrosis. Intra-
articular fluid will outline the chondral surface and will fill surface defects. Fluid
also may be forced between an unstable osteochondral fragment and the parent
bone. Compared with conventional MR imaging, MR arthrography has been shown
to be more sensitive to the detection of intra-articular bodies in the knee.2
Cartilage Abnormalities
MR arthrography has been shown to be superior to conventional MR imaging
in the evaluation of articular cartilage defects.31 Surgically created full-thickness
cartilage lesions in the femoral articular surface of cadaveric knees were studied using
conventional MR imaging, saline-enhanced MR arthrography and gadolinium-
enhanced MR arthrography. Gadolinium-enhanced MR arthrography allowed
detection of smaller lesions than saline-enhanced images. Gadolinium-enhanced
images also demonstrated high signal intensity differences between intra-articular
contrast agent and articular cartilage on both T1- and T2-weighted imaging
sequences.31
MR Arthrography 103
Ankle
MR arthrography can be used to evaluate osteochondral injuries and ligamentous
injuries about the ankle. In the setting of chronic ankle instability, MR arthrography
has been shown to have higher sensitivity and specificity than conventional MR
imaging in the detection of injury to the anterior talofibular and calcaneofibular
ligaments.32
Summary
The ultimate role for MR arthrography in the evaluation of internal derangement
of joints is not yet resolved. At present, it is best applied in very limited and specific
situations. While MR arthrography affords certain benefits over conventional MR
imaging, these benefits must be weighed against the added invasiveness, examination
time, and cost inherent to this examination. With further investigation and
reassessment of diagnostic imaging strategy, the role for MR arthrography will be
refined.
References
1. Hajek PC, Sartoris DJ, Gylys-Morin V et al. The effect of intra-articular gado- 7
linium-DTPA on synovial membrane and cartilage. Invest Radiol 1990;
25:179-183.
2. Brossman J, Pedowitz PA, Priedler KW et al. Detection of intra-articular bodies in
the knee with MR imaging and MR arthrography: Experimental observations in
cadavers. Radiology 1995; 197(P):334.
3. Palmer WE, Brown JH, Rosenthal DI. Rotator cuff: Evaluation with fat-suppressed
MR arthrography. Radiology 1993; 188:683-687.
4. Hodler J, Kursunoglu-Brahme S, Snyder SJ et al. Rotator cuff disease: Assessment
with MR arthrography versus standard MR imaging in 36 patients with arthroscopic
confirmation. Radiology 1992; 182:431-436.
5. Traughber PD, Goodwin TE. Shoulder MRI: Arthroscopic correlation with emphasis on
partial tears. J Comput Assist Tomogr 1992; 16(1):129-133.
6. Flannigan B, Kursunoglu-Brahme S, Snyder S et al. MR arthrography of the
shoulder: Comparison with conventional MR imaging. AJR 1990; 155:829-832.
7. Tirman PFJ, Bost FW, Steinbach LS et al. MR arthrographic depiction of tears of
the rotator cuff: Benefit of abduction and external rotation of the arm. Radiology
1994; 192:851-856.
8. Palmer WE, Brown JH, Rosenthal DI. Labral-ligamentous complex of the shoul-
der: Evaluation with MR arthrography. Radiology 1994; 190:645-651.
9. O’Connell PW, Nuber GW, Mileski RA et al. The contribution of the glenohumeral
ligaments to anterior stability of the shoulder joint. Am J Sports Med 1990;
18:579-584.
10. O’Brien SJ, Neves MC, Arnoczky SP et al. The anatomy and histology of the
inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;
18:449-456.
11. Turkel SJ, Panio MW, Marshall JL et al. Stabilizing mechanisms preventing ante-
rior dislocation of the glenohumeral joint. J Bone Joint Surg (Am) 1981;
63:1208-1217.
12. Neumann CH, Petersen SA, Jahnke AH. MR imaging of the labral-capsular com-
plex: Normal variations. Am J Roentgenol 1991; 157: 1015-1021.
13. Liou JTS, Wilson AJ, Totty WG et al. The normal shoulder: Common variations
that simulate pathologic conditions at MR imaging. Radiology 1993; 186:435-441.
14. Palmer WE, Caslowitz PL, Chew FS. MR arthrography of the shoulder: Normal
intra-articular structures and common abnormalities. Am J Roentgenol 1995;
164:141-146.
15. Massengill AD, Seeger LL, Yao L et al. Labrocapsular ligamentous complex of the
shoulder: Normal anatomy, anatomic variation, and pitfalls of MR imaging and
MR arthrography. Radiographics 1994; 14: 1211-1223.
16. Snyder SJ, Karzel RP, Del Pizzo W et al. SLAP lesions of the shoulder. Arthroscopy
1990; 6:274-279.
17. Cartland JP, Crues JV III, Stauffer A et al. MR imaging in the evaluation of SLAP
injuries of the shoulder: Findings in 10 patients. Am J Roentgenol 1992;
159:787-792.
18. Hodler J, Kursunoglu-Brahme S, Flannigan B et al. Injuries of the superior por-
tion of the glenoid labrum involving the insertion of the biceps tendon: MR imag-
ing findings in nine cases. Am J Roentgenol 1992; 159:565-568.
19. Williams MM, Snyder SJ, Buford D. The Buford complex-the cordlike middle
glenohumeral ligament and absent anterosuperior labrum complex: A normal ana-
tomic capsulolabral variant. Arthroscopy 1994; 10:241-247.
20. Tirman PFJ, Feller JF, Palmer WE et al. The Buford complex-a variation of normal
shoulder anatomy: MR arthrographic imaging features. Am J Roentgenol 1996;
7 166:869-873.
21. Neviaser TJ. The GLAD lesion: Another cause of anterior shoulder pain.
Arthroscopy 1993; 9:22-23.
22. Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion: A
cause of anterior instability of the shoulder. Arthroscopy 1993; 9:17-21.
23. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as
a cause of anterior shoulder instability. Arthroscopy 1995; 11:600-607.
24. Schwartz ML, Al-Zahrani S, Morwessel RM et al. Ulnar collateral ligament injury
in the throwing athlete: Evaluation with saline-enhanced MR arthrography. Radi-
ology 1995; 197:297-299.
25. Marianacci EB, Palmer WE, McCarthy JC. MR arthrography of the hip: Prelimi-
nary results with surgical correlation. Radiology 1995; 197(P):335.
26. Petersilge CA, Haque MA, Lieberman JM et al. MR arthrography of the hip for
diagnosis of acetabular labral tears. Radiology 1995; 197(P):335.
27. Czerny C, Hofmann S, Tschauner C et al. Evaluation of the acetabular labrum
with MR arthrography. Radiology 1995; 197(P):335.
28. Hodler J, Yu JS, Haghighi P et al. Degeneration and cyst formation in the acetabu-
lar labrum: Histologic and MR imaging findings in cadavers. Radiology 1995;
197(P):335.
29. Hodler J, Yu JS, Goodwin D et al. MR arthrography of the hip: Improved imaging
of the acetabular labrum with histologic correlation in cadavers. Am J Roentgenol
1995; 165:887-891.
30. Applegate GR, Flannigan BD, Tolin BS et al. MR diagnosis of recurrent tears in
the knee: Value of intra-articular contrast material. Am J Roentgenol 1993;
161:821-825.
31. Gylys-Morin VM, Hajek PC, Sartoris DJ et al. Articular cartilage defects: Detect-
ability in cadaver knees with MR. Am J Roentgenol 1987; 148:1153-1157.
32. Chadnani VP, Harper MT, Ficke JR et al. Chronic ankle instability: Evaluation
with MR arthrography, MR imaging, and stress radiography. Radiology 1994;
192:189-194.
CHAPTER 1
CHAPTER 8
Myelography
Jacqueline C. Hodge
Introduction
Myelography is the study of the spinal cord and its nerve root branches with the
use of intrathecal contrast. Despite more advanced and noninvasive technology, such
as magnetic resonance imaging (MRI), myelography has remained important in the
workup of the patient with back pain, radiculopathy, and/or spinal stenosis.1,2
However, myelography may not be the initial imaging study in the patient being
evaluated for disc disease, radiculopathy, and/or spinal stenosis. Rather myelography
is considered complimentary to MRI.3-5 Specifically, myelography may be reserved
for:
• those cases in which MRI findings are discordant with the clinical picture,
• evaluation of areas in which MRI gives limited detail (for example the
cervical nerve roots),
• those cases in which bone detail is important (CT would accompany
myelography), and
• patients unable to undergo MRI (those with contrast allergies,
claustrophobia, or devices that are contraindicated in the magnet).4,6
As a screening exam for intrathecal or cord pathology, MRI, with gadollinium,
has supplanted myelography.7,8 However, myelography has remained the procedure
of choice for:
• evaluation of CSF content (microorganisms, chemistries),
• determining CSF flow, and
• determining the contour of the thecal sac.
Specific indications are summarized below.
Pre-Myelogram Preparation
Review ancillary studies, such as MRI or previous CT/myelography. Check for
blood dyscrasias, a relative contraindication to myelography. This predisposes the
patient to an epidural hematoma with potential cord compression or paralysis
secondary to subarachnoid and/or subdural blood. Check for a history of contrast
allergies. Although some authors have shown that patients with a history of contrast
allergy tolerate intrathecal nonionic contrast without significant adverse effect, a
conservative approach is suggested—either premedicate the patient prior to
myelography or perform an alternate test on these patients.9 Nonionic contrast should
be used for myelography, in all patients. This is primarily due to the grave
consequences of using ionic contrast intrathecally, including seizures and other serious
or fatal complications.10-12

Lumbar Puncture
Indications
• meningitis, detection of other CSF content abnormality
• arachnoiditis
• CSF block
• spinal stenosis
• disc herniation
• radiculopathy
• discordance between MRI and clinical symptoms
Contraindications
• intracranial mass
• elevated intracranial pressure
• tumor or infection at puncture site
Equipment
A myelogram tray contains all the necessary supplies for performing myelography.
If it is not available, have the following supplies available: 26g or 22g 3-1/2" spinal
8 needle, 25g 5/8" needle (to administer local anesthetic), 18g 1-1/2" needle, 5cc,
10cc, and 20cc syringes, connecting tubing, 2-4 sterile tubes, sterile towels.
Technique
Obtain preliminary AP and lateral radiographs of the lumbar spine. Review the
radiographs for bone spurs that may hinder needle access to the thecal sac.
Keep the patient on a liquid diet for eight hours prior to the procedure. Place the
patient in the prone position with a pillow under the abdomen to eliminate the
natural lumbar lordosis. Using fluoroscopic guidance, identify the last rib-bearing
vertebra, T12. Number the next caudad vertebra as L1. Number the vertebra
consecutively until you reach the sacrum. Identify the L2-3 intervertebral disc space
in preparation for puncture. (The puncture for lumbar myelography can be made at
L2-3 or at any level caudad to the conus medullaris.) Alternatively, if the patient has
a laminectomy defect, this is by far the easiest site to puncture and therefore puncture
may be performed at any of the laminectomy sites distal to the conus medullaris.
Palpate and mark the skin at the L2 spinous process, site x. Sterilize the area with
Betadine (Poviodone-Iodine, Purdue Frederick) and drape. Substitute Stanhexidine
(Chlorohexidine Gluconate, Stanley Pharmaceuticals) in those patients with iodine
allergies. It is a good policy to sterilize a large area in the event that you will need to
approach the thecal sac from a level other than that initially attempted. Administer
1% Lidocaine as local anesthetic. (Omit local anesthetic in patients with allergies to
1% Lidocaine.) Starting from site x advance a 26g 3-1/2" spinal needle1 into the
thecal sac. Direct the needle such that its bevel is heading cephalad. You may feel a
slight pop once the needle has crossed the dura. To confirm the subarachnoid position
of the needle tilt the table top up approximately 30˚ to 45˚, and remove the stylette
1Generally speaking, the smaller the needle used, the better. Several studies have
shown that a smaller needle causes fewer side effects, in particular headaches.
Myelography 107
from the needle. If the needle is in the subarachnoid space, CSF will flow through
the needle and onto the patient’s skin. If there is no fluid return, rotate the needle
slightly and then recheck for fluid. If there is still no fluid return, have the patient
cough or Valsalva to demonstrate the flow of CSF. (The exception to this is if puncture
is performed at the level of a CSF block. Despite the suggested maneuvers, there
may be no CSF return.)
In patients with severe facet joint hypertrophy or Baastrup’s disease, you will
probably have to use a 22g, rather than 26g, spinal needle. In postoperative patients,
a 26g spinal needle may successfully pierce the dura so you should attempt this first.
If you are unsuccessful then proceed to a 22g spinal needle.
Alternatively, the lumbar puncture may be performed with the patient in the
lateral decubitus position (Fig. 8.1). However, this requires the use of a C-arm
fluoroscopy unit to confirm your needle position prior to injection of the entire
volume of contrast. The disadvantage of this fluoroscopy unit is that the table top
does not tilt. However, in a morbidly obese patient, the use of the C-arm can far
outweigh the disadvantages by allowing improved visualization of the spine.
To reduce the natural lordosis of the lumbar spine, have the patient flex their
knees and hips and hunch their shoulders. Post-procedure radiographs should be
obtained with a horizontal beam rather than with a vertical beam.13 A coaxial
technique, based on Lindblom’s technique for discography, has been described for 8
use in those patients that are morbidly obese. This technique shortens fluoroscopic
and total procedure time.14
Fig, 8.1. Lumbar myelogram in a 63 year old patient with a colostomy, unable to lay
prone. Myelography was performed, via an L3-4 puncture, with the patient in the left
lateral decubitus position, in fetal position. A, B) Using a C-arm for fluoro-scopic con-
firmation, spot radiographs were obtained at 0˚ and 90˚. The patient’s left nephrostomy
tube is incidentally noted cranially. Degenerative spurring and apex dextroscoliosis is
noted at L3-4. Fluoroscopic frontal, lateral and oblique spot radiographs were
satisfactory inspite of the inability of the C-arm table top to tilt.
Lastly, the lumbar puncture may be performed with the patient sitting on a
stool, only with their neck bent and their back rounded to open up the interspinous
space. Once the contrast has been successfully placed intrathecally, you then transfer
the patient to the fluoroscopy table and proceed as below. If you use this method, it
is imperative to have a technologist or other assistant close at hand during needle
placement. They may be needed to provide assistance in stabilizing the patient,
should he/she become vasovagal during the exam. 15
Cervical Puncture
The lateral cervical puncture technique was first described in 1963 for
percutaneous radiofrequency cordotomy, a method for treating patients with
intractable pain. A strontium-yittrium needle was inserted at 45˚ relative to the
sagittal plane, placed against the anterolateral spinal cord, and the nerve tracts
destroyed.16 In 1968, Kelly and Alexander, two neurosurgeons at Bowman Gray,
modified the technique for myelography.17 They described performing the procedure
with the patient in the supine position. Today, the cervical puncture is usually
performed with the patient in the lateral decubitus position, but can be performed
with the patient in the supine position. It requires a higher degree of skill than a
lumbar puncture due to the presence of the spinal cord at this level. It is reserved for
8 those clinical settings in which a lumbar puncture is contraindicated or in those
cases where the presence of a complete block precludes evaluation of the spine
proximal to the level of the block (Fig. 8.2). A cervical puncture avoids the influx of
intracranial contrast, relative to lumbar puncture.
Indications 13
• unsuccessful attempt at lumbar puncture (due to arachnoiditis, low CSF
delineate the proximal margin of a complete CSF obstruction
• documented by lumbar myelography
• lumbar spine pathology (including dysraphism, known stenosis, severe
hypertrophic changes, ankylosis, tumor, infection, post-operative changes)
Contraindications
• intracranial mass (relative)
• elevated intracranial pressure
• known tumor or infection at puncure site
Equipment
Refer to the “Equipment” subsection under “Lumbar Puncture”.
Technique
Place the patient in the lateral decubitus position. With fluoroscopic assistance,
confirm that the patient’s neck is in a true lateral position. The neck may be in
neutral position or slightly hyperextended. (Depending on the patient, the spinal
canal is wider in either of these positions.)18 Localize the posterior third of the spinal
canal at the level of C1-2, the level at which the thecal sac is widest. Your goal is to
place the spinal needle into the posterior third of the spinal canal.13 Avoid the anterior
Myelography 109
Fig. 8.2. Complete myelogram performed via an L2-3 puncture in a 46 year old female
with known melanoma and a three month history of severe midthoracic back pain.
The lumbar and lower thoracic myelogram were normal (not shown). A cervical punc-
ture and/or gadolinium-enhanced MRI was indicated because of the presence of a
complete block within the thoracic spine. A, B) Right anterior oblique (RAO), and left
anterior oblique (LAO) radiographs of the upper thoracic spine demonstrate no con-
trast cephalad to the T2-3 level, suspicious for a complete block. Thinning of the sub-
arachnoid contrast column suggests the presence of an intradural lesion. An intramed- 8
ullary component cannot be excluded. An extrinsic compression on the left anterolateral
aspect of the thecal sac suggests the presence of an extradural lesion. C) Transaxial CT
image, bone window technique, performed at three hours following myelography con-
firms the presence of a complete block at T2-3, as well as the presence of both intra-
and extradural lesions. Destruction of the posterior aspect of the vertebral body, not
identified on preliminary or post-myelography radiographs, is identified. On the basis
of these examinations the patient was admitted with a presumptive diagnosis of meta-
static melanoma, subsequently confirmed at surgery. The cervical spine and remainder
of the upper thoracic spine was evaluated with gadolinium-enhanced MRI rather than
myelography performed via a cervical puncture.
two thirds of the spinal canal as this is where the vertebral and posterior inferior
cerebellar arteries reside. Puncture to this site increases the risk of vessel puncture.19
Once the skin has been prepped and draped, and local anesthetic administered,
advance a 26g 3-1/2" spinal needle into the thecal sac. The needle should be angled
at 90˚ relative to the table top. As described above, it is best to use the smallest
needle possible to minimize adverse effects subsequent to the procedure. Remove
the stylette from the needle and check for the return of CSF—confirmation that the
needle is in the subarachnoid space. You may have to ask the patient to cough or
Valsalva to demonstrate the flow of CSF.
A C1-2 puncture can also be performed with the patient in the supine position.
The dentate ligament maintains the spinal cord centrally rather than letting it fall
posteriorly to a dependent position. Again your goal is to aim for the posterior third
of the spinal canal. Advance the spinal needle such that it remains parallel to the
table top. Use a C-arm to visualize the needle position.16
Contrast Agents
The earliest contrast agents used intrathecally were far from optimal. Ethyl
iophendylate (Pantopaque), an oil-based contrast agent, was used in English-speaking
countries.13 Because it was not water soluble, the majority of it had to be removed
from the thecal sac at the completion of the procedure (Fig. 8.3). Furthermore,
subtle pathology went undetected because Pantopaque did not fill the nerve root
sleeves as well as water-soluble agents. However, it was safe for total myelography.
During this same era, the other European countries, including Sweden where
Pantopaque was actually prohibited from intrathecal use, performed myelography
with methiodal sodium, a water-soluble contrast agent.13 Because of the agents ability
to mix with CSF, it gave a study of relatively superior quality. However, it was an
irritant, and therefore, could only be used to study the area distal to the conus.
Additionally, spinal anesthesia had to be administered prior to the intrathecal injection
of this agent.
The 1970s brought with it the use of meglumine iothalamate (Conray) and
meglumine iocarmate (Dimer X), water-soluble agents. These new agents did not
require spinal anesthesia. However, they contributed to clonic convulsions and again
could only be used below the conus.13
Metrizamide (Amipaque), the first nonionic water-soluble agent, was synthesized
8 by a Norwegian company in 1969.20 However, it was not used in clinical trials until
1972. Its main advantage over the previous agents was that it had a much lower
incidence of clonic convulsions and therefore could be used for total myelography.
Fig. 8.3. A, B) Preliminary AP and lateral radiographs in a 70 year old female dem-
onstrating prior laminectomies at L4-5 and L5-S1 and residual Pantopaque within
the spinal canal at the level of L5-S1. (Courtesy of B. Ghelman, The Hospital for
Special Surgery.)
Myelography 111
The second generation of nonionic water-soluble agents were introduced in the

early 1980s, including iopamidol (Isovue) and iohexol (Omnipaque).21 These agents
had even fewer adverse effects than their predecessors.
Today, these second generation nonionic agents remain the contrast media of
choice for intrathecal use. Two factors are important in determining the concentration
and volume of contrast used in a given case: the region to be evaluated, and thecal
sac capaciousness. As a rule of thumb, lower concentrations and smaller volumes of
contrast media are indicated in subtotal myelography and in those with relatively
small thecal sacs. The exception is the patient having a cervical myelogram, via a
lumbar puncture and vice versa. This should be treated like the patient having a
total myelogram because contrast will have to pass through the entire spine to permit
visualization of the region of interest. Specifically, a concentration of 170 mg iodine/
ml is isotonic with CSF and is considered adequate for examination of the lumbar
region when introduced by lumbar puncture. Concentrations of 230 mg iodine/ml
and 270 mg iodine/ml are considered adequate for examination of the thoracic and
cervical regions, respectively, when introduced via lumbar puncture.22 Volumes of 8
to 12 cc are standard for adult myelography. For pediatric patients, concentrations
of 170–250 mg iodine/ml and volumes ranging from 2–12 cc are satisfactory.23
Some general guidelines are listed in Table 8.1.
To avoid the misadministration of ionic contrast agents, check the bottle carefully 8
prior to drawing up the contrast agent into the syringe. If ionic contrast is
inadvertently administered prompt recognition and treatment are warranted. The
onset of uncontrolled seizures, rhabdomyolysis, respiratory compromise, and/or
hyperpyrexia herald the intrathecal administration of ionic contrast. Immediate
elevation of the patient’s head and trunk to prevent the transit of contrast to the
intracranial region, placement of a subarachnoid catheter to drain off CSF, elective
paralysis, and anticonvulsant therapy are the recommended modes of treatment.11,24
Most recently, pilot studies have been performed with intrathecal gadolinium
for MR myelography and cisternography.25 (As for intra-articular gadolinium,
intrathecol gadolinium is not FDA- or HPB-approved.) Doses varying from 0.2-1.0
ml of gadolinium (500mmol/l) were mixed with 5cc of previously removed CSF
and then reintroduced into the subarachnoid space. In the short-term, no adverse
neurological or behavioural alterations have been noted. However, further work is
necessary to evaluate the long-term safety of intrathecal gadolinium. If proven safe,
this could provide a valuable tool with which to study CSF dynamics .
Post-Puncture Protocol
Once CSF return is identified, attach a manometer and stopcock to measure the
opening pressure, if indicated. The normal opening pressure is 70–180 mm of water
in the lateral position. In the clinical setting of suspected meningitis or in those with
suspected intradural metastases, collect 2 to 4 cc of CSF in sterile tubes. Submit the
tubes to the lab in the following order: a) the first tube for bacteriology (including
gram stain, routine culture and sensitivity, and acid-fast bacilli and fungal cultures
and stains), b) the second tube for glucose and protein, c) the third tube for cell
count, and d) the fourth tube for special studies. Interpret the results based on
Table 8.2.26
Table 8.1. Guidelines for Contrast Media
Single Site Myelogram/ Single Site Myelogram/

Local Puncture Site Distant Puncture Site Total Myelogram
Adult 240mg I/ml 300mg I/ml 300mg I/ml
Pediatric 180 mg I/ml 240mg I/ml 240mg I/ml
Table 8.2. Normal CSF content
Opening Pressure Protein Glucose Cell

Color (mm H2O) (mg/100ml) (mg/100 ml) (#/mm)
Adult clear 70-180 15-45 45-80 0-5 lymphs
Newborn clear 70-180 20-120 2/3 serum glucose 40-60 lymphs
Lumbar Myelogram
Draw up 20 cc of Omnipaque 180 into a 10 or 20 cc syringe. Connect the
contrast-filled syringe to connecting tubing. Flush the contrast through the syringe
and attached tubing. Connect the tubing to the spinal needle making sure that fluid
8 is emanating from both the needle and the tubing at the time of the connection (i.e.,
a wet-to-wet connection. These last two steps are to reduce the chance of air bubbles
entering the subarachnoid space. With the table top remaining tilted approximately
30˚ to 45˚, inject 12 cc of Omnipaque 180 into the subarachnoid space under
fluoroscopic guidance. To ensure that contrast is entering the subarachnoid space
rather than the subdural or epidural space, utilize the lateral view. Subarachnoid
contrast will flow away from the tip of the needle quickly and will outline the nerve
roots. Subdural and epidural contrast will not mix with CSF and will appear relatively
dense (Fig. 8.4). Furthermore, subdural and epidural contrast will move much more
slowly than their subarachnoid counterpart.23 Epidural contrast will coat the periphery
of the dura and nerve root sleeves. Remove the spinal needle and connected tubing.
Obtain AP, three lateral (neutral, flexion, and extension) and bilateral oblique
radiographs of the lumbosacral spine (LSS) with the patient in a recumbent to
semi-recumbent position (Fig. 8.5).27 It may be necessary to flatten the table top to
evaluate the conus medullaris and upper lumbar nerve roots. Recently, Suojanen et
al have suggested obtaining a lateral weight-bearing film during myelography as a
means of improving detection of spinal stenosis.28
Cervical Myelogram
Most often a lumbar puncture will be performed for cervical myelography. In
this setting, with the table top tilted up approximately 30˚ to 45˚, inject 12 cc of
Omnipaque 300 into the subarachnoid space. Use the wet-to-wet technique to
minimize the risk of air entering the subarachnoid space. Remove the spinal needle
and the connected tubing. Place a pillow under the patient’s chin. Tilt the table
down approximately 30˚ to 45˚ such that the patient’s head is tilted down. Monitor
the flow of contrast with fluoroscopy. Your goal is to outline the cervical nerve root
sleeves while avoiding the intracranial transit of contrast material. This latter step
will limit potential neurotoxicity of the contrast agent.
Myelography 113
Fig. 8.4. Lumbar myelogram

performed via an L2-3 punc-
ture. A, B) PA and lateral
fluoroscopic spot films dem-
onstrate Omnipaque within
the subdural and subarach-
noid compartments. The
subdural contrast is more
peripheral in location (ar-
rows) and does not outline
the nerve roots as we expect
to see with subarachnoid
contrast. The subarachnoid
contrast is centrally located
within the spinal canal.
8
Fig. 8.5. Lumbar myelogram in a
71 year old female with spondy-
lolisthesis at L4-5. Lateral flexion
view demonstrates an almost two-
fold increase in the degree of
anterolisthesis at L4-5 as com-
pared with the lateral hyperexten-
sion view. The moderate-sized
ventral extradural defect noted in
the lateral flexion position has
increased to a large ventral extra-
dural defect in the lateral hyper-
extension position. A mild to
moderate increase in the ventral
extradural defects at L1-2, L2-3
and L3-4 is identified in the hy-
perextension lateral position as
compared to the flexion lateral
position.
If a cervical puncture has been performed, inject 12cc of Omnipaque 240 into
the subarachnoid space. Use the wet-to-wet technique to minimize the risk of air
entering the subarachnoid space. Remove the spinal needle and connecting tubing
as a unit. If contrast is well-distributed throughout the cervical spine, place a pillow
under the patient’s chin and position the patient for overhead radiographs. Otherwise,
under fluoroscopic guidance, tilt the table top to assist with the distribution of contrast
material. Again, try to avoid the intracranial flow of contrast.
Once you are satisfied with the distribution of contrast within the cervical spine,
obtain the following radiographs: an AP radiograph with 15–20˚ cephalad angulation,
three cross-table lateral radiographs of the upper and mid-cervical spine (neutral,
flexion, extension), three Swimmer’s views of the lower cervical spine (neutral, flexion,
extension) and bilateral 45˚ oblique radiographs with the central ray angled 15–20˚
cephalad relative to C4 (Fig. 8.6).29
Thoracic Myelogram
A thoracic myelogram will be performed via a lumbar or cervical puncture.
Therefore you will want to inject 12 cc of Omnipaque 300 into the thecal sac via
connecting tubing under fluoroscopic guidance. Use the wet-to-wet technique
described above. Remove the needle and tubing once the contrast has been
administered. Tilt the table top to help redistribute the contrast media. Once you
have adequately outlined the nerve root sleeves, position the patient for the following
radiographs: an AP radiograph, three lateral, radiographs (neutral, flexion, extension)
and bilateral 70˚ oblique radiographs.29
Total Myelogram
A total myelography refers to evaluation of the cervical, thoracic, and lumbar
spinal cord and nerve roots with intrathecal contrast media. Whether performed via
8 a lumbar or cervical puncture, administer 12cc of Omnipaque 300 into the thecal
sac via connecting tubing under fluoroscopic guidance. Use the wet-to-wet technique
described above. Remove the needle and tubing once the contrast has been
administered. Obtain radiographs of each area of interest as you proceed—i.e., if a
Fig. 8.6. Cervical myelogram, performed via an L2-3 puncture, in a 61 year old
male. A) The central AP fluoroscopic spot radiograph was obtained at approxi-
mately 15˚ cephalad angulation, tangential to the intervertebral disc spaces. The
oblique views demonstrate the exiting nerve roots adequately. Tarlov cysts are iden-
tified at the right C7 and probably C8 nerve root sleeves (arrowhead). B, C)
Cross-table lateral and swimmer’s radiographs of the cervical spine demonstrate
the entire cervical spine. The swimmer’s view is also ideal for demonstrating the
upper thoracic spine as well. Ventral extradural defects are present at C3-4, C5-6,
C6-7, and T2-3. A posterior extradural defect is present at C3 (arrow). (Courtesy of
B. Ghelman, The Hospital for Special Surgery.)
Myelography 115
lumbar puncture has been performed, obtain radiographs of the lumbar region prior
to redistributing the contrast to the thoracic region. In each area obtain AP, three
lateral (neutral, flexion, and extension), and bilateral oblique radiographs, angling
the x-ray tube as described in the appropriate subsections above.
Post-Myelography Computerized Tomography (PMCT)
PMCT should be obtained in every patient who has undergone myelography.
The accuracy of myelography and PMCT is greater than the accuracy of either
myelography or PMCT alone. 30 PMCT offers direct, rather than indirect,
visualization of the intervertebral disc. This improves PMCT’s sensitivity to small
discs over that of myelography.6 PMCT can distinguish between an extradural defect
due to bony spurs (hard discs) versus an extradural defect due to disc herniations
(soft discs) (Fig. 8.7). PMCT can also confirm a sequestered disc herniation (Fig.
8.8). Furthermore, PMCT can distinguish between severe spinal stenosis and a
complete spinal block (Fig. 8.9). PMCT can also demonstrate intradural metastases
not suspected on conventional myelography (Fig. 8.10).
For best results, obtain PMCT within an hour of myelography.31 In those cases
where severe stenosis is present, it may be necessary to delay or repeat PMCT at 6
hours post-myelography to demonstrate the intrathecal contrast media, and hence 8
improve the sensitivity of the examination at sites distant to the level of stenosis.
PMCT is usually not helpful after 24 hours as 85% of the contrast media has been
excreted into the urine by that time.31
PMCT may be obtained with the patient in the supine or prone position. Axial
images should be obtained through the entire region studied. Subsequently, thin
Fig. 8.7. Lumbar myelogram in a 35 year old female with left-sided sciatica. A, B)
Frontal and LPO fluoroscopic spot radiographs demonstrating focal stenosis of the
thecal sac on the left side at L4-5. The left L5 nerve root is effaced at the level of the
L4-5 intervertebral disc space (arrowhead). It does not exit beneath the left L5
pedicle as its contralateral nerve root does (small arrow). C) Transaxial CT image,
bone window technique, at L4-5 demonstrates 50% compression of the left side of
the thecal sac and displacement and/or compression of the left L5 nerve root (large
arrow).
Fig. 8.8. Lumbar myelogram in 79 year old male with right-sided sciatica. Preliminary
lumbar spine radiographs demonstrate six non rib-bearing lumbar vertebrae. A, B)
Frontal and lateral fluoroscopic spot radiographs demonstrate segmental spinal steno-
sis at L4-5, greater than at L5-6. Effacement of the both L5 and the right L6 nerve roots
at the level of the L4-5 and L5-6 intervertebral disc spaces, respectively, is noted. Pos-
terior L5 vertebral body osteophyte contributes to the ventral extradural defect at L4-5
(arrow). Apex levoscoliosis is centered at L4-5. C) Transaxial CT image, bone window
technique, at the level of L4-5. Vacuum is identified within a posterolateral soft tissue
8 mass consistent with a sequestered disc herniation (arrows).
Fig. 8.9. Complete myelogram, performed via an L3-4 puncture, in an 80 year old
male with transitional cell carcinoma, and prostate cancer. He has had a partial L5
vertebrectomy, placement of methylmethacrylate at L5, and posterior spinal fixa-
tion from L4 to S1 for metastatic prostate cancer. Myelography was requested for
increasing difficulty with urination. A, B) Frontal and lateral fluoroscopic spot ra-
diographs are suspicious for a complete block at L3-4. C) Transaxial CT image,
bone window technique, at L5 demonstrates subarachnoid contrast. This indicates
that the presence of a partial block at L3-4. Methylmethacrylate is centrally placed
within the residual L5 vertebral body, Cotrel-Dubosset rods are identified
posterolaterally. A large ventral extradural soft tissue mass is interposed between
the vertebral body and the thecal sac, consistent with metastatic tumor (arrows).
Myelography 117
Fig. 8.10. Complete myelogram, performed via an L2-3 puncture, in a 49 year old
male with vague low back pain. He has a history of non-Hodgkins lymphoma
which was diagnosed two years previously. Post-myelographic frontal and lateral
radiographs of the lumbar spine were normal (not shown). A marked dilutional
effect of Omnipaque 300 in this large patient rendered the thoracic spine radio-
graphs unhelpful. There was no delay in the transit of contrast from the lumbar to
the cervical spine. A) Transaxial CT image, soft tissue window, at the level of T9.
An intradural mass is identified along the left side, an extradural component can
not be excluded. A smaller intradural lesion is noted on the contra-lateral side. The
intramedullary region is spared. A Schmorl’s node is present along the anterior 8
aspect of the T9 vertebral body. Bilateral paraspinal soft tissue masses, left greater
than right, probably represent adenopathy. B, C) Transaxial T1-weighted spin echo
magnetic resonance images, pre- and post-gadolinium, at the level of T9. Low
signal intensity is identified within a left-sided spinal mass with intradural and
extradural components (asterisk), bilateral paraspinal soft tissue masses, and the
left erectae spinae muscle. Heterogenous enhancement of these masses is consis-
tent with metastatic lymphoma. The spinal cord is displaced. However, there is no
enhancement of the spinal cord.
sections, ranging from 3.0 to 5.0 mm, should be obtained parallel to the intervertebral
discs at 3.0 to 5.0 mm intervals. (In the cervical spine, slice thickness and interval
should be approximately 3.0 mm, whereas in the lumbar spine, section thickness
and interval should be closer to 5.0 mm.) In patients with moderate to severe scoliosis,
truer axial sections may be obtained by placing the patient in the decubitus position
and/or tilting the gantry.32
Patient Management
With the appearance of second-generation nonionic contrast agents, myelography
has become an outpatient procedure. Following myelography, the patient’s head
should be kept erect to prevent the intracranial passage of contrast. Although most
authors recommend bedrest to reduce CSF leakage and subsequent headache, a
minority encourage patient activity to promote the absorption of contrast media
through the arachnoid villi.31 A minimum of six hours bedrest and head elevation of
at least 10˚ is prudent. Adequate hydration is necessary, both 24 hours before and
24 hours after the exam, to abet renal excretion of contrast material. Administer
supportive therapy for adverse reactions as indicated. Intravenous hydration may be
necessary in patients with severe nausea and vomiting. Outpatients who have minimal
complaints may be discharged at four hours post-myelogram. A prolonged stay or

hospitalization may be required in those patients with more severe adverse effects.
Complications
Although a series of complications are listed below, by far the most frequent are
headaches, nausea, and vomiting.33 Postmyelography headaches are contributed to
by CSF leakage at the dural puncture site.34 Thus, headaches seem to be correlated
to the needle size.33,35 One of the most serious acute complications is herniation,
often avoidable if an existing head CT or MRI has been reviewed prior to
myelography. Reportable, but rare, complications include epidural hematoma,
paraplegia, dural venous thrombosis, seizures—seen in those patients who get larger
doses of contrast, and in those with a history of seizures.36-40
• headache
• nausea/vomiting
• nystagmus
• meningitis/meningeal irritation
• herniation
• paralysis
• spinal cord or nerve root puncture1
8 • blood vessel puncture1
• contrast injection into the cord1
Pathology
Evaluate CSF flow within the thecal sac as well as the contour, size, and location
of the thecal sac. CSF should flow freely throughout the subarachnoid space. The
thecal sac should be smooth and of uniform diameter, tapering within the lower
lumbar spine. It should sit centrally within the bony confines of the spinal column
(Fig. 8.11). Identify the conus medullaris , an area of relative radiolucency at L1-2
(L2-3 in infants less than three months). The contrast column should have uniform
density, without filling defects, except for the relatively radiolucent area representing
the spinal cord. The spinal cord has two fusiform areas of enlargement—C2 to T2
and T10 to the conus medullaris. Within the cervical spine, the spinal cord normally
occupies 50–75% of the subarachnoid space. The cervical spinal cord is considered
atrophied or enlarged if it is <50% or >80% of the subarachnoid space, respectively.
The nerve roots should exit bilaterally and symmetrically from the thecal sac, exiting
essentially perpendicular to the cervical thecal sac and exiting progressively more
obliquely down as they are more caudad. There are 31 pairs of spinal nerves: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. In the cervical spine the
nerve roots exit cephalad to the vertebra for which they are numbered—ie the C1
nerve roots exit between the occiput and the C1 vertebra. Caudad to the cervical
spine the nerve roots exit caudad to the vertebra for which they are numbered.
If the contour of the thecal sac is irregular, either focal or diffuse, consider the
diagnosis of arachnoiditis, a condition representing irritation of the arachnoid layer
1These complications have been reported with cervical punctures. However, they
may also occur in patients with a low-lying conus medullaris who undergo a lumbar
puncture.19
Myelography 119
Fig. 8.11. Thoracic post-myelogram CT scan, bone technique, in a 26 year old patient
status post-motor vehicle accident. A) At the level of T7, there is left anterolateral
displacement of the thecal sac, relative enlargement of the spinal cord as compared
with the thecal sac consistent with cord edema, and multiple fractures involving the
vertebral body and right transverse process. Bilateral paraspinal widening and pleural
effusions are identified. B) At the level of T6, the thecal sac is centrally located within
the spinal canal. The spinal cord occupies approximately 60% of the thecal sac. Frac-
tures involving the vertebral body and the right transverse process, and bilateral
paraspinal soft tissue widening and pleural effusions are again identified. (Courtesy of
B. Ghelman, The Hospital for Special Surgery.)
8
of the dura secondary to either contrast or subarachnoid blood (Fig. 8.12). Impaired
filling or clumping of the nerve roots may accompany the irregular, narrowed, or
shortened thecal sac. Focal smooth outpouchings of the dura only (meningoceles)
or dura and spinal cord/nerve roots (myelomeningocele) may occur anteriorly at
the level of the sacrum, or laterally at the level of the thoracic or lumbar spine.
Pseudomeningoceles refer to extravasated collections of CSF related to inadvertent
tears of the dura occurring at surgery. Meningoceles and myelomeningoceles fall
under the group of midline fusion anomalies that may affect mesenchymal, neural
or osseous structures. These anomalies, the spinal dysraphisms, also include spinal
lipomas, diastomatomyelia, and the dorsal dermal sinus.
The thecal sac may be focally or diffusely narrowed or enlarged. Most often there
will be focal narrowing of the thecal sac at one or more levels—an acquired condition
called segmental stenosis (Fig. 8.5). This diagnosis should be made when the thecal
sac acquires a waist at one or multiple level(s) or when the anteroposterior diameter
of the thecal sac on the lateral myelogram radiograph is ≤12 mm.1 Flexion and
extension myelogram radiographs with the patient in the lateral position may
demonstrate stenoses not present on the neutral lateral myelogram radiograph.
Ligamentum flavum hypertrophy or mineralization, posterior longitudinal ligament
mineralization, disc bulge or herniation, facet joint osteoarthritis, vertebral body
osteophytes, spondylolysis, conditions manifesting bone overgrowth, and/or
post-traumatic or post-operative bone fragments may all contribute to segmental
stenosis. The flow of CSF may be impeded depending on the severity of stenosis. In
cases of a complete block CSF will be prohibited from flowing throughout the
entire thecal sac. Diffuse stenosis of the thecal sac is usually congenital, as in
achondroplasia, a dwarfism characterized by diffuse narrowing of the spinal canal
and thecal sac in both their anteroposterior and transverse dimensions. (Narrowing
Fig. 8.12. Lumbar myelogram in

a 55 year old female several years
status post an L5-laminectomy for
spinal stenosis and multiple
intra-abdominal surgeries. Frontal
and LAO radiographs demon-
strate circumferential lobulations
and tapering of the contour of the
thecal sac at L4 and L5 (arrow-
heads). The presumptive diagno-
sis was arachnoiditis. (Courtesy of
B. Ghelman, The Hospital for Spe-
cial Surgery.)
of the interpediculate distance is present on plain radiographs of the spine.) Patients

with hypochondroplasia and Morquio’s may also manifest diffuse spinal stenosis.
Generalized widening of the thecal sac, dural ectasia, is a characteristic of
neurofibromatosis. This may be accompanied by posterior scalloping of the vertebral
bodies, widening of the neural foramina in association with dumbbell neurofibromas,
8 and/or lateral thoracic meningoceles.
Displacement of the thecal sac indicates the presence of an extradural mass which
may represent epidural fibrosis in the post-operative patient, epidural lipomatosis
in patients taking steroids or with Cushing’s disease, an epidural hematoma in the
setting of trauma, an extradural tumor (multiple myeloma, metastases, lymphoma,
sarcoma), or extension of a neighboring intraosseous or intradiscal process (Fig. 8.11).
The conus medullaris may lie caudad to its normal position, held in its place by
a fibrous band, bone spur or mass. This is referred to as a tethered cord and may be
suspected in the setting of fusion anomalies of the neural arches detected on plain
film.
The size of the spinal cord may be affected by trauma, tumor, infection, or
inflammation. Focal spinal cord enlargement, focal cord compression by retropulsed
bone fragments or traumatic disc herniation, cord transection or nerve root avulsion
may be present in the early post-traumatic period (Fig. 8.11). Focal spinal cord
atrophy with or without syringomyelia (a central collection of fluid within the spinal
cord) represents a delayed response to trauma. Tumors which enlarge the spinal cord
are intramedullary (Fig. 8.2A and B). Those tumors which displace the spinal cord
only are extramedullary/intradural. Those which displace both the spinal cord and
thecal sac are considered extradural (Fig. 8.10). The ependymoma is the most
common type of intramedullary tumor. Meningiomas, schwannomas, and
neurofibromas are the most common extramedullary/intradural tumors. Edema,
secondary to acute infection or inflammation, may result in cord enlargement.
Frequently, two or more nerve roots share a common nerve root sheath. These
conjoined nerve roots occur most often at L5-S1 (Fig. 8.13). CSF-filled outpouchings
occurring along nerve root sheaths, most often sacral nerve root sheaths, are called
nerve root cysts (Fig. 8.6A). They may cause symptoms mimicking disc herniation.
Myelography 121
Fig. 8.13. Lumbar myelogram in a 50 year old

male with left sciatica. A right anterior oblique
radiograph demonstrates two nerve roots exit-
ing beneath the left L4 pedicle consistent with
conjoined nerve roots (arrowheads). Subchon-
dral sclerosis and narrowing of the adjacent L4-5
facet joint is noted. (Courtesy B Ghelman, The
Hospital for Special Surgery.)
References
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media for myelography. Am J Neuroradiol 1992; 13:1515-9.
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13. Skalpe IO, Amundsen P. Lumbar radiculography with Metrizamide. A nonionic
water-soluble contrast medium. Radiology 1975; 115:91-5.
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16. Rice JF, Bathia AL. Lateral C1-2 puncture for myelography: Posterior approach.
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18. Raininko R, Sonninen P. Dorsal CSF space at CI-II level. Technique of cervical
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19. Katoh Y, Itoh T, Tsuji H et al. Complications of lateral C1-2 puncture myelogra-
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8 20. Grainger RG, Kendall BE, Wylie IG. Lumbar myelography with metrizamide—A
new nonionic contrast medium. Br J Radiol 1976; 49:996-1003.
21. Witwer G, Cacayorin ED, Bernstein AD et al. Iopamidol vs. metrizamide for my-
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8
CHAPTER 9
Discography
Jacqueline C. Hodge
Introduction
Discography is a diagnostic technique which permits evaluation of the
intervertebral disc. Via the injection of an intradiscal contrast agent, the nucleus
pulposus is demonstrated. Schmorl and Junghanns described its use, in vitro, in
1932.1 Although initially utilized, in vivo, in the lumbar spine by the Swedes as of
1948, Smith et al adapted the technique to the cervical spine in 1952.2,3 Subsequently,
its use has also been described in the thoracic spine.4
Radiography techniques, either biplane radiography, C-arm fluoroscopy, or
computerized tomography (CT), are utilized to localize the intervertebral disc in
vivo.5,6 Additionally, plain radiography or fluoroscopic spot views, consisting of AP
and lateral projections, may be used to document the exam at its completion (Fig.
9.1). Post-discography CT, providing an axial view of the intervertebral disc, is a
useful adjunct to post-discography plain radiographs, particularly in cases where
disc pathology is present (Fig. 9.2).7-9 Although craniocaudal and caudocranial
tangential radiographs have been suggested by some authors, these are not essential.5
Furthermore, tangential views have a series of disadvantages. They must be tailored
to each individual patient. Additionally, tangential views suffer from decreased
sharpness, especially in patients with advanced degenerative disc disease. Lastly,
tangential views result in larger doses of gonadal radiation than CT. However,
tangential views may be helpful when post-discography CT is unavailable to provide
information about the position, size, and shape of a herniated disc or annular tear. If
available, digital subtraction may be useful; it can improve image quality and
sensitivity of disc pathology in the cervical spine.10
Today, there is a broad spectrum of opinion regarding the efficacy of discography.
Those in favor remark on discography’s unique ability to supply information about
whether a pathologic-appearing disc is responsible for the patient’s symptomatology,
a factor of paramount importance to the surgeon contemplating discectomy.11 Further
support for discography comes from the findings of Jensen et al who found a relatively
high frequency of disc degeneration in asymptomatic volunteers.12 The opposition
camp comments on false-positive and false-negative test results, as well as the patient’s
unreliability to categorize his or her pain pattern.13,14 Some of the discordant results
of discography may be explained by the inadvertent injection of contrast into a
cavity which is not the true nucleus of the disc.15
The origin of discogenic pain is not known with certainty. Whether discogenic
pain is due to: a) injury to the disc that promotes neurochemical alterations within
the disc, b) phospholipase A2, an intradiscal substance that promotes an inflammatory
response, or c) events within the endplates of the vertebral bodies, discography remains
a pain-provoking procedure.16-18
Discography 125
Fig. 9.1. This 35 year old male had two level discography, both via lateral extradu-
ral approaches. A, B) At L4-5, the opacified intervertebral disc has the configura-
tion of a “hamburger on a bun” (normal). Contrast is confined to the nucleus
pulposus. At L5-S1, contrast opacifies the entire intervertebral disc space consis-
tent with degeneration of the disc.
Fig. 9.2. This 35 year old female presented with discogenic pain. Three level dis-
cography was performed. At the first appointment, discography was performed at
L3-4 and L4-5 (not shown), via an extradural approach. The configuration of the
discs was normal. The procedure was nonprovocative. At the final visit, L5-S1
discography was performed via a midline transdural approach with a coaxial tech-
nique. The examination was not provocative. A, B) Fluoroscopic frontal and lateral
spot views demonstrate contrast within the nucleus pulposus and annulus fibrosus
consistent with degeneration of the disc. C) On post-discography CT a midline
HNP, not visible on spot films, is noted (arrowheads).
Lumbar Discography
Indications
Lumbar discography is rarely performed as the initial study in the patient
presenting with low back pain. The exception to this may be in those practices
where magnetic resonance imaging (MRI) is not available and there is a strong clinical
suspicion of discogenic pain. Rather, lumbar discography is reserved for those cases
where the patient’s pain is felt to be discogenic in origin and lumbar CT, myelography,
CT/myelography, and/or MRI have been negative or provided conflicting results.
The following list includes the more frequent indications for lumbar discography:
• normal or equivocal MRI with persistent discogenic pain (Fig. 9.3),19,20
• normal or equivocal myelogram, CT/myelogram (Fig. 9.4, 9.5),21
• symptomatic assessment of a known degenerative disc,11,22
• pre-operative planning to determine the extent of arthrodesis (Fig. 9.6),23
• differentiate between recurrent disc herniation and fibrosis in the
post-operative lumbar spine surgery patient (Fig. 9.7),24,25 and
• pre-procedure assessment for percutaneous lumbar discectomy or
chemonucleolysis (Fig. 9.8).26
Contraindications
• posterior spinal fusion precludes midline posterior discography
• intertransverse fusion and/or complete sacralization preclude lateral
discography
Equipment
22g 6" spinal needle or 20g 3-1/2" and 25 g 6" spinal needles, 18g 1-1/2" and
25g 5/8" needles, 1cc and 10cc syringes, sterile towels
9 Technique
The patient should be kept on a liquid diet for approximately eight hours prior
to the procedure. Systemic premedication is not advised as it may interfere with the
provocative part of the examination.27 A single dose of prophylactic broad-spectrum
antibiotics, given intravenously (IV) 30 minutes prior to discography or intradiscally
with contrast agent, has been shown to reduce the incidence of discitis.28,29 However,
prophylactic antibiotic administration is not the standard of care, and its use can be
left to the reader’s discretion.
Lateral Approach30
The lateral approach is the preferred method for performing discography (Fig.
9.9). It is an extradural approach, thereby minimizing side effects. The patient is
placed in the prone position . The midportion of the intervertebral disc space of
interest, x, is localized fluoroscopically in the frontal projection. Determine a site, y,
on the side contralateral to the painful side and four fingerbreadths’ width lateral to
x. Cleanse the skin with Betadine (Poviodone-Iodine, Purdue Frederick) or
Stanhexidine (Chlorohexidine Gluconate, Stanley Pharmaceuticals). Administer 1%
Lidocaine as local anesthetic at the site of interest and in the proposed needle track.
(Omit local anesthesia in patients with Lidocaine allergies.) Starting at y, direct a
22g 6" spinal needle towards x. The needle should be angled approximately 45˚
relative to the patient’s back.
Needle position should be checked at frequent intervals with biplane or C-arm
fluoroscopy. Ask the patient to inform you of any radicular pain that occurs during
positioning of the needle. The acute onset of radicular pain suggests that the needle
is abutting a nerve. To redirect the needle, withdraw the needle to the very superficial
Discography 127
Fig. 9.4. This is a 53 year old female with a left L5 radiculopathy for several months.
A) Post-myelogram CT performed within 24 hours of post-discography CT was
normal at L4-5. B) Post-discography CT demonstrates a large left herniated disc
fragment laterally (arrowheads). (Taken from J Spinal Disorders 1994;7:473.)
Fig. 9.3. This 38 year old female is status/post transfacetal fixation at L5-S1. She under-
went two-level discography, via extradural approaches, for presumed discogenic pain.
A, B) The L3-4 and L4-5 discograms demonstrate normal configuration of the discs.
However, the exam is provocative only at the latter level. C, D) Transaxial CT scan, bone
window technique, confirms the normal appearance of the L3-4 and L4-5 disc spaces.
Fig. 9.5. Forty year old male with left lumbar radiculopathy. A) Frontal radiograph
taken after posterolateral extradural discography at L3-4 and prior to extradural L4-5
discography. Contrast is predominantly within the nucleus pulposus. However, a tiny
amount of contrast is noted within a Schmorl’s node at the superior endplate of L4
(arrow). B) Lateral tomogram at computerized tomography, at least 30 minutes after
discography. Contrast within the Schmorl’s node is now much more apparent. C)
Transaxial computerized tomography at L3-4 demonstrates pooling of contrast within
a central disc bulge. D) Transaxial computerized tomography at L3-4, more caudad to
those in C. Omnipaque is identified within the cavity of the L4-endplate.
subcutaneous tissues and then redirect it.) If bone is encountered, check the lateral projection
to determine what osseous structure is obstructing the needle transit (Fig. 9.10).
Lateral Approach (Alternate)31

This approach is reserved for those patients who are unable to lay prone. However,
the principle is the same as that for the approach described in the preceding section.
This approach is also extradural. The major disadvantage of placing the patient in
the lateral position is that the patient tends to rotate their pelvis away from the
needle introducing an oblique dimension to the lateral radiograph.
Place the patient in the decubitus position.31 In patients with a scoliosis, placing
a pillow under their waist will help straighten out their spine. Using aseptic technique,
Discography 129
Fig. 9.6. This 38 year old female

had known disc degeneration at
L4-5 and L5-S1. L3-4 discography
was requested to determine the
extent of spinal fusion. A) The AP
radiograph demonstrated a “ham-
burger on a bun” appearance of
the disc which represents a nor-
mal disc configuration. B) The lat-
eral radiograph confirms the nor-
mal configuration of the disc. The
exam was not provocative. Fusion
was limited to L4-S1 on the basis
of discography.
Fig. 9.7. This 44 year old female is 11 months status/post lumbar discectomy at L4-5.
She presents with recurrent back pain and right radiculopathy. A) Post-myelography
CT, bone window. A central and right paramedian soft tissue mass results in mild ven-
tral extradural compression of the thecal sac (arrows). There is volume averaging through
the adjacent vertebral endplate posteriorly. B) Post-discography CT, bone window. The
right paramedian soft tissue mass does not contain contrast implying that it probably
represents fibrosis (arrows). The shape of the soft tissue mass is unlikely to represent a
sequestered disc fragment (arrows). Partial voluming is noted along the posterior as-
pect of the intervertebral disc space.
direct a 22g 6" spinal needle towards the intervertebral disc space of interest. Start
advancing the needle from a site four finger breadths lateral to the midline, and
direct the needle towards the midline. The needle should be advanced from the side
contralateral to the painful side to avoid later confusion as to whether lateral soft
tissue contrast represents disc pathology or is related to technique.
Midline Approach
The midline, or posterior, approach is transdural and therefore has the
complications of myelography in addition to those of discography (Fig. 9.9). It may
only be utilized below the level of the spinal cord. Additionally, this approach requires
Fig. 9.8. Middle-aged male with left-sided sciatica and disc degeneration on MRI.
Two-level discogram was requested to evaluate disc symptomatology. A) Sagittal
T2-weighted fast spin echo image demonstrates mild loss of disc height and signal
at L4-5 and L5-S1. A disc herniation is identified at L4-5. B, C) Preliminary AP and
lateral radiographs, respectively. The frontal view demonstrates bone hypertrophy
on the left side of L4-5 (arrowhead). D, E) With the patient prone, a right posterolat-
eral approach was utilized for L4-5 discography. (The arrowhead denotes the hy-
pertrophic changes on the patient’s left side.) Frontal and lateral fluoroscopic spot
views, respectively, demonstrate disc degeneration with posterior extravasation of
contrast consistent with a disc herniation. The exam was provocative at this level
as well.
Discography 131
Fig. 9.9. Transaxial schematic

diagram of the lumbar spine
illustrating the three basic
approaches to discography:
1. midline, 2. posterolateral,
and 3. lateral.
Fig. 9.10. Lateral schematic of the lumbar spine

illustrating obstacles to lateral discography. With
the needle positioned at the level of the upper half
9
of the vertebral body, the transverse process may
obstruct needle transit (*). The facet joint may ob-
struct needle transit at the level of the lower half
of the vertebral body (o).
a coaxial technique utilizing a shorter/larger bore outer needle and a longer/smaller

bore inner needle (Fig. 9.2).
The patient is placed in the prone position. Identify the center of the intervertebral
disc space in the AP plane fluoroscopically (Fig. 9.11A). Next, rotate the C-arm 90˚
and localize the interspinous space relating to the intervertebral disc space of interest.
Using aseptic technique, and following the administration of local anesthetic, advance
a 20 gauge 3-1/2" spinal needle parallel to the interspinous space. Advance the needle
to the posterior bony margin of the spinal canal without piercing the dura, if possible
(Fig. 9.11B). Confirm the midline position of the 20 gauge spinal needle on the AP
projection. Remove the stylette of the 20 gauge needle and insert a 25 gauge 6"
spinal needle through its lumen, piercing the dura to enter the intervertebral disc
space. It may be necessary to deflect the tip of the 25 gauge needle prior to inserting
it into the lumen of the 20 gauge needle to facilitate its entry into the intervertebral
disc space (Fig. 9.11C).
If you have return of CSF when you remove the stylette from the 20 gauge spinal
needle, you have advanced the needle too far. However, there is no need to withdraw
Fig. 9.11. Schematic drawings of the lumbar spine illustrating the coaxial tech-
nique utilized in the transdural approach. A) AP view of the lumbar spine demon-
strating the midline position of the 20 gauge needle for L3-4 discography. The
needle is directed towards the head. B) Lateral view of the lumbar spine, L3-4. The
20 gauge needle is directed into the interspinous space, parallel to the adjacent
spinous processes. The 20 gauge needle should not be advanced beyond the pos-
terior margin of the spinal canal to avoid piercing the dura. C) Lateral view of the
lumbar spine, L3-4. The 25 gauge needle is placed through the lumen of the 20
gauge needle. The tip of the 25 gauge needle had to be deflected to guide the
needle into the nucleus pulposus.
Discography 133
the 20 gauge spinal needle because it has already pierced the dura. Ideally, you would
like to create as small a hole as possible in the dura to minimize the incidence of
post-procedure headaches. Therefore you would like to pierce the dura with the 25
gauge needle only.
At the completion of the exam it is important to remove both the 20 and 25
gauge needles together. Do not remove the 25 gauge needle separately, especially if it
has been bent. The needle is weakened at the site where it has been bent and is prone
to break when it is being passed back out through the lumen of the 20 gauge needle.
Posterolateral Approach32
Under ideal circumstances, this is an extradural technique with the needle passing
through the ligamentum flavum (Fig. 9.9). However, whether the puncture is intra-
or extradural, the needle will pass through the spinal canal. There is no advantage of
this approach as compared with the alternative approaches described above. However,
this technique is included for completeness.
Place the patient in the prone position. Locate the spot, z, that is 1.5 cm lateral
to the midline at the level of the interspinous interval. Following the administration
of local anesthetic, advance a 22 gauge 6" spinal needle at an angle of approximately
30° relative to the sagittal plane. If possible, approach the disc space from the side
that is contralateral to the symptomatic side.
The needle tip should be within the nucleus pulposus, the central third of the 9
intervertebral disc, on both AP and lateral views (Fig. 9.6). Once satisfactory needle
position has been achieved, draw up 1 cc of nonionic contrast into a 1 cc tuberculin
syringe. Inject 1.0 cc of nonionic contrast into the nucleus pulposus. Note the amount
of contrast administered and the resistance during the injection.32 Obtain AP and
lateral radiographs. Have the patient classify the pain pattern during the intradiscal
injection as concordant or discordant with their pain of presentation.
Typically, Omnipaque 180 or 300 is given intradiscally. In those patients with a
history of contrast reaction, intradiscal saline may be substituted for contrast. With
saline administration, the examiner will still be able to obtain information pertaining
to the provocative part of the exam. Limited information regarding the morphology
of the disc can be inferred from the amount of resistance during the injection of
saline. However, the examiner will not be able to visualize the distribution of saline
within the disc.
Post-discography CT may be performed at the intervertebral disc space of interest.
Sections should be obtained parallel to the disc space at 3 x 3 mm intervals. If the
patient has undergone recent CT/myelography, simultaneous interpretation of these
two sets of images, obtained at the same gantry tilt of the CT scanner, can distinguish
between post-operative fibrosis and recurrent disc herniation (Fig. 9.7).25
Complications
• discitis (0.7-4%)28,34,35
• nerve root irritation/trauma
• chemical meningitis (transdural approach)
• CSF leak (transdural approach)
• headache (transdural approach)

• retroperitoneal trauma
• needle breaks (coaxial approach)
Thoracic Discography
Thoracic discography is performed much less frequently than lumbar discography,
most likely related to the lower incidence of intervertebral disc disease in the thoracic
spine.36 However, the indications, contraindications, and complications are the same
for thoracic and lumbar discography. In addition, thoracic discography is
contraindicated in the presence of cord compression. Expansion of the disc during
contrast injection may create or exacerbate a myelopathy.5 Discontinue anticoagulant
therapy and document normal coagulation factors before proceeding with
discography.5 A pneumothorax may complicate a thoracic discogram.4
Equipment
25g 3-1/2" spinal needle, 18g 1-1/2" and 25g 5/8" needles, 1cc and 10cc syringes,
sterile towels
Technique4
Patient preparation is as described under “Lumbar discography”. With the patient
prone and at the disc space of interest, localize the region lateral to the pedicle and
9 medial to the rib head using fluoroscopy. Approach the intervertebral disc space
from the side opposite the painful side. If the pain is midline, you may approach
from either side. Prep and drape the region of interest. Administer local anesthetic.
Enter the disc space with a 25g 3-1/2" spinal needle directed towards the midline
and angled at approximately 30˚ relative to the sagittal plane. Angle the needle
slightly such that its tip points cephalad. This approach is similar to the posterolateral
approach described for lumbar discography (Fig. 9.9). The needle may be intra- or
extradural in its course.
Draw up 1 cc of nonionic contrast into a tuberculin syringe. Inject between 0.3
and 0.5cc of nonionic contrast into the disc. Note the volume and pressure during
contrast administration. Have the patient classify the pain pattern during the
intradiscal injection as concordant or discordant with their pain of presentation.
Obtain AP and lateral radiographs of the T-spine to document the exam, and an
erect chest radiograph to exclude a pneumothorax. Post-discography CT at 2 x 2cm
intervals with slices parallel to the disc space may be obtained.
Cervical Discography
Cervical discography is more commonly performed than thoracic discography,
but is much less commonly performed than lumbar discography. It is an extradural
procedure performed via an anterolateral approach (Fig. 9.12). The indications and
contraindications are as for lumbar and thoracic discography. The complications
include neurovascular injury in addition to nerve root irritation/trauma, discitis,
esophageal perforation, and contrast reaction.
Discography 135
Fig. 9.12. Transaxial

schematic drawing of
the cervical spine illus-
trating the course of the
20g 3 1/2" spinal needle
in relation to the sur-
rounding structures: 1.
internal jugular vein,
common carotid artery,
vagus nerve. 2. vertebral
artery and vein. 3.
esophagus.
Equipment
20g 3-1/2" and 25g 6" spinal needles, 18g 1-1/2" and 25g 5/8" needles, 1cc and
10cc syringes
Technique1
Patient preparation is identical to that described under “Lumbar discography”. 9
The patient should lie in the supine position with the neck slightly hyperextended,
to open up the intervertebral disc spaces anteriorly. With fluoroscopic guidance,
visualize the cervical spine in the lateral projection. Localize the disc space of interest
and determine the degree of cephalad angulation necessary to enter the intervertebral
disc space. Additionally, you will have to angle the needle 30-45˚ relative to the table
top. Prep and drape the skin, and administer local anesthetic. Approach the disc
anterolaterally with a 20 gauge 3-1/2" spinal needle. Place the needle along the
medial border of the sternocleidomastoid muscle, between the carotid artery and
the trachea (Fig. 9.12). Advance the 20 gauge needle to the annulus fibrosus. If you
encounter bone, walk the needle along the vertebral body until its tip enters the
periphery of the disc. Remove the stylette and place a 25 gauge 6" needle through
the 20 gauge needle. Direct the 25 gauge needle into the nucleus pulposus. Confirm
the needle position in the AP and lateral views.
Two additional pointers: it is unwise to attempt the procedure with a single 25
gauge 6" spinal needle because it is too flexible and, therefore, difficult to steer. In
removing the coaxial needle system, remove both components together to avoid the
remote possibility of needle breakage.
Draw up 1 cc of nonionic contrast into a tuberculin syringe. Under fluoroscopic
guidance, inject the nonionic contrast into the nucleus pulposus (Fig. 9.13). Note
the amount of contrast and the pressure during the injection. A normal cervical disc
nucleus pulposus should accept 0.2 to 0.3 cc of contrast and there would be a lot of
resistance to further injection of contrast agent. Have the patient classify the pain
Fig. 9.13. Forty-three year old female with cervicalgia. Previous computerized tomog-
raphy demonstrated disc bulges at C4-5 and C5-6. A, B) Frontal and lateral views of the
cervical spine demonstrate contrast diffusely throughout the C4-5 and C5-6 interverte-
bral discs consistent with disc degeneration. However, the examination was only pro-
vocative at C4-5. Note that the x-ray beam is tangential to the intervertebral disc spaces.
Typically, this would require cranial angulation of the x-ray tube. However, no angula-
tion of the tube was required due to the lack of cervical lordosis in this particular
patient. C, D) Transaxial computerized tomography at C4-5 and C5-6 confirm the
presence of contrast anterior to the thecal sac as was suspected on the lateral view.
Discography 137
pattern during the intradiscal injection as concordant or discordant with their pain
of presentation.
Obtain AP and lateral radiographs of the cervical spine. Post-discography CT
should be performed at 2 x 2 mm intervals, parallel to the disc space(s) of interest.
Post-Procedure Care
If discography has been uncomplicated and performed via an extradural approach,
the patient may leave the department immediately following CT. The patient should
be advised to drink lots of fluid over the next 24 hours to clear the contrast rapidly
from his/her system.
If discography has been performed via a transdural approach, a post-myelogram
protocol should be followed—i.e., bedrest and large amount of fluid intake. Their
head should be kept flat since there is no intrathecal contrast agent.
Interpretation
Five factors must be considered in the interpretation of discograms: volume of
injected contrast, pressure during contrast injection, patient symptomatology during
the injection, correlation with the clinical picture, and lastly the radiologic pattern
of contrast dispersion. The hallmark of degenerative disc disease (DDD) is a disc
that accepts an increased volume of contrast at reduced resistance. The normal volume
of contrast within the nucleus pulposus varies as described under each of the preceding
subsections. The radiographic pattern of contrast is described below.
9
Plain Radiographs
AP and lateral radiographs are the standard views obtained at the completion of
the discogram. These are helpful for distinguishing between:
• normal disc—central collection of unilocular or bilocular contrast (Fig.
9.1, 9.6)
• markedly degenerated disc (Fig. 9.8)
• large ruptured disc (Fig. 9.13)
Annular tears, disc bulges, small disc herniations, and early disc degeneration
may not be apparent on post-discography plain radiographs. In such cases,
post-discography CT is essential (Fig. 9.2, 9.14).
CT
The contrast may have one of five appearances within the intervertebral disc. For
practical purposes, it is impossible to distinguish between a ruptured disc with an
intact posterior longitudinal ligament (PLL) and that with disruption of the PLL.
• normal—contrast confined to the center of the disc
• degenerative disc disease (DDD)—diffuse spread of contrast within the disc
• DDD with bulging of the annulus—contrast diffusely within the disc
with bulging of the anterior, lateral, or posterior annulus; the annulus
remains intact
• ruptured disc—contrast extends from the disc through a rent in the
annulus; the PLL remains intact
• ruptured disc—contrast extends from the disc through rents within the
annulus and PLL.
Fig. 9.14. A 42 year old patient

with presumed discogenic pain.
L3-4 discography demonstrates an
annular tear at approximately 6
o’clock (arrowhead).
References
1. Stuck RM. Cervical discography. Am J Roentgenol 1961; 86:975-82.
2. Lindblom K. Diagnostic puncture of intervertebral disks in sciatica. Acta Orthop
Scand 1948; 17:231-9.
3. Whitecloud TS III, Seago RA. Cervical discogenic syndrome. Results of operative
intervention in patients with positive discography. Spine 1987; 12(4):313-6.
9 4. Schellhas KP, Pollei SR, Dorwart RH. Thoracic discography. A safe and reliable
technique. Spine 1994; 19(18):2103-09.
5. Matsui H, Tsuji H, Itoh T et al. Significance of tangential views in lumbar discog-
raphy. Clin Orthop 1987;221:165-71.
6. Murtagh FR, Arrington JA. Computer tomographically guided discography as a
determinant of normal disc level before fusion. Spine 1992; 17(7):826-30.
7. Sachs BL, Vanharanta H, Spivey MA, et al. Dallas discogram description. A new
classification of CT/discography in low-back disorders. Spine 1987; 12(3):287-94.
8. McCutcheon ME,Thompson WC III. CT scanning of lumbar discography. A use-
ful diagnostic adjunct. Spine 1986; 11(3):257-9.
9. Videman T, Malmivaara A, Mooney V. The value of the axial view in assessing
discograms. An experimental study with cadavers. Spine 1987; 12(3):299-304.
10. Voigt K, von Boltenstern M, Vogl G. Digital subtraction discography. ROFO
Fortschr Geb Rontgenstr Nuklearmed 1988; 148(5):537-40.
11. Horton WC, Daftari TK. Which disc as visualized by magnetic resonance imaging
is actually a source of pain? A correlation between magnetic resonance imaging
and discography. Spine 1992; 17(6)S:164-71.
12. Jensen MC, Brant-Zawadski MN, Obuchowski N, et al. Magnetic resonance im-
aging of the lumbar sacral spine in people without back pain. New Engl J Med
1994;331:69-73.
13. Walsh TR, Weinstein JN, Spratt KF, et al. Lumbar discography in normal subjects.
A controlled prospective study. J Bone Joint Surg 1990; 72A:1081-8.
14. Yasuma T, Ohno R, Yamauchi Y. False-negative lumbar discograms. Correlation of
discographic and histological findings in postmortem and surgical specimens. J
Bone Joint Surg 1988; 70A:1279-90.
15. Quinnell RC, Stockdale HR. An investigation of artifacts in lumbar discography.
Br J Radiol 1980;53:831-9.
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17. Wetzel FT, LaRocca H, Lowery GL, et al. The treatment of lumbar spinal pain
syndromes diagnosed by discography. Lumbar arthrodesis. Spine 1994; 19:792-800.
18. Heggeness MH, Doherty BJ. Discography causes end plate deflection. Spine 1993;
18:1050-3.
19. Brightbill TC, Pile N, Eichelberger RP et al. Normal magnetic resonance imaging
and abnormal discography in lumbar disc disruption. Spine 1994;19:105-7.
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nance imaging and computed tomographic discography in the assessment of lum-
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1982; 33(3):176-82.
22. Buirski G, Silberstein M. The symptomatic lumbar disc in patients with low-back
pain. Magnetic resonance imaging appearances in both a symptomatic and control
population. Spine 1993; 18(13):1808-11.
23. Murtagh FR, Arrington JA. Computer tomographically guided discography as a
determinant of normal disc level before fusion. Spine 1992; 17(7):826-30.
24. Bernard TN Jr. Using computed tomography/discography and enhanced mag-
netic resonance imaging to distinguish between scar tissue and recurrent lumbar
disc herniation. Spine 1994; 19(24):2826-32.
25. Hodge JC, Ghelman B, Schneider R et al. Disc vs. scar in the postoperative pa-
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literature and 12 cases. Mt Sinai J Med 1993;60:321-6.
CHAPTER 10
Percutaneous Blocks
Jacqueline Hodge
Facet Blocks
Facet block refers to the injection of medication into or around the facet joint
for diagnostic and/or therapeutic purposes. The technique, first utilized in the mid
1970s by the orthopedists, Mooney and Robertson, is a controversial one.1 There is
disagreement surrounding the site of the facet injection, the volume of medication
administered during facet injection, and even the efficacy of facet injection.
Nonetheless, in many medical centers, facet blocks play an important role in the
evaluation of the patient with low back pain. Therefore, this chapter will present a
brief description of the clinical, radiologic, and etiologic features of facet syndrome.
Based upon your preferences and your practice setting, you may select an optimal
method of performing facet blocks.
The initial description of the facet block described the intra-articular injection
of medication. However, some researchers have shown that there is no statistically
significant difference in outcome between intra-articular and peri-articular
administration of medication during facet block.2-4 Others argue that medication
must be administered directly into the facet joint, especially when the facet block
has been performed for diagnostic purposes. They argue that a positive response to
pain medications in the peri-facetal region does not imply that the facet joints were
responsible for the pain syndrome. The medication may have had an effect on the
surrounding paraspinal muscles, ligaments, or irritated nerve roots rather than
directly on the facet joint.5 In those patients in whom the primary role of facet
injection is therapeutic, the origin of their pain is irrelevant. However, in those
patients in whom facet coagulopathy, a thermoablation technique with potential
adverse effects, will be performed on the basis of their response to facet injection, it
is imperative to have precise localization of the pain.
The corollary to the statement that the facet injection must be performed
directly in the joint is that the volume of fluid injected must not exceed the capacity
of the facet joint. It is generally accepted that the normal cervical and lumbar facet
joints have a capacity of 0.5cc and 1.0cc, respectively. However, the capacity of the
pathologic facet joint is not known.5 Many others advocate injecting as much as
4.0cc of pain medication into the facet joint, with the goal of rupturing the joint
capsule and dispersing the medication into the peri-facetal tissues.
Candidates for facet blocks are those presenting with “facet syndrome”. This
term, coined by Ghormley, was introduced in 1933 to describe those patients with
radiating low back pain, those whose pain is relieved with alteration of posture or
exacerbated by hyperextension of the spine (i.e., mechanical back pain), or those
with focal tenderness over the facet joint.6

Percutaneous Blocks 141
Although the diagnostic criteria appear well-defined, the diagnosis of facet

syndrome is a difficult one. Clinical criteria for distinguishing pain due to the facet
joint and that due to disc herniation have been proposed, but no good objective test
has been developed. Both conditions may result in sciatica, abnormal deep tendon
reflexes, and electromyographic abnormality.7 Furthermore, each facet joint is
innervated by two dorsal rami, one at its own level and one from the level above.
This compounds the difficulty that clinicians have in localizing symptomatology to
a particular facet joint.
Radiography may or may not contribute to the diagnosis of facet syndrome.
Arthrosis is often seen at the facet joints in patients without pain. Conversely, the
facet joints may be entirely normal, radiographically, in those patients with debilitating
pain. Therefore, facet syndrome is often a diagnosis of exclusion and may be the initiating
reason for facet block.
The mechanism by which facet joints cause pain is unclear. However, some authors
propose that facet joint pain is due to inflammation of the synovial villi and/or to
trapping of the synovial villi between the articular processes of the facet joint.7
Neuropeptides, particularly substance P in the spinal cord and the calcitonin
gene-related peptide in the peripheral soft tissues, have been implicated in the
mechanism of pain in those with “facet syndrome”.5
The mechanism of pain relief during facet block is equally uncertain. However,
investigators are fairly sure that analgesia is not due to an inflammatory action of the
steroids. Several investigators feel that the preservatives containing the steroid, rather
than the steroid, causes a neurotoxic effect. Polyethylene glycol, which is the vehicle
for many steroids, is felt to denervate the capsular nerve endings.8 Other investigators
postulate that overdistention of the facet joint capsule (> 3 cc) results in diffusion of 10
medication into the epidural and lateral soft tissues where the medication works on
the synovial membrane and spinal nerves.1
Indications1,9-11
• low-back pain +/- sciatica
• focal tenderness over facet joint
• post-laminectomy syndrome not due to arachnoiditis or recurrent HNP
• persistent low-back pain after stable posterolateral spinal fusion
• to diagnose facet syndrome
• screening procedure prior to spinal fusion
Contraindications12
There are few absolute contraindications to facet blocks. The agents administered
may have to be modified, given the patient’s allergy history. Specifically, in those
patients with a history of lidocaine allergy, injection should be limited to steroids
only. Lidocaine and/or Bupivacaine should not be instilled into the facet joint.
Occasionally, the facet joint will not be accessible secondary to osteophytosis.12 Relative
contraindications include:
• coagulopathy
• infection at needle entry site
• cerebrovascular disease (for cervical facet block only)
Equipment
25g 5/8” needle, 26g 3-1/2” spinal needle, two 5cc syringes, connecting tubing
Technique
Lumbar Facet Injection-Method I
The goal of facet arthrography is to confirm needle placement for the subsequent
administration of steroids and anesthesia into the facet joint. Both lumbar and cervical
facet arthrography may be performed with the patient in the prone oblique position
rather than the prone position.7,14,15 Utilizing the former approach allows the
radiologists to direct the needle vertically into the articular recess of the facet joint.
Using fluoroscopy, oblique the patient until the facet joint spaces of interest are
profiled (Fig. 10.1A). This is achieved by rotating the patient such that the affected
side is elevated off of the table. Secure the desired patient position by placing a
wedge-shaped sponge beneath the elevated side. Mark the skin overlying the facet
joints of interest. Cleanse the skin with Betadine (Poviodone-Iodine, Purdue
Frederick) or Stanhexidine (Chlorohexidine Gluconate, Stanley Pharmaceuticals).
Drape the area with sterile towels. With a 25 g needle, administer 1% Lidocaine as
local anesthetic. Approach the perifacetal region with a 26g spinal needle oriented at
90˚ to the skin surface. Advance the needle, vertically, until it abuts cartilage or bone
(Fig. 10.1A,C).
Confirm the intra-articular position of the needle with the administration of
0.5-1.0cc of contrast (Fig. 10.1B). Any ionic contrast agent can be utilized. It is preferable
to utilize the agent with the lowest concentration of iodine, such as Conray 43. This
10 reduces the incidence and degree of synovial irritation while reducing overall costs.
If the needle is within the perifacetal region, within millimeters of the facet joint,
you can leave the needle in place and administer the medications at this site. If you
are unsure as to the needle position, you may perform a test injection of contrast.
Extra-articular contrast may pool at the tip of your needle whereas intra-articular
contrast will follow the contour of the joint and may collect in the inferior and/or
superior recesses.
With the needle in the intra-articular or perifacetal region, you are now ready to
administer medication (Fig. 10.1C). Always aspirate before administering medication.
This will reduce the likelihood of administering medication into the intradural or
intravascular compartment. You may administer one of the following steroids: 40mg
Methylprednisolone acetate (40 mg/cc). Additionally a 2-3cc mixture of the local
anesthetics 1% Lidocaine (short-acting) and/or Bupivacaine (medium-acting) should
be administered.
Lumbar Facet Injection- Method II

This method relies on the anatomic relationship between the two articular recesses
of the facet joint; that is, the superior articular recess is anteriorly located and the
inferior articular recess is posterior in position. Because kyphosis widens the inferior
recess, the radiologist’s target area, a pillow should be placed under the patient’s
abdomen to facilitate the procedure.16 The main advantage of this approach is its
efficiency in those patients scheduled for bilateral facet blocks. This approach requires
Fig. 10.1. This 36 year old male had 3 months of relief with prior left L4-5 and
L5-S1 facet blocks. He has returned for repeat facet injections. A) The patient has
been placed in the prone oblique position with his right side down. A wedge-shaped
cushion elevates his left side. Utilizing fluoroscopy, the left L3-4, L4-5, and L5-S1
facet joints are now in profile. With fluoroscopic guidance, a 22g spinal needle has
been positioned at the superior aspect of the L4-5 facet joint. The bevel of the
needle is slightly more cephalad than the needle hub indicating that the needle
was angled slightly cephalad during insertion. However, there is no angulation of
the needle in the medial/lateral direction. B) Conray 60 has been instilled into the
facet joint, via connecting tubing, utilizing fluoroscopic visualization. The contrast
outlines the facet joint and is pooled in the inferior (large asterisk) and superior
(small asterisk) recesses of the joint. C) Following the intra-articular injection of
10
Methylprednisolone acetate 40mg and 3cc 1% Lidocaine at L4-5, the needle has
been removed and the contrast demonstrates a dilutional effect. A second 22g
spinal needle has been positioned at the L5-S1 facet joint for the subsequent injection.
no interim change of patient position, thus allowing you to prep (both sides of the
back) at one time.
With the patient in the prone position and the x-ray beam vertically oriented,
the radiologist should target the inferior apophyseal process. If this is not well seen,
he/she should target the medial rim of the pedicle (Fig. 10.2). Once the entry site
has been marked and the skin sterilized, a 22 g 3-1/2” spinal needle should be vertically
advanced towards the target site. When the needle approaches bone, verify its position
with the administration of contrast material, as above. Lastly, administer the
corticosteroid and anesthetic agents into the facet joint in the quantities listed in the
preceding section.
Cervical Facet Injection
The Japanese literature describes a lateral approach for cervical facet puncture,
performed with the patient in the erect position.15 However, optimal fluoroscopic
visualization is not possible utilizing this approach. Therefore this technique will
not be described here.
Fig. 10.2. Posteroanterior radio-

graph of the lumbosacral spine.
The arrow indicates the point
where the superior rim of the
pedicle and the caudad margin
of the inferior articular recess of
the facet overlap. This is your
target area.
Cervical facet arthrography is performed with the patient in the prone oblique
position (Fig. 10.3). The patient’s neck should be flexed to align the facet joint(s)
10 vertically. The patient’s head should be turned away from the side of interest to
avoid superimposition of the spine on the facial bones.15
Once the facet joints of interest are profiled, proceed as described under “Lumbar
Facet Injection”.
Complications
The major complication of facet block, lumbar or cervical, is inadvertent dural
puncture which occurs in 0.5-2.5% of cases.7 Subarachnoid injection of lidocaine
may result in spinal anesthesia and chemical meningism.17 Additionally, infection is
a potential complication as with any percutaneous procedure. Cervical facet blocks
may also be complicated by vertebral artery injection of steroids and/or lidocaine
which can result in CNS toxicity and/or seizures. Additionally, the cervical cord is at
risk for inadvertent puncture.12
Post-Procedure Care
Patients may be discharged between 30 and 60 minutes following an
uncomplicated facet block. They should be advised to observe their symptoms during
the following two weeks. Specifically, they should be advised that they may experience
temporary pain relief (secondary to the 1% Lidocaine) and that their symptoms
may return once the effect of the short-acting anesthetic has worn off. Subsequently,
their pain may disappear for a period of months (secondary to the steroid). The
presumptive diagnosis of facet syndrome can be made in those patients who experience
temporary pain relief from a facet block. Facet block can be considered diagnostic
and therapeutic in those patients who receive long-term relief from facet injections.
Fig. 10.3. Thirty-eight year old male

with cervicalgia. Right and left (not
shown) C2-3 facet blocks were per-
formed. Note the uniform profiling
of the neural foramina. The needle
appears as a small circle indicating
its lack of angulation in the
medio-lateral and cranio-caudal
planes.
10
Synovial Cysts
These uncommon extradural fluid collections arise from facet joints, usually in
the setting of facet joint degeneration. They most frequently originate from the
L4-5 level, and to a lesser extent from L5-S1 and L3-4. Although these cysts may
protrude lateral to the facet joint (i.e., outside of the spinal canal), those that come
to clinical attention tend to protrude into the spinal canal, resulting in nerve root
compression. The diagnosis can be strongly suspected on CT or MRI.18 Facet joint
arthrography may confirm the diagnosis, if the communication between the cyst
and the facet joint is still patent. Both CT and MRI may demonstrate an encapsulated
mass, often between the ligamentum flavum and the thecal sac (Fig. 10.4A). However,
CT shows facet joint arthropathy to better advantage. Although the cysts may
demonstrate typical signal characteristics (i.e., low signal intensity on T1-weighted
spin echo sequence and high signal intensity on T2-weighted spin echo sequence),
they may be bright on both T1- and T2-weighted spin echo sequences because of
their gelatinous content (Fig. 10.4B). For this same reason, these cysts tend to have
attenuation values greater than those of simple fluid on CT examination.
Technique
Percutaneous aspiration of cysts, followed by steroid and anesthetic injection
into the cysts, is usually performed under CT. The patient should be placed in the
prone position and the entry site localized with CT guidance. Prep and drape the
area and administer local anesthetic. Approach the facet joint with a 26g 3-1/2”spinal
needle, angled at approximately 45˚ relative to the skin surface. Confirm the needle
position with CT prior to the administration of Depomedrol and 1% Lidocaine
(Fig. 10.5).
Potential complications are identical to those for lumbar facet blocks. It is prudent
to observe the patient for 30-60 minutes following the aspiration, especially if they
develop transient numbness of the lower extremity on the ipsilateral side of the
aspiration. (This may occur secondary to irritation of the adjacent nerve root.) You
should explain to the patient the potential for these cysts to recur, particularly if the
cyst appears to contain gelatinous material. Laminectomy and surgical removal of
the cyst is considered the definitive treatment in those patients who fail to respond
to aspiration or who develop recurrent symptoms.18,19
10 Sacroiliac Joint Block
Local anesthetic and/or steroids may be administered into the sacroiliac joints
for diagnostic and/or therapeutic purposes (Fig. 10.6). Osteoarthritic changes of the
sacroiliac joints on plain radiography or CT and/or sciatica in the absence of ipsilateral
disc herniation, facet joint arthropathy, or osteoarthritis of the hip may initiate the
request for steroid administration into the sacroiliac joint.20,21 Alternatively, sacroiliac
joint aspiration may be performed to exclude infection. Percutaneous sacroiliac joint
injection or aspiration may be performed either fluoroscopically or under
CT-guidance.22,23
Technique
For fluoroscopically guided injections, the patient is placed in the prone oblique
position, as for lumbar facet block. Once the joint is in profile and the skin has been
cleansed, a 26g 3-1/2” spinal needle is directed into the joint. The needle should be
advanced at 90˚ to the table top, appearing as a dot on your TV monitor.
CT-guided injections are performed with the patient in the prone position. Once
the joint has been localized, and the skin cleansed, a 26g 3-1/2” spinal needle is
directed anterolaterally, parallel to the sacroiliac joint. For aspiration, it is important
to advance your needle beyond the interosseous ligament to reach the joint cavity.
However, deep needle placement is not necessary for the injection of anesthetic
agents or steroids because these will spread throughout the dependent portion of the
joint irregardless of your needle depth.
Fig. 10.4. A) Transaxial FSE proton density weighted image demonstrates a right
posterior extradural mass that is hyperintense to the thecal sac. The lesion, result-
ing in moderate spinal stenosis, is closely apposed to the right L3-4 facet joint
consistent with a synovial cyst. B) Sagittal FSE T2-weighted spin echo image dem-
onstrates a predominantly high signal intensity extradural lesion at the level of
L3-4. There is uniform loss of intervertebral disc space signal intensity indicating
degenerative disc disease.
Fig. 10.5. Transaxial CT, tech-

nique intermediate to bone/ 10
soft tissue, at L4-5. A 26 g
spinal needle is in position
for Depomedrol and
Marcaine injection into the
lesion. Within one week, the
patient reported resolution of
left radicular symptoms,.
Unfortunately, her symptoms
recurred three months after
percutaneous intervention.
Lastly, whether using fluoroscopy or CT to direct your needle placement, it is

important that you direct your needle into the synovial part of the joint, its caudal
one half to two-thirds.23
There is little risk associated with sacroiliac joint arthrography. The iliac vessels,
along the anterior margin of the sacroiliac joint, are too distant for a 3-1/2” needle
to penetrate. The sacral ala protect the sacral nerve roots from inadvertent puncture.
Using aseptic technique, there is little risk of introducing infection into the sacroiliac
joint.
Fig. 10.6. This 75 year old female presented with radicular pain in the right thigh.
Lumbar spine CT, requested to exclude spinal stenosis, was remarkable only for
osteoarthritis of the right sacroiliac joint. Percutaneous CT-guided injection of the
right sacroiliac joint was performed with a 26 g 3-1/2” spinal needle. The patient
has remained asymptomatic at her three month follow-up visit.
10
Interspinous Ligament Blocks24,25
Patients with hyperlordosis of the lumbar spine are prone to the development of
Baastrup’s disease, a condition defined by subchondral sclerosis and cartilage loss at
the articulation between two adjacent spinous processes. As for the facet and sacroiliac
joints, a diagnostic and/or therapeutic block may be performed at this
pseudoarticulation. With the patient prone, a 22g 1-1/2” spinal needle is placed
into the interspinous space, angled parallel to the bony contours of the space.
Corticosteroids and 1% Lidocaine are instilled into the space (Fig. 10.7).
C1-2 Block26-28
This technique allows steroid administration into the C1-2 articulation, allowing
diagnostic and therapeutic information about disease processes involving this level.
The anatomy in the region is complex. Furthermore, one must proceed with
caution to avoid puncture of the carotid and vertebral arteries, and the jugular vein.
Because of these various vascular structures in the region, perilingual Valium is
administered some minutes before the injection. No local anesthetic is used.
Indications
• cervical or occipital neuralgia without significant radiographic change
• osteoarthritis
• rheumatoid arthritis
• ankylosing spondylitis
Fig. 10.7. A) Frontal radiograph of the lumbar spine. Laminectomy defects are present
at L5. There is evidence for Baastrup’s disease, degenerative changes at the inters-
pinous space, at L3-4 (arrow). B) With fluoroscopic guidance, Depomedrol 40 mg
and 4cc 1% Xylocaine are instilled into the L3-4 interspinous space via a 22 g needle.
Technique 10
The patient is seated and the C-arm rotated such that the cervical spine is viewed
in the lateral projection. Prep and drape the skin in the usual manner. Using a 20g
or 22 g 3-1/2” spinal needle, insert the needle behind the mastoid process. Direct
the needle towards the posterior aspect of the atlantoaxial articulation (Fig. 10.8).
Continue to advance the needle, using this posterolateral approach, until you abut
the laminae. A test injection is performed, using a nonionic, non-neurotoxic contrast
agent. If contrast outlines the posterior recess of the joint, your needle placement
has been successful. However, you must reposition your needle if contrast pools
around the tip of the needle. Once the joint capsule is opacified, take AP and lateral
radiographs of C1-2. Lastly, instill Depomedrol 20 mg (0.5 cc) into the joint cavity.
Complications
• inadvertent spinal puncture may result in a headache
• puncture of the vertebral artery or vein (reinsert the stylette into the needle
and start again, changing the angle of your needle slightly)
Miscellaneous Blocks
Basically, a block may be performed at any synovial joint as a means of ascertaining
if that articulation is the source of the patient’s symptoms. As well, the block may be
used as a form of treatment in patients who have pain that is attributed to a certain
site. I have extrapolated this technique to the iliac bone graft donor site, but I imagine
that it could be used elsewhere (Fig. 10.9).
Fig. 10.8. A). Lateral radiograph of the cervical spine demonstrating the puncture
site for an atlantoaxial joint injection (arrow). B) Transaxial CT at the level of C1-2
demonstrating the course of the needle for C1-2 arthrography (arrow).
10
Fig. 10.9. Computerized tomography through the pelvis, patient prone. This 71
year old male has complained of right-sided pelvic pain since posterior spinal fu-
sion. A) Radiopaque markers are used to localize the bone graft donor site in the
right iliac wing. B) 40mg Depomedrol and 4cc 1% Xylocaine are instilled into the
donor site, for attempted pain control, via 22g spinal needles.
References
1. Destouet JM, Gilula LA, Murphy WA et al. Lumbar facet joint injection: Indica-
tion, technique, clinical correlation, and preliminary results. Radiology 1982;
145:321-5.
2. Lilius G, Laasonen EM, Myllynen P et al. Lumbar facet joint syndrome. A ran-
domized clinical trial. J Bone Joint Surg 1989; 71B:681-4.
3. Lilius G, Harilainen A, Laasonen EM et al. Chronic unilateral low-back pain.
Predictors of outcome of facet injections. Spine 1990; 15:780-2.
4. Roy DF, Fleury J, Fontaine SB et al. Clinical evaluation of cervical facet joint
infiltration. Can Assoc Radiol J 1988; 39:118-20.
5. Jerosch J, Castro WHM, Liljenqvist U. Percutaneous facet coagulation. Indica-
tion, technique, results, and complications. Neurosurg Clin North America 1996;
7:119-34.
6. Ghormley RK. Low back pain with special reference to the articular facets with
presentation of an operative procedure. JAMA 1933; 101:1773-7.
7. Carrera GF. Lumbar facet joint injection in low back pain and sciatica: Descrip-
tion of technique. Radiology 1980; 137:661-664.
8. Thomson SJ, Lomax DM, Collett BJ. Chemical meningism after lumbar facet
joint block with local anesthestic and steroids. Anaesthesia 1991; 46:563-4.
9. Moran R, O’Connell D, Walsh MG. The diagnostic value of facet joint injections.
Spine 1988; 13:1407-10.
10. Bough B, Thakore J, Davies M et al. Degeneration of the lumbar facet joints.
Arthrography and pathology. J Bone Joint Surg 1990; 72B:275-6.
11. Hove B, Gyldensted C. Cervical analgesic facet joint arthrography. Neuroradiology
1990; 32:456-9.
12. Lamer TJ. Ear pain due to cervical spine arthritis: Treatment with cervical facet
injection. Headache 1991; 31:682-3.
13. Lewinnek GE, Warfield CA. Facet joint degeneration as a cause of low back pain.
Clin Orthop Rel Res 1986; 213:216-22.
14. Dory MA. Arthrography of the lumbar facet joints. Radiology 1981; 140:23-27.
15. Dory, MA. Arthrography of the cervical facet joint. Radiology 1983; 148:379-82.
16. Sarazin L, Chevrot A, Pessis E et al. Lumbar facet joint arthrography with the
posterior approach. Radiographics 1999; 19:93-104.
17. Goldstone JC, Pennant JH. Spinal anaesthesia following facet joint injection. A
report of two cases. Anaesthesia 1987; 42:754-6.
18. Koenigsberg RA. Percutaneous aspiration of lumbar synovial cyst: CT and MRI
10
considerations. Neuroradiol 1998; 40:272-3.
19. Parlier-Cuau C, Wybier M, Nizard R et al. Symptomatic lumbar facet joint syn-
ovial cysts: Clinical assessment of facet joint steroid injection after 1 and 6 months
and long-term follow-up in 30 patients. Radiology 1999; 210:509-513.
20. Maldjian C, Mesgarzadeh M, Tehranzadeh J. Diagnostic and therapeutic features
of facet and sacroiliac joint injection. Anatomy, pathophysiology, and technique.
Radiologic Clinics of North America 1998; 36:497-508.
21. Hodge JC, Bessette B. The Incidence of Sacroiliac Joint Disease in Patients with
Low Back Pain. Canadian Assoc Radiol J 1999; 50:321-3.
22. Hendrix RW, Lin P-JP, Kane WJ. Simplified aspiration or injection technique for
the sacroiliac joint. J Bone Joint Surg 1982; 64A:1249-52.
23. Resnick D. Arthrography, tenography, and bursography. In: Resnick D, Niwayama
G (Editor) Diagnosis of bone and joint disorders, Philadelphia, WB Saunders Comp.
1988:303-440.
24. Bywaters EG, Evans S. The lumbar interspinous bursae and Baastrup’s syndrome.
An autopsy study. Rheumatol Intl 1982; 2:87-96.
25. Beckers L, Bekaert J. The role of lordosis. Acta Orthopaedica Belgica 1991;
57S:198-202.
26. Chevrot A, Cermakova E, Vallée C et al. C1-2 arthrography. Skeletal Radiology
1995; 24:425-9.
27. Hove B, Gyldensted C. Cervical analgesic facet joint arthrography. Neuroradiology
1990; 32:456-9.
28. Mellström A, Grepe A, Levander B. Atlantoaxial arthrography. A postmortem study.
Neuroradiology 1980; 20:135-44.
CHAPTER 11
Epidural Blocks
Jim Sloan
Introduction
This Chapter addresses those procedures that, at the majority of institutions, fall
under the realm of the anesthesiologists. However, musculoskeletal radiologists may
take an interest in these procedures as they may offer an alternative treatment method
in the same patient population.
These procedures are largely therapeutic and diagnostic, similar to the facet block
which localizes the pain to a certain area by demonstrating relief of patient
symptomatology. The role that these procedures, such as the epidurogram, played in
determining the spread of retroperitoneal tumor has been replaced by cross-sectional
imaging studies, magnetic resonance imaging (MRI) and computerized tomography
(CT) most notably.
Epidural Injections
Normal Anatomy1,2
The epidural space lies between the ligamentum flavum and the dura and extends
from the foramen magnum, where the dura is fused to the base of the skull, to the
sacral hiatus, which is covered by the sacrococcygeal ligament. The accessible posterior
aspect of the epidural space has a variable width being 3-5 mm in the lumbar spine,
2-3 mm in the thoracic area and wider again at C7-T1 but narrowing to 1.5 mm at
C5. It contains the internal venous plexus (Batson’s), fat and areolar tissue, lymphatics
and the segmental nerve roots that traverse it to the intervertebral foramen (Fig
11.1).
Indications3
• administration of anesthesis
• for lysis of epidural adhesions (it is necessary to administer large volumes)
• administration of epidural steroids in close proximity to suspected inflamed
spinal nerves in degenerative disc disease of the lumbar or cervical spine
or traumatized thoracic nerve from mechanical compression neoplasm1
• administration of steroids to decrease inflammation and/or edema of nerve
roots in foraminal stenosis or spinal canal stenosis1
1These therapeutic interventions tend to be short-lived—i.e., 2-4 months with

methylprednisolone acetate or triamcinolone acetonide—as the underlying conditions
have not changed and the nerves are re-injured over time.

Epidural 153
Fig. 11.1. Line drawing illustrat-

ing the approach to the epidu-
ral space in the thoracic spine.
Reprinted with permission from:
Mulroy MF, ed. Recommended
handbook. Regional anaesthe-
sia: An illustrated procedure
guide. 2nd Ed.
• administration of autologous blood products for those patients with severe

post-myelogram or post-discogram (transdural approach) headache (The
epidural should performed at >48 hours following dural puncture, either
at the level of the previous puncture or one level caudad to the puncture.)4
• administration of autologous blood products in those patients with
postoperative dural leak/fistula5
• to perform an epidurogram for diagnostic purposes (to assess for neoplasm
or after spine surgery—i.e., sequestered disc, but much of this information
is better gained from MRI or CT/myelography)
Technique 11
One can access this space with a technique similar to that of doing a myelogram
(refer to Chapter 8, Myelography) choosing the midpoint between two spinous
processes and introducing the needle in the midline at 80-90˚ to the skin. It is best
to use larger blunter needles, such as the Tuohy needle (Concord/Portex, Keene,
NH), that are specifically designed for epidural use as they allow for easy identification
of the space while minimizing the risk of intrathecal penetration. As the pressure
within the epidural space tends to reflect the intrapleural pressure and is thus slightly
subatmospheric, the epidural space can be identified with loss of resistance techniques
using either saline or air. The ligamentum flavum connecting adjacent laminae is
usually thick and identifiable with the larger blunter needles as there is increased
resistance to advancing the needle.
Once through the ligament there is loss of resistance to a lubricated (NaCl or
local anesthetic) 5 cc glass syringe. If there is no cerebrospinal (CSF) return then the
needle bevel should lie within the epidural space.
Thoracic Epidural Space

Access to the thoracic epidural space is technically more difficult as there is little
space between the overlapping laminae and the needle requires a sharp angle cephalad.
The needle is best introduced one finger breadth lateral to the inferior tip of the
Fig. 11.2. Patient position for a

deep cervical block. M. mastoid
process. J. external jugular vein.
C. Chassaignac’s tubercle. S.
sternocleidomastoid muscle.
Reprinted with permission from:
Moore DC, ed. Regional block
anesthesia.
spinous process overlying the desired interspace angling both 45˚ medially and 45˚
cephalad to walk over the lamina to the ligamentum flavum and enter the epidural
space (Fig 11.1).
Cervical Epidural Space

The cervical approach is easier, done with the patient in a sitting position and
head fully flexed with the needle at approximately 80˚ between C6-7 or C7-T1. One
must be very careful when approaching the epidural space with the spinal cord only
a few millimeters away. The spinal cord flattens and ends at L1 so that epidural
techniques in the lumbar spine are less risky.
Complications
• local tenderness in the area of needle application for several days post
11 procedure, noticed particularly with flexion of the spine
• low CSF pressure-headache can occur if the epidural needle punctured
the dura (This headache can be severe and persistent as the epidural needles
are large bores—16 or 17 g—and thus the dural rent is large.)
• potential needle injury to the spinal cord with poor technique if the
procedure is done above L1
• if local anesthetic is used (it must be preservative free), there is the potential
for significant hypotension and bradycardia secondary to the anesthetic
block of sympathetic nerves as well as motor block of segmental nerves
that are in close proximity to the injection site
• with large doses of local anesthetics inadvertently injected subdurally, total
spinal block may occur (This requires full cardiorespiratory support.)
• epidural hematomas have been reported, sometimes with disastrous
consequence, as the epidural veins can be torn by the epidural needle and
there can be significant ongoing bleeding from the veins in patients on
anticoagulants or in patients with elevated epidural venous pressure—
such as parturients or patients with significant ascites
• potential for intravascular or intrathecal injection of anesthetics or steroids
if there is failure to recognize that the bevel of the needle is in a vein or
subarachnoid space
Epidural 155
Nerve Blocks
Paravertebral or Intraforaminal Approach to Somatic Nerves
Normal Anatomy
The thoracic, lumbar and cervical nerve roots emerge from the spinal canal
through their respective intervertebral foramina at the lateral border of the canal.
These foramina lie 2 cm anterior to the level of the transverse processes and are
positioned midway between these processes. With the exception of the transition
zone at T11-12, a transverse process can usually be located 3 to 4 cm lateral to a
spinous process and slightly cephalad to it. In the lumbar region, the superior border
of the processes will correspond to the transverse process and the nerve to be blocked
while in the thoracic region, the spinous process will be associated with the next
lower transverse process and nerve.
Indication
• mostly anesthetic to supplement other anesthetic techniques
• diagnostic purposes, particularly in the cervical or lumbar spine, in
situations of degenerative disease of the spine or neoplastic disease (The
clinical significance of foraminal stenosis can be difficult to judge. In
general, clinical—radiological correlation is poor in the pain syndrome of
the spine.)
• therapeutic perineural infiltration with long-acting corticosteroids—i.e.,
methylprednisolone acetate can be beneficial in post-operative nerve root
irritation or entrapment, degenerative disease of the spine and
spondylolisthesis, and neoplastic injury of a nerve root. (The use of
neurolytic solutions for somatic neurolysis should be limited to patients 11
with very poor prognosis as long term results are poor.)
Technique1,6,7
Cervical Spine
The tip of the mastoid process is located as is Chassaignac’s tubercle, the anterior
tubercle of the transverse process of C6. A straight line drawn between these two
points gives the approximate plane of the cervical transverse processes. The needle
(3.8 cm) entry site is approximately 0.5 cm posterior to this line as the somatic
nerves lie in the sulcus of the transverse process. The second cervical transverse process
is usually 1.5 cm below the mastoid process, the third 1.5 cm below the second, etc.
(Fig 11.2). The seventh cervical transverse process is difficult to palpate and there is
significant risk of pneumothorax if a block is attempted here.
Thoracic Spine
Thoracic vertebral block technique involves advancing a 4" needle perpendicular
to the skin through a point 3 cm lateral to the superior margin of the spinous process
of the level above the nerve to be blocked until the rib or transverse process is felt
(usually 2.5-3.5 cm). After bone is contacted, the needle is redirected cephalad to
walk over the upper margin of the process. There is a lot of resistance as the needle
Fig. 11.3. Transaxial line draw-

ing demonstrating the approach
for a paravertebral block. Re-
printed with permission from:
Mulroy MF, ed. Recommended
handbook. Regional anaesthe-
sia: An illustrated procedure
guide. 2nd ed.
penetrates through the costotransverse ligament. The needle is then advanced 1-2
cm deep to the transverse process. Five cc of solution should bathe the somatic nerve
(Fig 11.3). Intraforaminal approaches in the thoracic spine are discouraged as the
starting point is considerably lateral to the 3 cm described for the paravertebral
technique and thus the risk of pneumothorax is too high.
Lumbar Spine
In the lumbar spine, the intraforaminal approach is preferred by radiologists as
the foramen are easily visualized under fluoroscopy in the lateral position. A line is
11 drawn 8 cm lateral to the midline spines and parallel to the spinal column. The
point at which it intersects with the iliac crest is the entry point for the L5 root. If
points 2.5 cm apart are marked cephalad from this point along the line, they will
serve as entry points for the upper lumbar roots. A 3.5" 22 or 25 g spinal needle is
inserted 45˚ medial and 45˚ caudad to a depth of approximately 3-3.5" (Fig 11.4).
Paresthesias are frequently elicited. One can easily be in the epidural or even intrathecal
space with this approach, so it is best to verify the degree of intraforaminal penetration
with AP fluoroscopy (patient prone). Small doses—i.e., 3 cc—of 1% Xylocaine or
Bupivacaine should be sufficient to bathe the somatic root. If large doses are used,
there may be spread into the epidural space with a loss of diagnostic specificity.
Complications
• potential needle injury to somatic nerves (Utilize short bevel, small bore
needles to minimize nerve injury. Paresthesia will alert the operator so as
to avoid most injury.)
• inadvertent intrathecal administration of local anesthetic in the upper
cervical levels may result in total spinal block with respiratory arrest
• if a multi-level procedure is performed, hypotension can result from
significant volumes of local anesthetic accessing the epidural space
Epidural 157
Fig. 11.4. Lumbar plexus block–

Paravertebral approach. Re-
printed with permission from:
Carron H, Korbon GA,
Rowlingson JC, eds. Regional
anesthesia: Techniques & clinical
applications.
11
Fig. 11.5. Single needle sympathetic block. Although the needle is slightly lateral, con-
trast is well-distributed within the sympathetic chain. The intervertebral foramina are
spared. Reprinted with permission from: Swerdlow M, ed. Relief of intractable pain.
Sympathetic Block Technique8, 9, 10

Some radiologists have developed some familiarity with these techniques and, as
x-rays or fluoroscopy are used to check needle placement, these techniques will be
described. Neurolytic lumbar sympathetectomy for occlusive vascular disease is an
underutilized procedure in most medical centers.
Lumbar Sympathetic Block

The lumbar sympathetic ganglia lie on the anterolateral aspect of the vertebral
body—usually mid body to lower third.
Although the sympathetic nervous system is quite diffuse, there is some general
anatomical organization such the the L4 ganglion may be dominant to the foot.
However, consideration of the lumbar sympathetic chain anatomy suggests that all
lumbar sympathetic fibers pass through a synapse at the L2 ganglion level and most
pass through L3. Therefore a block of the chain at either of these levels should abolish
most sympathetic activity to the lower limb.
Technique
The technique as depicted in Figure 11.6 uses a 25 g 6" spinal needle inserted
8-10 cm lateral to the midline. The needle is advanced medially to glance off of the
anteromedial edge of the midpoint of the second and third vertebral body. The
needle tip should be 0.5 cm within the lateral edge of the vertebra when viewed in
the AP projection and at the anterior edge of the body on a lateral view. An injection
of 10 cc of 6% phenol or alcohol and Conray demonstrates a longitudinal spread of
contrast in a pre-vertebral plane (Fig 11.5).
Indications
• for the diagnosis of various forms of sympathetic dystrophy (Sudeck’s
atrophy, causalgia)
• to interrupt the neurological input in sympathetically maintained chronic
pain syndrome
• for the treatment of ischemic leg/foot pain when surgery is contraindicated
or there is inadequate post surgical revascularization (Rest pain of the
11 foot/leg responds much better than the pain of intermittent claudication.)
Complications
• the only significant complication of this technique when done with
neurolytic solution is a neuritis developing in a somatic nerve (L2- L3)
Fig. 11.6. Splanchnic nerve

block. Anatomy of the splanch-
nic nerves. Reprinted with per-
mission from: Swerdlow M, ed.
Relief of intractable pain.
Epidural 159
which is injured by the neurolytic solution following the needle tract in

close proximity to the somatic nerves
Splanchnic Nerve Block1, 7, 11
Normal Anatomy
The greater and lesser splanchnic nerves cross the retrocrural space at the upper
body of T12 prior to piercing the diaphragm and forming the celiac plexus. There is
an anatomical compartment formed between the pleura and vertebra, bounded
anteriorly by each crus of the diaphragm and posteriorly by the fibrous pleural
attachment to the posterior medial aspect of each vertebral body and annulus fibrosis
(Fig 11.6). The splanchnic nerves contain visceral sympathetic efferent fibers and
visceral afferent pain fibers which innervate the pancreas, gallbladder, liver capsule,
adrenal glands and upper gastrointestinal tract (except the esophagus).
Technique
The patient should be prone with a pillow under the abdomen to flatten the
thoracolumbar spine. Needle entry is made below the twelfth rib, 7 cm from the
midpoint of the spinous process of the first lumbar vertebra and angled slightly
cephalad and medial. The ideal end point for the needles are at the upper third of
the twelfth vertebral body, 0.5 cm dorsal to the anterior vertebral margin (Fig 11.7).
One can use fluoroscopy to make sure the needles are not in the diaphragm (no
movement with respiration) and Conray to assess confinement of dye spread to the
anatomical compartment (Fig 11.8). Generally, a diagnostic block using 10 cc 1-2%
Xylocaine on each side is successful at relieving pain from the affected organs if
followed at a later date with a definitive neurolytic block with alcohol or phenol 6%.
Indications 11
• malignant disease causing pain in the organs innervated by the splanchnic
nerves (One can expect marked improvement in 70% of painful pancreatic
carcinomas with this technique, failure usually resulting from extensive
retroperitoneal spread.)
Fig. 11.7. Splanchnic nerve block. Lateral and anteroposterior radiographs demon-
strating needle positions. Reprinted with permission from: Swerdlow M, ed. Relief
of intractable pain.
Fig. 11.8. Splanchnic nerve block. Lateral and anteroposterior radiographs demon-
strating the distribution of Conray. Reprinted with permission from: Swerdlow M,
ed. Relief of intractable pain.
11
Fig. 11.9. Needle placement for block of the superior hypogastric plexus. A) Antero-
posterior, B) Lateral radiographs. Reprinted with permission from: Hahn MB, McQuillan
PM, Sheplock GJ, eds. Regional anesthesia. An atlas of anatomy and techniques.
Epidural 161
• chronic painful inflammatory illinesses such as pancreatitis can also

improve although results are not as good as with malignant disease (Pain
usually recurs within several months.)
• as a diagnostic procedure (with local anesthesia) in chronic pain syndromes
to differentiate visceral from somatic pain
Complications
• hypotension invariably occurs with either local anesthesia or alcohol
injection in close proximity to the splanchnic nerves as splanchnic
vasodilation occurs very quickly. This can be treated with 1-1.5 litres of
sodium chloride or Ringers solution and ephedrine sulfate 5 mg every
2-3 minutes intravenously.
• with misplaced needles a pneumothorax can occur
• if the needle insertion is shallow, there is the potential for segmental somatic
nerve block or spinal intraforaminal epidural injection producing
paraplegia in the case of neurolytic solution
Hypogastric Nerve Block1,7
There has been some interest in the literature recently in techniques to block the
hypogastric nerves with local anesthesia, with or without alcohol/phenol to treat
visceral pelvic pain of various etiologies. It is my opinion and that of many others,
including gynecologists, that this technique is of little value diagnostically or
therapeutically.
Normal Anatomy
The superior hypogastric plexus, also referred to as the presacral nerve, represents
the pelvic extension of the abdominal sympathetic nervous system. Its preganglionic 11
cells of origin are located chiefly in the lower thoracic and upper two lumbar levels
of the anteromedial column of the spinal cord. The parasympathetic sacral ganglia
also contribute to this plexus which occupies the midline anteriorly at L4-L5. Near
the sacral promontory it begins to divide into the hypogastric nerves. It innervates
only the pelvic viscera and vasculature.
Indications
• favorable results have been reported for pain and tenesmus due to radiation
injury and rectal anastomosis and for visceral pelvic pain of neoplastic origin
Technique
With the patient prone and with padding beneath the pelvis to flatten the lumbar
lordosis, the L4-L5 interspace is identified and a point opposite the interspace above
the iliac crest 6-7 cm from the midline is identified. A 22 or 25 g 4-1/2" spinal
needle is inserted, after local anesthesia, 30˚ caudad and 45˚ mesiad to direct the
needle tip toward the L5 vertebral body. Once the vertebral body is contacted, the
needle is redirected in a slightly less mesiad plane so that its tip is “walked off ” the
vertebral body to lie in the retroperitoneal space. An injection of 3-4 cc of
water-soluble contrast will verify accuracy of placement (Fig 11.9). A volume of 15
cc of local anesthetic or alcohol/phenol is used to block the nerve plexus.
Complications
• vascular puncture and hematoma from the common and internal iliac
vessels is not uncommon
References
1. Mulroy MF, ed. Recommended handbook. Regional anaesthesia: An illustrated
procedure guide. 2nd ed. Boston: Little, Brown and Co., 1996.
2. Zarzur E. Anatomic studies of the human lumbar ligamentum flavum. Anesth
Analg 1984; 63:499-502.
3. Bogduk N, Cherry D. Epidural corticosteroid agents for sciatica. Med J Aust 1985;
143:402-6.
4. Weakland HJ. The epidural blood patch—current practices and concerns. Crna
1994; 5:156-63.
5. Abouleish E. The avoidance of surgery in the treatment of subarachnoid cutaneous
fistula by the use of an epidural blood patch: Technical case report. Neurosurgery
1995; 37:357.
6. Eason MJ, Wyatt R. Paravertebral thoracic block: A reappraisal. Anesthesia
1979;34:638-42.
7. Hahn MB, McQuillan PM, Sheplock GJ, eds. Regional anesthesia: An atlas of
anatomy and techniques. St. Louis:Mosby Year Book, Inc., 1996.
8. Boas RA. The sympathetic nervous system and pain relief. In: Swerdlow M, ed. ed.
Relief of intractable pain. New York: Elsevier, 1983:215-37.
9. Cousins MJ, Reeve TS, Glynn CJ. Neurolytic lumbar sympathetic blockade: Du-
ration of denervation and relief of rest pain. Anaesth Int Care 1979; 7:121-35.
10. Reid W, Watt JK, Gray TG. Phenol injection of the sympathetic chain. Br J Surg
1970; 57:45-50.
11. Singler RC. An improved technique for alcohol neurolysis of the celiac plexus.
Anesthesiology 1982; 56:137-41.
11
CHAPTER 1
CHAPTER 12
Tenography
Jacqueline C. Hodge
Introduction
Tenography refers to the opacification of tendon sheaths with a contrast agent.
Although any tendon sheath may theoretically be opacified, only those tendons that
can be consistently identified—i.e., have an anatomic landmark that allows
localization of the tendon sheath—and that are not in close proximity to major
vessels can be studied by this technique.1 Tenography has been performed most
frequently for assessment of the tendon sheaths of the ankle, but it has also been
useful in evaluation of tendon sheaths in the hand and rarely those in the hip.2,3
Ankle tenography, first utilized in 1970, had a much broader range of indications
twenty years ago.1,4 However, newer imaging modalities, particularly MRI, have
supplanted some of the indications for tenography. MRI is the ideal screening exam
in cases of suspected ankle pathology. More specifically, MRI is the examination of
choice to image intratendinous pathology—including tendon rupture, tendinitis,
and partial tears of the tendon—and tendon displacement by extrinsic soft tissue
masses.5 MRI has also replaced stress-tenography in the evaluation of injury to the
lateral ligaments of the ankle.6,7 MRI is also ideal for detecting suspected tenosynovitis.
However, because of the presence of fluid within the tendon sheaths of asymptomatic
patients, the presence of fluid within the tendon sheath may no longer be synonymous
with tenosynovitis.8 Furthermore, as the amount of fluid in the tendon sheaths is
not significantly different between those patients with and without tenosynovitis,
tenography may prove to be more specific for tenosynovitis than MRI.8 Dynamic
CT is the currently accepted standard to assess for bony causes of tendon subluxation
and/or dislocation.5 However, tenography remains the procedure of choice in
characterizing and, in some cases, providing relief for pathology confined to the
tendon sheath.
Indications
• detection of suspected tenosynovitis or tendon sheath tear:
– in those with pain, swelling and/or crepitus along the course of a tendon
sheath1
– in those with previous calcaneal or fibular fractures resulting in peroneal
dysfunction9
• characterization of tenosynovitis:
– detected by MRI
– in those with synovial arthritis4
– in those with inflammatory arthritis4
• treatment of known tenosynovitis4,10

Fig. 12.1A) Peroneal tenogram in

a forty year old female with
longstanding lateral ankle pain.
She denies any antecedent
trauma. A) The radiologists exam-
ines the patient prior to perform-
ing the tenogram. The radiopaque
clamp marks the patient’s site of
maximal tenderness (immediately
caudad to the posterior subtalar
joint along the lateral side of the
right ankle).
Contraindications
12 Tenography is a relatively safe procedure without major risks. Although no allergic
reactions to tenography have been reported to date, a strong allergic history to contrast
should be considered a relative contraindication.11
Equipment
25g 1" needle, connecting tubing, 5cc, 10cc, and 20cc syringes, sterile towels,
sterile gauze
Technique
Place the patient in the lateral or supine position, depending upon which tendon
sheath you are asked to investigate. For examination of the posterior tibial (PTT),
flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendon sheaths, the
lateral side of the ankle should rest against the fluoroscopy table. If the peroneus
longus (PL) or peroneus brevis (PB) tendon sheaths are being evaluated, place the
medial side of the ankle against the fluoroscopy table. For evaluation of the tibialis
anterior (TA), extensor hallucis longus (EHL), or extensor digitorum longus (EDL)
tendon sheaths, place the heel of the foot against the fluoroscopy table. Examine the
patient to determine the point of maximal tenderness (Fig 12.1).
Tenography 165
Fig. 12.1B) The injection site for tenography is approxi-

mately 4 cm cephalad to the patient’s maximal site of
tenderness. The needle position is satisfactory for an
initial attempt at peroneal tenography. The linear radi-
olucency within the tendon sheath represents the pero-
neus brevis tendon. A 2 cm filling defect is present within
the midportion of the peroneus brevis tendon sheath at
a site that corresponds to the patient’s site of maximal
tenderness (arrowhead). This represents a focal area of
stenosis within the peroneus brevis tendon sheath. Typi-
cally, two linear radiolucencies are identified with the
peroneal tendon sheaths—one representing the pero-
neus brevis tendon and the other representing the pero-
neus longus tendon. The absence of the second linear
radiolucency may be due to a lack of communication
between the two peroneal tendon sheaths (a normal
variant). Alternatively, the patient may have complete
stenosis of the peroneus longus tendon sheath, a possi-
bility in this patient with a focal area of stenosis in the
peroneus brevis tendon sheath. This patient demon-
strated no improvement in symptomatology following
tenography and steroid administration into the pero-
neus brevis tendon sheath.
Palpate two points along the course of the tendon of interest using anatomic
landmarks and passive foot motion. Draw a line on the skin connecting these two
points. Cleanse the skin surface along the length of the tendon. Place sterile towels
to provide an aseptic work place for yourself. Palpate and mark nearby arteries to
avoid injury to them during needle puncture (Table 12.1). Draw up 1% Lidocaine 12
in the 5cc syringe. Prepare a 1:1 mixture of Conray 43 and 1% Lidocaine in the
20cc syringe. Place 10cc of the contrast-lidocaine mixture into the 10cc syringe.
Attach the connecting tubing to the 10cc syringe and flush through to eliminate all
air bubbles from the line. Administer local anesthetic at the skin surface over the
most proximal extent of the tendon (Fig 12.1). (A very proximal site is chosen so
that the procedure can be attempted more distally if the initial attempt at tendon
sheath opacification is unsuccessful.) In planning your injection site, be sure to
perform tendon sheath injection at a site other than the site of maximal tenderness
to avoid potential confusion between iatrogenic tendon sheath alteration and
tenosynovitis.11
While the patient is contracting the tendon of interest, approach the tendon
with a 25g 1" needle. Hold the needle such that it forms a 45˚ angle with the table
top. Advance the needle until you feel resistance from a hard mass. The needle tip
should now be within the tendon. Attach the 10cc syringe, with connecting tubing,
to the hub of the needle. Center the patient’s ankle within the fluoroscopy field such
that the tip of the needle is at the top end of the TV screen. Under fluoroscopic
12
166
Table 12.1. Anatomy and Landmarks for Ankle Tendons13 (Modified from Radiology 1984; 151:576)
Lateral Origin Insertion Action Landmark NV Structure
PB mid lateral fibula dorsum 5th MT everts foot, lat mall posterior lateral
plantarflexes foot malleolear a.
PL mid lateral fibula, 1st cunieform, everts foot, lat mall posterior lateral
head of fibula, 1st MT plantarflexes foot, malleolar a.
lat tibial condyle supports arch
Musculoskeletal Procedures: Diagnostic and Therapeutic

Posterior
PTT posterior tibia, navicular,talus, plantarflexes foot, med mall posterior medial
proximal fibula, 3 cuneiforms, adducts foot, malleolar a.
interosseous m cuboid, inverts foot,
2nd,3rd,4th MT supports arch
FDL posterior tibia DP of 2nd,3rd, flexes toes, med mall posterior tibial
4th, 5th toes plantatflexes foot, a.,n.,v.
inverts foot
FHL distal fibula, DP 1st toe flexes DP, 1st toe, med mall posterior tibial
interosseous m inverts foot, a.,n.,v.
plantarflexes foot
Anterior
TA lat tibial condyle, 1st cuneiform, dorsiflexes foot, med mall anterior tibial a
lat tibia, 1st MT inverts foot
interosseous m
EHL mid fibula, DP 1st toe extends 1st toe, ankle joint dorsalis pedis a
interosseous m everts foot
EDL lat tibial condyle, MP & DP 2nd, extends toes, ankle joint dorsalis pedis a
fibular crest, 3rd, 4th dorsiflexes foot,
interosseous m 5th toes everts foot
NV = neurovascular; lat mall = lateral malleolus; med mall = medial malleolus; lat = lateral; a = artery; v = vein; n = nerve
Tenography 167
guidance, exert gentle pressure on the syringe while slowly withdrawing the needle
from the tendon. When the contrast-lidocaine mixture flows easily, the needle tip
should be within the tendon sheath. Fluoroscopy will assist in confirming the needle
position by demonstrating a drop of contrast that flows away from the needle tip.
Subsequently you will see a tubular collection of contrast (tendon sheath) with a
central radiolucent area (tendon) (Fig 12.2). Continue to fill the tendon sheath
until it no longer fills distally, contrast begins to extravasate proximally, or the patient
complains of discomfort. In the typical patient, without stenosis of the tendon sheath,
the sheath has a capacity between 10 and 20 cc.12 However, it is best to place
approximately 10 cc of fluid into the sheath during the diagnostic part of the exam
as you may want to administer steroids and 1% Lidocaine (5 cc volume) during the
therapeutic phase of the exam.
12
Fig. 12.2. PTT tenogram in a 35 year old female patient who felt a pop in medial
part of her right foot after slipping. She has had a 5 month history of right foot pain
which began at the time of injury. Her pain did not respond to six weeks of casting
of the right foot and ankle. Subsequent MRI was negative for PTT rupture, but did
demonstrate fluid within the PTT sheath. A) The needle is placed immediately dor-
sal to the medial malleolus. Ideally the needle should be positioned more ceph-
alad in the event that initial attempt(s) at tenography are unsuccessful. The first
drop of contrast is in a linear distribution confirming the position of the needle
within the tendon sheath. B) Contrast is identified within the posterior subtalar
joint indicating an abnormal communication between the PTT sheath and the
subtalar joint (arrowhead). There is a focal area of stenosis at the level of the tibiotalar
joint. C) The injection and steroid placement into the tendon sheath has been com-
pleted. The suspected area of stenosis is confirmed, measuring approximately 2
cm. Mild tenosynovitis is present. Additionally, contrast is also identified within
the talonavicular joint. The patient reported 100% pain relief two weeks following
the procedure.
If contrast pools at the tip of your needle you are not within the tendon sheath.
It is important to recognize this quickly because once too much contrast has collected
in the tissues around the sheath, it is difficult to place the needle within the sheath.
Starting at a slightly more caudal position along the tendon sheath, repeat the same
technique.
During the injection take several fluoroscopic spot films to document the site of
tendon sheath rupture, abnormal communications between adjacent tendon sheaths
or between tendon sheaths and adjacent joints (Fig 12.2). The entire cirumference
of the tendon sheath should be evaluated. Ideally, the procedure is performed in a
room with C-arm fluoroscopy. In this setting, the fluoroscopy unit is rotated through
180˚ while the patient remains stationary. Spot films are obtained at 20-25˚ intervals.
If a C-arm fluoroscopy unit is not available, the patient will have to rotate his/her
ankle so that you may evaluate the entire tendon sheath. Almost always, this requires
removal of the needle from the tendon sheath following contrast opacification. Then,
overhead roentgenograms are obtained at approximately 30˚ intervals to demonstrate
the tendon sheath.
Following filming, local steroids may be administered in the tendon sheath, as
trial therapy, if tenosynovitis is present. In the setting where C-arm fluoroscopy is
not available, this necessitates a second needle placement in the tendon sheath. Using
fluoroscopic guidance, the needle is easily placed into the tendon sheath which is
already opacified by contrast material. Methylprednisolone acetate 40 mg (40mg/
cc) and 1% Lidocaine 4cc are instilled into the tendon sheath. To assure that steroid
administration is confined to the tendon sheath, fluoroscopic guidance is utilized.
(The contrast within the tendon sheath becomes more dilute—and therefore less
dense—during steroid injection.)
Obtain overhead roentgenograms of the full length of the tendon sheath in the
anteroposterior, lateral, and both oblique positions (Fig 12.3). To determine the
12 therapeutic effect, if any, of your procedure, ask the patient to perform the activity
that elicited their presenting symptoms. After 15 to 30 minutes, re-evaluate the
patient. For those patients with improvement of symptoms, the tendon sheath was
at least partially responsible for their symptoms. For those patients without pain
relief, the origin of their symptoms is not the tendon sheath or they have a lesion
that is not amenable to conservative (non-operative) treatment.
Patient Management
Tenography is an outpatient procedure. The patient may leave the department
once you have re-evaluated them. They should be cautioned about contacting the
emergency room if signs of infection appear (fever, erythema and/or warmth) at the
injection site. If their symptoms have improved or resolved, they should be warned
that their symptoms will most likely recur once the local anesthetic wears off. They
should be notified that their symptoms may improve or resolve in approximately
two weeks, if the steroids take effect, and that pain relief may last for as long as six
months.
Tenography 169
Fig. 12.3. PTT tenogram in a 48 year old male with a two month history of left
ankle pain. A) Lateral fluoroscopic spot view demonstrating mild to moderate ir-
regularity of the PTT sheath consistent with mild to moderate tenosynovitis. The
anterior part of the tendon sheath is not visualized at the level of the tibiotalar
joint. Joint space narrowing and subchondral sclerosis at the talonavicular joint
indicates osteoarthritis. The posterior process of the talus is pointed and somewhat
sclerotic indicating early osteoarthritis at the posterior subtalar joint. B) The C-arm
has been rotated such that the left ankle appears in an external oblique position. A
focal 1.5 cm area of stenosis is identified in the tendon sheath at the level of the
tibiotalar joint (arrowhead). The patient experienced 50% improvement of symp-
toms two weeks after tenography and steroid administration.
Complications 12
• tendon rupture
Pathology
The pressure during injection of contrast into the tendon sheath should be
mentally noted. Typically, there is little to no resistance to injection of contrast,
provided that the needle is completely within the tendon sheath. A high resistance
to injection suggests the presence of adhesions within the tendon sheath (Fig 12.4).
Persistent attempts at injection in the face of high resistance may lyse the adhesions
allowing tendon sheath opacification and marked symptom relief during the
procedure.
The tendon sheath should be evaluated for its width (Table 12.2), distal extent
(Table 12.1), contour, stenosis or obstruction to the flow of contrast, abnormal
communication with another tendon sheath or adjacent joint, extrinsic
compression, and/or displacement. Rupture and/or enlargement of the tendon may
12 Fig. 12.4. Peroneal tenogram in a 30 year old dancer. There was a lot of resistance
to injection of the tendon sheath initially. This was followed by a sudden give in
the pressure. This raised the suspicion that the patient had had adhesions in the
tendon sheath (s) which were lysed during the initial attempts to inject the tendon
sheaths. She experienced 75% relief of symptoms at two weeks after tenography
and steroid administration. A) Lateral fluoroscopic spot view of the left ankle dem-
onstrates simultaneous filling of both the peroneus longus and peroneus tendon
sheaths, as is expected. There is mild-moderate irregularity of the tendon sheaths
consistent with mild-moderate tenosynovitis. B) AP fluoroscopic spot view of the
left ankle. The peroneal tendons overlie the lateral malleolus. It is difficult to dis-
tinguish the peroneus longus from the peroneus brevis in this projection.
be inferred from the shape and width of the central radiolucency within the
contrast-filled tendon sheath. Today, it is relatively uncommon to detect extrinsic
compression of a tendon sheath, displacement of a tendon sheath or tendon rupture
on tenography because the majority of patients with these disorders have already
undergone MRI.
Because of the proximity of the PTT and FDL tendon sheaths, infrequently the
radiologists will discover that he/she has injected the PTT tendon sheath rather
Tenography 171
Table 12.2. Mean Tendon and Sheath Widths for Ankle Tendons (Lateral
View)13 (Modified from Radiology 1984; 151:577-80.)
Mean Tendon Width Mean Sheath Width

/SD (mm) /SD (mm)
PB (distal calcaneus) 4.0 +/- 0.9 5.3 +/- 0.9
PL (distal calcaneus) 5.1 +/- 0.8 6.6 +/- 0.8
PTT (tibial plafond) 4.2 +/- 1.0 5.7 +/- 1.1
FDL (proximal calcaneus) 4.2 +/- 0.9 6.0 +/- 1.0
FHL (proximal calcaneus) 4.4 +/- 1.3 6.1 +/- 1.4
TA (tibiotalar joint) 4.9 +/- 1.2 8.7 +/- 2.1
EHL (tibiotalar joint) 2.8 +/- 0.7 5.7 +/- 3.0
EDL —- —-
SD=standard deviation
than the FDL tendon sheath (Fig 12.5). If this occurs, evaluate the tendon sheath
that has been injected and then proceed to evaluate the tendon sheath that you
originally intended to examine. Administer steroids in the inadvertently injected
tendon sheath if it demonstrates evidence for tenosynovitis.
Tendon sheath width, along with contour, are indicators of tenosynovitis. If a
tendon sheath terminates proximal to its expected distal extent this may represent a
normal variant. However, stenosing tenosynovitis should be excluded, if possible. It
is important to determine the presence of stenosing tenosynovitis or a focal occlusive
tenosynovitis because these findings indicate that the patient is not a candidate for
conservative therapy. These patients may respond to surgical intervention.12-14
Subjectively, based on the contour of the tendon sheath, the tenogram is
determined to be normal (smooth contour), or to demonstrate mild, moderate, or
severe tenosynovitis, depending on the degree of irregularity or nodularity of the
tendon sheath.14 Those patients with mild to moderate tenosynovitis are ideal for
nonoperative management, including local steroid injections. However, as is the 12
case in many other conditions, the severity of radiologic findings may not correlate
with the severity of patient symptoms. Additionally, there is no correlation to date
between severity of radiologic findings and response to therapy (Fig 12.6).
To determine abnormal communications between the tendon sheaths and adjacent
structures, a practical knowledge of tendon anatomy is required to distinguish
variations in tendon sheath anatomy from tendon sheath pathology (Fig 12.7). The
most frequently studied tendon sheaths are the PTT, PL, and PB. Relatively little
detail is listed for the TA, EHL, and EDL as these are infrequently studied. The
most common anatomic variations are listed below:15
PTT: contained within its own tendon sheath which terminates at the level of
the tarsal navicular bone; the tendon sheath normally narrows at the level of the
flexor retinaculum (tibiotalar joint)
FDL/FHL: in 50% of cadavers FDL and FHL share a common tendon sheath;
in those cases with a common tendon sheath the two sheaths unite at the level of the
tarsal navicular forming a “V” or “Y” when viewed in the internal oblique projection
(Fig 12.5B).
PB/PL: in 100% of cadavers the PB and PL tendon sheaths communicate, the
PL tendon sheath is dorsal and plantar to the PB tendon sheath at the level of the
Fig. 12.5. Thirty-five year old female with suspected right PTT tenosynovitis. A) Lateral
fluoroscopic spot view demonstrates two linear radiolucencies within the tendon sheath.
The more anterior tendon is the FDL tendon. There is mild tenosynovitis of the tendon
sheath. A wisp of contrast is identified within the PTT sheath. This contrast ap-
peared simultaneously with that in the flexor tendon sheath and was most likely
related to a mixed injection. B) Following rotation of the C-arm the right ankle is in
the internal oblique position. This view demonstrates the Y-shaped configuration
of the tendon sheath confirming that the common sheath of the FDL/FHL, rather
12 than the PTT sheath, has been predominantly injected. A linear wisp of contrast is
again seen outlining the PTT sheath (arrowhead). The more medial tendon is the
FDL tendon (large asterisk), the more lateral tendon the FHL (small asterisk). Prior
to completing the flexor tendon tenogram steroids were administered into the com-
mon tendon sheath. Tenography of the PTT sheath was performed immediately
after the completion of the flexor tenogram.
fibular metaphysis and at the level of the calcaneus, respectively; typically there is
focal expansion of the sheaths between the superior and inferior peroneal retinaculum
TA: tendon contained within its own sheath which terminates at the level of the
talonavicular joint; the tendon sheath runs anterior to the tibia and medial and
parallel to the EHL tendon sheath
EHL: tendon contained within its own sheath; the tendon sheath terminates
anywhere between the first metatarsal head and the IP joint of the great toe; the
tendon sheath runs along the anterior aspect of the tibia and between the TA and
EDL tendon sheaths
EDL: originates as one tendon and terminates as four tendons distributed to the
2nd through 5th toes; the tendons are contained within one sheath which runs
along the anterior aspect of the tibia and lateral to the EHL
Tenography 173
Fig. 12.6. Thirty-two year old female with previous TA tenosynovitis. A) AP fluoro-
scopic spot view of the right ankle during tibialis anterior tenogram. This patient
has minimal tenosynovitis. Steroids were administered into the tendon sheath at
the completion of the study. B) Subsequent lateral overhead radiograph of the right
ankle. The tendon sheath has a relatively smooth outline. The patient experienced
no pain relief following tenography.
References
1. Baker KS, Gilula LA. The current role of tenography and bursography. AJR 1990;
154:129-33.
12
2. Mrose RE, Rosenthal DI. Arthrography of the hand and wrist. Hand Clin 1991;
7:201-17.
3. Staple TW, Jung D, Mork A. Snapping tendon syndrome: Hip tenography with
fluoroscopic monitoring. Radiology 1988; 166:873-4.
4. Destouet JM, Monsees B, Gilula LA. Part IV: Ankle tenography. In: Procedures in
skeletal radiology, Grune & Stratton, Inc., 1984:679-99.
5. Cheung Y, Rosenberg ZS, Magee T et al. Normal anatomy and pathologic condi-
tions of the ankle tendons: Current imaging techniques. Radiographics 1992;
12:429-44.
6. Evans GA, Freyno SD. The stress-tenogram in the diagnosis of ruptures of the
lateral ligament of the ankle. J Bone Joint Surg 1979; 61B:347-51.
7. Schneck CD, Mesgarzadeh M, Bonakdarpour A. MR imaging of the most com-
monly injured ankle ligaments. Part II. Ligament injuries. Radiology 1992;
184:507-12.
8. Schweitzer ME, Leersum M, Ehrlich SS et al. Fluid in normal and abnormal ankle
joints: Amount and distribution as seen on MR images. AJR 1994; 162:111-4.
9. Resnick D, Goergen TG. Peroneal tenography in previous calcaneal fractures. Ra-
diology 1975; 115:211-3.
Fig. 12.7. Top: Lateral

ankle tendons and sheaths.
(Taken from Radiology
1984; 151:582) Bottom:
Medial ankle tendons and
sheaths. (Taken from Radi-
ology 1984; 151:582)
10. Eichelberger RP, Lichenstein P, Brogdon BG. Peroneal tenography. JAMA 1982;
247:2587-91.
11. Reinus WR, Gilula LA, Lesiak LF et al. Tenography in unresolved ankle tenosyno-
12 vitis. Orthopaedics 1987; 10:497-504.
12. Haller J, Resnick D, Sartoris D et al. Arthrography, tenography, and bursography
of the ankle and foot. Clin Podiatr Med Surg 1988; 5:893-908.
13. Teng MM, Destouet JM, Gilula LA et al. Ankle tenography: A key to unexplained
symptomatology. Part I: Normal tenographic anatomy. Radiology 1984;
151:575-80.
14. Gilula LA, Oloff L, Caputi R, et al. Ankle tenography: A key to unexplained symp-
tomatology. Part II: Diagnosis of chronic tendon disabilities. Radiology 1984;
151:581-7.
15. Netter FH, Mitchell GAG, Woodburne RT. Part I. Anatomy, physiology, & meta-
bolic disorders. In: Woodburne RT, Culin ES, Kaplan FS (Ed). The Ciba collec-
tion of medical illustrations. Musculoskeletal system; Ciba-Geigy Corp. Summit,
NJ 1987; 8:98-112.
CHAPTER 1
CHAPTER 13
Bone Biopsies
Jacqueline C. Hodge
Introduction
A biopsy is the removal and study, usually microscopic, of tissue from a living
body to establish a precise diagnosis. Biopsies may either be performed at surgery,
referred to as an open biopsy, or percutaneously, referred to as closed biopsy.
Open biopsies may be excisional or incisional. An excisional biopsy refers to
removal of the lesion and a margin of contiguous normal tissue. This is usually
performed if the lesion in question is felt to be benign and constitutes definitive
treatment. An incisional biopsy refers to resection of a selected part of the lesion and
a margin of adjacent normal tissue. This technique is performed for suspected
malignant lesions.1
Percutaneous biopsies are classified according to the instrument(s) used to secure
the specimen. When an aspiration-type needle is used for the biopsy, yielding a
liquid specimen, an aspiration biopsy has been performed. If a solid specimen has
been obtained with a cutting needle, this is called a trephine-like biopsy. (In the
strictest sense, a trephine biopsy refers to a specimen obtained with a serrated cutting
needle.)
The first successful series of percutaneous aspiration biopsies were performed,
on the axial and appendicular skeleton, at Memorial Hospital in 1930. Subsequently,
Robertson and Ball performed closed biopsies in the vertebral bodies in 1935. In
1947, Ellis performed the first modern trephine drill biopsy at London Hospital.2
Today, closed bone biopsies are usually performed by radiologists, usually
monitored by fluoroscopy or computerized tomography (CT). 2-4 However,
ultrasound-guided biopsies of osteolytic bone lesions have been successfully
performed, for chest wall lesions, as well as other relatively superficial lesions.5,6
Comparable results have been noted for open and closed biopsy techniques.
Accuracy rates for open biopsies range from 72-97% in relatively small patient groups.
Meta-analysis of the English literature demonstrated approximately 80% accuracy
in over 10,000 aspiration and trephine biopsies performed over a 50 year period.
However, more recent literature quotes accuracy rates of 84-94% for closed
biopsies.2,3,7-11
As for the incisional biopsy, a pitfall of the percutaneous biopsy is the diagnostic
error due to sampling a nonrepresentative region of the lesion. However, sampling
error is less likely to occur with the open biopsy than with the percutaneous biopsy
because of the larger volume of tissue removed at the biopsy. Nonetheless, the closed
biopsy remains the procedure of choice because of the many disadvantages of open
biopsies. The latter are more costly than closed biopsy because they take more time
to perform, and require hospitalization of the patient. In addition, there is a higher

morbidity associated with open biopsy, at least in part related to the need for general
anesthesia, and the risk of post-operative wound infection, post-operative hematoma,
and intra-operative tumor spillage.1,12-14 If surgical biopsy is indicated, careful planning
is necessary to avoid selecting an inappropriate biopsy site which could compromise
definitive surgery.
Closed biopsy is an outpatient procedure requiring local, rather than general,
anesthesia. These two factors contribute to the relatively lower cost and morbidity
for closed biopsy as compared with open biopsy. The decreased likelihood of a
pathologic fracture following closed biopsy probably contributes to the lower
morbidity of this method as well. Radiation therapy may be started shortly after
closed biopsy, as compared with open biopsy, where the surgical scar should heal
before administering therapy. Lastly, percutaneous biopsy permits biopsy of lesions
that are surgically inaccessible, as well as biopsy of more than one lesion, if necessary.7
If repeated attempts at percutaneous biopsy result in nondiagnostic specimens, open
biopsy is warranted.
Once the issue of percutaneous biopsy has been raised, the radiologist reviews
the clinical history, and all pertinent imaging studies. Bone scan, the most sensitive
exam for the detection of bone lesions, is helpful in determining the extent and
distribution of the disease.15 CT and MRI define the local characteristics of the
lesion(s).2,15,16 CT may demonstrate: a) lesions that were not detectable on plain
radiographs, b) the soft tissue component of a lesion, c) the presence/absence of
cortical involvement, and d) matrix calcification and/or ossification. These features
often play a role in determining the biopsy site, the type of needle that may be used,
and the needle direction.3,14,15 MRI can demonstrate the neurovascular bundle,
without the administration of contrast, the soft tissue component of the lesion, and
skip metastases.15 The radiologist may have to refer the patient for CT and/or MRI
if these studies have not been obtained previously. A biopsy is indicated only if it
will alter management.
If a biopsy is deemed necessary, the radiologist selects a biopsy site. The main
considerations in determining the biopsy site include the accessibility of the lesion,
and its proximity to vital structures, including the neurovascular bundle.3 Include
13 the surgeon in planning your approach to the lesion to avoid adversely affecting
subsequent management. Lastly, consult the pathologists prior to performing the
biopsy to confirm handling of the specimen(s). If an aspiration biopsy is planned,
you may be able to arrange for the cytopathologist to be present during the biopsy.
This can guarantee the adequacy of your biopsy specimen before the patient leaves
the radiology suite or eliminate further attempts to gain adequate tissue if you have
obtained an adequate specimen on the first pass. If the cytopathologist can not be
present for the biopsy, it is wise to obtain three specimens, if possible.
Lastly, decide whether the biopsy will be performed under fluoroscopic or CT
guidance. CT is recommended for lesions that are not detectable with fluoroscopy,
or that are in technically difficult locations, for example the cervical or thoracic
spine (Fig. 13.1).4 Otherwise, biopsies may be performed with fluoroscopic assistance.
A fluoroscopy unit with a C-arm is necessary to allow visualization of the needle in
a minimum of two planes. Fluoroscopy is faster and less expensive than CT with a
success rate approaching 80%.3 Additionally, the waiting time for the procedure
may be reduced if it is performed fluoroscopically. It is not uncommon for imaging
Bone Biopsies 177
Fig. 13.1. Percutaneous CT-guided biopsy performed to exclude metastatic disease

in a 59 year old male with head & neck cancer resected 2-1/2 years previously.
Bone scintigraphy was positive for a solitary hot spot in the sacrum. Plain radio-
graphs did not demonstrate the lesion and therefore fluoroscopy was not deemed a
viable biopsy method. With the patient in the prone position, CT scanning of the
sacral lesion was performed. (The iliac vessels would preclude biopsy via an ante-
rior approach.) A) CT scan, bone window. A 3 cm x 3 cm lytic lesion communi-
cates with the left sacroiliac joint via an area of cortical breakthrough (arrowhead).
B) CT scan, bone window. Using a 22 g 3-1/2" spinal needle, the osteolytic lesion
is approached via the adjacent sacroiliac joint. No fracture was identified on the
post biopsy CT scan of the sacrum. Bloody aspirate was obtained and submitted to
cytology. Smears demonstrated elements similar to those seen on the smears ob-
tained from the biopsy of his primary cancer—i.e., metastatic poorly differentiated
carcinoma consistent with poorly differentiated mucoepidermoid carcinoma.
centers to have excess demand for their CT scanner while their fluoroscopy suites
are relatively underutilized. The major drawback of fluoroscopically-guided biopsies
is that they require exposure of staff members to radiation during the biopsy.4
Indications
Aspiration or trephine biopsies may be performed in either osseous or soft tissue
lesions. The most common indications are listed below.
• determine the origin of a solitary bone lesion (Fig. 13.2) 13
• to exclude a metastasis/multiple myeloma in a compressed vertebral body
(Fig. 13.3)
• confirm metastasis in a patient with a known primary cancer (Fig. 13.4)
• evaluate for tumor recurrence
• determine if chemotherapy has been effective (Fig. 13.5)
• assess for multiple myeloma or another round cell lesion
• fracture in a patient without a known primary and who is not receiving
steroids
• assess for infection (Fig. 13.6)
• check for primary bone tumor (Fig. 13.7)
• confirm benign skeletal disease for treatment purposes (osteoporosis,
osteomalacia, renal osteodystrophy, sarcoid)
• to assess a lesion in a patient who is a poor surgical risk
Fig. 13.2. This 60-year old male, 6 months status post a liver transplant for hepato-
cellular carcinoma, has recently presented with a solitary painful lytic lesion of a
left posterolateral rib. Diagnostic considerations include opportunistic infection,
and lymphoma in this patient receiving immunosuppressants. Metastases and mul-
tiple myeloma are included in the differential diagnosis given the appearance of
the lesion. This biopsy could have been performed under fluoroscopy or CT given
that the lesion was apparent on chest radiograph. CT-guidance was selected be-
cause the patient was undergoing additional CT scanning following percutaneous
biopsy. A) CT scan, bone window, patient supine. A 3 cm x 4 cm lytic lesion with
cortical breakthrough is present in a left lateral rib. B) CT scan, bone window.
Because of cortical breakthrough, an aspiration technique was performed with a
22 g spinal needle. Erect post-procedure chest radiograph was negative for a pneu-
mothorax. There was no growth from the sample submitted to microbiology. Cytol-
ogy findings were consistent with metastatic hepatocellular carcinoma.
Fig. 13.3. Thirty-six year old

Phillipino nurse, without a
known primary tumor, who
presented with back pain.
Following demonstration of a
lytic lesion on plain radiographs,
she was referred for computer-
13 ized tomography and biopsy of
the L5 lesion. A) The patient was
placed prone and radiopaque
markers placed over the left
paraspinal region. B) Soft-tissue
cores were removed with a
19.5g Vacu-cut needle. Bone
and bloody aspirates were ob-
tained with 14g Ostycut and 20g
spinal needles, respectively. Pa-
thology and cytology specimens
were unrevealing. Six weeks
later, the public health depart-
ment reported growth of Myco-
bacterium tuberculosis from the
specimen sent to microbiology.
Bone Biopsies 179
Fig. 13.4. Sixty-seven year old female with surgical resection ten months and
chemotherapy nine months prior to the appearance of an osteolytic lesion of C7.
A 22g spinal needle was introduced into the osteolytic lesion via an anterior
approach. Note the neighboring jugular and carotid vessels (arrow). Bloody aspi-
rates were consistent with metastatic melanoma.
Contraindications
There are no absolute contraindications to biopsy. Although PT and PTT values
are frequently used to predict the occurence of hemorrhagic complications, recent 13
studies indicate that abnormalities in these values do not correlate with an increased
risk of hemorrhage following percutaneous puncture.17 The following relative
contraindications exist:
• decreased platelet count (< 50,000)16,17
• bleeding diathesis
• suspected vascular lesion in thoracic vertebra (to avoid potential cord
compression secondary to hemorrhage)
Biopsy Instruments
Aspiration Needles
A disposable, fine-gauged needle with a stylette used to aspirate fluid. Examples
include spinal and Chiba needles (Manan Medical Products Inc., Northbrook,IL).
Spinal needles are available in 18, 20, 22, 23, and 25 gauge and in 4,5,6,9,10,15,18,
and 20 cm lengths. Chiba needles are available in 18, 20, 22, and 23 gauge and in 9,
15, and 20 cm lengths.
Fig. 13.5. Forty-three year old female with metastatic breast cancer, post--
radiotherapy. Percutaneous biopsy is performed to determine if the mixed lytic/
sclerotic L2 lesion represents post-radiation fibrosis or active metastatic disease.
With the patient in the prone position, an Ackermann needle is placed into the left
posterolateral aspect of the vertebral body. The sample was disease-free, consistent
with post-radiation change in that region. Unfortunately, simultaneous biopsy of a
similar lesion at L1 (not shown) was positive for residual/recurrent metastatic disease.
Thus the patient was treated accordingly.
Cutting Needles
These needles, usually disposable, may be utilized to obtain solid specimens,
either soft tissue or bony. The majority of these needles do not contain a coaxial
sheath. Therefore the operator must make a new puncture for every sample he/she
13 attempts to obtain. Examples include:
• Tru-cut needle (Baxter Health Care Corp., Deerfield, IL)
• Ostycut needle (Baxter Health Care Corp., Deerfield, IL)
• Vacu-cut needle (Baxter Health Care Corp., Deerfield, IL)
• Jamshidi needle (Kormed Co., Minneapolis, MN)18,19
• PercuCut needle (E-Z-EM Canada Inc., Anjou, QC)
The Tru-Cut needle consists of a needle and syringe system. A syringe is necessary
to create a negative pressure effect. The needle comes in 14, 17, and 18 gauge and in
3, 4.5, and 6" lengths.
The Ostycut needle consists of a needle and stylette system. A syringe is required
to create a negative pressure effect. The needle is available in 13, 13.5, 14, 15, 16,
and 17 gauge and in 5, 7.5, 10, 12.5, and 15 cm lengths.
The Vacu-Cut needle consists of a needle and stylette system. Negative pressure
is created by a unique feature within the needle hub when the stylette is withdrawn.
Therefore, there is no need for a syringe.
Bone Biopsies 181
Fig. 13.6. Seventy-six year old female with known bladder cancer. At magnetic
resonance imaging, bone marrow and disc space edema was identified at two con-
secutive lumbar vertebra, suspicious for infection. Percutaneous biopsy of the left
paraspinal soft tissue mass was performed with a 14 g Ostycut needle, the patient
prone. Cultures were positive for Mycobacterium tuberculosis.
13
Fig. 13.7. Percutaneous excision of an osteoid osteoma of the right tibia was per-
formed in this fifty-nine year old female. A part of the lesion was removed with an
Ackermann needle. Pathology results confirmed the excision of at least part of the
tumor. The absence of recurrent symptoms at six months post-biopsy supports ex-
cision of the nidus of the osteoid osteoma.
The Jamshidi needle, developed in 1971 by Jamshidi and Swaim, is a reusable

needle which consists of four parts:18,19
• cutting needle—this is a nonserrated device with a tapered end
• stylette—sits within the cutting needle
• comfort cap—used to help screw the needle into the bone
• probe—used to expel the cut specimen
This needle yields specimens that have a lower incidence of crush artifact as
compared with specimens obtained with the trephine needles. Today a disposable
version of the Jamshidi needle is available at Baxter Health Care Corp. This needle
comes in 15, 16, 17, and 18 gauge and in 7 and 10 cm lengths.
The PercuCut needle may come with or without a sheath, in addition to the
cutting needle and stylette. The sheath minimizes soft tissue damage with repeated
attempts at sample removal. The needle requires utilization of a syringe to create a
negative pressure effect. It is available in 18, 19.5, and 21 gauge and in 5,10,15,20,
and 28 cm lengths. The 15 cm length needle may be accompanied by a 10 cm long
sheath.
Trephine Needles
These are large-gauge needles with a serrated cutting edge. Examples include the
Craig needle (Baxter Health Care Corp., Deerfield, IL)20, Ackermann needle (Cook
Co., Bloomington, IN) 21, Franseen needle (Manan Medical Products, Inc.,
Northbrook, IL).
The Craig needle was first utilized by Frederick Craig in 1956 for a vertebral
body biopsy.20 Today this is the most frequently used device for percutaneous biopsy.1
This reusable needle has five parts, in addition to a cap which gives additional leverage
to screw in the cutting needle:
• trocar—a blunt instrument used to chart the way to the selected biopsy site
• cannula—a hollow case that passes over the trocar displacing, rather than
injuring, adjacent vessels and nerves. Subsequently, the cutting needle
passes through the cannula to reach the biopsy site. With this device the
operator can perform multiple biopsy attempts without repeated trauma
13 to the adjacent skin and soft tissues.
• cutting needle—a device with serrated edges which allows the operator to
obtain bone cores
• stylette—a blunt device which is placed into the cutting needle to help
remove the bone specimen. The stylette can also be used to indirectly
determine the length of the specimen during the biopsy.
• worm—a two-pronged instrument used to retrieve tissue that is too
fragmented for retrieval by the cutting needle
The Ackermann needle, a reusable trephine needle, was first used in 1956 by
Ackermann.21 It is similar to the Craig needle but has a smaller diameter, ideal for
biopsy of smaller bones, particularly metacarpal or metatarsal bones in adults, or
long bone or spine biopsies in pediatric patients (Fig 13.5). Unlike the Craig needle,
the Ackermann needle does not have a worm. Most importantly, the trocar of the
Ackermann needle has a quarter-sized metal head. Because of this feature, it is
necessary to insert the trocar and cannula together and then remove the trocar. If
Bone Biopsies 183
you insert the trocar alone, you will not be able to pass the cannula over it and
therefore you will have to repeat this step again.
The Franseen needle is a disposable trephine needle. It does not contain a sheath.
It is available in 16, 18, 20, and 22 gauge and in 4, 5, 9, 15, and 20 cm lengths. It is
utilized in the same manner as an aspiration needle.
Accessory Devices22-25
A hand drill is necessary when the lesion of interest is located within the medullary
cavity with intact overlying cortex or when the lesion is surrounded by osteoblastic
bone response. The Zimmer hand drill is composed of a body and 5" long drill bits
of varying diameters.2 As the hand drill is infrequently indicated for percutaneous
biopsies, consider purchasing it in conjunction with another department.
Alternatively, you may borrow a drill when indicated.
Pre-Biopsy Considerations
Non-biopsiable Lesion
If the lesion is unsuitable for percutaneous biopsy, the radiologist may still be
helpful in presurgical localization of the lesion.26-28
Blood Tests
At the time of determining whether or not the biopsy is feasible, ask the referring
physician about the patient’s platelet count or any history of coagulopathy.3
Antibiotics
If the biopsy is being performed for assessment of infection, ask the referring
physician to discontinue antibiotics at least 48 hours prior to performing the biopsy.
Premedication
You may request that the referring physician prescribe Valium or other anti-anxiety
medications for the patient to utilize on the day of the biopsy. Although anti-anxiety
medications are often sufficient, some patients will require intravenous or
intramuscular pain medication for the biopsy. The radiology nurse should have access
to morphine, midazolam, etc. Patients should be advised to arrive at least 45 minutes
13
in advance to the scheduled biopsy time so that if medication is necessary, it can be
administered and be effective by the time he/she is positioned on the biopsy table.
Heavy sedation is not recommended. Ideally, the patient should be alert enough to
advise the radiologists if his/her needle is abutting a neural structure.
Post-Biopsy Care
Because you will not always have advance knowledge as to which patients will
require anti-anxiety or pain medication, at the time of scheduling, requests that all
biopsy patients arrange for an escort to take them home.
Biopsy Planning
Explain the potential complications of the procedure and obtain written consent
for the biopsy. Obtain pre-biopsy radiographs, fluoroscopic spot films or CT of the
lesion. When positioning the patient for the biopsy, make sure that he/she is
comfortable, and that the part to be biopsied is in a stable position. Otherwise, the
patient will not remain stationary for the duration of the procedure.
Technique
Cleanse the skin with Betadine (Povidone-Iodine, Purdue Frederick) or
Stanhexidine (Chlorohexidine Gluconate, Stanley Pharmaceuticals). After draping
the sterile area, administer 1% lidocaine as local anesthetic. (Omit local anesthetic if
the patient has a history of lidocaine allergy.) If a bone or soft tissue core biopsy is
planned, make an approximately 2 cm skin incision and dissect the subcutaneous
tissues with a spreader. No skin incision is required for an aspiration biopsy. Administer
local anesthetic, via a 22g 3 1/2" or 6" spinal needle, along the needle track and
directly onto the periosteum of bone. You may leave the spinal needle in place as a
guide for subsequent needle placement. For solid lesions, plan to perform both core
and aspiration biopsy. Studies have shown that these techniques are complimentary.29,30
Craig Needle, Ackermann Needle

Direct the trocar down to the bone parallel to the anesthetic needle and
perpendicular to bone to avoid the needle from sliding off of the bone. Remove the
anesthetic needle. Place the cannula over the trocar and remove the trocar. Place the
cutting needle through the center of the cannula. Under fluoroscopic guidance,
advance the cutting needle into the lesion. Confirm the intraosseous position of the
cutting needle in a second plane, preferably at 90° to the initial plane. To determine
the length of the specimen, place the stylette through the cutting needle. Under
fluoroscopic guidance, mentally record the distance between the tip of the cutting
needle and the tip of the stylette. This is the length of the bone specimen within the
cutting needle. Apply a gentle rotating motion to the cannula, cutting needle, and
stylette to loosen the core of bone within the cutting needle from the surrounding
bone. Remove the cutting needle and the stylette only. The cannula remains in place
for additional passes. The cannula is only removed with the last pass.
Osty-Cut Needle, Tru-Cut Needle

Once the needle is in the desired position, remove the stylette and attach a 10 cc
13 syringe to the hub of the needle. Withdraw the plunger on the 10 or 20 cc syringe to
its maximum to produce a vacuum phenomenon within the system. Withdraw and
advance the needle/syringe complex by small increments several times and then
remove the entire complex from the biopsy site. Typically each needle is used only
once as the vacuum is no longer present after the initial use of the needle.
Vacu-Cut Needle
Once the needle is in the desired position, withdraw the stylette 1-2 cms. This
creates a natural vacuum within the needle system. Withdraw and readvance the
needle/stylette device by approximately 2 cm increments several times within the
biopsy tract. Remove the needle/stylette complex. Holding the needle/stylette over
a sterile container, advance the stylette through the needle removing a core of tissue.
Typically each needle is used only once as the vacuum is no longer present after the
initial use of the needle.
Bone Biopsies 185
Obtain post-procedure radiographs at the site of the biopsy, particularly if the

biopsy has been performed in a weight-bearing bone. Inform the patient of any
iatrogenic lesions (e.g., biopsy-related fracture) or other complications.
Specimen Handling
In all cases, a solid or liquid specimen should be submitted to bacteriology to
exclude infection. Ideally, the first sample obtained should be the specimen submitted
to microbiology. (This specimen is assumed to have the lowest risk of contamination.)
Blood and other liquid specimens should be placed in a 50% alcohol solution.
The volume of fixative should be approximately ten times that of the specimen
volume. The sample should be submitted to cytology promptly. Cytology results are
usually available within 24 hours, unless special stains are required.
Soft tissue or bone specimens should be placed in formalin, approximately ten to
twenty times the volume of the tissue, and submitted to surgical pathology promptly.
Analysis of bone specimens requires a minimum of three days, the length of time
required to decalcify the specimen. As for cytology, special stains may delay the final
diagnosis by a few additional days.
Complications
A rate of 0.2% complications and a death rate of 0.02% have been reported.2
Serious neurologic injury rate is 0.08%. The following complications have been
reported, depending on the site of the biopsy10, 37-40:
• pneumothorax
• paraplegia, quadriplegia
• footdrop from neural injury
• meningitis
• compression fracture/pathologic fracture1
• tumor spread along needle track
• infection spread along needle track resulting in draining sinus
• hemorrhage
• nondiagnostic
13
Additional Considerations
• It is preferable to biopsy a lytic lesion rather than a sclerotic lesion. The
lytic lesion allows easier access and also a higher diagnostic yield (Fig
13.4).31 If all lesions are sclerotic, select the lesion that has the least amount
of sclerosis. Sclerosis often represents the reaction to the underlying
disorder.
• Try to avoid biopsying necrotic tissue. These areas are likely
underrepresentative of the patient’s condition.
• Examine the lesion carefully. This will allow you to make the diagnosis
via the simplest route. If there is a soft tissue component to the lesion,
you can biopsy the soft tissue mass (Fig 13.6). Similarly, if there is an area
of cortical breakthrough, you may attempt to make the diagnosis by fine
1 especially in patients who have undergone previous chemotherapy

needle aspiration technique rather than by trephine needle technique (Fig

13.1).4 Although a large diameter needle minimizes crush artifact on the
specimen, it has a higher rate of complications than do smaller diameter
needles.
• Consider the relative diagnostic yield as you select your biopsy site. The
yield is often higher in vertebral bodies than in flat bones.32
• If the biopsy is performed in the cervical or thoracic spine, it is preferable
to use a smaller needle, if possible, to reduce the potential complications.32,33
• You should have a working diagnosis when doing the biopsy. This can be
helpful in planning the biopsy approach and specimen collection. For
example, if a cartilaginous tumor is suspected, a larger amount of tissue is
necessary to make the diagnosis than if a noncartilaginous lesion is
suspected .34 Additionally, aspiration alone is not recommended for the
diagnosis of primary bone tumors because it is difficult to make a definitive
diagnosis from a small sample of heterogenous material.35 An exception
to this rule is the diagnosis of round cell tumors -multiple myeloma,
retinoblastoma, neuroblastoma -and recurrent tumor (Fig 13.2).
• Submit all material obtained on biopsy. Blood clot may contain diagnostic
material.9 Rinse all syringes and place the contents in a container. Submit
the sample to cytopathology.35
• Contrary to some anecdotal reports, lidocaine does not interfere with
percutaneous biopsy results in the setting of infection. Lidocaine may be
used generously to minimize the pain associated with biopsy in this patient
population.36
MR-Guided Intervention41-44
Infrequently, MRI has been utilized to guide percutaneous biopsy and aspiration
of soft tissue lesions. It has been helpful in the biopsy of prostate, breast and head
and neck masses. Because of MRI’s excellent soft tissue resolution and multiplanar
capabilities, it is an excellent device for directing biopsies. However, its major
13 drawbacks have been accurate localization of needle tip and needle-associated artifact
(related to relatively high-field strength magnets, needle orientation within the
magnetic field and pulse sequence) and magnet configuration. The latter problem
has been resolved with the open magnet, although these are not widely available.
More recent work has shown needle tip localization to within 1 mm utilizing spin
echo sequences. Biopsy results with this new system suggests that it is a safe and
reliable system, yielding accurate diagnoses.
References
1. Goodrich JA, Difiore RJ, Tippens JK. Analysis of bone biopsies. Am Surg 1983;
49:594-8.
2. Murphy WA, Destouet JM, Gilula LA. Percutaneous skeletal biopsy 1981: A pro-
cedure for radiologists- results, review, and recommendations. Radiology 1981;
139:545-9.
3. Kattapuram SV, Rosenthal DI. Percutaneous biopsy of skeletal lesions. AJR 1991;
157:935-42.
Bone Biopsies 187
4. Tikkakoski T, Lahde S, Puranen J et al. Combined CT-guided biopsy and cytology

in diagnosis of bony lesions. Acta Radiol 1992; 33:225-9.
5. Civardi G, Livraghi T, Colombo P et al. Lytic bone lesions suspected for metasta-
sis: ultrasonically guided fine-needle aspiration biopsy. J Clin Ultrasound 1994;
22:307-311.
6. Targhetta R, Balmes P, Marty-Double C et al. Ultrasonically guided-aspiration
biopsy in osteolytic bone lesions of the chest wall. Chest 1993; 103:1403-1408.
7. Schajowicz F, Derqui JC. Puncture biopsy in lesions of the locomotor system:Review
of results in 4050 cases, including 941 vertebral punctures. Cancer 1968;
21:531-548.
8. Ayala AG, Zornosa J. Primary bone tumors:percutaneous needle biopsy.
Radiologic-pathologic study of 222 biopsies. Radiology 1983; 149:675-679.
9. Hewes RC, Vigorita VJ, Freiberger RH. Percutaneous bone biopsy:the importance
of aspirated osseous blood. Radiology 1983; 148:69-72.
10. den Heeten GJ, Oldhoff J, Oosterhuis JW et al. Biopsy of bone tumours. J Surg
Oncol 1985; 28:47-251.
11. Ng CS, Salisbury JR, Darby AJ et al. Radiologically guided bone biopsy: Results of
502 biopsies. Cardiovascular & Interventional Radiology. 1998; 21:122-128.
12. Skrzynski MC, Biermann JS, Montag A et al. Diagnostic accuracy and
charge-savings of outpatient core needle biopsy compared with open biopsy of
musculoskeletal tumors. J Bone Joint Surg 1996; 78A:644-9.
13. deSantos LA, Murray JA, Ayala AG. The value of percutaneous needle biopsy in
the management of primary bone tumors. Cancer 1979; 43:735-44.
14. Murphy WA. Radiologically guided percutaneous musculoskeletal biopsy. Orthop
Clin North Am 1983; 14:233-241.
15. Heare TC, Enneking WF, Heare MM. Staging techniques and biopsy of bone
tumors. Orthop Clin North Am 1989; 20:273-285.
16. Gold RI, Seeger LL, Bassett LW et al. An integrated approach to the evaluation of
metastatic bone disease. Radiol Clin North Am 1990; 28:471-483.
17. Darcy MD, Kanterman RY, Kleinhoffer MA, et al. Evaluation of coagulation tests
as predictors of angiographic bleeding complications. Radiology 1996; 198:741-4.
18. Jamshidi K, Swaim WR. Bone marrow biopsy with unaltered architecture: A new
biopsy device. J Lab & Clin Med 1971; 77:335-42.
19. Shaltot A, Michell PA, Betts JA et al. Jamshidi needle biopsy of bone lesions. Clin
Radiol 1982; 33:193-196. 13
20. Craig FS. Vertebral body biopsy. J Bone Joint Surg 1956; 38A:93-102.
21. Ackermann W. Vertebral trephine biopsy. Ann Surg 1956; 143:373-85.
22. Ahlstrom KH, Astrom KG. CT-guided bone biopsy performed by means of a
coaxial biopsy system with an eccentric drill. Radiology 1993; 188:549-52.
23. de Vries J, Karthaus AJ. A new instrument for bone drill biopsy. Eur J Surg Oncol
1989; 15:11-2.
24. Cohen M, Zornoza J, Finkelstein JB. Percutaneous needle biopsy of long bone
lesions facilitated by the use of a hand drill. Radiology 1981; 139:750-1.
25. Astrom KG, Sundstrom JC, Lindgren PG et al. Automatic biopsy instruments
used through a coaxial bone biopsy system with an eccentric drill tip. Acta Radiol
1995; 36:237-42.
26. Prasad R, Olson WH. Bone marking for biopsy using radionuclide bone imaging.
Cancer 1987; 60:2205-7.
27. Renzoni SA, Convery FR, Ashburn W et al. Intraoperative osteoscintigraphy as an
aid to bone biopsy. Clin Nucl Med 1986; 11:619-20.
28. Froelich JW, McKusick KA, Strauss HW et al. Localization of bone lesions for
open biopsy. Radiology 1983; 146:549-50.
29. Schweitzer ME, Gannon FH, Deely DM et al. Percutaneous skeletal aspiration
and core biopsy: Complimentary techniques. AJR 1996; 166:415-8.
30. Hodge JC. Percutaneous biopsy of the musculoskeletal system: A review of 77
cases. Canadian Association of Radiology Journal 1999;50:121-125.
31. Jacobsson H. Percutaneous bone biopsy with a simple punch instrument. Acta
Radiol 1982; 23:415-22.
32. Debnam JW, Staple TW. Trephine bone biopsy by radiologists. Radiology 1975;
116:607-9.
33. Evarts CM. Diagnostic techniques. Closed biopsy of bone. Clin Orthop 1975;
107:100-11.
34. Simon AM. Biopsy of musculoskeletal tumors. J Bone Joint Surg 1982; 64A:1253-7.
35. El-Khoury GY, Terepka RH, Mickelson MR et al. Fine-needle aspiration biopsy of
bone. J Bone Joint Surg 1983; 65A:522-5.
36. Schweitzer ME, Deely DM, Beavis K et al. Does the use of lidocaine affect the
culture of percutaneous bone biopsy specimens obtained to diagnose osteomyeli-
tis? An in vitro and in vivo study. AJR 1995; 164:1201-3.
37. Arca MJ, Biermann JS, Johnson TM et al. Biopsy techniques for skin, soft-tissue,
and bone neoplasms. Surg Oncol Clin N Am 1995; 4:157-174.
38. Markel DC, Neumann KU, Steinau HU. Appropriate techniques for musculosk-
eletal tumor biopsy. Orthop Rev 1994; 23:176-80.
39. Mankin HJ, Mankin CJ, Simon MA. The Hazards of biopsy, revisited. J Bone
Joint Surg 1996; 78A:656-63.
40. Tampieri D, Weill A, Melanson D et al. Percutaneous aspiration biopsy in cervical
spine lytic lesions. Neuroradiology 1991; 33:43-7.
41. Orel SG, Schnall MD, Newman RW et al. MR imaging-guided localization and
biopsy of breast lesions: Initial experience. Radiology 1994; 193:97-102.
42. Duckwiler G, Lufkin RB, Teresi L et al. Head and neck lesions: MR-guided aspi-
ration biopsy. Radiology 1989; 170:519-22.
43. Lewin JS, Duerk JL, Jain VR et al. Needle localization in MR-guided biopsy and
aspiration: Effects of field strength, sequence design, and magnetic field orienta-
tion. Am J Roentgenol 1996; 166:1337-45.
44. Neuerburg J, Adam G, Bucker A, et al. A new MR-compatible bone biopsy sys-
13 tem: First clinical results. Rofo 1998; 169:515-20.
CHAPTER 1
CHAPTER 14
Percutaneous Treatment of Osteoid

Osteoma
Jacqueline C. Hodge
Introduction
Osteoid osteoma, a benign osseous neoplasm, is characterized radiographically
by a central nidus and surrounding reactive sclerosis. The pathognomonic clinical
history is that of night pain which is dramatically relieved by nonsteroidal
anti-inflammatory agents. Accounting for slightly more than 10% of benign bone
tumours, the diagnosis of osteoid osteoma is confirmed by plain radiography, com-
puterized tomography (CT), and/or bone scintigraphy.1 Because the pain associated
with the osteoid osteoma has been attributed to the nerve fibers surrounding the
vessels contained within the nidus, removal of the nidus is necessary for definitive
treatment and resolution of patient symptoms.2
Traditionally, osteoid osteoma has been treated with surgical excision. However,
intraoperative localization of the nidus has been difficult because of the reactive
bone surrounding the nidus. Preoperative localization of the nidus using radiotrac-
ers or methylene blue has assisted the surgeon in his quest for the nidus. However,
these are tedious, cumbersome techniques. CT placement of a wire within the nidus
has been more efficient, but has led to an excessive amount of bone being resected,
resulting in an increased risk of fracture and lengthening of the post-operative re-
covery period.2
Within the past decade, radiologists have developed alternative techniques for
the treatment of osteoid osteoma. These percutaneous therapies have been remark-
ably successful, allowing the use of local anesthesia in some instances and outpatient
care for this disease entity. Furthermore, these techniques have minimized the risk
of fracture because only small amounts of bone need be excised. The discussion that
follows will focus on drill resection of the nidus and radio-frequency ablation.
Percutaneous Drill Resection2-4
This technique is essentially that of CT-guided percutaneous biopsy (Please re-
fer to Chapter 13). However, some authors have chosen to use general, rather than
local, anesthesia to reduce patient discomfort. Alternatively, a peripheral block may
be used with lesions of the extremities. However, a tourniquet should be placed
proximal to the lesion, during excision, to reduce local bleeding.
For this procedure, the patient is positioned prone or supine, depending upon
the target bone. Following CT scan through the region of interest, select and mark
a puncture site. In planning your approach, you should chose a path where you are
unlikely to encounter the neurovascular bundle. Prep and drape the area in sterile

fashion. Make a skin incision large enough to pass a trocar needle (e.g., Craig needle)
through. Line up the trocar with the nidus precisely. Remove the trocar, leaving the
trocar cannula in place. Insert the hand drill through the cannula and verify the
position of the drill relative to the nidus. Turning the drill, remove the nidus as a
core. Place in formalin and submit to surgical pathology for confirmation of the
diagnosis. You may have to repeat this technique if the nidus is larger than the
diameter of the drill tooth.
Percutaneous Radio-Frequency Ablation1,5,6
This method relies on the use of a radio-frequency electrode to obliterate the
nidus of the tumor by heat necrosis. The disadvantage of this method is that you
have no tissue confirmation of the diagnosis prior to the application of thermal
ablation. Therefore, you must be fairly certain of your diagnosis, by clinical and
radiologic studies, prior to the application of thermal damage to the lesion.
Patients are sedated with either general or spinal anesthetic. Skin preparation
and localization of the lesion are identical to that performed for percutaneous bi-
opsy. Because of the risks of thermal damage to neighboring structures, the nidus
must be more than 1 cm from vital soft tissue structures—i.e., the neurovascular
bundle. Place the trephine needle into the lesion and remove the bone enroute to
the nidus (Fig 14.1). Send this specimen for histologic evaluation. Because the speci-
men requires decalcification, the diagnosis will not be confirmed until 48 to 72
hours after radio-frequency ablation.
Introduce the rigid electrode device through the trephine cannula. The electrode
is insulated throughout its length, except for its terminal 5 mm tip which will be
exposed to the lesion. Position the tip of the electrode into the tumor such that no
portion of the nidus is more than 6 mm away from the electrode tip. If this is not
possible, you may need a second entry site to ablate the remainder of the nidus.
Connect the electrode to a radio-frequency generator (RF-5 Generator,
Radiotronics) and supply sufficient current to heat the electrode tip to approxi-
mately 90˚C. Once your electrode tip is in place, apply the tip to the nidus for
approximately 4 minutes. Withdraw the electrode tip and instill 1-2 cc of Bupivicaine
into the lesion via the trocar cannula. Apply a bandage to the puncture site and
discharge the patient.
14 Post-Procedure Care
The patient may leave the radiology suite immediately after the ablation therapy.
He (she) may bear full weight on the extremity immediately. The patient is asked to
refrain from vigorous activity (running, jumping, etc) for three months after the
ablation therapy if it has been performed in a weight-bearing bone.
No long-term sequelae have been attributed to radio-frequency ablation therapy.
Bone and bone marrow necrosis is limited to a 1 cm radius, regardless of the size of
the electrode tip or the duration of heating.7
Percutaneous Treatment of Osteoid Osteoma 191
14
Fig. 14.1. Young adult with intermittent pain. A) Frontal radiograph of the left hip
shows an osteolytic lesion with a sclerotic periphery along the lateral aspect of the
acetabular dome (arrow). It’s radiographic appearance is consistent with that of an
osteoid osteoma. B) A trocar-type needle is identified as it approaches the nidus of
the osteoid osteoma. (Courtesy of Dr. Phil Landers, Montreal General Hospital,
Montreal, QC.) Transaxial CT image throught the left hip, bone window technique.
This image confirms the presence of a large central region (the nidus) and a reac-
tive rim of sclerosis in the lateral part of the acetabulum. C) Transaxial CT scan, the
same level as in Fig 14.1B. A trocar-type needle is identified as it approaches the
nidus of the osteoid osteoma. (Courtesy of Dr. Phil Landers, Montreal General
Hospital, Montreal, QC.)
References
1. Rosenthal DI, Springfield DS, Gebhardt MC et al. Osteoid osteoma: Percutane-
ous radio-frequency ablation. Radiology 1995; 197:451-4.
2. Mazoyer J, Kohler R, Bossard D. Osteoid osteoma: CT-guided percutaneous treat-
ment. Radiology 1991; 181:269-71.
3. D’Erme M, Del Popolo P, Diotallevi R et al. CT-guided percutaneous treament of
osteoid osteoma. Radiologia Medica 1995;90:84-7.
4. Assoun J, Railhac J, Bonnevialle P et al. Osteoid osteoma: Percutaneous resection
with CT guidance. Radiology 1993; 188:541-7.
5. Rosenthal DI, Hornicek FJ, Wolfe MW et al. Percutaneous radiofrequency coagu-
lation of osteoid osteoma compared with operative treatment. J Bone Joint Surg
1998; 80A:815-21.
6. Lindner NJ, Scarborough M, Ciccarelli JM et al. CT-controlled thermocoagula-
tion of osteoid osteoma in comparison with traditional methods. Z Orthop 1997;
135:522-7.
7. Tillotson CL, Rosenberg AE, Rosenthal DI. Controlled thermal injury of bone:
Report of a percutaneous technique using radiofrequency electrode and generator.
Invest Radiol 1989; 24:888-892.
14
CHAPTER 1
CHAPTER 15
Vertebroplasty
Jacqueline C. Hodge
Introduction
Cementoplasty refers to the percutaneous placement of a biosynthetic material
into an osteolytic lesion of a vertebral body or other bone.1,2 The earliest cases of
vertebroplasty, the placement of methyl methacrylate into a vertebral body, were
performed for the stabilization of aggressive spinal hemangiomas.3-5 Although a
relatively recent technique, with the earliest reports dating back to the late 1980s,
vertebroplasty is gaining momentum, particularly within the oncologic, and palliative
care communities.
The goal of vertebroplasty/cementoplasty is twofold, to provide pain control
and stabilization of vertebra or other osseous structures. The ideal candidate for the
procedure is one with an osteolytic metastasis, multiple myeloma, plasmacytoma, or
an osteoporotic compression fracture.6,7 Alternatively, vertebroplasty may be used as
an alternative to vertebrectomy and placement of intervertebral bone struts,
particularly in patients who are considered poor surgical candidates.
Cementoplasty/vertebroplasty are excellent adjunctive therapies to other
noninvasive antitumor therapies, potentially providing short-term (within 72 hours)
pain relief. However, these interventions should not be considered as alternatives to
radiotherapy because no tumoricidal properties have been attributed to methyl
methacrylate. Radiotherapy is still necessary for reducing tumour bulk and providing
long-term pain control.6
Indications6,8
• debilitating pain localized to a focal area
• intractable pain following radiotherapy
• a lesion threatening spinal or lower extremity stability
Contraindications6
• severe (>70%) vertebral compression fracture (relative)
• very porous appearing vertebra or other bone
• vertebra with disruption of the posterior cortex of the body
• vertebra where the pedicle has been destroyed
• patients with existing spinal or foraminal stenosis
• bleeding dyscrasias
Equipment
• 25-gauge 5/8" needle
• disposable blade

• two disposable 11-gauge Manon biopsy needles

• several disposable 3cc syringes
• one disposable 10cc syringe
• disposable glass or bowl to mix cement
• one box of methyl methacrylate
• disposable sterile gown(s)
• disposable sterile drape
• disposable masks
• sterile gloves
Methyl Methacrylate
The methyl methacrylate (Howmedica Inc., Rutherford, NJ) solution is
prepared by mixing a white powder, consisting of polymethyl methacrylate,
methyl methacrylate-styrene monomer composed of methyl methacrylate,
NN-dimethyl-p-toluidine, and hydroquinone. It is suggested that the person mixing
the cement double glove to avoid contact dermatitis, which may be caused by the
lipid solvent. All personnel in the fluoroscopy suite should wear masks due to the
potential hazardous effects from the vapors of the lipid solvent. (They are an irritant
to the eyes, respiratory tract, and/or liver).
Pre-Procedure Protocol
As cementoplasty/vertebroplasty is a relatively new technique within the
nonradiology medical community, the radiologist is often the one to detect lesions
that may be amenable to vertebroplasty. Potential lesions include: 1) mild to moderate
compression fracture, 2) osteolytic lesion in a setting where it is likely to alter patient
function- such as patient mobility or the patient’s ability to eat or dress himself
(herself ).
Once detecting such a lesion, the radiologist may call the referring physician,
describe the procedure, and ascertain whether or not the patient is a potential
candidate for vertebroplasty. An osteolytic lesion alone is not sufficient for undertaking
vertebroplasty. The patient must have a significant degree of pain that can be localized
to the lesion in question. As well, if there are several lesions in a given area,
vertebroplasty should only be performed if the pain can be attributed to one or two
of these lesions.
Plain radiographs are adequate for selecting patients for extraspinous
cementoplasty (Fig. 15.1). A pathologic fracture with displacement or angulation or
15 very porous-appearing bone are considered exclusion criteria for cementoplasty. In
these cases it is probable that the cement will seep into the surrounding soft tissues,
rather than remain and harden within the osteolytic lesion.
Pre-vertebroplasty computerized tomography (CT) is required for all patients
who are considered potential candidates for vertebroplasty (Fig. 15.2). Exclusion
criteria include destruction of the posterior cortex of the vertebral body or pedicle,
or the presence of intracanalicular or intraforaminal tumour (Fig. 15.3).
In the case of the bony destruction, the concern is that cement will leak into the
canal (posterior cortex destruction) or that the bony tunnel for your needle(s) no
longer exists (pedicle destruction). Thus, these are both absolute contraindications.
Vertebroplasty 195
Fig. 15.1. A) Frontal plain radiograph in a 48 year old male with metastatic gastric
cancer. An osteolytic proximal metaphyseal lesion is noted. There is no pathologic
fracture. B) Transaxial CT following cementoplasty. Methyl methacrylate and a small
bit of air occupy the vast majority of the medullary cavity. Soft tissue gas is related
to the needle track.
The presence of tumor within the canal or foramina is a relative, rather than
absolute, contraindication. Because these spaces are more confined than normal
when tumor extends into these areas, any leakage of cement into the canal or foramina
has increased potential for permanent neurologic sequelae.
Once the patient has qualified as a candidate for cementoplasty or vertebroplasty,
verify that his/her prothrombin and prothrombin time are normal. Obtain a
hemoglobin or hematocrit level as a baseline. Discontinue any anticoagulant therapy
that the patient is taking.
Technique
Thoracic or Lumbar Vertebroplasty 15
All patients undergoing vertebroplasty should have an intravenous line for pain
medications and sedation. Next, the patient should be put on the fluoroscopy table
in the prone position. IV sedation should be administered. We usually use Fentanyl
and Versed, but you may use any analgesic. Ideally, the patient should be easily
arousable so that they can cooperate for a neurological check during the procedure,
if necessary.
Localize the two pedicles at the level of interest on both AP and lateral C-arm
fluoroscopy. Mark the two sites with a pen and administer local anesthetic at these
sites. Make a vertical skin incision at each site. (The incision should be large enough
for the 11 gauge Manon needles to pass through.)
Fig. 15.2. A) Transaxial CT in a 63 year old woman with endometrial cancer. Initial
compression fracture detected on lateral chest radiograph (not shown). Patchy os-
teosclerotic metastatic disease identified within the T6 vertebral. Most importantly,
the posterior cortex of the vertebral body is intact, qualifying the patient as a can-
didate for vertebroplasty. B) Fluoroscopic spot film with the C-arm in neutral posi-
tion. Note that the first needle has been placed into the pedicle contralateral to the
15 radiologist. A pathologic compression fracture of the T6 vertebra is noted. Diffuse
osteopenia is present, likely post-menopausal. C) Fluoroscopic spot film with the
C-arm in neutral position. The second needle is in place, ipsilateral to the radiolo-
gist. The contralateral needle has been removed following the instillation of me-
thyl methacrylate. D) Transaxial CT scan, post-vertebroplasty. A large mass of ce-
ment is present within the right side of the vertebral body. Despite a clump of
intracanalicular cement on the left, the patient remained neurologically intact. The
procedure was considered successful in that she regained her ability to sleep and
her morphine dose was reduced by half.
Vertebroplasty 197
Fig. 15.3. Transaxial CT in a

potential vertebroplasty candi-
date. The procedure was not
performed, due to the loss of
integrity of the posterior cortex.
Fig. 15.4. A) Fluoroscopic spot with the C-arm at 90°, patient prone. Two parallel
Manon biopsy needles are shown traversing the pedicles. The tip of one lies in the
posterior one-third of the vertebral body, while the tip of the second just approaches
the superficial edge of the pedicle (arrow). B) Transaxial CT, post-vertebroplasty.
Methyl methacrylate is scattered throughout the L4 vertebral body. There has been 15
some extravasation into the spinal canal, despite the preservation of cortical integ-
rity on the pre-vertebroplasty CT. The patient experienced a transient neuritis and
decreased mobility of her left leg. Her gait returned to normal and her leg pain
resolved within 72 hours.
Confirm the pedicle position once again on the AP view and then begin to
advance the Manon needle, via the pedicle, under lateral fluoroscopy (Fig. 15.4).
This technique is identical to that used for a transpediculate biopsy. Once the needle
is at the junction of the posterior and middle thirds of the vertebral body, repeat this
technique to place the second needle into the vertebral body. Use the angle of the
first needle to help determine the degree of angulation (craniocaudal) necessary to

place the second needle through the pedicle and into the vertebral body. Ideally, the
two needles would be parallel to one another. Note, it is much easier to position the
needle in the contralateral pedicle first, and then subsequently place the Manon
needle into the ipsilateral pedicle (Fig. 15.2B-C).
Once both needles are in place, double glove, mask and prepare the methyl
methacrylate mixture. Have a technician or other assistant draw up the cement into
the 3cc syringes while you begin to instill the methyl methacrylate into the vertebral
body. Because the cement hardens within minutes of its preparation, do not fill too
many syringes or else the cement will harden in the syringes. It is better to let the
cement harden in the glass bowl where you can alter the cement consistency by
adding more of the liquid monomer.
Once you’ve begun the injection, it is imperative to watch the spinal canal (lateral
fluoroscopy) for the leakage of methyl methacrylate. Immediately stop the injection
if any cement is identified overlying the spinal canal. A small amount of paraspinal
soft tissue extravasation is acceptable. However, you should terminate the injection
if moderate or large amounts of methyl methacrylate extravasate into the paraspinal
tissues because of the potentially hazardous long-term effects of thermal injury.
The volume of cement instilled into the lesion depends primarily on the size of
the lesion, the porosity of the bone, and the patient’s pain tolerance. In my experience,
the average lumbar vertebral lesion can hold 3-7 cc’s of methyl methacrylate. However,
the only absolute endpoint for the injection of methyl methacrylate is leakage into
the canal or neural foramina. Relative endpoints to terminate the injection include
resistance to the cement injection or cement that reaches the posterior cortex of the
vertebral body.8 One should note however that the amount of pain relief the patient
experiences is not related to the volume of cement instilled into the lesion.7
Cervical Vertebroplasty
Once again, all patients for vertebroplasty should have an intravenous line. Sedate
with Fentanyl and Versed as needed. Place the patient supine, with the neck slightly
hyperextended. Utilize the anterolateral approach as is used in cervical discography.
Place your finger on the jugular and carotid vessels and then localize and mark the
skin site where you will enter the vertebra. Utilizing lateral fluoroscopy, approach
the vertebral body using a single 15 gauge needle. Your target position is the junction
of the anterior and middle thirds of the vertebral body.
15 Sacral Vertebroplasty
Because the spine is a common site for metastases, the sacrum being no exception,
vertebroplasty is not infrequently indicated for a sacral lesion. The transpediculate
approach is precluded by the presence of the sacral foramina. Therefore, the transiliac
approach, previously described by Smith-Petersen, has been used successfully.9,10
Once the patient has been given intravenous sedation, he should be placed in the
prone position. Using lateral fluoroscopic guidance, your Manon needle is centered
in front of the spinal canal and subjacent to the superior endplate of S1. The needle
is advanced under anteroposterior fluoroscopic control, parallel to the axial plane
and above the level of the S1 foramina (Fig. 15.5). Once the needle has been advanced
into the anterior central portion of the sacrum, the methyl methacrylate mixture is
Vertebroplasty 199
Fig. 15.5 Schematic drawing, in the axial plane, demonstrating the transiliac
approach. Note that the needle avoids the ipsilateral sacral foramen.
introduced into the vertebral lesion in similar fashion to that described under Thoracic
and Lumbar Vertebroplasty (Fig. 15.6A), although some advocate vertebral
phlebography, that is, injection of contrast into the area where your methyl
methacrylate is intended. This gives the operator a chance to reposition his/her needle
prior to the methyl methacrylate injection into the lesion. In cases where the lesion
has been inadequately filled by the transiliac approach, the direct posterior approach
to the sacrum may be employed to complete filling of the lesion. Once the lesion has
been adequately filled, as subjectively judged by the operator, transaxial CT need
only be performed if the patient’s clinical condition warrants it. Through experience,
we have learnt that routine post-vertebroplasty CT, although documenting the
position of extraosseous cement, does not contribute to the procedure (Fig. 15.6B).
Kyphoplasty
Kyphoplasty is a recently developed technique whereby an inflatable balloon,
often referred to as an inflatable bone tamp (IBT), is expanded within a compressed
vertebral body with the intent of restoring the height of the vertebral body. Once
the balloon has been removed, the cavity created by the balloon is filled with methyl
methacrylate (Fig. 15.7). As with vertebroplasty, kyphoplasty is also intended to 15
provide significant pain relief at the site(s) where it is employed. However, the
indications for kyphoplasty are more limited than those for vertebroplasty; the
outcome of kyphoplasty is best when the technique is utilized for the treatment of
relatively acute osteoporotic compression fractures, i.e., those occurring three months
or less from the time of kyphoplasty. In chronic spinal deformities, and/or compression
fractures, the odds of restoring vertebral body height are much lower. Perhaps because
of patient longevity issues and the chances of tumour spread, kyphoplasty is not
indicated for the treatment of metastatic or myelomatous compression fractures.
The other contraindications for kyphoplasty are similar to those listed for
vertebroplasty (see p.193).
Fig. 15.6. A) Spot film taken during anteroposterior fluoroscopy. The transiliac
approach of the needle is noted. Dense material, representing methyl methacrylate, is
noted within the S1 segment of the sacrum. Residual contrast is noted within the
left common iliac vein, due to drainage from previous phlebography. A second
vertically-oriented needle was advanced into the lesion to supplement methyl
methacrylate placement into the lesion. B) Transaxial CT image, soft tissue window
technique, demonstrating both needles within the right hemi-sacrum. The centrally-
positioned methyl methacrylate was placed via the transiliac needle, whereas the
methyl methacrylte and air within the left lateral wing of the sacrum was placed
via the posterior needle. (Courtesy of Drs. Amir R. Dehdashti, Jean-Baptiste Martin,
Beatrix Jean, and Daniel A. Rufenacht, Department of Neuroradiology, Hopitaux
Universitaires de Geneve, CH-1211 Geneva 14, Switzerland.)
15 Figure 15.7. Three lateral lumbar spine schematics. A. Moderate compression de-
formity of the affected vertebral body. B. Restoration of the height of the vertebral
body following inflation of the ballon device. C. Following removal of the balloon,
the hollow cavity has been filled in with methyl methacrylate.
The patient preparation, pre-procedural and post-procedural protocols are

identical to those used for vertebroplasty. The approach required for kyphoplasty
consists of transpediculate placement of a working cannula which may or may not
require a hand drill given the large bore of the working cannula. Once the working
cannula is in place, the IBT is inserted. Inflation pressure is applied until either a
maximum pressure is attained or the balloon abuts any one of the cortical margins.
Subsequently, the cement cannula is inserted through the working cannula and the
Vertebroplasty 201
methyl methacrylate is instilled into the vertebral body. As with vertebroplasty, the
cement injection should be performed under fluoroscopic visualization to monitor
for cement leakage. Complications are identical to those described for vertebroplasty
because the adverse reactions are all related to the methyl methacrylate. No balloon-
related complications have been described to date.9,10
Cementoplasty
This refers to placement of methyl methacrylate in any extraspinous bone. As for
vertebroplasty, an intravenous line should be placed and sedation given, as necessary.
Patients may have more sedation than for spine procedures because there is no need
for a neurologic check during the procedure as the risk of neurological damage is
relatively insignificant.
The patient position is dependent upon the target bone. Following the
administration of local anesthetic, approach the lesion with a single 10 gauge Manon
biopsy needle. Rather than standard AP and lateral fluoroscopic views, any two
views, approximately 90° to one another, show the needle position adequately. Once
the needle is in place, proceed with the instillation of the cement mixture as above.
There is no definitive endpoint for the extraspinous skeleton as is the case in the
spine. However, you may stop when you deem the lytic lesion is adequately filled,
when contrast begins to leak into the adjacent soft tissues, or if the patient has
excruciating pain during the injection.
Patients need not be routinely admitted after this treatment nor need they undergo
routine CT. CT need only be performed if the patient’s clinical condition warrants
it. However, all patients who have undergone methyl methacrylate injections should
be monitored in the recovery room for 4-6 hours after the exam. The staff should be
advised to watch for signs of pulmonary emboli, change or deterioration in neurologic
exam, or unusually high fever. Patients who have known or suspected intracanalicular
or intraforaminal methyl methacrylate should have more frequent neurologic checks
than those without methyl methacrylate leakage into these critical areas (Fig. 15.2D
and 15.4B).
Assessing Your Intervention11
The radiologists should visit the patient as his condition warrants. In the typical
case, this will require one visit at the time of discharge from the recovery room. At
that time you may assess for:
• alteration in the neurologic exam 15
• changes in the severity of pain at the injection site
• changes in the patient’s mobility and/or ability to function
A more objective method of your intervention may be obtained by asking the
following questions which are taken from the McGill-Melzack Pain Questionnaire:
• Pain: none(0), mild(1), discomforting(2), distressing(3), horrible(4),
excruciating(5)
• Pain pattern: brief (0), periodic (1), constant (2)
• Sleep: good(0), fitful (1), can’t sleep (2)
• Activity: good (0), some (1), little (2), none (3)
• Food intake: good (0), some (1), little (2), none (3)
Taking the sum of the values in these five categories (range 0-15) before and after
cementoplasty/vertebroplasty, you can get an idea of whether or not the patient
benefited from your intervention.
In addition to the above questionnaire, kyphoplasty outcome may be assessed by
improvements in pulmonary and gastrointestinal dysfunction, a direct consequence
of an exaggerated kyphosis, and by the degree of restoration of vertebral body height.
This latter criteria requires a good set of lateral spine radiographs of the site of
interest both before and after kyphoplasty 10 As for vertebroplasty, ex vivo
biomechanical studies have shown that kyphoplasty too increases vertebral body
strength. Moreover, kyphoplasty restores vertebral body stiffness to initial values in
contradistinction to vertebroplasty.12
Common Side Effects
Transient fever and pain at the injection site may occur as part of the inflammatory
response to the heat engendered by the polymerization of methyl methacrylate.
Nonsteroidal or steroidal anti-inflammatory drugs may be administered to minimize
these adverse effects.
Complications
There is little risk to cementoplasty performed in extraspinous areas. No serious
or permanent sequelae have been reported as a result of methyl methacrylate leakage
into the surrounding soft tissues. However, methyl methacrylate leakage is not an
uncommon problem during vertebroplasty. Fortunately, permanent sequelae—i.e.,
cord compression requiring surgical decompression or radiculopathy—are rare.
Nonetheless, a neurosurgeon should be available, should surgical decompression be
necessary following vertebroplasty. Precautions should be taken to avoid methyl
methacrylate extravasation into the adjacent soft tissues as the orthopedic literature
has reported long-term soft tissue damage attributed to the thermal properties of
methyl methacrylate.
• cord compression (due to leakage of cement) <1%
• persistent nerve root compression/radicular pain (due to methyl
methacrylate leakage) <1%
• pulmonary emboli (highly vascular lesion, liquid consistency of methyl
methacrylate both predispose to PE) <1%
• stroke, myocardial infarction, sudden death (reported with intraoperative
methyl methacrylate use only) <<1%
15 • risk of collapse of vertebra adjacent to the site of vertebroplasty13 *
*Several authors have noted a risk of collaspe (approximately 10%) of the vertebra adjacent to
the site of vertebroplasty in patients undergoing this procedure for pain related to an osteoporotic
compression fracture. The majority of these fractures occur within one month of vertebroplasty.
At least three schools of thought exists as to why this occurs: 1) in patients who have undergone
vertebroplasty for osteoporosis, some believe that it is the natural evolution of osteoporosis
that these patients go on to develop additional compression fractures; 2) others believe that,
due to pain relief, post-vertebroplasty patients become more active, thus increasing axial loading
on the spine and consequently increasing their fracture risk; 3) still others believe that
verebroplasty, by increasing the strength and stiffness of the segment of the spine where it has
been performed, alters the distribution of forces in the region and that this increases the risk of
fracture of the neighbouring vertebral bodies. Probably all three of these factors contribute to
the increase in fracture risk post-vertebroplasty.
Vertebroplasty 203
Future Developments in Vertebroplasty8

With the progression of time and experience, the indications for vertebroplasty
have expanded to include symptomatic osteoporotic compression fractures, vertebral
lymphoma, eosinophilic granuloma and aneurysmal bone cysts. It is likely that the
list of indications will expand even more should other injectable products, now
undergoing investigation, become available for clinical use. Two such categories of
products on the horizon include osteo-formative and osteo-conductive substances.
References
1. Cotton A, Chabanne B, Deprez X et al. Cimentoplastie percutanée des osteolyses
malignes du cotyle. Rev Im Med 1994; 6:287-291.
2. Hodge JC. Cementoplasty and the oncologic population. Singapore Med J SMJ
2000; 41(8):407-409.
3. Nguyen JP, Djindjian M, Pavlovitch JM et al. Hemangiomes vertebraux avec signes
neurologiques. Les resultats therapeutiques. Enquete de la S.N.F. Neuro-Chirurgie
1989; 35:299-303.
4. Galibert P, Deramond H. La vertebroplastie acrylique percutanée comme traitment
des angiomes vertebraux et des affections dolorigenes et fragilisantes du rachis.
Chirurgie 1990; 166:326-334.
5. Cortet B, Cotton A, Deprez X et al. Interet de la vertebroplastie couplée a une
decompression chirurgicale dans la traitement des angiomes vertebraux agressifs. A
propos de trois cas. Revue du Rhumatisme 1994; 61:16-22.
6. Weill A, Chiras J, Simon JM et al. Spinal metastases: Indications for and results of
percutaneous injection of acrylic surgical cement. Radiology 1996; 199:241-247.
7. Cotton A, Dewatre F, Cortet B et al. Percutaneous vertebroplasty for osteolytic
metastases and myeloma: Effects of the percentage of lesion filling and the leakage
of methyl methacrylate at clinical follow-up. Radiology 1996; 200:525-530.
8. Cotten A, Boutry N, Cortet B et al. Percutaneous vertebroplasty: State of the art.
Radiographics 1998; 18:311-320.
9. Lieberman IH, Dudeney S, Reinhardt MK et al. Initial outcome and efficacy of
“kyphoplasty” in the treatment of painful osteoporotic vertebral compression frac-
tures. Spine 2001; 26:1631-1638.
10. Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and
vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine
2001; 26:1511-1515.
11. Evans AJ, Jensen ME, Kip KE etal. Vertebral compression fracture: pain reduction
and improvement in functional mobility after percutaneous polymethylmethacrylate
vertebroplasy-retrospective report of 245 cases. Radiology 2003; 226:366-372.
12. Belkoff SM, Mathis JM, Fenton DC et al. An ex vivo biomechanical evaluation of
an inflatable bone tamp used in the treatment of compression fracture. Spine 2001; 15
26:151-156.
13. Uppin AA, Hirsch JA, Centenera LV et al. Occurrence of new vertebral body frac-
tures after percutaneous vertebroplasty in patients with osteoporosis. Radiology
2003; 226:119-126.
CHAPTER 16
Ultrasound
Patrice-Etienne Cardinal and Rethy Chhem
Introduction
Ultrasound is a useful technique for imaging musculoskeletal soft tissue pathology.
As an imaging modality, ultrasound is extremely accessible, does not involve the use
of ionizing radiation, and is relatively inexpensive as compared with computerized
tomography (CT) and magnetic resonance imaging (MRI). Real-time ultrasound
can be utilized to guide musculoskeletal interventions and has the advantage of
being able to monitor needle position at all times. Aspiration of fluid collections
and abscesses, installation of drainage catheters, percutaneous biopsy, steroid
injections, and aspiration of soft tissue calcifications are among the procedures that
can be performed under ultrasound guidance.
Pre-procedure Preparation
Prior to any interventional application of ultrasound, a thorough ultrasound
examination should be performed to characterize the lesion and to localize the lesion
relative to surrounding structures. Proper sonographic investigation of musculoskeletal
structures requires high-resolution high-frequency linear array transducers, generally
5 or 7.5 MHz. Occasionally, a 3.5 MHz transducer will be required for imaging
deep structures in obese patients. Similarly, a 10 MHz transducer will infrequently
be required to evaluate very superficial structures. Ideally, color Doppler examination
should be performed to assess the vascularity of the lesion and to prevent inadvertent
puncture of an aneurysm or other vascular mass. Doppler is also useful in identifying
local vessels adjacent to the lesion of interest.
Coagulation parameters should be checked and a history of blood dyscrasias
obtained from the patient. The prothrombin and partial thromboplastin times should
not exceed 1.5 seconds and 5 seconds above the control values, respectively. The
bleeding time should range from 1 to 7 minutes. Ideally, the platelet count should
be greater than 50,000/cc.1 Informed consent should be obtained following a
description of the procedure and relevant complications.
Once the lesion is localized and the approach planned, the skin should be prepped
and draped. 1 or 2% Xylocaine should be administered as a local anesthetic. Most
procedures do not require patient sedation. However, occasionally for drainage
procedures, sedation will be indicated. In this setting, an intravenous line should be
started and a combination of midazolam and fentanyl administered. Patient vital
signs should be monitored, and a pulse oxymeter attached to the patient.
Equipment
Injection syringes (1,3,or 5 cc), aspiration syringes (10,20, or 50 cc), injection
needles (22 or 25 g), aspiration needles (18, 20 or 21 g), local anesthetic (1 or 2%
Ultrasound 205
Xylocaine), (skin antiseptic) Proviodine, alcohol swabs, gauze pads, gloves, and
culture tubes.
Technique
The patient should be positioned comfortably. The lesion should be studied in
at least two planes and the depth of the biopsy site determined. Select the shortest
and most direct needle path that will allow you to avoid major neurovascular
structures. Select the needle length accordingly and mark the required depth of
penetration on the needle with sterile tape. At this time you should determine whether
you will use a free-hand technique to direct the needle. Alternatively, a device can be
installed on the transducer to hold and direct the needle if necessary.
After the skin is sterilized and draped, Xylocaine is administered as local anesthesia.
The transducer should be sterilized using proviodine. If a commercially available
sterile transducer sleeve is installed, nonsterile gel can be used within the sleeve.
However, sterile gel must be used on the skin.
The needle should be advanced utilizing ultrasound guidance. The needle will
be visualized as a bright echogenic line and is best seen if the transducer is oriented
parallel to the needle track (Fig. 16.1). The needle is usually easily visualized within
a fluid collection but may be harder to detect within soft tissues. If the needle is
difficult to identify, gently shake the needle to assist with its identification. If the
needle can not be localized, it is best to pull out the needle and repeat the approach.
Contraindications
Arthrocentesis should be avoided if there is obvious cellulitis of the overlying
skin to reduce the risk of introducing infection into the joint.2 Generally, this rule
should be strictly adhered to when puncture of any sterile collection is under
consideration. Bacteremia, such as endocarditis, is a relative contraindication to joint
aspiration since it may potentiate seeding of bacteria. Corticosteroids should never
be injected when there is suspicion of underlying infection. Steroids tend to mask
inflammation, allowing significant tissue destruction to occur before clinical detection
of the inflammatory process.2 Allergies to local anesthetic constitute a relative
contraindication.
Pathological Conditions
Cysts, Fluid Collections, and Abscesses
Cysts are common conditions afflicting the musculoskeletal system. Ganglion
cysts, synovial cysts, and meniscal cysts are among some of the more frequent cystic
collections. These cysts may cause pain and disability. When they are refractory to
conservative management, i.e., anti-inflammatory drugs, needle aspiration, with or 16
without corticosteroid injection, may be performed.
Ultrasonography, including Doppler imaging, is performed to confirm the cystic
nature of the lesion and to exclude an aneurysm or pseudoaneurysm. Using aseptic
technique, an 18 or 20 g needle is used to aspirate the contents of the cyst. Avoid
using a smaller needle as it may be difficult to aspirate gelatinous material or synovial
fluid from ganglion and synovial cysts, respectively. Alternatively, a sheath-needle
(Cathlon) may be used for puncture and cyst aspiration. With this system, a plastic
Fig. 16.1. Percutaneous aspira-
tion of a Baker’s cyst (BC) in a
patient with rheumatoid arthri-
tis. With the transducer oriented
along the plane of the needle,
the needle (arrows) appears as
a hyperechoic line within the
hypoechoic synovial cyst.
component remains within the lesion once the stylet has been removed. This insures
that the needle does not fall out of the cyst as it shrinks during aspiration. If steroid
administration is planned, be sure not to completely empty the cyst of its fluid
contents.
Soft tissue abscesses, most commonly seen with trauma and osteomyelitis, may
be seen in association with diabetes, renal insufficiency, and immunosuppression.1
A similar approach to that used for cysts is used for aspiration of soft tissue abscesses.
Aspiration of small abscesses is generally performed to obtain a sample for culture
and sensitivity, although complete evacuation of the abscess should be attempted to
facilitate treatment. A large bore needle, such as a 16 or 18 g, is recommended for
aspiration of potential pus.
Larger abscesses may require installation of a drainage catheter. Initially, an 18 or
20 g needle is placed within the lesion under ultrasound guidance. Once the diagnosis
has been confirmed, i.e., pus is aspirated, a 0.035 guide-wire is inserted into the
collection via the needle. Ample guide-wire length should be within the abscess
cavity to insure that the wire does not fall out upon further manipulation. Following
serial dilatation of the track over the wire, an 8 or 10 french drainage catheter is
installed and looped within the abscess.
For large superficial collections, we prefer to use a trocar-catheter system. Once
we have confirmed that the tip of the trocar is within the abscess, the trocar is gently
removed as the catheter is advanced further into the cavity. Alternatively, a
16 trocar-catheter system can be inserted into the lesion in tandem fashion with the
first needle.1
The depth can be marked on the catheter with sterile tape or the position of the
trocar monitored at all times with real-time ultrasound. Once the tip of the trocar is
identified within the abscess, the inner stylet is removed and a guide-wire inserted
through the remaining metal sheath. The catheter is then advanced along the
guide-wire. The appropriate position of the catheter is confirmed with ultrasound
and the abscess is drained. Installation of a second catheter may be required if
evacuation of the abscess is incomplete.
Ultrasound 207
Occasionally, a large hematoma may be aspirated, especially if it is necessary to

exclude infection. Additionally, aspiration of a muscle hematoma helps to
reapproximate muscle fibers which accelerates healing.3
Bursae and Synovial Sheath
Bursitis and tenosynovitis are characterized by the accumulation of synovial fluid
in the bursae and synovial sheaths of tendons. Inflammation may result from trauma,
hemorrhage, crystal or from systemic diseases such as rheumatoid arthritis,
sero-negative arthropathies, gout, amyloidosis, tuberculosis and sarcoidosis.3
Proliferation of synovial tissue may accompany inflammation. Patients are often
sent for aspiration of synovial fluid after unsuccessful attempts by the referring
physician.
Using sterile technique, puncture is performed with an 18 or 20 g needle. Synovial
fluid samples should be sent to pathology (in a heparinized glass tube) for analysis of
crystals and to microbiology for culture and antibiogram. If there is a high suspicion
of infection, a Gram stain should be obtained as soon as possible. Hematology may
perform a white blood cell count with a differential to help distinguish inflammatory
from non inflammatory conditions. In those patients on longterm dialysis, synovial
fluid may also be sent to pathology for the detection of amyloidosis.4
Joint Arthrocentesis
Joint fluid aspiration may be required to investigate infection, inflammatory and
crystal arthropathies or amyloid arthropathy. Articular lavage may be requested in
the treatment of septic arthritis. Ultrasound-guided joint aspiration is an excellent
alternative to fluoroscopy- or arthrography-guided puncture, especially in young
and/or pregnant patients due to the lack of ionizing radiation with ultrasound.5
Approach varies depending on the joint to be aspirated.
The shoulder joint is accessible by posterior or anterior approach. The posterior
is preferable, unless there is a massive amount of fluid as fluid tends to accumulate
in the posterior recess of the glenohumeral joint first.6 The hip joint is more easily
evaluated from the anterior aspect with an oblique sagittal plane parallel to the long
axis of the femoral neck. Fluid can be easily identified in the synovial recesses (Fig.
16.2). Knee effusions can be aspirated under ultrasound guidance in the clinically
difficult situation—i.e., the morbidly obese individual, a patient with very swollen
lower extremities or a patient with a tiny amount of joint fluid. Small amounts of
fluid accumulate within the lateral recesses of the femoropatellar joint and should
be approached from medial or lateral, whereas larger amounts of fluid are easily
accessed from the suprapatellar recess. Fluid may also accumulate in the
semimembranosus-gastrocnemius bursae, a site ideally accessed via a posterior
approach. The Baker’s cyst should first be evaluated with conventional ultrasound 16
and Doppler to exclude an aneurysm and to localize the popliteal vessels prior to
puncture. The elbow is best punctured from a posterior approach allowing access to
the olecranon recess. The anterior approach should be avoided, if possible, because
of the proximity of the neurovascular bundle. The ankle is usually approached
anteriorly, after localizing the anterior tibial artery by palpation with Doppler
ultrasound.
Fig. 16.2. Percutaneous ultrasound-guided aspiration of a hip joint effusion in a

pregnant female. A) Sagittal oblique sonogram of the left hip. The effusion appears
as a anechoic collection which distends the joint capsule (arrows). B) Absence of
joint fluid following needle aspiration. a. acetabulum, h. femoral head, n. femoral
neck, c. hip joint capsule.
Soft Tissue Biopsy

Soft tissue masses may be biopsied under ultrasound guidance following discussion
with the orthopedic surgeon to select the most appropriate puncture site. Because of
potential spreading of malignant cells along the needle track, the biopsy track will
have to be resected along with the contaminated muscle compartment if the lesion
is found to be malignant. For cytology, aspiration may be performed with a 20 or 22
g spinal or Chiba needle. Once the needle tip is identified within the lesion, suction
with a 20 cc syringe is applied as the needle is gently moved in a to and fro motion
within the lesion. A cutting needle, for example a Tru-Cut needle (Baxter Healthcare
Corp., McGaw Park, IL), will provide a sample which can be manually harvested or
which can be harvested with a biopsy gun for histological analysis (Fig. 16.3). In
selecting the proper needle length, take into account the fact that the needle should
penetrate the lesion by approximately 2 cm during aspiration of the sample. If a
lymphoma is suspected, a larger 18 g needle should be utilized. Infrequently,
ultrasound is utilized to select an area of muscle abnormality for biopsy in those
with childhood neuromuscular disease.7
Aspiration of Calcification
Calcific tendinitis of the shoulder is a potentially disabling condition which can
be treated with anti inflammatory drugs, physiotherapy, coticosteroid injection or
iontophoresis. Patients who are refractory to conservative treatment may benefit
16 from needle aspiration of the calcium combined with local corticosteroid injection.
The technique has been described using fluoroscopic and CT but calcium deposits
may also be aspirated using ultrasound.8-10 A preliminary ultrasound survey of the
shoulder is initially performed to exclude a rotator cuff tear. (This may be difficult
in patients with a lot of calcium due to acoustic shadowing from the calcifications.)
Calcifications within the rotator cuff are then localized and measured in two planes
(Fig 16.4). Correlation with plain radiographs can be performed, if necessary.
Ultrasound 209
Fig. 16.3. Soft tissue mass bi-

opsy. The cutting needle (ar-
rows) traverses a hypoechoic
heterogenous mass within the
rectus abdominus muscle.
Ultrasound-guidance insures
that the peritoneum (open
curved arrows) is not inadvert-
ently punctured. (Courtesy of B.
Aubin, Montreal, QC)
Fig. 16.4. Ultrasound-guided

aspiration of rotator cuff calcifi-
cation. Longitudinal (coronal
oblique) sonogram illustrating
the needle (curved arrows) en-
tering the rotator cuff (straight
arrows) for aspiration of calcifi-
cations (arrowheads). H. hu-
meral head.
Calcifications are occasionally associated with local swelling of the rotator cuff. When
there is more than one calcific deposit, using local pressure, an attempt should be
made to determine which calcification seems to be responsible for the patient’s
symptoms. Using aseptic technique and following the administration of local
anesthetic, a 19-22 g needle is advanced into the calcification under ultrasound
guidance. The calcium is then aspirated using a 10 cc syringe connected to a tube
and containing 1% Lidocaine, Bupivacaine or saline. Repeated suction is then applied
and the calcium is aspirated—which appears as a turbid solution. Lavage can be 16
facilitated occasionally by inserting a second needle into the calcification.9 Typically
only part of the calcification is aspirated due to the difficulty associated with aspirating
a solid density. Once aspiration is completed, corticosteroids are injected locally. As
many as one third of the patients will have severe pain following aspiration. In these
cases, the local application of ice and oral anti-inflammatory therapy should be
utilized.
Periosteal and Bone Lesions

Lytic bone lesions destroying the cortex can be identified on ultrasound as an
interruption of the bright echogenic line of cortex, especially if accompanied by a
soft tissue mass. Once identified, they are amenable to biopsy. Typically bone biopsies
are performed with fluoroscopic or CT guidance. However, they can be performed
with ultrasonography. Good results for ultrasound-guided fine needle aspiration,
utilizing a 20 or 22 g Chiba needle, have been reported in patients with metastatic
disease.11,12 A similar approach can be used to aspirate periosteal abscesses in children.13
In conclusion, ultrasonography is a useful technique for imaging fluid, soft tissue,
and osseous lesions of the musculoskeletal system. It can be utilized to guide
interventional procedures. Proper training and a sound knowledge of anatomy insure
that the procedures are done safely and with optimal efficacy.
References
1. Christensen RA, van Sonnenberg E, Casola G et al. Interventional ultrasound in
the musculoskeletal system. Rad Clin North Am 1988; 26:145-56.
2. Schaffer TC. Joint and soft-tissue arthrocentesis. Arthritis 1993; 20:757-70.
3. van Holsbeeck M, Introcasso JH. Musculoskeletal ultrasonography. Rad Clin North
Am 1992; 30:907-25.
4. Cardinal E, Buckwalter KA, Braunstein EM et al. Amyloidosis of the shoulder in
patients on chronic dialysis: Sonographic findings. Am J Roentgenol 1996;
166:153-6.
5. Zawin JK, Hoffer FA, Rand FF et al. Joint effusion in children with an irritable
hip: US diagnosis and aspiration. Radiology 1993; 187:459-63.
6. van Holsbeeck M, Introcasso JH. Sonography of the shoulder. In:van Holsbeeck
M, Introcasso JH, ed. Musculoskeletal ultrasound. Chicago:Mosby Year Book 1990;
265-84.
7. Heckmatt JZ, Dubowitz V. Ultrasound imaging and directed needle biopsy in the
diagnosis of selective involvement in muscle disease. J Child Neurol 1987; 2:205-13.
8. Laredo JD, Bellaiche L, Hamze E et al. Current status of musculoskeletal
interventional radiology. Rad Clin North Am 1994; 32:377-98.
9. Farin PU, Jaroma H, Soimakallio S. Rotator cuff calcifications: Treatment with
US-guided technique. Radilogy 1995; 195:841-3.
10. Hodge JC, Schneider R, Freiberger R et al. Calcific tendinitis in the proximal
thigh. Arthritis & Rheumatism 1993; 36:1476-82.
11. Civardi G, Livraghi T, Colombo P et al. Lytic bone lesions suspected for metasta-
sis: Ultrasonicallt-guided fine-needle aspiration biopsy. J Clin Ultrasound 1994;
22:307-11.
12. Chhem RK, Schmutz GR, Huynh HH et al. Ultrasonography of bone metastasis.
Can Assoc Radiol J 1992; 43:138-40.
13. Abernethy LJ, Lee YCP, Cole WG. Ultrasound localization of subperiosteal ab-
16 scesses in children with late-acute osteomyelitis. J Ped Orthop 1993; 13:766-8.
CHAPTER 1
APPENDIX
Contrast Reactions1-3
The vast majority of the literature addressing contrast reactions in radiology
refers to the use of intravenous and/or intra-arterial contrast. Little has been published
about the risk of adverse reactions with the administration of intrathecal or intra-
articular contrast. Intuitively, we would expect a much lower incidence of adverse
reaction with contrast administered by the intrathecal and/or intra-articular routes
because of the much lower volumes and blood concentrations of contrast agents
administered for myelography, arthrography, and discography. This is probably true
for those adverse reactions that are chemotoxic (nonidiosyncratic). It is well known
that the prevalence of chemotoxic reactions is proportional to the total contrast dose
and the concentration of contrast agent.1 However, there is probably little difference,
if any, in the prevalence of anaphylactoid (idiosyncratic) reactions in patients receiving
extravascular, rather than intravascular, contrast. Acute adverse reactions occur in
approximately 10% of those patients receiving ionic, high osmolality, intravascular
contrast agents. 2 This figure is reduced by fivefold with the intravascular
administration of nonionic contrast media.2 Extrapolating from this data, without
knowing the proportion of idiosyncratic to nonidiosyncratic reactions, it is probably
safe to assume that the frequency of significant adverse reactions during myelography
is far less than 2%.
Whatever the exact incidence of contrast reactions, it is likely to decrease in the
coming years as we explore the use of gadolinium as a contrast agent, both intrathecally
and intravascularly, for CT and interventional radiology.3-5 It has been documented
that the incidence of adverse reactions to intravascular gadolinium is less than 1 in
1000.6
The spectrum of contrast reactions varies from mild nausea and/or emesis to
anaphylactic shock. Knowledge of the patient’s risk factors and allergies, prompt
recognition of the type of adverse reaction, and immediate intervention can prevent
a mild reaction from progressing to a life-threatening reaction. Basic drugs, such as
epinephrine, atropine, and diphenhydramine, as well as standard emergency
equipment, including oxygen cannula and masks, oxygen tanks, and equipment for
intubation and intravenous hydration should be readily accessible in the radiology
department. Most importantly, call for additional assistance early. Emergency
situations are best handled by those who encounter similar situations daily, the code
team.
The following paragraph categorizes the types of adverse reactions. Table A outlines
the acute management of anaphylactic reactions.7 These lists are not meant to be
complete guides to patient management during adverse reactions. Rather, they form
the basis for emergency assessment and intervention until a more experienced help
arrives.

Table A. Acute Management of Anaphylaxis* (Taken from American J Roentgenol

1988; 151:264.)
Urticaria:
• usually requires no treatment
• Diphenhydramine 50 mg IV, IM, or PO, if severe
Facial/Laryngeal Edema:
• evaluate airway, intubate if necessary
• Epinephrine 1:1000 0.1-0.3cc SQ every 15 min x 3 as needed (total dose
not to exceed 1.0cc)
• if there is no response administer:
– Cimetidine 300 mg IVin 5% dextrose over 15 minutes or
– Diphenhydramine 50 mg IM or IV
Bronchospasm:
• two litres of oxygen via cannula or mask
• Epinephrine 1:1000 0.1-0.3cc SQ every 15 min x 3 as needed (total dose
not to exceed 1.0cc)
• if there is no response, administer:
– Aminophylline 250 mg IV in 5% dextrose over 10-20 minutes, then
0.4-1.0 mg/kg/hr, as needed, or Terbutaline 0.25-0.5 mg IM or SQ; and/
or beta-agonist inhalers (Metaproterenol or Albuterol)
– Cimetidine 300 mg IV in 5% dextrose over 15 minutes
– Diphenhydramine 50 mg IV or IM
Severe Hypotension:
• large volumes of isotonic fluid, 0.9% normal saline for example
• two litres of oxygen via nasal cannula or mask
• if there is no response, administer :
– Epinephrine 1:10,000 1-3 cc IV or 1-3 cc added to 7-9 cc of saline
intratracheally, every 5-10 minutes x 3, as needed
• if there is still no response, proceed to:
– Cimetidine 300 mg IV in 5% dextrose over 15 minutes
– Diphenhydramine 50 mg IM or IV
– Dopamine 2-20 µg/kg/min IV
– Atropine 0.5—2.0 mg IV
*Doses quoted above are for an average-sized patient. Steroids may be administered
acutely and over a course of up to 48 hours following anaphylaxis to prevent
recurrence of anaphylaxis-type symptoms. They probably do not alter the acute course
of an anaphylactoid reaction however.
Acute adverse reactions to systemic contrast media include: a) nausea and

vomiting, b) urticaria and hives, c) bronchospasm or asthma-like symptoms, d)
hypotension with bradycardia (vasovagal reaction), e) hypotension with normal sinus
rhythm or tachycardia, f ) cardiac reactions including congestive heart failure, angina,
Appendix and/or myocardial infarction, g) seizures, and h) anaphylactoid reaction including
severe bronchospasm, facial/laryngeal edema, and profound hypotension.
Appendix 213
Prophylaxis for Contrast Reactions2,7-10

In those patients with a history of prior allergic reaction to contrast media or
with a known allergic history to iodine-containing foods and compounds, consider
an alternative diagnostic procedure. If contrast administration is deemed necessary,
utilize a nonionic (low osmolality) contrast agent.
Lasser et al demonstrated that two-dose premedication with corticosteroids
significantly reduced the frequency of all types of adverse reactions in patients with
previous contrast reactions or allergies.8 Thus, in addition to utilizing nonionic
contrast media in these patients, they should receive oral Metyhlprednisolone 32
mg at 12 and 2 hours prior to the procedure. Furthermore, in cases where there is
concern for a severe anaphylactoid reaction, for example a patient with a prior episode
of laryngeal edema, arrange for anesthesia to be present during the examination.
To minimize the nephrotoxic effects of contrast media, all patients should be
kept well-hydrated 24 hours prior to and 24 hours following contrast administration.
Utilize nonionic contrast media in patients at higher risk for adverse contrast reactions,
including those with renal failure, significant cardiac disease and recent seizures.
In patients with asthma or significant allergies, utilize a nonionic contrast agent.
Consider pre-treatment with steroids and/or antihistamines administered at a
minimum of six hours prior to the examination.
As a general precaution, store contrast media in a warm area. It has been shown
that the prevalence of adverse reactions is significantly less if contrast media is
administered at body temperature.
Selecting a Contrast Medium
The indications for the procedure, as well as patient factors, will help determine
the type of examination—single or double contrast study. In general, a single contrast
examination is adequate for documentation of a procedure (such as joint aspiration),
to demonstrate abnormal communication with adjacent structures or to demonstrate
adhesive capsulitis. Air or carbon dioxide may serve as adequate contrast in those
patients with contrast allergies. Double contrast studies are preferred for the evaluation
of fibrocartilaginous structures, such as the glenoid and acetabular labra and the
menisci, and hyaline cartilage, such as in osteochondritis dissecans or chondrolysis.
Whether single or double contrast examination is desired, it is important to
select a contrast medium that will minimize patient discomfort and risk of adverse
reaction while maintaining healthcare costs at a reasonable level. Were it not for this
latter consideration, the ideal contrast medium would be low osmolality agents,
particularly nonionic agents. However, given the relatively high cost of these agents,
conventional (high osmolality) contrast media are the rule.
In comparing individual agents, the concentration of iodine is important (Table
B). The iodine content refers to the percentage of iodine (weight) per volume of
contrast. In general, lower concentration contrast media may be used for digital
subtraction arthrography than with conventional arthrography. Appendix
Table B. Commonly Used Intravenous Contrast Media
Trade Name Generic Name Iodine Content Distributor

(mg/ml)
Nonionic
Optiray Ioversol 240, 320, 350 Mallinckrodt
Omnipaque Iohexol 180, 240, 300 Sanofi
(Winthrop)
Isovue Iopamidol 200, 300, 370 Bracco
(Squibb)
Low Osmolality Ionic
Hexabrix Ioxaglate meglumine/ 200, 320 Mallinckrodt
ioxaglate sodium
High Osmolality Ionic
Conray (43%,60%) Iothalamate meglumine 202, 282 Mallinckrodt
Hypaque (50%,76%) Diatrizoate sodium/ 300, 370 Sanofi
(Winthrop) diatrizoate meglumine
Renografin (60%,76%) Diatrizoate sodium/ 288, 370 Bracco
(Squibb) diatrizoate meglumine
Paramagnetic Nonionic*
ProHance Gadoteridol n/a Bracco
(Squibb)
Paramagnetic Ionic*
Magnevist Gadopentetate dimeglumine n/a Berlex
* These agents are utilized for magnetic resonance imaging.
For single contrast arthrography, I have found Conray 43 to be a reasonable

compromise. Although it is a high osmolality agent, it has a relatively low iodine
concentration. In addition, small quantities are adequate for arthrography. The actual
volume of intra-articular contrast may be further reduced by diluting the contrast
with 1% Xylocaine in a ratio of 2:1, a common practice by Gilula et al. In addition
to the effect of intra-articular anesthesia, the incidence and severity of synovitis is
probably reduced. For double contrast arthrography, it has been my subjective
experience that compounds with relatively high iodine concentrations, such as
Hypaque 60 or 76, accentuate the air-contrast interface without significantly altering
the incidence of synovitis as compared with that in single contrast arthrography—
because of the small volume of contrast media utilized in the double contrast
arthrography.
Contrast media for MRI include ionic and nonionic paramagnetic agents,
administered intravenously or intra-articularly, diluted in saline in the latter instances.
Appendix It is essential to dilute the contrast sufficiently for intra-articular use, otherwise the
contrast will mask intra-articular pathology on subsequent MR images. Typically,
we place 0.5 to 1.0 cc of gadolinium in a 50 cc bag of saline.
Appendix 215
References
1. Thrall JH. Adverse reactions to contrast media. In: Swanson DP, Chilton HM,
Thrall JH, eds. Pharmaceuticals in medical imaging. New York, Macmillan,
1990:253-77.
2. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: Types,
risk factors, recognition, and specific treatment. Am J Roentgeno 1991;
157:1153-61.
3. Zeng Q, Xiong L, Jinkins JR et al. Intrathecal gadolinium-enhanced MR myelog-
raphy and cisternography: A pilot study in human patients. AJR 1999; 173:1109-15.
4. Gierada DS, Bae KT. Gadolinium as a CT contrast agent: Assessment in a porcine
model. Radiology 1999; 210:829-34.
5. Hammer FD, Goffette PP, Malaise J et al. Gadolinium dimeglumine: An alterna-
tive contrast agent for digital subtraction angiography. European Radiology 1999;
9:128-36.
6. Murphy KJ, Brunberg JA, Cohan RH. Adverse reactions to gadolinium contrast
media: A review of 36 cases. AJR 1996; 167:847-9.
7. Cohan RH, Dunnick NR, Bashore TM. Treatment of reactions to radiographic
contrast material. AJR 1988; 151:263-70.
8. Lasser EC, Berry CC, Talner LB et al. Pretreatment with corticosteroids to allevi-
ate reactions to intravascular contrast media. N Engl J Med 1987; 317:845-9.
9. Halpern JD, Hopper KD, Arredondo MG et al. Patient allergies: Role in selective
use of nonionic contrast material. Radiology 1996; 199:359-62.
10. Vergara M, Seguel S. Adverse reactions to contrast media in CT: Effects of tem-
perature and ionic property. Radiology 1996; 199:363-6.
Appendix
Index 217
INDEX
A Ascites 154
Aspiration 62, 63, 79, 81, 86, 90,
Acetabulum 52, 191, 208 146, 17-177, 183, 184, 186,
Index
cartilage 52, 53 204-210
fossa 57
labrum 47, 52, 57, 100 B
Adhesive capsulitis 1, 4, 12, 28, 33,
34, 47, 57, 78, 88 Bacteremia 205
Allergies 205 Balloon inflation 199, 200
contrast 47, 63, 78, 79, 105 Biopsy 86, 175-177, 179, 182-186,
iodine 106 189, 190, 194, 197, 201, 204,
lidocaine 126 205, 208, 210
Amyloidosis 207 closed 175, 176
Anatomy 72, 78, 88, 148, 158, 171, open 175, 176
210 Bleeding diathesis 179
Anesthetic 1-4, 20, 21, 33, 34, 48, 49, Blunting 57
65, 106, 109, 126, 132-135, Bone graft 149
142-144, 146, 148, 153-156, Bulge 119
161, 165, 168, 184, 190, 195, Bupivacaine 86, 141, 142, 156, 209
201, 204, 205, 209 Bursa 7, 9, 10, 17, 49, 59, 67, 73, 95,
Ankle instability 81, 103 96
Anterior talofibular 103 greater trochanteric 59
Anticoagulant 134, 154, 195 iliopsoas 52, 55
Arachnoiditis 38, 106, 108, 118, 141 Bursae 67, 76, 207
Artery 79, 88, 135, 144, 149, 207
Arthritis 163, 207 C
inflammatory 55 Cartilage 3, 4, 27, 32-35, 38, 39, 47,
osteoarthritis 38, 53, 63, 119, 146, 50, 52-55, 62, 63, 65, 69, 70, 73,
148 78, 80, 81, 85, 86, 95, 98, 101,
rheumatoid 16, 26, 78, 90, 148, 102, 142, 148
207 Cementoplasty 193-195, 201, 202
septic 26, 49, 50, 55, 86, 207 Cervical 105, 108, 111-114, 117,
Arthrodesis 86, 88, 126 118, 124, 135, 137, 140-144,
Arthrogram 4, 7, 12, 21, 32, 33-35, 148, 149, 152, 154-156, 176,
38, 49, 65, 73, 76, 80, 81, 86, 186
88, 95 Chondromalacia patellae 62, 63
prearthrogram evaluation 79 Contrast 3-5, 7, 8, 13, 16, 20-22,
Arthrography 1, 2, 5-12, 16, 20, 22, 24-28, 32-35, 38, 39, 47-50, 52,
26-28, 32-35, 38, 39, 47, 48, 54, 57-59, 63, 65, 67, 70, 73, 78-81,
57, 62, 63, 65, 69, 70, 73, 78-81, 83, 85, 86, 88, 90, 94-100, 102,
83, 85, 86, 88, 90, 94-103, 142, 105, 107, 108, 110-115, 117,
144, 145, 147, 207 119, 124, 126, 129, 134, 135,
ankle 78, 79, 88 137, 142, 143, 149, 158, 161,
distention 4, 88 163-165, 167-170, 176, 201
Articular recess 32, 48, 50, 52, 57, adverse effects 111, 118
142
double 4, 6, 7, 10, 11, 20, 21, 79, F

80, 83, 85, 88
ionic 20, 34, 105, 111, 142 Facet joint 107, 119, 140-146
nonionic 2, 4, 7, 20, 34, 79, 105, Facet syndrome 140, 141, 144
117, 133-135 Femoral 102, 207
single 4, 6, 7, 12, 20, 21, 48, 80, cartilage 52
Index
86, 88 head 52
Cord compression 105, 120, 134, neck 48, 56, 207
179, 202 Fibrosis 33, 73, 90, 120, 126, 133,
CSF (cerebrospinal fluid) 105-112, 159
117-120, 132, 133, 153, 154 Flexor hallucis longus 81, 164
block 106, 107 Focal spot 2, 20, 67
Cyst 26, 39, 54, 67, 146, 205-207 Fovea centralis 52
meniscal 67, 69, 73
popliteal 67, 69, 73 G
synovial 20, 26, 33, 39, 55, 205
Cytology 185, 208 Ganglion 67, 78, 158, 205
Gas bubbles 50
D Gout 207
Detachment 12, 57, 98 H

Diaphragm 159
Disc disease 105, 124, 134, 137, 152 Hematoma 105, 118, 120, 154, 176,
degenerative 124, 137 207
Disc morphology Herniation 106, 115, 118, 120, 126,
annulus fibrosus 135 133, 141, 146
nucleus pulposus 124, 133, 137 disc 106, 115, 120, 126, 133, 141,
Discectomy 124, 126 146
Discitis 126, 133, 134 Hip 47-50, 52, 53, 56, 57, 59, 100,
Discogenic pain 124, 126 146, 163, 207
Discography 107, 124, 125, 128, 129, Hypogastric nerve 161
134, 135, 137, 198 Hypotension 154, 156, 161
cervical 134, 198 I
lumbar 126, 134
thoracic 134 Infrapatellar 67, 73
Discoid 63, 72 Interspinous space 148
Displacement 57, 120, 163, 170, 194 Intra-articular 4, 5, 7-9, 13, 20, 21,
Doppler 204, 205, 207 24, 26, 27, 34, 35, 39, 94-102,
Dysplasia 53, 88 111
Dysplasia epiphysealis hemimel 88 Intradural 111, 115, 120, 142
extramedullary 120
E intramedullary 120
Ephedrine sulfate 161 Intrathecal 105, 110, 111, 114, 115,
Epidural 105, 112, 118, 120, 141, 137, 153, 154, 156
152-154, 156, 161 J
Extradural 115, 120, 126, 128, 133,
134, 137, 145 Joint bodies 33, 35, 39, 47, 55, 57,
Extravasation 21, 33, 35, 59, 73, 83, 69, 70
88, 198, 202
Index 219
K Osty-cut 180
spinal 142, 143, 146, 148, 149,
Kyphoplasty 199, 200, 202 156, 158, 161, 179, 184
Tru-cut 180, 208
L Vacu-cut 180
Nerve 108, 112, 126, 141, 145, 146,
Labral 11, 12, 53, 57, 98-100
Index
152, 154-156, 158, 159, 161,
Ligaments 81, 97, 98, 100, 103, 140, 182, 189
163 lumbar 112
anterior talofibular 81 splanchnic 159, 161
calcaneofibular 103 sympathetic 154
collateral 28, 62, 66 Nerve roots 105, 110, 112, 114,
cruciate 62, 65, 67, 73 118-120, 133, 134, 140, 147,
deltoid 83 152, 155, 202
lateral 163 Neural injury 185
PLL (posterior longitudinal Neuritis 158
ligament) 119, 137 Neurofibromatosis 120
posterior talofibulart 81 Nondiagnostic 176, 185
Ligamentum teres 52
Longitudinal 72, 119, 137, 158 O
Loose body 26, 27, 50, 56
Low back pain 125, 140 Osteochondral fracture 27, 73
Lumbar 2, 3, 106-108, 111, 112, Osteochondritis dissecans 56, 85
114, 115, 117-119, 124, 126, Osteoid osteoma 189
134, 140, 142, 144, 146, 148,
152, 154-159, 161, 198, 199 P
Lymphatic filling 55
Pancreas 159
M Pathology 62, 70, 73, 95, 105, 108,
110, 124, 129, 163, 171, 185,
Menisci 62, 65, 72 190, 204, 207
Metastases 111, 115, 120, 176, 198 Pelvis 47, 128, 161
Myelogram 106, 111, 114, 118, 119, Periosteal 99, 210
137, 153 Phenol 158, 159, 161
cervical 111 Pigmented villonodular synovitis 26,
thoracic 114 54, 62, 71, 78
Pneumothorax 134, 155, 156, 161,
N 185
Posterior subtalar joint 81, 88, 90
Needle 141-143, 146-149, 153-159, Postoperative 33, 35, 62, 73, 94, 101,
161, 164, 165, 167-169, 175, 107, 153
176, 179, 180, 182-186, 190, Premedication 50, 126, 183
191, 193-195, 197-199, 201, Prepatellar 67
204-210 Puncture site 88, 106, 118, 189, 190,
Ackermann 182 208
Chiba 179, 208, 210
Craig 182, 190 Q
Franseen 182, 183
Jamshidi 180, 182 Quadriplegia 185
R T
Radial 25, 26, 33-35, 72 Tear 1, 4, 5, 10, 11, 62, 63, 67, 72,
Radicular pain 126, 202 81, 83, 95-98, 100, 101, 124,
Radiculopathy 202 163, 208
Recess colli 48, 50 Technique 1, 2, 4, 6, 10, 14, 16, 20,
Index
Retroperitoneal 134, 152, 159, 161 21, 24, 48, 50, 65, 70, 78, 79,
86, 96, 107, 112-114, 124, 132,
S 133, 140, 143, 147-149,
154-156, 158, 159, 161, 163,
Sacroiliac joint 146, 147, 148 168, 175, 179, 186, 189, 190,
Saline 2, 4, 5, 28, 33, 34, 49, 70, 95, 193, 194, 197, 204, 205,
96, 102, 133, 153, 209 207-210
Side effects 105, 126 Tendon 1, 7-12, 16, 52, 64, 66, 67,
headache 117, 118, 134, 149, 153, 72, 79, 81-83, 85, 94-98, 141,
154 163-165, 167-172, 207
meningitis 106, 111, 118, 133, 185 peroneus brevis 164
nausea 118 peroneus longus 164
seizures 105, 111, 118, 144 posterior tibial 65, 88, 164
vomiting 118 Tenosynovitis 79, 163, 165, 168, 171,
Specimen 175, 176, 182, 184-186, 207
190 Tibiotalar joint 171
Spinal anesthesia 110, 144 Transducer 204, 205
Spinal cord 105, 108, 109, 114, 118, Trauma 16, 56, 57, 70, 79, 86, 120,
119, 129, 141, 154, 161 134, 182, 206, 207
atrophy 120 Trephine 175, 177, 182, 183, 186,
diastomatomyelia 119 190
dysraphism 108
edema 120, 152 V
syringomyelia 120
Spinal stenosis 105, 106, 112, 115, Vertebroplasty 193-195, 198-203
120
acquired 119 Z
congenital 119
segmental 119 Zona orbicularis 50
Steroids 63, 78, 86, 88, 120, 141, 142,
144, 146, 148, 152, 154, 155,
167, 168, 171, 177, 205
Subarachnoid 105-107, 109, 111-113,
118, 119, 144, 154
Subdural 105, 112
Subtalar joint 78, 81, 88, 90
Synovial 78, 83, 90, 141, 142, 147,
149, 163, 205, 207
metaplasia 56, 70
osteochondromatosis 26, 56, 70
synovial plicae 63, 70
Synovitis 1, 7, 24, 34, 35, 38, 39, 52,
54, 55, 58, 62, 70, 78, 79, 81, 90
Synovium 7, 26, 47, 57, 79, 80
LANDES LANDES
BIOSCIENCE V ad e me c u m BIOSCIENCE V ad e me c u m
Table of contents
1. Shoulder Arthrography 13. Bone Biopsies
Musculoskeletal
2. Elbow Arthrography
3. Wrist Arthrography
14. Percutaneous Treatment
of Osteoid Osteoma
15. Vertebroplasty
Procedures:
4. Hip Arthrography
5. Knee Arthrography
16. Ultrasound Diagnostic and Therapeutic
Appendix
6. Ankle Arthrography
7. MR Arthrography
8. Myelography
9. Discography
10. Percutaneous Blocks
11. Epidural Blocks
12. Tenography
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training of physicians and the care of patients, by medical students, medical house
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Maryse Guerin, M.D.

Musculoskeletal Procedures: Diagnostic and Therapeutic, edited by

Fig. 1.2. Double contrast

Fig. 1.3. Double contrast

Double Contrast Shoulder Arthrography

Fig. 1.4. Normal CT shoulder arthrogram at mid-glenoid level. The triangular-shaped

Fig. 1.5. Normal MR shoulder arthrogram—oblique coronal sections. A) Spin-echo

Fig. 1.6. Normal MR shoulder arthro-

Fig. 1.7. Radiograph showing

Fig. 1.8. Full- thickness rota-

Fig. 1.9. CT arthrography showing

Fig. 1.10. MR arthrography

Fig. 1.11. Anterior Bankart

Fig. 1.12. Severe changes following recurrent anterior shoulder dislocation. CT

Fig. 1.13. Moderate changes following recurrent anterior shoulder dislocation. CT

For fluoroscopic or ultrasound guidance, you should localize the calcifications in

Fig. 1.14. MR arthrography show-

Fig. 1.15. A) CT localization of calcification in the shoulder. B) Needle placement

Fig. 1.16. Acromio-clavicular

Fig. 2.2. Osseous subchondral defect. A) An area of lucency in the subchondral

Fig. 2.3. Normal double contrast

Fig. 2.5. Elbow arthrogram

arthrography is another excellent method of determining whether an opacity

have demonstrated the superiority of elbow arthrography over plain radiographs in

Fig. 2.9. Dissecting neuropathic joint. A) Left elbow radiograph of a neuropathic

Fig. 2.10. Arthrogram of a dislocated prosthetic joint. A) Initial puncture of the

Musculoskeletal Procedures: Diagnostic and Therapeutic, edited by

• detect cartilage abnormalities

Yin et al have suggested injection of the contralateral asymptomatic MCJ, and

arthrography. Conversely, overdistention of a compartment may result in

scaphotrapezialtrapezoidal CT plane).19 The wrist is placed in ulnar deviation to

The ligaments may be perforated, in which case contrast traverses between

Fig. 3.2. Coronal arthrogram—

Fig. 3.3. Coronal arthrogram—

Fig. 3.4. Anterior coronal arthro-

Fig. 3.5. Coronal arthrogram—CT. A) Mid-coronal section demonstrates a tiny com-

Fig. 3.6. Arthrogram—CT. Ulnar impaction syndrome secondary to ulnar positive

Fig. 3.7. Arthrogram—CT. Coronal

Fig. 3.8. Arthrogram—CT. Coro-

Fig. 3.9. Arthrogram—CT. Lateral

Fig. 3.10. Arthrogram—CT.

Fig. 3.11. Arthrogram—CT. Coro-

Fig. 3.12. Arthrogram—CT. a.

Fig. 3.13. Arthrogram—CT. Coronal

10. Smith DK. Lunotriquetral interosseous ligament of the wrist: MR appearances in

Musculoskeletal Procedures: Diagnostic and Therapeutic, edited by

Fig. 4.2. Approaches for hip

At this point, aspiration of synovial fluid is attempted. If successful, synovial fluid is

Fig. 4.5. Normal hip arthro-

Fig. 4.6. Normal acetabular labrum.

Fig. 4.7. Iliopsoas bursa opacification

Fig. 4.9. Synovial diverticula

Fig. 4.10. Advanced osteoarthritis in hip dysplasia. A) Plain radiograph demonstrating

Fig. 4.11. Hip arthrogram, during

HA may also be useful in the etiology and evaluation of subchondral cysts.3 A

Fig. 4.12. Early stages of osteoarthritis. A) 65˚ lateral radiograph demonstrating 4