0:00

With that, we can move on to pressure augmented CT myography.

0:03

It has a temporal advantage over conventional myography and detecting of slow C

0:07

S F leaks.

0:07

You can perform it entirely in CT or you can split it between fluoroscopy and

0:11

ct. Um, when I do that, I tend to do a D S M in, in, um, uh,

0:15

in fluoroscopy and actually do that first,

0:17

and then I'll send the CT and use the CT as sort of my delayed image. Um,

0:21

I usually raise the pressure with a manometer and I, I,

0:24

I utilize both contrast and Elliot B solution. Um,

0:27

I put them in the lateral decubitus position on the side of most interests.

0:31

So the side with the most suspicious looking, um, uh,

0:34

peroneal cyst on the M R I, I'll put 'em on that side.

0:36

So if the left side's most suspicious,

0:38

I'll put 'em left side down or left lateral decubitus, uh,

0:40

prep their skin and essentially I'll access 'em with a 22 gauge needle in this

0:44

case because I wanna be able to get a really accurate pressure.

0:47

So I need to get some flow of C S F back and forth to kind of get an idea of

0:50

what the pressure is dynamically as I'm injecting additional, um, solution. Um,

0:54

but normally I inject 10 mls of Omni 300, and if I'm doing it under ct,

0:59

I just put 'em on a bolster in CT with the, the bolster underneath their hips,

1:02

uh, which is in contradistinction to what we were talking about earlier. The,

1:05

the rapid CT gram we're injecting and everything with their head elevated.

1:09

I would normally have the bolster with those rapid cases with the,

1:11

the bolster under their shoulders. In this case,

1:12

I'm gonna put the bolster under their hips,

1:14

so the contrast goes ahead and flows basically all the way up the spine.

1:18

And as you, you might imagine if they're on their thigh,

1:22

what tends to happen is that contrast just sort of runs into and drips into each

1:26

one of those perineural cysts, almost like the, the, um, uh,

1:30

reservoirs in an ice cube tray.

1:32

And then after I finish dripping the contrast into all of these,

1:36

the next thing that I will do is I will raise their pressure with Elliot Bs.

1:39

You can also use, um, uh, um, normal saline. I mean, it,

1:43

it's a little bit more painful for them, but you can use it. Um,

1:46

it causes kind of a pressure sensation for some patients. Um,

1:49

but basically I raise their pressure to between 30 and 35 centimeters of water.

1:53

Some people just wait. Some people just, um, uh, essentially, um, uh,

1:58

raise their pressure until their headache is gone. I, I,

2:01

I raise it to 35 to give me my, my best chance of seeing it. Um,

2:04

and then I complete the scan in that position.

2:07

And then the delayed scan is usually performed an hour later.