Understanding Myelograms in Medical Malpractice Litigation: A Comprehensive Overview

A myelogram is also a myelography or a CT myelogram. It is an advanced maging test used to see the spinal canal, spinal cord, and surrounding nerve roots. Magnetic resonance imaging (MRI) has largely become the first choice for spinal imaging over the past four decades. However, the myelogram remains an important tool in modern medicine. In the legal arena—specifically in medical malpractice cases—myelograms play a vital role. They serve as critical objective evidence to detect, confirm, or assess spinal injuries. Surgery error, epidurals done wrong, spinal infections that are not diagnosed, or failed medical procedures can cause these injuries.

1. History of the Myelogram: From Oil Dyes to Modern CT

To understand how myelograms function in medical malpractice cases, it helps to understand their historical evolution:

• 1920s — The Early Days: Doctors performed the first myelograms using Lipiodol, an iodized poppy seed oil. Oil does not break down in body fluids. Thus, this early contrast agent remained inside the spinal canal forever. That is, unless removed with surgery or with manual action, occasionally causing chronic inflammation.
• 1940s — The Pantopaque Era: The introduction of Pantopaque (iophendylate) marked a major step forward in image clarity. However, the providers still had to suck oil out through a needle at the end of the procedure. Incomplete removal frequently led to adhesive arachnoiditis—a painful condition with chronic inflammation of the meninges could cause disability. This spawned widespread medical malpractice lawsuits throughout the late 20th century.
• 1970s to 1980s — Water-Soluble Dyes & CT Combination: The development of non-ionic, contrast agents (such as metrizamide and later iohexol) that break down in water improved safety. The human body naturally absorbs and gets rid these dyes through the kidneys. This eliminates the need for suction after the procedure. Paired with Computed Tomography (CT myelogram), providers got unprecedented views of nerve roots.
• Modern Era: MRI gained in the late 1980s. However, a myelogram combined with CT scans remains the gold standard when MRIs are inconclusive, contraindicated, or distorted by surgery hardware.

2. How the Myelogram Procedure Works

A myelogram is a procedure in two parts. It includes a special spinal shot (lumbar puncture) with fluoroscopic X-rays. It follows with a high-resolution CT scan.

Step-by-Step Procedure

1. Patient Preparation & Positioning: The patient lies face down (prone) or on their side on a tilt table that can adjust. The skin over the lower back is thoroughly sterile and numbed with a local anesthesia.
2. Lumbar Puncture (Spinal Tap): Fluoroscopy (live X-ray) guides it in real time. The provider guides a thin needle between the vertebrae into the subarachnoid space. That is the area with fluid that surrounds the spinal cord and nerve roots.
3. CSF Sampling & Contrast Injection: The provider often draws a small sample of cerebrospinal fluid (CSF) for laboratory analysis. Then, the provider slowly puts an iodinated contrast dye that breaks down in water into the subarachnoid space.
4. Table Tilting & Fluoroscopic Capture: The providers tilt the X-ray table up and down. Gravity moves the radiopaque contrast fluid up or down the spinal canal. That is from the lumbar region up to the spine into the chest or neck. X-rays document how the contrast flows around nerve roots and whether any blocks, compressions, or leaks exist.
5. CT Myelography (Post-Injection CT): Immediately after the X-ray phase, the provider transfers the patient to a CT scanner. The CT captures thin section slices of the spine filled with contrast. This creates a detailed 3D of the spinal canal and nerve exits (intervertebral foramina).

Healthcare Providers Involved

• Ordering Doctors: Typically requested by an orthopedic spine surgeon, neurosurgeon, neurologist, pain management specialist (physiatrist), or emergency room doctor.
• Performing Physician: Performed by an interventional radiologist or neuroradiologist—doctors trained in spinal procedures guided by image.
• Clinical Team: Assisted by a radiologic technologist (operating the fluoroscopy and CT equipment) and radiology nurses who monitor vital signs, assist with sterile preparation, and manage recovery after the procedure.

3. Diagnostic Capabilities: What a Myelogram Can and Cannot Show

In medical malpractice claims, deciding whether a myelogram ordered was proper—or whether its results were correctly read—depends on understanding the test’s scope.

What a Myelogram CAN Show:

• Cerebrospinal Fluid (CSF) Leaks: Pinpoints dural tears caused by surgery nicking or lumbar punctures.
• Dynamic Nerve Compression: Detects root sleeve impingement under functional putting in position or loads bearing weight.
• Hardware-Obscured Pathology: Visualizes nerve canals cleanly in patients with metal spinal rods, cages, or pedicle screws that create heavy metal artifacts on MRI.
• Nerve Root Avulsions: Delineates subtle tears or stretch of nerve roots exiting the spinal cord. An example would be the nerve damage in an Erb’s Palsy.
• Arachnoiditis & Scars: Demonstrates clumping of nerve roots or block of fluid flow due to scars or infection after surgery.

What a Myelogram CANNOT Show:

• Intrinsic Spinal Cord Disease: Cannot clearly show demyelination (e.g., Multiple Sclerosis), spinal cord edema, or ischemia inside the cord substance itself.
• Soft Tissue Outside the Canal: Provides limited detail on paraspinal muscle tears, ligaments, or soft tissue tumors away from the fluid space.
• Vascular Cord Lesions: Ischemias or small vascular malformations inside the spinal cord tissue require special MRI sequences or digital subtraction angiography.
• Non-Spinal Causes of Pain: Cannot evaluate peripheral neuropathy, hip joint problem, or vascular claudication mimicking spine symptoms.

4. Medical Malpractice Injuries That Require Evaluation by a Myelogram

Medical malpractice in spinal care or anesthesia can result in severe, brain injuries that can alter life. When a patient suffers new or neurological deficits that get worse following a medical procedure, a CT myelogram is often the tool used to diagnose and establish liability and document the physical mechanism of injury.

Diagnostic Decision Flow for Suspected Spinal Injury:

1. Suspected Iatrogenic Spinal Injury
2. Determine Diagnostic Pathway:
   • If MRI is Feasible & Clear: Used primarily for soft tissue evaluation or intrinsic cord pathology.
   • If MRI is Contraindicated or Obscured: (Due to metal implants, pacemakers, or suspected occult CSF leaks) Order CT Myelogram.
3. Key Conditions Pinpointed by CT Myelogram:
   • Iatrogenic Dural Tear: Detects active CSF leakage.
   • Nerve Impingement: Identifies compression by bone fragments or extruded bone cement.
   • Surgical Hardware Misplacement: Shows pedicle screw intrusion into the canal.

Primary Medical Malpractice Injuries Evaluated by a Myelogram

A. Surgical Hardware Misplacement (Pedicle Screws, Rods, Cages)

During spinal fusion or decompression surgery, orthopedic surgeons and neurosurgeons insert pedicle screws, cages, and metal plates to stabilize the spine.

• The Injury: If a surgeon places a pedicle screw wrong, going through the medial wall of the pedicle, the screw can directly impinge upon or cut a spine nerve root or press on the spinal cord.
• Why a Myelogram is Needed: Standard MRI scans suffer from metal artifacts—massive distortion caused by metal alloys that render surrounding nerve tissue invisible on the scan. A CT myelogram does not have this limitation, clearly showing the metal screw relative to the contrast-filled subarachnoid space and confirming hardware impingement.

B. Iatrogenic Dural Tears and Persistent CSF Leaks

A dural tear (durotomy) occurs when a surgeon inadvertently punctures or tears the dura mater—the protective outer membrane enclosing the spinal cord and fluid.

• The Malpractice Aspect: A dural tear during spinal surgery, or when the surgical team fails to recognize, repair, or monitor the tear postoperatively. Unrepaired dural tears can lead to incapacitating intracranial hypotension (positional headaches), pseudomeningoceles, meningitis, or nerve root herniation through the dural defect.
• Why a Myelogram is Needed: CT myelography is widely considered the gold standard for locating active CSF leaks. The contrast medium escapes through the dural gap, precisely highlighting the location and size of the tear for corrective revision surgery.

C. Retained Bone Fragments, Bone Cement, or Surgical Debris

During procedures like vertebroplasty, kyphoplasty, or laminectomy, surgical materials or displaced bone fragments can be pushed into the spinal canal.

• The Injury: In vertebroplasty, PMMA (polymethyl methacrylate) bone cement can leak out of the vertebral body into the epidural space or neural foramina before hardening, causing thermal and mechanical destruction of nerve roots or cord compression.
• Why a Myelogram is Needed: A CT myelogram illustrates the exact boundary between the extruded cement/fragment and the compressed dural sac, proving structural nerve compression caused during the index procedure.

D. Misdiagnosed Postoperative Epidural Hematoma or Abscess

Following spinal surgery or epidural anesthesia, bleeding (hematoma) or infection (epidural abscess) can accumulate within the tight confines of the spinal canal.

• The Malpractice Aspect: Misdiagnosis or failure to promptly diagnose and surgically evacuate an epidural hematoma or abscess when a patient exhibits progressive motor loss or bowel/bladder dysfunction constitutes a critical failure in the standard of care. Delayed treatment can cause permanent paralysis (paraplegia or quadriplegia).
• Why a Myelogram is Needed: If the patient has metal construct artifacts after surgery or cannot undergo an emergency MRI (e.g., due to a non-compatible pacemaker), a CT myelogram is urgently performed to reveal the extradural mass effect squeezing the spinal cord.

E. Anesthesia & Injection Negligence (Nerve Root Trauma & Arachnoiditis)

Epidural steroid injections (ESIs), spinal anesthesia, and also diagnostic lumbar punctures require precise needle placement.

• The Injury: Direct needle trauma to nerve rootlets or accidental intrathecal injection of irritating chemicals (such as certain preservatives or non-approved drugs) can cause severe nerve root injury or adhesive arachnoiditis.
• Why a Myelogram is Needed: A CT myelogram demonstrates characteristic features of arachnoiditis, such as nerve roots clumped together, empty dural sac appearance, or severe loculation of CSF flow.

5. Medical Malpractice Claims Involving the Myelogram Itself

Beyond looking at injuries caused by other medical procedures, the myelogram procedure itself can be the subject of a medical malpractice lawsuit if the performing radiologist or medical staff fails to adhere to accepted standards of care.

Primary Risks & Medical Malpractice Standard of Care Breaches during a Myelogram:

• Infection Control Failures: Failure to maintain strict sterile technique during lumbar puncture, with bacteria directly into the intrathecal space and causing bacterial meningitis or epidural abscess.
• Direct Spinal Cord Injury: Performing a lumbar puncture above the L1–L2 level in adults, risking direct needle into the conus medullaris (lower tip of the spinal cord).
• Failure to Screen Contraindications: Administering intrathecal contrast to a patient with known severe contrast allergies, elevated intracranial pressure (risking brain herniation), or uncorrected bleeding disorders (risking spinal hematoma).
• Improper Post-Procedure Monitoring: Discharging a patient too soon or failing to instruct them to remain upright/hydrated, leading to severe post-dural puncture headaches or unmonitored CSF leaks.

Summary on Myelogram and Medical Malpractice

In spinal cases, a myelogram bridges the gap between a patient’s pain complaints and objective radiological evidence. Whether finding that a pedicle screw is pushing on a nerve or finding an CSF leak from surgery that has not been repaired, a CT myelogram remains a critical tool for medical experts, attorneys, and courts in medical malpractice.

If you have a potential medical malpractice case, then visit our free consultation page or video. Then contact the Kopec Law Firm at 800-604-0704 to speak directly with Attorney Mark Kopec. He is a top-rated Baltimore medical malpractice lawyer. The Kopec Law Firm is in Baltimore and pursues cases throughout Maryland and Washington, D.C.