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and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists,
radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it
has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR
Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice guideline and technical standard by those entities not providing these services is not authorized .
These guidelines are an educational tool designed to assist Therefore, it should be recognized that adherence to these
practitioners in providing appropriate radiologic care for guidelines will not assure an accurate diagnosis or a
patients. They are not inflexible rules or requirements of successful outcome. All that should be expected is that the
practice and are not intended, nor should they be used, to practitioner will follow a reasonable course of action
establish a legal standard of care. For these reasons and based on current knowledge, available resources, and the
those set forth below, the American College of Radiology needs of the patient to deliver effective and safe medical
cautions against the use of these guidelines in litigation in care. The sole purpose of these guidelines is to assist
which the clinical decisions of a practitioner are called practitioners in achieving this objective.
into question.
I. INTRODUCTION
The ultimate judgment regarding the propriety of any
specific procedure or course of action must be made by This guideline was revised collaboratively by the
the physician or medical physicist in light of all the American College of Radiology (ACR) and the American
circumstances presented. Thus, an approach that differs Society of Neuroradiology (ASNR).
from the guidelines, standing alone, does not necessarily
imply that the approach was below the standard of care. Myelography has been an important diagnostic modality
To the contrary, a conscientious practitioner may for a wide range of spinal disease processes for more than
responsibly adopt a course of action different from that 80 years. Cisternography using intrathecal contrast media
set forth in the guidelines when, in the reasonable has also been used for many years in the diagnostic
judgment of the practitioner, such course of action is evaluation of disease processes involving the basal
indicated by the condition of the patient, limitations of cisterns and skull base.
available resources, or advances in knowledge or
technology subsequent to publication of the guidelines. These procedures typically involve performance of a
However, a practitioner who employs an approach lumbar puncture under fluoroscopic guidance followed by
substantially different from these guidelines is advised to the fluoroscopically monitored introduction into the
document in the patient record information sufficient to subarachnoid space of a nonionic water soluble iodinated
explain the approach taken. contrast medium that is FDA approved for intrathecal
administration. Alternatively, when the lumbar approach
The practice of medicine involves not only the science, is contraindicated or less advantageous, the contrast
but also the art of dealing with the prevention, diagnosis, medium may be introduced into the thecal sac via a lateral
alleviation, and treatment of disease. The variety and C1 to C2 puncture, which is described in section V.C.9.
complexity of human conditions make it impossible to Following the introduction of a sufficient quantity of
always reach the most appropriate diagnosis or to predict intrathecal contrast medium, the needle is withdrawn.
with certainty a particular response to treatment.
With the aid of a tilting table, the opacified cerebrospinal
fluid (CSF) is positioned in the desired region of the
Certification in Radiology or Diagnostic Radiology by the Continuing education should be in accordance with the
American Board of Radiology, the American Osteopathic ACR Practice Guideline for Continuing Medical
Board of Radiology, the Royal College of Physicians and Education (CME).
Surgeons of Canada, or the Collège des Médecins du
Québec, and the performance of myelography with B. Registered Radiologist Assistant
acceptable success and complication rates.
or A registered radiologist assistant is an advanced level
Completion of a residency or fellowship training program radiographer who is certified and registered as a
approved by the Accreditation Council for Graduate radiologist assistant by the American Registry of
Medical Education (ACGME), the Royal College of Radiologic Technologists (ARRT) after having
Physicians and Surgeons of Canada (RCPSC), the Collège successfully completed an advanced academic program
des Médecins du Québec, or the American Osteopathic encompassing an ACR/ASRT (American Society of
IV. EQUIPMENT SPECIFICATIONS The clinical history and findings are to be reviewed by the
performing physician.
A. Myelographic Facility
1. Prior to myelography, any prior pertinent
The minimum requirements for the facility are: imaging studies, including lumbar CT or MRI,
should be reviewed. The review should include
1. High-quality radiographic/fluoroscopic imaging evaluation for the position of the conus, as well
equipment, film or digital records of the as lumbar stenosis or any other potential hazard
examination, and a tilt table. The tilt table should prior to choosing the level for LP or myelogram.
be capable of –30 degrees of tilt in the head 2. The patient should be asked specific questions
downward direction. A proper support device for about relevant medications, prior seizures, prior
securing the patient on the tilt table should be allergic reactions, and clotting ability.
available. 3. Patients who are taking Plavix (clopidogrel) for
2. An adequate selection of spinal needles and prophylaxis of myocardial or cerebral ischemia
appropriate nonionic contrast media approved for should discontinue this drug for at least 5 days
intrathecal use. prior to undergoing myelography.
3. Appropriate facilities and equipment for treating 4. For patients with hematologic disorders or other
adverse reactions (e.g., seizure, vasovagal conditions affecting blood coagulation, a platelet
reactions, and/or cardiorespiratory collapse). count and international normalized ratio (INR),
4. Appropriately trained personnel to provide prothrombin time (PT), and partial
proper patient care and operation of the thromboplastin time (PTT) values within one
equipment. week of the procedure should be available.
5. A CT scanner to perform postmyelogram CT 5. Informed consent should be obtained and
studies. Multiplanar reconstruction capability for documented. The patient should be informed of
CT is highly desirable. the risks and the benefits of the procedure.
6. The patient should be adequately hydrated.
B. Surgical and Emergency Support 7. If utilized, sedation should be administered in
Although serious complications of myelography are accordance with the ACR–SIR Practice
infrequent, there should be prompt access to surgical and Guideline for Sedation/Analgesia.
interventional management of complications.