- Department of Neurological Surgery, New York Medical College, Valhalla, New York, USA
- Department of Radiology, New York Medical College, Valhalla, New York, USA
Department of Radiology, New York Medical College, Valhalla, New York, USA
DOI:10.4103/2152-7806.155698Copyright: © 2015 Neil JA This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Neil JA, Laurent D, Das K, Mehta H. Retrograde cysto-myelogram: Case Report. Surg Neurol Int 22-Apr-2015;6:
How to cite this URL: Neil JA, Laurent D, Das K, Mehta H. Retrograde cysto-myelogram: Case Report. Surg Neurol Int 22-Apr-2015;6:. Available from: http://sni.wpengine.com/surgicalint_articles/retrograde-cysto%e2%80%91myelogram-case-report/
Background:In the scenario of blunt trauma with suspected bladder injury, conventional retrograde cystography is the gold standard for accurate diagnosis.
Case Description:The authors report the case of a 54-year-old patient who presented with pelvic and sacral fractures and a ruptured bladder after being hit by a vehicle. A retrograde computed tomography cystogram demonstrated extraperitoneal extravasation of the contrast agent, which traversed violated sacral nerve roots, resulting in contrast entering the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots.
Conclusions:This is the first known report of an accidental myelogram imaging performed through a retrograde cystogram.
Keywords: Bladder rupture, extravasation, myelogram, retrograde cystogram, sacral fracture
Pelvic fracture may occur in the setting of severe blunt trauma, particularly with motorcycle accidents.[
A 54-year-old male was struck by a truck while riding a motorcycle and consequently impacted a guardrail. He was reportedly conscious, ambulatory, and unable to bear weight on his left leg at the scene. His pelvis was temporarily stabilized at an outside hospital, and he was transferred to our facility. A pelvic X-ray and a computed tomography (CT) scan of the chest, abdomen, and pelvis from the outside hospital demonstrated diastases of the left pubic symphysis and a fracture involving the left sacral wing extending to the left sacroiliac joint and a ruptured bladder. On arrival, he underwent a retrograde cystogram during Foley catheter placement, which demonstrated extraperitoneal bladder rupture.
The patient underwent an additional CT scan with contrast enhancement of the chest, abdomen, and pelvis with reconstructions of the thoracic and lumbar spine. At the same time, a CT scan of the head and cervical spine was performed. The images demonstrated extensive hyperdensity within the spinal canal subarachnoid space related to extravasation of contrast material, which was not previously observed on the outside hospital imaging [
The imaging suggested that the contrast material extravasated out of the bladder into the extraperitoneal space [
Coronal (a and b) and axial (c) CT scans of the lumbosacral spine demonstrating extensive fracturing of the left sacral pelvic tube, with violation of left sacral nerve roots, allowing contrast to enter the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots
The patient underwent emergent repair of the bladder by the urological surgeon, and the pubic symphysis was secured with plates by the orthopedic team. Two days later, the patient underwent open reduction and internal fixation of the left sacrum and percutaneous pinning of the left sacroiliac joint by the orthopedic surgeons. The dural tear and cerebrospinal fluid leak were treated conservatively.
The patient was discharged home 13 days after presentation with family support, physical therapy, wheelchair, and crutches with instructions for no weight bearing on the left lower extremity. On follow-up 3 months later, X-rays demonstrated stable alignment, and on physical examination, he was healing well without complication.
This report is the first to demonstrate myelography inadvertently performed via retrograde cystography. Of all mechanisms of blunt trauma, motorcycle injuries are associated with the highest incidence of pelvic fracture. Following the liver, the bladder and urethra are the most common organs injured in fractures of the pelvis.[
Introduced by Jean-Athanse Sicard and Jacques Forestier in 1921, myelography allows for the visualization of subarachnoid structures within the spinal canal.[
There have been reports of contrast dye entering the subarachnoid space following unrelated contrast-dependent imaging modalities. For example, Gurer et al.[
We present this paper to demonstrate the plausibility—albeit, unlikely—of an inadvertent myelogram following retrograde cystography in a patient with bladder rupture. To the best of the authors’ knowledge, this is the first report of its kind. In cases of severe pelvic fractures with bladder injuries, a clinical concern for communication between these spaces should be considered.
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