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Objective To describe the technique, safety profile, and outcome of computed tomography (CT)–guided atlanto-axial lateral articulation injections performed at our institution. Methods Consecutive cases of all CT-guided atlanto-axial injections performed from January 2017 to April 2022 at our institution were searched in the electronic medical records. Patient charts were reviewed for demographics, characterization of pain, potential altered anatomy, pain level before and immediately after the procedure, procedure technique, complications, and follow-up outcomes, if available. Results Forty-five injections in 40 different patients were included. The average age was 67.4 years, and 28 (70%) of the patients were female. Of the 45 injections, 43 (96%) were technically successful. The average change in pain score (0–10) from immediately before to immediately after the injection was –3.36 (SD = 2.87, range = –8 to +3). Of all injections, 14 (31%) had a postprocedural pain score of zero. In 2 cases (4%), patients reported an increase in pain score immediately after the injection. In 3 cases (7%), transient non–vertebral artery vascular uptake of contrast was documented during the procedure, which could be cleared with needle repositioning. There were no complications. Conclusion CT-guided atlanto-axial lateral articulation injection is a safe procedure with a high technical success rate. It allows for direct visualization of vital structures and provides an alternative option to the traditional fluoroscopic guidance, especially in cases of prior technically unsuccessful fluoroscopically guided injection or altered anatomy. [ABSTRACT FROM AUTHOR]

Dynamic CT myelography is used to precisely localize fast spinal CSF leaks. The procedure is most commonly performed in the prone position, which successfully localizes most fast ventral leaks. We have recently encountered a small subset of patients in whom prone dynamic CT myelography is unsuccessful in localizing leaks. We sought to determine the added value of lateral decubitus dynamic CT myelography, which is occasionally attempted in our practice, in localizing the leak after failed prone dynamic CT myelography. We retrospectively identified 6 patients who underwent lateral decubitus dynamic CT myelography, which was performed in each case because their prone dynamic CT myelogram was unrevealing. Two neuroradiologists independently reviewed preprocedural spine MRI and all dynamic CT myelograms for each patient. Lateral decubitus positioning allowed for precise leak localization in all 6 patients. Five of six patients were noted to have dorsal and/or lateral epidural fluid collections on spine MRI. One patient had a single prominent diverticulum on spine MRI (larger than 6 mm), whereas the others had no prominent diverticula. Our study suggests that institutions performing dynamic CT myelography to localize fast leaks should consider a lateral decubitus study if performing the study in the prone position is unrevealing. Furthermore, the presence of dorsal and/or lateral epidural fluid collections on spine MRI may suggest that a lateral decubitus study is of higher yield and could be considered initially. [ABSTRACT FROM AUTHOR]

Spontaneous cerebrospinal fluid (CSF) leaks can be an intractable cause of orthostatic headaches but have several treatable causes. CSF-venous fistulas are an increasingly recognized cause of rapid CSF leaks. Although CSF-venous fistulas have been previously reported in the literature, their imaging appearance, associated anomalies, and treatment are incompletely understood. We present a case of a CSF-venous fistula draining to adjacent venous malformations with symptoms responding to surgical treatment. This is the first such case to our knowledge showing enhancement of venous malformations on computed tomography myelography. A 61-year-old woman with known soft tissue venous malformations presented with progressive hearing loss, headaches, and nausea. Brain magnetic resonance imaging performed at an outside institution showed findings of CSF hypotension. Her symptoms were refractory to a single-level blood patch. Digital subtraction and computed tomography myelography performed at our institution showed CSF-venous fistulas arising from thoracic nerve root sleeve diverticula and draining to paraspinal venous malformations. She was treated with surgical ligation of the fistula and associated nerve roots. At 3-month follow-up, she reported improvement in her headaches, and magnetic resonance imaging showed resolution of all brain abnormalities. CSF-venous fistulas are a relatively uncommon cause of spontaneous CSF leaks. Though difficult to diagnose, they can respond to surgical treatment as seen in this case. In our experience, decubitus digital subtraction myelography combined with computed tomography myelography is instrumental in making the diagnosis and fully characterizing any abnormalities associated with the fistula. This case also supports the suggested association between CSF-venous fistulas and venous malformations, which is worthy of continued study. [ABSTRACT FROM AUTHOR]