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MRI Essentials for the Spine Specialist

MRI Essentials for the Spine Specialist

A. Jay Khanna, MD, MBA
Associate Professor
Departments of Orthopaedic Surgery and Biomedical Engineering
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Division Chief
Johns Hopkins Orthopaedic and Spine Surgery–National Capital Region
Bethesda, Maryland

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Library of Congress Cataloging-in-Publication Data
MRI for spine surgeons and specialists / [edited by] A. Jay Khanna.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-60406-877-1 (alk. paper)—ISBN 978-1-60406-878-8 (eISBN)
I. Khanna, A. Jay., editor of compilation.
[DNLM: 1. Spinal Diseases—surgery. 2. Spine—surgery. 3. Magnetic Resonance Imaging—methods. 4. Spine—
anatomy & histology. WE 725]
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v . and our children. Roma. Rajan and Priya.I dedicate this book to the most precious people in my life—my wife.

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Jay Khanna. A. Joseph R. Jay Khanna 8 Tumors of the Spine 211 Daniel M. Carrino. Aditya Daftary. A. Sciubba. J. Patricia L. Buchowski. Dana Dunleavy. and A. Carrino. Buchowski. Wasserman. and Paul D. Okubadejo. Wasserman. and A. Rick W. and Joseph R. and A. Jacob M. John A. Douglas P. Bruce A. Jay Khanna. Obray. Carrino. John A. Chad M. Aditya Daftary. Fayad 2 Normal Spine MRI Anatomy 19 Swati Deshmukh. and Laura M. and Ziya L. Jacob M. Carrino vii . Shih-Chun David Lin. Silverberg. Singla 4 A Systematic Approach to the Review of Spine MRI Studies 68 A. John A. John A. Gjolaj and John A. Beall. Bruce A. Reeder. Carrino. and Aneesh K. Carrino. Jay Khanna 7 The Lumbar and Thoracic Spine 155 Gbolahan O. John D. Zebala. Haines. Jay Khanna 3 Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 45 Josemaria Paterno. Sponseller III Special Conditions 10 Advanced Techniques in Spine MRI 253 Joseph P. Jay Khanna II Spine 5 The Occipitocervical Junction 87 Colin M. O’Brien. Gokaslan 9 MRI of the Pediatric Spine 237 A. O’Brien 6 The Cervical Spine 111 Lukas P. Jay Khanna. Contents Foreword ix Preface xi Acknowledgments xiii Contributors xv I Initial Considerations 1 Essentials of MRI Physics and Pulse Sequences 3 Shivani Ahlawat. Zadnik. John A.

A.viiiâ•…â•…Contents 11 Correlation of MRI with Other Imaging Studies 267 Shivani Ahlawat. Fayad 12 MRI Safety Considerations for the Referring Clinician 280 Monica D. Jay Khanna. Uma Srikumaran. and Laura M. Watkins and Bruce A. Wasserman Glossary 289 Index 291 .

he has constantly striven to create new resources to many studies have shown that the sensitivity of MRI help spine surgeons and specialists utilize this tech- technology and the presence of age-appropriate de. mation that all spine practitioners should read and priate clinical context. on the ultimate outcome of our patients. The lower success rates of editor and all the authors for their commitment to spinal interventions and surgery may arguably be this educational endeavor and anticipate that this the result. and minimize the treatment utilize as a resource in the diagnosis and treatment of nonrelevant pathology is truly an art form in the of our patients with spinal disorders. The second part on a topic that is universally critical to all practitio. The editor of this textbook. I congratulate the edi. conducted meetings. University of Southern California MRI for Spine Surgeons and Specialists is a textbook Spine Institute written by spine surgeons. MD tremely valuable resource for all spinal practitioners. The ability to interpret and relate ies with other imaging studies. journals. In addition. Co-Director. of patients with a broad range of spinal pathologies. of the text is focused on the different anatomic areas ners who care for patients with spinal pathologies. and the correlation of MRI stud- spinal pathology. but it arguably is the single and special considerations for pediatric patients. tu- most important advancement in the evaluation of mors. The last The introduction of MRI technology revolutionized portion of the text explores more advanced concepts all medical diagnostics. has It is important for any practitioner to be able to ac. I believe this text is a crucial collection of infor- ity to detect spinal pathology. spinal abnormalities. Department of Orthopaedic Surgery tor and all the authors of this text for putting forth Los Angeles. to the spine. detected on the MRI study. He has created several educa- some findings can be quite subtle. I commend the treatment of our patients. As a noted expert in the field. text will be well received by all spine specialists. Jeffrey C. although educator on this topic. into this is a comprehensive compilation of all aspects the treatment algorithms for our patients is an es. Regardless. and ra. Wang. Taken as a whole. Orthopaedic Spine Service diologists to detail the relatively complex MRI anat. operative and nonoperative. great experience in MR imaging and is a passionate curately interpret an MRI study because. the core concepts of MRI technology as they relate and textbooks available in the area of spinal disor. put it in the appro. spine specialists. it is refreshing to see a practical. at least in part. the ability to accurately interpret spinal MRI studies is critical. Jay Khanna. Dr. Foreword Given the large number of publications. Professor of Orthopaedic Surgery and Neurosurgery€ omy of the spine and the spectrum of pathological University of Southern California findings in spinal disorders. of the spine from the occiput to the sacrum. the consequences tional efforts in this specific area and has taught sev- of making inaccurate interpretations or “missing” eral courses. MRI safety. with correlative chapters on anatomic ders. of the use of MRI for imaging the spine and spinal sential element in the successful clinical treatment pathologies. Chief. with increasing age should be considered. nology in order to ultimately help with better care generative changes that occur normally in patients for our patients. The abil. and this textbook is an ex. focused text pain generators and MRI findings. California ix . both emphasizing the significance of some MRI findings. of “over-reading” or over. and edited other significant pathology can have catastrophic effects texts on MR imaging.

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sonal interest in providing a more in-depth evalua- operative decisions based on those readings. by experience gained throughout void of imaging resources for clinicians who care for their training and in clinical practice.” from my recognition of the fact that the ability to ac. (2) Anatomical Regions of the Spine: Spectrum noninterventional pain specialists. region-specific and concept-specific. I have helped de. should be familiar when reviewing an MR imaging paedic and neurosurgical backgrounds). they also serves as a ref- for clinicians. Considerations.. with sections on spe- care of patients with spinal pathology. and ad- teach the reader how to systematically evaluate and ditional illustrative material. “Normal reference for diagnostic radiologists who interpret Spine MRI Anatomy. The region-spe- est and background in musculoskeletal imaging and cific chapters (e. interpret MR imaging studies of the spine. we may be more Publishers has graciously allowed me to reuse some likely to evaluate the images in a less organized man. traumatic lines. Special. MRI for Orthopaedic Surgeons. content with current theories and practices. suits the individual chapter’s content and the goal xi . physiatrists.g. or each gists. sor of this book. As such. interest or expertise in the management of patients before reading the chapters on individual spinal re- with spinal disorders. and drawings from MRI ner and to rely on our anatomic expertise and expe. study of the occipitocervical. degenerative pathology. and (3) Advanced Concepts and Special radiologists..” and Chapter 3. and Chapter 7.” These two chapters provide Although there are many excellent books that fo. which may not be the most effective method. and Lumbosacral Spine. “Common Clini- spine MRI studies and would like to gain a better ap. chapter. which ous pulse sequences that are available for obtaining was also published by Thieme Medical Publishers. it is clinically oriented and erence point when evaluating the pathologic images presents the information from a perspective that a in a region-specific chapter.g. sports medicine specialists. and radiologists specifically bar. cervical. this one is unique in anatomic structures and concepts with which one that it is written by spine surgeons (with both ortho. This book features two different types of chapters: My desire to create this book stems from my inter. pathology. most clinicians learn this skill in an ologists and radiologists in training. I realized that many of the text. spine surgeon or specialist will appreciate. Each of these three sections. How. “The Lumbar and Thoracic Spine”) curately evaluate MR imaging studies is critical to the share a common organization. ever. “Advanced Techniques systematically evaluate MR imaging studies of the in Spine MRI”) are organized in a fashion that best spine. books and other resources on the topic of spine MRI cal to the clinical and surgical care of patients with are written by radiologists and directed toward radi- spine pathology. the spine. rheumatologists. The concept-spe- in practice and in training that teach them how to cific chapters (e. and postoperative findings. infectious condi- velop and deliver several courses for spine surgeons tions. Thieme Medical MRI studies in a systematic fashion. Chapter 10. interven. thoracolum- tional pain specialists. and post. “The Cervical Spine. Many of us clinicians prefer to read our That textbook provided an overview of MR imaging patients’ MR imaging studies ourselves rather than of the entire musculoskeletal system by anatomic rely solely on the “official” radiologist’s report. we patients with spine and other musculoskeletal pa- may not have (or need) a thorough understanding of thologies led me to compile and edit the predeces- the science and physics of MR imaging and the vari. Along these cialized pulse sequences and protocols. We region. images. of the relevant text. intraoperative. over the last several years. tion of my primary area of clinical interest. the images. Chapter 6. can be read independently. As a result. This perceived informal fashion. neurolo. unlike radiologists who are trained to evaluate we decided to create this textbook. interventional of Disease. will butions authored by acknowledged experts. The chapters of MRI Essentials for the Spine Special- ists who may benefit from reading and referencing ist are organized into three sections: (1) Core Con- this book include spine surgeons. cal and Correlative Pain Generators of the Cervical preciation of the associated clinical aspects. and I have built upon that rience. a moderately comprehensive evaluation of the key cus on MR imaging of the spine. and lumbosacral spine. Given the success of that book and my per- learn to make preoperative. contri- This text. the clinician should review Chapter 2. In particular. Preface Although the ability to evaluate MRI studies is criti. MRI Essentials for the Spine Specialist. but the textbook sicians or allied health professionals who have an is best read in sequential chapter order. interventional and cepts. This book is also an excellent gions. and any other phy. In doing so. for Orthopaedic Surgeons.

xiiâ•…â•…Preface of providing spine surgeons and specialists with the Most of the chapters have been authored by spine information they need to maximize their proficiency surgeons. A. Others (e. Some. Khanna’s book. but the presentation of the material or radiologist should be able to recognize and define was specifically designed with a clinician audience in when evaluating an MRI study of the spine. These questions will also allow the and systematically evaluate MR imaging studies of the reader to review the material efficiently and test his spine. contains a new feature. interventional pain specialists. “Essentials of MRI ed to help illustrate and teach the essential anatomy Physics and Pulse Sequences”) were written solely and pathology that a spine surgeon. MRI for Ortho- paedic Surgeons. Jay Khanna. and radi- in evaluating and interpreting MR imaging studies. other clinician. from their standpoint. I hope that it accomplishes this goal for you. ologists. this book two groups of physicians in clinical practice. MRI Essentials for the Spine Specialist contains have spine surgeons as the primary authors. As such. MBA † added to figure legend or table title indicates that the figure or table was borrowed from Dr. The collaboration between clinicians and radi- much of the material can be reviewed effectively by ologists that has been used to produce this textbook evaluating the images and illustrations along with emulates the optimal relationship between these the associated figure legends. or her comprehension of some of the key concepts from each chapter.g. mind. by radiologists. In addition. with nearly 450 MR images and approximately 150 artist’s radiologists as co-authors for accuracy and clarity drawings that have been carefully selected and creat. which is a set of Common This book was envisioned to be a practical aid to Clinical Questions (with answers and explanations) develop and/or refine the skills needed to effectively for each chapter. MD. .. such as the region-specific chapters.

to Jennifer Pryll for conceptualizing and creating the ence. medical illustrator extraordinaire. I would like to express my greatest appre- ing us to follow in the success of our previous book ciation to Elaine Henze. the clinical presentation of our patients and the ra- tive editor at Thieme. production editor. as Hopkins University’s Department of Orthopaedic well. to Judith Tomat at Thieme for her outstanding Surgery. Finally. this book. cover art. which has culminated in the information. execu. She. Thanks. and willingness to of their time and willingly shared their knowledge work through many rounds of revisions. which creatively illustrates the intention of packed pages of this book. and legend. medical editor for The Johns together. to Kenneth Chumbley. table. Acknowledgments First and foremost. has efforts in bringing this book through the publishing spent countless hours on this project at work and process and helping us navigate our way through the on her own time during an especially challenging various steps from concept to final product. xiii . a sincere thank you to Kay Conerly. I thank Elaine for helping me with also. for inviting me to help create diographic manifestations of their spinal conditions. Her and specifically for helping us solve the puzzle of commitment to accuracy and focus on quality have merging numerous images and illustrations with the helped ensure this book is the excellent product you text to create a beautiful layout. figure. They have given generously for his skill. Thanks also gained from years of clinical and research experi. with the support of Jenni Weems. I would like to thank the many you to Tony Pazos. Thanks. image. contributors to this text. for his the multiple rounds of edits and revisions for ev- meticulous work during the final phase of the book ery chapter. attention to detail. this book under the Thieme banner and for allow. which is to focus on the convergence of Next. MRI for Orthopaedic Surgeons. personal year. A very special thank see today.

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Louis. Maryland Division Chief Swati Deshmukh. Carrino. Orthopaedic Department of Radiology. Maryland Associate Professor of Radiology and Orthopaedic Surgery Colin M. MD. Maryland Shih-Chun David Lin. Maryland€ Imaging The Russell H. India Baltimore. PhD J. Oklahoma Ziya L. Morgan Department of Radiology Douglas P. MD Johns Hopkins Orthopaedic and Spine Surgery– Department of Radiology National Capital Region Johns Hopkins Hospital Bethesda. Maryland A. MD. Maryland Baltimore. MD. Maryland Oklahoma City. Louis Director. MD and Radiological Science Chief of Radiology Services The Johns Hopkins University School of Medicine Clinical Radiology of Oklahoma Baltimore. Buchowski. Gokaslan. Anthony Oklahoma City. New York Bethesda. Neurosurgical Spine Program Washington University in St. Neurosurgical Spine Metastasis Center St. MD Clinical Instructor Associate Professor of Radiology. MD The Johns Hopkins University School of Medicine Department of Orthopaedic Surgery Section Chief. MD Summit Medical Center Assistant Professor€ Edmond. Haines. Gjolaj. Oklahoma Department of Orthopaedics and Rehabilitation Adjunct Faculty University of Miami Miller School of Medicine Department of Orthopedics Bone and Joint Hospital Miami. FACS Donlin M. DC Radiological Science Baltimore. Department of Neurosurgery Department of Orthopaedic Surgery Director. Fayad. MBBS Departments of Orthopaedic Surgery and Consultant Radiologist Biomedical Engineering InnoVision Imaging and SportsMed Mumbai The Johns Hopkins University School of Medicine Mumbai. MD Neurosurgeon Director of Interventional Radiology Suburban Hospital Windsong Radiology Group Johns Hopkins Medicine Buffalo. MS Professor of Neurosurgery. Missouri Department of Neurosurgery The Johns Hopkins University School of Medicine John A. MD. Musculoskeletal Radiology George Washington University Russell H. MPH Baltimore. MD. Contributors Shivani Ahlawat. MD Laura M. Musculoskeletal Section Surgery. Florida at St. MBA Associate Professor Aditya Daftary. Dana Dunleavy. Beall. Long Professor Jacob M. Oncology and Associate Professor of Orthopaedic Surgery and Orthopaedic Surgery Neurological Surgery Vice Chairman. Jay Khanna. and Oncology The Johns Hopkins University School of Medicine Director of Translational Research for Advanced Baltimore. Oklahoma Chief of Radiology Services Joseph P. Maryland xv . Morgan Department of Radiology and Washington.

MBA Director Professor and Head Spine and Pain Medicine–Dixie Regional Medical Department of Pediatric Orthopaedics Center Johns Hopkins Bloomberg Children’s Hospital St.xviâ•…â•…Contributors Joseph R. MD. MD. FAAOS Uma Srikumaran. MD Brigham and Women’s Hospital Professor of Radiology Department of Anesthesiology and Pain Medicine Director of Diagnostic Neurovascular Imaging Harvard Medical School Russell H. Reeder. Massachusetts Rick W. George. Maryland€ Director of Imaging Proscan Imaging Columbia Monica D. MD Columbia. New York Johns Hopkins Community Physicians Baltimore. DC Harvard Medical School Boston. Sponseller. Maryland The Johns Hopkins University School of Medicine Baltimore. Zebala. DO The Johns Hopkins University School of Medicine Musculoskeletal Radiologist and Interventionalist Baltimore. Singla. DC Lukas P. Obray. Maryland Neuroradiologist American Radiology Daniel M. MD Interventional Pain Fellow Bruce A. Sciubba. MD Southwest Spine and Pain Center Paul D. BA Department of Neurosurgery Chad M. MPH Associate Professor of Orthopaedic Surgery and Physician and Partner Neurologial Surgery National Spine and Pain Centers George Washington University School of Medicine Bethesda. Maryland Progressive Radiology Washington. MD Howard County General Hospital (a Johns Hopkins Assistant Professor of Neurosurgery affiliate) Department of Oncology and Orthopaedic Surgery Columbia. MD. Maryland and Health Sciences Lecturer Washington. Okubadejo. Louis. MD. Zadnik. Louis St. Utah Baltimore. Morgan Department of Radiology and Boston. Silverberg. Maryland Gbolahan O. Missouri . O’Brien. Watkins. Massachusetts Radiological Sciences The Johns Hopkins University School of Medicine John D. MPH Aneesh K. FACR Baltimore. MD Spine Surgeon Assistant Professor of Orthopaedic Surgery The Institute for Comprehensive Spine Care Johns Hopkins Shoulder and Sports Medicine New York. Maryland Josemaria Paterno. Maryland Patricia L. Wasserman. MD Assistant Professor Department of Orthpaedic Surgery Washington University in St. MD.

Iâ•… Initial Considerations .

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and T2* C. However. nuclei with an odd total number IV. two decades and will likely continue to increase. Beall. Douglas P. When the total number of protons and B. Contrast-Enhanced Imaging neutrons is even.2 3 . Fat Suppression with T1-Weighted ties of the nucleus of an atom and its components. and TI ■⌀ Fundamentals of MRI II. John D. T2-Weighted SE and T2-Weighted Understanding how an MR image is generated re- FSE quires some knowledge of the basic physical proper- 3. and T2-Weighted that is.1. align parallel to the MRI is an essential tool in the accurate diagnosis and external magnetic field in one of two orientations: treatment of spine disease. T1. John A. gen. MRI Applications Magnetization of Nuclei and Tissues A.1–6 the Larmor Equation B.1 Essentials of MRI Physics and Pulse Sequences Shivani Ahlawat.1). neutrons and protons. 3D Gradient Echo generate a magnetic field called a magnetic dipole (Fig. The body also contains a lesser amount of ing how an MR image is generated. A A small excess of nuclei align in a spin-up orientation detailed understanding of the fundamentals of MRI (because it has slightly greater stability) and generate physics is not required to review images. Standard Sequences and the Larmor Equation 1. When placed in a magnetic field. their magnetic dipoles cancel each III. reader with a sufficient working knowledge of the odd-numbered nuclei that is the basis for the signal technology to enable the reader to acquire and in.2). be- cause of their magnetic moments. It is the manipulation within an external showing spine anatomy. Rick W. Artifacts other out. Fayad terpret high-quality images in a reasonable amount Chapter Outline of time.3). The number of MRI ap. Gradient Echo. neutrons. odd-numbered nuclei. basic working knowledge of certain key principles is Conveniently. Gradient Coils and Signal Localization D. TR. although a an overall small net magnetization vector (Fig.€1. All neutrons and pro- 4. which can be represented as a vector. and in fat. whose nucleus contains 9 protons and 10 what basic sequences are important for optimally neutrons. This chapter provides the reader with a basic un. This chapter is only a brief introduction to what most would consider a complex technology.€1. Carrino. by emphasiz. and Laura M. that ultimately generates an MR image. Magnetization of Nuclei and Tissues and more detailed explanations. Fig. the human body is replete with hydro- important for the accurate utilization of the technol. MRI Pulse Sequence and TE. Obray. and by describing fluorine. Reeder. Summary of protons and neutrons generate a net magnetic mo- ment. STIR tons within the nucleus spin about their axes and 5. spin-up (in the same direction as the field) or spin- plications has increased dramatically over the past down (in the opposite direction to the field. whose nucleus consists of one proton and no ogy. Fundamentals of MRI and the reader is referred to additional sources for A.€1. I. T1-Weighted SE 2. This hydrogen is most common in water derstanding of the physics behind MRI by addressing (which makes up the majority of the body’s mass) its specific applications for the spine. The intent is to provide the magnetic field of this small number of excess spin-up. T2.

1.1â•… Neutrons and protons within the nu- cleus spin about their axes and generate a direc- Fig.4 Iâ•… Initial Considerations Fig. The two smaller arrows depict the direction of the external magnetic field (M). the dipole is pointing upward. which in turn can be used to create an MR image.† . In states when placed in an external magnetic field: spin-up or spin- this illustration.† Fig. and it produces a net magnetization vector (large arrow) that can be manipulated to create an RF signal. 1. parallel to and aligned with the external magnetic field (large arrow) or parallel to and in an opposite direc- tion to the external magnetic field. The spin-up orientation (z) is a slightly more stable energy state. 1.2â•… Odd-numbered nuclei may exist in one of two energy tional magnetic field called a magnetic dipole.3â•… The slight excess of nuclei in the spin-up orientation is the result of the increased stability of the spin-up orientation relative to the spin-down orientation. that is.† down orientation.

this ternal magnetic field strength measured in tesla (T) signal can be optimized. for instance. Fig. and the Equation 1: transverse vector dissipates (Fig.€1. and ultimately units. with T1 being defined as the time constant representing 63% recovery of the equilibrium lon- gitudinal magnetization vector. a signal as it precesses around a receiver coil. the transverse mag- netization vector decays exponentially because of spin dephasing as the local magnetic fields of the individual nuclei interact with each other. that is.3 . they are precessing in synch with nuclei and the external magnetic field interact and one another. the ω0 is In summary. and T2* differ for individual tissues. that is.4â•… All nuclei.5).6). an RF signal can be generated and subsequently When an RF pulse (at the Larmor frequency for used to create an image. The T2* relaxation time represents the loss of the transverse magnetization vector due to both T2 effects and the spin dephasing caused by local magnetic field inhomogeneities. 1â•… Essentials of MRI Physics and Pulse Sequences 5 When spinning nuclei are exposed to an external cessing nuclei initially are also “in phase” with one magnetic field. when an RF pulse that is interacting with termined by the strength and duration of the RF pulse nuclei in an external magnetic field is turned off. tor.€1. The magnitude of the flip angle is de. whereas large molecules and solids gener- precession is related to the strength of the external magnetic ally have short T2 times. the precess- Larmor equation: ing nuclei relax. hydrogen at a given field strength) is applied within an external magnetic field. and it is key for form the longitudinal magnetization vector within a the localization of the MRI signal within space (see sample or tissue into a transverse magnetization vec- details below). This synchronized precession maxi- cause the nuclei to precess. and tissues with a short T1 include fats and interme- similarly to the way a spinning top standing on its point wob. they return to their original orientation. The return or recovery of external magnetic field. recorded. transverse and longitudinal magnetization vec- netization vector (parallel to the external magnetic tors take to relax and generate the MRI signal. and T2* tain angle (flip angle). The T1 relaxation time is also known as the longitudinal or spin–lattice relaxation time. whereas a 180-degree netic field. Once the RF pulse is turned off. T1.2 On the other hand. the longitudinal vector returns. The frequency of liquids. and γ is the gyromagnetic ratio measured in transformed into MR images by Fourier analysis. B0 is the ex. applied. T2. the pre. As one might expect. and T2 is also known as the transverse or spin–spin relax- ation time. This flipping process produces a transverse magnetization vector (perpendicular to The terms T1. This is known as T2 decay or T2 relaxation. As the nuclei ω0 = B 0 × γ relax. after the RF pulse is turned off. the T2* relaxation time is always shorter than the T2 relaxation time. precess (wob- ble) about their axes when placed in an external magnetic field. As would be expected. stated. T2. the longitudinal RF pulse aligns the magnetization vector in a plane magnetization vector returns to equilibrium value parallel to. aligns the precessing nuclei return to their original equi- the magnetization vector in a plane perpendicular librium state and realign with the external mag- to the external magnetic field. the before the RF pulse does.† usually is short for fat and water. the transverse magnetization vector produces where ω0 is the precessional frequency. the net magnetization vector flips from its longitudinal direction by a cer. the longitudinal magnetization is known as T1 re- covery. mizes the transverse magnetization vector (additive The frequency of precession can be described by the effect). the magnetic fields of the spinning another. After the RF pulse. in which T2 is defined as the time in which the transverse mag- netization vector has decayed by 63% of its maxi- mum. Conveniently.1 megahertz per tesla unit. T2. diate-size molecules. Therefore. The T2* relaxation time field as determined by the Larmor equation (ω0 = B0 × γ).2.€1. and T2* pertain to the times the the external magnetic field) and a longitudinal mag. 1. including hydrogen nuclei. but in a direction opposite to that of. A 90-degree RF pulse.4). or “wobble” (Fig. T1. by using an RF pulse to flip the ex- constant for every atom of a particular element at a cess spin-up hydrogen nuclei and ultimately trans- particular magnetic field strength. Tissues with a long T2 include bles under the influence of the gravity field. Tissues with a long T1 include water and large protein molecules. As field) (Fig.

external magnetic field). the external magnetic field. based on the strength and duration of the applied RF pulse. (b) The lon- gitudinal component of the magnetization vector decreases and the transverse component of the magnetization vector increases. that is. will flip the direction of the net magnetization vector 90 degrees relative to the external magnetic field. is called the flip angle. 1. (a) An external RF pulse administered at the Larmor frequency can flip the direction of the magnetization vector from the longitudinal to the transverse direction. The angle the net magnetization vector makes with the longitudinal axis. (c) A 90-degree RF pulse.6 Iâ•… Initial Considerations a b c Fig.5â•… Manipulation of the magnetization vector (EMF. for instance.† .

As previ. axial. respectively. main magnetic field and include section-selection In gradient-echo sequences. y. quences. As previously .€1. 1â•… Essentials of MRI Physics and Pulse Sequences 7 Fig. ously stated. and T2* directly image (i.g. T2.€1.1. y. z) in which each transverse magnetization signal (T2. typically the gradients are applied to mini- particular type of tissue (e. or yz plane. y.1 The deter- dinal magnetization signal (T1) and the decay of the mination of the direction (i. In conventional SE and gradient-echo sequences. which localize the signal in two or three MRI’s ability to resolve subtle differences in the T1. and frequen. coronal) and the structures affect the strength of the RF signal emitted from a involved. Several concepts in addition to those discussed above are important when interpreting an MRI pulse The transverse magnetization signal is localized sequence: TE. and z directions on the maximizes the recorded signal at readout (Fig. xz. and TI and pathology within the musculoskeletal system. T2. One might ques- The phase-encoding gradient causes a phase shift tion why it is necessary to refocus at all. within tissue via the use of gradient coils. “recall the echo” at TE and use a negative gradient cy-encoding gradients. and T2* A frequency-encoding gradient causes a frequency time constants related to the recovery of the longitu. such as fat and that enables localization of the signal by its phase. see below) within the patient that enables this tech- nique to produce images of such high spatial resolu- tion and to provide information about the anatomy MRI Pulse Sequence and TE.7).e. By al. 1. This technique field gradients in the x.2. it is possible to identify is at its maximum) (Fig. to a more stable energy state. Gradient coils superimpose small TE/2 to allow for spin rephasing at TE. T2*) after an RF gradient is applied depends on the orientation of the pulse. TR. with recovery of the longitudinal component and loss of the transverse component of the magneti- zation vector. whereas a voxel is a 3D unit. and T2* characteristics of various tissues and as. ing a unit of volume within the dataset/image. fat or water) at a given mize artifacts in the region of interest. A pixel is a 2D unit in the xy.5 time and ultimately can be converted to visual dif. the TE is the time from the initial RF pulse (used to cess at a particular frequency when subjected to an flip the longitudinal magnetization vector into the RF pulse. sagittal..1 focus the signal at readout (Fig. nuclei in an external magnetic field pre. An MRI pulse sequence is the sequence of RF pulses and magnetic field gradients used to generate an im- Gradient Coils and Signal Localization age.8). or return. dimensions.6â•… After the discontin- uation of an RF pulse. transverse plane/transverse magnetization vector) tering the external magnetic field and creating gradi. enabling localization by frequency. the net magnetization vector will re- lax. T2. as described by the Larmor equation. water. gradients are used to gradients. and z planes. In conventional SE se- the location of signal within tissue based on its emit. followed by a positive gradient (gradient echo) to re- selection) gradients select the section to be imaged. Data within the MR image are divided into pixels ferences in tissue contrast on the final image. and TI. TR. shift.e. These differences in T1.. a phase-encoding gradient is applied at ted RF and phase. represent- sign the differences to a discrete location (pixel/voxel.3 It is and voxels. to the center of the echo signal (time when signal ents in the x. x.† In summary.7). have reasonably well-defined T1. The strength of the transverse component of the magnetization vector is what is ultimately used to generate the MR image. individual tissues. phase-encoding gradients..1 Section-selection (or slice.€1.

.1–3 signal is at a maximum. TR primarily affects T1. the precessing nuclei.g. A long TE (>60€ ms) tive to a positive value (near zero). 1. that is. The bottom line depicts the dients also are shown.8 Iâ•… Initial Considerations Fig. and readout or frequency-encoding gra- encoding gradients are also shown. 1.2.7â•… In this example of a conventional SE pulse sequence. When all degrees) and a larger TE favor T2* weighting.8â•… In this example of a standard gradient-echo pulse the top line shows an RF pulse sequence consisting of a 90-degree sequence. The most ate TR (>1000 ms but <2000 ms) and a short TE common tissue that is suppressed is fat. A refocusing gradient (readout or fre- RF signal or “echo” recorded at TE. In gradient-echo sequences. flip angle (70 to 110 degrees) and a short TE favor ing (using a perfectly timed gradient echo) rephases. The 180-degree pulse is re. the recorded weighted image.”† described. degree pulse is used at TE/2 that generates an echo at herent differences in T1 and T2 among tissues on MRI TE. the transverse and a long TR (>2000€ ms) result in T2-weighted magnetization vector generated by the RF pulse from images on the T2 SE sequences (i. More specifically.. a phase-encoding gradient. a short TE (<30€ ms) and a short TR (<1000€ ms) applying a 90-degree pulse as the longitudinal vector result in T1-weighted images (T1 effects maximized of a certain tissue (e. and rephas. For example.2 attenuated inversion recovery. T1 and T2 relaxation properties are . T2 effects maxi. the transverse magnetization degrades be. and a readout or frequency. when creating an MR image is known as intermedi- cause of dephasing effects on time scales represented ate weighting. a phase- gradients.1. Section-selection gradients. TE primarily affects T2 in TI is the time to inversion used in inversion re- conventional SE sequences and T2* in gradient-echo covery MRI pulse sequences. quency selection gradient sequence).5 which es- mized and T1 effects minimized).1–3 the density of the protons within that tissue on In summary. in conventional SE sequenc. encoding gradient. such as STIR and fluid- sequences. A larger transverse magnetization vector/signal.† produces an echo at TE.e. Why use a sequences. TR is the time interval between the initial RF it represents the time interval between the initial pulse of the basic pulse sequence and the subsequent 180-degree pulse used to invert the longitudinal repetition of the initial RF pulse.1 In conventional SE magnetization vector and the subsequent 90-degree sequences.e. 180-degree pulse followed by a 90-degree pulse? By es. and STIR se- (<30€ms) minimize differences in T1 and T2 within quences are commonly used in musculoskeletal radi- tissues and result in an image based primarily on ology for this purpose. A second 180- TE and TR can be manipulated to visualize the in. that type of tissue is very small or zero. TE. it is important to note that occa- conventional SE sequences. TR varies quantitatively by T2 and T2*. the top line shows the RF pulse resulting in a pre- pulse followed by a 180-degree refocusing pulse. tion vector into the transverse plane. sponsible for the echo at a specific time. A low the nuclei are in phase. whereas a smaller flip angle (5 to 20 or resynchronizes. hence the name “gradient echo. and TE. TR. Fig. the differences in T1 and T2 effects within tissue T2. sentially nulls the signal from that tissue. at which time the signal is recorded. or the recovery of pulse used to convert the longitudinal magnetiza- the longitudinal magnetization vector. This minimalization of sionally there is confusion regarding the terms T1. T1 weighting.1. which refocuses signal. or precessing in synch (i. water) crosses from a nega- and T2 effects minimized). flip angle and a short TE result in an intermediate- vectors pointing in the same direction).. An intermedi. Dephasing weakens the and is related to the flip angle and the TE. Section-selection determined flip angle.

Fast-flowing blood may gen- • Postgadolinium T1-weighted image erate a flow void and appear dark on T1-weighted Various other proprietary terms and acronyms sequences. T1-weighted images.€1.. edema. cesses and fractures). the brighter the fluid appears on combination of pulse sequences is used in a stan. such as conventional radiography methemoglobin). ages (Figs. and substances • T2-weighted image that do not have mobile protons. are also useful in showing within tissue and therefore the MR image generated musculoskeletal anatomy. such as STIR or fat- bone or other calcified structures (e. T2* gradient-echo sequences. perceptible visually.1). T2 often alter the intrinsic properties of the affected tis. its relative brightness or darkness. Each MR pulse sequence has its own enous tissue and fat.€1.11). such as abscesses. 1â•… Essentials of MRI Physics and Pulse Sequences 9 characteristics of a given tissue and are intrinsic to spine anatomy. although it is inferior to that of intermediate- is the reason that MRI is helpful in the detection of weighted and T1-weighted sequences. differences in T1. and T2* effects omy. the appearance of biologic tissue with MRI. pathology. Tissues with rameters of the MR pulse sequence used to acquire mixed characteristics (with some fluid and some the images. fat-suppressed T1-weighted imaging Conventional SE (and FSE) sequences make up after gadolinium contrast administration represents the bulk of sequences in the MRI assessment of the sequence of choice because the high signal from . T1-weighted images. but they are used within tissue. Conversely. T2-weighted sequences from that tissue. or infection. provide tissue and may be modified by the radiologist. it is possi. Standard Sequences T1-Weighted SE Standard MRI pulse sequences used in spine imaging include T1-weighted. each specific MRI sequence has some optimal and some less than optimal characteristics ■⌀ MRI Applications (Table 1. as such. mostly because of a lack of refocusing of (such as FLASH. or tumors). melanin. tering the TE and TR in a pulse sequence. therefore. or FLAIR). (250 to 700 ms) and a short TE (10 to 25 ms) to max- ing techniques. and simple cysts. bone-marrow as it relates to the “standard” pulse sequences used for abnormalities (including marrow-infiltrating pro- most musculoskeletal MRI has been simplified by us. have been but not by the 180-degree pulse. For the assessment of tumors dard examination. are extrinsic to the highest signal-to-noise ratio and.g. GRASS.10). calcific ten- suppressed T2-weighted image dinitis). such as cortical • Fluid-sensitive sequence.g. such as CSF. depending on the and complex cysts. reactive that is. and cer- In contrast to imaging techniques based on X. For the purposes of this text. or collagenous tissue). blood products. and typically a content of the fluid. the nomenclature The ability to depict anatomic detail. such as air. and STIR-weighted Standard T1-weighted SE sequences use a short TR sequences. tain blood products (intracellular and extracellular ray absorption. Fluid-sensitive sequences include T2. fat-suppressed T2-weighted. in fact. and ing the following terms: enhancement after the administration of gadolini- um are the strengths of T1-weighted SE sequences. Thus. Intermediate-weighted sequences that tissue.3 • T1-weighted image Proton-poor substances. primarily for their fluid sensitivity and their ability to create an image that allows these differences to be to detect pathology that has a high fluid content (e. By al. show low signal on stan- mined to a great extent by the operator-chosen pa. is deter. Usually. and T2*. produce no detectable signal and produce • Gradient-echo image a relative signal void. such as fat. dard T1-weighted sequences (Fig. tend to have the poorest signal-to-noise ratio. bone-marrow edema. and contrast-enhanced imaging tech. which provide nearly as high ble to manipulate the visually perceived differences a signal-to-noise ratio. Depending on the clinical situation. The fact that disease processes ligament tears. better resolution than T2-weighted FSE images do. T2-weighted. appear bright on T1-weighted im- and CT. and STIR sequences. 3D imag. synovium. T2. CSF may appear bright.1 niques. which is excited by the 90-degree pulse primarily in the radiologic literature. and signed to take advantage of the intrinsic differences therefore the poorest resolution. T2. the higher the protein specific strengths and weaknesses. melanin.. MR pulse sequences are. tend to show intermediate signal MR pulse sequence and the selective parameters in intensity that is somewhere between that of collag- that sequence. that is.9 and 1. fatty bone marrow. intermediate in signal intensity. Fluids. de. Other tissues. avoided. imize T1 differences of the tissues being imaged. dark. TR and TE are parameters of are useful because they produce images with the the pulse sequence and. sequences can also give a rough depiction of anat- sue and subsequently alter the T1. commonly used the blood.

J Bone Joint Surg Am 2001.1â•… Basic pulse sequences for MRI Image Type TR TE Signal Intensity Advantages Disadvantages Fat Water T1 Short Short High Low Best anatomic detail. Poor visualization of rapid acquisition pathology/edema T2 Long Long Intermediate High Moderately sensitive Poor spatial resolution. part 2):128–141.9â•… Sagittal T1-weighted images of vertebral marrow in the thoracic spine. brighter than the adjacent intervertebral disc). Magnetic resonance imaging of the knee: current techniques and spectrum of disease. which is seen as a mixture of fatty marrow (which appears as bright signal) and red marrow (which appears as intermediate signal. (a) This image shows normal bone marrow. Long Short Intermediate/high Intermediate Excellent for evaluation weighted of meniscal pathology Source: From Khanna AJ. et al. Mont MA.83A(suppl 2. a b Fig. (b) This image from a different patient (with metastatic breast cancer) shows vertebral bodies that are diffusely dark (hypointense) because of marrow replacement (abnormal bone marrow).10 Iâ•… Initial Considerations Table 1. Adapted with permission. . for pathology/edema time-consuming Fat-suppressed Long Short Very low Very high Most sensitive for Susceptible to artifacts T2 pathology/edema related to magnetic field inhomogeneity Gradient echo Short Short Intermediate Intermediate/high Excellent for evaluation Very susceptible to of articular cartilage. metallic artifacts PVNS. Cosgarea AJ. and blood (prostheses) Intermediate. 1.

1â•… Essentials of MRI Physics and Pulse Sequences 11 a b c Fig. Its major weakness is the relatively lower with pathologic processes such as tumors. sensitivity for detecting soft-tissue edema compared fractures.12). Both sequences. when combined with An additional strength of T1-weighted imaging re. blends in with the CSF on the T2-weighted image. and (c) STIR images show advanced lumbar epidural lipoma- tosis extending from L4 to the sacrum with circumferential compression of the thecal sac. which appears bright and is often associated cesses. 1. (b) T2-weighted. Short scan times (because of the relatively short TRs) and excellent spatial T2-weighted SE and FSE sequences use a relatively resolution and depiction of anatomic detail are the long TE and long TR to maximize the T2 differences major advantages of a T1-weighted pulse sequence. Note that the lipomatous tissue is most obvious on the T1-weighted image. Sagittal (a) T1-weighted.3 evaluating ligaments and fluid-filled structures such . are excellent for detecting edema/ mains its ability to show marrow replacement pro.€1. making enhancement of abnormal T2-Weighted SE and T2-Weighted FSE tissue more conspicuous. and ligamentous injury (Fig. infection.10â•… Lumbar epidural lipomatosis. fluid. fat suppression. The with fluid-sensitive sequences such as fat-suppressed T2-weighted SE and FSE sequences are also good for T2-weighted and STIR sequences.† fat is suppressed. (d) An axial T1-weighted image at the L4-L5 level shows severe compression of the thecal sac by the d extensive lumbar epidural lipomatosis. and suppresses (becomes dark) on the STIR image. in the tissues.

linear region of in- Fig.8 One of the limitations of standard T2-weighted The major weakness of T2-weighted SE and SE sequences is the relatively long image acquisition T2-weighted FSE sequences is their inability to de- times. that permits much more rapid imaging by using T2 cal bone. representing desiccation. of echoes is called the echo train. 1.12â•… A sagittal T2-weighted image of the lumbar spine shows loss of normal bright signal at the L4-L5 intervertebral disc. replaced standard T2-weighted SE sequences. Because of their fast acquisi- been shown to be useful for differentiating between tion times.1. Hyperacute multiple echoes during a single TR period. A focal. T2-weighted FSE sequences have largely fluid and tissue with a high fluid content. 1. calcified structures. represents a high-intensity zone or an annular fissure (arrow).12 Iâ•… Initial Considerations Fig. FSE imaging represents a technical innovation tect marrow pathology when not combined with . corti. These sequences also have the echo train length. air. and the number of cellular methemoglobin) are bright on T2-weighted echoes produced in a single TR period is known as SE and FSE sequences. The series blood (oxyhemoglobin) and subacute blood (extra. as cysts. and fast-flowing blood contrast7 and multiple 180-degree RF pulses to create appear dark on T2-weighted sequences. As on T1-weighted SE sequences.11â•… Note the dark (hypointense) CSF on this sagittal creased T2-weighted signal at the posterior aspect of the disc T1-weighted image.

STIR sequences air.3 This effect is most prominent with 20 degrees) and a large TE favor T2* weighting. Because of this phase- refocusing inversion pulse. gradient-echo sequences field inhomogeneities seen with fat-suppression are very sensitive for the detection of certain types techniques (see the following section). pathology when the trabecular bone is not destroyed fluid appears bright and makes the edema and flu.14). and blood products. On fluid-sensitive images such as STIR. such as in the shoulder flip angle and a short TE result in an intermediate- and ankle. due large flip angle (70 to 110 degrees) and a short TE to local magnetic field inhomogeneities and suscep. the hyperintense intraosse. or of any body part in the presence of weighted image. however.3 mors. favor T1 weighting. gradient-echo and edema when administered with a long TE.g. STIR images also tend to overestimate the size or promi- can be used as an alternative to T2-weighted imaging nence of osteophytes within the spine and marrow (Fig. STIR sequences are less Fat suppression commonly is achieved by spectral susceptible to magnetic field inhomogeneities and fat suppression or a STIR technique. Unlike T1-weighted and T2-weighted fat-suppressed sequences. This limitation is due sequences (Fig. as just mentioned. These inhomogeneities can be created by blood. Similarly. Combined with T2-weighted characteristics similar to those of fat. which often result suppression imaging is restricted to MRI systems in inhomogeneous fat suppression on SE and FSE se- with midlevel and high magnetic field strength quences. STIR uses a 180-degree RF inversion Fat Suppression with T1-Weighted pulse.15). certain types of hem- contusion and microtrabecular fractures appears orrhage. cervical and thoracic MR imaging. Additionally. The STIR FSE technique has been shown to because of the necessity of identifying distinct fat be superior to the fat-suppressed FSE technique for and water resonance peaks and selectively sup. which produce magnetic field inhomogeneity. scribed above. and proteinaceous fluid) will also particularly conspicuous in contrast to the adjacent have its signal suppressed. focal air collections. Gradient Echo. quired for non-fat-suppressed MRI. conspicuous than they are on non-fluid-sensitive depending on what tissue is being evaluated. like T2-weighted sequences by that instrumentation. melanin. ligament tears. 1╅ Essentials of MRI Physics and Pulse Sequences 13 fat-suppression techniques.g.13). Such pathology includes os- to fat and water both being bright on non-fat. abscesses. hemorrhage As indicated above. metal or air.3 Gradient-echo sequences may be T2*- id associated with certain types of pathology more weighted. fat suppression can en- able the differentiation of fat-containing masses (e.10 One of the major pressing the signal arising from adipose tissue. followed by a 90-degree RF pulse after TI to and T2-Weighted Images nullify the signal from fat. the TR One of the disadvantages of T2 and T1 sequences varies and is related to the flip angle and the TE.. gradient-echo MRI pulse se- within tissue).3 suppressed normal marrow fat signal. gradient to refocus the signal at readout. STIR or intermediate-weighted imaging. such as calcification.9 Spectral fat. is that it process that depends on the presence of a relatively suppresses the signal from all tissue with T1 signal strong magnetic field. Because of the suscepti- with fat suppression. Spe- the presence of fat within a lesion and to increase cifically.€1. As de- enhanced T1-weighted images. primary bone tu- suppressed T2-weighted FSE and SE sequences. teomyelitis. Additionally.. A low images of curved surfaces. A is incomplete suppression of the signal from fat. .€1. metastases. fat sup. and thus all tissue ous fluid that accumulates secondary to osseous with the same TI as fat (e. fractures. whereas a small flip angle (5 to tibility effects. (Fig. it can be used to verify quences use gradients to recall the echo at TE. of tissue. subsequent susceptibility effects. ties similar to those of fat tissue. in gradient-echo sequences. Gradient-echo sequences are more sensitive than pression requires higher-strength magnets (>1 T) to SE sequences to local magnetic field inhomogene- ensure proper fat suppression than is generally re. or calcium within tissue or can be intrinsic to the often are used to overcome the effects of magnetic MRI unit itself. Therefore.€1. and bone contusions. a negative gradient is followed by a positive the conspicuity of enhancing masses on contrast.. gradient-echo sequences STIR of tissue that contains surgical instrumentation (metal) tend to produce substantial artifact due to STIR is another MRI pulse sequence commonly used the disturbance in the local magnetic field created in spine imaging and. As a result.g. this technique pulse sequences should not be used with gadolinium is particularly useful in detecting bone bruises and contrast because gadolinium has relaxation proper- osseous stress injury. T1-weighted. 3D Gradient Echo lipoma/liposarcoma) from other tissue that may con- tain elements of increased signal (e. a weaknesses of the STIR sequence. or intermediate-weighted. ities. On T1-weighted images. is excellent for detecting fluid bility effects of the trabecular bone.

16) useful at low field strengths.11: sitions) have a higher signal-to-noise ratio because • Solid from cystic lesions an entire volume of tissue is sampled rather than a • Soft-tissue phlegmon from inflammation from single thin section. 1.14 Iâ•… Initial Considerations a b Fig. and can be oriented in brain barrier also show enhancement. ■⌀ Artifacts Contrast-Enhanced Imaging Common artifacts seen in MRI include motion arti- facts. spinal lesions and differentiation of the following3. truncation artifacts. yz. in the xy. creased vascularity generally show enhancement on tire volume of tissue (i. This optimal signal-to-noise ratio abscess makes the 3D acquisition pulse sequences especially • Surgical scars from disc fragments (Fig. 3D sequences (also known as volume acqui. especially through the cervical spinal canal. or nearly so. In 3D gradient-echo sequences. In for intravenous contrast include the evaluation of general. (a) A T2-weighted image of the cervical spine with frequency-selective fat suppression shows heterogeneous signal. signal from an en. Patient venous imaging is analogous to that of the iodinated motion results in misregistration of the MR signal and contrast agent used in CT. Specific uses any way that is helpful for interpreting the dataset. Gadolinium is commonly used as an intravenous Motion artifacts in MRI are common and are direct- contrast agent in spine imaging. This volume of tissue techniques are commonly used with gadolinium be- then may be partitioned into sections in any plane. and xz planes) postcontrast T1-weighted images.5 The major disadvan- tages of 3D gradient-echo pulse sequences are the relatively long acquisition times and the tendency toward susceptibility and motion artifacts. 1. (b) A sagit- tal STIR image through the lumbar spine shows homogeneous fat signal because it is an inversion recovery sequence rather than a frequency-selective method of suppression. and susceptibility effects. subsequent blurring of the MR image. ly related to patient motion within the scanner.11 These sections obtained from the 3D volume dataset Areas in which there is breakdown of the blood– may be isotropic.e. Motion from the . due to failure of fat suppression. Fat-suppression is acquired at the same time. Its function in intra.13â•… Comparison of fluid-sensitive techniques. cause of their sensitivity to detecting gadolinium.. and tissues that show in.

and briefly important for the optimal use of MRI technology.€1. are the result of local field in. image (different patient) shows a prominent right paracentral Truncation artifacts occur in MRI and are related disc protrusion (arrow). air. or blood products within the tis. calcium.15â•… Cervical spine imaging.12 Truncation artifacts that can be seen include ring artifacts. interface edge enhancement. These magnetic field anatomic assessment. This type of artifact foraminal stenosis (arrow). to the way the MR signal is processed during image creation and. these phenomena are due to the produces partial reproductions of the pulsating vessel presence of susceptibility artifact. which is compatible with a chronic fracture. can localize the tissue of interest.17). to the Fourier transfor- mation method used to process the MR signal data. sues being imaged. ed magnetic field. (b) An axial gradient-echo in the phase-encoding direction. which is of paramount impor- inhomogeneities can be related to the magnet or to tance. Note the diffuse edema in the vertebral body.3. This imaging modality is well suited for evaluating homogeneities within the scan field that create areas spine abnormalities because it provides an accurate of focal signal loss (Fig. ■⌀ Summary and distortion of adjacent tissues at parallel high- contrast interfaces.† b Fig. 1â•… Essentials of MRI Physics and Pulse Sequences 15 a Fig. in particular.14â•… A sagittal STIR image shows a linear region of increased signal intensity compatible with edema in the L2 vertebral body (arrow).12 A fundamental knowledge base of MRI physics is Susceptibility artifacts seen in MRI. which could be mistaken for diffuse bone-marrow involvement by a neoplastic process. but it also exaggerates the degree of tion artifact or pulsation artifact. (a) An axial gradient-echo image shows the posterior osteophyte to a better advantage pulsation of arteries results in a particular type of mo. note the high-intensity disc herniation compared with the low signal of the osteophyte in part a. which is compatible with an acute fracture. 1. discussed previously.5 and the signal produced can be Fourier-transformed . artificial edge widening at parallel high- contrast interfaces. There is no increase in signal intensity in the L4 vertebral body (arrowhead). appropriately applied within a grad- metal. 1. than SE imaging does. RF pulses.

and TI. and gradient images provide the highest signal-to-noise ratio echo) has its own strengths and weaknesses. The a combination of various sequences is typical for primary disadvantage of intermediate-weighted the evaluation of the joints and spine. In contradistinction. and wheth. sion. T1-weighted sequences is the lack of pure contrast compared images are optimal for showing anatomic detail with that of T1-weighted and T2-weighted images. 1. and T2* relaxation time constants of the spe. and they Gradient-echo sequences are useful for identifying . T1. and these values determine the associated with an increased fluid content. T2. the strength of the signal. Intermediate-weighted culoskeletal imaging (SE. for showing abnormal contrast enhancement. STIR.16 Iâ•… Initial Considerations a b c d Fig. (c) axial noncontrast and (d) post- contrast fat-suppressed T1-weighted images show a left paracentral abnormality with thin peripheral enhancement (arrow on both) consistent with a recurrent disc herniation. showing soft-tissue edema. or intermediate as trauma and tumors.16â•… (a) Axial. T2-weighted images are The primary pulse sequence parameters in MRI excellent for detecting edema/fluid and processes are TE. consistent with epidural fibrosis. articular cartilage evaluation but are relatively in- er a certain type of tissue (e. fat) is suppressed. fat-suppression technique.g. and and are excellent for showing anatomic detail.g. FSE. and bone/bone-marrow abnormalities. cific tissue but also by the parameters that are used to Conversely. into an image. T1-weighted images are not optimal for assess the region of interest. noncontrast and (b) postcontrast fat-suppressed T1-weighted images show a left paracentral abnormality with homogeneous delayed enhancement. This image is defined not only by the are excellent.. when combined with fat suppres- T1. TR. such weighting of the image (e. T2. They also may be useful for weighting).. sensitive to marrow fluid unless combined with a Each of the standard pulse sequences used in mus.

enables the imager to adjust the scanning techniques and image protocols to obtain the highest- quality images possible. Gradient-echo sequences are very sensitive mogeneity. frequency-selective when it obscures the tissue of interest. In the presence of metal. 3D gradient-echo sequences can be ob- for the detection of certain types of tissue. and as a volume of tissue. 1╅ Essentials of MRI Physics and Pulse Sequences 17 the gadolinium).╇STIR quency-specific fat suppression (because inversion D. the susceptibility artifact is exagger. along with how these elements interact. Which sequence is best used for distinguish- Frequency-specific suppression is useful but may be ing recurrent disc herniation from epidural affected by magnetic field heterogeneity.╇ Contrast-enhanced T1-weighted image ated on gradient-echo images compared with SE images. most often with fre- C. True or false? time. Intravenous injections also may be used for indirect arthrography. focal air collections. Common Clinical Questions 1. True or false? suppression or by inversion recovery techniques. D.╇ T2-weighted image tive cervical spine shows marked susceptibility artifact around C. that produce magnetic field 3D gradient-echo imaging is the long acquisition inhomogeneity. Epidural lipomatosis is seen as bright signal on T1-weighted images and on T2-weighted images without fat suppression. 2. The primary disadvantage of blood products. tained in one sequence and examined in any plane such as calcification. B.╇STIR the lateral mass screws. Fat suppres. 5. the same susceptibility to magnetic field inho- mogeneity that may be useful is also a disadvantage 4. This optimization is impor- tant in all subspecialty imaging but is especially so in musculoskeletal imaging. Which sequence is best used for assessment of marrow replacement process in the spine? A. A clear understanding of the ba- sic elements of MRI. although direct injection of gadolinium may often be necessary to achieve optimal joint distension and visualization of the appropriate anatomy. It is frequently said that MRI is a compromise and that no gain in image quality is obtained with- out sacrificing some other portion of the sequence or the examination.╇ T1-weighted image Fig.17╅ An axial gradient-echo image through a postopera. fat-suppression techniques should be used sion may be accomplished by frequency-specific instead of STIR techniques.╇ T2-weighted image um is used as a contrast agent. 1.╇ Postcontrast T1-weighted image recovery techniques may suppress the signal from . True or false? blood products or metal that causes magnetic inho- 3. where elucidating the anatomy is fundamental to analyzing the structure for the presence of pathology.╇ T1-weighted image suppresses tissue with the same TI as fat. Gadolini- B. Inversion fibrosis in the postoperative spine? recovery fat suppression is homogeneous but also A.

and post- contrast T1-weighted images enables the dif- ferentiation of recurrent disc herniation from epidural fibrosis in the postoperative spine. 2003 used for the assessment of marrow replace- ╇3. types of tissue. Magnetic Resonance Imag. and the postopera- ╇6. Failure of fat suppression is promi- nent in the presence of metal or air. Anderson MW. MD: with most pathology. . which 12. 2005 ation of infection. Review of Radiologic Physics.26(2):513–537 PubMed 1. STIR sequences are less suscep- tible to magnetic field inhomogeneities. Fat suppression in MR imaging: techniques Explanation: One of the disadvantages of and pitfalls. Hannafin JA. Philadelphia.161(6):1147–1157 PubMed sequences. such as calcification and blood Magnetic resonance imaging of articular cartilage in the products. Ed. Wilson AJ. Fisher DJ. On the T1- NM. Johnson G. Czervionke LF. Because of this phase-refocusing inver- sion pulse. Dussault R. bright. AJR Am J Roentgenol Explanation: Gradient-echo sequences are 1996. Allen AA. whereas a marrow-replacing process. including nonmalignant Lippincott Williams & Wilkins. 2001:1–21 such as metastasis. Czervionke JM. Fast scanning and fat-suppression MR im. Musculoskeletal MRI. STIR uses a 180-degree RF inversion pulse before the 90-degree RF pulse to null the signal from fat.19(2):373–382 PubMed frequency-selective fat-suppression sequenc- 11. Stoller DW. Cotten A. Technical advances in musculoskele. A ╇2. Beltran J. Major ment processes in the spine. Anderson MW. The Physics of Clinical MR Taught through Images. Explanation: Epidural lipomatosis follows aging of musculoskeletal disorders. 1988 2. et al.80(9):1276–1284 PubMed fact generated by ferromagnetic substances. Magnetic Resonance Imaging in Ortho. because of the susceptibility arti- knee. Runge VM. NY: Thieme. Faulkner WH Jr. Potter HG. Leung G. sequences. tumors. Helms CA. PA: WB Saunders. the marrow fat remains PA. T1-weighted images are useful for the evalu- New York. Unlike T2-weighted fat-suppressed sequences. D Explanation: Comparison of pre. Wehrli FW.151(6):1219–1228 PubMed precess. ╇4. Haas SB. Marchandise 4. True a conventional spin-echo sequence. Schmeets SH. Kneeland JB. NY: VCH Publishers. Hunter JC.18 Iâ•… Initial Considerations References Answers to Common Clinical ╇1. Desai well as malignancies. In: Kaplan weighted images. Methodology. netic Resonance Imaging: Principles. Biomedical Mag. Huda W. PA: Lippincott Williams & Wilkins. Shaw D. Mirowitz SA. son SD. Dussault R. Bitar R. Lejay H. Basic principles of musculoskeletal MRI. 5. more sensitive to the edema that is seen ing in Orthopaedics and Sports Medicine.167(5):1223–1227 PubMed very sensitive in the detection of certain ╇9. Baltimore. eds. Characteristic features of MR truncation artifacts. ed. False X. 2007:1–28 processes such as fracture and infection as ╇5. es is incomplete suppression of the signal paedics and Sports Medicine. tive spine. Delfaut EM. Haughton VM. True ╇7. Daniels DL. Helms CA. Philadelphia. Radio- graphics 2006. Holland BA. MR pulse sequences: what Questions every radiologist wants to know but is afraid to ask. New York. Perng R. Usefulness of turbo spin-echo MR imag- ing in the evaluation of meniscal tears: comparison with 3. An evaluation with use of fast-spin-echo imaging. In: Stoller DW. Philadel. J Bone Joint Surg Am 1998. including fat-suppression pulse ╇8. AJR Am J Roentgenol the signal of subcutaneous fat on all pulse 1993. Linklater JM. PA: Lippincott William & Wilkins. and Applications. Nitz WR. AJR Am alter the frequency at which protons in fat J Roentgenol 1988. Slone RM. Explanation: T1-weighted images are best phia. 2007 from fat because of local magnetic field inho- mogeneities and susceptibility effects. T2-weighted images and STIR images are tal imaging. Rousseau J. Radiographics 1999. Escobedo EM. Contrast-enhanced NK. has low signal intensity. Zink-Brody GC. Eds. 10. Kaplan PA. Harri. Major NM.

Thoracic Spine ary ossification centers. which develops by the seventh or eighth week. General Spine Anatomy standing of the relevant pathologic conditions and A. The figures and line draw. Spinal Cord F. There are three A. The fibrous joints include the ings serve to highlight the structures with which ligamentum flavum. it is essential to have a basic understanding The intervertebral discs represent fibrocartilagi- of its normal anatomy and appearance under MRI. Epidural Space pathologic conditions. Vascular Structures and articulations that provides a flexible support J. The spine (C2 through the sacrum) includes three different types V. the sacrum. The spinal column also serves as protection II. Axial MRI cervical vertebrae. Axial MRI ops by the eighth week of life. The facet joints This chapter provides an overview of the normal MRI are synovial joints between the superior and inferior appearance of the spine. Facet Joints The spinal column is a series of vertebrae. Jay Khanna before interpreting an imaging examination of the Chapter Outline spine. Sagittal MRI sification center for the vertebral body. Coronal MRI center for each vertebral arch. 5 lumbar D. D. CSF E. B. John A.2 Normal Spine MRI Anatomy Swati Deshmukh. 12 thoracic vertebrae. Intervertebral Discs regional anatomic alterations that represent various C. J. Vertebral Bodies facilitate recognition and differentiation of the subtle B. and su- the spine specialist or radiologist should be familiar praspinous ligaments. interspinous ligaments. Fully understanding the normal MRI appear- ance of the spine will enhance the clinician’s under- I. Cervical Spine for the spinal cord and nerve roots. Dana Dunleavy. Roots and Foramina H. and the coccyx. Sagittal MRI The spinal column is typically composed of 7 C. There are multiple second- III. and pelvis. I. abdomen. nous symphyses between vertebrae. and one ossification D. thorax. ligaments. Anatomy adolescence. Anatomy primary ossification centers of the vertebrae: one os- B. Carrino. and A. 19 . Ligaments ■⌀ General Spine Anatomy G. articular processes. Coronal MRI vertebrae. Lumbar Spine longitudinal growth pattern during childhood and A. Muscles structure for the cranium. The spinal column shows a IV. which devel- C. Sacrum and Coccyx of joints: • Intervertebral discs • Facet joints (zygapophyseal joints) • Fibrous joints To evaluate an MRI examination of the spine ef- fectively.

20 Iâ•… Initial Considerations Vertebral Bodies that form the strongest bond between adjacent ver- tebrae.€2.€2. outer annulus appears hypointense on T2-weighted ner of the vertebral body. Fat-suppression techniques can be used to ful for accentuating fluid and edema. ages and hypointense on T1-weighted images.€2. In the cervical spine. The posterior shows a normal variant limbus vertebra.€2. is indistinguishable from the hy- has no vertebral body and the axis (C2) has an odon. Special attention the evaluation of neoplastic and infiltrative processes. sequestration.4).6). .1 A Schmorl node results from protrusion of the cartilage of in- tervertebral discs through the vertebral end plate and into the adjacent vertebra (Fig. The common location is within the anterior superior cor.€2. whereas the atlas (C1) type-II collagen. the intervertebral discs show interme- vertebra is a defect within a vertebral body caused diate signal intensity on T1-weighted images and by intraosseous disc herniation (Fig. or infection. the signal basivertebral veins is seen at the midportion of the intensity of the nucleus pulposus decreases on T2- posterior vertebral bodies. perintense nucleus pulposus. In the lumbar spine. are use- (Fig. The spinal and radicular weighted images.5). The entry site of the the disc degenerates and as patients age. appears hyperintense on T2-weighted im- longitudinal ligaments. yond the end plate. Additional pulse sequences.3). and straight or convex at L4-L5 and L5-S1. the annulus fibrosus is much thicker anteriorly with a crescentic mass of collagen. which is com- The subaxial cervical vertebral bodies all have a posed of fibrocartilage and a high proportion of similar appearance (Fig. Intervertebral discs are present between each of the The end plate is a flat.1â•… A sagittal T1-weighted image of the lumbar spine increases inferiorly except at L5-S1. most commonly within the anterior superior corner of terior margin should project no more than 1 mm be- the vertebral body. The anterior and posterior collagen. or other Intervertebral Discs pathology that may be contributing to central canal or neural foraminal stenosis. The superior and inferior • Annulus fibrosus end plates should be intact and parallel to one an.1 As ies. tumors. the nucleus pulposus. osseous disc with a slightly vertebral bodies from the axis to the sacrum. The pos- niation. whereas the inner annulus. T1-weighted images provide optimal evaluation of anatomy. The annulus is composed of type-I collagen fi- bers (Sharpey fibers) that are attached to the ring apophysis periosteum. disc height gradually Fig. A limbus vertebra is a margin is concave in the upper lumbosacral spine defect within a vertebral body caused by intraosseous disc her. and the structure becomes dark arteries course around the cord’s anterior. • Nucleus pulposus other in the absence of vertebral compression frac- tures. poste. T1- weighted images also clearly delineate the relation- ships of the vertebral bodies. intervertebral discs. Compared with nor- toid process. The most high signal intensity on T2-weighted images. and other osseous detail. • Cartilaginous end plate ent in the thoracic spine. 2. on all pulse sequences.1). seen along the vertebral bod.€2. They elevated rim secondary to the attached ring apophy- are immensely strong fibrocartilaginous structures sis. which produces a central depression in the end plate that is occupied by hyaline cartilage. extrusion. Each of the lumbar vertebral bodies also mal vertebral marrow. and normal kyphosis should be pres. and posterior elements. The normal discovertebral complex has three Normal lordosis should be seen in the cervical and components: lumbar spine. The annulus also blends with the anterior and posterior longitudinal ligaments. have low signal intensity. which has a similar appearance (Fig.2 The annulus fibrosus is essentially deficient postero- laterally. rior. other fractures. as do the thoracic is composed of a proteoglycan matrix and type-II vertebral bodies (Fig. and lateral aspects within the vertebral canal such as fat-suppressed T2-weighted images. which may nullify marrow signal and increase the sensitivity in help in delineating spine pathology.2). should be given to the posterior aspect of the disc on sagittal and axial T2-weighted images to evaluate for disc protrusion. central canal. fracture lines. A limbus Overall. images.

2.2â•… Artist’s sketches of the cervical vertebral bodies: (a) lateral vertebral bodies from C1-T1. (b) AP vertebral bodies from C4-C7. (c) axial vertebral body at C4. (d) lateral vertebral body at C7. 2â•… Normal Spine MRI Anatomy 21 Vertebral body Uncovertebral joint Superior articular process C1 Spinous process Vertebral Transverse body C2 foramen Inferior articular Transverse process foramen b Vertebral body (C4) Superior articular process Uncovertebral Pedicle joint Inferior articular C7 process Lamina Spinous process c a Vertebral body (C7) T1 Transverse foramen Pedicle Transverse process Superior articular Transverse foramen process Spinous process Inferior articular Lamina process Spinous process e Lamina Inferior articular d process Fig.† . and (e) axial vertebral body at C7.

and (d) lateral views.3â•… Artist’s sketches of the L3 and L4 lumbar vertebral bodies: (a) posterior.† . (b) anterior. (c) axial.22 Iâ•… Initial Considerations Superior articular process Mamillary process Transverse process Superior articular process Vertebral body b Transverse Superior process articular process Transverse process a Spinous process Superior Vertebral body Pedicle articular process Lamina Pedicle Mamillary process Inferior articular Spinous process process d Transverse process Mamillary process Lamina Superior articular process Spinous process c Fig. 2.

and (d) lateral views. Rib Mammilary Lamina process T6 Superior articular Spinous process process a T7 Pedicle Superior articular process Costovertebral Transverse ligs. 2. Costovertebral joint Ring apophysis Pedicle Transverse process Accessory Transverse process T5 Costotransverse process lig. Superior articular Accessory process process Spinous process Inferior articular process Costotransverse Lamina d lig. c Spinous process Fig.† .4â•… Artist’s sketches of the osseous structures of the thoracic spine. 2â•… Normal Spine MRI Anatomy 23 Bony end plate Anterior longitudinal lig. (b) lateral. (c) posterior oblique. the costovertebral joints. process Spinous process b Rib Lamina Superior articular process Transverse Inferior articular process process Costovertebral ligs. and the costotransverse and costovertebral ligaments: (a) axial.

5â•… A 3D artist’s sketch (axial view) of the spinal.’s Fig.’s Posterior branch to paraspinal m. CSF is seen surrounding the spinal cord in the cervical. CSF has low signal intensity on T1- weighted images and high signal intensity on T2- weighted images. the thecal sac the vertebral end plate and into the adjacent vertebra. nerves.€2. the ligamentum Fig. At L5-S1. Posterior radicular a. Thus. Schmorl nodes in the lumbar spine. inter- costal.6â•… A sagittal T2-weighted image shows multiple flavum. Anterior spinal a.7â•… An axial fat-suppressed T2-weighted image shows flow. tho- racic. Tarlov cysts are common extradural CSF-filled sacs that occur in the S1-S4 region of the spinal cord and are often asymptomatic (Fig. from protrusion of the cartilage of intervertebral discs through pouchings to the nerve roots. are often asymptomatic. . and usually no epidural fat is seen on MRI. enlarges. A Schmorl node results The dura extends caudally to S2 and has lateral out. and the posterior longitudinal ligament. Intercostal a. On sagittal and axial images. Posterior spinal a. CSF Like other fluids. Tarlov cysts are extradural spine and can be mistaken for multiple intradural. and other arteries that supply the thoracic spine.24 Iâ•… Initial Considerations Aorta Segmental a. 2. Contents include epidural fat.7). 2. which are most commonly seen in the thoracic multiple Tarlov cysts in the sacrum. blood vessels. T2-weighted images provide a myelographic appearance that allows for the detection of spinal stenosis. and lumbar spine and around the cauda equina in the lower lumbar spine. CSF-filled sacs that occur in the S1-S4 region of the spine and extramedullary lesions. One should be aware of the potential for imaging artifacts relating to CSF Fig. Anterior radicular a. Epidural Space The epidural space in the spinal canal is the true space between the dura and bone. 2.

The ligamentum flavum may also calcify and lead to osseous spur formation and resul- tant neuroforaminal stenosis. a more appropriate term is zygapophy- nulus fibrosus and cortical bone.€2.10).14). anteriorly by the vertebral bodies and discs. and defines the zygapophyseal joint is oriented in a transverse/ the anterior margin of the anterior epidural space at oblique plane. It is with the superior articular process of the posterior loosely attached to the intervertebral discs. su. poste- ation of spinal cord morphology and the presence of riorly by the facet joint and articular processes. The anterior epidural space is seal joint is oriented coronally.15).” The posterior longitudinal ligament extends from The anatomy of the zygapophyseal joint is ori- the body of the axis to the sacrum. The eight cer- vical nerve roots exit above the similarly numbered Ligaments vertebral bodies.3 The posterior longitudinal ligament Vascular Structures is attached to the intervertebral discs and margins of the adjacent vertebral bodies.5 mm in thickness. attached to the posterior varying biomechanical stress. thick. menisci. In the thoracic spine. tion of these structures may be limited with MRI be- cause of partial volume averaging with the adjacent vertebral body. perficial fibers span up to four articulations. In conus medullaris ends around the level of the infe- the lumbar spine. The low signal tually represents only the articular cartilage surface on MRI blends with the peripheral portion of the an. On gadolinium-enhanced MRI.12). Visualiza. when evaluating MRI studies of the spine and spinal tend between adjacent vertebrae. The normal mentum flavum is typically 1. Although elements of the next vertebra (Fig. The cord should have homo. are located in and around the cervical vertebral bodies (Fig. Specialized se. Additional neural structures.8). including L2 level in adults. The posterior noses) (Fig. the sympathetic chain. The dorsal pathology. 2â•… Normal Spine MRI Anatomy 25 Spinal Cord Roots and Foramina As noted above.€2. The facet joint is the articulation of the inferior artic- The anterior longitudinal ligament is broad. and hyaline (articular) cartilage lining the terior longitudinal ligament is narrow in the cervical reciprocating surfaces. Facet Joints The anterior longitudinal ligament extends from the anterior margin of the foramen magnum to S1. In the cervical spine. The exiting nerve root is located just detailed evaluation of central gray matter (Fig.and T2-weighted images. The posterior lon. On axial T2-weighted images. ular process of the posterior elements of a vertebra and adherent to the anterior vertebral bodies. posterior to the vertebral artery in the cervical spine The spinal cord should terminate at or above the L1. sagittal/oblique plane. the central and ventral nerve roots can be identified within the gray matter can be faintly identified. The an. In the lumbar spine. The ligamen. has low the anterior spinal artery and two posterior spinal signal on both T1. hancement of the dorsal root ganglion. the zygapophy- the midline (Fig. Nerve roots geneous signal intensity in the absence of intrinsic pass laterally through the neuroforamen. arteries that originate from the vertebral arteries. The nerve roots have and is best visualized on axial images. The ligamentum flavum blends with cap.€2.13). (Fig. . the dura. There is no attachment Normal vascular anatomy is important to recognize at the center of the vertebral bodies.€2. In the cervical spine. vertebral cortex via the midline septum. seal joint or “z-joint. Deep fibers ex. and extrinsic compression. superiorly and inferiorly by pedicles. of the joint.€2. the ligamentum flavum is 4 to 6 rior end plate of L1 in adults. ented differently throughout the spine because of gitudinal ligament is thin. Because the term “facet” ac- spine and broad in the lumbar spine.€2. the liga.11). neural foramina on the parasagittal images and the quences obtained with high-field magnets enable axial images. whereas superfi. It should be noted that the C2 nerve root exits the spine above the C2 pedicle and runs Normal ligaments should have low signal intensity parallel to the C1-C2 facet joint (Fig. synovium. the sagittal T2-weighted images The neuroforamina or neural canals are bordered provide a myelographic effect that allows the evalu. not apparent at the disc level because the posterior the zygapophyseal joint is typically oriented in the longitudinal ligament fuses to the discs. The 12 on all pulse sequences. cord (even when evaluating for nonvascular diag- cial fibers bridge three to four bodies. there is normal en- sules of facet joints.€2. It is a syno- deep fibers span one intervertebral articulation. mm in thickness. The superior cord is supplied by longitudinal ligament. high-signal-intensity fat on T1-weighted images and brae and is seen as a hypointense band posterior to by high-signal-intensity CSF on T2-weighted images.9) similarly numbered vertebrae. like most ligaments. intermediate signal intensity and are surrounded by tum flavum connects the lamina of adjacent verte. vial-type joint that consists of a capsule. The transverse ligament can thoracic and 5 lumbar nerve roots exit below the be seen posterior to the odontoid process (Fig.€2.

Internal Vertebral a. Anterior scalene Superior m. capitis m. Multifidus m. longitudinal lig.’s Common carotid a. and colli m. Longissimus cervicis m. and epidural fat. Normal flow voids are seen within the carotid and vertebral arteries. jugular v. Sternocleidomastoid m. Semispinalis Spinous process Longissimus capitis m. Levator Cord scapulae m. the CSF within the subarachnoid space. Vagus n. 2. Exiting External n. Ligamentum flavum Splenius capitis m.† . b Trapezius m.26 Iâ•… Initial Considerations a Thyroid cartilage Anterior Carotid longitudinal lig. Fig. sheath Posterior Omohyoid m. Longus capitis Sternothyroid m. root jugular v. articular Medial scalene facet m.8â•… This (a) axial T2-weighted image and (b) artist’s sketch clearly define the gray and white matter of the cervical spinal cord.

C2 C3 C2 C3 C4 C2-C3 disc a Dura Posterior longitudinal lig. C1 (transverse part) C1 C1 Atlanto-dens interval Transverse lig. (longitudinal part) Alar lig.† (c) A coronal T1-weighted image shows the alar c ligaments (arrows). bone Apical lig. b Fig. Pharyngeal tonsil Occipital Anterior atlantooccipital lig. of dens Posterior atlanto- occipital membrane Cruciform lig. Tectorial membrane Basilar a. Apical lig. including the alar ligament. of dens Cruciform lig. (atlas) C2 Vertebral a. . 2â•… Normal Spine MRI Anatomy 27 Tectorial membrane Cruciform lig.9â•… These (a) sagittal and (b) PA artist’s sketches showing the ligamentous structures of the skull base and cervical spine. cruciform ligament. and atlantooc- cipital ligaments. 2.

2.11â•… An axial artist’s sketch shows various anatomic structures around the spi- nal cord. space (pink) Epidural fat Ligamentum flavum Fig. a Fig. Interspinous lig. Ventral ramus Dorsal root Dorsal ramus ganglion Dorsal root ganglion Dorsal root Subarachnoid Dentate lig. Arachnoid Dura Ventral Epidural fat root Sympathetic ganglion Pia Vertebral a. † Posterior longitudinal lig. Supraspinous lig. Posterior longitudinal lig.28 Iâ•… Initial Considerations Ligamentum flavum Anterior longitudinal lig. 2. .10â•… This (a) sagittal T2-weighted image and (b) artist’s sketch (lateral view) show the midsagittal b ligaments of the cervical spine.

and (c) axial perspectives. 2â•… Normal Spine MRI Anatomy 29 Dorsal root Fig. 2. Anterior rami Paravertebral ganglion Posterior dorsal rami Exiting Medial branch Rami n.† Cord Recurrent Dura meningeal n. Facet joint Medial branch Posterior of dorsal rami b dorsal rami c . (b) lat- Dorsal root facet Spinal n.12â•… Artist’s sketches of the neu- ganglion ral structures in and around the cervical Superior articular spine from the (a) anterosuperior. root of dorsal rami communicantes Anterior rami Paraspinal m. eral.’s Vertebral a. Ventral ramus Posterior primary division (ventral ramus) Sympathetic ganglion Anterior primary Vertebral disc division (ventral ramus) a Sympathetic ganglion Paravertebral ganglion Rami communicantes Vertebral a.

30 Iâ•… Initial Considerations Spinal cord Greater occipital n. The facet joint is the articulation of the inferior articular process of the posterior ele- ments of a vertebra with the superior articular process of the pos- terior elements of the next vertebra.† Motor root of C1 C1 Posterior arch of C1 Dorsal root of C2 Vertebral a.14â•… Facet joints in the cervical spine. b Fig. 2.13â•… A posterior 3D artist’s sketch of the up- per cervical spine shows the location of the vertebral artery relative to the posterior arch of C1 and the exit of the C2 nerve root above the pedicle of C2. Fig. 2. (a) Parasagittal T1-weighted MR and (b) axial CT images show normal facet joints in the cervi- a cal spine. .

the spinal cord is vul- nerable to infarction in the case of systemic hypo- tension or compromise of a major radiculomedullary feeding vessel. In 85% of cases. and spinal cord and enter via the neural foramina. The T4-T5 radiculomedul- lary artery arises from the intercostal artery. Posterior spinal a. There are several major radiculomedullary arter- ies that merit additional attention. Anterior branch Radicular a. or the artery of cervical enlargement.15â•… This 2D time-of-flight sequence shows the normal configuration because of the differential growth of vascular anatomy of the upper cervical spine. more uniform in caliber than the anterior spinal ar- ninges. The artery of Adamkiewicz has a “hairpin loop” Fig. me. Radicular arteries arise from tery (Fig. The spinal radicular arteries supply the vertebrae. L3-L4 Segmental a. The C3 radicu- lomedullary artery arises from the vertebral artery. and the thoracolumbar spinal cord (Figs. posterior intercostal. There is infre- enter through the neuroforamina and divide into an. also known as the artery of lumbar enlargement or the artery of Ad- amkiewicz.4 In 15% of cases. In watershed areas. arises from an intercostal or lumbar ar- tery. meninges.€2. 2.16â•… An artist’s sketch of the arterial vasculature of the lumbar spine (axial perspec- tive at the L3-L4 level). the spinal cord.€2.€2. and lateral sacral arteries.16). of the cord between the posterior spinal arteries and Inferior vena cava Aorta Fig. The C6 radiculomedullary artery.’s . it arises from T5-T8.17).18). the artery of Adam- kiewicz arises from the left T9-L2 levels. the midthoracic. connected by frequent intercommunications across lumbar. 2. The T8- conus radiculomedullary artery. Posterior branch to paraspinal m. Radicular arteries the dorsal surface of the spinal cord.4 The posterior spinal arteries are smaller and Spinal radicular arteries supply the vertebrae. There are watershed areas at the margins of each region where adequate collateral flow is not always available. quent intercommunication along the lateral surfaces terior and posterior branches (Fig. deep cervical. and spinal cord. 2â•… Normal Spine MRI Anatomy 31 The anterior spinal artery supplies three major regions: the cervicothoracic. arises from the thyrocervical or costocervical trunk. The two posterior spinal arteries are the vertebral.5 and 2.

scalene. . On gadolinium-enhanced MRI. 2. enhancement of the vessels of the epidural plexus and the basivertebral venous plexus. The deep muscles of the cervical.€2. longus colli. Abdominal aorta Lumbar a. 2. rotatores. They help support the spine and assist Pial plexus with motion of individual bones and of the core as a whole. ascending lumbar veins.’s azygous system (Fig. Prevertebral deep muscles include the rectus capitis.’s intercostal a.€2. there is normal Common carotid a. erector spinae. multifidus.’s muscles include the rectus capitis. interspinalis. The basi- Basilar a. Subclavian a.32 Iâ•… Initial Considerations the anterior spinal artery through the circumferen- tial pial arterial plexus. thoracic. oblique capitis Lumbar a.’s The paraspinal muscles are the group of superficial and deep muscles that run adjacent to the spine (Fig. Fig. The paraspinal Common iliac a. Venous drainage occurs via the external verte- bral plexus and subsequently the internal vertebral Posterior spinal a. root Anastomosis Anterior spinal a. Posterior radicular a. spinal a. and oblique capitis inferior. and Spinal radicular a. The superficial or extrinsic paraspinal mus- Posterior cles include the trapezius. Posterior spinal a. plexus via basivertebral veins (Fig. and intertransverse. and psoas.’s scapulae. levator Radicular a. between the posterior spinal artery and the anterior spi- nal artery. and lumbar spine include the splenius capitis. Exiting n. Suboccipital deep Cauda equina a. Fig. latissimus dorsi. splenius cervicis. superior. vertebral plexus has a Y-shaped appearance on axial images. and rhomboid major. into the vertebral vein. semispinalis.€2.20).19). rhomboid minor.17â•… An artist’s sketch of the arterial vascu- Posterior lature of the spine from an anterior perspective.18â•… An artist’s sketch depicts the anastomoses Anterior radicular a.21). lar and intervertebral veins through neuroforamina Anterior spinal a. longus capitis. The cord and vertebral plexi drain via radicu- Vertebral a. Aorta Muscles Posterior intercostal a.

flat bone that encircles the cerebellum as it gives rise to the pons and medulla in the poste- rior fossa. Basivertebral v. Prelaminar branch Posterior external v. a term sometimes used as a synonym for the external occipital protuberance. The clivus is the portion of the sphenoid bone that meets the oc- cipital bone. Posterior Posterior radicular v.19â•… A sagittal fat-suppressed T2-weighted image shows nuchal lines. external plexus Basivertebral v. The sphenoid bone also contributes to the anterior aspect of the posterior fossa. The foramen magnum is the opening at the base of the skull. 2â•… Normal Spine MRI Anatomy 33 muscles should be evaluated by MRI to assess for asymmetry. musculature. Other important ex- ternal landmarks include the superior and inferior Fig. The external occipital protuberance corresponds internally with the confluences of the sinuses. a b Anterior internal plexus . 2. The external occipital protuberance is the attachment site of the ligamen- tum nuchae and the trapezius muscle. which are attachment sites for cervical venous drainage in the spine. is actually the highest point of the external occipital protuberance. atrophy. 2. ■⌀ Cervical Spine Anatomy The occiput is labeled as C0. and laterally by the occipital condyles.20â•… Artist’s sketches detail the venous drainage of the Anterior vertebral plexus spine from (a) sagittal and (b) axial perspectives. internal plexus Dura Posterior external plexus Anterior internal plexus Posterior internal plexus Anterior radicular v. The occipital condyles con- tain the hypoglossal nerve as it courses anteriorly to exit the hypoglossal foramen. and/or pathology. It is defined anteriorly by the basion. The occipital bone is a broad. The inion. Internal Fig. posteriorly by the opisthion.

as well as the superior and inferior articular processes of the L1-L2 facet joint. Longissimus m. Spinous process Multifidus m. root Transverse process Superior articular facet Iliocostalis m. 2.21â•… This (a) axial T2-weighted image and (b) artist’s sketch of a the normal anatomic location of the paraspinal muscles and other neu- rovascular structures.† Inferior vena cava Aorta Traversing n. root b L1-L2 Exiting spinal n. . Semispinalis m. These views at the level of the L1-L2 intervertebral disc show the conus medullaris and the L1 spinal nerve root. Rotatores m. Spinalis m.34 Iâ•… Initial Considerations Fig.

articulates with the anterior arch of C1 (Fig. is a ring-shaped struc- ture that lacks a vertebral body. or the odontoid process. also known as the atlas. the subaxial cess of C2.€2. The primary motion of the atlantooccipi- tal joint is flexion-extension by which the occipital condyles glide in the sockets of the atlas. instead. The C1-C2 ar- anatomic articulation of the lateral masses of C1 and C2. Lateral flex- ion is constrained by the contralateral alar ligament. The cause of os odontoideum is unknown and may be a congenital Fig.€2. 2╅ Normal Spine MRI Anatomy 35 C1. is a protuberance from the axis.22╅ A coronal T1-weighted image shows the normal failure of fusion secondary to trauma.23). ligamentous stabilizing structures are present and include joint capsules.€2. C2 is termed the axis. and grooves for the vertebral artery.24╅ A sagittal T1-weighted image shows the cup- articulation of the anterior arch of C1 and the odontoid pro. com- posed of two lateral masses. a longer posterior arch. or odontoid process of C2.22). 2. The C0-C1 articulation is termed the atlantooccipital joint and is a cup-shaped configuration (Fig. The lateral masses of C1 articulate inferiorly via facet joints with C2 (Fig. It is. 2.€2.24). shaped configuration of the craniocervical joint. The right and left lateral masses are connect- ed by the anterior and posterior arches. The dens. ticulation is termed the atlantoaxial joint. a short anterior arch. and C0-C2 ligaments. 2.25). In addition to primary stabilization from the morphol- ogy of the joint. The dens. anterior and posterior atlantooccipital membranes. There are Fig. An os odon- toideum is a variant in which the dens is separate from the body of the axis (Fig.23╅ A sagittal T1-weighted image shows the normal Fig. . facet joints are also well visualized.

spinal cord. The tectorial membrane is dorsal The T1-weighted and T2-weighted sagittal im- to the cruciform ligament and is contiguous with the ages should be reviewed first to evaluate the spinal posterior longitudinal ligament inferiorly and the anatomy (Fig. a ticulation. and the anterior and posterior longitudinal ligaments. It passes posterior to the odontoid process and attaches at the lateral tubercles of the atlas. arch of the atlas. The transverse or horizontal cruciform transversarium from C1-C6. often a normal variant where the dens is separate from the body of the axis.36 Iâ•… Initial Considerations Fig.9). Flexion- extension is limited by the transverse ligament and the tectorial membrane. The lateral atlantoaxial joint is formed be- tween the lateral masses of the atlas and the superior Fig. cervical junction ligaments. C1-C2 joint and pierce the dura above the C1 arch.€2. foramen and short bifid spinous processes.26).26â•… This (a) sagittal T1-weighted midline image and articular surface of the axis.† trast-enhanced MR images. The apical ligament attaches the tip of Sagittal MRI the odontoid to the basion and has uncertain biome- chanical function. They contain a large triangular vertebral that best shows the entire cervical spinal cord and . as well as the anterior and posterior elements of the cervical tal or in part. The cervical vertebrae of C3-C7 are small but rela. as appreciated on T2-weighted and con. other key ligaments of the craniocervical junction The vertebral arteries ascend in the bilateral foramen (Fig. and membrane plays a role in cervicogenic headaches. These joints may communicate in to. The median atlantoaxial (b) artist’s sketch of the cervical spine depict the cervical cord. intervertebral discs. joint is formed between the dens and the anterior CSF. thecal sac. There is a In addition to the alar ligament. They pass lateral to the ligament is the largest and strongest of the cranio. 2. paired lateral articulations and a midline medial ar. The anterior and pos. The primary movement of the atlantoaxial joint is axial rotation. posterior elements.25â•… A sagittal T1-weighted image shows an os odon- toideum.€2. spine and the intervertebral discs. The posterior atlantooccipital ies. To find the midsagittal image. The midsagittal image from the dura of the clivus superiorly. cervicomedullary to cervicothoracic junctions is a terior atlantooccipital membranes attach the atlas to good anatomic screen of the cervical vertebral bod- the foramen magnum. Lateral bending is limited by the contralateral alar ligament. there are several raised lip on the upper surface of the vertebral body. the sagittal series should be reviewed for the image tively broad. 2.

The The cervical vertebral body has bright signal in- foramina have an oblique orientation to the sag. (dens) Lamina (C2) Epiglottis Spinal cord Ligamentum Hyoid nuchae Glottis Trapezius m. T1-weighted images are spine lordosis should be observed. the annular. and the CSF tal images show the short cervical pedicles.6. Normal cervical to artifactual narrowing. 2.7 Often.3. The in the adjacent thecal sac. The AP diameter somewhat limited because they afford poor dif.5 The posterior longitudinal anterior and posterior longitudinal ligaments are ligament. of facet joints and neural foramina (Fig. which can cause distortion and lead ence of normal fatty bone marrow.5 The CSF–extradural interface is well cal defect is seen in the midportion of the posterior defined on T2-weighted images. an osseous spur. midbrain. channel and is a normal finding. Cricoid cartilage C7 spinous process T1 spinous process b Tracheal rings T1 vertebral body Fig. tensity on T1-weighted images because of the pres- ittal plane. Odontoid Oblique process capitis m.26â•… Continued the odontoid process. The and fourth ventricle. and a myelographic vertebral body. .€2.27). Cerebellum Posterior Anterior arch of atlas (C1) arch of atlas (C1) Rectus capitis m. opisthion. this defect represents a vascular appearance is produced on T2-weighted sagittal im. of the canal tapers from the first to third cervical ferentiation of the vertebral body. and CSF depicted as low-signal-intensity linear structures all appear as a low-intensity signal on T1-weighted along the vertebral bodies. a small corti- sagittal images. ages because of the high signal intensity of CSF. a disc herniation. intervertebral discs show intermediate signal inten- Sequential evaluation of the sagittal series away sity on T1-weighted images and high signal intensity from the midsagittal image allows for assessment on T2-weighted and gradient-echo images. Parasagit- posterior longitudinal ligament complex. basion. 2â•… Normal Spine MRI Anatomy 37 Transverse lig. Thyroid Splenius cartilage capitis m. levels and then is relatively constant.

† FC.27â•… A sagittal T2-weighted paramidline image of the cervi.28â•… Artist’s axial sketch shows spinal cord anatomy. most im- aging workstations have tools that enable the ver- tebral bodies to be identified using the numbering techniques just mentioned. Given the potential risk of wrong-level surgery. Compared with sagittal images.8). including the various spinal cord tracts. which enables evaluation of spinal cord or nerve root compression. axial cal spine shows the vertebral artery in long axis coursing through T2-weighted images can provide a higher-resolution the transverse foramina of the cervical spine.6.€2.38 Iâ•… Initial Considerations Axial MRI Evaluation of the cervical spine MR images in the axial plane requires the correct identification of the spinal level. as shown here. 2. The facet joints are depiction of the cord (because of the smaller field of most easily evaluated in the parasagittal plane. 2. In addition. fasiculus gracilis. T2-weighted images have good CSF-to-cord contrast (Fig.28) can help a clinician correlate the clinical and radiographic findings in a patient with known or suspected spi- Fig. FG. which facilitates rapid localization on the midsagittal images while evaluat- ing the associated axial images.8 special care should be taken to identify the level by using a combination of these two labeling techniques. Cervical spine anatomy and anatomic pathology are well visualized on axial T1-weighted images. the sagit- tal and axial images can often be linked on viewing stations and with image-viewing software to enable definitive localization of pathology in the sagittal and axial planes. fasiculus cuneatus.† view).3. In addition. nal cord injury. which can be accomplished by using the local- izing sagittal images or by evaluating signal-intensity differences between the intervertebral discs and ver- tebral bodies and sequentially numbering the levels caudal to the odontoid process. enabling a more sensitive assessment of its Lateral corticospinal Posterior Dorsal Dorsal tract white column spinocerebellar Dorsal tract root ganglion Rubrospinal FG FC tract Lateral white column Lateral reticulospinal tract Ventral root Ventral spinocerebellar tract Lateral spinothalamic tract Ventral spinothalamic Reticulospinal tract tract Olivospinal tract Anterior Spinoolivary fibers white column Tectospinal tract Ventral corticospinal tract Fig.7 Knowledge of the loca- tion of the various spinal tracts (Fig.€2. .

The facet ages may be especially valuable for evaluating the joints are coronally oriented. and ligamentum flavum hypertrophy) should be noted. discs are fairly uniform in shape and size. The quently than that of the lumbar and cervical spine. Aberrant vertebral arteries should be identified preoperatively. coronal im. cases. and lateral atlantoaxial joints. which can cause each neural foramen to be visualized on different parasagittal or axial images. superior articular facets are often concave. and L4 dorsal nerve root ganglion.€2. Normal flow voids are stance. especially with patients who have scoliosis or poor positioning in the scanner. Furthermore. Sagittal images are also help- ful in evaluating signal abnormalities in the spinal cord because one image can show a long segment of the spinal cord. 2.29). and the posterior border is the facet joint (Fig. Neural foramina are best depicted with gradient-echo and T2-weighted images and should be evaluated on axial and parasagittal im- ages. 2â•… Normal Spine MRI Anatomy 39 signal characteristics. The transverse processes are thin and long. bifurcation. Fig. along with conventional radiographs. also facilitate evaluation of the rarely oc- curring cervical scoliosis because the entire scoliotic ■⌀ Lumbar Spine spine can be included within a single imaging plane. tween the vertebral body and the rib head) and the lantooccipital joints. root.† The thyroid should also be evaluated for size and to exclude large nodules. Coronal plane MR images. Evaluation of the neural foramina in the axial and sagittal planes improves with experience and training. lymph nodes in the neck should be evaluat. Anatomy The lumbar vertebrae have relatively large bodies. the vertebral arteries should show normal hypointense pulsation signal. the de- gree of contribution of the three primary contribu- tors to cervical spinal stenosis (disc pathology. Coronal MRI unique in that the ribs form two additional articula- Coronal images show the craniocervical spine articu. L4 spinal nerve potential pathology or incidental findings. tions with the vertebrae: the costocentral joint (be- lations. especially if a cervical corpectomy is being considered. intervertebral discs. in addition to the structures detailed previously.29â•… An axial T2-weighted image of the lumbar spine all imaged structures should also be evaluated for at the L4-L5 level shows the cauda equina. For in. uncinate processes. just below the aortic ed for size and the presence of a normal fatty hilum. There is a triangular spinal foramen in most MRI of the thoracic spine is obtained far less fre. . It is important to note the location and course of the vertebral arteries on the axial images. Care should be taken to evaluate the axial T2-weighted images and to recognize the normal shape and size of the central canal and the neural foramina. at. and their combined contribu- tion to the degree of central and foraminal steno- sis should be assessed. The thoracic intervertebral information for diagnosis in most cases. As with any radiographic study. whereas The anatomic structures in the thoracic spine are the inferior articular facets are often convex. seen within the common iliac arteries.3 costotransverse joint (between the transverse pro- Although the sagittal and axial images provide enough cess and proximal rib). ■⌀ Thoracic Spine The fifth lumbar vertebra should have the largest body. Specifically. facet arthropathy. craniocervical junction or assessing for spinal tumors. The anterior border of the neural foramen is the disc.

intervertebral discs. The midsagittal image graphic effect.30 and 2. the facet joints and neural foramina. This image shows the assist by providing improved evaluation of end plate full profile of the sacrum and most of the lumbar and osteophyte anatomy and differentiation of the vertebral bodies. and vertebral bodies Coccyx Sacral hiatus are better differentiated on the T2-weighted images than on T1-weighted images.† b . Spinal cord L1 L2 Conus medullaris Cauda equina Filum terminale L3 Dura-arachnoid Nerve roots and arachnoid space L4 Epidural fat Ligamentum flavum L5 Anterior longitudinal lig. The T1-weighted ial sequence to confirm laterality. spinal cord. 2.40 Iâ•… Initial Considerations Sagittal MRI ating the midsagittal image. and cauda equina in anterior and posterior longitudinal ligaments from patients without substantial scoliosis. T1-weighted gradient-echo images should be evaluated first. Posterior longitudinal lig.€2. The bright signal images are best used for evaluating the anatomic from CSF on T2-weighted images provides a myelo- detail of the lumbar spine.31). S1 S2 S3 Filum terminale a S4 Fig. After evalu. The posterior longitudinal ligament. the cortical bone.30â•… This (a) sagittal T2-weighted midline image and (b) artist’s sketch of the lumbar spine show the conus medullaris and other important structures as identi- fied. The sagittal tained with T1-weighted and T2-weighted pulse images can be concurrently evaluated with the ax- sequences (Figs. the sagittal images are sequentially evaluated toward each side to assess Sagittal imaging of the lumbar spine is usually ob.

€2.† Axial MRI tween the intervertebral discs and vertebral bodies allows for the distinction between vertebral levels.31â•… This (a) parasagittal T2-weighted image and (b) artist’s sketch of the lumbar spine show the neural foramina and exiting nerve roots at multiple levels. When evaluating axial MR images. L1-L2 intervertebral L1 foramen L1-L2 disc L2 L3 Pedicle L4 (L3) vertebral body Spinous L4 exiting process spinal (L3) n. In complex cases where severe canal and the neural foramina (Fig. The relationship be- On axial images. 2.€2. and ligamentum flavum hypertrophy) tool is frequently available on imaging workstations. Specifi- pathology is present at multiple levels. root Lamina (L3) L5 vertebral body a b S1 Fig. This arthropathy.32). the difference in signal intensity be. which can be achieved by using the localizing the evaluation of the sagittal images. the degree of contribution of the three primary be helpful to use the spine-labeling tool discussed contributors to spinal stenosis (disc pathology. be carefully assessed (Fig. and their combined contribution to often with imaging software that includes studies the degree of central and foraminal stenosis should provided on a CD/DVD or via Internet connection. recognize the normal shape and size of the central bral body from L5-L1. 2â•… Normal Spine MRI Anatomy 41 Anterior longitudinal lig.33). facet previously in the section on the cervical spine. Care should be sagittal image. it may also cally. tween the superior articular process from the caudal . should be noted. In addition. each level can be identified taken to evaluate the axial T2-weighted images and by starting at the sacrum and numbering each verte. it is important to Accurate and consistent evaluation of the axial imag- accurately identify the level at which the pathology es requires more experience and training than does exists.

also facilitate evalua- eral recess and foraminal stenosis. Because lordosis increases nal zone should also be studied at each level to rule toward the caudal aspect of the lumbar spine. these structures junction. Iliocostalis m. tapers. Semispinalis m.42 Iâ•… Initial Considerations Anterior a b L1-L2 longitudinal lig. The sacrum enabling the identification of the vertebrae and in. The psoas muscles are impossible to obtain one image that visualizes the seen adjacent to the vertebral bodies in the lumbar entire spinal canal and its contents. along with because hypertrophy of this structure leads to lat. There are anterior and posterior foramina. as well as the superior and inferior articular processes of the L1-L2 facet joint. It general alignment and anatomy of the lumbar spine. Rotatores m. Along with the spine. . The coronal spine (Fig. 2. tion of lumbar scoliosis. ment and transitional anatomy at the lumbosacral bral bodies. disc space Aorta Inferior vena cava Posterior longitudi- nal lig.33). Spinalis m. and the major vessels (including the plane images can be used to evaluate spinal align- aorta and vena cava) are seen anterior to the verte. should also be evaluated for pathologic processes such as aneurysm. The extraforami. and infection. coro. ■⌀ Sacrum and Coccyx Coronal MRI The sacrum is a block of bone at the base of the ver- Coronal images provide a clear evaluation of the tebral column that consists of the fusion of S1-S5. Fig. Right kidney Exiting Dural sac spinal n. As with the cervical spine. is normally triangular in shape with broad cephalad tervertebral discs. it is out far-lateral disc pathology.32â•… This (a) axial T2-weighted image and (b) artist’s sketch of the spine at the level of the L1-L2 intervertebral disc show the conus medullaris and the L1 spinal nerve root. thrombosis.€2. Spinous process Multifidus m. supports the spine and transmits load. conventional radiographs. root Transverse process Conus medullaris Superior articular facet Ligamentum flavum Longissimus m.† level and the exiting nerve root should be evaluated nal plane MR images of the lumbar spine.

” D. the joint enlarges but remains flat.╇ Sagittal gradient-echo images The sacroiliac joint shows sequential changes D. B. Which pulse sequence provides a “myelo- across the pelvis. Osteophytes develop in the fifth and sixth decades. During the second decade. During the first decade of life.€2.╇ Anterior inferior corner tebrae. 13 thoracic vertebrae. The spinal column typically comprises 7 seen within the common iliac arteries. C. The term “sacrum” literally translates to C.╇ Sagittal postcontrast T1-weighted images is a strip of mesenchyme that undergoes cavitation. True or false? movements. 5 bifurcation. just below the aortic cervical vertebrae.34â•… An axial T1-weighted image shows the normal ap- pearance of the sacroiliac joints.╇ Sagittal T1-weighted images physis through the pelvis between the ischium and B. Normal ligaments are bright on T1-weighted There are no associated muscles that execute active images. The axis of movement passes obliquely 5. 2â•… Normal Spine MRI Anatomy 43 Fig.╇ Posterior inferior corner The sacroiliac joint has a small range of motion with essentially passive movements (Fig. the sacrum. L4-L5 intervertebral disc shows the cauda equina. for the assessment of spinal stenosis? With extension.34).╇ Posterior superior corner “holy bone.╇ Anterior superior corner and represents the fusion of four rudimentary ver.╇ Coronal T1-weighted images with age. 2. the axis passes from the pubic sym- A. and the coccyx. the sacroiliac joint E.33â•… An axial T2-weighted image at the level of the the superior and inferior articular processes. .† lumbar vertebrae. 4. the axis passes back- graphic” view of the spine and best allows ward from the pubic symphysis to the sciatic notch. Common Clinical Questions 1. In the embryo phase. The most common location for a limbus vertebra is the: The coccyx articulates with the sacrum inferiorly A. True or false? 3. L4 spinal True or false? nerve root. and L4 dorsal root ganglion. The facet joints are synovial joints between Fig.╇ Sagittal T2-weighted images the coccyx. Normal flow voids are 2. 2. With flexion. there is cor- rugation of joint surfaces. and large interdigitating os- teophytes can develop during the eighth decade.

site spine surgery. In: Frymoyer JW. Current techniques and spectrum of disease. Santini JJ. Lazorthes G. ╇6. ╇4. Arterial vascularization of the spinal cord. Magnetic resonance imaging of the spine. Explanation: The spinal column typically surg 1971. Holland BA. nance imaging of the cervical spine. Daniels AH. Bianco AJ. Magn Reson Imaging Clin N Am 2000. J Bone Joint Surg Am 2002. Lee RR. Clin Radiol 1999. . 5 lumbar vertebrae.23(24):2701–2712 PubMed sacrum. Wrong. Palumbo MA. It is a synovial joint. Gouaze A. White ML. The ligaments and annulus fibrosus of 1. Saifuddin A.54(11):703–723 PubMed ╇2.44 Iâ•… Initial Considerations References Answers to Common Clinical ╇1. Carbone JJ. Lazorthes Y. Recent 2. Esmende S. 12 (not 13) ╇5. MRI of the lumbar intervertebral Questions disc. Spine (Phila Pa Explanation: The facet joint is formed by the 1976) 1999. The Adult Spine: Prin. Herzog RJ. Khanna AJ. False 84-A(Suppl 2):70–80 PubMed Explanation: Normal ligaments should have ╇8. B Explanation: Sagittal T2-weighted images provide a view of the spine and spinal cord that is similar to that seen with a conven- tional or CT myelogram in terms of contrast between the spinal cord (low signal) and CSF (high signal).35(3):253–262 PubMed comprises 7 cervical vertebrae. Explanation: The most common location for 1997:563–629 a limbus vertebra is within the anterior supe- ╇7. False studies of the anastomotic substitution pathways. J Neuro. 4. A ciples and Practice. 3. Zadeh JO. Kebaish KM. True human adult cervical intervertebral discs. the (Phila Pa 1976) 1998. et al. J Am Acad Orthop Surg 2013. low signal intensity on all pulse sequences. discussion 627–628 PubMed articulation between the superior articular ╇3. Spine thoracic vertebrae. Morgan S. Cervical spine: MR imaging techniques and process from the caudal vertebral body and anatomy. Kaiser JA. Mercer S. Bogduk N.21(5): 312–320 PubMed 5. ed. Burdin P. Imaging of the cervical spine. This contrast allows for the optimal detection of spinal stenosis in the sagittal and axial planes.8(3): the inferior articular process from the cranial 453–470 PubMed vertebral body. rior corner of the vertebral body. Boden SD. Philadelphia. Magnetic reso. PA: Lippincott-Raven. and the coccyx.24(7):619–626.

Discogenic Axial Back Pain cian. and sacral levels and the asso- MRI is a highly sensitive imaging modality for the ciated patterns of radiculopathy. Correlative Anatomy of Lumbar Disc Pathology or annular bulge in the cervical spine. or other treating physi- A. C5 Nerve Root ranging from 20% to 36%. Nonradicular Axial Back Pain surgeon. Correlative Anatomy of Cervical Disc Pathology have reported the prevalence of disc herniations as A. pa- 1. Because a tematic Approach to the Review of Spine MRI Stud- specific anatomic pain generator can be difficult to ies). manifestations. Fissures The purpose of this chapter is to provide the reader with correlation among the anatomic. C8 Nerve Root 100 asymptomatic patients. L5 Nerve Root ings with MRI pathology. material in the region-specific chapters that follow ings in the evaluation of patients with known or sus. Disc Herniation Pathology aging studies involving asymptomatic volunteers IV. S1 Radiculopathy) count concordant physical examination findings.3 Boden et al2 noted that of B.€3.1). Examination of Neurologic Spinal Levels pain. interpretation B. This chapter focuses on nerve root compression at the cervical. The information in evaluation of spine pathology. L2. C7 Nerve Root on MRI of the lumbar spine. A. Biochemical Basis of Radicular and proportion to advancing age. End-Plate Changes presenting nature of each radicular pain syndrome 2. if available. 57% had disc protrusion V. appropriate therapy can be 3. this chapter complements the content in Chapter 2 standing of the anatomic basis of disease is essential (Normal Spine MRI Anatomy) and Chapter 4 (A Sys- to interpreting imaging findings correctly. Silverberg. will enable the reader to better understand the imaging has become a useful adjunct to clinical find. including disc herniations and discogenic II. 79% had an- nular bulges and 36% showed actual herniated discs C. C6 Nerve Root 67 asymptomatic patients older than 60. S1 Nerve Root directed at one or more specific levels by the spine VI.3 Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine Josemaria Paterno. Im- III. clini- 3. Singla It is well known that intervertebral disc pathology Chapter Outline is a frequent finding in symptomatic and asymptom- atic patients.1–4 Degenerative changes Discogenic Pain (Fig. Posterior Element Axial Back Pain ogies. with a specific focus on MRI findings that have VII. interventionalist. and correlate the imaging findings to their clinical pected spinal pathologies. L3 Radiculopathy) the midst of asymptomatic findings. Chad M. and Aneesh K.2. The foundation provided by this trio of chapters isolate by history and physical examination alone. an under. however. By correlating clinical find- 2. A. L4 Nerve Root tient history. and. High-Intensity Zones and Annular along with the corresponding MRI pathology. and MRI findings in patients with spinal pathol- B. lumbar. Lower Lumbar Nerve Roots of disc pathology found on MRI should take into ac- (L4. L5. 45 . Summary a high degree of correlation with clinical symptoms. A causal diagnosis requires understanding the 1. may or may not present symptomatically. interval changes from previous imaging studies. Upper Lumbar Nerve Roots Because symptomatic disease is often present in (L1. with an increasing incidence in relative I. Disc Herniations cal. Jay Khanna. Teresi et al4 noted that of D.

a b to axial back pain symptoms without concomitant ■⌀ Biochemical Basis of Radicular radiculopathy.7 such as with Knowledge of the dermatomal and segmental dis- transforaminal and interlaminar epidural steroid in. herniation. at the specific symptomatic level. such as ular pain requires not just mechanical compression the facet joints. caused only modest discomfort. symptoms from posterior pain generators. and previously implanted spinal hardware. (a) A sagittal T2-weighted image shows bright signal within the lumbar disc corresponding to normal disc morphology and hydration at each level in the lumbar spine. scenarios. infection. traction on nerves in contact evaluation.1â•… Normal versus desiccated discs.46 Iâ•… Initial Considerations Fig. Herniated disc material. such Before using MRI evaluation to narrow the differen- as annular fissures or disc herniations. imaging correlation.6 This model Spinal Levels justifies a therapeutic antiinflammatory approach to treating new-onset radicular pain. 3. Kuslich et al5 showed that in a popula. which pain generators of the posterior disc. has been shown to initiate a cytokine/ inflammatory cascade that transforms an impinged ■⌀ Examination of Neurologic nerve into an acute pain generator. tribution of spinal nerves is necessary to localize jections. Pain Animal and human studies have suggested that radic. the lack of bright T2-weighted signal within the nucleus pulposus in this sagittal view is compatible with disc desiccation. pathologic levels. This innervation provides an anatomic path by trauma. (b) In another patient. osteoarthritis. the clinician must evaluate the . terventions such as fluoroscopically guided spinal traction on nerves not in contact with disc material injections and discography. however. specifically the nucleus pulposus. creating challenging clinical tory response. including but not limited to disc of the sinuvertebral nerve. can often overlap. and diagnostic in- with disc material caused radicular pain. Broad subsets of pathology can The annulus fibrosus is innervated by branches affect nerve roots. and nonradicular discogenic pain of neural elements but also a concomitant inflamma. malignancy.8 Discogenic pain can be a potentially and Discogenic Pain confounding factor in attempting to isolate clinical pain symptoms without imaging correlation. ly. Disc desiccation can be seen in asymptomatic pa- tients as a component of degenerative disc disease. particularly posterior. Isolating the primary pain generator of- tion of nonsedated patients undergoing discÂ�ectomy ten requires a multimodal approach using clinical under local anesthesia. contribute tial considerations.

assisted full range of motion against gravity or full range of motion with gravity eliminated (i. rhage. grade 4. but disc her- niations will change this characteristic shape. In grading a muscle. the normal ovoid morphology of the annulus fibrosus becomes abnor- mal and extends beyond the normal margin of the disc (see Chapter 7. therefore. an axial view shows a central disc protrusion extend- rhage shows associated T2 hyperintensity. facet joints. In general. Mechanical pressure on the nerve root can pro- duce a decrease in muscle strength. Most disc herniations show a low-signal-intensity annulus on T2-weighted Fig. whereas the annulus fibrosus is of low signal intensity. ■⌀ Disc Herniation Pathology Most disc herniations occur in the posterolateral di- rection because of the anatomic protection provided by the posterior longitudinal ligament. The Thoracic and Lumbar Spine MRI). grade 2. dermatome. which is secondary to hemor- fat and. grade 1.e. only pertrophic osteophyte formation involving the end 22% of cervical radiculopathies were caused by a disc plates. With disc protrusions and extrusions. there is loss of contrast. grade 3. ■⌀ Correlative Anatomy of Cervical Disc Pathology herniation. decreased/hyporeflexic. When an acute hemor.000 for females. Normally. Note the the appearance is similar to that of adjacent epidural brighter T2-weighted signal.€3. patient. 3. which can be secondary to spondylotic or hy- for males and 65/100.10 In the cervical spine. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 47 relevant myotome. cervical ra. full range of motion against gravity without assistance. absence of con- tractility. and grade 5. or uncovertebral joints (joints of . contractile activity but absence of joint motion. of disc material but also have an osseous compo- diculopathy had an annual incidence of 107/100. disc her. the clinician can a note symmetric/normal.10 Notably. When evaluating sensation. the convention is the Oxford muscle strength test. On T2-weight- ed MRI sequences. ing posterior to the margins of the adjacent vertebral bodies niations may be more difficult to identify because and indenting the anterior aspect of the thecal sac.to 5-point scale9: grade 0. many lesions caus- ing cervical radicular pain are not composed solely In an American population-based study. full strength. horizontal plane). each dermatome level is tested for light touch and pain perception by a cotton swab and light pinpricks. Disc herniations may contain regions of high b T2 signal if there is corresponding nucleus pulposus or acute hemorrhage (Fig. Re- flex arcs must be compared with those on the other side because baseline individual reflex activity varies from patient to patient.2). full range of motion against limited resistance. or increased/hyperreflexic reflex responses.. respectively.2â•… Morphology of disc herniations. a 0. providing a contrast to adjacent epidural fat. the nucleus pulposus in nondes- iccated discs is of high signal intensity. phology of the adjacent vertebral bodies. and reflex arc that correlate to the suspected level. (b) In a different which aids in identification.000 nent. (a) A normal cervi- cal disc on an axial T2-weighted image conforms to the mor- images. in the acute disc herniation. the morphology of the disc is ovoid.

3). Classic testing is by flexing the elbow a concordant distribution with possible numbness against resistance.48 Iâ•… Initial Considerations Facet joint hypertrophy Uncovertebral spurring b a Fig. The biceps shares innervation from the cause myelopathy secondary to mass effect on the musculocutaneous nerve. The principal mo- nerve is most likely to be impacted by a disc her. Patients with cervical radiculopathy of. including The C5 nerve root innervates the muscles responsible facet arthropathy. It is a flexor of the elbow and supinator of border of the scapula and radiating down the arm in the forearm. Patients often in the lumbar region. the most common cause C5 Nerve Root of cervical radiculopathy is a foraminal constriction that may have several different etiologies. Cervical disc herniations that present with numbness and localized shoulder pain undergo spontaneous regression are expected to that may be confused with a primary shoulder con- correlate with an improvement in symptom burden dition. axillary nerve.€3. therefore. The deltoid muscle is divided into cervical nerves exit in the inferior aspect of the three heads: anterior (flexion). paresthesias. Thus. from C5 and C6. the exiting. a nerve root compressive lesion in the cervical level and is characterized by weakness in the proxi- region is less likely to regress completely than is one mal muscles of the upper extremities.† (b) An axial T2-weighted image shows cervical foraminal nerve root compression by a right-side disc herniation. acromion to the distal elbow. uncovertebral joint and end-plate for shoulder abduction and elbow flexion (Fig.5). hypertrophy. The spinal pain and weakness of shoulder abduction. The C5-C8 The dermatome of C5 corresponds to the lateral cervical neurologic levels are the most vulnerable skin overlying the deltoid and the lateral arm from the to disc herniation and a radicular presentation. Unlike those in the lumbar region. Luschka) (Fig. which originates predominantly from the herniated disc occasionally is central and can C5 and C6.3â•… This (a) artist’s sketch shows cervical foraminal stenosis and nerve root impingement from facet joint hypertrophy and uncovertebral spurring resulting in cervical nerve root compression. middle (abduction).10 There. nerves most commonly affected by disc herniations pain from a pathologic shoulder condition is associ- are reported to be C6 and C7. for abduction. The cervical deltoid muscle weakness with impaired shoulder nerves exit above the same-numbered pedicle. which also originates cervical cord. A rotator cuff tear may present with shoulder from a resultant compressive neuropathy. whereas radicular pain is not. 3. Deltoid weakness is best assessed by example.€3.4). C5 radiculopathy results from pathology at the C4-C5 fore. ally and impinges on the nerve root at the inferior The deltoid is almost entirely innervated by the aspect of the neural foramen (Fig. muscle is divided into two heads: the brachii and the ten complain of neck pain referred to the medial brachialis. a cervical disc herniates posterolater. foramen.€3. . and loss of disc space height. and weakness in the same distribution. a C5-C6 herniation will affect the exiting shoulder abduction against resistance.10 ated with increased range-of-motion pain and pain Generally. however. tor deficit of C5 radiculopathy is supraspinatus and niation or a disc–osteophyte complex. not the traversing and posterior (extension) heads. However. The biceps C6 nerve. Numbness. on provocative testing.

8) extends from the neck to the lat- or spondylosis at the C5-C6 level (Fig.† or dysesthesias in this region may represent a C5 ra. 3. The symptoms of C6 radiculopathy may mimic The brachioradialis tendon is tapped at the distal carpal tunnel syndrome. bilized and the wrist extended against resistance. Radicular pain from the C6 nerve root derma- vical radiculopathy and results from disc herniation tome (Fig. the lateral forearm via deficits in the wrist extensors are the most common. the musculocutaneous nerve (from C5-C6). and the To test wrist extension. for example. (c) lateral recess. and (d) foraminal.7). Because the Weakness of the biceps.4â•… Artist sketches of four types of disc herniations in the cervical spine: (a) central. upper limb nerve entrapments C6 Nerve Root such as carpal tunnel syndrome are characterized by pain. Compression of the C6 median nerve.€3. and it often includes the index finger. dorsum of the lateral hand to the tip of the thumb. it is important that of referred pain with entrapment neuropathies is the patient’s forearm remain in supination to prevent that pain commonly radiates proximally to the site muscle stabilization. Motor eral aspect of the biceps. which is caused by me.11 Unlike cervi- cal radiculopathy.€3. The unique clinical feature C5 and C6. end of the radius. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 49 a b c d Fig. at the wrist. paresthesia. may cause referred pain to the arm and even to the neck. supinator. rity is best isolated by the brachioradialis reflex. and pronator biceps reflex also tests the C5 nerve root.6). and weakness in multiple The C6 nerve root primarily innervates the muscles nerve root distributions (C6-T1) reflective of the of wrist extension (Fig. the forearm should be sta. .€3. C6 integ- teres may be present because of coinnervation. The biceps reflex corresponds to verse carpal ligament. (b) posterolateral.11 Compression of the median nerve sides could indicate pathology of C5 or C6. nerve root is the second most common cause of cer. dian nerve entrapment at the wrist by the trans- dicular syndrome. For the biceps reflex. Reflex discrepancies between of entrapment.

5â•… These artist’s sketches show the key features of the C5 motor. The proximal lateral forearm is the typical dermatomal region affect- ed by C5 radicular symptoms.50 Iâ•… Initial Considerations Deltoid C5 MOTOR MOTOR Biceps SENSORY C6 C5 T1 REFLEX Fig. The C5 nerve root is shown in anatomic context. and reflex examination. . The deltoid and biceps muscles are the primary motor innervation of C5. 3. sensory. The biceps reflex is elicited by tapping on the biceps brachii tendon as it courses through the cubital fossa.

sensory. The primary motor innervation of C6 includes the biceps muscle but is isolated by the major functional muscles of wrist extension (extensor carpi radialis longus [ECRL] and extensor carpi radialis brevis [ECRB]). 3. The distal lateral forearm up to the thumb and index finger are the typical dermatomal regions affected by C6 radicular symptoms. The brachioradialis reflex is elicited by tapping on the brachioradialis tendon at the distal radius. The C6 nerve root is shown in anatomic context. and reflex examination. .6â•… These artist’s sketches show the key features of the C6 motor. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 51 MOTOR Biceps C6 C7 MOTOR Wrist extensors ECRL ECRB C6 T1 C8 REFLEX Fig.

which can be tested by and finger extension. the dorsal and ventral surfaces of the middle but it may not be noticed by the patient until it be. usually without sensory involvement. C7 is con.13 which is caused by de. Biceps strength was still symmetric. so even subtle discrepancies in asking the patient to make a closed fist and flex. Triceps weakness can be substantial. and finger extensors (Fig. the exten.9). (a) A sagittal T2-weighted im- age shows C5-C6 and C6-C7 disc protrusions. the patient is asked to flex the in. motor symptoms of C7 radiculopathy may be con- including the primary extensor group.€3. which should be placed on the posterior interosseous nerve is a pure motor con- the dorsum of the extended proximal phalanges. dysesthesia. Re- elbow extension. a continuation of the deep branch of the radial is stabilized in a neutral position and the patient nerve.52 Iâ•… Initial Considerations b Fig. but typically the pa- sidered the most frequently involved nerve root in tient may present with pain. tapped with the reflex hammer where it crosses the tend the forearm against resistance. entrapment of the examiner’s hand.12. flexors. of the forearm. ally. The C7 dermatome varies. and/or cervical radiculopathy. making the comes severe because gravity often aids in passive long finger most typically representative of C7. C7 Nerve Root terphalangeal joints to help isolate the long finger extensors and eliminate contribution from the in- C7 primarily innervates the elbow extensors. Wrist flexion is olecranon fossa. the wrist nerve. finger are within the C7 dermatome. and down to the middle finger. Additionally. the also innervates several finger extensor muscles. dition.7â•… Impingement of exiting cervical nerve root. This entrapment would present with weak- extends the metacarpophalangeal joints against ness in the finger extensors. the dorsolateral aspect root innervates the triceps muscle. and the Simultaneously. This patient presented with paresthesia in the right lateral forearm and thumb as well as subtle weakness with wrist extension. triceps and wrist flexors are not affected. numbness radiating from the posterior aspect of the generative changes at the C6-C7 level. which is stabilizing the elbow and asking the patient to ex. the posterior arm. Triceps testing is performed by flex testing of C7 is via the triceps tendon. The C7 nerve shoulder. . Notably. but the brachioradialis reflex was slightly a diminished. Usu- bow extensor. To test finger extension. the primary el. (b) An axial T2-weighted image shows a C5-C6 broad-based right paracentral/foraminal disc protrusion that narrows the right neural foramen and contacts the exiting right C6 nerve root. fused with entrapment of the posterior interosseous sor digitorum. predominantly controlled by the C7 median nerve C8 also assists the innervation for wrist flexion via the flexor carpi radialis. the examination of the wrist and fingers may still be ing the wrist against resistance. 3. wrist trinsic hand muscles. The radial nerve consistent with C7 radiculopathy.

3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 53 C2 C2 C3 C3 T1 C4 C4 T2 C5 C6 C5 T3 T4 C7 C6 T1 C8 T2 T5 T3 T6 T4 T1 T7 T5 T8 T6 T9 T7 T10 T8 C5 T11 T9 T10 C7 T12 L1 C8 T11 C6 L1 C6 T12 L2 L3 S1 C8 L4 S2 C7 L2 L5 S3 S4 L3 S5 L4 L5 L5 S2 S1 S1 L4 S1 L5 a L4 b Fig. .8â•… Artist’s sketches show (a) AP and (b) PA views of the dermatome map. 3.

54 Iâ•… Initial Considerations MOTOR C5 C6 C6 Triceps C7 C7 C8 T1 T1 Finger extensors MOTOR Wrist flexion Flexor carpis radialis REFLEX C6 SENSORY C7 T1 C8 Fig. sensory. and reflex examination. wrist flexion by the flexor carpi radialis. . is the classic dermatomal region represented in isolation by pure C7 radicular symp- toms. The primary motor innervation of C7 is responsible for several functional movements including elbow extension by the triceps muscle. 3.9â•… These artist’s sketches show the key features of the C7 motor. The middle of the hand. and finger extension by the extensor digitorum group. especially the third finger. The triceps reflex can be elicited by tapping on the triceps tendon as it crosses the olecranon fossa. The C7 nerve root is shown in anatomic context.

€3. and distal interphalangeal joints. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 55 C8 Nerve Root the metacarpophalangeal. sensory. medial distal forearm and ring and small fingers. . the pa. The lis flexes the proximal interphalangeal joint via the ulnar side of the small finger is the most specific lo- median nerve. The flexor digitorum superficia. To test finger flexion strength. MOTOR C7 C8 T1 Finger flexors SENSORY C6 T1 C8 NO REFLEX Fig. The flexor digitorum profundus flexes straighten the patient’s fingers. Then the examiner C8 primarily innervates the finger flexor muscles interlocks fingers with the patient and attempts to (Fig.10). cation for testing C8 sensation. There is no classic re- tient is asked to flex all of the finger joints. constitute the classic dermatomal region affected by C8 radicular symptoms. 3. proximal interphalangeal. and reflex examination. There is no typical reflex easily elicited for C8 testing. including flex test for C8. The primary motor innervation of C8 includes the intrinsic muscles of the hand responsible for finger abduction/adduction and finger flexion. including the medial two fingers. The C8 nerve root is shown in anatomic context.10â•… These artist’s sketches show the key features of the C8 motor. The distal medial forearm and hand. the distal interphalangeal joints via the C8 ulnar The C8 dermatome is classically the skin of the and median nerves.

For example. The L4-L5 and L5-S1 segments have the greatest ary to impingement of the traversing L5 nerve root motion in the lumbar spine and are thus the most by the herniated disc as the nerve root travels in an vulnerable to disc herniation injuries.14 Of all lumbar disc herniations. radicular pain syndrome or radiculopathy second. 90% are cen- Disc herniations may also affect the exiting nerve tral or paracentral (5% are foraminal and 5% are far root at the level of disease. A midline disc herniation is rare because of the perior region of the foramen (Fig. levels. L1-L2 intervertebral L1 foramen L1-L2 disc L2 L3 Pedicle L4 (L3) vertebral body Spinous L4 exiting process spinal (L3) n. root Lamina (L3) L5 vertebral body a b S1 Fig. Therefore. inferior to the vertebral pedicle and above the interspace disc.13).€3. a disc her.56 Iâ•… Initial Considerations niation at the L4-L5 level may affect the L4 nerve root ■⌀ Correlative Anatomy of through two possible mechanisms: (1) a posterolat- Lumbar Disc Pathology eral disc extrusion with cephalad migration of disc material in the neural foramen or (2) a far-lateral In the lumbar spine. lateral). a large midline herniation at the L4-L5 disc nerve root.15). resulting in combined L5 and S1 radic- posterolateral L4-L5 disc herniation results in an L5 ular symptoms (Fig.€3.€3.† .12 and 3. For ing nerve root but rather impinge on the traversing example. the exiting nerve passes im.12). which exits the foramen under the next could compress the L5 and S1 nerve roots in the lat- lower vertebral pedicle (Fig. Approximately inferior direction to exit from the next lower neural 90% of lumbar disc herniations occur at these two foramen (Figs. the foramen above the interspace level in the su. if it does occur. a eral recesses.14).14 Anterior longitudinal lig.11). For example.€3.12 and 3. but most lumbar disc herniations do not affect the exit.€3. strength of the posterior longitudinal ligament. disc protrusion/extrusion that compresses the same- mediately inferior to the vertebral pedicle and exits level exiting nerve (Figs. 3. Note how the lumbar nerve roots exit in the superior foraminal region.11â•… This (a) parasagittal T2-weighted image and (b) artist’s sketch of the lumbar spine show the typical neural foramina and exiting nerve roots at multiple levels. it can involve two nerve roots.

The result is that a nerve root is commonly involved in herniations of the disc located above its point of exit from the neural foramen. (d) axillary. Lauryssen. (b) At the level of the L4-L5 disc. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 57 Axillary a herniated nucleus pulposus Disc Exiting n. (a) A sagittal T2-weighted image shows L4-L5 disc protrusion (arrow). This patient presented with numbness in the first web spaces of the left foot and diminished strength with hip abduction and great toe extension. Each arrow indicates the direction of herniation. (a) The posterior view shows their locations at the L2-L5 levels.† . Before it exits the neural foramen. and (e) far-lateral disc pathol- ogy. the nerve root does not cross the disc space below. (c) posterolateral. 3. the nerve root turns at a 45-degree angle immediately beneath the vertebral pedicle.13â•… Traversing nerve root impingement.) a b Fig. NY: Thieme Publishers. FM. Note how the far-lateral herniation impinges on the same-level nerve root while the posterolateral herniation impinges on the tra- versing nerve root. The Lumbar Intervertebral Disc. The corresponding axial views show the (b) central. Because the pedicle is situated in the upper third of the vertebral body. New York. Reprinted by permission. 2009. C. this axial T2-weighted image shows a left central/subarticular disc protrusion (arrow) contacting the travers- ing left L5 nerve root in the left lateral recess. root Central herniated nucleus pulposus b c Foraminal/ Posterolateral far-lateral herniated herniated nucleus nucleus pulposus pulposus d e Fig. 3. (From Phillips.12â•… Artist’s sketches of types of herniated nucleus pulposus. Note how the lumbar nerve roots exit from the superior region of the neural foramen.

8). L2. hip adduction (adductors). L2. Individually. each of these three nerve roots lacks a specific representative muscle and a corresponding reflex. The derma. and magnus muscles b are innervated by L2. distin- guishing upper versus lower lumbar nerve root pa- thology is important clinically. The iliopsoas muscle (L1.58 Iâ•… Initial Considerations a Fig. To test hip flexion strength. nent of the L5-S1 disc extrusion contacting the exiting left L5 tomes resemble spiral bands starting with L1 at the nerve root. ducing compression of the traversing left S1 nerve root. The adductor brevis. and L3 provide sensation over parasagittal T2-weighted image shows the foraminal compo- the anterior groin and thigh (Fig.15â•… Multiple nerve root contact. longus. 3. and L4 via the obturator nerve and are responsible for hip adduction. 3. Functionally. the pa- tient was unable to perform an adequate heel walk. Hip ad- duction is tested by having the examiner’s hands on Fig. (a) This axial T2- weighted image shows a moderate-sized left paracentral disc the medial sides of both knees and asking the patient extrusion at the L5-S1 level (with a foraminal component) pro- to adduct the thighs against resistance. L3 Radiculopathy) The upper lumbar levels function together to inner- vate large muscle groups responsible for hip flexion (iliopsoas).€3. Upper Lumbar Nerve Roots (L1. Nevertheless. The patient presented with paresthesias in the medial right foot and weakness with dorsiflexion. . and leg exten- sion (quadriceps). L3. the patient is seated on the edge of the ex- amining table and actively lifts the thigh off the table against resistance. L2. progressing to L2 in the both the L5 and S1 dermatomal distributions. L3) produces hip flexion.14â•… This axial T2-weighted image shows a broad-based disc protrusion at the L4-L5 level with a far-lateral component that contacts the extraforaminal course of the right L4 nerve root. (b) A Nerves from L1. This patient presented with radicular pain along groin and inguinal region.

. and reflex examination.16â•… These artist’s sketches show the key features of SENSORY the L4 motor. Dorsiflexing the foot against resistance is the classic test for the tibialis anterior Lower Lumbar Nerve Roots muscle. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 59 mid-thigh.8). The L4 nerve root is shown in anatomical context. and ending in L3 from mid-thigh to im. testing for an isolated L4 radiculopathy because of its mediately above the knee. 3. even The L4 nerve root innervates the muscles of knee a subtly diminished patellar reflex on one side may extension and foot and ankle dorsiflexion/inversion still represent a severely compressed L4 nerve root (Fig. the patient is asked to walk on his labral tear or osteoarthritis. sensory. may be confused with referred sible for dorsiflexion and inversion of the foot. The patellar reflex is elicited by tapping on the patellar tendon and observing the knee extend. therefore. or her heels. radicular pain from tested via the tibialis anterior muscle. To test pain from intraarticular hip pathology such as a functional ability. in more advanced radiculopathy. though.€3. L4 radiculopathy is specifically responding dermatome. and L4. Notably. vation by L2 and L3. Notably. The quadriceps muscle is less sensitive in because of L2 and L3 coinnervation. a foot drop may be evident. Although the pa- L4 Nerve Root tellar tendon reflex is supplied by L2. which is in- an L1 lesion is often described by patients as groin nervated by the deep peroneal nerve and is respon- pain and. MOTOR Tibialis anterior m. L5. Nerve root impingement great strength and bulk and because of its coinner- will result in referred pain or paresthesias to the cor. including the great toe (Fig. Although the L4 nerve root is also involved in knee extension.16). L4 L5 L4 Patellar tendon S1 Fig. L3. The cutaneous region over the anterior thigh and knee to the medial leg down to the big toe is the classic dermatomal region affected by L4 radicular symptoms. the primary isolated motor innervation of L4 is represented by dorsiflexion via the tibialis anterior muscle. S1 Radiculopathy) of the leg and extends to the medial side of the foot. it primarily reflects L4 integrity.€3. The L4 dermatome includes the medial side (L4.

€3. Functionally. The inferior gluteal nerve from S1 then against resistance with the examiner pushing innervates the gluteus maximus. There is no classic reflex that can truly isolate L5 clinically. The deep peroneal ing L5 sensory function (Fig.€3. The gluteus medius is inner- vated by the superior gluteal nerve of L5 and enables hip abduction. The dorsum of the foot. toe extensors. ankle plantar flexion. though the first web space is the typical site for test- sors and hip abductors (Fig. the hip. al- The L5 nerve root innervates the major toe exten. difficulty with standing from MOTOR Extensor hallucis longus L4 L5 SENSORY NO REFLEX S1 L4 L5 Fig. The patient first tension. while the other hand alis posterior muscle can provide an L5 reflex. and foot/ankle ever- fully abducts the lower extremity against gravity and sion (Fig. respectively.60 Iâ•… Initial Considerations L5 Nerve Root The L5 dermatome distribution corresponds to the lateral leg and central dorsal area of the foot. The palpable crest nerve innervates the extensor hallucis longus and of the tibia from the knee to the ankle is the general extensor digitorum longus. and lateral four toes. . which extends down on the lateral thigh above the knee. which extend the great division between the L5 and L4 dermatomes. including the web space between the first and second toe. There is no quintessential reflex test for L5. is the classic dermatomal region affected by L5 radicular symptoms. but it provides resistance against extension of the great toe is not easy to elicit routinely. the clinician seats the patient and sta. To test gluteus medius function.8). The L5 nerve root is shown in anatomical context. the S1 Nerve Root patient lies on the asymptomatic side while the ex- aminer stabilizes the pelvis and ensures that the hip The S1 nerve root innervates the muscles of hip ex- flexors remain in a neutral position. sensory. To test the skin lateral to the division being innervated by L5. and reflex examination. especially the great toe via exten- sor hallucis longus.17â•… These artist’s sketches show the key features of the L5 motor.€3. The primary motor innervation of L5 includes extension of the toes. 3. with toe and four remaining toes.18).17). The tibi- bilizes the foot with one hand.

the ists against which to judge provocative discography region classically vulnerable to the typical shooting or MRI diagnosis.8). while holding the lateral aspect of the foot from the intervertebral disc. Provocative discography has been radicular pain (sciatica) of a herniated disc impinging traditionally used to diagnosis discogenic pain. modern . The examiner should stabilize the ankle with of axial low back pain. The primary motor innervation of S1 includes plantar flexion of the foot and ankle. Discogenic Axial Back Pain The S1 superficial peroneal nerve innervates the peroneus longus and brevis. 3.€3. and reflex examination.18â•… These artist’s sketches show the key features of the S1 motor. However. but it on an S1 nerve root. The posterior thigh and leg down to the lateral foot including the fifth toe and lateral plantar surface is the classic dermatomal region affected by S1 radicular symptoms. S1 mediates the Achilles tendon has come under scrutiny because of its invasive na- reflex. which evert the foot and Discogenic back pain. one of the most common causes ankle. L5 SENSORY S1 Soleus m. diagnosis of discogenic pain is challenging. S1 sensation covers a dermatomal band extend. hammer to elicit a slight plantar flexion. that innervate the outer third of the annulus fibrosis.15 refers to pain that originates one hand. REFLEX Plantar flexion of foot MOTOR Fig. specifically the sinu- with the other hand. The Achilles reflex is elicited by tapping on the Achilles heel and observing plantar flexion. ing from the buttocks down to the posterior thigh because no pathologic or surgical gold standard ex- and leg to the lateral and plantar foot (Fig. sensory.16 Nevertheless. The gastrocnemius and soleus muscles are in- nervated by the tibial nerve from S1 and S2. as the patient everts against vertebral nerve and the gray rami communicantes resistance. The reflex is elicited by gently dorsiflexing the ture and potential for harm. Because these muscles are quite strong. a seated position could indicate weakness from S1 foot and striking the Achilles tendon with the reflex radiculopathy. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 61 L4 S1 L5 L4 Gastrocnemius m. The S1 nerve root is shown in anatomic context. adequate functional testing requires the patient to rise up on his or her ■⌀ Nonradicular Axial Back Pain toes several times or walk on them across the exami- nation room.

Images plate changes. These degenera. 3. (b) The correspond- ing sagittal T1-weighted image shows subtle low signal in the same areas.€3. par- with intervertebral disc pathology. a combined imaging and clinical approach flammatory state. an associated radicular pain component. Fig. a b . are axial spine pain evaluation of degenerative end-plate changes because generators of discogenic origin that may not have they provide the greatest visualization of end plates. in the sagittal plane provide the highest yield for the and central disc herniations. essary to differentiate Modic types II and III. High-Intensity Zones and Annular Fissures End-Plate Changes High-intensity zones and annular fissures have a Degenerative end-plate changes are often associated high association with axial back pain symptoms. achy. This pain is often described Fluid-sensitive sequences such as fat-suppressed T2- as a deep.1. such as end. MRI findings sequence with a T1-weighted pulse sequence is nec- described in the following paragraphs. particularly in the aging population. inflammatory/edema-like signal abnor.19 generators. a combination of a fluid-sensitive objects or prolonged standing or sitting.19╅ Modic type-I degenerative end-plate changes. ticularly in studies involving evaluation with discog- tive end-plate changes are classified using an MRI raphy.20). however. type-II and type-III changes are less is necessary to isolate these entities as primary pain likely to serve as pain generators. type-III. midline paraspinous pain that can be weighted or STIR images are ideal for identifying type- exacerbated with axial loading such as lifting heavy I changes. fat-like signal abnormalities. shown to have the strongest association with pain atic patient population and increase with patient age. the annulus but without the identified annular de- malities. symptoms because they likely represent an active in- therefore. and formity seen with disc herniations (Fig. (a) A sagittal STIR image shows bright signal compatible with edema within the inferior L3 and su- perior L4 end plates. sclerosis-like signal abnormalities (Fig.19).18: type I. type II.€3. high-intensity zones/annular fissures. Many of Type-I degenerative end-plate changes have been these entities can also be present in the asymptom.62 I╅ Initial Considerations MR imaging can provide a reasonable likelihood of di.19 High-intensity zones are hyperintense T2 characterization originally described by Modic et foci within the disc that can extend to the margins of al17. agnosing discogenic pain.

Interestingly. weakness and involve- from a nonherniated disc whose annulus is incom. subchondral cysts. and with paraspinal palpation on examination. permitting the slow escape of uncontained nucleus pulposus. the pain can tion of the annulus fibrosus. petent. foraminal.21).25 Notably. subarticular. tectural changes of osteoarthrosis (e. lar component. and loading maneuvers (hyperextension and twisting) any contact of adjacent nerve roots should be noted. 3. Diag- However. osteophyte forma- tion) are common findings in asymptomatic and symptomatic patients.€3. exacerbated with certain movements such as facet- tral.. Newer MRI systems can provide imaging with the spine under axial load or with physiologic posi- tioning. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 63 or fat-suppressed MR images. Such situations may call for im- aging technologies that recreate physiologic condi- tions. herniations may be ablation have been shown to be effective for facet- associated with radicular or nonradicular discogenic mediated pain in multiple studies. the inflammatory process associ. pedicles. resemble cervical radicular pain. such axial back pain should not have any neurologic or radicu- The morphology of a disc herniation should be eval.26–28 pain symptoms because of the inflammatory bio. Advanced Techniques in Spine MRI). which can place the compressive element in clearer view (see Chapter 10. originating in the In addition. ment of the distal upper extremity should be absent. This patient as facet arthropathy or synovitis. in isolation. compatible with an annular fissure. In axial cervical neck pain from degenerative chemical cascade of events involved in the disrup. has been described as a chemical radiculitis As in the lumbar spine.21 The mechanism of pain relates to the incompetent annulus fibrosus. the presence of moderate to high-grade synovitis has a good correlation with Disc Herniations pain generation (Fig. herniation extent (protrusion or extrusion).g. a radicular or referred pain component can often cation and a bright linear signal abnormality in the L5-S1 disc originate from a posterior spinal column source such posteriorly. presented with axial discogenic back pain symptoms and pro.20. fracture instability. patients can also present with clini- cally evident radicular pain or radiculopathy but no evidence of a neural compression lesion on standard recumbent imaging. disc disease or after whiplash injury. and spinous processes. initiating an inflammatory cascade along adjacent nerve roots. paracen. or extraforaminal). Zamani et al22 showed that 40% of already mildly desiccated discs showed an increase in disc bulging when imaged in an erect extended position compared with a recumbent posi- tion. Weishaupt et al23 also observed more instances of disc–neural contact in images obtained in seated position compared with those obtained in the supine position. axial cervical pain can have and can be seen with enhanced studies such as pro. Although the archi- longed sitting intolerance without radicular pain.24.22 Posterior Element Axial Back Pain Other causes of generalized low back pain without Fig. However. For example. joint space narrowing. along and malignancy. many disc herniations may not contact nostic lumbar medial branch blocks followed by RF exiting nerve roots. pain or more worrisome causes (mentioned in the . neck and radiating to the shoulder and medial bor- ated with radicular pain symptoms. MRI with gadolinium contrast. Neural foraminal narrowing in the seated erect position was also significantly associated with increased pain. More worrisome causes of such back uated on axial and sagittal images to categorize the pain include spinal infection. Posterior-column axial pain can be with the location of the herniation (central. but originating der of the scapula. sacroiliac disease.20â•… A sagittal T2-weighted image shows disc desic. components of myofascial injury and facet arthritic vocative discography.

fat- suppressed T1-weighted image shows enhance- ment of the facet joint fluid and of the thickened joint capsule. (a) An axial T2-weight- ed image at the L4-L5 level shows bilateral facet joint effusions. postgadolinium. When symptomatic disease is present in the midst diagnostic cervical medial branch blocks followed by of asymptomatic MRI findings.20 in Chapter 4.€4. imperative to correlate imaging pathology with the eral studies and in a randomized controlled trial for concordant symptomatology and physical examina- cervical facet pain after whiplash injury. especially with facet-loading ■⌀ Summary maneuvers. These findings have a high correlation with pain generation.21â•… Facet synovitis.29–32 tion (see Fig. As with the lumbar spine. and tenderness over the corresponding paraspinal facet regions. A Systematic Approach .’s Synovitis hypervascularity Fig. the clinician faces an RF ablation have been shown to be effective in sev. Patients typically have limited neck range of motion. (b) An axial. 3. confirming the presence of synovitis and facet joint inflammation.64 Iâ•… Initial Considerations a b Paraspinal m. preceding paragraph). (c) A cor- c relative artist’s sketch illustrates several of the key Subchondral bone-marrow edema imaging findings.

the end-plate region. and a decision root irritation exist. In the cervi. several manifestations of nerve findings. findings correspond to the most prominent imaging cal and lumbar spine.╇Modic type-II changes appear bright on by a cervical disc herniation. The most likely nerve root involved is 4.╇ Inferior/inferior disc material B. 5. A patient comes to the clinic complaining D. bar nerve roots exit in the aspect of A. Therefore. the most salient examination guide accurate diagnosis and treatment.╇ Superior/superior tion at L4-L5 D. A. not the with axial discogenic back pain. Select the true statement(s) below: would most likely result in a radicu. osseous overgrowth impingement. whether by a variety of disc her. between patient and physician must be made about niations.╇Modic type-I changes appear dark on T1- of lower back pain and right lower extrem.╇L5 nerve root/posterolateral disc hernia.╇ C6/inferior end-plate marrow. nerve blocks. whereas lum- (select all that apply). C.╇ C6/superior ages and reflect fatty infiltration of sub– B. systematic fashion. Common Clinical Questions 1. to the great toe.╇ C7 and C8 . the foramen. On examination.╇ C8/inferior ages and reflect fatty infiltration of sub– end-plate marrow. but sometimes they do not. the exiting.╇L5 nerve root/posterolateral disc hernia. A C6 disc herniation at the C6-C7 foramen 3.╇ Superior/inferior C. proach through medications.╇ C7/inferior both T1-weighted and T2-weighted im- E. and specifically the first web space. in the cervical spine. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 65 to the Review of Spine MRI Studies). Often. or any combi. spinal which levels or anatomic targets to address first in a stenosis.╇ C6 and C7 disc material E.╇L4 nerve root/posterolateral disc hernia.╇ C7/superior C. C. nerve is most likely to be affected B. disc gical intervention to treat the complexities of spinal herniations.╇L5 nerve root/far-lateral disc herniation A. tion at L5-S1 with caudal migration of A. and sur- of imaging pathology. an anatomic basis of clinical pain symptoms is highly knowledge of the correlative history and physical applicable to the neurologic levels and their patterns examination works in synergy with radiographic of radicular symptoms because both the imaging and findings to guide nonoperative and interventional the examination are complementary data points to treatments. traversing. In these all-too-common cases.╇ C3 and C4 at L5-S1 B. C. often evident pain adequately. both T1-weighted and T2-weighted im- tion and great toe extension.╇ Inferior/superior B. weighted images and bright on T2-weighted ity pain and weakness.╇S1 nerve root/posterolateral disc hernia. the patient E. and facet arthropathies.╇ C5 and C6 tion at L5-S1 with cephalad migration of D. 2. the weighted images and dark on T2-weighted cervical nerves exit in the aspect of images and have the lowest correlation the foramen. fluoroscopically guided many patients present to clinic with combinations spinal injections. sum of the foot. The cervical nerve roots most commonly tion at L4-L5 involved in a disc herniation injury are: D.╇ C4 and C5 E. both T1-weighted and T2-weighted im- A. Knowledge of at multiple levels. RF ablation. Isolating and treating the prima- nation thereof. The MRI could reasonably show aspect of the foramen.╇Modic type-II changes appear dark on D. Sensation is ages and represent sclerotic changes to diminished along the lateral leg and the dor.╇Modic type-III changes appear dark on demonstrates 4/5 strength with hip abduc. including Modic changes. Although many images in this chap. or an incompetent annulus. ry pain generator(s) often requires a multimodal ap- ter show clear pathologic findings at a single level. Intermittent sharp images and have the highest correlation pain is described along the right lateral leg with axial discogenic back pain.╇Modic type-I changes appear bright on T1- lopathy because. Cervical nerve roots commonly exit in the the .

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In exits the foramen under the next lower ver- the lumbar spine. sclerosis-like signal. not the travers- originally described by Modic et al: type I. In this case. therefore. D at the same level of disease. neural foramen. nerve is most likely to be impacted by a inflammatory/edema-like signal abnormali- disc herniation or a disc-osteophyte complex. which herniation or a disc-osteophyte complex. a C6-C7 erative end-plate changes have been shown herniation will affect the exiting C7 nerve. Explanation: Degenerative end-plate changes cervical nerves exit in the inferior aspect of the are classified using an MRI characterization foramen. foramen and impinges on the exiting L5 ates posterolaterally and impinges upon the nerve root (option E). a cervical disc herni. Additionally. not affect the exiting nerve root but. Type-I degen- numbered pedicle. B and D foramen. for this reason. Classically. ing. E symptoms because they likely represent an Explanation: In the lumbar spine. D lad migration of disc material into the neural Explanation: Generally. fat-like signal abnormalities. thy. as in option B. the exiting. the exiting. because most lumbar nerves exit above the same-numbered pedicle. disc herniations are posterolateral. type II. Therefore. Therefore. they do Therefore. the exiting nerve passes im- tebral pedicle. to have the strongest association with pain 2. rather. a far-lateral L5-S1 disc herniation monly affected by disc herniations are would impinge on the exiting L5 nerve root. a disc hernia- tion may also affect the exiting nerve root 5. and The cervical nerves exit above the same- type III. a mediately inferior to the vertebral pedicle and posterolateral L4-L5 disc herniation results in exits the foramen above the interspace level in an L5 radicular pain syndrome or radiculopa- the superior region of the foramen. ties. D. nerve is most likely to be impacted by a disc impinge on the traversing nerve root. reported to be C6 and C7. nerve passes immediately inferior to the ver- 4. as in Explanation: The spinal nerves most com- option D. The cervical the foramen. In contrast to the lumbar region. B. . B tebral pedicle and exits the foramen above Explanation: Cervical nerves exit in the the interspace level in the superior region of inferior aspect of the foramen. nerve root at the inferior aspect of the neural 3. the exiting active inflammatory state. These symptoms stem from impinge- most lumbar disc herniations do not affect the ment of the traversing L5 nerve root by the exiting nerve root but rather impinge on the herniated disc as the nerve root travels in an traversing nerve root. not the traversing. a disc herniation at the L5-S1 level Questions may cause an L5 radiculopathy if a postero- lateral disc herniation extrudes with cepha- 1. 3â•… Common Clinical and Correlative Pain Generators of the Cervical and Lumbosacral Spine 67 Answers to Common Clinical Finally. which exits the foramen inferior direction to exit from the next lower under the next lower vertebral pedicle.

4. Step 2: Evaluation of T2-Weighted Images improved accuracy and reliability in the interpreta- tion of MRI studies. may lead to less accurate uation described in this chapter. The adoption of such a system D. Postgadolinium T1-Weighted Images systematic fashion. and laboratory study results to evaluated. Evaluation of specialized MRI pulse sequences ating an MRI study begins with a systematic approach. identify the most likely differential diagnostic er workstation. Step 4: Evaluation of Specialized Pulse be divided into the following five steps: Sequences 1. III. Step 1: Determination of Pulse Sequences appropriate pulse sequences and imaging techniques Available for Review for the study of a given region or pathologic process. Step 5: Correlation of Imaging Findings with tion of areas of increased T2-weighted signal Patient History and Examination Findings to that are not expected or physiologic Determine the Most Likely Diagnosis 3. Pattern Recognition and personalized method of study evaluation. Postgadolinium T1-Weighted Images 2. that may be specific to the region or disease Less experienced clinicians may have a tendency to process that is being evaluated review imaging studies without paying special at. Steps 1–4 with the patient’s history. Summary proved detection of anatomic detail and cor- relation of the alteration in local and regional anatomy on the T1-weighted images with areas of increased signal intensity on the T2- weighted images As with any new skill. Cervical Spine Example to incorporate a more informal method of evaluating B. Evaluation of T1-weighted images for im- VI. Correlation of the imaging information from tention to the type of pulse sequences that are be. physical ing evaluated or to the plane in which they are being examination. Fat-Suppressed T2-Weighted Images or is to provide the clinician or radiologist with a meth- STIR Images od for evaluating MRI studies in an organized and C. Evaluation of T2-weighted images for recogni- V. Determination of which conventional and A. in conjunction with and less reliable MR study interpretation. Over time. MR Angiography Images early in a clinician’s experience is believed to lead to II. T1-Weighted and T2-Weighted Images The purpose of this more clinically oriented chapter B. Lumbar Spine Example MRI studies and rely more on their own experience C. 5. A. When reviewing MRI studies on a comput. Fat-Suppressed T2-Weighted or STIR specialized MRI pulse sequences are available Images for review B. they may also tend to review only one considerations pulse sequence or one or two imaging planes. the more region. learning the technique of evalu.and concept-specific information 68 . Step 3: Evaluation of T1-Weighted Images The evaluation of an MRI study of the spine can IV. clinicians may be able A. especially early in a clinician’s experience The use of a general technique of MRI study eval- in evaluating MRI studies. Jay Khanna Chapter 1 (Essentials of MRI Physics and Pulse Chapter Outline Sequences) provided a summary of the technical foundation that radiologists often use to select the I. These shortcuts. 4 A Systematic Approach to the Review of Spine MRI Studies A.

Recognizing these values gorithms and processes are used to “suppress” the may enable the clinician to determine whether signal that is coming from fat. • Recognition of an area within an image that is known to contain fluid. such as CSF (Fig. “darker” than images obtained via other techniques nique or similar techniques are used. Specifically. which are using techniques similar to those for conventional often printed on the film or are visible on the T2-weighted images. the suppression of signal from fat in either of these tional details. such sequences include at least T1-weighted and conventional T2-weighted images. including the following: • Fat-suppressed T2-weighted images or STIR images Fig. If the TR areas of edema with markedly greater conspicuity . that image is likely T2-weighted. With newer and is T1-weighted or T2-weighted using the following more variable pulse sequences. 4. If this fluid is noted to be bright or of high signal Fat-Suppressed T2-Weighted Images intensity. For patients with spinal deformities such as scoliosis. which may other- images. Fat-suppressed T2-weighted images are acquired • Recognition of the TR and TE values. In addition to conventional T1-weighted and T2- weighted pulse sequences. • Postgadolinium T1-weighted images Note that the CSF is of high signal intensity.2).€4. 4â•… A Systematic Approach to the Review of Spine MRI Studies 69 provided in subsequent chapters. T1-Weighted and T2-Weighted Images the image likely is T1-weighted. ■⌀ Step 1: Determination of Pulse Sequences Available for Review The first step in the evaluation of an MRI study is to determine which pulse sequences are avail- able for review.€4. When this tech. this method techniques: may be less reliable. the images tend to appear quite a bit Physics and Pulse Sequences). will help improve a clinician’s ability to interpret MRI studies of the spine accurately. see Chapter 1. this technique and is unable to use the technique in which facilitates the evaluation of bone-marrow edema and fluid recognition allows the differentiation of edema secondary to other pathologic processes.† • MR angiography images number is noted to be in the hundreds range. this suppressed T2-weighted images or STIR images show technique is a good second option. the One should be able to determine whether an image image likely is T2-weighted. and then various computer al- workstation screen. A more “pure” way of an image is T1-weighted or T2-weighted. images case the signal from fat is not acquired. acquired in the sagittal and axial planes. If the clinician evaluates the image wise be missed (Fig. In achieving this goal is to acquire a STIR image.1). If the TR num- ber is found to be in the thousands range. Because of are acquired using an SE technique (for addi. Essentials of MRI techniques. in which most institutions and in most cases. Fat- T1-weighted and T2-weighted images. images may also be obtained in the coronal plane.1â•… A sagittal T2-weighted image of the cervical spine. If or STIR Images the region of the fluid is noted to be dark. the TR (such as conventional T2-weighted images) and thus value is usually 300 to 800 ms for T1-weighted help accentuate the increase in T2-weighted signal images and 2000 to 5000 ms for T2-weighted (relative to the adjacent tissues). that image is likely T1-weighted. For most cases. there are other pulse se- quences that are often acquired and that should be recognizable.

they should be viewed in sequential order. degenerative or congenital scolio- es (see individual chapters for applications of these sis). plane by plane. The same process bral compression fracture. aside from the pathologic After the clinician has identified all of the T2- fluid. the clinician should evaluate the areas in which one may expect to find physiologic fluid. the technique of TR evaluation described previously can also be used to differentiate a postÂ� gadolinium T1-weighted image (TR is in the hun- dreds range) from a T2-weighted image (TR is in the thousands range).€4. or scar. then the images are T2-weighted. If this fluid seems to be dark.3).70 Iâ•… Initial Considerations typically obtained for the evaluation of infection. a finding quite obvious (Fig. whereas a fat-suppressed should be used when evaluating an imaging study on T2-weighted image or a STIR image would make such a computer workstation.2â•… A sagittal STIR image of the thoracolumbar spine T2-Weighted Images accentuates the edema along the track (arrow) of a stab injury to the conus medullaris. sagittal T1-weighted or T2-weighted images starting with all sagittal images. it may be best to begin with the coronal T2- techniques for region-specific pathology). evaluate the sagittal T2-weighted imag- Postgadolinium T1-weighted images and fat-sup. then the image is likely a postgadolinium T1-weighted image.g. such as CSF in the spine. the clinician should begin with sagittal T2-weight- ed images of the cervical or lumbar spine. These latter images are also useful for determining whether a vertebral compression fracture represents a chronic fracture Cervical Spine Example or an acute or subacute fracture (Fig. These images are obviously different in appearance from the im- ages acquired using the more conventional pulse se- quences and MRI techniques. In addition. A description of the evaluation of the cervical spine serves as an illustrative example. These images can sometimes be confused with T2-weighted images because they may show areas of increased signal in the presence of pathology (Fig. In almost all instances. Specifically. As an example. ■⌀ Step 2: Evaluation of Fig. and the pathology seems to be bright.5). es. and then all coronal images. In rare instances. If this fluid is bright. Ensure that all of the sagittal T2-weighted pressed postgadolinium T1-weighted images are images are being visualized in order from one . this image is quite “dark.4).€4. tures. the distinc- tion can be made using the techniques just outlined. such as for the patient with a spinal than that seen on conventional T2-weighted imag- deformity (e. weighted images. the hydrated discs in this young patient. in the evaluation of a patient with If the images are being evaluated as films on a back pain secondary to vertebral compression frac- light box. MR Angiography Images MR angiography images highlight the blood ves- sels and enable evaluation of the arterial and ve- nous vascular structures (see Chapter 10. then all axial im- may not show edema in an acute or subacute verte- ages. Postgadolinium T1-Weighted Images • First. Note that. tu- mor.€4. 4.3). Advanced Techniques in Spine MRI) (Fig.€4.”† evaluated. and the CSF weighted images. they should be systematically within the spinal canal. postsurgical changes..

84(suppl 2. Kostuik JP. (b) The associated postgadolinium T1-weighted image shows that the mass has uniform contrast enhancement. 4. (b) A sagittal STIR image shows that the T6 ver- tebral compression fracture has increased signal compatible with edema within it. Magnetic resonance imaging of the cervical spine: current techniques and spectrum of disease. 2002. (From Khanna AJ. 4â•… A Systematic Approach to the Review of Spine MRI Studies 71 Fig.) . which is repre- sentative of an acute or subacute fracture. pt 2):70–80.† a b a b Fig. III. Was- serman BA. This mass was found to be a schwannoma.3â•… Vertebral compression fracture. (a) A pregadolinium sagittal T1-weighted image shows an intradural-extramed- ullary mass at the C5-C6 level.4â•… Postgadolinium contrast enhancement. (a) A sagittal reconstructed CT image shows vertebral compression fractures at the T6 and T8 levels. The T8 vertebral compression fracture shows no increase in signal within it. which is compatible with a chronic vertebral compression fracture. Reprinted by permission. Kebaish KM. Carbone JJ. J Bone Joint Surg Am. Riley LH. Cohen DB. 4.

evaluate all of the images in expected course of the right vertebral artery (arrowheads). the next sequential number after that on the previous sheet.9). stenosis.72 Iâ•… Initial Considerations –â•fi The only way to be 100% positive about which side of the cervical spine is being visualized is to evaluate the coronal local- izing pulse sequence. The other way to determine whether a specific pathologic finding (for example. An- line image by noting that the spinal cord is other option is to “link” the sagittal and seen in its entirety (in the patient without axial images with the available image- scoliosis).€4. the cervical spinal cord. ies in the subaxial cervical spine. contains lines corresponding with num- • Next. sequence to view the cervical spinal cord Note the normal course of the left vertebral artery (arrows). –â•fi Confirm that the midline image is being evaluated by noting the basion and opis- Lumbar Spine Example thion at the foramen magnum. a disc herniation) is right or left or paracentral is to correlate the sagittal images with the findings seen on the axial images. of the spinal level being evaluated. which (Fig. In addi- The same technique just described for the cervical tion. es. descending from the left. • First.8). look for the midline image (Fig. recognize the –â•fi Each institution has its own convention as midline image by noting that the spinal to whether the images for sagittal images cord is seen in its entirety (in the patient are acquired from left to right or right to without scoliosis). continue the review to the left or right side to the other. look for the midline image (Figs. recognize the mid. extending from the midbrain to viewing software so that a line on the the upper thoracic spine. image. • Next. evaluate the sagittal T2-weighted imag- cess is seen in profile with its domed tip.€4. –â•fi For the lumbar spine. and the odontoid pro. thoracolumbar spine to the level of L1-L2 . correlating the axial image number side to the other (in this case.6).10). which often displays numbers that correspond to the numbers seen on the sagittal images. 4. sagittal midline image shows the level of –â•fi Visualize the CSF anterior and posterior to the axial image. from left to right) with the sagittal localizing image. evaluate all of the axial T2-weighted im- ages from the OCJ to the lower cervical spine (Fig.7 and bers that indicate the level of the axial 4.5â•… An MR angiogram (anterior view) from a 2D time. vertebral bodies are seen as rectangular or square structures. side to evaluate for foraminal or lateral recess • Next. –â•fi The only way to ensure that all of the im- ages are seen in sequence and that none is missed is to look at the image numbers on the printed film or on the workstation screen and to confirm that the image num- ber at the beginning of one sheet of film is.€4.† and note that there is CSF (bright signal) around it and adequate space available for the nerve roots at the neural foram- ina. –â•fi Confirm the location at the OCJ by noting that the odontoid process appears different from the remaining cervical vertebral bod- Fig. indeed.€4. Ensure that all of the sagittal T2-weighted • After evaluating all of the structures in the images are being visualized in order from one midline. the spine can also be used for the lumbar spine. of-flight acquisition shows absence of signal intensity in the –â•fi Finally. will ensure accurate identification –â•fi For the cervical spine. the fourth ventricle is visualized.

The midline image (c) should be identified. These T2-weighted images should be viewed in order from (a) left to (e) right. 4.† . 4â•… A Systematic Approach to the Review of Spine MRI Studies 73 a b c d e Fig.6â•… Sequential sagittal imaging of the cervical spine.

and fourth ventricle are seen in profile. 4. 4. Cricoid cartilage C7 spinous process T1 spinous process a b Tracheal rings T1 vertebral body Fig. (dens) Lamina (C2) Epiglottis Spinal cord Liga- Hyoid mentum nuchae Glottis Trapezius m. CSF is seen anterior and posterior to the spinal cord.7â•… A midline sagittal T2-weighted image of the cervical spine. Thyroid cartilage Splenius capitis m. Transverse lig. and the vertebral bodies. Cerebellum Posterior Anterior arch of atlas (C1) arch of atlas (C1) Rectus capitis m. Odontoid Oblique process capitis m.† . Note that the spinal cord is seen in its entirety. and anterior and posterior longitudinal ligaments.74 Iâ•… Initial Considerations Fig. odontoid process.8â•… This (a) sagittal T1-weighted midline image and (b) artist’s sketch of the cervical spine depict the cervical spinal cord. as well as the anterior and posterior elements of the cervical spine and the intervertebral discs. CSF.

† . 4.9â•… Sequential axial imaging of the cervical spine. These T2-weighted images should be viewed in order from (a) C6 to (f) T1. 4â•… A Systematic Approach to the Review of Spine MRI Studies 75 a b c d e f Fig.

76 Iâ•… Initial Considerations

–â•fi As with the cervical spine example just
discussed, the only way to be 100% positive
about which side of the lumbar spine is
being visualized is to evaluate the coronal
localizing pulse sequence, which often
displays numbers that correspond to the
numbers seen on the sagittal images. The
other way to see whether a specific patho-
logic finding (for example, a disc hernia-
tion) is right or left or paracentral is to cor-
relate the sagittal images with the findings
seen on the axial images.
• Next, evaluate all of the axial T2-weighted
images from the lumbosacral junction to
L4-L5 (Fig.€4.12), to the upper lumbar spine
(Fig.€4.13).
–â•fi As with the cervical spine example dis-
cussed previously, the only way to ensure
that all of the images are seen in sequence
and that none is missed is to look at the
image numbers on the printed film or on
the screen and to confirm that the image
number at the beginning of one sheet is
the next sequential number after that on
the previous sheet.
–â•fi Confirm the location at the lumbosacral
junction by noting that the sacrum ap-
pears different (similar to Napoleon’s hat;
see Fig.€4.14) from the remaining lumbar
Fig. 4.10â•… A midline sagittal T2-weighted image of the lum- vertebral bodies in the lumbar spine.
bar spine. Note that the spinal cord is seen in its entirety; CSF –â•fi Finally, evaluate all of the images in se-
is seen anterior and posterior to the spinal cord; and the verte- quence to view the neural structures in the
bral bodies and sacrum are seen in profile.† lumbar spine (spinal cord, conus medul-
laris, and cauda equina) and note whether
there is CSF (bright signal) around them
and adequate space available for the nerve
(which is the typical location of the conus roots at the neural foramina. Correlating
medullaris). the axial image number with the sagit-
–â•fi Visualize the CSF anterior and posterior to tal localizing image, which contains lines
the spinal cord and around the nerve roots corresponding with numbers that indicate
of the cauda equina in the lumbar spine the level of the axial image, will ensure
below the conus medullaris. accurate identification of the level being
–â•fi Confirm that the midline image is being evaluated. Another option is to “link” the
evaluated by noting the spinal cord and sagittal and axial images with the available
conus medullaris. Additionally, the sacrum image-viewing software so that a line on
should be seen in sagittal cross-section the sagittal midline image shows the level
with a normal AP length equal to that of of the axial image.
the L5-S1 disc and the other interverte-
bral discs of the lumbar spine. Lastly, the
lumbar vertebral bodies should be seen as Pattern Recognition
square or rectangular structures.
• After evaluating all of the structures in the The next step is to evaluate for any areas of increased
midline, continue the review to the left or right T2-weighted signal that should not have increased
side to evaluate for foraminal or lateral recess T2-weighted signal. This evaluation may be rela-
stenosis (Fig.€4.11). tively easy for a clinician with extensive experience
–â•fi Each institution has its own convention as in evaluating MRI studies of a particular region. Most
to whether the images for sagittal images clinicians would agree that in determining these ar-
are acquired from left to right or from right eas of increased T2-weighted signal, they tend to use
to left. a gestalt method. However, for the less experienced

4â•… A Systematic Approach to the Review of Spine MRI Studies 77
Anterior
longitudinal lig. L1-L2 intervertebral
L1
foramen

L1-L2 disc

L2

L3

Pedicle
L4
(L3)
vertebral
body
Spinous
L4 exiting process
spinal (L3)
n. root
Lamina
(L3)

L5 vertebral
body

a b S1

Fig. 4.11â•… This (a) parasagittal T2-weighted image and (b) artist’s sketch of the lumbar spine show the neural foramina and exiting
nerve roots at multiple levels.†

Fig. 4.12â•… An axial T2-weighted MR image at the level of the L4-L5
intervertebral disc shows the cauda equina, L4 spinal nerve root, and
L4 dorsal root ganglion. Normal flow voids are seen within the common
iliac arteries, just below the aortic bifurcation.†

78 Iâ•… Initial Considerations
Anterior
a b L1-L2 longitudinal lig.
disc space Aorta

Inferior
vena cava Posterior
longitudi-
nal lig.
Right
kidney

Exiting Dural sac
spinal
n. root
Transverse
process Conus
medullaris
Superior
articular
facet Ligamentum
flavum
Longissimus
m.

Iliocostalis m.
Rotatores m.
Spinalis m. Spinous process
Multifidus m.
Semispinalis m.

Fig. 4.13â•… This (a) axial T2-weighted image and (b) artist’s sketch of the spine at the level of the L1-L2 intervertebral disc show
the conus medullaris and the L1 spinal nerve root, as well as the superior and inferior articular processes of the L1-L2 facet joint.†

remember exactly where the increase in T2-
weighted signal was seen.
–â•fi Increased T2-weighted signal outside of
that pattern on the current study may rep-
resent an area of pathology.
–â•fi This technique of pattern recognition is
commonly used by experienced radiolo-
gists to read imaging studies. Although
clinicians tend to use this technique for in-
office patient evaluation, it may or may not
be a safe and effective technique.1
• The other method that one can use to evaluate
for areas of abnormal increased T2-weighted sig-
Fig. 4.14â•… An axial T2-weighted image of the sacrum at the nal is to note all areas of increased T2-weighted
S1 level shows the “Napoleon’s hat” configuration of this level. signal within a given image and then ask oneself
whether water does, indeed, “belong” in that area.
For example, if the sagittal T2-weighted images
of a cervical spine MRI study are being evaluated
clinician or the clinician in training, several tech-
and a small region of high signal is seen within
niques can be used to determine whether or not
the spinal cord (an anatomic structure that is
an area should show increased T2-weighted signal.
obvious to even the least experienced clinician),
These techniques rely on the concepts of pattern rec-
then one may assume that it represents fluid (or
ognition and experience:
edema) within the spinal cord (Fig.€4.15). The
• Recall the evaluations of the last 20 to 50 MRI question, then, is whether it is a normal (physi-
studies of the region of interest and attempt to ologic) or an excessive (pathologic) amount

4â•… A Systematic Approach to the Review of Spine MRI Studies 79

nicians and radiologists is declining. Nevertheless,
the most appropriate way to evaluate an MRI study
fully and most effectively is to review all of the im-
ages and pulse sequences.
Therefore, after identification of the pulse se-
quences obtained (Step 1) and evaluation of the T2-
weighted images (Step 2), the next step is to review
the T1-weighted images for improved evaluation of
anatomic detail. This author’s routine is to corre-
late the areas of increased T2-weighted signal seen
during the very detailed and systematic evaluation
of the T2-weighted images just described with the
same region on the T1-weighted images. The im-
proved spatial resolution of the T1-weighted images
facilitates the evaluation of regional and local dis-
turbances in anatomic detail. For example, if a sagit-
tal fat-suppressed T2-weighted image of a vertebral
compression fracture shows a somewhat indistinct
area of increased T2-weighted signal within a verte-
bral body, the clinician may decide that it represents
a vertebral compression fracture, but the clinician
may also consider the possibility of other diagno-
ses such as tumor or infection. However, a relatively
sharp and discrete fracture line seen within the sag-
ittal T1-weighted image would likely leave no doubt
in the clinician’s mind that it represents a fracture
and not some other process.
In addition, the T1-weighted images may help the
Fig. 4.15â•… A sagittal T2-weighted image shows a large cen- clinician determine the type of tissue that is pres-
tral disc extrusion at the C5-C6 level with associated increased ent in a lesion. Central to this concept is the fact that
cord signal intensity (arrow) compatible with myelomalacia.
T1-weighted images tend to show fat as bright signal
Note the elevation of the posterior longitudinal ligament
(arrowhead).† and fluid as dark signal. Therefore, lesions such as a
lipoma are noted to be bright on T1-weighted im-
ages and, in fact, follow the signal of subcutaneous
fat on all pulse sequences, including fat-suppressed
or STIR pulse sequences. As another example, one of
of fluid. The ability to make this determination the few lesions that is bright on both T2-weighted
comes from experience (i.e., the recognition of and T1-weighted images is a hemangioma, which is
lack of such a region of increased T2-weighted often seen in the vertebral body (Fig.€4.16). Thus, if
signal within the spinal cord on many previous the lesion is seen to be bright on both of these images
studies of other patients) or from a developed and displays the typical pattern of striations, the di-
fund of knowledge (such as the review of Chap- agnosis of vertebral body hemangioma can be made
ter 6, The Cervical Spine) that would enable the with relative certainty.
clinician to develop a focused differential diagno- Like T2-weighted images, T1-weighted images
sis for this finding. should be evaluated in all planes and in the same se-
quence as described in Step 2.

■⌀ Step 3: Evaluation of ■⌀ Step 4: Evaluation of
T1-Weighted Images Specialized Pulse Sequences
T1-weighted images enable optimal evaluation of
anatomic detail. However, with current improve- Fat-Suppressed T2-Weighted
ments in MRI techniques and equipment, including or STIR Images
dedicated surface and other coils, T2-weighted im-
ages also often show excellent anatomic detail. This The fat-suppressed T2-weighted or STIR pulse se-
improvement may be the reason that the author be- quences are used to accentuate the increase in sig-
lieves the routine use of T1-weighted images by cli- nal and edema seen in pathologic processes such as

80 Iâ•… Initial Considerations

a b

Fig. 4.16â•… These sagittal (a) T1-weighted and (b) T2-weighted images show a lesion at the T12 level with high signal intensity on
both images and with the typical striations compatible with a vertebral body hemangioma. An incidentally noted vertebral com-
pression fracture is seen at the L1 level.†

fracture, infection, and tumor. On conventional T2- suppressed T2-weighted images can be used to evalu-
weighted images, the signal from bone-marrow fat is ate for nondisplaced fractures and to determine the
maintained, and one attempts to recognize edema by approximate age or chronicity of fractures, including
noting the presence or absence of a very bright re- vertebral compression fractures.
gion (marrow pathology or edema) within a bright
background (fatty marrow) (Fig.€4.17a). On fat-sup-
pressed T2-weighted images, all of the subcutane- Postgadolinium T1-Weighted Images
ous, bone-marrow, and other fat is suppressed, and
one can more easily recognize an area of edema as a Postgadolinium T1-weighted images are often ac-
bright region within a dark background (Fig.€4.17b). quired to evaluate for the presence or absence of
This author considers fat-suppressed T2-weighted infection and tumor and to assess the postoperative
and STIR images to be somewhat like a three-phase spine. For example, postgadolinium T1-weighted im-
nuclear scintigraphy (bone scan) study (see Chapter ages can help differentiate recurrent disc herniation
11, Correlation of MRI with Other Imaging Modali- from epidural fibrosis and scar (Fig.€4.18). The rec-
ties), which is relatively sensitive to increased bone ommended method for evaluating these images is to
turnover but not very specific. Similarly, if a region is place the postgadolinium T1-weighted images side
evaluated with fat-suppressed T2-weighted imaging by side with the pregadolinium T1-weighted im-
or STIR imaging and there is no area of increased sig- ages. The region of interest is then compared in the
nal, one can be somewhat reassured that a pathologic same planes and on matching images. Higher signal
process is not present in that region. Conversely, if intensity in the region or structure of interest on the
an area of increased signal is noted, it may represent postgadolinium T1-weighted images is termed post-
pathologic change or a normal region of increased gadolinium (or contrast) enhancement. An evalua-
signal such as physiologic fluid within a facet joint tion can then be made with regard to the degree and
or CSF. Other pulse sequences, such as T2-weighted pattern of enhancement. For example, peripheral
and T1-weighted images, provide better anatomic rim enhancement with a central region of nonen-
detail for evaluation and help the clinician identify hancement in a relatively well-circumscribed lesion
a more specific diagnosis. As discussed previously is considered, in the appropriate clinical setting, to
and in the subsequent region-specific chapters, fat- be a finding suggestive of an abscess.

4â•… A Systematic Approach to the Review of Spine MRI Studies 81

a b

Fig. 4.17â•… Vertebral compression fracture. (a) A sagittal T2-weighted image of the lumbar spine shows an L1 vertebral body com-
pression fracture of an indeterminate age, given that edema is not definitely seen. (b) A sagittal STIR image of the same patient
shows edema within the L1 vertebral body, which is compatible with an acute or subacute vertebral compression fracture.

It is essential that clinicians use this advantage to help
■⌀ Step 5: Correlation of Imaging maximize the accuracy and reliability of their MRI in-
Findings with Patient History terpretations. This point is especially true for the eval-
and Examination Findings to uation of patients with spinal pathologies because it is
well known that many patients with pathology seen
Determine the Most Likely on their spine MRI studies are asymptomatic,2–5 and
Diagnosis it is imperative that the clinician treat the patient and
not just the MRI findings.
Clinicians and radiologists have distinct advantages The author believes that an accurate diagnosis,
and disadvantages relative to one another in terms of or differential diagnosis, occurs at the “intersection”
evaluating MRI studies of the spine. Radiologists have of a patient’s history, physical examination results,
the advantage of often being trained with a process radiographic findings, and laboratory study results
similar to the one just described and frequently have, (Fig.€4.19). With an understanding of the clinical
and take, the time to evaluate the images in a system- scenario, clinicians can arrive at an accurate diag-
atic fashion. However, clinicians have the advantage of nosis, especially when they are armed with the ap-
knowing the patient’s history and physical examina- propriate techniques for evaluating the MRI studies.
tion findings, laboratory results, and other parameters. One way to leverage the strengths of clinicians and

(b) T1-weighted. However.g. if a patient with scan. the diagnosis of a vertebral compression to evaluate further the osseous anatomy in both pa- fracture can be suggested. The second patient might also benefit from edema has a linear appearance on the T2-weighted a primary malignancy survey. set of low back pain (particularly at night). Note that the disc is difficult to see on (b) the T1-weighted image and shows peripheral enhancement on (c) the postgadolinium T1-weighted image. and a CT-guided biopsy.18â•… Recurrent lumbar disc extrusion. if a patient presents with low back a history of a primary malignancy. To help determine the correct region of increased STIR signal within the T12 ver. similar imaging findings presents with no history proach to the evaluation of patients with complex of trauma. and the MR image shows a differential diagnosis. (d) Axial T2-weighted. and (c) postgadolinium T1-weighted imag- es in a patient with a history of previous L4-L5 discectomy show a large disc extrusion (arrow on each) that has migrated proximally and is located behind the L4 vertebral body. metastatic disease) might be higher on the racolumbar junction.. the clinician would likely obtain a CT scan tebral body. especially if the region of tients.82 Iâ•… Initial Considerations a b c d e f Fig. is elderly. and has For example. sis (e. another diagno- pain after trauma and is point-tender at the tho. a three-phase bone and T1-weighted images. . 4. diagnosis. (a) Sagittal T2-weighted. and (f) postgadolinium T1- weighted images at the L4-L5 level show the left paracentral extradural lesion (arrows on each) that appears to be disc material on (d) the T2-weighted image and shows peripheral enhancement on (f) the postgadolinium T1-weighted image compared with (e) the pregadolinium T1-weighted image. (e) T1-weighted.† radiologists is to use a collaborative and team ap. has a history of insidious on- spinal pathologies.

╇Greater knowledge of the range of the various disease processes that can affect the spine D. (a) In a patient for whom the A. quence and correlate the image number HNP. T2-weighted images provocative tests D.╇ Axial.╇Determine the level based on the size of it is difficult to identify a diagnosis or to narrow a differential diagnosis. 4. herniated nucleus pulposus.╇ Axial.╇Tendon D. physical examination.19â•… The concept of intersecting lines for diagnosis nal level of an axial image in the lumbar spine? and surgical decision making. Evaluation of what structure or region will enable one to differentiate T1-weighted and a T2-weighted images? A. imaging findings.C6 C5 pulse sequences by viewing an image. B. T1-weighted images Response to injections. what is the best way to confirm the spi- Fig.╇Greater likelihood of being able to cor- relate the imaging findings with patient’s history and physical examination findings to determine the most likely diagnosis E.╇Bone gh tC 6 C.╇ Increased T2-weighted signal C.╇Determine the level based on the shape history. C. One should begin the interpretation of an MRI Ph y ing ag Im study of the cervical or lumbar spine with which imaging plane and pulse sequence? A.╇ Loss of signal on all pulse sequences B. for a patient with a smaller region of the spinal canal intersection.╇CSF pa ak in we P HN E. What is the primary advantage that clinicians have relative to radiologists when evaluating MRI studies of the spine? A. fracture. C. D.╇ B and D c 5. E. and response of the vertebral body to provocative tests do not “intersect” within a small circle.╇ C and D . T1-weighted images B. Aside from “counting” levels up from the sa- crum.╇“Link” the sagittal and axial images with the available image-viewing software so that a line on the sagittal midline image demonstrates the level of the axial image.╇ Sagittal. 3. Conversely. What is the most common MRI manifestation Good but temporary response to provocative tests of almost all pathology such as tumor.╇Utilize the sagittal localizing pulse se- one may expect to see a C5-C6 disc protrusion on MRI (c). on the axial image with those on the localizing pulse sequence/image.╇ Better understanding of spinal anatomy B.╇Muscle Ri B. T2-weighted images E. such as one with a right C6 radiculopathy (b).╇ Increased T1-weighted signal E. or infection in the spine? A.╇ Sagittal. T2-weighted images 2.╇ Increased signal on all pulse sequences 4.╇ Decreased T2-weighted signal b D. 4â•… A Systematic Approach to the Review of Spine MRI Studies 83 Common Clinical Questions cal Hi ysi st or 1.╇It is not possible to differentiate these two C6 .╇Greater likelihood of having formal train- ing in the evaluation of MRI studies C.╇ Coronal.

tient with a spinal deformity (e. J Bone Joint Surg Am 2001. clinicians have the advantage of knowing the patient’s history and physical ex- amination findings. Boden SD. Teresi LM.84 Iâ•… Initial Considerations ■⌀ Summary Answers to Common Clinical Questions In summary.50(4):613–628 PubMed represents the edema (free extracelluar fluid) ╇4. and configuration of the vertebral body or spinal canal are not reliable methods of determining a spinal level. and frequently have.g. the clini- strongly believes that such a systematic technique cian should begin with the midline sagittal should be used for the evaluation of all MRI stud. Ab. and other parameters. the time to evaluate the images in a systematic fashion. of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven. shape. it may be best to not reported by the radiologist. et al. One ad. This author Explanation: In almost all instances. 2007 3. asymptomatic subjects. time. J Bone fracture. Bogduk N. Reicher MA. which provides MRI study using this technique and then to evalu. Explanation: The most common MRI manifes- normal magnetic-resonance scans of the lumbar spine in tation of almost all pathology such as tumor. 5. this method of checking one’s own evaluation 2. The size. and take. O’Mara JW Jr. Lufkin RB. flin. One can correlate the image number on the axial image with that on the localizing pulse sequence/image or “link” the sagittal and axial images with the available image-viewing software so that a line on the sagittal midline image shows the level of the axial image. 1. that image is likely T2-weighted. . In rare instances. Asymptomatic one another in terms of evaluating MRI studies of degenerative disk disease and spondylosis of the cervical the spine. will allow one to differentiate T1-weighted evaluate MRI studies accurately. Davis DO. et al. How Doctors Think. If the region of the References fluid is noted to be dark. Groopman J.164(1):83–88 PubMed ten being trained. T1-weighted. 4. degenera- Occasionally. the best way to confirm the spinal level of an axial image in the lumbar (or cervical) spine is to use the localizing sagittal pulse sequence.72(3):403–408 PubMed er structure in the musculoskeletal system) ╇3. the clinician notes findings that were tive or congenital scoliosis). Boden SD. Radiol is increased T2-weighted signal because it Clin North Am 2012. Boston: Houghton Mif. E Explanation: Aside from “counting” levels up from the sacrum. the five-step technique described in this chapter will help guide the clinician in systematical. such as likely result in a continuously improving ability to CSF. such as for the pa- the degree of correlation between the two readings. and T2-weighted images. Over begin with the coronal T2-weighted images.. C ly evaluating MRI studies of the spine. CSF and the neural elements provides a my- ditional suggestion is to always attempt to read the elographic view of the spine. Borenstein DG. Radiologists have the advantage of of- spine: MR imaging. A prospective investigation.83-A(9): Explanation: Clinicians and radiologists have 1306–1311 PubMed distinct advantages and disadvantages relative to ╇5. It is essential that clinicians use this advantage to help maximize the accuracy and reliability of their MRI interpretations. D year follow-up study. B ╇2. Wiesel SW. However. The value that is common to most pathologic processes. If this fluid is noted to be bright or of high signal intensity. that image is likely ╇1. Patronas NJ. or infection in the spine (or any oth- Joint Surg Am 1990. Radiology 1987. T2-weighted images of the cervical or lumbar ies and that the tendency to become less meticulous spine because the high contrast between the and systematic over time should be avoided. Degenerative joint disease of the spine. and vice versa. Dina TS. a good “overview” of the condition of the ate the “official” radiologist’s reading to determine spine. D against that of another trained specialist will serve as Explanation: Recognition of an area within an a method of quality control and assurance and will image that is known to contain fluid. laboratory results.

IIâ•…Spine

5 The Occipitocervical Junction
Colin M. Haines, A. Jay Khanna, John A. Carrino, Shih-Chun David Lin,
and Joseph R. O’Brien

mentous attachments, rather than its intervertebral
Chapter Outline discs, are the basis of its stability.2,3 An understand-
ing of occipitocervical craniometry adds value in the
I. Occipitocervical Craniometry
diagnosis of pathology at the OCJ. The treatment of
II. MRI Anatomy and Imaging Protocols pathologic conditions involving the OCJ requires a
III. Pathology of the OCJ thorough understanding of osseous, ligamentous, and
A. Primary/Congenital Conditions neurovascular anatomy (see Chapter 2, Normal Spine
1. Congenital Anomalies of the Occiput MRI Anatomy). Most orthopedic surgeons without
2. Congenital Anomalies of the Atlas advanced training in spine surgery do not have a great
deal of experience in evaluating and treating pathol-
3. Congenital Anomalies of the Axis
ogy in this area. However, the ability to recognize the
4. Chiari Malformations most common abnormalities in this region is impor-
5. Klippel-Feil Syndrome tant so that the patient can be referred appropriately
B. Acquired Conditions for treatment, if needed.
1. Basilar Impression
2. RA/Cranial Settling
C. Neoplasms ■⌀ Occipitocervical Craniometry
1. Primary Osseous/Extradural Tumors
2. Intradural-Extramedullary Tumors The OCJ may be imaged with conventional radiogra-
3. Intramedullary Tumors phy, MRI, and CT to evaluate pathologic conditions.4–8
Although normal relationships were originally de-
IV. Miscellaneous
fined with radiographs,7,9–11 many of these relation-
A. Down Syndrome ships and lines are also used with MRI (Table€5.1 and
B. Trauma to the OCJ Fig.€5.1), which offers more clarity and accuracy.8
1. Occipitocervical Trauma Wackenheim’s clivus baseline aids in diagnos-
2. Trauma to the Atlas ing superior migration of the odontoid. The line is
3. Trauma to the Axis formed by creating a line along the rostral surface
of the clivus11; protrusion of the odontoid tip above
4. Traumatic Spondylolisthesis of the
or posterior to this line is considered abnormal. The
Axis
clivus canal angle is formed by intersecting Wacken-
V. Summary heim’s line and a line connecting the posterior ver-
tebral bodies. In extension, 180 degrees is normal;
in flexion, 150 degrees is normal. Chamberlain’s line
is drawn between the hard palate and the opisthion
The OCJ, also termed the craniovertebral junction in (posterior lip of the foramen magnum), with >3 mm
the literature, refers to the articulations among the of dens protrusion indicating abnormality.9 Use of
occiput (C0), atlas (C1), and axis (C2). The OCJ is highly this line may be limited by the difficulty in identify-
mobile, with ~50% of cervical flexion–extension and ing the hard palate and the margin of the opisthion
rotation coming from the C0-C1 and C1-C2 articula- on the lateral radiograph. McGregor’s line is drawn
tions, respectively.1 This region’s strong capsuloliga- from the hard palate to the most inferior point on

87

88 IIâ•…Spine

Table 5.1â•… Anatomic relationships and lines for use with MRI, CT, and conventional radiography†
Eponym Parameters Abnormality
Wackenheim’s clivus baseline Tangent drawn along the superior surface Dens should be below line.
of the clivus
Clivus canal angle Angle formed between Wackenheim’s line Normal ranges are 180 degrees in extension
and the posterior vertebral body line to 150 degrees in flexion. An angle of
<150 degrees is considered abnormal.
Chamberlain’s line Between the hard palate and opisthion Protrusion of the dens >3 mm above this line
is considered abnormal.
McRae’s line From the basion to the opisthion Protrusion of the dens above this line is
considered abnormal.
McGregor’s line From the hard palate to the most caudal Odontoid process rising >4.5 mm above this
point on the midline occipital curve line is considered abnormal.
Ranawat’s criterion Distance between the center of the pedicle Measurement of <15 mm in males and
of C2 and the transverse axis of C1 <13 mm in females is abnormal.
Welcher’s basal angle Tangent to the clivus as it intersects a tan- The normal range is 125 to 143 degrees.
gent to the sphenoid bone Platybasia exists when the basal angle is
>143 degrees.

the midline occipital curve.10 If the odontoid pro-
cess rises >4.5 mm above this line, it is considered ■⌀ MR Anatomy and
pathologic.10 Difficulty in identifying the hard palate Imaging Protocols
can limit the use of this line, but use of the occiput
can be easier than use of the opisthion. McRae’s line MRI has enabled the detailed study of the normal
is drawn from the opisthion to the basion (anterior anatomy17 and the pathology8,18,19 of the OCJ. The wide-
lip of the foramen magnum), and any rostral odon- spread use of MRI for studying this area has resulted
toid elevation above this line is pathologic.12,13 Again, in part from its ability to image directly in the sagit-
identification of the opisthion may be difficult on the tal and coronal planes.20 Previously, detailed study of
lateral radiograph. The Ranawat’s criterion is calcu- the OCJ required the use of polytomography or thin-
lated by measuring the distance between the center section CT with coronal and sagittal reconstructions
of the pedicle of C2 and the C1 transverse axis.14 In rather than images obtained directly in the coronal or
men, <15 mm is abnormal; in women, <13 mm is sagittal planes.21 In general, MRI produces images in
abnormal.14 which cortical bone has a low signal on T1-weighted
Platybasia is measured by drawing Welcher’s basal and T2-weighted images. However, low signal intensi-
angle15 (Fig.€5.2). This condition, originally described ty does not limit the usefulness of MRI in studying the
by Virchow16 to denote flattening of the skull base, OCJ. Specialized pulse sequences may be used to eval-
is associated with basilar invagination or occipital- uate fully the particular details of the OCJ anatomy.17,22
ization of the atlas. Welcher’s basal angle is created Many authors have reported difficulty in visual-
from a line parallel to the clivus as it intersects a line izing the alar ligaments with standard MRI proto-
along the surface of the sphenoid. The normal range cols,23–26 and others have reported abnormal signals
is 125 to 143 degrees, and platybasia exists when the in healthy volunteers.27,28 Krakenes et al17 developed
basal angle is >143 degrees. an MRI protocol with which to address the need
It is important to note that the previously men- for accurate visualization of the craniovertebral
tioned radiographic parameter has a sensitivity or ligaments: intermediate-weighted sequences with
negative predictive value of >90% on conventional 2-mm sections obtained with a standard 1.5-T coil
radiographs alone.8 Therefore, it is recommended with the patient’s head in the neutral position. Their
that any suggestion of cranial settling on conven- protocol has been validated by recent studies22,29 that
tional radiographs be investigated with MRI or CT.8 visualize the normal ligaments of the OCJ (Fig.€5.3).

5â•… The Occipitocervical Junction 89

Wackenheim’s

McRae’s
Occiput

Chamberlain’s

Hard
McGregor’s
palate

Ranawat’s

a

Wackenheim’s
Cerebellum

Pons

Chamberlain’s

McRae’s
Hard
palate Opisthion
C2
Ranawat’s

C3

b

Fig. 5.1â•… Lines and measurements for the evaluation of basilar invagination. (a) Artist’s sketch of a case of normal relationships at
the OCJ.† (b) An artist’s sketch of a case with basilar invagination and Chiari type-II malformation.

90 IIâ•…Spine
Fig. 5.2â•… This (a) sagittal T1-weighted image (dotted line,
Wackenheim’s clivus baseline) and (b) artist’s sketch of platyba-
sia. Welcher’s angle measures 160 degrees in this case; the nor-
mal measurement is 125 to 143 degrees. (a, from Smoker WRK.
MR imaging of the craniovertebral junction. Magn Reson Imag-
ing Clin N Am 2000;8(3):635–650. Reprinted by permission.)

a

Wackenheim’s

Tuberculum
To Nasion sellae
Cerebellum

Pons

Basion

C1

Opisthion
Hard
palate

Chamberlain’s

b

which may be best seen with Chamberlain’s spine. they are useful for character- izing the space available for the cord. Correlation of axial images with the sagittal or coronal localizing images is vital when evaluating the OCJ to confirm the level (occiput versus C1 versus C2) that is being evaluated. The presence or absence of pannus at the C1-C2 articulation also may be delineated on the sagittal images (Figs.33 Basioccipital hypoplasia results in a shortened instance.21.17 Coronal im- ages show the lateral masses of C1 and the apical and alar ligaments. use of the term basilar invagination is but are more easily visualized on (b) a specialized intermediate.31–33 Failures of formation include edema from abnormalities. 5â•… The Occipitocervical Junction 91 from one occipital condyle to the other. clivus from poor development of the sclerotomes sion is best visualized on T2-weighted images. atlantoaxial subluxation. Coronal sections are taken from the anterior arch of the atlas to its posterior arch. and other parenchymal both basioccipital and occipital condyle hypopla- lesions while minimizing CSF pulsation artifact. ■⌀ Pathology of the OCJ OCJ pathology can result in compression of neural elements and odontoid elevation. or basilar impression using Wackenheim’s line.6).8 For instance. a Axial sections. (Fig. Coronal images are useful for evaluating the cer- ebellar tonsils and the C0-C1 and C1-C2 articula- tions.21. although it often results in basilar invag- the brainstem.33. the deformity . b Primary/Congenital Conditions Fig. Conditions affect- ing the OCJ can be classified as primary/congenital or acquired. appropriate. Congenital Anomalies of the Occiput The gross anatomy of the OCJ is precisely displayed Anomalies of the occiput may be the results of fail- on high-signal-to-noise T1-weighted images. of segmentation.34 This condition has a wide range of clini- Sagittal images are ideally suited for evaluation of cal severity.17 provide de- tailed information on the cross-sectional anatomy of the OCJ. fourth ventricle.12. In particular. craniometry measurements may be made from sagittal MRIs. myelomalacia from spinal cord compres. the posterior space available for the cord.3â•… The intact alar ligaments (arrows) in a normal spine When congenital conditions result in brain stem are very difficult to identify on (a) a coronal T2-weighted image compression.€ 5.30 Gated ure of formation (often referred to as hypoplasias) or T2-weighted images produce high signal from CSF. which is essential for planning before surgical procedures at the C1 and C2 levels. typically obtained from the fora- men magnum to the base of the dens.4 and 5.5).30 For sia. Parasagittal images may detail the C0-C1 and C1-C2 articulations.€5. and vertebral artery anatomy within C1 and C2. 5.21 In occipital condyle hypoplasia.30 weighted image. midsagittal MRIs can be used to measure the atlanto–axial interval. and upper cervical ination.17 As detailed above. The sagittal and parasagittal images are also useful for mapping the vertebral ar- tery anatomy.30 Sagittal and parasagittal sections are taken line.

92 IIâ•…Spine a b Fig. . 5. the pannus has caused substantial osseous erosion. 5.4â•… C1-C2 pannus formation. in this case. (a) A sagittal T1-weighted image shows a large pannus in the atlanto–dens interval in a patient with RA and cranial settling. (b) A sagittal T2-weighted image of a patient with a large pannus posterior to the odontoid shows it is causing cord compression.5â•… These sagittal (a) T1-weighted and (b) STIR images of another patient with RA and large pannus formation that. a b Fig.

35 Shortened. 5.21. 5.39. In contrast to failure of segmenta- atlantooccipital joint motion.111:1046–1052. It is important to note that the midline physis of myelopathy.42 eral population has been reported to be 0. with an incidence of 4% in autopsy specimens. Clinically.36 The incidence in the gen. The basion is more curved than normal. (From Noudel R.40 Posterior atlantooccipital assimilation (Fig. Reprinted by permission. Scherpereel B. and to the odontoid process and are rarely associated with the anterior arch fuses with the lateral masses at 6 basilar invagination21 but may result in atlantoaxial . the atlantooc- cipital joint axis angle seen on coronal MRI is wid- ened. also been reported.41. with increased MRI signal intensity on fluid-sensi- tooccipital assimilation should be educated on the tive sequences is more indicative of a Jefferson frac- natural history of the disease and the warning signs ture. Rousseaux P.6â•… A sagittal T2-weighted image shows basioccipital hypoplasia with Chiari type-I malformation (single arrow) and a shortened clivus (double arrow). Eap C. they may be associated with posterior neck pain after minor trauma. unilateral cases have there is superior migration of the odontoid process. failure of formation of the atlas is only rarely Failure of segmentation at the OCJ may result in associated with basilar invagination.1% of autopsy discovered on imaging after patients present with specimens41.36 closes at 4 years of age.12. and notably. Incidence of basi- occipital hypoplasia in Chiari malformation type I: comparative morphometric study of the posterior cranial fossa. a defect myelopathy. with an incidence of 0.42 Anterior arch clefts ma-shaped basion.7â•… A sagittal T2-weighted image shows atlantooccipi- tal assimilation.36 Approximately clefts and may mimic a Jefferson fracture. flat condyles result in basilar invagination.€5.13.21.) Fig. Congenital anomalies of the axis usually are confined es with the lateral masses at 3 to 4 years of age.41.42.37–39 Families of children with atlan. Jovenin N. only 3% are at the 2.13. J Neurosurg 2009.12.44 Overall.33. sulcus for the vertebral artery.21. Pierot L.7).21 This finding is often incidentally are more rare. be partial or complete.21 In normal development.41–43 In contrast. tion.36 and sagittal MRI scans often reveal a com.42 Well- half of patients with C0-C1 assimilation progress to corticated margins and the lack of a posterior tuber- subsequent atlantoaxial instability and early-onset cle suggest an arch defect.21.08% to Most of these clefts are midline. Congenital Anomalies of the Atlas Congenital Anomalies of the Axis Rachischisis is the developmental failure of the at- las. and is usually bilateral. which may atlas arch clefts are the most common pattern seen. the posterior arch fus. this condition may result in limited to 8 years of age.76%. however. 5â•… The Occipitocervical Junction 93 Fig. axial MRI views best illustrate any C1 defects.

€5. corpus information. fourth valuable. The an.45 myelomeningocele and can present with multiple Although diagnosis of fusion failures of C2 may anatomic anomalies. and Chiari malformation. Chiari Malformations view of the physiologic axis development is detailed.53.41 It is not generally associ- images and show edema on T2-weighted and fat. MRI provides more detailed plasia of intracranial structures (falx cerebri.54 Associated conditions include basilar to an ossicle that is above the body of C2. (a) A sagittal T2-weighted image of an os odontoi- deum.10). and Klippel-Feil syndrome in 5%.52 is defined as a defect a Bergman ossicle. but a chronic odontoid fracture.21. and medulla). Fusion of the dentocentral synchondrosis magnum. or the Arnold- Down syndrome. atlantooccipital assimilation in terior arch of C2 is rounded and hypertrophic. Fractures lack cortication on T1-weighted ventricle. and downward displacement of poste- acute fractures. including hydrocephalus.94 II╅Spine instability.50 To differentiate fusion failures from callosum). however.54 Midsagittal the body of C2 has a well-corticated.46 Failure of fusion of the terminal ossicle results in A type-I Chiari malformation51. a re. the tonsils >5 mm below the plane of the foramen nificance. hypo- be made on radiography. ated with atlantooccipital assimilation or basilar suppressed T2-weighted images. results from dysgenesis of Morquio syndrome.55 involving abnormalities of connective tissue such as A type-II Chiari malformation. invagination. invagination in 50%.€5. some authors have referred to normally occurs at 6 years of age. as seen on (b) a sagittal T2-weighted image. This term refers and 5. coronal and sagittal cuts are most rior fossa content (inferior cerebellar vermis.9 in an os odontoideum (Fig. typically re- tains the typical anatomic architecture of the odontoid.48 Failure of fusion downward displacement from 3 to 5 mm as a border- or fracture of the dentocentral synchondrosis results line diagnosis based on clinical parameters (Figs. 5.8).21 a Fig.53.21. An os is often round and does not preserve the shape of the dens. spondyloepiphyseal dysplasia.21 Atlantoaxial instability is a hallmark of this displacement and decreased CSF content in the ret- disorder. convex upper images most consistently show the downward tonsil margin.49 Odontoid aplasia is extremely the hindbrain.45 To clarify the formation anomalies.21 It is almost always associated with rare and is associated with atlantoaxial instability.21 which may be confused with a in the cerebellum with a downward displacement of type-I odontoid fracture47 and is of little clinical sig.45 It is associated with congenital diseases rocerebellar space.8╅ Os odontoideum versus chronic odontoid frac- ture. and 10%. b .

.10â•… These sagittal (a) T1-weighted and (b) T2-weighted images of a patient with a type-I Chiari malformation who has undergone a suboccipital decompression procedure. Cerebellum Basion Opisthion C1 C2 C3 a b Fig. 5. 5. Opisthion C1 C2 C3 5â•… The Occipitocervical Junction 95 Cerebellum Cerebellum Basion Basion Opisthion Opisthion C1 C1 C2 C2 C3 C3 a b Fig.9â•… Artist’s sketches show the typical features of (a) type-I and (b) type-II Chiari malformations.

occurs rarely. which is a hernia.11â•… Cranial settling. resulting in cranial settling tion of the odontoid process.21. that generates enzymatic erosion of supporting liga- mentous structures.64 It is important softening. This pathologic is the term used to denote the odontoid’s superi.20 This Klippel-Feil Syndrome condition may occur with RA or psoriatic arthritis.20 Basilar im- a triad of a low posterior hair line. 5.61 Once the odontoid begins to occupy imperfecta. ero- the skull base.60. osteomalacia. sion of the lateral masses of C1. Cranial settling differs from hypoplasia without cerebellar herniation. rickets.60–63 Most commonly. atlan- toaxial instability develops secondary to erosion of the Acquired conditions cause pathology by softening ligaments at the OCJ.11).96 IIâ•…Spine A type-III Chiari malformation. a relatively more rostral position. thereby potentiating odontoid eleva.61. the occipital condyles. Basilar Impression tion of the hindbrain into a high cervical encephalo- cele.61 As the disease progresses. this con- dition may affect both the craniocervical junction and Acquired Conditions the subaxial cervical spine. tion.€5. Basilar invagination results from a loss of skull height Klippel-Feil syndrome is classically described as secondary to congenital abnormalities. Basilar impression brain stem and vertebrobasilar system. Many disease processes may cause such eleva.60. including osteogenesis (Fig. there must be failure of segmentation of at least two cervi- cal vertebrae. cervical fusions. the C1 arch a b Fig. which resulted in decreased brainstem compression.30 to note that.60. Paget disease.61 In the cervical spine. process is postulated by some as the cause of sudden or migration in the setting of acquired skull base death in those with advanced RA. and ankylosing spondylitis.21. and pression results from skull base softening secondary limited neck mobility in association with congenital to an acquired condition such as Paget disease. in contrast to other disorders.56 It is useful to review certain terms related to cra- A type-IV Chiari malformation involves cerebellar niocervical instability. The synovial joints develop a pannus lack of segmentation. Cranial settling is vertical subluxation of the odontoid caused by a loss of supporting ligamentous structures.21. (b) A sagittal T1-weight- ed image with metal suppression after instrumented reduction from the occiput to C5.60. basilar invagination and basilar impression. (a) A sagittal T1-weighted image shows cranial settling in a patient with RA. and facets of C2 occurs.21.59 Coronal RA is a systemic disease that causes inflammation of and sagittal images are most useful in diagnosing the synovial joints. .58.57 For the diagnosis to be made.58 Accelerated degeneration of adjacent RA/Cranial Settling levels and increased susceptibility to cord injury after minor trauma have been reported. it compresses the RA. short neck.

MR images of giant cell • Giant cell tumor tumors typically show lytic lesions.€5.67. • Extradural • Intradural-extramedullary • Intramedullary teriorly and to arise from the midline. Tu- mors of the Spine).12) and imaging characteristics. and spinous based on size: lesions <1. 5â•… The Occipitocervical Junction 97 migrates with the skull base to lie in a more caudal po. and biopsy is the only method for definitive diagnosis. or space available for the cord. tissues. Aggressive or atypical hemangiomas can lose this characteristic • Hemangioma appearance if they grow to considerable size. A cord space. osteoid osteomas. Boden and colleagues60. in most cases they arise within the vertebral body.12â•… An artist’s sketch shows anterior extradural and compartments: posterior intradural tumors at the OCJ.59. Hemangiomas. Although the imaging mo. of >14 mm on MRI was associated with better Anterior clinical outcomes than was a space of <10 mm. as evidenced by • Various sarcomas cortical destruction and infiltration of the surrounding The differential diagnosis of these primary bone tu. 5.65 Because of the erosion of the osseous structures that takes place. and the performed with a combination of conventional ra.69 Sarcomas usually • Chordoma have an invasive appearance on MRI. bly” appearance on T2-weighted MRI sequences.66 The distinction between a chordoid rest and a chor- doma largely depends on the lesion’s size and clini- Primary Osseous/Extradural Tumors cal history. chordoid rests. Most primary Osteoid osteomas and osteoblastomas appear tumors of the spine originate within the posterior similar on imaging studies. They have a spiculated. chordomas. This technique uses the vertical distance from McRae’s line to the C2-C3 disc space to gauge cranial settling. chordoid rests. lamina. osteomas. and chordomas treatment paradigm.5.5 cm are termed osteoid processes). and osteoblastomas tend to can be divided into primary and metastatic lesions. with clearly defined margins. They tend to be anteriorly located and have a mors can be narrowed based on the tumor’s location varying degree of soft-tissue component. tu- mors of the OCJ can be located within one of three Fig. arise from the posterior elements of the spine. and MRI. but they are distinguished elements (pedicles. facets.60. . a distinction that becomes critical when applying a Hemangiomas. CT. the method of Redlund-Johnell and Pettersson7 may be used to gauge settling.61 tumor intradural tumor Dura Neoplasms The neoplastic abnormalities that can affect the craniocervical junction are similar to neoplasms that affect the rest of the spine (see Chapter 8. which extradural Posterior was associated with a poor prognosis. pars. and giant cell tumors are more likely to be located an.21 In some cases. larger lesions are called osteoblastomas. Chondroblas- Osseous neoplastic lesions within this region tomas. Both lesions have areas of blastic and clastic activity. (Fig. it has been reported to be as inferior as the C2-C3 disc space. “wagon-wheel” ap- The primary osseous tumors in this region are: pearance. doid rests and chordomas tend to have a bright “bub- dalities can help narrow the differential diagnosis.58. bone tends to show evidence of remodeling. more aggressive tumors typically exhib- • Osteoid osteoma it varying degrees of osseous erosion.68 • Chondroblastoma In contrast. Imaging of this region is best are most frequently slow-growing tumors.61 report- ed on the use of MRI to measure the space available for Odontoid the cord as a technique for predicting recovery after process (C2) cervical stabilization for patients with RA and atlan- toaxial instability. Hemangiomas also tend to be anteriorly located. Cerebellum sition. Giant cell tumors • Osteoblastoma are often hypodense on T1-weighted and T2-weighted • Chordoid rest images and frequently enhance on T1-weighted images • Aneurysmal bone cyst with contrast administration. Chor- diography. As with the rest of the spine.

and the degree • Neurofibroma of contrast enhancement usually correlates with the • Metastatic disease (less commonly) grade of the tumor. can help confirm the diagnosis of • Glial tumors aneurysmal bone cyst.74 ally seen to be eccentric in location within the spinal cord and often have a large syrinx associated with them. • Ependymoma aging.13) mise. glial tumors usually do not have an asso- ciated syrinx or distinct margins on imaging studies. For patients treated surgically.70 that of meningiomas.g. and they homogeneously these lesions usually is the result of overt instability and enhance with contrast administration (Fig.€5. transverse. On MRI. or a central sclerotic area. Tumors seen in this region are: endymomas.72 Multiple septate and small • Vascular lesions (i.82 Intradural-extramedullary abnormality in this re. can all help to guide the surgical or nonsurgical and neurofibromas usually have a less midline location treatment. They are often the central canal and are slow-growing lesions. of these lesions can be varied. on T1-weighted and T2-weighted MRI sequences and and nuchal ligaments are very thick in this region. These tumors are vi- • Schwannoma sualized best on T2-weighted imaging..€5. and postcontrast T1. The apical. a definitive diagnosis is made with an open or may be seen with schwannomas and neurofibromas.e. . osteosarcoma). They are usu- prevents direct compression from epidural extension. These lesions are best characterized using MRI feeders and draining veins. T2-weighted. epidural extension of the tumor at the level of are most often hypointense on T1-weighted and T2- the OCJ is unusual. presence vascularity on angiography (hemangiopericytomas or absence of instability. and degree of neural compro- are very vascular lesions). They anteriorly located and show substantial osseous de. diagnosis. beyond the main bulk of the tumor. root. it may show hyper.66.81 osseous compression rather than epidural extension of Hemangioblastomas are also commonly hypointense the tumor. posterior longitudinal. representing areas of hemorrhage in different • Hemangioblastoma stages of evolution. these lesions can be difficult to distin- hypointense to isointense on T1-weighted and T2. in the generate and then narrow a differential diagnosis.98 IIâ•…Spine giving a characteristic target appearance on CT imag.. These tumors typically produce a The MRI characteristics of the multitude of tumors “dural tail. fluid space between the tumor and the spinal cord at vascularity in the surrounding musculature that may either end of the tumor can suggest a nerve sheath tu- suggest a more aggressive appearance of the lesion mor over a meningioma in the differential diagnosis. Spinal cord compression seen with weighted MRI sequences. Unlike ep- weighted sequences). cavernous malformation lobulations are usually present on T2-weighted im. A spinal If MR angiography is performed. but it often resembles podense area. are usually centrally located. Compared with metastasis to other levels of dally.75–77 Although this finding sequently. grow rostrally and cau- struction. contained within a calcified margin. The imaging ing. • Meningioma The cord has a swollen appearance (increased diam- • Hemangiopericytoma eter) in the region of the tumor. These lesions also tend to display substantial tion in regional anatomy. but in reality. at the OCJ are: pansile rim and fluid-fluid levels on T2-weighted im. guish from transverse myelitis and spinal cord signal weighted MRI.79 They originate from the nerve preoperative planning and postoperative follow-up. Given the imaging characteristics Meningiomas and hemangiopericytomas tend to be of a glial tumor. along with the location of the tumor. Sub- subdural space along the dura. without a dural tail. Schwannomas (Fig. The tissue its presence suggests a meningioma or hemangioperi. a thin ex. surrounded by a hy. They the spine. percutaneous (usually image-guided) biopsy. MRI charac- and usually extend toward (and sometimes through) teristics can help select the approach and assist with the neural foramen. anywhere within the spinal cord substance. and frequently have an associated syrinx.14). Angiography can be useful in showing the vas- gion is also similar to that of all other levels of the cularity of the tumor and the location of the arterial spine. or arteriovenous malformation) ages but may be imperceptible on T1 sequences. change secondary to myelopathy and ischemia. degree of stenosis.70 trast administration.78. Areas of hemorrhage of different ages may be Intradural-Extramedullary Tumors seen surrounding the tumor and can markedly vary the appearance of these tumors on MRI. the hypervascu- larity is a reactive phenomenon and still compatible with the benign diagnosis of osteoid osteoma.” which appears as an epidural extension of just described that can be seen at the OCJ can be used to the tumor. which enhance with contrast administration.83 Glial tumors can arise (T1-weighted.71 Intramedullary Tumors Aneurysmal bone cysts are characterized by a slowly growing lesion with sclerotic boundaries on The intramedullary abnormalities that can be found conventional radiographs or CT. altera- cytoma.73 Lesions that metastasize to the osseous spine often Ependymomas arise from the ependymal layer of appear aggressive on imaging studies. (e. and they strongly enhance with con. which explains the eccentric nature.80.

5.13â•… These (a) coronal T2-weighted. 5â•… The Occipitocervical Junction 99 a b Fig. and (c) coronal postgadolinium T1-weighted images c show a schwannoma at C2 extending into the foramen magnum. (b) sagittal T2- weighted. .

(c) An axial T2-weighted image shows that the lesion (between arrowheads) is located within the spinal cord.† . 5. (d) An axial postgadolinium T1-weighted image shows similar findings with enhancement of the tumor.14â•… Cervical ependymoma. (b) A sagittal postgadolinium T1-weighted image shows that the tumor is located at C4-C5 and that the signal change extended from C2 to C7 shown in (a) represents edema proximal and distal to the lesion. (a) A sagittal T2-weighted image shows a large cervical ependymoma centered at C4-C5 but with cord signal change extending from C2 to C7.100 IIâ•…Spine a b c d Fig. which is seen as a thin sliver of low signal intensity surrounding the lesion (arrow).

4% best performed with parasagittal and coronal CT im- had trauma to the cervical spine. A value of 1 is considered normal. corre- lating with worse neurologic outcomes.96–98 In 2007. which often accompanies the disso- ■⌀ Miscellaneous ciation. which were originally described by tients with cranial settling associated with RA. the potential for posterior dis- more conventional degenerative stenosis (Fig.97.99 whereas the sagittal plane. 24% involve C2 and one third are odontoid postmortem studies.112 On open-mouth radiography. The Powers ratio106 dren with Down syndrome and are used widely as (Fig. been shown to be better than the Powers ratio for drome have higher incidences of os odontoideum and diagnosing dislocation. 5â•… The Occipitocervical Junction 101 osseous edema.114 Elderly vital for the practicing spine surgeon.102 Therefore.96–98 Postmortem studies show that approximately one third of individuals who die as a result of traffic accidents have this injury.96. C2 is the most commonly fractured cervical spine ported. avulsion injuries (Fig.13 Sir Geoffrey Jefferson.93 associated ligamentous injuries.94 surgical decision making should be The distance from the basion to the posterior arch based on neural impingement seen on MRI.30.20).93 Fractures occur in a bimodal incidence: the advanced imaging appearance of the ligaments is one spike in the young and one in the elderly.114 Of cervical fractures secondary to blunt the C0-C1 junction may be injured.17) may also teriorly displaced.97.99 onal CT images. astating injury.€5.96.95 on the basis of osseous versus ligamentous involve- ment.107 MRI will highlight the fracture and also the with cervical fracture. the Harris technique has It is important to note that patients with Down syn.12. .22. including Occipitocervical dislocation (Fig. Fracture morphology. the Spine Trauma Study Group provided Trauma to the Atlas a consensus statement on measurement techniques for upper cervical spine injuries. and suggestive of a dislocation. the basion–dental interval disorders associated with Down syndrome. even without frank dislocation. and the basion–posterior axial line interval are cal- tous laxity figures prominently.84–91 ments >12 mm for the basion–dental interval and Although flexion-extension conventional radiographs basion–posterior axial line interval are abnormal can be used to detect atlantoaxial instability92 in chil.16) can be a dev.107 Large osseous fragments have been noted to be more stable and have a greater chance at healing Trauma to the OCJ with nonoperative immobilization. screening tools. Among the tion. Adjuvant dynamic MRI may also be helpful in illustrating the transverse ligament injury. Down Syndrome The Harris technique (Fig.104 patients tend to have odontoid fractures that are pos- Atlantoaxial dissociation (Fig. can be best illus- with odontoid fractures or osseous displacement in trated on lateral cervical radiography or CT.18) is useful in the radiographic diagnosis of atlantooccipital disloca- Down syndrome is caused by trisomy 21. which is paramount Occipitocervical Trauma for stability.99 hypoplasia of the arch of the atlas than does the gen.89 Measure- lantooccipital instability have also been described. culated on midsagittal MRI sequences.93.19) has also been used to calculate injury. an anterior dislocation must be sus- with known or suspected instability secondary to pected.91 Flexion.93.15). axial T2-weighted images can directly assess transverse ligament injury.99 Many of the tech.21).€5.100 Delays Trauma to the Axis in diagnosis averaging 2 days after the injury. familiarity with fractures.€5. If in patients with Down syndrome. Occipital condyle injuries have been classified eral population. level.103.111. T2-weighted sequences are most MRI can assess neural compression and also provide useful in identifying a transverse ligament injury or insight regarding the age of the fracture (Fig.069 patients with blunt trauma. important in be the result of a traumatic event.21.99. alized on open-mouth odontoid radiographs or cor- ed in the setting of OCJ trauma.€5.€5.109 Although characterization of occipital condyle fractures is In a study of 34. 34% had an injury to the OCJ.93 Of those patients ages. However. Recognition of OCJ trauma is crucial because of the devastating effects of injury to this anatomic area. the rule of Spence110 indirectly measures the integ- rity of the transverse ligament.106 However. as it is in patients the value is >1. An axial load to the OCJ at the atlas may result in niques reviewed were developed for studying pa.€5.€5.113. Atlantoaxial and at. is divided by the distance from the anterior arch to extension MRI can also be used to evaluate for stenosis the opisthion. ligamen.108.105 It is associated determining the healing potential.17. have been re. location exists. and if it is <1.110 The injury is typically visu- Different measurement techniques are recommend. To use this tool. 2. burst fractures. as indicated by trauma.101 In addition.

5.102 IIâ•…Spine a b c Fig. .15â•… A dynamic MRI sequence in a patient with atlantoaxial instability. whereas (c) sagittal T2-weighted and (d) axial T2-weighted images in flexion show severe cord compression and widening of the anterior atlanto–dens interval. (a) Sagittal T2-weighted and (b) d axial T2-weighted images in extension show only mild cord compression.

The midsagittal image shows an increased distance between the basion and tip of the odontoid. . 5. and (c) parasagittal T2-weighted images show atlantooccipital dissociation.16â•… These (a) midsagittal. 5. (b) coronal.17â•… These (a) sagittal T2-weighted and (b) coronal T2-weighted images of atlantoaxial dissociation show edema and dis- traction (arrows on each) through the C1-C2 joint. whereas the coronal and parasagittal images show edema in the C0-C1 joint. a b Fig. 5â•… The Occipitocervical Junction 103 a b c Fig.

18â•… An artist’s sketch depicts the Harris technique. is used to evaluate the relationship between the occiput and cervical spine in cases of known or suspected atlantooccipital dissociation.19â•… An artist’s sketch depicts the Powers ratio. A. opisthion. B A O C . B. basion. posterior arch of C1. 5. like the Harris technique. C.104 IIâ•…Spine Fig. 5. which is used to evaluate the relationship between the oc- ciput and cervical spine in cases of known or suspected at- lantooccipital dissociation. O. (mm) Basion Posterior axial line (mm) Tip of dens C1 C2 C3 Fig. which. anterior arch of C1.

5.21â•… These sagittal (a) T1-weighted and (b) T2-weighted images of a type-II odontoid fracture (arrow). . Note the osseous and paravertebral edema or hematoma (arrowhead).20â•… An axial T2-weighted image shows prominence and edema at the insertion site of the transverse ligament (arrow- head) on the lateral masses of C1 (arrows). 5â•… The Occipitocervical Junction 105 Fig. which indicates an acute or subacute fracture. 5. a b Fig.

5. Chiari malformation? ful in assessing for superior migration of C2. and the atlantoaxial joint. represent metastases.╇ Welcher’s basal angle D. Which of the following is true of a type-II line.╇Congenital loss of skull height resulting conventional radiographs. E.106 IIâ•…Spine Traumatic Spondylolisthesis of the Axis Common Clinical Questions Levine and Edwards115 were the first to describe thor.╇It is the downward herniation of the the cerebellar tonsils. From the following list. Aggressive lesions. mas or metastases.╇The Harris technique is useful in tissue masses.╇ Diagnosis is typically delayed. Midsagittal images may be used to calcu- late the Powers ratio and Harris technique for atlan- tooccipital dissociation or the atlanto–axial interval for C1-C2 instability. fourth ventricle. Both axial and sagittal images are useful for correlating neurologic compression in the traumatic or nontraumatic setting. A. . C. Using midsagittal sequences. and Ranawat’s criteria are use. they are now used on MR in an elevated odontoid images with increased accuracy. T1-weighted sequences show normal anatomy odontoid well. Although many measurements and iden. whereas benign or diagnosis. All of the following are radiographic mea- oughly the clinical and radiographic findings of trau. Coronal images are useful in di- agnosing transverse ligament disruption by calculat- ing the rule of Spence.╇ Pannus formation in the subaxial spine tous disruption. are classified as extradural. On T2-weighted on MR imaging in a rheumatoid spine? sequences.╇ Posterior ligamentous complex laxity for surgery at the OCJ.╇ Cranial settling enable localizing the vertebral artery when planning D.115 MRI B. posteriorly based A. A tumor’s vascularity is most E. These modalities C. and the into an encephalocele.╇This injury is associated with high lesions are primary. 1. surements useful for detecting cranial set- matic spondylolisthesis of the axis.╇Acquired skull softening resulting in up- and edema. the cerebellar tonsils only.╇ McGregor’s line ■⌀ Summary 2. which is seen earliest Trauma is well assessed by MRI.╇ It is associated with basilar invagination.╇ Ranawat’s criteria E. B. typically A. less soft-tissue mass effect. Wackenheim’s clivus baseline. and medulla. Similarly. typically show bony erosions.╇ Occipital condyle erosion Many special measurements can aid in traumatic diagnoses. 4. which may be well assessed with MR im. whereas anterior masses usually mortality.╇ Wackenheim’s clivus line best viewed on CT but also evident on MRI. C. McRae’s 3. All of the following are true about atlantooc- ages. In general. odontoid process. cipital dissociation except: ullary. atlantooccipital joint. slow-growing tumors appear less destructive and cause D. intradural-extramed. Vertebral artery injury may be seen B.╇ It most commonly results in death. Treatment is guided tling except: by the fracture displacement and angulation. Axial MRI sequences are also invalu. such as sarco. C. E. B. edema is apparent with bony or ligamen.╇Acquired loss of ligamentous support MRI enables excellent imaging and assessment of the resulting in upward migration of the OCJ. midsagittal MRI sequences most clearly show malfor. A. McGregor’s line. whereas T2-weighted sequences highlight CSF B.╇It is the inferior herniation of the cerebel- able in identifying many OCJ malformations. soft. occipital condyles.╇ The rule of Spence is useful in diagnosis. including lar vermis. Tumors. readily apparent on MR angiography but is often evident on both T1-weighted and T2-weighted sequences. or intramedullary. and hypervascularity. Coronal images best illustrate D. the alar and apical ligaments.99. Which of the following defines cranial settling? A. ward migration of the odontoid tification lines were originally created for use with C.╇ The Powers ratio is useful in diagnosis.╇ Pannus formation between C1 and C2 on both MRI and MR angiography.╇It occurs when the hindbrain herniates mations of the hindbrain. ring defects of C1 or C2.╇ Chamberlain’s line is obtained to evaluate for cord or nerve compression.

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3. Welcher’s basal 113.1). D Explanation: The rule of Spence is used to evaluate integrity of the transverse ligament— typically with Jefferson burst fractures. The management of traumatic lar invagination and basilar impression. Report of four cases. Cranial spondylolisthesis of the axis. Spine 1998. 112. 5. Horlyck E. fourth ventricle. Ranawat’s criteria. Br J Surg Answers to Common Clinical 1920. Treatment of stable burst frac. and a review of those previously recorded. Cervical spine injuries.110 IIâ•…Spine 110.12(6):1105–1110 PubMed Explanation: Wackenheim’s clivus line. B Explanation: Pannus formation between C1 and C2 is an early finding of RA that can be seen on MRI of the cervical spine. It involves herniation of the inferior cerebellar vermis. A 1992. Levine AM. Edwards CC. 1. This condition may occur with RA or psoriatic arthritis. Fractures of the atlas vertebra.45(6):845–853 PubMed detection of platybasia. Rahbek M. Both the Harris technique and the Powers ratio can be used to diagnose atlantooccipital dissociation. or the Arnold-Chiari malformation. and diagnosis is typically delayed. AJNR Am J Neuro. 4. Basilar invagination results from a loss of skull height secondary to congenital abnormalities. Lee C. C Explanation: A type-II Chiari malformation. Petrin DR. It is not generally associated with atlantooccipital assimilation or basilar invagination. Basilar impression results from skull base softening secondary to an ac- quired condition such as Paget disease. and medulla and is associat- ed with myelomeningocele. Atlan- tooccipital dissociation is associated with high mortality. . settling is vertical subluxation of the odontoid 67(2):217–226 PubMed caused by a loss of supporting ligamentous structures. The other findings tend to occur in patients with more advanced RA. results from dysgenesis of the hindbrain. J Bone Joint Surg Am 1985. Henderson JJ. Acta Orthop angle is a measurement that is useful for the Scand 1974. Unstable Jefferson variant atlas frac- tures: an unrecognized cervical injury.7:407–422 Questions 111. Ryan MD. Lee TT. Jefferson G. Green BA. and ture of the atlas (Jefferson fracture) with rigid cervical col. Chamberlain’s line. McGregor’s line can all be used to evaluate for lar. 114. The epidemiology of fractures and fracture-dislocations of the cervical spine. 5. Woodring JH.23(18):1963–1967 PubMed cranial settling (see Fig. Injury 2.23(1):38–40 PubMed Explanation: Cranial settling differs from basi- 115. C radiol 1991.

and I. and the postoperative spine. Tumors used in the cervical spine is beyond the scope of this B. Traumatic Conditions 7. 2. Amyloidosis 2. Intradural Infections • Axial T2-weighted FSE V. Trauma to the Atlas 6. Jacob M. Aditya Daftary. 111 . Degenerative Disc Disease and Protocols B. Multiple Sclerosis sequences are discussed in the following paragraphs. Atlantoaxial Dissociation Deposition Disease C. Juvenile RA 3. Joseph R. Characterization of Spinal Cord Injury F. Specialized Pulse Sequences and Protocols Granulomatous Diseases II. Subacute Necrotizing Myelopathy of gadolinium contrast. Classification of Cervical Spine Trauma C. Acute Transverse Myelopathy T1-weighted images are useful in identifying frac- ture lines. John A. Spinal Stenosis specific indications can vary among institutions. and A. Summary D. Carrino. Gout 3. Zebala. Jay Khanna Chapter Outline 5. Other Pathologic Conditions A detailed discussion of all the imaging sequences A. Intrinsic Inflammatory Myelopathies chapter. Parasitic. Metabolic or Toxic Diseases A. salient features of commonly used 1. Because they are sensitive to the presence 3. which is helpful in assessing Syndrome neoplasms. Psoriatic Arthritis 1. Axial Load Injuries 3. Characterization of Cervical Spine Instability III. Epidural Abscess • Axial gradient-echo C. OCJ Injuries 4. Hyperflexion Injuries 1. Vertebral Artery Injury VI. Acquired Immune Deficiency trast-enhanced imaging.6 The Cervical Spine Lukas P. Viral Diseases 6. they are also used for con- 4. Buchowski. Hyperextension Injuries 2. Arthritides 1. Cervical Vertebral Osteomyelitis and • Sagittal T1-weighted SE Discitis • Sagittal T2-weighted FSE B. RA dard MRI of the cervical spine for degenerative pathol- IV. Disc Displacement Although imaging protocols of the cervical spine for C. Bacterial. however. RA 2. Penetrating Trauma E. Infectious Conditions ogies usually includes the following pulse sequences: A. stan- D. Ankylosing Spondylitis B. Calcium Pyrophosphate Dihydrate 4. O’Brien. infections. Trauma to the Axis 7. Degenerative Conditions ■⌀ Specialized Pulse Sequences A. Atlantooccipital Dissociation 5.

radiographs or CT images may be detected by the which are seen as abnormally bright signal. especially imaging. acquired. of spinal stenosis. and are not detected with radiography. • MR incompatibility of some ventilators. These obstacles include the following: result of the technique. Gadolinium-enhanced MR angiog. CT may be a better choice for pected on sagittal T2-weighted images. diography or CT and is useful for the assessment ing ligamentous injuries. tients may have clinically significant neurologic defi- aging may also provide flow-velocity information. which provides isotropic vox.11 neck. these images can also over. This out consequences. subtle thrombi. Unfortunately. time-of-flight imaging shows • Lack of availability of MRI capabilities on an fat or subacute thrombus as bright signal and may be urgent basis useful in detecting small. especially on T2-weighted FSE helpful in assessing fractures of the occipital con- images. although presence of vertebral body edema on MR images. where osseous these areas more conspicuous. the exact appearance of the osseous components tecting cord abnormalities and confirming lesions sus. care must be taken with regard to to 3% of blunt-trauma accidents. the sagittal orientation is subject to linear bright artifact Although MRI is extremely sensitive in identifying within the cord (Gibbs phenomenon). prompt identification and management of cervical flammation.1 T2-weighted images are also most sensitive for tion. For this reason. can be challenging. degree achieved with STIR or fat-suppressed T2-weighted im. trauma. Theoretically. • Lack of clinical access to patients during the raphy may also be obtained and is extremely accurate. or an un- them useful for detecting small areas of hemorrhage. and additional fracture evalua- ages. many cervical spine injury should be evaluated initially of these conditions can coexist. trac- niques require more time and are slightly less sensitive tion devices. assessing such details. the exact compo- volume set can then enable one to characterize the sition of a gunshot fragment is seldom known. this important characteristic makes cervical spine injury. therefore such patients can usually be imaged with- els and enables reformations in multiple planes. MR angiography can be obtained without con. spine injuries important. and degeneration. overlap on conventional radiographs makes frac- tained by applying a fat-suppression pulse to produce ture detection difficult. reliable physical examination. because pa- flowing and stationary structures. However. studies can be obtained with higher resolu.2 the potential for interpreting bone-marrow edema because it may be instability and critical neurologic injury makes seen with a variety of conditions. and such visualization is best of spinal cord injury. It should be noted that there are obstacles to ob- trast. Although ede. MRI is indicated specifically when neurologic formations. and other equipment to slow flow states. ligamentous injury. and even as a 3D volume set. lateral. and therefore fat suppression is used to make dyles and cervicothoracic junction. The 3D tech. CT is especially lesions can be difficult. a ferrous gunshot fragment may be- tion than that required for other pulse sequences and come mobile. As a cits. These sequences create contrast between with regard to cervical spine trauma.3–8 such as with cervical spine trauma and vascular mal. therefore MRI remains controversial and dependent For the evaluation of vascular structures in the on the clinical need. Patients with suspected ma may focus attention toward an abnormality. Visualizing edema is helpful in identify. Sometimes the differentiation of fat. FSE is now open-mouth odontoid views).10. cervical spine fractures. using 2D or 3D time-of-flight or phase-contrast taining MRI studies in the trauma setting. or soft-tissue injury is sus- estimate the degree of canal and foraminal stenosis pected in the setting of trauma. ■⌀ Traumatic Conditions T2-weighted images are sensitive to water (and thus edema) and are useful in identifying areas of potential Although the cervical spine is injured in only 2% pathology. deficit. Phase-contrast im. in. fat-suppressed postgadolinium T1-weighted images are used to make lesions more conspicuous. However. This sequence can be ob. the evaluation of obtunded patients or those with netic artifacts.9 Use of MRI in of the rapidity with which gradient-echo images are imaging spinal gunshot injuries is controversial. so additional analysis with conventional radiographs (AP. and cervical foramina in the appropriate oblique plane. including infection. but most bullets are nonferrous. Because assessing posttraumatic sequelae. MRI is useful for Gradient-echo images are very susceptible to mag. neurologic deficits. vascular injury. CT imaging offers routinely used to acquire T2-weighted images at speeds greater osseous detail than conventional radiogra- up to 64 times faster than conventional SE T2-weighted phy does and may reveal fractures or details that images. Occult fractures not visible on conventional evaluating the cord parenchyma for lesions and edema. In addition. and is required before finalizing a conclusion. imaging study .112 IIâ•…Spine Typically. water. their characteristics and axial T2-weighted images serve as a useful tool for de. It is also useful in secondary to artifact from the adjacent bone. MRI provides soft-tissue fat-suppressed T2-weighted images or by obtaining a visualization superior to that of conventional ra- STIR sequence.

cervical spine injuries as follows: In addition.1). vertebral body Posterior element fracture integrity. to de. herniation) Regardless of the specific institutional MRI protocol.16 A systematic evaluation mechanism of spinal failure (vertical compres. Melhelm ER. to evaluate for spinal stenosis.€6. the Subaxial Injury Classification system mechanism of injury. but commonly Table 6.2). and avoid missing pathologic conditions (see Table€6. of these three components can be used to guide the sion.1 therefore clinicians may choose to broadly classify for important cervical spine structures to evaluate). neu- egories of fractures based on the suspected position rologic injury.15.2) to a severe teardrop or quadrangular . and distractive ex- tension13) (Fig. cervical spine injuries can be subdi- indicated) and CT (see Chapter 11. distractive flexion. cipitocervical spine: • OCJ • Suboccipital cervical spine (C1-C2) Classification of Cervical Spine Trauma • Subaxial cervical spine (C3-C7)14 Cervical spine injuries can be classified based on the More recently. which enables the dis. Hemorrhage fine disc pathology better. A Systematic In many instances.€6. Magn Reson Imaging Clin N Am 2000. trauma. fractures. flexion. the mechanism of injury can be Approach to the Review of Spine MRI Studies) for the difficult to determine from an analysis of the clinical evaluation of cervical spine MRI should be used to situation (in the absence of imaging findings). compressive flexion. compressive extension. 6â•… The Cervical Spine 113 MRI protocols vary by institution.1â•… Evaluation of cervical spine trauma used sequences in trauma evaluation include the Anatomy Evaluation following12: Spinal column/ Alignment • Sagittal T1-weighted images to assess the vertebral bodies Vertebral body fracture alignment of the cervical spine. MR imaging in cervical spine osseous degeneration. tinction between bone fragments and a disc Modified with permission. evaluate injuries based on fracture morphology. lateral treatment of patients with cervical spine fractures. including conventional radio- graphs (with flexion and extension views if clinically In addition. it is essential that the MRI findings be • Secondary to blunt trauma interpreted in conjunction with the other available • Secondary to penetrating trauma imaging modalities. Vascular Vertebral artery tion (high signal in the disc even with severe Source: Takhtani D. and spinal cord caliber Edema • Sagittal T2-weighted images to assess for the Degenerative change presence of cord edema. ligaments marrow edema Ligamentum flavum • Axial T1-weighted and T2-weighted images to Evaluation for edema/rupture assess for the presence of posterior element Spinal cord Edema fractures. Correlation of MRI vided based on the region of injury within the oc- with Other Imaging Studies). and the integrity of the discoligamen- of the spine at the time of injury and the dominant tous complex (Table 6. the classification scheme is sim- plified here into three broad categories: Hyperflexion Injuries • Hyperflexion Flexion-compression injuries range from the mi- • Hyperextension nor anterior compression of the anterosuperior end • Axial loading plate (Fig.8:615–634. and to confirm the Compression precise location of abnormalities detected on Syrinx sagittal images Epidural space Hematoma • Sagittal T2-weighted gradient-echo images (in Disc herniation some institutions) to assess for the presence of Osseous fragment acute spinal cord hemorrhage and disc hernia. Although the Allen-Ferguson (also known as the SLIC system) has been developed to classification system originally described six cat. compression. a systematic approach (see Chapter 4. and Ligaments Anterior longitudinal ligament spondylotic changes Posterior longitudinal ligament • Sagittal STIR images to assess for the presence Interspinous and supraspinous of paraspinal ligamentous injury and bone.

Ducker TB. The Adult Spine: Principles and Practice. 6. In: Frymoyer J. Anderson PA. PA: Lippincott-Raven.) . 1997:1245–1295. Reprinted by permission. 2nd ed.1â•… An artist’s representation of the Allen-Ferguson mechanistic classification system for subaxial cervical spine fractures. eds. Philadelphia. Cervical spine trauma.114 IIâ•…Spine Fig. Hadler NM et al. (From Chapman JR.

g.. neurology. Spine Trauma Study Group. Patel AA. or advanced-stage 4 flexion-compression injury) Discoligamentous complex Intact 0 Indeterminate (e. facet perch. or dislocation) 2 Neurologic status Intact 0 Root injury 1 Complete cord injury 2 Incomplete cord injury 3 Continuous cord compression in setting of neuro deficit (neuro modifier) +1 Source: Vaccaro AR. hyperextension) 3 Rotation/translation (e. Spine 2007. The subaxial cervical spine injury classification system. facet dislocation. and integrity of the disco-ligamentous complex.g.32:2365– 2374. .. et al.g. Sagittal (a) T2-weighted and (b) T1-weighted images show the fracture (arrow on each) with minimal loss of height..† a b Table 6. isolated interspinous widening. unstable teardrop.2â•… C7 vertebral compression fracture. A novel approach to recognize the importance of morphology. widening of disc space. Reprinted by permission. 6â•… The Cervical Spine 115 Fig. facet perch. 6..g. Hulbert RJ.2â•… Subaxial Cervical Spine Injury Classification System Scale Morphology Points No abnormality 0 Compression 1 Burst +1 = 2 Distraction (e. MRI signal change only) 1 Disrupted (e.

(b) sagittal recon- structed CT image. IL: American Academy of Orthopaedic Surgeons. In: Rao RD. and (c) axial CT image show a flexion-compression injury (quadrangular fracture) at C5. Reprinted by permission. Subaxial cervical spine injuries. (d) A sagittal T2-weighted image shows similar features as well as spinal cord compres- sion and prevertebral edema. 6. (a) A lateral radiograph. Rosemont. (From Khanna AJ. Orthopaedic Knowledge Update: Spine 4. the sagittal plane fracture can be seen in c. eds. Retrolisthesis of the C5 vertebral body can be seen in a and b.) d .3â•… Quadrangular fracture. Smuck M. Kwon BK. 4th ed.116 IIâ•…Spine a b c Fig. 2012:221–233.

dislocations. 6.17 The role of MRI in the treatment algorithm of • Vertebral body-height loss patients who present with bilateral cervical facet dis- • Translation locations (Fig. an extruded disc fragment.5). eral facet dislocations is to rule out the possibility of Flexion-distraction forces can lead to facet sublux. These injuries are associated with injuries represent a spectrum of osteoligamentous pa- retrolisthesis. The radiographic evaluation of tion to fracture of the facet and lateral mass. kyphosis. MRI helps flexion-compression injuries includes inspection for assess the compromise of posterior musculature. or combined approaches. ligamentum flavum. MRI provides additional diagnostic value while monitoring the patient’s neurologic examina- and can assist with the determination of treatment tion.17–19 One of the purposes of sessment of spinal cord compression and posterior obtaining an MRI study before the reduction of bilat- element compromise.3).€6.17–19 The treatment options Although conventional radiographs and CT scans can include MRI before attempting closed reduction or evaluate fracture pattern.† . angulation. Bilateral facet dislocation a Torn posterior longitudinal lig. which may displace into ations. (a) A lateral view of osseous structures shows that the facets are perched and that additional translation will lead to complete dislocation. Disc Disc extrusion with cord compression Disc herniation b c Dura Spinal cord Fig. alignment. in- the following: terspinous ligaments. These the spinal canal during a closed reduction (Fig.4â•… Artist’s sketches illustrating the pathology in bilateral facet dislocation. and circumferential soft. posterior. or fracture-dislocations.4) without neurologic compromise • Angulation is the subject of substantial debate in the literature • Posterior element competence and among spine surgeons. and facet capsules that is often seen with flexion-distraction in- • Anterior and middle column compromise juries. options for such patients because it facilitates the as. and surgical intervention via anterior. and surgical intervention. thology. Torn posterior longitudinal lig. ranging from the purely ligamentous disloca- tissue disruption. 6â•… The Cervical Spine 117 fracture (Fig.€6.€6. (c) A lateral view after reduction shows that the intervertebral disc has displaced into the spinal canal and compressed the spinal cord during the reduction maneuver. closed reduction with traction translation. (b) A lateral view before reduction shows ~50% translation of the superior vertebral body relative to the inferior one and displacement of the intervertebral disc.

poten- and MRI is particularly effective for the assessment tial findings include the following5. and flexion-extension radiographs may be nondiag- rior translation or rotation of a vertebral body in the nostic because of poor excursion secondary to pain.5â•… Bilateral cervical facet dislocation.12.€6.23: of the following12: • Tear(s) of the anterior longitudinal ligament • Alignment • Avulsion of the intervertebral disc from an ad- • Fractures jacent vertebral body • Ligamentous injury • Horizontal intervertebral disc rupture (Fig.12. 6. MRI is of limited value for the assessment produced by rear-impact motor vehicle collisions or of whiplash.20. either chron- ic degenerative changes or hyperflexion sprain • Prevertebral hematoma (Fig.9) • Widening of the disc space Facet joint injuries may be seen on parasagittal or • Posterior ligament complex edema axial images.22.7).† Most flexion injuries are well visualized on MRI.5 Hyperextension Injuries Whiplash injuries often have no associated os- seous injury on standard radiographs or CT images. (a) A sagittal T2-weighted image shows anterior translation of C7 over T1 with an as- sociated disc extrusion (arrow) and cord compression.8) • Cord abnormalities More severe and potentially unstable hyperexten- • Acute disc herniations sion injuries may be associated with the following5: • The cause of anterior subluxation. positive MRI findings in the absence of neurologic . terior infolding of the ligamentum flavum upon a spinal canal already narrowed by posterior vertebral osteophytes.23 Hyperextension injuries often are However. especially fat-suppressed T2-weighted or out fracture or ligamentous injury because of pos- STIR images (Figs. which show increased signal on T2- • Herniated disc weighted images secondary to edema from facet capsule tears. (b) Parasagittal T2-weighted and (c) gradient-echo images show the inferior articular process of C7 (arrow on each) displaced anterior to the superior articular process of T1 (arrowhead on each). 6.5.6 and 6.20–22 Injury to posterior ligaments may Elderly patients with spondylosis and kyphosis of be seen as areas of hyperintensity on T2-weighted the cervical spine may suffer spinal cord injury with- images. Cervical spine extension injury results in the poste. sagittal plane. several studies have failed to show direct facial trauma.118 IIâ•…Spine a b c Fig. In cervical spine hyperextension injuries.12.€6.

20.† condyles. may be best visualized with MRI because it can detect osseous edema and hemorrhage not seen on conventional radiographs or CT images. patients with a fused cervical spine secondary to ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis may benefit from an MRI examination to assess for acute fracture. or neurologic compromise. through the occipital (arrow) compatible with a partial tear.22 Fig.12.22 Subtle fractures. Axial load injuries are caused by the axial transmis- weighted signal in the ligamentum flavum at the C7-T1 level sion of force through the skull. This force transmission Fig. Smuck M (eds). 6â•… The Cervical Spine 119 symptoms. 6. with widening of the interspinous process space (between arrowheads). Rosemont (IL): American Academy of Ortho- paedic Surgeons.10). and into the spine. In such pa- tients.27 Intervertebral disc injury may range from tear(s) of the outer annulus fibrosus (seen as increased T2-weighted signal in the outer annular fibers) to frank intervertebral disc hernia- tion. Kwon BK.12. (b) A sag- ittal STIR image shows edema in the region of the interspinous and supraspinous ligaments between C4 and C5 (arrow). 2012:221–233.28.20–22.26 Finally.6â•… A sagittal STIR image shows edema in the supraspi.7â•… A discoligamentous complex injury. the fused cervical spine acts like a long-bone fracture. Ed 4. MRI can assess intervertebral disc injury and subtle fractures caused by any of the aforemen- tioned mechanisms. instability. (From Khanna AJ.29 Intervertebral disc separation from the adjacent vertebral body may be seen as a horizontal hyperintense T2-weighted sig- nal.) a b . which is com- patible with injury to the discoliga- mentous complex. Orthopaedic Knowledge Update: Spine 4.21. The identification of an annular tear on MRI does not indicate acute traumatic injury and can be seen in asymptomatic individuals.20.25 In contrast. Axial Load Injuries nous ligament region (arrowheads) and interspinous region at C6-C7 and C7-T1. with a small. (a) A lateral radio- graph shows bilateral facet sub- luxation at C4-C5.12. Reprinted by permission.24. such as vertebral end-plate fractures. Subaxial cervical spine injuries. focal region of increased T2. In: Rao RD. 6.€6. and even minimally displaced fractures may be unstable (Fig.

8â•… A sagittal STIR image shows an intervertebral disc rupture at C4-C5 (arrow) in a patient who sustained a hyperextension injury to the cervical spine. Reprinted by permission. anterior soft-tissue edema also is visible (ar- rowheads). with forcible extension of the neck. IL: American Academy of Orthopaedic Surgeons.120 IIâ•…Spine Fig. Orthopaedic Knowledge Update: Spine 4. Smuck M. eds. (b) A sagittal reconstructed CT scan shows avulsion from the C4 inferior end plate (arrow). 6. The patient was treated nonsurgically because of the absence of severe instability or cord compression. 4th ed. Subaxial cervical spine injuries.† a b c Fig. 2012:221–233. (c) A sagittal T2-weighted image shows the acute tensile failure of the C4-C5 disc. In: Rao RD. with bright signal within the disc (arrow). Kwon BK. 6.9â•… Extension-distraction injury with incomplete spinal cord injury in a 35-year-old man who was injured in a fall from a scaf- fold. Note the associated prevertebral hematoma and the severe multilevel degenera- tive stenosis with associated cord signal change. (a) A lateral radiograph shows substantial edema in the anterior soft tissues (arrowheads). Rosemont. (From Khanna AJ.) .

devastating effects31–34 (see Chapter 5. 2012:221–233.12 For burst fractures. Atlantooccipital dissociation is any separation of weighted and other images carefully for evidence the atlantooccipital articulation. The Occipito- tion on axial images.23 However. which could easily be missed. MRI is useful for the assessment of C1 compression fractures and associ. 6â•… The Cervical Spine 121 a b c d Fig. It is important to keep in mind that MRI studies axial force subjects the posterior capsuloligamen. 6.) can cause a Jefferson burst fracture or burst fractures OCJ Injuries of the subaxial cervical spine. there often is some degree of spine flexion that may cause injury to the posterior Atlantooccipital Dissociation spinal elements. or superiorly. these posterior conventional radiographic and CT imaging. and the structures because such injury will lead to consider. for a detailed discussion of occipi- useful for diagnosing associated spinal cord injury tocervical craniotomy and the various measurement caused by an acute herniated disc or retropulsion techniques for evaluation of occipitocervical pathol- of osseous fragments (Fig. Reprinted by permission. on coronal images. eds. Because a purely ogy). IL: American Academy of Orthopaedic Surgeons. structures should remain intact. posteriorly. (c) Sagittal T2-weighted and (d) STIR images show the same fracture (arrows on each).8% in one study30). of the OCJ should be reviewed in conjunction with tous structures to compression only. and transverse ligament disrup. Although injury to the OCJ occurs in a small percent- ated pathologies such as lateral mass displacement age of blunt-trauma victims (0.23 It is important to scrutinize the fat-suppressed T2.12. Subaxial cervical spine injuries.10â•… Ankylosing spondylitis. which can be detected by MRI.€6.11).31–34 The primary injury is to for patients with cervical burst fractures. the ligaments that provide structural support to the . Kwon BK. In: Rao RD. Atlantooccipital dissociation can decompression and fusion that is often performed be a devastating injury. during the traumatic event. (a) Sagittal and (b) axial CT images of the cervical spine in a patient with ankylosing spondylitis show a nondisplaced fracture at the T1 level (arrows on each). In (d). Smuck M. (From Khanna AJ. The skull may dis- of injury to the posterior ligamentous and osseous place anteriorly. Rosemont. MRI is cervical Junction. 4th ed. displacement may be complete (dislocation) or par- ation of posterior fusion in addition to the anterior tial (subluxation). atlanto–dental interval increase recognition of such injuries is crucial because of their on sagittal images. Orthopaedic Knowledge Update: Spine 4. edema at the fracture site indicates a relatively acute injury.

(c) An axial T2-weighted gradient-echo image and (d) corresponding artist’s sketch show the sagittal split component of the fracture (arrow[s] on each). 6.122 IIâ•…Spine a b c d Fig. retropulsion. (a) A sagittal fat-suppressed T2-weighted image and (b) corresponding artist’s sketch show a C5 burst fracture (arrow on each) with moderate loss of height.11â•… Cervical burst fracture.† . and spinal cord contusion (arrowhead on a).

g. MRI can assist in the evaluation of these Axial load to the OCJ at the atlas may result in a fractures by providing assessment of the degree of burst fracture of the atlas. C2 is the most commonly fractured cervical spine ments (e.12â•… Type-II odontoid fracture.9 mm is associated with transverse lig. (a) A sagittal T2- weighted image and (b) corresponding artist’s sketch† of a type-II odontoid fracture show edema at the fracture site (arrow on a).30 In the elderly. Fracture location. even without to the transverse ligament. odontoid fractures tend to be cipital membrane and capsular ligaments. which can et al. the occiput–C1 junction may be carefully scrutinized for increased T2-weighted sig- injured. tion provides insight into the age of the fracture ages. In addition.12. as indicated by postmortem studies. brainstem. The injury is visualized on edema at the fracture site (Fig. apical. 6â•… The Cervical Spine 123 cervicocranial junction. These images should be frank dislocation. CT imaging may be used to assess as- sociated fractures or relationships among the basion. indicating an acute or subacute fracture. occipital condyles.. Note a the prevertebral edema or hematoma (arrowhead on a). level. cruciate.36. dens. tectorial posteriorly displaced. improvement in The ligament should also be evaluated for regions of resuscitative and medical treatment has increased discontinuity. C1 interior arch C2 type-II C1 fracture C2 Edema C2 Retroesophageal space C3 Anterior longitudinal lig. though this injury may be fatal. atlantooc. . b Fig. whereas MRI is better at detecting injury to the cervicocranial liga. T2-weighted images should also be carefully evalu- ament rupture and indicates a relatively unstable Jef. survival rates. The sagittal and axial over C2 of ≥€6. 6.€6. displace- membrane).32 Al.35 ment. and atlas in conjunction Trauma to the Axis with atlantooccipital dissociation.37 As indicated by the cadaver study of Spence (acute versus subacute versus chronic). Lateral cervical radiographs and CT scans can be used to character- Trauma to the Atlas ize such fractures and better evaluate the osseous detail. This informa- open-mouth odontoid radiographs or coronal CT im.38 combined overhang of the lateral masses of C1 be used to guide treatment.31. or spinal cord. transverse.22.12). nal in or along the course of the transverse ligament. and angulation are important factors that as- sist with clinical decision making. ated to determine the degree of neural compression ferson burst fracture. The axial T2-weighted images from either a displaced fracture or underlying de- can be critically evaluated to rule in or rule out injury generative changes.

or hemorrhage. but it can be associated potentially devastating injury may occur with cervi. and location of the applied of the transverse ligament should be evaluated along force) and the underlying health of the spinal cord. Gradi- arteries22. ing the degree of neurologic loss. and length of the the expected course of the vertebral artery and as spinal cord lesion are important factors in determin- an acute thrombus in the foramen transversarium.12 Spinal cord contusion is a more Vertebral Artery Injury severe injury and may be caused by transient com- pression or stretching of the spinal cord. with the approximate size of the anterior atlanto– Spinal cord insult may range from a concussive in- dens interval. edema. duration. Spinal cord concussive in- spine radiographs (Fig.g. This measurement is more frequently jury (purely functional and reversible) to complete evaluated on flexion and extension lateral cervical transection (irreversible). MRI is useful for assessing the Atlantoaxial dissociation may be caused by distrac. MRI characteristics of an injured spi- pecially with such fractures. with an incidence as high as 11%. niation (Fig. each of which may have ing blood creates a signal void on axial SE images and a different pattern of signal changes on various pulse is seen as a bright signal on gradient-echo images. Initial neurologic dissection as a tapering of the vessel. who have underlying degenerative or congenital Missiles can cause spinal cord injury by direct pen..22.15) or an osseous fragment. the abnormality on the T2-weighted images. Trauma patients by projectiles (e. the axis or by odontoid fractures with anterior or posterior displacement of C1 relative to C2.€6. These images should be carefully evaluated in the Penetrating Trauma sagittal and axial planes for regions of effacement of the ventral or dorsal CSF spaces.€6. dissection. or a blast available for the spinal cord. edema. extent. with a specific compressive lesion such as disc her- cal spine fractures extending into the transverse fo. MRI is very useful for detecting ligamentous and spinal The severity of spinal cord injury depends on the cord injury. edema and merging the data from these two modalities can help acute hemorrhage are seen as bright signal. Specifically. morphology.” is the result of the magnet- ography shows vertebral artery thrombosis as the ic susceptibility artifact from methemoglobin. Flow.124 IIâ•…Spine Atlantoaxial Dissociation processes can deflect the penetrating object into the paraspinal soft tissues. The osseous architecture of the spine often Clinical and experimental evidence has shown protects the spinal cord from direct injury from a that surgical decompression of stenotic areas has stabbing mechanism because the lamina and spinous a beneficial effect on neurologic recovery. and transec. sequences. es. or the edema is transient and resolves with time. MRI clearly depicts the associated pathology seen with Characterization of Spinal Cord Injury atlantoaxial dissociation.6 The absence of flow-related enhancement on images in anatomic location.22 MR angiography may nal cord segment are based on the degree of swell- show areas of vascular stenosis or occlusion.42 (Fig. which .39 This to those of spinal contusion. rologic recovery than is associated with a spinal cord or the presence of an extraluminal thrombus or a slit injury with predominantly edematous changes. or hemorrhage. specific location. Spinal cord Vertebral artery injury is associated with blunt cervi. ent-echo images show dark areas that are larger than The types of vertebral artery injuries are throm. jury often has no MRI evidence of edema (increased T2-weighted signal). and type of cord injury from tion with superior migration of the atlas away from penetrating trauma. Highly T2-weighted images offer a myelographic effect for the assessment of spinal cord compression. ramen. but it is associated most often with unilateral An injured spinal cord segment may have an in- or bilateral facet dislocations. stenosis are at increased risk for spinal cord injury etration. displacement of bone fragments into the because of the decrease in the cross-sectional area spinal canal. may be used to assess vertebral artery patency.6 or dark band through the lumen. bullets) or puncture mechanisms. Major clues to the extent of spinal cord damage by hemorrhage to vascular injury include changes in vessel caliber.€6. compressing the spinal cord. effect. The relationship of the atlas to the axis characteristics of the traumatic event (including is clearly visible with MRI. or edema. ing.43 and transection (rare). MR angi. the integrity the amount.41 MR angiography crease in cord diameter because of swelling.6 Evidence of parenchymal hemorrhage on loss of the normal rounded shape. which indicate spi- Penetrating injury to the cervical spine can be caused nal stenosis and cord compression.6. This en- bosis. or “blooming.40. deficit and potential for recovery are related directly tion as a focal discontinuity of the vessel. largement.12 As noted above.13). compression may show injury characteristics similar cal trauma. whereas determine the status of blood flow in the vertebral chronic hemorrhage is seen as darker signal.14).44 On T2-weighted images. increase in caliber MRI may predict worse functional outcomes or neu- from proximal to distal (except at the carotid bulb).

13â•… Atlantoaxial instability. 6â•… The Cervical Spine 125 Fig. VA e f . (e) An axial T2-weighted image† and (f) corresponding artist’s sketch also show that prominence (arrowhead) and edema at the insertion site of the transverse ligament on the lateral masses of C1 (arrows). Widening of the atlanto–dens interval C2 Vertebral a. Bilateral edema at insertion of transverse lig. C1 Transverse lig. 6. C2 c d C1 anterior arch Transverse lig. a b Basilar a. (c) A sagittal T2-weighted image† and (d) corresponding artist’s sketch show prominence of the transverse ligament (arrow). (a) Lateral extension† and (b) flexion† radiographs show instability at the C1-C2 level with widening of the anterior atlanto–dens interval on the flex- ion radiograph (arrow on b) relative to the ex- tension radiograph.

126 IIâ•…Spine a b c d Edema Left vertebral Right vertebral a. e f . patent dislocation Left vertebral a. C6 Partial jumped facet left side Avulsion of anterior longitudinal lig. thrombus normal. thrombus Edema in the Edema interspinous C5 and supraspinous ligs. Partial facet a.

which has been recognized cord signal intensity (arrow) compatible with myelomalacia.45. 6â•… The Cervical Spine 127 makes prompt identification of stenotic areas and distinguishing these areas from simple contusions important.22. Artist’s sketches in the (e) sagittal and (f) axial planes show the displacement that leads to vertebral artery injury in this scenario. (c) An axial image from a 3D gradient-echo acquisition shows an oval area of low signal intensity in the right foramen transversarium (arrow). (d) An axial FSE image obtained at a similar level to that in (c) shows a high-signal-intensity thrombus (arrow) in the right foramen transversarium.49 • Transverse ligament Fig. Prevertebral edema (small arrowheads) and edema in the posterior paraspinal musculature (large arrowhead) are present.23. Flanders AE. (a–d from Torina PJ.† (especially kyphosis)25. Note the normal flow void of the left vertebral artery in the left foramen transversarium (arrowhead). et al. Ligamentous injury contributing to cervical spine instability may be assessed with flexion and extension lateral cervi- cal spine radiographs and by physical examination. (a) A sagittal T2-weighted image shows an injured disc at C5-C6 with increased signal intensity in the disc and probable avulsion of the anterior longitudinal ligament (arrow).8. Cervical spine instability may be caused by damage to the osseous and/or ligamentous structures.48 Im- portant ligaments to assess include the following23: • Anterior longitudinal ligament • Posterior longitudinal ligament • Posterior column ligament complex (supraspi- Fig. Incidence of vertebral artery thrombosis in cervical spine trauma: correlation with severity of spinal cord injury. (b) An MR angiogram (anterior view) from a 2D time-of-flight acquisition shows absence of signal intensity in the expected course of the right vertebral artery (arrowheads). Con- ventional radiographs and CT scans often provide the best assessment of osseous injuries. Reprinted by permission. nous ligament. 6.46 Characterization of Cervical Spine Instability White et al47 defined cervical spine instability as the inability to maintain a normal association between vertebral segments while under a physiologic load.12 In addition. and lig- tral disc extrusion at the C5-C6 level with associated increased amentum flavum). Note the normal flow-related enhancement in the left foramen transversarium (arrowhead). 6.) .26:2645–2651. MRI assessment of cervical spine fractures in obtunded or uncooperative pa- tients may identify disc herniations that may cause spinal cord compression and iatrogenic or progres- sive neurologic injury during fracture reduction. MRI can also be used to evaluate for ligamentous in- jury. AJNR Am J Neuroradiol 2005. interspinous ligament. indicative of a thrombosed vertebral artery. Note the normal course of the left vertebral artery (arrows).14â•… Vertebral artery injury after unilateral facet dislocation at C5-C6 without spinal cord injury. the sensitivity for detection of such injuries is greatest within 24 to 72 hours postinjury. Carrino JA.20. corre- sponding to a thrombus in the right vertebral artery.15â•… A sagittal T2-weighted image shows a large cen. Note the elevation of the posterior longitudinal ligament as an important restraint to spinal instability (arrowhead).

24 With the increasing availability of flexion-exten- sion (kinematic) cervical spine MRI. 6. and after frank instability of the cervi- Fig. These find- ings are compatible with injury to the posterior ligamentous structures.50 Although such informa- tion provides insight into the degree of spinal insta- bility. 6. (b) Image obtained in extension shows moderate stenosis at the C6-C7 level secondary to buckling of the ligamentum flavum (arrow) and disc bulge.52 Patients who have sustained severe trauma to the cervical spine are likely to be immobilized.16) or loss of ligament continuity (normally a low-intensity continuous signal). Despite the ca- pability of MRI to detect ligamentous injury.17).51. a dynamic as- sessment of cervical spinal instability and associated stenosis can be obtained. minor motor vehicle accidents that result in acute whiplash injury of the cervical spine without fracture do not need emergent MRI evaluation for ligamentous in- jury and may be treated symptomatically only.24 For example. upright MR system shows no substantial stenosis.† . Ligamentous injury is best assessed on STIR or fat-suppressed T2-weight- ed images. not all MRI-detected ligamentous injuries result in spinal in- stability or warrant treatment.17â•… Sagittal T2-weighted images of a patient after C4-C6 anterior cervical decompression and fusion with allograft and plate. (a) Image obtained in flexion on an open.16â•… A sagittal STIR image of a patient who sustained a hyperflexion injury to the cervical spine shows increased signal intensity within the region of the supraspinous and in- terspinous ligaments between C3 and C6 (arrow). After a period of im- mobilization. it tends to be most useful for the evaluation of patients with degenerative disorders of the cer- vical and lumbar spine (Fig.€6.† a b Fig.23 A ligament strain. may be seen as an elongated or redun- dant ligament on sagittal MR images.23.128 IIâ•…Spine MRI characteristics of ligamentous injury include increased T2-weighted signal (from edema) with- in the ligamentous and other posterior structures (Fig. without complete disruption.€6.

56 Boden T2-weighted images (Fig. whereas disc desiccation graphic and MRI abnormalities do not always corre. On MRI. along with the imaging body end-plate sclerosis can be best evaluated on ra- findings. As the disc degenerates and desiccates. In addition.58 The re- mainder of the nucleus pulposus consists of proteo- ■⌀ Degenerative Conditions glycans and collagen that attract water.€6. Degenerative pathology may af. tears and disc herniation. tears are seen as areas of high signal intensity especially important when evaluating the MRI stud. Specifically. or a more focal neurolog.€6. The findings of degen- radiculopathy. erative disc disease seen on MRI should also be cor- ic deficit. .54 MRI is usually sion may occur secondary to the decreased width considered the preferred initial advanced imaging and height of the adjacent neural foramina caused modality for the evaluation of symptomatic cervical by disc height loss. poste. it is important to understand that radio. or combined surgical approaches. lus fibrosus. The structural enable the surgeon to decide among anterior.57. T2-weighted sequences. a joints.54. Conventional radiographs are often of intervertebral disc elasticity exposes these small the initial screening studies for evaluating cervical vertebral joints to increased motion and instability. this practice is images.53 Cervical spine abundant anteriorly but deficient posterolaterally. and superior ies can be used to guide surgical treatment and may and inferior cartilaginous end plates. and uncinate spine degeneration. ligament reinforces this deficient area. which creates pressure that enables the nucleus pulposus to resist Degenerative changes of the cervical spine are com. diminishing the disc’s ability to support load. phy and osteophyte formation.55 This increased stress on facet and uncover- single cervical spine level may have multiple degen. a kine- matic cervical spine MRI study can be considered. the degree of vertebral be taken into consideration.3). or complete tears. axial loading. myelopathy. radial. and this information should spine radiographs. annulus bulging. The laterality and level of the symptoms related with the degenerative changes seen on cervical should also be assessed.55 • Uncovertebral joints of Luschka Disc desiccation leads to bulging of the annulus fi- • Ligaments brosus and loss of disc height. Nerve root compres- more advanced imaging techniques. radiculopathy. and oblique radiographs will best show fo- nonoperative and surgical treatment options. one should disc pathology based on the extent of annulus bulging know whether a patient is presenting with neck pain. including tion of the intervertebral disc changes and water is the following: lost.54. within the annulus (Fig. raminal stenosis secondary to osteophyte formation. The collagen fibers in the annulus are mon after the fourth decade of life. the proteoglycan composi- fect multiple areas in the cervical spine. shows as low signal intensity on T1-weighted and late with a symptomatic degenerative lesion. the loss erative changes.58 The posterior longitudinal stiffness.18).55 et al53 reported that almost 60% of their asymptom. composition of the intervertebral disc changes with rior. Discogenic pain may be associated with aging findings (see Chapter 4.55 A weakened annu- ies of a patient with a suspected cervical or lumbar lus fibrosus may lead to a spectrum of intervertebral spine degenerative disorder. Specifically. age: the water content of the nucleus pulposus and annulus fibrosus decreases from ~90% in the first year of life to 70% to 75% in the eighth decade. degeneration may be asymptomatic or have acute or creating a potential weak area at risk for degenerative insidious onset of symptoms. it may result in pain. tebral joints propagates osteocartilaginous hypertro- erative pathologies and cause adjacent-level degen. causing increased • Paravertebral musculature stress transfer to adjacent facet and uncovertebral Because these elements are biomechanically linked. A Systematic Approach transverse. a normal specificity of 91% for the detection of cervical degen.19). an inner nucleus pulposus. concentric annular fibers. myelopathy. and disc herniation (Table 6. annular tears.55 Despite this high sensitivity and on T1-weighted images and high signal intensity on specificity. intervertebral disc has intermediate signal intensity erative changes. spine degeneration and may guide the selection of furthering their degeneration. degenera- atic patients >40 years old had cervical spine degen.58 manent disability. 6â•… The Cervical Spine 129 cal spine has been ruled out with patient-controlled Degenerative Disc Disease flexion-extension cervical spine radiographs. An intervertebral disc is composed of an outer annu- The information obtained from such kinematic stud.54. in deamination of and change in the architecture of the Although one should always correlate the pa.55 On T2-weighted to the Review of Spine MRI Studies). The nucleus pulposus is replaced with more fibrous • Intervertebral discs structures and blends with the adjacent annulus fi- • Facet joints brosus into amorphous fibrocartilaginous tissue. it has a reported sensitivity and process and facet hypertrophy. and even per. when making a choice among the various diographs. With advancing age.20. tive changes also affect the annulus fibrosus and result erative disc disease on MRI.20 These changes may lead to tient’s history and physical examination with the im.

18â•… Multilevel degenerative disc disease. (a) A sagittal T2-weighted image shows multilev- el degenerative disc disease as evidenced by the loss of the normal high signal intensity within the discs.3â•… Intervertebral disc pathology Disc Pathology MRI Findings Bulge Symmetric extension of annulus beyond confines of adjacent end plates Protrusion Focal area of disc material that extends beyond vertebral margin. (d) A sagittal reconstructed CT image also shows multilevel degenerative disc disease and provides improved osseous detail that com- plements the information seen on the MR imag- es. Kebaish KM. J Bone Joint Surg Am. Magnetic resonance imaging of the cervical spine.84:70– 80. Modified with permission. 2002. et al. (b) An axial T2-weighted image at the C3-C4 level shows a right paracentral disc bulge (arrowhead). and the multi- level anterior osteophyte formation (arrowheads). Note the gas-containing subchondral cyst at the inferior end plate of C6 (arrowhead) and the multilevel anterior osteophyte formation. 6. and C7-T1. Note the degenerative spondylolisthesis at C2-C3. C3-C4 (subtle). resulting in moderate stenosis with asymmetric cord compression. . Carbone JJ.† a c d Table 6. (c) An axial T2-weighted im- age at the C5-C6 level shows moderate central b stenosis. but remains contained within the outer annular fibers Extrusion Herniation of nucleus pulposus beyond confines of annulus with disc attached to remainder of nucleus pulposus by a narrow pedicle Sequestration Portion of disc fragment entirely separated from parent disc Source: Khanna AJ.130 IIâ•…Spine Fig. There is also a loss of the normal cervical lordosis.

present with radiculopathy. 6. (which are located more laterally than those in the thy. the MRI placements varies widely among radiologists and study should also be scrutinized for the presence or .21) more likely to produce symptoms than a similar pro- • Lateral (compression of the nerve root only) trusion in a patient with a capacious spinal canal. els with greatest motion (C5-C6 and C6-C7) and may foraminal. The terms bulge. The Thoracic and Lumbar Spine). and configuration of disc displacement. protrusion. be generally classified as the following: With regard to the size of the disc abnormality. For example. it may be more important to note the degree of mass • Central (compression of the medial portion of effect on neural structures than the size of the ab- the spinal cord) (Fig. a small protrusion in • Posterolateral (compression of the lateral por- a person with developmental spinal stenosis will be tion of spinal cord and nerve root) (Fig. are described as central.22) In addition to an evaluation of the level. 6. Although a task force has provided formal guidelines for the description of lumbar disc patholo- Along with the degenerative disc disease and the gy59 (see Chapter 7. disc herniation positions in the cervical spine Disc herniations most commonly occur at the lev. It should material toward the neural elements and produce be noted that the anatomy of the cervical facet joints the clinical findings of radiculopathy or myelopa.19â•… Annular tear. and those with posterolateral disc herniations tend to there is no subarticular recess in the cervical spine. (a) Sagittal and (b) axial T2-weighted images show a high-inten- sity zone in the posterior annulus at C5-C6 (arrow on each). (Fig. Patients with large central disc herniations tend lumbar spine) essentially makes them the posteri- to present with symptoms of myelopathy. normal aging process described in the preceding similar guidelines have not been widely adopted for paragraphs.20) normality itself. whereas or wall of the intervertebral nerve root canals. direc- The nomenclature used to describe cervical disc dis. Thus. ex- pulposus and compromise of the structural integrity trusion. 6. and far lateral. paracentral (left or right). 6â•… The Cervical Spine 131 b Fig. This finding is compatible with a an annular tear that may be responsible for the patient’s discogenic neck pain.3). elevated pressures within the nucleus the cervical spine. tion. 6. and sequestration are commonly used to de- of the annulus fibrosus can lead to migration of disc scribe cervical disc pathology (Table 6.† Disc Displacement clinicians.

15 and 6.† tively well-hydrated) or “hard” (poorly hydrated) disc (Fig. Conversely. and stenosis is seen posterior osteophyte formation.20â•… An axial T2-weighted image at the C5-C6 level shows a central disc bulge (arrow) with moderate stenosis. The findings on MR images should be used to es the nerve root. MRI lated with the findings seen on lateral and oblique in patients with ossification of the posterior lon- cervical spine radiographs. which runs along the pos- cal disc protrusion can be classified as a “soft” (rela.22â•… An axial T2-weighted image at the C5-C6 level shows a lateral or foraminal disc protrusion (arrow) on the left patient with unilateral radiculopathy.€6.18).61 These findings should be corre.132 IIâ•…Spine Fig. On most MR images showing cervical steno- sis secondary to disc displacement (for example. which would be expected in a patient with a soft disc herniation. longitudinal ligament. This information may help in determining whether an anterior or posterior approach is chosen for the treatment of a patient with unilateral cervical radiculopathy.€6. 6. and vertebral end.60.62 . Figs. Note that the signal is different from that of differentiate cervical disc disease and protrusions the bone. which produces severe foraminal stenosis and compress. a hard disc herniation shows low signal on T2-weighted images and may also show associated osteophytes on gradient-echo and other pulse sequences. terior aspect of the vertebral bodies (Fig.† deformity of the right side of the spinal cord and severe fo- raminal stenosis (between arrowheads). 6.25). which produces mild and deformity of the spinal cord. the pathology and stenosis is absence of areas of calcium deposition. The Fig. side.€6.€6. 6.24). anterior or based at the level of the disc. Such a determination can be made by reviewing the images for increased T2-weighted signal within the displaced disc.23).21â•… An axial T2-weighted image at the C5-C6 level disc bulge and ligamentum flavum hypertrophy (arrowhead) shows a right posterolateral disc protrusion with associated act to produce effacement of the ventral and dorsal CSF spaces uncovertebral joint hypertrophy (arrow).54. trusion and migration (Fig. only behind the vertebral body in cases of disc ex- plate changes.† from ossification of the posterior longitudinal liga- ment.55. This combi- nation of hard disc disease and associated osteophyte is often referred to as a disc–ridge complex and may preclude the performance of a posterior keyhole fo- raminotomy and discectomy for the treatment of a Fig. gitudinal ligament shows stenosis at the level of Additional scrutiny of the imaging findings also the disc and also along the course of the posterior enables the surgeon to determine whether a cervi. Note the normal size of the neural foramen on the left side. Conversely.

6. (a) A sagittal T2-weighted image shows a large disc extrusion at the C4-C5 level (arrow) that has migrated proximally. (b) A sagittal T1-weighted image shows the disc extrusion at the C4-C5 level (arrow) that is isointense to the intervertebral disc. the osteophyte creates most of the stenosis. (b) Moder- ate central stenosis secondary to a large central disc protrusion with an associated osteophyte complex (arrow). 6. Disc (nucleus pulposus) cervical spine.† . which produces severe foraminal stenosis and deformity on the left side of the cord.† Spinal nerve root Lateral mass Vertebral a. 6â•… The Cervical Spine 133 Disc (annulus fibrosus) Fig.23â•… Axial illustrations show the difference be- Uncinate process tween soft and hard disc pathology in the subaxial Vertebral a.24â•… Cervical disc extrusion. Compressed cord a Spinous process Posterior tubercle Superior articular facet surface Lamina b a b c Fig. tenting the posterior longitudinal ligament. (a) A left posterolateral disc protrusion (arrow) resulting in mild deformity of the cord and compression of the exiting nerve root. Transverse process Pedicle Posterior longitudinal lig. (c) An axial T2-weighted image shows a left paracentral disc extru- sion (arrow).

obtained a few millimeters lateral to the midline.† and (e).25â•… Ossification of the posterior longitudinal ligament (OPLL). suggests that the posterior longitudinal ligament is thickened and that the stenosis is present at the level of the vertebral bodies and discs from C3 to C7.† (b) A parasagittal T2-weighted image. obtained at the same level as (c). The stenosis appears to be centered at the level of the disc spaces on this midline image. 6. obtained farther from the midline. show ossification of the posterior longitudinal ligament extending from C3-C4 to C5-C6.† (d) A parasagittal reconstructed CT image.134 IIâ•…Spine a b C2 C3 OPLL C4 C5 c d e Dura Fig. .† (c) A parasagittal T2-weighted image. corresponding artist’s sketch. (a) A midline sagittal T2-weighted image shows multilevel degenerative disc disease and moderate stenosis from C3-C4 to C6-C7. shows that the posterior longitudinal ligament is markedly hypertrophied and nearly fills the spinal canal (between arrows).

.† (h) An axial T2-weighted image shows severe left paracentral stenosis secondary to what appears to be a disc protrusion (arrow) but is actually a focal region of ossification of the posterior longitudinal ligament at the level of the C4 vertebral body. 6.† (i) An axial CT image.† (g) An axial T2-weighted image at the level of the C4-C5 disc shows similar findings. corresponding artist’s sketch. 6â•… The Cervical Spine 135 h f i C4 g j Fig. shows that what appears to be a disc protrusion on MRI is actually a focal region of ossification.† and (j).25 (Continued)â•… (f) A midline sagittal reconstructed CT image shows anterior osteophyte formation but no substantial ca- nal stenosis. obtained at the same level as (h).

CT imaging can be ob. Effacement.€6. stenosis superimposed on preexisting congenital The degree of central canal stenosis can range from stenosis (Fig.4). Spinal steno. or neural foramina (Fig. and (d) foraminal. mild encroachment on the ventral subarachnoid space a b c d Fig. patients can also develop degenerative patients with focal and concentric spinal stenosis. niation or uncovertebral or facet joint hypertrophy.28): osseous detail. The importance of this differentia- • Disc bulge or herniation tion lies in the fact that anterior decompression for • Uncovertebral joint osteophyte formation patients with ossification of the posterior longitu- • Ligamentum flavum hypertrophy dinal ligament tends to be difficult and is associ- • Facet arthrosis ated with higher rates of durotomy and bleeding. 6.€6. cord on sagittal images and circumferentially around cesses. Foraminal stenosis may be caused by a disc her- terior longitudinal ligament. (c) lateral recess. lateral re. the spinal cord on axial images.26). (b) posterolateral. tained to rule in or rule out this diagnosis.26â•… Artist’s sketches show four types of disc herniations in the cervical spine: (a) central. best seen on the sagit- Spinal Stenosis tal and axial T2-weighted images.€6. given that Central canal stenosis is most often caused by a com- it provides optimal visualization of calcification and bination of two or more of the following (Fig.” in which the CSF is seen The term spinal stenosis describes the compression as bright signal anterior and posterior to the spinal of the neural elements in the spinal canal.136 IIâ•…Spine In patients with suspected ossification of the pos. calcification. discon- sis can develop from congenital or acquired causes tinuity. or ossification of and therefore surgeons may prefer to proceed with the posterior longitudinal ligament or other posterior decompression even though the primary structures compression is located ventral to the spinal cord. or displacement of this CSF space is seen in (Table 6.27).† . central canal stenosis is characterized by compression of the thecal sac. On MRI. • Thickening. Such images pro- vide a “myelographic effect.

ossification of the posterior longitudinal ligament. (b) A sagittal T2-weighted image shows a small disc bulge at the C4-C5 level that causes spinal cord signal abnormality. (c) An axial T2-weighted image shows the moderate to se- c vere central canal stenosis.27â•… Degenerative stenosis superimposed upon congenital stenosis.4â•… Acquired and congenital factors associated with spinal stenosis Type Factor Acquired Intervertebral disc pathology Uncovertebral joint hypertrophy Facet joint hypertrophy Ligamentous origin (ligamentum flavum hypertrophy/ossification.† . (a) A sagittal T1-weighted image shows a developmentally shortened AP dimension of the spinal canal. 6. diffuse idiopathic skeletal hyperostosis) Spondylosis Metabolic causes Postinflammatory pathology Spondylolisthesis Postoperative pathology Neoplasm Congenital Idiopathic stenosis with short pedicles Skeletal growth disorders Down syndrome Achondroplasia Mucopolysaccharidosis Scoliosis a b Fig. 6â•… The Cervical Spine 137 Table 6. representing spondylotic myelomalacia (arrow).

and gradations such as moderate–severe. MRI findings may correspond to and degree of effacement of the CSF column and the severity and duration of the compression.63 This ratio is often MRI study (see Chapter 4. A Systematic Approach to used to evaluate for congenital stenosis in athletes. Facet joint hypertrophy Facet joint hypertrophy Ligamentum flavum a hypertrophy b Spinal cord Posterior longitudinal stenosis Ligamentum flavum Uncovertebral lig.29). The midline sagittal T2. parasagittal.8 defined as stenotic.28â•… Artist’s sketches show various potential contributors to cervical spinal stenosis: central disc bulge.€6. severe. and axial T2-weighted images. The authors’ sug. and ligamentum flavum hypertrophy. facet joint hypertro- phy.† to severe compression and flattening of the spinal cord weighted images provide a global view of the levels with myelomalacia. canal diameter of <13 mm. and degree of degenerative cervical spinal defined as an AP canal diameter of <10 mm. most cli- evaluation of the degree of spinal cord and nerve nicians and radiologists tend to grade the degree of root compression on the sagittal. whereas the parasagittal changes of spinal cord compression can be seen as images enable visualization of lateral recess and fo- cord edema (high signal areas on T2-weighted im. The information from ages). with gested approach for the evaluation of a cervical spine a ratio <0. (d) A 3D superolateral view shows foraminal stenosis. hypertrophy spurring Midline posterior Facet joint vertebral ridging hypertrophy c d Fig. (a) An axial view shows central stenosis. cystic degeneration.54 Early spinal cord compression. high signal on T2-weighted images). one should have a systematic approach to or Pavlov ratio is calculated by dividing the AP ca- the evaluation of these studies. which show the same pathology in an and syrinx formation (low signal on T1-weighted and orthogonal plane. and absolute stenosis is location. (c) A lateral view shows central stenosis with cord compression. The Torg stenosis. 6. raminal stenosis (Fig.€6. progressive compression may cause spinal cord these images should be correlated with that from the necrosis and atrophy (Fig. (b) An axial view shows foraminal stenosis.138 IIâ•…Spine Facet joint hypertrophy Uncovertebral Disc Midline posterior spurring Posterior longitudinal vertebral ridging lig. axial images.54 There are several objective measures of cervical Given that the great majority of cervical spine spinal stenosis. moderate. The . nal diameter by the AP vertebral body diameter. and spinal stenosis using the terms mild. Relative stenosis is defined as an AP MRI studies are obtained to evaluate for the presence.30). the Review of Spine MRI Studies) includes a critical Although such definitions are well known.

There is focal thickening of the ligamentum flavum at the C5-C6 level (arrow). (b) A sagittal T1-weighted image shows a segment of low signal intensity within the spinal cord from C4-C5 to C6-C7. (c) An axial T2-weighted image at the C4-C5 level shows atrophy of the spinal cord and indistinct margins a b between the spinal cord and the surrounding CSF. 6â•… The Cervical Spine 139 c Fig.30â•… Cervical stenosis. 6.† a b c Fig. (a) A midline sagittal T2-weighted image shows multilevel degenerative disc disease with mild spon- dylolisthesis at C3-C4 and thickening of the posterior longitudinal ligament at multiple levels. changes are seen at the C5-C6 level (arrowhead). but less severe.29â•… Spinal cord atrophy. (c) A parasagittal T2-weighted image obtained farther laterally in the plane of the neuroforamina shows severe foraminal stenosis at the C4-C5 level (arrow) and moderate foraminal stenosis at the C5-C6 level (arrowhead). (b) A parasagittal T2-weighted image obtained several millimeters lateral to the midline shows effacement of the ventral CSF space and moderate stenosis at the C4-C5 level (arrow) due to osteophyte formation and thickening of the posterior longitudinal ligament.† . with resultant atrophy of the spinal cord at the level of C5 and regions of cord edema prox- imal and distal to the region of atrophy. 6. (a) A sagittal T2-weighted image shows moderate–severe stenosis at C4-C6. Similar.

(c) An axial T2-weighted image at the C4-C5 level shows moderate stenosis secondary to more substantial central disc bulge (arrow). • Moderate—stenosis occupying between one tions (Figs. ligamentum flavum hypertrophy (arrowhead). findings similar to those of mild stenosis • Mild—stenosis occupying less than one third of but with compression and minimal flattening normal canal dimension. and facet arthropathy (asterisk). ligamentum flavum hypertrophy (arrowhead).32): third and two thirds of normal canal dimen- sion. with very and facet arthropathy.140 IIâ•…Spine authors tend to use the following terms and defini.31â•… Grading of cervical stenosis: mild to moderate–severe.31 and 6. in which the ventral and deformity of the spinal cord and dorsal CSF spaces are partially effaced by • Severe—stenosis occupying more than two disc bulging. (b) An axial T2-weighted image at the C5-C6 level shows mild stenosis secondary to a central disc bulge (arrow).† . (a) A sagittal T2-weighted image shows minimal spondylo- listhesis at C4-C5 with moderate stenosis at this level. 6. and facet arthropathy (asterisk). (d) An axial T2-weighted image (different patient) shows moderate–severe stenosis at the C5-C6 level as a result of even greater central disc bulge (arrow) and ligamentum flavum hypertrophy (arrowhead). thirds of normal canal dimension. ligamentum flavum hypertrophy. no mass effect on the pronounced flattening and deformity of the cord spinal cord that is obvious on both sagittal and axial T2-weighted images a b c d Fig. 6.

(c) An axial T2-weighted image at the C4-C5 level shows severe.64–66. and facets of C2 occurs. (a) A sagittal T2-weighted image shows severe stenosis at the C3-C4 level and moderate to moderate–severe stenosis at the C4-C5. it compresses the brainstem and vertebrobasilar sys- RA is a systemic disease that causes inflammation tem. some cases.)† RA gins to occupy a relatively more rostral position. The synovial joints develop pan. stenosis with compression and deformity of the spinal cord with minimal CSF seen in the lateral recesses bilaterally. (b) An axial image at the C3-C4 level shows very severe stenosis with complete obliteration of the CSF space and compression of the spinal cord to an AP diameter of 2 mm second- ary to a central disc bulge and severe ligamentum flavum hypertrophy (arrow).64.64–66 trast to other disorders.65 A cord space. and C6-C7 levels. the C1 arch migrates with In the cervical spine.69 It is important to note that in con- tous structures and the associated instability. resulting axial instability.70 Two studies reported on monly.64–68 Most com. the vical stabilization for patients with RA and atlanto- occipital condyles. This pathologic process is postulated by some of synovial joints. MD. Lemma.65 As the disease cord as a technique for predicting recovery after cer- progresses. erosion of the lateral masses of C1. 6. the C2-C3 disc space. vanced RA.64–66. (Images courtesy of Mesfin A.32â•… Grading of cervical stenosis: severe.64. it has been reported to be as inferior as cal spine. or space available in cranial settling.66 In craniocervical junction as well as the subaxial cervi. for the cord. 6â•… The Cervical Spine 141 b a c Fig. but less severe than in (b). as described subsequently. as the etiology of sudden death in those with ad- nus secondary to erosion of supporting ligamen.64–66 As the odontoid process be. C5-C6. this condition may affect the the skull base to lie in a more caudal position. of >14 mm on MRI was associated with . atlantoaxial instability develops secondary to the use of MRI to measure the space available for the erosion of the ligaments at the OCJ.

(b) A sagittal T2-weighted image in flexion shows exacerbation of the occipitocervical stenosis to severe. diagnostic cal spine well before conventional radiographic testing.72 does not account for the commonly occurring sub- luxations in such patients that are exaggerated with movement. edema.65 present with a rheumatoid discitis that manifests as Flexion-extension MRI is particularly useful for eval. The substantial differences be- instability at the OCJ and suboccipital cervical spine tween imaging and clinical features of RA in the (Fig. and antimicrobial therapy. Similar information can be obtained by combining the information obtained from a static ■⌀ Infectious Conditions (conventional) MRI study and flexion-extension cer- vical spine radiographs (Fig. which was associated with a poor prognosis.† . and fusion) an early indolent course and early symptoms may be a b Fig. Multilevel degenerative disc disease is also seen. Patients with RA may also mm. In addition. A delay in diagno- signs become evident.33). especially because supine extension MRI spine have been documented and are well known.€6. increased T2-weighted and decreased T1-weighted uating patients with RA and specifically those with signal in the disc.64. (a) A sagittal T2-weighted image obtained with the patient in neutral position shows moderate stenosis at the OCJ and at the C5-C6 level.13). a challenge despite advances in imaging.142 IIâ•…Spine better clinical outcomes than was a space of <10 may be detected on MRI.71.€6. (c) An axial T2-weighted image at the C5-C6 level shows moderate stenosis at the C5-C6 level from degenerative changes and a left paracentral disc c protrusion (arrow). 6. involvement of sis is common because spinal infections often have the facet joints (inflammation. The treatment of spinal infections continues to be MRI can detect pannus formation in the cervi.33â•… Occipitocervical stenosis.

spinal instability.73 Anatomic dural space.74 It Mycobacterium tuberculosis infection of the spine is found in 50% to 65% of culture-positive cases and has some distinct differences: accounts for >80% of pediatric spinal infections.34). chronic infection. Proteus) may occur after genitourinary hancement on T2-weighted images. the vertebral compression. and neck or back pain. conventional radiographs or CT and more specific dural space. ism causing cervical osteomyelitis and discitis.73–76 end plate may have an irregular appearance be- Neurologic deficits secondary to spinal infection cause of infectious destruction.20. disc en- immunodeficiency. epidural space.79 With appropriate treatment of the infec- center.74 infections. Immunocompromised patients are sus- • Tuberculous spondylodiscitis is a slow-grow- ceptible to infections with atypical pathogens such ing process that often results in marked col- as Aspergillus. and the edema tends not to cross based on the level of spinal involvement. contrast enhance- spine infections and are less common than thoracic ment in the disc. In adults.73 hancement is an essential factor for the diagnosis Bacterial inoculation of the spine may occur of discitis. intervertebral discs. intervertebral discs. followed by segmental . develop within the area of previous infection with MRI is the imaging modality of choice for the di. teristics are the same as those of many spine pa- cal spine infections to have a more aggressive and thologies. osteo- agnosis and evaluation of spinal infections and for phytic bridging may occur. intervertebral disc destruction may occur tensity.77 • Intervertebral discs are damaged less or com- Gram-negative infections (Escherichia coli. leading monitoring the response to treatment. or deformity. and a vast venous plexus) may allow cervi. Nocardia asteroides. and epi- (~40%) or lumbar (~50%) spine infections. In comparison with other bacterial infections. these imaging charac- space. and My- lapse of the vertebral bodies.. a regression of the T2-weighted signal hyper- nulus fibrosus..74 Infectious spondylitis may preÂ�sent with findings such as low T1-weighted signal with Cervical Vertebral Osteomyelitis or without high T2-weighted signal (high signal is and Discitis often more evident on fat-suppressed T2-weight- ed or STIR images). Neurologic symptoms may vary vertebral body. muscle strain. Unfortunately. paraspinous soft-tissue abnormali- spine (smaller canal diameter relative to the size of ties. Candida.20. On gadolinium-enhanced images. Children with sickle cell observed. posterior tebral osteomyelitis. and enhancement of the vertebral sub- through hematogenous seeding. erosion of end plates. In adult intervertebral disc is seen as a region of low signal in- infections. and tion.73.74 High sen- to a misdiagnosis of more common spinal ailments sitivity (96%).74. degenerative disease). neoplastic weight loss. Over time. that do not vary processes tend to have their epicenters within the with activity level. 6â•… The Cervical Spine 143 nonspecific (e. specificity (93%).21. muscle spasm). increased T2-weighted signal Infections of the cervical spine account for ~10% of within the intervertebral disc. and posterior element involvement20. Spine in. A region of mottled signal intensity may also through bacterial proteolytic enzyme infiltration. have been reported for the MRI diagnosis of ver- fections may involve the vertebral body. and disc height are more common in patients >50 years old and in loss or collapse may occur with progressive infec- those with comorbidities such as diabetes.76. than nuclear scintigraphy in identifying vertebral osteomyelitis. or the spinal cord. direct inoculation. and accuracy (94%) (e. including fever (~50% of the time). including neoplastic disease. differentiate infection from other processes affect- ment. Pseu- pletely spared and may not show signal en- domonas. epidural fluid differences between the cervical and thoracolumbar collections. In addition. One can rapid progression that requires expedited treat.76 Scar formation within the vertebral body metaphysis and end plate.78 the spinal cord. the clinical presentation of ver. ing the vertebral body bone marrow by noting that tebral osteomyelitis and discitis has variable signs the epicenter of the former pathology tends to be and symptoms. Gadolinium-enhanced MRI also is essential for tilaginous growth plate into the nucleus pulposus. Conversely. blood vessels reach only the an. and epidural (Fig. adjacent level may be seen. cobacterium.g. chondral bone may indicate a well-established and or contiguous spread from local infection.74.g.60 MRI is more sensitive than elements. neck pain. monitoring the efficacy of treatment of vertebral allowing direct deposition of bacteria into the disc infection. tion. Isolated discitis is common in the pediatric popu- lation because vascularity extends through the car.76 coccus aureus is the most commonly cultured organ. at the intervertebral disc.74 In general. limiting bacterial deposition to the intensity is observed. spinal cord the intervertebral disc. RA. disease may develop spine infections secondary to • Telescoping of one vertebral body disc into an Salmonella. subarachnoid space. Pseudomonas infections may occur in • Subligamentous spread of infection is often intravenous drug abusers. Staphylo.€6.20. sub. associated contrast enhancement. subchondral marrow.

C4-C7).76 It should be noted.74 Epidural abscesses are less common in the graft enhancement occurs. Bone and may be located anterior or posterior to the spinal graft usually has high signal intensity on T2-weight. scess.80. but it is often less intense cervical spine than in the thoracic or lumbar spine and less uniform than that caused by infection. An epidural abscess enhancement of the subchondral bone and marrow is usually associated with vertebral osteomyelitis. evaluation for cervi.144 IIâ•…Spine a b c Fig. in the vertebral body’s epi- dural component. (a) A sagittal T2-weighted image shows obliteration of the C5-C6 disc space with associated edema in the C5-C6 vertebral bodies and an associated epidural component.74 Graft material and na.74 Multiple spinal segments are usually involved ed images during the first postoperative year. and (most commonly.81 In the postoperative patient.74 features in the setting of clinical improvement do not necessarily indicate failure of treatment.74 An enhancing mass with risk factors for spinal infections. MRI findings of A spinal epidural abscess is a collection of purulent infection in a postoperative patient include contrast material outside the dura mater. Note the prevertebral edema and soft-tissue fullness (between arrows). Epidural Abscess cal spine infection may be complicated by the normal enhancement of the uninfected disc. and adjacent to the infected disc. the number . that a lack of adjacent to the graft or a graft dislodgment is a sign improvement on MRI and even deterioration of MRI of potential infection. cord. and in the prevertebral space. which produces moderate spinal ste- nosis in a patient with infectious symptoms and findings.† fusion. (b) Pregadolinium and (c) postgadolinium T1-weighted images show enhancement at the disc space.34â•… Cervical spine discitis and osteomyelitis. After several months. however. 6.74 the signal gradually decreases with time as the bone Along with the increase in the number of patients graft is vascularized and fused. direct extension from an adjacent infected vertebral tive vertebrae should not enhance within the first body is the most common source for an epidural ab- few days after spinal surgery.

A subdural • Assesses the extent of spinal cord compression abscess.76 man immunodeficiency virus) Hematogenous seeding of bacteria is the most com- • Intravenous drug abuse mon etiology. tumors because it: • Provides unparalleled soft-tissue detail • Evaluates the neural elements Intradural Infections • Reveals important tissue characteristics of the tumor (e. Mass effect from the abscess com. Contrast enhancement is beneficial for Spinal leptomeningeal infections can be caused increasing the detection of most intramedullary by many organisms.74. and intradural-extramedullary tumors. Cryptococcus sp. or myelitis. leptomeningitis. a basic understanding of possible tu- from a thin. • Intramedullary ed and fat-suppressed T2-weighted images also show the boundaries of the epidural abscess and allow for A reasonable differential diagnosis may be estab- the assessment of the degree of spinal cord compres. vascularity. with MRI characteristics as described • Trauma previously. • Diabetes Spinal cord infections and abscesses are uncom- • Immunodeficiency (e.20. These factors also increase the risk for developing an epidural abscess. physical sion. 6â•… The Cervical Spine 145 of patients with cervical epidural abscess is also in. In addition. Early cord infection shows increased • Male gender T2-weighted signal and poorly defined enhancement • Malignancy with gadolinium. of interest. hu- mon but are associated with a high mortality rate. cord. T1-weighted images provide anatomic • Extradural detail of the location and extension of the abscess • Intradural-extramedullary and any associated vertebral infections. as described previously.. from medications. including Neisseria meningiti. myelopathy. or paralysis. lished by incorporating a clinical history. and viral organisms. density. hematogenous spread. peripheral pattern (which may repre. or myelitis. Axial images may be helpful for specific areas ischemia.76 Progressive infection may cause • Malnutrition spinal cord cavitation. MRI is the diagnostic study of choice for the evaluation of an Spine tumors are categorized by their anatomic loca- epidural abscess. but meningeal enhancement of the spinal cord • Alcoholism is abnormal. Tumors of the Spine) as follows75: suppressed.74. or a syrinx. is caused by direct extension from The entire spine needs to be evaluated because an epidural abscess. rogenic contamination. mor location.75 However.. the spi- • Recent systemic illness nal cord may become edematous and enlarged from • Tobacco use the infection. The risk factors associated with vertebral MRI shows abnormal meningeal enhancement along osteomyelitis include the following: the surface of the cord or nerve roots.g.75 sent a collection of liquefied pus with a surrounding A definitive diagnosis often requires a biopsy of the rim) to a homogeneous pattern seen with a phleg. extent of marrow involvement) ral abscess. which is clinically indistinguishable from an epidural abscess. depicted as areas of low signal • Obesity intensity on T1-weighted images and high signal in- • Previous spinal procedure tensity on T2-weighted images. Coccidioides immitis. tion (see Chapter 8. lesion. can be screened with sagittal T1-weighted SE im- scess next to a compressed spinal cord. T2-weighted ages and sagittal T2-weighted FSE images to ob- images show an associated signal intensity change tain a myelogram-like examination of the spinal within the spinal cord secondary to compression. dis. Tumors As it is for vertebral osteomyelitis. The clinical presentation for an epidural abscess may be similar to that of vertebral osteomyelitis.74 T2-weight. ■⌀ Other Pathologic Conditions pressing the spinal cord or nerve roots may present as radiculopathy. and the MRI examination findings.82 Meningeal enhancement can be seen incidentally over the • Age >50 years brain. Gadolinium-enhanced creasing. The spinal cord may be evaluated for the level MRI is an effective technique for imaging spine and amount of compression. or iat. mon. Treponema gadolinium enhancement may obscure the contrast . of possible skip lesions from intrathecal seeding.g. vascular per- Intradural infections may be categorized as subdu- fusion.74.76 Gadolinium-enhanced. Gadolinium-enhanced MRI multiple primary sites. fat. The spinal cord shows the enhancing intradural-extramedullary ab. pallidum.. Gadolinium enhancement patterns may vary examination.

83 Gradient-echo ment also vary. MRI findings .86 MRI findings may include increased signal on T2-weighted sequences. gradient-echo imaging may reveal areas of calcification or hemorrhage within the tumor (see Subacute necrotizing myelopathy is a rare. sensory abnormalities. Symptoms range from Intrinsic Inflammatory Myelopathies spastic to flaccid paraparesis. occupy less than half the spinal cord diameter. For osseous Subacute Necrotizing Myelopathy tumors. progressive Chapter 8.89 images usually are not helpful in imaging spinal cord tumors because of the limited ability to distinguish between soft tissue or tumor and CSF.146 II╅Spine between metastatic lesions and normal bone mar. may be caused by direct human immunodeficiency ing paragraphs are the most common inflammatory virus infection. and bowel and bladder dysfunction. acute in. causing venous congestion. opportunistic infections. patchy cord enhancement multiple viruses affecting immunocompetent and with gadolinium administration. and are located peripherally in Viral Diseases the spinal cord. more than three or four spinal segments.35). ischemia. or granulomatous infection.€6. Tumors of the Spine. MRI characteristics or atrophy with larger plaques (Fig. viral infections. and infarction of the spinal cord. There are multiple causes.91 There is no spinal cord. vascular disorders. Human immunodeficiency virus myelitis or minimal stenosis. also have brain plaques. sensory. meningitis. Bacterial. Parasitic. and sphincter impairment. a spongy degeneration primarily involving the posterior and lateral spinal columns causing pro- gressive ataxia and paraparesis.75 elopathy. and 90% of patients with cord plaques cord swelling or gadolinium enhancement. and Granulomatous Diseases idiopathic processes. postinfectious states. Vacuolar my- their MRI findings.83 and often is attributed to spinal dural arteriovenous fistula. as noted above. and diffuse atrophy. lymphoma. Clinical symptoms of myelitis.85. often involving ulitis can result from spinal cord invasion by bacterial. Although orthopaedic edema with peripheral contrast enhancement. and characteristic. immunodeficiency virus myelitis and vacuolar my- ry myelopathy in the presence of incidentally noted elopathy.88 Enlarge. col. with T2- weighted pulse sequences showing areas of hyperin.90 T2-weighted MR images re- Approximately 60% to 75% of multiple sclerosis veal cord atrophy and symmetric hyperintense focal plaques outside of the brain occur in the cervical lesions in the dorsal and lateral columns. myelopathies affecting the cervical spinal cord and or metabolic and vascular disorders. they should realize that they exist and can be differentiated from myelopathy second. including inflammatory processes. Acquired Immune Deficiency Syndrome ary to extrinsic compression. decreased signal Viral infections of the spinal cord may be caused by on T1-weighted images. depending on which virus is the flammatory condition of the entire spinal cord that underlying cause of the infection.84 A basic understand- ing of these processes is important. specifically so Spinal cord disease in patients with acquired immune that surgery is not considered for the treatment of a deficiency syndrome is common and includes human patient who presents with an intrinsic inflammato. MRI typically re- The most common cause of myelopathy is extrinsic veals a long segment of fusiform cord swelling and compression. for a more detailed myelopathy that occurs most often in elderly persons discussion). parasitic. Briefly described in the follow.85 is the most common Multiple Sclerosis spinal cord disease associated with acquired immune deficiency syndrome.87 of viral infection vary according to which virus is causing the infection and may include hyperintense areas on T2-weighted images. and radic- tensity of various length and width. and cord swelling immunocompromised patients.85 surgeons typically do not treat intrinsic inflammato- ry myelopathies.85 Gadolinium enhancement varies by spinal cord area Acute transverse myelitis is a monophasic. Acute Transverse Myelopathy clumping and enhancement. and lagen vascular disease. produces motor.85 MRI findings vary.86 Most plaques span two or fewer vertebral levels. ment of the spinal cord and gadolinium enhance- row if fat suppression is not applied. nerve root thickening.

6â•… The Cervical Spine 147 a b c d Fig. these findings are compatible with multiple sclerosis. d) signal within the spinal cord (arrow on each).† . 6. (c) axial T2-weighted.35â•… Multiple sclerosis. (b) sagittal T1-weighted. and (d) axial T1-weighted images show a focal region of increased (a. c) and decreased (b. In the appropriate clinical setting. (a) Sagittal T2-weighted. the diagnosis can be confirmed with lumbar puncture and CSF analysis.

Specifically. radiculopathy.36). should be evaluated with cervical evaluation of these conditions often begins with spine radiographs with flexion and extension views. loss of mobility. MRI is useful for the evaluation of contrast enhancement corresponding to cord necro. The dorsal and lateral spinal columns show demy. edema.36â•… Subaxial subluxation in RA. MRI depicts the extent of periodontoid Arthritides pannus formation.93 In addition. MRI may show nal involvement.92 of atlantoaxial and subaxial subluxation. Note the improved osseous detail provided by the CT image compared with the MR image. RA is the most common inflammatory arthropathy.93 Patients Common arthritic conditions that affect the cer. MRI is the preferred rim-enhancing lesions. cord edema.€6.93 The destructive process is through increased signal in the dorsal and lateral columns an inflammatory synovitis. and spinal cord compression (Fig. extent of osseous involvement. conventional radiographs to assess the pattern and If evidence of instability is noted on conventional a b Fig. associated dens fractures.148 IIâ•…Spine vary and may include cord swelling.85 Radiation myelopathy is a lage. ligament. and gliosis. there is spondylolisthesis at C3-C4 and C4-C5 and retrolisthesis at C5-C6. Metabolic or Toxic Diseases RA Subacute combined degeneration is a complication of vitamin B12 deficiency or nitrous oxide poisoning. myelopathy. Imaging joint replacement. and periarticular destruction. carti- on T2-weighted images. and and sudden death. MRI may reveal cord swelling. with RA who are undergoing elective surgery for vical spine and characteristic MRI findings are another musculoskeletal condition. cancer. and the cervical spine is the most common area of spi- elination. deformity. leading to bone. and nerve enhancement. axonal loss. and perivertebral erosions. paralysis. basilar in- vagination.85 modality for the assessment of the spinal cord and neural elements. treated with radiation therapy for head and neck paresthesias. 6. Clinical progressive myelopathy most often seen in patients symptoms include pain. the craniocervical junction and for the assessment sis. nodu- lar fibrosis. such as major described in the following paragraphs. and gliosis. (a) Sagittal T2-weighted and (b) sagittal reconstructed CT images show multilevel subaxial subluxation and degenerative disc disease. demyelination.† .

6â•… The Cervical Spine 149 radiographs. phalangeal joint. MRI should be considered to evaluate Amyloidosis further. T1-weighted images.94 acute fractures. sec- ondary. or mimics inflammatory arthritis in its destructive na- systemic disease (10%).96 Amyloid deposits are found in the in- tervertebral discs. intervertebral discs or ligaments.95 ticular inflammation involving the first metatarso- A common clinical scenario is one in which a pa. Gouty involvement of the spine. is a chronic inflammatory arthropathy of arthritides. MRI is useful for distinguishing unknown origin that affects ~1% of the general popu.96 Amyloid arthritis findings may mimic those of degen- Ankylosing spondylitis. and spinous process. The classic presentation is monoar- gical treatment. and scapulohumeral arthritis. producing a charac- with RA. the Ankylosing Spondylitis deposits have affinity for the atlantoaxial region. or tumor. Conventional radiographs articular manifestations. has a par- disorder in children and may present as one of three ticular affinity for the musculoskeletal system and types: oligoarthritis (60%). The disease begins in the thoracolumbar and lumbosacral junctions and ascends to involve the thoracic and cervical spine. cord compression.93 MRI characteristics of may show ankylosis of the cervical (or lumbar) gouty tophi include intermediate signal intensity on spine but no evidence of fracture or displacement. infectious destruction. is rare and ing spondylitis presents with a complaint of neck is seen in patients with long-standing peripheral pain after minor trauma.93. β2-microglobulin. polyarthritis (30%). Areas affected with Axial skeleton radiographic findings are similar to calcium pyrophosphate dihydrate deposition appear those seen with RA. is characterized by polyarticular in- hematoma. and synovial tissue.93 In addition. a seronegative spondyloar. and dialysis-associated patterns. gouty nephritis.93 As it is for the adult form. carpal tunnel syn- phy. ture.93 MRI is useful for Gout the evaluation of early development of ankylosing spondylitis. variable signal intensity on T2- It is important to note that such patients may have weighted sequences. images relative to brain tissue. and deformity.10). Deposition Disease This common crystal-induced arthritis affects pe- Psoriatic Arthritis ripheral joints and occasionally the spine.93 MRI flammation. tient with known or previously unknown ankylos. it is also asso- sion in the juvenile form. Gout. . cartilage and bone destruction. ligaments.93 Although the classic triad of β2-microglobulin MRI is excellent for identifying synovial hypertro. vertebral body subluxations. Males are affected more often than are females. renal stones. sity on T2-weighted images. The Juvenile RA is the most common connective tissue dialysis-associated form. intensity on MRI sequences and have variable enhance- and symptoms appear in late adolescence and early ment patterns on contrast-supplemented sequences.93 Sometimes. Such fractures are best seen on fat-suppressed T2-weighted images Calcium Pyrophosphate Dihydrate (Fig.93 teristic “crowned dens” sign. ferential diagnosis.€6. advanced degenera. and variable contrast enhance- an unrecognized nondisplaced fracture.93 ciated with destructive spondyloarthropathy of the cervical spine. Amyloid deposits exhibit low signal eton. amyloid deposition destruction from others in the dif- lation93 and predominantly involves the axial skel. erative change. and joint effu. calcifi- arthritis is indistinguishable from that of patients cation may surround the dens.97 obtained to rule out the presence of a nondisplaced fracture through the ankylosed spine. MRI can be ment patterns. inflammatory thropathy. and marked peripheral the atlantoaxial damage in patients with psoriatic enhancement with gadolinium. deposition includes shoulder pain. epidural metabolism. Spinal involvement may include calcium deposition in the Psoriatic arthritis may present before skin lesions. which is caused by an imbalance in uric acid tive changes. amyloidosis displays primary. especially for atlantoaxial instability. Amyloidosis is characterized by extracellular depo- sition of insoluble fibrillar proteins throughout the Juvenile RA body.93 adulthood. soft-tissue tophi. mixed signal inten- vertebral end plates.93 MRI may reveal disc space as isointense or hypointense signal on T1-weighted narrowing and erosions of the apophyseal joints. drome. especially cervical and lumbar regions. and findings often provide guidance for medical and sur. familial. On MRI.

as discussed in Chap. 5. trusions.╇Multilevel disc pro- modality for the evaluation of symptomatic cervi. Common Clinical and E. or an ing study can be obtained unreliable physical examination. A Systematic Approach to the Review of Spine ligament.8 tive conditions. B.╇ Torg ratio >0.╇Spinal tumor.╇ Conventional radiographs only B. and what imag- with cervical spine injury. Despite this high sensitivity and specific.╇ Canal cross-sectional area <100 mm2 of the cervical spine is the evaluation of degenera. in.╇ 90% ography.╇ 30% D. are C. neurologic deficits.╇ Axial T2-weighted images specific diagnoses. infectious conditions. MRI with a symptomatic degenerative lesion and.╇ Sagittal STIR images suspected cervical spine injury begins with conven.╇ Axial T1-weighted images among institutions and should be modified when B.╇ Single proton emission CT scan E. this modality is also frequently and E. patient with clinical evidence of cervical radicu- ditional fracture evaluation. and tis of the spine who presents with neck pain various arthritides. and in Chapter 3. it is and without gadolinium very important that the spine surgeon or specialist contrast enhancement correlate the findings on MRI with the patient’s his. conventional ity. What percentage of asymptomatic patients tional radiographs and/or CT imaging. Which MRI pulse sequence is the best for the evaluation of degenerative pathologies includes evaluating the integrity of the posterior liga- T2-weighted and T1-weighted images in both sagit. MRI with and without Correlative Pain Generators of the Cervical and Lum. What imaging study should be obtained to mations. CT MRI Studies. it is important to understand that radiographic radiographs and MRI abnormalities do not always correlate with C.╇ Conventional radiographs and MRI D.╇ AP canal diameter <13 mm Although the most common indication for MRI C.╇ Sagittal T2-weighted images The initial evaluation of patients with known or E. after a fall? A. However.╇Multilevel disc hernia- changes.╇ 60% is superior to that of conventional radiography or CT and is useful for the assessment of spinal cord injury. conventional cal spine degeneration and is highly sensitive and radiographs specific for the detection of cervical degenerative B. D. lopathy and myelopathy and the single sagittal ful for the evaluation of obtunded patients or those T2-weighted image shown here. D.╇ AP canal diameter <10 mm placement. 3. mentous complex in patients with known or tal and axial planes. such as infection or tumor. and ad. spinal tumors.╇Ossification of the post- tory and physical examination.╇ 20% C. D. degree of spinal stenosis. tions. A. disc degeneration. MRI provides soft-tissue visualization that B.╇ 40% E. What is the definition of absolute stenosis? evaluated on cervical spine MRI include disc dis.150 IIâ•…Spine ■⌀ Summary Common Clinical Questions The typical MRI protocol of the cervical spine for 1. erior longitudinal ter 4. 2. A.╇ Three-phase bone scan . which provide >40 years old have evidence of degenerative greater osseous detail and may reveal fractures or disease on their cervical spine MRI? details that are not detected with conventional radi.╇Epidural abscess. MRI is use. gadolinium contrast enhancement bosacral Spine.╇ Sagittal T1-weighted images being considered.╇ Conventional radiographs and CT C. evaluate a patient with ankylosing spondyli- flammatory processes involving the spinal cord. to confirm this diagnosis? MRI is the preferred initial advanced imaging A. In addition. imaging protocols of suspected cervical spine trauma? the cervical spine for specific indications can vary A. thus. and spinal stenosis. What diagnosis should be considered in a ligamentous injury.0 effectively used for the evaluation of patients with nondegenerative conditions such as Chiari malfor. Degenerative conditions that can be 4.╇ Torg ratio <1.

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fracture site. Such fractures are best terior longitudinal ligament. thus. congenital stenosis in athletes. Sagittal STIR or 4. The Torg Explanation: Boden et al53 reported that al. C or other intervention. may show increased radiotracer activity at the MRI in patients with ossification of the poste. Single proton emission CT is based at the level of the disc. This fact is important notic. the pathology and stenosis placed fracture. D minor trauma. This ratio is often used to evaluate for in that the finding of degenerative changes. vides optimal visualization of calcification weighted images. A three-phase bone scan of disc extrusion and migration. seen on fat-suppressed T2-weighted images. On most MR im. are clinically one in which a patient with known or previ- significant. alone. MRI can be obtained to rule out the be used to differentiate cervical disc disease presence of a nondisplaced fracture through and protrusions from ossification of the pos. on MRI is not an indication for surgical 5. E ment. and the the level of the disc and also along the course demonstration of osseous detail and fracture of the posterior longitudinal ligament. D as an AP canal diameter of <10 mm. The patient should have Explanation: A common clinical scenario is clinical findings that correlate. of <13 mm. ages showing cervical stenosis secondary to CT imaging may not demonstrate a nondis- disc displacement.154 IIâ•…Spine Answers to Common Clinical which runs along the posterior aspect of the Questions vertebral bodies. but such activity may not be seen rior longitudinal ligament shows stenosis at in the early postinjury time period. The findings on MRI should fracture. this image suggests the ment. T2-weighted or STIR images. or Pavlov ratio is calculated by dividing the most 60% of their asymptomatic patients AP canal diameter by the AP vertebral body >40 years old had cervical spine degenerative diameter. with a ratio <0. It is important to note that such patients diagnosis of ossification of the posterior longi. and stenosis is imaging is best for the evaluation of isthmic seen only behind the vertebral body in cases spondylolisthesis. and/or are not amenable to or have ously unknown ankylosing spondylitis preÂ� not responded to nonoperative management. and absolute stenosis is defined 2. sents with a complaint of neck pain after 3. may have an unrecognized nondisplaced tudinal ligament. A fat-suppressed T2-weighted images are su- Explanation: There are several objective perior to T2-weighted images in that they are measures of cervical spinal stenosis. In patients with suspected ossification of the posterior longitudinal liga- 1. . Conventional radiographs may Explanation: Although it is difficult to make a show ankylosis of the cervical (or lumbar) diagnosis with a single image in a single plane spine but no evidence of fracture or displace- from an MRI study.8 defined as ste- disc disease on MRI. given that it pro- may be seen as areas of hyperintensity on T2. Conversely. Relative more “fluid sensitive” and. the ankylosed spine. accentuate stenosis is defined as an AP canal diameter the edema seen with ligamentous injury. pattern will be superior with MRI. especially fat-suppressed and osseous detail. CT imaging can be obtained to rule in Explanation: Injury to posterior ligaments or rule out this diagnosis.

Epidural Abscess II. Degenerative Conditions specific indications can vary among institutions. John A. Schmorl Nodes sagittal STIR B. so 155 . Signal on T1-weighted images G. Three-Column Concept D. Discitis Protocols C. Infectious Conditions A. Specialized Pulse Sequences and Imaging B. Pseudomeningocele b. Buchowski. Lumbar Herniated Nucleus Pulposus • Sagittal T1-weighted SE • Sagittal T2-weighted FSE 4. Burst Fracture b. Epidural Lipomatosis increases in the presence of gadolinium contrast. Annular Tears 3. After Instrumentation/Fusion 2. Carrino. Epidural Hematomas d. Vertebral Translation or ■⌀ Specialized Pulse Sequences Dislocation and Imaging Protocols III. They also help E. ede- ma has low signal on T1-weighted images and may F. Assessment of Stability C. After Decompression without Trauma Instrumentation/Fusion 1. Vertebral Osteomyelitis I. Assessment of Neural Compromise VII. Nomenclature and Classification of Lumbar Disc Pathology Although imaging protocols of the lumbar spine for IV. Tuberculosis A. Jacob M. Classification of Thoracolumbar Spine Trauma VI. and A. Hematoma a. Discs and End Plates standard MRI studies of the lumbar spine for de- generative pathologies usually include the following 1. Summary a. Aditya Daftary. Facets • Axial T2-weighted FSE 1. Jay Khanna Chapter Outline V. Degenerative Disc Disease sequences: 2. Postoperative MRI Findings B. Cauda Equina Syndrome foramina and the epidural spaces. Disc Pathology c. Scoliosis be difficult to identify. However. Lumbar Spinal Stenosis anatomy and assessing the quantity of fat in neural D. Evaluation of Fracture Morphology B. Traumatic Conditions D. Thoracic Disc Herniation • Sagittal T2-weighted with fat suppression or 5. Spondylolisthesis identify the presence of fracture lines. Role of MRI in Thoracolumbar Spine A. Synovial Cyst T1-weighted images are good for identifying C. A.7 The Lumbar and Thoracic Spine Gbolahan O. Facet Arthropathy • Axial T1-weighted SE or axial gradient echo 2. Okubadejo. Posterior Ligamentous Complex E. Arachnoiditis 3.

which is to avoid missing pathologic conditions (see Table€7. On vertebral bodies Vertebral body fracture the other hand. ing modalities. including conventional radiographs ages should always be interpreted in conjunction (with flexion and extension views if clinically indi- with other MR pulse sequences because they may be cated) and CT (see Chapter 11. this susceptibility also causes gradi. such im. jury. their characteristics be obtained to make edema more conspicuous. neoplasms. Adjust- ments in the “flip angle. For this reason. A System- joint effusions. gradient-echo im- ages can be acquired much more quickly. abnormalities. such as those that Spinal column/ Alignment occur with trauma and vascular malformations.156 IIâ•…Spine these images are used to assess for contrast enhance. subtle fractures. they can be obtained with higher Interspinous ligament Edema/rupture resolution and even as a 3D volume. including the degree of stenosis. T2-weighted and fat-suppressed or soft-tissue injury is suspected in the setting of T2-weighted or STIR images are extremely helpful trauma. Posterior element fracture ent-echo images to overestimate canal and foraminal Edema Degenerative change stenosis because of artifact from the adjacent bone. Melhem ER. . including A systematic approach (see Chapter 4. Correlation of MRI prone to artifacts that exaggerate or underestimate with Other Imaging Studies). which makes isotropic voxels and reformations in multiple planes Spinal cord Edema possible. By decreasing the degree to which protons are “flipped” during image acquisition (compared with T1-weighted and T2-weighted images. Ligaments Anterior longitudinal ligament ter problem. However. infection. As with other In addition. Hemorrhage Compression Syrinx Epidural space Hematoma ■⌀ Traumatic Conditions Disc herniation Osseous fragment Patients with suspected lumbar spine injuries should Source: Takhtani D.” TR. vascular injury. Advances in MRI techniques are decreasing the lat. Magn Reson Imaging Clin N Am 2000. evaluation. Gradient-echo images spine trauma are very susceptible to magnetic susceptibility arti- Anatomy Evaluation facts. It is also useful for the assessment of post- in identifying ligamentous injury. and associated findings such as epidural T2-weighted images are sensitive to edema. and pared with conventional radiographs or CT images vascular malformations. and fluid collections.1 Because of the rapidity with which im.1 similar to that of images obtained with conventional for important lumbar spine structures to evaluate). indicated when neurologic deficit.1â•… Evaluation of lumbar and thoracic T2 weighting in these images. ventional radiographs and may reveal fractures or ment. CT may be a better choice ed images for patients with spinal instrumentation for assessing these aspects of the fractures. MR imaging in cervical spine be evaluated initially with conventional radiographs. the evaluation of lumbar spine MRI should be used elogram” that provides a nice perspective. Contrast enhancement is particularly useful in details that are not detected with radiography. Distinc. and TE can create T1 and Table 7. Contrast enhancement may and is useful for the assessment of ligamentous in- be made more conspicuous by obtaining postgado. CT imaging offers greater osseous detail than do con. ceptibility artifacts. additional fracture linium fat-suppressed images. fat suppression Although MRI is extremely sensitive in identifying via a fat-suppressed T2-weighted or STIR image may thoracolumbar spine fractures.8:615–634. MRI is because STIR images are less prone to magnetic sus. Posterior longitudinal ligament ages are acquired. Modified with permission. tional radiographs or CT images may be detected by tion between fat and fluid (edema) may be difficult on the presence of vertebral body edema on MR images. traumatic sequelae. in which they are flipped by 90 to 180 degrees). T2-weighted images. Occult fractures not visible on conven- is usually one of the early signs of pathology. these MR images can be used terpreted in conjunction with other available imag- to evaluate for spinal stenosis. which makes them quite useful for the detec- tion of small areas of hemorrhage. degree of spinal stenosis. it is essential that the MRI findings be in- myelographic images. nents can be challenging. atic Approach to the Review of Spine MRI Studies) for Highly T2-weighted images produce an “MR my. neoplasms. myelography and CT myelography. STIR and the exact appearance of the osseous compo- images are preferred over fat-suppressed T2-weight. MRI differentiating recurrent disc pathology from scar provides superior visualization of soft tissues com- tissue and in assessing infection. trauma. which hematomas.

poor ture. etc. A new classification of thoracolumbar injuries. es- • Integrity of the posterior ligamentous complex pecially in patients with degenerative disc disease. translation/rotation.) .) and the position of classification systems.11 It in medical decision making.1â•… Artist’s sketches of the three major morphologic descriptors in the Thoracolumbar Injury Classification and Severity Score (compression. for sally accepted.10. those for the evaluation of various osseous fragments relative to their anatomic thoracolumbar spine trauma have not been univer.30:2325–2333.€7. In addition.6. the rostral spinal column becomes separated from the caudal segment because of distractive forces.7 Studies have shown should be noted. Reprinted by permission. ab.6 The Thoracolumbar Injury Classifi.2–4 Like many fracture (compression. the vertebral body buckles under load to produce a compression or burst fracture. (stability or potential for neurologic compromise) where end-plate anatomy and vertebral morphol- • Neurologic status of the patient ogy are affected by the degenerative changes.€7. CT is superior to conventional radiography and validity. components are used here to review and highlight which typically enables the detection of subtle or the role of MRI in the evaluation of patients with subacute fractures on conventional radiographs. MRI may help verity Score recognizes the importance of the follow. Hurlbert RJ. Combinations of these morphologic patterns may occur. morphology of lumbar injury is the assessment of fracture morphol- fracture. ogy. Furthermore. the integrity of the posterior ligamentous complex. subtle fractures may be difficult • Fracture morphology (Fig. The first element in the MRI evaluation of a thoraco- tors such as mechanism of injury. The morphology description includes the type of sence. and distraction). As discussed above.9 siderations for bone-marrow edema in a vertebral a b c Fig. burst. however. and presence. These descriptors are determined from a combination of conventional radiographs. that the differential con- that it has excellent reliability and validity.8. lack of reproducibility. almost immediately after injury and can persist nostic information and has been found to be helpful for several months or even a year thereafter. all of which are based on a variety of fac.2) provides prog. provide additional information regarding the mor- ing three factors5: phology of a fracture in a limited number of situations. MRI because of the excellent spatial resolution and The Thoracolumbar Injury Classification and Se. and neurologic status. Spine 2005. and MRI sequences. For example. a system. osseous detail it provides (Fig. CT images. There are many classification systems.€7. (b) In translation/rotation. the assessment of the osseous components of a frac- sult of their complexity. (From Vaccaro AR. thoracolumbar spine trauma. et al. or any combination thereof. patients with osteoporosis or os- tem is outside the scope of this chapter. This bone-marrow edema often appears cation and Severity Score (Table 7.1) to identify on CT or conventional radiographs. ous injury. (c) In distraction. This lack of acceptance may be the re. origin and to the spinal canal. Lehman RA Jr. 7â•… The Lumbar and Thoracic Spine 157 Classification of Thoracolumbar Role of MRI in Thoracolumbar Spine Trauma Spine Trauma Thoracolumbar spine trauma is a common and Evaluation of Fracture Morphology complex condition. involvement of columns. pressed T2-weighted or STIR images are excellent culation of an injury severity score5 can be used to for identifying areas of subtle bone-marrow edema guide the treatment of patients with thoracolumbar and focusing attention on an area of potential osse- spine fractures. or degree of neural compromise. the vertebral column is subjected to shear or torsional forces that cause the rostral part of the spinal column to translate or rotate with respect to the caudal part.2). The importance of injury morphology. Fluid-sensitive pulse sequences such as fat-sup- atic evaluation of these three components and cal. these three teopenia may show less osseous reactive change. Although a detailed review of this classification sys. (a) In compression.

Thoracolumbar spine trauma classification.12. vertebral aug. Panjabi et al15 have defined spinal sta- be challenging (Figs.158 IIâ•…Spine Table 7.2). A horizontal linear bright imaging techniques. especially in elderly bility as the degree of motion that prevents pain. The most of the vertebral body is infiltrated with tumor definition can also be extended to include the ability (Fig. and infection. end-plate degeneration.13 In a study of patients with chronic (1 year) vertebral Because contrast enhancement is often seen with compression fractures treated with vertebroplasty.€7. Therefore. Two key concepts in the MRI determination of spinal stability are the three-column concept and the • Convex posterior margin of the vertebral body assessment of the posterior ligamentous complex. care should be taken tumors.18(2):63–71.14 definitively correlated with the presence of prepro- cedural bone-marrow edema. the most reliable sign of a nonmalignant fracture For patients in whom vertebral compression (Fig. of the posterior aspect of the vertebral body. Assessment of Stability presence. Neoplastic processes tend to fracture when neurologic deficit. tures for metastatic lesions.2 and 7. it is essen- tial that the MR images be reviewed for the absence. tiple fractures.3). conus medullaris Incomplete ╇3 Complete ╇2 Cauda equina — ╇3 Posterior ligamentous complex integrity Intact — ╇0 Suspected/indeterminate — ╇2 Disrupted — ╇3 + = 1 additional point given to the morphology Source: Patel AA. acute benign fractures. J Am Acad Orthop Surg. fracture line on T2-weighted images is considered portant for making a definitive diagnosis. underlying tumor include a retropulsed fragment off mentation procedures such as vertebroplasty or ky.2). and clinical information is im.3). and degree of bone-marrow edema for each fracture (Fig. Denis2 introduced the concept • Presence of other osseous lesions of the three-column spine and its clinical significance . Other signs that decrease the likelihood of fractures are associated with pain.4) • Abnormal signal in the posterior elements Three-Column Concept • Epidural mass and neural encasement by the same focal paraspinal mass More than 25 years ago. mul- phoplasty may be considered as a treatment option.€7. Vaccaro AR.12. The term spinal stability refers to the ability of the Differentiating posttraumatic and osteoporotic spine to limit neurologic compromise under physi- fractures from neoplastic or pathologic fractures can ologic loads. Key MRI features that suggest the presence of the spine to avoid the development of spinal defor- of a malignant fracture include the following12: mity. and abnormal angulation. it is no longer considered di- Brown et al11 found that clinical improvement was agnostic for an underlying lesion or malignancy. patients. For not to mistake additional osteoporotic vertebral frac- this reason. 2010. 7. and normal bone-marrow signal.€7.2â•… Thoracolumbar Injury Classification and Severity Score Injury Characteristic Qualifier Points Injury morphology Compression — ╇1 Burst +1 Rotation/translation — ╇3 Distraction — ╇4 Neurologic status Intact — ╇0 Nerve root — ╇2 Spinal cord. body are varied and include other entities such as In the search for other lesions. (from tumor infiltration) (Fig.€7. correlation with other imaging findings.

d . 7â•… The Lumbar and Thoracic Spine 159 a b c Burst fracture T12 L1 Linear region of increased signal intensity (edema) Fig. The osseous margins are clearly defined.† (d) An artist’s sketch illustrates the find- ings described in the preceding images.† (c) A sagittal reconstructed CT image shows the osseous details of the L5 fractures. L2. characteristic Chronic of a benign osteoporotic fracture. and T11.2â•… Osteoporotic vertebral fractures. Note the diffuse edema in the vertebral body that could L4 be mistaken for diffuse bone-marrow involvement by a neoplastic process.€7. There is no increase in signal intensity in the L4 vertebral body (arrowhead). (a) A sagittal T2-weight- L3 ed image shows multiple vertebral fractures. and a burst fracture at T12. and the retro- pulsed posterior fragment characteristic of a benign osteoporotic fracture is evident at T12.† (b) A sagittal STIR image shows superior end-plate a linear region of increased signal intensity compatible with edema fracture in the L2 vertebral body (arrow). which is compatible with a chronic fracture. including vertebral compression fractures at L4. which is compatible with an acute fracture. Note the bright T2-weighted signal fracture line at L2.

.3â•… Vertebral body metastasis in a patient with lung cancer. and the posterior longitudinal ligament • Posterior: facet joints. Note that the anterior aspect of the vertebral body appears expanded as it is infiltrated with tumor.† umns leads to a highly unstable spine.16 it is still used frequently to help evaluate the degree of spinal instability. sidered stable. Note the diffusely increased signal within the vertebral involvement.5): • Anterior: anterior longitudinal ligament and the anterior portion of the vertebral body and annulus • Middle: posterior vertebral body and annulus.9. (c) An axial T2-weighted image shows heterogeneous signal intensity within the vertebral body. The three columns are defined as follows (Fig.€7. Spinal instability may be assessed based on the number of columns involved in an injury. with two-column involvement. and posterior ligaments (supraspinous and inter- spinous ligaments and ligamentum flavum) If one column is involved. posterior elements. (b) A sagittal STIR image shows markedly increased signal intensity in the same region (arrow). (a) A sagittal T2-weighted image shows heterogeneous bone-mar- row signal intensity in multiple vertebral bodies (which can be seen with osteoporosis) but most prominently within the anterior half of the T12 vertebral body (arrow). and the involvement of all three col- body and the convex posterior margin of the vertebral body.160 IIâ•…Spine a b c Fig. Although the reliabil- ity and validity of the Denis system have been ques- tioned.€7. the ture of the L3 vertebral body in a patient with metastatic lung spine is variably stable. depending on the degree of cancer.† in the evaluation of spinal stability in patients with acute thoracolumbar injuries. A percutaneous biopsy confirmed evidence of metastatic lung cancer.4â•… A sagittal STIR image shows a pathologic burst frac.€7. the spine is generally con- Fig.

Supraspinous lig. the edema identified on MRI may be helpful in combination with close scrutiny of the The posterior column and posterior ligamentous CT images to identify subtle fractures. a three columns of the spine as described by Denis. interspinous ligament. Interspinous Anterior Anterior Posterior lig. However. the intent of describing these ligaments to be intact. Ligamentum flavum Interspinous lig. Anterior lig.€7. or severe (see the subsequent discussion of lumbar indeterminate. moderate. ligamen.5 The three tous complex. lig. the complex is an area of increasing concern in spi.5â•… Artist’s sketches illustrate the Anterior longitudinal lig. or disrupted. 7â•… The Lumbar and Thoracic Spine 161 Fig. It has determine the cause of compression. Discontinuity of the neural compromise and is excellent in its ability to dark signal of the fibers is also seen on MRI. they may show increased signal on fluid-sensitive pulse sequences (T2-weighted fat.1c). longitudinal lig. longitudinal lig.5 spinal stenosis).20 ligaments that constitute the posterior ligamentous complex normally appear as dark and continuous bands on T1-weighted and T2-weighted images. or foraminal). Assessment of Neural Compromise When traumatized. MRI plays its most vital role in the assessment of suppressed and STIR) (Fig. true role of MRI in these instances is in identifying nal stability (Fig. Posterior longitudinal lig.5. longitudinal Posterior longitudinal longitudinal Supraspinous lig.17–19 The components of the ligamentous injuries and hematomas. In addition to an evaluation of the Subtle fractures and dislocations of the facet joints degree of stenosis.€7. (c) middle.2 (a) An axial view. but be described (central. the type of stenosis should also and posterior elements are detected well on CT. and (d) posterior columns. lig.€7. and the facet joint capsules. Neural com- been suggested that the MR images be reviewed with promise can be graded on MRI as mild. The lateral views show the (b) anterior. In . 28% to 47% of posterior ligamentous complex include the supra. timated to have disruption of the posterior ligamen- tum flavum. b c d Posterior Ligamentous Complex in some instances. lateral recess.6). patients with thoracolumbar burst fractures are es- spinous ligament.

leading to a focus of high intensity on T2- weighted images.8) from a hemorrhage is related directly to the state of the . extrusions. Rupture of a few annular fibers leads to a small amount of fluid tracking from the nucleus pulposus to between the an- nular fibers.7) between a disc extrusion and a hematoma or fluid collection are the hematoma’s larger size. extrusions.€7. one should note whether there is compres- sion of specific neurologic structures.9) and is suggestive of an annular tear. The MR images should be carefully evaluated for the absence or presence and degree of stenosis. addition.† disc pathology such as protrusion.28 sess on CT. and they can be spine trauma include the following: difficult to differentiate from disc protrusions and • Burst fractures extrusions. This finding of focal high intensity in the annulus is referred to as a high-intensity zone (Fig.€7.€7.21–23 MRI is the modality of choice for assessing such abnormalities and associated areas for potential neurologic compro- Fig. and MRI is far more accurate. obtuse margin along the posterior aspect of the vertebral body with maximum dimension at the Although CT is excellent in assessing the osseous midvertebral body level. the associated neural by the central septum (which attaches the posterior compression and hematoma may be difficult to as. different Burst Fracture signal. The sagittal and axial T2-weighted im- by increased signal intensity in the interspinous and supraspi. the sagittal T2-weighted images should be evaluated in the midline for the degree of posterior vertebral body wall encroachment on the spinal canal. the degree of neural compro- mise should be noted (see the subsequent sections). Hematomas often resolve spontaneous- • Disc pathology ly and may provide an explanation for patients who • Epidural hematoma show a rapid and spontaneous resolution of appar- • Vertebral translation or dislocation ent disc herniations. and sequestrations. as evidenced disc disease). It is impor. such as the spi- Epidural Hematomas nal cord or a specific nerve root. The former involves injury to the anterior and middle columns. Common causes of Hematomas may occasionally be seen in association neural compromise in patients after thoracolumbar with thoracolumbar spine trauma. the axial T2-weighted images can be reviewed to determine the location and de- gree of neural compromise in an orthogonal plane. Next.162 IIâ•…Spine compression fracture (Fig. and se- questrations.€7. ages should be carefully evaluated for the presence of nous region between T10 and T11 (arrow). its level of importance is controversial because it is also seen as a natural process of disc degeneration and may or may not be associated with acute pain. Specifically.27. or to any combination thereof. CSF column. whereas the latter involves injury to the anterior column only. Disc Pathology Traumatic compressive forces on the disc may lead to annular tears (also known as annular fissures). longitudinal ligament to the vertebral body). the parasagittal images should be evaluated for the same.2). Finally.24–26 Key differentiating features • Penetrating trauma (Fig. and possible containment component of a burst fracture. If present. disc protrusions. The signal pattern associated with epidural tant to differentiate a burst fracture (Fig.6â•… A sagittal STIR image shows a T11 flexion-distraction mise (see the subsequent discussion of degenerative injury with compression fracture of T11 and an associated injury of the interspinous and supraspinous ligaments.€7. or cauda equi- na. spinal cord. which can be secondary to the fracture alone or to preex- isting degenerative changes. Although this finding may be seen in association with trauma.

(a) A sagittal T2-weighted image of the thoracic spine shows a linear track (arrow) from the skin to the conus medullaris with an associated region of increased signal within the conus medullaris. . Dur. 7â•… The Lumbar and Thoracic Spine 163 a b c Fig. indicates an alteration of spinal alignment in all ing the acute phase.7â•… Cord injury from a stab injury to the conus medullaris. Within 2 to 4 days after injury. may produce canal or foraminal narrowing with as- and T2-weighted images show heterogeneous areas sociated neural compression.20 By 8 to 10 days. In the acute phase. Dislocation of the spine of increased and decreased signal intensity. T2-weighted signal (or fluid) in the facet T1-weighted and T2-weighted images may show in. the prima. (c) A sagittal STIR image of the lumbar spine accentuates the edema along the track (arrow) and also that within the conus medullaris. Typical MRI signs of appears isointense or slightly low in signal intensity dislocations include the following: compared with that of the normal spinal cord on T1-weighted images and as a hypointense signal on • Altered facet joint anatomy with increased T2-weighted images. joints: the osseous anatomy is often bet- creased signal intensity. T1-weighted images show signal that is isointense The posttraumatic translation of vertebral bodies compared with that of the adjacent spinal cord. (b) A sagittal T1-weighted image of the thoracic spine also shows the track (arrow) but does not show the edema within the conus medullaris. deoxyhemoglobin is the main three planes and the displacement of one vertebral component of the hematoma. but as mentioned previously.29 for a subtle injury. Deoxyhemoglobin body relative to an adjacent one. ter seen on CT.† oxygenation of the blood that pools in the regions Vertebral Translation or Dislocation of interest adjacent to the cord. compatible with edema.€7. edema and fluid on MRI help focus the search which is hyperintense on T1-weighted images. ry component of the hemorrhage is methemoglobin.

• Vertebral body translation: sagittal and coronal images are excellent in determining transla- tion of vertebral bodies (Fig. there may be uncovering of the disc. ■⌀ Nomenclature and Classification of Lumbar Disc Pathology Fig.† ly applied.10). Note that the posterior-superior margin of the vertebral body has displaced and rotated into the spinal canal.€7. Fardon and Milette30 have provided a . This displaced and rotated fragment (arrow on each) has been termed the sentinel or culprit fragment. osseous in- jury. The L3-L4 disc is normal. or pars defects.164 IIâ•…Spine Fig.€7.€7. Sentinel fragment b ed image† and artist’s sketches in the (b) axial plane and (c) pos- terolateral perspective show an L1 burst fracture. which gives the appearance of a her- niation (pseudoherniation). Also noted is The nomenclature used for describing lumbar degenerative disc disease at L5-S1 with moderate loss of disc disc pathology should be consistent and uniform- height.9â•… A sagittal T2-weighted image shows a high-intensity zone at the posterior annulus of L4-L5 (arrow).8â•… (a) A sagittal T2-weight. facet joint displacement. Care should be taken in determining whether translations are the result of facet degeneration. Posterior superior corner of L1 compressing conus medullaris c L1 Conus medullaris a L2 • Disc herniation or pseudoherniation: with translation of one vertebral body in relation to the adjacent one.

€7. (c) An axial T2-weighted image shows that the facets are “naked” or dissociated. the line on each points to the T1 vertebral body. 7â•… The Lumbar and Thoracic Spine 165 b a c d Fig. This (a) sagittal T2-weighted image and (b) zoom-in show anterior dislocation of T3 relative to T2 without fracture. Surgery. support and recommend the use of the no- menclature and classification scheme represents menclature described here. This no. Several other societies. suspected lumbar disc pathology and the evaluation can Society of Spine Radiology. with resultant severe cord compression. Surgeons and radiolo- the recommendations of the combined task forces gists involved in the care of patients with known or of the North American Spine Society.10â•… T2-T3 dislocation.† comprehensive review of the nomenclature and including the American Academy of Orthopaedic classification of lumbar disc pathology. deformity. . the Ameri. (d) A sagittal reconstructed CT image also shows the dislocation and confirms the absence of a fracture. and the American of their MR images should consider reviewing this Society of Neuroradiology. a finding better seen on the left side (arrow). publication30 for additional details. and acute signal change within the cord.

or horizontal disruption of the annulus without associated displacement of disc material beyond the limits of the in- tervertebral disc space. it involves ≤50% of the disc circumference and Fig. herniation Herniation is defined as a localized displacement • Inflammation/infection: inflammatory spondy- of disc contents beyond the borders of the interverte- litis of subchondral end plate and bone marrow bral disc space (Fig. rectly. primary or metastatic Most clinicians tend to describe disc pathology using • Morphologic variant of unknown importance the terms bulge. annular tears (also tion. (From Milette PC.11). Degenerative changes can also are congenitally abnormal or that have under- be subcategorized as spondylosis deformans (chang- gone changes in morphology secondary to ab- es in the disc associated with a normal aging process) normal growth of the spine and intervertebral osteochondrosis (consequences of • Degenerative/traumatic lesion: annular tear.€7. (c) Intervertebral osteochondrosis. (a) A normal disc.€7. The proper terminology for reporting lum- bar intervertebral disc disorders. lows: A herniation is considered “localized” if lae (Fig. in this case).12â•… Schematic sagittal drawings show differentiating disc MRI characteristics.) . (a) Normal disc.€7.18:1859–1866. The distinction between these three entities is usually possible on all imaging modalities. or other injuries of the fibers that The currently accepted nomenclature is as fol- involve one or multiple layers of the annular lamel. or a combination of those materials. • Neoplasia: all pathologic entities that may be annular tissue. and sequestra- In the degenerative category. Although the last two terms are often used cor- called annular fissures) are separations between an. AJNR Am J a b c Neuroradiol 1997. concentric. herniation.12). (c) A disc herniation. defects normal (no lesion) and sclerosis of the end plates. a more clearly pathologic process) (Fig. avulsion of fibers from their vertebral variability in the use of the first two terms. The disc material may in- manifested as Modic type-1 MRI changes31–34 clude nucleus. The term tear is used to refer to a localized radial. and osteophytes at the • Congenital/developmental variant: discs that vertebral apophyses.166 IIâ•…Spine With this system. there seems to be a high degree of interobserver nular fibers. (b) Spondylosis deformans. fi- follows: brosis. narrowing of the disc space. degeneration. (b) An annular tear (radial tear. a b c Reprinted by permission. extensive fissur- • Normal: a young disc that is morphologically ing. (From Milette PC. and the annulus (internal and external) corresponds to the white portion of the intervertebral space. fragmented apophyseal bone.€7. Reprinted by permission. disc lesions are classified as The degenerative process includes desiccation. The proper terminology for re- porting lumbar intervertebral disc disorders. Nuclear material is shown in black.18:1859–1866. AJNR Am J Neuroradiol 1997. mucinous degeneration of the annulus. diffuse bulging of the annulus beyond the disc space.11â•… Schematic sagittal drawings show differentiating MRI features of disc pa- thology. including conventional radiographs. extrusion. cartilage.) Fig.€7. body insertions.13a).

peripherally. in a left posterior direction. a b c d e f Fig.15). Contained same plane. (From Fardon DF. Intravertebral herniation is a herniated disc in ent if the greatest distance between the edges of the craniocaudal direction through a defect in the the disc material beyond the disc space is less than vertebral body end plate.€7.13c). there is no continuity between the disc space and based” if the herniating disc content is between 25% the disc fragment. by the edges of the verte- bral ring apophyses. Disc tissue noted circumferen. Each disc space is continuous with disc material within abnormal presentation of disc pathology has specific the disc space. A localized dis. and American Society of Neuroradiology. Nomenclature and classification of lumbar disc pathology. (d) Symmetrical presence (or apparent presence) of disc tissue “circumferentially” (50% to 100%) beyond the edges of the ring apophyses may be described as a “bulging disc” or “bulging appearance” and is not considered a form of herniation.13f) are also commonly used in is sequestration (Fig. An extrusion is present when any features that can be detected with MRI (see the fol- one distance between the edges of the disc material lowing section).€7. Milette PC. a focal herniation involves <25% (90 degrees) of the disc circumference.€7.) . Uncontained her- of origin. between 50% and 100%. The base is the cross-sectional area of herniations are displacements of disc material that disc material at the outer margin of the disc space are retained by the outer annulus.€7. and beyond the edges noted if the displaced disc material is completely of the ring apophyses is termed bulging. (a) Localized extension of disc material beyond the intervertebral disc space.€7. Herniations can also be the distance between the edges of the base in the described as contained or uncontained.13e) and site of extrusion. Extrusion may be further classi- and 50% (Fig. (b) By convention. A protrusion is pres. American Society of Spine Radiology.€7. fied as sequestered and migrated. the context of disc herniation. a broad-based herniation involves between 25% and 50% (90 to 180 degrees) of the disc circumference.13b) and “broad. Sequestration is tially.€7.13d). Recommendations of the Combined Task Forces of the North American Spine Society. Spine 2001. which is discontinuous with the parent disc. Bulging is a descriptive term for the shape of the disc contour and not a diagnostic category.26:E93–E113. exclusive of osteophytic formations. Reprinted by permission. (f) Extrusion (see definition in text). (c) By convention. The terms protrusion (Fig. beyond the disc space is greater than the distance placement is considered “focal” if <25% of the disc between the edges of the base (Fig. 7â•… The Lumbar and Thoracic Spine 167 “generalized” if it involves >50%. (e) Protrusion (see definition in text).13â•… Schematic drawings of disc herniation. regardless of whether or not there extrusion (Fig. where disc material displaced beyond the niations are not retained by the outer annulus. the interspace is defined. In disc herniation. Migration con- not considered by some to be a form of herniation sists of displacement of disc material away from the (Fig.14) or when circumference is involved (Fig.€7. which qualifies as a disc herniation.

A follow-up study of those disc disease. Clas- sification. or symptoms of neurogenic asymptomatic.3% had pars lesions and 39.168 IIâ•…Spine Fig. diagnostic imaging. and imag- ing characterization of a lumbar herniated disc. (c) A subligamentous herniation with downward migration of disc material and sequestered fragment (arrow). which serves as reference for the definition of protrusion and extru- sion.4% have already been evaluated with conventional radi. Radiol Clin North Am 2000. When a relatively large amount of disc material is displaced. In any situation. by definition. degenerative disc disease and the associated ste. arthritic and hypertrophic changes involv- ■⌀ Degenerative Conditions ing the facet joints. The Cervical Spine. disc herniation. Reprinted by permission. (From Milette PC. They usually have had at least 6 weeks 15. which cannot be assessed on CT images and is seldom appreciated on MR images.38 .2% had normal MRI evaluations and 84.) Fig. showed evidence of disc desiccation and bulg- ography. Most patients present with low back pain. In the craniocaudal direction. the distance between the edges of the base. and the lesion therefore qualifies as an extrusion.36 A study of 33 lower extremity pain. lumbar for a discussion of inflammatory arthropathies. (b) A subligamentous herniation with downward migration of disc material under the posterior longitudinal ligament. Along with cervical degenerative disorders. may differ from the distance between the edges of the aperture of the annulus. the length of the base cannot exceed. and hypertrophy of the liga- mentum flavum (see Chapter 6. Classification. (a) A small subligamentous herniation (or protru- sion) without substantial disc material migra- tion. The purpose of MRI in this situation is most ing. distinc- tion between (a) protrusion and (b. Radiol Clin North Am 2000.38:1267– a b c 1292.38:1267–1292.35.14â•… Schematic drawings of protru- sion and extrusion. (From Milette PC. c) extru- sion is usually possible only on sagittal MR sections or sagittal CT reconstructions. (c) Although the shape of the displaced material is similar to that of a protrusion. including ankylosing spondylitis). such as degenerative disc low back pain. diagnostic imaging. not necessarily be symptomatic. It is important nosis are the most common indications for MRI of to note that patients exhibiting MRI changes may the spine. 67 patients concluded that the MRI findings were Lumbar spine degeneration typically includes a not predictive of the development or duration of constellation of changes. elite tennis players showed that claudication. and imaging characterization of a lumbar herniated disc. and degenerative asymptomatic patients.35 The high incidence of abnormal lumbar spine frequently to evaluate for the presence or absence MRI studies was described by Boden et al37 in 67 of spinal stenosis.€7.15â•… Schematic drawings of various types of posterior central herniations.€7.8% had of unsuccessful nonoperative management and often abnormalities: 27.) a b c disease. the height of the intervertebral space. Reprinted by permission. the great- est craniocaudal diameter of the fragment is greater than the craniocaudal diameter of its base at the level of the parent disc.

consist of decreased signal intensity on T1-weighted generation may present with a linear hyperintensity and T2-weighted sequences and are associated with parallel to the end plate. This classifica- tion system describes five grades of progressively As noted above. the vertebral body bone marrow and end plate ad- ing is the intervertebral disc vacuum phenomenon jacent to degenerating discs. even better than do T1-weighted and T2-weighted The more chronic. To summarize. becomes increasingly hypointense on T2-weighted Modic et al32. ity may be the reason it is not commonly used by and intervertebral osteochondrosis to describe the most clinicians.17). the grading system degenerative lumbar disc (Fig. Type-3 changes reproduction of pain at discography.16â•… Modic type-1 (fibrovascular) changes.39 Early signs of disc degeneration on MRI in.€7. Its complex- the use of the terms normal. to degenerative end- of the vertebrodiscal complex.39 Advanced de.€7. which results from the of the normal disc signal on T2-weighted images. type-1 changes have been found to have Fig.€7. Gradient. The specific describes the lumbar disc degenerative process as a changes seen on MRI correlate with the pathogenesis continuum that progresses from a normal disc.39 (Fig. clude infolding of the anterior annulus and a hypoin.€7. The first finding in the secondary to a collection of intradiscal nitrogen. from hematopoietic (red) to fatty (yellow) marrow.12). leading to relatively increased signal on T1-weight- tense central region—often seen before any loss of ed images and slightly diminished signal intensity disc signal intensity—which may be associated with on T2-weighted images (Fig. Sagittal (a) T1-weighted and (b) fat-suppressed T2-weighted images show. An alternative find. subchondral sclerosis on radiographs31. The nucleus pulposus plate changes and sclerosis.€7. sequence of changes is fibrovascular ingrowth that which manifests as a linear area of signal void on results in diminished signal intensity on T1-weight- T1-weighted and T2-weighted sequences.16).33 described signal changes within images because of desiccation. Fardon and Milette30 have suggested increasing degenerative disc disease.† . which is thought to rep. at the L2-L3 level.18). ed images and a corresponding increase in signal in- echo sequences may show this particular finding tensity on T2-weighted images (type 1) (Fig. to spectrum of changes that occur in the various parts increasing loss of disc height. type-2 changes involve a change images. the typical pattern (arrow on each) of decreased signal intensity on the T1-weighted image and increased sig- nal on the T2-weighted image that is seen a b with Modic type-1 end-plate changes. to loss of degenerative disc disease.39 changes. resent separation of the nucleus pulposus from the Among the three types of degenerative end-plate hyaline cartilage end plate. spondylosis deformans. 7â•… The Lumbar and Thoracic Spine 169 Discs and End Plates Pfirrmann et al40 introduced a grading system for lumbar degenerative disc disease based on MRI find- Degenerative Disc Disease ings on sagittal T2-weighted images.

Note that degenerative changes and stenosis are also seen at other levels. at the L5-S1 level.18â•… Modic type-3 (sclerotic) changes. the typical pattern (arrows on each) of increased signal intensity on the T1-weighted image and decreased signal on the T2- weighted image that is seen with Modic type-2 end-plate changes.€7.† . Sagittal (a) T1-weighted and (b) fat-suppressed T2-weighted images show.17â•… Modic type-2 (fatty) changes. Note that degenerative changes are seen at other levels and that there is also evidence of lumbar scoliosis.170 IIâ•…Spine a b Fig. at the L2- L3 level. Sagittal (a) T1-weighted and (b) fat-suppressed T2-weighted images show.€7. the typical pattern (arrow[s] on each) of decreased signal intensity that is seen with Modic type-3 end-plate changes.† a b Fig.

€7. Radial tears extend from the nucleus through the an- nulus and may extend into the outer annulus.19â•… Lumbar degenerative disc disease. bar degenerative disc disease using the methods just ranging from intermediate to high signal intensity described. Studies have shown a cor- lumbar disc degeneration by noting the amount of relation between high-signal-intensity annular tears disc space height loss (Fig. (b) moderate.45 T2-weighted sequences have been used to show the following three types of annular tears: • Concentric • Radial • Transverse Concentric tears involve the entire extent of the an- nulus. potentially leading to radiculopathy without overt mechanical nerve root a compression.44. one should also describe the degree of on T2-weighted images.41–43 In addition to an assessment of the type of lum. The high-intensity zone is defined as a focal area of high signal intensity within the posterior annulus of the degenerating disc.19). 7â•… The Lumbar and Thoracic Spine 171 the greatest correlation with the presence of disco.€7. separate from the nucleus. or (c) severe lumbar degenerative disc disease (arrow[s] on each).34. The degree of disc T2-weighted signal and height loss should be evaluated and graded as (a) mild. Annular Tears genic back pain.9). These b c Fig.€7. mani- fested on MRI as a high-intensity zone (Fig.† . Annular tears have a variable appearance on MRI.45 Some investigators have suggested that the inflammation associated with these annular tears results in irrita- tion of the adjacent nerve root. Transverse tears occur at the periphery of the disc as a result of disruption of the Sharpey fibers. in the lumbar spine and painful concordant annu- lar tears seen at provocative discography.

21â•… Lumbar disc protru- sion. of herniated nucleus pulposus have been addressed logic information provided on fluoroscopic images previously (see the section on Nomenclature and and on postdiscography CT.€7.† a b . Classification of Lumbar Disc Pathology). • Extrusion (Fig. with extension into the right lateral recess and far laterally at the L4-L5 level (at arrow on a and between arrows on b).20) diagnosis of discogenic low back pain continues to be • Protrusion (Fig. Lumbar Herniated Nucleus Pulposus nous gadolinium administration. The terms used to describe the progressive states tients with annular tears.€7.46. the patient’s pain re. Shown here sponse can be used to help predict whether an an. however. (a) a b Sagittal and (b) axial T2-weighted images show a right paracentral disc bulge that is asymmetric to the right.€7. that the use of discography in the • Bulge (Fig.† Fig.20â•… Lumbar disc bulge.39 Discography can be used to further evaluate pa. In addition to the morpho.172 IIâ•…Spine high-intensity zones may also enhance after intrave.€7. (a) Sagittal and (b) axial T2- weighted images show a central disc protrusion at the L4-L5 level (arrow on each).22) Fig.21) debated and is not uniformly accepted at all centers.€7. are the MRI appearances of each: nular tear or other degenerative pathology is the patient’s pain generator.47 It is important to keep • Normal in mind.

39 a protrusion usually has a broad base against . sion from extrusion. infe.22â•… Lumbar disc extrusion. then an extrusion sequestrated fragment can migrate superiorly. is present in >90% of cases.39. 7â•… The Lumbar and Thoracic Spine 173 a b c d Fig. A disc protrusion is a her. confined by the pos. The of the spinal canal diameter. (c) An axial T2-weighted image at the level of the L4-L5 disc shows what appears to be a central disc bulge (arrow). If herniated disc material becomes detached • If the AP diameter of the herniated disc is >50% from the parent disc. posterior to the thecal sac. Extrusions occur when following: the nuclear material breaches the outer annular fi- bers. an axial T2-weighted image at the L5 vertebral body level shows the disc extrusion (arrow). or occasionally. used to aid this differentiation. Several MRI signs may be niation with an intact annulus. it is termed sequestrated. (a) Midline sagittal and (b) parasagittal T2-weighted images show a large disc extrusion at the L4-L5 level and distal migration of the disc fragment (arrow on each) to behind the L5 vertebral body in a patient with transitional lumbosacral anatomy.48 riorly.† The status of the annulus provides insight into the It is often difficult to differentiate protru- status of a herniated disc. including the terior longitudinal ligament. (d) However. Note the advanced degenerative disc disease at this level. In. • Examination of the base of the disc shows that tradural disc herniation is very rare.€7.

the clinician or radiologist should • Far lateral (Fig.€7. a Axillary herniated nucleus pulposus Disc Exiting n. Protrusions are terms should be used to describe the location of the limited by the outer annular fibers and tend to protrusion (primarily based on the appearance of the have a smooth outline. 90% are central or para- tration) and should also describe several additional central (5% are foraminal and 5% are far lateral). carefully evaluated to determine the location of the • Protrusions and extrusions can also be dis. a posterolateral disc • Level of the disc pathology protrusion at the L4-L5 level will likely produce an L5 • Precise location relative to the disc space radiculopathy. disc protrusion or other pathology.50 It key characteristics of the disc pathology. New York: Thieme.€7.39.€7. an extrusion has a base that is nar.26) When reviewing an MRI study that shows lumbar • Foraminal (Fig. whereas a far-lateral disc protrusion at • Size and degree of neural compression the same level will likely produce an L4 radiculopathy. The Lumbar Intervertebral Disc.28) use the appropriate term to describe the morphol- ogy of the disc (bulge. Each arrow indicates the direction of herniation. Patel DN.20 through 7.) . root Central herniated nucleus pulposus b c Foraminal/ far-lateral Posterolateral herniated herniated nucleus nucleus pulposus pulposus d e Fig.€7. The following tinguished by their outlines. 2009:76–83.49 • Central (Fig. (c) posterolateral (paracentral).22 for exam. The corresponding axial views show the (b) central. for example. the hernia. broader than any other part of With regard to location of the disc pathology. Lauryssen C (eds). Reprinted by permission. seques. (d) lateral recess. the axial and sagittal T2-weighted images should be rower than the extruded material. extrusion. trusion compresses the traversing nerve root. protrusion. Vaccaro AR.€7.24): have a poorly defined outer margin. where- ples of such descriptions): as a far-lateral disc protrusion compresses the exiting nerve root. Of all lumbar disc herniations. including should be noted that a typical posterolateral disc pro- the following (see Figs. extrusions axial T2-weighted image) (Figs. 7.174 IIâ•…Spine the parent disc. (Modified from Kerr SM.23 and 7. 7. in contrast.27) disc displacement.23â•… Artist’s sketches of types of herniated nucleus pulposus.25) • Posterolateral or lateral recess (Fig. and (e) far-lateral disc pathol- ogy. (a) The posterior view shows their locations at the L2-L5 levels. Thus. In: Phillips FM. Clinical features of herniated nucleus pulposus.

(a) Sagittal and (b) axial T2-weighted images show a central disc protrusion (arrow on each) at the L4-L5 level. (From Wiltse LL. Reprinted by permission. McCulloch JA.24â•… Artist’s sketch shows the anatomic “zones” identi- (lateral recess) Central canal zone fied on axial images.) (far-lateral zone) Foraminal zone (pedicle zone) a b Fig. A system for reporting the size and location of lesions of the Extraforaminal zone spine.25â•… Central disc protrusion.€7. Berger PE. Spine 1997.€7. 7â•… The Lumbar and Thoracic Spine 175 Subarticular zone Fig.† .22:1534–1537.

€7.26â•… Posterolateral disc protrusion.176 IIâ•…Spine a b L4-L5 L5 traversing n. (a) Sagittal† and (b) axial† T2-weighted images and (c) artist’s sketch show a left posterolateral disc protrusion (arrow on each) at the L4-L5 level that is in the subarticular zone and causes compression of the traversing L5 root. d e . (d) Anterior and (e) posterior dermatomal maps show the distribution of pain or sensory deficit that may be seen in this patient. root L5 c Fig.

27â•… Foraminal disc protrusion. 7â•… The Lumbar and Thoracic Spine 177 a b c L4-L5 L4 Exiting n. (e) Anterior and (f) posterior dermatomal maps show the distribution of pain or sensory defi- cit that may be seen in this patient.† Note the patency of the neural foramen at the L3-L4 and L5-S1 levels (arrowheads). (c) An axial T2-weighted image† and (d) artist’s sketch at the L4-L5 level show a left-side disc protru- sion (arrow) in the foraminal zone.€7. root Traversing n. . and L5-S1 lev- els. root d Fig.† (b) A parasagittal T2-weighted image at the level of the neural foramen shows disc material (arrow) within the left L4- L5 foramen. (a) A sagittal T2-weight- ed image shows disc bulges at the L3-L4. with resultant compression of the exiting L4 nerve e f root. L4-L5.

178 IIâ•…Spine a b c d e .

the spine surgeon will benefit Thoracic disc herniations are rare.30).29).† (e) The axial T2-weighted image (and [f] corresponding artist’s sketch†) confirms that the disc protrusion is in the far-lateral zone (arrow) on the right side. Sagittal T2-weighted images obtained in the (a) midline.€7. .€7. be “soft” or “hard.† (c) at the level of the pedicle. 7â•… The Lumbar and Thoracic Spine 179 L4-L5 L4 f g h Fig. location. constituting only from knowing whether the disc can be expected to 1% to 2% of all disc herniations. Specifically.51 When they do occur. primarily of nucleus pulposus.28â•… Far-lateral disc protrusion.† and (d) lateral to the pedicle and foramen show a right-side far-lateral disc herniation that is seen primarily on d (arrow on each) at the L4-L5 level. likely the result of the increased mobility and load in thology may consist of a chronic and desiccated disc this region. that often correlates with a soft disc at surgery.† (g) Anterior and (h) posterior dermatomal maps show the distribution of pain or sensory deficit that may be seen in this patient. Another characteristic of the disc pathology that Thoracic Disc Herniation should be evaluated is its expected consistency at surgery. and axial T2-weighted increased signal within the disc protrusion.€7. T2-weighted images occasionally show show thoracic disc herniations. whereas hard disc pa. a finding images allow additional characterization of the size. They can also be seen in association with protrusion or a posterior or posterolateral osteophyte Scheuermann disease. Sagittal T2-weighted images (Fig. and morphology of the lesion (Fig.† (b) a few millimeters lateral to midline.” A soft disc protrusion consists they are seen most often in the lower thoracic spine.

root Fig.30â•… Thoracic disc protrusion and stenosis.† a b Fig. arrowheads).† .€7.180 IIâ•…Spine Disc herniation Thecal sac compression a Posterior central ridging or osteophyte b Spinal n. The arrow on each indicates the direction of herniation.€7. Note the multilevel degenerative disc disease at other levels and the Schmorl nodes (a.29â•… Lumbar disc pathology. (a) Sagittal and (b) axial T2- weighted images show moderate-severe stenosis at the T10-T11 level secondary to a moderate-sized central disc protrusion (arrow on each) and underlying degen- erative stenosis. Artist’s sketches show the difference between (a) soft and (b) hard disc pathology in the lumbar spine.

Facet Arthropathy vertebral disc through weak areas in the adjacent vertebral end plates and into the vertebral body.39 Cases in which the Schmorl node is associated with increased T2-weighted signal in the adjacent bone marrow are more commonly as- sociated with back pain and may represent an acute or subacute Schmorl node. is difficult to associate them with a particular clini- with no dependency on age or gender. When symptoms instability on flexion-extension radiographs and. Advanced degenerative disc disease is also seen at the L5-S1 level.30).31â•… Facet arthropathy and dynamic instability. they appear as extensions of disc material (with direct a continuity with the disc) into the vertebral body. surrounded by a rim of low signal intensity second- ary to reactive sclerosis. This series of images shows that degenerative changes and excessive fluid within the facet joints may be associated with instability. the spondylolisthesis may not be seen on the sagittal MR images.€7. Patients may be asymptomatic or have images (Fig. (c) A standing lateral radiograph shows an obvious Meyerding grade-1 spon- dylolisthesis at the L4-L5 level. the patient may present with axial back pain.53 Scheuer. 7â•… The Lumbar and Thoracic Spine 181 Schmorl Nodes Facets Schmorl nodes represent herniations of the inter.52 Although it is now accepted that the facet joints They are found most commonly in the thoracic and may be a cause of pain in the degenerated spine. cal syndrome.54 b c Fig.† . MRI provides the optimal detection of Schmorl nodes (Fig. Observation of such fluid within nonspecific pain that may not be directly related to the facet joints suggests the potential for dynamic the presence of the Schmorl node.55–57 One of the earliest MRI findings mann kyphosis is one of several processes that is of facet arthropathy is seen as fluidlike intraarticu- associated with Schmorl nodes and premature disc lar signal intensity on sagittal or axial T2-weighted degeneration. it lumbar spine and occur in ~10% of the population.€7. (a) An axial T2-weighted image at the L4-L5 level shows bilateral facet arthrop- athy with fluid within and distending the L4-L5 facet joints (arrows).50. given that MRI is performed with the patient in the supine po- sition. are the result of the Schmorl node(s).€7.31). (b) A sagittal T2- weighted image (obtained with the patient in a supine position) shows evidence of stenosis at this level and also suggests the possibility of a subtle L4-L5 spondylolisthesis.

reflecting synovitis from osteoarthritis or transverse dimension (Fig. Finally. articular recess.59 near-complete loss of cartilage. osteo.€7.58. and <25% increase in facet joint et joints. (b) moderate.to 3-mm) osteophytes.32â•… Facet arthropathy.182 IIâ•…Spine therefore. Effusions may also be seen within fac- lar cartilage. and (c) severe facet arthropathy. and 25% to 50% increase dispose to degenerative disc disease and eventual in facet transverse dimension (Fig.32b) scoliosis. compromise. minimal sub. may affect the selection of surgical op. osteophytes Renfrew and Heithoff27 described a practical and >5 mm. Axial T2-weighted images at the L4-L5 level in three different patients show (a) mild. mild narrowing of articu.† . arthritis. • Severe: additional progression of disease with tions for patients who demonstrate this finding.€7. asymmetric facet disease may pre- phytes up to 3 to 5 mm. and joint width >50% of expected simple way to assess facet arthropathy: transverse dimension (Fig.32c) • Mild: mild undulation of the margins with Facet joint hypertrophy may cause canal.60–62 a b c Fig.€7. or foraminal stenosis and neural chondral sclerosis.32a) a synovial proliferative process in an inflammatory • Moderate: more pronounced changes.€7. sub- small (1.

This compression is a b c Lumbar synovial cyst d e Traversing n. facet joint pression and may appear on a sagittal T2-weighted hypertrophy and osteophyte formation.33â•… Lumbar synovial cyst. or posterolat- image as a hyperintense cyst with a hypointense rim eral encroachment from the disc in the form of bulg- (Fig.€7. T2-weighted MR images in the axial plane es. (d) The axial T2-weighted image shows that the cyst (arrowhead) likely originates from the right L4-L5 facet joint and that the thecal sac (between arrows) is severely compressed and shifted toward the left. Note the intense peripheral enhancement of the lesion on c.€7. Neural foramen stenosis may arise from a reduction in the A synovial cyst. 7â•… The Lumbar and Thoracic Spine 183 Synovial Cyst show the degree of lateral recess stenosis. . root thecal sac Fig. and extrusions.† (e) An artist’s sketch in the axial plane illustrates the findings seen in the preceding images.† and (c) postgadolinium fat-suppressed T1-weighted† images show a large L4-L5 lesion compatible with a facet joint cyst when correlated with (d) the axial T2-weighted image. narrowing of the intervertebral disc space. root Compressed Exiting n. which originates most commonly height of the neural foramen because of degenerative from lumbar facet joints.33). may also cause neural com. Sagittal (a) T2-weighted. the postgadolinium T1-weighted image.† (b) T1-weighted. protrusions.

and a generalized narrow appearance of the spinal canal relative to the AP diameter of the vertebral bodies. CSF should be seen ventral to the cauda with known or suspected lumbar spinal stenosis is equina. This procedure should be repeated on the parasagittal T2-weighted images in each direction (left and right from center) to evalu- Lumbar Spinal Stenosis ate for lateral recess and foraminal stenosis. and low back erally at each level to rule out stenosis secondary to pain. MRI can be considered. lateral re.€7. L4- L5. reditary-idiopathic or associated with disorders of ment of lumbar spinal stenosis begins with a sys. These images show the conus medullaris in vertebrae. the spinal canal. or neural foramina. including ligamentum fla- vum hypertrophy (arrowheads) and facet arthropathy (arrows). which con- degenerative. Next. and narrowing of the cross- the patient without scoliosis.34â•… Degenerative changes superimposed on congenital lumbar stenosis. sectional area of the central spinal canal (Fig. or ligamentum flavum pathology.63 On occasion. congenital) of lumbar spinal stenosis.g.64. in which case they may dorsal margin of the thecal sac should be evaluated not have the typical bright fluid signal on T2-weighted on these images to evaluate for focal hypertrophy of images and may appear gray or dark on all sequences. The evaluation of patients Specifically. nature. obtained.65 Patients with lumbar stenosis typically with the patient in a supine position. (b) An axial T2-weighted image at the L4-L5 level shows minimal to moderate stenosis secondary to underlying congenital stenosis with superimposed degenerative changes. or central canal of the lumbosacral should be evaluated to determine the degree (i. the may contain air or may calcify. the The term spinal stenosis describes the compression axial T2-weighted images are sequentially evaluated of the neural elements in the spinal canal. spine and is usually developmental or acquired in mild to severe).184 IIâ•…Spine evaluated best on far-lateral parasagittal T1-weighted ologist should carefully trace the posterior margin of and T2-weighted images that visualize the neural fo. stitutes ~15% of all cases of spinal stenosis.† . the ligamentum flavum.€7.. patients and conventional radiographs have been Spinal stenosis may involve the neural foramina. synovial cysts that there is no effacement of the CSF space. facet. given that most studies are obtained bar spine. and L5-S1.34). is he- The authors’ suggested method for the assess. with evidence of stenosis from disc bulges at these levels (arrowheads). The MR images lateral recesses. cesses. The clinician or radi. (a) A sagittal T2-weighted image shows multilevel degenerative disc disease at L3-L4. a b Fig. After the sagittal T2-weighted images have been evaluated. level (i. skeletal growth. After nonoperative management fails for such disc.e. Developmental spinal stenosis. the vertebral bodies and intervening discs to ensure ramina in cross-section. and type (e.63 MRI of the hereditary form shows tematic evaluation of the midsagittal T2-weighted minor hypoplasia of the posterior osseous arch of the images.. L1 to S1).e. The lateral re- present with combinations of radicular leg pain or cess and foraminal region should be evaluated bilat- weakness. neurogenic claudication. short pedicles.. which is often displaced posteriorly within one of the primary indications for MRI of the lum. from the sacrum toward the upper lumbar spine. ligamentum flavum hypertrophy (arrows).

7â•… The Lumbar and Thoracic Spine 185

Sagittal images may show progressive narrowing of sociated with the presence of intermittent neuro-
the AP dimension of the spine in the caudal direc- genic claudication. Speciale et al67 evaluated observer
tion, indicating developmental spinal stenosis. variability in assessing lumbar spinal stenosis on
Acquired central spinal canal stenosis may arise MRI in relation to cross-sectional spinal canal area
from hypertrophic or degenerative changes of the and found only a fair level of agreement among the
intervertebral discs, facet joints, or ligamentum fla- observers; however, they found that the ability of the
vum (Fig.€7.35). On MRI, central canal stenosis is various readers to predict the degree of central ste-
characterized by compression of the thecal sac, best nosis was high.
seen on sagittal and axial T2-weighted images. Fat- Another method for evaluating the degree of lum-
suppressed T2-weighted and STIR images provide a bar spinal stenosis and its potential for contribution
“myelographic effect,” in which the CSF is seen as to clinical symptoms is the “sedimentation sign,” a
bright signal anterior and posterior to the neural ele- phenomenon named by Barz et al,68 who also defined
ments on sagittal and axial images. Effacement, dis- a positive sedimentation sign as an absence of sedi-
continuity, or displacement of this CSF space is seen mentation of nerve roots in patients with a diagno-
in patients with focal and concentric spinal stenosis sis of lumbar spinal stenosis (Figs. 7.37 and 7.38). In
(Fig.€7.36). patients without lumbar spinal stenosis, the lumbar
There are several objective measures of lumbar nerve roots “sediment” to the dorsal part of the the-
spinal stenosis.66,67 Hamanishi et al66 found that a cal sac (Fig.€7.39). Conversely, in patients with symp-
cross-sectional area of <100 mm2 at more than two tomatic and morphologic central lumbar stenosis,
of three lumbar intervertebral levels was highly as- such sedimentation is rarely seen.68

Midline posterior Thecal sac
a vertebral ridging compression
b Spinal cord
Neuroforamina stenosis

Exiting
n. root Normal
n. root

Superior articular
process hypertrophy
Hypertrophied Midline posterior
ligamentum vertebral ridging
Hypertrophied
flavum
ligamentum
flavum

Superior articular d Exiting
c process hypertrophy n. root
Exiting
n. root

Superior articular
process hypertrophy
Normal
n. root
Inferior articular
process

Neuroforamina

Fig.€7.35â•… Artist’s sketches illustrating the anatomic changes that lead to lumbar stenosis. (a) An axial view. (b) A midline sagittal
view. (c) A parasagittal view at the level of the neural foramina. (d) A magnified axial view shows the left lateral recess and foramen.†

186 IIâ•…Spine

a b

Fig.€7.36╅ Lumbar stenosis. (a) A sagittal T2-weighted image shows multilevel stenosis
in the lumbar spine. (b) An axial T2-weighted image at the L4-L5 level shows moderate-
severe stenosis secondary to contributions from a central disc bulge (arrow), ligamentum
flavum hypertrophy (arrowheads), and facet arthropathy (asterisks).†

a

b

Fig.€7.38â•… An artist’s sketch showing (a) negative and (b)
positive sedimentation signs. (From Barz T, Melloh M, Staub LP,
Fig.€7.37╅ An axial T2-weighted image of the lumbar spine at Lord SJ, Lange J, Roder CP, Theis JC, Merk HR. Nerve root sedi-
the L4-L5 level shows the cauda equina, L4 spinal nerve root, mentation sign: evaluation of a new radiological sign in lumbar
and L4 dorsal nerve root ganglion. Note the “sedimentation” spinal stenosis. Spine (Phila Pa 1976) 2010;35(8):892–897. Re-
of the nerve roots in the dorsal aspect of the thecal sac.† printed by permission.)

7â•… The Lumbar and Thoracic Spine 187

• Moderate: findings similar to those of mild ste-
nosis but with compression and minimal flat-
tening and deformity of the thecal sac. The AP
canal diameter is between 50% and 75% of ex-
pected normal.
• Severe: advanced stenosis with very pro-
nounced flattening and deformity of the thecal
sac that is obvious on both sagittal and axial
T2-weighted images. The ligamentum flavum
is often thickened to >4 mm. The AP canal di-
ameter is <50% of expected normal.
It should be noted that in some cases, canal narrow-
ing can be downgraded if there is ample CSF sur-
rounding the neural structures and upgraded if the
surrounding CSF is scant. Similar terminology can
be applied to grading stenosis in the subarticular re-
cesses or foramina.
Fig.€7.39╅ An axial T2-weighted image of the lumbar spine In addition to evaluating the degree of central and
shows the cross-sectional area and AP measurements and canal stenosis, the lateral recess, foraminal, and extra-
depicts a positive sedimentation sign. (From Fazal A, Yoo A, foraminal zones should also be specifically assessed
Bendo JA. Does the presence of the nerve root sedimentation (Fig.€7.24). Lateral recess and foraminal stenosis are
sign on MRI correlate with the operative level in patients un- most often the result of a combination of pathologies:
dergoing posterior lumbar decompression for lumbar steno- facet arthropathy, ligamentum flavum hypertrophy,
sis? Spine J. 2013;13(8):837–842. Reprinted by permission.)
and disc bulge or protrusion. Specifically, hypertro-
phy of the superior articular process from the caudal
level often leads to the development of foraminal ste-
nosis. In addition, degenerative disc disease with the
To show the clinical utility of the sedimentation associated loss of disc height and subsequent loss of
sign and compare it with other, more traditional foraminal height and volume can lead to the devel-
measures of lumbar stenosis, Fazal et al69 performed opment or exacerbation of foraminal stenosis from
a retrospective review of the preoperative MRI stud- other degenerative pathologies. Many clinicians and
ies of 71 consecutive patients who presented with radiologists evaluate for the presence of foraminal
lumbar spinal stenosis and underwent a lumbar stenosis in the axial plane. However, parasagittal im-
decompressive procedure. They evaluated several ages are also quite useful in confirming the presence
radiographic parameters, including the sedimenta- of foraminal stenosis (Figs. 7.27 and 7.28). The normal
tion sign, and found that the sedimentation sign was foramen has an ovoid configuration on parasagittal
noted to be positive in 120 of 134 (89.5%) operated images (see Chapter 2, Normal Spine MRI Anatomy)
levels. Based on this and other findings, those au- where the superior aspect of the foramen contains the
thors suggested that the sedimentation sign allows exiting nerve root and the inferior aspect of the fora-
physicians to evaluate the degree of spinal stenosis men shows high signal intensity on both T1-weight-
objectively and that the sign is most often present ed (from perineural fat) and T2-weighted (from CSF
in patients who undergo lumbar decompressive sur- within the nerve root sleeve) images. On parasagittal
gery; they also found good degrees of correlation be- images, patients with foraminal stenosis have pro-
tween the sedimentation sign and other radiographic gressive narrowing of the foramen, with resultant
parameters, including cross-sectional area, AP canal compression of the nerve root.
diameter, and degree of facet joint hypertrophy.69
Although the formal measurements of lumbar
stenosis on MRI just described are well known, most Cauda Equina Syndrome
clinicians and radiologists tend to grade the degree
of spinal stenosis as mild, moderate, or severe. The Cauda equina syndrome is typically characterized
authors use the following terms and definitions: by unilateral or bilateral sciatica, perianal or saddle
anesthesia, bowel and bladder incontinence, and
• Mild: stenosis in which the canal begins to as- sensory and motor deficits in the lower extremi-
sume a triangular shape, the thecal sac is not ties.70 Often, it is caused by a space-occupying mass
compressed, and there is only minimal (<2 mm) compressing against the cauda equina and/or conus
thickening of the ligamentum flavum. The AP ca- medullaris. There can be numerous etiologies, in-
nal diameter is >75% of expected normal without cluding disc herniation, severe stenosis, trauma, tu-
nerve root crowding. mor, or infection.71,72

188 IIâ•…Spine

MRI is the preferred imaging modality for the
evaluation of the patient with suspected cauda
equina syndrome. MRI allows visualization of space-
occupying lesions within the spinal canal as well as
identification of compression of neural structures.
Lumbar myelography with CT of the lumbar spine is
indicated in patients who are unable to undergo MRI.
Given that the treatment of cauda equina syndrome
is urgent decompression, one of these imaging stud-
ies should be obtained without delay.

Spondylolisthesis
Spondylolisthesis is defined as anterior displacement
of a vertebral body relative to the one caudal to it. Ret-
rolisthesis is seen when the superior vertebral body
is displaced posterior to the one caudal to it. Wiltse et
al73 classified lumbar spondylolisthesis on the basis of
etiology: dysplastic, isthmic, degenerative, traumatic,
iatrogenic, or pathologic. Meyerding74 described the
various degrees of forward slippage (from grade 1 to
grade 4) based on a division of the superior surface of
the lower vertebra into quarters (Fig.€7.40). According
to this system, a complete slip of L5 on S1 is termed
spondyloptosis. Each manifestation of spondylolisthe-
sis has specific associated MRI findings.
The system of Wiltse et al73 details the features of
spondylolisthesis as follows:
• Dysplastic spondylolisthesis: may present with
degeneration and pseudobulging of the lum-
bosacral disc, with potential compression of
the cauda equina between the neural arch of L4 Fig.€7.40â•… An artist’s sketch of the Meyerding classification,
and the superoposterior aspect of the sacrum which is used to quantify the degree of spondylolisthesis. Grade
(for a slip at L5). A parasagittal T1-weighted SE 1 is 0% to 25% slip, grade 2 is 26% to 50% slip, grade 3 is 51% to
75% slip, and grade 4 is 76% to 99% slip. A = width of the supe-
image may show severe compression of the ex-
rior end plate of S1, a = distance between the posterior edge of
iting L5 nerve root. the inferior end plate of L5 and the posterior edge of the supe-
• Isthmic spondylolisthesis: sagittal T2-weighted rior end plate of S1. (From Cavalier R, Herman MJ, Cheung EV,
images often show obvious spondylolisthesis Pizzutillo PD. Spondylolysis and spondylolisthesis in children
at the L5-S1 level (Fig.€7.41). Parasagittal im- and adolescents. I. Diagnosis, natural history, and nonsurgical
ages at the level of the pedicle may show com- management. J Am Acad Orthop Surg 2006;14:417–424. This
pression of the exiting L5 nerve root between reprinted illustration was modified with permission from Her-
the bulging L5-S1 disc and the undersurface man MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylo-
of the L5 pedicle, along with reduction of fo- listhesis in the child and adolescent athlete. Orthop Clin North
raminal height. The parasagittal images should Am 2003;34:461–467. Reprinted by permission.)
also be scrutinized for the presence of a pars
intraarticularis defect or reparative granula-
tion tissue in that region; CT imaging may help
confirm the presence of the pars defect.
• Degenerative spondylolisthesis: seen most com-
monly at the L4-L5 level. MRI can be used to • Traumatic spondylolisthesis: MRI shows the as-
evaluate narrowing of the central canal, lateral sociated soft-tissue injury, which may include
recesses, and neural foramina and compres- rupture of the intervertebral disc and posterior
sion of the cauda equina and exiting nerve ligamentous complex, as seen with bilateral
roots. Facet joint cysts are not uncommon in facet dislocation (Fig.€7.10).
the presence of degenerative spondylolisthe- • Pathologic spondylolisthesis: MRI shows very
sis. Sagittal and axial T2-weighted images de- focal changes at the level of the pars intraartic-
lineate these entities clearly (Fig.€7.42). ularis based on the specific pathology involved.

7â•… The Lumbar and Thoracic Spine 189

a b

c d

Fig.€7.41╅ Isthmic spondylolisthesis. (a) A lateral radiograph shows bilateral pars intraarticularis defects (arrow) at the L5-S1 level
with Meyerding grade-2 spondylolisthesis. (b) A sagittal T2-weighted MR image obtained via a closed system with the same patient
in a supine position shows grade-1 spondylolisthesis. (c) A sagittal T2-weighted MR image obtained via an open MRI system with
the patient in a standing position shows that the spondylolisthesis progresses to grade 2. (d) A sagittal T2-weighted image obtained
via an open MRI system with the patient in a flexed position shows that the grade-2 spondylolisthesis progresses compared with
images in the (c) neutral and (b) supine positions.†

• Iatrogenic spondylolisthesis: may occur after Scoliosis
laminectomy, facetectomy, and extensive resec-
tion of the facet joint and neural arch without
Scoliosis is a lateral curvature of the vertebral column
fusion. MRI shows changes directly correlated
in the coronal plane involving lateral and rotational
to the specific areas altered during surgery.
vectors, and it may be associated with spinal cord or
Recently, the focus in spondylolisthesis has moved other neuronal abnormalities that are best visualized
beyond the slippage of the vertebral bodies to include, with MRI before operative intervention. The most
among other issues, its etiologic factors and spino- common indication for MRI in patients with scolio-
pelvic alignment. This change in focus has led to the sis is degenerative scoliosis. In this scenario, MRI is
development of more comprehensive classification obtained to evaluate for the presence, degree, and
systems that may be better at predicting progression levels of stenosis. Because of the unique challenge of
of the disease, especially in younger individuals.75–77 obtaining contiguous visualization of the spinal canal

190 IIâ•…Spine

a b

Fig.€7.42╅ Degenerative spondylolisthesis. (a) A sagittal T2-weighted image shows Meyerding grade-1 spondylolisthesis at the
L4-L5 level with severe stenosis and evidence of a high-intensity zone at the posterior annulus of the L4-L5 disc. (b) An axial T2-
weighted image shows severe stenosis from a central disc bulge, ligamentum flavum hypertrophy, and facet arthropathy.†

content in the scoliotic spine, specific protocols should thoracic curve and who are neurologically intact,79–81
be followed to obtain the best views. Redla et al78 de- others have found a high incidence of spinal cord
scribed the use of sagittal T1-weighted SE and T2- abnormalities (17.6% to 26%) in patients with infan-
weighted FSE sequences, beginning from above the tile and juvenile forms of scoliosis.78,82 Those studies
foramen magnum and including the brainstem down stressed the importance of MRI in children younger
to the sacrum. However, for typical thoracolumbar than 11 years old. Spinal cord abnormality is suggest-
scoliosis, MR images are obtained of the thoracic and ed by several physical examination findings, including
lumbar spine only. When the curve is severe, sagittal a left thoracic curve, absent abdominal reflexes, lower
sequences are obtained parallel to the two major por- limb neurologic deficits, and cutaneous stigmata of
tions of the curve and are planned from the coronal occult spinal dysraphism.78
plane. Axial T1-weighted images are obtained through Specific MRI findings for abnormalities seen with
the apices of the curve, providing a second view of scoliosis secondary to an underlying neurologic ab-
the cord. A coronal T1-weighted sequence also is ob- normality include the following:
tained, especially to assess the vertebral bodies for
congenital anomalies. In patients with degenerative • Tethered cord: thickened filum terminale and
stenosis, the sagittal and axial T2-weighted images spinal lipoma, seen on sagittal T1-weighted SE
should be evaluated in correlation with each other and T2-weighted FSE images
to determine the degree and type of stenosis at each • Syringohydromyelia: dissection of CSF through
level (Fig.€7.43). This information helps determine the cord substance, best seen on T2-weighted
the levels for decompression in a patient who is being images with increased signal within the cord,
considered for surgical intervention. sometimes associated with sacculation
Aside from the evaluation of the patient with lum- • Diastematomyelia: a midline sagittal cleft of
bar degenerative scoliosis and suspected stenosis, the the spinal cord most commonly involving the
indications for MRI in patients with scoliosis have lower thoracic and lumbar region, seen as two
been the subject of debate (see Chapter 9, MRI of the hemicords on MRI, with each having a single
Pediatric Spine). Although some studies have shown dorsal and ventral horn and a septum seen
that routine MRI is not indicated for patients with ad- from the dorsal aspect of the vertebral body
olescent idiopathic scoliosis who have a typical right and extending into the cleft between the cords

€7.43â•… Scoliosis. The primary Epidural lipomatosis is a condition in which there differential consideration includes an intraspinal is excessive deposition of fat in the epidural space lipoma. leads to spinal stenosis and neural in the anterior thoracic spine. The characteristic feature of lumbar epidural lipomatosis is the presence of epidural tis- sue that follows the signal characteristics of sub- Epidural Lipomatosis cutaneous fat on all pulse sequences. normalities tend to have a low T1-weighted signal ated with excessive glucocorticoid levels. may occur in up presence of >6 mm of fat posterior to the cord is to 6. (b) An axial T2-weighted image at the L2 level shows rotation of the vertebral body but no substantial stenosis.2% of patients with idiopathic scoliosis83 diagnostic. spontaneous or idiopathic. the with developmental scoliosis.44).† • Neurofibromatosis: a congenital condition that may be exogenous or endogenous but may also be may show dural ectasia. 7â•… The Lumbar and Thoracic Spine 191 a b c Fig. pseudomeningocele.€7. and neurofibromas on MRI epidural fat surrounding and compressing the the- • Pars defects: a common occurrence in patients cal sac is the key finding.84–86 In the lumbar spine. In the thoracic spine. which and can be excluded. in turn.87 Other epidural ab- compression. (c) An axial T2- weighted image at the L3-L4 level shows rotation of the vertebral body level and moderate to severe ste- nosis secondary to degenerative changes. The syndrome is primarily associ. which is typically focal and is often located that. . (a) A coronal T1-weighted im- age shows advanced thoracolumbar degenerative scoliosis that is primarily left convex with the apex of the curve at the L2 level. including fat-suppressed sequences (Fig.

and suppresses (becomes dark) on the STIR image. with a sensitivity of >82% infection .192 IIâ•…Spine a b c d Fig.90 Infection involving ■⌀ Infectious Conditions the vertebral body occurs through one of three pri- mary routes91: Vertebral Osteomyelitis • Hematogenous (most common) Cases of vertebral osteomyelitis comprise between • Direct inoculation through surgery or pen- 2% and 4% of all skeletal infections.88. blends in with the CSF on the T2-weighted image. (d) An axial T1-weighted image at the L4-L5 level shows severe compression of the thecal sac by the extensive lumbar epidural lipomatosis.44â•… Lumbar epidural lipomatosis.€7.89 MRI is usually etrating trauma regarded as the imaging modality of choice for the • Contiguous spread from an adjacent soft-tissue detection of this process. (b) T2-weighted. Note that the lipomatous tissue is most obvious on the T1-weighted image. (a) Sagittal T1-weighted. and (c) STIR images show advanced lumbar epidural lipoma- tosis extending from L4 to the sacrum with circumferential compression of the thecal sac.† and a specificity of 53% to 94%.

(a) Sagittal postgadolinium T1-weighted and (b) STIR images show enhancement and increased signal within the L3-L4 disc space and edema within the adjacent vertebral bodies in a patient with infectious symptoms and findings.93 nal intensity of the intervertebral disc with The general MRI signal changes in patients with loss of the nuclear cleft on T2-weighted im- osteomyelitis include the following: ages89. However.€7.91.45). with jacent vertebral bodies. Gadolinium enhancement may be seen in ad- bral disc and adjacent vertebral bodies.€7. gadolinium may a b Fig. • Decreased signal intensity of the interverte. often sparing the • An abnormal configuration and increased sig- central portion of the vertebral bodies. (c) An axial T2-weighted image at the L3-L4 disc level also shows heterogeneous and increased signal c within the disc space.45â•… Vertebral osteomyelitis and discitis.91–93 Infection then spreads from the vertebral adjacent to the involved disc on T2-weighted body and marrow to the contiguous intervertebral images disc and adjacent vertebral body.94 (Fig.† . compatible with discitis. 7â•… The Lumbar and Thoracic Spine 193 Hematogenous seeding occurs through nutrient a discernible margin between the two on T1- arterioles of the vertebral bodies or by retrograde weighted images spread through the paravertebral venous plexus of • Increased signal intensity of vertebral bodies Batson.

194 IIâ•…Spine also cause edematous marrow to blend in with the weighted images. Patients with vertebral osteomyelitis Staphylococcus epidermidis and Staphylococcus aureus.99 If a rim of soft tissue around the affected intervertebral space is Disc infection often causes edema. a b c Fig.97.€7. which essentially is discitis with from fat and provide increased contrast.96 STIR im.39. The most common infecting organisms are of the Spine). it also causes loss of definition of the normal fatty marrow. tend to have the epicenter of the pathologic change at MR images often show Modic type-1 changes at the level the disc space. No enhancing the vertebral body and do not cross the disc space. concern about septic spondylodiscitis hyperintensity of the disc and the end plate on T2. to occur in 0. signal on T1-weighted images and increased signal in- tious processes are based at and cross the disc space. which can be ruled out with disc biopsy. Sagittal (a) T2-weighted. have an associated paraspinal inflammatory mass. Note the increase in signal at the disc space on the T2-weighted image. Tumors infection. cent vertebral marrow.99 Intraoperative con- tebral osteomyelitis should be differentiated from that tamination usually is the most common mechanism for in patients with spinal tumors (see Chapter 8. and gadolinium enhancement hancement eliminates this problem.95 Combining fat-suppressed vertebral end plates. arises. elography.94 STIR images within the disc. tensity on T2-weighted images) and enhancement of whereas neoplastic processes are typically based in the disc when contrast is used (Fig. It also may be seen after discography or my- anatomic detail from T1-weighted sequences. arrow).99 Postoperative spondylodiscitis is believed The pattern of vertebral body involvement in ver.† .46). inflammatory changes in the adja- T1-weighted images with gadolinium contrast en. which leads to noted to enhance. vertebral osteomyelitis. it is not uncommon to may also be used for the MRI evaluation of osteomy. infec. the decrease in signal on the T1-weighted image.1% to 3% of patients. (b) T1-weighted.98 In addition. may be seen after lumbar disc ages are especially useful when combined with the surgery. and the postgadolinium enhancement of the small epidural component (c. tissue should be seen outside the intervertebral space.46â•… Discitis.€7. elitis because they suppress the high signal intensity Spondylodiscitis. and (c) postgadolinium T1-weighted images show the typical find- ings of discitis at the L2-L3 level (arrows on a and c). In other words. Normal vertebral bone marrow has low signal intensity on T1-weighted images and high signal intensity on Discitis T2-weighted and contrast-enhanced images. and those with tumors tend to have the of the operated disc (vertebral end plate with decreased epicenter at the vertebral body.

again with peripheral enhancement.† . Such collections are usually the spinal cord on T1-weighted images and which located anteriorly in the spinal canal and originate usually have high signal intensity on T2-weighted from the posterior aspect of the vertebral body and images96.95 MRI is also useful in An epidural abscess is a purulent epidural collection visualizing phlegmon and epidural abscesses. (c) A sagittal postgadolinium T1-weighted image shows peripheral enhancement. (d) An axial postgadolinium T1-weighted image shows the ventral epidural collection (arrow). (a) A sagittal T2-weighted image shows a ventral epidural collection (arrow) posterior to the L5 ver- tebral body in a patient with infectious symptoms and findings. then it may be associated with a linium enhancement for better visualization. (b) A sagittal T1-weighted image shows the same collection. The a b c d Fig.99 (Fig. necessitating gado- enous sources. abscess and CSF may be difficult. If the abscess originates from hematog. MRI is very sensitive in the detection of these abscesses. The differentiation of epidural disc space.€7. which of material without involvement of the vertebral usually are isointense or hypointense compared with body or the disc space. 7â•… The Lumbar and Thoracic Spine 195 Epidural Abscess positive blood culture. the abscess is producing moderate to severe stenosis.€7.47).47â•… Epidural abscess.

linium-enhanced images provide additional abscess However.196 IIâ•…Spine high signal intensity of the enhancing mass can be It is not uncommon to see paraspinal involvement distinguished easily from the lower signal inten. iatrogenic instability (such as with facetecto- gitudinal ligament to adjacent vertebral bodies. given fect the musculoskeletal system. the introduction of titanium pedicle screws delineation. CT may be best for more precise determination bodies makes the spine susceptible to infection. observation of disc space sparing and enhancement of ment also can aid in differentiating between epidural granulation tissue is highly suggestive of tuberculosis. of the resultant artifacts that were commonly seen.100 The intervertebral disc becomes less vascularized • Decompression of a stenotic spinal canal or in adolescence. fluid collection (such as hematoma or CSF). The rich vascular supply of the vertebral fusion. Continu- ous destruction of the anterior cortices of single or After Decompression without contiguous vertebral bodies can lead to kyphotic de. a condition termed tuberculosis myelitis.90 phlegmon and an abscess. The addition from the ascending branch of the posterior spinal of myelography to CT imaging provides excellent de- artery and superiorly from the descending branch termination of the presence and degree of spinal ste- of this artery.99 Contrast enhance. sis.105 trient foramen.48). dense homogeneous en- hancement of the mass suggests phlegmon. and evidence of seeding. Gado. which results in increased rates of infection • Removal of herniated disc material within the bodies. It is important to note that MRI may not always be the best imaging modality for the evaluation of Tuberculosis has reappeared in the developed world the postoperative lumbar spine. The ate an abscess from epidural fat. infection. 5% of all cases of tuberculosis af.100 foraminotomies. and they are commonly associated Previously. it may lead to collapse of vertebral bodies. MRI may be best for evaluating create a network of vessels in the anterior epidural for the presence or absence of infection.100 that they enable the evaluation of overall spinal align- Tuberculosis usually results from hematogenous ment. Sometimes fat suppression is necessary to differenti. and postoperative fluid collections. hemilaminotomy with foraminotomy.99 and specialized pulse sequences has improved the MRI visualization of the central spinal contents101–106 (see also Chapter 10. ease progresses. for various postsurgical findings. . A of the presence or absence of fusion. position of instrumentation. MRI spine are performed via a posterior approach. Tuberculous osteomyelitis usually involves the for existing instability (such as spondylolisthe- ventral trabecular bone marrow adjacent to the in. patients with an instrumented lumbar fusion. Almost all decompressive procedures in the lumbar it is usually seen in individuals <30 years old. scoliosis. and residual or recurrent stenosis. These with gadolinium is the best imaging modality for this procedures include a midline laminectomy and bilateral phenomenon. ical scenario. formed with the following goals in mind: sis between the vertebral end plate and the disc. gadolinium sity of the CSF and spine on T1-weighted images. Children are at an increased risk for Surgical procedures in the spine are typically per- discitis because they still have an arterial anastomo. and it spreads via the anterior lon.99 enhancement usually is seen only in the periphery. recurrent teries that enter the vertebral body through the nu. disc herniation. As the dis. or its absence. Tuberculosis may also directly involve the spinal cord. the spine surgeon and radiologist can There also may be a hyperintense signal within the use MRI (and other imaging modalities) to evaluate disc on T2-weighted images (Fig. These two arteries anastomose and nosis. Advanced Techniques in Spine Tuberculosis MRI). Conventional radio- because of the emergence of acquired immune defi. or posttraumatic injury) or after tervertebral disc. MRI had been considered to have limited with swelling of the psoas on T1-weighted images use in evaluating the instrumented spine because and increased signal on T2-weighted images. Arteries end within the vertebral neural foramen bodies. whereas peripheral or ring enhancement of the mass suggests an abscess.99 MRI my or multilevel laminectomies) signs of tuberculosis infection are hypointense signal • Excision of tumor or infection on T1-weighted images and hyperintense signal on Based on the type of surgery performed and the clin- T2-weighted images seen in the subchondral tissue.€7. with an associated epidural abscess. usually have low signal intensity on T1- weighted images. whereas granulation tissue enhances throughout.100 • Stabilization and fusion of motion segments. also well visualized ■⌀ Postoperative MRI Findings with MRI. postoperative space. Paraspinal abscesses. with abscess formation. Instrumentation/Fusion formity. In abscesses. graphs are typically the starting point for the study of ciency syndrome. loosen- vertebral body receives its blood supply inferiorly ing. The network then leads to three or four ar.

There also may be a disc fragments. depending on the length determination of the extent of bone removal during of time between surgery and the imaging study. CT imaging may be considered. 7â•… The Lumbar and Thoracic Spine 197 a b Fig.€7. The axial T1-weighted images (which component of disc height loss. After discectomy.49). Sagittal (a) T2-weighted and (b) T1- weighted images show destruction and partial collapse of the L5 vertebral body (between arrows on a) with relative preservation of the intervertebral discs. epidural soft-tissue edema with disruption of the .€7. compatible c with an abscess. Annular en- sion of the thecal sac by scar tissue or recurrent/residual hancement may also be seen. If addition. images up to 2 months after surgery. follow the con. depending on the ag- show more osseous detail than do T2-weighted images) gressiveness of the discectomy.107 Anterior planning. a high-signal-intensity band ex- sagittal and axial T2-weighted images. an epidural al information may benefit the surgeon for preoperative mass effect is observed in 80% of patients.48â•… Tuberculosis of the spine. T1-weighted images should be carefully reviewed for areas of postsurgical show increased soft tissue within the anterior epi- absence of the osseous structures (Fig. specific changes may be noted careful review of the sagittal and axial images permits around the affected area. (c) An axial T2-weighted image at the L5 level shows signal change within the anterior aspect of the left psoas muscle (arrow). one should review the the level of the disc. and also heterogeneous signal within the vertebral body (arrowheads).† and hemilaminotomy with discectomy. and look for focal areas of posterior nular disruption may be appreciated on T2-weighted expansion of the thecal sac or for regions of compres. tending from the nucleus pulposus to the side of an- tour of the thecal sac. In most cases. dural space immediately after surgery. At previous operations. Specifically.

It can sue changes continue to be seen up to 3 months after take from 2 to 6 months after surgery for a normal surgery. An enhancing subcutaneous disruption and edema.) posterior annular margin secondary to disc curettage is virtually gone by 6 months. (b) T2-weighted. the anterior thecal sac. After 6 months.107. intermediate signal intensity on T1-weighted imag- hancement decreases by 3 months after surgery and ing and hypointensity on T2-weighted imaging. with low signal intensity evaluating MRI studies in the first 6 weeks after sur. and (c) postgadolinium T1-weight- ed images show partial removal of the right-side lamina. Radiol Clin North Am.198 IIâ•…Spine a b Fig. 2012. Khanna AJ.109 One should use caution when of the paraspinal muscles. on T1-weighted images and high signal intensity on gery because there may be a large amount of tissue T2-weighted images.108. identify- ing the laminotomy site (arrows on each).49â•… Osseous defect after right L4-L5 hemilaminotomy. Carrino JA. resolved.50(4):731–747.110 Posterior soft-tis- can mimic the appearance of disc herniation. .€7. Axial (a) T1-weighted.107 The remaining scar tissue shows low to ing in the immediate postoperative period. Thakkar SC. Malloy JP IV. This en. all of the acute postoperative chang- Nerve root enhancement secondary to breakdown es secondary to hemorrhage and edema usually have of the blood–nerve barrier is another common find. (From Thakkar RS. producing a mass effect on track may be seen with gadolinium enhancement. Imaging the postoperative spine. These changes include disruption and edema signal to return. Reprinted with c permission.

the T1-weighted image.112 MRI central area of nonenhancement on postgadolinium can be used to differentiate recurrent disc hernia. the postgadolinium T1-weighted image. for surgery in patients with only scar tissue and no and a large meta-analysis has indicated the rate is recurrent disc herniation.50â•… Recurrent lumbar disc extrusion.50). the pregadolinium T1-weighted image.118–122 MRI in patients with 7% in patients who undergo limited discectomy and recurrent disc herniation shows a focal extradural 3. a b c d e f Fig. Axial (d) T2-weighted. Conversely. compared with e. and (f) postgadolinium T1- weighted images at the L4-L5 level show the left paracentral extradural lesion (arrow on each). (b) T1-weighted. the T2-weighted image. and (c) postgadolinium T1-weighted im- ages in a patient with a history of L4-L5 discectomy show a large disc extrusion (arrow on each) that has migrated proximally and is located behind the L4 vertebral body. the postgadolinium T1-weighted image.5% in patients who undergo aggressive discecto. and shows peripheral enhancement on c. patients tion from scar tissue. which appears to be disc material on d. T1-weighted images (Fig.† . typically in the posterolateral or lateral re- my. 7â•… The Lumbar and Thoracic Spine 199 Unfortunately. lesion. Sagittal (a) T2-weighted. of the epidural tissue.113–117 The importance of making with epidural fibrosis show uniform enhancement the differentiation between recurrent disc hernia. recurrent disc herniation is a tion and scar tissue or epidural fibrosis lies in the relatively common occurrence after surgery for a fact that outcomes for revision surgery for recurrent lumbar disc herniation. The reported range for the disc herniation are substantially better than those incidence of recurrent disc herniation is 2% to 18%.1%.€7. and shows peripheral enhancement on f. that has peripheral enhancement with a recurrent lumbar disc herniation to be 7. (e) T1-weighted.111 Another recent series found the incidence of cess region. Note that the disc is difficult to see on b.€7.

the central canal can be adequately vi. (a) A sagittal T2- a weighted image shows junctional stenosis (arrow) at the L2-L3 level in a patient who has undergone L3-L5 laminectomy and instrumented fusion. Note that the presence of the pedicle screws obscures the region of the lateral recess and foramen but does not prevent the evaluation of the status of the central canal. (b) An axial T2-weighted image at the L3 pedicle screw level shows moderate to severe stenosis and also shows the pedicle screws (arrows). Note the minimal ar- tifact from the pedicle screws (arrowheads). and ante- These images can enable the detection of postop. tion. even accurately show the degree of thecal sac magnetic and produce the greatest degree of image compression from these fluid collections.† b c . In addi- degradation secondary to magnetic susceptibil. pseudomeningocele. rior lumbar interbody fusion) can also be assessed Fig. Even with images (Fig.200 IIâ•…Spine After Instrumentation/Fusion erative fluid collections (such as hematoma. posterior lumbar interbody fusion.51â•… Junctional lumbar stenosis above instrumented fusion. (c) An axial T2-weighted image at the L2-L3 level shows severe stenosis and only minimal residual artifact (arrow) from the pedicle screw below this level in the L3 vertebral body. Note the localizing sagittal image seen as an inset with each axial image (b. se- roma. fusion. which are not superparamagnetic. conventional T2-weighted and T1-weighted pulse The position of interbody fusion devices (such as sequences. above and below an instrumented lumbar fusion plants. produce can be seen well on sagittal and axial T2-weighted less artifact than does stainless steel.51).122 Titanium and tantalum spinal im. the degree of adjacent-level stenosis at levels ity artifacts.€7. c).€7. those placed for transforaminal lumbar interbody sualized in patients with titanium pedicle screws. and abscess) and can Stainless steel implants are considered superpara.

52). and the posterior as. patients of- confines of the interbody space. the associated inflammatory changes and epidural tebral body. ten present with severe radicular pain and/or weak- pect of the interbody device after a transforaminal or ness. (a) A sagittal T2-weighted image shows retropulsion of an L4-L5 transforaminal inter- body device (arrow) into the spinal canal. 7â•… The Lumbar and Thoracic Spine 201 by MRI. a b d c Fig. In cases of posterolateral graft extrusion fibrosis (Fig. MR images show the contours of the interbody posterior lumbar interbody fusion procedure should device compressing the thecal sac or nerve root and be positioned within the posterior margin of the ver. .€7.† (c) T1-weighted image.€7.52â•… Retropulsed interbody device.† An axial (b) T2-weighted image. These devices should be located within the into the spinal canal or neural foramen.† and (d) artist’s sketch show that the interbody device (arrow on each) is retropulsed beyond the margin of the posterior vertebral body (arrowhead on b and c) and is producing right lateral recess stenosis.

€7. In both of these situations. such as multilevel be an incomplete closure of the dural opening. there may as well as after larger procedures.€7. and contain fluid that matches Fig. and it can occur after “small” cedure or in a patient who undergoes resection of an decompressive procedures. Al. subarachnoid space. Axial T2-weighted images at the (b) L3-L4 and (c) L4-L5 levels show the hematoma (between arrows on each) and the associated compression of the thecal sac.53) and posterior spinal fusion. resultant leakage of CSF into the operative site and though CT is excellent for visualizing osseous detail and posterior soft tissues. and de. with laminectomy (Fig. intradural lesion. location.53â•… Postoperative lumbar epidural hematoma. such as a microdiscectomy. (a) A sagittal T2-weighted a image shows a large and compressive fluid collection (between arrows) at the L3-L5 level in a patient after revision L4-L5 laminectomies.† b c .122 Pseudomeningoceles typi- an epidural hematoma) and the size.202 IIâ•…Spine Hematoma Pseudomeningocele Postoperative epidural hematoma typically develops A pseudomeningocele typically occurs in a patient within a few days after a posterior lumbar surgery that who sustains a durotomy during an open surgical pro- includes decompression. cally are well circumscribed. communicate with the gree of compression of the thecal sac it produces. MRI is superior arachnoid and dura. but rather by a pseudomeninges for visualizing postoperative fluid collections (such as of reactive fibrous tissue. This collection of CSF is termed the precise location of spinal instrumentation relative a pseudomeningocele because it is surrounded not by to the spinal canal and neural foramen.

adhesion of the nerve roots to the meninges (giving MRI is the preferred initial advanced imaging rise to an “empty” thecal sac sign). Degenerative conditions that can be evaluated ■⌀ Summary on lumbar spine MRI include disc displacement. noid space. and abnormalities do not always correlate with a symp- the previous use of myelographic contrast dye.€7. pathology should be consistent and uniformly ap- weighted and T1-weighted images in both sagittal plied. The images show a well-circumscribed fluid collection that does not compress the thecal sac. Note that on (b) the axial image at the L5 level.55). a b Fig. Therefore. as shown in Chapter 6. portant to understand that radiographic and MRI bar puncture. treated perioperative infection. The Cervical Spine.54). spinal stenosis. disc degeneration. and tumor are being considered. recurrent disc hernia- meningocele is often similar to that of the subarach. the central canal can be well visualized in the presence of pedicle screws. The typical MRI protocol of the lumbar spine for the The nomenclature used for describing lumbar disc evaluation of degenerative pathologies includes T2.€7.123 suspected lumbar spine injury begins with conven- tional radiographs and/or CT imaging. However. which is homoge. including the trauma of the surgery itself. MRI provides soft-tissue visualization Signs of arachnoiditis include central adhesion of the that is superior to that of conventional radiography nerve roots within the thecal sac into a central clump or CT and is useful for the assessment of spinal cord of soft-tissue signal (pseudocord) instead of their injury. it is im- blood after the repair of a durotomy.122 tomatic degenerative lesion.124 Various fac. and spondylolisthesis. degree of spinal stenosis. the spine surgeon or specialist must correlate the findings on MRI with the patient’s history and physical examina- tion. (a) Sagittal and (b) axial T2-weighted images of a patient who sustained a durotomy during revi- sion L4-S1 laminectomy and instrumented posterior fusion.€7. modality for the evaluation of symptomatic lum- matory mass that fills the thecal sac.† . previous lum. specific for the detection of degenerative changes. which pro- vides greater osseous detail and may reveal fractures Arachnoiditis or details that are not detected with conventional radiography. and axial planes. lumbar spine for specific indications can vary among ages and high signal intensity on T2-weighted images institutions and should be modified when specific (Fig. and an inflam. 7â•… The Lumbar and Thoracic Spine 203 the signal characteristics of CSF. peripheral and additional fracture evaluation.54â•… Pseudomeningocele. ligamentous injury. bar spine degeneration and is highly sensitive and tors can lead to the development of arachnoiditis. these collections often compress the thecal The initial evaluation of patients with known or sac less than do postoperative epidural hematomas. imaging protocols of the neous and has low signal intensity on T1-weighted im. normal feathery appearance (Fig. tion. Given that the pressure within a pseudo. diagnoses such as infection. intradural Despite this high sensitivity and specificity.

Common Clinical Questions 1.╇ Fracture morphology B. this modality is also frequently and effectively used for the evaluation of patients with nondegenerative conditions such as trauma. (b) The axial image is at the L4-L5 level.╇ Traumatic Fig. Note the central adhesion of the nerve roots within the thecal sac into a central clump of soft- tissue signal (pseudocord) instead of their normal feathery ap- pearance.╇ Degenerative B. infec- tion. and postop- erative complications and findings.€7.╇ Pathologic E. Which of the following is not one of the cri- teria that the Thoracolumbar Injury Classifi- cation and Severity Score has recognized as being important in the evaluation of patients with thoracolumbar trauma? A.† .╇ Isthmic C.╇ Iatrogenic b D.204 IIâ•…Spine Although the most common indication for MRI a of the lumbar spine is the evaluation of degenera- tive conditions.╇ Integrity of the middle column E.╇ Neurologic status of the patient D. ╇Integrity of the posterior ligamentous complex C. spinal tumors.55â•… Arachnoiditis. various arthritides. What type of spondylolisthesis is shown in the figures below? A.╇ C and D 2. (a) Sagittal and (b) axial T2- weighted images of a patient after L4-L5 laminectomy and instrumented posterior fusion who had had several previous decompressive surgeries.

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therefore. typically are well circumscribed. hematomas. and spondylolisthesis. same. Most clinicians tend to describe disc Explanation: These sagittal (a) and axial (b) pathology using the terms bulge. T2-weighted images show a well-circum- extrusion. but rather by a pseudomeninges of the edges of the disc material beyond the reactive fibrous tissue. that in patients with spinal tumors. The diagnosis of discitis and osteomy- The presence of the bilateral pars defects elitis may be confirmed with a CT-guided indicates that this is an isthmic spondylolis. B STIR (b) images has its epicenter at the disc Explanation: The lateral radiograph shows space and is. a localized displacement of disc contents beyond the borders of the intervertebral disc 5.123 . Migration refers to displacement is usually similar to that of the subarachnoid of disc material away from the site of extru. a vertebral compression fracture is seen in the vertebral body at the site of the fracture 3. with resultant leakage of CSF into the space of origin. most compatible with bilateral pars intraarticularis defects (arrow) discitis and vertebral osteomyelitis. as described by Wiltse et al73. and adjacent vertebral bodies on the sagittal and neurologic status of the patient. protrusion. space. regardless of whether or not there is thecal sac less than do postoperative epidural sequestration. In both of these situations. increased signal seen within the L3-L4 disc ity or potential for neurologic compromise). postgadolinium T1-weighted (a) and sagittal 2. the disc fragment.122 Pseudomeningoceles disc space is greater than the distance be. An extrusion cele because it is surrounded not by arachnoid is present when any one distance between and dura. this type the pathogen and selection of the appropriate is most commonly seen at the L5-S1 level but antibiotic therapy. A tumor at the L5-S1 level with Meyerding grade-1 would more likely “spare” the disc space. biopsy. integrity have the epicenter at the vertebral body. communicate tween the edges of the base or when there with the subarachnoid space. and contain fluid is no continuity between the disc space and that matches the signal characteristics of CSF. there the thecal sac in a patient who has undergone seems to be a high degree of interobserver an L4-S1 laminectomy and instrumentation variability in the use of the first two terms.210 IIâ•…Spine ANSWERS TO COMMON CLINICAL 4. The base is the cross-sectional area of may be an incomplete closure of the dural disc material at the outer margin of the disc opening. these collections usually compress the sion. Explanation: A disc herniation is defined as and the adjacent disc has normal signal. D space. The of the posterior ligamentous complex (stabil. which would enable identification of thesis. Although the scribed fluid collection that does not compress last two terms are often used correctly. Extrusion may be fur. A fusion procedure. and those with tumors tend to bar trauma5: fracture morphology. A pseudomeningocele typi- protrusion is present if the greatest distance cally occurs in a patient who sustains a durot- between the edges of the disc material be. there plane. This beyond the disc space is continuous with disc collection of CSF is termed a pseudomeningo- material within the disc space. omy during an open surgical procedure or in a yond the disc space is less than the distance patient who undergoes resection of an intra- between the edges of the base in the same dural lesion. The increased signal with can also be seen at other levels. C in patients with acute or subacute fractures. and sequestration. disc space. which is homogeneous and has low signal ther classified as sequestered and migrated. D QUESTIONS Explanation: The pattern of vertebral body involvement in patients with vertebral 1. D osteomyelitis should be differentiated from Explanation: The Thoracolumbar Injury Clas. Given material is completely discontinuous with the that the pressure within a pseudomeningocele parent disc. and the sagittal T2-weight. intensity on T1-weighted images and high Sequestration is noted if the displaced disc signal intensity on T2-weighted images. tuberculous infection would likely do the ed MR image shows the spondylolisthesis. Patients sification and Severity Score has recognized with vertebral osteomyelitis tend to have the importance of the following three factors the epicenter of the pathologic change at the when evaluating a patient with thoracolum. where disc material displaced operative site and posterior soft tissues.

they must have an 4. Gokaslan Spine tumors are traditionally classified by anatomic Chapter Outline location into three compartments1–6: I.14 In addition. followed by the paravertebral region. A. Multiple Myeloma roots. Wasserman. Bruce A. and the epidural space. Neuroblastic Tumors tate. As systemic therapies for a.3. Ependymoma and Low-Grade Astrocytoma to have metastatic (rather than primary) disease in B. nerve 1. lung. Extradural Tumors • Intramedullary A. Sciubba. D.8 Tumors of the Spine Daniel M. Metastatic Disease The extradural compartment consists of all structures B. Zadnik.6 Metastases can occur in any compartment 3. Hemangiopericytoma the cervical spine and sacrum (10%). and Ziya L. 7.9–13 Pros- 1. Aneurysmal Bone Cyst nicate effectively with neurosurgical colleagues. although B. Angiolipoma lesions. Osteosarcoma/Osteogenic tancy of such patients has increased. Osteochondroma provide comprehensive patient care and to commu- 6. Meningioma and intradural compartment. Hemangioblastoma the vertebral body (rather than in other locations) C. Osteoblastoma of the extradural compartment. Although or- thopedic surgeons most commonly manage tumors 3. including the osseous structures. Giant Cell Tumor understanding of the other two compartments to 5.7–9 Such lesions oc- 3.14 Epidemiologic data suggest that most patients IV. Chondrosarcoma metastatic disease have improved and the life expec- b. Specialized Pulse Sequences and Imaging • Extradural Protocols • Intradural–extramedullary II. followed by the lumbar spine (20%) and then E. most lesions within 2. Osteoid Osteoma musculature). Intramedullary Tumors with suspected spine tumors are eventually shown A. Up to 40% of patients with cancer develop visceral c. Patricia L. especially 4. Chordoma cur mostly in the extradural compartment. Vertebral Hemangioma the paravertebral region (including the paraspinal 2. the incidence Sarcoma of metastatic spread to the spine has also increased. Malignant Peripheral Nerve Sheath Tumor ~70%). Sarcomas in the osseous structures. Other Tumors most common site of osseous metastases. Although a large number of primary lesions may occur in the spinal cord. Primary Benign Tumors outside the dura. Summary 211 . but the vertebral body is the III. epidural space. and the spinal column is the D. and osseous spine. Lymphoma of the spinal column. 1. Ewing Sarcoma or osseous metastases. dura. Schwannoma all segments of the spine can be affected. Intramedullary Metastases V. Solitary Bone Plasmacytoma the spine are metastatic tumors. Neurofibroma sions occur most often in the thoracic spine (rate. Primary Malignant Tumors as primary or metastatic. such le- C. and breast cancer account for most of such 2. Eosinophilic Granuloma Spine tumors also are classified by type of origin C. Intradural–Extramedullary Tumors site most commonly affected (~85% of occurrences).

nerve roots. medical history. The compartment location of the lesion in the most disorders of the spine. including spine tumors. etc. niques that permit identification of the compartment though these steps may often lead the clinician and the MRI appearance of the most common tumors Table 8. CT present in pediatric patients often are extreme. medullary. Such a meticulous yielding precise anatomic detail of osseous compression evaluation not only guides the type and loca.). the following steps are fol. Such localization may provide a narrowed tumors and metastatic lesions in the spine. instrumented spine (usually with stainless steel or 3. the previ.1. such tial diagnosis based on patient demographics as the intervertebral discs. or invasion of neural and paraspinal structures. lowed rigorously when reviewing imaging studies. gery. me- and clinical characteristics. the initiation of a proposed treatment plan (sur- agnosis of a spine tumor. the ideal method back pain should be assumed to be a symptom. For this most any age. of evaluating a patient with a suspected or known atic spinal metastasis until proven otherwise. the working diagnosis based on current imag- partment of the spine and in men or women of al. tumors that scopic or CT myelogram for optimal evaluation. The patient’s demographic information and titanium). vides superior resolution of soft-tissue structures. rather than merely suggest. In addition. MRI is limited in its detection In this way. ing techniques is not always accurate. radiographs and/or CT imaging with MRI. in resolution of calcification in areas within or around patients with a history of cancer. which may prohibit accurate assessment clinical presentation are used to narrow the of neural compression and necessitate a fluoro- differential diagnosis. imaging serves to corroborate or of calcifications and small osseous fragments6 and is refute. radiation therapy. spinal cord. tion of such imaging but also provides substan. it is still imperative that. Although most lesions have particular reason. a role in obtaining a definitive diagnosis before to arrive efficiently and effectively at the correct di.20. and paraspinal musculature. or MRI) can be used to narrow This chapter describes image interpretation tech- the differential to a working diagnosis.21 This in- differential diagnosis. intradural–extra. and symptoms (Table 8. or intramedullary) must be identi. it should be noted that malignant) can occur within any segment and com. neck pain or soft-tissue structures. and neurologic signs provides clarity at the osseous–soft-tissue interface. also provides superior osseous detail and permits ly rare in adults and vice versa.15–19 spinal column (extradural. subject to metal-induced artifact when used in the ously hypothesized differential diagnosis. Despite this excellent anatomic and soft-tissue tial insight as to the true underlying pathology. CT.2 MRI is the preferred imaging modality for evaluating 1.1). The clinician generates a preimaging differen. MRI is more sensitive than conventional radiographs. CT. or bone scans in detecting primary malignant bone fied. Various imaging modalities (conventional ra. MRI age. Al. image-guided or open biopsy often has identifying characteristics. however. spinal mass involves a combination of conventional 4. creased sensitivity results from the fact that MRI pro- 2. For instance. sex. Therefore.1â•… Differential diagnosis of spine lesion by anatomic compartment† Compartment Malignant Benign Nontumorous Growths Extradural Metastases Hemangioma Myeloma Aneurysmal bone cyst Lymphoma Giant cell tumor Ewing sarcoma Osteoid osteoma Osteosarcoma Osteoblastoma Chordoma Osteochondroma Leukemia Eosinophilic granuloma Chondrosarcoma Intradural extramedullary Metastases Nerve sheath tumors Lipoma Malignant nerve sheath Schwannoma Epidermoid tumors Neurofibroma Dermoid Meningioma Arachnoid cyst Hemangiopericytoma Paraganglioma Intramedullary Astrocytoma Astrocytoma Metastases Hemangioblastoma Ependymoma .212 IIâ•…Spine and that metastatic and primary lesions (benign and to the correct diagnosis. diographs. In addition. chemotherapy. depiction. such as patient ninges.

13. followed by primary sarcoma. lineate epidural and paraspinous soft-tissue involve- sions. Hodgkin disease. with tases with cord compression. followed by primary benign tumors of the spine. and germ cell tumors. ■⌀ Specialized Pulse Sequences Pedicle and Imaging Protocols Exiting MRI protocols vary widely among institutions and in n. The dura often appears to be draped and neuroblastoma.16. but they usually involve the lower thoracic and lum- Metastatic Disease bar spine because of the higher proportion of red bone marrow in those locations. Tumor origin in Dura Cord cient creation of a differential diagnosis (Table 8.7 Spinal metastases in the adult can occur at any level. enhancing lesions in the epidural space are better seen with fat suppression. melanoma.4 Autopsy studies reveal vertebral metastases ment. and frac. On the other hand. the hallmark of such lesions is focal dis.22–24 Gadolini- um enhancement often provides improved anatomic detail of spinal tumors and may supply signature clues to the underlying pathology.1â•… An artist’s sketch (posterior oblique view) depicts unless hemorrhage is suspected. facilitating the systematic and effi.28 The spinal column is the most common site of os. soft-tissue masses are metastases (Fig.20. over the mass. multiple myeloma.27 malignant tumors of the spine. dura are displaced. and spine.8. the MRI protocol for any patient suspected of having a spine tumor should include T1-weighted and T2-weighted images and gadolinium-enhanced studies in the axial and sagittal planes.22 Because of the high signal intensity of fat within an adult’s marrow on T1-weighted images.2 Similarly. the initial site of metastatic tumor nign extradural masses are degenerative and traumatic growth in the spine typically is the posterior ver- lesions. and the most common extradural spine disease because of its unparalleled ability to de- malignant spine tumors in adults are metastatic le. renal cancer.€8.28 Conversely. causing circumferential cord compression.€8. metastatic tumors in children This chapter discusses extradural neoplastic lesions of typically invade the spinal canal via the neural fo- the spine. and prostate cancer. 8.† may be helpful in distinguishing benign and patho- logic compression fractures. and adjacent soft tissues. Gradient-echo sequences are not as useful in assessing spine tumors Fig. root relation to the spinal region involved. In adults. Imaging patterns of such lesions can reveal focal . ramina. fat-suppression techniques are useful in evaluating osseous lesions that enhance with contrast. with solid malignant tumors develop spinal metas- placement of the thecal sac away from the mass. both malignant and benign. bral body (arrow) into the extradural space. with 5% of adults presenting with epidural spinal cord compression. in up to 40% of patients with systemic cancer.26 ■⌀ Extradural Tumors Most spine metastases in adults arise from lung. metastases most often are caused by Ewing sarcoma nal cord (Fig.4 pedicle. tebral body. followed less frequently Extradural masses typically arise from the osseous by lymphoma. The depicted mass extends from the verte- stricted diffusion in a vertebral body with a tumor. 8â•… Tumors of the Spine 213 in each location. The spinal cord and diffusion-weighted imaging. The most common malignant extradural rhabdomyosarcoma. MRI is the method of choice for imaging metastatic seous metastases. the characteristics of an extradural mass. breast. followed by the epidural space and tures. osteophytes.8 Approximately 5% of children With MRI.7. followed by osteogenic sarcoma.1) vertebral body for any spine tumor evaluated with MRI.1).2).25 Consultation with a neuroradiologist generally is advisable for the selec- tion of the ideal imaging protocol. sarcoma. Despite such variation.10. which often reveals re. such as disc herniations. particularly in the lumbar spine in which the epidur- al space is composed primarily of fat. spine an obliterated subarachnoid space and compressed spi.4 The most common be.27 In such cases. intervertebral discs.2.

29.to hy. it may exhibit aggressive growth. lytic. combined with hancement36 (Fig. creased signal intensity on both T1-weighted and T2- tures than with osteoporotic fractures. 8.2) that help dif- lesions tend to be hypointense on both T1-weighted ferentiate them from malignant lesions.16.33 This benign vascular tumor of the ver- MRI also may be useful for distinguishing benign. MRI sequences of the typical (fatty) hemangioma tense on T1-weighted images and more hyperintense on show lesions that are hyperintense on T1-weighted T2-weighted images than are normal vertebral bodies. although the signal pattern can be variable and depends on the degree of fatty marrow.32. (b) Non- small-cell lung cancer metastasis to the upper thoracic spine with epidural extension. osteoporotic fractures from pathologic. diffusion-weighted images. focal blastic/sclerotic.€8. and Primary Benign Tumors diffuse inhomogeneous lesions. Loss of vertebral body height is noted (arrow). making them difficult to .€8. Diffuse homogeneous and inhomogeneous lesions are hypointense on T1- weighted images and hyperintense on T2-weighted Vertebral Hemangioma images. ment of the spine have characteristic MRI findings perintense on T2-weighted images (Fig.24.3). Contrast en. tumor-related can be associated with vertebral body collapse and fractures. with robust contrast en- Additionally.4. on signal intensity identical to that of neighboring normal rare occasions. often shows one of the very few spinal tumors that show in- more extensive restricted diffusion with pathologic frac.2 The identifica. such lesions are more tion of epidural or paraspinal soft-tissue involvement is vascular and may appear isointense or hypointense also helpful for confirming a pathologic etiology.25. axis tumor. Vertebral hemangioma is the most common spinal hancement of such lesions is extremely variable as well. images and T2-weighted images.31. Sclerotic and patient demographics (Table 8. weighted images. (a) Prostate metastasis (arrow) to the thoracic spine with epidural extension.2╅ Sagittal T2-weighted images of extradural metastatic lesions reveal compression and distortion of the underlying dura and spinal cord in two different patients. on T1-weighted images. diffuse homogeneous.30 The most com- mon pattern seen is multifocal lytic lesions.4).31 and T2-weighted images.32 Benign fractures typically have marrow epidural extension with spinal cord compression.21.34.214 II╅Spine a b Fig. often discovered incidentally on imaging. Vertebral hemangiomas are apparent diffusion coefficient mapping. which are Benign primary tumors of the extradural compart- hypointense on T1-weighted images and hypo.35 vertebral bodies. Pathologic fractures are more hypoin. tebral body. Occasionally.

eggshell-like rims Eosiniophilic granuloma Vertebral body T > L. Abbreviations: C. T. Table 8. L > C Most common All Bright on T1-weighted image Osteoid osteoma Neural arch L. 8â•… Tumors of the Spine 215 a b Fig. arch. (a) A sagittal T1-weighted image shows a hypointense lesion occupying the L3 vertebral body. MRI is the best modality for bone.37 MRI.or isointense on T1-weighted .5 tion” pattern on sagittal images. S Rare <20 Fluid-fluid levels. S Uncommon <30 Expansile. T > L. as a result of the cm in size. sacral. Cysts. thoracic. C Rare <15 Vertebra plana Source: This table was published in Diagnostic Neuroradiology. and most occur within the lumbar spine. transverse C > > T. and tumorlike lesions of the spine and spinal cord. T. usually <1. fol- promise of aggressive lesions.2â•… Benign primary tumors of the extradural compartment Lesion Location in Spinal Incidence Age Imaging Clue Segment Segment (years) Hemangioma Vertebral body T. thoracic distinguish from metastases. Copyright Elsevier (1994).33 for detecting and characterizing these lesions than is Multiple lesions are seen in 25% to 30% of patients. L Rare in spine 5 to 30 Mushroom-shaped processes Aneurysmal bone cyst Neural arch C. Almost all of these lesions involve the neural characterizing the epidural extent and cord com. 8. Osborn AG (ed). lytic. Adapted with permission. is often surrounded by a ring of sclerotic thickened trabeculae. This benign. C > T Common 10 to 20 Target lesion <2 cm Osteoblastoma Neural arch C > L. vascular Osteochondroma Spinous. The nidus is hypo. tumors. 876–918. (b) The disease extent is more evident on this sagittal fat-suppressed T2-weighted image. cervical.3â•… Lumbar spine metastasis from breast carcinoma. Although such lesions lowed by the cervical. S. lytic >2 cm Giant cell tumor Vertebral body S > > C. L Uncommon 20 to 50 Expansile. Although CT images Osteoid Osteoma show the typical “polka dot” appearance on axial im- ages and the typical “corduroy” or “jailhouse stria. L. lumbar. osteoid-producing tumor. primarily involve the vertebral body. and sacral regions. 10% to 15% have Bone scintigraphy and CT are generally more helpful concomitant involvement of the posterior elements. T.

possess atypical features and behave aggressively.5 cm). the classic “polka dot” appearance of the vertebral body is noted.43–45 Occasionally.. The lesion is hypo. osteoblastomas dynamic sequences (e. these lesions originate in with such imaging. are similar histologically to osteoid osteomas enhancement is variable. fluid–fluid levels are Osteoblastomas. articular pil- port severe nighttime pain. they may be centered in the pedicle.€8.or isointense on T1-weighted images and iso. pain as opposed to the intense night pain caused by tern. images and varies from hypo. (>1. serial postcontrast images).4â•… Lumbar vertebral hemangioma.to hyperintense on but are differentiated from them largely by size T2-weighted images. 8.45 The surrounding reactive zone enhances more slowly Like osteoid osteomas. with extensive peritumoral edema (flare phenomenon). is best seen on osteoid osteomas. related to muscle spasm.6). with infiltration into the anterior epidural space divided by a cleavage plane formed by the midline septum (arrow). often with surrounding hyper. This spinal hemangioma is somewhat atypical in that there is in- volvement of the posterior wall and extension into the spinal canal. also known as giant osteoid osteo. Contrast mas. Of note. This asymptomatic lesion is centered in the vertebral body and appears hyperintense on (a) T1-weighted postcontrast and (b) T2-weighted sagittal images (arrow on each). with extension into the vertebral body. up to 70% of patients may the neural arch but exhibit greater mass expan- present with scoliosis. (c) On axial T2-weighted imaging. Most heman- c giomas remain confined to the vertebral body.5).41 Patients often re.42 lar. typically located within the nidus.44 .38–40 The rapid enhancement pat.216 IIâ•…Spine a b Fig. Clinical symptoms also can help to dis- intensity that likely is related to a local inflammatory tinguish these lesions: osteoblastomas cause a dull response (Fig.or hyperintense on Osteoblastoma T2-weighted images. often present within the lesion (Fig.€8. concavity on the side of the tumor.4 Thus.g. lamina. or pars interarticularis. with sion. transverse or spinous process.

plasmacytoma. bone cyst. 8â•… Tumors of the Spine 217 a b Fig. and/or cystic cavities with fluid–fluid lev- Giant cell tumors are locally aggressive. and sacrococcygeal teratoma in children. aneurysmal on T2-weighted images (Fig. corresponding to sclerotic bone. corresponding to the osteoma c (arrow). (b) An axial T2-weighted image reveals a hypointense cen- ter (arrow). Contrast enhance. surrounded by a region of high signal intensity. blood.€8.32.to hyperintense signal includes giant cell tumor. MRI shows risk of recurrence. tumors.46 Hemorrhage is common secondary to the must be monitored with MRI or CT because of the hypervascular stroma of these lesions. 8. It is important to note that the dif- expansile lesions with hypo. chordoma. lytic tumors els. and metastases in adults ment often is heterogeneous.7). (a) An axial CT myelo- gram image shows the characteristic hyperdense center with sclerotic rim (arrow). commonly surround.to isointense signal on ferential diagnosis of midline tumors in the sacrum T1-weighted images and iso. Giant Cell Tumor ing areas of necrosis. blood degradation products.5â•… Right-side cervical osteoid osteoma.46 and therefore patients with these tumors tology. corresponding to reactive edema.14 . (c) On 3D CT reconstruction. the osseous outgrowth.47 Such lesions can undergo sarcomatous transfor- in the vertebral body and sacrum and are named for mation (10% of cases) to become malignant giant cell the osteoclast-like giant cells that are present on his. is seen.

5. .6â•… Left-side cervical osteoblastoma. 8.218 IIâ•…Spine a b c d Fig. 8.7â•… Sacral giant cell tumor. Axial (a) precontrast and (b) postcontrast T1-weighted images show a lesion similar to (but larger than) the osteoid osteoma shown in Fig. 8. a b Fig. The lesion shows heterogeneous contrast enhancement with infiltration into the epidural space. (c) An axial T2-weighted image also shows the lesion. (d) A sagittal CT reconstruction highlights the osseous destruction and expansion associated with the osteoblastoma in the spinous process (arrow). This expansile lesion shows heterogeneous enhancement on (a) a coronal postcontrast T1- weighted image and high signal intensity on (b) an axial fat-suppressed T2-weighted image.

commonly with exten. Multiple Myeloma pear as central hyperintense lesions surrounded by hypointense calcified cortex. focal lesions appear in the vertebral bodies MRI is the preferred imaging modality for measur. hypercalcemia.60–62 Such lesions are lytic. cell histiocytes.8). although visual. the posterior breakdown products (Fig. which usually have early pedicle involvement. Only 5% of weighted images but present with variable intensity these growths occur within the spine (compared on T1-weighted images. Ver. with low to intermediate signal intensity on T1- ing the cartilaginous cap and determining the sta. T2-weighted images reveal heterogeneous to be motionless for a few minutes before imag. precede multiple myeloma by several years.50 The cartilaginous Multiple myeloma is the multifocal. plana). This lytic lesion of the vertebral body classically nous exostosis. nonos. metastatic. tiple myeloma usually involves the pedicle late in the course of disease. Postgadolinium enhancement is often pres- for malignant transformation to chondrosarcoma. mul- ating for fractures. epidural space. The classic presentation is a bal. vertebral body. T1-weighted images reveal a solitary lesion lated neural arch masses.58 Compared with other metastatic lesions. confirming the contiguity of the nal levels. A substantial propor. leaving fractures associated with soft-tissue masses and a thinned “eggshell” cortex. they are located mostly in the cervical spine. and tense compared with muscle and can show curvilin- adjacent vertebral bodies and ribs. and neural compression is ization of these levels often requires the patient varied. or fibrous dysplasia. Multiple myeloma also is revealed on CT may be used for evaluating the osseous struc. ing. the lesions appear as lobu. which occurs with such lesions. the absence of oth- toma.€8. destructive.59 Clini- tion of aneurysmal bone cysts are associated with cal differentiation from multiple myeloma requires preexisting osseous lesions.to isointense on T1-weighted images systemic presentation of a solitary bone plasmacyto- and iso.57 Like solitary bone plasma- and exhibits peripheral enhancement of cartilage. a biopsy-proven solitary lesion. elements are involved. signal within the lesion with focal hyperintensities.51–55 They anemia. Contrast enhancement is with 85% in long-bone metaphyses). Contrast enhancement may be present at the Mild to moderate diffuse contrast enhancement is periphery of the tumor and in the septations. The lesions are hyperintense on T2- shaped lesions with cartilaginous caps. such as an osteoblas.or mushroom. particularly at C2. 8â•… Tumors of the Spine 219 Osteochondroma Eosinophilic Granuloma Osteochondroma. er such lesions in the skeleton. and peripheral (rim) contrast enhance- tebral body collapse may occur secondary to the ment is rare. MRI by diffuse marrow involvement at multiple spi- ture of the lesion.or isoin- sion into the vertebral body. On T1-weighted and fractures that may lead to severe collapse (vertebra T2-weighted images. and the absence of sifying fibroma.10). ent (Fig. and renal involvement sug- arise in the neural arch. medullary cavity with the parent bone.€8. they ap. consists of cartilage-covered osse. and evalu. giant cell tumor.to hyperintense on T2-weighted images ma (see next paragraph). On T1-weighted and T2-weighted images. in the spine in one third of patients. and they appear hyperintense on T2-weighted Thickening of the cap (>1 cm) should raise concern images.64 . centered in the vertebral body that is hypo. and cap is hypo. and often accompanied by compression loon-like expansile remodeling of bone.49 These lesions and consists of a benign proliferation of Langerhans grossly appear to be cauliflower.49 cytomas.63 Scanning of the entire skeleton is man- extensive vertebral body destruction associated datory to identify a secondary lesion. chondroblastoma. common.14 These lesions most commonly arise from the spinous and transverse processes. In most cases. but when they robust.4.€8. presents with a single collapsed vertebral body ous protuberances with a medullary cavity that is (vertebra plana) in patients <10 years old (Fig.48.46. weighted images compared with normal bone mar- tus of regional neural and musculoskeletal tissue.14 Aneurysmal Bone Cyst Solitary Bone Plasmacytoma These lesions are expansile benign neoplasms containing thin-walled cavities filled with blood Solitary plasmacytoma presents as a mass of mono- and blood products that occur most commonly clonal plasma cells from bone or soft tissue and may in patients <20 years old. but most extend into the gesting systemic myeloma. row.14.56 do.9) contiguous with the parent bone. 51 Intratumoral ear low-signal areas and/or cortical infolding caused cysts contain fluid–fluid levels secondary to blood by end-plate fractures. Primary Malignant Tumors but they also may arise from the vertebral body. also known as osteocartilagi.

65 Chordomas compared with intervertebral discs and CSF. 8. The more common type.or isointense (compared with marrow). (Fig.67 . Sagittal (a) T1-weighted and (b) T2-weight- ed images of the sacrum show a large T1 hypointense tumor with multiple cysts containing fluid–fluid levels indicative of blood breakdown products. Contrast-enhanced images range from tebral body (15%). size at discovery.€8. (c) A 3D CT reconstruction (posterior coronal view) shows osseous destruc- c tion of the sacrum secondary to tumor growth. followed by lumbar and thoracic These malignant tumors arising from notochord areas. spinal canal. soft tissues. lesions are hyperintense and is termed chondroid chordoma. Chordoma bodies. known as cent vertebrae. Chordomas often are several centimeters in remnants typically present in one of two histo. is composed of lobules and discs.4.14 For lesions within the vertebral contrast blush to robust enhancement. STIR or fat-suppressed T2-weighted im- ly at the sacrococcygeal (50%) and sphenooccipital ages can help in defining borders with neighboring (clival) (35%) areas and less commonly in the ver.11). sec- present as lytic. but they are found more common. surrounding paravertebral soft tissues.8â•… Aneurysmal bone cyst.220 IIâ•…Spine a b Fig.65 are hypo.66. On T1-weighted images. usually involve two or more adja- logic patterns. destructive lesions arising in the ondary to the high intratumoral mucin content. midline of the spinal column at any location from and are septated by low-signal fibrous bands clivus to coccyx. a cervical location (particularly at C2) is most common. the lesions tracytoplasmic vacuoles and abundant mucin. and extend into the intervertebral a typical chordoma. which contain in. The less common type contains cartilaginous foci On T2-weighted images. and sheets of physaliphorous cells.

well-circumscribed.† Fig. 8. The diagnosis of multiple myeloma can be confirmed by correlation with CT imaging and also with urine and serum protein electrophoresis. In this case. 8. 8â•… Tumors of the Spine 221 Fig. high-signal-intensity lesions through- out the lumbar spine. a b . Note the associated kyphotic deformity.10â•… Multiple myeloma.9â•… A sagittal T2-weighted image of an eosinophilic granuloma shows the typical finding of a vertebra plana (arrow). (a) Mid-sagittal and (b) parasagittal T2- weighted images of the lumbar spine show multiple. there is also an epidural mass that displaces the spinal cord.

lytic tumors of chondrocytes are vertebral body or sacrum. primarily in the posterior spinal elements. woven osteoid and can occur as primary Neuroblastic Tumors tumors or as malignant degeneration in individuals with Paget disease. 4% occur in the spine and sacrum. myeloma. or bone infarcts.71 have imaging characteristics similar to those of os- teomyelitis. can occur as primary tumors or as malignant tion rather than extensive bone loss. The spine is a rare site for Ewing sarcoma. Sarcomas on all pulse sequences. Because Ewing sarcoma is histologically a small. 8. which are derived from These tumors present primarily in the vertebral bod. sarcoma.222 IIâ•…Spine a b Fig. secondary to matrix miner- alization (Fig. all of which involve the spine only occasionally.68.69 Chondrosarcomas are hypo. and tissue. irradiated bone. weighted images may show fluid–fluid levels. (b) The lesion appears mostly hypointense with focal regions of hyperintensity. and Ewing sarcoma. can cause cortical disruption.41 Usually centered in the These malignant.72 These malignant. On T2-weighted intensity in areas of hyaline cartilage and low inten. it usually represents a metastatic tumor from another site of origin. noncalcified soft- mas. all of which do not enhance with metastatic neuroblastoma. lymphoma. Primary fibrosarcomas Ewing Sarcoma of the spine are extremely rare. In addition. Ewing sarcoma often causes characterized by the formation of cartilaginous ma. images. Ewing sarcoma may also contrast (Fig. aging study for delineating extension of soft-tissue ages are helpful in delineating soft-tissue invasion. mass. exist as a spectrum ranging from ies. similarly to patients with Langerhans cell histiocytosis. and necrosis. lesions are hyperintense. to intermediate- ments. these lesions into surrounding soft tissues.72.70 and ~5% occur bone marrow.€8.73 In the telangiectatic form.14 T2-weighted images reveal high signal despite extraosseous tumor spread. When it Chondrosarcoma does occur. Other Tumors blasts are characterized by the formation of im- mature. and can extend tissue mass.75 On T1-weighted images. commonly with extension into the posterior ele. neural crest cells.€8.to isointense compared with surrounding can occur wherever cartilage exists. round cell tumor. Contrast-enhanced images show strong enhance. it can be radiographically identical ment of the septa with “ring and arc” patterns that to primitive neuroectodermal tumors. and the cortex usually is preserved in the spine. these lesions have an extraosseous. to the most .13). T2- Primary sarcomas include chondrosarcoma. Langerhans delineate areas of hyaline cartilage. and typically have focal areas of low signal differentiated ganglioneuroblastomas. T1-weighted im.74 Fifty percent of degeneration of osteochondromas and enchondro. a “moth-eaten” or permeative type of bone destruc- trix. osteo. lytic tumors of osteo. cystic mucoid cell histiocytosis. leukemia.11â•… This (a) axial fat-suppressed T2-weighted image of a sacral chordoma reveals a hyperintense lesion that has extended into the pelvis and left gluteal muscles.12). the most benign ganglioneuromas. patients with Ewing sarcoma Osteosarcoma/Osteogenic Sarcoma may present with vertebral body collapse. MRI is the ideal im- sity in areas of mineralized matrix. These embryonal tumors.76 Of all primary osteogenic sarcomas. likely repre- senting hemorrhage or mucinous material on an axial T1-weighted image.

78 . (b) The lesion is hyperintense on an axial postgadolinium. 8. malignant neuroblastomas.12â•… These axial (a) precontrast and (b) postcontrast T1- weighted images show an exophytic. 8â•… Tumors of the Spine 223 a b Fig.to isointense on T1-weighted almost exclusively in patients <10 years old and al. (a) An axial T1-weighted image of a left-side osteosarcoma of the sacrum and ilium.to hyperintense on T2-weighted most exclusively as abdominal or thoracic paraspinal images. Contrast enhancement var- ral foramen. within vertebral bodies. images and hypo. found to be a chondrosarcoma.14).13â•… Osteosarcoma. ies but often surrounds areas of internal hemorrhage gies and compressing the spinal cord (Fig. a b Fig. creating dumbbell-shaped morpholo. cauliflower-shaped lesion. fat-suppressed T1-weighted image with a central hypointense.4 The lesions are nal masses. These tumors present The lesions are hypo. 8. Although classically they present as paraspi- masses with intraspinal extension. arising from the lateral mass of C2.77. cystic/necrotic area. or necrosis. they may appear as metastatic lesions typically large and extend through a widened neu.€8. (c) The c lesion shows the “ring and arc” pattern on an axial T2-weighted image.

16).to hypointense areas around T2-weighted images.84 may provide added detail because these tumors can MRI is ideal for defining the spinal compartment calcify. but spinal cord on T1-weighted images and hyperintense it generally has high signal intensity.14 sions do not show vascular flow voids. Osse- These benign lesions of adipose and vascular ele. Interestingly. most lesions are compared with the spinal cord on T1-weighted and hyperintense with iso. Intramedullary masses show prominent vascular components. however. of such masses.83 Only 3% to 4% of all malig. they rarely present in an intramedullary lo. non-Hodgkin lymphoma is far more Most of these tumors are slow growing. Angiolipoma often isointense or hyperintense compared with the spinal cord.€8.15). but with the spinal cord on T1-weighted images and . The lesion is hyperintense compared with muscle.224 IIâ•…Spine a b Fig. with a diag- heterogeneous enhancement. Nerve sheath tumors (schwannomas and (most common). In the spine. These lesions may destroy adjacent bone in the anterior epidural space. the lesions are isointense compared isointense on T1-weighted images and variable. and based on the dura mater.€8. Classic MRI findings include Lymphoreticular neoplasms present with variable a widened ipsilateral subarachnoid space in which imaging manifestations within the spine.85 tramedullary (least common). Leptomeningitic cation.86 Classically. osseous structures. not primary le- sions arising in the spine. Epidural lesions are ity.81. intense on T2-weighted images.to hyper- masses.80 ■⌀ Intradural–Extramedullary Tumors Lymphoma These lesions arise within the dura but not from within the spinal cord. Therefore. Meningioma nant bone tumors are primary osseous lymphomas. the cord and roots are displaced away from the mass cations of the spine may be affected: epidural space (Fig. benign common than Hodgkin disease. (>95%). and in. (a) An axial T2-weighted fat-suppressed image shows a lesion adjacent to the vertebral body and anterior to the psoas muscle. lymphomatous neurofibromas) and meningiomas account for >80% meninges (within the subarachnoid space). suppressed T1-weighted images with contrast are Contrast-enhanced images show diffuse uniform most useful for defining this lesion and often show enhancement regardless of the location. and >80% of such le. with surrounding edema on T2-weighted images. fat. nostic accuracy of 99%. with sparse intralesional and peripheral enhancement. ous lesions are hypointense compared with normal ments present in the spine primarily as epidural marrow on T1-weighted images and iso.79 Because the lesions are composed of fat and lymphomas result in thickening of the nerve roots. although only rarely in the posterior epidural space.14 Lymphomas of the spine are usually metastatic lesions. MRI is still the ideal imaging modal- within which the tumor resides. on T2-weighted images (Fig. 8.86 CT imaging sions are of B-cell origin. vascular tissues.82 All lo. The lesion may cord thickening that is isointense compared with the appear heterogeneous on T2-weighted images.14â•… Left-side paraspinal ganglioneuroma. (b) An axial postgadolinium T1- weighted image shows the lesion to be isointense compared with muscle. MRI shows heterogeneous signal occasionally with focal nodules. On T1-weighted images. which are isointense intensity. these le.

15â•… Epidural B-cell lymphoma surrounding and compressing the caudal thecal sac in the lumbosacral spine. Contrast- enhanced T1-weighted images show prominent en- hancement. 8. 8. which are usually anterolateral. expanding the canal at S1 (ar- rows).89. Most lesions are solitary and occur most commonly in the thoracic spine Exiting (80%).† T1-weighted images show enhancement that may . the lesion is isointense compared with the nerve roots and fills the spinal canal.16â•… An artist’s sketch (dorsal view) depicts the imaging perintense on T2-weighted images.17).88 Dura Schwannoma These benign neoplasms of the peripheral nerve sheaths are the most common intradural–extramed- ullary masses and appear as well-circumscribed le- sions that may be intradural–extramedullary (75%). 8â•… Tumors of the Spine 225 a b Fig.87. (b) On a sagittal postgadolinium T1-weighted image. Focal areas of hypointensity occur in the presence of calcifications or flow voids.€8. sometimes with a broad-based dural attachment (dural “tails”). (a) On a sagittal T2-weighted image.† Spinal cord iso. meningiomas Tumor are usually located dorsal to the cord. completely extradural–paraspinal (15%). such as widening of the neural foramen or vertebral scalloping. Postgadolinium characteristics of an intradural–extramedullary mass.to hypointense lesion rela- tive to the spinal cord that may be associated with adjacent osseous erosion. the lesion (arrows) shows robust enhancement. most schwannomas are hy- Fig.4 T1-weighted images often show an iso.90 In con- trast to meningiomas. followed by the cervical spine (16%) and lum- n. root bar spine (4%).88 Compared with nerve sheath tu- mors. or intra- and extradural (dumbbell-shaped).to hyperintense on T2-weighted images (Fig.87.

the le- bromatosis type II should be considered. or rim-enhancing • Optic glioma around cystic areas (Fig. but when these lesions occur at neurofibroma on imaging occur in an individual with multiple concurrent sites. rofibromatosis type I mas than with neurofibromas. peripheral • Short-segment thoracic scoliosis or kyphosis nerves. showing cord displacement and widening of the ipsilateral CSF space. characteristic of intradural– extramedullary lesions. not schwanno- mas.17â•… Cervical meningioma.92 Even when isolated.226 IIâ•…Spine a b Fig.18). the lesion is slightly hyperintense compared with the spinal cord. Hemorrhage and cys. 8. lesions. heterogeneous. and end organs and are divided into malignant • Axillary or inguinal freckling schwannomas and neurofibrosarcomas.€8. Addition- Neurofibroma ally. Approximate- • Café-au-lait spots ly 50% to 60% are associated with neurofibromatosis . neurofibromas on T2- weighted images often have a peripheral area of high These benign neoplasms of the peripheral nerve signal intensity surrounding a central area of low to sheaths can present as focal. the diagnosis of neurofi- characteristics of neurofibromatosis type I.† be homogeneous. these lesions are usually associated with neurofibromatosis type I. (a) A coronal postgadolinium T1-weighted image shows a widely dural-based lesion (arrow) that enhances and is hyperintense compared with the spinal cord. and unlike schwannomas. Neurofibromas have MRI characteris- lack a cystic component. • Lisch nodules (hamartomas of the iris) of neu- tic degeneration are more common with schwanno. diffuse. or plexiform intermediate signal intensity known as a target sign. neural plexuses. Solitary lesions are Therefore. (b) On a sagittal T2-weighted image. They can undergo transformation to malig- Also unlike schwannomas. neurofibromas typically nant tumors. but they often occur as multiple lesions in a patient with the stigmata of familial neurofibromatosis91: Malignant Peripheral • Vertebral anomalies Nerve Sheath Tumor • Meningoceles • Dural ectasia These malignant spindle-cell sarcomas of neural origin • Intramedullary astrocytomas involve the spinal roots. sions are likely to be neurofibromas.€8. if lesions that look like a schwannoma or usually sporadic. tics (Fig.19) similar to those of schwannomas.

type I. these dural-based lesions are hypervas. >95% are ependymomas and low-grade astrocyto- mas.€8. Malignant meningiomas may look similar to tense compared with muscle on T1-weighted images hemangiopericytomas.99 giomas.20). and 30% to 35% of peripheral nerve sheath tumor should be suspected intraspinal neoplasms in children. hemangiopericytomas. soft-tissue masses. these lesions may be difficult to distinguish from 5% to 10% of all central nervous system tumors. but these lesions are very rare.92. Because of this character. ing soft tissue may lead to indistinct margins.95–97 In children. multi- bone and exhibit large soft-tissue components.18â•… Sagittal images of a schwannoma in the lumbar spine.14 More than 90% in the presence of sudden growth in a preexisting of these lesions are gliomas.93 T1-weighted images with contrast and fat hyperintense compared with surrounding fat on suppression show robust. 20% benign spinal schwannomas. more locally aggressive. They most commonly present as large (>5 cm). reveals multilobular masses hypointense on T1- infiltrative.98 The remaining le- sions include hemangioblastomas and metastases. and isoin.14. Therefore. Although radiographically very similar to menin. They often erode and replace adjacent general. resulting in heterogeneous signal. hemorrhagic. schwannoma or neurofibroma. Classic MRI findings show a diffuse. 8. Intradural–extra- medullary masses often may show a dumbbell config. MRI segmental smoothly enlarged cord or filum terminale . homogeneous enhance- T2-weighted images and on STIR images. 8â•… Tumors of the Spine 227 a b Fig. (a) The lesion (arrow on each) is slightly hyperintense com- pared with the cord on a T2-weighted image and (b) shows strong homogeneous contrast enhancement with gadolinium on a T1-weighted image.94 Of spinal cord gliomas. ment. and more prone to ating possible spinal cord tumors and myelopathy in metastasis. T1-weighted images with contrast show sess finger-like processes rather than the lobules of marked enhancement. Infiltration into surround. The lesions are images. however. These lesions of the spinal cord itself account for istic. Hemangiopericytoma astrocytomas are more common. MRI is the diagnostic procedure of choice in evalu- cular. ■⌀ Intramedullary Tumors uration with widening of the intervertebral foramina and erosion of the pedicles. with ependymomas being more common (60%) than astrocytomas (30%). Hem- orrhage and necrosis within the mass may be seen. but meningiomas often pos- (Fig.86 MRI weighted images and hyperintense on T2-weighted is the preferred imaging modality. a malignant of intraspinal neoplasms in adults.

.19â•… Multiple thoracolumbar neurofibromas. 8. Sagittal (c) T2-weighted and (d) fat-suppressed T2-weighted images show hyperintense le- sions. Sagittal T1-weighted images show isointense lesions (a) precontrast that (b) enhance postcontrast. (e) Axial T2-weighted image shows foraminal widening e by bilateral neurofibromas (arrows).228 IIâ•…Spine a b c d Fig.

most specifically ependymomas. or cyst-like cavities within the cord. often in a nodular.101 Ependymomas more commonly have Fig. 8. root Low-Grade Astrocytoma Tumor Ependymomas and low-grade astrocytomas appear nearly identical on MRI. in which the hyper- intense CSF signal is contrasted against the less intense cord signal. the lesion (arrow on each) is (a) hyperintense on an axial fat-suppressed T2-weighted image and (b) isointense on an axial T1-weighted image.102–104 Because . The mass diffusely enlarges weighted images that appears in areas of hemosid. peripheral. which • Contrast-enhancing most commonly occur in the cervical spine. or eccentric to the canal in a longitudinal orientation (Fig.100 Widening of the cord secondary to infiltration and syringomyelia are most Dura obvious on T2-weighted images. teristics of an intramedullary mass.20â•… Right-side sacral malignant peripheral nerve sheath tumor.† mass with gradual surrounding subarachnoid efface- Spinal cord ment. T1- weighted images usually reveal lesions that are iso.or hypointense relative to the surrounding spinal cord (Fig. or heterogeneous pattern.” referring to a focal hypointensity on T2.21). such lesions typically pos- sess high signal intensity on T2-weighted images. 8â•… Tumors of the Spine 229 a b Fig. the cord over multiple spinal segments. Such lesions usually are located in the cervical and/or thoracic spinal cord. A helpful tool for learning to identify intramedullary spinal cord tumors. extending within the central canal of the cord. intramedullary tumors gener- ally show robust enhancement. tumor necrosis. is recalling the five Cs: • Central within the cord • Cervical in location Unlike cellular or mixed ependymomas. Many lesions are associated with syringomy- elia.€8. Ependymoma and Exiting n.23. Additionally.22). myxo- • (Associated with) cysts papillary ependymomas most often occur in the • Cap sign conus medullaris and filum terminale.† erin at the cranial or caudal margin of the tumor. or cyst formation has occurred.100 Mixed-signal lesions are seen if hemorrhage (more typical of ependymomas).23. With the adminis- tration of contrast.€8. Compared with muscle.21â•… An artist’s sketch (dorsal view) depicts the charac- a “cap sign. 8.

. A syrinx also extends cranially from the lesion. which is seen as a thin sliver of low signal intensity surrounding the lesion. 8. Sagittal (a) T2-weighted and (b) STIR images show a large cervical ependymoma centered at C4-C5 but with abnormal cord signal extending from C2-C7. (d) An axial T2-weighted image shows that the lesion is located within the spinal cord. Note the hypointense hemosiderin “cap” (arrows on each). (c) A sagit- tal T1-weighted image shows that the tumor is located at C4-C5 and that the abnormal cord signal change extending below the lesion is secondary to the formation of a septated syrinx (between arrows).230 IIâ•…Spine a b d c Fig.22â•… Cervical ependymoma.

cauda equina. 8â•… Tumors of the Spine 231 these lesions typically are slow growing. (b) Sagittal and (c) axial T1-weighted postcontrast images reveal robust enhancement of the lesion (arrow on b). with a large conus le. 8. the there is no widening of the cord at the level of the neural foramina also may be enlarged. Although derived from the filum. (a) A sagittal T1-weighted precontrast image shows a hypointense lesion (arrow). although these lesions grow from ependymal images creates a meniscus-like sign around the le- cells of the conus and filum. (d) A sagittal T2-weighted image shows the lesion (arrow) is heterogeneously hypointense. CSF signal on T2-weighted ingly.€8. . Therefore. Interest.23). they most commonly appear body scalloping is common.23â•… Myxopapillary ependymoma of the lumbar region. making them intra. a b c d Fig. vertebral medullary in origin. epen- dymomas in this segment of the spine reside in the intradural–extramedullary compartment. like intradural–extramedullary masses because sion that fills the entire lumbosacral thecal sac. sion (Fig.

Hemangioblastoma Hemangioblastomas typically appear as highly vas- cular nodules within the subpial compartment. it displays soft-tissue structures at a higher cluded in the differential diagnosis include autoim. edema out of propor- tion to a focal. and melanoma. cause symmetric cord expansion. gen- sociated with an enhancing tumor. tumors. resolution than other modalities. whereas benign erating a preimaging differential diagnosis. Fig.108 Primary malignancies accounting fied into extradural. ous extradural compartment. spine tumors are traditionally classi- even if isolated. paragangliomas often show promi- nent foci of high-velocity signal loss (“flow voids”). show contrast enhancement. and arteriovenous malformations. Its unparalleled abil- mune or inflammatory myelitis. Tumor and the spinal column is the most common site of os- cysts are smaller.14 Most spinal cord metastases are localized to the pia mater.107 When a spinal hemangioblastoma is suspected on MRI. and do not diagnosis. and MRI almost always shows prominent flow voids (Fig.84 On MRI.24). robust homogeneous contrast enhancement within the tumor nodule is the rule.232 IIâ•…Spine Paragangliomas are rare tumors that most com- monly present in the cauda equina.24â•… A sagittal postgadolinium fat-suppressed T1- weighted image of a cervical hemangioblastoma reveals a small. and In 20% of patients. Although primary lesions carcinomas. incorpo- cysts are rostral or caudal to the tumor. intradural–extramedullary. and using various imaging modalities. Proper diagnosis of spinal tumors positioned within the cord. have smooth rating patient information to narrow the differential walls.106 Because of the highly vascular nature of such lesions.22. Multiple le- sions can occur in the presence of von Hippel–Lindau syndrome. often eccentrically seous metastases. small cord lesion suggests metastasis. cord ischemia or ity to delineate epidural and paraspinous soft-tissue infarction. representing only 4% to 8. In addition.110 MRI is the preferred imaging modality for spinal Other lesions of the spinal cord that must be in. they lie closer to the surface of the cord than do ependymomas and astrocytomas. most lesions within the spine are first presentation of cancer for the patient. it is advisable to image the entire central nervous system to exclude multiple lesions. those associated with intramedullary tumors. these lesions are typically seen as well-defined areas of intense enhancement after contrast administration. involves identifying the compartment location. or for such lesions are most commonly lung and breast intramedullary locations. and almost always as. Anatomically. with rare extensive involvement of the leptomeninges.5% of all central nervous system metas- tases.105 They are as- sociated with extensive cyst formation that diffusely enlarges the cord in up to 70% of patients. in which they appear as a thin rim of enhancement along the cord surface on postcontrast ■⌀ Summary T1-weighted images.4 involvement is particularly useful in the context of .† Intramedullary metastases are rare. corresponding to enlarged feeding arteries and/or draining veins. eccentrically located robustly enhancing tumor nodule Intramedullary Metastases (arrow) associated with a large cervicothoracic syrinx. leukemia. intramedullary metastasis is the osseous spine.109 may occur in the spinal cord.14 metastatic tumors and typically7–9 occur in the osse- MRI with and without contrast can be quite help. thus. where they often are indistinguishable from myxopapillary ependy- momas. 8.€8. dura. Up to 40% of patients ful in distinguishing benign cysts or syrinxes from with cancer develop visceral or osseous metastases. nerve roots. Because of their high degree of vascularity. referred to as leptomeningeal heman- gioblastomatosis. lymphoma. more irregular.

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