European Journal of Radiology 84 (2015) 757–764

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

How to image patients with spine pain

R. Siemund a , M. Thurnher a,b , P.C. Sundgren a,∗
a
Department of Diagnostic Radiology, Institution of Clinical Sciences Lund, Lund Univeristy, Lund, Sweden
b
Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria

a r t i c l e i n f o a b s t r a c t

Article history: Different radiological methods play an important role in the work-up of patients complaining of spine
Received 13 June 2014 pain. Depending on the symptoms and the suspected underlying etiology different methods are selected.
Accepted 24 June 2014 In the following presentation we briefly present the different radiological and magnetic resonance tomo-
graphy methods that are at hand, give some guidance in which method to use, and present the typical
Keywords: imaging findings in some of the most common conditions that presents with spine pain.
Computer tomography
© 2014 Elsevier Ireland Ltd. All rights reserved.
Magnetic resonance imaging
Spine imaging
Spine injury

1. Introduction 2. Radiological imaging methods

Different radiological methods play an important role in the
work-up of patients complaining of spine pain. The causes for
spine pain vary including for example degenerative changes, spinal
stenosis, disk herniation, synovial cysts, traumatic injuries, bone
lesions secondary to metastatic disease or primary bone tumors
that might cause pain and postsurgical treatment failure with
remaining pain. Depending on the symptoms and the suspected
underlying etiology different methods are preferred. In general
computer tomography (CT) is the method preferred when eval-
uating the bone structures of the spine while MRI of the spine
are the method of choice for evaluation of the spinal cord, liga-
ments and lesions in the spinal canal and for demonstration of
widespread degenerative changes in the spine. Several interven-
tional procedures are also performed under fluoroscopic guidance.
In the following presentation we briefly present the different radio-
logical and magnetic resonance tomography methods that are at
hand, give some guidance in which method to use, and present the
typical imaging findings in some of the most common conditions
that presents with spine pain.
∗ Corresponding author at: Department of Diagnostic Radiology, Institution of
Clinical Sciences, Lund Univeristy, SE 211 85 Lund, Sweden. Tel.: +46 46 173032;
fax: +46 46144165.
E-mail address: Pia.sundgren@med.lu.se (P.C. Sundgren).
2.1. Plain film
Conventional radiographs of the spine have a very limited role
in the work-up of patients with back pain. On the other hand, plain
films might still have a value to evaluate the bony structures of the
spine in combination with CT or MRI of the spine and fluoroscopic
guidance are often needed when performing some interventional
spine procedures such as kyphoplasty and vertebroplasty. Fluoro-
scopic guidance can also be used for injection of steroids and local
anesthesia in foramina and facet joint in patients with spinal pain
conditions.
2.2. Computed tomography (CT)
When assessing the bony structures of the spine, CT is the exam-
ination of choice. The choice of imaging parameters determines
the image quality and the radiation dose. Overall the image quality
and the diagnostic performance depend on the choice of imaging
parameters and also of the post-processing such as reconstruc-
tion algorithm and reformatting parameters. High kV and mAs
settings, thin collimation, and low pitch result in the best image
quality. In general, thin slices with reconstruction in soft tissue- and
bone algorithms should be performed, followed by 3D reformat-
ting in sagittal, coronal, and axial planes [1]. In trauma patients the
multi-trauma protocols is an established imaging protocol today.
To reduce the high radiation dose to the patient there is a rapid
increase of different so-called “low dose protocols” by improve-
ments of the CT scanners and development of dose modulation- and
new reconstruction techniques that decrease the radiation dose to
the patient without sacrificing image quality.

http://dx.doi.org/10.1016/j.ejrad.2014.06.021
0720-048X/© 2014 Elsevier Ireland Ltd. All rights reserved.

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758 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764

Fig. 1. (A and B) CT-myelogram of the thoracic spine: CT-myelogram performed in 55 year old female with continuous thoracic pain after a resection of thoracic lesion. Despite
the hardware causes some artifacts the kinking of the thoracic cord can be well seen on the CT-myelogram (A) compared to the fluoscopic image (B) obtained after the
injection of contrast media.

2.3. Myelography and myelo-CT
Myelography (perimyelography) is an old established tech-
nique. Even if not used as frequent anymore due to MRI it is still a
valuable method for assessing nerve root compression in the lateral
recess and neural foramina [2], for assessing spinal canal stenosis,
and allows for dynamic imaging sequences, including positional
changes of the patient and thereby provides valuable diagnostic
information beyond the limits of conventional MRI. In addition, CT
myelography is very useful in the evaluation of postoperative spine,
with fewer artifacts related to surgical hardware than MR imaging
(Fig. 1). Furthermore, myelography or myelo-CT is the only method
to evaluate patients in which MR imaging is not possible for safety
reasons (e.g. pacemaker, metallic objects, etc.), in patients with
severe kyphoscoliosis. A recent study has also shown that myelog-
raphy combined with myelo-CT is “more reliable and reproducible
than MRI” when deciding the level on which decompressive lum-
bar surgery should be performed [3] and better evaluate the degree
of the spinal stenosis [4,5].
2.4. Magnetic resonance tomography (MRT)
the vertebral bodies than T2-weighted images, T1-weighted sagi-
ttal and axial images after contrast administration are needed when
the clinical question is spinal tumor, infectious, demyelinating or
inflammatory disease and in post-surgical patients, especially, if
they are evaluated for recurrent disk herniation versus scar tis-
sue. More recent new imaging techniques like diffusion weighted
imaging (DWI) and perfusion (PWI) have been suggested to be
helpful in detection and differentiation of benign from patho-
logical vertebral body compression fractures [6–9]. In patients
with pain secondary to suspected vascular lesions such as AVM
or fistula MR angiography (MRA) of the spine might be valu-
able. Reports on the reliability of findings on lumbar spine MR
imaging show overall good inter-and intraobserver agreement in
rating disk degeneration, and good intraobserver agreement in rat-
ing spondylolisthesis, “Modic changes”, facet arthropathy but only
moderate interobserver agreement in rating spondylolisthesis,
“Modic changes”, facet arthropathy [10,11]. Other studies demon-
strated good intraobserver agreement in assessing spinal stenosis
but only moderate agreement in assessing foraminal stenosis and
nerve root impingement [12].

Magnetic resonance imaging is “the method of choice” to exam-
ine the intervertebral discs, ligaments, spinal cord, spinal canal
content and is also valuable in evaluation of the paravertebral
soft tissue. Standard morphological MRI sequences for the eval-
uation of the spine include sagittal and axial T1- and T2-weighted
images, sagittal STIR (short TI inversion recovery) – a sequence that
is less specific but even more sensitive to signal abnormalities in
3. Degenerative spine disease
Degenerative spine changes can cause both pain and motor and
sensibility disturbances depending on type and severity. General
degenerative changes such as reduced height of the interverte-
bral space, osteophytes, sclerosis, Schmorl’s nodes, endplate shape
alterations and calcifications, facet joint disease, and narrowing of

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 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764 759

the spinal canal and the neural foramina can be well demonstrated
on plain radiographs, CT, and MRI of the spine.

3.1. Disk disease and disk herniation

MRI is the best method for the evaluation of degenerative

disk disease, providing primary diagnosis as well as grading the
disk degeneration. Routine morphological sagittal and axial MRI of
the spine T1-weighted and T2-weighted images and post-contrast
enhanced T1-weighted images, if patient is previously operated for
disk herniation, is the “gold standard” for evaluation of degenerated
disk and disk herniation. In addition, it have been suggested that
axial T2* mapping is effective to detect early stages of degenera-
tive disk disease with potential diagnostic benefits [13]. Diffusion
weighted imaging (DWI) might be useful to differentiate degener-
ative endplate changes from infectious changes [14].
There are three main types of vertebral endplate and bone mar-
row degenerative changes. Type I changes of the endplates and
bone marrow demonstrate hyperintensity on T2 images with low
signal on T1-weighted images, contrast enhancement after contrast
administration may occur. These changes are thought to represent
more acute changes of degenerative disk disease. Type II changes
presents with increase on T1-weighted images and iso- to hyper-
intense on T2-weighted images while type III changes present as
hypointense on both T1- and T2-weighted images and correlate
with the sclerotic changes seen on spine radiographs [15].
Degenerative intervertebral disk changes demonstrate devel-
opment of low T2 signal intensity within the disk, vacuum disk
phenomenon manifested as a signal void on both T1-and T2-
weigthed images can occur. A calcified disk typically presents with
absent or low signal on MR imaging but, the calcified disk can be
hyperintense on T1-weighted images depending on the amount of
calcium particulate [16]. Complete or partial annular tears or fis-
sures which either involve the fibers themselves or their insertions
on the adjacent endplates are seen as hyperintense T2 signal just
beneath the annulus fibrosus which normally has a low T2 signal.
Different classification scheme for degenerative changes exists as
the one by Pfirrmann et al. [17].
A disk herniation is defined as extension of disk material beyond
the margins of the disk space and can be considered localized when
less than 50% of the total circumferences of the disk is involved,
or generalized, when more than 50% is involved. A localized disk
herniation is subdivided into focal, less than 25% diameter, or
broad-based, 25–50% of the diameter of the disk [18]. Disk her-
niation can be further subdivided in protruded, i.e. when the base Fig. 2. (A and B) Disk herniation: Sagital (A) and axial (B) T2-weighted images of the
of the herniation is broader than the displaced disk material in any lumbar spine demonstrating a broad-based right paramedian right disk herniation
at the L5–S1 level impinging on the right S1 nerve root.
plane or extruded disk when the base is narrower, in either axial or
sagittal plane, than the displaced disk material (Fig. 2). If the her-
niated disk is separated from its origin it is called a sequestration,
often named as a “free disk fragment”. Posterior and posterolateral is a focal eccentricity of the disk contour, change in nerve root thick-
disk herniations are more common than far lateral, or extraforam- ness due to direct compression by the herniated disk material or
inal disk herniations. MRI is the method of choice to evaluate compressive nerve root swelling or nerve root displacement, and
for disk herniation regardless of location with sensitivity ranging loss of the epidural fat surrounding the nerve root [23].
from 60% to 100% and specificity of 43–97% [19]. Recently, other
sequences such as obligue turbo spin-echo T2-weighted images 3.2. Facet joint disease
[20], 3D high-spatial resolution diffusion weighted MR neurog-
raphy [21], and radiculography through 3D MR rendering using In patients presenting with lumbar facet-mediated pain
conventional spin-echo sequence and 3D coronal fast-field echo standard radiographs is the initial assessment including AP, lateral,
sequences with selective water excitation [22] have been suggested and oblique views. The curved configuration and sagittal orienta-
as additional methods to better evaluate far lateral or extraforami- tion of the lumbar facet joints generally limits the utility of frontal
nal disk herniation. A central and lateral disk herniation can easily and lateral views but the lateral view gives useful information about
be detected whereas a foraminal or far lateral disk herniation are possible pars interarticularis defect, as well as showing facet joint
more difficult to detect and are often overlooked due to the lack of angulation [24]. CT of the spine with reformatted images in sagittal
accurate evaluation of the foraminal and extraforaminal areas on and axial plane with bone algorithms is excellent to demonstrate
routine axial and sagittal images. Typical MRI findings that might degenerative changes of the facet joints, to show central canal
suggest a far lateral herniation with or without foraminal extension stenosis, in grading lateral recess- and neural foraminal narrowing

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760 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764
Fig. 3. (A and B) Synovial cyst and facet joint hypertorphy: Axial (A) and saggital (B)
T2-weighted images of the lower lumbar spine at the level of L4-L5 demonstrating a
large right-sided synovial cyst and increased fluid in the right facet joint. In addtion
facet joint hypertrophy bilaterally. The synovial cyst and the facet joint hypertrophy
casues narrowing of the spinal canal and spinal stenosis at this level.
secondary to facet osteoarthritis with associated so called “wrap
around bumper” osteophyte formations along the capsular attach-
ments of the facet joint. Similar findings of facet joint hypertrophy
as well as increased fluid in the facet joint and thickened liga-
menta flava can be seen with MRI (Fig. 3). A standard MRI-based
classification system for lumbar facet joint osteoarthritis has been
developed by Fujiwara et al. [25]. They also demonstrated that MRI
tends to underestimate the severity of osteoarthritis of the facet
joints, compared with CT.
3.3. Spondylolisthesis
Spondylolisthesis is the term for used for displacement of the
vertebral body either anterior or posterior in relation to an immedi-
ately inferior vertebral body. Degenerative spondylolisthesis most
often occurs at L4–L5 levels where there is a more vertical orien-
tation of the facet joints leading to both displacement anteriorly of
the superior vertebral body and to cranio-caudal facet subluxation
[18].
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3.4. Synovial cysts
Synovial cysts associated with facet joint arthritis and degen-
erative spondylolisthesis have been noted as potential causes of
lower back pain, unilateral radicular pain, neurogenic claudication,
and cauda equina syndrome. These cysts are common intraspinal
extradural masses, located postero-lateral to the thecal sac, most
commonly seen at the L4–L5 region, followed by the L5–S1, L3–4,
and L2–3 segments [26]. Lumbar synovial cysts are more commonly
seen in patients in their 60s with a slight female predominance
[27]. Their MRI signal characteristics are variable depending on the
presence of hemorrhagic debris or calcification within the cysts but
commonly demonstrate hyperintense centers with hypointense
rim on T2-weighted images and hypo/isointense on T1-weighted
images (Fig. 3). CT-arthrography has been suggested as additional
test to document communication with a native facet joint prior to
surgical resection or spinal intervention [27].
3.5. Spinal canal stenosis
The loss of disk height with misalignment of the articular pro-
cesses, increased segmental axial mobility, degenerative changes
including facet hypertrophy with osteophyte formation, ligamenta
flava hypertrophy, facet joint fluid, synovial facet joint cysts as
well as degenerative spondylolisthesis may all cause narrowing of
the spinal canal, especially of the lateral recesses and the neural
foramina. Spinal canal stenosis or foraminal stenosis may result in
compression of the intraspinal or foraminal segments of the nerve
roots and are associated with symptoms that are usually aggra-
vated by spinal posture [28]. Narrowing of the entire spinal canal
is associated with compression of the thecal sac and cauda equina.
According to Emch and Modic the degree of canal narrowing is best
classified in the axial plane and described as either mild (less than
1/3 diameter narrowing of the canal), moderate (1/3–2/3 narrowing
of the canal) and severe (greater than 2/3 narrowing of the canal)
[18]; the same schema can also be applied in grading the degree of
neural foraminal stenosis [29] (Fig. 3).
4. Traumatic spine injuries
The majority of the spinal injuries (60%) affect young healthy
males between 15 and 35 years of age with cervical spine injuries to
be most common. The main cause for spinal injuries is blunt trauma
most commonly due to motor vehicle accidents (48%) followed
by falls (21%), and sport injuries (14.6%). Assault and penetrating
trauma account for approximately 10–20% of the cases. Multi-slice
CT is the initial method of choice when evaluating the cervical
spine for bone injuries after blunt trauma allowing for whole spine
examination in a very short time and fast reformatting of images
in multiple planes allows for better and more exact diagnosis of
bone- and soft tissue abnormalities [30]. With the introduction
of these new CT imaging techniques most trauma centers have
set up dedicated acute (multi-) trauma protocol(s) which include
CT of the brain, cervical spine, thorax and abdomen, with subse-
quent reformatting of images of the thoracic and lumbar spine. A
high resolution CT imaging protocol with reformatted 1.25–2 mm
thin slices in the C1–C2 region, 2–3 mm thin slices in the rest
of the cervical spine and 3–4 mm thin slices in the thoracic and
lumbar spine are typically chosen for axial presentation. Reformat-
ted sagittal and coronal images of the entire spine are produced
from contiguous sub-millimeter (0.3–0.75 mm) axial images, or,
on the older scanners, from thicker slices that have been recon-
structed with overlapping (e.g. at 1.5 mm). Reconstructions shall
always be performed with both bone and soft tissue algorithms.
MRI is the method of choice for assessing soft tissue injuries,
 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764 761

Fig. 4. Osteoprosis and compression fracture: Sagittal CT image of the lumbar spine in
a 67 year old female demonstrating severe osteoprosis and a compression fracture
of the L1 vertebral body with some air/gas in the ventral protion of the compressed
vertebrae and a bony fragment displaced into anterior aspect of the spinal canal. In Fig. 5. Metastsis of spine: Sagittal T1-weighted image of the cervical and thoracic
addtion, mild compression of the upper endplate of the L3 vertebral body and gas spine in a 64 year old female with breast cancer demonstrating multiple metastatic
in the disk L2–L3. lesions in the spine.

diagnostic accuracy in predicting metastatic disease but may be

spinal cord injury, intervertebral discs and ligaments, and vascu-
lar injuries. Any patient who has a persistent neurologic deficit
after spinal trauma should undergo an MRI to exclude instability,
prove/exclude cord- or disk injury in patients with focal neuro-
logical signs, and in those who need pre-operative spinal canal
clearance prior to surgery. In addition, posttraumatic squeals such
as syrinx formation, myelomalacia, cord atrophy or tethering are
typically examined and evaluated with MRI. An acute spinal trauma
MR imaging protocol of the cervical spine shall include 3 mm thick
sagittal T1 (T1W) and T2-weighted (T2W) and short tau inversion
recovery (STIR) sequences and 3 mm thick axial T2*-GRE images
without contrast. In the thoracic and lumbar spine, 4 mm thick sag-
ittal T1W, T2W, and STIR sequences and axial 4 mm thick T1W,
T2W, and T2*GRE images without contrast is recommended. Fat-
saturated T2W images are valuable to evaluate for ligamentous and
soft tissue injuries, and T2* GRE to evaluate for small hemorrhage
or blood products in the spinal cord. Traumatic spine injuries with
undergo surgical treatment rather than radiological interventional
producers in the acute stage, while some chronic post-traumatic
pain conditions can be treated with interventional procedures.
5. Non-traumatic vertebral body compression fractures
Osteoporosis is the most common cause for non-traumatic ver-
tebral compression fractures in the elderly population [31] (Fig. 4).
The differentiation between osteoporotic and malignant fractures
based on clinical and imaging findings is particularly challenging in
the acute setting. Morphological signs, such as complete replace-
ment of vertebral marrow, involvement of the posterior elements,
and epidural or paraspinal masses, can be used to improve the
equivocal [32–34] (Fig. 5). Up to one third of fractures in patients
with known primary malignancy are benign, and approximately
one quarter of fractures in apparently osteopenic patients are due
to metastases.
Nowadays, MRI of the spine is the most common imaging tech-
nique to evaluate compression fractures as the technique allows
for evaluation of the vertebral bodies and the content of the spinal
canal and spinal cord by performing sagittal T1-w, T2-w and FLAIR
images of the whole spine. Some newer techniques like DWI-MRI,
in-phase and out-of-phase gradient echo imaging, and MR per-
fusion have recently been used in the attempt to differentiate
benign from malignant acute vertebral fractures. In the first pub-
lished study benign osteoporotic fractures were hypointense or
isointense on SSFP-based DWI, while malignant fractures showed
hyperintensity [6]. Several other reports have presented similar
findings with the exception for sclerotic metastases and treated
metastases that appear hypointense and give false negative results
[7,8,35–38].
The diagnostic utility of DWI to differentiate benign from malig-
nant acute compression fractures is still controversial, mainly due
to the considerable overlap in ADC values which can in part be
due to different techniques in performing the sequences with or
without fat-saturation. The calculated diffusion coefficients of nor-
mal bone marrow are systematically decreased when fat saturation
is not applied. The use of in-phase and out-of-phase imaging to
differentiate benign and malignant lesions is based on the assump-
tion that malignant lesions completely replace vertebral body fat
whereas in benign lesions fat is still present. A recent study demon-
strated that a signal intensity ratio for in- and out-of-phase images
of >0.8 was able to predict metastatic disease whereas a ratio of <0.8

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762 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764

Fig. 6. (A–D) Aggressive hemangioma: Sagittal (A) and axial (B) CT images demonstrating a compressed, partely destructed, molded vertebral body with pattern of dots
so-called “polka dots”. On sagittal STIR (C) image the lesion is hypterintense. Axial T1-weighted image (D) with contrast shows intense enhancement of the vertebral body
and the associated perivertebral soft tissue which also extends into the spinal canal compressing the thecal sac.

could predict benign compression fractures [39]. A recent study
using vertebral T1 and T2 relaxation times of the fat and water com-
ponents, and ADCs in patients presenting with vertebral lesions
demonstrated significant differences between normal-appearing
vertebral bone marrow and the lesions [40], while the ADCs deter-
mined with a DW-ss TSE technique showed significant differences
between osteoporotic fractures and malignant lesions.
Recently, MR perfusion curves have received some interest
[41,42] and a recent study has demonstrated significant differences
between perfusion parameters like slope and maximum enhance-
ment of benign and malignant fractures but not when using the
time–intensity-curve (TIC) patterns [43].
6. Other bone lesions that might cause pain
6.1. Hemangioma
Vertebral body hemangioma is a benign lesion of the spinal col-
umn and represent 4% of all spinal tumors with an incidence is
10–12% based on autopsy and imaging studies [44,45]. They vary
in size and might be multiple in up to 30% and predominantly
affect the thoracic and upper lumbar vertebral bodies but may
involve the pedicles and rarely the spinous processes or extend
into the soft tissue. Most of the vertebral hemangiomas are asymp-
tomatic. Symptomatic hemangiomas are rare and represent <1%
of all hemangiomas. Typical symptoms are pain, myelopathy, and
radiculopathy due to bone expansion compressing the thecal sac
or the nerve roots [46,47]. Thoracic vertebral hemangiomas are
reported to produce neurological symptoms more often than lum-
bar ones. This is thought to be due to the smaller ratio of the
spinal cord to the spinal canal in the thoracic segment, and the
presence of normal thoracic kyphosis, both of which may facilitate
early compression [48]. Occasionally the hemangiomas may cause
a pathological fracture, especially if aggressive in nature or large
in size, especially if located posterior in the vertebral body and/or
extending into the pedicles.
The vertebral hemangioma has typical imaging features. The
radiographic appearance of a hemangioma is characteristic with
vertical trabeculae with soft-tissue stroma, so-called honeycomb
pattern, and the vertebral body looks molted with less bone den-
sity [49,50]. On CT the hemangioma shows the pattern of multiple
dots so-called “polka dots” representing a cross section of rein-
forced trabeculae, and may demonstrate contrast enhancement
[51]. On MRI the common imaging features of active hemangiomas
are punctate areas of low or isointense signal compared to bone on
T1-weighted images and high signal intensity on T2-weighted MRI
images, whereas, if non-active, they present with high signal on
both T1-and T2-weighted images. Homogenous contrast enhance-
ment after contrast administration is common. Hemangiomas can
sometime be more aggressive with compression of the vertebral
body and associated soft tissue (Fig. 6). Conventional digital angiog-
raphy will demonstrate the vascular nature of these lesions. The
management and treatment of symptomatic hemangioma vary and
include kyphoplasty, embolization or surgical stabilization.

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 R. Siemund et al. / European Journal of Radiology 84 (2015) 757–764 763

Fig. 7. (A and B) Myeloma: Sagittal T1-weighted and T2 weighted MR images of the cervical and thoracic spine in a 70-year-old male with myeloma. Multiple focal lesions
and diffuse bone marrow involvement with decreased bone signal intensity on T1 weighted images iso- or hypointense to the intervertebral discs (A) and more patchy mixed
pattern on the T2-weighted image (B).

6.2. Multiple myeloma
Multiple myeloma is a low-grade non-Hodgkin’s B-cell lym-
phoma arising from a monoclonal proliferation of malignant
plasma cells in the bone marrow. Multiple myeloma is behind
metastases the second frequent neoplastic disease in the spine.
Spinal involvement is present in about two thirds of patients with
this disease and can be diffuse, tumorous or both. Plasmocytoma
represents the solitary, focal form of this disease without evidence
of systemic spread.
Pain due to altered bio-mechanic vertebral stability or patholog-
ical vertebral compression fractures are a common primary clinical
presentation of multiple myeloma. Neurological deficits can occur
due to compression of nerve structures by bone fragment disloca-
tion and/or epidural tumor components.
Early stages of multiple myeloma can easily be overseen on
radiographic images if significant destructions or compression frac-
tures are absent. Due to its usually low osteoblastic activity multiple
myeloma can neither reliably be detected by scintigraphy.
On CT multiple myeloma presents as osteoporosis with multi-
focal lytic lesions, which can increase, to larger destructions of the
vertebral structures.
MRI is the preferable modality in imaging of multiple myeloma
as it above skeletal destructions also depicts bone marrow involve-
ment and extra-osseous components. The common features are
multiple focal lesions with low signal intensity on T1-weighted
images and high signal on STIR/T2-weighted images. The diffuse
bone marrow involvement is characterized by general decrease of
the bone signal intensity on T1 weighted images iso- or hypointense
to the intervertebral discs or can occur as a micro-nodular pattern.
In advanced stage disease and following treatment cases the pre-
sentation can change to a patchy mixed pattern (Fig. 7). Contrast
administration yields beside better characterization of the extra-
osseous no significant information [52].
7. Summary
Imaging has an important role for detection of underlying causes
for spine pain. CT and MRI being the most used imaging modali-
ties for detection and differentiation of spine lesions. MRI and CT
are more commonly used prior to and after surgical procedures
whereas CT and fluoroscopic imaging are the tools used during the
interventional procedures.
Conflict of interest
None of the authors have any conflict of interest.
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