Lumbar Anatomy and Imaging

Brad Goodman, M.D.

OrthoAlabama
Spine Intervention Society
Lumbar Hands-On Lab
Spain, 2018
Disclosure
 Acknowledgements
• Images / illustrations contributed by:
• Nik Bogduk, MD
• Charles Aprill, MD
• Cryomicrotome sections: Wolfgang
Rauschning
• Deepest gratitude to our devoted SIS staff,
those assisting us on-site, and all those who
do the work to organize these courses
 Vertebral Enumeration
Carrino Radiology 2011:
– 24 vertebral segments 92%
– 23 vertebral segments 5%
– 25 vertebral segments 3%
– 7 cervical vertebra is a constant
– > 10%: anomalous number or
distribution of thoracolumbar
segments
– Transitional segments at LS
junction: 15%;TL junction : 4%
 Vertebral Enumeration
Carrino, Radiology 2011
• Presence of transitional LS segment strongly associated
(7 fold) with anomalous number of vertebral segments
• L5 cannot be identified in isolation by purely anatomic
markers
• Transitional LS segment: variation in radicular
distribution, alteration in sclerotomal innervation
patterns
• Counting must occur from skull base, but C-T is
practical alternative
– Entire spine MRI scout view
– Radiographs
– Fluoroscopic observation: count from
up-sloped T1 transverse process
Castellvi Classification of Transitional
Lumbosacral Segments Spine 1984
• Type I: Dysplastic
Transverse Process 42%
• Type II: Incomplete
Sacralization 38%
• Type III: Complete
Sacralization 8%
• Type IV: Mixed 5%
7% with complete
Lumbarization of S1,
25 vertebral
segments
 Transitional Lumbosacral Segments

AP: Expanded transverse processes; pseudo-articulation

Lateral: Narrow, rudimentary disc; parallel endplates; bridging bone
Midline Sagittal
Sagittal: Neural Foramen
Coronal: Neural Foramen
 Lumbar Radiographs
True AP: center spinous True lateral: superimpose
processes between pedicles iliopectineal (pelvic) lines
 sap

tp

sp

L3 usual apex of
lumbar lordosis

© N Bogduk 2012
 Spine Motion Segments
Articulations

Discovertebral Complex
• Nuclear compartment
– Absorbs axial load, disburses it radially
• Annulus
– Constrains nucleus
• Cartilaginous endplate
– Constrains annulus, accepts load, transmits
nutrients
The Intervertebral Disc
L1-L4 discs posterior
annulus: concave
L5 disc posterior
annulus: convex

Loss of T2
hyperintensity in the
nucleus is age-related
change only, present in
50% of 21 year olds
Endplate Inflammatory Change
Modic Classification

Modic I Modic II Modic III

 High Intensity Zone (HIZ)

Focus of T2 hyperintensity in posterior

annulus
Enhancement, implying vascularization
 Discogenic Pain
Internal Disc Disruption
• Diagnosis by strict SIS criteria for provocation
discography
• Imaging predictors: in a population with
suspected discogenic pain:
– Modic I or II
• > 25% of vertebral body, + LR = 3.4
• 69% chance of positive disc stimulation
– High intensity zone
• + LR = 4
• 73% chance of positive disc stimulation
 The Lumbar Zygapophyseal Joint
• Paired, planar or curved synovial
joints between inferior articular
process (IAP) and superior
articular processe (SAP)

• On axial images the IAP is

dorsomedial, SAP is ventrolateral

• In the axial plane, the joint

surfaces may be:
– Straight
– C-shaped
– J-chaped
 Facet or Zygapophyseal Joint
L3 SAP

SAP

IAP

IAP

•Curved (coplanar) joint: an x-ray beam will “see” a joint space

over a wide arc; most posterior joint seen with least obliquity
•Obliquity of joint increases L1 through L5
 Facet Joint Imaging
Morphologic imaging evidence of osteoarthritis has no
correlation with pain
Physiologic imaging
T2 hyperintensity: edema
Gadolinium enhancement: hypervascularity, leaky capillaries
SPECT: hyperemia and increased bone turnover
Conceptually appealing, but no validation against MBB
Poor correlation between SPECT/CT & MRI
Lehman, et al Comparison of Facet Joint Activity on 99mTc-MDP SPECT/CT
with Facet Joint Signal Change on MRI with Fat Suppression ISIS ASM 2014
 Ligamentous Structures of the Lumbar Spine

•Anterior Longitudinal
Ligament (ALL)
•Disc
•Posterior Longitudinal
Ligament (PLL)
•Posterior Ligamentous
Complex
Ligamentum flavum
Facet joint capsule
Interspinous
ligament
Supraspinous
ligament
 Spinal Stability: 3 Column Model
Denis, Spine 1983

•Anterior Column: ALL, anterior

fibrous annulus, anterior vertebral
body
•Middle Column: PLL, posterior
fibrous annulus, posterior
vertebral body
•Posterior Column: posterior
bony arch and posterior
ligamentous complex
•Failure of two columns results in
instability
 Anatomic Spaces
• Subarachnoid space (thecal
sac)
– Neural tissue, CSF
• Subdural extra-arachnoid
space
– Split within dura, not a
potential space Subdural, extra-
• Extradural or epidural space arachnoid injection
– Fat, venous plexus, ventral
median raphe, traversed by
spinal nerve
• Paraspinal space Epidural
lipomatosis
– Musculature, lumbar plexus
 Subarachnoid Space

Normal myelogram, subarachnoid space Mixed subarachnoid,

epidural injection
 L2 L3

Subarachnoid Space

L4 L5

•Numerous rootlets contribute to each dorsal & ventral root, which will comprise
the spinal nerve
•There is spatial organization in the thecal sac: most distal rootlets reside in the
most central and dorsal thecal sac, they coalesce and move ventral & lateral as they
prepare to enter the root sleeve to exit under the pedicle
 Subdural Extra-arachnoid Space

Mixed subdural and subarachnoid injection

Note denser contrast, sharp margination to the
subdural component
Epidural Space
•Prominent venous plexus
•Normal enhancement of
venous plexus, basivertebral
veins
•Ventral epidural space is
prominent at L4, L5
•Ventral epidural
space divided by
central plicae
 Mid-Sagittal & Foraminal Zone MRI

T2 T1 T2 T1
T2 Weighted Axial Images,
Mid-Lumbar
T1 Weighted Axial Images,
Mid-Lumbar
CT Axial Images
Mid-Lumbar
Contiguous T2 MRI Images L5
L5 DRG

S1 Root
Contiguous Myelo CT Images L5
 Disc Herniation Nomenclature
Fardon, et al Lumbar disc nomenclature: version 2.0: recommendations of the combined task
forces of the North American Spine Society, the American Society of Spine Radiology, and the
American Society of Neuroradiology. Spine (Phila Pa 1976) 2014; 39 (24): E1448-65.

Bulge: Generalized extension of disc material > 25% of

disc circumference, < 3mm beyond apophysis
Herniation: Localized displacement of disc material
beyond ring apophysis < 25% of disc circumference
Protrusion: width of displaced disc material, in any
plane, does not exceed its base
Extrusion: width of disc material exceeds its base or
aperture in any plane
Sequestration: Loss of continuity with parent disc
Migration: displacement from parent disc
Disc Herniation Nomenclature
 Zones
Disc & Levels Nomenclature:
Herniation of the Spinal Canal
Location
Disc Protrusion

54, M right posterior thigh, calf pain

MRI: right central disc protrusion
Right S1 TFESI
 Disc Extrusion
25 M L5

Left S1 radiculopathy

Left L5 central &

subarticular
extrusion with
caudal migration of
disc material
S1

Note ñ T2 signal in
extruded disc
 Foraminal Disc Extrusion
Foramen: evaluate on
L3
sagittal CT or MRI
Neural Foramen:
Teardrop shaped
Stenosis causes:
Disc extrusion
Osteophytes
Synovial cyst
Spondylolisthesis
(spondylolysis)
L3 foraminal extrusion (arrow)
displacing the L3 DRG
posteriorly (curved arrow)
 Sequestration

T2
T1
T1+C
Right S1 radiculopathy
Sequestered fragment, enhancing granulation tissue right
subarticular zone (lateral recess)
Gadolinium has useful problem solving role
 Gadolinium Enhancement
T1 weighted images
– Fat saturation increases
conspicuity
Normal enhancement
– DRG
– Vasculature
– Epidural space
Pathologic enhancement
– Neoplasm
– Inflammation
Sequestration, inflammatory
enhancement

Tissue fills right L4 foramen

Vast majority of the tissue enhances
(inflammatory reaction) about a small disc
fragment
 Disc Herniation:
Contrast

L3

Left hip pain

Enhancing annular fissure
Inflammatory enhancement about exiting L3 root
Chemical Radiculitis
 Anatomic Disc Herniation
Imaging Natural History
•Spontaneous involution of herniated disc
• 50% of conservatively treated disc herniations causing
radicular pain ⇓ by 75% on F/U Saal, Spine 1990
• 65% of conservatively treated herniations ⇓ by 75 -
100% in volume on F/U CT. Largest herniations
showed greatest resolution Maigne, Spine 1992
• 76% of 165 pts with extrusions / sequestrations
showed complete or partial resolution on F/U. 74% of
pts with annular bulges: no change.
• Pts with resolution: younger, shorter duration of
symptoms, highly + SLR Bush, Spine 1992
 Disc Extrusion: Resolution
2006

2010

Resolution of L5 disc extrusion, new L4 disc extrusion

Spinal Innervation
Disc: outer annulus
Sinuvertebral nerve
Grey rami
Sympathetic plexus
Ventral epidural space
Sinuvertebral nerve
Facet, multifidus muscle
Medial branch,
dorsal ramus
Dual level innervation
Longissimus muscle
Intermediate branch, dorsal ramus
liocostalis muscle
Lateral branch, dorsal ramus
 Spinal Innervation: Facet Joint
Dual level innervation
L4-5 facet innervation:
• Medial branch arising
from L3 dorsal ramus
• Medial branch arising
from L4 dorsal ramus
• Medial branch crosses
junction of SAP and
transverse process,
beneath mamillo-
accessory ligament
Lumbar medial branches pass around the SAP
from its inflexion with the transverse process
to the mamillo-accessory notch below the
mamillary process (mp)
 Arterial Anatomy of the Spinal Cord:
Why is this important?
Catastrophic complications: cord
infarction
Embolization of anterior spinal artery by
particulate steroid
Artery of Adamkiewicz
Primary supply to the anterior spinal artery
of the low thoracic cord / conus
Arises typically from a left sided intercostal
or lumbar artery
There is a radicular artery which may
communicate with the anterior spinal
artery at all lumbar levels
Image courtesy of Dr N Murthy
Murthy NS, Maus TP, Behrns CL. Intraforaminal location of
the great anterior radiculomedullary artery (artery of
Adamkiewicz): a retrospective review. Pain Med 2010; 11
(12): 1756-64.
• 83% left, 17% right
• T2-L3
– 92% T8-L1
– 28% at T10
• 97% in upper ½ of
foramen
• Never seen in lower
20% of foramen
Kroszczynski AC, Kohan K, Kurowski M, Olson TR, Downie SA.
Intraforaminal location of thoracolumbar anterior medullary
arteries. Pain Med 2013; 14 (6): 808-12.
• Cephalo-caudal position in foramen
– Upper 1/3 74%
– Middle 1/3 23%
– Lower 1/3 3%
• Anterior-posterior position relative to
DRG-VR complex
– Anterosuperior 54%
– Anterior 41%
– Anteroinferior 5%
– Artery was never found posterior (dorsal)
to DRG-VR complex
 Sacroiliac Joint
Joint volume
Fortin: ave 1.08cc, 0.8 - 2.5cc in patients
Fortin: ave 1.6cc; Dreyfuss ave 1.5cc in
asymptomatic volunteers
Anatomy
Primary axis: posteromedial to anterolateral
Sacral side : Thicker hyaline cartilege
Iliac side : Thinner fibrocartilege
Degenerative changes most prevalent on iliac side
Synovial space makes up 20% of width of perceived
joint, may be obliterated with aging
Communications between joint space and: dorsal sacral
foramina, L5 root sheath, lumbosacral plexus
Sacroiliac Joint
 Sacroiliac Joint

Posterior

Anterior

Medial joint line is posterior

Lateral joint line is anterior
Initial filling of inferior recess
 Sacroiliac Joint

Male, 42
Disabling axial low back, buttock pain
since bilateral hip replacements
Sacroiliac Joint

Note medial position accesses

joint
Thank you for your attention