Golden keys in

Spine imaging

By

Yasser Zakaria Abdel-Aziz

Resident of Radio diagnosis
Damietta Cancer Institute
 Spinal imaging in a simplified way

Damietta cancer institute {DCI}

AL-MANSURA {my lovely city}
My great workplace and proud
of that

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 Contents
Congenital and developmental disorders......................4

Trauma........................................................................60

Degenerative diseases and inflammatory arthritides..103

Infections....................................................................132

Inflammatory & Autoimmune disorders.....................149

Neoplasms .................................................................159

Non-Neoplastic Cysts and tumour mimics....................194

vascular lesions ..........................................................206

Spinal Manifestations of Systemic Diseases ................ 218

Plexus & Peripheral Nerve lesions................................227

Post-Radiation and Chemotherapy Complications.......246

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 Congenital
&develpmental
disorders

Abnormalities of
Neurulation
Chiari 2
Myelomeningocele
Lipomyelomeningocele
Spinal Lipoma

Posterior Element Incomplete Fusion

Dorsal Dermal Sinus
Dermoid and Epidermoid Tumors

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 Chiari 2
 Complex hindbrain malformation of hindbrain virtually 100% associated with
neural tube closure defect, usually lumbar myelomeningocele.

Golden modalities
MRI brain + spine.
Protocol advice
Initial screening MR (brain, spine)
Follow-up for:
• Symptoms of brainstem compression.
• Increasing ventricular size.
• Increasing spinal symptoms.

Golden findings
Presence of myelomeningocele.
Small posterior fossa.
Elongated, "straw-like" 4th ventricle.
Pointed anterior horns of lateral
ventricles.
Beaked tectal plate.

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 Myelomeningocele
 Posterior spinal defect lacking skin covering → neural tissue, CSF, and meninges
exposed to air.

Golden modalities
MRI.
Protocol advice
 Obstetrical ultrasound: Initial
MMC diagnosis, delivery
planning (Caesarian section),
triaging for possible fetal
surgery
 Head CT: Hydrocephalus
evaluation.
 MRI: Sagittal and axial T1WI
and T2WI; must include entire
sacrum.

Golden findings
 Wide osseous dysraphism, Low-
lying cord/roots, post-operative skin
closure changes.
Location
 Lumbosacral (44%) > thoracolumbar
(32%) > lumbar (22%) > thoracic
(2%).

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 Lipomyelomeningocele
 Lipomyelocele = neural placode-lipoma complex contiguous with subcutaneous
fat through dysraphic defect, attaching to and tethering spinal cord.
 Lipomyelomeningocele = lipomyelocele + meningocele, enlargement of
subarachnoid space, displacement of neural placode outside of spinal canal.

STIR
T2 T1

Golden modalities Golden findings

 MRI  Subcutaneous fatty mass
Protocol advice contiguous with neural
 STIR or chemical fat- placode/lipoma through
saturated techniques posterior dysraphism.
confirm fat composition. Location
 Lumbosacral.

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 Spinal lipoma

Golden modalities
MRI
Protocol advice
 Ultrasound in infants for screening;
confirm with MRI if positive.
 Sagittal, axial T1WI to define
lipoma(s) extent and relationship to
neural placode, adjacent tissues.
* Image through tip of thecal sac to
avoid missing fibrolipoma or
terminal lipoma.
Golden findings
 Hyperintense (T1 WI) intradural
mass.
 Real Time: Echogenic intraspinal
mass +/- reduced conus motion.
Location
Intradural:
 Thoracic (30%) > cervicothoracic
(24%) > cervical (12%) >
lumbosacral spine.
 Dorsal (73%) > lateral/anterolateral
(25%) > anterior (2%).
Terminal:
 Lumbosacral.

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Posterior element incomplete fusion

{Spina bifida occulta}

 Spinous process/lamina fusion failure without underlying neural or dural
abnormality.

Golden modalities
 Plain films most economical screening
tool.
 MR best for definitive exclusion of
significant underlying abnormality.
Protocol advice
 Ultrasound for infants with sacral
dimples or other cutaneous stigmata.
 Sagittal and axial T1WI, T2WI best
screen for tethered cord, neural
anomalies.

Golden findings
 Incomplete lumbosacral posterior
element fusion.
Location
 Lumbosacral junction (L5 > S1) > >
cervical (C1 > C7 > T1), thoracic.

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 Dorsal dermal sinus
 Midline/paramedian stratified squamous epithelial-lined sinus tract extending
inward from skin surface for a variable distance.

Golden modalities
 MRI.
Protocol advice
Sagittal and axial T1WI, T2WI:
• Adjust window/level to best
delineate subcutaneous tract.
Ultrasound supplements MR in
infants < 1 year; use MR to confirm
positive ultrasound study.

Golden findings
 Hypointense sinus tract
superimposed on hyperintense
subcutaneous fat.
Location
 Lumbosacral (60%) > occipital
(25%) > thoracic (10%) > cervical
(1%).

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Dermoid and epidermoid tumors
 Benign spinal tumor composed of cells that embryologically comprise skin and its
appendages (hair follicles, sweat glands, and sebaceous glands).

Golden modalities
 MRI.
 CT myelography for patients with MR
contraindications or inconclusive MR
studies.
Protocol advice
 Sagittal and axial T1 WI and T2WI.
 MRI to include entire conus and cauda
equina to coccyx.

Golden findings
 Lumbosacral or cauda equina CSF T2WI
isointense/isodense mass.
Location
40% intramedullary, 60%
extramedullary; extradural rare.
 Dermoid: Lumbosacral (60%), cauda
equine (20%), infrequent in the
cervical and thoracic spine.
 Epidermoid: Upper thoracic (17%),
lower thoracic (26%), lumbosacral
(22%), and cauda equine (35%).
Acquired epidermoid cysts almost
uniformly occur at cauda equina.

T1 fat sat

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 Anomalies of the Caudal
Cell Mass
Caudal Regression Syndrome

Tethered Spinal Cord

Terminal Myelocystocele

Anterior Sacral Meningocele

Occult Intrasacral Meningocele

Sacrococcygeal Teratoma

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 Caudal regression syndrome
 Constellation of caudal developmental growth abnormalities with associated
regional soft tissue anomalies.

Golden modalities
 Consider ultrasound for infant
screening.
 MR imaging to confirm ultrasound
findings, treatment planning
 Sagittal MRI to demonstrate
extent of lumbosacral deficiency,
distal spinal cord morphology, and
presence/absence of tethering.
 Axial MRI to detect osseous spinal
narrowing, hydromyelia, other
associated lesions.

Golden findings

 Lumbosacral dysgenesis with

abnormal distal spinal cord.

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 Tethered spinal cord
 Symptoms and imaging findings referable to low-lying conus medullaris tethered
by a short, thick filum terminale.

Golden modalities
 MRI.
Protocol advice
 Ultrasound < 1 year old; confirm
positive study with MRI.
 Thin-section sagittal, axial T1WI and
T2WI, phase contrast MRI; extend
axial slices to thecal sac termination.

Golden findings

 Conus ends below L2 inferior endplate;

tethered by thickened filum +/-
fibrolipoma, terminal lipoma.

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 Terminal myelocystocele
 Complex spinal malformation → hydromyelic low-lying tethered spinal cord
traversing a meningocele to terminate in myelocystocele.

Golden modalities
 MRI.
Protocol advice
 Sagittal MR imaging for diagnosis and
estimating length of hydromyelia,
sizing cysts, and identifying associated
abnormalities
 Axial MR imaging to clarify extent of
rachischisis, evaluate associated
anomalies.

Golden findings
 Hydromyelic tethered cord
traversing dorsal meningocele
to terminate in a dilated
terminal ventricle cyst.
Location
 Sacrum/coccyx.

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 Anterior sacral meningocele
 Sacral meninges herniate anteriorly into the pelvis through focal erosion or
hypogenesis of sacral +/ coccygeal vertebral segments.

Golden modalities
 MR imaging confirms cyst contiguity with
thecal sac
 T1WI also shows +/- epidermoid,
lipoma/dermoid.
 T2WI demonstrates +/- entrapped neural
tissue.
 CT imaging best depicts osseous defect,
absence of rim calcification.
Protocol advice
 Ultrasound for initial screening during
infancy.
 Sagittal and axial MR imaging to confirm
positive ultrasound studies, pre-operative
planning, and post -operative surveillance.

Golden findings
 Presacral cyst, contiguous with thecal
sac, protruding through an anterior
osseous defect.
Location
 Sacrum/coccyx.

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Occult intrasacral meningocele
 Spinal extradural arachnoid cyst localized to sacrum.

Golden modalities
 Magnetic resonance imaging best
modality for initial diagnosis.
 CT myelography may help reveal
connection between cyst and
subarachnoid space.
Protocol advice
 Sagittal and axial T1 WI and T2WI to
identify cyst, clarify relationship to
adjacent structures.

Golden findings

 Smooth, cystic enlargement of central

sacral canal.

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 Sacrococcygeal teratoma
 Congenital sacral tumor containing elements of all three germ layers.

Golden modalities
 Prenatal: Obstetrical ultrasound +/- fetal
MRI.
 Post-natal: MRI.
Protocol advice
 MRI +/- CT to determine full extent of
mass, treatment planning.
• Sagittal and axial MR imaging for
surgical planning.
• CT with oral/IV contrast to delineate
extent of bone destruction, calcification.

Golden findings
 Large heterogeneous sacral mass in an
infant.

T2 GRE T1 C+ fat sat.

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 Anomalies of Notochord
Development

Diastematomyelia

Neurenteric Cyst

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 Diastematomyelia
 Sagittal division of spinal cord into two hemicords, each with one central canal,
dorsal horn, and ventral horn.

Golden findings
Fibrous or osseous spur splits spinal cord into
two hemicords:
• Split cord and spur often occur in conjunction
with intersegmental fusion.
Location
 Thoracolumbar cleft (85% between T9 and S1) >
> upper thoracic, cervical cleft.

Type 1: Two dural tubes separated by osseous bridge.

Type 2: splitting of distal cord into two hemicords

within single dural tube.

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 Golden modalities
MRI
Protocol advice
Consider ultrasound to screen infants with skin
dimple or cutaneous marker.
MR imaging most definitive:
• Coronal, axial images best demonstrate
hemicords, spur.
• T1WI to evaluate for filum lesions (e.g.,
fibrolipoma), vertebral anomalies.
• T2WI to determine number of dural sacs, +/-
syringohydromyelia.
• T2* GRE to detect spur.
Supplement with bone CT +/- myelography to
optimally define spur anatomy for surgical
planning.
 Sagittal, coronal reformats excellent for
depicting osseous anatomy, extent of spur.

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 Neurenteric cyst
 Intraspinal cyst lined by enteric mucosa.

Golden modalities
 Multiplanar T1 WI, T2WI to assess for
vertebral anomalies, cord
compression, and cyst relationship to
adjacent structures.
 Bone CT/3D CT to characterize osseous
anomalies, surgical planning.

Golden findings
Intraspinal cyst + vertebral
abnormalities (persistent canal of
Kovalevsky, segmentation and
fusion anomalies).
Location
Thoracic (42%) > cervical (32%) > >
lumbar spine, intracranial/basilar
cisterns (rare).

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 Anomalies of Vertebral
Formation and
Segmentation
Failure of Vertebral Formation

Partial Vertebral Duplication

Vertebral Segmentation Failure

Klippel-Feil Spectrum

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 Failure of vertebral formation
 Partial or complete failure of vertebral formation:
 Partial formation failure →wedge vertebra.
 Complete formation failure →vertebral aplasia, hemivertebra, butterfly
vertebra.

Golden modalities
 MRI.
Protocol advice
Long-cassette weightbearing radiographs →
quantitate scoliosis, "counting" to definitively
localize abnormal vertebral level.
Multiplanar T1WI, T2WI MR → identify vertebral
anomalies; evaluate spinal cord and soft tissues.
• Most vertebral and spinal cord anomalies seen
best in coronal, sagittal planes.
3D Bone CT useful to characterize scoliosis and
vertebral anomalies for pre-operative planning.

Golden findings
 Sharply angulated, single curve or focal scoliosis
with deformed vertebral bodies.
Location
 Thoracolumbar most common.

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 Partial vertebral duplication
 Partial duplication of vertebral column produces one or more supranumerary
("extra") vertebra.

Golden modalities

Plain films for counting, quantitating scoliosis.

Multiplanar MR imaging to evaluate vertebral
anatomy, assess for associated abnormalities.
CT with 3D reconstructions – demonstrates
hemivertebra and scoliosis.

Golden findings
 Atypical scoliosis (sharply angulated, single
curve, or focal) with one or more "extra"
hemivertebra.
Location
 Thoracolumbar < cervical.

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Vertebral segmentation failure
 Vertebral column malformations (block vertebra, pediculate bar, neural arch
fusion) resulting from deranged embryological development → failure of normal
segmentation.

Golden modalities
Weight bearing plain films to evaluate scoliosis,
"count" to determine abnormal vertebral levels.
MR imaging:
 Multiplanar T1 WI to evaluate vertebral
anatomy.
 Vertebral anomalies seen best in coronal,
sagittal planes.
 T2WI to evaluate spinal cord pathology,
compression.
CT to characterize osseous structures.
 3D CT useful for pre-operative planning.
Golden findings
 Sharply angulated, single curve or focal scoliosis
with abnormal fused vertebra.
Location
 Lumbar> cervical> thoracic.

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 Klippel-Fell Spectrum
 Congenital spinal malformation characterized by segmentation failure of two or
more cervical vertebra.

Golden modalities
 Radiography to evaluate and follow
instability, degenerative changes
 MRI to exclude cord compression, detect
degenerative change.
Protocol advice
Serial neutral and flex/extend plain radiographs
to detect progressive instability, degenerative
disease
Multiplanar MRI to evaluate canal compromise,
cord compression, soft tissue degenerative
changes
Ultrasound or CECT to detect and characterize
associated visceral organ abnormalitiesbest in
coronal, sagittal planes.

Golden findings
 Single or multiple level congenital cervical
segmentation and fusion anomalies.
Location
 C2-3 (50%) > C5-6 (33%) > CVJ, upper thoracic
spine.

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 Normal Anatomical
Variations
Craniovertebral Junction Variants

Limbus Vertebra

Conjoined Nerve Root

Filum Terminale Fibrolipoma

Bone Island

Ventriculus Terminalis

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Craniovertebral junction variants
 Flattening or malformation of clivus, anterior C1 ring, or odontoid process.

Golden modalities
 Radiography to evaluate and follow
instability, degenerative changes.
 MRI to exclude cord compression & detects
degenerative change.
Protocol advice
 Serial neutral and flex/extend plain
radiographs to detect progressive instability,
degenerative disease.
 Multiplanar MRI to evaluate canal
compromise, cord compression, soft tissue Flattened, bifid clivus
degenerative changes.
 Ultrasound or CECT to detect and characterize
associated visceral organ abnormalitiesbest in
coronal, sagittal planes.

Golden findings
 Single or multiple level congenital cervical
segmentation and fusion anomalies.
Location
 C2-3 (50%) > C5-6 (33%) > CVJ, upper thoracic
spine.

Foreshortened clivus,
platybasia, and a retroflexed
odontoid

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 Limbus vertebra
 Distinct type of cartilaginous node formation.
 Intraosseous disc penetration at junction of cartilaginous endplate, developing
osseous rim apophysis.

Golden modalities
 Plain radiographs usually diagnostic.

Protocol advice
Plain radiographs to establish diagnosis.
MRI helpful (if necessary) to assess for
edema or inflammation in context of acute
symptoms.

Golden findings
 Small corticated bone fragment matching
osseous defect of anterosuperior vertebral
margin.
Location
 Mid-lumbar> mid-cervical.
 Anterior> > posterior.

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 Conjoined nerve roots
 Asymmetric anomalous origin of an enlarged nerve root sleeve containing two
nerve roots.

Golden modalities
Sagittal and axial MR imaging.
 Both T1 WI and T2WI MR needed.
• Sagittal slice prescription must extend
lateral to neural foramina.
• Contrast useful to locate DRG.
CT myelography demonstrates relationship of
root sleeve to osseous structures well.
 Use for inconclusive MR imaging or when
MR contraindications exist.

Protocolfindings
Golden advice
Plain radiographs to establish diagnosis.
 Enlarged root sleeve containing two roots
MRI helpful (if necessary) to assess for edema or
originating midway between expected positions
inflammation in context of acute symptoms.
of two contributing nerve root.
Location
 Lumbar spine> > cervical, thoracic spine
• L4/5 > L5/S1 > L3/4.

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 Filum terminale fibrolipoma
 Asymptomatic presence of fat within otherwise normal size filum terminale.
 No tethered cord, conus normal position.
 Symptomatic patient implies diagnosis of intraspinal lipoma, not asymptomatic
fibrolipoma.

Golden modalities
 MR imaging: T1 WI shows typical fat
appearance, normal conus position and
morphology.

Protocol advice
 Plain radiographs to establish diagnosis.
 MRI helpful (if necessary) to assess for edema
or inflammation in context of acute symptoms.

Golden findings

 Linear fat signal within filum terminale on

T1WI.

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 Bone island
 Asymptomatic focal areas of bony sclerosis.

Golden modalities
 CT: Evaluation of solitary
indeterminate lesion.
 MRI: Evaluation of multiple lesions.

Protocol advice
 Bone scan for definition of solitary lesion
metastasis vs. Bone Island.
Golden findings

 Small focal areas of sclerosis, with brush-

like margins.
Location
 Any bone may be involved:
• Vertebral body or posterior elements
may be involved.
 Most common in pelvis, femur, ribs.

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 Ventriculus terminalis
 CSF signal/density within central spinal cord, canal expansion at conus/proximal
filum level.

Golden modalities
Newborns:
 Ultrasound to screen for congenital
anomalies:
• Distinguish ventriculus terminalis
from syrinx or cord neoplasm.
• Abnormal findings should be
confirmed with MR imaging.
Children, adults, & infants (with positive
ultrasound studies):
 Thin-section sagittal T1WI & T2WI MR
imaging (3 mm slice thickness).
 Axial T1WI & T2WI (4 mm slice thickness)
distal cord to sacrum
• Best to exclude occult dysraphism,
lipoma, or thick filum.
 T1 C+ MR in sagittal, axial planes to
exclude mass.
Golden findings

 Mild cystic dilatation of distal central

spinal cord canal without cord signal
abnormality or enhancement.
Location
 Distal spinal cord, between conus
medullaris tip and filum terminale origin.

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 other congenital and
developmental
abnormalities
Chiari I Malformation
Lateral Meningocele
Dorsal Spinal Meningocele
Neurofibromatosis Type 1
Neurofibromatosis Type 2
Dural Dysplasia
Congenital Spinal Stenosis
Scoliosis
Idiopathic Scoliosis
Congenital Scoliosis and Kyphosis
Neuromuscular Scoliosis
Idiopathic Kyphosis
Schmorl Node
Scheuermann Disease
Thanatophoric Dwarfism
Achondroplasia
Mucopolysaccharidoses
Sickle Cell
Osteopetrosis
Ochronosis
Connective Tissue Disorders
Osteogenesis Imperfecta

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 Chiari 1
 Caudal protrusion of "peg-shaped" cerebellar tonsils below foramen magnum.

 Golden modalities
 MR brain with thin sagittal
views of the craniocervical
junction.
Protocol advice
 Multiplanar T1 WI, T2WI of
spinal axis and posterior fossa,
PC+ MRI CSF flow study.

Golden findings
 Pointed cerebellar tonsils ≥ 5
mm below foramen magnum +/-
syringohydromyelia (14 -75%).

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 Lateral meningocele
 Meningeal dysplasia → CSF filled dural/arachnoidal sac protrudes laterally
through neural foramen.

Golden modalities
 MRI.
Protocol advice
 Consider sonography for newborn screening.
 Follow-up with MRI to clarify positive ultrasound
study.
 MR imaging for diagnosis, pre-operative planning.
 Bone CT to evaluate pedicles, vertebral bodies
(particularly if surgery is contemplated).

Golden findings
 CSF signal/density meningeal protrusion through
neural foramen into adjacent
intercostal/extrapleural space.
Location
 Thoracic> lumbar spine.
 R> L - 10% bilateral
• Bilateral meningoceles nearly always associated
with NF1, but may be seen in Marfan syndrome.

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 Dorsal spinal meningocele
 Dorsal herniation of dura, arachnoid, and CSF into spinal subcutaneous tissue.

Golden modalities
 MR imaging best shows dural sac
characteristics associated vertebral
or spinal cord anomalies.
Protocol advice
 Sagittal and axial T1 WI and T2WI:
• Sagittal images useful to evaluate
cord.
• Axial T1 WI most helpful to
evaluate size of dysraphic defect &
excludes lipoma.
• Axial T2WI best for detecting
nervous tissue within sac.

Golden findings
 Skin covered dorsal dural sac
protruding thorough posterior
osseous defect.
Location
 Anywhere along dorsal spinal canal;
 Lumbosacral junction, sacrum >>
cervical, thoracic.

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 Neurofibromatosis type 1
 Autosomal dominant mesodermal dysplasia characterized by plexiform and
nerve root neurofibromas, spinal deformity, neoplastic and non-neoplastic brain
lesions, and cutaneous stigmata.

Golden modalities
 MRI
Protocol advice
 Radiography to quantitate and follow
kyphosis, scoliosis.
 Multiplanar enhanced MRI (especially STIR,
fat-saturated T2WI and T1 C+ MR) to evaluate
cord, nerve pathology.
 Bone CT to optimally define osseous anatomy
for surgical planning.
Golden findings

 Kyphoscoliosis +/- multiple nerve root tumors,

plexiform neurofibroma, dural ectasia/lateral
meningocele.

Plexiform neurofibroma Optic nerve glioma

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 Neurofibromatosis type 2
 Rare autosomal dominant disease from chromosomal 22 defect in which all
patients develop CNS tumors.
 Mnemonic for NF2 tumors = MISME: multiple inherited schwannomas,
meningiomas, & ependymomas.

Golden modalities
 Contrast-enhanced MR screening of
entire neuraxis (brain, spine).
Protocol adivce

Contrast-enhanced imaging is best method

for detecting lesions regardless of size.
Golden findings

Multiple spinal tumors of various

histologic types.
Location
Schwannomas:
• Intradural, extramedullary; occur
anywhere.
• Rarely intramedullary; arise primarily
or secondarily extend from nerve root
tumor.
• May extend extradurally.
Meningiomas:
 Intradural, extramedullary; typically
involving thoracic spine but occur
anywhere.
 Ependymomas: Intramedullary;
typically upper cervical cord or conus
but occur anywhere.

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 Dural dysplasia
 Patulous dural sac with posterior vertebral scalloping.

Golden modalities
 MRI is most useful modality to exclude
syrinx or tumor as cause of canal
enlargement before attributing to dural
ectasia.

Golden findings

 Smooth "C" shaped scalloping of

posterior vertebral bodies with patulous
dural sac.
Location
 Lumbar> cervical, thoracic.

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 Congenital spinal stenosis
 Reduced AP canal diameter 2ry to short, squat pedicles and laterally directed
laminae.

Golden modalities
 CT with sagittal and coronal reformats to
evaluate osseous structures.
 Narrowed angle of laminae best
appreciated in coronal plane.
 MR imaging to assess degree/presence of
spinal cord, dural sac compression:
 Also demonstrates osseous anatomy
well; permits complete imaging
assessment with a single imaging study.
 Sagittal MR best demonstrates AP canal
narrowing assesses for cord/cauda
equina compression.
 Axial MR images confirm pedicle
configuration, assess severity of canal
narrowing.
Golden findings

 Short, thick pedicles producing narrowed

anteroposterior (AP) spinal canal diameter.
Location

 Lumbar> cervical> thoracic.

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 Scoliosis
 General term for any lateral curvature of the spine.
 Dextroscoliosis: Curve convex to the right.
 Levoscoliosis: Curve convex to the left.
 Kyphoscoliosis: Scoliosis with a component of kyphosis.
 Rotoscoliosis: Scoliosis which includes rotation of the vertebrae.
 S-curve scoliosis: Two adjacent curves, one to the right and one to the left.
 C-curve scoliosis: Single curve.
 Terminal vertebra: Most superior or inferior vertebra included in a curve.
 Transitional vertebra: Vertebra between two curves.
 Apical vertebra: Vertebra with greatest lateral displacement from the midline.
 Primary curvature: Curvature with greatest angulation.
 Secondary or compensatory curvature: Smaller curve which balances primary
curvature.

Golden modalities
 Radiography for initial diagnosis.
Protocol adivce
MRI to screen for bone, cord abnormalities:
• Coronal and Sagittal T1 WI and T2WI.
•Include craniocervical junction.
• Axial T2WI through areas of suspected
abnormality.
• Axial T2WI through conus.
CT for surgical planning:
• 1-3 mm multidetector CT with reformatted
images
• 3D helpful
CT for surgical complications:
• Thin, overlapping sections minimize artifact.
• Bone and soft tissue windows.

43
 Golden findings

 Lateral curvature of the spine which returns

to midline at ends of curve.
Location

 Most commonly thoracic or thoracolumbar.

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 Idiopathic scoliosis
 Scoliosis of undetermined etiology, without underlying bony or neuromuscular
abnormalities.

Golden modalities
 Radiography.
Protocol adivce
MRI should include coronal T1WI or PDWI
to evaluate vertebral bodies.

Golden findings

 Smooth, S-shaped spinal curvature of

thoracic and lumbar spine.
Location

 Thoracic, lumbar most common

 Occasionally involves cervical spine in
addition.

45
Congenital scoliosis and kyphosis
 Spinal curvature secondary to vertebral anomalies.
 Hemivertebra: Unilateral or anterior vertebral hypoplasia.
 Butterfly vertebra: Central vertebral cleft due to failure of central vertebral body
development.
 "Fused" vertebrae: Embryological failure of segmentation rather than fusion.
 Also called block vertebrae; may affect vertebral body, posterior elements, or
both.
 Affected vertebrae narrow in mediolateral and anteroposterior dimensions.
 Rudimentary disc may be present.
 Vertebral bar:
 Bony or cartilaginous connection between adjacent vertebrae
 Often associated with rib fusions
 Klippel-Feil syndrome: Multiple cervical segmentation anomalies.

Golden modalities
Multiplanar MRI best modality to evaluate full
spine in children:
 Avoids CT radiation dose, excludes associated
neural axis abnormalities.
CT preferable for surgical planning in adults
becauseof superior spatial resolution, 3D
rendering capabilities.

Golden findings
Butterfly vertebra.
 Vertebral anomaly in patient with scoliosis or
kyphosis.
Location

 Most common in thoracic spine, but can occur at

any level.

46
 Hemivertebra

Fused vertebrae.

47
 Neuromuscular scoliosis
 Scoliosis due to neurologic or myopathic diseases.

Golden modalities
 Radiography and MR.
Protocol adivce
Sagittal T1WI and STIR, coronal T1 WI
through entire spine including
craniocervical junction.
Axial T2WI images through conus,
syringomyelia (if present).

Golden findings

 Long, single curve scoliosis.

Patient with paraplegia
Location

 Thoracic and lumbar.

48
 Idiopathic kyphosis
 Thoracic kyphosis without underlying structural abnormality.

Golden modalities
 Radiography.
Protocol adivce
 MR or CT to exclude underlying bone
abnormality.

Golden findings

 Thoracic kyphosis greater than

approximately 40 degrees.
Location

 Upper to mid-thoracic spines.

49
 Schmorl node
 Node within vertebral body due to vertical disc extension through weakened
vertebral body endplate.

Golden modalities
 CT & MRI.
Protocol adivce
 Analyze contiguity with parent disc on all
sequences.
Golden findings

 Focal invagination of endplate by disc

material surrounded by either sclerotic
(old), or abnormal (acute) bone.

Location
 T-8 to L1 region most common.

50
 Scheuermann disease
 Kyphosis secondary to multiple Schmorl nodes → vertebral body wedging.

Golden modalities

 Plain film for diagnosis.

 MRI to exclude disc herniations.
Golden findings

 Three or more wedged thoracic vertebrae

with irregular endplate.

Location
 75% thoracic.
 20-25% thoracolumbar.
 < 5% lumbar only.
 Rarely cervical.

51
 Thanatophoric dwarfism
 Lethal short-limbed dysplasia.

Golden modalities

 Antenatal ultrasound.

Golden findings

 Severe dwarfism with narrow chest and

short ribs.
Location
 Entire spine affected.

52
 Achondroplasia
 Autosomal dominant dwarfism affecting spine and extremities.
 Rhizomelic dwarfism; most severe growth disturbance in proximal portions of
limbs.

Golden modalities
 Single AP "babygram" at birth shows skull,
spine, and pelvic abnormalities.
Protocol adivce
 2-3 mm multi detector CT.
 Coronal and sagittal reformations for
surgical planning.
 Axial, sagittal MR through foramen
magnum in all infants and children to
assess for stenosis.

Golden findings

 Interpediculate distance decreases in

caudal direction in lumbar spine (reversal
of normal relationship).
Location
 Spine, skull, pelvis, extremities.

53
 Mucopolysaccharidoses
 Inherited lysosomal storage disorders:
 Specific enzyme deficiency → inability to breakdown specific
glycosaminoglycans (GAG).
 Failure to break down GAG →intracellular accumulation and toxicity.

Golden modalities
 MRI.
Protocol adivce
 Spine MR imaging to elucidate cause/site of
cord compression.
 Plain radiographs to characterize osseous spine
and limb abnormalities
 Flexion-extension radiographs or fluoroscopy to
detect craniovertebral instability.
Golden findings

 Dens hypoplasia, craniovertebral junction (CVJ)

stenosis, and thickened dural ring at foramen
magnum.
Location
 Spine: CVJ, thoracolumbar spine, pelvis.
 Extraspinal: Brain, visceral organ deposition.

54
 Sickle cell
 Hereditary hemoglobin abnormality resulting in anemia, deformed (sickle) red
cells which occlude blood vessels.

• Homozygous: (sickle cell anemia).

• Heterozygous: HbSA (sickle cell trait, asymptomatic), HbSC (less severe form).

 Sickle cell crisis: Acute episode of severe bone, abdomen, chest pain.

Golden modalities

 Radiography.

Golden findings

 H-shaped vertebral bodies.

Location
 Spine: 43-70% of patients.

55
 Osteopetrosis
 Heterogeneous grouping of hereditary osteoclast disorders.

Golden modalities

 Radiography.

Golden findings

 Diffuse increase in bone density.

 "Bone-within-bone" appearance not
pathognomonic; may also be seen in
young children during growth spurts.

Location
 Involves entire skeleton.

56
 Ochronosis
 Deposition of homogentisic acid and its metabolites secondary to absence of
homogentisic acid oxidase enzyme.
 Ochronosis: Abnormal pigmentation caused by deposition of homogentisic acid.
 Alkaptonuria: Homogentisic acid in urine.

Golden modalities

 Radiography.

Golden findings
 Calcified intervertebral discs.
Location
 Lumbar spine> thoracic> cervical.

57
 Connective tissue disorders
 Group of congenital disorders with similar imaging findings.
 Most common types are Marfan, Ehlers-Danlos (EDS), and Stickler syndrome.

Golden modalities
 MRI.
Protocol advice

 Include entire sacrum on sagittal images.

Golden findings

 Dural ectasia.

Location
 Most commonly lumbar spine and sacrum.

Dural ectasia

58
 Osteogenesis imperfecta
 Genetic disorder of type 1 collagen resulting in bone fragility.
 Codfish vertebra: Cupping of superior and inferior vertebral body endplates.
 Terms "congenita" and "tarda" no longer used.

Golden modalities
 Radiography.
Protocol advice

 Low kVp technique to compensate for

osteoporosis.

Golden findings

 Severe osteopenia and multiple fractures.

Location
 Entire skeleton.

59
Trauma

60
 Vertebral Column, Discs,
and paraspinal muscles
Atlanto-Occipital Dislocation
Occipital Condyle Fracture
Jefferson C1 Fracture
Odontoid C2 Fracture
Burst Fracture, C2
Hangman's C2 Fracture
Hyperflexion Injury of Cervical spine
Hyperextension Injury of Cervical spine
Hyperflexion-Rotation Injury of Cervical spine
Burst Fractureof Cervical spine
Hyperextension-Rotation Cervical spine
Lateral Flexion Injury of Cervical spine
Posterior Column Injury of Cervical spine
Anterior Compression Fracture of Thoracic spine
Lateral Compression Fracture of Thoracic spine
Burst Thoracolumbar Fracture
Facet-Lamina Fracture of Thoracic spine
Chance Fracture of Thoracic spine
Distraction Fx of Low Thoracic spine
Anterior Compression Fracture of Lumbar spine
Lateral Compression Fracture of Lumbar spine
Burst Fracture of Lumbar spine
Facet-Posterior Fracture of Lumbar spine
Sacral Traumatic Fracture
Sacral Insufficiency Fracture
Traumatic Disc Herniation
Apophyseal Ring Fracture
Rhabdomyolysis
Traumatic Spinal Muscle Injury
Pedicle Insufficiency Fracture

61
 The Three-column Concept

{ Denis Classification}

 Anterior: ALL, anulus, anterior vertebral body.

 Middle: posterior wall of vertebral body, anulus, PLL.
 Posterior: facets, posterior elements, posterior ligaments.

62
 Atlanto-occipital dislocation
 Disruption of stabilizing ligaments between occiput and C1.

Golden modalities
 CT scan with coronal + sagittal reformations.
Protocol advice

 1 mm helical multidetector CT.

Golden findings

 Widened distance between Odontoid and C1.

63
 Occipital condyle fracture

Golden modalities
 Bone CT for fracture.
 MRI for soft tissue.
Protocol advice

 CT: Thin-section with sagittal, coronal

reformats.
 MRI: Sagittal & coronal STIR.

Golden findings

 Occipital condyle fracture on CT.

With left cerebellar infarction

64
 Jefferson C1 fracture
 Compression fracture of C1 arch.

Golden modalities

 Any lateral spread of C1 pillars on open-

mouth x-ray view requires CT.
 CT bone reconstruction algorithm details
sites of fracture
 Distinguishes well-corticated margins
of congenital clefts from jagged edges
of fracture defect
 Thin-section (1 mm) cuts mandatory,
reformations very helpful.
 Evaluate entire cervical spine (and even
upper thoracic) as associated fractures
occur in 24-48% of cases.

Golden findings

 Lateral displacement of both articular

masses of C1 from those of C2 on open-
mouth radiograph.

65
 Odontoid C2 fracture

Golden modalities
 Plain x-rays (especially lateral, open-mouth
views) initially suggest need for CT.
 Thin-section (1 mm) axial slices with bone
reconstruction algorithm with fastest possible
scan times for optimal reformation into
sagittal, coronal planes
 MRI with T1WI in sagittal/coronal planes (3
mm slices), T2WI in sagittal plane to evaluate
canal size, cord injury
 GRE imaging to detect blood in cord if
myelopathy is present.

Golden findings

 Lateral radiograph shows anterior or posterior

displacement of C1 arch vs. C2, + swelling of
prevertebral soft tissue.

66
 C2 Burst fracture
 Compression injury often with displaced fracture fragments causing cord
compromise.
 Highly associated with hangman fracture.

Golden modalities
 CT Bone.
Protocol advice
 CT: Acquire axially with sagittal & coronal
reformats.
 MRI: Add sagittal STIR & GRE
 MRA: Add axial fat-saturated T1 to evaluate
for luminal hematoma.

Golden findings

 Comminuted fracture of C2 body with

multiple fragments dislocated
anteroposteriorly.

67
 Hangman's C2 fracture
 Bilateral avulsion of C2 vertebral body from its arch.

Golden modalities
 Any anterior subluxation of C2 vs. C3 on
lateral x-ray deserves CT.
 Thin-section (1 mm) cuts mandatory,
reformations very helpful to assess degree of
subluxation, canal status.
 Evaluate entire cervical spine (and even
upper thoracic) as associated fractures occur
in 33% of cases.
 MR if neurologic symptoms are present
 Get MRA, CTA, or conventional angiogram if
fracture line involves transverse foramen.

Golden findings

 Anterior displacement of C2 vb, C1, & skull vs.

C3 on lateral x-ray.
 Classic imaging appearance: Defects through
pedicles of C2, C2 vertebral body anterior to
C3 body, laminae aligned.
• CT defines components of fracture to best
advantage.
• May see various patterns of arch, vb
disruption.
• Soft tissue swelling anterior to vb common
• May not see malalignment despite pedicle
disruption.
• C1 & skull ride with anteriorly subluxed C2
vertebral body.

68
 Cervical Hyperflexion injury
 Flexion force disrupting capsular and posterior ligaments, with anterior vertebral
displacement/ angulation.

Golden modalities
 High-resolution CT best shows
facet relationships.
 Fluoroscopy helpful to show lax
ligaments in flexion.

Golden findings

 Focal kyphosis, abnormal vertical

separation of facets/spinous
processes.

Location
 Mid or lower cervical spine.

69
 Cervical Hyperextension injury
 Fracture of the laminae due to forceful posterior displacement of head and/or
upper cervical spine.

Golden modalities
 Must obtain CT once plain film findings
suggest fracture.
 CT may show more fractures at other levels.
 Thin-section (max 1 mm) cuts mandatory.
 Reformations very helpful.
 MR vital if neurologic signs present to
evaluate cord injury, compression.
 Consider CTA, MRA to exclude dissection.

Golden findings

 Bony defect through posterior arch with

posterior element malalignment.

Location
 Typically mid- or lower cervical spine.

70
Cervical Hyperflexion- rotation injury
 Traumatic disruption of cervical spine (ligaments alone, or together with bony
elements) causing facet subluxation.

Golden modalities
 5 view cervical spine series starts work-up.
 CT with thin axial sections & reformations
recommended with serious trauma, or if patient
cannot cooperate.
 Always evaluate the following relationships
when examining C-spine trauma x-rays.
 Anterior vertebral body edges should trace
gentle C-like lordosis
 Posterior edges of vertebral body should parallel
the anterior curve.
 Facets should align on lateral and oblique views
 Posterior laminalline (point of junction of the
laminae) should show the same gentle lordotic
curve as anterior + posterior vb edges on lateral
view
 Prevertebral soft tissue should show half
thickness of AP vertebral body diameter or less.
 AP x-ray should show regular spacing between
spinous processes, all vertically aligned in
midline.
 Disc space height loss can be clue (in absence of
degenerative changes.
Golden findings

 Malalignment of adjacent facets and spinous

processes on lateral x-ray, with focal vertebral
body angulation.

Location
 Typically mid- or lower cervical spine.

71
 Cervical Burst fracture

 Comminuted fracture of vertebral body extending through both endplates due to

axial compression.

Golden modalities
 Always obtain CT if FX of cervical vertebral
body seen on radiographs.
 Thin-section axial slices with sagittal
reformations, bone and soft tissue windows.
 MR vital if neurologic symptoms/signs
present.
 MRA or CTA if FX involves vertebral artery
foramen.

Golden findings

 Edged lower cervical vertebral body with end

plate defect, focal gibbus on lateral
radiograph.

Location
 Typically mid- or lower cervical spine.

72
Cervical Hyperextension-rotation injury
 Unilateral facet or laminar fracture due to hyperextension + rotation combined,
typically with ligament disruption.

Golden modalities
 CT.
Protocol advice
 Thin-section slices with bone
algorithm for reconstruction of axial
and reformatted images.

Golden findings

 Unilateral posterior element fracture.

Location
 Below C2.

73
 Lateral flexion injury of cervical spine
 Fracture of articular mass, often associated with fracture of transverse, uncinate
processes & vertebral body.

Golden modalities
 High-resolution CT with bone algorithm for
reconstruction of axial and reformatted
slices.
Protocol advice
 1 mm slices are best.

Golden findings

 Fracture of articular pillar on AP view with

widening of uncovertebral joint.

Location
 Mid, lower cervical spine.

74
 Cervical Posterior column injury
 Posterior column: Spinal architecture beyond PLL, anulus, posterior vertebral
body margin.
 Includes facets, their joint ligaments, laminae, ligamentum flavum, interspinous
ligaments, and spinous processes.

Golden modalities
 CT with soft tissue + bone windows,
reformations.
Protocol advice
 1 mm slice thickness, bone algorithm
reconstruction of CT slices, isotropic
reformations.

Golden findings

 Disrupted alignment, relationships of

posterior arch in adjacent vertebral levels.

75
Anterior compression fracture of thoracic spines

 Vertebral body fracture compressing anterior cortex, sparing middle/posterior

columns.

Golden modalities
 CT best to differentiate from Chance, burst
fracture.
Protocol advice
 Multidetector CT with thin overlapping
helical sections.
 Sagittal/coronal reformations essential to
detect signs of ligament injuries.
 If patient undergoing thoracic multidetector
CT because of trauma, dedicated spine CT
not needed.
 Small field of view coronal/sagittal
reformations obtained from original data
set.
 Bone (edge-enhancing) algorithm can be
applied after scanning in soft tissue
algorithm.

Golden findings

 Wedge-shaped vertebral body.

Location
 May occur at multiple levels, contiguous or
noncontiguous.
 Mid-/lower thoracic most common.

76
 Lateral compression fracture of thoracic spines

 Thoracic vertebral body Fracture with ↓ vertebral height, predominantly lateral

location.

Golden modalities
 CT > > radiography.
 MRI for neurologic deficit(s).
Protocol advice
 CT: Sagittal & coronal reformats
 MRI: STIR & fat-saturation T1 C+.

Golden findings

 Lateral wedge deformity of affected thoracic

spine vertebral body.
Location
 Bimodal: Larger peak at thoracolumbar
junction, smaller peak at T6-T7.

77
 Burst thoracolumbar fracture
 Comminuted fracture of vertebral body extending through both superior and
inferior endplate.

Golden modalities
 Thin-section axial slices with sagittal
reformations, bone and soft tissue windows.
 MR vital if neurologic symptoms/signs
present.

Golden findings

 Compressed thoracic vertebral body with

fractured endplates, widened pedicles.
Location
 Typically mid- or lower thoracic spine, upper
lumbar spine.

78
 Thoracic Facet-lamina fracture
 Fracture through thoracic vertebral arch.

Golden modalities Golden findings

 Thin-section bone CT most effective in
characterizing posterior column fractures.  Cortical
 MRI best for cord evaluation: disruption/discontinuity
 Must be included in imaging workup of through laminae, facet
patients with neurologic deficit. joints of thoracic vertebra.
Protocol advice Location
 Sagittal reformation from axial CT.  T1-T10 stabilized by ribs.
 Demonstrates extent of canal  60% of thoracolumbar
compromise. fractures occur between
 Shows horizontal fractures through Tl2 and L2.
posterior elements.  90% of fractures involve
 Sagittal STIR or T2WI with fat T11 to L4.
suppression for posterior ligamentous
injury.

79
 Chance fracture
 Injury involving compression of anterior column with distraction of middle and
posterior columns.

Golden modalities
 CT scan for surgical planning Allows
distinction between Chance, burst,
compression fractures to be most reliably
made.
Protocol advice
 1-3 mm overlapping helical multidetector
CT.
 Coronal/sagittal reformations
reformations essential.
 If multidetector CT performed for
evaluation of chest, abdomen injuries,
obviates need for dedicated spine CT.
• Reformatted images coned to spine.
• Expedites treatment of multi trauma
patients.
Golden findings

 Wedging anterior vertebral body + increased

interspinous distance or spinous process
fracture.
Location
 Usually occurs at T11-L3.
 Occasionally at mid-thoracic spine.

80
 Low thoracic Distraction fracture
 Vertebral body wedge compression & anterior displacement of spine above
fracture with facet subluxation.

Golden modalities
 Must obtain CT once plain film findings
suggest fracture, or show focal kyphosis;
look for intra-abdominal injury.
 MR to evaluate cord injury, compression.

Golden findings

 Focal kyphosis at thoraco-lumbar junction

with wedging of vertebral body.
Location
 Typically thoracolumbar junction or upper
lumbar spine.

81
Lumbar Anterior compression fracture
 Fracture of anterior cortex of vertebral body without displacement of posterior
wall or involvement of neural arch.

Golden modalities
 Earliest diagnosis by MRI.
 CT may better distinguish from pathologic
fracture.
Protocol advice
 Sagittal T1 WI, STIR.

Golden findings

 Loss of height of anterior portion of

vertebral body.
Location
 Trauma: Most common upper lumbar.
 Osteoporosis: Any level.

82
Lumbar Lateral compression fracture

Golden modalities
 CT > > radiography.
 MRI for neurologic deficit(s).
Protocol advice
 CT: Sagittal & coronal reformats.
 MRI: STIR & fat-saturation T1 C+.

Golden findings

 Lateral wedge deformity of affected

lumbar spine vertebral body.
Location
 50-65% are between T12 & L2.

83
 Lumbar Burst fracture
 Vertebral fracture due to axial load, involving all 3 columns.

Golden modalities
 CT for surgical planning.
Protocol advice
 1-3 mm overlapping helical images.
 Coronal, sagittal reformations.

Golden findings

 Retropulsion of posterior vertebral body

cortex.
Location

 Most common upper lumbar.

 60% of thoracolumbar spine injuries of all
types occur between T11 and L1.
 Thoracic spine relatively stabilized by
ribs/sternum, coronal alignment of facet
joints.

84
Lumbar Facet-posterior fracture

Golden modalities
 Bone CT

Protocol advice
 Sagittal + coronal reformats CT for surgical
planning.

Golden findings

 Lumbar facet Fracture line +/- facet joint

distraction.

85
Sacral traumatic fracture

Golden modalities
 Multidetector CT scan.

Protocol advice
 1-3 mm overlapping helical images, coronal
& sagittal reformations.

Golden findings

 Disruption of sacral arcuate line.

Location
 95% vertical or oblique.
 5% horizontal.

86
 Sacral insufficiency fracture
 Stress fracture resulting from normal physiological stress on demineralized bone
with decreased elastic resistance.

Golden modalities Golden findings

 Fat suppression sequences  Bilateral or unilateral sacral
valuable. marrow edema adjacent to
 STIR or FSET2 with fat sacroiliac joint(s) on MR.
suppression accentuates marrow  Characteristic HONDA sign in
edema. isotope scan.
 Imaging in oblique coronal plane Location
better visualizes fracture lines.  Sacral alae:
 MRI - CT coronal reformation. • May be unilateral.
 Nearby sacroiliac joints.

87
 Traumatic disc herniation
 Disc herniation induced by trauma.

Golden modalities
 MRI is modality of choice.
 CT Bone depicts associated osseous injuries
better.
Protocol advice
 Best seen with sagittal T2WI.
 Add GRE to assess for cord hemorrhage.
 STIR for ligamentous & soft tissue injury.

Golden findings

 Herniation of disc material most evident on

T2WI.
Location
 Cervical spine most frequently.
 50% of traumatic disc herniation occurs at
level of injury or one level below/above.

88
 Apophyseal ring fracture
 Fracture or avulsion of vertebral ring apophysis due to injury in immature
skeleton:
 Fracture of anterior ring termed limbus vertebra.
 Fracture of posterior ring termed posterior apophyseal ring Fracture (PAR-Fx).

Golden findings

 Concentric bone fragment displaced from

endplate margin.
Location
 Lumbosacral spine most common; rare
thoracic> cervical.
 L3-S1; PAR-Fx commonly L4, Sl.
 Inferior or superior end plate may be
involved; limbus vertebra usually superior.
 Fractured apophyseal fragment usually
midline.
Golden modalities
 CT with bone as well as soft tissue windows.
Protocol advice
 Thin-sections, sagittal reformation.

89
 Rhabdomyolysis
 Clinical and biochemical syndrome resulting from damage of integrity of skeletal
muscle, with release of toxic muscle cell components into circulation.

Golden modalities
 Bone scan to total body extent of damage.
 MRI for extent of focal muscle damage.

Protocol advice

 T2WI in multiple planes.

Golden findings

 Increased T2 signal within affected skeletal

muscle group.
Location
 Skeletal muscles.

90
Traumatic spinal muscle injury
 Strain = muscle fiber disruption from indirect forces.
 Sprain = ligamentous injury.

Golden modalities
 MRI
Protocol advice

 T2 + fat suppressing technique.

Golden findings

 Muscle T2 hyperintensity.

91
 Pedicle insufficiency fracture

 Fracture of spinal pedicle not related to direct acute trauma.

Golden modalities
 CT shows fracture, displacement,
contralateral abnormality.
Protocol advice

 Thin slice CT with multi planar reformats.

Golden findings

 Linear low attenuation on CT through pedicle,

well-defined margins.
Location
 Lumbar pedicle> cervical> thoracic.

92
 Cord, Dura, and
Vessels injuries
Post-Traumatic Syrinx
Spinal Cord Contusion-Hematoma
Central Spinal Cord Syndrome
Spinal Cord Herniation
Lumbar Fracture with Dural Tear
Epidural-Subdural Hematoma
Vertebral Artery Dissection
Carotid Artery Dissection
Traumatic Dural AV Fistula

93
 Post-traumatic syrinx
 Cystic cord cavity that may (hydromyelia) or may not (syringomyelia)
communicate with central canal.

Golden modalities
 T2WI, T1 C+ MR.
Protocol advice

 Axial images confirm location and clarify

relationship to adjacent anatomical
structures.
 Sagittal sequence most useful for defining
craniocaudal extent.
 Contrast essential to exclude neoplasm.
 Consider cine PC CSF flow study if suspect
obstruction to CSF flow (e.g., arachnoid
adhesions). Golden findings

 Cystic expansile cord lesion.

Location
 Rostral to injury site in 81 %, caudal in 4%,
both directions in 15%.

94
Spinal cord contusion-hematoma

Golden modalities
 MRI.
Protocol advice

 Add STIR & GRE.

Golden findings

 Abnormal cord MR signal.

Location
 Most common level of spinal cord injury is
C5, then C4 & C6.
 In cases resulting in paraplegia, most
common level is TI2, then 11 & T10.

95
 Central spinal cord syndrome
 Acute post-traumatic paralysis affecting arms> legs, with bladder dysfunction,
variable sensory loss.

Golden modalities
 MRI in any case of post-traumatic
cord signs is mandatory.

Golden findings

 T2WI shows high signal in cord.

Location
 Predominates at C3-4 through CS-6
level.

96
 Spinal cord herniation
 Herniation of spinal cord through defect in dura of ventral canal.

Golden modalities
 CT post-myelography.
Protocol advice

 Thin-section slices.
 Sagittal reformations.
 Delayed scan to see filling of
extradural sac.

Golden findings

 Focal anterior displacement of cord

with expansion of dorsal
subarachnoid space.
Location
 Typically in mid-thoracic spine.

97
Lumbar fracture with dural tear

Golden modalities
 Must obtain CT once plain film findings
suggest fracture:
 Thin-section (1-3 mm) cuts mandatory,
reformations very helpful.
 Intrathecal dye necessary to
demonstrate dural tear.
 Dural tear warns surgeon to look for
NR if posterior fusion planned.

Golden findings

 Wedged vertebral body on lateral view with

focal kyphosis, widened pedicles on AP view
with vertical fracture through laminae.
Location
 Thoracic or lumbar vertebral bodies.

98
 Epidural-subdural hematoma
 Extravasation of blood into the epidural or subdural compartment of the spine.

Golden modalities
 MR, with T1WI, T2WI, multiple planes.
Protocol advice

 Fat-saturation helps exclude lipomatosis as

cause, outlines collection to better
advantage.

Golden findings

 Long segmental extra-axial mass encasing or

displacing cord or cauda equina.
Location
 Anywhere along spinal canal.

99
 Vertebral artery dissection
 Hemorrhage into vessel wall with subsequent stenosis or pseudo aneurysm.

Golden modalities
 CTA with 3D reformation from origin of neck
vessels to vertex.
 Intra- and extra cranial MR angiogram if
intravenous iodinated contrast
contraindicate.

Golden findings

 Intramural hematoma: Crescentic T1

hyperintensity surrounding diminished flow
void.
Location
 Most common between C2 & C1 vertebrae.

100
 Carotid artery dissection
 Traumatic-induced injury to carotid intima resulting in blood dissecting into
media creating false lumen.

Golden modalities
 Neck CTA.
Protocol advice

 Add axial T1 WI with fat-saturation to best

image arterial wall hematoma.

Golden findings

 Tapering luminal narrowing.

Location
 ICA at or near the bifurcation is most
common:
 ICA between bifurcation & base of skull.
 CCA proximal to bifurcation.
 ICA at base of skull is least common.
 Rarely extends intracranially.

101
Traumatic dural AV fistula

Golden modalities

 Digital subtraction angiography.

Golden findings

 DSA demonstration of AVF nidus with

enlarged draining veins.
Location
 Dural or extradural.
 Any segment; cervical> lumbar.

102
degenerative diseases
and Inflammatory
Arthritides

103
Degenerative Disc Disease
Degenerative Endplate Changes
Instability
Vertebral Disc Bulge
Vertebral Disc Anular Tear
Intervertebral Disc Herniation, Cervical
Intervertebral Disc Herniation, Thoracic
Intervertebral Disc Herniation, Lumbar
Foraminal Disc Extrusion
Spondylolisthesis
Spondylolysis
Cervical Facet Arthropathy
Lumbar Facet Arthropathy
Facet Joint Synovial Cyst
Lumbar Acquired Spinal Stenosis
Cervical Acquired Spinal Stenosis
Degenerative Scoliosis
Neurogenic (Charcot) Arthropathy
DISH
OPLL
Ossification Ligamentum Flavum

104
105
 Degenerative disc disease
 Generalized and multifactorial process affecting the discovertebral unit leading
to biomechanical/morphologic alterations.
 Asymptomatic or associated with back/neck pain +/-radiculopathy.

Golden modalities
 MR shows intrinsic disc signal changes,
anular tears, bulge, herniation, and stenosis.
Protocol advice

 Standard T1WI and T2WI in sagittal/axial

planes (4 mm maximum slice thickness).

Golden findings

 Decreased signal of intervertebral disc on

T2WI.
Location
 Intervertebral disc, adjacent endplates.

106
 Degenerative endplate changes
 MR signal abnormalities involving vertebral body endplates related to
degenerative disc disease.
 Type I: Hypointense on T1 WI, hyperintense on T2WI.
 Type II: Hyperintense on T1 WI, isointense on T2WI.
 Type III: Hypointense on T1 WI and T2WI.

Golden modalities
 MRI.
Protocol advice

 Sagittal T1 WI and T2WI defines lesions and

classification.

 Parallel signal alteration of vertebral

endplates, associated with evidence of disc
degeneration.
Location
 Most common in lumbar spine, may occur in
any vertebral body.

107
 Instability
 Loss of spine motion segment stiffness, where applied force produces greater
displacement than normal, with pain/deformity.

Golden modalities
 Flexion/extension plain film.
Protocol advice

 MR findings useful as secondary tool for

degeneration, endplate changes, stenosis
and herniation.

Golden findings

 Deformity which increases with motion and

increases over time.
Location
 Any spinal motion segment (comprised of
two adjacent vertebrae, disc and connecting
spinal ligaments.

108
 Vertebral disc bulge
 Generalized extension of disc beyond edges of vertebral ring apophyses.

Golden modalities
 T1WI and T2WI MRI with sagittal and axial
planes.

Golden findings

 Circumferential disc "expansion" beyond

confines of vertebral endplates.
Location
 Cervical: C5-6 and C6-7 most common.
 Lumbar: L4-5 and L5-S1 most common.

109
 Vertebral disc anular tear
 Disruption of concentric collagenous fibers comprisingthe anulus fibrosus.

Golden modalities
 Sagittal heavily T2WI with thin-sections.
 Contrast-enhanced T1WI.

Golden findings

 Abnormal signal focus (high intensity zone)

at posterior disc margin on MRI.
Location
 Posterior margin of lumbar, thoracic, or
cervical disc.

110
 Cervical Intervertebral disc herniation

 Localized )> 50% of disc circumference ( displacement of disc material beyond

edges of vertebral ring apophyses.

Golden modalities
 MRI.
Protocol advice

 Sagittal, axial T1 WI and T2WI; intravenous

contrast if question of tumor, infection.
Golden findings

 Small mass in spinal canal, contiguous with

intervertebral disc.
Location
 Ventral epidural.
 C6-7 level most common, with compression
of C7 root.
 C5-6 second most common location,
compressing C6 root.

111
Thoracic Intervertebral disc herniation
 Localized )> 50% of disc circumference ( displacement of disc material beyond
edges of vertebral ring apophyses.

Golden modalities
 MRI.
Protocol advice

 Sagittal, axial T1WI and T2WI; intravenous

contrast if question of tumor, infection.

Golden findings

 Small mass in spinal canal contiguous with

intervertebral disc.
Location
 Ventral epidural.
 T6 → T11 most common.
 Rare in upper thoracic spine (T1-T3).

112
Lumbar Intervertebral disc herniation
 Localized (> 50% of disc circumference) displacement of disc material beyond
confines of disc space.
 Protrusion: Herniated disc with broad-base at parent disc.
 Greatest dimension of disc herniation in any plane ≤ distance between edges
of the base in same plane.
 Extrusion: Herniated disc with narrow or no base at parent disc.

Greatest dimension of disc herniation in any plane> distance between edges of the
base in same plane.

 Sequestered: Free fragment.

Extruded disc without continuity to parent disc.

 Migrated: Disc material displaced away from site of herniation Regardless of

continuity.
 Intravertebral herniation: Schmorl node.

Golden modalities
 MRI: T2WI and T1 WI in sagittal and axial
planes.
Protocol advice

 Intravenous gadolinium in post-operative

patients:
• Distinguishes scar tissue from recurrent
disc herniation.
Golden findings

 Anterior extradural mass contiguous with

disc space extending into spinal canal.
Location
 Most common: L4-5 or L5-S1:
• 90% of lumbar disc herniation.

113
 Foraminal disc extrusion
 Extruded disc material within neural foramen.

Golden modalities
 T1WI and T2WI MRI in sagittal and axial
planes.

Golden findings

 Obliterated perineural fat in neural foramen

on sagittal images.
• Soft tissue mass contiguous with parent
disc.
Location
 Lumbar: L3-4 and L4-S most common.
 Cervical: CS-6 and C6-7 most common.
 Thoracic: Rare.

114
 Spondylolisthesis
 Displacement of vertebral body, described relative to inferior vertebra.
 Anterolisthesis: Anterior displacement of vertebral body relative to one below.
 Retrolisthesis: Posterior displacement of vertebral body relative to one below.
 Spondyloptosis: Vertebral body displaced completely anteriorly, with inferior
displacement to level of vertebral body below.

Golden modalities
 CT scan.
Protocol advice

 Thin-slice CT with sagittal reformations.

Golden findings

 Displacement of posterior cortex of vertebral

body on lateral radiograph.
Location
 Most common in lower lumbar spine.

115
 Spondylolysis
 Defects in pars interarticularis thought to result from repetitive stress injuries.

Golden modalities
 Axial thin-section CT with bone algorithm.
• Sagittal and oblique reformation.

Golden findings

 Elongation of spinal canal at the level of pars

defects on axial imaging.
Location
 Most common at L5: 82%.
 L4 second most common: 11%.
 1O-15% unilateral defects:
• Unilateral healing or union of fractures
those were initially bilateral.

116
 Cervical Facet arthropathy
 Osteoarthritis of synovially-lined apophyseal joint.

Golden modalities Golden findings

 Plain films useful to
demonstrate presence and  Osseous facet overgrowth impinging
severity of facet on neural foramina in conjunction
degenerative changes. with articular joint space narrowing.
 Sagittal and axial T1WI and Location
T2WI best demonstrate  Normal anatomy:
degenerative facet • C2 → C7 levels have two sets of
compression of adjacent paired joints:
thecal sac. • Facet or zygapophyseal joints
 3D gradient echo T2* for posteriorly, with oblique orientation.
foraminal details. • Uncovertebral joints (joints of
 Consider CT myelography if Luschka, neurocentral joints) formed
MRI contraindications or by curved edges of vertebral bodies at
when MRI does not lateral margins.
adequately demonstrate  Arthropathy most common in
facet relationship to neural mid/lower cervical spine.
foramina.

117
 Lumbar Facet arthropathy
 Osteoarthritis of synovially-lined lumbar apophyseal joints.

Golden modalities Golden findings

 Plain films useful to demonstrate presence
and severity of facet degenerative  Osseous facet
changes. overgrowth impinging on
 Sagittal and axial T1 WI and T2WI best the neural foramina in
demonstrate degenerative facet conjunction with articular
compression of adjacent thecal sac and joint space narrowing.
fat-filled neural foramina. Location
 Consider CT myelography if MRI  Facet joints of lumbar
contraindications or MRI does not spines.
adequately demonstrate facet relationship
to neural foramina.

118
 Facet joint synovial cyst
 Synovial cyst formed from degenerative facet joint.

Golden modalities
 MRI of lumbar spine
• Axial and sagittal T2WI.

Golden findings

 Posterolateral extradural cystic mass

communicating with facet join.
Location
 Posterolateral to thecal sac.
 Adjacent to facet joint.
 Lumbar spine: 90%:
• 70-80% at L4-5.
• L3-4 and L5-S1: Less common.
 Uncommon:
• Cervical and thoracic spine.
• Foraminal.
• Far lateral extra-foraminal.
• Bilateral.

119
 Acquired spinal stenosis of lumbar spine
 Spinal canal narrowing in lumbar spine.
 Secondary to multifactorial degenerative changes, being progressive and
dynamic process.

Golden modalities
 MRI.
Protocol advice

 Conventional T1W and T2W sagittal and

axial images with 4-5 mm slice thickness.

Golden findings

 Trefoil appearance of lumbarspinal canal on

axial imaging.
Location
 Most common in lower lumber spine where
there is most mobility (L4-5).

120
Acquired spinal stenosis of cervical spine
 Spinal canal and neural foraminal narrowing in cervical spine secondary to
multifactorial degenerative changes.

Golden modalities
 Sagittal and axial T1 WI, sagittal T2WI, axial
T2* imaging (2-3 mm thickness, 3D
preferred).
Golden findings

 Completely effaced cerebral spinal fluid in

cervical spine at disc level.
Location
 Cervical spine, ventral epidural, centered at
disc levels.

121
 Degenerative scoliosis
 Lateral curvature in spine due to degenerative disc and facet disease in older
patients.

Golden findings Golden modalities

 Noncontrast MRI
 Lateral curvature in spine • Similar sensitivity and specificity
with associated as CT-myelography.
degenerative changes. • Non-invasive.
Location Protocol advice
 T12 to L5:
• Most common from L1 to  Include coronal T1 on lumbar MRI:
L4. • Characterization of scoliosis.
 Apex of curvature most • Additional information on
common at L2-3 interspace. lateral endplate spurring, disc
bulge, and far lateral nerve root.

122
Neurogenic (charcot) arthropathy
 A destructive arthropathy which occurs when pain and proprioception are
diminished or lost, while joint mobility is maintained.

Golden modalities
 CT: Preserved bone density, bony debris best seen on
CT, helps distinguish from infection.
Protocol advice

 Thin-section CT with reformatted images in coronal

and sagittal plane.

Golden findings

 Florid destruction of discs and facet joints with

preserved bone density, involving 1-2 spinal level.
Location
 Almost always in lumbar spines.
 Sometimes occurs in lower thoracic spines.

123
 Diffuse idiopathic skeletal hyperostosis
(DISH)
 Bulky flowing ossification of anterior longitudinal Ligament.

Golden modalities
 Lateral radiography inexpensive, reliable Golden findings
for detecting DISH.
Protocol advice  Flowing anterior
vertebral ossification
 AP and lateral plain radiographs. with relatively
 Axial bone algorithm CT with sagittal and minimal degenerative
coronal reformats to confirm plain film disc disease, facet
diagnosis (if necessary). arthropathy, and
 MRI unnecessary for DISH diagnosis: absent facet ankylosis.
• Reserve MRI to evaluate for co-existent Location
OPLL {Ossification of posterior  Thoracic spine (100%)
longitudinal ligament} or if cord > cervical (65-80%),
compression or spondylosis are being lumbar spine (68-
considered within differential diagnosis. 90%); R> L.

124
Ossification of posterior longitudinal ligament
{OPLL}

 Ossification within spinal posterior longitudinal ligament.

Golden modalities Golden findings

 Multiplanar MR imaging.
Protocol advice  Flowing multilevel
ossification posterior to
 Sagittal T1 WI, T2WI to evaluate spinal vertebral bodies, with
cord compression, extent of ligamentous relatively minimal
ossification degenerative disc disease,
 Axial T2WI images to determine stenosis absent facet ankylosis.
severity, confirm cord signal abnormality Location
 CT with sagittal reformats to confirm MR  Midcervical (C3-C5) > mid-
diagnosis and clarify extent of thoracic (T4-T7).
ossification for surgical planning.

125
Ossification ligamentum flavum
 Ossification of spinal ligamentum flavum.

Golden modalities
 CT imaging best modality for primary
diagnosis, "lesion conspicuity".
 Sagittal reformats excellent for
determining longitudinal extent.
 Multiplanar MR imaging to determine
relationship to and effect on regional
soft tissues
 Sagittal T1WI, T2WI evaluate
longitudinal extent of ligamentous
ossification, degree of cord
compression
 Axial T1 WI, T2WI evaluate canal
caliber.
Golden findings

 Linear thickening of ligamentum

flavum with imaging characteristics
similar to adjacent vertebral marrow
ossification.
Location
 Ligamentum flavum (ventromedial to
facets and lamina, dorsal to thecal
sac).
 Lower thoracic> cervical, upper
thoracic, lumbar.

126
 Inflammatory
Arthritides
Adult Rheumatoid Arthritis

Juvenile Chronic Arthritis

Seronegative Spondyloarthropathy

Gout

127
 Adult rheumatoid arthritis
 Most common inflammatory arthritis involving synovium.
 Inflamed and thickened synovium is called pannus.

Golden modalities Golden findings

 Cervical spine
radiographs in C1/2 subluxation in patient with peripheral
flexion/extension to rheumatoid arthritis.
assess for instability. Location
 Plain radiographs of Involves synovial joints (facet and
hands and/or feet to uncovertebral joints).
confirm diagnosis.  Involves synovium of bursae (e.g., odontoid
 Thin-section bone process bursa) and tendon sheaths.
algorithm CT with Most often involves hands, feet.
sagittal and coronal Never involves spine without hands and/or
reformats for surgical feet.
planning.  Cervical spine: Approximately 60% of RA
 MR imaging in patients patients.
with cord symptoms.  Rarely involves sacroiliac joints and lumbar
spine.

128
 Juvenile chronic arthritis
 A spectrum of idiopathic inflammatory arthropathies occurring in childhood.

Golden modalities
 earliest diagnosis by MR.
Protocol advice

 Sagittal T1 WI, STIR, axial T2WI FSE.

 Gadolinium increases sensitivity in early diagnosis, but
usually not needed.
Golden findings

 Cervical spine subluxations and growth disturbance.

Location
 Cervical spine.
 Occasionally thoracic spine.
 Juvenile onset ankylosing spondylitis (AS): involves
sacroiliac joints, uncommonly progresses to remainder
of spine.
 Peripheral arthropathy: Oligo articular in large joints,
or mimicking adult RA in small joints.

129
Seronegative spondyloarthropathy
 RF (rheumatoid factor) negative inflammatory arthritis and enthesopathy
affecting the spine and sacroiliac joints.
 Syndesmophyte: Paraspinous ligamentous or disc ossification bridging two
adjacent vertebral bodies.
 Enthesopathy: Inflammation at attachments of ligaments and tendons
(entheses).

Golden modalities
 Start with plain films; use CT if plain films
are negative.
Golden findings
 MR/CT in combination to evaluate bone and
cord status following trauma.
 Sacro iliac joint erosion or ankylosis.
Location
 First involves sacroiliac joints.
 Second involves thoracolumbar junction.
 May involve entire spine.

130
 Gout
 Arthropathy secondary to urate crystal deposition.
 Tophus: Focal mass consisting of crystals and host reaction.

Golden modalities
 MRI to show tophi, impingement on cord
and nerve roots.
Protocol advice

 Sagittal T1 WI, STIR, axial T2WI.

Golden findings

 Erosive arthritis centered on disc in patient

with known gout.
Location
 Generally involves only 1-2 levels.
 Disc or facet joints.
 Sacroiliac joints.
 Usually have peripheral disease also.

131
Infections

132
Pyogenic Osteomyelitis

Granulomatous Osteomyelitis

Osteomyelitis, C1-C2

Septic Facet Joint Arthritis

Epidural Abscess

Subdural Abscess

Paraspinal Abscess

Viral Myelitis

HIV

Myelitis-Cord Abscess

Spinal Meningitis

Echinococcus

Schistosomiasis

Cysticercosis

133
 Pyogenic osteomyelitis
 Bacterial suppurative infection of vertebrae and intervertebral disc.

Golden modalities Golden findings

 Sagittal and axial T2WI and T1WI MRI:
• Sensitivity 96%, specificity 92%, accuracy  Ill-defined hypointense
94 %. vertebral marrow on T1WI
 SPECT Ga 67 scan good alternative. with loss of endplate
 Sensitivity and specificity 90%. definition on both sides of
Protocol advice the disc.
 STIR or FSET2 with fat suppression most Location
sensitive for marrow edema and epidural  All spinal segments involved:
involvement.  Lumbar (48%) > thoracic
 Post-gadolinium T1WI with fat suppression (35%) > cervical spine
also improves MR sensitivity. (6.5%).

134
 Granulomatous osteomyelitis
 Granulomatous infection of spine and adjacent soft tissue typically caused by
tuberculosis {Pott's disease} or brucellosis.

Tuberculous spondylitis

Golden modalities
 Sagittal and axial T1 WI, T2WI and T1 C+
MR:
• Evaluate extent of disease and assess
response to treatment.
Protocol advice

 Sagittal STIR or FSE T2 with fat-saturation

most sensitive for bone marrow edema and
epidural involvement.

135
 Brucellar spondylitis

Golden findings

 Gibbus vertebrae with relatively intact intervertebral discs and

large para spinal abscesses in tuberculous spondylitis {Pott's
disease}.
 Anterosuperior epiphysitis at L4 with associated sacroiliitis in
brucellar spondylitis.
Location
 TS{ tuberculous spondylitis}:
• Mid-thoracic or thoracolumbar> lumbar, cervical.
• Anterior vertebral body.
• Isolated posterior element involvement possible.
• Laminae> pedicles > spinous process> transverse process.
 BS {brucellar spondylitis}:
• Lower lumbar spine (L4) > cervical = thoracic
• Sacroiliac joints.
• Posterior elements not effected
 Anterior endplate at diskovertebra junction involved in focal
BS.
• Entire vertebral body affected in diffuse BS.

136
 Septic facet joint arthritis
 Suppurative bacterial infection of facet joint, adjacent soft tissue.

Golden modalities
 Sagittal and axial T1 WI and T2WI MRI.
Protocol advice

 Sagittal STIR or FSET2 with fat-saturation most

sensitive for bone marrow edema and epidural
involvement
 Post-gadolinium T1WI with fat-saturation better
delineates extent of facet, epidural, and
paraspinal involvement.
Golden findings

 Abnormal enhancement within facet joint with

associated facet marrow, adjacent soft tissue
edema.
Location
 Lumbar spine most common: 97%.

137
 Epidural abscess
 Extradural spinal infection with abscess formation.

Golden modalities
 Sagittal and axial T1 WI and T2WI MR with
gadolinium.
Protocol advice

 Sagittal STIR or T2WI with fat-saturation

increases lesion conspicuity by suppressing
signal from epidural fat and vertebral
marrow.

Golden findings

 Findings of spondylodiscitis, with adjacent

enhancing epidural phlegmon ± peripherally
enhancing fluid collection.
Location
 Posterior epidural space (80%) > anterior
(20%) > circumferential (caudal to S2).
 Lower thoracic and lumbar> cervical and
upper thoracic.

138
 Subdural abscess
 Collection of pus in "potential" space between dura and arachnoid.

Golden modalities
 Sagittal and axial T1 WI and T2WI MR.
Protocol advice

 Intravenous gadolinium increases sensitivity

in detecting SSA { Spinal subdural abscess}.
• Axial imaging confirms subdural location.

Golden findings

 Intradural extramedullary ring-enhancing

fluid collection on axial imaging.
Location
 Thoracolumbar region most common.

139
 Paraspinal abscess
 Infection of soft tissues surrounding spine.

Golden modalities
 Sagittal and axial T1 WI and T2WI MRI with
gadolinium.
Protocol advice

 T2WI with fat suppression or STIR improves

detection of early para spinal inflammation.
 Post-gadolinium T1 WI with fat suppression
also improves lesion conspicuity.
Golden findings

 Paravertebral enhancing phlegmon or

peripherally enhancing liquefied collection.
Location
 Prevertebral space
 Paravertebral soft tissue:
• Psoas.
• Iliacus.
• Posterior paraspinous muscle.

140
 Viral myelitis
 Acute inflammatory insult of spinal cord due to direct viral infection or post-viral
immunologic attack.

Golden modalities
 MRI.
Protocol advice

 T2Wl with thin (3 mm) sagittal sections; T1 C+

to exclude focal lesion as cause of cord
edema.

Golden findings

 Swollen, edematous cord with segmental

contiguous involvement.
Location
 Cervical, thoracic segments; isolated conus
involvement: rare.

141
 HIV
 Myelopathy resulting from primary HIV infection.

Golden modalities
 MRI C+.

Golden findings

 Spinal cord T2 hyperintensity which may

show patchy enhancement.
Location
 Thoracic> cervical; mid to low thoracic cord
with ↑ rostral involvement as disease
progresses.

142
 Myelitis-cord abscess
 Infection of spinal cord with necrosis.
 Pyogenic infection most common.

Golden modalities
 MRI with contrast defines cord abnormality,
edema, enhancing abscess.

Protocol advice
 Sagittal, axial T1 W, T2W images, post-
contrast sagittal, axial T1 WI.

Golden findings

 Ring-enhancing mass within cord, with

appropriate clinical history of
inflammation/infection.
Location
 Intramedullary.

143
 Spinal meningitis
 Infection of spinal cord leptomeninges and subarachnoid space.

Golden modalities
 Axial and sagittal T1 WI and T2WI MRI:
• Positive in advanced bacterial meningitis
or granulomatous infection.

Protocol advice

 Intravenous gadolinium increases sensitivity

in detecting meningeal disease.

Golden findings

 Diffuse, extensive subarachnoid

enhancement.
Location
 All spinal segments involved.

144
 Echinococcus
 Disease caused by cyst stage of infestation by tapeworm of genus echinococcus.

Golden modalities
 MR shows bone, epidural, paravertebral
extension and degree of neural compromise.
 CT shows bone morphology, degree of bone
destruction.

Protocol advice

 Sagittal, axial T1 WI + T2WI, post-contrast

sagittal, axial T1 WI.

Golden findings

 Multiloculated, multiseptated T2
hyperintense vertebral body/posterior
element mass without significant
enhancement in endemic area for
echinococcus.
Location
 Thoracic spine most common.

145
 Schistosomiasis
 CNS infection from parasitic trematodes (blood flukes) of genus Schistosoma.

Golden modalities
 MR with contrast.

Protocol advice

 Sagittal, axial T1 WI + T2WI, sagittal + axial

post-contrast.

Golden findings

 Myelopathy, cord enhancement, edema in

patient from endemic area.
Location
 Thoracic cord, conus.

146
 Cysticercosis
 CNS parasitic infection caused by pork tapeworm {Taenia solium}.
 Classified as extraspinal (vertebral body) or intraspinal (extradural,
subarachnoid, intramedullary).

Golden modalities
 MR imaging with contrast defines intradural
extramedullary, intramedullary cysts,
associated edema.

Protocol advice
 Sagittal, axial T1 WI, T2WI, T1 C+, include
brain imaging in addition to spine imaging.

Golden findings

 Intradural cyst with evidence of similar

lesions in brain (cyst with "dot"
appearance).
Location
 Parenchymal, leptomeningeal,
intraventricular, spinal:
• Spinal NCC rare.
• Spinal involvement is thoracic 60-75%.

147
 Inflammatory &
Autoimmune
disorders

Guillain-Barre Syndrome

CIDP

Lumbar arachnoiditis

Lumbar arachnoiditis

Sarcoidosis

Multiple Sclerosis of the Spinal Cord

Spinal Cord ADEM

Idiopathic Acute Transverse Myelitis

Vitamin B12 Deficiency

148
 Guillain-barre syndrome
 Autoimmune post-infectious or post-vaccinial acute inflammatory demyelination
of peripheral nerves, nerve roots, cranial nerves.

Golden modalities
 Sagittal and axial T1WI without and with
gadolinium contrast.

Golden findings

 Smooth pial enhancement of the cauda

equina and conus medullaris.
Location
 On imaging, typically the cauda equina,
especially ventral root.

149
 Chronic inflammatory demyelinating polyneuropathy

(CIPD)

 Chronic acquired, immune-mediated demyelinating neuropathy characterized by

relapsing or progressive muscle weakness +/- sensory loss.

Golden modalities
 T2WI, enhanced coronal and
axial T1 WI sequences with fat
suppression best delineate nerve
lesions.
 Brain MRI to detect subclinical
CNS demyelination.

Golden findings

 Enlargement and abnormal T2

hyperintensity of nerve roots,
plexi, or peripheral nerves.
Location
 Spinal nerve roots and
peripheral nerves
(extraforaminal > intradural)
 Lumbar> cervical, brachial
plexus, thoracic/intercostal>
cranial nerve.

150
 lumbar Arachnoiditis
 Post-inflammatory adhesion and clumping of nerve roots.

Golden modalities
 Spine T1W1 and T2WI MRI in sagittal and
axial planes with gadolinium.

Golden findings

 Absence of discrete nerve roots in thecal sac.

Location
 Lumbar spine
• Cauda equina.

151
 Lumbar Arachnoiditis ossificans
 Intradural ossification associated with post-inflammatory adhesion and clumping
of lumbar nerve roots.

Golden modalities
 Axial thin-section bone CT
with sagittal reformation.

Golden findings

 Focal calcific density on CT or

hyperintensity on T1WI and
T2WI within lumbar nerve
root aggregate.

152
 Sarcoidosis
 Non caseating granulomatous disease of spine and spinal cord.

Golden modalities
 Sagittal and axial T1WI and
T2WI MRI with gadolinium.

Golden findings

 Combination of
leptomeningeal and
peripheral intramedullary
mass-like enhancement
suggestive of spinal
sarcoidosis.
Location
 Intramedullary:
• Cervical.
• Upper thoracic.
 Extramedullary intradural:
• Cauda equina.
• Dural involvement without
segmental predilection.
 Extradural.
 Vertebral:
• Lower thoracic and upper
lumbar spine.

153
 Spinal cord multiple sclerosis
 Primary demyelinating disease of central nervous system with multiple lesions
disseminated over time and space.

Golden modalities
 T1WI and T2WI spinal cord MRI in sagittal
and axial planes with gadolinium.

Golden findings

 Concomitant intracranial lesions in

periventricular, subcallosal, brain stem, or
cerebellar white matter.
Location
 10-20% isolated spinal cord disease.
 Cervical is the most commonly affected
spinal cord segment.
• Two-thirds of cord lesions.
 Dorsolateral aspect of cord.
 Does not respect gray-white boundary.

154
 Spinal cord ADEM
 Para/postinfectious immune mediated inflammatory disorder of the white
matter.

Golden modalities
 pre- and post-contrast MR.

Protocol advice

 Include brain MRI whenever suspicious cord

lesions found.

Golden findings

 Multifocal white matter lesions with

relatively little mass effect or vasogenic
edema.
Location
 Anywhere in the spinal cord white matter.
 Brain almost always involved.

155
Idiopathic acute transverse myelitis
 Inflammatory disorder involving both halves of spinal cord resulting in bilateral
motor, sensory, and autonomic dysfunction.

Golden modalities
 Sagittal and axial T2WI and T1WI MRI
through spinal cord with gadolinium.

Golden findings

 Central cord lesion more than two vertebral

segments in length with eccentric
enhancement.
Location
 Thoracic more common.
 10% in cervical cord.
 Central cord location on axial imaging.

156
 Vitamin B12 deficiency
 Vitamin B12 deficiency produces selective degeneration of dorsal +/-lateral
spinal cord columns.

Golden modalities
 Multiplanar T2WI to confirm localization in
dorsal columns, exclude cord infarct or
spondylosis.

Golden findings

 Mild spinal cord enlargement, abnormal T2

hyperintensity within dorsal columns.
Location
 Dorsal spinal cord columns +/-lateral
columns.

157
Neoplasms

158
 Extradural tumours
Blastic Osseous Metastases
Lytic Osseous Metastases
Hemangioma
Osteoid Osteoma
Osteoblastoma
Aneurysmal Bone Cyst
Giant Cell Tumor
Osteochondroma
Chondrosarcoma
Osteosarcoma
Chordoma
Ewing Sarcoma
Lymphoma
Leukemia
Plasmacytoma
Multiple Myeloma
Neuroblastic Tumor
Angiolipoma

159
 Blastic osseous metastases
 Extension of primary tumor to spine, where bone production exceeds bone
destruction.

STIR

Golden modalities Golden findings

 MR image entire spinal axis
 Standard MRI + STIR or fat-  Lesion destroys posterior cortex,
suppressed T2WI. pedicle.
 Contrast-enhanced, fat-saturated Location
T1WI.  Vertebral body and posterior
 Radionuclide studies for screening of elements.
entire skeleton.

160
 Lytic osseous metastases
 Extension of primary tumor to spine, where bone destruction exceeds bone
production.

Owl winking sign

Golden modalities
Golden findings
 MR scan entire spinal axis:
 Standard MRI + STIR or fat-  Lesion destroys posterior
suppressed T2WI (scan entire cortex, pedicle (owl winking
spine). sign).
 Contrast -enhanced, fat -saturated Location
T1W.  Vertebral body and
 Radionuclide studies for screening of posterior elements.
entire skeleton.

161
 Hemangioma
 Benign vertebral body vascular tumor.
 Incidental lesion identified on imaging performed for unrelated reasons.
 Radiographic diagnostic criteria are lesion growth, bone destruction, vertebral
collapse, absence of fat in lesion, and active vascular component.
 Rarer presentation (clinical or radiographic) is "aggressive hemangioma".
 May extend epidurally and cause cord compression.

Golden modalities
 Both CT and MR can permit a specific
diagnosis:
 MR best demonstrates aggressive
characteristics
• Sagittal and axial T1WI images most useful
to characterize composition.
• Axial T2WI and enhanced T1WI best for
characterizing epidural extent and cord
compromise (aggressive lesions).
 Axial bone algorithm CT is most useful for
characteristic features that distinguish
hemangioma from metastatic lesion.

Golden findings White polka dots

 Well-circumscribed, hypodense lesion with

coarse vertical trabeculae ("white polka
dots") on axial CT.
Location
 Vertebral body, posterior elements.

162
 Osteoid osteoma
 Benign osteoid-producing tumor < 1.5 cm in size.
 The tumor is often called a "nidus" to distinguish it from the surrounding
sclerotic, reactive bone.

Golden modalities
 Bone CT with 1 mm helical sections, IV
contrast not needed.

Golden findings

 Small radiolucent tumor nidus with

surrounding sclerosis.
Location
 10% occur in spine.
 Almost all involve neural arch.
 Involvement of vertebral body rare.
 59% lumbar, 27% cervical, 12% thoracic, 2%
sacrum.

163
 Osteoblastoma
 Benign tumor forming osteoid.
 Differentiated grossly from osteoid osteoma by larger size (> 1.5 cm).

Golden modalities
 CT with sagittal, coronal reformations.

Golden findings

 Expansile mass occurring in posterior

elements.
Location
 40% of osteoblastomas occur in the
spine.
 40% cervical, 25% lumbar, 20%
thoracic, 15-20% sacrum.
 Originate in neural arch.
 May be centered in pedicle, lamina,
transverse or spinous process, articular
pillar, or pars interarticularis.
 Often extend into vertebral body.

164
 Aneurysmal bone cyst
 Expansile benign neoplasm containing thin-walled blood-filled cavities.

Golden modalities
 CT best for diagnosis based on specific
imaging features.
 CT best to differentiate from telangiectatic
OGS {osteogenic sarcoma}:
 Narrow zone of transition in ABC.
 Absence of infiltration into surrounding
soft tissues.
 MRI shows epidural extent, cord
compromise.
Golden findings
Protocol advice
 Expansile multiloculated neural arch mass
 .with fluid-fluid level.
Location
 10-30% of ABC occurs in spine/sacrum.
 Arise in neural arch.
 75-90% extends into vertebral body.

165
 Giant cell tumor
 Locally aggressive neoplasm composed of osteoclast-like giant cells.

Golden modalities
 CT scan for diagnosis.
 MR for evaluation of spinal canal, nerve
roots.

Protocol advice
 Thin-section CT with sagittal, coronal
reformations.

Golden findings

 Lytic lesion in vertebral body or sacrum.

Location
 Spine: 3% of all GCT.
 Centered in vertebral body.
 Sacrum: 4% of all GCT.
 Rarely involves multiple sites.

166
 Osteochondroma
 Cartilage-covered osseous excrescence contiguous with parent bone.

Golden modalities
 MR imaging.

Protocol advice

 MRI to measure cartilage cap,

determine status of regional neural
and musculoskeletal tissue.
 Bone CT to assess mineralization,
confirm continuity with vertebral
marrow space.

Golden findings

 Sessile or pedunculated osseous

"cauliflower" lesion with
marrow/cortical continuity with
parent vertebra.
Location
 Bones forming through endochondral
ossification.
•Metaphysis of long tubular bones
(85%) common, particularly knee.
 < 5% occurs in spine.
• Cervical (50%, C2 predilection) >
thoracic (T8 > T4 > other levels) >
lumbar> > sacrum.
• Spinous/transverse processes>
vertebral body.

167
 Chondrosarcoma
 Malignant tumor of connective tissue, characterized by formation of cartilage
matrix by tumor cells.

Golden modalities
 CT shows bone destruction, calcification, extent.
Protocol advice
 CT to evaluate for chondroid matrix, cortical
destruction, intra- and extraosseous extension.
 MRI to evaluate intramedullary extent and
relationship to neurovascular bundle.
Golden findings

 Lytic mass with or without chondroid matrix,

cortical disruption and extension into soft tissues.
Location
 Flat bones:
• Pelvis: 25%.
• Ilium: 15%.
• Pubis and ischium: 9%.
• Scapula: 5%.
 Ribs and sternum: 12%.
 Metaphysis/diaphysis of long bones may extend
into epiphysis.
• Femur: 15%
• Tibia: 5%.
 Humerus: 10%.
 Craniofacial bones: 2% can arise from laryngeal
cartilage.
 Spine and sacrum: 5%.
 Soft tissues (extraskeletal chondrosarcoma).

168
 Osteosarcoma

Golden modalities
 CT scan.

Protocol advice

 MDCT 1-3 mm with reformatted images.

 MR useful to evaluate for cord, nerve root
impingement
 Staging should also include bone scan and
chest CT scan.

Golden findings

 Aggressive lesion forming immature bone.

Location
 4% of all primary Osteogenic sarcoma occur
in spine and sacrum.
 79% arise in posterior elements.
 17% involve 2 adjacent spinal levels.
 84% invade spinal canal.

169
 Chordoma
 Malignant tumor arising from notochord remnants.

Golden modalities
 MR for soft tissue (STIR/fat-
saturated T2WI, contrast-
enhanced T1WI)
 NECT for bone detail.
Golden findings

 Mass is hyperintense to discs

on T2WI, with multiple septa.
 Histologic identification of
physaliphorous cell confirms
diagnosis.
Location
 Sacrococcygeal> spheno-
occipital> > vertebral body.

170
 Ewing sarcoma
 Round cell sarcoma of bone.

Golden modalities
 MRI best shows involvement of adjacent bones &
soft tissues, which can be underestimated on CT
scan.
 May overestimate tumor size due to peritumoral
edema.

Golden findings

 Permeative lytic lesion of vertebral body or

sacrum.
Location
 Spine: 5% of all Ewing tumors.
 Involve vertebral body before neural arch.
 Sacrum more common site than spine.
 May involve adjacent bones: Vertebrae, ribs, or
ilium.
 Contiguous spread along peripheral nerves from
spine or sacral primary.
 May originate in soft tissue.

171
 Lymphoma
Golden modalities
 MRI + C.

Protocol advice

 Fat-saturated T1WI.
 STIR may be helpful.

Golden findings

 Epidural: Enhancing epidural mass +/- vertebral

involvement
 Osseous: Bone destruction ("ivory" vertebra, rare).
 Leptomeningitic: Smooth/nodular pial enhancement
 Intramedullary: Poorly-defined enhancing mass.
Location
 Multiple types with variable imaging manifestations:
• Epidural lymphoma (epidural): Thoracic> lumbar >
cervical
• Osseous lymphoma (osseous): Long bones> spine
• Lymphomatous leptomeningitis (leptomeningitic)
• Intramedullary lymphoma (intramedullary):
Cervical> thoracic> lumbar
 Secondary> primary involvement
• 30% of systemic lymphomas have skeletal
involvement.
• Primary osseous lymphoma = 3-4% of all malignant
bone tumors.
 Extradural> intradural> intramedullary.
 Common: Epidural extension from adjacent
vertebral/paraspinous disease.
T1 fat sat.

172
 Leukemia
 Acute or chronic myeloid or lymphoid white blood cell neoplasia with spinal
involvement as component of systemic disease.

Golden modalities
 MR imaging.

Protocol advice

 Multiplanar T1WI, T2WI (+ fat-

saturation) or STIR, T1 C+ MRI.
 Whole body STIR MRI (WBMR) proposed
for staging, assessing lesion burden.
 Bone CT with multiplanar reformats to
clarify osseous lesions& quantitate STIR
compression fracture.

Golden findings

 Diffuse osteopenia with multiple

vertebral fractures +/- lytic spine
lesions.
Location
 Children: Multiple long bones and spine
(14%).
 Adults: Predominately axial skeleton.

T1C+

173
 Plasmacytoma
 Solitary monoclonal plasma cell tumor of bone or soft tissue, with no evidence of
multiple myeloma (MM) elsewhere.
 Diagnosis requires:
 Solitary lesion, biopsy showing plasma cells.
 Negative skeletal survey, negative MR spine, pelvis, proximal femora/humeri.
 Negative clonal cells in marrow aspirate.
 No anemia, hypercalcemia, or renal involvement suggesting systemic myeloma.
 Some variations in definitions such as including 2 bone lesions, or < 10% bone
marrow plasmacytosis.

Golden modalities
 Standard MR + STIR, scan entire spine.
 CT-guided biopsy/fine needle
aspiration.
Golden findings

 T1 hypointense marrow with low-

signal, curvilinearareas (charecteristic
minibrain appearance).
Location

 Vertebral body = most common site of

SBP {Solitary bone plasmacytoma}.

Minibrain appearance

174
 Multiple myeloma
 Multifocal malignant proliferation of monoclonal plasma cells within bone
marrow.

Golden modalities
 MRI or MDCT more sensitive than plain films or bone
scintigraphy in MM staging.
• MRI in combination with MDCT as initial staging
modalities.

Protocol advice

 FSE T2 with fat-saturation, STIR, or post-gadolinium

T1WI with fat suppression increases lesion conspicuity.

Golden findings

 Multi-focal, diffuse, or heterogeneous T1 hypointensity.

Location
 Axial skeleton (red marrow) > long bones:
• Spine, skull (mandible), ribs, pelvis.
 87% vertebral fractures between T6 and L4.

175
 Neuroblastic tumor
 Embryonal tumors derived from neural crest cells.

Golden modalities
 MR imaging for diagnosis, pre-surgical
planning.
 MIBG for staging, post-treatment
surveillance.

Protocol advice

 Multiplanar enhanced MRI for tumor

evaluation.
 Bone CT with multi planar reformats to
evaluate bone disease, detect calcifications
 MIBG +/- bone scan for staging, surveillance.

Golden findings

 Abdominal or thoracic paraspinal mass +/-

intraspinal extension, calcification.
Location
 Abdominal (40% adrenal, 25% paraspinal
ganglia) > thoracic (15%) >, pelvic (5%) >
cervical (3%); miscellaneous (12%).

176
 Angiolipoma
 Benign tumor of adipose and vascular elements.

Golden modalities
 Fat suppressed contrast-enhanced T1WI.

Protocol advice

 Axial, sagittal T1 and T2 weighted images pre

contrast.
 Axial and sagittal post-contrast fat suppressed
T1W.
Golden findings

 Hyperintense mass on unenhanced T1WI,

showing enhancement on fat suppressed T1W.
Location
 Uncommon tumors of extremities, trunk, neck.
 Spine involvement uncommon: Extradural> >
intramedullary
 C6 → L4 level
 Rare reports of mediastinal angiolipoma with
spinal canal extension.

177
 Intradural Extramedullary
neoplasms
Meningioma

Hemangiopericytoma

Schwannoma

Neurofibroma

Malignant Nerve Sheath Tumors

CSF Disseminated Metastases

178
 Meningioma
 Slow growing, benign tumor originating from and based on the dura matter.

Golden modalities
 Contrast-enhanced MRI.
 CT (if densely calcified).

Golden findings

 Enhancing intradural/extramedullary mass

with dural "tail"
• 90% intradural (10% extradural and/or
"dumbbell").
 Ca++ < 5%.
 If tumor is dorsal to cord, almost always
meningioma, not neurinoma (nerve roots are
anterolaterally located).
Location
 Typically intradural, extramedullary.
• Can rarely be intraosseous, extradural, even
paraspinous.

179
 Hemangiopericytoma
 Hypervascular neoplasm arising from pericytes.

Golden modalities
 T1 C+ with fat-saturation.

Protocol advice

 Scan entire neural axis to look for primary,

as metastases common, especially in
previously treated cases.
Golden findings

 Vividly enhancing lesion expanding/eroding

spinal canal, with large soft tissue
component.
Location
 Dural based if primary.
 Epicenter in bone if metastatic.

180
 Schwannoma
 Neoplasm of nerve sheath in peripheral nervous system.

Golden modalities
 Best imaging tool: T2WI and T1 WI MRI in sagittal
and axial planes.

Protocol advice

 Post-gadolinium imaging with fat suppression.

 Scan entire spine in asymptomatic patients with
suspected neurofibromatosis type 2.

Golden findings

 Well-circumscribed, "dumbbell" shaped, enhancing

spinal mass.
Location
 70-75% intradural extramedullary.
• Most common intradural extramedullary mass.
 15% completely extradural.
 15% "dumbbell".
• Both intra- and extradural.
 Rare intramedullary.
 Thoracic> cervical = lumbar.

181
 Neurofibroma
 Localized, diffuse, or plexiform neoplasm of nerve sheath.

Golden modalities

 T2WI and T1WI MRI in sagittal and

coronal planes with gadolinium.

Protocol advice

 T2WI with fat suppression or STIR

improves lesion detection.
Golden findings

 Bulky multilevel spinal nerve root tumors

in patient with stigmata of
neurofibromatosis type 1.
Location
 Intradural extramedullary
 Paraspinal
 Variable involvement of spinal root,
neural plexus, peripheral nerve, or end
organs.
 NFl
• Cervical> thoracic and lumbar.
• Uni- or bilateral.

182
Malignant nerve sheath tumors
 Malignant lesion of neural origin involving spinal root, neural plexus, peripheral
nerve, or end organs.

Golden modalities
 MRI: Best soft tissue delineation.

Protocol advice

 T1WI, T2WI, and T1 C+ MR in multiple

planes.

Golden findings

 Large infiltrative, often hemorrhagic, soft

tissue mass related to neurovascular
bundle.
Location
 Paravertebral, rare intraspinal:
• Posterior mediastinum
• Retroperitoneum
 Proximal portion of extremities.

183
 CSF Disseminated metastases
 Spread of malignant tumors through the subarachnoid space.

Golden modalities
 Image entire neuraxis:
 High-resolution T2WI.
 Contrast-enhanced, fat suppressed T1
WI.
 STIR (look for bony metastases).
 Do it prior to craniotomy.

Golden findings

 Smooth/nodular enhancement along cord,

roots.
Location
 Any point along CSF pathway (including
central canal).

184
 Intramedullary
neoplasms
Astrocytoma
Cellular Ependymoma
Myxopapillray Ependymoma, of the spinal Cord
Hemangioblastoma of the spinal Cord
Spinal Cord Metastases
Paraganglioma
Melanocytoma

185
 spinal cord Astrocytoma
 Primary neoplasm of astrocytic origin within spinal cord.

T1 c+ T2 T2

Golden modalities
 Contrast-enhanced MR is single best test for
any form of myelopathy.

Golden findings

 Enhancing infiltrating mass expanding cord.

Location
 Cervical> thoracic.

186
 Cellular Ependymoma
 Neoplasm of ependyma lining spinal cord central Canal.

Golden modalities
 T2WI and T1WI MR in sagittal and axial
planes with gadolinium.

Protocol advice
 Fat suppression with T2WI and T1WI plus
gadolinium.

Golden findings

 Circumscribed, enhancing cord mass with

hemorrhage.
Location
 Cervical> thoracic> conus.

187
 Myxopapillary Ependymoma
 Slow growing glioma arising from ependymal cells of filum terminale.

Golden modalities
 Sagittal and axial T2WI and T1 WI MRI with
gadolinium.

Protocol advice
 Always include the conus in patients with back
pain.

Golden findings

 Enhancing cauda equina mass with hemorrhage.

Location

 Almost exclusively in conus, filum terminale, cauda

equina.
 Ependymomas outside of CNS rare:
 Metastases or direct extension of primary CNS
lesion after surgery.
• Direct extension to sacrococcygeal area from
cord ependymoma or myxopapillary
Ependymoma.
• Primary presacral, pelvic, or abdominal lesion.
• Primary myxopapillary Ependymoma of skin or
subcutaneous tissue in sacrococcygeal region.

MR Myelography

188
 Hemangioblastoma
 Low grade, capillary rich neoplasms of cerebellum and spinal cord that occur
sporadically or in setting of von Hippel-Lindau syndrome.

Golden modalities
 Contrast-enhanced MR.
 Scan brain, entire spine in patients with
known/suspected VHL.
 DSA for large lesions/pre-operative
embolization.
Golden findings

 Intramedullary mass with serpentine "flow

voids.
Location
 Subpial.
 Posterior aspect of the spinal cord - often
associated with intraspinal cyst.
 Rarely anterior aspect of cord.

189
Spinal cord metastases

Golden modalities
 MRI.
 T2WI and T1 C+.
 Fat-saturation helps conspicuity.

Protocol advice
 Double-contrast or delayed contrast T1 WI
in clinically suspected case.

Golden findings

 Focal, enhancing cord lesion(s) with

extensive edema.
Location
 Any cord segment.
 Conus least common.

190
 Paraganglioma
 Extra adrenal, spinal paraganglioma composed of chromaffin cells (groups of
cells associated to the autonomous system).

T1 T1 C+ T2

Golden modalities
 Contrast-enhanced MRI (do entire
spine).
Golden findings

 Vascular cauda equina mass.

Location
 Spine is rare extra-adrenal site of
paraganglioma
 Most common in cauda equina.
 Rarely occur: cervical, thoracic spine.

191
 Melanocytoma

 Pigmented primary neoplasm of the CNS, involving cord or meninges.

 Distinct from other melanotic lesions such as meningioma, schwannoma,
melanoma.

Golden modalities
 MR C+ of entire spine, brain to exclude
additional lesions and possiblity of
metastatic melanoma.

Protocol advice
 T1, T2WI and post-contrast T1WI.

Golden findings

 Intradural enhancing mass showing T1

hyperintensity, not fat suppressing.
Location
 Intradural mass} either
intradural/extramedullary or rarely
intramedullary.

192
 Non-Neoplastic
Cysts and Tumor
Mimics

Cysts
Arachnoid Cyst
Posterior Sacral Meningocele
Perineural Root Sleeve Cyst
Syringomyelia

193
 Arachnoid cyst
 Intraspinal extramedullary loculated cerebral spinal fluid (CSF) collection.

Golden modalities
 Sagittal and axial T2WI and T1 WI MR with
gadolinium.

Protocol advice
 Delayed imaging on post-myelography CT to
allow filling of AC.

Golden findings

 Nonenhancing extramedullary loculated CSF

intensity collection displacing cord or nerve
roots.
Location
 Primary AC:
• Extradural: Posterior or posterolateral
lower thoracic spine.
• Intradural: Dorsal mid thoracic spine.
• Anterior location uncommon.
 Secondary AC: without specific location.

194
 Posterior sacral meningocele
 Posterior herniation of dural sac through vertebral arch defect in lumbosacral
spine.
 Spina bifida: Spinal dysraphism involving bony elements of spine.

Non-union of neural arch> unfused vertebral body.

Golden modalities
 Sagittal and axial T2WI and T1WI MRI.

Protocol advice
 Image entire spine to exclude other
congenital spinal lesions.

Golden findings

 Focal outpouching of thecal sac through

defect in posterior arch of a vertebra.
Location
 Lumbosacral> cervical or thoracic.

195
 Perineural root sleeve cyst
(Tarlov perineural cyst)
 Dilatation of arachnoid and dura of spinal posterior nerve root sheath,
containing nerve fibers.

STIR T2

Golden modalities
 Sagittal and axial T2WI and T1 WI MRI.

Protocol advice
 Gadolinium to exclude solid mass if signal
intensity not entirely cystic.
Golden findings

 Cerebral spinal fluid (CSF) density/intensity

masses enlarging sacral neural foramina.
Location
 Anywhere along spine:
• More common in lower lumbar spine and
sacrum.
• S2 and S3 nerve roots most commonly
involved.

196
 Syringomyelia
 Hydromyelia = cystic central canal dilatation.
 Syringomyelia = cystic spinal cord cavity not contiguous with central cord canal
 Syringobulbia = brain stem syrinx extension.
 Syringocephaly = brain/cerebral peduncle syrinx extension.
 Syringohydromyelia = features of both syringomyelia and hydromyelia.

Golden modalities
 MR imaging.

Protocol advice
 Sagittal and axial T1WI, T2WI, T1 C+ MR.
 Cine PC CSF flow MR.

Golden findings

 Expanded spinal cord with dilated, beaded, or

sacculated cystic cavity.
Location
 Intramedullary spinal cord.

197
 Non-Neoplastic Masses
and Tumor mimics

Epidural Lipomatosis

Heterogeneous Fatty Marrow

Langerhans Cell Histiocytosis

Acquired Epidermoid Tumor

Fibrous Dysplasia

Kummel Disease

198
 Epidural lipomatosis
 Excessive accumulation of intraspinal fat causing cord compression and
neurologic deficits.

Golden modalities
 Sagittal and axial T1WI and T2WI MRI.

Protocol advice
 Fat suppression to confirm adipose tissue.

Golden findings

 Abundant epidural fat in mid-thoracic and

distal lumbar spinal canal compressing thecal
sac.
Location
 Thoracic spine: 58-61%:
• T6-T8.
• Dorsal to spinal cord.
 Lumbar spine: 39-42%:
• L4-5.
• Circumferential surrounding thecal sac.

199
 Heterogeneous fatty marrow
 Irregularly distributed fatty, hematopoietic and fibrous elements in bone
marrow.
 Red marrow: Hematopoietic marrow.
 Yellow marrow: Fatty marrow.

Golden modalities
 CT in questionable cases to exclude lytic lesions.

Protocol advice
 1-3 mm helical scans with sagittal, coronal
reformations.
Golden findings

 Red marrow signal intensity equal or higher than

intervertebral disc on T1 WI.
Location
 Vertebral bodies.
 Yellow marrow often distributed around central
perforating vein.
 Yellow marrow adjacent to endplates in
degenerative disc disease.
 After bone marrow transplantation: Fat centrally in
vertebral body, red marrow at periphery.
 Loss of red marrow in regions of radiation therapy.

200
 Langerhans cell histiocytosis
 Abnormal histiocyte proliferation producing granulomatous skeletal lesions.

Golden modalities
 MR imaging.

Protocol advice
 Multiplanar enhanced MRI to evaluate soft
tissues, determine epidural extension.
 Bone algorithm CT with multiplanar reformats to
define osseous destruction, vertebral height loss.

Golden findings

 Child presenting with vertebra plana sparing disc

space.
Location
 Calvarium> mandible> long bones> ribs> pelvis>
vertebrae.
 Spinal involvement
• Thoracic (54%) > lumbar (35%) > cervical (11 %).
• Children> adults.

201
 Acquired epidermoid tumor
 Acquired intraspinal mass arising from iatrogenically implanted epithelial
elements.

Golden modalities
 Sagittal and axial T2WI and T1WI MR with
gadolinium.

Protocol advice
 Heavily T1 weighted sequence may
distinguish subtle extramedullary mass from
CSF.
• Inversion recovery or SPGR.
 CT myelography can supplement MRI in
delineating extramedullary CSF-isointense
mass.
 Navigated diffusion imaging may be helpful
in diagnosing epidermoid tumor.
Golden findings

 Nonenhancing intradural mass similar to

cerebral spinal fluid (CSF) intensity within
cauda equina.
Location
 Lumbar spine most common.

202
 Fibrous dysplasia
 Monostotic: Single lesion.
 Polyostotic: Multiple lesions - often associated with growth disturbances.
 McCune Albright Syndrome: Polyostotic FD, precocious puberty, cafe-au-lait skin
lesions.

T1 T1 fat sat

Golden modalities
 CT scan.

Protocol advice
 1-3 mm sections.
Golden findings

 Mildly expansile lesion with "ground glass" bone

matrix.
Location
 Rarely involves spine:
• Neural arch> vertebral body.
• Spine involvement almost always with
polyostotic disease.
 Commonly involves pelvis:
• Innominate bone much more frequently
involved than sacrum.

203
 Kummell disease
 Delayed, post-traumatic collapse of vertebral body.

Golden modalities
 CT scan.

Protocol advice
 1-3 mm thick helical images with sagittal
and coronal reformations.

Golden findings

 Gas-filled cleft in vertebral body.

Location
 Thoracic or lumbar vertebral body.

204
 Vascular
lesions
Type I DAVF

Type IIAVM

Type III AVM

Type IV AVF

Cavernous Malformation, Spinal Cord

Spinal Cord Infarction

Subarachnoid Hemorrhage

Spontaneous Epidural Hematoma

Subdural Hematoma

Superficial Siderosis

205
Spine vascular malformation
classification

 Type 1: Dural arteriovenous fistula (DAVF):

• Most common = type1 (up to 80%).

 Type II: Intramedullary glomus type AVM (similar to brain AVM).

 Type III: Juvenile-type AVM (intramedullary, extramedullary).
 Type IV: Intradural extra/perimedullary AVF.

206
 Type 1 DAVF
 Spinal arteriovenous (AV) fistula, present within dura, with intradural distended
draining veins.

Golden modalities
 First perform focused MR imaging with small
field of view, thin-slices in both sagittal (3
mm/0 mm gap) and axial planes (4 mm/0
mm gap)
 T1 WI, T2WI, T1 C+ sequences in both
planes
 CTA technically less demanding than MRAi is
capable of superior resolution of nidus
location, draining veins
 Use selective spinal arteriography to confirm
diagnosis and direct treatment planning.
 Myelography no longer primary or
secondary diagnostic tool with availability of
MRA, CTA.

Golden findings

 Abnormally enlarged, hyperintense distal

cord covered with dilated pial veins.
Location
 Intradural, extramedullary flow voids from
distended draining veins.
 Most commonly occur at level of conus.

207
 Type II AVM
 Direct arterial/venous communications forming compact nidus within cord.

Golden modalities
 Contrast-enhanced MRI; consider spinal
angiography +/- embolization.

Golden findings

 Type II: Intramedullary nidus (may extend to

dorsal subpial surface).
Location
 Type II: Intramedullary nidus within cervical
or thoracic cord.

208
 Type III AVM
 Direct arterial/venous communications without capillary bed involving cord.

Golden modalities

 Contrast-enhanced MRI; CTA; consider spinal

angiography +/- embolization.

Golden findings

 Type III: Nidus may have extramedullary and

extra spinal extension.
Location
 Type III: Intramedullary - extramedullary.

209
 Type IV AVF
 Direct intradural, extramedullary arterial/venous communication from ASA, or
PSA to draining vein without capillary bed.

Golden modalities

 Contrast-enhanced MRI; CTA; consider spinal

angiography +/- embolization.

Golden findings

 Ventral fistula (venous varices displace,

distort cord).
Location
 Intradural location for fistula, adjacent to
the cord.
 Draining veins may be pronounced on dorsal
or ventral surface of cord.

210
 Cavernous malformation
 Vascular lesion with lobulated, thin sinusoidal vascular channels, no interspersed
neural tissue.

T2 T2*GRE
T1

Golden modalities
 MRI spine (use gradient echo, contrast
sequences to exclude other etiologies)
 Scan the brain (may show other lesions).

Golden findings

 Locules of blood with fluid-fluid levels

surrounded by very T2 hypointense rim.
Location
 Spinal cord uncommon site, 3-5% of all
cavernous malformations.

211
 Spinal cord infarction
 Permanent tissue loss in spinal cord due to vessel occlusion, typically radicular
branch of vertebral artery (cervical cord) or aorta (thoracic & lumbar cord).

Golden modalities
 T2WI sagittal and axial, 3 mm slice
thickness; DWI of cord.

Golden findings

 Focal hyperintensity on T2WI in slightly

expanded cord.
Location
 Most frequent in thoracic cord because of
arterial border zone.

212
 Subarachnoid hemorrhage
 Hemorrhage into spinal subarachnoid space from variety of etiologies.

Golden modalities
 MRI for evaluation of underlying
etiology (AVM, tumor).

Protocol advice
 Sagittal, axial T1WI, T2WI,
Gradient echo + post-contrast
T1WI.
 Scan whole spinal axis, + brain if
unknown etiology.

Golden findings

 Fluid-fluid level within thecal sac.

Location
 Lumbar> thoracic> cervical.

213
Spontaneous epidural hematoma
 Accumulation of hemorrhage between dura & spine not caused by significant
trauma or iatrogenic procedures.

Golden modalities
 Sagittal and axial T1 WI and T2WI MR
• NECT may be helpful in confirming acute
T1 isointense SSEDH with focal enhancement
• Post-myelography CT in patients with
instrumentation.
 Spinal angiography not indicated unless
findings of arteriovenous malformation
present.

Golden findings

 Extradural multisegmental T1 hyperintense

fluid collection.
Location
 Thoracic, lumbar> cervical.
 Cervicothoracic region more common in
children.
 Dorsal> ventral> circumferential.

214
 Subdural hematoma
 Accumulation of blood between dura, arachnoid.

Golden modalities
 Sagittal and axial T2WI and T1WI MR.
 Spinal angiography not indicated unless
findings of arteriovenous malformation
present.

Golden findings

 Intradural collection hyperintense on T1 WI,

predominantly hypointense on T2WI or
gradient-echo imaging.
Location
 Thoracolumbar> lumbar or lumbosacral>
cervical.
 Ventral, dorsal, lateral, or circumferential.

215
 Superficial siderosis
 Recurrent subarachnoid hemorrhage (multiple etiologies) causing hemosiderin
deposition on cord, nerve surface.

Golden modalities
 MR brain/spine.
 Diagnosis of siderosis necessitates search for
underlying cause of repetitive subarachnoid
hemorrhage.

Protocol advice
 Brian MR: T1WI, T2WI, FLAIR, post-contrast
T1WI, T2* GRE.
 Spine: Scan total spine with sagittal T2WI,
T2* GRE, post-contrast T1 WI.

Golden findings

 Diffuse hypointensity of cord/brain surface

on T2WI, gradient echo images.
Location
 Cerebellum, brain stem, cerebrum, cord
cranial nerve.

216
 Spinal
Manifestations of
Systemic Diseases

Paget Disease

Hyperparathyroidism

Renal Osteodystrophy

Hyperplastic Vertebral Marrow

Myelofibrosis

Extramedullary Hematopoiesis

Tumoral Calcinosis

217
 Paget disease
 Chronic metabolic disorder of abnormal bone remodeling in adult skeleton.

Picture framing sign

Golden modalities
 Radiography cost effective.
 CT if question of metastasis/bone
destruction.
 MR best in evaluating neurologic symptoms
 Bone scan best in determining extent of
disease, assessing disease activity,
monitoring response to treatment.

Golden findings

 Enlarged vertebra with trabecular

coarsening and cortical thickening.
Location
 Lumbar spine most common: L3, L4.

218
 Hyperparathyroidism
 Increased levels of hyperparathyroid hormone.
 Osteitis fibrosa cystica: Florid bony changes due to longstanding HPT.
 Brown tumor: Reactive giant cell lesion due to HPT.
 HPT may be primary, secondary or tertiary.

Rugger-gersey spine

Golden modalities
 Radiography of hands:
• Subperiosteal bone resorption, cortical
thinning, acro-osteolysis.

Golden findings

 Osteopenia.
 Endplate erosions (arrows) are clue to
diagnosis.
Location
 Peripheral skeleton> spine.

219
 Renal osteodystrophy
 Bony changes due to chronic, end-stage renal disease.
 Secondary hyperparathyroidism (HPT), osteomalacia, bone sclerosis, aluminum
toxity contribute to finding.

Rugger-gersey spine

Golden modalities
 Radiography.

Golden findings

 "Rugger jersey" spine.

Location
 Involves axial and appendicular skeleton.

220
Hyperplastic vertebral marrow
 Physiologic process where fatty marrow is converted to red marrow in response
to systemic stress.

Golden modalities
 MRI modality of choice in marrow imaging
• High sensitivity in detecting increased
marrow cellularity on T1 WI.

Protocol advice
 STIR or T2WI MRI with fat-saturation
• To distinguish hematopoietic elements
from marrow edema or neoplastic
infiltration.
 Pre & post-gadolinium T1 WI with fat
suppression also helpful.

Golden findings

 Intervertebral discs Hyperintense compared

to vertebral marrow on T1 WI.
Location
 Calvarium, spine, ribs, pelvis initially
involved.
• Followed by extremities.

221
 Myelofibrosis
 Histomorphologic pattern of fibrosis in bone marrow which may be associated
with various disorders.
 Myelodysplastic syndromes: Myeloproliferative disorders which may show
myelofibrosis at some point in their evolution.

Golden modalities
 MRI.

Protocol advice
 Sagittal T1WI, T2WI, STIR.

Golden findings

 Very low signal intensity in bone marrow on

all sequences of MR.

222
Extramedullary hematopoiesis
 Epidural ± paravertebral proliferation of hematopoietic tissue in response to
profound chronic anemia.

Golden modalities
 Sagittal, axial T2WI + T1 C+ MR.

Golden findings

 Minimally enhancing isointense thoracic

intra- or paraspinal masses with associated
diffuse marrow hypointensity.
Location
 Mid thoracic> cervical, lumbar:
• Epidural.
• Paravertebral.

223
 Tumoral calcinosis
 Benign periarticular soft tissue hyperplasia, calcification.

Golden modalities
 CT shows calcific lesions, extent, presence or
absence of bone destruction.

Protocol advice
 Axial thin section CT, multiplanar reformats.

Golden findings

 Nonaggressive appearing calcific mass

centered about large synovial joints:
• Rare.
• Commonly misdiagnosed.
Location
 Predilection for large joints:
• Hip
• Shoulder
• Elbow
• Spinal involvement uncommon.

224
 Plexus &
Peripheral Nerve
lesions

225
Superior Sulcus Tumor
Muscle Denervation
Brachial Plexus Traction Injury
Traumatic Neuroma
Thoracic Outlet Syndrome
Idiopathic Brachial Plexus Neuritis
Radiation Plexopathy
Hypertrophic Neuropathy
Peripheral Nerve Tumor
Peripheral Neurolymphomatosis
Radial Neuropathy
Femoral Neuropathy
Ulnar Neuropathy
Suprascapular Nerve Entrapment
Median Nerve Entrapment
Common Peroneal Neuropathy
Posterior Tibial Nerve Entrapment

226
 Superior sulcus tumor

{pancost tumor}
 Benign or malignant tumor extending to superior thoracic inlet with severe
shoulder/arm pain along C8, T1, T2 nerve trunks, Horner syndrome, weakness +
atrophy of intrinsic hand muscles (Pancoast syndrome).
 Non-small cell lung carcinoma most frequent cause.

Golden modalities Golden findings

 MR and CT complementary:
• MR demonstrates apical soft tissue  Soft tissue mass involving
involvement & relationship to brachial
lung apex with rib
plexus/subclavian vessels.
• CT shows mediastinal nodes, pulmonary, destruction.
hepatic or adrenal metastases. Location
 Lung apex and adjacent
Protocol advice chest wall, brachial
 3 plane T1 W, T2W images, post-contrast plexus, cervicothoracic
axial to define bone, epidural extension, junction vertebral bodies.
relationship to vessels/scalene musculature.

227
 Muscle denervation
 Muscle signal/density alteration and volume change following denervation.

Golden modalities
 MR imaging.

Protocol advice
 Axial T1 WI, fat-saturated T2WI or STIR MR
best to assess for muscle denervation.
Golden findings

 Asymmetric muscle volume loss with fatty

replacement → chronic denervation.
Location
 Paraspinal +/- iliopsoas muscles.

228
 Brachial plexus traction injury
 Stretch injury or avulsion of ≥ 1 cervical roots, brachial plexus.

Golden modalities
 High-resolution MR imaging (MR
Neurography).

Protocol advice
 Coronal, sagittal oblique T1WI and
STIR MR.
 CT myelography if MR
inconclusive.
Golden findings

 Lateral CSF-containing dural sac

outpouching(s) devoid of neural
element.
Location
 Brachial plexus, pre- or post-
ganglionic nerve roots.

229
 Traumatic neuroma
 Non-neoplastic nerve growth secondary to major or minor trauma.

Golden modalities
 MR imaging.

Protocol advice
 T1 and T2WI along long and short axes of
nerve.
 T1 C+ in two planes to confirm enhancement,
origin in nerve.

Golden findings

 Mass arising in nerve at stump or site of

nerve injury.
Location
 Post amputation.
 Head and neck secondary to tooth extraction.
 Brachial plexus.
 Morton neuroma: Interdigital plantar nerve,
usually between 3rd and 4th toes.

230
 Thoracic outlet syndrome
 Neural, venous, and/or arterial compressive syndrome at thoracic outlet.

Golden modalities
 MR imaging.

Protocol advice
 Multiplanar T1WI and STIR MR through
thoracic outlet.
 Plain radiography or CT → cervical rib, aberrant
transverse process
 MRA/MRV in neutral, abducted arm position.

Golden findings

 Radiography: Cervical rib in symptomatic

patient.
 MRI: Neural or vascular compression within
interscalene or costocervical tunnels.
Location
 Interscalene, costoclavicular space,
retropectoralis minor space (subcoracoid
tunnel).

231
 Idiopathic brachial plexus neuritis
 Immune-mediated neuropathy of brachial plexus.

Golden modalities
 MR imaging.

Protocol advice
 T1WI, T2WI or STIR along long and short axes
of symptomatic muscles.
 MRI of shoulder should have 16-18 cm FOV on
coronal images.
 Include spinoglenoid notch, quadrilateral
space to exclude mass in these regions.
 Imaging of brachial plexus excludes brachial
plexus mass.
 Not needed if patient gives characteristic
history, unless symptoms do not resolve.

Golden findings

 Homogeneously increased signal on T2WI in

one or more muscles of shoulder.
Location
 Any muscle innervated by brachial plexus:
 Most common: Rotator cuff, deltoid,
biceps, triceps.
 Uncommon: Brachialis, forearm muscles,
diaphragm, serratus anterior (long
thoracic nerve).
 Sometimes bilateral.
 May cause pure sensory nerve deficit.

232
 Radiation plexopathy
 Post-radiation brachial plexus or lumbosacral plexus inflammation.

Golden modalities
 High-resolution MRI (MR Neurography).

Protocol advice
 Coronal, sagittal oblique T1WI, STIR, fat-
saturated T1 C+ MR.
Golden findings

 Smooth, diffuse T2 hyperintensity +/-

enhancement of multiple plexus element.
Location
 Upper BP (C5-7) > lower BP (C8, T1)
 Lumbosacral plexus following radiotherapy
for prostate, cervical carcinoma.

233
 Hypertrophic neuropathy
 Hereditary disorder characterized by focal or diffuse peripheral nerve
enlargement.

Golden modalities
 High-resolution MR imaging (MR
Neurography).

Protocol advice
 Axial T1WI, fat-saturated T2WI or STIR, fat-
saturated T1 C+ MR.

Golden findings

 Focal or diffuse peripheral nerve

enlargement + distal extremity atrophy.
Location
 Peripheral nerves +/- spinal nerve roots.

234
 Peripheral nerve tumors
 A grouping of benign and malignant primary tumors of peripheral nerves.

Golden modalities
 MRI.

Protocol advice
 T2WI or STIR, T1 C+ long and short axis of
tumor.

Golden findings

 Mass along course of peripheral nerve.

235
 Peripheral neurolymphomatosis
 Perineural plexus or peripheral nerve lymphomatous infiltration.

Golden modalities
 MR imaging.

Protocol advice
 Multiplanar high-resolution MRI (T1 WI, fat-
saturated T2WI or STIR, fat-saturated T1C+.

Golden findings

 Diffusely infiltrating plexus or peripheral

nerve lesion in patient with lymphoma.
Location
 Plexus or peripheral nerve.

236
 Radial neuropathy
 Radial nerve injury at one of several characteristic locations along nerve course.

Golden modalities
 MR imaging.

Protocol advice
 Axial T1 WI, fat-saturated T2WI or STIR, T1 C+ MR.
Golden findings

 Focal radial nerve enlargement, abnormal T2

hyperintensity.
Location
 Radial nerve may be injured proximally (brachial
plexus) → distally (posterior interosseous, radial
sensory nerves).
 Most commonly entrapped at mid humeral shaft or
fibrous arch of Frohse above elbow.

237
 Femoral neuropathy
 Femoral nerve entrapment or injury secondary to direct trauma, compression,
stretch injury, or ischemia.

Golden modalities
 High-resolution MR imaging.

Protocol advice
 Axial T1 WI, fat-saturated T2WI or STIR MR,
fat-saturated T1 C+ MR.

Golden findings

 Femoral nerve enlargement, abnormal T2

hyperintensity.
Location
 Injury most common in psoas muscle body,
iliopsoas groove, or femoral canal.

238
 Ulnar neuropathy
Cubital tunnel syndrome
 Partial fixation, compression, or distortion of ulnar nerve.
 Most commonly occurs within cubital tunnel at elbow; uncommon within Guyon
tunnel at wrist, or secondary to brachial plexus inflammation.

Golden modalities
 High-resolution MR peripheral nerve imaging
(MR Neurography).

Protocol advice
 Axial T1WI, fat-saturated T2WI, and STIR
imaging using surface coil.

Golden findings

 Ulnar nerve enlargement +/- T2

hyperintensity at cubital or Guyon tunnel in
symptomatic patient.
Location
 Most common at elbow near medial
epicondyle (cubital tunnel), less common at
ulnar wrist (Guyon tunnel).

239
Suprascapular nerve entrapment
 Suprascapular nerve: Motor nerve to supraspinatus and infraspinatus muscles.
 Impingement may occur at either spinoglenoid or suprascapular notch.
 Spino glenoid notch: at superior border of scapula, roofed by superior transverse
ligament.

Golden modalities
 MRI.

Protocol advice
 Routine shoulder MRI, field of view to include
spinoglenoid notch.
Golden findings

 Mass compressing nerve and abnormal signal

in innervated muscles.
Location
 Occurs at suprascapular or spinoglenoid
notch:
• Suprascapular notch: Entrapment affects
both supraspinatus and infraspinatus.
• Spinoglenoid notch: Entrapment affects
infraspinatus only.

240
 Carpal tunnel syndrome
 Carpal tunnel: Fibro-osseous tunnel at volar aspect of wrist.
 Contains median nerve and flexor tendons.

Golden modalities
 MRI.

Protocol advice
 STIR sequences in long and short axis of
nerve.
 T1 WI or PDWI in axial plane for definition of
anatomy.
Golden findings

 Increased signal in nerve on STIR MRI.

Location
 Elbow or wrist.

241
 Common peroneal neuropathy
 Common peroneal nerve entrapment at fibular head.

Golden modalities
 High-resolution MR imaging (MR
Neurography).

Protocol advice
 Axial T1WI, fat-saturated T2WI, and STIR (T1
C+ MR if scar or neoplasm suspected) using
surface or knee coil.
Golden findings

 Common peroneal nerve enlargement +/- T2

hyperintensity, architectural distortion at
fibular head in symptomatic patient.
Location
 Knee (fibular head level).

242
 Posterior tibial nerve entrapment
{Tarsal tunnel syndrome}
 Entrapment of posterior tibial nerve in the tarsal tunnel.

Golden modalities
 MRI.

Protocol advice
 Coronal, axial T2WI with fat-saturation.

Golden findings

 Space-occupying lesion in tarsal tunnel.

Location
 Tarsal tunnel
 Fibro-osseous tunnel beneath medial
malleolus, inferior to sustentaculum tali.
 Anterior tarsal tunnel
 Fascial continuation of constricting space
along lateral and medial plantar n.

243
 Post-Radiation and
Chemotherapy
complications

Radiation Myelopathy

Post irradiation Vertebral Marrow

244
 Radiation myelopathy
 Damage of neural tissue in spinal cord following therapeutic radiation of intrinsic
or nearby disease.

Golden modalities
 MRI with T1 C+.

Protocol advice
 Fat-saturated T1 C+.

Golden findings

 Cord swelling& intramedullary

enhancement.
Location
 Within radiation field.
 Mainly in white matter of lateral
spinothalamic tracts, dorsal columns.

245
Post irradiation vertebral marrow
 Transformation of vertebral marrow into fatty marrow after therapeutic
irradiation.

Golden modalities Golden findings

 MRI is the modality of choice in
marrow imaging.
• T1 WI most sensitive.  Marrow signal intensity within
radiotherapy portal similar to
Protocol advice
 STIR or FSET2WI with fat-saturation to subcutaneous fat on T1WI.
better assess recurrent or residual
marrow disease.
 Pre- and post-gadolinium T1 WI with Location
fat-suppression also increases lesion
 Corresponds to site of irradiation.
conspicuity.

246
 REFERENCES

The text material reference is: diagnostic imaging

{spine}.

Thank you

247