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N EURO -R ADIOLOGY R AJ R EDDY Neurosurgery Prince of Wales Hospital SPINE.

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Presentation on theme: "N EURO -R ADIOLOGY R AJ R EDDY Neurosurgery Prince of Wales Hospital SPINE."— Presentation transcript:

1 N EURO -R ADIOLOGY R AJ R EDDY Neurosurgery Prince of Wales Hospital SPINE

2 Objectives  Review spine anatomy on X-ray, CT and MRI  Approach to interpretation of imaging  Differential diagnoses for common spine lesions

3 Imaging Modalities

4 Basic Imaging Types  X-ray  CT (Computed Tomography)  MRI (Magnetic Resonance Imaging)  Angiography

5 X-ray  Limited Use  Evaluation of:  Bones (fractures)  Calcification

6 Computed Tomography

7 Computed Tomography (CT)  Tomography  Imaging in sections, or slices  Computed  Geometric processing used to reconstruct an image  Computerized algorithms

8 Computed Tomography  Uses X-rays  Dense tissue, like bone, blocks x-rays  Gray matter weakens (attenuates) the x-rays  Fluid attenuates even less  A computerized algorithm (filtered backprojection) reconstructs an image of each slice

9 CT Image Formation X-ray detector X-ray X-ray tube

10 CT Image Formation Backprojection

11 CT Image Reconstruction – 6 Slices

12 CT Image Reconstruction – 12 Slices

13 CT Image Reconstruction – Final

14 Magnetic Resonance Imaging

15 What is MR?  Not an X-ray, electromagnetic  Electromagnetic field aligns all the protons in the brain  Radiofrequency pulses cause the protons to spin  Amount of energy emitted from the spin is proportional to number of protons in the tissue  No ferromagnetic objects

16 Angiography

17  Real time X-ray study  Catheter placed through femoral artery is directed up aorta into the cerebral vessels  Radio-opaque dye is injected and vessels are visualized  Gold standard for studying cerebral vessels.

18 Angiography AP Right ICA Lateral Right ICA

19 Angiography AP Right Vertebral

20 Planes of Section  Axial (transverse)  Sagittal  Coronal  Oblique

21 Anatomy

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26 Radiographic Anatomy

27 Cervical Spine – AP View

28 Cervical Spine – Lateral View

29 Cervical Spine – Open-Mouth (Dens) View

30 Cervical Spine – Oblique View

31 Lumbar Spine – AP View

32 Lumbar Spine – Lateral View

33 Approach to Xrays

34 Approach to Spine Imaging A – adequacy/alignment B – bone C – cord/canal/cartilage D – disc E – extras

35 C7-T1

36 Alignment 1. prevertebral2. anterior spinal3. posterior spinal4. spino-laminar

37 Cartilage  Predental Space should be no more than 3 mm in adults and 5 mm in children  Increased distance may indicate fracture of odontoid or transverse ligament injury

38 Cartilage  Disc Spaces  Should be uniform  Assess spaces between the spinous processes

39 Soft tissue  Nasopharyngeal space (C1) - 10 mm (adult)  Retropharyngeal space (C2-C4) mm  Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults)  Extremely variable and nonspecific

40 CT Anatomy

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43 CT

44 MRI Anatomy

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55 Compartments of the Spine a. Intradural, intramedullary b. Intradural, extramedullary c. Extradural, extramedullary a.c.b.

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61 Pathology

62 Spine Pathology  Trauma  Degenerative disease  Tumors and other masses  Inflammation and infection  Vascular disorders  Congenital anomalies

63 Trauma

64 Evaluating Trauma  Fracture – plain film / CT  Dislocation – plain film / CT  Ligamentous injury – MRI  Cord injury – MRI  Nerve root avulsion – MRI

65 To x-ray or not to x-ray?  13 million trauma patients at risk for cervical spine injury  very low incidence of cervical spine fracture In alert and stable trauma patients:  x-rays performed on 69%  CT performed in 5%  acute injury in 2.6%  stabilization in 2.2% Stiell IG et al. The Canadian C-Spine Rule versus NEXUS in Patients with Trauma. N Engl J Med

66 NEXUS C-Spine Rules

67 Canadian C-Spine Rules (CCR) Stiell IG. The CCR in Alert and Stable Trauma Patients. JAMA

68 Which one is better? NEXUS  Pro: easy to use  Con: poor sensitivity and specificity (90.7% and 36.8%)  Con: more x-rays (67%) CCR  Pro: great sensitivity and specificity (99.4% and 45.1%)  Pro: less x-rays (55.9%)  Con: more difficult to remember and use Stiell IG et al. The Canadian C-Spine Rule versus NEXUS in Patients with Trauma. N Engl J Med

69 Plain film findings may be very subtle or absent! Anterolisthesis of C6 on C7 (Why?)

70 CT Fractures of C6 left pedicle and lamina

71 CT – 2D Reconstructions Acquire images axially… …reconstruct sagittal / coronal

72 26M MVA

73 Vertebral body burst fx with retropulsion into spinal canal 2D Reformats

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76 Vertebral Artery Dissection/Occlusion Secondary to C6 Fracture

77 Hyperflexion fx with ligamentous disruption and cord contusion

78 Nerve root avulsion Axial Coronal Sagittal

79 Degenerative Disease

80 Degenerative Disc (and Facet Joint) Disease Foraminal stenosis Thickening/Buckling of Ligamentum Flavum

81 Degenerative Disc (and Facet Joint) Disease

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84 Lumbar Spinal Stenosis

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89 Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis Note the trefoil shape of stenotic spinal canal

90 Lumbar Spinal Stenosis Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis Note the trefoil shape of stenotic spinal canal

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92 Foraminal Stenosis Neural foramen

93 Cervical Spinal Stenosis

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95 MRI - Degenerative Disc Disease  % have degenerated disc  % have degenerated disc  % have degenerated disc  <6020% have asymptomatic disc herniation Age: Conclusion:Abnormal findings on MRI frequently DO NOT relate to symptoms (and vice versa) !

96 MRI – Herniated Disc Levels  85-95% at L4-L5, L5-S1  5-8% at L3-L4  2% at L2-L3  1% at L1-L2, T12-L1  Cervical: most common C4-C7  Thoracic: 15% in asymptomatic pts. at multiple levels, not often symptomatic

97 Annular

98 Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

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103 Protrusion Extrusion Extrusion Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

104 Protrusion Protrusion w/ migration Protrusion w/ migration + sequestration Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

105 Abnormal Disc Bulge SymmetricAsymmetric Herniation Broad-basedFocal ExtrusionProtrusion SequesteredMigratedNeither > 180º< 180º < 90º90º–180º No waistWaist* Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” *(In any plane)

106 Central Disc Protrusion

107 L5-S1 Disc Extrusion Into Lateral Recess with Impingement of R S1 Nerve Root L-S1 Disc R-S1

108 Schmorl’s Nodes

109 Cervical Radiculopathy

110 Lumbosacral Radiculopathy (Sciatica) Important: A herniated disc at (e.g.) L4-5 may impinge either the L4 or L5 nerve roots!

111 L5-S1 Disc Extrusion Into Lateral Recess with Impingement of R S1 Nerve Root L-S1 Disc R-S1

112 Spondylolysis / Spondylolisthesis

113 Confusing “Spondy-” Terminology Spondylosis = “spondylosis deformans” = degenerative spine Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.) Spondylolysis = chronic fracture of pars interarticularis with nonunion (“pars defect”) Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)

114 Tumors and Other Masses

115  Extradural = outside the thecal sac (including vertebral bone lesions)  Intradural / extramedullary = within thecal sac but outside cord  Intramedullary = within cord Classification of Spinal Lesions

116  Herniated disc  Vertebral hemangioma  Vertebral metastasis  Epidural abscess or hematoma  Synovial cyst  Nerve sheath tumor (also intradural/extramedullary)  Neurofibroma  Schwannoma Common Extradural Lesions

117  Nerve sheath tumor (also extradural)  Neurofibroma  Schwannoma  Meningioma  Drop Metastasis Common Intradural Extramedullary Lesions

118  Astrocytoma  Ependymoma  Hemangioblastoma  Cavernoma  Syrinx  Demyelinating lesion (MS)  Myelitis Common Intramedullary Lesions

119 Classification of Spinal Lesions Extradural Intramedullary Intradural Extramedullary DuraCord

120 Extradural: Vertebral Body Tumor

121 Extradural: Vertebral Metastases T2 (Fat Suppressed) T1 T1+C (fat suppressed)

122 Extradural: Vertebral Metastases T2 (Fat Suppressed) T1 T1+C (fat suppressed) ?

123 Vertebral Metastases vs. Hemangiomas Hemangiomas (Benign, usually asymptomatic, commonly incidental): Bright on T1 and T2 (but dark with fat suppression) Enhancement variable Metastases: Dark on T1, Bright on T2 (even with fat suppression) Enhancement

124 Vertebral Hemangiomas

125 Diffusely T1-hypointense marrow signal may represent widespread vertebral metastases as in this patient with prostate Ca This can also be seen in the setting of anemia, myeloproliferative disease, and various other chronic disease states Extradural: Vertebral Metastases

126 Extradural: Epidural Abscess

127 Extradural: Nerve Sheath Tumor (Schwannoma)

128 Intradural Extramedullary: Meningioma

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130 Intradural Extramedullary: Nerve Sheath Tumor (Neurofibroma)

131 Intradural Extramedullary: “Drop Mets” T2 T1 T1+C

132 Intradural Extramedullary: “Drop Mets”

133 Intradural Extramedullary: Arachnoid Cyst T2 T1

134 Intramedullary: Astrocytoma

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136 Intramedullary: Cavernoma

137 Intramedullary: Ependymoma

138 Seen with: congenital lesions Chiari I & II tethered cord acquired lesions trauma tumors arachnoiditis idiopathic Intramedullary: Syringohydromyelia

139 Seen with: congenital lesions Chiari I & II tethered cord acquired lesions trauma tumors arachnoiditis idiopathic Intramedullary: Syringohydromyelia

140 Confusing “Syrinx” Terminology Hydromyelia: Fluid accumulation/dilatation within central canal, therefore lined by ependyma Syringomyelia: Cavitary lesion within cord parenchyma, of any cause (there are many). Located adjacent to central canal, therefore not lined by ependyma Syringohydromyelia: Term used for either of the above, since the two may overlap and cannot be discriminated on imaging Hydrosyringomyelia: Same as syringohydromyelia Syrinx: Common term for the cavity in all of the above

141 Infection and Inflammation

142 Infectious Spondylitis / Diskitis Common chain of events (bacterial spondylitis): 1. Hematogenous seeding of subchondral VB 2. Spread to disc and adjacent VB 3. Spread into epidural space  epidural abscess 4. Spread into paraspinal tissues  psoas abscess 5. May lead to cord abscess

143 Infectious Spondylitis / Diskitis T2 T1 T1+C T1+C

144 Infectious Spondylitis / Diskitis

145 Pyogenic Spondylitis / Diskitis with Epidural Abscess

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149 T1 T2

150 T1 + C Spinal TB (Pott’s Disease) Prominent bone destruction More indolent onset than pyogenic Gibbus deformity Involvement of several VB’s

151 Spinal TB (Pott’s Disease) Prominent bone destruction More indolent onset than pyogenic Gibbus deformity Involvement of several VB’s

152 Transverse Myelitis Inflamed cord of uncertain cause Viral infections Immune reactions Idiopathic Myelopathy progressing over hours to weeks DDX: MS, glioma, infarction

153 Multiple Sclerosis Inflammatory demyelination eventually leading to gliosis and axonal loss T2-hyperintense lesion(s) in cord parenchyma Typically no cord expansion (vs. tumor); chronic lesion may show atrophy

154 Multiple Sclerosis Inflammatory demyelination eventually leading to gliosis and axonal loss T2-hyperintense lesion(s) in cord parenchyma Typically no cord expansion (vs. tumor); chronic lesion may show atrophy

155 Cord Edema As in the brain, may be secondary to ischemia (e.g. embolus to spinal artery) or venous hypertension (e.g. AV fistula)

156 Vascular

157 Spinal AVM / AVF

158 Congenital

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160 Spine Imaging Guidelines 1.Uncomplicated LBP usually self-limited, requires no imaging 2.Consider imaging if: Trauma Cancer Immunocompromise / suspected infection Elderly / osteoporosis Significant neurologic signs / symptoms 3.Back pain with signs / symptoms of spinal stenosis or radiculopathy, no trauma: Start with MRI; use CT if: Question regarding bones or surgical (fusion) hardware Resolve questions / solve problems on MRI (typically use CT myelography) MRI contraindicated

161 4.Begin with plain films for trauma; CT to solve problems or to detail known fractures; MRI to evaluate soft-tissue injury (ligament disruption, cord contusion) 5.MRI for sx of radiculopathy, cauda equina syn, cord compression, myelopathy 6.Fusion hardware is safe for MRI but may degrade image quality; still worth a try 7.Indications for IV contrast in MRI: Tumor, infection, inflammation (myelitis), any cord lesion Post-op L-spine (discriminate residual/recurrent disk herniation from scar) 8.Emergent or scheduled? Emergent only if immediate surgical or radiation therapy decision needed (e.g. cord compression, cauda equina syndrome) 9.Difficult to image entire spine in detail; target study to likely level of pathology 10.CT chest/abdomen/pelvis includes T-L spine (no need to rescan trauma pts*) * If image data still on scanner (24-48 hours) Spine Imaging Guidelines


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