Teaching Atlas of Spine Imaging
Teaching Atlas of Spine Imaging
Ruth G. Ramsey Professor of Radiology Head, Section of Neuroradiology The University of Chicago Chicago, Illinois
1999
ew
York. Stuttgart
Thieme New York
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Executive E d i tor: Jane E. Penn i ngton, P h . D . Editorial Assistan t : J i n nie Kim Editorial D i rector: Ave McCracken Devel opmental Ed itor: Kathleen P. Lyons Director, Production & Manufacturi ng: M ax i n e Lllngweil Production Editor: M ichek M u l l igan Marketing D i rector: Phyllis Gold Sales Manager: David Bertelsen Chief Financial Offteer: Seth S. Fishman Preside n t : B ri a n D . Scan l a n Cover Designer: Kevin KII II Compositor: B i -Comp, I nc. Pri n t er: Courier. I n c. Library of Congress Cataloging-in-Publication Data
Ramsey. R u th G . Teaching a tlas o f spine imaging / Ruth G . Ramsey. p . cm. I n cludes bibliographical references and i ndex.
ISBN 0-86577-778-0.-ISBN 3-13-115791-7 I. Spine-imaging-Allases. 2. Spine- I maging-Case studies. I . Tille. [ DNL M : 1 . Spinal Diseases-diagnosis atlases. 2. Spinal Diseases diagnosis cllse sludi es. 3. Spi ne-p athology Iltillses. 4. M a gnetic Resonance I maging aliases. WE ISR lS3t 1995J
RD76S.R36 1998 617.5'60754-de2 I D N LMIDLC for Library of Congress
98-27857 OP
Copyright © IlJ99 by Thieme M edical Publisbers. In c. This book. i ncluding all parts thereof, is legally protected by copyright. Any use, explo i t a t io n or commercializat ion outside the narrow lim its set by copyright legislation , without the publis her's consent, is illegal and liable to prosecution. This applies i n particular to photostat reproduction, copying, mimeographing or dupl ication of any kind, transla t i ng, preparation of microfilm, and electronic data processing and storage. Important note: Medical knowledge is ever-changing. As new research and cl i n ical experience broaden our knowledge, changes i n
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0-86577-778-0 3-13-115791-7
For Michael, Thomas, and Timolhy thanks for all your understanding
Contents Pre face . . Acknowle dgments
xv xvi i
I. Normal Anatomy
A. Ce rvic a l spin e E xample 1 . Sagitt al Example 2. Midsagittal B. Thoracic spine E xample I. Sagittal short T R image E xample 2. Sagittal long TR image . E xample 3. Sagittal short TR image i n a pe di atric patie nt Example 4. Sagittal long TR image i n a pe diatric patie nt C. Lumbar spine Example 1. Mi dsagitt al short TR image s Example 2. Mi dsagit tal short TR image s Example 3. Coronal short TR images . Example 4. P arasagittal short TRun age s Example 5. N orma l pe diat ric lumbar spine E xa mple 6. Sagittal hort T R image s E xample 7. Axial short T Ri mage s . Example 8. Pre infusion and posti nfusion axial short TR image s Example 9. Long TR i mage s . . Example 10 . Axial long TRi mage s Example 1 1 . A xial compute d tomographyi mage s Example 12 . M ultiple T arlovc ysts .
5 9 20 22 24 25 03 34 35 37 40 42 45 51 52 54 56 58
O. Congenital
Case l . Case 2. Case 3. Case 4. Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case 1 I. Case 12. Case 1 3. Case 14. Case 1 5 . Case 1 6.
Chiari I mal[ormation with focal syrinx cavity Chiari [ malformation wi th lowe r ec rvical and thoracic syrin x cavity Chiari I malformation andt horacic syrulX . Chi ari type I [ ma l format ion wi th a lar ge meningomye loce el , s acral age ne is s . Chiari 1 1 malformation wi th me n ingomye loce el . dysraphic spine , ec er be llar ton sillar he rniation, et the er d coru, de forme d verte brae , a nde xpanueu forame n magnum Chiari I malformati on with syrinx cavity, postope rative change s with shunt tube place me nt . Chiari type III malformation A nte rior sacral mye lome ni ngoce el Te the er d cord. me ningomye loce e, l and coccyge al age ne sis Sacral age ne sis wi th filum et rminale lipoma and lowe r-than-normal spi nal cord Caudal er gre ssion syndrome with et the er d cord and multiple ve rte bral anomalie s . Partial sacral and coccyge al age ne sis, sinus tract, spinal dysraphi sm, et the er d spinal cord Tet he er d cord, sacral age ne is s, horse shoe, pe lvic kidne y . . Te the er d cord with filum et rminale lipoma, syrinx of the distal cord.e xpande d lumbar ve tre bral canal Te the er d cord, sinus rt act T ethe er d cord, lipoma, mye lome ningocele
67 71 74 77 08 83 86 88 90 93 97 01 0 01 2 104 107 109
�1E ACH I N G ATLAS Of' SPIN E I MA G I N G Case 17. Kl ipple-Feil an o maly associa ted with the Chiari I malformation, tethered cord, lipom a, sacral agenesis Case 1 8. D i astematomyelia, scoliosis, vertebral body . Case 19. Diastematomyelia . . Case 20. Diastematomyelia with atrophic spinal cord with two slightly asymmetric hemicords and an associated syrinx cavity, forme fruste of a Chiari I malformation with deformity of the posterior fossa Case 21. Neurollbromatosis type 1, multiple neurofibromata along the spine, a large plexiform neurofibroma along the course of the brachial plexus on the right arm Case 22. Neurofibromatosis type 2, with mUltiple schwannomas, postoperative changes, spinal cord tethering Case 23 . Bilateral acoustic schwannomas and m ultiple spinal schwannomas; small right internal auditory canal lipoma . Case 24. Down's syndrome with Cl-2 dislocation , congenital heart disease with atrial septal defect
112 115 119 122 125 128 130 133
10. Spinal Cord Tumors
A. Intramedullary Case 1. Ependymoma Case 2. Astrocytomas; neurofibromas of the dorsal root ganglion bilateraUy Case 3. Pilocytic astrocytoma . Case 4. Glioma of the cervical spinal cord and cerebellum, confirmed at surgery Case 5 . Spinal cord lesion, a metastasis from the patient's known leiomyosarcoma, confirmed at surgery . Case 6. Pilocytic astrocytoma, confirmed at surgery Case 7. Postoperative changes in a patient who had previous surgical removal of a spinal cord ependymoma . Case 8. Pilocytic astrocytoma, confirmed by biopsy Case 9. Astrocytoma, confirmed at surgery; tumor arose from within the spinal cord and grew in an exophytic fashion; soft tissue schwannomas B. Intradural Case 1. Schwannoma . Case 2. Isolated schwannoma Case 3. Schwan noma; multiple myeloma Case 4. Schwannoma at L3; osteoporosis; postoperative changes Case 5 . Men ingioma, confirmed at surgery Case 6. Meningioma . Case 7. Myxopapillary ependymoma Case 8. MyxopapiUary ependymoma with areas of hemorrhage Case 9. Ependym oma; dil ated Virchow-Robin spaces in the brain of unknown significance . Case 10. D rop metastasis from recurrent posterior fossa ependymoma Case 11 . Metastatic colon carcinoma . C. Neurollbromatosis Case 1. Neurofibromatosis type 1 with multiple plexiform neurofibromas Case 2. Neurofibromatosis type 1 with multiple plexiform and dumbbell-shaped tumors Case 3. Neurofibromatosis type 1 with m ultiple plexiform neurofibromas at all levels on the spine Case 4. Neurofibromatosis type 2 with plexiform neurofibromas in the intervertebral foramina, deep to the sternocleidomastoid muscle, and in the i ntradural space in the cervical and thoracic region Case 5. Probable nonenhancing low grade astrocytoma of the distal spinal cord Case 6. Neurofibromatosis type 2 with multiple spinal schwannomas, men ingiom as, and ependymomas, as well as cerebral meningiomas and acoustic schwannomas . Case 7. Neurofibromatosis with bilateral acoustic schwannomas, meningiomas, and spinal cord ependymomas
137 1 41 145 149 151 154 161 164 167 175 178 180 182 184 186 189 192 195 198 201 211 217 225 230 233 235 241
CONTENTS
D. Miscellaneous Case 1 . Chordoma, with postoperative chang es . Case 2. Metastatic chordomas: postsurg ical chang es Case 3. Chordoma within the vertebral body of L 3, confirmed at biopsy Case 4. M ultiple hemang ioblastomas in a patient with von Hippel-Lin dau disease Case 5. Sacral teratoma . Case 6. Dermoid tumor, low spinal cord (proved at surgery) . . .
249 25 3 256 258 260 263
IV. Trauma
Case 1 . Case 2. Case 3. Case 4. Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case 11 . Case l 2. Case ] 3. Case 1 4. Case] 5 . Case 1 6. Case 1 7. Case 1 8.
T raumatic compression fracture with spina l cord edema . Compression fracture of L 1 and distraction of the inteli acet jointsti t the L1-2 level . Fracture dislocation of T 6-7 with cord contusion and paraspinal hematom a formation . F lexion inj ury with fracture dislocation of the Ll -2 spinous proce. ses with tear in the dura and leakag e of cerebrospinal fl uid and blood into the soft tissue and muscles of the back Compression fracture of L l with spinal cord hematoma . T raumatic anterolisthesis of C4 on C5 with a traumatically herniated disc on the left side at the C4-5 level . Probably old fracture dislocation of C4 on C5 associa ted with a cs oliosis and formation of a posttraumatic syrinx cavity at C4; presumed child a buse Fracture dislocation of C2 on C3 ni a " hang man' s" type of fract ure with a traumatically herniated disc at the C2-3 level Old odontoid fracture; type 2 odontoid fracture Bilateral perched facets . Anterior dislocation of C5 on C6 with disruption of the nucal L gi ament and traumatic herniation of the intervertebral disc at the C5-o level . Small epidural hematoma Epidural hematoma; blood in the thecal sac: air in the vertebral canal in the lower thoracic reg ion Spontaneous epidural hematoma . . Spontaneous epidural hematoma in the m id thoracic reg ion secondary to coumtlu in treatment Benig n compression fractures of T4 and T1 2 secondary to osteoporosis Multiple compression fractures Multiple be nig n compression fractures secondary to osteoporosis
269 272 276 282 284 286 289 292 298 300 30 2 30 6 30 8 31 3 3] 7 320 322 324
V. Metastases
Case 1 . Case 2. Case 3. Case 4. Case 5 . Case 6. Case 7. Case 8. Case 9. Case 01 .
I solated metastatic breast carcinoma to the L3 vertebral body, proved at biopsy P ostradiation chang es . Metastatic osteoblastic prostate cancer within the bone marrow; multiple para-aortic lymph nodes also show sig ns of metastatic disease . Postsurgi cal chang es with placement of a metallic plate and multiple screws in the vertebral bodies at C5,6 , and 7; diffuse metastases to m ultiple vertebral bodies and spinous processes V ertebral metastases and mU ltiple patholog ically enlarg ed lymph nodes secondary to non-H odg kin' s lymphoma Diffu e metastases secondary to innumerable osteoblastic lesions related to the prostate cancer . Metastatic adenocarcinoma with bone des truction a nd spinal cord compression Metastatic breast cancer with vertebral body ni volvement and patholog ic adenopathy Metast atic breast cancer involving multiple vertebral bodies and the brachial plexus Metastatic lung cancer, b iopsy proved; mu ltiple additional lung nodules were present on the chest CT scan .
331 33R 340 344 347 350 353 357 360 36 2
TEACHING ATLAS OF S PlNE I MAGING
Case I I . M etastatic colon carcinoma to T 1 2 with bone expansion and cord compression Case 1 2. Metastatic Ewing' s sarcoma with cord compression at the T2 level . Case 1 3. Metastatic renal cell cancer to the rig ht lung and the vertebrae in the thoracic and l umbar reg ion and i nvolving the para tracheal lymph nodes . Case1 4. Chloroma, secondary to acute myelog enous leukemia Case 1 5. Metastatic renal cell carcinoma involving t he C3 vertebral body with cord compression Case 1 6. B reast cancer. metastatic to the C2 vertebral body with cord compression Case 1 7. Metastatic lung cancer with bony and epidural metastases and cord compression Case l 8. Multiple myeloma with i nvolvement of the spine and bony calvariam . Case 1 9. Multiple myeloma with diffuse marrow involvement and m ultiple pat holog ic compression fractures . Case 02 . Multiple myeloma . Case 21 . Diffuse metastases involving m ultiple vertebral bodies with a patholog ic fracture at T6 Case 22 . Mu lti ple myeloma with rapid prog ression . Case 23. Multiple myeloma involving the bony structures and forming a sort tissue mass dorsal to the spinal cord resulting in cord compression Case 24. Mu ltiple myeloma with di rfuse infi ltration of the bone marrow or the vertebral bodies and with a sof t tissue mass Case 25. Multiple myeloma; m ultilevel epidural hematoma predom inantly posteriorly, but also present an teriorly; bilateral bloody pleural effusions . Case 26. Metastatic h reast cancer with diffuse osteoblastic metastases . Case 27 . B reast cancer with osteoblastic metastases with soft tissue epidural component and spinal cord compression . Case 28. Metastatic osteoblastic prostate carcinoma Case 29. D iffuse osteoblastic metastatic disease with mild soft tissue component in the lower cervical reg ion and multiple patholog ic fr actures Case 03 . D i ffuse osteoblastic metastases from the patient's known primary osteog enic sarcoma
367 369 37 1 37 7 380 383 386 389 392 395 397 399 04 2 04 4 04 7 410 4J 2 41 4 417 42 l
VI. Carcinomatosis
C ase l . Case 2. Case 3. ase 4.
Case 5. Case 6. Case7 . Case 8. Case 9. Case10 .
Spinal and cerebral mening eal carcinomatosis secondaryt o breast cancer, with involvement of the leptomening es (pia and arachnoid) of the spine and brain; presumed metastatic deposit ni the inferior end plate of the L4 vertebrae Recurrent cerebralg lioblastoma multiforme with drop metastases and resulting men i ng eal carcinomatosis Diffuse bone metastases and spinal mening eal carcinomatosis . D iffuse leukemic infi ltrate throug hout the visualzi ed marrow, resulting in diffuse decreased sig nal within the marrow of the vertebral bodies; minimal patholog ic fracture of the L l vertebral body; metastases in the distal end of the thecal sac; mening eal carcinomatosis; polycystic disease of the kidney (incidentalfi nding ) Metastatic colon cancer in the subarachnoid space . Recurrent posterior fossa medulloblastoma with multiple drop metastases from medulloblastoma G erminoma with drop metastases and resulting spin al mening eal carcinomatosis L eukemic infi ltrate in the marrow of the vertebral bodies and mening eal carcinomatosis with enhancement of the nerve roots of the cauda equina . Metastatic breast cancer to the vertebral body marrow and the spinal epidural space Diffuse osteoblastic and osteolytic metastatic deposits throug hout the bony structures; cerebral mening eal carcinomatosis
42 9 433 439
443 447 449 451 455 458 461
VII. Inflammatory
Case
I.
D iscitis with soft tissue component a nd destruction of the vertebral body end plate
467
CONTENTS
Case 2. Case 3 . Case 4 . Case 5.
Discitis, following trauma with an unusual organ ism as the etiolog ic ag ent; bilateral psoas abscesses and an abscess surrounding the abdominal aorta . Discitis, i nvolving the intervertebral disc with paraspinal extensio n ; en hancement of the vertebral body reflects the prese nce of vertebral osteomyelitis P ostoperative wound infection with draining sinus tract and posto perative disc i ne[ ction; i nfl ammatory process exte nds into the soft tissues of the back and into the intervertebral foramenae bilaterally . . . . . Discitis and epidural and paraspinal abscess secondary to
Mycobacterium tuberculosis . Discitis, vertebral osteomyelitis; bilateral psoas abscesses; epid ural abscess extending f rom the lumbar region throug h the thoracic ps ine; bt ick-rimmed thoracic p araspin al muscle absce ss . . . . Case 7 . M ulti level anterior and posterior epidural abs cess, meningitis a n d mul tiple dorsal and paraspinal, and psoas muscle abscesses . . Case 8. Loculated, multilevel anterior and posterior epidural abscess seco ndary to retropharyngeal abscess; etiologic org anism was not cultured . Case 9. Chemical meningitis with arachnoid adhe sions . Case 01 . Probably pneumonitis and mening itis with Mycobacterium tuberculosis Case 1 . Mycobacterium tuherculosis without evide nce of sarcoidosis Case1 2. Mycobacterium tuberculosis in the interfaeet joints of the thoracic and lumbar regions . Case1 3. Cervical spinaL cord i nvoL vement with sarcoidosis Case1 4. Cytomegalovirus radiculitis
470 477 48 0 483
Case 6.
487 49 1 498 50 3 50 7 50 9 51 2 15 6 51 9
Vlll. Cervical Spine
Case 1 . Larg e he rniated disc at the C5-6 leve l on the right side Case 2. Rig ht-sided herniated i ntervertebral disc at the C5-6 level Case 3 . Left lateral hern iated disc at the C4 5 - level . . Case 4. H erniated midline andL eft paracentral cervical disc at t he C4-5 el vel Case 5. Deg enerative changes with osteophyte formation and trauma resulting in myelomalacia . Case 6. Rheumatoi d arthr itis with C1-2 dislocation ; hern iated disc at the C3-4 and C4-5 levels Case 7 . Atlantoaxialf usion: K lippel-Feil anomaly; right-sided herniated disc a t the . . . . C4-5 level . . Case 8. H erniated disc at C3-4 level; posterior longitudinal ligament ossification . Case 9. Posterior longitudinal l igament calcifi l c ltion/ossifi cation . . Case 01 . Recent surg ery F or disc removaL at the C4 -5 and C5-6 levels with bony fusion plug s in place Case 1 1 . Larg e midline herniated disc at C3-4; postoperative changes with fusion at the C5-6 and C6-7 levels . . . Case1 2. P ostoperative changes with fusion at C4-5; bony osteophyte at the C4-5 level with compromise of the suba rachnoid space; area of myelomalacia at the C4-5 level Case 1 3. Deg enerative chang e in the cervical spine with subse4 uent posto perative changes . Case1 4. Right-sided herniated nucleus pulposus at C5-6 and resulting m yelomalacia Case 1 5. Postoperative changes; ec rvical spinal cord syrinx Case 16. Dif uf se idiopathic skeL etal hyperostosis .
527 35 2 535 538 540 544 549 553 557 56 1 563 567 570 574 579 581
IX. Thoracic Spine
Case1 . Case 2. Case 3. Case 4.
H erniated intervertebraL disc at the T6-7 level Calcif ied, herniated intervertebral disc at the T6-7 level H erniated, calcifi ed intervertebraL disc at the T8-9 level Calcifi ed, herniated intervertebral disc at the T6-7l evel with compromise of the vertebral canal in the midline and on theL eft side . . Case 5. von Hippel-Lindau di sease with muL tiple cerebellar hemangioblastomas and spinal . . . . cord hemangioblastomas . .
587 59 1 593 595 599
�I
I TEACHING ATLAS OF SPINE IM AGING Case 6. Case 7. Case 8.
Thoracic spinal cord ischcmia and presumed infarction Probable spinal cord ische mia with are as of enhanceme nt Spinal cord arte riove nous malformation with subarachnoid hcmorrhage and spinal cord ischemia
06 2 06 7 610
X. Lumbar Disc
Case I .
Lu ge herniated d isc at the L 4 -S level; degenerated discs at the L3-4 and . . . LS-S 1 levels Hern ialed,e xtruded disc . Laterally herniated disc at thc LS-Sl leve l Large left paracentral herniated disc at the LS-S 1 and a mO derately size d disc at the L4-S level . . Herniated, sequestered disc with nerve root enhancement . Large recurrent herniate d disc fragm ent with peripheral enhancement . Recurrent herniate d disc which has migrated he hind the L S verte bral body Herniate d disc, probably arising fr om the L2-3 level; surgicall y prove d Left laterally he rniatcd disc at the L4-S el vel withe ncroachment on the i ntervertebral forame n M idline hern iatcd disc at the L2-3 el ve ;l large extrude d he rniated disc with a sequestereCl fragment at the L4-S . G rade 1 spondylolisthe si s secondary to bi lateral spondyloly. sis at thc lA -5 el vel Bilateral spondylolysis and grade1 spondyloU sthesis . G rade 4 spondyloU sthe sis Synovial cyst . . Synovial cyst arising from the left inte rfacet joint at the L3-4 level Spinal stenosis at the L3-4 lev el es condary to hypertrophy of theU g\\ me ntum f1 av um and encroachment upon the dorsal aspect of the vertebral canal; incide ntal Pagct'� dise asc of thc l umbar spine at the L 5 , S1 , and S2 el vels, as well as the sacral alae and the ili ac crests . Diffusely bulging disc, l arge st on the left side; lateral recess stenosis on the right side . . Spinal ste nosis with vacuum degene rative changes of the inte rvcrtcbral disc . Spinal sten os is at the L45 and L3-4 levels with bulging discs at L3-4, L4-5, and LS-S1 .
Case 2. Case 3. Case 4. Case S. Case 6 . Case 7. Case S. Case Y. Case 10 . Case 1. l Case 1 2. Case 1 3. Case 1 4. Case I S. Case 1 6.
..
Case 1 7. Case 1 8. Case 1 9.
61 9 622 62S 629 632 637 64 0 64S 647 65 1 65 S 6S9 662 666 670
673 677 6 79 6 18
Xl. Miscellaneous
Case I . Case 2. Case 3. Case 4. Case S. Case 6 . Case 7. Case 8. Case 9. Case10 . Casc 11. Case1 2. Case1 3. Case 1 4. Case I S. Case 1 6. Case 1 7. Case IS.
M ultiple sclerosis of the brain and spinal cord M ultiple � clerosis of the brain and spinal cord P robable mult i ple sclerosis . M ul ti ple sclerosis of the spinal cord . . M ul tiple sclerosis of the spinal cord . Transv erse mye litis of unknown cause . P ostimmuh zi ati on t ransverse myelopathy (mye litis) P ostvaccinatio ne ncephalomyelopathy (acute disse minate de ncephalomye lopathy) es condary to v accination . Transverse myeli tis, most lik ely secondary to multiple scle rosis Transve rse myelitis, cause unknown . Postradiation change s in the spinal cord and the vertebral bodies Postradiation change withe nhancement of the spinal cord . P ostradiation change . . Retained pantopaque: hernj ated disc at IA,S . Extensive postopcrativc change s with scarring and adhesions of the ne rve roots of the cauda eq uin a P ostoperative adhe sive arachnoiditis . . . . Epidural he matoma M ultile ve le pidur al hcmatoma in the lumbar e r g ion
689 694 699 70 3 70 7 07 9 17 2 716 17 9 722 72 5 728 73 1 733 736 739 742 744
CONTENTS
Case1 9. Case 20 . Case 21 . Case 22. Case 23. Case 42 . Case 25. Case 26. Case 27. Case 28.
Spinal cord lipoma . Epidural lipomatosis Extramedul lary hematopoiesis Sickle cell anemia with multiple bone i n fitrcts Amyloidosis secondary to chron ic renal failure with f32 microgloblinerrila Scoliosis with dorsal encroaclun ent secondary to degenerative changes, no tumor; secondary to poliomyelitis; postpolio syndrome . . Postpolio syndrome Postoperative change with focal atrophy of th e spi nal cord and anterior tethering of the cord to the posterior margin of the vertebral body M ultiple endplate herniations of the intervertebral discs called Schmorl's node deformities Cavernous angioma of the spinal cord with hemorrhage .
47 7 750 752 756 758 760 766 768 77 1 773
XII. Unknown Cases
Case1 . Case 2. Case 3. Case4 . Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case11 . Case 1 2. Case1 3. Case 14 . Case 1 5. Case 1 6. Case 17. Case1 8. Case1 9. Case 20 . Case 12 . Case2 2. Case 3 2 .
Index
Discitis with vertebral osteomyelitis at the L34 level and sevcre spinal stenosis Epidural and prevertebral abscess Multiple sclerosis of the brain and spinal cord Neurofibromatosis type2 with multi ple schwan nomits Diffuse osteolytic and osteoblastic metastases involving all the visualized bony structures . Epidural hematoma, cause un known D iffuse osteoblastic and osteolytic metastases from prostate cancer M ultiple schwannomas and postoperative changes with larrilnectomy and tethering of the spinal cord posteriorly at the T12-Ll level . Des moid tumor (unrelated to the recent trauma) . . Chiari I malformation, postoperative changes in the posterior fossa; syrinx cavity Neurofibromatosis type 1 with plexiform neurofibroma tit at all levels in the cervical spine . Lipoma at the L2 level with tethered spinal cord and diastematomyelia Cl-2 subluxation in assoeia tion with Down syndrome Large far laterally herniated disc at the L34 level; small midline herniated disc a t t h e L4 -5 level Chordoma of the distal lumbar spine, i liac crest, sacrum, and coccyx Cavernous angioma of the spinal cord . . . . Metallic fusion plate and fixating screws Diffuse bony metastases with pathologic fractures of TIO, Ll, and L2 and a metastatic deposit in the right lobe of the liver . Metastatic cancer involving the T11 and L4 vertebral bodies with epidural metastases Spinal cord ependymoma with an associated syrinx cavily . Leukemic infiltrate of the bone marrow; leptomeningeal carcinomatosis von Hippel-Lindau disease with multiple spinal and cerebral hemangioblastomas Di ffuse leukemic infiltrate of the marrow of the vertebral column; granulocytic 'arcoma (chloroma) of the soft tissues of the neck; dural based meningeal metastases; bony calvarium metastases (?) ch loroma .
781 785 790 793 795 799 �0 2 � 40 R06 180 18 3 81 8 8 23 8 26 83 1 83 4 838 48 2 48 5 84 9 853 857 86 1 87 1
Preface Teaching Atlas o/Spine Imaging, a collection of both classic and challenging cases. is formatted to reflect "real-life" presentations. These cases. the em phasis of which is not rare and unusual cases, but those seen in a busy practice regardless of the clinical settin g, begin with a brief clinica l presenta tion, followed by a series of images, and a section entitled Radiologic Find ings. The large form at of the vo lume allows life-size presentation of the images to simulate the clinical setting at the time of interpretation. Armed with the clinical presentation, the i mages, and the radiologic findings, the reader should be able to make a diagnosis. which is subsequently provided, along with the differential diagnosis and a brief discussion of the abnormality. The need for clinical correlation and relevance is repeatedly emphasized. The clinical information, often not included on the consultation request, i frequently the key to diagnosis. I n cases in which it is not possible to arrive at a diagnosis at the time of initial imaging evalua tion, follow-up images are provided as well. Practical guidelines to diagnosis and imaging, cal led pearls and pitfalls, are highlighted in the margins. Because the ability to evaluate abnormal anatomy req uires an understanding of normal anatomy, the first section of t he book evaluates the normal spine. The next nine sections-Congenital, Spinal Cord Tumors, Trauma. Metasta ses, Carcinomatosis. In flamm atory, Cervical Spine. Thoracic Spine, Lumbar Disc, and Miscellaneous Cases-address a wide variety of abnormalities that alTeet the vertebral column and the spinal cord. An up-to-date bibliography is included with each section. The final sect ion is devoted to unknown cases. The reader may use these cases for sel f-assessment by either using the given clin ical data or by using the i mages alone. These typical clinical cases cover a wide variety of clinical entities. Evaluation of the vertebral column and spinal cord has evolved from plain film evaluation to the use of computed tomography (CT). to CT in conjunc tion with myelography, and most recently to magnetic resonance (MR) imaging in conjunction with a variety of basic and sophisticated techniques. At present, MR imaging has essentially replaced ot her imaging methods for evaluation of the vertebral spinal column and spinal cord. Although these news modalities are better for diagnosing spine abnormalities, this technology requires a keen eye and solid understanding of how the various abnormaLities are imaged. It is my hope that this volume, developed as a response for an easy to use imaging guide for a variety o f abnormalities of the spine will be used by both new and experienced practitioners alike to diagnose these special patients.
Acknowledgillents The vast majority of the photography was performed by Mr. Harold Tyler, without whose help this book would have been very difficult. Special thanks to the Neuroradiology fellows as well, especially Rajiv Shah who a lways watched for i nteresting teach ing cases, Donna Bower Kim, Rohert Wank mul ler, V ivek Sehgal, and Sundeep Nayak. Thanks to Sharon Byrd for many of the pediatric cases. Thanks to the residents whose q uestions allowed me insight into what is complicated and diffi cult for them to understand about spine imaging. Thanks also to my clinical colleagues who suffered through all the teaching files that were made during the course of this project. Thanks to Anne Healy, who always pruvided the necessary technical assis tance and support, Margaret Caldwell my secretary, as well as the entire secretarial staff who pitched in when needed: Charlene Sheridan, Leslie Cleveland, Debbie Cop, and Evelyn Ruzik. The entire technology staff, who made certain that excellent images were obtained on all our patients. The film library staff also deserve special thanks for helping me to find the cases. I would certai nly be remiss if I did not mention tbe staff at Thieme Medical P ubl ishers, includi ng Hilary Evans, whu encouraged me to start this project; Jane Pennington for her excellent advice; Michele Mulligan for her patience and perseverance; Kathy Lyons, who listened to all the phone calls and shepherded all the images through the process; and their colleagues in the New York office. Thanks to Martin 1. Li pton, Chairman of the Department of Radiology, for his help and encouragement.
Section I
Normal AnatoDlY A. Cervical Spine
N ORMAL ANATOMY
I
Cervical Spine Evaluation of the normal cervical spine includes sagittal short and long TR images. Intermediate TR images in the sagittal plane may also be obtai ned. Axial images are obtained through any areas of interest using short TR sequences or sequences that result in increased signal intensity cerebrospi nal fluid. Contrast material is used in any patient who h as had previous surgery. Contrast material should also be used in patients who are being evaluated for a possible tumor in the cervical region, an inflammatory process or a process such as meningeal carcinomatosis, or demyelinating disease such as m ultiple sclerosis. The standard imaging sequences and pla nes may be modified in a variety of ways depending upon the clinical presentation and anatom ic area and level of interest. For various diseases, the following sequences are suggested: 1. Disc disease •
•
Sagittal short and long TR images: fast spin-echo sequences may be used . Axial short TR images or axial gradient-echo images: axial images should be obtained through all abnormal levels.
2. Intramedullary tumor •
Sagittal short and long TR images.
•
Sagittal short TR images postcontrast.
•
Axial short TR images precontrast and postcontrasL.
3. Cervical spinal cord multiple sclerosis •
Sagittal short and long TR images.
•
Sagi ttal short TR i mages postcontrast.
•
Axial short TR images precontrast and postcontrast.
•
Axial long TR images or gradient echo images.
4. Cervical spi ne tumor •
Sagittal short and long TR images.
•
Sagittal short TR images postcontrast.
•
Axial short TR images precontrast and postcontrast.
I TEACHING ATLAS OF SPI N E I M A G I NG 5. Cervical spine syrinx cavity with and without Chiari malformation •
Sagittal short and long TR images including the skull base.
•
Axial short TR images.
•
•
Sagittal and axial images should include the entire length of the syrinx cavity. The thoracic spinal cord should also be evaluated to determine the entire exten t of the syrinx cavity.
6. Cervical spine congenital maliormation •
Sagittal short and long TR images.
•
Axial short TR images.
•
Axial images with increased signal intensity cerebrospinal fluid.
•
Additional images as needed for evaluation of the abnormality.
•
Short TR images post contrast materi£ll
£IS
needed.
Additional imaging sequences, such as fat-saturated images in any plane, should be used as necessary. Many cases need to be evaluated on a case by-case basis. [n complic£l l ed cases, it is necessary to monitor the imaging and alter the sequences and the planes of imaging as necessary for complete ancl accurate evaluation .
NOR MAL ANATOMY
Example 1
A
(Fig. A) Normal cervical spine short TR sagittal image. The outer table and the inner table of the bony calvaria both appear as linear areas of decreased signal intensity. T he diploe of the c
�I
I
TEACHING
ATLAS OF SPINE
IM A G I N G
B
(Fig. B) Normal long TR sagittal image. 0, odontoid process; S, spinous process; while arrow, small prominence of the C5-6 i ntervertebral disc; black arrows, longitudin a l lines of increased and decreased signal intensity within the spinal cord secondary to truncation artiract; open arrow, basiverteb ral venous plexus.
6
NORMAL ANATOMY
c (Fig. C) ormal long TR coronal image of the cervical spine. The right and left vertebral arteries appear as areas of now void within the foramena transversarium bilaterally. The left vertebral artery is larger than the right vertebral artery, a normal anatomic variant. The uncinate process is a small protuberance of bone that is beveled such that the vertebral body above is held in place by these bony processes. Degenerative changes frequently occur around these uncinate processes. 0, odontoid process; B, body of the C2 vertebral body; L, lateral mass of the Cl verLehral body; d, intervertebral disc; open arrow, joint space between the lateral masses of Cl and C2; short black arrow, unci nate process; lung black arrow, origin of the vertebral artery; curved arrow, entrance of the right vertebral artery i nto the foramen transversarium at the C6-7 level.
I
TEACH I N G ATLAS OF SP I N E I M AG I NG
D
(Fig. D) Normal axial short TR image at the level of C4. The uncinate process defines the l ateral margin of the vertebral body. D, intervertebral disc; arrow, marrow-filled uncinate process.
NORMAL ANATOMY
Example 2
A
(Fig. A) M idsagittal short TR image of the cervical spine. 1, odontoid process; 2, small osteophytes on the anterior-in ferior aspects of the end plate of C5 and the anterior-superior aspects of the end plate of C6; 3, small posterior osteophyte on the posterior-superior aspects of the end plate of C6; 4, anterior arch of the Cl vertebral body; straight black arrow, normal, irregularly marginated, high sig nal intensity area of fat that identifies the bottom of the clivus and projects just above the odontoid process. The high signal intensity of the fat is helpful in identifying the anterior margin of the foramen magnum. curved black arrow, normal posterior margin of the foramen magnum.
I
TEACHING ATLAS OF SPLNE IMAGING
B
(Fig. B) Sagittal short TR image. Tonsillar "ectopia" is downward displace ment of the cerebellar tonsils below the foramen magnum and is considered a normal anatomic variant. 1, base of the spinous process; 2, entrance of the venous plexus into the vertebral body; 3, laryngeal ventricle; 4, black arrow, behin d the C2 vertebral body and extending to the level of the inferior end plate of C3, there is a streak of increased signal intensity that is the contrast-enhanced norn1al epidural venous plexus; curved arrow, posterior margin of the foramen magnum. The Chiari I malformation is defined as: 1) downward displacement of one cerebellar tonsil at least 5 mm below the foramen magnum; 2) both cerebellar tonsils 3 to 5 m m below the foramen magnum into the upper cervical canal; 3) no h istory of myelomeningocele or radiologic evidence of a Chiari II malformation; 4) no prior cranial or cervical spinal surgery; 5) no mass causing the herniation .
NORMAL ANATOMY
c
(Fig. C) Para agittaJ short TR image at the level of the foramina transvers aria. The vertebral artery en ters into the foramen transversarium between the C6 and C7 vertebral bodies.}, vertebral artery in the foramen transvers arium; 2, anterior and middle scalenus muscles; black arrow, the nerve i n the i ntervertebral foramen surrounded b y normal high signal intensity fat.
11
I TEACHING ATLAS OF SPINE IMAGING
D
(Fig. D) Parasagittal short T R image at the level of the interfacet joint. normal in terfacet joint; while arrow, normal dorsal root ganglion.
],
NORMAL ANATOMY
E
(Fig. E) Sagittal long TR image. 1, normal low signal i n tensi ty of the trans verse and cruciate ligaments; 2, anterior arch of Cl; 3, normal intervertebral disc; 4, norma l decreased signal intensity of the supedor end plate of the vertebral body; f-arrow, identifies the fat at the inferior end of the clivus and marks the anterior margin of the foramen magnum; open arrow, flow void of the vertebral body.
TEACHING ATLAS OF SPINE IMAGING
F
(Fig. F) Normal short TR image postinfusion. Open black arrow, j ugular vein; open white arrow, flow void of the left vertebra l artery; short solid white arrow, uncinate process; long solid while arrow, enhancing dorsal root ganglion; long solid black arrow, spinous process.
G
(Fig. G) Axial short TR unage in the lower cervical region. Black arro ws, nerves of the brachial plexus surrounded by high signal intensity fat; while arrow, the curvilinear high signal intensity of the marrow-filled uncinate process.
NORMAL ANATOM Y
I
H
(Fig. H) Axial short TR image in the lower cervical region. Just lateral to the spi ne, the nerves of the brachial plexus are positioned between the anterior and middle sca lenus muscles. SharI black arrows, nerve roots of the brachial plexus; long arrow, dorsal root ganglion; L, lamina of the vertebral; E, esophagus
Section I
Nonnal AnatoDlY B. Thoracic Spine
NORMAL ANATOMY
Thoracic Spine Imaging of the normal thoracic spine includes sagittal short and long TR images as wel l as axial short TR images through any areas of i n terest or demonstrated abnormality. Contrast material is generally not used for the evaluation of thoracic disc disease. However, contrast material is mandatory if the patient has had previous surgery, for the evaluation of a spinal cord tumor, for evaluation of a tumor in the thoracic vertebral canal, for the evaluation of meningeal carcinomatosis, or for the evaluation of a v(lscular malformation. Axial images may also be obtained with a variety of other imaging sequences that result in increased signal intensity cerebrospinal fluid. Images should be annotaleu such that they include the skull base or the distal end of the lumbar vertebral column so that the exact level of any abnormality can be identified in the l u mbar spine.
I TEACHING ATLAS OF SPINE I M A G I NG
Example l \
A
(Fig. A) Normal short TR image of the thoracic spine. The spinal cord fol lows a normal curvilinear path along the posterior margin of the vertebral column. There is a normal thoracic kyphosis. The spinal cord appears as intermediate signal intensity surrounded by the decreased signal intensity of the normal cerebrospinal fluid. Q, high signal intensity subcutaneous fat; S, spinous process; F, normal high signal intensity epidural fat; black arrows, small Schmorl's node deformities in the inferior end plates of three lower thoracic vertebral bodies.
N O RMAL A NATO M Y
B
(Fig. B) Normal sagittal long TR image. The black arrows identify a curvilin ear area of decreased signal intensity which is an area of flow-related en hancement secondary to movement of the cerebrospinal fluid dorsal to the thoracic spinal cord. The spinal cord appears as decreased sign al intensity surrounded by the high signal intensity of the cerebrospinal fluid.
I TEACHING ATLAS OF
SPINE
IMAGING
Example 2
A
(Fig. A) Sagillal long TR image reveals that the cerebrospinal nuid appcars as increased signal intensity. Within the cerebrospi n al fluid and dorsal to thc spinal cord (arrows), there are areas of decreased signal intensity second a ry to flow-related enhancement of cerebrospinal fluid.
IR
NORMAL ANATOMY
B
(Fig. B) Axial long TR i mage also reveals the areas of decreased sign(ll intensity dorsal to the spinal cord secondary to flow-rela ted enh(lncement of the cerebrospinal fluid (arrow). Be aware that this type of flow-related en h(lncement may occur. This finding of flow-related enhancement does not indicate the presence of a spinal cord arteriovenous malform(l lion .
231
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TEACHING ATL A S OF SP[NE I M A G I NG
ExaDlple 3
(Fig. A) Sagittal short TR i mage of the thoracic spine in a pediatric spine. The i ntervertebral disc (disk) and adjacent cartilagenous end plates of the adjacent vertebral bodies appear as increased signal i ntensity (white arrows). The vertebral body appears as decreased signal intensity as compared to the intervertebral disc; this is the reverse of the appearance seen in adults. The thoracic spinal cord enlarges slightly in its distal portion and ends at the level of Ll intervertebral disc (0); this is slightly higher than the normal l evel.
NORMAL ANATOMY
Example 4
A
(Fig. A) Pediatric thorllcic spine. Sagittal long TR image of the thoracic spine reveals curvilinear areas of decreased signal intensity dorsal to the spinlll cord (white arrows) and a long thin area or decreased signal intensity ventral to the spinal cord (black arrowheads). These areas represent turbu lent flow dorsal to the spinal cord and smooth linear flow ventral to the spinal cord. The normal intervertebral discs appear as increased signlll intensity.
Section I
Normal Anatomy c. Lumbar Spine
NORM A L AN ATOMY
Lumbar Spine M
Indications for Contrast Enhancement Evaluation for disc disease does not require the use of contrast materi
",
I
TEACH I N G ATLAS OF SPINE I M A G I N G
ExalDple 1
A
(Fig. A) M idsagittal short TR image. The verlebral body height and interver tebral disc height are normal al all levels. The point of entrance of the normal basivertebral venous p lexus is seen in the posterior margin of the verlebral body (open arrow). The normal spinal cord ends at the level of the inferior end plate of the Ll vertebral body. The normal epidural fat appears as increased signal i ntensity dorsal lo lhe thecal sac. Thc normal dorsal epidural fat is tri angular in co nfiguration and is outlined by the base of the spi nous processes of thc vcrtebral bodies. The first sacral segment is positioned at an angle to the L 5 vertebral body and tapers inferiorly.
NORMAL ANATOMY
B
(Fig. 8) Midsagittal short TR image postcontrast. The normal intra vertebral basivertebral venous plexus enhances (open arrow). There is enhancement of the normal epidural venous plexus behind the L4 and L5 vertebral bodies.
31
I
�AGING
TEACH J N G ATLAS OF SPIN E I
c
(Fig. C) Midsagittal long TR image demonstrates the tapered distal end of the thoracic spinal cord (solid arrow) as it ends at the level of the Ll vertebral body. The filum temtinale is seen as a linear area of decreased signal intensity i n the distal end of the thecal sac (open arrow). Multiple superimposed lines represent the lines of the levels that are scanned in a routine m agnetic resonllnce study of the lumbar spine. The study utilizes a fast spin-echo techniq ue, so the normal h igh signal intensity fat remains high signal inten sity. When using the standard spin-echo technique, the normally high signal intensity fat would appear as slightly decreased sign al intensity.
NO RMAL ANATOMY
I
D
(Fig. D) Midsagittal long TR image using standard spin-echo technique reveals the decreased signal intensity spinal cord surrounded by i ncreased signal intensity cerebrospinal fluid. The intervertebral disc appears as in creased signal intensity. The epidural fat appears as decreased signal inten sity (arrow).
33
I
TEACHING ATLAS OF S PI N E l M A G I N G
Exatnple 2
A
(Fig. A) Midsagittal short TR image of the lumbar spine f, norm al high signal intensity fat in the epid ural space; S, normal first sacral segment; s, spinous process of L5; open arrow, normal termination of the distal end of the thecal sac at the level of the midbody of the second sacral segment. .
34
NORMAL ANATOMY
I
Example 3
A
(Fig. A) Coronal short TR image at t he level of Ll (Ll ) . arrow, the termina t ion of the distal end of the spinal cord at the level of the L l vertebral body.
TEACH ING ATLAS OF SPINE I M A G ING
B
(Fig. B) Normal short TR coronal image. K, kidney; psoas, psoas muscle; p, pedicle; lon.g white arrow, normal nerve; lon.g black arrow, normal nerve; curved black and white arrow, dorsal rool ganglion; short white arrow, "ax illa" of the normal root sleeve; open arrow, flow void of one of the vessels of the venous plexus.
NORMAL ANATOMY
Example 4
A
(Fig. A) Parasagittal short TR i mage at the level or the intervertebral foram ina. P, pedicle; white arrow, dorsal root ganglion.
TEACHIN G ATLAS OF SPINE 1 MA GI N G
B
(Fig. B) Parasagittal short TR image at the level of the intervertebral fora men. The dorsal root ganglion is anatomically positioned immediately below the level of the vertebral body pedicle. It is intermediate signal intensity and is surrounded by high signal intensity fat. The intervertebral disc projects into the lower portion of the intervertebral foramen . Thus, a herniated disc will encroach upon the nerve as it exits via the in tervertebral foramen. p, pedicle; open arrow, flow void of the vessels of the basivertebral venous plexus; straight arrow, flow void of one of the vessels of the basivertebral venous plexus; curved arrow, intervertebral disc.
NORMAL ANATOM Y
c
(Fig. C) Parasagittal short TR image at the level of the lateral margin of the vertebral body. A rrows, flow voids of the basivertebral venous plexus as they surround the vertebral body.
39
I TEACHING ATLAS
OF
SPINE I M AGING
Example 5 Normal pediatric lumbar spine.
A
(Fig. A) Sagittal short TR image. Wide arrows, intervertebral discs; open. arrow, entrance of basivertebral venous plexus; curved arrow, low signal intensity of the anterior margi n of the vertebral body.
4 (")
ORMAL ANATOM Y
B
(Fig. B) Sagittal long TR image. The dotted l ines on both images outline the vertebral body. On the short TR images, the cartilagenous end plates of the vertebral bodies appear as i ncreased signal intensity, while the cartilage appears as decreased signal intensity on thc long TR images. In general, the intervertebral disc appears as increased ign al intensity on all imaging sequences, but tbis appcarance is much more marked with the longer TR or more T2-weigbted i mages. solid arrows, intervertebra l disc; open arrow, entrance of basivertebral venous plexus.
I
TEACH I N G ATLAS OF SPINE I M A G IN G
ExaDlple 6
A
(Fig. A) Sagi ttal short TR image of the l umbar spine. The vertebral body height and in tervertebral disc height is normal. The spinal cord is normal in posi tion. However, there are multiple enlarged lymph nodes in the prever tebral space. The patient has acquired immunodeficiency syndrome (AIDS) and systemic lymphoma.
NORMAL ANATOM Y
B
(Fig. 8) Sagittal intermediate signal intensity image reveals chemical shi rt artifact with the inferior end plates of the vertebral bodies appearing as decreased signal intensity while the superior end plates appear as intermedi ate signal intensity with an adjacent increased signal i ntensity parallel line.
I
TEACH I N G ATLAS OF S PI N E IMAG I N G
c
(Fig. C) Precontrast (left) and postcontrast (right) axial short TR images reveal multiple prevertebral lymph nodes (white arrows) which project to the left of the flow void of the abdominal aorta (A) . The intravertebral portion of the basivertebral venous plexus is also seen (open arrows).
44
NOR M A L A ATOMY
Example 7
A
(Fig. A) A xial short TR image at the level of the in tervertebral disc. Long while arrow, normal nerve surrounded by high signal i ntensity fat; s/arrow, superior articulating facet; ilarrow, inferior articulating facet; !, normal epi dural fat between the laminae of the vertebral bodies at the base o[ the spinous process; p , psoas muscle.
45 1
I
TEACHI N G ATLAS OF S PI N E I M A G I N G
B
(Fig. B) Axial short TR image. The psoas muscle projects on either side of the vertebral body. The aorta is an area of flow void anterior to the vertebral body and j ust to the left of the midline, while the i n ferior vena cava is an oval-shaped area of flow void j ust to the r igh t of the midline. s, spinous process; g/arrow, normal dorsal root ganglion; long chin white arrow] anterior epid ural vei n ; curved arrow, ligamentum fiavum; long thick white arrow, interfacet joint with degenerative changes with cupping of the superior articulating facet around the inferior articulating facet.
NORMAL ANATO M Y
c
(Fig. C) Axial short TR image at the level of th e verlebral pedicle. Open arrow, decreased signal intensity of the corlical margin of the vertebral body; black-and-white arrow, decreased signal intensity of the cortical margin of the lamina of the verlehral body.
I
TEACH I N G ATLAS OF SPINE I M AGING
D
(Fig. D) Axial short TR image at the same l evel as Figure C, postcontrast. The basivertebral venous plexus typically forms a Y -shaped area within the vertebral body. Open arrow, flow void of the vessel of the basivertebral venous plexus; p, pedicle; T, transverse process; solid arro ws, en hancing i n travertebral portion of the basivertebral venous plexus; open arrow, flow void of vein of basivertebral venous plexus.
N O R M A L AN ATO M Y
E
(Fig. E) Axial long TR image at the level of the i n tervertebra l disc. The normal nerves of the cauda equina appear as sm a l l rounded areas of interme diate signal intensity within the thecal sac (arrows). The annulus fib rosus appears decreased signal i n tensi ty and surrounds the nucleus pulposus. The normal nucleus pulposus is identified with N.
I
TEACHING ATLAS OF SPINE IMAGING
(Fig. F) Axial long TR image. The lateral recess is formed by the superior articul ati ng facet and the posterior margi n of the vertebral body. The dis tance between these structures should not be less tha n 5 mm. White arrow, the normal low signal intensity of the cortical bone of the inferior articulating facet adjacent to the intermediate signal intensity of the i nterfacet joint; L-arrows, the normal lateral recess; black arrow, nerve root as i t passes through the lateral recess; i, inferior articulating facet.
NORMAL ANATOMY
I
Example 8
(Fig. A) Prein [usion (left) and postinfusion (right) axial short TR i mages at the level of the dorsal root ganglion. The normal dorsal root ganglion i seen bilaterally (black arrows point to the right dorsal root ganglion) which enhances postinfusion (right). This normal enhancement should not be mis taken for a schwannoma.
51
I
TEACH I
G ATLAS OF SPIN
I MAGIN G
Example 9
A
(Fig. A) Long TR image at the level of the nerve root ganglion of the L5 vertebral body. The vertebral body is lemon shaped at the L5 level. The dorsal root ganglion appears as an area of intermediate signal i n tensity surrounded by normal high signal intensity fat. The cerebrospinal fluid appears as i ncreased signal intensity, and the nerve roots of the cauda equina appear as dotlike areas of intermediate signal i ntensity within tbe thecal sac.
NORMAL ANATOMY
B
(Fig. B) Long TR image at the level or the L3-4 intervertebral disc. The disc has a normal concave margin which follows the posterior margin of the vertebral body. The intermediate signal intensity of the normal nerve roots are surrounded by high signal inten ity cerebrospinal Ouid. The nerve roots that are positioned laterally will soon exit from the thecal sac (arrows).
I TEACI l!
G ATLAS OF SPINE I MA G I NG
Example 10
A
(Fig. A) Axial long TR image at the level of the dorsal nerve root ganglion. Therc are dcgenerative changes involvi ng the interfacet joints bi laterally with cupping of the superior articulating facet around the inferior articulating facet. There is also widening of the i nterfacet joint on the left side (arrow).
N O RM AL ANATOMY
B
(Fig. B) Axial long T R image at the level of the intervertebral disc reveals di ffuse expansion or bulging of the disc. The fluid within the interfacet joint appears as increased signal intensity (arrow). The nerve roots of the cauda equina appear as small rounded areas of intermediate signal inte nsity within the thecal sac.
I
TE A C H I N G ATLAS OF S P I NE I M AG IN G
Exalllple 11
A
(Fig. A) Axial computed tomographic (CT) image postmyeLogram at the level of the vertebral pedicle reveals the poi nt o[ entrance of the basivertebral ven ous plexus into the posterior aspect of the vertebral body (open arro w). The nerve roots of the cauda equina appear as rounded areas of intermed iate density within the contrast-filled thecal sac. The filum terminale a t the very distal end of the spinal cord appears as a slightly larger rounded area of intermediate density (solid arrow). Below this level, the normal filum term inale cannot be differentiated from the nerve roots of the cauda equina.
N O R M A L ANATOMY
I
B
(Fig. B) Axial CT image reveals the nerve roots of tbe cauda equina in the dorsal aspect of the thecal sac. t, transverse process; s, ba'e of superior articulating facet; i, inferior articulating facet.
I TEACH I
G ATLAS OF SPINE IMAG I NG
Example 12 M ultiple Tarlov cysts (nerve root meningocele).
A
(Fi g A) Parasagittal short TR image in the lumbar region reveals that the vertebral heights and intervertebral disc heights all appear normal. The laminae of the vertebral bodies are visualized in cross sectio n (while arrow al L3). The ligamentum navum is visualized as an intermediate signal intensity structure extending fro m one vertebral body laminae to the next (long black arrow). There is a lobulated intermcdiatc s ign al intensity mass i n the low lumbar region at the level of the S I and S2 vertebral body (wide black arrow). .
-
58
ORMAL ANATOMY
B
(Fig. B) Parasagittal long TR image in the lumbar region reveals that the lobulated intermediate signal intensity area seen in Figure A appears as increased signal intensity on the long TR images (white and black arrow). The normal nerve roots of the cauda equina are seen in the thecal sac (arrows). There was no change postcontrast (not shown).
I TEACH ING ATLAS OF SPIN E I M AGING
c
(Fig. C) Axial 'hort TR images at the level of the Ll vertebral body reveal m ultiple, bilateral, lobulated decreased signal intensity lesions projecting within the vertebral canal into the region of the neural foramen bilaterally (arrows). There is pressure erosion and expansion of the surrounding bony structures because of the longstanding n ature of this process.
1 60
ORMAL ANATOM Y
o
(Fig. D) Three-dimen 'ional magnetic resonance (MR) myelography reveals the normal appearing lumbar thecal sac. The nerve roots of the cauda equina appear as areas of decreased signal intensity within the thecal sac. There are multiple cystlike areas of increased signal intensity arising from the distal end of th� thecal sac. Tarlov cysts are anatomic variations with dilatation of the nerw root sleeves of the (;(luda equi na. These cystic dilatations may also he seen in the thoracic and cervical region, hut arc less common t her�. G cncrally, they are not t hought to caus� symptoms (although I his patient, a 5 1 -year-old female, presented with a history of back pain radiating to the left buttock and wea kness of the gastrocnemius m uscle), btlt the appearance may mimic a disease process stich as multiple schwannomas or multiple neurofibromas. This confusion arises particularly when there is only a single schwannoma. Note the pressure erosion of the surrounding bone structures, which renects the longstanding nature of these lesions. Ncurofibromas may also cause pressure erosion; schwannomCis and neurofibromas exhibit enhancement postcontrast. The use of M R myelography has greatly aided in the evaluation of patients stich as this.
61
I TEACHING ATLAS OF SPINE I M AG ING MR myelography can be performed on any level of the vertebral column. I mages can be generated using a variety of techniques. These techniques include th ree-dimensional gradient-echo pulse sequences, fast spin-echo se quences, or rapid acquisition with relaxation enhancement (RARE) se quences. The time for acquisition of these three-dimensional images ranges from 2 seconds (RARE imaging) to 13 minutes. These images mimic the appearance of a myelogram with the cerebrospinal fluid appearing bright with the surrounding vertebral canal decreased signal intensity. As seen in Figure D, the distal spinal cord can be seen as well as the individual nerve rootlets of the cauda equina. In some cases, the blood vessels adjacent to the spine can also be seen (arrows). Myelography may also be used to differentiate between schwannomas, neu rofibromas, and metastases; however, it is no longer necessary since the availability of MR imaging. It should be noted that congenital abnormalities such as sacral meningocele which do not communicate freely with the subarachnoid space may not be visualized by myelography but are readily demonstrated by three-dimen sional myelography.
ORMAL ANATOMY
Suggested Readings B[I;:ger R K , Wil liams AL, Daniels D L , et al. Contrast en hancem ent in spinal MR imaging. AlNR. 1989:10:633-637.
B radky WG. Usc of gadolinium chelates i n MR imaging of the spint:o JM R I . 1997;7:38. Champlin AM, Rael J , Benzel EC, e t al. Preoperative spinal angiography for latcral cxtracavi tary approach to thoracic and l u mbar spine. AJNR. 1994 ; 1 5 : 73 . Constable RT, Gore Jc. Th e loss of small objects in variable TE imaging: implications ror FSE, RARE, and E P I . M([gn
Resun
Meel. 1 992;28:9- 24 .
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cr fi n d ings.
Nellroradio/. 1995;37:308.
JM, Daniels DL, Haugh ton VM. Characteristic features of M R AJNR. 1988;9:815-824.
Czervionke LF, Czervionke truncation artifacts.
Demaerel P, Van Hover P, B roeders A , el al. Rapid l umbar spine MR myelogra phy: imaging findi ngs using a single shot techniq ue. Rivista di NeliroradioloKia. 1 997; 1 0: 1 8 1 - 187. Du Boulay GH. Pulsatile movements in the CSF pathways. EI Gammal
HI' J
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T, Brooks BS, et a l . MR myelography: imaging fi ndi ngs.
A.IR. 1 995: 164: 1 73-1 77.
EI Gammal TAM, Crews CEo MR myelography of the cervical spine. RadioGraphies. 1 996; 1 6:77. Enzma n n D R, DeLaPaz RL, Rubin JB. Magnetic Resonllnce oJ the Spine. S t. Louis: Mosby; 1 990:441 . Enzmann DR, Pelc N J . Normal flow patterns of in tracra n i al and spinal CSF de fi n ed with phase-contrast ci ne
MR imaging. Radiulugy. 1 99 1 ; 1 7 8 :467-474.
Georgy B A , Hesse l i n k JR. MR imaging of the spine: recent advances in pulse sequences and special techniques. AJR. 1994:162:923-934. Henkelman R M , Hardy PA, Bishop JE, Poon CS, Plewes DB. Why fat is bright i n RARE a n d fast spin-echo imaging. J MaKn Reson Imaging. 1992;2:533-540. Hennig J, Friedburg H, et a1. Rapid nonl omographic approach to M R myelography without contrast agents. J Comptlt Assist Tomogr. 1986 ; 1 0 : 375-378. Hennig J, Nauerth A , et al. RARE i magi ng: a fast imaging method fnr clinical MR. Magn Reson Med. 1986;3:823-833.
Ho PSP, Y u S, Sether L, Wagner M, Ho KC, Haughton VM. Ligamentum flavum: appearance on sagittal and coronal M R images.
Radiology. 1 988; 1 68:469-472.
Holsheimer J , den Boer JA, Struijk JJ, et al. MR assessm e n t of the normal position of the spinal cord in the spinal can a l . A JNR. 1994; 1 5 :951 .
11. Cerebrospinal iluid pulsation at myelography: a videodensitometry Radiology. 1 974 ; 1 1 0:5 7 9-587 .
Lane B, Kricheff study.
Monajati A, Wayne WS, Rauschning W, E k holm S E . MR of the ca uda equina. I1JNR. ·l lJR7 ;R:R93-900. Nordqvist L. The sagittal diameter uf the spinal cord and subarachnoid space i n different age groups (a roentgenographic post-mortem study). Acta Radiol. I 964:227(suppl):1 -96. Quencer RM, Donovan Pust MJ , Hinks RS. Cine MR in the eva l u ation of n ormal a n d abn ormal C S F flow: i ntracranial a n d intraspi n al studics. Neurnmriilli. 1 990;32:371-3Yl. Ridd D, Thorpe JW, Thumpson AJ. e t al. Spinal cord M R using multi-array coils and fast spin echo. Neurology. 1 993 ;43: 2632-2637. Rubi n J B , Enzmann DR, Wright A. CSF-gated M R imagi n g of the spine: theory and clinical i m plementation. Radiology. 1987:1 63:784-789. Shapiro R. The extradural space. I n : Shapiro R , ed. Myelography. 3rd ed. Chicago, I I I : Year Book Medical P u b lishers; 1976;90-92. Sherman JL, Citrin CM, G a n garosa RE, Bowen BJ. The MR appearance of CSF pulsation
in the spinal ca nal. AJNR. 1 986;7:879-884.
Sherman JL, Nassaux PY, Citrin CM. Measurements of the normal cervical spinal curd on MR imaging. AJNR. 1 990;1 1 :369-372. Spirnak JP, Nieves
N,
Betz TA. I dentification of vascular anatomy on sagittal scuut M R
images. Radiology. 1 995 ;1 9 4: 385. Sze G, Bnlvu S, Baieri P, Shim kin PM . Developing spi na l col u m n : gaduli nium -enhaneed M R imaging.
Radio lugy. 1991:180:497-502.
TEACHlNG ATLAS OF SPI
E IMAGING Tam J K , Bradley WG J r, Goergen S K , et al. Pattern s spine at M R imaging with si ngle- and triple-dose
or contrast enhancement in the pediatric gad o l i nium . Radiology. 1 l)l)6 ; 1 l)H:273.
W i l l i ams PL, Wa rw ic k R . The joi nts of the vertehral hodies. In: Wi lli ams PL, Wa rw ick R , eds. Gray's Ant/fumy. 36th British cd. Phi ladelphia, Pa: W B Saunders; 1 980;443-444. Yu JL, du Boul ay G H , Stevens J M , Kendall B E . Morphology and measurements o f the cervical spinal cord in computer-assisted myelogra p hy . Neuroradiof. 1 985;27:399-402.
\ 64
Section n
Congenital
CON G E !ITAL
I
Case 1 Clinical Presentation The patient is an I S-year-old male with nystagmus and upper extremity weakness.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals downward displacement of the cerebellar tonsils (T) into the upper cervical spinal canal. The cerebellar tonsils also are pointed in shape. The posterior margin of the Foramen magnum is identified and is the point where the low signal intensity of the inner table of the calvarium meets the low signal intensity of the outer table of the calvarium (curved arrow). The posterior fossa is small in size. There is a 1.2 X0 .8 cm oval are ... of decreased signal intensity within the cervical spinal cord at the level of C3. Incidentally, the odontoid process is deformed and has an irregular margin (arrowhead). Sagittal long TR image (Fig. B) reveals that the decreased signal intensity area at C3 exhibits increased signal intensity. The downward d isplaced cerebellar tonsils are also seen.
I TEACHING ATLAS OF SPINE IMAGING
•
C
D
CONG EN ITAL
I
E
Radiologic Findings (continued) Axial short TR image at the level of the foramen magnum (Fig. C) reveals the cerebellar tonsils (t) filling the subarachnoid space dorsal to the medulla and deforming and flattening the dorsal aspect of the medulla. The vertebral artery is seen as an area of now void anterior to the cervical spinal cord
(arrow). Axial short TR image (Fig. D) reveals a central area of cerebrospinal fluid signal intensity at tbe level of the cavity (arrow). The cervical spinal cord is expanded i ll size. Axial long TR image (Fig. E) at a slightly lower level reveals that the nuid within th e cavity is increased in signal intensity.
TEACHING ATLAS OF SPINE I M A G I N G
Diagnosis Chiari
PEARLS •
•
The diagnosis of the Chiari I malformation is relatively straightforward with the use of MR imaging. However, the clinical diagnosis may not be so straightforward because symptoms of Chiari I malformation may m imic other clinical entities such as posterior fossa brain tumor or vascular insult. In older patients, the clinical ctiagnosis may be associated with or suspected in those who present with symptoms such as o ciLlopsia (rotatory nystagmus) and/or an unsteady gait.
PITFALLS •
•
Routine MR imaging should generally include sagittal short TR images that demonstrate the foramen magnum. This standard approach to imaging will readily evaluate the presence or absence of tonsi llar hern iation . I f a Chiari I malformation is found, the cervical spinal cord also should be evaluated to rule out the presence of a syrinx cavity. In some cases, the cavity may involve the entire length o� the spinal cord, although involvemen t of only the cervical spinal cord is more typical. Occasionally, the syrinx cavity will spare the cervical spinal cord, but affect other areas of the spinal cord.
I
malformation with focal syrinx cavity.
Differential Diagnosis •
Ch i ari I m alform a t i on with focal syrinx cavity
•
posterior fossa brain tumor
•
vascular insult
Discussion There a re generally considered to be tbree types of Chiari malformation , previously called the Arnold Chiari malformation. They are divided into type I, type II (see Case 4) , and type III (see Case 7). The Chiari four malformation has been eliminated from the classification. The various ana tomic changes seen in all three classes of Ch iari malformation are best evaluated by magnetic resonance (MR) imaging.
In Chiari type T malformation, there is downward displacement of tbe cere bellar tonsils below the level of the foramen magnum. This is defi ned vari ously as: 1. Downward displacement of one cerebellar tonsil at least 5 mm below the foramen m agnum, or
2. Displacement of both cerebellar tonsils 3 to 5 mm below the foramen magnum into the upper cervical vertebral canal 3.
No h i story of myelomeningocele or rad i o l og i c evidence of Chiari II malformation .
4. No prior cranial or cervical spin a l surgery
5. No mass causing the herniation In addition to their downward displacement, the cerebellar tonsi ls are mis shapen and appear as downward pointed deformed tonsils. The fourth ventri cle is displaced inferiorly. The posterior fossa structure appears to be small in size and crowded into a small posterior fossa. There is an increased incidence of hydromyelia with the Ch iari mal formation. Patients with Cbiari I malformation may h ave such symptoms as nystagm us or thermi tte's sign when the head i s in a certain posi tion. On tbe other hand, even elderly asym ptomatic patients may be identified with the Chiari I malformation. Tonsilla r ectopia is defined as i n feri or displacement of the cerebellar tonsils to the level of the foramen magnum, but not below the foramen magnum. This term does not imply the associated anatomic abnorm alities that are seen with the true Chiari malformati on.
CON G EN ITAL
I
Case 2 Clinical Presentation The patient is a 6-year-old male unable to keep up with his class mates i n gym class.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals the posterior margin of the foramen magnum (long arrow). This bone is thin ned secondary to long-standing pressure from the downward displacemen t of the inferior cerebellum and the cerebellar tonsils. The cerebellar tonsils are displaced below the level of lhe foramen magnum and appear pointed. The posterior inferior cerebellar artery appears as a curvilinear area of flow void (short arrow). The tapered upper end of a centrally placed cavi ty can be seen at the level of C6 (s) . The cavity extends i n feriorl y into the thoracic spine region. Sagittal short TR image (Fig. B) reveals the syrinx cavity with mu ltiple internal seplae (arrows).
I
TEACH I N G ATLAS OF SPINE TMA G l N G
c
D
Radiologic Findings (continued) Sagittal short TR image including the distal spinal cord (Fig. C) reveals the multiple internal septations (arrows) exten ding to the distal end of the spinal cord. The lower cervical and thoracic spinal cord are expanded throughout thei r length and occupy almost the entire thoracic vertebral cana l, resul ti ng i n ob literation of the surrounding subarachnoid space. The vertebral canal is en larged throughout its length, which reflects the long-standing nature of this process. Axial short TR image in the distal thoracic region (Fig. D) reveals the low signal intensity cavity, which is slightly eccentrically placed within the spinaL cord. There is a small rounded area of increased signal intensity within tbe dorsaL aspect of the cavity (arrow). The normal epjduraL fat appears as increased sign al i n tensity (n.
7'2
CON G EN ITAL
PEARLS •
•
the patient with a Chiari I malformation, the entire spinal cord should be evaluated to determine the exact extent of the cavity. In
The small rounded area of increased signal intensity within the syrinx cavity is secondary to an area of flow related enhancement.
PITFALL •
At the time of surgery, the multiple internal septae may make shunting of th syrinx cavity di fficult because these septae may interfere with free communication between the various compartments.
I
Diagnosis Chiari T malformation with lower cervical and t horacic syrin x cavity.
Differential Diagnosis •
Chiari I malformation with lower cervical and thoracic syrinx cavity
Discussion Although Chi ari I malformation is one of the more COI1U110n congenital anomalies of the central nervous system that exhibits typical findi ngs on i maging, there are frequently minor variations on the theme of these deform ities. There are often variations in the appearance of the low lying tonsils, a highly variable difference in the size of the syri n x cavity, and a variety of clinical presen tations. Typical surgical treatment of this anomaly includes removal of the inferior aspect of the occipital bone to allow free flow of cerebrospinal fluid around the region of the foramen magnum. For a definition of Chiari
I
malformation, see Case 1.
I
TEACH 1 N G ATLAS OF SPINE IMA G I N G
Case 3 Clinical Pres entati on The patient is an 8-year-old male with progressive lower extremity weakness.
A
B
CONGENITAL
I
c
Radiologic Findings Sagittal short TR image (Fig. A) reveals a small, multisegment, loculated syrinx cavity in the mid and distal thoracic spinal cord. The cerebrospinal nuiJ (CSF) containing cavity begins at the level of thc infcrior cndplate of T7 and extends to the level of the midbody of Ll. There is slight expansion of the spinal cord throughout thc spinal cord at the area of t he syrinx cavity. 8 T8 vertebral body. =
Sagittal long TR image (Fig. B) reveals that the nuid within thc syrinx cavity exhibits marked increased signal intensity. Note the areas of decreased signal intensity dorsal to the spinal cord superior to the syrinx cavity (arrowheads). Thcse represent areas of flow void in thc CSF secondary to transmi tted heart beat and respi ration.
I
TEACHING ATLAS OF SPINE I M A G I N G
Axial short TR im
(upper image).
Diagnosis Ch iari
I
malform ation and thoracic syrinx.
PEARLS •
•
The cervical spinaL cord also should be evaluated to rule out the presence of a syrinx cavity. In the presence of a Chiari I malformaLion and a cervical spinal cord syrinx cavity, tbe entire length of the spinal cord should be evaluated.
PITFALL •
The multipLe areas of decreased signal intensity dorsal to the thoracic spinal cord represent areas of flow void secondary to transmitted hearL beat and respiration and should not be mistakcn for the flow void of an arteriovenous malformation.
Differential Diagnosis •
Chiari I malformation and thoracic syrinx
Discussion There was downward displacement of the cerebel lar tonsils below the level of the foramen magn um in this patient consistent with a Chiari I malforma tion (not ill ustrated). There was no syrinx ca vity present in the cervical spinal cord. The location of the syrinx cavity in the thoracic region is uncom mon, but otherwise typical of Chiari I malformation. The size and location of the syrinx cavity in patients with Chiari I malforma tion is highly variable. In some patients these cavities are small, whereas in others they are large. There is also variation in the number of internal septations that may be seen. CSF flow may be eval uated by magnetic reso nance im aging with directional annotation so that caudal flow h as i ncreased signal intensity while cepahalad flow exhibits decreased signal intensity. The flow m ay also be quantitative and therefore, changes that may occur following any corrective surgical procedure can bc evaluated. For a definition of Chiari I malforn1ation, see Case
I.
CO N G EN ITA L
I
Case 4 Clinical Presentation The patient is a newborn male with a large soft tissue mass arisi ng in the lower dorsal region of the l umbar spine.
A
B
Radiologic Findings Sagi ttal short TR image at the Level of the cervical spine (Fig. A) reveals cerebellar tonsillar herniation (straight arrow). The cervical spinal cord is displaced posteriorly into the lower cervical region and the upper portion of a sylinx cavity is seen in the upper thoracic region (curved arrow). The cervical vertebral canal is expanded. Incidentally, there is pl atybasia o( the s kull base, with absence of the normal curvilinear angulation between the brain stem, medulla, and upper spinal cord.
I
TEACHING ATLAS OF SPIN E I M A G I N G
c
Radiologic Findings (continued) Sagittal short TR image of the lumbar vertebral canal (Fig. B) reveals a multiloculated syrinx cavity that extends from the thoracic region into the lumbar region. The spinal cord is tethered distally at the level of L3 (straighl black arrow). Spinal dysraphism and a heart-shaped, thick-walled meningo myelocele (while arrows) in the lower lumbar region are visible. The menin gocele extends outward from the dysraphic lumbar vertebral canal in to the subcutaneous area. The disordered neural tissue (open arrow) can be seen extending into the meningomyelocele. There is an increase in the normal epidural fat in the lower Lumbar region. The sacrum is missing below the level of Sl (curved arrow). Axial short TR image (Fig. C) reveals the th ick-walled meningomyelocele (straight arrows). The disordered neural tissue-the neural plaquode-can be seen extending into the vertebral canal (curved arrow). Spinal dysraph ism is visible. There is an increase in the epidural rat in the widened vertebral canal and an increase in the amoun t of adipose tissue in the subcutaneous tissue adjacent to the meningocele.
I�
CONGEJ TTAL
PEARLS •
•
•
The entire pinal cord should be visualized to evaluate for tethering of the 'pinal cord and the presence and extent of syringohydromyelia. Magnetic resonance imaging accurately reflects the anatomic findings and surgery can be based on the e findings. This patient also has sacral agenesi with an increase in the amount of subcutaneous fat. In 30 % of cases, infants with sacral agenesis have a diabctic mother. The dorsal displacement of the upper portion of the thonlcic pinal cord is probably secondary to dorsal tethering of the spinal cord at this level. The normal basal angle, formed by a line connecting the nasion to the tuberculum sellae to the anterior margin of the foramen magnum is 125 to 1 43 degrees.
I
Diagnosis Chiari type II malformation with a large meningomyelocele, sacral agenesis.
Differential Diagnosis •
Chiari type I1 malformation with a large meningomyelocele, sacral agenesis
Discussion In the Chiari II malformation, the cerebellar tonsils are downwardly dis placed and a meningocele or meningomyelocele is found in the lumbar region. There may be an associated syrinx cavity within the spinal cord, or an associated aqueduct stenosis and therefore an associated hydrocephalus. Other abnormalities of the brain that may be seen in association with the Chiari II malformation include enlarged massa i ntermedia, downward pointed floors of the lateral ventricles, towering vermis of the cerebellum, scalloping of the posterior margi n of the petrous bones, kinking of the brainstem, colpocephaly, absent septum pellicidum, absence of the corpus callosum, enlarged foramen magnum, and tecta I beaking. This patient exhibits a large constellation of findings that may be �een i n patients with congenital anomalie o f the spine. A s with congen ital anomalies of the brain, when one anomaly is present, there are frequently additional anomal ies. It a lso may be helpful or even necessary to evaluate the intracra nial contents in these patients to fully evaluate the extent of abnormalities.
PITFALL •
Vertebral anomaliel> m ay also be seen in patients with tbe Chiari mal formations.
22 .1
I
TEA C H T N G ATLAS OF S P I N E I M AG I NG
Case 5 Clinical Presentation The patient is a I-year-old male with a history meningomyelocele repair at birth.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals extraordinarily marked downward displacement of the cerebellar tonsils (solid arrow). The tonsils are elongated and pointed and extend down to the TI level (open arrow).
CONGENITAL
c
D
I
I TEACHING ATLAS or S PINE IMAGING Radiologic Findings (continued) Sagittal short TR image of the lumbar spine (Fig. B) reveals a deformed, lobulated spinal cord that is tethered at the level of the lower lumbar vertebral canal (open arrows). There is ectasia of the lumbar vertebral canal. A bilobed cerebrospi nal fluid filled sac in the lumbar region is present, which contains a small amount of neural tissue (arrowheads). Several of the lower lumbar vertebral bodies are deformed (long arrow), with a hemiverte brac in the upper l umbar region (h) and two fused vertebrae (j). There is a scoliosis with a rotational component. Sagittal long TR image (Fig. C) reveaJs the tethered cord, the meningomyelo cele, the internal neural tissue (arrowheads), the dilated vertebral canal and thecal sac, and the deformed vertebral bodies. Axial short TR image (Fig. D) reveals the bilobed meningomyelocele. The disordered neural tissue can be seen in the anterior portion of the meningo cele (open arrow). The vertebral body is deformed (d). Note the area of marked thinning of the skin over the meningomyelocele (solid arrow).
PEARLS •
•
Thi constellation of findings is seen in association with tbe Chiari 11 malform ation. Therefore, if any of tbese abnormalities is present, the patient should be evaluated for the presence of the others. A
syrinx cavity may also be seen in these patients.
PITFALLS •
•
The length of the spinal cord should be eva luated to rule out the presence of a syrinx cavity. M R of the brain may reveal additional anomalies.
Diagnosis Chiari II malformation with meningomyelocele, dysrapbic spinc, cerebellar tonsillar herniation, tethered cord, deformed vertcbrae, and expanded fora men magnum.
Differential Diagnosis •
Chiari TT malformation with meningomyelocele, dysraphie spine, cerebellar tonsillar herniation, tethered cord, deformed vertebrae, and expanded foramen magnum
Discussion This patient exhibits the extreme example of cerebellar tonsillar herniation that may be seen in patients with Chiari I I malformation. In addition, a large portion of tbe cerebellum i displaced into the upper cervical vertebral canal. This tissue obliterates the foramen magnum. The cervical vertebral canal is greatly expanded. Incidentally, the curve of the cervical spi ne is reversed and the medulla is kinked. The value of magnetic rcsonance (MR) imaging is readily apparent in this example. M ultiplanar M R imaging is able to identify the abnormalities totally noninvasively. Prior to the availabil ity of MR i maging, this type of patient would have needed to undergo myelo graphic examination in addition to plain film evaluation; bowever, neither of thcse would allow for as complete evaluation of the anomaly as M R imaging. For a definition of Chiari 1I malformation. see Case 4.
CON G EN ITAL
I
Case 6 Clinical Presentation The patient is a 56-year-old woman with previous occipital decompression for Chiari I malformation . Surgery also had been performed for cervical syrinx cavity decompression 1 year previously. Th is SlUUY is the 1 - year postsurgery fol low-up.
A
I TEACHING ATLAS OF SPI ' E I MAGING
B
1 84
c
CONG EN ITAL
I
Radiologic Findings Sagittal short TR image (Fig. A) reveals that there has been a previous occipital craniectomy. The anticipated position of the posterior margin of the foramen magnum is identified by the straight arrow. The present, postsur gical , posterior margin of the foramen magnum is positioned posteriorly and superiorly (curved arrow). An elongated remaining portion of a cerebro spinal fl uid (CSF) containing cavity is visible, with i ts widest dimension at the level of C4 (4). The cavity extends from t he level of C2 through the level of C6. Axial short TR image (Fig. B) reveals the slightly eccentrically placed CSF containing cavity within the cervical spinal cord. An internal smaller rounded area of low signal intensity also is noted (while arrow). Incidentally noted is a small scar in the subcutaneous tissue secondary to the previous surgery (black arrow).
PEARLS •
•
Prior to occipital decompression, this patient had the typical findings of Chiari I malformation. Following surgery the cerebellar tonsils have assumed an essentially normal appearance. Chiari I malformation is associated with syringohydromyelia in up to 30 % of case .
PITFALL •
It is frequently very difficul t to identify a shunt tube in plaee within a syrinx cavity. Tbe small eccentrically positioned area of decreased signal intensity within the spinal cord on the axial images represents the shunt tubing device in the central portion of the syrinx cavity. 'ote that surgical hi tory is very helpful for complete evaluation and accurate interpretation of the images.
Sagittal long TR image in the lower cervicaillhoracic region (Fig. C) faintly reveals the shunt tubing device in place wi thin the syrinx cavity (small arrowheads follow the shunt tube). The tip of the shunt tube is identified by the very tiny area of decrcased signal i ntensity j ust at the tip of the tube (large arruwhead). This accentuation of the tip of the catheter is secondary to a small amount of metal and resulting magnetic susceptibi lity artifact. The shunt tube has been placed via a thoracic laminectomy at T3-4 that can be identified by the absence of the spinous processes i n the upper thoracic region (*) .
Diagnosis •
•
Chiari I malformation with syrinx cavity. postoperative changes with shunt tube placement. Post surgical changes following removal of a spinal cord tilinor could have a similar appearance
Differential Diagnosis •
Chiari 1 malformation with syrinx cavity, postopertltive changes with shun t tube placement
Discussion Magnetic resonance evaluation is the best method for evaluating response to shunt placement in pa tients with syrinx cavity. In addition to determin ing the size of the syrinx cavity, any changes. such as tethering of the spinal cord sewndary to scarring, also may be evaluated. For a definition of Chiari I malformation, see Case
1.
TEACHING ATLAS OF SPINE I M A G I N G
Case 7 Clinical Presentation The patient is a newborn with a compressible soft tissue mass at the back of the skull.
A
Radiologic Findings Sagittal short TR image of the skull that includes the upper cervical spinal region (Fig. A) reveals that the inner table of the occipital bone ends much higher than in the normal patient (black arrow). There is a small posterior fossa ,mu a small cerebellum. The cerebellar tonsils project inferiorly into the upper cervical vertebral canal. There is a thin-walled cystic cavity in the cervical spinal coru. The upper end of the cavity ends at the C5 level. A variable signal intensity 4-cm mass appears to contain multiple cystic areas with internal septae. The lateral ventricles are enlarged. The corpus callosum is not well seen.
1 86
CON G E NTTAL
I
Diagnosis Chiari type III malformation.
PEARL •
The physical findings in this patient are obvious to the clinician; therefore, the clinical diagnosis is obvious. There are typical findings whlch are seen in a patient with this diagnosis, and these changes should be looked for when eval uating the images.
PITFALL •
If one is unaware of the typical findings, the various subtleties of the case may not be appreciated.
Differential Diagnosis •
Chiari type
TTl
malformation
Discussion The Chiari 111 malformation includes the presence of an occipital meningo cele or meni ngoencephalocele. There may a lso be an associated cervical spinal cord syrinx cavity. In this patie nt, there is an occipital meningoenceph alocele, cerebellar tonsillar herniation, agenesis of the corpus cal losum, kinking of the brainstem, syringohydromyelia of the cervical spinal cord, and a small posterior fossa. This constellation of findings is seen in the patient with the Chiari III malformation. It is important to determine the contents of the soft tissue mass. Tf the mass con tains only meninges without cerebellar tissue, it can be removed surgicaJly with impun ity. However, if the sac a lso contains cerebral tissue, then the surgical implications are much greater, and surgery cannot be attempted without danger to the patient. MR imaging is the procedure of choice for evaluation.
I
TEACHING ATLAS OF SPIN E I MAGING
Case 8 Clinical Presentation The patien t is a 2-year-old female with lower extrem ity paralysis and bowel and bladder incontinence; a pelvic mass was identified on ul trasound.
A
B
Radiologic Findings Sagittal short TR image in the lower lumbar region (Fig. A) reveals extension of the thecal sac into the pelvis anterior to the sacrum. The thecal sac is expanded, with a large component extending anteriorly into the pelvis (arrow). The material within the sac is a combination of cerebrospinal fluid (CSF) and the deformed n eural tissue; therefore, the signal intensity within the sac is variable and is secondary to this wide variety of soft tissue struc tures. The bowel and bladder are both d ilated . Sagittal long TR image (Fig. B) reveals the nerve roots of the cauda equina extending into the sacral meningocele. The sac contains CSF and neural tissue (short arrow). The distal end of the sacrum is absent (long arrow), as is the coccyx.
CONG EN ITAL
I
Diagnosis Anterior sacral myelomeni ngocele.
PEARLS •
·
•
•
There also is caudal regression with absence of a portion of the sacrum and the coccyx, and tethering of the spinal cord. cr
scanning also may be helpful to better evaluate the bony abnormalities.
The remainder of the spine should be evaluated for the possibility of a syrinx cavity within the spinal cord. A sacral teratoma could have a similar appearance but would not communicate with the thecal sac.
ITFALL •
Communication may occur with the gastroi ntestinal tract. resulting in central nervous ystem infections.
Differential Diagnosis •
retrorectal cyst-hamartoma (tailgut cyst)
•
dermoid cyst
•
duplication cyst of rectwll
•
neurenteric cyst
•
rectal leiomyosarcoma
•
chordoma
•
sacral teratoma
Discussion Prior to the development of magnetic resonance (MR) imaging, evaluation of sacral meningocele was performed with myelography. Following the injec tion of iodinated contrast material into the subarachnoid space, radiopaque contrast material would accumulate in the meningocele. The myelogram would typically be followed by a computed tomography (Cf) scan, which would then evaluate the amount or neuntl tissue elements and CSF within the sac. This was a much more invasive and less accurate examination than MR imaging. In general, surgery may be planned in these patients based solely on the MR findings.
I TEACHING ATLAS OF SPI N E IMAGING
Case 9 Clinical Presentation The patient is a 3-month-old female with a small dimple on the lower back.
A
B
Radiologic Findings Sagittal short TR image of the lumbar spine (Fig. A) does not demonstrate the true con us. The spinal cord is a solid structure down to the level or the junction between the sacrum and the coccyx (long arrow). A vitamin E capsule (£) identifies the skin abnormality. There is absence of the coccyx and a small irregularly marginated accumulation of fat (*) marks the distal end of the vertebral col umn. The vertebral bodies and intervertebral discs demonstrate their immature form. The vertebral body is identified with a V and the superior and inferior cartilaginous end plates are marked with curved arrows. The intervertebral disc is i dentified with an arrolvhead.
1 90
CONGENITAL
c
D
I
I
TEACHI N G ATLAS OF SPI N E I MA G I N G
Radiologic Findings (continued) On the long TR image (Fig. B) the cartilaginous endplates of the vertebral bodies appear markedly decreased in signal intensity (arrows), whereas the intervertebral disc appears bright. The lumbar vertebral canal is en larged throughout. The di lated vertebral canal appears as increased signal intensity; the spinal cord is not seen. The axial short TR image in the lower lumbar region (Fig. C) reveals a dysraphic spine and the soft tissue density material replacing the subcutane ous fat (arrow). Axial short TR image in the sacral. region (Fig. D) reveals a dysraphic spine and the tethered spinal cord positioned posteriorly in the thecal sac (arrow). There is no lipoma of the distal cord; however, the neural tissue is abnormally located outside of the vertebral canal.
PEARL •
Evaluation of the craniovertebral junction may reveal the presence of low lying cerebellar tonsils.
Diagnosis Tethered cord, meningomyelocele, and coccygeal agenesis.
Differential Diagnosis •
tethered cord, meningomyelocele, and coccygeal agenesis
PITFALL •
The entire sacrum and coccyx should be visualized so that anomalies can be identified.
Discussion The presence of a low lumbar skin dimple may herald the presence of a tethered cord or other anomaly. Magnetic resonance imaging is the best method for evaluation. Patien ts m ay be asymptomatic in younger life, but in later life may deve lop symptoms such as Ulinary retention. If there is a sinus tract associated with the skin dimple and resulting communication wit h the spi nal subarachnoid space, repeated central nervous system (CNS) infections such as meningitis may occur. A sinus tract should not be probed for fear of introducing infection into the CNS.
CONGENITAL
I
Case 10 Clinical Presentation Newborn male with imperfont le
A
a n us.
B
I
TEACHING ATLAS OF SPINE I M A GI N G
c
D
CON G E
ITAL
I
E
Radiologic Findings Sagittal short TR image (Fig. A) reveals that the spinal cord ends at the level of the inferior endplate of L2 (curved arrow). Tbere is an increased signal intensity elongated soft tissue mass that begins at the level of the midbody of L3 and extends inferiorly to mid-L5 (thin black arrow). The S l vertebral body (Sl ) i s deformed (thick black arrow), a n d there is an increase in the amount of fat in the subcutaneous area in the anticipated position o f the sacrum and coccyx (P). The rectum and distal bowel are greatly dilated. Sagittal intermediate TR image (rig. B) reveals that the cerebrospinal fluid now appears as intermediate signal intensity; the soft t issue mass appears as increased signal intensity. Long TR image (Fig. C) reveals that the soft tissue mass now appears decreased signal intensity (arrow). Axial short TR image at tbe level of L4 (Fig. D) reveals that the filum termi nale (arrow) appears as an area of rounded decreased signal intensity within the i ncreased signal intensity mass seen in Figures A through C. Short TR image at the level of the intervertebral disc of L4-5 (Fig. E) reveals chemical shift artifact (arrow) associated with the i ncreased signal intensity mass.
I
TEACHING ATLAS OF SPINE IMAGING
PEARL is reported that 30% of infant with caudal regression syndrome are born to mothers with diabetes mel litus. It
•
Diagnosis Sacral agenesis with fi lum terminale lipoma and lower-than -norm a l spinal cord.
Differential Diagnosis PITFALLS The entire sacrum and coccyx should be included at the time of imaging.
•
Plain :film evaluation necessary.
•
•
may
CT scanning may better demonstrate the bony abnormalities.
96
be
•
an area of subacute hemorrhage could rnirrli c the appearance of lipoma
•
sacral teratoma (unlikely)
Discussion Other anomalies such as kidney lesions also may be seen in patients with sacral agenesis. Magnetic resonance imaging is the procedure of choice for diagnosis. The entire vertebral column should be evaluated for the presence of various anomalies and the possibility of a syrinx cavity in the spinal cord. Abdominal imaging with CT and/or ul traso und and in the evaluation of related organsystem anomalies.
CONGENITAL
I
Case 11 Clinical Presentation The patient is a 6-month-old male with lower extremity weak ness.
A
B
Radiologic Findings Anteroposterior (Fig. A ) and l ateral (Fig. B) views of the abdomen reveal that there is incomplete development of the sacrum and coccyx. Only a small rod-like bone appears in the anticipated position of the sacrum a nd coccyx (short arrow, Figs. A and B ) . L3 is a small rounded malformed piccc of bone. L4 (long arrow, Figs. A and B ) is a hentivertebrae with a deformed pediclc on the right side. L5 (5, Fig. B) appears to be incompletely (ormed with a hemivertebrae on the left side (open arrow, Fig. A).
I TEA C H I N G ATLAS OF SPINE I M A G I '0
c
Radiologic Findings (continued) Sagittal short TR image (Fig. C) reveals tha l the spinal cord is tethered and extends caudally to the level o[ L5 (5; upen arrow). The dural sac is expanding into the lumbar region. L3 can be seen as a small rounded segment of bone (white arrow). L4 and L5 appear similar in appearance to the plain spine f11 m s. The rod-l i ke structure of the sacrum and coccyx are seen surrounded by high signal intensity fat (black I1rrows).
CON G E N ITA L
Diagnosis
PEARLS •
30%
I
of infants with caudal
regression syndrome have diabetic mothers. • Magnetic resonance imaging is
the ideal method of evaLuating congenital abnormalities of the spine.
Caudal regression syndrome with tethered cord and m ulti ple vertebraL anomalies.
Differential Diagnosis • sacral teratoma • dermoid
�ITFALLS
•
lipoma
• If a myelogram is attempted in
a patient with a tethered spinal cord, the needLe shouLd be placed eccentrically
in
the outer
thirds of the thecal sac such that the needle will not injure the tethered spinal cord. •
Tethered cord may poten ti ally be associated with low cerebellar tonsils (as if the tethered spinal cord "pulls" the cerebellar tonsils inferiorly). Therefore, if a cervical spinal tap is attempted the cerebellar tonsils could potentially be at risk for i nj u ry.
Discussion The b u Lbous, frequently squared off appearance of the d istal spina l cord is typical of the caudal regression syndrome. However, other anomalies such as spinal cord lipomas may also be seen in association with this anomaly.
I
TEACHING ATLAS OF SPINE I MAGING
Case 12 Clinical Presentation The patient is a 2-day-old female with spinal dysraphism with hypoplasia of the lowesl lWo l umbar and firsl sacral verlebral body segmenls on plain film exami nation . The opening of a dermal defect is visi ble i n the lower lumbar region on direct physical examination.
A
CON G EN ITAL
Radiologic Findings
PEARL •
The intermediate signal intensity l inear structure represents the sin us tract. In some patients the sinus tract may be very small in size and only faintly or not at all visible on MR imaging. Therefore, a vitamin E capsule taped to lhe patien t s skin is useful to mark the position of the opening of the sinus tract and to aid in the identification and characterization of the abnOlmality by MR imaging. '
PITFALL •
I
The sinus tract should not be probed for fear of introducing infection .
Sagittal short TR image ( F ig . A) reveals a faint i n termediate signal in tensi ty linear structure extending from the ski n defect to the level of the l umbar thecal sac (black arrow). The distal end of the spinal cord is blunted, bulbous, and distorted (whire arrow). There is increased fat in the anterior epidural space from LS through the sacrum .
Diagnosis Partial sacral and coccygeal ag enesis sinus tract, spinal dysraphism, tethered spinal cord. ,
Discussion The full extent of the sinus tract may not be visible on magnetic resonance (MR) examination; however, its location can be identi fied by scanning, and the s i n us tract may t h en be followed t o i ts term ination at the time of surgery. Mul t iple anomalies are common in pa t ients with caudal regression therefore when one anomalie is identified, evalu ation should be made for additional anomalies. These additional anomalies m ay be w i th in the cen tral nervous system and/or in other organ systems. ,
I TEACHING ATLAS OF SPI
E
I M A CilNG
Case 13 Clinical Presentation Newborn male with flaccid anal sphincter.
A
1 1 02
CONGEN ITAL
I
B
Radiologic Findings S
PEARL •
The newborn is difficult to i mage because of i ts very small size. It may be advantageous to image such a small child in a smal l coil such as the knee coil.
Diagnosis Tethered cord, sacral agenesis, horseshoe, pelvic kidney.
Differential Diagnosis •
tethered cord, sacral agenesis, horseshoe, pelvic kidney
Discussion MUltiple anomalies
1 03 1
I
TEACH I N G ATLAS OF SPINE IMAGING
Case 14 Clinical Presentation The patient i s a 2-year-old male with right foot varus deformity and de creased reflexes bilaterally in the lowcr extremities. Patient h as hypo- and hyperpigmentation on the lower back, j ust above the gluteal fold. There is no sinus tract or abn ormal hair patch noted.
A
l..}Q4
B
CONGENITAL
. . . ...
c
D
I
TEACHING ATLAS OF SPfNE IM AGING
Radiologic Findings S ag itta l short TR image (Fig. A) reveals a high s ignal intensity mass in the lower por t io n o f the ve r teb r al canal that measures 6 X 3 X 2 cm. There is expan sion of tbe vertebral canaL. There are mu l ti pl e curvilinear i n t e r n al areas of decrcased sig n a l intensity. A l ar ger accum ul ation o f r e ta i n ed neural tissue is identified anteriorly (black arrow) . The s p i n al cord is tethered and there is a syrinx cavity i n the distal p orti o n of the sp in a l cord (white arrows). Long TR image (Fig. B) reveals m arked e xp ansion of the distal thoracic and lumbar ve rt e bra l can a L A mass appears as decreased si gn al i n ten si ty on the TI - we i gh te u i m a ge . Axial short TR i ma ge (F i g . C) reveals the s y rinx c a v i t y
at t h e
level of
L2 (arrow ). Axial short TR i ma ge (Fig. D) reveals an i nc re as ed signal i n tensity mass co n ta in ing the decreased signal i nten s it y t i s sue a n t eri o rly ( arrow ) . Othcr internal curvilinear areas of decreased sig nal i nte n s i ty a re a lso seen along the right side of the increased signal i n t ens i t y mass. The vertebral canal is expanded and the laminae of the vertebral body at t he LS level are th i nned a n d disp l aced posteriorly.
Diagnosis PEARL •
M a gnet ic resonance (MR) imaging of th e entire vertebral column is suggested for comp lete evaluation to rule out the presence of other areas of syrinx formation and to evaluate the presence or absence of t h e Chiari malformation or other associated mal fo rm atio n s .
PITFALL The MR s ig n a l characteristics of increased s i gn a l in the sh ort TR im age and decreased s ignal i n te n s ity on the lo n g TR im ages is typica l for lipoma. Subacute blood in the form of methemoglobin would be increased signal inte nsit y on both t he short TR and long TR i m a ges . •
Tethered cord with filum terminale l i pom a , panded lumbar vertebral canal .
syrinx
of the d i s t al
co rd , ex
Differential Diagnosis •
h ematom a
•
tertoma
•
( unlikely)
(unl i kely)
derm o i d (unlikely)
Discussion Note thc chemical shift artifact t hat results in an increased si gna l inten sity ri m proj ectin g superior to the curvilinear top of the lipoma on the short TR ima ge in Figure A and a decreased sig n a l inte n s i t y s u per io r rim o n th e long TR im a ges in Figure B . The che m i cal sh ift artifact occurs along the frequency e n cod i n g d i rect ion . The internal areas of decreased s ig n a l i n te nsi ty are consiste nt w i th d i so r dered neural t issue conta in ed wi thi n th e l i p om a . A I ipllmll 1Iisn a ppears i n the s ubcu ta n eo us tissue on th e back , with a c ur v i l i n e a r dec rc ascd sign a l i n te n s i ty upper m argi n fa in t ly seen at the level of a ppr o x i ma tely L3. In add i t i o n t o a ppe a r i n g as increased signal i n ten sit y on the short TR images, a hem a to ma would not exhibit the chemical shift artifact that is see n with a li pom a. In addition, the p a tie nt with hematoma would have a di f fe re n t clinical presentation.
CONGENITAL
I
Case 15 Clinical Presentation The patient is a 3 m ont h ol d male with a small d i mp le just above the intergl u teal cleft. -
-
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals lhe skin dimple (solid arrow). An intermediate signal i n tensity structurc follows a cu rv il in ear course through the high signal i ntensity of th e subcutaneous fat (arrowheads), first inferiorly and then superiorly along the dorsal aspect of the lumbar thecal sac (open arrow). The thecal sac is dilated; the vertebral canal is expanded. The epidural fal is increased surrounding the distal end of the thecal sac.
lJm
I TEACHING ATLAS
OF
SPINE IMAGING
PEARL •
The sinus tract may extend for a variable distance up the vertebral canal. Surgical dissection is necessary for complete evaluation.
PITFALL •
The skin dimple in these patients may be very small and may be hidden in the intergluteal cleft.
1 08
Diagnosis Tethered cord, sinus tract.
Discussion The sinus tract forms a pathway for the entrance of h
CONGENITAL
I
Case 16 Clinical Presentation The patient is a 3-month-old male, healthy newhorn with a soft tissue mass in the lower lumbar region. No abnormal neurologic signs were identified and spine radiographs were reported as normal.
A
B
1 09
I TEACHING ATLAS OF SPI N E IMAG I NG
c
D
Radiologic Findings Sagillal short TR midline image (Fig. A) reveals that the spinal cord is a solid struct ure that extends down to the level of L4. An irregularly marginated increased signal intensity mass is pre.sent in the d i stal end of the thecal sac (L). The vertebrae and intervertebrae exhibit t h e ir infantile appearance. The vertebral body ( V) appears relatively decreased in signal in tensity compared with the intervertebral disc. The disc appears higher in signal intensity than the vertebral body and contains a decreased signa l intensity line the nuclear cleft (curved arrow). The endplates of I he vertebral bodies arc cartilagenous (straight urrow). Parasagittal image on the right side (Fig. B) reveals that the increased signal intensity mass ( L) extends superiorly along the lateral margin of the thecal sac to the level of L2. No dorsal elements arc visible at the level of S2. Increas t:d s ignal intensity tissue containing internal areas of decreased signal intensity t issue (arrow) extend outside of the vertebral canal and into the clin ically noted prominent subcutaneous fat in the lower l umbar and upper sacral region.
CONG EN ITAL
I
Parasagittal image on the left side (Fig. C) reveals two sm
arrow).
EARL Magnetic resonance (MR) imaging is the procedure of choice for evaluation of any patient su peeted of having a meningocele.
•
ITFALLS •
•
Plain films must be evaluated carefully: Although the plain fiJms for this patient were reported a normal, a dysraphic :pine wa noted on the MR scan. The lower lumbar and sacral region may be difficult to evaluate in the very young patient because of overlying bowel gas.
Sagitt
Diagnosis Tethered cord, lipoma, myelomeningocele.
Discussion The increased signal intensity tissue is a lipomll lind the internal areas of curvil inear intermediate signal intensity are the disordered neural tissue. These deformed nerve roots can be sccn as areas of intermediate signal intensity that extend into the subcutaneous fat/lipoma of the lower back. Patients with tethered cord may become symptomatic as they grow older because the vertebral column continues to grow and tbe spinal cord is "pulled" up into the vertebral canal . Bee
lJJJ
I
TEACI I I NG
ATLAS OF SPINE IMAGING
Case 17 Clinical Presentation The patient is a 1 9-year-old female with lower extremity weakness.
A
Radiologic Findings Sagittal shurl TR image (Fig. A) reveals fusion uf multiple cervical vertebral budy segments (upper arrow). Tl and T2 a re also fused (lower arrow). as are T6 and 17.
112
CONGENITAL
I
C
B
Radiologic Findings (continued) (Fig. B) Sagittal intermediate TR image at the level of T8 (8) there is sl ight expansion of the vertebral canal. The fusion between T6 and T7 is better demonstrated. Sagittal short TR image at the level of the lumbar spine (Fig. C) reveals that the spinal cord is a solid structure throughout the lumbar s ubarachnoid space (curved arrow). There is a mass at the anticipated level of S2 (open arrow), and the distal sacrum and coccyx are absent (slraight arrow). Also present is a mass at the level of the foramen magnum.
Diagnosis Klipple-Feil anomaly associated with the Ch iari cord, l ipoma, sacral agenesis.
T
malformation, tethered
,13
I TEACH ING ATLAS
OF
SPINE I M A GI N G
fEARL •
Directed surface coiJ images with a small field of view should be obtaineu or any areas of interest.
PITFALLS •
•
The entire length of the vertebral column should be studied, including the sacrum and coccyx. Axial short TR images should be obtained through the levels of the abnormal vertebral bodies to rule out dia tematomyelill llnd two h em icorus.
Discussion Magnetic resonance imaging is the proce d ure of choice for evalulltion of the spinal column because it a llows evaluation of both the vertebral bodies and the soft tissues of the spi nal cord.
CONGEN ITAL
I
Case 18 Clinical Presentation The patient is a lO-year-old female wi l.h scoliosis and lower extremity wellkness.
A
l�
I TEACH ING ATLAS
Uf
SPINE I M AGING
B
c
CONGE ITA L
I
D
Radiologic Findings A nteroposterior myelogram (Fig. A) reveals t h e JilateJ thet:al sac a nd the two hemicords. The thecal sac extends around the spur within the vertebral canal (arrow). Axial computed tomography (CT) myelogram images ( Figs. B through D) reveal the two hemicords within one thecal sac. The dorsal clements of the s pin e are absent. There is a small bony spur anteriorly that extends into the vertebral canal and deform ity of t h e vertebral bodies a l I h is l e v e l .
PEARLS •
•
Magnel ic resonance imaging is the ideal method for evaluation . Thin section cr scanning or radiographic tomography are helpful to demonstrate the vertebral body anomaly.
Diagnosis Diastematomyelia, scoliosis, vertehral body anomal ies.
Discussion Diastematomyel ia is always associated with an abnormally developed verte bral body. This abnormality may be '0 subtle that it is undetectable on plain fi lm e x a m ina tion. With this anomaly, either a bony or fibrous sp u r diviJes t h e spinal cord into two hemicords. Note that the term diplomyelia-Jouble spinal cord-does not apply here. and this anomaly of two separate spinal cords is actually very rare, if it exists at all. The two divisions of the spinal cord may be symmetric or asymmetric and both cords are enclosed within the subarachnoid space. I I
II
I TEACHING ATLAS OF SPINE I M AGING PITFA LLS •
The spur may be fibrous as well as bony.
•
The patient also should be evaluated for the presence of a syrinx.
The dural and subarachnoid spaces divide at the level of the spur and then rejoin below. There also may be downward displacement of the cerebel lar tonsils, as i f they are being pulled down by the diastematomyelia spur. Therefore, it is prudent to evaluate the entire spi nal cord in the patient who has diastematomyelia to rule out Ihis additi onal anomaly. Patients with diastematomyelia often have an assodated syringomyelia.
CONG EN ITAL
I
Case 19 Clinical Presentation The patient is a 7-year-old male with a history of scoliosis, progressive lower extremity weakness, and bowel and bladder incontinence.
A
B
lJ..2J
I
TEACH I N G ATLAS or SPI N E I M A G I N G
c
D
CONG EN ITA L
I
Radiologic Findings Sagittal short TR images (Fig. A) reveal a cystic area of cerebrospi nal fl uid signal i n tensity in the distal thoracic spi nal cord (while arrow). The spinal curu "ppears as a solid structure down to the level of L3 where there is a lobulated, elongated area of increased signal intensity that extends from the lower ma rgi n of L3 through the distal end of the thecal sac. The t he cal sac is diffusely enlarged. There is a lobulated area of soft tissue signal i ntensity dorsal to the spinal cord ex t e nding from 1'1 2 t o L2 (Mllck arrow heads) . Coronal short TR images (Fig. B) reveal a rounded area of increased signal inten sity in the midportion of the lower thoracic vertebral canal (curved arrow). The spinal cord below this level is divided into two separate cords. The area of increased signal intensity projects just to the right of the d ist,, 1 end of thc hemicords, which join togeth e r a t t h is level. There i s a deformed, butterfly type vertebral body a t the level of the curved arrow. Axial short TR image in the lumbar r egi on (Fig. C) reveals two hemieords in the dilated spinal vertebral canal. The vertebml hody is deformed in a curvilinear pattern. The dorsal elements of the vertebral body are absent at this level. Midsagittal short TR image of the brain (Fig. D) reveals thinning of the anterior portion of the corpus callosum (open arrow). The genu of the co rp us callosum is hypoplastic. There is an area of pachygyria in the frontal region (black arrowheads). There is downward displacement o f the cerebel lar tonsils into the foramen magnum.
PEARL •
Tb ere are freq uently multiple congenital abnormalities present. Imaging should be per form e u of the entire vertebral column and evaluation should also be per[ormed of tbe brain.
Diagnosis D i aste m a tomyel ia
Differential Diagnosis •
PITFALL •
If
a spinal tap is necessary, care must be taken to avoid tbose ar e as of the vertebral canal that contain neural tissue.
vertehral anomalies
Discussion Vcrtebral anomalies with diastematomyelic spur, syringomyelia, deformed neural plaquode of tissue ( h l a ck arrowheads), tethered cord, two hemicurds, lipoma, and spinal dysraphism? Associated cerebral anomal ies include pari tal agenesis of the corpus callosum, pachygyria, and low t:erebelfar tonsils.
1 :2 1 1
I
TEACHING ATLAS OF SP1 N E IMAGING
Case 20 Clinical Presentation The patient is a lO-year-old female with unsteady gate and progressive sco liosis.
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals a small posterior fossa. The quadri geminal plate is deformed and pointed. The fourth ventricle is elongated, inferiorly displaced, and small. The cerebellar tonsils are deformed and pointed. There is basilar kyphosis with a very small basal angle of the calvarium and partial agenesis of the corpus callosum.
[R2
B
CONG ENHA L
I
c
D
1 :23 1
I TEACH ING ATLAS OF SPINE IMAGING Radiologic Findings (continued) Anteroposteriur view of the abdomen (Fig. B) reveals a small area of bone density that projects in the middle of the vertebral canal at the level of Tl O-1 1 (arrow). The vertebral bodies of T I O and T l l are deformed, with slight loss of vertebral height on the left side. Axial Tl-weighted (TIW) image at the level of L2 (Fig. C) revelils two atrophic hemicords (arrows) within the dilated vertebral canal. Axial T1 W i mage (Fig. D) reveals an atrophic spinal cord with a ce rc brospi nal fluid containing cavity within the central portion of thc spinal cord.
PEARL •
Note that the hemicords are identified at the L2 level, below the anticipated position of the normal ending of the spinal cord, a sign of spinal cord tethering.
PITFALL •
The entire length of the spinal cord should be imaged for evaluation of additional anomalies.
Diagnosis Diastematomyelia with atruphic spinal cord with two slightly asymmetric hemicords and an associated syrinx cavi ty,Jormfrusle of a Chiari I malforma tion with deformity of the posterior fossa.
Discussion Diastematomyelia is always associated with an abnormal vertebral body. However, the abnormality may be very subtle by plain film evaluation. Computed tomography (CT) scanning, with its increased sensitivity to bonc, may provide thc best evaluation of the bony anomaly. However, magnetic resonance (MR) imaging, with its ability to demonstrate soft tissue, is the best overall method for evaluatiun. In some patients both CT scanning and MR scanning may be needed [or complete evaluation.
v . ,
' 1
I � 24
CO
G ENITAL
I
Case 21 Clinical Presentation The patient is a 21-ye ar-old male with pain in the righ t axi llary area and atrophy of the right hand i n the radial and median nerve distribution.
A
B
1121
I
TEACH T N G ATLAS OF SPlNE IMAG ING
c
D
CONGEN ITAL
I
Radiologic Findings Coronal short TR image of the chest and thoracic spine (Fig. A) reveal multiple paraspinal intermediate signal intensity masses on the left sille. There is scoliosis of the thoracic and lu mbar spine with a soft tissue mass on the left side of the spine in the lower (horacic region (arrow). Short TR image of the right supraclavicular region (Fig. B) reveals diffuse enlargement of the nerves uf the brachial plexus (black arrows) just distal to thei r point of urigin from the cervical vertebral canal. The flow void of the vertebral artery can he seen where i t arises from the subclavian artery (white arrow, u). The subclavian and axillary arteries can be seen projecting below the level of the mass. The long TR image (Fig. C) reveals that the masses, which extend into the axilla, all exhibit increased signal intensity (arrows). Axial posteontrast image at the level uf the mill humerus (Fig. D) reveals that the mass appears as increased signal intt:nsity (thick arrow). Additional nerves in the arm are alsu increased signal intensity (thin arrow).
PEARLS •
•
These plexiform neurofibromas of the spine may extend into the vertebral canal at one or mUltiple ItweIs.
MR without and with the infu ion o( contrast material and multiplanar imaging is the best method of evaluation.
PITFALL Surgical management of these multilevel lesions is difficult. •
Diagnosis Neurofibromatosis type1 (NFl ), multiple neurofibromata along the spine, a large plexiform neurofibroma along the course of the brachial plexus on the right arm.
Discussion Identification of plex i form neurofibromata is important becH use NFl is autosomal dominant, with an abnormality of chromosome 1 7 with variable penetrance. Because the di&ease is inherited. genetic counseling is in order. In this case, the patient's brother also had NFl . N F l is also known as the peripheral furm of neurofibromatosis. It is associ ated with plexiform neurofibromas and may result in "dumbbell" type of tumors that involve the vertebral canal and paras pinal area. Magnetic reslI nance (MR) imaging is the best method of evaluating these abnormalities.
lEI
I
T EACH I N G ATLAS OF S P I N E I M AGING
Case 22 Clinical Presentation The patient is a 24-year-old male who underwent previous surgery to remove a thoracolumbar schwannoma.
A
CONG ENITAL
PEARLS •
•
Tethering of the spinal cord at the surgical site is not an indication of a surgical complication, but rather occurs not infre4uently at the point where the dura is opencd at the time of surgery. Patients' symptoms may i mprove following surgical removal of a tumor, only to recur when there is secondary tethering of the pinal cord beca use of scar formation at the surgical site. Magnetic resonance imaging is the procedure of choice fOl" evaluation.
Radiologic Findings Sagittal short TR postcontrttst MR image (Fig. A) reveals mult iple rounded areas of enhancement scattered throughout the lowcr thoracic and upper lumbttr thecal sac. The larger of thesc masses arc highlighted (small arrows). Multiple addi tional smaller masses are also present. Postlami nectomy changes tt re noted in the lower thoracic and upper lumbar region with absence of the spinous processes of the vertebrae at multiple levels. Tht.: spi nal cord is tethered posteriorly in the lower thoracic/upper lumbar region at the level of the previous surgery (thick arrow). Thc central portion of the tethered cord is at the level of T12.
Diagnosis Neurofibromatosis type 2 (NF2) with m ultiple schwannomas, postoperative changes, spinal cord tethering.
Differential Diagnosis PITFALL •
Cl in ical history is very helpful in the evaluation of these patients, particularly to rule out metastases ver us multiple schwannomas.
•
drop metastases (unlikely)
Discussion NF is an autosomal domi nant hereditary disease with a defect on chromo some 22 with varitt ble penetrance. It is also known as the central form of NF and is typicttlly associated with bilateral acoustic schwannomas. Spinal cord ependymomas are the typical tumor that is seen i n these patients. This disease may be remembered with tbe mnemonic M I S M E: multiple inherited sehwannomas, meningiomas. and ependymomas. The meni ngiomas typically involve the cercbral meningies wheretts the ependymomas typically al�'cct the spinal cord.
I TEACH I NG ATLAS OF SPINE I M A G I N G
Case 23 Clinical Presentation The palienl is a 48-year-old male wilh known neurofibromalosis type 2 (NF2), with bilateral deafness who now presents wi lh low hack pain.
A
B
CON G EN ITAL
I
c
Radiologic Findings Precontrast axial short TR image (Fig. A) reveals a small, high signal inten sity soft tissue mass in the right internal auditory canal (arrow). Postcontrast axial short TR image (Fig. B) reveals enhancement of bilateral acoustic masses (right larger than lefl). The right-sided acoustic mass extends slightly into the cerebeJlopontine angle (arrow); the left acoustic mass is intracanalicular. Postcontrast sagittal short TR of the l umbar spine (Fig. C) reveals multiple small (1 -2 mm) rounded areas of enhancement along the t10rsal aspect of the distal thoraeic spinal cord and the nerve roots or the eauda eq uina (arrows).
1l2.1
I TEACHING ATLAS OF SPINE IMAGI PEARL •
The mnemonic of MISME (multiple inherited, .\'chwannomas, meningiomas, and ependymomas) helps one to remember the lesions that arc seen in the patient with NF2.
Diagnosis •
Bilateral acoustic schwannomas and mUltiple spinal schwannomas
•
Small right internal auditory canal lipoma
Differential Diagnosis •
PITFALL •
Because lipomas of the internal auditory canal may exist without schwannomas, and because their increased signal intensity could be mistaken for an enhancing lesion if only a po ·ti n fusion study is performed, all studies of the internal auditory canals should be performed prior to and following the infusion of contrast material and should not be performed postinfusion only. A very rare entity such a hemorrhage into the nerves in the internal auditory canal may also appear as increased signa l int en sity o n t h e precontrast images.
G
hemorrhagic infarct of right eighth cranial nerve
Discussion Neurofibromatosis type 2 is known as central neurofibromitlosis. These patients may appear clinically normitl and do not have th e external stigmata seen in patients with NF lype 1 . NF type 2 is characterized by bilateral acoustic schwannomas, spinal ependymom as and meningomas. Symptoms tend to p resent at a younger age than in patients with NFl . ,
CONGENITAL
I
Case 24 Clinical Presentation The patients is an 18-year-old female with polycythemia d u e to cyanotic congenital heart disease, visual disturbance. head shaking, and poor respon siveness lasting a few minutes.
A
B
Radiologic Findings Lateral view of the cervical spine (Fig. A) reveals posterior subluxation of the odontoid process relative to the anterior arch of C l . Sagittal short TR image (Fig. B) reveals posterior dislocation of the odontoid process relative to the anterior arch of Cl a nd widen ing of the �pace between Cl and C2. There is pos t erior curvilinear displacement of t he spi nal cord. There is com p ro mise of the subarachnoid space at the level of Cl-2 and the foramen magnum.
I TEACH ING ATLAS OF SPINE IMAGING PEARL • Because 1-2 subluxation may be present in Down's syndrome patients, MR imaging may be used for eva luation prior to al lowing these patients to participate in athletic competition.
Diagnosis Down's syndrome with Cl -2 dislocation, congenital heart disease with atrial septal defect.
Differential Diagnosis •
rheumatoid arthritis with Cl -2 di location
•
posttraumatic dislocation
PITFALL •
MR imaging evaluation may include short TR images in the sagittal plane with the patient in the neutral, liexed, and extended positions.
Discussion Subluxation results in compression of the upper spinal cord and medulla. Long TR magnetic resonance (MR) images may Teveal areas of increased signal intensity within the spinal cord if compTession is sufficient. It is thought that the areas of increased signal intensity are secondary to vascular compro mise. Sagittal short TR im ages also may be performed with the patient's neck nexed and extended to better demonstrate the amount of encroachment upon the vertebral canal and spinal cord in these positions. Care must be used when man ipulating the neck i n t hese patients. Because there is an increase in the amount of space surrounding the cervical spinal cord i n the upper cervical region compared with the remainder of the spine, the spinal cord frequently follows a cu rvilinear course around the posteriorly posi t ioned odontoid process. A similar type of increased mobility of the odontoid process also may occur in patients with rheumatoid arthritis. In these cases the increase in mobil ity is secondary to laxity of the transverse and cruciate ligaments, which nor m ally hold the odontoid process againsl the anterior a rch of the C L vertebral body. Rheumatoid arthritis is seen in older patients and is generally associ ated with other changes in Ihe bony structures.
1 34
Section ill
Spinal Cord Tumors A. Intramedullary
SPINAL CORD TUMORS
I
Case 1 Clinical Presentation The patient is a 49-year-old male with progressive upper extremity weakness, right arm greater than left.
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals expansion of the cervical spinal cord beginning at the level of the midbody of C2 and extending to the level of CS . There is compromise of the subarachnoid space from the level of C2 inferiorly to approximately CS. At the level of C3 , there is an amorphous streaklike area of decreased signal intensity (arrowhead).
I TEACHING ATLAS OF SPINE I MA G I NG
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Radiologic Findings (continued) Sagittal short TR image postcontra t (Fig. B) reveals a nodule of enhance ment (e) in the anterior two thirds of the spinal cord beginning at the level of the C2-3 intervertebral disc and extending to the inCerior end plate of C3. The area of decreased signal intensity in Figure A is visible in the infcrior portion of the enhancing nodule. Sagittal long TR image (Fig. C) reveals that there is an oval-shaped area of increased signal intensity extending from the base of the odontoid process (top black arrow) to the inferior end plate of C5 (lower black arrow) . There are several patchy and curvilinear arcas of persistent decreased signal intensity within the area of incrcascd signal intensity at the level of C3 (open arrow). Axial short TR image at C3 after the infusion of contrast (Fig. D) revcals the enhancing nodule (e) in the right side of the cervical spinal cord. The right side of the spinal cord is expanded at this level. Axial long TR image (Fig. E) reveals the central area of decreased signal intensity (arrow) surrounded by i ncreased signal intensity within the ex panded spinal cord.
1]2]
I TEACH ING ATLAS OF SPI 'E IMAG ING PEARLS •
•
The tumor nodule is the enhancing nodule at the C3 level with edema extending above and bt::l uw this level. Enhancement is the rule with spinal cord tumors, although rarely no enhancement may be seen. The enhancement pattern may also be effected by the admi nistration of steroids, which decrease the amount or enhancement.
PITFALLS •
The areas of persistent decreased signal intensity may alsu be '!een with areas of calcification.
•
Computed tomographic (CI') scanning is more accurate tban magnetic resonance scanning for the evaluation of the presence of calcification. However, as treatment will probably not be altered whether calcification is present or not, the need [or CT is not urgent.
�o
Diagnosis Ependymoma.
Differential Diagnosis •
spinal cord astrocytoma
•
spinal cord metastascs
Discussion Ependymomas may exhibit areas of hemorrhage that appear as areas or decreased signal intensity secondary to magnet ic suscept i h i l i t y artiract, as sccn in th is case. A spinal cord astrocytoma wuld have a similar appearance, but the area of hemorrhage wi t h hemosiderin makes this diagnosis less likely. Spinal cord metastases may also have a similar appearancc; however. spinal cord metastases are uncom mon. Intramedullary metastases may de velop from such primary tumors as medulloblastoma, breast and lung cancer, and various sarcomas. Olher tumors that may cxhibit areas or decreased signal intensity are vascular tumors such as occult vascular malformations or cavernous angiomas. Cav ernous angiomas are more common in the brain but may also be seen in the spinal cord. The cavernous malformation tends to have a typical appear ance of a central area of increased signal intensity on the short TR images with a surrounding, slightly irregularly marginated, peripheral rim or de creased signal intensity. This decreased signal i n t ensi t y is thought to be secondary to episodes of hemorrhage, with leaking of blood i nto the tissues surrounding the cavernous angioma.
S PINAL CORD TU M O RS
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Case 2 Clinical Presentation The patient is a 37-year-old female with neurofibromatosis type 1 with upper extremity weakness.
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Radiologic Findings Sagittal short TR image postcontrast (Fig. A) rcvcals a 1 .2-cm oval area or enhancement at the C6 level that extends to the level of the intervertebral disc aL C5-6. There are also smaller less well-defined areas of cnhancement above and below this level . There is reversal of the curve of the spine and expansion of the spinal cord. Note the incidental finding of congenital fusion between the C2 and C3 vertebral bodies. Sagittal long TR image (Fig. B) reveals expansion of the spinal cord from C3-4 through approximately C7. There are areas of increased signal in Lensi Ly within the central portion of the spinal cord from the C4-5 level through the C7 level. The increased signal has faint concentric rings of increased signal intensity with a few internal curvilinear areas of decreased signal intensity (curved arrow). Axial long TR i mage (Fig. C) reveals a thick-walleu ring or increased signal intensity in thc right side of the spin al cord (arro w). There are oval-shaped areas of increased signal intensity in thc region of the dorsal root ganglia bilaterally (squares). Axial short TR inlage postcontrast (Fig. D) reveals a rounded area of enhancement in the right side of the cervical spi n al cord (arrow). The mass in the region of the righ L dorsal root ganglion is also seen to enhance (square).
PEARL Because these tumors may metastasize, the entire spinal column should be evaluated.
•
Diagnosis ASLrocyLoma; neurofibromas of the dorsal
mi ll
ganglion bilaterally.
Differential Diagnosis ITFALL •
The areas of decreased sign al intensity could represent areas of hemosiderin deposition, making ependymoma a diagnostic consideration.
•
astrocytoma
•
ependymoma
Discussion Astrocytomas of the ccrvical spinal cord are less common than those in the brai n . In the spinal cord, both the astrocytoma and the ependymoma arise from the glial cells of the spinal cord. Astrocytomas are the most common primary tumor in the spinal cord , particularly in the pediatric age group, but Lhey may be seen i n any age gro up. These tumors m ay be rocal or extend over mUltiple vertebral body segments. Exophytic growth may also occur. The pattern of enhancement generally reveals a dense area of en hancement in the cervical cord, which is localized to a one or two seg ment region. There may be associa ted cysts within the tumor, and there may also be an associated syrinx cavity. Typically, spinal cord astrocytomas exhibit enhance ment on the postcontrast study, although very rarely enhancement will not be seen. If there is an associated syrinx cavity, the wall of the syrinx typically does not enhance. Although attempts have been made to differenti ate astro cytoma from ependymoma based on the a natomic location with i n the spinal
TEACHING ATLAS OF SPINE I M AG I NG
cord, this is usually not p ossihl e . The pattern of enhancement in astrocytoma generally reveals a dense area of enhancement in the cervical cord thaI is localized to a one or two segment region. The axial images usually reveal Ihal the tumor is not in the midli ne, but rather is off center. It does not appear that this is a reliable i maging method. Mixed cell type tumors m ay also be seen. Treatment is surgical with resection of as much of the tumor as possible. A specific h istologic type of astrocytoma is the pilocytic astrocytoma. This tumor derives its n am e of "pilocytic" because the cells that make up the tumor are long. thin, and "hair like" (i.e., pilocytes). These may occasionally be metachronous lesions or may represent metastatic lesions.
The differential diagnosis would i nclude ependymoma, al though astrocy toma would be more common in the setting of a pati en t with neurofibro matosis type l . It is said that astrocytomas tend 10 involve multiple segments while ependymomas are less ex tensive. The presence of areas of decreased signal intensity withi n the tumor is more consistent with the diagnosis of ependymoma. It is impossible to differentiate between the diagnosis of ependymoma and astrocytoma by i maging appearances alone.
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Case 3 Clinical Presentation The patient is a 39-year-old female with Ji fficulty signing her name.
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Radiologic Findings Sagittal short TR image of the cervical spine (Fig. A) reveals a multiloculated cyst that extends from the intracnt nial medulla throughout the entire visual ized spinal cord. There is an isointense soft tissue mass that hegins at the level of the midbody of C3 and extends through the level of the intervertebral disc at C5-6.
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I TEACHI N G ATLAS O F SPINE I M AG LNG Radiologic Findings (continued) Sagittal short TR image in the midthoracic level (Fig. B) reveals a syrinx cavity extending into the lower thoracic region. There are faint internal sep tations. Sagittal short TR image postcontrast (Fig. C) reveals dense, slightly in homo geneous enhancement of the nodule of tumor. There is a slightly lobulated peripheral margin that corresponds to the posterior margins of the verte bral bodies. Sagittal long TR image (Fig. D) reveals persistent decreased s ignal intensity within the tumor nodule. The cystic areas become markedly i ncreased in signal intensity.
PEARL •
The entire spinal cord should be evaluated because other areas of enhancement secondary to the presence of tumor may be seen. The study should be performed with the infusion of contrast to identify those portions of the tumor th!!l enhance. The non enhancing areas presumably represent edema without the presence of tumor.
Axial short TR image postcontr!!st (Fig. E) reveals a I -cm eccentrically placed nodule of enhancement i n the right side of the spinal cord (t). The decreased signal intensity cavity can also be seen just lateral to t he enhancing nodule (curved arrow). The spinal cord is expanded and there is only a thin remain ing margi n. Axial short TR image in the m idportion of the tumor (Fig. F) reveals dense enhancement on the t umor nodule in the central portion of the expanded cervical spinal cord (t).
Diagnosis Pilocytic astrocytoma.
Differential Diagnosis •
PITFALL •
This tumor cannot be differentiated from a spinal cord ependymoma. Ependymomas may develop metastases with seeding of the subarachnoid space; therefore, the entire thecal sac should be imaged.
ependymoma
Discussion The neoplastic portion of the tumor is the portion that enhances after the infusion of contrast mate ri!!1. The tumor is associated with !! "benign" I11 u ltiloculated syrinx that involves the medulla, the cervical spinal cord, and the majority o f the thoracic spinal cord. In a patient with a smaller tumor, the multi loculated syrinx cavity could be mistaken for a benign syrinx. The soft tissue component should be closely evaluated with a contrast-enhanced study and multiplanar imaging after the infusion of contrast material.
SPINAL CORD TUM O RS
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Case 4 Clinical Presentation The patient is a l O-year-old with ataxia and upper and lower ex tremity weakness.
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ATLAS OF SPINE I M A G I NG
Radiologic Findings Sagittal Tl W image (Fig. A) reveals widening of the cervical spinal cord from C2 through C6. There are mottled areas of both increased and de creascd signal i ntensity within the spinal cord. There is essentially complete obliteration of the suharachnoid space dorsal to t he spinal cord. Also note the approximately 1.5- to 2.0-cm cystic <tppearing mass in the inferior p
PEA R L •
Clinical correlation with a possible history of neurofibrom
Diagnosis Glioma of the cervical spinal cord and cerebellum, confirmed at surgery.
Differential Diagnosis •
pilocytic astrocytoma
•
ependymoma
PITFALLS •
•
Alth ough unlikely, cerebellar and spinal cord metastases could have a imilar appearance. Areas of hemorrhage within the cervical spinal cord could have a similar appearance with either decreased or increased signal intensity or both. The areas of decre
1 1 50
Discussion Caleification was identified within the cervic
S PINAL CORD TU M O R S
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Case 5 Clinical Presentation The patient is a one-year-old female with a history of leukemia and new onset of right-sided numbness.
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Radiologic Findings Sagittal short TR ilTI
EARLS •
•
The clinical history is very im portant in this patient to allow an accurate diagnosis. Surgery was justified by the fact that this patient was becomi ng paraplegic; this reversed following surgical removal of the tumor.
Axial long TR image (Fig. D) reveals that the soft tissue mass exhihits increased signal intensity. There is a slightly irregular peripheral margin. Additional history reveals that the patient is known to have a primary leiomyosarcoma with seconuary leukemia.
Diagnosis Spinal cord lesion, a metastasis from the patient's known leiomyosarcoma, confirmed at surgery.
Differential Diagnosis PITFALL The entire spinal cord and spinal subarachnoiu space should be screened for additional lesions, as the presence of multiple lesions may dictate a different approach to management. Multiple lesions would favor treatment with radiation therapy rather than surgery.
•
ependymoma
•
astrocytoma
•
Discussion The differential diagnosis in this patient would include a primary spinal cord tumor such as an ependymoma or astrocytoma; these diagnoses would be much more likely than a metastasis to the spinal cord. In addition to this spinal cord lesion, the patient had widespread metastatic disease to the lungs and skeletal system.
l�
I TEACHING ATLAS OF SPINE IMAGING
Case 6 Clinical Presentation The patient is a 26-year-old female with spasticity in the lower extremities, right greater than left. There is flaccidity in the right uppcr extrcmity and pare is in the left upper extremity.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals a 1 X 1 .5-cm cystic lesion in the medulla just below the leve l of the foramen of M agc ndi c and j ust above the foramen magnum. The cervical spinal cord is expanded from the level of the foramen magnum through the length of the visualized spinal cord. There arc curvilinear areas of both decreased and increased signal intensity at the level of the first t horacic vertebrae (open arrow). The C3 vertebral body is identified with 3. Sagittal short TR i mage postcontrast ( Fig. B) reveals that the cystic lesion has a peripheral rim of en hancement along its posterior inferior margin (arrow). An a rea of moderate enhancement in a relatively inhomogeneous pattern can be seen beginning at the level of the foramen magnum and extending through the C2-3 level. There are also multiple smaller patchy areas of enhancement throughout the visualized cervical spinal cord. Sagittal long TR image (Fig. C) reveals a large area of persistent decreased signal intensity within the central portion of the cervical spinal cord. This extends from the Cl level through the TI level. There is a small curvilinear area of decreased signal i n tensity at the lower end (open arrow). The verte bral artery appears as an area of flow void at the skull base (solid arrow). ParasagittaJ long TR image (Fig. D) reveals that the cyst in the posterior fossa becomes markedly increased signal intensity (open ar row) . There is a small rounded area of decreased signal intensity with i n the spinal cord at the C3 level (solid arro w). Sagittal short TR image in the thoracic spine (Fig. E) reveals diffuse enlarge ment of the spinal cord. There is almost complete obliteration of the suba rachnoid spal:e. S agittal long TR image (Fig. F) reveals an elo n gated scalloped marginated segment of variable increased sign al intensity throughout the length of the spinal cord . ,
Axial short TR image postcontrast at the level of Cl (fig. G) reveals a curvilinear area of enhancement in the left side of the spinal cord (open a rrow) . The two long white arrows identify th� compromised subarachnoid space. The lateral mass of CI is identified with I . Axial short TR image at the tip of the odontoid (Fig. H ) reveals m ultiple small i rregular areas of enhancement wi t hin the sp i nal cord (open arrow). Axial short TR image at C2 (Fig. I ) reveals a speckled area of faint enhance ment throughout the spin a l cord. There is only a thin semi l u nar area of spinal cord remaining on the left side (arrows). The lateral mass of C2 is identified with 2.
SPINAL CO RD TUMORS
PEARLS •
It is not pos ible to different iate a pilocytic a. trocytoma from an ependymoma by imaging alonc. Magnetic resonancc imaging is the ideal method for di agno i as wel l as follow-up in these patient .
•
The presence of
Diagnosis Pilocytic astrocytoma, confirmed at surgery.
Differential Diagnosis •
astrocytoma
Discussion The multilevel segment of involvement seen in this case is typical of astrocy toma. The cystic portion of the tumor seen hcrc in the cerebellum would be typical of a pilocytic astrocytoma. The intcrnal areas of decreased signal intensity represent areas of hemorrhage or calcification. The increased signal i n tensity in the thoracic spinal cord is secondary to formation of
J
PITFALL •
Because these tumors may spread, the entire vertebral canal should be evaluated for the presence of additional lesions.
K
Sagittal short TR imagc postcontrast (Fig. J) reveals that the cervical spinal cord is markedly thinned and displaced posteriorly in the vertebral canal. Sagillal long TR image (Fig. K) reveals that the cervical spinal cord cannot be demonstrated with certainty from the level of thc foramen magnum to the level of CS. A shunt tubing device can bc seen with the tip at the level of C4 (open arrow). Several rounded arcas of decreased signal intensity are seen in the tube in the thoracic region ( white arrows) .
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L
M
Axial short TR image (Fig. L) reveals the cervical spinal cord displaced posteriorly in the vertebral canal . The spinal cord is flattened, more on the righ t side than on the left side (arrow). Axial short TR image (Fig. M) reveals the flattened spinal cord. A small rounded area of decreased signal intensity within the spinal cord represents the shunt tube in place with in the spinal cord (arrow). These postoperative changes are the result of total removal of the spinal cord pilocytic astrocytoma. The posterior displacement of the spinal cord is due in part to adhesions tethering the cord posteriorly.
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Case 7 Clinical Presentation The patient is a 53-year-old male who presents for follow-up.
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Radiologic Findings Pre- (Fig. A, lefi) and postcontrast (Fig. A, right) sagittal short TR images in the cervical spine reveal that the patient has undergone a laminectomy with removal of the cervical spinous processes (left, arrowheads). There is an 8-mm cystic area within the central portion of I he cervical spinal cnru at the C6 level (left, white arrow). Postcon l rast (right) there is a triangular shaped area of enhancement just above the level of the cyst (bluck arrow). The spinal cord is markedly thinned above the level of the cyst. There are extensive degenerative changes with anterior and posterior osteophytes at multiple levels. These are encroaching on the subarachnoid space and displacing I he spinal cord posteriorly. The 7th vertebral body is identi fleu by 7. The cystic area (Fig. B) appears as increltseu signal intensity (short arrow) on sagittal long TR image. There is also a decreased signal intensity area dorsally, which results in a multisegment encroachment on the subarachnoid space (long arrow). Pre- (Pig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal the
open arrow).
PEARL •
The most helpful approach for evaluation in this patient is add ilional follow-up magnetic resonance (MR) scans.
Diagnosis Postoperative changes in a patient who has had previous surgical removal of a spinal cord ependymoma.
Differential Diagnosis ).>ITFALLS •
•
The area of enhancement may simply be normal postoperative enhancement and does not necessarily imply remaining or recurrent tumor. In addition to remaining tumor, scarring and tethering of the spinal cord to tbe dura may occur at tbe level of tbe laminectomy. MR imaging is the ideal method for evaluating these changes.
•
posttraumatic syrinx cavity
•
Wallerian degeneration
•
ependymoma
Discussion It is not possible to determine if the small triangular area of enhancement is or is not remaining lumor. There are extensive postoperli live changes with straightening of the spine, postlaminectomy changes, and dorsal en croachment on the subarachnoid space secondary to scar formation. In the appropriate clinical setting, a posttraumatic syri nx cavity could have a similar appearance. Wallerian degeneration may also be associated with surgery or be seen following spinal cord trauma. This type of degeneration may result in areas of increased signal intensity. Ependymomas may develop metastases with seeding of the subarachnoid space. This spread of tumor may be very extensive; therefore, the entire spinal subarachnoid space should be evaluated to determine the exten t of the disease.
I TEACHING ATLAS OF SPINE I M A G I N G
Case 8 C1inical Presentation The patient is a 1 5-year-old female with a cl inical h is t ory of progressi ve upper and lower extremity weakness.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals marked expansion of the cervical spinal cord. The medulla is also grea tly expanded . There is also an approxi mately 5 mm area of i ncreased signal intensity at the apex of the fourth ventricle
(arro w).
Also visible arc marked expansion of the vertebral canal
in the cervical region and marked accentuation of the cervical spine lordosis. Sagittal short TR i m age posteontrast (Fig.
B) reveals d,ense, slightly inhomo
geneous enhancement of the soft tissue mass in the cervical spinal cord.
There
are also additional rounded areas of enhancement in the bottom of
the fourth ventricle (1 ) , a t the ven t ra I lIspect of the cervicomeclullll ry j un ction
(open arrow),
and at the apex of the fourth ventricle (2) . There are several
smaller nodu les of e n hancement in the region of the foramen of Mage n d i e and along the bottom o f t h e cerebellar tons ils. Sagittal long TR i mage (Fig. C) reveals a m ultilobul ated decreased signal i ntensity soft tissue mass within the cervical spinal cord. There are a few i n ternal areas of increased signal intensi ty, and a variable p a ttern of areas of increased and decreased signal in ten sity in the med u l l a and bottom of the fourth ventricl e . Pre- (Fig. D, Icfl) a n d postcontrast (Fig. D, right) a x i a l short TR images reveal the marked ly e xpanded cervical spinal cord. There is dense enhancement postcontrast (right). There are several internal areas of smoothly marginated
PEARL •
The e n tiTe vertebral canal and in tracranial contents should also b e evaluated. Magnetic resonance represents the method of choice for foll o w - up in
a
decreased signa l intensity anteriorly within the spinal cord
(righl, arrows).
Postoperative changes are noted in the dorsal aspect of the neck (X) .
Diagnosis Pilocytic astrocytoma, con fi rmed by biopsy.
patient such as this.
Differential Diagnosis rITFALLS •
•
astrocytoma
•
ependymoma
Total surgical removal of a tumor such as this is genera lly not possible.
•
These patients may have only minor symptoms relative to the size of the lesion. Surgery may be attempted, primarily (or diagnosis of celJ type and to dictate treatment. However, surgery is unlikely to be curative with such an extensive lesion.
1 1 66
Discussion The m ul tisegment involvement seen in t h is case is typical of astrocytoma. The cystic portions would be consistent with a pilocytic astrocytoma. The multiple additional smaller lesions represent either metastatic deposi ts or additional synchro nous lesions. Tn this patient, the legion is very extensive. The areas of decreased sign al i n tensity seen on the axial short TR images of the cervical spi nal cord probably represent internal areas of calcification. An ependymoma with metastatic spread to the brain and spinal cord could h a ve a similar appearance.
SPfN A L CO RD TUMORS
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Case 9 Clinical Presentation The patient is a 34-year-old male with neurofibromatosis type 2 who now presents with upper extremity weakness.
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Radiologic Findings Sagittal short TR image (Fig . A) reveals su rgi ca l fusion of m ulti p le cervical vertebral bodies with reversal of the normal cervical lordosis extending up to t he level of th e odontoid. There is a ssociat eu posterior curvi li nea r distor tion of the cervical spinal cord. There is a small oval area of decreased signal intensity in the upper cervical regi on (open arrow). There is a focal area of widening of the cervical spinal cord in the upper thoracic regi o n that appe ars slightly decreased in signal i ntens ity (solid arrow). The s p in o us processes are surgically absent in the cervical region. Sagittal short TR image p ostco n t rl:l s( (Pig. B) reveals enhancement of multi ple lesions within the medull
Sagittal long TR i ma ge (Fig. D) reveals that the area of decreased signal intensity anterior to the spinal cord appears more prominent than on t he other images. There is an area of focal widening of the spinal cord in the upper thoracic a re a . Pre- (Fig. E, left) and pos(contrast (Fig. E, right) axial short TR images reveal a densely enhancing approximately 3-mm nodule within the dorsal portio n of the cervical spinal cord (right, arrow). Pre- (Fi g . F, left) and postcontrast ( Fig. F, right) axial short TR i mages reveal a small irregular area of enhancement within the spinal cord (right, open arrow). There are also two enhl:lncing soft tissue masses in the neck on the right side (A, b). The more anterior lesion (A) enhances densely in its centrl:ll portion and has a decreased signal i ntensity ri m (righI, solid
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S P I N AL CORD TUMORS
arrow). There is effacement of the oral pharynx at the level of this mass. The second lesion (b) is smaller and arises at the level of the interverte bral foramen.
PEA RLS •
The preinfusion scans on these patients may be normal, li nd the enhancing lesions are only visible after the infusion of contrast material.
•
Multiplllnar imaging with thin slice may be helpful to define the extent of the lesion as well as the anatomic compartment of origin.
Pre- (Fig. G, left) and postcontrast (Fig. G, righl) axial short TR images reveal that the spinal cord is enlarged. There is a dense area of enhancement on the postinfusion portion of the study. This area has a slightly irregular peripheral m argin and extcnds to the dorsal surface of the spinal cord adjacent to the dura (righi, curved arrow) .
Diagnosis A strocytoma; confirmed at surgery. The tumor lIrose from within the spi nal cord and grew in an exophytic fashion soft tissue schwannomas.
Differential Diagnosis PITFALL •
•
•
The exophytic portion of the tumor compressed against the dorsal aspect of the vertebral canal, giving the appearance of an intradural mass invaginating into the cervical spinal cord.
•
ependymoma
Discussion
There is an increased incidence of all types of hrain and spinal cord tumors in patients with neurofibromatosis; although the diagnosis was astrocytoma in this patient, ependymoma would be a more likely diagnosis. The exophytic nature of this tumor is unusual. The appearance also suggests that this could Spinal cord ependymomas i n be an intradural mass that i nvaginates into the spinal cord rather tban a n patients with neurofibromatosis exophytic tumor growing out o f the spinal cord . The decreased signal inten may have multiple lesions at sity areas seen in both the short and long TR images a nterior to the spinal various levels, so the entire cord is magnetic susceptibility art ifact secondary to the surgical clips from pinal cord should be evaluated. the patient's previous su rgery. Because seeding may also occur into the spinal subarachnoid space, the entire thecal sac should be evaluated.
The patient also had a h istory of surgical removal of multiple soft tissue schwannomas and lIcoustic neuromas. This history of mul tiple meni ngiomas and schwannomas is typical for patients with neurofibromatosis type 2; however, a diagnosis of spinal cord ependymoma would be more likely than astrocytoma.
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Section ill
Spinal Cord Tmnors B. Intradural
SPI N A L CORD TUMORS
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Case 1 Clinical Presentation The patient is a 29-year-old female with a one-year h istory of right-sided low back pain.
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Radiologic Findings Anteroposterior view of a lu mbar myelogram (Fig. A) reveals a co mplete block to the flow of contrast m aterial at the level of the mjdbody of There is fl aring of the contrast column at th is level (arrows).
L4.
Laten� l view of the myelogram (Fig. B) reveals a com plete block to the flow of contrast material. There is a upwardl y convex soft tissue mass that forms acute angles with the contrast column a n teriorly and posteriorly
(arrows).
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Radiologic Findings (continued) Coronal reconstruction view of the postm y e l ogram comput ed t o m ographi c (Cl') scan (Fig. C) reveals a filling defect i n the contrast col u m n at the L4 level. The nerve roots of the ca uda eq uina are displaced l aterally. Sagittal
r ec
o nstruct ion view of the post myelogram CT (Fig. D) rcveals a L4 l ev el . The nerve roots of the
fi l ling defect in the contrast col umn at the ca uda equina are d isplaced dorsally. Sagittal sho rt
TR image ( F ig. E) rev e als an oval-sha ped m ass of s lightly
higher si gn al intensity than t:ere brospi nal tluid. The mass exhibits an acute
PEARLS •
Schwannomas ma y hemo r rhage and therefore may appear
increased s igna] in tensity on the preinfusion scan. If h emorrh age is presen t, a va ri e ty of sig na l
a ngle with the subarachn oid space at the level of the supe ri or end pl ate of L4 (solid arro w), and the inferior margin is sccn at the level of the lowcr portion of the L4 vert eb ra l body (open arrow). The sagittal
short TR imagc postcontrast enhancement (Fig. F) reveals
dense slightly inh om ogeneo us enhancement of the schwannoma. The normal
basivertebral plexus also e nhance s and is well demons t ra ted at the L3 l evel
(arrow).
intensities w i t h various
resonance imagc sequences may result.
magnctic
•
The pat ient with neurofibromatosis type 2 may ha ve m u ltiple schwannoma .
PITFALLS •
hem orrh agic schwannoma could be mistaken for a hematoma. However, 1 n the p ati ent with a h e matoma one would anticipate a history of r ece n t spin a l tap, spinal anesthesia, or other type of A
,
spinal trauma. •
In some cases, th e soft tissue mass may be very subtle on the precontrast i mages, and i t is p oss ibl e to overlook the
presence of such a mass. Therefore, careful evaluation should be performed when necessary.
Diagnosis Schwannoma
Differential Diagnosis •
schwannoma
•
ne uro fi broma
•
myxopapillary
•
drop me tastasis
ependymoma
Discussion Schwannomas ma y be cystic or may revea l central area of necrosis th a t appear a s areas o f internal decreased signal i nt ensity a s seen in this e xampl e . Schwannomas may occur at
any level of the spinal cord, but are most
common in the lumbar rtgi o n . Th ey are seen as isolate d tumors or in association with neuro fi b rom a to si s. They a re slightly more common than neurofi bromas. Schwannomas, if sufficiently large, could mimic the appear ance of a myxopapillary e pendym o ma. In this case, the differential di agnosis would include schwannoma, sol itary neurofi broma, myxopapiUary cpcndy morn a, or remotely, a d ro p metastasis from a central nervous system primary or other metastatic tumor.
1m
I TEACH ING ATLAS OF S P I N E IMAGING
Case 2 Clinical Presentation The patient is a 47-year-old female school teacher with a h istory of Hodgk in's disease who has had increasing lower extre,mity weakn ess,
A
1 78
SPIN A L CORD TU MORS
I
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, righl) s agi tt al short TR images reveal a slightly lobulated area of soft tissue signal intensity at the T6 level. There is curvilinear erosion of the posterior margin of the vertebral body at this level. Neither the spinal cord nor the dorsal epidural fa t can be seen at this level . Th e postco n trast study reveals dense homogeneous enhance ment or the mass. There are smaU curvil i near and dot like areas of enhance ment below the level of the mass (righl, arrows). Coronal short TR image postcontrast (Fig. B) reveals enhancement of the bilobed mass. The spinal cord is displaced to the right (small arrows). Epi dural fat if) is seen above the level of the mass. The pedicle projects below the mass on the left side (plan'ow) .
PEARLS •
•
Schwannom as may be s ol ita ry or multiple. Solitary neurofibromas are rare. A menin gi oma could rarely have this appearance, but it is very unlikely because typically meningiomas do not have an extradural component or the "dumbbell" appearance seen in this case.
PITFALL •
B ecause neurofibromas are rarely s oli tar y, the entire length of the ve rte bral canal should be evaluated.
Diagnosis Isolated schwannoma
Differential Diagnosis •
neurofibroma
Discussion The tumor appears bilobed at the point w h e re i t extends through the inter vertebral fora men, forming a typical dumbbell appearance. The mass is both intradural and extradural. The epidural fat is widened on the side of the lesion because the dura is displaced away from the lateral aspect of tbe vertebral canal . The faint curvilinear areas of enhancement seen below the mass repre ent dilated vessels on the dorsal aspect of the spin a l cord.
A neu rofibroma could also have this appearance . Neurofibromas are typi cally multiple and are seen in the clinical se tti ng of neu rofibromatosis type 1 .
I TEACH I N G ATLAS OF SPINE I MAGING
Case 3 Clinical Presentation The patient is an 86-year-old male with known multiple myeloma and new complaints of gradual onset of progressive low back pain.
A
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images in the lumbar region. There is a faint rounded area, approximately 8 mm at i ts greatest diameter, at the L2-3 level in the middle of the vertebral canal. A fter the i nfusion of contrast material, there is dense enhancement of the slightly irregularly marginated mass. The marrow within the vertehral bodies and spinous processes exhibits diffu e mottled signal intensity.
SPINAL CORD TUMORS
PEARLS •
•
•
Multiple myeloma is occasionally better see!'l by computed tomographic (CT) scanning than magnetic resonance (MR) imaging because CT may demonstrate the areas of cortical bone destruction that cannot be appreciated by MR scanning. The back pain in this patient was probably due to the schwannoma, although multiple myeloma may also cause low back pain . If there is question OT concern regarding the clinical condition in this patient, a follow-up MR study with contrast enhancement is an excellent, noninvasive method of follow up.
PITFALLS •
•
I
Diagnosis Schwannoma; multiple myeloma.
Differential Diagnosis •
schwa nnoma
•
metastatic disease
Discussion The rounded dense pa LLer n of enhance m e n t is typical of schwa n n o m a . The clinical history of m ultiple myeloma i n th is patient is helpful to arrive at a correct diagnosis. The densely enhanci ng lesion is i n de pe n d e n t of the diagno sis of multiple myeloma. The entire vertebral column should be evaluated to search for additional lesions and pathologic fractures and to rule out cord compression. In this p a tient , there are a ls o areas of degenerative change. There is a sl i gh t a n terior spondylol isthesis of L2 on L3 a n d slight enhancement of the disc posteriorly at the L2-3 level (right, arrow ) . There is disc space narrowing at th e L3-4 through LS-Sl levels seco ndary to degenerative disc disease. Differential diagnosis in this patient would include metastatic prostate carci noma. Small diffuse metastases from any primary tumor could have a simi l a r appearance.
The mottled pattern of decreased signal intensi t y could be mistaken fOT the mottled increased signal intensity of osteoporosis.
A solitary n eurofibroma could have a similar appearance b ut would be unlikely in this patient.
l�
I TEACHING ATLAS OF SPINE IMAGING
Case 4 Clinical Presentation The patient is a 76-year-old female was recently exacerbated.
with a
I O-year history of back pain that
SPINA L CO RD TUMORS
Radiologic Findings Sagittal short TR inlage without contrast material (Fig. A ) reveals an approx inlately 9-mm oval soft tissue mass in the midportion of the vertebral l:anal at the L2 level (white arrow). A polypoid defect is visible in the supcrior end plate of the L3 vertehral hody «()pen arrow ) . There is diffuse increase in signal i n te nsi ty in the marrow of all the visualized vertebral bodies. Compression fractures of the L3, L4, and L5 vertebral bodies can be seen. There is anterior spondylolisthesis with forward displacement of L4 on L5; this is secondary to interfacet degenerative changes. In addition, there a re small rounded areas of decreased signal in tensity in the suft tissues of the back at the LS-S l level (arrmvhear/s). The L I vertebral body is identified with 1 .
Diagnosis Schwan noma at L3; osteoporosis; postoperative changes.
PEARLS •
Multiplanar imaging should be performed to identify the laterality of the lesion so that a surgical approach can be performed appropriately.
PITFALLS •
•
•
This schwan noma could potentially have been present at the time of the patient's previous surgery. When evaluating a patient for low back pain, the imaging should include up to the TlO vertebral body because a ma�s as high as T I O may cause symptoms that m i mic the low back pain of lumbar disc disease. This evaluation may be performed with magnetic resonance imaging and should also be performed in the patient who has bad a myelogram.
Differential Diagnosis •
schwannoma
•
drop metastasis
•
epidermoid
Discussion This pllt ient has an isolated schwannoma. The nerve roots of the cauda equina are displaced posteriorly in the vertebral canal. There is a Schmorl's node deformity in the superior end plate of the L3 vertebral body. This occurred because the end plate was weak, the nucleus pulpns us fractured the end plate, and it herniated i n to the vert ebral body. There arc ben ign compression fractures of the lowest three lumbar vertebral bodies. The postoperative cha nges in the lower lumbar region are secondary to lam in e l:tomy. The very low signal intensity rounded areas are secondary to magnetic susceptibility artifact because of the previous surgery. These changes may be seen even if no metallic clips are visible on plain film evalu atiol1. Osteoporosis results in an increase in the amount of adipose tissue within the vertebral body. Fat is high signal intensity on short TR images, so all the vertebrae appear as i ncreased signal intensity. The vertebrae are weaker when there is osteoporosis, so benign compression fractures may occur. This appearance is typical of a schwannoma , and i t is the 1110st likely diagno sis. However, a drop metastasis from a primary tumor such as breast or lung carcinoma could have a similar appearance, as could metastatil: mela noma. An epidermoid secondary to previous spinal tap might also have a simi lar appearance.
I TEACHING ATLAS OF SPJ 'E I M AC-; ING
Case 5 Clinical Presentation The patient is a 33-year-old female with clinical myelopathy presenting with lower extremity wcakness. The imaging study was pe r for med to rule out dcmyelinating disease.
B
A
c
1 84
SPIN AL CORD TU M ORS
I
Radiologic Findings PEARLS •
•
The convex "meniscus" sign is typical for an intradural lesion. My el ogra phy may be performed; howe ve r , in a case such as this, the m yel o gram would need to be performed via bot h a lumbar and a cervica l spi na l tap with instilJation of contrast material. Ma gne t ic resonance scanning is th e better method of evaluation and is essen tially noninvasive.
Sagi t t a l short TR image ( Fi g. A) reveals an oval-sbaped soft tissue mass i n the midthoracic area that displ aces the spinal cord pos teriorl y . The mass forms an acute angle with the spinal cord an te ri o r l y (short arrow). There is widening of the subarachnoid space (double arrow) on top of the mass. Si m il ar ch an ges are also present below the mass. The T7 vertebral body is identified with 7. Sagittal short TR im age after the infusion of con trast material (Fig. B) rev eals dense homoge n e o us enhancement of th e mass. The mass is at the level of the T7 vertebral body (7). A xial short T R im age postcontrast (Fig. C ) reveals dense enhancement o f wh ich i s anterior t o the spi n al cord. T h e spinal cord i s an intermedi ate sig nal intensity s t r u ct u re that is compressed into a crescentic shaped dorsal to the mass (arrow). t h e mass,
Diagnosis PITFALLS •
•
N o te that in one plane the spinal cord will appear displ a ced away from the mass a n d com pressed by the mass, while in the opposite plane the spinal cord wil l appear widened be ca us e it is comp resse d and fla ttened. There(ore, it is vi t a l to obtain ort h ogo n al views to prove that the mass is arising outsid e of the spinal cord and not from within the spina l cord.
Meningiomas ma y calcify, an d areas of calcification may be i den t i fi ed by co m p u te d tomographic scanning, rarely by plain film evaluation.
Me ningioma confirmed at surgery. ,
Differential Diagnosis •
meningioma
•
schwannoma
Discussion The thoracic region is the typical location of these spi nal cord meningiomas, 80% of which are found in women . The appearance is typical of an intradural mass. These masses arise from the dura and displace the spi n al cord away fro m the site of origin. The ce re brospinal fluid space is widened on the side of the tu mor, and the spinal cor d is compressed and displaced by th e tumor. A schwannoma could h ave this appearance, but is less l ikel y. Spinal meni ngi om a s may exhibit a dual ta il sign similar to that seen with cer eb ra l m en ingi omas .
l�
I
TEACHING
ATLAS OF S P I N E I M AGING
Case 6 Clinical Presentation The
patient is a 57-year-old female with a history of progressive lower extremity weakness and unsteady gai t .
A
B
1 86
sri
i\L COR D TUMORS
_ _ _ .... .. _
I
c
D
l�
I TEACHING ATLAS OF SPINE I M AG I NG Radiologic Findings Lateral view of a myelogram performed via cervical tap (Fig. A) reveals a mass with an upwardly convex border that forms an acute angle with the margins of the dura anteriorly and posteriorly (arrows). The spinal cord (c) is displaced anteriorly. The contrast-filled subarachnoid space is widened dorsally.
PEARLS •
•
The appearance is typical for a meningioma. Magnetic resonance imaging with contrast enhancement with multiplanar imaging is the procedure of choice for diagnosis and eval uation of a patient with any type of spine or spinal cord tumor.
Axial computed tom()graphic (CT) scan at the level of the mass (Fig. 8) reveals the spinlil cord (c-arrow) displaced toward the left side. Thc dotted line marks the interface between the mass and the spi nal cord. Axial pnstmyelogram CT scan j ust above the level of the mass (Fig. C) reveals the spinal cord (c-arrow), which is flattened into an oval shlipe and displaced to the left. The top of the mass is visible in the suharachnoid space on the right side. Sagittal reconstruction view of the plJstmyelogram CT scan again (Fig. D) reveals the spinal cord displaced anteriorly (c) and the widening of the contrast-filled subarachnoid space posteriorly (arrows).
Diagnosis PITFALLS •
•
The postmyelogram cr scan helps to define both the upper and lower margins of the mass so that surgery can be planned appropriately. If
a myelogram is performed via lumbar spinal tap, care should be taken to remove only a very small amount of contra t material. If thcre is complete block to flow of contrast material, removal of a large amount of contrast may make the patient's condition worse because of the creation of a vacuum below the level of the block.
1 1 88
Men ingioma.
Differential Diagnosis •
meningioma
•
schwannoma
•
drop metastasis
Discussion The age and gender of the patient as well liS the location of the mass make the diagnosis of meningioma the most likely diagnosis. A schwan noma could also h ave this appearance. A drop metastasis could also have a similar appearance, but the latter two diagnoses are less likely than men ingioma. The appelirance of this meningioma visualized by myelography is very similar to the patient illustrated in case S.
SPI N AL CO R D TUM O R S
Case 7 Clinical Presentation The patient is a 20-year-old male with urinary retention, back pain, and i mpo tence .
A
B
Radiologic Findings Sagittal short TR postcontrasl image (Fig. A) reveals a normal appearing upper and midthoracic spinal cord . There arc mUltiple small rou nded, bead like areas of enhancement along the dorsal aspect of the spinal cord in the lower thoracic region (thin arrow). In the very low thoracic spine region, there is an intradural slightly irregularly enhancing mass anterior to thc spinal cord in the low thoracic/upper lumbar region (thick arro w). The spinal cord is displaced posleriorly an d compressed. The subarachnoid space is widened anterior to the spinal cord and the spinal cord is compressed. Sagi ttal short TR image postcontrast (Fig. B) reveals dense homogeneous enhancement of the mass, which extends from the l evel of the midbody of Ll through the midbody of L3.
1 891
I TEACH I N G ATLAS or SPI
E I M AG ING
c
Radiologic Findings (continued) Axial sh o rt TR postcontrast images in I he lower thoracic region ( Fig. C) reveal the tiny bcadlike areas of enhancement on the surface of the spinal cord. At the level of T12-Ll , the enhancing mass (l(}wer righi, arrow) v is u al ized on the sagittal view is also seen on the axill l view. The m ass is approxi mately 1 cm in diameter and d i splll l:es I h c spinal cord posteriorly. The cerebrospinal tl u i d - fi l1 ed subarachnoid space is almost completely obl i l erated.
1J.3l
SPlNAL CORD TU M O RS
PEARL •
The location and enh ancing characteristics are typical for a myxopapillary ependymoma.
I
Diagnosis Myxopapillary ependymoma.
Differential Diagnosis PITFALL •
Care must be taken to evaluate the entire visualized length o f t h e pinal cord and spi nal subarach noid space. In this example, the abnormality was initially visualized only at the very inferi or margin of the image.
•
myxopapillary ependymoma
•
drop metac;tasis
Discussion This appearance is typical of myxopapillary ependymoma. These ependymo mas may also contain areas of hemorrhage and so may appear as decreased signal intensity on both the short and long TR images. A drop metastasis from a primary central nervous system tumor such as medu lloblastoma, ependymoma, or pinealoma could also have a similar appearance.
l�
I
T EACHING ATLAS OF SP[NE l M A G l N G
Case 8 Clinical Presentation The patient is
(I
35-year-old male with a hi story of low back pain and impo
tence.
"�. A
B
Radiologic Findings Sagittal short TR image in the l umbar region (Fig. A) reveals a mottled area of slight increased and decreased s ignal intensity that begins at the leveJ of the superior end plate of Ll and extends to the midbody of L2. Areas of increased signal intensity are seen in the l ower portion of t he mass
(arrow).
Sagittal sh ort
TR
image postcontrast (Fig.
B)
reveals dense enh ancement
of the mass. There is a remaining area of persisten t decreased signal intensity wi Lhin the central portion of the mass
(arro w).
S PI N AL CORD TUM ORS
I
D
E
l�
I
TEACH I N G A TLAS OF SPINE IMAGING
Radiologic Findings (continued) Axial short TR image preinfusion (Fig. C) reveals a slightly inhomogeneous mass that is located in the right side of the vertebral canal.
PEARL •
The area of decreased signal intensity is consisten t with an area of hem orrhage, and tbe presence of this type of hemorrhage is very typical of ependymoma in the lumbar region.
PITFALL •
Calcification could also give the appearance of decreased signal intensity within the mass, but would be much l ess l ikel y than hemorrhage. Areas of calcification may also exhibit areas of increased signal intenSity on short TR images s econdary to the p aradox ical effect related to the chemical comp osition of the areas of calcifica tion.
Axial short TR i mage postcontrast (Fig. D) reveals dense homogeneous enhancemen l or lhe ma ss, w h i ch fills the entire vertebral canal.
Axial shorl TR i mage al lhe level of the midportion of this mass (Fig. E) reveals the central area of decreased signal inlensity. Th i s a rea has a sl igh tly irregular peri pheral ma rg in .
Diagnosis MyxopapilJary ependymoma with areas of hemorrhage.
Differential Diagnosis •
myxopapiUary ependymoma
Discussion The age and appearance of the mass are typical of the diagnosis of myxopapil lary ependymoma. The elongated appearance is because the mass takes on the configuration of the lumbar vertebral canal. Metastases from these tu mors may occur and can be quite extensive, occupying the entire sp i na l subarachnoid space. Therefore, the length of the spi nal subarachnoid space sho u l d be evaluated . The a reas o r in creased s i g n a l inlensity on the short TR im age s a re presumably related to areas of hemorrhage with methemoglo bin formation.
SPINAL CORD TU MORS
I
Case 9 Clinical Presentation The patient is an 18-year-old male with low back pain and urinary retention.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals an isointense, slightly elonga led rou nded soft tissue mass in the vertebral canal at the level of L1 (arrow). Sagittal short TR image postcontrast (Fi g. B ) reveals dense, slightly inhomo gen eous enhancemen t of the soft tissue mass. Above the level of the mass, there is a streaklike area of enhancement along the dorsal aspect of the distal spinal cord (white arrow). Below the mass, th ere is a second rounded area of enhancement (black curved arrow).
I TEACHING ATLAS OF SPINE I M A G I N G
c
PEARLS Because ependymoma may lead to metastatic deposits, the entire length of the vertebral canal should be eval uated. Eval uation of the spine should include studies without and with the infu 'ion of contrast material. •
•
Tumors that are primary in the brai n may also metasta ize to the spinal subarachnoid space. If this is a diagnostic consideration, magnetic resonance (MR) i maging of the brain without and with contrast should be performed.
Radiologic Findings (continued) Axial short TR image of the brain (Fig. C) reveals multiple bilateral rounded areas of cerebrospinal fluid signal intensity.
Diagnosis Ependymoma; dilated Virchow-Robin spaces n ificance.
Differential Diagnosis •
ependymoma
•
metastasis
in
the brain of unknown sig
SP[NA L CO RD TU MORS
PITFALLS • The MR appearance of the
spinal cord
lesion is also typical
of schwannorna, and schwannoma would be the most likely
diagnosis
in this patient
in the absence of a history of
previous •
ependymoma.
Discussion Th is patie nt had a history of previous resection for a s p i nal cord ependy moma. The i n ternal areas of decreased signal inten sity arc probably related to areas of hemorrhage. The areas of enhancement above and below the m ass are dilated vessels in the subarachnoid space . Dilated vessels are occasionally seen above the level of a mass th at is ca using a com plete block to the flow of contrast materi al. In an older pa tient, a me tastasis from a primary tumor such as mela noma could have a similar appearance .
Meta s t atic spread [rom a primary tumor outside of the central nervous system may also havc a similar appearance.
l�
I TEACH!
G ATLAS OF SPTNE I M AG I N G
Case 10 Clinical Presentation The patient is a S-year-old femille with recurrent ependymoma of the spine who is status posteran ial ilnd spinal radiation and now presents with lower extremity weakness.
A
1 1 98
B
SPIN A L CORD TUMORS
I
c
o
l�
I
TEACHING ATLAS OF SPTNE IMAG ING
Radiologic Findings Sagittal short TR image in t he cervical re gio n (Fig. A) reveals a sligh tly lobulated mass arisi n g anterior to the spinal cord at the level of Tl (arrow). Sagittal short TR image postcontrast (Fig. B) reveals dense enhancement of the mass. Axial short TR image precon trast ( Fig. C) reve a ls that the spinal cord is displaced far poste ri orly and compressed into a crescentic sh ape (arro w ) . Axial short TR image postcontrast (Fig. D) reveals dense homogeneous enhancement of the m ass anteriorly and on the left side displaci ng the spinal cord posteriorly and to the right (arrow).
PEARL •
The clinical h istory is important here for the correct diagnosis. The entire spina l axis should be evaluated for complete evaluation in this patient.
PITFALL •
In a patient with a t u mo r known to metastasize to t he craniospinal axis , evaluation of the entire system should be ob tained at the t ime of initial d i agn osis as well as at the time of fo llow-up .
�o
Diagnosis Drop metastasis from recurrent posterior fossa
ependymoma.
. . I Dlagnosls ' Differentia •
drop metastasis
•
schwannoma
•
neurofibroma
Discussion The magnetic resonance eva l u a lion of the poslerior fossa reveals postsurgical ch ange as well as an enhancing lesion consistent with reCUl1"ent tumor. Analysis of the cerebrospinal fluid also revealed cells compatible with recur rent ependymoma. The appearance is consistent with a drop metastasis from a primary ependymoma. A drop metastasis from a disease process such as medulloblastoma could also h ave this appearance. A schwannoma or neurofibroma could also have t his a ppea r a nce .
S PT N A L CO R D TUM ORS
I
Case 11 Clinical Presentation The patient is a 49-year-old female with evidence of cord compression with progressive inability to walk.
A
B
I
TEACHING ATLAS OF SPINE IMAGING
c
D
202
S P I N AL CORD TUMORS
E
I
I
T EACHI N G ATLAS OF SPI N E IMAGING
G
Radiologic Findings Sagittal short TR i mage in the cervical region (Fig. A) reveals a slightly irregularly marginated mass behind the odontoid process of C2. The spinal cord and lower medulla are displaced posteriorly. Sagittal short TR image postcontrast (Fig. B) revel:lls d e n se enha ncem e n t of the soft tissue mass . There is a short extension of these areas of enhance ment along the dura anteriorly (white arrow). Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal that the spinal cord (c) is displaced posteriorly by the soft tissue mass. On the postcontrast study (rif?ht) , the mass exhibits inhomogeneous enha ncement and has an irregular peripheral margin. S agi ttal long TR image (Fig. D) reveals that the mass exhibits increased signal intensity with two rounded areas of decreased signal intensity. The medulla and upper cervical spinal cord reveal marked increased signal inten sity (large arrows). There is l:I ro u n ded l:I rel:l of low densi ty anterior to the medulla behind the clivus (small arrow).
S P I N A L CO RD TUMORS
Parasagittal long TR imagc (Fig. E) reveals that the mass appcars as variablc signal intensity and contains large areas of decreased signal intensity. Parasagittal short TR image postcontrast (Fig. F) reveals a second area of variable enha ncement arising from the dura i n the floor or the posterior fossa. This mass appears to have a small extension along the dura (arrow). ' Axial short TR image postcontrast (Fig. G) reveals irregu lar enhancement of the mass, which projects up i n to the right cerebellar hemisphere. The cerebellar tonsil (I) is displaced medially. PEARL Findings mu t be correlated with clinical hi tory. In a patient with a clin ical history of neurofibromatosis type 2, these Ie ions could represent either meningiomas or schwannomas. •
Diagnosis Metastatic colon carcinoma.
Differential Diagnosis •
metastatic disease
•
meningioma
PITFALL •
While meningiomas may exhib i t a "dural tail sigo," other tumors may also have a dural tail, as i n thi case of metastatic colon cancer. Meningiomas typically have a more rounded peripheral margin.
Discussion The patient was known to have widespread colon cancer. The metastases had even involved the subcutaneous t issues of the patient's forearms. Metastatic colon cancer may be mucin producing and so m ay appear as variable signal intensity on various magnetic resonance imaging sequences. The "dural tails" with extension along the dura suggest that mUl tiple meningiomas could be a diagnosis in this patient. Contrast enhancement with multiplanar imaging is very helpful for complete evaluation, and evaluation should incl ude imaging of the entire brain and spine in this patient. Work up should also include evaluation of other or gan systems. The rounded area of low density anterior to the medulla behind the clivus is the flow void of the vertebral artery. Metastatic di ease from a primary tumor such as breast cancer, l ung cancer, or melanoma could also have a similar appearance. Melanoma may also be hemorrhagic and so exhibit variable signal intensity on a variety of pulse sequences; melanoma may also develop skin metastases.
TEACHING ATLAS OF
SPINE I M AG I NG
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FT, Kroon
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in
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Klatte
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Radiol. 1 992;33:207-212.
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Marty R, M i ncklcr DS. Radiation myelitis simulating tumor. A td, Nellrol. 1 973;29:352-354. Mascalchi M, \)HI P07.ZO G, Bartolozzi C.
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Ruptured spinal l1t:rmoid cyst with chemical arachnoiditis
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Shiono T, Yoshikawa K ,
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lumbar spinal cystic neurinomas with unusual
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Zimmerman A, eds. The Radiology
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spinal lIiscasc.;,. AiNR. 1 988;9: 1 53- 1 63. Sze U, Abramson A, Krol G , ct al. Gadolinium-DPTA i n evaluation of i n tradural extramedul la ry spinal diseases. AiR. 1988; 1 50:9 1 1 -92"1 . Sze
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Section ill
Spinal Cord Tumors c. Neurofibromatosis
CON G E N ITA L
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Case 1 Clinical Presentation The patient is a 15-year-old male with recent difficulty voiding who is being evaluated to rule out cord compression.
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Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A , right) sagittal short TR images in the cervical region reveal diffuse widening of the cervical spinal cord from the level of C2 through the level of Ci-6. There is reversal of the lordotic curve of t he cervical spine. The postcontrast study reveals multiple flocculent areas of enhancement extending from the C2 through the C6 levels. Pre- (Pig. B, left) and postcontrast (Fig. B, right) parasagittal short TR images reveal diffuse enlargement of the intervertebral fora men at all levels in t he cervical region by m ultiple, soft tissue, intermediate signal intensity masses. There is dense enhancement on the postinfusion study (squares). Pre- (Fig. C, top) and postcontrast (Fig. C, /)()I/om) axial short TR images reveal bilateral soft tissue signal intensity masses in the region of the interver tebral foramen. There is dense, slightly inhomogeneous enhancement of these soft tissue lesions (bottom, e) that extend into the vertebral canal via the intervertebral foramen and compress the spinal cord into an elongated oval shape (top, s). Soft tissue masses displace the flow void of the carotid artery anteriorly (top, long arrows); the jugular vein is compressed and displaced posterior and laterally (shorr arrows). Pre- (Fig. D, top) and postcontrast (Fig. D, bottom) axial short TR i mage at the level of C4 reveal bilateral soft tissue signal intensity masses in tbe region of the intervertebral foramen. On the left side, there are several contiguous soft tissue masses which extend along the course of the brachial plexus (rop, open arrows). There is another mass between the tlow voids of the carotid artery and j ugular vein (m, top); a similar smaller mass is seen on the opposite side. Within the vertebral canal, there is a rounded area of enhancement that obliterates the vertebral canal (curued arrow). The spinal cord cannot be iden tified with certainty. There is dense, sligh tly inhomoge-
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neous enhancement of these soft tissue lesions on the postinfusion study
(boltom, e-arrows) . Precontrast axial short TR i mage� in the lower cervical region at the C5-6 level (Fig. E) reveal a slightly lobulated mass that follows the course of the brachial plexus on the left side (top, dOlled line). The anterior scalenus muscle projects anterior to this mass (top, m). There are soft tissue masses between the internal carotid artery and j ugular vein (lap, n). Pre- (Fig. F, lefl) ami postcontrast (Fig. F, right) parasagittal short TR images reveal enlargement of the intervertebral foram ina at all levels of the lumbar spine. There is slightly inhomogeneous enhancement of all the soft tissue masses in the intervertebral foramina (righi, square.I·) . Parasagittal long TR image (Fig. G) reveals diffuse increased signal intensity within aU of the soft tissue masses in the intervertebral foramina. Thcre is a central a rea that does not exhibit increased signal in the lower lumbar region (arrow).
PEARLS •
•
This is the typical appearance of extensive plexiform neurofibroma in the patient with neurofibromatosis type 1 . The entire veltebral column should be evaluated for accurate determination of the extent of the disease because symptoms may actually be minimal even when the lesions are quite extensive.
PITFALLS •
•
Without multiplanar imaging, the appearance uggests that these are really intramedullary rather than intradural masses. Patient with neurofibromatosis type 2 may have multiple intramedull a ry tumors, such as ependymomas, even when there arc minimal or no clinical symptoms.
Axial long TR image at the level of L 1 (Fig. H) reveals multiple rounded and oval areas of increased signal intensi ty. These a re in the region of the intervertebral foramen (squares), in the para-aortic region, and in the mus cles of the paraspinal region.
Diagnosis eurofibromatosis type
1
with multiple plexiform neurofibromas.
Differential Diagnosis Intramedullary enhancing lesions
Discussion The sagittal pre- and postcont rast images in the cervical region reveal dense enhancement of the multiple plexiform neurofibromas. These plex iform tumors extend into the cervical vertebral canal at multiple levels and mark edly compress the cervical spinal cord medially, widening the spinal cord. This gives the false impression that there are multiple intramedullary enhanc ing lesions. However, the axial image confirms the fact that these lesions are adually intradural and extradural rather than in tramedullary. The axial image also reveals that there is a soft tissue neurofibroma of the vagus nerve in the vascular bundle in the neck on the righ t side that displaces the carotid artery anteriorly and the j ugular vcin posteriorly as seen in Figure C. Neurofibromatosis type 1 is an hereditary disease that is autosomal dominant with involvement of chromosome number 1 7.
SPINAL CORD TUMORS
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Case 2 Clinical Presentation The patient is a 22-year-old female with minimal lower extremity weak ness.
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Radiologic Findings Precontrast (Fig. A, left) coronal short T R image reveals multiple soft tissue d ensi ty m£lsses in the supraclavicular regions bilateraUy (circles) . The post contrast (Fig. A, right) coronal short TR image shows dense enhancement of multiple areas within the vertebral canal (medial triangles), a l ong the anterior margin of the middle scalenus muscle (triangles), and in the supracla vicular region (circles). Parasagittal short TR image at the level of the intervertebral foramen (Fig. B) reveals that the normal increased signal i ntensity fat is replaced by soft tissue signal intensity masses at all levels of the intervertebral foram ina (squares). The i ntervertebral foramina arc enlarged. There £Ire also multiple small soft tissue density masses along the coursc of the anterior scalenus muscle (arrows). Pre- (Fig. C, Ie/I) and postwntntst (Fig. C, righr) axial short TR i mages at the level of C5 reveal separation of the anterior (a) and middle (m ) scalenus muscles by soft tissue density masses (dotted line). These masses exhibit dense enhancement postinfusion (righi, circles). The a n terior scalenus mus cle is displaced anteriorly and flattened. Axial short TR image at the level of C2 (Fig. D) reveals enhancing soft tissue masses in the intervertebral foramina bilaterally (e). There is a small enhancing mass that extends into the vertebr£ll c£lnal on the right side
(arrow). Axial short TR image after the infusion of contrast material (Fig. E) reveals mul tiple enhancing soft tissue density masses that surround the flow void of the vessels at the level o f the thoracic inlet (circles). The vessels that are seen i nclude: right subclavian vein (1), left subclavian vein (LSY), innomi nate artery (INN), left carotid artery (4), and left subclavian artery (5), trachea (T). Axial short TR image at the level of L2 (Fig. F) reveals a lobulated soft tissue mass on the right side that extends i nto the vertebral canal via the intervertebral foramen (long white arrow). Multiple additional rounded soft tissue masses in the left paraspinal region and in the paraspinal muscles are a lso visible (short whire arrows). There is a rounded soft tissue mass in the paraspinal muscles of the back (black arrow). Axi£l l iong TR image at the same level as Figure E (Fig. G ) reve£lls that the spinal cord is displaced to the left (open arrow). A large lobulated mass is noted on the right side. A portion of the tumor extends posteriorly (darrow). There are also multiple a reas of increased sign£ll intensity in the paraspinal regions and within the paraspinal muscles. Axial short TR image slightly below the levels of Figures F and G (Fig. H) reveals marked expansion of the intervertebral foramen. The spinal cord is displaced far to tbe left (arrow). The kidney is seen on the left side. Axial long TR image (Fig. I) reveals the lobulated soft tissue mass that appears as increased signal intensity. The spinal cord is compressed and d ispl a ced to the left (arrow). There are multiple smaller areas of increased signal intensity in the paras pinal muscles of the back. Pre- (Fig. J, left) and postcontrast (Fig. J, right) parasagittal short TR images reveal enhancement of a lohulated mass. A portion of this mass herniates
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TEAC H I N G ATLAS OF S P I N E I M A G ING
over the rib (rlarrow) into the soft tissues of the back. This is the same mass seen in Figure G. Coronal short TR image of the orbit (Fig. K) reveals bi lateral soft tissue masses that projcct above the globes uf the orbit (arrows).
PEARL •
In patients with neurofibromatosis, large masses may be seen even in the patient with minimal or mild symptoms. Because t he slow growth of these lesions may allow them to reach a relatively large size, imaging with magnetic resonance using intravenous contra t material will allow an accurate determination of the extent of the disease and also provide a baseline for future comparison at the time of follow-up.
PITFALL •
The entire canal should be evaluated because neurofibromas mety be present even when t here are no symptoms.
Diagnosis Neurofibromatosis type 1 with multiple plexiform and dumbbel l-shaped tumors.
Differential Diagnosis •
Neurofibromatosis type 1 .
Discussion The appearance is typical of patients with neurofibromatosis type 1 . In the cervical region, there is enlargement of all of thc intervertebral foramina because of neurofibromas ett all levels of the cervical spine. These neurofi bromas appear as increased signal intensity on the long TR i mages. There is pressure erosion of the bony structures at the level of the intervertebral foramen because of the longstanding nature of these lesions. In the lumbar region, the spinal cord is displaced toward the left side. The spinal cord is also compressed into a triangular shape. The posterior lobulation of the mass seen in Figure G on the right side is secondary to herniation of a small portion of the mass through the ribs into the paraspinal muscles of the back. Symptoms may be minor because the neurofibromas are very slow growing and the spinal cord is able to accommodate compres sion when it occurs ovcr a long period of time.
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Case 3 Clinical Presentation The patienl is a 16-year-old male with progressive scoliosis, increasing lower l eft leg pain, and bowel and bladder incontinence.
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Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images reveal multiple soft tissue masses in the prevertebral region, within the spinal canal (solid arrows), and in the pelvis. Note fiuidltluid level in the bladder with accumulation of gadolinium in the dependent portion of the hi adder (righi, open arrow). Axial short TR image postcontrast at the level of L5 (Fig. B) rcveals multiple soft tissue masses within thc vertebral canal (open circles), in thc \eft prever tebral area, and in the paraspinal region (solid circles).
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Radiologic Findings (continued) Axial long TR image in the pelvis (Fig. C) reveals mul tiple cunnuent rounded areas of increased signal intensity that surround the distal colon and rectum
(arrowheads). Axial short TR image postcontrast a t the level of L3 (Fig. 0) reveals multiple rounded areas of enhancement adjacent to the i nferior vena cava and in the paraspinal region within the psoas muscles.
PEARL Magnetic resonance imaging (MRT) with contrast enhancement is t he most sensitive method of evaluation of these patients. The study should be performed with multiplanar i maging. •
PITFALLS •
•
•
pinal tap may be very diffic ult in a patient such as this case because the multiple intradural and extradural m asses obliterate the subarachnoid space. Previously myelography was used for evaluation of these patients. However, since the availability of MR, this newer technique h as replaced the use of myclography and po tmyelography computed tomography for evaluation Tbese patients are difficult to manage because of tbe presence of multiple lesions.
Axial postcontrast image in the upper lumbar region (Fig. E) reveals a rounded, enhancing mass (black arrow) which displ aces the i n feriur vena cava anteriorly (i, white arrow). Axial short TR image postcontrast (Fig. F) reveals the pressure erosion of the lateral margin of the vertebral body (white arrowheads), with an associ ated soft tissue mass in the paraspinal area . There is a rounded, enhancing, soft tissue mass on the left side also (black arrow). Parasagittal long TR image in the thoracic region (Fig. G) reveals that all the intervertebral foramina are enlarged by soft tissue masses that appear as increased signal intensity on the long TR images.
Diagnosis eurotibromatosis type 1 with multiple plexi form neurofibromas at all levels on the spine.
Differential Diagnosis •
Neurotibromatosis type
1
with multiple plexiform neurofibromas.
Discussion There is extension of the multiple plexiform neurofibroma into the ex panded distal vertebral canal. In addition, there are multiple, intradural enhancing lesions in the distal lumbar vertebral canal a nd para-aortic neuro fibromas. Pressure erosion of the lateral margin of the vertebral body second31)' to the neurofibromas is also visible. These fi ndings are typical of patients with neurofibromatosis type 1 with multiple plexiform neurofibromas. Sur gery is fre4uently impossible in these patients because the extensive n ature of these tumors makes surgical removal impossible.
I TEACH ING ATLAS Of' S P I N E I M A G ING
Case 4 Clinical Presentation The patient is an l 1 -year-old male with left arm pain after stretching. PhysieCil exam revealed brisk deep tendon reflexes and positive Babinski's sign.
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Radiologic Findings Sagittal short T R image after the infusion of contrast (Fig. A) reveals two small rounded areas of enhancement projecting lI n l erior to the spinal cord at the C2 level. Sagittal short TR image postcontrast (Fig. B) revcals three small oval-shaped areas of cnhancement in the distal thoracic region (tong arrow). There is also a very small rounded area of enhancement anterior to the spinal cord in the upper thoracic region (short arrow).
EARLS •
•
Magnetic resonance imaging is the ideal mt:l hod (or evaluation of the multiple lesions that may be !\.Cen in patients with this disease. The study should be peliormed with contrast enhancement. It is not uncommon that the patient may palpate these neurofibromas, which are more superficial in location, particularly those that are beneath the sternocleidomastoid muscle.
Pre- (Fig. C) and postcontrast (Fig. D) axial short TR images Ihrough the cervical spine a t the CS level reveal bilateral enhancement of the soft tissue masses at the level of the intervertebral foramen (thin arrows). There arc also multiple soft tissue density masses projecting beneath the sternocleido mastoid muscle on the left side (thick arrows). The right vertebral artery (Fig. D, v/arrow) is abutted along its posterior m a rgin by an en hllnl:ing lesion in the right intervertebral foramen.
Diagnosis Ncurofibromatosis type 1 with plexiform neurofibromas in the in tervertebral foramina, deep to the sternocleidomastoid muscle, and in the intradural space in the cervical and thoracic region.
Differential Diagnosis •
Schwannomas
•
Metastatic deposits
Discussion PITFALL •
It i · possible to fail to appreciate those neurofibromas which are remote [rom the spinal or paraspinal area.
The process is less extensive in this patient than in many patient with neurotibromatosis. The relatively small number of lesion seen in this patient would raise the possibility that these represent multiple schwa nnomas rather than neurofibromas. Schwannomas may also be seen in patients with neuro fibromatosis. In addition , the possibility of multiple metastatic deposits is also a c1iniclll consideration.
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Case 5 Clinical Presentation The patient is a 1 3-year-old male with lower extremity weakness.
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Radiologic Findings Sagittal short TR image at the level of the conus medullaris (Fig. A) reveals focal widening of the distal end of the sp inal cord . There is a central area of decreased density within the spinal cord . Sagittal intermedi ate TR image (Fig. B) reveals i ncreased signal intensity w ithin the distal end of the spi nal cord (arrow).
PEARLS Watchful wa itin g may be the best cours e of action in this patient. MR provides the ideal method of follow-up.
•
Most spinal cord tumors exhibit enhancement postcontrast, so the lack of enhance me n1 in till s patient is nOl in favor of a neoplasm.
•
PITFALL •
Subtle changes in t h e appearance of the spinal cord may not be appreciated, particularly if there is no enhancement of the lesion. Knowledge of the clinical presentation is very h e lpfu l when i nterp reLi n g images in which Lhere a re on ly subtle changes.
734
Diagnosis Probable nonenhancing low grade astrocytoma of the d istal s pi n a l cord.
Differential Diagnosis •
Neurofibromatosis type 1
•
Sp i n al cord infarct
•
Acute d is se min ated en ce pha lomyelitis (ADEM)
•
Ependymoma
Discussion There is an increased incidence of brain and spinal cord tumors in patients with neu rofibromatosis type 1. In an older pa ti e nt , this magnetic resonance (MR) appearance would be consistent with a spinal cord infarct. However, this would be very unlikely in a 13-year-old patient. An area of transverse "myelitis" coul d also have a similar appearance. The patie n t should be evaluated for a p ossi b le recent viral infection and a resulting ADEM. An other h istologic type of spinal cord tumor sllch as an ependymoma would also have a similar appearance.
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Case 6 Clinical Presentation The p<1lienl is a 14-year-old remi11e with deafness and headaches.
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Radiologic Findings Sagittal Tl -weighted image of the cervical and thoracic spine (Fig. A) reveals reversa l of the normal lordotic curve of the cervical spine. The spinal cord appears normal in size throughout. There is a broad-based approximately 8 mm soft tissue mass dorsal to the spinal cord at the T3 level (arrow).
EARLS •
•
•
•
The appearance of the constellation of findings in this patient is really p athognomonic of neurofibromatosis type 2. This disease is autosomal dontinant and is associated with a defect on chromosome number 22. This disease is also typically associated with bilateral acoustic sehwannomas, which are thought to be diagno tic. A lthough many of these tumors are relatively benign and if surgicaUy removed will result in a cure, their location may preclude removal. Additionally, the number of lesions may make atjsfactory treatment very di fficult. The mnemon ic of M-J-S-M E-multiple. i nherited schwannomas, meningiomas, and ependymomas-is very helpful for recalling the lesions associated with neurofi bromatosis type 2. Neurofibromatosis type 2 has been called "central" neurofibromatosi , while neurofibromatosis type I has been called "peripheral" neurofibromatosis. These names reflect the anatomic locations of t he abnormalities and are a practical, if not scien tific method, of differentiating between the two diseases.
Sagittal TI-weighted image postcontrast (Fig. B) reveals dense enhancement of a 2 to 3 mm schwannoma dorsal to the cord at the C2 1evel (black arro w). There are multiple additional smaller areas of enhancement at the level of C2 and C4 (white arrow). A broad-based, enhancing mass that can be seen at T3 (white arrow with black square). There is also a second, smaller broad based mass j ust superior to this large mass, which is also fai nLly seen on the preinfusion study in Figure A. Follow-up I year later. Sagittal TI-weighted image postcontrast again (Fig. C) reveals the new enhancing lesions at the level of T3-4 (arrow) . On this image, there are also mUltiple enhancing intrameduUary lesions that begin at the level of the lower medulla and are visible in the cervical region and then again in the midthoracic spinal cord down to the level of T8. The T3 thoracic level is iden ti fied with 3. Sagittal Tl -weigh ted images postcontrast (Figs. 0 and E) reveal multiple small areas of enhancement scattered throughout the lower thoracic and upper lumbar subarachnoid space. The largest of these (Fig. D, arrow) is also seen in Figure G. Axial Tl-weigh ted image at the level of TI2 (Fig. F) reveals the densely enh ancing mass seen in Figure D (while arro w). There are also m u l tiple, additional rounded areas of enhancement. Axial TI-weighted image postcontrast in the region of the cauda equ ina (Fig. G) reveals mUltiple small areas of enhancement, the largest of which is highlighted by the wh ite arrow. Sagittal TI-weighted image postcontrast (Fig. H) reveals dense enh ancement of the falx cerebri. There are also mUltiple focal areas of i ncreased en hance ment. The intramedullary spinal cord enhancing l esion is again seen (arrow); this lesion is consistent with an ependymoma. The patient also h ad bilateral masses in the internal auditory canals.
Diagnosis Neurofibromatosis type 2 with m ultiple spinal schwannomas, meni ngiomas, and ependymomas, as wel l as cerebral meningiomas and acoustic schwannomas.
Differen tial Diagnosis •
Meningioma
•
Intramedullary ependymomas
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PITFALL •
Evaluation of tbe brain is helpful in patients with neurofibromatosis type 2 because, as in tbis case, these patients may also have m ultiple asymptomatic meningiomas in addition to bilateral acoustic schwannomas. Although treatment may not be undertaken at the time of diagnosis, scanning provides a baseline for future evaluation and determi nation of any change in the size Of the lesions.
G
Discussion The broad-ba ed mass at T3 is consistent with meningioma (Fig. B, while arrow with black square). The second smaller broad-based mass j ust superior to this large mass, which is also faintly seen on the preinrusion study i n Figure A , is probably a second meningioma. There are multiple intramedullary enhancing masses as seen in Figure C. These enhancing lesions are consistent with multiple intramedullary ependy momas. Although multiple enhancing intramedullary lesions mClY be seen with this entity, the patient may be completely or relatively asymptomatic. The m ultiple rounded enhancing lesions in the spinal subarach noid space are consistent with multiple schwannomas (Figs. D to H ) . The multiple areas of thicken i ng of the falx are consistent with multiple falx meningiomas. Multiple meningiomas are a typical finding in patients with neurofibromatosis type 2.
S P I N AL CORD TU M O RS
I
Case 7 Clinical Presentation The patient is a 24-year-old female who presented with total dea fness.
A
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B
c
SPINAL CORD T U M O R S
D
E
I
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F
Radiologic Findings Sagittal Tl-weighted images. The preinfusion image (Fig. A, left) reveals a cystic lesion in the region of the cerebellar tonsils. The spinal cord at the level of the cervicomedullary j unction is enlarged. There is a rounded signal inten ity mliSs located slightly h igher than spinll l cord with in the spinal cord at the C2 level (arrowhead). Posti n fusion (Fig. A, right) there is a rounded area of enhancement at this level (arrowhead) . On the postinfusion study, there is also enhancement of a lobulated mass in the cervical spinal cord above the level of the midbody of the C2 vertebral body extending to the level of the bottom of the fourth ventricle. M agnetic susceptibility artifact, noticeable on both images (g) , marks the loca l ion of metallic sutures from previous surgery. There is also a smal l broad-based mass that projects behind the intervertebral disc at the C5-6 level (lefl, arrow). Sagittal long TR image (Fig. B). The cystic lesion in the floor o( the posterior (ossa is increased in signal intensity. The spinal cord tumor appear as an area of decreased signal i n tensity in the upper spinal cord (arrow). Axial short TR image postcontrast (Fig. C) reveals bilateral enhllncing acouslic schwannomas. There is a small cyst that projects behind the right itcoustic tumor (arrow). A slightly higher image sl ice (Fig. D) reveals the bilateral internal auditory canal and densely enhancing masses, including a mass along the anterior margin of the petrous bone on the left side (arrow). Parasagittal postcontrast short TR image (Fig. E) reveals the enhancing mass in the right internlli liuditory canal with the cystic com ponent projecting posteriorly (arrow). Coronal short TR images postcontrast (Fig. F) reveal the cystic mass in the posterior fossa (open white arrow, left) at the level of the foramen magnum. There is a densely enhancing Jel"! parietal, parasagittal mass (fong while arrow, lefl and right); slightly more anteriorly the right-sided acoustic neu-
SPINAL CORD TUM O RS
PEARLS •
•
The finding of bilateral acoustic schwannomas is typical of the diagnosis of neurofibromatosis type 2. In tramedullary ependymomas are found in patients with neurofibromatosis type 2; however, because patients may he asymptomatic, it is advised that these tumors be observed rather than operated.
roma is again seen (open black arrow, right). Two enhancing lesions are seen in the upper spinal cord (open white arrow, right). There are surgical defects in the bony calvaria bilaterally from previous craniectomies for removal of convexity tumors.
Diagnosis Neurofibromatosis, with bilateral acoustic schwannomas, meningiomas, and spinal cord ependymomas.
Differential Diagnosis •
PITFALLS •
•
If a postcontrast study is not performed, the intramedullary ependymomas may not be appreciated. While the multiplicity of lesions could suggest the diagnosis of metastases, the distribution of the lesions and their pattern of occurrence is not in favor of metastatic disease.
Neurofibromatosis
Discussion Clinical history is very helpful in the diagnosis of this abnormality. Neurofi bromatosis is described by using the helpful mnemonic of MlSME (mUltiple, inherited schwannomas, meningiomas, and ependymomas). Using this mne mon ic is very helpful because it aids in the identification of these various abnormalities. The previous surgery was for removal of cerebral menin giomas.
21101
Section ill
Spinal Cord Tumors D. Miscellaneous
S P I N A L CORD T U M O RS
]
Case 1 Clinical Presentation The patient is a 53-year-old male with a history of neck pain and upper and lower extremilY wea kness.
A
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B
c
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SPINAL CORD TUMORS
Radiologic Findings Pre- (Fig. A , lefl) and postcontrast (Fig. A , right) sagittal short TR images at the level of the skull base and upper cervical spine reveal a lobulated soft tissue mass ( T), which has destroyed the inferior margin of the clivus, the odontoid process, and the C3 vertebral body. The rem
�earls Clinical history is very important in this patient. Chordomas frequently recur following surgery, and total removal is almost impossible. M u l tiplanar imaging, as in this case, will frequently allow demon tration of the . pinal cord in at least one plane, even in the presence of extensive meta llic fixating wires, screws, or plates.
•
•
Magnetic resonance is the ideal method for diagnosis and follow up.
itfall If the metallic artifact from previous surgery is sufficiently exten ive and the spinal cord and its relation hip to the surrounding structures cannot be demonstrated, it may be necessary to perform a myelogram a nd postmyelogram computed tomographic scan.
Axial short TR image postcontrast (Fig. C) reveals multiple varying sized m asses ( T) in the prevertebral, paraspinal. and lateral neck region. The j ugular vein is seen on the left side as an area of flow void (jIarrow). The carotid artery is surrounded by the masses on the right side ( wide whife arrow). The now void of the external carotid (lrteries are seen anteriorly (long while arrows). The spinal cord is identified (circle), and the surrounding subarachnoid space is effaced along the left lateral and anterior margins. There are multiple oval and rounded areas of decreased signal intensity with the increased signal intensity rims again identified (arrowheads). A thin decreased signal intensity line in the midline dorsally in the subcutaneous fat indicates a previous laminectomy.
Diagnosis Chordoma, with postoperative changes.
Differential Diagnosis •
Chordoma
•
Metastatic deposits
•
Rheumatoid arthritis
•
Discussion Chordomas occur from remnants of the primitive notocord of the spine. They typically occur at the far upper end of the spi n(ll cord i n the region of the clivus or at the very distal end of the notochord in the region of the sacrum. However, chordomas may occur at any point along the vertebral column. Metastatic deposits might be a consideration in this case; however. met(lstases tend to be more permeative in nature. In Figure B, the smal l internal areas o f flow void are secondary t o multiple enlarged arteries and
2.2l 1
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G ATLAS OF SPINE I MAGING
uraining veins. Rheumatoid arthritis, with pannus formation, would not result in such extensive changes. Magnetic susceptibility artifact is visible because of multiple metallic wires that hold the spine in place. The artifact results in the multiple areas of decreased signal intensity. The increased signal in tensity is secondary to previous radiation therapy and a relative increase in tbe amount of adipose tissue within the marrow of the vertebral bodies.
�2
SPINAL
CORD TUMORS
I
Case 2 Case Presentation The patient is a 35-year-old male with a h istory of previous surgery for a tumor arising from the clivus. The patient now p resents with progressive lower extremity weakness and difficulty breathing.
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Radiologic Findings Sagittal short TR image after the infusion of contrast material (Fig. A) reveals postoperative changes in the upper cervical region with fusion be tween the lower end of the clivus, the odontoid process, and the body of C2 and the anterior arch of Cl. There are two irregularly m arginated areas of bone graft in place at the Cl and C2 levels. There arc multiple rounded areas of enhancement noted . These are in the suprasel lar cistern, in the upper anterior mllrgin of the pons, lind in the medulla. M ultiple rounded and oval areas of decreased signal intensity with increased signal intensity peripheral rims appear in the suboccipital region and extend down the spinous processes in the upper cervical region dorsally. Axial short TR image (Fig. B) reveals the rounded area of enhancement in the medulla, which is on the left side and extends to the midline (arrow).
Diagnosis Metastatic chordomas; postsurgical changes.
Differential Diagnosis •
Metastatic tumor
•
Metastatic chordoma
SPI NAL CORD TUMORS
Pearl •
•
•
The entire vertebral column and intracranial contents should be evaluated in a patient such as this. Because these tumor are often slow growing, patients may survive multiple surgical resections. Magnetic resonance is the i deal method of diagnosis and follow up.
lPitfall •
Total surgical removal of chordomas i almost impossible.
Discussion The patient's initial surgery was ror removal of a clivus chordoma. A lthough unusual, metastatic deposits rrom an aggressive chordoma may occur. More typically, chordomas recur with local extension in and around the bed of the original tumor. Other metastatic tumors could have a si milar appearance; however, the previous history in this patient makes mctastatic chordoma the li kely diagnosis. Chordomas freq uently appear as variable signal intensity because of areas of calcification and because of the variahle internal h istologic make-up. The multiple areas of decreased signal intensity with increased signal intensity peripheral margins are magnetic susceptibility artifacts from metallic wi res at the skull base and extending into the upper cervical region.
I TEACHING ATLAS OF SPINE IMAGING
Case 3 Clinical Presentation The patient is a 68-year-old previously healthy male physician with a recent history of low back pain.
A
B
Radiologic Findings Sagittal short TR image of the lumbar spine (Fig. A) reveals es entially complete replacement of the L3 vertebral body with dccreased signal inten sity soft tissue. There are small rounded areas of decreased signal i ntensity within the marrow of the L2 and L4 vertebral bodies. I ncidentally noted is marked disc space narrowing and a nterior a nd posterior osteophytes at the LS-Sl level. There is also hypertrophy of the ligamentum flavum with encroachment upon the dorsal suharachnoid space at L2-3 and L3-4 (curved arrows). This results in central spinal stenosis at this level. Sagittal short TR image with fat-suppression technique reveals enhancement of the L3 vertebral body with persistent i nternal a reas of decreased sig nal i ntensity.
LQ6
SPINAL CORD TUMORS
;PEARLS •
•
Computed tomographic-guided biopsy would be very helpful for diagnosis. Magnetic resonance is an excellent method of evaluation and readily evaluates the presence of encroachment upon the vertebral canal.
PITFALLS •
•
The diagnosis in this patient cannot be made based on imaging alone. The midlumbar location of this tumor is very unusual.
Diagnosis Chordoma within the vertebral body of areas of chordoma in L2 and L4.
L3 ,
con firmed at biopsy. Probable
Differential Diagnosis •
Chordoma
•
Metastatic disease
Discussion The diagnosis of chordoma is unusual in this cl i n ical setting. Chordomas can occur within the vertebral body, but occurrence at the far cephalic or far caudal end of the vertebral column is much more common. These tu mors are generally associated with a soft tissue component rathcr than being entirely within the vertebral body. Metastatic disease from a primary tumor such as lung cancer, colon cancer, or thyroid cancer would be a more likely diagnosis.
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OF SPIN E I M AG I NG
Case 4 Clinical Presentation The patient i a 25-year-old male with an elevated hematocri t level.
A
B
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SPLNAL CORD TUMORS
Radiologic Findings Sagittal short TR image of the cervical spine (Fig. A) reveals multiple small rounded areas of enhancement in the cerebellum (open arrows) and in the cervical region (solid arrows). These areas do not exhibit surrounding edema. The normal epidural high signal intensity fat is identi fied with f. Axial short TR image in the cerebellum (Fig. B) reveals multiple varying sized densely enhancing rounded areas of enhancement (open arrows). These are both in the cerebellar hemisphere and adjacent to the spinal cord.
earl •
Prior to attempting surgical removal, angiography may be helpful to determine the vascularity of these lesions.
Pitfall •
This entity is a systemic disease and is one of the neurocutaneous syndromes. Angiomas may also occur in the liver, cy ts in the pancreas and kidneys, and tumors of the kidneys which may be malignant and lead to death in these patients.
Diagnosis Multiple hemangioblastomas in a pati ent with von Hippel-Lindau disease.
Differential Diagnosis •
Hemangioblastomas
•
Vascular metastases
•
Pheochromocytomas
Discussion Hemangioblastomas or the spinal cord typically occur in association with von Hippel-Lindau disease (cerebelloretinal hemangioblastomatosis). They may be multiple in the spinal cord and associated with lesions in the cerebel lum, which may be multiple. These lesions are typically very vascular and therefore exhibit dense enhancement after contrast enhancement. They may also be cystic. Hemorrhage may occur. T2-weighted images may reveal evidence of hemosiderin deposition. Clinically these patients may have an elevated hematocrit level; this polycythemia has been reported to disappear following removal of the tumor in some cases. Other entities that may mimic this disease include multiple vascular metasta ses such as from malignant melanoma or even metastatic renal cell carci noma, which may also be very vascular and even hemorrhagic. Pheochromo cytomas may also occur.
2�
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Case 5 Clinical Presentation The patient is an R-month-old with an abdomi nal and pelvic mass.
A
�o
SPIN A L CORD TU M O RS
B
Radiologic Findings Sagittal Tl-weighted image (Fig. A) reveals a large presacral m ass that appears to arise within the pelvis and to extend upward into the abdominal cavity. There is a 2-cm ring-shaped area of increased signal intensity with i n the lower portion o f t h e mass. In the more superior portion o f t h e mass, there are small areas of decreased signal in tensity secondary to calcification (arrows) . The lumbar thecal sac is expanded . The distal end of the thecal sac ends at the level of the midbody of LS. There is an increased a mount of fat (f) surrounding the very distal end of the thecal sac. Sagittal T2-weighted image (Fig. B) reveals that the mass appears as i n creased signal intensity but exhibits internal areas of decreased signal i n ten sity. The area of increased signal intensity on the Tl-weighted image now appears decreased signal i ntensity. This appea rance i s consistent with acute hemorrhage. The more superior area of decreased signal intensity can now be seen to be an approxi mately 2.5-cm ring-shaped area of decreased signal with some associated surrounding areas of decreased signal intensity consis tent with areas of calcification.
2� 1
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S P I N E I M AG IN G
Pearl •
Computed tomographk (Cf) scanning is also very helprul in cases such a s this where the calcification is present because cr is more sensitive in the evaluation of calcification than MR scanning.
Pitfall •
•
There is a female predominance.
In pa tients between 4 m on th s and 5 years of age, these tumors have a 50 to 60% chance of being malignant. Before and after that time period, they have only an approximately 5% chance of being malignant.
1 262
Diagnosis Sacral teratoma.
Differential Diagnosis •
Teratoma
•
Ch ordoma
Discussion Teratomas are described as tumors that develop rrom al\ th ree germ cell layers. Because of this origin, these tumors typical ly exhibit variable ignal intensity on the various magnetic resonance (MR) imaging sequences. Be cause fat is a frequent component, there are often internal areas of increased signal intensity. These tumors may be malignant and are typically associated with only minimal destruction of the sacrum. They frequently contain both solid and cystic componen ts . The possibility of a chordoma is also a consideration.
SPINAL CORD TUMORS
I
Case 6 Clinical Presentation The patient is a 12-year-old male with lower extremity weakness.
A
B
Radiologic Findings Sagittal Tl-weighted image precontrast reveals that the distal end of the spinal cord (Fig. A) appears to terminate at the level of L2-3. There is expansion of the distal end of the spi n al cord and an approximately 2.S-em
2�
I TEACH ING ATLAS
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S P I N E I M A G ING
soft tissue mass expanding the dist(ll end of the spinal cord. The lumbar vcrtcbral canal is di ffusely enlarged. Sagittal Tl -weightcd imagc postcontrast (Fig. B) reveals a thi n peripheral rim of enhancement surrounding the soft tissue mass (curved black arrow). The acute angle formed with the thecal sac is scen dorsally (while arrow). Pearl Epidermoid tumors may also occur and can form following spinal tap in which elements or the epidermis are introduced into the vertebral canal. •
Pitfall •
Although myxopapillary ependymoma could be a tli agno tic consideration, dense enhancement would be anticipated as well as internal areas of decreased ignal intensity.
Diagnosis Dermoid tumor; low spinal cord, (proved at surgery).
Differential Diagnosis •
Dermatoid tumor
•
Schwannoma
•
Metastatic deposit
Discussion Dermoid tumors (I re seen equally in males and females. Large, longstanding lesions may expand the vertebral canal. DerTl10id tumors are formed from keratin, collagen, and cholesterol, and their imaging characteristics reflect this make-up. These tumors may also contain fat and therdore be increased 'ignal intensity on short TR images. A schwannoma is a consideration, but is unlikely because schwannomas generally demonstrate enhancement a [ter the i n fusion of contrast material. A metastatic dcposit from a central nervous system primary tumor such as medulloblastoma, ependymoma, or pinealoma could have a imilar appear ance but would generally exhibit enhancement. A metastasis from a primary tumor outside the central nervous system could also have a similar ap peClrance.
1 264
SPINAL CORD TUMORS
Suggested Readings Altman N R. Altman D H . MR imaging of spinal dysraphislII. AINR. 1 9H7;K533-53/i. Barkovich AJ, Edwards MS. Cogcn PH. MR ev�lu�tion of spinal dermal sinus tracts in children. AINR. 1 99 1 ; 1 2 : 1 453-1460. Brunberg J A. Latchaw RE, Kanal E. Burk
L,
Albright L. Magnetic resonance imaging o f
spinal dysraphism. Radio Ciin North Am. 1 988;26: 1 8 1 -205. Byrd SE. Harvey C. Darling CF. MR of t"rminal myelocystoceles. Ellr I Radiol. 1 <)95;20:2 1 5 . Coleman LT. Zimmerman RA. Rorke LB. Ventriculus terminalis o f t h e conus medullaris: MR findings i n children. AINR. 1 995:16:142 1 . Drevelengas A . Kalaitzoglou I . Giant lumbar meningocele in a patient with neurofibro m H tosis. Nellrorndiol. 1 995:37: 1 95. H u n t P, Van Leeuwen G . Bingham H , et al. Sacrococcygeal teratomas. A report of three cases and survey of present knowledge. eli" Pedilltr. 1 91i8 :7: l 1i5.
Jonsson A , Jonsson
K.
K,
Eklund
et al. Computed radiography i n scoliosis: diagnostic
i n formation and radiation dose. A cta Radiul. 1995;36:429. Kliewer MA, I lertzberg BS. George PY, et al. Fetal bifid sacrum artifact: normal develop
mental anatomy simulating malformation. Radiulugy. 1 99 5 ; 1 <)5:1i73.
List CF. I n t raspinal epilh.:rmoids. dermoids, and dermal sinuses. S"rg Gyneeol Obstet. 1 94 1 ;73:525.
Long FR, Hunter J V, Mahboubi
, Kalmus A, Templeton J M Jr. Tethered cord and associated
vertebral anomalies in children and infants with imperforate anus: evaluation with M R imaging � n d plain radiography. Radiology. 1 996;200:377. Mclhel1l ER. Tethered cord and associated anomalies in children and i n fants with imperforate anus: evaluation with MR imaging and plain radiography. Radiology. 1 \191i;200:3 1 8Naidich TP, McLane DG, Hawood-Nash DC. Spinal dysraphisllI. I n : Newton TH , Potts D G . cds. Mudem Neurnradinlngy. Vol. 1 . Computed tomography of t h e spine a n d spinal cord. San Anselmo. Cal: C1audcl; 1 982:299-353. aidieh TP, McLane
DCi,
Hawood-Nash DC. Spinal dysraphism. I n : Newton TH, Potts D G ,
eds. Mode", Nellroradiology. Vol. San Anselmo,
I.
Computed tomography o f the spine and spinal cord.
al: Clavedcl Press; 1 983a.
Naidieh TP. McLane DG, Mutluer S. A new understanding of dorsal dysraphism with lipoma (Iipomyeloschsis): radiologic evaluation and surgical correction. AINR. 1 983c:1 984;22 1 . Nievelstein R A J , Valk J , Slllit LME. e t a\. M R of the caudal regression syndrome: embryologic i mplications. AINR. 1 994; 1 5 : 1 02 1 . Rastogi H . Behari S , Phadke RV. e t al. Spinal segmental maldevelopment with a dermal si n us. Nellroradiol. 1 996;38:658. Robbin M, Filly RA. Goldstei n RD. Normal location of the fetal conus medullaris .
.J
Ultra
soulld Med. 1 994;13:54 1 .
Scatliff J l I , Kendall BE, K i n gsley PE, Britton J , Grant N , l Iayward H D . Closed spinal dysraphism. flINR. 1989;1 0:269-277. Schey WL,
hkolnick A , White H. Clinical and radiographic considerations of sacrococcygea l
teratomas: a n analysis of 26 new cases a n d review of t h e literature. Radiolugy. 1 977; 1 25 : 1 8\1. Schwend R M . Hennrikus W, Hall J E. ct al. Chi ldhood scoliosis: clinical indication, for magnetic resonance i m aging (ab). Radiology.
I 9Y.'i; I Y5:�8�.
Sherman JL. Barkovich AJ, Citrin CM. The MR appearance o f syringomyelia: new observa t i ons . AJNR. 1 986;7:985-995. Smoker W R K. Cranivertebral j unction: normal anatomy. craniometry, and congenital anoma lies. RadioGraphies. 1994; 1 4:255. So C, Li D . A nt"folateral cervic�1 meningocele i n association with IIctlrotihrmnatosis: M R and Tam
CT studies. I COlllPl/t Assist Tomgr. 1 989; 1 3 :692-6Y5. J K , Bradlcy WG Jr, Goergen SK. et 31. Patterns of contrast
cnhanecment in the pediatric
spine at MR imaging with single- and t riple-dose gadoli n nium. Rlillioingy. 1 9%:1 9::\:273.
265
Section IV
Trauma
TRAUMA
I
Case 1 Clinical Presentation The patient is a 45-year-old female who developed severe back pain after ra iling from a sitting position when the boat in which she was a passenger hit a large wave.
A
Radiologic Findings Sagittal short (Fig. A, left) and long (Fig. /\ , right) TR images reveal a marked compression fracture of the L2 vertebral body (left, arrow). There is retropulsion of the posterior superior m argin of the vertebral houy into the vertebral canal. A linear area of increased signal intensity can be seen behind the vertebral body of L2. The long TR image reveals an area of increased signal intensity within the central portion of the distal spinal cord (bLack arrow). A rounded a rell o r mottled but generally increased signlll intensity is seen in the Tl 1 vertebral body (right, white arrow).
269
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TRAUMA
Radiologic Findings (continued) Axial short TR images at two different levels or L2 (Figs. B and C) reveal the posterior displacement of the posterior portion or the vertebral body inlo the vertebral canal (Fig. B, solid arrow). A similar appearance is present at a slightly lower level (Fig. C, arrowheads). There is a small paraspinal soft tissue mass on the right side (Fig. B , open arrow).
PEARL •
•
Computed tomographic scanning i . useful to identify additional mall fracture fragment that may afrect the vcrtcbral bodies. Magnetic resonance imaging is valuable because it provides a noninvasive method for evaluating the presence of injury to the spinal cord and a lso may be used to identify later changes. such as the presence of a syrinx cavity following trauma to the spinal cord.
PITFALL •
The spine should be evaluated for the pre ence or an undcrlying abnormality such as meta talic disease or osteoporosi .
Diagnosis Traumatic compression fracture with spinal cord edema.
Differential Diagnosis •
metastatic disease
•
osteoporosis
Discussion In a 45-year-old female, this type of compression fracture is unusual unless there is an underlying abnormality such as metastatic disease. This type of fracture may also occur in a patient with osteoporosis. Occasionally a traumatic(llIy hern iated disc may occur; however, in this case, the encroach ment upon the vertebral canal appears 10 be secondary to the bone of the vertebral body. The increased signal i n tensity within the thoracic spinal cord is secondary to a contusion and spinal cord edema. A n incidental hemangioma is noted in the Tl i vertebral body (Fig. A, right, while arrow ) . There should b e concern regarding the possibility of a pathologic fracture of the vertebral body. A radionuclide bone scan could be perrormed to evaluate the presence of other areas of bone involvement in addition to the fractured vertebral body. However, a fracture may occur even with a normal vertebral body if there is sufficient trauma.
I TEACH ING ATLAS OF S P I N E I MAGING
Case 2 Clinical Presentation The patient is
I
A
B
Radiologic Findings Sagittal short TR image in the lumbar region (Fig. A) reveals loss of vertehral height at the L1 level (white arrow). There is a thin slightly irregular line in the upper one third of the vertebral body of Ll (open arrow). There is slight retropulsion of the posterior margin of the Ll vertebral body with slight compromise of the subarachnoid space at this level. The spinal cord is noted to end at the T12 level (T) .
TRAUMA
c
I
D
E
27 �
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Radiologic Findings (continued) Sagittal long TR image (Fig. B) reveals patchy areas of increased signal intcnsity in the upper portion of the L1 (solid arrow) vertebral body (open arrow) . There is slight compromise of the subarachnoid space at this levcl. There is reversal of the normal lordotic curve at the LI level. Parasagittal long TR image (Fig. C) reveals the compression fracture of the L1 vertebral body (open arrow). The normal interfacet joint is seen at L3-4. The interracet joint is widened at the Ll-2 level (curved solid arrow). There is increased signal intensity at t he level of the i nterfacet joint at L l -2. The normal interfacet joi n t is seen at the L3-4 level (srraight solid
arrow).
PEARLS •
Computed tomographic (CT) scan n ing may also be helpful to evaluate the presence of comminuted fracture , which may be associated with this type of i njury. ['
scanning with sagittal reconstruction view greatly aids in identifying the separation of the i nterfacet joints. CT is also helpful for visualization of small bone fragment which may encroach upon the veltebraJ canal. •
Magnetic resonance imaging (MRI) is an ideal method for evaluating this type of fracture and is often used in conj unction with CT scanning.
PITFALLS •
•
Small bone fragments may not be demonstrated by MR scanning and are be t evaluated by CT scanning. CT scanning doe' not demonstrate the spinal cord, therefore presence of spinal cord edema or hematoma cannot be evaluated by CT scanning.
Axial long TR image at the level of the interfacet joint of Ll-2 (Fig. D) reveals that the interfacet joints (arrows) are widened on the right more than the left. The nerve roots of the cauda equina are seen in the posterior portion of the lumbar thecal sac. Axial long TR image at the level of Ll (Fig. E) reveals an oblique, increased ignal intensity line through the vertebral body of Ll (arrows).
Diagnosis Compression fracture of Ll and distract iun Ll-2 level.
of
the interfacet joints at the
Differential Diagnosis •
compression fracture
•
Chance fracture
Discussion This is a typical compression fracture of the lumbar spine. The decreased signal intensity line through the L1 vertebral body is secondary to edema or possibly compacted trabecular bone within the marrow of the vertebral body. The severe nexion has resulted in widening of the interfacet joint at the level of the fracture. There is a lso increased fluid within the interfaeet joint and edema secondary to soft tissue injury. The combination of these changes results in increased signal intensity. Typically retropulsion of a portion of the vertebral body is seen when there is a compression fracture, as in this case. The retropulsion may result in spinal cord injury if it is sufficiently severe. This patient exh ibits the fortunate anatomic variation of a high position of the conus medullaris such that the retropulsed portion of the bone does not damage the spinal cord. The normal termination of the d istal end of the spinal cord is at the inferior end plate of L1 or the superior end plate of L2. Should the spinal cord be damaged, this results in edema or even the formation of a hematoma within the spinal cord. In addition, if there is edema or spinal cord contusion, this may ultimately result in the formation of a syrinx cavity within the damaged portion or the spinal cord.
TRAUMA A Chance fracture is a similar but sligh tly di rferent fracture. A Chance fracture is also a flexion injury but occurs when the patient has a se a t bel t in place, a n d there i s severe flexion over t h e seat belt. This results i n a fracture through the midportion of the Ll vertebral body with extension th rough the vertebra l body pedicle and lamina of the vertebral body. The end result is a sepa ration between the upper and lower portion s of the vertebrae. There is also soft tissue injury with a Chance fracture: this resul ts in edema which appears increased signal intensity on long TR i m ages .
22QJ
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Case 3 Clinical Presentation The patient is a 27-year-old male who was involved in a motorcycle accident and was admi tted with m i l d lower extremity weakness.
A
B
TRAUMA
c
D
I
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E
F
TRAU M A
G
Radiologic Findings Anteroposterior view of the thoracic pine (Fig. A) reveals left lateral offset of the T6 relative to the 1'7 vertebral body. The dotted l ine represents the anticipated position of the later
2 /91
I TEACHING ATLAS OF SPINE I M A G I NG Radiologic Findings (continued) Axial computeu tomographic (CT) scan at the level of T6 (Fig. D) reveals that the vertebral body is shall.ered. The posterior elements of the vertebral laminae are also fractured. There is compromise of the vertebral canal and a halo of soft tissue density signal intensity surrounding the vertebral body (arrowheads). Large bilateral pleural effusions are visihle, as is air in the sort tissues and paraspinal muscles of the back (open arrows).
PEARLS • cr
and M RI are frequently complimentary for the evaluation of vertebral fracture . Therefore, both techniques are frequently used to evaluate a patient with an injury such as this. In general, the cr scan is obtained initially at the time the patient presents in the emergency department. MR scanning may be obtained later in the course of tbe evaluation.
•
•
MRI L also an excellent noninvasive method of following these patients, particularly if they develop new symptoms that could suggest the presence of formation of a syrinx cavity. A syrinx cavity may develop even in patient who are not shown to have any apparent damage to the spinal cord at the time of the initial trauma.
PITFALLS • cr
scanning will not be able to demonstrate pinal eord hematomas, and MR is superior for evaluation of this abnormality.
•
M RI better demon trates the relationship of the spinal cord to the surrounding structure .
Axial CT scan at the T7 level (Fig. E) reveals a comminuted fracture of the left lateril l {lspect of the vertebral body. There is an intermediate signal intensity soft tissue mass nn the left side (H). There are both short (short black arrow) and loug (long black arrow) bone fragments extending across the mid portion of the vertebral canal. The spinous process (s) is fractured off of the comminuted vertebral body laminae and exhibits a fracture at the base of the spinous process. Both transverse processes are fractured. There is air adjacent to the vertebral body on the right side (long white armw) and in the paraspi n{l l muscles (shorl white arrows). Axial short TR i mage at the 1'7 level (Fig. F) revea Is right anterior effacement of the cerebrospinal fluid (arrow). There is an intermediate signal intensity soft tissue mass surrounding the vertebral body. Axial short TR image at the 1'7 level (Fig. G) reveals right anterior and left lateral intermediate signal intensity masses (H). There is also intermedi ate signal intensity material in the right hemithorax (H). A platelike area of increased signal intensity appears dorsally at the level of the base of the spinous process (black arrow). Effacement of the right anterior margin of the subarachnoid space (white arrow) is also visible.
Diagnosis Fracture dislocation of T6-7 with cord contusion and paraspinal hema toma formation.
Differential Diagnosis •
compression fracture
Discussion There is a markeuly comminuted compression fracture of the To vertebral body and a comminuted fracture of the 1'7 vertebral body. The intermediate signal intensity anteriorly and paraspinal masses are hematomas related to the fractures. The multiple tiny bone fragments that are well demonstrated by the CT seem could not be visualized by t he magnetic resonance ( M R) images. This demonstrates the value of cr imaging for the identi nc{l tion of small bone fragments. The increased signal within the spinal cord represents areas of contusion, and the increased signal in the short TR images suggests that this represents methemoglobin formation with a small hematoma. There is disruption of the interspinous ligllment and widening of the interspinous
TRAUMA
distance with edema and hemorrhage into the soft tissues. Also visible a re bilateral hemothoraces and subcutaneous air, probably secondary to an open skin laceration. Although visible on MR imaging, the CT scan better demonstrates the nature of the right anterior compromise uf the suharachnoid space secondary to retropulsion of the vertebral botly.
2J3l 1
I TEACH I N G ATLAS
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S P I N E I MAGING
Case 4 Clinical Presentation The patient i. all 8-year-old male with a history of being thrown from a car following a high speed motor vehicle accident. The patient presented with bilateral lower extremity weakness.
A
B
TRAUMA
Radiologic Findings Sagittal short TR image of the lower thoracic and lumbar region (Fig. A) revellis a lobulated intermediate soft tissue de nsity mass (arrow). There is slight reversal of the curve of the lumbar spine. The intervertebral disc at Ll-2 bulges anteriorly. The intervertebral disc at L2-3 bulges posteriorly. There are ill-defined streaky areas of decreased signal intensity throughout the subcutaneous fat of the lower thoracic and lumbar region (arrowheads). Sagittal long TR image of the lower thoracic and upper lumbar region (Fig. B) reveals that the area of intermediate signal intensity seen in Fig. A (arrow) exhibits variable areas of increased and decreased signal intensity that projects between the spinous processes o[ L l and L2 (arrow). The more superficial areas of decreased signal intensity seen in Fig. A (arrowheads) now exhibit increased signal intensity. There are also diffuse mottled areas o[ decreased signal intensity throughout the subcutaneous fat.
EARLS •
•
If MRI is not available, this patient hould be evaluated with a myelogram with contrast instilled via a cervical tap and followed by a postmyclogram cr scan. The exact level of fluid leak can usually be demonstrated by using multiplanar MR I . lt may be necessary to use a variety of MR pulse sequences, such as both short and long TR sequences, to demonstrate the point of origin of the CSF leak.
PITFALLS •
•
A study such as thi should be correlated with a cr scan for more thorough evaluation of the extent of bony involvement. mall bone fragments secondary to fracture are more readily demon trated by cr than by MR scanning.
Axial short TR image (Fig. C) reveals ill-defined areas of intermediate ignal intensity in the muscles of the back (open arrows ). The e areas extend from the lower thoracic region to the level of L4. There is pu lsation artifact from the abdominal aorta wh ich extends through the vertebral canal (solid
arrows) .
Diagnosis Flexion injury with fracture dislocation of the Ll-2 spinous processes with tear in the dura and leakage of cerebrospinal fl uid am.! blood into the soft tissue and muscles of the back.
Differential Diagnosis •
fracture
Discussion The cerebrospinal fluid and the blood both appear as intermediate ignal intensity on the short TR images. The blood, which is acute and in the deoxyhemoglobin phase, exhibits decreased signal intensity on the short TR images, while the cerebrospinal fluid exh ibits increased signal in tensity on the long TR images. The presence of bony fractures would be better demon strated by computed tomography (CT) rather than magnetic resonance (MR) evaluation. In this patient, there is complete disruption of the interspi nous ligament. The mottled signal intensity in the subcutaneous fat is second ary to areas of acute blood accumulation. The blood and cerebrospinal fluid (CSF) have dissected through the m uscles of the back and obliterated the normal soft tissue planes. The spinal cord appears intact in this patient. The nerve roots of the cauda equina are never seen and are probably disrupted or markedly stretched.
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I TEACH I NG ATLAS OF SPINE
IMAG I N G
Case 5 Clinical Presentation The patient is a 34-year-old male who was in a motor vehicle accident.
B
A
c
284
TRAUMA
Radiologic Findings Sagittal short TR imClge (Fig. A) reveals loss of vertebral body height of the L1 vertebral body (Ll). There is retropulsion of t he posterior, superior corner of the L1 vertebral body into the vertebral eanClI and Cln acute kyphosis at the level of the fracture. The spinal cord is not seen at this level (open arrow). Mottled areas of increased signal intensity appear within the verte bral canal in the anticipated position of the spi nal cord both above and below the level of the frClcture. There is a streaklike area of increased signal in the epidural space behind the vertebral bodies of L2 and L3 (solid arrow).
EARL •
Magnetic resonance imaging (MRI) allows direct visualization of the spinal cord and demonstrates its relationship to surrounding soft ti sues and bony structure . MRJ also best demonstrate the amount of damage that has occurred to the spinal cord secondary to the trauma.
Sagittal long TR imClge (Fig. B) reveals a lobulated areCl of decreased signal intensity just above the level of the compressed L 1 vertebral body. Superior to this, within the vertebral canal, there is an i rregularly marginated area of decreased signal intensity in the Clnticipated location of the spinal cord (arrow). B elow the level of the compression fracture the cerebrospinClI fluid appears as decreased signal intensity. Axial short TR image (Fig. C) reveals the posterior ma rgin of the vertebral body extending into the vertebral canal (arrowheads) and com pre sing the spinal cord (s) posteriorly.
Diagnosis Compression fracture of Ll with spinal cord hematoma.
PITFALLS •
•
Computed tomographic (Cf) scanning is necessary for evaluation of the presence of bony fractures and generally would be used in conjunction with MRI for evaluation of this type of patient. MRI is less sen itive than cr for the evaluation of small bony fragments that eouJd encroach upon the vertebral canal.
Differential Diagnosis •
compression fracture, with hemCltoma
Discussion There is a compression fracture or the Ll vertebral body wilh marked compromise of the vertebral canal. The spinal cord is compressed and com pletely disrupted. There is a lobulated hematoma within the vertebral canal and a hematoma within the distal spinal cord (arrow in Fig. B). Below the fracture, the cerebrospinal fluid is admixed with acutc blood, so it appears as deereClsed signal intensity. Tn Figure A, there is increased signClI intensity blood in the anterior epidurClI space.
785 1
I TEACH I
G ATLAS OF SPINE IMAG ING
Case 6 Clinical Presentation The patient is a S-year-old female who presents with CS radiculopathy following a motor vehicle accident.
A
B
Radiologic Findings Sagittal short TR image of the cervical spine (Fig. A) reveals forward sublux a tion of C4 on CS. The intervertebral disc at C4-S protrudes posteriorly into the vertebral canal (arrow). There is straightening of the spine with loss of the normal cervical lordosis. Sagittal long TR image (Fig. B) better demonstrates the forward displace ment of C4 on CS. The arrowhead marks the posterior superior corner of the CS vertebral body. The C2 vertebral body is identified with 2.
1 /86
TRAUMA
I
I TEACHING ATLAS OF S P I N E I M AGING PEARLS •
•
•
MRI is the ideal method of evaluating this type of injury because it allows direct visualization of the spinal cord and its relationship with the sur rounding bony structures. The presence of a hematoma can also be readily evaluated by the use of MRI. Long TR images may also demon trate increased signal inten ity surrounding the interfacet joints where there is soft tissue damage.
Surgery can be performed, if n ecessary, based totally upon the findings in t he MR images.
Radiologic Findings (continued) Axial long TR image at the C4-S level (Fig . C) reveals a decreased signal i ntensity soft tissue mass that encroaches upon the left anterior portion of the subarachnoid space (open arrow). Sagittal midline reconstruction view of the cervical spine (Fig. D) reveal the forwa rd displacement of C4 on CS. No fractures are seen. The CS vertebral body is identified with S.
Diagnosis Traumatic anterolisthesis of C4 on CS with a traumatica lly herniated disc on the left side at the C4-S level.
Differential Diagnosis •
herniated disc
Discussion PITFALLS •
This study should be performed i n co nj unct ion with computed tomographic (Cf) scanning to ru l e out the presence of fractures. A lt h o ugh demonstrable by MRI, facet dislocation, not seen in thi pati ent, is also best demonstrated by CT scanning.
1 788
Magnetic resonance (MR) imaging provides the ideal method for evaluating the presence of a herniated disc. The nucleus pulposus can be seen migrating from its normal localion into the vertebral canal and superiorly behind the vertebral body of C4. The spinal cord is otherwise normal in size and configuration through out . There is no abnormal signal intensity within the spinal cord to suggest that there is either hematoma or contusion within the cord. The herniated disc is a lso localized o n the axial view where there is encroachment upon the in tervertebral foramen. This encroachment would compres ' the nerve roots in the intervertebral foramen and cause this pa tient's symptoms.
TE CHING ATLAS OF S P I N E IMAG ING
C
D
Radiologic Findings Sagittal short TR image in the cervic;tl region (Fig. A) reveals a small , low signal i n tensity area within the cervical spinal cord at approximately the C4 level (arrow ) . There is forward subluxation of the vertebral body of C4 on CS and forward subluxat ion of the spinous processes of C4 on CS. There is a scoliosis of the cervical and thoracic spine. Sagittal short TR image again (Fig. B) reveals the forward subluxation of C4 on CS. There is curvilinear distortion of the cervical spinal cord. The subarachnoid space is obliterated at the CS level. There is a small rounded area with signal intensity similar to the remaining vertebral bodies (arrow ) . The C 5 vertebral hody is identified with S. Coronal short T R image in the cervical region (Fig. C) reveals the decreased sign;tl intensity area within the cervical spinal cord (arrow ) . The pinal cord is slightly expanded ;tt this level. Sagittal midline reconstruction images from a computed tomographic (CT) scan (Fig. D) reveal the forward subluxation of C4 on C5. There appears to be an oblique fracture of the posterior superior corner of the vertebral body of CS. The rounded edges suggest that this is old rather than acute. The posterior elements of vertebral bodies 1-4 are also displaced forward.
I TEACHING ATLAS OF S P I N E IMAG ING
C
o
Radiologic Findings Sagittal short TR image in the cervical region (Fig. A) reveals a small, low signal intensity area within the cervical spinal cord at approximately the C4 level (arrow). There is forward subluxation of the vertebral body of C4 on CS and rorward subluxation or the spinous processes of C4 on CS. There is a scoliosis of the cervical and thoracic spine. Sagittal short TR image again (Fig. B) reveal the forward subluxation of C4 on CS. There is curvilinear distortion of the cervical spinal cord. The subarachnoid space is obliterated at the CS level. There is a mall rounded area with signal intensity similar to the remaining vertebral bodies (arrow). The C S vertebral body is identified with S. Coronal short TR image in the cervical region (Fig. C) reveals the decreased signal intensity area within the cervical spinal cord (arrow) . The spinal cord is slightly expanded at this level. Sagittal midline reconstruction images from a computed tomographic (CT) scan (Fig. D) reveal the forward subluxation or C4 on CS. There appears to be an obliyue fracture of the posterior superior corner or the vertebral body or CS. The rounded edges suggest that this is old rather than acute. The posterior element s or vertebral bodies 1 -4 are also displaced forwa rd.
TR A U M A
I
Radiologic Findings (continued) The odontoid process is separated from the body of C2 (arrow) and is in close proxim ity to the skull base. The posterior arch of Cl is adj acent to the occipital bone.
PEARLS •
•
The cr can better demon trates the fracture of the vertebral body of CS, which is not seen on tbe MR scan. MRl is the procedure of choice as it demonstrates the spinal cord relative to the sun-ounding structures. A posttraumatic lesion could cause subluxation at the C4-S level; however, trauma would not cause the other anomalies.
PITFALL •
The syrinx cavity would nOl be demonstrated by CT scanning but is readily demonstrated by MRI.
Diagnosis Probably old fracture dislocation of C4 on CS associated with a scoliosis and formation of a posttraumatic syri nx cavity at C4; presumed child abuse.
Differential Diagnosis •
old fracture
Discussion The appeara nce of the fracture suggests tha I these changes are old. The formation of a syrinx cavity within the spinal cord also suggests that the change is old ratber tban acute. The an terolisthesis, involv ing the vertebral bodies as well as the posterior elements of C4 on CS, resul ts in a severe spinal stenosis at the C5 level. Magnetic resonance i maging ( MRI) nicely demonstrates the spinal cord and the surrounding bony structures as well as the syrinx cavity, which is probably a result of the trauma that ca used the subluxation of C4 on CS. There is also atlanto-occipital fusion with the anterior arch of Cl adherent to the bottom of the clivus and the posterior arch of Cl fused to the skull base. This is a congenital deformity and is possibly an incidental finding in this patient. However, the clinical history suggests that the child suffers from abuse; therefore, additional evaluation is advised. There is a remote possibility that this represents a diagnostic consideration; however, this possibility seems unlikely. If tumor is a consideration, a posti n fusion study should be performed as most spinal cord tumors will exhibit enhancement.
I TEACHING
ATLAS OF
SPI N E IMAGING
Case 8 Clinical Presentation The patient is a 27-year-old male who is a victim of battery who presented to the emergency room with a history of being hit on the baek of the head wilh a board. The patient was quadriparetic.
B
�2
TRAUMA
c
D
E
I
I TEACHING ATLAS OF SPINE IMAGING
F
G
H
TRAUM A
I
I
TEACHING ATLAS OF S P I N E I MAGING
Radiologic Findings Lateral view of the cervical spine (Fig. A) reveals a fracture dislocation at the C2-3 level. The body of C2 is markedly displaced forward over the vertebral body of C3. The posterior elements of C2 have been separated (arrowheads) by approximately 1 cm (arrow) . There is posterior displace ment of the spinous process of C2. The spinous proce�ses of C2 and C3
TRAUMA
PEARL •
B eca use there is a generous
amount of subarachnoid space urroundi ng the spinal cord in t he upper cervical region a significant amount of distortion of the vertebral column and sp inal conI may occur beCore the patient becomes symptomatic. However, MRI p ro vides an ideal method of evaluation of changes related to trauma with or without hematoma formatio n .
Diagnosis Fracture dislocation of C2 on C3 in a "hangman's" type of fracture with a tra uma tica l ly herniated disc at the C2-3 level.
,
PITFALL •
Life-threatening inj uries may preclude the use of MRI in the acutely injured setting. However, if proper life support is available, MRI may be used for diagnosis and to direct surgery.
Differential Diagnosis •
fracture dislocation
•
herniated disc
Discussion Magne tic resonance imaging (MRl) r ead ily demonstrates the compression of the cervical spinal cord at the level of the fracture dislocation. Hematoma formation appears dorsally at the C2-3 1cvel. The epidural hematoma extends behind the d u ral and benea th the spi nous process of C2. There is also increased s ignal intensity hematoma in the soft tissues of the dorsal spine. There is a high signal intensity traumatically herniated n ucleus pulp osu s of the intervertebral disc at tbe C2-3 l eve l. The small area of decreased signal i nte nsi ty within the spinal cord seen in Figure I is a small area of ma g neti c s uscep ti bi lity artifact secondary to hemorrhage and associated de positi o n of hemosiderin. A h a ngman s fracture is defined as a fracture dislocation of C2 on C3 with i nvolvement of the vertebral p edi cles . A hangma n s fracture is freyuen tl y a forced extension injury, as wh en tbe han gman s knot is placed un de r the victim's chin which is snapped back with the fall of the banging and forces the vertebral body o[ C2 forward on C3. In this p a tien t , the mechanism was '
'
'
somewhat di fferent.
2�
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I MA G I
G
Case 9 Clinical Presentation The patient is a 48-year-old alcoholic male who is status post fal l and presents to the emergency room with neck pain.
A
298
B
TRAUMA
PEARLS •
Type I odontoid fracture involve the upper tip of the odontoid process. Type II odontoid fractures are broad based and extend into the uppcr portion of the C2 vertebral body.
•
Because odontoid fractures frequently occur in the plane of tbe cr image slices, their presence may not be appreciated. Reconstruction images of the axial lices into the sagittal plane may provide better evaluation of the odontoid region.
PITFALLS •
•
Odontoid fractures are occasionally not visible acutely, SO the index of suspicion must be high for this type of abnormality. The presence of soft tissue swelling is typically seen when there is an acute fracture. Because of the difficulty evaluating them, odontoid fractures are frequently the source of medical legal problems. Therefore, careful attention should be taken to rule out an odontoid fracture.
Radiologic Findings Sagittal short TR image in the upper cervical region (Fig. A) reveals an area of increased signal intensity between the base of the odontoid process and the body of the C2 vertebrac (curued arrow). There is slight posterior displ
Diagnosis Old odontoid fracture; type
TI
odontoid fracture.
Differential Diagnosis •
old fracture
Discussion This fracture appears old because thcre are no areas of acute angulation at the ends of the fracture fragments. There is no prevertebral soft tissue swelling. There may be evidence of increased signal intensity hematoma formation behind the C2 vertebral body and odontoid proce s; however, fibrous scarring seems more likely. Computed tomographic (CT) scanning is helpful for evaluation of these fractures. They are occasionally di fficult to demonstrate on plai n film evaluation. The type I I I fractures extend into the vertebral body and, when impacted, are di fficult to demonstrate on cr because the fracturc is in the plane of im(lging. The sagittal reconstruction views and the presence of prevertebral soft tissuc swelling are helprul ror the identification of these fractures. Fractures are usually associated with soft tissue prominence secondary to hematoma formation because of bleeding. Follow-up imaging is helpful and the patient should be immobilized in a collar i r a rracturc is suspected.
2.22.\
I TEACH I N G ATLAS OF SPINE I MAGING
Case 10 •
Clinical Presentation The patient is a 1 6-year-old male with neck pain following a football injury in which he susta ined acu t e neck flexion.
A
Radiologic Findings Lateral p lain ftlm radiograph (Fig. A) reveals slight forward subluxation o f C4 on CS. The normal relationship of the interfacet joint is present at CS-6 (arrowheads) where the facets rest adjacent to one another. At the C4-S level, the inferior portion of the facet of C4 rests in direct apposition to the superior portion of the facet of CS (arrows). The CS vertebral body is identified with S.
�o
TRAUMA
rEARLS •
•
•
Computed tomographic (CI) scanning may rcveal additional smaU fractures which are not seen on the plain film radiography. MRI will demonstrate the exact relationship of the spinal cord to the surrounding bony slructures and the presence or abscncc of abnormal signal within the spinal cord. Treatment can inel ude follow up imaging to determine if, after traction upon the cervical spine, there has been reduction in the facet dislocation. Therefore, follow-up imaging provides an ideal method of evaluation.
PITFALLS •
•
Small fractures may be missed without performing a CI scan. Becausc a syrinx cavity may occur after trauma even when there is no obvious damage lO the spinal cord, follow-up with MR( i useful for additional evaluation.
Diagnosis Bilateral perched facets.
Differential Diagnosis •
perched facets
Discussion Radiculopathy may also occur if the nerve rootlets are compressed by the displaced bony structures. If viewed after 09 degree rotation of the radio graph, this results in a "bow tie" appearance, whieh is typical of perched facets. If unilateral, there is a scoliosis of the spine, and in this case, the anteroposlerior view will reveal that the spinous processes are not aligned. Treatmenl is usuaUy muscle relaxation and traction. If conservative trcat ment fails to return the facets to normal alignment, the facets are directly visualized and manipulated back into place with surgical tools. Magnetic resonance imaging (MRI) is an excel lent method of evaluation and will revcal areas of increased signal intensity in the soft tissues where there has been sufficient damage to cause edema. The pat ien t should be evaluated to determine if there are bilateral or unilat eral i-Ibnormalities involving the facets because the surgici-Il approach will be different between the two.
I TEA
HING ATLAS OF SPIN E I MAGING
Case 11 Clinical Presentation The patient is a 17-year-old male victim of assault.
A
Radiologic Findings Lateral plain film radiograph of the cervical spine (Fig. A) reveals marked forward subluxation of C5 on C6. The posterior superior corner of the C6 vertebral body is marked with the black a rrow. The inferior portion of the facet at the C5 level is markedly displaced forward and is anterior to the superior portion of the articula t ing racet of C6 (white arrows). There is blunting or the ends or the racets. The identical anatomic areas are identified with small arrows at the C3 level white (arrowheads). There is prevertebral soft tissue swelling and the trachea is displaced far forward (open arrow). The C3 vertebral body is identified with 3.
1 3UL
TRAU MA
B
c
I
I TEACH I NG ATLAS OF SPI N E I M AG I NG
D
Radiologic Findings (continued) Sagittal intermediate (Fig. B, left) and long (Fig. B, right) TR images reveal the forward subluxation of CS on C6. There is prominence of the interverte bral disc at this level (left, arrow). On the long TR image, there is an area of increased signal intensity within the central portion of the cervical spinal cord (right, arrow). There is widening of the i nterspinous distance arKI increased signal intensity soft tissue between the spinous processes ( * ) . Axial short TR images (Fig. C) reveal complete obliteration of the normal h igh signal intensity fat that surrounus the thecal sac;. There is a linear area of decreased signal intensity that projects behind the vertebral body of CS (bottom left, arrow). The intervertebral disc seen in Figure B projects in the midline and toward the left side (bottom right, arrowhead) and markedly compresses the spinal cord. The thecal sac is surrounded by intermediate signa I intensity soft tissue. Axial computed tomographic (CT) scan (Fig. D) reveals the forward sublux ation of CS on C6; the posterior marking of the vertebrae are highlighted by the white arrows. The CS vertebral body is identified with S.
Diagnosis Anterior dislocation of CS on C6 with disruption of the nucal ligament and traumatic herniation of the i ntervertebral disc at the CS-6 level.
Differential Diagnosis •
herniated disc
•
fracture dislocation
TRA U M A
PEARLS scanning reveaLs small fracture fragments better than MR!. Sagittal reconstruction views will also allow for evaluation of the amou nt of compromise of the vertebral canal.
• CT
•
MRJ demon trates the presence of soft tissue swelling and/or hematoma formation. MRI readily demonstrates any change in the size of the spinal cord a nd whether it is related to edema or hematoma formation.
Discussion Magnetic resonance imaging (MRI) allows ready evaluation of the spinal cord and its relationship to the s urrounding body structures. The area of increased signal intensity within the cervical spinal cord is an area of edema or contusion. The herniated disc also compresses the cervical spinal cord, and the combination of changes results in marked spinal stenosis at the C5-6 level. There is widening of the interspinous distance and a hematoma in the soft tissues between the spinous processes of C5 and C6, which appears a s increased signal intensity. There is also soft tissue edem a. Both CT and MRI are excellen t methods for evaluating the lower portions of the cervical spine when this area cannot be visual ized by plane film evaluation. MRI is frequently more useful than CT scanning in many cases because, when the patient has very large shoulders, the lower cervical spine cannot be seen on CT images.
PITFALL •
While MRI is the method of choice for evaluation of the pinal cord, other life threatening injuries may preclude the use of MRI in the acute setting.
3i2§J
I TEACHI N G ATLAS
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SPI 'E IMAGlNG
Case 12 Clinical Presentation The patient is a 35-year-old remale with continued back pain following epidural block for vaginal delivery. The patient developed a spinal headache, and blood patches were attempted to decrease the headache. The patient also has lower extremity weakness, which is greater in the right leg than the left.
B
A
c
306
TRA U M A
I
Radiologic Findings Sagittal short TR image in the l umbar region (Fig. A) reveals a lobulated area of increased signal i ntensity at the level of L5 and S] (arrows ) . Sagittal long TR i m age (Fig. B) reveals a thin curvilinear line of decreased signal intensity (black arrows) deep to the area of i ncreased signal inte nsity seen in Figure A . There is also posterior extension of the intervertebral disc into the vertebral canal at the L4-5 level ( white arrow). Axial short TR image (Fig. C) reveals a lentiform area of increased signal intensity that encroaches upon the dorsal and left lateral aspect of the thecal sac (arrow ) .
EARL •
Magnetic resonance imaging is the ideal method of evaluating this type of abnormality.
Diagnosis Small epidural hematoma.
Differential Diagnosis PITFALL •
Computed tomographic scanning will not demonstrate the presence of a hematoma.
•
epidural hematoma
•
epidural lipoma (unlikely)
Discussion The epidural hematoma is methemoglobin, therefore, it appears increased signal intensity on short TR i mages. The decreased signal intensity line seen in Figure B is secondary to the dura, which is displaced an teriorly. TL is unknown whether the epidural hematoma is secondary to the blood patch or the epidural anesthesia. There is also a herniated disc at the L4-5 level . In this patient, i t i s uncerta in what the significance o f the herniated disc is rela tive to the patient's back pain .
3iEJ
I TEACH1NG ATLA
OF SPINE IMAG ING
Case 13 Clinical Presentation The patient is a 78-year-old male who developed severe back pain and inability to move his lower extremities rollowing plaeemenl of an epidural catheter for spinal anesthesia for popli teal-femoral artery bypass.
A
1308
B
TRAUMA
I
c
D
3Q2J
I TEACH ING ATLAS OF SPINE IMAGING
E
F
G
TRAUMA
Radiologic Findings Sagittal short TR image in the lower thoracic and lumbar region (Fig. A) reveals two rounded lIrelis of very decreased signal intensity at the level of T I I - 12 (long hluck arrow ) . A curvilinear area of increased signal intensity begins at the level of L1 (lipper short black arrow) and extends to the lower end of the vertebral canal (lower short black arrow). There are degcncrative changes with osteophytes at all levels of the lumbar spine. Sagittal short TR image in a slightly di fferent planc from Figure A (Fig. B) reveals that the area of increllsed signal i ntcnsity extends from Ll through S I (arrows).
,PEARLS •
•
Magnetic resonance imaging (MRI) is the procedure of choice for evaluation of blood or bleeding into the epidural space or into the thecal sac. B lood may exhibit a variety of signal i n tensities because of the phase of metabolism. Acute bleeding in the deoxyhemoglobin phase appears as decreased signal intensity, while ubacute blood in the methemoglobin phase appears as i ncreased signal intensity. Chronic blood i n the hemosiderin phase (not seen in this patient) is decreased signal in ten ity.
If surgery is performed for removal of a localized hematoma, M R I provides an ideal diagnostic method for follow-up.
PITFALL •
It is not always possible to determine the exact location of area of hemorrhage or the exact anatomic compartment because the blood may compress and distort the thecal sac.
Sagittal short TR image in the thoracic region (Fig. C) reveals linear areas of increased signal i ntensity surrounding the thoracic spinal cord ( white arrows). There are rounded and curvilinear areas of decreased signal inten sity with partial halos of increased signal intensity in the lower thoracic region (black arrow). Axial short TR image at the level of the kidneys (Fig. D) reveals thllt the thccal sac is not visualized and there is increased signal intensity soft tissue filling the vertebral canal (arrow). Axial short TR image (Fig. E) reveals the t hecal sac filled with increased signal intensity material (straight arrow). There are bilateral paraspinal curvi linear areas of increased signal intensity (curved arrows). Bilateral curvilinear areas (Fig. F) of i ncreased signal intensity (curved arrows) are visible at approximately the L3 level. The thecal sac is higher than normal signal intensity, and there is a surrounding hlilo of increased signal inten ·ity (straight arrow). At the L5 level, there is increased signal intensity soft tissuc (Fig. G) which fills t he thecal sac (arrow).
Diagnosis Epidural hematoma; blood in the thecal sac; air in the vertebral canal in the lower thoracic region.
Differential Diagnosis •
epidural hematoma
•
epidural inflammatory process
Discussion When an epidural catheter is placed, it is thrcaded from the lumbar region superiorly into the lower thoracic region. Air can be injected into thc cathe ter, and in this case lIppears as areas of markedly decrellsed signal intensity in the lower thoracic region. There is a halo of increascd signal intensity
I TEACH I
G ATLAS Of S P I N E IMAGING
surrounding these areas because of magnetic susceptibility artifact. There is increased signal intensity blood surrounding the spinal cord in the thoracic region, probably in the subarachnoid space. In the lumbar region, the blood is both epiuural and intrathecal. There are bilateral paraspinal hematomas in the midlumbar region as seen in Figures E and F. An epidural inflammatory process is a rem()te consideration but appears unlikely i n this clinical setting.
[lL2
TRAUM A
Case 14 Clinical Presentation The patient is an 87-year-old female whu is tak i ng coumadin and developcd severe low back pain and luwer extremity weakness.
A
Radiologic Findings Sagittal short TR i magc in thc upper lu mbar region ( Fig. A) reveals an i rregularly shaped area of increased signal intensity in the dorsal epidural space (arrowhead). There are severe degenerative changes in the spine.
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TEAC H I N G ATLAS OF S P I N E I M A G I N G
B
c
31 11
TRAU M A
D
Radiologic Findings (continued) SagittaL short TR image utilizing a "straightening" algorithm better (Fig. S) reveals the area of increased signal intensity in the dorsal epidural space at the U -2 level (open arrow). The method of manual identification of the line of reconstruction is seen on the right side (shari arrow), and the volume of tissue evaluated is seen on the left side (long arrow). Axial short TR image at the level of L2 (Fig. C) reveals the lentiform area of increased signal intensity on the right side (arrow). The thecal sac is compressed and displaced to the left. The normal increased signal Ln tensity fat is seen in the epidural space (f). AxiaL short TR image at the level of L1 (Fig. D) reveals the lentiform area of i ncreased signal intensity in the dorsal epidural space (b).
Diagnosis Spontaneous epidural hematoma.
Differential Diagnosis •
epidural hematoma
3 1 '.1
I TEACH I N G ATLAS OF SPINE I M A G I NG PEARL •
Magnetic resonance imaging is the ideal method for evaluating areas or hemorrhage involving the spinal cord or the surrounding structures.
PITFALL •
Epidural fat. wbich also appears as increased signal intensity on short TR images, would have a similar appearance and would be a diagnostic consideration in another clinical setting.
Discussion Patients who are treated with coumadin or other "blood thinners" may experience hemorrhages. In this case, the hemorrhage is i nto the epidural space resul ti n g in spinal canal compromise. The straightening algorithm is very helpful ror evaluation of tbis type or abnormalily where the scoliosis may compromise the evaluation of the position or the lesion and its relationship 10 the surrounding structures. The clinical history of coumadin is very helpful ror evaluation of the cause of this patient's epidural hematoma and resulting back pain .
TRAUMA
Case 15 Clinical Presentation The patient is a 68-year-old male who presented with lower extremity wea k ness. The patient is taking eoumadin and suffered a recent tall.
A
B
3J.Z.1
I TEACHING ATLAS OF S P I N E IMAGING
c
Radiologic Findings Sagittal short TR images in the midthoracic region pre- (Fig. A, left) and postcontrast (Fig. A, righ.t) injection reveal a mottled area of variable signal intensity in the epidural region (left, arrow) in the midthoracic spine ex tending from T3 through T7. The spinal cord is displaced anteriorly and compressed against the posterior margin of the spine. The normal h igh signal intensity of the thoracic epidural fat is obliterated at the level of the hematoma. There is no enhancement after the injection of contrast material (righ.t). Axial short TR image at the level of T5 (Fig. B) reveals the triangular shaped area of increased signal intensity in the right dorsal aspect of the vcrtebral canal (arrows). There is a central area of decreased signal intensity. The spinal cord (0) is displaced anteriorly and to the left side. Below the level of the area of increased signal intensity (Fig. C), the epidural fat is widened (arrow). The subarachnoid space is compressed.
Diagnosis Spontaneous epidural hematoma in the midthoracic region secondary to cOllmadin treatment.
TR A U M A
PEARL ·
'canning would not be helpful in the diagnosis or evaluation of the abnormality in this p atient. Follow-up of resolution or response to surgery can be easily performed with MR evaluation.
PITFALL •
Differential Diagnosis
cr
Epidural fat also appears as increased signal i ntensity on bort TR images; however, this location is unlikely, and the clinical history i consi tent with an area of hemorrhage.
•
hemorrhage
•
hemophilia
Discussion Magnetic resonance imaging is the ideal method of evaluating the presence of an area of hemorrhage whether within the spinal cord or in the epidural space. The relationship o f the area of blood collection is easily seen relative to the posi tion of the spinal cord. The variable signal in tensity in Figure A is secondary to the accumulation of both methemoglobin and deoxyhemo globin. In Figure B, the central area of decreased signal intensi ty is dcoxy hemoglobin, which is surrounded by increased signal intensity methemoglo bin. Patients with hemophilia may also experience areas of hemorrhage. Knowledge of the clinkal setting is important for accurale evaluation of the abn ormality.
31 9 1
I TEA
HING ATLAS OF S P I N E I M A G I NG
Case 16 Clinical Presentation The patient is a 32-year-old female who is status post kidney transplant with severe and worsening back pain.
A
B
Radiologic Findings Sagillal short TR image of the cervical and thoracic spine ( Fig. A) reveals a compression fracture of the T4 vertebral body. The remainder of the vertebral bodies are normal. There is accentuation of the thoracic kyphosis at the T4 level. The T7 vertebral body is identified with 7. Sagittal short TR image in the lower thoracic and l umbar region (Fig. B) reveals a marked compression fracture of the T12 vertebral body. The posterior margin of the T12 vertebral body is retropulsed into the vertebral canal, and curviJinear posterior displacement of the spinal cord is visible (open arrow). Compression deformity can be seen at the superior end plate of the Tl l vertebral body (solid arrow). There is reversal of the normal lumbar lordosis because of the fracture. The T6 vertebral body is identified with 6.
IRO
TRAUMA
PEARL Magnetic resonance imaging is the ideal method of evaluation, and the entire vertebral column can be easily evaluated with the use of phased array coils.
Diagnosis
•
PITFALL Evaluation should be made for possible metastatic disease. A radionuclide bone scan would be helpful to evaluate for the presence of other areas of increased signal intensity.
Benign compression fractures of T4 and T l 2 secondary to osteoporo
i .
Differential Diagnosis •
osteoporosis
•
compression fracture
•
metastatic disease
•
Discussion There is diffuse increased signal intensity of the m a rrow of all the visualized vertebral bodies secondary to os teuporosi s. The patient has been on steroids related to her kidney transplant. O therwise there is no abnormal signal i n te n si ty within the vertebral marrow to suggest other underlying disease such as metastases. There is also widening of the interspinous dist ance at thc T4-5 level because of the fracture.
321
I
TEACH I N G ATLAS OF SPI N E I M A G I NG
Case 17 Clinical Presentation The patient is a 73-year-old remale with b ack pain.
A
B
Radiologic Findings Sagittal short TR image in the mid and lower thoracic region (Fig. A) reveals compression fractures of T4 (open arro w), TiO, and Ti l . There are areas of decreased signal intensity involving the superior portions of the vertebral bodies at the levels of the fractures. There is slight i rregularity of the superior end plates of the vertebral b od ies of Tl0 and Til . There i s an area of decreased signal i ntensity b etween the spinous processes (s), which is well seen at the T9-i0 level . ' Sagittal long T R image (Fig. B) reveals increased signal intensity o f the areas of decreased signal intensity seen on the short TR images. There is slight compromise of the subarachnoid space at the T9-i0 l evel but no abnormal signal intensity within the spinal cord .
TR AUMA
Diagnosis PEARL Magnctic rcsonance imaging is the ideal method of evaluation. Multiple compression fractures. Tn general, in the presence of a benign compression fracture, Differential Diagnosis the vertebral body pedicle is normal; while in a pathologic compression fractures fracture, the vertebral body pedicle is replaced by decreased metastatic disease signal inten ity tumor. This is not always the case, and follow osteoporosis up may be necessary for complete evaluation. •
•
•
•
Discussion
PITF A LL •
Thc changcs seen here could also bc related to multiplc myeloma, so cOITclation should be made with the analysis of the patient's serum chemical analysis.
These multiple compression fractures are secondary to osteoporosis. There is diffuse mOllled increased signal intensity within the marrow o( the visualized vertebral bodies. The soft tissue structure in Figure A is the ligamentum flavum and this is seen at multiple levels. The portions of the vertebral bodies that appear as decreased signal intensity on the short TR images becomc increased signal intensity on thc long TR images. This change is secondary to edema related to these relatively acutc fractures. The remote possibility of metastases is a consideration; however, the lack of focal areas of decreased signal intensity make this unlikely.
I TEACHING ATLAS OF SPINE IM A G I N G
Case 18 Clinical Presentation The patient is an 87-year-old female who presents with marked accentuation of the dorsal kyphosis.
A
B
Radiologic Findings Sagittal short TR image of the thoracic spine (Fig. A) reveals compression fractures of multiple thoracic vertebral bodies. There is complete loss of height of the vertebral body of T4 (upper long arrow). There is only a very small triangular area of increased signal intensity posteriorly, which represents the posterior portion of the vertebral body. The remainder is sufficiently compressed that it is n o longer seen. The 17 vertebral boLly is likewise markedly compressed. The end plates are in apposition anLl appear as an area of linear decreased signal intensity (short arrow). A compression fracture of T6 is greater posteriorly than anteriorly. There is a marked compression fracture of Tl 0 (lower long arrow). Axial short TR image in the lumbar spine in the same patient (Fig. B) reveals that the vertebral body pedicle appears increased signal intensity (P).
1324
TRAU M A
PEARLS •
•
•
Magnetic resonance imaging (MRI) is the ideal method of evaluation of these abnormalities. The entire vertebral column can be easily evaluated. MRI allows ready evaluation of the vcrtebral body pedicles, which a re important in the differen tiation of benign versus malignant involvement of the vertebral body. MR also allows a nonin vasive method of evaluation o f encroachment upon the vertebral canal by retropulsed vertebral b ody fragments. Hcmatomas may occasionally occur and are also readily visualized by MRl.
PITFALLS •
•
In those cases where there is m arked compression fracture of the ve rtebral body and complete loss of vertebral body height, the absence of the vertebral body may be difficult to appreciate. The accentuation of the kyphosis provides a clue to the diagnosis. Alth ough involvement of the vertebral body pedicle with decreased signal intensity tumor is helpful for diagnosis, follow up may be the only method by which an absolute diagnosis between benign and malignant compression fracture can be made.
I
Diagnosis MUltiple benign compression fractures second a ry to osteoporosis.
Differential Diagnosis •
osteoporosi s
•
metastatic disease
Discussion The edema within the vertebral body is decreased signal intensity and ex tends to the base of the pedicle bilaterally (arrows, Fig. B). If the decreased signal intensity was secondary to metastatic disease, the pedicle would then also be decreased signal intensity secondary to this involvement with tumor. If the pedicle is n ot i nvolved, this suggests a n ormal vertebral body. The combination of all of these changes results in the accentuation of the d orsal kyphosis and the clinical appearance of the "dowager's hump. "
TEACHI N G ATLAS OF SPIN E I M A G rN G
Suggested Readings A nderson LD, D' Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint
Sttrg Am. 1 �74;50: 1 663- 1 fi74.
Becerra .IL, Puckett W R , Hiester ED, et al. M R-pathologic comparisons of Wallerian degen eration in spinal cord injury. A.lNR. 1995; 16:125- 1 33. Brandser E A , EI-Khoury GY. Thoracic and lumbar spine trauma. Radial
Ciill
North
A m.
1 997;35:533.
Caldemeyer KS, Mocharia R , Moran CC, et al. Gadol inium enhancement i n the center of a spinal epidural hematoma in a hemophil iac. leA T 1 993:17:321 Castillo M , M ukhcrju SH. Vertical fracture of the dens. A lN R. 1 996:17: 1627-J 630. Coffin CM, Weill A, Miaux Y, et al. Posttraumatic spinal subarachDuiu cyst. Ellr Radiol. 1996;6:523-525.
Davis SJ, Khangure MS. Review of magnetic resonance imaging in spinal trauma. A uslralas
Radiol. 1994:38:241 . Ehara S , EI-Khoury G Y , Clark CR. Radiologic evaluation o f dens fracture: role o f plain radiography and tomography. Spine. 1 992;1 4:475-479. EI-Khoury G Y , Kathol M H , Daniel WW. Imaging of acute injuries of the cervical spine: value of plain radiography, cr, and MR imaging. AlR. 1 995;163:43-50. Fclsberg G J , Tien RD, Osumi AK, et al. Utility of M R imaging i n pediatric spinal cord injury. Pediatr Radiol. 1 995:25 : 1 3 1 - 1 35. Flanders AE, Schaefer D M , Doan HT, Mishkin M M , Gonzalez CF, Northrup BE. Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit.
Radiology. 1 990; 177:25-33. Forster B B , Koopmans RA. Magnetic resonance imaging of acute trauma of the cervical spine: spectrum of findings.
Carlati Assoc Radiol l.
I �<)5;4o:1 6R-173.
Gebarski SS, Maynard FW. Gabrielsen TO, Knake .I E , Latack JT. Post t raumatic progressive myelopathy. Radiology. 1985;157:379-385. Gundry D R , Heithoff KB. Epidural hematoma of the lumbar spine: 1 8 surgically conlirmeu cases. Radiology. 1993;187:427. Hackney D B , Asato R, Joseph PM, et al. Hemorrhage and edema in acute spinal curu compression: demonstration by MR imaging. Radiology.
1 '1Hfi;1 fi1 :387-390.
Hackney D B , Ford JC, Markowitz RS, et al. Experimental spinal cord injury: imaging the acute lesion.
AJNR.
1994;15:960.
Harris J H Jr, Burke JT, Ray R D , ct a l . Low (type I I I) odontoid fracture: a new radiugraphic sign. Hadiology. 1984;153:353-356. Ito M, O h k i M, Hayashi K , Yamada M, Uelani M, Nakamura T. Trabecular texture analysis of
cr
images in the relationship with spinal fracture. Radiology. 1995;194:55.
Kang JD. Figgie
MP,
Bohlman HH . Sagittal measurements of tbe cervical spine i n subaxial
fractures and dislocations: analysis of two hundred and eighty-eight patients with and without neurological detidts (ab). Radiololgy. 1 995; 1 95:885. Kerslake RW, Jaspan T, Worthington BS. Magnetic resonance imaging of spinal trauma. Br
J Radial. 1 '19 1 ;04:386-402. Lee RR. MR imaging and cervical spine injury. Radiology. I W6;201 :617. Lovblad K-O, Baumgartner RW, Zambaz B-D, et al. Nontraumatic spinal epidural hernato mas: MR features. A cta Radial. 1 997;38:8- 1 3. McConnell
cr
Jr, Wippo1d FJ I I , West OC, et al. "Open" exit foramen: new sign of
unilateral interfacetal dislocation or subluxation in the lower cervical spine. Emergency
Radiol. 1 995;2:296. McGrory B J , Klassen RA, Chao EYS, et al. Acute fractures and dislucations of the cervical spine i n children and adolescents (ah). I?adiology. 1994; 1 9 1 :296. M i rvis SE, Geisler FH, Jelinek JJ, Joslyn IN, Gellad F. Acute cervical spine trauma: evaluation with 1 .5T MR imaging. Radiology. 1 988;1 66:807 816. Murphy MD, Batnitzky S, Bramble J M . Diagnost ic imaging of spinal trauma. Radial Ciill NOr/I!
Am. 1 989;27:855-872.
Noguchi K, Ogawa T, I n ugami A, et al. Acute subarachnuiu hemurrhage: MR imaging with fluid-attenuated inversion recovery pulse sequences. Radiology. 1995:196:773-777.
TRAUMA Nunez D B J r. Zuluaga A, Fuentes-Bernardo DA, Rivas L A , Becerra J L . Cervical s pine trauma: how much more do we learn by routinely u�ing helical CT1 RlldioGraphicl·. 1 990; I n: I 307- 1 32 1 . Nussbaum ES, Se br i ng L A , Wolf A L , et a l . Myelographic and enhanceu computed tomo graph i c appearance of acute traumatic spinal cord avulsion. Ncurosurg. 1 992:30:43-48. Orrison WW .Ir, Benzel EC. Willis B K, et al. Magnetic resonance imaging evaluation of acute spine tra um a . Emergency Radiol. 1 995;2: 1 20. Pen n i ng L. Prevertehral hematoma i n cervical spine injury: incidence and etiologic signifi cance. AlN R. I lJSO:l :557 -565.
Petersilge CA , Lewin JS,
Duerk JL. et al.
Optimizing imaging parameters for M R evaluation
of the spi n e with titanium pedicle screws. A1R. 1 996; 1 66:1 2 1 3 - 1 2 1 8. Petcrsilge CA. Pathria M N , Emery SE, Masaryk TJ. Thoracolumbar burst fractures: evalua tion with MR imaging. Radiology- 1 995;1 ,)4:4,)-54. Post M J D , Becerra .IL. Madsen PA. et al. Acute spinal subdural hematoma: M R and . findings with p
cr
Oueneer RM, B unge Egnor M, Green B A . Puckett WR, Post M J D . Acute traumatic central cord synurome: M R I-pathological correla tion. Neurorllliiol. 1 9lJ2:34:85-94. Reany S M , Parker M S , M i rvis SE, et al. Ahdominal aortic i njury associated with transverse lumbar spine fracture-imaging
fIndi n gs.
Cli" Radial. 1995;50:R34-X31i.
RM, B l ack G B . Pediatric Chance frac t u re s: sea t belt use. Tra/./ma. 1990;30:384-39 1 .
Reid A B , Letts injuries and
association with intraabdominal
Shanmuganathan K , M irvis S E , Levine A M . Traumatic i sola tio n o f the cervical pillar: imagi nary observations i n 2 1 patients. Al R. 1996; I Il6:RlJ7-902. Stevens, Olney JF, Kcndall BE. Post-traumatic cystic and
n on -cystic
myelopathy. NCllrora
dial. 1 985;27:48-56.
Terac S. Ta kahashi C, Abc S, et al. ud-DPT A-enhanced M R imagi ng of inj ured spinal cord. CIi" Imag. 1 997;21:82-89.
Terk M R , HlIme-Neal M. Fraipont M, et al. Injury of t he posterior ligament complex i n patients with acute spinal trauma: evaluation hy M R imagi ng. A.IR. 1 997: 1 68: 1 48 1 - 1 486. Wallace
K. Cohen WA. Ste rn EJ , Reav DT. J udicial hanging: postmortem radiographic,
cr, and MR imaging features with a utopsy cunfirmation. Radiology. 1 9lJ4; 1 93:263. Wasenko JJ,
Hochhauser L.
Hols a p p le JW, et al. MR of
pos ttraumati c
spinal cord lesions:
unexpected improvement of hemorrhagic le sion s. Ciin Imag. 1 997;21 :246-25 1 .
Weingarut J P , Rogers LF. Bilateral locked facets o f the cervical spine: correlation between associated fractures and neurolugie outcome. Emerge"cy Radiol. 1 994; I: 1 72.
Section V
Spine Metastases
SPI
E MET AST ASES
I
Case 1 Clinical Presentation The patient is a 40-year-old female with a h istory of breast cancer d iagnosed in 1989 and treated w ith modi fied radical mastectomy, chemotherapy and tamoxifen. The patient has subsequently been disease free. She presents with a recent history of low back pain.
A
B
I TEAC H I r-." G ATLAS OF SPI N E I M A G I
G
•
c
D
SPINE METASTASES
E
I
F
J33 1
I
TEACH I N G ATLAS OF SPI N E I MAGING
G
H
S P I N E METASTASES
J
Radiologic Findings Lateral view of the lumbar spine (Fig. A) reveals that the pedicle on the right ide is not seen at the L3 level (while arrow). The superior end plate of the L3 vertebral body is indistinct. The remainder of the vertebral bodie are normal. Sagittal plain film view (Fig. B) reveals that there is a smoothly marginated area of decreased density in the posterior margin of the L3 vertebral body (open arrow). This low density extends posteriorly to involve the pedicle at the L3 level. 3351
I
TEA C H l N G ATLAS OF SPINE IMA GING
Radiologic Findings (continued) Sagittal short TR i mage or the lumbar spine (Fig. C) revea ls that the vertebral body of L3 exhibits diffusely decreased signal intensity. The remaining vertebral bodies appear normal in configuration and signal intensity. Sagittal postcontrast short TR inlage (Fig. D) reveals enhancement of the L3 vertebral body. A mild compression fracture appears in the midportion of the L3 vertebral body. There is slight retropulsion of the posterior margin of the vertebral body into the vertebral canal and slight encroachment upon the subarachnoid space. Sagittal intermediate TR and long TR images (Figs. E and F) reveal an area of h igher than normal signal intensity in the posterior portion of the vertebral body of L3 (white arrows). There is expansion of the vertebral body and slight encroachment upon the subarachnoid space. Anterior (Fig. G, left) and posterior (Fig. G, right) views or a tech neti urn bone scan reveal an area of increased activity in the L3 vertebral body (arrows). Pre- (Fig. H, top) and postcontrast (Fig. H, boltom) short TR axial images of the L3 vertebral body reveal enhancement of the right side of the L3 vertebral body (large white arrow). There is a small soft tissue component that extends beyond the margins of the vertebral body of L3 posLeriorly (curved arrow) with slight encroachment upon the subarachnoid space ante riorly. Pre- (Fig. T, top) and postcontrast (Fig. J, bOllom) short TR axial images of the L3 vertebral body reveal enhancement in the posterior and right portion of the L3 vertebral body. There is also enhancement of the pedicle on the right side (bottom, curved arro w). The right transverse process also en hances. The dorsal root ganglion is well seen on the left side (top, arro whead).
Clinical Course Because the patient had no other evidence of disease, we elected to biopsy the L3 vertebral body using computed tomographic (CT) guidance. The distance from the patient's skin ( + ) to the vertebral body biopsy site is measured (Fig. J). The trajectory of the needle is determined and the bone biopsy needle is advanced into the area of bone destruction (Fig. K). Note that the bone of the transverse process has been destroyed (white arrow heads). The pedicle is not visible on the right side because it has been destroyed. The plain film reveals the destroyed pedicle on the right side as seen in Figure A. The biopsy should include the margin of the destroyed bone as well as ao aspiration of any material w ithin the central portion of the affected vertebral body.
Diagnosis Isolated metastatic breast carcinoma to the L3 vertebral body, proved at biopsy.
SPIN E M ETASTASES
PEARLS •
•
Cancer tends to affect the vertebral pedicle early in the course of metastatic spread. Particular attention should be paid to the vertebral pedicle because this may be the only sign of metastases. It has been reported th at 50% destruction of the vertebral body is requjred before the destructive changes are apparent on the plain film evaluation.
PITFALLS •
•
Not aU metastatic deposits enhance after contrast injection. Not all metastatic deposits appear increased signal in tensity on the long TR image .
Differential Diagnosis •
metastatic disease
•
multiple myeloma
Discussion This patient presented with metastatic disease after an 8 year disease-free interval. This is not un usual; pa tients with metastatic breast cancer m ay present after a disease-free period of up to 20 years. Therefore, in a patient with new complaints, evaluation MUST be made for possible metastases. Magnetic resonance (MR) imaging is the most accurate method for evalua tion of metastases. In general, a postinfusion scan is not necessary in the p atient with only bony metastases. However, in the patient with a soft tissue component, the postinfusion MR scan better demonstrates the full extent of the soft tissue component. Metastatic deposits have a random distribution, and their location is not predictable. The pedic1es are a very vascular part of the vertebral body, so hematogenous spread of metastatic disease frequently affects this part of the vertebral body. In addition, this anatomic region is nicely eval uated by plain film evaluation as seen in Figure A, which shows the destruction of the superior end plate of the vertebral body. The changes of metastascs, however, are a pparen t earl ier on the MR scan; therefore, MR is the procedure of choice for the eval uation of the presence of metastases. Metastatic deposits replace the normal increased signal intensity fatty bone marrow with decreased signal intensity tumor. The extent and amount of these changes are readily apparent by MR imaging in the majority of cases. Metastases have a variable response to the long TR sequences. In particular, osteoblastic metastases may appear very low in signal intensity on the various imaging sequences, with a decreased signal intensity appearance similar to cortical bone, while osteolytic metastases may appear as increased signal intensity on the long TR images and are more likely to reveal enhancement on the postcontrast images. An additional method of evaluation is the use of fat-suppression short TR images after the infusion of contrast material. Using this technique, the fatty bone marrow is suppressed and appears as decreased signal intensity while the tumor enhances. Metastatic disease is the most likely diagnosis in this patient; however, a primary bone tumor, such as osteogenic carcinoma, could h ave a similar ap pearance.
I
TEACHING ATLAS OF SPI N E IMAG ING
Case 2 Clinical Presentation The patient is a 52-year-old female with a history of cervical cancer who now presents with low back pain.
A
B
SPINE M ETASTASES
I
Radiologic Findings Sagittal short TR image of the lumbar spine (Fig. A) reveals increased signal intensity within the vertebral bodies beginning at the level of the superior end plate of the L2 and extending through the sacrum. There are anterior osteophytes incidentally noted at the L2-3 level (open arrow). There is a Schmorl's node deformity in the inferiur end plate of the Ll vertebral body. There are two small. ill-defined areas of decreased signal intensity within the vertebral body of Sl (solid arrows). Axial short TR image at the level of L12 (Fig. B) reveals the anterior osteophyte at the L2 level (open arrow). The marrow appeHrs as diffusely increased signal intensity, and this highlights the decretlsed signal i ntensity of the peripheral cortical margin of the vertebral body (curved arrow).
PEARL A clinical history of previous radiation is not always given; however, the straight margin of the area of increased signal is consistent with postradiation change and correspond with the radiation port. •
PITFALLS Postradiation changes may be more subtle than in this case. •
•
The postradiation changes may also be seen in association with marrow replacement by decreased signal i ntensity tumor.
Diagnosis Postradiation changes.
Differential Diagnosis •
postradiation changes
•
paraspinal mass
Discussion Clinical history is vital for absolute diagnosis in a case where postradiation changes are suspected. These postradiation changes o1'increased signal inten sity become apparent approximately 4 weeks following radiation and persist indefinitely. Following radiation, there is an increase in the amount of fat within the bone marrow, which results in increased signal intensity on the short TR images. The areas of decreased signal intensity within the vertebral body of Sl are consistent with a "bone bruise" (Fig. A , solid arrows). These bone bruises are thought to be caused by internal aretls of focal edema within the vertebral body. Compacted trabecular bone may also have a similar appearance. Evaluation of the paraspinal area should also be performed to rule out a paras pinal mass. The radiated bone is weaker than the normal bone, so compression (ractures may occur. Schmorl's nodes are focal areas of herniation of the intervertebral disc into the vertebral body end plate. The appearance is typical for postradiation change.
I TEACH I N G ATLAS OF S P I N E I M AGING
Case 3 Clinical Presentation The patient is a 65-year-old male with a history sudden onset of pain at the T4 level.
A
34U
of p rostate c a n ce r
with
B
SP1 N E M ETASTASES
c
D
I
I TEA C H I N G ATLAS OF SPINE lMAGI 'G
E
SPIN E M ETASTASES
Radiologic Findings Sagi lla l short TR image of the thoracic spine (Fig. A) reveals multiple rounded and irregularly marginated areas of decreased signal in tensity within the vertebral body marrow at m u ltiple levels. There is also decreased signal intensity within the spinous process of one of the upper thoracic vertebral bodies (open arrow). The spinal cord is demonstrated throughout i ts length and appears normal in size and configuration. Short TR image postcontrast (Fig. B) reveals that there is enhancem ent and resulting partial obscuration of the mUltiple lesions demons trated on the preinfusion scan. Sagittal short TR image in the l umbar region (Fig. C) reveals m ultiple areas of decreased signal intensity that involve all of the visualized vertebral bodies. In addition , there are multiple soft tissue masses surrounding the abdominal aorta (black arrow). Sagittal intermediate signal intensity image of the thoracic spine (Fig. D) reveals very faint scattered areas of increased signal intensity but is otherwise unremarkable.
PEARL •
The thin increased signal intensity line within the central portion of the thoracic spinal cord seen in Figure E is truncation artifact. The long TR image in the sagittal projection readily demonstrates the thoracic spinal cord and evaluates the presence or absence of spinal cord compression.
Sagittal long TR image (Fig. E) reveals that the cerebrospinal n uid appears as increased signal intensity, mimicking the appe arance of a myelogram . In the central portion of the thoracic spinal cord, there is a very faint line of increased signal intensity (black and white arrows). There are a few scattered areas of increased signal intensity within the marrow of several vertebral bodies. A x ial short TR image pre- (Fig. F, left) and postinfusion (Fig. F, right) reveals multiple areas of decreased signa l intensity within the vertebral marrow of one of the upper l umbar vertebral bodies. The postcontrast (right) reveals enhancement and reSUlting obscuration of multiple lesions. Multiple soft tissue masses surround the abdominal aorta (arrowheads).
Diagnosis PITFALLS •
•
Postcontrast studies may reveal that the tumor is totally obscured by the enhancement. Therefore, it is important to obtain both pre- and postcontrast studies, and these images hould be carefully compared side by side. The truncation artifact within the spinal cord may be mistaken for a true abnormality.
Metastatic osteoblastic prostate cancer within the bone marrow; multiple para-aortic lymph nodes also show signs of metastatic disease.
Differential Diagnosis •
metastatic prostate cancer
Discussion Metastatic prostate cancer is osteoblastic in greater than 85% of cases. Metastatic prostate carcinoma freque ntly exh ibits diffuse bony involvemen t. Lymph node involvement may also be seen. Prostate can cer may be stable for long periods of time and multiyear survival is not uncommon. Many types of tumors may reveal this pattern of metastatic involvement.
I
TEA C H I N G ATL A S
OF
SPINE IMAGING
Case 4 Clinical Presentation The patient is a 47-year-old female with known breast cancer who had previou surgery for spine stabilization.
A
344
SPI
E METASTASES
B
c
Radiologic Findings Sagittal short TR image (Fig. A) reveals distortion of the image at thc sitc of the previous surgery at the CS-7 level. There are areas of decreased signal i ntensity with peripheral areas of curvilinear areas of increased signal intensi ty (while arrow). Although the images are somewhat distorted, for ward su bluxation of CS o n C6 is visible. The C2 vertebral body and odon toid reveal increased signal intensity, while the remainder of the vertebral bodies appear as diffuse, sligh tly irregular, decreased signal in tensity throughout.
T� I\CHJNG ATLAS or SPINE I MAGING
Radiologic Findings (continued) The spinous processes of C5 and C6 (open circles) exhibit decreased signal intensity, and there is widening of the interspinous distance at the CS-6 level (double arrow). Axial short TR image at the CS level (Fig. B) reveals oval
PEARL • The increased signaL intensity within the marrow of C2 is secondary to radiation treatment. In addition, this vertebral body is not involved with decreased signaL intensity metastatic disea e.
PITFALLS • A wide variety of mel.
Diagnosis Postsurgic
Differential Diagnosis •
metastatic disease
•
multiple myeloma
Discussion
The widened interspinous distance seen in Figure A is secondary to forward subluxation of C5 on C6 and slight kyphosis at this level. The metallic pl
1 34 6
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Case 5 Clinical Presentation The- patient is a 44-year-old female with a history of an abdominal mass who i. status-post-bone marrow transplant with hip pain and leg pain of recent onset.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals decreased signal intensity in the anterior half of the L3 and L4 vertebr
Diagnosis PEARLS • The postcontrast i mage results in an almost normal appearance Vertebral metastases and multiple pathologically enl a rged lymph nodes of the vertebral bodies. For this (N, n) secondary to non-Hodgkin's lymphoma. reason, it i importa nt to perform both pre- and Differential Diagnosis postinfusion studies for complete evaluation. • lymphoma •
Additional history revealed that thi patient had a diagnosis of non-Hodgkin's lymphoma.
PITFALL • At the time of i mage evaluation, special attention should be paid to the paraspi n al and prevertebral areas for the presence of masses or adenopathy.
•
metastases
Discussion The appearance of the paraspinal adenopathy is typical of lymphoma. The para-aortic lymph nodes surround the flow void of the abdominal aorta and infcrior vena cava. In a patient with neurofibromatosis type 1 , this type of adenopathy could be interpreted as plexiform neurofibroma. Therefore, to ensure correct interpretation and diagnosis, it is import
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TEACH I N G ATLAS OF S P I N E I M A G I N G
Case 6 Clinical Presentation The patient is 78-year-old male with known prostate cancer who now pre sents with severe back pain.
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Radiologic Findings Sagittal short TR image in the cervical and upper thoracic region (Fig. A) reveals that there is a marked scoliosis, and the spinal cord can be visualized in only a portion of its length. All the visualized vertebral bodies are involved with multiple, variable sized lesions that exhibit marked decreased signal intensity. There is reversal of the normal lordotic curve in the cervical region. Sagittal short TR image in the lumbar region (Fig. 8) reveals that the vertebral bodies are involved with variable sized rounded and irregularly shaped areas of markedly decreased signal intensity. The lumbar thecal sac is only seen in the lower lumbar region because of a scoliosis of the spine. Sagittal short TR images following the use of a computer generated program that allows the images to be corrected for the presence of a scoliosis (Figs. e and D) reveals that the spinal cord is now demonstrable in its entirety.
Diagnosis Diffuse metastases secondary to innumerable osteoblastic lesions related to the prostate cancer. 35�1
TE A CH I N G ATLAS OF S PI N E T M A G ING
Differential Diagnosis •
osteoblastic metastases
Discussion PEARL •
The use of a reformatting technique should be used for complete evaluation of the vertebral canal and to eval uate for cord compression .
PITFALL • If
a reformatting program is not available, it may be necessary to p erform m ultip l an ar imaging, including the coronal plane, for complete evaluation of the presence or absence of cord compression or compromise of the vertebral canal. In some case , it may be necessary to perform a myelogram for complete evaluation.
Prostate cancer is osteoblastic in approxima tely 85-90% of cases, although the remain der of the cases are osteolytic. Osteoblastic metasta tic deposits remain as decreased signal intensity on all imaging sequences. This occurs because the hydrogen protons arc locked in the crystal lattice of the bone m a trix and cannot be affected by the radiofrequency w aves of the magnetic resonance (MR) scanner. Therefore, they do not return a signal and appear markedly decreased in signal intensity. In general, osteolytic metastatic deposits, which appear as decreased signal intensity on short TR images, are more l ikely to appear as increased signal intensity on the long TR images. The scoliosis correction program or curve reform at p rogram is very helpful in the evaluation of the presence or absence of spinal cord compression. The use of this method generally allows the visualization of the spinal cord and its relationship to the surrounding bony structures. The MR appearance is typical for osteoblastic metastases. Therefore, the greatest consideration should be for those primary tumors that will ca use metastatic osteoblastic lesions, the most common of which is metastatic prostate cancer. Another consideration would be osteoblastic metastatic breast cancer, even in a male patient. Multiple myeloma in the clinical setting of POEMS (polymyelopathy, organomegaly, endocrinopathy, and m yeloma), which causes osteoblastic lesions, could also h ave a simjlar ap peara nce.
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Case 7 Clinical Presentation The patient is a 43-year-old female with stage 1 b uterine adenocarcinoma. The patient is status-post chemotherapy and radiation therapy to the pelvis and now presents with severe upper thoracic pa in and paraplegia.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals a large t issue mass in the prcvcrte bral area at the T3 level. There is marked accentuation of thc thoracic kyphosis at this level, as wel l as anterior compression fracture of the T4 vcrtcbral body and erosion of the anterior superior corncr of the T5 verte bral body. Sagittal long TR image (Fig. B) revcals that thc mass appears slightly in creased in signal intensity with somc faint internal area ' of decreased signal intensity. The spinal cord is displaced posteriorly. The 1'3 vertebral body is completely absent; this is at the level of the marked kyphosis. Sagittal fat-suppressed image postcontrast (Fig. C) reveals that the mass enhances dcnscly. There are curvilinear areas of internal decreased signal intcnsity (arrows). There is a streak-like arca of i ncreased signal intensity that extends into the vertebral col umn at the level of T3 and into the vertebral canal. The area of enhancement is in the vertebral canal and displaces the spinal cord posteriorly (arrowhead). Axial short TR image precontrast (Fig. D) rcvcals a very large right para spinal mass. The mass extends antcrior to the vertebral column and sur rounds the vertebral body at the T3 level. The mass extends into the vertcbral canal from the left side (see Fig. E) where it obliterates the normal increased signal intensity fat in the intervertebral foramen and displaces the spinal cord (arrow) to the right. Axial short TR image postcontrast (Fig. E) reveals i nhomogeneous enhance ment of the paraspinal and prevertebral component of the mass. The soft tissue componcnt extending into the vertebral canal cnhances and can be seen on the left side (arrow). The normal cpidural fat is obliterated by the mass.
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PEARL •
Notc that in this patient thc cerebrospinal fluid below t he level of the cord compression in Figure C appears markedly increased in signal intensity. The cerebrospinal fluid above the level of the block appears relatively decreased in signal intensity. There are two reasons for this. The first is the fact that the cerebrospinal fluid below the level of the block contains an increased protein content. It contains an increase in the number o( hydrogen protons and therefore is brighter. The second is that there is transmitted pulsation of hea11 beat and respiration, which results in motion of the cerebrospinal fluid above the level of the block. This motion causes the cerebrospinal fluid to appear decreased signa l intensity.
?ITFALLS •
•
In any patient with metastatic disease, the entire length of the vertebral column should be evaluated. When there is a marked compression fracture or extensive bony de tructi ve change that completely destroys a vertebral body, the absence ot this vertebral body may be difficuLt to appreciate. The only abnormality may be accentuation of the dorsal kyphosis.
Diagnosis Metastatic adenocarcinoma with bone destruction and spinal cord com pression.
Differential Diagnosis •
metastatic disease
Discussion This type of m etastatic deposit is unusual in a patient with uterine cancer. The fat-suppressed technique results in a low signal in tensity of the fat containing structures, such as the normally high fat content bone marrow. This allows for easier demonstration of areas of cnhancement such as thc enhancing tumor in this patient. The presence of spinal cord compression is also easily appreciated. Multiplanar i maging allows for much easier ap precia tion of the cord compression . Fat is an excellent intrinsic contrast m aterial in magnetic resonance imaging; therefore, evaluation of the interruption or obliteration of this fat signal intensi ty is very helpful in evaluation of the changes that can be seen with metastatic disease. Lung cancer would be a more likely tumor to result in this appearance. Other tumors, such as osteogenic sarcoma or even Ewing's sarcoma in a younger patient, could also have this appearance. Remotely, multiple my eloma might also have a similar appearance although the large sort tissue component would be unl ikely.
S P I N E METASTASES
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Case 8 Clinical Presentation The patient is a 5 1 -year-old (em
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Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagillal short TR images reveal a small area of decreased signal intensity in the vertebral bodies of C2 (left, open arrow). There is also decreased signal intensity replacing the vertebral bodies of C6 and C7 and the posterior portion of Tl . An intermedi ate signal intensity mass anterior to the spine is visible at the T 1 -2 level
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Radiologic Findings (continued) (left IJnd righI, white arrow). The postcontrast study reveals cnhancement of all of these areas. There is essentia lly complete disappearance of the T I lesion (white arrowhead). There is a compression fracture o f t h e T l vertebral body with rctropulsion of the posterior margin of the vertebral body i nto the vertebral canal. Pre- (Fig. B, left) and posteontrast (Fig. 8 , right) parasagittal shorl TR i mages reveal multiple, rounded, intermediate signal i ntensity sort tissue masses projecting anterior and lateral to the spine (arrows). Pre- (Fig. C, lefl) and posteontrast (Fig. C, righr) parasagittal short TR images reveal a soft tissue mass anterior to the flow void of the carotid artery, which displaces the carotid artery posteriorly (left, arrow-c). The mass enhances on the postcontrast study. Axial short TR image posteontrast at the level or C7 (Fig. U) revea ls Iwo large confluent masses on the left side (long black arrows on right) that exhibit enhancement. The nerve roots of the brachial plexus arc displaced posteriorly by tbis mass (curved arrow). There is dense enhancement of the C7 vertebral body and compromise of the subarachnoid space with posterior compression of the cervical spinal cord (white arrow). The anterior scalenus muscle (A) and middle scalenus muscle (M) are seen on either side or Ihe nerve roots of the brachial plexus on the right side (black arrow on left). The low signal intensity air filled trachea is displaced to the right.
PEA RLS •
•
Vascular displacement as well as encroachment can be readily demonstrated by MR imaging.
PITFALL •
Diagnosis
Remember Ihat the bracbial plexus extends rTom tbe level of Metastatic breast cancer with vertebral body involvcment and pathologic adenopathy. the spi nal cord to the level of the axilla.
Evaluation should be made of the paraspinal area as well as the vertebral bodies.
Differential Diagnosis •
metastatic disease
•
inflammatory process
Discussion A clinical history or a primary tumor would he very helprul for accurate and complete evaluation. In this patient, there are multiple greatly enlarged metastatic lymph nodes in the neck in the supraclavicular region. There is compromise of the subarachnoid space and cord compression at the C7 level. The brachial plexus is also compressed by these pa thologically enlarged supraclavicular lymph nodes. Although the remote possibili ty of an innam matory process is a consideration, the adenopathy and lack of intervcrtebral disc involvement favor metastatic disease. Analysis of the cercbrospinal fluid may be helpful in differentiating between metastatic versus inflamma tory disease. M agnetic resonance (MR) i magi ng is the best method ror evaluation or the brach ial plexus. The entire course of the brachial plexus should be visualized ror complete evaluation.
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Case 9 Clinical Presentation The patient is a 63-year-old female with known breast cancer who presents with left upper extremity weakness.
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Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images reveal that multiple vertebral bodies a re replaced by decreased signal inten sity soft tissue. An aCLlte kyphosis is visible at the T4 level, and there is marked destruction of the T4 vertebral body and retropulsion of the poste rior margin of the vertebral body into the vertebral ca nal (Left, arrow). The postcontrast study reveals extensive enhancement of the vertebrae at all levels. There is marked compromise of the subarachnoid space and curvilin ear posterior d ispl acement and indentation of the spi nal cord at the level of maximal kyphosis. The Ll vertebral body is identified with 1, the L5 vertebral body with 5.
PEARL •
In
cases where there is a severe pathologic fracture of the vertebral body with complete collapse, the resulling apparent ab ence of the vertebral body may not be appreciated. When there is marked collapse of a vertebral body, there is typically accentuation of the dorsal kyphosis.
Coronal short TR image (Fig. B) reveals thickening of the nerve roots of the brachial plexus (bLack arrows) as they course just superior to the f�ow void of the subclavian artery.
Diagnosis Metastatic breast cancer involving m ultiple vertebra l bod ies and the bra chial plexus.
Differential Diagnosis •
metastatic disease
PITFALLS •
•
The postcontrast study may give the appearance of totaU y normal vertebral bodies, so the studies should be performed both pre- and postcontrast. With such marked destruction, a missing vertebral body may not be appreciated on the images.
Discussion The brachial pl exus extends from the origin of the nerve roots from the spinal cord to the level of the axilla. Metastatic disease may affect the nerves at any location along the course of these nerves. Magnetic resonance imaging provides the best method of evaluating the brachial plexus. Studies may also be performed using the fat saturation technique. With this technique, the fat appears as decreased signal intensi ty, while enhancing lesions appear as increased signal intensity. In this cli nical setting, metastasis is the most probable diagnosis.
3�
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SPINE I MAGING
Case 10 Clinical Presentation The patient is a 76-year-old previously healthy male with a history of 2 days of lower back p
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D
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G
Radiologic Findings Posteroanterior (Fig. A) and lateral (Fig. B) views of the chest reveal flat tening of the hemidiaphragms bilaterally and three faint nodula r densities in the left lung (Fig. A, arrowheads). Th e vertebrae appear norm a l on the lateral view. Pre- (Fig. C, left) and postcontrast (Fig. C, right) sagittal short TR images reveal questionable loss of vertebral height at the C3 level . There is mottled signal intensity within the marrow of this vertebral body and questionable patchy enhancement (left, curved arrow). The vertebrae otherwise appear normal. Pre- (Fig. D, lOp) and postcontrast (Fig. D, bottom) axial short TR images reveal extensive replacemen t of the vertebral body of Tl l with decreased sign al i ntensity soft tissue. This exhibits marked enhancement on the post contrast study. There is expansion of the pedicle (bottom, long black arrow) and encroachment upon the right side of the thecal sac. The spinal cord is displaced to the left. There is also an enhancing soft tissue mass on the right side (bottom, wide arrow). Pre- (Fig. E, lOp) and postcontrast (Fig. E, bottom) axial short TR images at a slightly different level reveals a bilobed, enhancing, soft tissue mass that encroaches upon the anterior aspect of the vertebral canal (bottom, curved arrow) and extends into the vertebral body (bottom, straight arrow). Computed tomographjc (CT) scan with CT-guided biopsy (Fig. F) reveals the soft tissue mass with the needle in place. The extensive destruction of the bone of the vertebral body can be appreciated. The soft tissue paraspinal component is reamly visualized. The wide window width image (Fig. G) better reveals the destructive process.
J6�1
I TEACH ING ATLAS OF SPINE I M AG I N G PEARL Diagnosis • OccasionalJy, bony destructive Metastatic lung cancer, biopsy p ro ved. Mul t i ple addition(ll lung n od ul es cbanges are better appreci a t ed were present on the chest CT scan. One is visible in the lung on the righ t on the cr scan than on the side in Fi g ure G (arrowhead). MR scan. This is because cr is more sensitive for destructive changes of the cortical bone, which may not be visible on the Differential Diagnosis MR scan. In general, however, • me t (lst a t ic dise(lse MR is the procedure of choice for the eval uation of the • mul t i pl e m ye lo m (l presence or absence of metastatic disea se.
Discussion PITFALL • The entire spine should be evaluated in a patie nt with possi ble metastatic disease.
Greater than 50% destruction of the vertebral body is necessary before these destructive changes can be identified. Magnetic resonance (MR) imagi ng is very sensitive to the presence of bony metastases and is positive in a high percentage of cases that have bony metastases. MR is more accurate than bone scanning because it is generally more specific. However, radionuclide bone scanning is helpful for ev a l u (l ting other hnny areas of in vo lve m ent. In the patient who has back pain, MR is the i m aging procedure of choice for evaluation of the presence of metastases. Chest CT is more accurate than plain film in tbe eva l uation of the prese nce or lung cancer or l un g n odules secondary to metastatic disease. Multiple myeloma could have a similar appearance. Metastases from any primary tumor could appear similar.
S P I N E METASTASES
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Case 11 Clinical Presentation The patient is a 57-year-old with baek pain and lower extremity weakness.
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Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A. right) sagittal short TR i mages reveal complete replacement of the T12 vertcbral body with decreased signal intensity tumor. The remainder of thc vertebral bodies are diffusely increased in signal intensity. The postcontrast i m age (right) reveals d i ffuse i rregular enhancement of the TI2 metast atic deposit. There is an enhancing soft tissue component that extends into and obliterates the vertebral canal. Axial short TR image precontrast (Fig. B, top) reveals that the tumor has replaced the vertehral body of TI2. The spinal cord is compressed and displaced t( ) the fa r right (curved double arrow). Postcontrast (Fig. B, bOllom) image reveals a tumor tbat extends latcrally on the left i nto the paraspinal rcgion to involve the ribs and the transverse process (opell arrows). There is also a soft tissue mass in the right paraspinal area (solid arrow).
PEARLS •
•
Additional clinical history revealed that the patient had a k nown history of colon cancer metastatic to the liver. The increased signal intensity of the l umbar vertebral bodies is secondary to radiation treatment.
Diagnosis Mctastatie colon carcinoma to TI2 with bone exp,m sion and cord com pression.
Differential Diagnosis , metastatic disease
Discussion PITFALL •
The entire vertebral column should be evaluated to rule out the presence of other areas of involvement.
A cli nical h istory of a known primary tumor is important in this patient. The preinfusion scan readily allows one to make the correct diagnosis of a metastie deposit in the TI2 vcrtebral body. While many primary tumors may metastasize and have a similar appearance, the known primary tumor makes this the most likely diagno is. The postcontrast study is probably not ncce sary to make the diagnosis, but i ncreases the eonspicuity of the abnormality. The axial images are very distorted from normal, and the exact position of the spinal cord is difficult to determine based on one axial slice. Therefore, if a surgical approach is palnncd, it is vital to determine the position of the spi nal cord. Evaluation should be made of the images C1bove and below the level of the abnormality, so the spinal cord position can be determined at a normal level and then followed down to thc abnormal level. In this way, the exact location of the spinal cord can be accurately determined. A Cf-guided biopsy may also be used to identify the nature of tbe abnormality and the source of the primary tumor. Metastatic thyroid cancer, breast cancer, or lung cancer could have a similar appearance, as could a plasmacytoma or primary bone tumor.
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Case 12 Clinical Presentation The patien t is a 24-year-old female with known Ewing's sarcoma with lower extremity weakness and a �ensoryl level at T8.
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Radiologic Findings Sagittal short TR image without contrast (Fig. A) reveals expansion of the spinous process at the T2 level (upper arrow). The normal epidura l fat at the T2 (2) level is replaced by intermediate soft tissue signal in te nsity mate rial. The TS vertebral body spi nous process reveals a rounded area of de creased sign al intensity (arrowhead). There is a compression fracture at T8 with retropulsion of the posterior margi n of the vertebral body into the vertebral canal (lower arrow). Sagittal short TR image with contrast m ate rial (Fig. B ) reveals enhancement of the soft tissue epidural mass at the T2 level (arrow). The normal epid ural fat has been replaced by the soft tissue mass. The subarachnoid space dorsal to the spinal cord is compressed, and the spinal cord is compressed forward
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I TEACHING ATLAS OF SPIN E IMAGING Radiologic Findings (continued) against the posterior margin of the vertebral body. There is diffuse enhance ment of the TR vertebral body (8). The spinal cord is compressed slightly along i ts anterior margin and displaced slightly posteriorly. There is obliterll tion of the subarachnoid space anterior to the spinal cord at this level .
PEARLS •
•
Ewing's sarcoma is a very malignant tumor, and metastatic disease is common. Thc postcontrast examination bctter evaluates the soft tissue component associated with the metastatic deposits.
PITFALL •
The cord compression is present at the 1'2 level, while the clin ical level i at T8.
Diagnosis Metastatic Ewing's sarcoma with cord compression at the T2 level.
Differential Diagnosis •
Ewing's sarcoma
•
metastatic disease
Discussion The clinical examination does not always accurately reflect the anatomic level of involvement with tumor or metastases. This patient has two poten tial levels of cord compression. The 1'2 level appears to be t he more severe area of involvement by magnetic resonance evaluation, while the T8 h as greater symptoms in the clinical setting. In the patient with potential cord compression, the entire length of the vertebral column should be evaluated. This is best performed with short TR images with multi planar imaging. The eval uation of the entire vertebral column Jetermines if there is more thlln one level of cord compression or if the involvement is localized. Thus, treatment may be directed to the multiple areas involved. This patient is a good example of multiple abnormal levels with symptom at only one level. It should be noted that myelography may be performed in a patient such as this. However, if the study i performed via a lumbar tap, flow of contrast may be completely blocked at T8, the lower level of metastatic disease. When the study is performed via a cervical tap, flow of contrast may be completely blocked at 1'2, the upper level of spread of tumor. Therefore, the areas between these two l evels of block to the flow of contrast would not be evaluated. Ewing's sarcoma typically may have an area of bone involvement with a much larger soft tissue component. In this clinical setting of known Ewing's sarcoma, multiple metastases from the primary tumor are the most l i kely diagnosis.
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Case 13 Clinical Presentation The patient is a 49-year-old female with renal cell cancer and new onset of upper back pain.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals an intermediate signal intensi ty mass in the dorsal epidural space at the T6 level (6). The normal dorsal epidural fat (f) is obliterated. There is a very subtle area of decreased signal intensity in the posterior two thirds of the T6 vertebral body (arrow). Sagittal long TR image (Fig. B) reveals that the sort tissue mass and the lesion in the posterior portion of T6 (white arro w) both become increased signal intensity.
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c
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Radiologic Findings (continued) Parasagittal short TR image (Fig. C) reveals expansion of the pedicle at the T6 1evel (p). This expansile process extends superiorly to involve the superior articu lating facet and inferiorly to involve the inferior articulating facet. The upper s identifies the involved superior articulating facet, whi le the lower s identifies the normal superior articulating facet of the vertebral hody below. The normal increased signal inten ity fat in the intervertebral foramina at TS-6 and T6-7 is obliterated by the soft tissue mass (curved arrows). The 1'7 vertebral body is identified with 7. Sagittal short TR image postcontrast (Fig. D) reveals enhancement of the soft tissue density material in the T6 vertebral body (white arrow) and the superior and inferior articulating racets (i).
3 72
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E
Radiologic Findings (continued) Axial short TR image postcontrast at the level of the vertebral body pedicle (Fig. E) reveals marked expansion of the pedicle (p) and superior articulating facet (i). Both reveal enhancement. The spinal cord is displaced toward to the right side and compressed. Multiple enlarged soft tissue masses surround the area of the tracheal bifurcation. Axial short TR image (Fig. F) reveals a large soft tissue mass in the right lung (while arrow). The expanded inferior a rticulating facet is seen en croaching upon the left side of the vertebral ca nal (white arrowhead).
I TEACHING ATLAS OF SPINE I MA G I NG
G
H
Radiologic Findings (continued) Parasagittai pre- (Figs. G and I ) and postcontrast (Figs. H ami J) images reveal that the pedicle (Figs. I and J, p) and inferior articulating facet are replaced by soft tissue, which enha nces postcontrast.
SPINE M ETASTASES
I
J
Diagnosis Metastatic renal cell cancer to thc right lung and the vertebrae in t he thoracic and lumbar region and involving the parat racheal lymph nodes.
Differential Diagnosis •
mctastatic disease from another primary
•
multiple myeloma
•
primary bone tumor
Discussion Clinical history is helpful for diagnosis in this patient The findings could also be related to metastatic lung cancer with the prim a ry cancer in the .
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PEARL •
Evaluation of incidental findings on the image may be helpful and very rewarding for determining the patient's diagnosis and condition.
PITFALL •
The tech nique of filming may cause omission of the paraspinal areas, so sufficient attention should be paid to the paraspinal and prevertebral areas and should be included when indicated.
right lung field. The clinical h istory of back pain in any patient with known cancer warrants additional workup. Magnetic resonance (MR) is the best imagi ng method ror evaluating these cases. The en tire vertebral column should be eval uated , so treatment may proceed according to the abnormal fi ndings. Surgery or radiation therapy may be plan n ed based on the findi ngs on the MR scan. MR imaging is also an excellent noninvasive method that may also be llsed for follow-up. MR is superior to other diagnostic methods because the presence or absence or cord compression is also easily evaluated. In addition, trea tment and rollow-up can both be based upon the MR findings. While myelography co ult.l be perrormed in a patient such as this and demon strate a block to the now of contrast m aterial, the rull extent of the spread of the disease can be best appreciated by M R imagi ng. Also MR is less i nvasive than myel ogra phy and postmyelography comp uted tomographic scanni ng. Primary lu ng ca ncer, breast cancer, or any other soft tissue cancer, such as lymphoma. which may lead to metastatic disease may have a similar ap pearance.
SPINE M ET AST ASES
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Case 14 Clinical Presentation The patient is a 25-year-old male wi th newly diagnosed acute myelogenous leukemia (AML), presenting with new neurol ogic deficit, with bilateral lower extremity weakness and right facial droop.
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c
D
Radiologic Findings Parasagittal short TR images (Figs. A and B) reveal a paraspinal soft tissue mass at the level of T3 and T4 (Fig. A, open arrow; Fig. B, white arrow), which extends through the in Lervertebral foramen and several levels, obliter ating the perineural increased signal intensity fat at these levels (Fig. B, black curved arrow). There is also a second soft tissue mass in the lower thorax at approximately the T6-8 levels (Figs. A and B, long white arrows). Axial short TR image at the T4 (T4) level (Fig. C) reveals bilateral paraspinal masses with anterior extension to surround the descending aorta (arrows). There is no involvement or the verteh ral canal at this point.
SPINE M ET AST ASES
Radiologic Findings (continued) Axial short TR image at the L3 (L3) level (Fig. D) reveals a left paraspinal sort t issue mass that extends through the intervertebral foramen on the lert side and into the vertebral canal (solid arrow) where there is obli teration of the normal epidural fat. There is slight effacement of the lumbar thecal sac anteriorly (open arrows).
PEARL •
Because of thi patient's ymptoms, the brain should also be evaluated for the presence of metastatic disease.
Diagnosis Chloroma, secondary to A ML.
Differential Diagnosis •
chloroma
•
soft tissue tumor
•
hematoma
ITFALL •
The entire spinal column should be evaluated.
Discussion A chloroma is a mass of leukemic cells that may occur in any anatomic location; it has also been called granulocytic sarcoma. This mass has a greenish hue when visualized at the time or surgery and thus is called a chloroma. Chloromas may occur in the central nervous system in the brain or spinal cord. in the spinal cord or spinal col umn area, chloromas may cause spinal cord compression. Diagnosis may be made at the time or surgery, or a needle biopsy may be performed. Chloromas in the brain may present with the typical signs and symptoms of any other brain tumor. In these cases, the absolute diagnosis can be m ade only by biopsy. They may be seen in any age group. The development of a chloroma is a poor prognostic sign in patients with leukemia and is associ ated with a blast crisis. Chloromas may be single or multiple. Any soft tissue tumor such as lung cancer or breast cancer could have a similar appearance, as could metastatic neuroblastoma, extramedullary hematopoesis, or even infarction. An inflammatory process i . unlikely be cause or the lack of involvement or the intervertebral disc. A hematoma might also have a sim ilar appearance and could potentiaUy be included in the diagnosis; hematoma would not be anticipated to exhibit enhancement.
I TEACH ING ATLAS OF SPINE I MA G I N G
" Case 15 Clinical Presentation The patient is a 73-year-old female with a history of metastatic rcnal cell carcinoma to the liver who now presents with neck pain.
A
Radiologic Findings. , Pre- (Fig. A, lefl) and postcontrast (Fig. A, right) sagittal short TR images reveal ma,ked cxpansion of the spinous process of the C3 vertebral body (righi, *) . Thc spinous process is also rcplaced by intermediate signal intcnsity matcrial. Dorsal encroachment upon the subarachnoid space essentially completely obliterates the subarachnoid space. There is an area of decreased signal intensity within the cervical spinal cord at the C3 level (le/i, arrow head), anterior to the expanded spinous proces of the C3 vertebral body. The marrow within the cervical vertebral bodies is replaced by dccrcascd signal intcnsity soft tissue. The postcontrast short TR image (righl) reveals di ffuse enhancement of the spinous process or C3. Patchy areas of enhance ment in the vertebral bodies of C3 and C2 (while arrow) are also visible on pre- and postcontrast images.
SPINE METASTASES
B
Radiologic Findings (con ti n ued) Axial short TR image precontrast (Fig. B) reveals that the spinous process, laminae, and lateral mass of C3 area are replaced by a decreased signal intensity process ( *). There is obli teration of the subarachnoid space (small arrow). The area of enhancement in Figure A with in the C3 vertebral body is identified in the right side of the vertebral hotly (arrowhead).
PEARL •
Treatment with radiation or surgery as well as follow-up can be based upon the magnetic resonance fi ndings.
Diagnosis Metastatic renal cell carcinoma involving the C3 vertebral body with cord compression.
Differential Diagnosis PITFALL •
The marked compromise of the ubarachnoid space is consistent with impending cord compression.
•
meta tatic disease
Discussion The marrow of the vertebral bodies of C3 throughout the visualized cervical spine is probably replaced with decreased signal intensity tumor. There is only patchy enhancement of the areas of tumor i nvolvement, except for the expanded tumor replaced spinous process of C3. The vertebral artery appears as an area of flow void surrounded by tumor on the right side of the C3 vertebral body (Fig. B, thick white arrow). The left vertebral artery is seen with a central area of increased signal secondary to flow-related enhancement (Fig. B, long thin arrow). The marrow of the vertebral bodies of C3 throughout the visualized cervical spine is probably replaced with decreased signal intensity tumor. This dc-
TEACH I NG ATLAS OF SPINE I MAGING
creased signal intensity results in a "disc reversal" between the abnormal decreased signal marrow and the relatively increased signal intensity of the intervertebral disc. However, there is only patchy enhancement of the areas of tumor involvement, except for the expanded tumor replaced spinous process of C3. Note that the clivus is also replaced by decreased signal intensity tumor. The area of decreased si gn al intensity within the cervical spinal cord (seen in Fig. A) at the C3 level is secondary to edema. Thyroid cancer metastatic to the bone could result in a similar appearance, as could a plasmacytoma. Metastatic lung or breast cancer are also considera tions.
S P I N E M ETASTASES
Case 16 Clinical Presentation The patient i ' a 58-year-old fem<:lle with lower extremity weakness.
A
Radiologic Findings Pre- (Fig. A, left) and posteontrast (Fig. A, right) sagittal short TR images reve<:ll decreased signal intensity soft material replacing the odontoid pro cess, the C2 vertebral body, and the posterior arch of C2 (left, arrow). The odontoid process is expanded and compromises the subarachnoid space, displacing the spinal cord posteriorly. The spinal cord is distorted in a curvilinear fashion at the C I -2 level . The postcontrast sagiual short TR image reveals dense enhancement of the peripheral margin of the odontoid process. The abnormal ity can be seen expanding the C2 vertebral body <:Interiorly and extending into the prevertebr(ll space.
I TEACH I NG ATLAS OF SPINE I M A G I N G
B
c
SPI E METASTASES
Radiologic Findings (continued) Sagittal long TR image (Fig. B) reveals that the process involving the C2 vertebral body is intermediate signal intensity. There is a faint area of increased signal intensity within the lower medulla and upper cervical spinal cord just above t he level of maximal compression (curued arrow). There is marked comprom ise of the subarachnoid space and forward subluxation of the posterior arch of Cl relative to the posterior arch of C2 (white arrows). Axial short TR image postcontrast image at the level of C2 (Fig. C) reveals dense enhancement of the entire C2 vertebral body. There is circumferential encroachment upon the cervical subar�chnllid space (arrowhead) and slight effacement of the right �n terior margin of the spinal cord on the right side (black arrow). The vertebral arteries are surrounded by and narrowed by enhancing tumor (arrow- V on the righl side and wide arrow on the lef' side). The lamina of the C2 vertebral body is expanded and enhances.
PEARL •
[n a patient with such extensive metastatic disease, there may be significant spinal cord encroachment, which may result in spinal cord compression.
PITFALL •
uch extensive disease may result in pathologic fractures and acute quadriplegia. Therefore, neurologic status hould be evaluated and spine stabilization performed as indicated.
Diagnosis Breast cancer, metastatic to the C2 vertebral body with cord compression.
Differential Diagnosis •
rheum(ttoid arthritis
•
calcium pyrophosphate deposition disease (pseudogout)
•
amyloidosis
•
intiammatory process
Discussion Rheumatoid arthritis results in (tn increase in the amount of soft tissue pannus and may result in such extensive destructive changes in the bone as seen in this case. The decreased signal intensity central portion of the odon toid process seen on the postcontrast study (Fig. A, right) is presumed necrotic tumor. Calcium pyrophosphate deposition disease (pseudngout) may also have a similar appearance, as may amyloidosis. However, thc extensive bone destruction is against these l(ttter two diagno es. The long TR images should be evaluated to determine if there is myelomalacia and resulting increased signal intensity within the spinal cord. An unlikely diagnosis includes an inflammatory process such as Mycobacte rium tuberculosis, MycobaClerium auium il1lracellulare, or some other infec tious organism. The lack of prevertebral soft tissue swelling and sparing of the intervertebral disc does not favor an inflammatory process.
I
TEACH ING ATLAS OF SPINE I M A G I N G
Case 17 Clinical Presentation The patient is a 76-year-old male with non-small-cell carci noma of the lung with recent onset of lower extremity weakness.
A
�6
B
SPINE M ETASTASES
c
D
I
I
TEACH I NG ATLAS OF SPIN E I M AGING
Radiologic Findings Sagittal short TR image of the thoracic spine (Fig. A) reveals multiple scattered areas or decreased signal intensity through out the marrow of multiple vertebral bodies. The normal increased signal intensity of the epi dural fat is replaced with intermediate signal intensity at two levels. This is subtle in the upper thoracic region (open arrow) and more obvious in the midthoracic region (black arrow). Sagittal long TR image (Fig. B) reveals persistent areas of decreased signal intensity in the upper (white arrows) and midthoracic (thick white arrow) re gions. Axial short TR image (Fig. C) reveals an in termedi ate signal in tensity soft tissue that compresses the thoracic spinal cord b ilaterally (curved arrow). There is a small right-sided pleu ral effusion (open arrows) and thickening of the pleura on the left side. Axial short TR image in the upper lumbar region (Fig. D) reveals decreased signal intensity in the vertebral body pedicle on the lert side (arrow).
PEARLS •
Evaluation of the paraspinal areas may reveal pleural effusions, as seen in patient.
•
In some patients with metastases, a spin e screening study may be performed that does not include long TR images, but rather short TR images pre- and postinfusion . In these cases, careful evaluation of the short TR images should be performed to evaluate fOT the presence of subtle interruptions of the epidural fat andlor cerebrospinal fluid surrounding the spinal cord.
PITFALL •
Subtle areas of interruption of the epidural fat may be difficult to appreciate.
Diagnosis Metastatic lung cancer with bony and epidural metastases and cord com pression.
Differential Diagnosis •
metastatic disease
•
inflammatory disease
Discussion The involvement of the vertebral body pedicle is very typical of metastatic disease. Occasional ly, the differential diagnosis may include entities such as in nammatory disease. However, the involvement of the pedicle would not be seen in inflammatory disease; this makes the diagnosis of m etastases much more likely. Subtle areas of interruption of the epidural fat may be difficult to appreciate; however, they are more li kely seen on the long TR images. Evaluation of the paraspinal areas may reveal pleural effusions, as seen in this patient. Metastatic prostate cancer would also be a strong diagnostic consideration in this patient. Multiple myeloma, lymphom a, or metastases from any other primary cancer could have a similar appearance.
SPINE METASTASES
I
Case 18 Clinical Presentation The patient is a 78-year-old man with a history of low hack pain and progres sive anemia.
A
B
3�
I TEACHI
G ATLAS OF S P I N E IMAGING
D
Radiologic Findings A nteroposterior plain film of tbe spine ( Fig. A) reveals decreased density thc pcdicle at tbe L3 level. The cortical margin surrounding the pedicle also appears less dense than the adjaccnt vcrtebral bodies. of
Pre- (Fig. B, left) and postcontrast (Fig. B, right) sagittal short TR images of the cervical spine reveal faint, diffuse, tiny areas of randomly distributed areas of decreased signal intensity throughout tbe marrow of the vertebral bodies. There are mild degenerative changes with small osteophytes both anteriorly and posteriorly at CS, 6, a nd 7. The TS vertebral body is identi fied with S. Postinfusion computed tomographic (CT) brain scan (Fig. C) reveals a small area of expansion of the bone (long white arrow) in the posterior frontal region of the right side with a small extracra nial soft tissue component (thick
white arrow). CT scan imaged on high density bone window widths (Fig. D) reveals an area of bone destruction (arrow) in the abnormal area identified in Figure C. In addition, there are multiple additional areas of mottled bony destructive change throughout the bony ca lvari am.
SPINE MET AST A S ES
PEARL •
Correlation with a radionuclide bone scan is helpful to determine the fuU extent of involvement.
�ITFALL •
A radionuclide bone scan when there is extensive diffu e and symmetrical involvement may appear normal.
Diagnosis Multiple myeloma with involvement of the spine and bony calvariam
Differential Diagnosis •
multiple myeloma
•
metastatic disease
Discussion In the bony skeleton and in th e axial skeleton, multiple myeloma may h ave the appearance of diffuse deossi fication by plain film eval uation . The pedicle is typically spared. This appearance may mimic osteoporosis. Some studies have suggested that magnetic resonance (MR) imaging may appear normal in a patient with multiple myeloma. These studies conclude that subtle areas of bone destruction and cortical bone destruction are better demonstrated by CT than by MR imaging. Multiple myelomll is typically seen in olde r males who may present with low back pain and anemia. It is secondary to a malignant increase in the p l asma cells. Solitary accumulations, caUed plasmacytomas, also may occur; these plasmacytomas may occur in the bone or in the soft tissues. Clinical correlation with urine p rotein electrophoresis for abnormal Bence Jones proteins is necessary for complete evaluation . Multiple myeloma mlly 1I1so be associated with amyloid deposition in the marrow of the vertebral body. Diffuse metastases from primary breast cancer may occasionally h ave a similllr appearance.
3111
I TEACH ING ATLAS OF SPINE I M A G I NG
Case 19 Clinical Presentation The patient is a 76-year-old female with hypercalcemia and back pain. There is a new compression fracture of L5 with possible compression of T8.
A
1 392
B
SPINE METASTASES
c
Radiologic Findings Sagittal short TR image of thc thoracic spine (Fig. A) reveals mottled signal intensity involving the marrow of all of the thoracic vertebral hodies. There are a few scattered areas of increased signal in tensity, probably the only remaining normal marrow (black arrow). There is a very sLight compression fracture of one of the upper thoracic vertebral bodies (white arrow). Sagittal short TR image prim to the infusion of contrast material (Fig. B) reveals almost complete replacemcnt of the marrow of the vertebral bodies with decreased signal intensity soft tissue. The LJ ( 1 ) ve rtehral body is normal signal intensity. There are compression fractures of TI2 and Ll, 2,
I
TEACHING ATLAS OF SPINE IMAGING
Radiologic Findings (continued) 3, 4, and 5. The most marked compressi on is or the LS vertebral body (arrow). There is slight re trop ulsion of the poster ior margin of the LS vertebral body into the vertebral canal. Sagittal short TR image postcontrast (C+) enhancement (Fig. C) reveals minimal diffuse en hancemen t throughout the marrow of the vertebral bodies (white arrow at LS) . The Ll vertebral body is i d entifi ed with 1 .
PEARL •
Tn a patient with such extensive metastatic disease, there m ay be significant spinal cord encroachment, which may result in spi n al cord compression.
Diagnosis Multiple myeloma with d i ffuse mllTTOW involvement and m u ltiple pathologic compression fractures.
Differential Diagnosis •
multi ple myelom a
•
metastatic disease
•
leu ke mi a
•
l ymphoma
PITFALL •
In occasional cases of m ultiple myeloma, there is homogeneous enhancement of the involved vertebral body marrow after the infusion of contrast material. This results in obliter ation of the ability to appreciate the diffuse marrow replacemen t with tumor. This may occasionally occur with other tumor involvement as well. Therefore, a postinfusion o nly study should not be performed. In rare cases, the involvement may be so diffuse and the areas of abnonnal tumor d ep os i t i on so small that the scan may appear normal. In these rare cases, computed tomographic scanning may b e more useful and accu r ate for the diagnosis of multiple myeloma.
Discussion Multiple myeloma is more common in men than in women, altho ugh the diffuse nature of the process makes multiple myeloma a strong consideration in this patie n t . Metastatic breast cancer could also have a similar appearance, even in a p atien t who is not known to have breast cancer. The amount of enhancement seen postinfusion is very variab le in a patient with metastatic cancer, and a predictio n of the extent and type of cancer cannot be made based upon the enhancement characteristics. There may be a soft tissue component with multiple myeloma , so cord compression may occur. M u ltiplanar imaging with magnetic resonance is the most sensitive diagnostic proced u re .
If there is di ffuse hom ogeneo us involvement of the marrow, the sca n may appear normal. In those cases, compalison with an uninvolved area such as the iliac crest or hip bone marrow m ay be helpful for more complete and accurate evaluation. Leukemia, lymphoma, or di ffuse me tastases from any primary soft tissue tumor could have a similar appearance (white arrow at LS).
SPIN E METASTA SES
Case 20 Clinical Presentation The patient is a 68-year-old female with anemia and low back pain.
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals di ffuse scattered areas of decreased signal intensity in the visual ized marrow. There is a moderate compression fracture of the Ll vertebral body (short arrow) and a mild compression fracture of the superior end plate of the L4 vertebral body (long arrow). There is anterior bulging of the discs at multiple levels. Axjal short TR image (Fig. B) reveals a small soft tissue mass that surrounds the vertebral body (arrows) and extends into the vertebral canal anteriorly,
3�
I
TEA CH I NG ATLAS OF S P I N E I M A G I N G
B
PEARL •
M R i maging of the spine may be normal in the patient with multiple myeloma. In these case , cr scanning may reveal the subtle areas of bone destruction not demonstrated by MR imaging, such as those involving the transverse process in thi s case. Correlation should also be m ade with laboratory evaluation of the presence or absence of elevated protein, such as Bence Jones proteins.
compressing the subarachnoid space. There is also an i ndistinct margin around the cortex of the vertebral body (curved arrow) in the area o[ the transverse process.
Diagnosis Multiple myeloma.
Differential Diagnosis •
metastatic disease
•
multiple myeloma
•
osteoporosis
PITFALLS •
•
In the patient with m ultiple myeloma, the postcontrast tudy may reveal that the spine returns to a normal appearance. Therefore, the study should not be performed as a postinfusion only study as the abnormality may then be appreciated. Patients with multiple myeloma may also have a ociated renal failure, so consideration of this clinical condition must be given prior to the i nfu ion of contrast material.
Discussion The diffuse increased signal of the bone marrow could be secondary to osteoporosis. The areas of uecreased signal are secondary to involvement with myeloma. Because there is no paraspinal mass in a patient with osteopo rosis, the presence of a mass favors metastatic disease. It has been shown that computed tomographic (CT) scanning may demonstrate areas of involvement with myeloma and particularly areas of cortical bone destruc tion that are not visible by magnetic resonance (MR) imaging. Therefore, if clinical symptoms warrant and the M R scan is negative, CT should be obtained. However, it should be conversely noted that M R is generally more sensitive than CT scanni ng, and CT may fail to identify changes readily demonstrated by MR imaging. Diffuse metastatic breast cancer could also have a similar appearance, as could metastases from any soft tissue primary tumor.
SPI N E M ETASTASES
Case 21 Clinical Presentation The patient is a 43-year-old female with known breast cancer who presented with moderate dorsal spine pain.
A
Radiologic Findings Pre- (Fig. A, lefl) and postcontrast (Fig. A, righT) sagittal short TR i mages reveal very subtle diffuse patchy decreased signal intensity throughout the marrow of the vertebral bodies. A subtle compression fracture of the T6 vertebral body (lefl and righI, arrows) is also visible. There appears to be a very small soft tissue component that extends posteriorly into the vertebral canal at the level of T6 and compromises the subarachnoid space. Sagittal reconstruction image (Fig. B) of the thoracic spine following a computed tomographic (CT) scan reveals the compression fracture of the T6 vertebral body (arrow) with a bilobed area or low density in the midportion of the vertebral body that extends to the corlex posteriorly and inferiorly. The remaining vertebral bodies appear normal in the CT scan.
I TEACH ING ATLAS OF SPINE IMAGING
B
PEARL The cli nical history i very important in the evaluation of tbis patient.
Diagnosis
•
PITFALL •
The MR scan potentially could be considered within normal limits without knowledge of the clinical bi tory a nd close evaluation of the images.
Di rfuse metastases involving multiple vertebral bodies with a pathologic fracture at T6.
Differential Diagnosis •
metastatic d isease
•
multiple myeloma
Discussion In this patient, it required a combination of both cr and magnetic resonance (MR) to diagnose tbe wide extent of the changes secondary to metastases. Cl inical correlation with serum protein electrophoresis is necessary to evalu ate the presence or absence of mUltiple myeloma. Radionuclide bone scan ning may also be helpful to determ ine the extent of involvement. When there is d iffuse involvement, the abnormality may not be appreciated and the i ndex of suspicion should be high regarding the possibility of meta static disease. M ultiple myeloma would be a consideration in this patient but would be unl ikely in a patient aged 43 years. D iffuse metastases from lung cancer could also have this appearance.
SPI E M ETASTASES
Case 22 C1inical Presentation The patient, a 68-year-old malc with known proslllle Cllncer, presented 3 months ago with macroglobulinemia and new L1 level back pain withoul radicular component. He now presents with more marked low back pain.
A
B
I TEACH!
G ATLAS OF S P I N E I MAGING
c
D
Radiologic Findings Sagittal short TR image (Fig. A) reveals mild compression fractures of L4 and L5. There is decreased signal intensity of the vertebral body end plates adjacent to the end plates of L3 and L4. There is anterior herniation of the disc at the L3-4 level. The remainder of the vertebral bodies reveal a few mi nor scattered areas of decreased signal intensity. The Ll vertebral body is iuentified with 1 . Three months later the patient presents with even more marked low back pain. Sagittal short TR image at the time of follow-up (Fig. B) reveals a new compression fracture of Ll . There is retropulsion of the posterior superior corner or the L1 vertebral body into the vertebral canal with obliteration of the subarachnoid space. There is encroachment upon the vertebral canal anteriorly at this level. The spinal cord is displaced posteri orly, and increased compression deformity of the L4 (4) and L5 vertebral bodies can be noted. The remainder or the vertebral bodies reveal mottled decreased signal intensity within the marrow spaces. The T12 vertebral bouy is identified with 1 2.
1 400
S P IN E M ETASTASES
Radiologic Findings (continued) Long TR image (Fig. C) reveals the mottled signal inte nsity of the marrow within t he vertebral bodies and better demonstrates the encroachment upon the vertebral canal at Ll . The vertebral pedicles are expanded bil a terall y . Pre- (Fig. D, top) and postcontrast (Fig. D, bottom) axial short TR i mages at the L4 level ubt"ined reveal diffuse enhancemen t of the vertebral body on the postcontrast image. A small paraspinal mass that surrounds the vertebral body (boltom, arrow.\') is also visible. Importantl y , there is destruc tion of the normally decreased signal intensity cortical margin of the verte bral body on the right side (top, arrows).
:PEARL •
The diffuse involvement of all the visualized bony structures wi th very small decreased signal metastases is ty p i cal of myelo m a.
PITFALL •
The patient could aJso have metastatic prostate cancer, as thi cancer may metastasize with a similar appearing pattern. However, the cortical bone destruction is more in favoT of m ultiple myeloma. Metastases from prostate cancer are more l i k e l y to be osteoblastic.
Diagnosis Multiple m yeloma with rapid progression.
Differential Diagnosis •
multiple myeloma
•
metastatic disease
Discussion The rapid progression may be seen in m u l tip l e myeloma. Clinical correlation should be performed with serum electrophoresis and identification of the typical Bence Jones proteins in urine. Metastatic prostate cancer would also be a consideration; however, no focal lesions are seen. The "bsence of focaJ lesions does not rule out metastatic prostate cancer, as occasionally the appearance could be si milar to this case. Therefore, clinical correlation with the other la bo ra tory tests, particularly p rotein electrophoresis, is necessary. The rapid progression could occur in either disease.
I TEACH I NG ATLAS OF SPI N E I MA G I N G
Case 23 Clinical Presentation The patient is a 72-year-old male with a history or anemia and lower extrem ity weakness.
A
B
Radiologic Findings Sagittal long TR image of the lower cervical and upper thoracic spine (Fig. A) reveals mottled signal intensity of multiple vertebral bodies. There is increased signal intensity in the C7 vertebral body. Incidentally noted are mild degenerative changes i n the cervical spine. The spinous processes are also i nvolved with decreased �ignal intensity metastatic disca e. In the tho racic region, beginning dorsa lly at the T2-3 Icvcl, there is a soft tissue epidural mass (m) that extends inferiorly. The thoracic spinal cord is disph:H.:ed anteri orly and compressed against the posterior margin of the thoracic vertebral bodies. The cerebrospinal fluid-containing space posterior to the spinal cord at the C7 through T2 level is enlarged. The spinal cord. soft tissue mass, and expanded cerebrospinal nuid space meet at the T3 level (arrow).
14 U2
Sagittal short TR image arter contrast enhancement (Fig. B) reveals dense homogeneous enhancement of the epidural mass (m). The thoracic spinal cord appear as an area of intermediate signal intensity compressed against
SPI
E METASTASES
c
the posterior margin of the vertebral bodies. The n arrowed subarachnoid spa ce projects anterior to the mass and behind the spinal cord (arrow). A x ilil s h o r t T R postcontrast image (Fig. C) reveals the soft tissue mass (m) almost totally surrounding the thoracic spi n al cord (arrow-c). The spinal cord is compressed into a tria ngular shaped mass.
PEARLS •
Chloroma may also result in a similar appearance.
•
Findings should be correlated with a history of any known primary cancer.
PITFALL •
Metastases of any type could cause a similar appearance.
Diagnosis Mul tiple myeloma involving the bony structures and formi ng a soft tissue m ass dorsal to the spinal cord resulting in cord compression.
Differential Diagnosis •
multiple myeloma
•
chloroma
•
metastatic disease
Discussion Mul tiple myeloma is typically a disease of the ma rrow of the bones; however. it may occasionally present, as this patient did, with a soft tissue mass. Myeloma and plas m acytoma may also occur in the soft tissues remote from the bony structures. A chlorom a or metastatic disease from a variety of primaries m ay also have a si mila r appearance. These i ncl ude metastatic breast and l ung cancer as well as more unusual primary tumors. The diagnosis was confirmed at surgery, and CT-guided needle biopsy or ope n surgical biopsy may be necessary for final diagnosis.
I TEACHING ATLAS OF SPINE IMAGING
Case 24 Clinical Presentation The patient is a 68-year-old female with a severe low back pain and lower extremity weakness.
A
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images reveal replacement of the normal high signal intensity epidural fat with decreased signal i ntensity tumor at the level of L3 (left, while arrow). This soft tissue mass enhances following the infusion of contrast material (right, black and white arrow). There is a compression fracture of the L5 vertebral body and a faint area of decreased signal intensity is seen in the anterior portion of the L5 vertebral body (right, open white arrow). Incidentally there are degenerative changes at multiple level. with anteriur anJ posterior osteophytes. The marrow within the vertebral bodies reveals a fa int pattern of mottled decreased signal intensity on the precontrast scan and diffuse enhancement post contrast.
1 4 U4
SPTN E M ETASTAS E S
B
c
I
I TEACH I NG ATLAS OF SPINE IMAG ING Radiologic Findings (continued) Parasagittal postcontrast short TR i magc (Fig. B) reveals an enhancing soft tissue mass on the right side (arrows). The mass obliterates the normal epidural fat and com presses the thecal sac a long the upper margin of the mass. Axial short TR image obtained pre- (Fig. C, lap) and postcontrast (Fig. C,
bottom). There is a soft tissue mass in the right paraspinal region (asTerisk) that extends medially into the vertebral canal via the intervertebral foramen. The mass erodes the posterior margin of the vertebral body (open white arrow) and extends into the vertebral canal. The mass extends dorsally within the vertebral canal to obliterate the dorsal epidural h igh signal intensity fat (solid arrow). This is at the level of L3, as identified on the sagittal view. The mass enhances post contrast (bottom). There is probably extension into the dorsal paraspinal muscles. There appears to be fatty infiltration of the paraspinal muscles (top, arrowheads). PEARL The postcontrast appearance of the vertebral bodies is essentially normal. Wllile this appearance may be seen with any metastatic tumor. multiple myeloma is the primary tumor that typically results in this diffuse homogeneous enhancement. •
Diagnosis Multi ple myeloma with diffuse infiltration of the bone marrow of the verte bral bodies and with a soft tissue mass.
Differential Diagnosis •
metastatic disease
•
multiple myeloma
•
Ewing's sarcoma
p rTFALLS •
Multiple myeloma may present with a wide variety of appearances. A number of metastatic tumors might have a similar appearance.
Discussion In an elderly fem ale patient, a disease such as metastatic breast or lung cancer are strong considerations. In a male patient, metastatic prostate carcinoma may have a inJilar appearance. A pri mary thyroid cancer with metastase could also have a similar appearance. I n a much younger patient, Ewing's sarcoma might have a similar appearance. Ewing's sarcoma tends to have a small component extending into the vertebral canal , but a large soft tissue component. The multiplanar inJaging of magnetic resonance allows the eV(lluation of the paJaspinal regions and the determination of the extent of the soft tissue component. The entire vertebral column should be evaluated.
1 1106
SPIN E M ETASTASES
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Case 25 Clinical Presentation The patient is a 69-year-old female with and a history of chronic renal failure.
A
a
rapidly progressive paraplegia
B
I TEAC H I N G ATLAS OF SPI N E IMAG ING
c
D
I �08
SPIN E M ETASTASES
Radiologic Findings Sagiual short TR image in the cervical and upper thoracic region (Fig. A) reveals a slightly irregularly marginated area of i ncreased signal i ntensity dorsal to the spinal cord throughout the entire visualized length (single arrows). There is a smaller linear area of i ncreased signal intensity anterior to the spi nal cord at the C7-TI level (double arrows anteriurly). The normal increased signal intensity epidural fat has been obliterated. The vertebral bodies reveal di ffuse mottled decreased signal i ntensity. Sagittal long TR i mage (Fig. B ) reveals that the area of increased signal demonstrated in Figure A now appears even greater in increased signal i ntensity both anterior and po terior to the spinal cord (arrows). The verte bral marrow reveals patchy areas of increased signal intensity. Axial short TR image (Fig. C) reveals bilateral areas of increased signal intensity masses (white arrows) that are d isplacing the cord (hluck arrowhead anleriurly) and compressing it. Increased signal intensity pleural efhlsions are visible bilaterally. Sagittal short TR image in the lumber region (Fig. D) reveals that every visualized vertebral body contains small areas of decreased signal intensity. These areas are also present in the spinous processes. One is well demon strated at the L4 level (open arrow). Compression fractures of multiple vertebral bodies can be noted. PEA RLS B leeding tendencies must be evaluated clinically. •
•
The possibility of two disease processes in a single patient, as seen in this case, must be considered.
PITFALL •
Osteoporosi , which may also lead to m u ltiple compression fractures, results in increased signal i ntensity within the vertebral bodies secondary to increased fat deposition. M ultiple myeloma results in decreased signal intensity tumor replacing the norlllal marrow.
Diagnosis M u ltiple myeloma; multilevel epidural hematoma predominantly posteri orly, but also present anteriorly; bilateral bloody pleural effusions (Fig. C,
open arrows).
Differential Diagnosis •
multiple myeloma
•
metastatic disease
Discussion Patients with mUltiple myeloma may have abnormalities of many organ systems. This patient exhibits the typical ehanges of multiple myeloma in the marrow of the vertebral bodies, but in addition, has an epidural hematoma secondary to low platelets that has resulted in spinal cord compression. If a postinfusion-only magnetic resonance study is performed, one could mistake the increased signal intensity areas of blood for areas of enhance ment. Therefore, a study should not be performed postinfusion only. The subtle interruption of epidural fat may be d ifficult to (Ippreeiate but may be identified with careful evaluation. Metastatic breast cancer in a female and metastatic prostate cancer in a male could also have a similar appearance as the bony changes in this patient. Epidural hematoma in a patient with mu ltiple myeloma is a diagnostic consideration. Cases of multiple myeloma with masslike lesions may result in a similar appearance (see Case 23).
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TEACHING ATLAS OF S P I N E IMAG ING
Case 26 Clinical Presentation The patient is a 68-year-old female with a clinical history of stiff neck and a 5-day h istory of increased neck pain with head rotation.
A
B
810
SPLNE METASTASES
Radiologic Findings Sagittal short TR images of the cervical spinc pre- (Fig. A , P) and postcon trast (Fig. A, £) enhancement. Thc prcinfusion scan reveals the "disc rever sal" sign of diffuse dccrcased signal intensity of the marrow o[ the vertebral bodies and spinous processes. In the normal patient, the vertebral body bonc marrow is increased signal intensity because of the intrinsic amount of adipose tissue. In this patient, the intervertebral disc is increaseu signal intensity relative to the vertebral bouy because of the marrow replacement with osteoblastic tumor. The postinfusion scan reveals patchy areas of en hancement. Note the soft tissue component obl itcrating the normal high signal intensity fat between the spinous processes of C6 and C7 which enhances after contrast infusion (right, arrow). Proton density (Fig. B, PD) and long TR (Fig. B , T2) images reveal mottled increased signal intensity. The areas of osteoblastic meta tases remain dc creased signal intensity.
Diagnosis Metastatic breast cancer with diffuse osteoblastic metastases.
PEARL •
Correlation with plain film evaluation will readily demonstrate the osteoblastic meta tases.
PITFALLS •
When the marrow is diffusely abnormal, the appearance may m i m ic a normal spine.
•
In rare cases, the abnormalities may be completely obliterated on the postin [usion portion of the study.
•
RadionucLide bone scanning may also be helpful to determine the extent of the disease.
Differential Diagnosis •
metastatic disease
•
multiple myeloma
Discussion Osteoblastic met,astases tend to remain decreased signal on long TR images because of the dense bone formation associated with the various diseases. In a male patient, metastatic prostate cancer is most l i kely to exhibit this appearance. Occasionally, multiple myeloma may be osteoblastic, particu larly in t he clinical setting of the POEMS synurome (organomegally, eosino philia, endocrinopathy, and myeloma). In the female patient, metastatic breast cancer that was originally 0 teolytic but has been treated and the growth slowed will become osteoblastic later in the course of the disease. ' Even untreated metastatic breast cancer may rarely appear osteoblastic in some patients. i Radionuclide bone scanning and correlation with other laboratory tests, such as for Bence Jones protein, is necessary for absolute eV
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TEACHI N G ATLAS OF SPINE IMAGI
G
Case 27 Clinical Presentation The patient is a 53-year-old female with known breast cancer. The patient presented with upper a nd lower extremity weakness.
A
SPIN E M ETASTASES
Radiologic Findings Sagittal short TR image obtained pre- (Fig. A, left) and postcontrast (Fig. A, right) enhancement reveal that C7 through T4 are essentially totally replaced with decreased sign�1 intensity soft tissue; C6 (right, 6) is incom pletely replaced with decreased signal intensity soft tissue. The spinous processes of C7 through the upper thoracic region are also replaced with decreased signal intensity tumor; this markedly low signal intensity is com patible with replacement with osteoblastic tumor. Note that the spinal cord cannot be visualized on the preinfusion scan at the level of C7 through T4 because it is surrounded by isointense soft tissue material. The postcontrast study (right) reveals variable enhancement of the marrow within the verte bral bodies. In addition, there is circumferential enhancement of an epidural soft tissue mass surrounding the spinal cord. There is enhancement of the epidural space extending dorsally at the level of C5-7 (open arrows). The spinous process of the first thoracic vertebral body is identified with T\ . Axial short TR image postcontrast enhancement (Fig. B) reveals diffuse enhancement of soft tissue surrounding t he thecal sac and the spin�l cord (short armw). There is marked compression of the subarachnoid space, which is visible as a thin low signal intensity � rea (long arrow). The vertebral body exhibits markedly decrea ed signal intensity.
PEARL •
When the spinal cord and its surrounding subarachnoid space are not well demonstrated, the possibility of tumor or another soft tissue involvement should be considered.
PITFALL •
Osteoblastic metastases are markedly decreased in signal intensity because they are bone producing.
Diagnosis Breast cll ncer with osteoblastic metastases with soft tissue epidural compo nent and spinal cord compression.
Differential Diagnosis •
metastatic disease
•
meningeal carcinomatosis
•
melanoma
Discussion The i nability to visualize the subarachnoid space is consistent wi th an abnor mality. The obliteration of the subarachnuid space could be secondary to the fact that the spinal cord is enlarged. On the other hand, the soft tissue encroaching upon the subar�chnoid space may be causing the obliteration. When this appearance is present, the study should be performcd with a postinfusion scan, long TR images, or a combination of these imaging tech n iques. Meningeal carcinomatosis coulu also have a similar appearance; however, the abnormal bony structures strongly suggest that this is a soft tissue component associated with bony metastases. The thin anatomic structure of the spinous processes makes them difficult to visualize, so involvement of the spinous processes with tumor may be difficult to appreciate. The multi planar i maging capability of magnetic reso nance makes it very helpful for evaluaiton a nd typically precludes the need for myelography. In a male, met�static prostate cancer would be a strong consideration . Melanoma could also have decreased signal intensity metastases, but this is far less likely.
I
TEACHIN G ATLAS OF S PI N E IMA GING
Case 28 Clinical Presentation The patient is a 65-year-old man with known prostate cancer who now presents with low back pain .
A
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR image reveals di ffuse replacement of multiple vertebral bodies with decreased signal inte nsity tumor . A pathologic fracture of the L3 vertebral body is visible, with extension of the tu�or into the vertebral ca n al at the L3 level (3). The postcontrast study reve als patchy enhancement of the vertebral bodies, enhancement of the soft tissue component extending i nto the verte bral can al and into the epidural space above and below the L3 vertebral body, and enhancement of the para-aortic lymph nodes surrounding the abdominal aorta (white arrows). Enhancement of the tumor extends into the lumbar vertebral canal at the L3 level, and the thecal sac is essentially completely obliterated at this level, resulting in cauda equina compression. Incidental ly tumor can be seen obliterating the normal epid ural fat at the level of L2-3 (curved arrow).
SPI N E M ETASTASES
I
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c
Ll 1 51
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TEACHING ATLAS OF SPfNE IMAGING
Radiologic Findings (continued) SCigittal long TR i mCige (Fig. B) reveals that there is variable increased signal intensity of the vertebral metastases. The para-aortic lymph nodes also become increased signal intensity. Th e relropulsed portion of the L3 verte bral body is seen io the vertebral canal (arrow) . Axial short TR postcontrast image (Fig. C) reveals lobul ated tumor ex tending into the vertebral canal (black arrows) and compressing the th ecal sac and cauda equinCi. There is involvement of the pedicle on the left side.
PEARL •
Fat saturation postcontrast study may better identify bony metastases.
Diagnosis Metastatic osteoblastic prostate carcinoma.
Differential Diagnosis PITFALL •
Magnetic resonance imaging may n ot allow differentiation between soft tissue melastatic disease versus bony metastases encroaching upon the vertebral canal. cr scanning may be necessary to differentiate between the two processes if surgery is contemplated for relief of symptoms of cord compression.
•
metastatic disease
•
multiple myeloma
Discussion In addition to the most likely diagnosis of metastatic prostate cancer in this pCltient, multiple myeloma m ight a lso have a similCir Clppearance. Metastatic prostate cancer may occasionally have very subtle presentation with very th i n "on ion skin paper"-like metastatic disease with expansion of the bone. In some cases, if surgery is an option, computed tomography (CT) may allow a more accurate evaluation of the amount of bone involvement with reSUlting compromise of the vertebral canal or spinal cord. In a female patient, metastatic breast cancer should also be considered in multiple my eloma. A CT-guided bone biopsy or even open decompressive biopsy may be necessary for complete eval uation. Radionuclide scan ning may also allow for a more accurate evaluation of the true extent of the disease.
SPI N E M ETASTASES
Case 29 Clinical Presentation The patient is a 43-year-old female with known diffuse osteoblastic bony metastases who now presents with severe low back pain and leg weakness.
A
Radiologic Findings Sagittal short TR image of the lower cervical and upper thoracic spine (Fig. A) reveals that all the vertebral bodies are diffusely replaced with decreased signal intensity soft tissue. in addition, there is a soft tissue compo nent that encroaches upon the vertebral canal in the lower cervical region, obliterating the cervical spinal cord (white arrow). The spinous processes and the interfacet joints are also diffusely involved with low signal intensity soft tissue material.
I TEACH I
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c
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SPINE METASTASES
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D
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Radiologic Findings (continued) S
419
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TEACHI N G ATLAS OF SPINE IMAGING
Radiologic Findings (continued) small solid arrows). There is forward displacement of L3 relative to L4 (left, lhick solid arrow). The postcontrast images reveal variable enhancement. ParasagittaJ short TR image postcontrast at the level of the lumbar interver tebral foramen (Fig. C) reveals a "halo" of soft tissue metastatic disease surrounding all the intervertebral foramen (black arrows). There is also encroachment upon the intervertebral foramen at all levels with enhancing soft tissue. There is a fracture through the pedicle of the L3 vertebral body (Fig. D,
open arrow). Axial short TR images obtained pre- (Fig. E, left) and postcontrast (Fig. E, right) reveal diffuse involvement of the vertebral body with a soft tissue component. The postcontrast study reveals the p araspinal soft tissue compo nent, which exhibits enhancement. The mass is larger on the left side than on the right side. There is extension into the intervertebral foramen bilater ally (right, a rro ws) .
PEARLS •
•
The entire vertebral column should be evaluated in a patient with metastatic disease. Osteolytic metastases may become osteoblastic deposits after chemotherapy or radiatio therapy when tumor growth ha. slowed sufficiently to allow bone growth.
PITFALL •
A surgical approach to a patient such as this would probably not be successful because there is no focal mass that couJd be removed.
4 20
Diagnosis Diffuse osteoblastic metastatic disease with mild soft tissue component in the lower cervical region and multiple pathologic fractures.
Differential Diagnosis •
osteoblastic metastatic disease
•
multiple myeloma
•
metastatic disease
Discussion Osteoblastic metastatic breast cancer may remain relatively stable in appear a nce for long periods of time. If sufficiently extensive, as in this patient, there may be a soft tissue component with extension into the vertebral canal and into the foramina, which results in severe constriction of the nerve structures. Such severe involvement, as in this case, is not amenable to surgical treatment. This patient's postinfusion scan highlights the soft tissue component of the soft tissues of the interspinous ligament. This latter finding is somewhat unusual. If involvement is sufficiently extensive, the scan may, in some patients with less advanced disease, appear almost normal . There fore, the index of suspicion should be high and correlation performed with other tests, such as radionuclide scanning as well as CT-guided bone biopsy. In any patient with metastatic disease, the entire length of the vertebral column should be evaluated. In a male patient, metastatic prostate cancer would be the most likely diagnosis.
S P I N E M ETASTASES
Case 30 Clinical Presentation The patient is an 18-year-old with known osteoge nic saf(;oma of the lower extremity who now presents with lower extremity weakness.
A
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A , right) sagittal short TR images of the l umbar spine reveal pathologic compression fractures of all of the lumbar vertebral bodies except L2 and L5. In addition, all the visualized vertebral bodies are replaced with markedly decreased signal intensity tissue. There is expansion or the L5 vertebral body with encroachment upon the lumbar subarachnoid space. The postcontrast study reveals enhancement of the T1 2 vertebral body (right, broad arrow) and enhancement of the tissut: extending posterior to the vertebral hody of L5 (open curved arrow).
42 1 1
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1Q2
c
SPINE M ETASTASES
Radiologic Findings (continued) Sagittal long TR image in the lumbar region (Fig. B) reveals that the in terver tebral disc appear increased signal intensity. However the vertebral bodies : continue to appear markedly decreased i n signal intensity. There is retropul sion of the posterior margin of one or the upper vertebral bodies into the vertebral canal. The L2 vertebral body has preservation of the normal height but is markedly decreased in signal intensity (arrow). Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images rev eal the ill-defined p eripheral margin of the L5 ve rtebra l body w ith the enhancing soft tissue surrounding the vertebral body (right, arrowheads).
PEARL •
Osteoblastic metastases reveal diffuse decreased signal intensity in response to all pulse sequences.
Diagnosis D iffuse osteoblastic metastases from the patient's known prim ary osteo genic sarcoma.
Differential Diagnosis PITFALL •
•
osteoblastic metastatic disease
If
the involvement is diffuse and symmetric, the study could potcntial1y appear nonn al .
Discussion In a young patient with less extensive disease, the decreased signal intensity m arrow could be interpreted as normal. However, the presence of mUltiple compression fractures is definitely abnormal. Radionuc1ide bone scanning might be helpful for more complete evaluation. In the presence of osteoblastic bony metastases, osteogenic sarcoma is a strong consideration. In the very young patient, med ulloblastoma may also exhibit osteoblastic metastases and would be a consideration . Neuro blastoma may also exhibit di ffuse involvement. The clinical history and evaluation of other organ systems would be helpful for more complete evaluation and would be necessary in any patient such as this. In a female patient, metastatic osteoblastic breast cancer could have this appearance; while in a male, metastatic prostate cancer could have this ap pearance.
42 3 1
TEACHING ATLAS OF SPINE I M A G I N G
Suggested Readings n, Wood GW, Eames FA, Hicks R A . Cf-guided needle aspiration biopsy of
Abrahams
an intraspinal synovial cyst (gangl ion): case report and review of the literature. Al NR. 1988;9: 39R-400.
Bender CE,
Berquist
TH , Wold LE. Jmaging assisted percutaneous biopsy of the thoracic
spine. Mayo Clin Proc. 1986;61 :942-950. B lack P. Spinal metastasis: cutTent status and recommended guidelines for management. Neurosurgery. 1979;5:726-746.
Boukobza M , Mazcl
C, Touboul E . Primary vertebral and spinal epidural non- H odgk in's
lymphoma with spinal cord compression. Neuroradiol. 1996;38:333-337. Brugieres P, Gaston A , Heran F, Voisin MC, M a rsClull
e. Pcrcutaneous biopsies
o f t he
thoracic spine under CT guidance: transcostovertebral approach. lCA T. '1990; 1 4:446-448. Byrne TN , Waxman SG. Paraplegia and spinal cord syndromes. In: Bradley WG, D a rof(
RE, Fenichel G M , Marsden CE, eds.
Neurology in Clinical PraClice: Principles of Diagnusis
and Managemem. 2nd ed. Boston, M A : Butterworth-Heinemann; 1996:345-358.
C h amberla i n MC, Friedman HS. Leptomeningeal metastases: presentation, di agno s i s, and management considerations. I n : Levin V A , ed. Cancer i n t h e Nervous System. New York,
NY : Church ill Livingstone;
1996:281-2c,lO.
Constans JP, De Devitis E, D o n zelli R, Spaziante R, Meder JF, Haye
e. Spinal metastases
with neu rological manifestatio ns: review of 600 cases. 1 Neurosurg. 1 983;59: 1 1 1 - 1 1 8 . Cotton A, Dt:watre F, Cortet B, et a l . Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of tbe percentage of lesion filling and the leakage of methyl methylacry late a t clin ical follow-up. Radiology. 1996;200:525-530. Crasto S, Duca S , Davini
0, et al. MRI diagnosis of intramedullary metastascs from extra
CNS tumors. t'ur Radial. 1 997;7:732-736. Cronquist
S, Greitz D, Maeder P. Spread of blood in cerebrospin al fluid following cra n iot
omy simul ates spinal metastases. Ncuroradiol. 1993;35:592-595. D u n n RC, Kelly W A, Wohns RNW, Howe of thc results
of surgical therapy.
Jf. Spinal epidural nt:oplasia: a IS-year review
l. Neurosurg. 1 980;52:47-5 l .
Ga ngi A , Dietemann J-L, Schultz A, Mortazavi R, Jeung M Y , Roy C . In terventional radio logic procedures with Cf guidance in cancer pain management. RadioGraphies. 1996;16: 1289-1306.
Gilbert RW, Kim J H , Posner J B . Epidural spinal cord compression from metastatic t umor: diagnosis and treatment. Am Neural. 1 978;3:40-51 . Haaga JR, Alfidi
RJ. Precise biopsy localization by computed tomography.
R adiology.
1 976 ; 1 1 8:603-607.
Jen k i ns CN], Colquhoun IR. Case report: symptomatic metastasis from a sacrococcygeal chordoma. Clin Radiol. 1995;50:4l6-4 17. J ones K M . Scbwartz R B , Mantello MT, t:t a l . Fast spin-echo M R i n the detection of vertebral metastases: comparison of three sequences. AlNR. 1994; 1 5 :401.
Hamzc B , Jank iewicz P, Tubiana J-M. Acute vertebral cr findings i n ben ign and malign an t nontraumatic cases. Radiology. 1 91)6;1 99:
Laredo J-D, Lakhdari K, Bella'iche L, collapse: 541 -549.
in multiple n. Assessment o f fracture risk with M R imaging of spinal bone marrow.
Lecouvet FE, Malghem J , Michaux L, el al. Vcrtcbral compression fractures myeloma: part
Radiology. 1997;204:201-205.
Lecouvet FE, Vande Berg BC, Maldague BE, el al. Development of vertebral fractures in paticnts with multi p le myeloma: does MRl enable recognition of vertebrae that will collapse? lCAT. 1998;22:430-436.
Levitt LJ, Dawson O M , Rosenthal D S , Moloney We. Central nervous system involvcment i n the non-Hodgkin'S lymphomas. Cancer. 1980;45:545-552.
KE, Pe rrin RG. The neurosurgical management of spinal melast ast:s ca usi ng cord cauda equina compression. 1 Neurosurg. 1 978;839-843.
Livingston and
Markus
18. Magnetic resonance imaging of intramedullary spinal cord mt:tastases.
CIin
imago 1996;20:238.
Masca1chi M , Torselli P, Falaschi 1995;37:303.
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F, e t a1. MR[ of spinal epidural lymphoma.
Neuroradinl.
SPINE M ETASTASES Mauney M, Sciotto CO. Primary malignant l y mphoma of the eauda equina. A m J SLlrg PatllOl. 1 983;7:185-190. Mead OM. Kennedy P. Smith JL, t:t al. Invulvement of the central nervous system by non Hodgkin's lymphoma m adults: a review of 36 cases.
QJM. 1986:60:699-7 l4.
Mehta RC, Marks MP. Hinks RS, t:t al. MR evaluatiun u f vt:rtebral metastases: TI -weighted, short-inversion-time inversion recovery, f,tst spin-echo, and inversiun-recovery fast spin-echo sequences. AJNR. 1 91)5;16:281 -28K Moulopoulos LA, Dimopoulos MA. Magnetic resonance of the bone marrow in hematologic malignancies. Blood. 1 91)7;90:21 27-2147. Moulopoulos LA, Kumar AJ, Leeds NE. Second look at unenhanced spinal magnetic reso nance imaging of malignant leptomeningeal disease. Clill Imag. 1 997;21 :252-259. Mou lopoulos L A. Yoshimitsu K, Johnston DA. el al. M R prediction of benign and malignant vertebral compression fractures. lMRI. 1 '1'16;(,:067-674. Pedersen AG, Bach F. Melgaard B. Frequency, diagnosis, and prognosis of spinal cord compression in small cell bronchogenic carcinoma: a review of 8 1 7 consecutive patients. Cancer. 1 985;55: 1 8 1 8- 1 822. Price RA, Johnson WW. The central nervous system in childhood leukemia. I . The arachnoid. Callcer. 1 973;31 :520-533. Sajjad Z, Haq N, Kandula V. Cast: repu r t : granulocytic sarcoma (GS) presenting in acute cord compression in a previously undiagnosed patknt. c/ill Radiul. 1 997;52:69-7 1 . Smith TP, Gray
L.
Weinstein IN, Richardson WJ, Payne CS. Preoperative transarterial
embolization of spinal column neoplasms. J VIR. 1995:6:863-869. Stabler A, Baur A, Bartl R. t:t al. Cuntrast enhancement and quantiative signal analysis in M R imaging of multiple myeloma: assessment of focal and diffuse growth pattern, in m arrow correlated with biopsies and survival rates. AJR. 1996:167:1029-1036. Stark RJ, Henson RA. Evans SJW. Spinal metastases: a rt:truspt:ctive survey from a general hospital. Brain. 1 982;105:1 89-213. Struk DW. Knapp TR, Munk PL, et al. Pituitary and intradural spinal metastases: unusual initial presentation of lung cancer. Cancer Assoc Radiol J. 1 995;46: 1 1 8- 1 2 1 . Sze G , Krol G , Zim merman R D . Deck M D . Malignant extradural spinal tumors: M R imaging with Gd-DTPA. Nadiology. 1 988;167:21 7-223. Tien R D . Fat-suppression M R imaging in neuroradiology: techniques a n d clinical application. A JR. 1 992; 1 58:369-379. Vande Berg BC, Michaux L, Lecouvet
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et al. Nonmyelomatous mononclonal gammopa
thy: correlation of bone marrow MR i mages with laboratory findings and spontaneous clinical outcome. Radiology. 1 997;202:247-25 1 . Weill A , Chiras
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Simon 1 M , Rose M , Sola-Ma.1inez T. Enkaoua E. Spinal metastases:
indications for and results of percutaneous injection of acrylic surgical cement. Radiology.
1 996; 199:241 -247. Weiner M D , Boyko OB, Friedman HS, Hochenberger B . Oakes WJ. False-positive spinal M R findings for subarachnoid spread of primary CNS tumor in postoperative pediatric patients. A1NR. 1990;1 1 :1 1 00- 1 1 03.
Section VI
Spinal Meningeal Carcinomatosis
•
SPIN A L M ENING E A L CARCI N O MATOSIS
I
Case 1 Clinical Presentation The patient is a 65-year-old female with a history of known breast carcinoma who now presents with increasing lower extremity weakness. Previous bone scan revealed abnormal uptake in L2 and L4.
A
B
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E
G
I
F
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SPINE I M AG LNG
Radiologic Findings Sagittal short TR image (Fig. A ) reveals that the vertebral bodies and intervertebral disc spaces all appear normal. Surrounded by normal sub arachnoid space, the thoracic spinal cord is well demonstratcd. Howcver, the cauda equina is never well seen, and thc cntirc lumbar thecal sac appears dirrusely im;reased in signal intcnsity. There is a rounded area of decreased signal intensity in the inferior end plate of the L4 vertebral body (arrow). The L2 vertebral body appears normal. Sagittal short TR image postcontrast (Fig. B) reveals diffuse enhancement of the nerve roots of the cauda equina (three bottom white arrows). The distal spinal cord is also seen and is surrounded by a ring of densely enhancing soft tissuc (upper white arrow). There is normal enhancement of the interver tcbral basivertebral venous plexus (curved black arrow af L2). Axial short TR image precontrast (Fig. C) reveals the distal end of the spinal cord and the nerve roots of the cauda equina. Short TR image postcontrast (Fig. D) reveals dense enhancement of the nerve roots of the cauda equina (arrows). Short TR images of the brain in the coronal (Figs. E and F) and axial (Fig. G) projections reveal diffuse enhancement of the cerebral men inges.
PEARL •
Inflammatory meningitis and lymphoma could also bave a similar appearance. as could meningeal metastases from any pri mary tumor, including metastatic lung cancer or a tumor ucb as melanoma.
J>ITFALLS •
•
The only abnormalities present on the precontrast scan may be the inability to identi fy the individual nerve roots of the cauda equina and a relatively increased signal intensity of tbe spinal cercbrospinal fluid bccausc of the presence of tumor replacing the cerebrospinal fluid. The i ndex of suspicion needs to be high so that th is diagnosis is not ignored and 80 that a po tinfusion 'can is obtained.
Diagnosis Spinal and cerebral meningcal carcinomatosis secondary to breast cancer, with involvement of tbe leptomeninges (pia and arachnoid) of the spine and brai n. Presumed metastatic deposit in the inferior end plate of the L4 vertebrae.
Differential Diagnosis •
meningeal carcinomatosis
•
inflammatory meningitis
•
lymphoma
Discussion If meningeal carcinomatosis is a suspected clinical diagnosis, it is necessary to perform the examination with the inFusion of contrast matcrial. When the pattern of enhancement illustrated here is identified, a primary tumor must be sought. The primary tumor may be within the central nervous system, such as an ependymoma, medulloblastoma, pinealoma, or glioblas toma; or from a primary tumor outside of the nervous system, such as primary lung or b reast cancer, or mclanoma. The extension of the enhancement into the sulci of thc brain confirm the involvement of the Icptomeninges because it is the pial layer of the brain that extends dcep into the sulci. Meningeal carcinomatosis is the most likely diagnosis in this clinical setting. Inflammatory meningitis secondary to a bacterial organism, sllch as Myco baClerium tuberculosis or a similar organism, . could have a similar appearance, as could lymphoma.
SPINAL M E N INGEAL CA RCINOMATOSIS
Case 2 Clinical Presentation The patient is a 34-year-old male with glioblastoma multi forme of the left frontal lobe who is status post chemotherapy, radiotherapy, and surgery. The patient now presents with new onset or bladder and fecal incontinence as well as back pain.
A
B
Radiologic Findings Precontrast (Fig. A, left) sagittal short TR image in the lumbar region appcars essentially normal. Postinfusion (Fig. A, right) sagittal short TR image reveals irregular enhancement of the meninges dorsal to the distal spinal cord (black arrow). There is enhancement along the surface or the distal spinal cord anteriorly and enhancement of the nerve roots of the cauda equina (white arrows). There is also tumor enhancing in the very distal end of the thecal sac (curved open arrow). Incidentally noted is narrowing of the LS-S I intervertebral d isc. Axial short TR image in the l umbar region postcontrast (Fig. B) reveals dense enhancement of the nerve TOots of the cauda equina (open arrows).
I TEACHING ATLAS OF SPI N E IMAGING
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D
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SPIN A L MENINGEAL CARCINOMATOSIS
E
I
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TEACHING ATLAS OF SPINE l MAGING
G
H
SPINAL MENINGEAL CARCINOMATOSIS
Radiologic Findings (continued) Axial short TR image of the brain postcontrast (Fig. C) reveals postoperative changes in the left frontal region. There is a postoperative area of porenceph aly that exhibits slightly irregular peripheral areas of enhancement with a thin rim anteriorly (open arrow) and a thicker ri m posteriorly (long arrow). There is also mild edema posterior to the tumor and a few rounded areas of enhancement in the basal ganglia on the left. Although there is no mass (probably because of the decompression secondary to the surgery), the findings are highly suggestive of recurrent brain tumor. Coronal short TR images postcontrast reveal (Fig. D) patchy, poorly margin ated areas of enhancement in the left frontal lobe projecting j ust inferior and lateral to the frontal horn of the left lateral ventricle. In spite of chem otherapy and radiation treatment, the patient's condition became worse and a follow-up scan was obtained 2 weeks later. Sagittal short TR image in the lumbar region (Fig. E) reveals that the entire l umbar thecal sac is filled with intermediate signa l i ntensity soft tissue. The nerve roots of the cauda equina cannot be visualized. Sagittal short TR image postcontrast (Fig. F) reveals dense, linear, and patchy areas of enhancement throughout the lumbar thecal sac and sur rounding the distal thoracic spi n a l co rd .
Sagittal long TR image (Fig. G) reveals variable, scattered areas of decreased signal intensity in the distal thecal sac and patchy areas of increased signal intensity within the distal end of the spinal cord. Incidentally noted is a herniated disc at the LS-Sl level. Pre- (Fig. H, left) and postenh ancement (Fi g. H , righl) axial short TR im ages in at the Sl level reveal homogeneous signal intensity soft tissue material filli ng up t he thecal sac on the preinfusion image and dense enhancement o f t h i s tissue postcontrast (right, arrow).
PEARL •
A lthough not common, glioblastoma multiforme may lead to drop metastases to the spinal meninges.
Diagnosis Recurrent cerebral gli oblastoma multifonne w ith drop metastases and re sulting meningeal carcinomatosis.
Differential Diagnosis •
drop metastases with meningeal carcinomatosis
•
i n fective meningitis
Discussion Cunical information is v ital for complete evaluation in this patient, especially in l ight of the rapid progression in the 2-week period between the initi al scan and the follow-up scan 2 w e e ks later. Brain imaging may also be necessary in any patient in which meningeal carcinomatosis is a cunical
�
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TEACHING ATLAS OF S P I NE I M A G IN G
PITFALLS •
•
Meningeal carcinomatosis from a primary central nervous system tumor, such as a pinealoma, or metastases from tumor outside of the central nervous system, such as primary lung or breast cancer, lymphoma, or melanoma, could have a similar appearance.
A postinfusion scan is absolutely necessary for complete evaluation of the patient with meningeal carcinomatosis. Without contrast enhancement, the presence of meningeal carcinomatosis of the spine or brain is usuaUy not identi fi ed.
438
consideration. This rapid progression is unusual in a patient; however, with patients living longer because of better methods of treatment, we are seeing an increased incidence of meningeal carcinomatosis. Drop metastases with meningeal carcinomatosis is the most likely diagnosis in this patient. In a pediatric patient, a PNET (primitive neuroectodermal tumor) could also resul t in a similar appearance. Infective meningitis could have a similar appearance but is unlikely in this clinical setting.
SPIN A L MENINGEAL CARCINOMATOSIS
I
Case 3 Clinical Presentation The patient is a 45-year-old female with hreast cancer with widespread metastases, now presenting with headache and lower extremity weakness.
A
B
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D
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SVINAL MEN I N G EAL CARCIN OMATOSIS
Radiologic Findings Sagittal short TR i mage (Fig. A) reveals that the Tll through the S l vertebral bodies are almost completely replaced by decreased signal intensity soft t i ss ue. The upper anterior portion of TlO is also replaced by decreased sign al intensity tumor (white arrow). T he spinous processes exhibit mottled sign al intensity. There is expansion of the LS vertebral body with a soft tissue component (open arrow) that extends into the vertebral canal. Sagi ttal intermediate TR i mage (Fig. B) reveals that the entire thecal sac appears homogeneous in signal intensity. The vertebral body marrow now reveal faint mottled decreased signal i n tensity within the L3 (open arrow) and T12 vertebral bodies. Sagi ttal long TR im age ( Fig. C) reveals that the vertebral bodies now appear al most normal in si gnal i n te nsity. On l y L4 reveals faint mottled decreased si g n al intensity. The soft tissue expansion of the LS vertebral body is seen extending into the vertebral canal (open arro w).
PEARL •
Note that in the i ntermediate and long TR i mages, as well as in the postcontrast image, the diffuse bony metastases are partially obscured. This appearance is dramatic in this patien t, b ut may be seen in many patients to a variable degree.
Sagi ttal short T R image postcontrast (Fig. D) reveals diffuse irregular en hancement of the marrow within the lumbar vertebral bodies. There is enh ancement of the soft tissue mass behind the vertebral body of L5 (arrow). Preinfusion (Fig. E, Left) axial short TR image reveals that the nerve roots are well demonstrated as individ ual structures. Postcontrast (Fig. E, right) sca n shows dense contrast enhancement of all of the nerve roots i n the thecal sac. This change is secondary to men ingeal carcinomatosis. This change is seen better on the axial than the s agi tta l images.
Diagnosis Di ffuse bone metastases and spinal meningeal carci nomatosis.
PITFALLS •
•
B eca us e the vertebral marrow abnorm ali ty m ay be obscured, both pre- and postinfusion studies should be obtained. The presence of meningeal in volvement with either tumor or inflammation may n ot be appreciat ed on t he noninfused scan.
When the cerebrospinal fluid appears homogeneous in signal intensity with the nerve roots of the cauda cquina, the possibility of involvement with tum or or i nflammat ion should be considered.
Differential Diagnosis •
meningeal carcinomatosis
•
m e n i ngi ti s
Discussion The brain was also involved with di ffuse meni ngelll carci nomatosis . The o nly normal remaining m a rrow appears as areas of increased signal intensity as seen on Figure A (white arrow). Meningitis could also have a similar appearance with the enhancement of the meninges; however, the combination of the in volvement of the vertebral marrow as well as the enhancement of the meningitis is more consistent with meningeal carcin o ma tosi s . These studies should also be correlated with cerebrospi nal fluid analysis w hen appropriate.
I TEACHI
G ATLAS OF SPI N E I M AG ING
F
Follow-up sagittal long TR image obtaint:d several months later (Fig. F) reveals multiple rounded areas of decreased signal intensity in the cervical and thoracic region (white arrowheads). These are consistent with mUltiple metastatic nodules within the thecal sac. The patient refused the infusion of contrast material.
442
SPINAL MEN I NG E A L CARCINOMATOSIS
I
Case 4 Clinical Presentation The patient is a 50-year-old m ale with amyelogenous leukemia refractory to two chemotherapy trials. The patient also has chronic hematuria. The patient now presents with a 4-day history of back pain, a 2-Jay history of urinary and recal incontinence, and dysesthesia in the S2 dermatome.
A
B
443 1
I TEACH ING ATLAS OF SPI IE J MAGING
c
D
SPINAL M E N I N G EAL CARCINOMATOSIS
E
Radiologic Findings Sagittal short TR image (Fig. A) reveals di ffuse decreased signal i ntensity i n the bone marrow of all the visualized vertebral bodies. There is slight loss of height of the L1 vertebral body. There is increased signal intensity soft tissue in the distal end of the thecal sac at the LS-S I level (open arrow). Sagittal and parasagittal long TR images (Figs. B and C) reveal decreased signal intensity soft tissue in the distal end of the thecal sac. Axial long TR i mage (Fig. D) reveals multiple cystic lesions in the kidneys bilaterally. There is a fluid/fluid level within one of the cysts on the right side (curved arrow). Sagittal short TR i mage postcontrast (Fig. E) reveals en hancement of the thickened nerve roots of the cauda equina (straight arrows) and enhancemen t of the soft tissue mass in the distal end of the thecal sac (curved arrow). (The scan is degraded by some motion artifact.)
Diagnosis Diffuse leukemic infiltrate throughout the visualized marrow, resulting in di n'use decreased signal within the marrow of the vertebral bodies. Minimal
�
I TEACHING ATLAS
OF
S P I N E I MA G I NG
PEARLS Eval uate the para pinal areas. Thc diffuse low signal intensity of the marrow of the vertcbral bodies is secondary to replacement of the normal fatty marrow with leukemic cell . •
•
If meningeal carcinomatosis or drop metastases are suspected, a postin[u ion study is required for complete evaluation.
PITFALL •
The slightly higher than normal tissue density soft tissue mass in the distal end of the thecal sac could be mistaken for a hematoma.
pathologic fracture of the L1 vertebral bouy. Metastases in the distal end of the thecal sac; meningeal carcinomatosis. Polycystic disease of the k i dney (incidental findi ng).
Differential Diagnosis •
meningeal carcinomatosis
•
infective meningitis
Discussion Clinical history is vital in this patient to arrive at a correct diagnosis. The thickened roots of the cauda equina are consistent with meningeal carcino matosis. In a patient with leukemia, evaluation should include the paraspinal area to rule out pathologic adenopathy. In this patient, there is no adenopa thy; however, the kidneys have multiple cysts secondary to polycystic disease. The decreased signal intensity seen in some A I OS patients within the marrow of the vertebral bodies could be mistaken for infiltration with tumor. Hcmor rhage within the thecal sac could have a similar appearance: however, hcmor rhage would not be expected to enhance.
SPJNAL M ENINGEAL CARCINOMATOSIS
Case 5 Clinical Presentation The patient is a 65-year-old with colon cancer metastatic to the liver, lungs, and subcutaneous tissues now presenting with upper anu lower extremity weakness.
A
B
Radiologic Findings Sagittal short TR postcontrast i mage at the level of the cervical spine (Fig. A) reveals multiple small rounded areas of enhancement in the sub arachnoid space (arrow at C4 ventrally anil llrrowhead at C2 dorsally).
r TEACH I NG ATLAS OF S PINE IMAGING
•
P EARLS •
•
orrelation should also be made with the evaluation of the cerebrospinal fluid. Close collaboration with the referring physicians is very helpful in these cases. If the clinical presentation is more ominou than the scan might sugge t, a postinfusion scan is probably warranted to rule out the presence of an abnormality uch a meningeal carcinomatosis.
Radiologic Findings (continued) Sagittal short TR postcontrast image in the lumbar region (Fig. B) reveals multiple small areas of enhancement scattered in the lumbar subarachnoid space (arrows). Axial short TR postcontrast image at the level of the C2 vertebral body (Fig. C) reveals two small enhancing metastases in the cervical subarachnoid space (arrows).
Diagnosis Metastatic colon cancer in the subarachnoid space.
PITFALLS •
•
The preinfusion scan in patients with meningeal carcinomatosis may be normal. Therefore, the index of suspicion must be high, and a postinfusion scan mu t be obtained (or complete evaluation of these patients. As the distribution is not predictable and because the clinical symptoms may not correlate with the patient's symptoms, the entire vertebral canal should be evaluated. The brain and other intracr'a nial content should also be evaluated as appropriate.
Differential Diagnosis •
metastal ic disease
Discussion This type of aggressive metastasis is very uncommon in colon carcinoma. However, in this patient, the tumor was extremely malignant and aggressive, including metastases to the subcutaneous tiss ues of the forearms. The changes of metastatic disease in the subarachnoid space may be very subtle. A postinfusion sca n is absolutely necessary for complete diagnosis and for evaluation of the extent of disease. Other very aggressive types of primary tumors that m ay lead to this type of metastatic disease are lung cancer and breast cancer, as well as aggressive melanoma. Other primary tumors, including primary lung or breast cancer or melanoma, may result in a similar appearance. Other primary CNS tumors. such as pinealoma or medulloblastoma, may also develop drop metastases.
SPINAL M EN I NG EAL CARCI NOMATOSIS
I
Case 6 Clinical Presentation The patient is a 6-year-old male presenting with headache and unsteady gait who had a primary medulloblastoma removed from the posterior fossa 1 year prior to this study.
B
A
c
�
I TEACHI N G ATLAS OF SPINE IMAG I NG Radiologic Findings Postinfusion computed tomographic scans (Figs. A and B ) reveal postopera tive changes in the occipital bone of the posterior fossa. There are rounded areas of enhancement in the posterior fossa, in the right side of the pons and in the left middle cerebellar peduncle. There are also modular lesions in the supratentorial region that reveal varying degrees of enhancement (arrows in Fig. B). There is mild ventricular enlargement. Sagittal short TR image postcontrast (Fig. C) reveals multiple, varying sized, rounded and oval areas of enhancement in the dorsal spinal subarachnoid space (open arrows). There is also a larger area of enhancement in the upper thoracic subarachnoid space (white arrow). Rounded and triangular shaped areas of enhancement in the posterior portion of the vertebral bodies are the enhancing basivertebral venous plexus (arrowhead).
PEARL •
Hemorrhage may occur into these metastatic deposits and may lead to a patient's demise.
i'ITFALL •
Initial evaluation and staging as well as follow-up in these patients should also include eval uation of the spinal subarachnoid spact!.
Diagnosis Recurrent posterior fossa medulloblastoma with mUltiple drop metastases from medulloblastoma.
Differential Diagnosis •
medulloblastoma
•
drop metastases
•
infl amm atory process
Discussion Metastases may occur into the supratentorial compartment as well as into the spine and subarachnoid space. Metastases from medulloblastoma may also spread superiorly into the supratentorial or infratentorial subarachnoid space, or into the cerebral parenchyma, as in t.his case. If metastases spread into the supratentorial compartment, it is not uncommon to find involvement of the suprasellar cistern. In these cases, the normal low density cerebrospinal fluid is replaced with increased density tumor. This tumor exhibits marked enha ncement after the infusion of contrast material. [n the absence of a known primary tumor an inflammatory process, such as tuberculosis menin gitis or some other innammatory disease, would be a consideration. Drop metastases from primary medulloblastoma are the most likely diagno sis in th is patient.
450
SPINAL MENINGEAL CARCINOMATOSIS
I
Case 7 Clinical Presentation The patient is a 5-year-old female with a and lower extremity weakness.
h i s t ory
of headaches, lethargy,
B
I
TEACHING ATLAS OF SPINE IMAGING
c
D
452
SPI NAL M ENINGEAL CA RCINOMATOSIS
I
E
G
453
I TEAC H I N G ATLAS OF SPINE I M AGING Radiologic Findings Sagittal short TR i mages after the infusion of contrast material (Figs. A and B) reveal diffuse enhancement of long areas of scalloped marginated areas of soft tissue surrounding the spinal cord and obliterating the subarach noid space. The normal spinal cord is never demonstrated with certainty at any level (arrows). Sagittal short TR image at the level of the distal end of the spinal cord (Fig. C) reveals enhancement of a thick layer of tissue along the dorsal aspect of the d istal spinal cord (arrows). Sagittal short TR image of the brain postcontrast (Fig. D) reveals dense enhancement of a slightly irregularly marginated 3.5 em mass in the region of the pineal gland. The lateral and third ventricles are enlarged. There arc several small rounded areas of enhancement in the subarachnoid space at the level of the foramen magnum (arrow). Axial short TR i mage of the brain postcontrast (Fig. E) reveals dense enhancement of a 3.5 cm oval-shaped mass in the region of the pineal gland. There is obstructive hydrocephalus with dilitation of the lateral and third ventricles. Axial intermediate TR i mage at the level of the pineal gland (Fig. F) reveals an oval-shaped area of increased signal intensity (curved arrow) in the anterior portion of the mass identified in Figure E. A halo of increased signal intensity surrounds the frontal horns of the lateral ventricles bilater ally (arrows). Axial long TR image at the level of the pineal gland (Fig. G) reveals that the mass remains as decreased signal intensity. The dilated lateral and third ventricles appear as increased signltl intensity.
PEARLS •
Other tumors may occur in the region of the pineal gland, such as pineoblastomas and pinealocytomas; however, germinoma i the most likely tumor to develop drop metastases.
PITFALL Correlation with cerebrospinal fluid analysis should also be performed. However. in the case of a large intracranial mass lesion, a spinal tap should be performed only with great care and a fter consideration. •
1 4 54
Diagnosis Germinoma with drop metastases and resulting spinal meningeal carcinoma tosis.
Differential Diagnosis •
germinoma
•
drop metastases
Discussion G erminoma is more common in males than in females. Metastases are conunon with germinomas. Because of the possibility of metastases to the suprasellar cistern as well as to other areas of the intracranial contents and the spinal meninges, posti nfusion studies of the brain and spinal cord shuuld be performed. This study should be performed at the time of init ial diagnosis as well as at the time of follow-up.
SPINAL M EN IN G EAL CARCINOMATOSI
Case 8 Clinical Presentation The patient is a 32-year-old male with acute lymphocytic leukemia who is status post two episodes of bone marrow transplant. The patient now pre sents with a positive B abinski sign and lower extremity weakness.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals that the marrow within all of the vertebral bodies appears as decreased signal intensity. This replaces the normal increased signal intensity of the ratty bone marrow. There are small patchy a reas o r i ncreased signal intensity within the L3 vertebral hody
(arrow).
Sagittal short TR linage postin fusion (Fig. B) reveals that there is faint patchy enhancement witbin the marrow of the vertebral bodies, as well as dense, streaky enhancement of the nerve roots or the cauda equintt amI surrounding the terminal aspect of the spinal cord (arrows).
4 55 1
I TEACHING ATLAS OF SPINE I M AGING
c
D
SPINAL MENINGEAL CA RCIN OMATOSIS
Radiologic Findings (continued) Sagittal long TR image (Fig. C) reveals decreased signal intensity of the distal nerve roots of tbe cauda equina at the LS-Sl level (arrows). Axial short TR preinfusion (Fig. D, left) image reveals decreased signal intensity of the marrow within the marrow of the vertebral body. Postinfusion (Fig. D, right) image shows diffuse enhancement of the nerve roots of the cauda equina (arrow).
PEARL •
A postcontrast study is necessary for evaluation of tbe presence or absence of meningeal carcinomatosis.
Diagnosis Leukemic infiltrate in the marrow of the vertebral bodies and meningeal carcinomatosis with enhancement of the nerve roots of the cauda equina.
Differential Diagnosis PITFALL •
Because or the marrow's homogeneous nature, diffuse involvement of the marrow may be mistaken for normal. Correlation with other noninvolved areas of tbe body, such as tbe femur or femoral neck and head, may reveal a more normal appearing marrow and allow one to make a diagnosis of abnormal spinal marrow. Correlation with a radionuclide bone scan may also be h elpful for more complete evaluation.
•
lymphoma or leukemia
•
metastatic disease
Discussion In the normal patient, the marrow should be higher in signal intensity than the intervertebral disc because it contains adipose tissue. The "disc reversal sign" occurs when the vertebral body bone marrow is lower in signal intensity than the intervertebral disc signal intensity. The disc reversal sign implies that there is a diffuse abnormality such as might be typically seen in a patient with a disease such as lymphoma or leukemia. The enhancement of the cauda equina is definitely abnormal and occurs because there is diffuse infil tration of the men inges by tumor. Metastatic prostate carcinoma migh t h':lVe a similar appearance; however, this does not usually exhibit meningeal carcinomatosis.
I TEACHI NG ATLAS OF SPINE I M AGING
Case 9 Clinical Presentation The patient is a 56-year-old female with known breast cancer who presents with back pain and lower extremity weakness.
A
B
458
SPINAL MENINGEAL CA RCINOMATOSIS
Radiologic Findings Pre- (Fig. A, left) and postinfusion (Fig. A, righl) sagittal short TR images in the upper thoracic region reveals di ffuse patchy areas of decreased signal intensity in the marrow of all the visualized vertebral bodies and spinous processes. There are m ultiple patchy areas of interruption of the normal epidural fat. After the infusion of contrast (righ.t). there is enhancement of a soft tissue mass dorsal to the spinal cord in the anticipated location of the normal epidural fat (arrow). Enhancement is also present anterior to the spinal cord. Pre- (Fig. B, left) and postin fusion (Fig. B, righl) sagittal short TR images in the lower thoracic region reveal patchy areas of decreased signal intensity in all the visualized bony structures. The normal high signal intensity of the epidural space is replaced by intermediate signal soft tissue (lefl, white arrow). The epidural areas of enhancement are again seen (righI, black
arrows).
1>EARL •
The areas of high signal inteD ity within the vertebral marrow represent small area ' of remaining normal vertebral marrow. Close evaluation (or replacement of the nonnal high ignal inten ity [at will allow the more ready appreciation of replacement with metastatic tumor.
Axial short TR image postinfusion at the level of the cervicothoracic junction (Fig. C) reveals expansion of the vertebral pedicle and circumferential en croach ment upon the low signal intensity of the subarachnoid space. There is enhancement of the marrow in the vertebral body, the vertebral body pedicle with encroach ment upon the lateral aspect of the subarachnoid space (black arrow), and the transverse processes, as wel l as in the visualized portions of the ribs.
Diagnosis Metastatic breast cancer to the vertebral body m arrow and the spinal epi dural space.
I
TEACHING ATLAS OF S P I N E IMAG ING
PITFALL •
There i variable enhancement after contra t enhancem en t . The pattern of enhancement from diffuse and homogeneous to the absence of enhancement are all possible in patients with metastatic disease.
Differential Diagnosis •
metastatic disease
• multiple
myeloma
Discussion Multiple myeloma could have a similar appearance, as could metastasis from any t u mor that results in osteolytic or osteoblastic metastatic deposits In the male patient, the most likely primary tumor would be prostate cancer. .
�o
SPINAL MENING E A L CARCINOMATO IS
I
Case 10 Clinical Presentation The patient is a 53-year-old remale with breast carcinoma now presenting with neek pain and a new right Horner's syndrome.
A
B
46 1
I TEACHING ATLAS OF SPINE I M A G I
G
C
Radiologic Findings Sagittal short TR image (Fig. A) reveals mottled areas of decreased signal intensity in the marrow of multiple vertebral bodies. This is seen in the midportion of C5 and in the upper half of the T1 vertebral body (arrows).
PEARLS •
•
Th e
mottled areas of variable decreased signal intensity area are secondary to mixed osteoblastic and osteolytic metastatic deposits. Osteolytic metastatic disease, such as breast cancer, may become osteobla tic after treatment. Treatment results in lowing of the destructive process and a l lows the bone to become 0 teoblastic.
462
Sagittal long TR image (Fig. B) reveals persistent areas of decreased ignal inte nsity throughout m ultiple vertebral hodies. The body of C7 reveals faint mottled areas or increased and decreased signal intensity (arrow). The Tt a n d T2 vertebral bodies reveal internal areas or increased signal i n tensity and decreased signal intensity. Pre- (Fig. C, left) and pos tin ru s io n ( Fig. C, right) axial short TR images of the braiJl reveal dirruse enhancement of the leptomeninges (right, open arrow). There are also patchy areas of expansion of the calvariam that reveal
enhancement (right, black and white arrow).
Diagnosis Diffuse osteoblastic and osteolytic metastatic d eposits th roughout the bony structures; cerebral meningeal carcinomatosis
SPINAL M E NINGEAL CARCINOMATOS IS
PITFALL •
When the metastases are diffuse and relatively symmetric, the study may appear normal.
Differential Diagnosis •
metastatic disease
•
multiple myeloma
•
myelofibrosis
Discussion Multiple myeloma would also be a possible diagnosis in this patient. Any primary tumor could resul t in a similar appearance. Tn the appropriate setting, the possibility of multiple marrow infarcts would also be a diagnostic consideration. Myelofibrosis that is idiopathic, secondary to a toxic chemical, or secondary to chemotherapy should also be considered.
Section VII
Inflammatory Diseases of the Spine
I NFL A M M ATORY D I SEASES OF T H E S P I N E
Case 1 Clinical Pres entation The patient is a middle-aged female with back pain.
A
B
I
I TEACH I N G ATLAS OF SPINE IMAGING Radiologic Findings Plain film evaluation (Fig. A) reveals narrowing of the intervertebral disc space between the L3 and L4 vertebral bodies. There is sclerosis of the lower half of the L3 vertebral body and indistinctness of the superior end plate of the L4 vertebral body. The anterior superior corner of L4 is not visualized. A slight loss of height of the L3 vertebral body can be noted. Degenerative changes with anterior osteophytes are noted at L5 (5). An area of increased bone density extends from the inferior end plate to the midportion of the vertebral body of L3. A calcificd abdominal aortic aneu rysm is displaced anteriorly by a soft tissue mass that extends from the inferior end plate of L2 through the inferior end plate of L4. Computed tomography (CT) at the level of the L3-4 intervertebral disc (Fig. B) reveals irregularity of thc visualized vertebral body endplate. There is anterior and Icft paraspinal expansion of the disc. The anterior and left lateral margins of the vertebral body are absent, as seen on the plain film cvaluation . The anticipated margin of the vertebral body is idcntified by the open arrow and the bulging disc and soft tissuc are identified by the large white arrow. The soft tissue component extends anteriorly to the vertebral body as well. Thc calcificd wall of the abdominal aorta projects anteriorly. The soft tissue cxtcnds posteriorly into the vertebral canal and obli terates the thecal sac, resulting in a severe spinal stenosis at this level. The mass also obliterates the left intervertebral foramen (curved arrow). I ncidentally there are degenerative changes involving the intcrfacet joints bi laterally.
Diagnosis Discitis with soft tissue component and destruction of the vertebral body cnd platc.
Differential Diagnosis PEARLS •
Cf-guided needle aspiration is helpful for diagnosis.
•
Incidental abdominal aortic aneurysm is displ aced anteriorly away from the anterior margin of the spine by soft tis ue mass a ociated with the infected intervertebral disc.
•
It is also important to evaluate the paraspinal regions in any patient in whom an innammatory process is suspected.
14 68
•
metastases
Discussion The involvcd disc exhibits decreased signal intensity on short TR i mages and may appear widened or narrowed depending on the stage of involvement. On long TR images, the intervertebral disc appears as increased signal intensity because there are an increased number of protons in the form of increascd edema and pus. Typically thcrc is irregularity of the adjacent end plates. Thi� aids in thc differentiation of the disci tis from a simple degenerative Liisc. With an in fected disc, enh,mcement is usually visible on the postinfusion portion of the examination; the amount of enhancement is highly variable. There may be paraspinal abscess formation that also exhibits enhancement. In addition , there may be extcnsion in to the psoas muscle when the lumbar spine is involved. Therefore, specific evaluat ion should bc madc for psoas muscle i nvolvcment.
I NFLAM M ATORY D I SEASES OF THE SPINE
PITFALLS •
•
Early or subtle changes related to discitis may be mistaken for degenerative disc disease. However, in degenerative disc disease, signal intensity is typically decreased on long TR images; when there is inflammation, signal intensity is generally increased on long TR images. MR with contrast infusion is the procedure of choice for evaluation and reveals enhancement of the infected disc and the associated soft tissue component.
Diagnosis may be confirmed by blood cultures or, even more accurately, by direct needle aspiration of the involved disc level. Note that the organism may not be identified or cultured following needle aspiration because the patien t has typically been partially or extensively treated with broad spec trum antibiotics by the time needle aspiration is performed. However, in occasional cases where there has been incomplete or no response to antibiot ics, the needle aspiration may identify an organ ism not previously suspected and not responsive to the antibiotics that have been given to th at point. CT-guided needle biopsy and/or disc space aspiration is strongly suggested in cases that do not respond to antibi otics. Prior to magnetic resonance (MR) imaging, discitis was evaluated with plain film examination and CT scanning, and occasionally nuclear medicine studies, which revealed increased activi ty. The early changes with plain 111 m examination were often subtle and difficult to iden tify. Plain film changes were frequently not obvious until the disease had progressed to a late stage. The bone sclerosis (Fig. A) involving the i n ferior half of the L3 vertebral body is secondary to reactive bone formation and may have preceded the inflammatory process. Compacted trabecular bone and an entity called " bone bruising" may also exhibit a similar appearance. Bone bruising is probably secondary to edema within the bone marrow a fter bone trauma. Bone bruises may also be seen with athletic injuries.
I
TEA CHING ATLAS OF SPINE IMAGING
Case 2 Clinical Presentation The patient is a 16-year-old male who developed back pain following a football game in which he was tackled very hard. There was no history of drug abuse.
A
B
INFLAM MATOR Y DISEASES OF THE SPINE
c
D
I
I TEACHING ATLAS OF S P I N E IMAG I NG
E
lNFLA MM ATORY DISEASES OF THE SPI N E
I
...._ . _ G
H
473
I TEACHING ATLAS OF SPINE IMAG ING Radiologic Findings Initial lateral plain film radiograph (Fig. A) of the spine was obtained approximately 2 weeks following the injury. At the level o r the U-4, the scan or the intervertebral d isc (white arrow) reveals that the uperior end plate of the L3 vertebral body (open arrowheads) is indistinct compared to the remai ning normal vertebral body endplates. Pre- (Fig. B, left) and postcontrast (Fig. B, right) sagittal short TR images approximately 1 month following the plain spine eval uation reveal narrowing of the intervertebral disc pace with destruction of the adjacent vertebral body endplates (left, white arrow). A small anterior paraspinal soft tissue mass is visible, and there is reversal of the curve of the spine and posterior d isplacement of the vertebral body and intervertebral disc into the vertebral canal. The postcontrast tudy reveals dense enhancement of the interverte bral disc as well as the prevertebral soft tissue mass. There are internal areas of rounded low signal intensity (rixht, arrowhead) consistent with areas of flow void within vessels in the prevertebral abscess. The disc projects posteriorly into the vertebral canal and indents the distal spinal cord and cauda equina. Sagittal intermediate TR (Fig. C, left) and long TR (Fig. C, right) images reveal that the intervertebral disc and the prevert ebral ahscess all exhibit increased signal intensity. The posterior projection of the disc into the vertebral canal is easily seen. Coronal postcontrast short TR image (Fig. D) reveals the right lateral offset of L3 relative to L4. There are large mottled areas of increased signal intensity with internal areas of decreased signal intensity in the psoas muscles bilaterally at the level of the intervertebral disc and extending inferiorly (open white arrows). A small rounded area of now void is (black arrowhead) is seen within the area of soft tissue prominence. Computed tomographic (CT) scan (Fig. E) at the same time as the magnetic resonance (MR) scan reveals the irregular, " moth eaten" appearance of the vertebral body end plate adjacent to the abnormal intervertebral disc. There is an ill-defined area of low density faintly visible in the psoas muscle on the right side (white arrow). Pre- (Fig. F, left) and postcontrast (Fig. F, right) axial short TR images reveal the diffusely bulging disc with some encroachment on the anterior aspect of the thecal sac. The decreased signal intensity cystic c(lvity is seen in the right psoas muscle (arrowhead) surrounded by (In increased signal i ntensity thick walled rim that exhibits dense enhancement on the postinfu sion scan. There is extension into the left psoas muscle as well as seen on the coronal images. Axial intermediate (Fig. 0, left) and long (Fig. 0, right) TR images reveal that the intervertebral disc and the psoas muscle lesion all exhibit i ncreased signal i ntensity. There is a rounded area of i ncre
474
I N FLAMMATORY DlSEASES OF TH E SPI N E
PEARLS In the patient who does not improve with treatment or in the patient in whom the diagnosi. is in question, CT guided biopsy is helpful, and strongly advised, for complete evaluation.
•
•
Enhancement of the intervertebral disc is a typical finding of an inllammatory process. Metastatic disease would be very unlikely.
ITFALLS •
•
The index of suspicion must be high in cases of infection, so an MR scan can be obtained early in the course of the patient's illness. Evaluation by CT scanning may mimic the appearance of severe degenerative disc disease.
Diagnosis Discitis, following trauma, with an unusual organism as the el iologic agent. There are bilateral psoas abscesses and an abscess surrounding the abdom i nal aorta.
Differential Diagnosis •
discitis
•
metastases
•
degenerlitive disc disease
Discussion Plain spine imaging was essential ly normal in this patient early in the course of the il lness. Because MR imaging was not performed i nitially, il is uncertain if it would have been normal or abnormal. However, MR imaging in general is more sensitive than plain film evaluation and should be performed early in the course of an illness if an inflammatory process is suspected. The late follow-up in tbis patient revealed complete fusion between the two vertebral bodies, which is a known result of an inflammatory process involving the intervertebral disc. The pre- lind postcontrast M R images (Fig. F) reveal Ihal the process in the psoas m uscle is a thick walled psoas abscess. The pus filled abscess cavity is demonstrated as a central area of decreased signal intensity (Fig. F, arrowhead) and increased signal intensity in the intermediate and long TR images (Fig. G). On postcontrast enhancement, there is dense peripheral enhancement of a thick wall surrounding the psoas abscess (Fig. G, right). The nerve roots of the cauda equina also appear prominent, probably second ary to an element of meningitis involving the leptomeninges. Following the abnormal MR scan the patient was initially placed on high doses of broad spectrum antibiotics, but did not i mprove. Therefore, after a follow-up MR scan did not reveal i mprovement, a CT-guided biopsy was obtained with aspiration of material from the psoas m uscle abscess. Aspiration revealed that the etiologic agent was Pseudomon.as aell.rgin{)sa. With this diagnosis, the antibiotic was changed to a more lippropriate one, and the patient improved.
4 /0 1
I TEACH I N G ATLAS OF SPI N E I M A G I NG
Figure I is the final follow-up spine film and reveals fusion between the L3 and L4 vertebral bodies (arrow).
INFLAMMATORY D ISEASES OF THE SPIN E
I
Case 3 Clinical Presentation The patient is a 50-year-old m ale with a history of in travenous drug abuse , presenting with hi lateral lower extremity weakness.
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals loss of height of the Ll and L2 vertebral bodies anteriorly and apparent disproportionate widening or the intervertebral disc. There is destruction of the inferior en d plate of the Ll vertebral body and of the superior end pl ate or the L2 vertebra l body. There is reversal of the no rm a l lordotic curve at the U-2 level . There is encroach ment upon the anterior epidural space and curvilinear posterior displacement of the spinal cord.
I TEACH ING ATLAS OF SPINE IMAGING
C
Radiologic Findings (continued) Sagittal short TR image postcontrast (Fig. 8) reveab dense slightly irregular enhancement of the intervertebral disc at the Ll-2 level. The enhancement extends into and lnvolves the superior end plate of the L2 vertebral body. Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images at the level of the lntervertebral disc reveal dense enhancemenl of the intervertebral disc with extension into the dorsal paravertebral m uscles on the left side (white arrow). There is diffuse enhancement surrounding the lumbar thecal sac. The normal high signal intensity epidural fat surrounding the thecal sac is obliterated.
Diagnosis D iscitis, involving the intervertebral disc with paraspinal extension. The enhancement of the vertebral body reflects the presence of vertebral osteo myelitis.
Differential Diagnosis •
discitis
•
degenerative disc disease
INFLA MMATORY D ISEASES OF TH E SPINE
PEARLS Care should be taken that an i n fected disc is not mistaken for a degenerated disc. A degenerated disc generally does not enhance on the postcontrast study.
•
•
Cf-guided aspiration and culture of the disc space i helpful for more complete evaluation.
ITFALL •
Metastases to not typically affecl the intervertebral body and adjacent disc spaces.
Discussion If there is question regarding :m individual case, and if there is a need to differentiate between infection and degenerative changcs, it may be neces s(lry to evaluate the patient with other te ts such as radionuclide bone scann ing or gall ium scanning. In some cases, a final diagnosis may not be possible at the time of the initial study, and the patient may need to return for addi tional follow-up at a later date. The studies should be performed without and with the i nfusion of contrast material. Bec
cobacterium tu.berculosis. CT-guided biopsy with aspiration of cells as well as fluid is very helpful for complete evaluation and frequently eliminates the need for open surgical biopsy. Care must be taken to send the samples for aerobic as well as anaerobic bacteriological analysis.
11 7 9
I
TEAC H I N G ATLAS OF SP] N E I MAGING
Case 4 Clinical Presentation The patient is a 60-year-old female with a history of recent surgery for herniated disc and a new h istory of severe low back pain and a draining surgical incision.
A
B
fNFLAMMATO R Y D ISEASES OF THE SPINE
c
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images. The precontrast study reveals expansion of the intervertebral disc li t the LS-Sl level. There is irregularity of the superior end plate of the Sl vertebral body, lind there is both anterior and poslerior prominence of the interverte bral disc. There are postsurgical changes in the soft tissues of the back with disruption of the normal configuration of the dorsal paraspinal muscles of the back. The postcontrast study reveals dense enhancement of the interver tebral disc. The disc is distorted into a "butterfly" configuration, extending posteriorly into the vertebral canal where it compresses the thecal sac. The soft tissues in the lower spinal region dor 'al to the thecal sac also enhance. Pre- (Fig. B, left) and postcontrast (Fig. B, right) parasagittal short TR images reveal dense enhancement of the intervertebral disc. There is also extension of the enhancement into tbe intervertebral foramen (right, curved arrow). Tbe intervertebral foramen is obliterated with enhancing soft tissue; the normal intervertebral foramen is seen as iln area of increased signal fat surrounding the normal dorsal root gangliun (right, open arrow). This enhancement extends into the soft tissues of thc back. Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal enhancement and diffuse bulging of the disc. The enhancement is also present in the intervertebrill foramen hilateraJly (righi, curved arrow). There is prevertebral soft tissue component which extends beyond the mar gin of the vertebral body (ril{ht, white arrows), and enhancement of the muscles in the dorsal paraspinal region on the right side (right, asterisk), which extends up to the level of the skin. The point of drainage on the skin is also identified (left, open arrow).
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PEARL MR imagi ng is the most efficient method to evaluate discitis. Thc convenient m ultiplanar capability of MR to image the spine and discs allows accurate evaluation both for diagnosis as well as follow up.
•
Diagnosis Postoperative wound infection with draining sinus tract and postoperative disc infection. The inflammatory process extends into the soft tissues of the back ,md into the intervertebral rora menae bilateral ly.
Differential Diagnosis •
discitis
•
epidural abscess
ITFALL •
The patient who does not respond to antibiotics should be considered for Cf-guided biopsy so that treatment may be altered appropriately depending upon the organism that is identified.
Discussion Severe pai n , as seen in this patien t, is a very common clin ical symptom in a patient with disci tis or epidural abscess. However, the absence of pain makes the diagnosis less likely. In a patient with a drai ning wound , with a compatible clinical course, an inflammatory process is a strong clinical consideration. Magnetic resonance (MR) imaging is the most sensitive and accurate method to evaluate this abnormality. Because of the extension into the intervertebral foramenae, radicular pain would also he a common symptom in a patient presenting like this. CT-guided biopsy with culture as well as histology is very helpful for com plete di agnosis.
INFLAMMATORY D I SEASES OF THE SPIN E
Case 5 Clinical Presentation The patient is a 48-year-old male presenting with a h istory of intravenous drug abuse and active pulmonary tuberculosis. The patient has a new history of a sensory level with decreased sensation at the level of T4 to T8. There is progressive weakness in the lower extremi ties.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals decreased signal i n tensity i n the T3 and T4 vertebral bodies. There is anterior loss of vertebral body height and poor definition of the intervertebral disc space. An approximately 2em-wide anterior prevertebral mass, whieh extends from approximately C6 through T6 (arrows), is visible. The spinal cord is poorly seen from the level of T2 through TS. There is anterior kyphosis at the T3-4 level.
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Radiologic Findings (continued) Sagittal short TR image (Fig. B) reveals enhancement of the intervertebral disc at the T3-4 level. The prevertebra I son tissue mass exhibits enhancement with streaks of decreased signal intensity. Small vessels within the anterior soft tissue mass appear as rounded areas of decreased signal intensity flow void (solid while arrows). There is also a crescent shaped area of enhance ment that extends into the vertebral canal at the T3-4 intervertebral disc level and extends both above and below the disc level posterior to the vertebral bodies. There is a l inear area of enh,tncement that extends superi orly in the epidural space up to the level of C7 (open arrows). The T5 level of the spine is identified by 5. Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal a large paraspinal area of enhancement surrounding the T3 vertebral body. The open white arrows identify the edge of the vertebral body and the edge of the paraspinal mass. There is extension into the in tervertebral foramen on the left side (righI, bl(lck arrow). Th e transverse aorta is dis placed anteriorly. Axial short TR image at T4 (Fig. D) reveals marked compression of the thecal sac (white arrow) by the large anterior soft tissue mass.
Diagnosis Oiscitis and epidural and paraspinal abscess secondary to Mycobacterium lU
berClilosis.
Differential Diagnosis •
PEARLS • There
may be multiple levels of involvement with
Mycob(lcterium tu berculosis (TBc). •
The enti re vertebral column should be evaluated at the time of initial evaluation.
discitis
Discussion The imaging appearance is typical of discitis secondary to MYClinaclerium tuberculosis (TBc). The ill ness progresses so slowly that patients may experi e nce mild symptoms relative to the degree of ahnormality de monstrated on the images. An inflammatory process is the most likely diagnosis in this patient. A CT-guided biopsy with aspiration is helpful to identify the organ ism that is causing the inflammatory process. In addition to the i nvolvement of the intervertebral disc, there may also be a paraspinal abscess; therefore, evaluation and filming should be performed to include these areas in the final images.
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PITFALL •
surgery, the anterior vertebral body soft tissue component may represen t only granulation tissue and not a true absccss.
At
A chest x-ray should be obtained in any patient with a suspect diagnosis of Mycobacterium ruberculosis. Chest x-ray in thcsc paticnts will typically re veals evidence of an intlammatory process consistent with tuberculosis. I n the acq uired immunodeficiency syndrome patient, however, thc x-ray may be negative even in the presence of an active infection. In addition, follow-up after a suitable period of medical management is also helpful for patient management. Magnetic resonance imaging with contrast enhancement is the most sensitivc mcthod of eval uation.
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Case 6 Clinical Presentation The patient is a 28-year-old male with a history of intravenous drug abuse who presented with fever, severe back pain, and paraplegia.
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Radiologic Findings Sagittal short TR imagc (Fig. A) reveals disc space narrowing at the L4-S level. An intermediate signal intensity soft tissue mass, anterior to the verte bral bodies in the lower lumber region (open arrows). There is a low signal intensity mass thot exhibits a scalloped morgin extending rrom L4 through LS. This process obl iterates the normal dorsal epidural fat and compresses the lower end of the lumbar thecal sac. Areas of intermediate signal intc nsity i nvolving the inferior end plate of L4 and superior end plate of LS are adjacent to the i ntervertebral disc. The anterior margins of both L4 and LS appear as decreased signal intensity, and this decreased signal intensity also involves the superior end plate of the L4 vertebral body. The LJ vertebral body is identified by 3. Intermediate (Fig. B, lef!) and long (Fig. B, righl) TR images reveal that the i ntermediate signal intensity areas demonstrated on the short TR images now oppear as increased signal intensity, as does the intervertebral disc at L4-S. A soft tissue mass of intermediate signal intensity projects posteriorly to the L4 vertebral body and slightly compresses the thecol soc. Axial short TR image postcontrast (Fig. C) reveals 0 " U " shaped area of enhancement in the region of the intervertebral disc (upen while arrow). Areas of enhancement are seen in the region of the left psoas muscle (solid straight white arrow) and in the region of the right psoas muscle (curved white arrow). A triangular shaped area of enhancement is dorsal to the t hecal sac on the right side «(hick black arrow), and a broad curvilinear area or enhancement is dorsal to the intervertebral facets (curved black arrow). A densely enhancing, thick-walled, irregularly marginated area of enhance ment in thc paraspinal m uscles on the right (open black arrows) is also dcmonstrated. There is a central area of decreased signal intensity.
PEARL •
Multiplanar imaging using short TR sequences without and with contrast enhancement is very helpful in the evaluation of any multilevel inflammatory process. Because contrast was injected prior to evaluation of the thoracic region in this patient, it was elected to perform fat-suppressed short TR images to determine the superior extent of the in flammatory process. The normally increased signal intensity fat is therefore suppressed while the areas of enhancement-in this case a multilevel area or enhancement-appear as areas or increa ed signal intensity.
Fat-suppressed sagittal short TR i mage (Fig. D) reveals di ffuse enhancement of tissue dorsal to the thecal sac throughout the entire thoracic region
(arrows) .
Diagnosis D iscitis, vertebral osteomyel itis, bilateral psoas abscesses, epidural abscess extending rrom the lumbar region through the thoracic spi ne, and thick rimmed thoracic paraspinal muscle abscess.
Differential Diagnosis •
discitis
Discussion The intravenous drug abuser is susceptible to a variety or inrectious diseases in various organ systems. Spinal i n fections may also occur, and they may be caused by un usual organ isms. In addition, there has been a recent i ncrease in the occurrence of inrection with such previously uncommon organ isms as Mycobacterium aviwn imracellularae. Infection with Mycobacterium luber-
TEACI I I NG ATLAS OF S P I N E IMA G ING
PITFALL •
Abscesses in the paraspinal muscles may not be appreciated because they are remote from the normal anl icipated areas of involvement. images should be obtained that include sufficient para pinal tissue for evaluation of these abnormalities.
culosis may also occur. In those cases, aspi ration biopsy is strongly suggested, o the causative organism can be identified, and the correct treatment insti tuted. It should be noted that Mycobacterium auium intracellularae is a common organism in the environmenl and becomes a pathogen in only the immunocompromised host. Of some concern is th a i I his organism is known to be drug resislanl in both immunocompetent and immunocompromised hosts. The areas of decreased signal intensity in Figure A are presumably related to reactive bony sclerosis. The area of decreased signal inlensity behind the vertebral body of L4 in Figure B is the compressed, anteriorly compressed nerve roots of the cauda equina. Follow-up scanning with magnetic resonance with conlrasl infusion is t h e ideal method of following the clinical response of these patients to lrea lment.
I NFLAMMATORY D ISEASES OF THE SPINE
Case 7 Clinical Presentation The patient is a 57-year-old male with a history of diabetes mellitus who was admitted with complaints of right lower back pain, diabetic ketoacidosis, and methacillin resistant Staphylococcus aureus bacteremia with persistent fevers while on antibiotics. There is increased pain in the cervical and lumbar regions and weakness in the lower ex tremities.
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Radiologic Findings Sagittal short T R image preinfusion (Fig. A, lp.ft) image reveals that the ent ire lumbar subarachnoid space is isoin tense with the signal intensity of the spinal cord (open arrows). The normal cerebrospinal fl uid (CSF) is not visible surrounding the spi nal cord. A postcontrast image (Fig. A, right) reveals linear enhancement of the meninges in the lumbar region (white arrow). This extends superiorly to the level of the thoracic spine, where a thin line of enhancement is seen along the ventral and dorsal aspects 01" the thoracic spinal cord. There is enhancement dorsal to the thecal sac in the lower thoracic region (black arrow at TI L). The enhancement extends inferi orly in the epidural space down to the level of L5 (black arrowheads L3 to L5). A linear area of low signal intensity is posterior to the vertebral body of L5 (black arrow on right).
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Radiologic Findings (continued) Sagittal short TR image (Fig. R) in the thoracic region reveals that the nnrm(ll spinal cord is n ever demonstrated. The entire subarachnoid space is obl iterated. Diffuse increased signal intensity soft tissue material in the anticipated position of the subarachnoid space extends throughout the tho r(lcic region and superiorly into the cervic(ll region. (T6 is identified with (I white arrow.) There is a soft tissue intermediate signal intensity mass in the cervical region at tbe level of C3-5 (asterisks). The normal epidural fat at all levels in the thoracic spin e and cervical region is obliterated. Sagittal short TR image postcontrast (Fig. C) reveals enhancement of the membmne (Issociated with the vertenml canal extending throughout the entire length of the vertebral canal (black arrows). In the cervical region, the intermediate signal intensity pinal cord (white arrow) can be seen to be displaced anteriorly and compressed against the posterior margin of the cervical vertebral bodies. The dorsal epidural soft tissue mass at C3-6 is enhancing (asterisks).
I TEACHING ATLAS OF S P I N E IMA GING Radiologic Findings (continued) Axial short TR images postcontrast at t he level o f T6 (Fig. D) reveals the rounded area of enhancement of a soft tissue mass (lefl, while arrow). Just inferiorly, the area of enhancement is again seen (righI, while arrow). The spinal cord is noted to be displaced posteriorly (right, long black arrow, while arrowhead). A right-sided paraspinal mass (righI, open arrow) and bilateral pleural effusions (righI, asterisks) are visible. Axial long TR i mage in the lumbar region (Fig. E) reveals m ultiple, curvilin ear, patchy areas of increased signal intensity in the paraspinal muscles of the back of the spine (small open arrows). There is also a rounded area of incre(lsed signal in the psoas muscle on the right side (solid arrow). Pre- (Fig. F, left) and posteontrast (Fi g. F, right) axial short TR i mages in the lumbar region. The precontr(lst (left) image reveals complete obliteration of the normal epidural fa t (thin white arrows) within the vertebral canal by an intermediate intensity soft tissue mass. A rounded, intermediate signal intensity paraspinal mass is also seen disrupting the normal architecture of the paraspin(ll m uscles (lefl, large while arrow). Postcontrast (right) there are i rregularly marginated ring-shaped are(ls of enhancement surrounding bilateral psoas and paraspinal muscle cystic areas (open arrows). Enhance ment of an anterior epidural abscess (right, long white arrow) with posterior displacement of the thecal sac is also visible. Axial short TR image preeontrast at the level of C2 (Fig. G) reveals that the entire cervical spinal cord is encircled by intermediate signal intensity soft tissue. The lamina of the vertebral body is marked by the open arrow: the subarachnoid space (long while arrow) is eircumferentially compressed and closely applied to the cervical spinal cord. Axial short TR image postcontrast (Fig . H) reveals curvi linear (lreas of enhancement dorsal to the spinal cord (small white arrows) (lnd enclosing a low signal intensity area dorsal and to the right of the cervical spinal cord (long while arrows). Min imally enhancing soft tissue is anterior to the cervical spinal cord.
Diagnosis Multilevel anterior and posterior epidural abscess, meningitis and m U ltiple dorsal and paraspinal, and psoas m uscle abscesses.
Differential Diagnosis •
inflammatory process
•
meningitis
•
met(lstases, meningeal carcinomatosis
INFLAMM ATORY D ISEASES OF THE SPIN E
PEARL •
Evaluation of the entire length of the spine is vital to determine the extent of i nvolvement. Multilevel laminectomy may be performed, as in this patient, if appropriate; the exact levels of involvement should be identified prior to surgery.
PITFALLS •
•
This case ill ustrates the need for multi planar imaging at all levels of abnormality.
It i be t to obtain pre- and postcontrast images so a more accurate evaluation of the level of the abnormalities can be made.
Discussion The clinical history is particularly helpful here as it leads one to suspect an innammatory process. The sagittal short TR images (Figs. A, B, and C) revealed that the normal CSF surrounding the spinal cord is not scen because the entire suharachnoid space has becn obl iterated by the space-occupying epidural abscess. In addition, the l umbar subarachnoid space is diffusely increased in signal intensity because of the involvement of the nerve roots with an inflammatory process and because of the increased protein content. A meningitis could have a similar appearance to that seen in the l umbar subarachnoid space; however, the epidural component would be more con sistent with an epidural abscess. Metastases would not be likely to give this appearance on imaging. In this patient the clinical symptoms were confi ned ( 0 (he lumbar region. For this reason, contrast material was injected prior to evaluation of the thoracic region. Therefore, the fat saturation images were obtained to dem onstrate the possible areas of enhancement. This fat suppression techniq ue results in suppression of the norm ally increased signal intensity of the epi dural fat. Therefore, the area of increased signal intensity in the dorsal epidura l space is secondary to enhancement and not epidural fat because normal epidural fat would have been suppressed by using the fat suppres sion technique. A spinal tap with cerebrospinal fluid analysis would be helpful for more complete cvaluation. The extent of this process is unusual. lts treatment would require a wide, multilevel laminectomy to remove the purulent material and to relieve the cord compromise.
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Case 8 Clinical Presentation The patient is a 75-year-old male with a h istory or right sided weakness. Previous computed tomographic (CT) neck scan revealed a retropharyn geal abscess.
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Radiologic Findings Sagittal Tl W image of the cervical spine (Fig. A) reveals that the normal cervical spinal cord is not visualized. The entire subarachnoid space is fil led with material that is isointense to the cervical spinal cord. The C5 and C6 vertebral bodies are decreased in signal intensity, and there is narrowing or the C5-6 intervertebral disc space. Incidentally, note the degenerative changes in the cervical spinc with both anterior and postclior osteophytes at multiple levels. A streaklike area or decreased signal intensity at thc c2-3 level is parallel to the cervical spinal cord. There is a large prevertcbral soft tissue mass (white arrow); the trachea is displaced anteriorly. The C4 vertebral body is identified with 4 .
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Radiologic Findings (continued) Sagittal short TR image postcontrast (Fig. B) reveals an area of enhancement posterior to the vertebral bodies of C2-3 (curved arrow); this enhancement extends inferiorly to the level of C7. The cervical spinal cord is compressed and displaced posteriorly. There is dense enhancement of the C5 and C6 vertebral bodies. Anterior to the intervertebral disc at the C5-o level, there is a low signal intensity oval-shaped area; this is surrounded by enhancenient of the prevertebral soft tissue mass (solid white arrow). Dorsal to the spinal cord at the Tl level, there are two parallel lin e of enhancement (open white arrows) that surround an area of decreased signal intensity. The enhance ment extends superiorly in the dorsal epid ural space to the level of C4 (open black arrows) and continues as a thin line of enha ncement in the epidural space (long black arrows). There is dense enh ancement of the intervertebral discs at C5-6 and C6-7. At TI , there is an elongated area of decreased signal i ntensity surrounded by two areas of en hancement (open white arrows). Parasagittal postcontrast image (Fig. C) reveals the loculated area of en hancement in the anterior epidural space (black arrows). Multiple small internal areas of decreased signal intensity can be identi fied. The low signal intensity central portion of the prevertebral soft tissue m ass can be seen i n the retrophaJyngeal space anterior to C5 and C6. The prevertebral enhancing soft tissue mass extends superiorly to the level of C2 and inferiorly to the level of C7. There is persistent decreased signal intensity within the lateral portion of the C5 vertebral body. The trachea is displaced anteriorly. Axial short TR image in the upper cervical region at the C3 level (Fig. D) reveals that the spinal cord is displ aced markedly posteriorly by a soft tiss ue m ass anterior to the spinal cord (thick white arrow) and compressed into a seminar configuration. There is also a prevertcbral soft tissue mass in the prevertebrallretropharyngeal space (small whiTe arro ws). Axial short TR image postcontrast in the midcervical region (Fig. E) reveals the peripherally enhancing loculated soft tissue mass in the anterior epidural space. The abscess is sligh lIy larger on the right side (solid arrow). There is also a bilobed prevertebrallretropharyngeal soft tissue mass that exhi bits peripherally enhancing margins and b ilateral low signal intensity areas (open arrows) and l inear dense dorsal enhancemen t in the epidural space. The spinal cord (c) is compressed more on the left side th an the right and displaced dorsally and to the left. The trachea is displaced anteriorly. Axial short TR image in the cervical region (Fig. F) reve
Diagnosis Loculated, multilevel anterior and posterior epidural abscess secondary to retropharyngeal abscess. The etiologic organism was not cultured.
EQl J
I TEACHING ATLAS OF SPINE IMAGING Retropharyngeal abscess with bilateral loculated accum ulations, discitis at multiple levels, vertebral osteomyel itis at the C5 amI Cn levels, loculated anterior and posterior epidural abscesses.
Differential Diagnosis •
discitis
•
osteomyelitis
Discussion
P EARLS The entire length of the spinal column should be evaluated to determ ine the extent of the abscess. •
•
cr-guided aspiration of tbe abscess in the retropbaryngeal space may aUow identification of tbe etiologic organism.
PITFALL •
If the spinal cord is not demonstrated or visible on the short TR images, this i mplies tbat the CSF containing subarachnoid space is replaced by intermediate ignal intensity material. A postcontrast study is necessary for complete evaluation.
In this diabetic patient, the most likely diagnosis is that of a retropharyngeal abscess that ha progressed to disci tis involving the C5-6 intervertebral disc. Progression then led to anterior and posterior epidural ahscesses and vertebral osteomyelitis. There is decreased signal intensity pus within the loculated abscesses (Figs. B, C, E, and G). The vertebral bodies of C5 and C6 enhance densely (Fig. B), a finding consistent with vertebral osteomyelitis. The midline post contrast image reveals enhancement of the margins of a loculated anterior epidural abscess that projects behind the body of C2·3 and extends inferiorly to the level of T1. There is also a dorsal epidural loculated abscess cavity (Fig. B). Dense enhancement of a prevertebraJ/retropharyngeal abscess extends from the level of C2 througb the level of the thoracic inlet (while arrows in Figs. A and B). There is a persistent area of low signal intensity j ust anterior to C5 and C6, consistent with a pus-filled abscess cavity. Incidentally, a small oval area of decreased signal intensity in the posterior aspect of the intervertebral disc at the C5-6 level is an area of vacuum degenerative change. It is important to perform a postinfusion scan to completely evaluate a case such as this. The decreased signal intensity central areas surrounded by dense enhancement are consistent with pus-containing abscess cavities. The C5 vertebral body contain areas of decreased signal intensity most likely secondary to bony sclerosis. Although metastatic disease could be a possible diagnosis, the combination of findings with the prevertebral abscesses make this diagnosis unlikely.
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Case 9 Clinical Presentation The
pat ient is a 5-ye <:l r-old male with head<:lche <:Ind emesis. The patient had a history o f Ch i a ri type 1 malform ation and is status posteranintomy.
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Radiologic Findings Sagitl<:l1 short TR images posteontrast enhancement (Figs. A a nd B) re veal diffuse enhancement of the meni n g es, which extends superiorly intracrani ally to involve the meninges of the anterior aspect of the pons (arrows). The inferior portion of the occipital bone and the posterior margin of the foramen magnum has been surgically removed.
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Radiologic Findings (continued) S
Diagnosis Chemical meningitis with arachnoid adhesions.
Differential Diagnosis PEARL •
Culture of cerebrospinal fluid is vital for complete evaluation.
PITFALL •
Because many patient are placed immediately on broad spectrum, highly effective antibiotics, it is common that an organism cannot be cultured in spite of multiple evaluations of blood culturcs and ccrebrospinal fluid evaluation.
I tl06
•
meningitis
•
meningeal carcinomatosis
Discussion An infectious organism was never cultured in this patient; however, the use of broad spectrum antibiotics m
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Case 10 Clinical Presentation The patient is a three month old with upper and lower extremity weakness and fa il ure Lo thri ve.
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PEARLS •
•
•
The appearance is consistent with a diffuse meningeal process, either inflammatory or neoplastic. Cerebrospinal fluid analysis should be performed and evaluated for an inflammatory proces , including anaerobic as well as aerobic organisms, and malignant cells. The presence of a lung infiltrate and the absence of a known malignant process makes infectious meningitis the more likely diagnosis.
PITFALL •
Many patients are placed on potent broad spectrum antibiotics; therefore, t he cerebrospinal fluid analysis is often negative for culture of an organism.
Radiologic Findings Sagittal short TR preinfusion magnetic resonance scan (Fig. A) reveals that the cervical spinal cord is indistinct below the level of CS . There is i ntermediate signal intensity soft tissue fil l ing the subarachnoid space below the CS level. Sagittal short TR image postcontrast (Fig. B) reveals dense enhancement of the meninges beginning at the level of CS and extending inferiorly (solid arrow). Note that the vertebrae exhibit an "infantile" appearance. The vertebral body appears as decreased signal intensity (arrow. V) while the intervertebral disc (open arrow) appears as increased signal intensity. The cartilagenous end plates of the vertebral bodies also appears as increased signal intensity and are similar in signal intensity to the intervertebral disc.
Diagnosis Probably pneumonitis and meningitis with Mycobacteriu.m hl.berculosis (TBc). The infant died; no organism was cultured.
Differential Diagnosis •
meningitis
•
meningeal carcinomatosis
•
medulloblastoma with drop metastases
•
pinealoma with drop metastases
Discussion [n the presence of TBc meningitis, the source is generally secondary to TBc pneumonia. Therefore, central nervous system studies should be evaluated in correlation with evaluation of other organ systems. It is not possible to differentiate with certainty the cause of t he meningeal enhancement without pathologic/histologic or culture correlation.
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Case 11 Clinical Presentation The patient is a 54-year-old female with (t clinical diagnosis of central nervous system (CNS) sarcoidosis.
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Radiologic Findings Sagittal short TR image (Fig. A) reveals diffuse widening or t h e cervical spinal cord rrom the level of the odontoid process throughout the length of the cervical vertebral canal. The medulla is narrowed at the level of the eraniocervieal junction. I nciden tally noted is mild bulging of the disc at the C5-6 level.
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Radiologic Findings (continued) Long TR image (Fig. B ) reveals irregularly marginated linear areas of i n creased signal in the center of the upper cervical spinal cord to the level of C2 and extending through the midbody of C3. Thcrc are patchy areas of increased signal within the lower portions of thc cervical spinal cord (arrows ) . Sagittal short TR image postcontrast (Fig. C) reveals diffuse enhancement of the leptomeninges surrounding the cervical spinal cord (open arrows) and extending superiorly both anterior to the pons and posteriorly to the obex of the fourth ventricle in to the fourth ventricle at thc Icvel of the foramen o( M agendie ( curved arrow) . Axial short TR image postcontrast (Fig. D) revcals that the cervical suba rachnoid space is fil led with enhancing soft tissuc. The cervical spinal cord is compressed bilaterally in a curvilinear, scalloped fashion both anteriorly and posteriorly (open arrows) by the enhancing soft tissue material sur rounding thc spinal cord.
Diagnosis Mycobacterium TUberculosis without evidence of sarcoidosis.
PEARL •
In tbe evaluation of meningeal carcinomatosis, CSF analysis with large amounts of CSF arc necessary.
PITFALLS •
Because tuberculosis is a treatable disease entity, great care must be taken to determine if change noted by i maging could be caused by an organium uch as
Mycobacterium wberculosis. •
Sarcoidosis may have a wide range of appearances by imaging.
Differential Diagnosis •
infection with Mycobacterium tuberculosis
•
infection with Mycobacterium auium intrucellulare
•
meningeal carcinomatosis
•
sarcoidosis
Discussion B ecause treatment is possible for mycobacteria infections, di fferentiation with cerebrospinal fluid (CSF) analysis and culture as well as possible biopsy are necessary for complete diagnosis. Sarcoidosis of the CNS could have a similar appcarance, and changes in the CNS should be correlated with a chest x-ray, particularly i f the chest findings are consistent with sarcoidosis or tuberculosis. Culture of infections with Mycobacterium species may take up to 6 weeks (or organism identification. In some cases, empiric trcatment for tu berculosis is started prior to tinal bacteriologic diagnosis. Final diagno sis in a case such as this would rely on histologic or pathologic findings.
5JJJ
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Radiologic Findings (continued) Long TR image (Fig. B) reveals irregularly marginated li near areas of in creased signal in the center of the upper cervical spinal cord to the level of C2 and extending through the midbody of C3. There are patchy areas of increased signal within the lowcr portions of the cervical spi nal cord (arrows). Sagittal short TR image postcontrast (Fig. C) revea.ls diffuse enhancement of the leptomcni nges surrounding the cervical spinal cord (open arrows) and extending superiorly both anterior to the pons and posteriorly to the obex of the fourth ventricle in to the fourth ventricle at the level of the foramen of Magendie (curved arrow). Axial short TR image postcontrast (Fig. D ) revcals that the cervical suba rachnoid space is filled with enhancing soft tissue. The cervical spinal cord is compressed bilaterally in a curvilinear, scalloped fashion both anteriorly and posteriorly (open arrows) by the enhancing soft tissue material sur rou nding the spinal cord.
Diagnosis Mycobacterium tuberculosis without evidence of sarcoidosis.
PEARL •
In the evaluation of meningeal carcinomatosis, CSF analysis with large amount of CSF are necessary.
PITFALLS •
Because tuberculosis is a treatable disease entity, great care must be taken to determine if cbanges noted by imaging could be caused by an organium such as
Mycobacterium tuberculosis. •
Sarcoidosis may have a wide range of appeara.nces by imaging.
Differential Diagnosis •
infcction with Mycobacterium tuberculosis
•
infection with Mycobacterium (luium intracellulare
•
meningeal carcinomatosis
•
sarcoidosis
Discussion Because treatment is possiblc for mycobacteria infections, differentiation with cerebrospinal fluid (CSF) analysis and culture as well as possible biop y a re necessary for complete diagnosis. Sarcoidosis of the CNS could have a similar appearance, and changes in the CNS should be correlated with a chest x-ray, particularly if the chest fi ndings arc consistent with sarcoidosis or tuberculosis. Culture of infections with Mycobacterium species may take up to 6 weeks for organism identification. In some cases, empiric treatment for tuberculosis is startcd prior to final bacteriologic diagnosis. Final diagno sis in a case such as this would rely on histologic or pathologic findings.
INFL A M M ATO RY DTSEASES OF THE SPI N E
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INFLAMMATORY D IS EASES OF THE SPI N E
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Radiologic Findings (continued) Sagittal short TR image postcontrast (Fig. B) reveals dense enhancement of the soft tissue at the T8 level (8, solid arrow). The pedicle enhances along its lower margin (open arrow). Pre- (Fig. C, above) and postcontrast (Fig. C, below) axial short TR images at the level of the pedicle of the T8 vertebral body reveal soft tissue signal intensity material that extends into the vertebral canal and ohliterates the normal epidural high signal intensity fat along the lateral margin of the epidural space (long white arr()w). This soft tissue extends into the paraspinal area on the left side (thick white arrow). The postinfusion images reveal enhancement of the areas of abnormal soft tissue. Parasagittal short TR image in the paraspinal area of the lumber spine (Fig. D) reveal that the inteliacet faint at the T I2-LJ level is indisti nct (black arrow). There is a rounded area of decreased signal intensity in the posterior inferior portion of the T1 2 vertebral body (open arrow). Parasagittal short TR image postcontrast enhancement (Fig. E) reveals enhancement of the interfacet joint at T12-Ll (black arrow). The area of decreased signal in the T12 vertebral body enhances (open arrow). Pre- (Fig. F, upper) and postcontrast (Fig F, lower) axial short TR images reveals the enhancement of the interfacet joint 00 the left side (l()ng while arrow), and reveals that there is a small associated soft tissue component (top, thick white arrow; boltom, black arrow) that exhibits enhancement. .
PEARLS •
•
The radion uclide bone scan was also abnormal at these two levels. Cerebrospinal fluid analysis may be helpful for complete evalua t ion, although infection may be present with an organism such as Mycobacterium tuberculosis and still be normal.
Diagnosis Mycobacterium tuberculosis in the i n terfacet joints in the thoracic and lum ber regions.
Differential Diagnosis •
inflammatory process
•
metastases
Discussion PITFALL •
ubtle abnormalities such as this could be easily overlooked during routine evaluation. Care should be taken to be aware of the other abnormalities in this type of patient, so a correlation may be made with the neuroradiologie imaging abnormalities.
This patient had no known risk factors and did not have AIDS. However, he was also found to have involvement of the right temporal bone with TBc. This temporal bone involvement ultimately led to an int racerehral brain £Ibscess secondary to the TEc organism. Multiple levels of i nvolvement with TBe arc not uncommon in the spine. Careful evaluation should be made for additional areas of involvement. Metastases would be very unlikely with a presentation such as this. An inflammatory process is the most likely di agnosis. The previous hi tory of a cerebral abscess secondary to TBc was particularly helpful in this patient. The final diagnosis would be found at the time of surgery or CT-guided needle aspiration with culture.
5�
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TEACH I N G ATLAS OF SPINE IMAGING
Case 13 Clinical Presentation The patient is a 35-year-old female with progressive mild upper extremity weakness.
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals that the cervical spinal cord is diffusely enlarged in size. There is compromise of the subarachnoid space throughout the length of the cervical subarachnoid space . Sagittal short TR image postcontrast (Fig. B) reveals dense slightly lobulated enhancement in the dorsal aspect of the cervical spinal cord that extends from the level of C4 through the level of C6. The area of enhancement is in the dorsal aspect of the spinal cord. Other areas of the cervical spinal cord that are edematous do not exhibit areas of enhancement. Axi al short TR image postcontrast (Fig. C) reveals dense enhancement of a ro unded area in a white matter distribution (arrows).
I NFLAMMATORY D ISEASES OF THE SPI N E
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Diagnosis Cervical spinal cord involvement with sarcoidosis.
Differential Diagnosis
PEARLS •
•
The enhance m e n t is in a white matter distribution in the cervical spinal cord. At the time of spine imaging, the area of the sella turcica may be visualized, and this should be evaluated for possible enhancement of the pituitary stalk that would substantiate the diagnosis of sarcoidosis.
PITFALL •
A spinal cord tumor could have this appearance; however, the white matter distribution of enh ancement and the very mild clinical symptoms relative to the size of the lesion make the diagnosis of an inflammatory process in this case more likely.
•
central nervous system (CNS) sarcoidosis
•
meningeal carcinomatosis
•
astrocytoma
Discussion Sarcoidosis of the spinal meninges may exhibit a variety of appearances. The primary pattern ma y be that of diffuse meningeal enhancement, which mimics the appearance of meningeal carci nomatosis. In other patients, the imaging appearance is very similar to that illustrated in this example. A significant clue is that the clinical symptoms are minor rela tive to the ab nor mal extent of the imaging appearance. In the patient where diagnosis is not certain, imaging of the brain may also be helpful for final diagnosis. Sarcoidosis in the brain typically involves the pituitary stal k, which appears thickened and to exhibits dense enhancement on the postcontrast study. In other cases, there may be mass-like areas with in the parenchyma of the brain. In some patients, there is a diffuse nodular/meningeal pattern of enhancement. These i maging changes should be correlated with cerebrospinal fluid anal ysis. Correlation with a chest x-ray may demonstra te the typical appearance of hilar and paratracheal adenopathy that is seen in sarcoidosis. This confirms the diagnosis of cen tral n ervous system sarcoidosis. Spinal cord tumor such as astrocytoma would be a strong consideration in a patient such as this. Because of this possibility, the area of en hancement was biopsied and revealed sarcoidosis. Cerebrospinal fluid ana lysis is impor tant for complete evaluation.
Mycobacterium tuberculosis may also mimic the appearance of sarcoidosis. Because tuberculosis is a treatable disease every attempt should be made to rule out this diagnosis.
I N FLA M M ATOR Y DISEASES OF THE SPINE
I
Case 14 Clinical Presentation The pati e n t is
a 3-year-old with a h i s Lury ur amyelogenous lymphatic leuke mia who is status postchemotherapy with new onset or i n ability LO walk.
A
Radiologic Findings Sagittal short TR image postcontrast (Pig. A) reveals enhancement anteri orly in the lower thoracic and uppe r lumbar region (arrows).
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[NFLAMMATO R Y DrSEAS E S OF THE S P I N E
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Radiologic Findings (continued) Axial short TR im age postcontrast (Fig. B) reveals tha t the enhancement seen on the sagittal view is actually the n erve roots of the cauda equina
(arro ws). Computed tomographic (CT) scan of the brai n (Fig. C) reveals diffuse low density throughout the brain in a white matter distribution. This is thought to be secondary to i nvolvement of the cerebral tissue with the cytomegalovirus (CM V) virus.
Diagnosis CMV radiculitis.
Differential Diagnosis
PEARL •
Mcningcal carcinomatosis of the spinal cord could have a si milar appearance; therefore, evaluation should be made for a p rimary tumor within or outside of the central nervous system .
PITFALL •
The cr appearance of the brain has been reported i n Guilla in-Barre syndrome; however, this is a very rare clinical syndrome.
•
CMV radiculitis
•
cerebral ventriculitis
•
men ingeal carcinomatosis
Discussion Cl inical history would be vital in this patient to arrive at a correct diagnosis. An alysis of the cerebrospinal fluid would also allow more accurate evalua tion. Such analysis should include aerobic and anaerobic cultures, cell count, and cytology for complete evaluation. CMV radiculitis has also been re ported in AIDS patients. In these cases, there is typical ly enhancement involving the nerve rools of the cauda e q ui na. Cerebral ventriculi tis is a typical inflammatory process that may affect the central nervous system. In these cases, the postinfusion scan reveals d ense periventricular enhancement. Meni ngeal carcinomatosis with limited involvement of the spinal meninges would also be a diagnostic consideration in this patient. A Lypical pri mary tumor wou ld be medulloblastoma or pinealoma. In addition , the CT appearance of the brain could suggest a disease process such as a metabolic or degenerative disease.
TEACHING ATLAS OF SPINE IMAGING
Suggested Readings EJC, McConneiJ JR, Chadduck W M , FI;migan S. MR im aging of spinal epidural A1NR. 1987:8:879-883.
A n gt uaco sepsis.
B a ker AS, Ojl:lllann RG, Swartz M N , Richardson Med. 1 975;293:463-468.
EP Jr. Spinal epidural abscess.
N En.g 1
Barakus J A , Mark AS, Dillon WP, Norman D . M R imaging of acule transverse myel itis and AIDS myelopa thy.
leA T
1 990; 1 4:45-50.
Bt:rLinu RE. Portcr B A , Sti mac GK, Tepper S1. Imaging spinal osteomyelitis and cp idural abscess with shorl T 1 inversion recovery (STI R ) . A1NR. 1988:9:563-564. Bonaldi VM, D u ong
H. Starr M R , e t al. Tophaceous gout of thc l u m bar spine mimick ing
an epidural abscess: M R features. AINR. 1996; 1 7 : 1 949- 1 952. Bushara KO. Petermann G, Waclawik AJ. t:I al. San;uidosis of the spinal cord
with extl:lIsivc
vertebral involvement: ease report. Compllt Med imaK Graph. 1 995: 1 9:443-446. Danner RL, Hartman Bl. U pd
cr and MR1 uf the norm al and disease perivertebral space.
Neuroradiol. 1 9 95;37:388-394.
Demaerd P, Wilms G. Van Licnk, S. e l al. Lymc disease in childhood presenling as primary leptomeningeal e n h a ncemenl without parenchymal findi ngs on MR. A1NR 1 994 : 1 5 :302-304. Enzman DR, DelePaz RL, Rubin
J B . I n fection and inflammation. I n :
Magnetic Resunllnce
of the Spine. SI. Louis, MO: CV Mosby: 1990.
Feder HM. Zalneriatis EL, Reik L. Lyme disease: acute focal meni nguenl:ephalitis in a child. Pediatrics. 1 988;82:93 1 -934.
Feydy A , Carlier R , Mompoint D , et al. B rain and spinal cun] MR imaging i n a case of acute disseminated encephalomyelitis. Eur Radiol.
] 997;7:415-4.17.
Friess HM, Wasenko JJ. MR of staphylococcal myeli t is o f t he cervical spinal cord. A1NR. E lY7; I X:455-458.
Georgy B A , Chong BW, Chamberl ain M , et al. MR of the spint: in G u illain-Barrc syndrome.
A1NR.
1 l)l)4; 1 5 :30n-301 .
Gem B, Sze G, Sharif H. MR imaging of intradural inflammatory disease of the spine. A .lNR. 1 99 1 ;12: 1 00l)- l Ol l). G raham
E. James DG. N e urosarcoidosis.
H e enan SD, Britton
Sarcoidosis. 1988;5 : 'l 25 -1 3 1 .
J . Septic arthritis i n a lu mbar facet joint: rare cause o f a n epidural
a bsce ss . Neururadiol. 1 995;37:462-464.
H i ra i T, Korogi Y, H am a t ake S, et al. Case report-varicella-zoster virus myelitis-se rial MR findings. Br .l Radiol. 1 l)l)6;69: 1 l 87-1 1 90. J i nkins J R, Bazan C II I, Xiong L. MR of disc protrusion engendered by inft:ctiuus spondylitis. lCA T. 1 996;20:71 5-7 1 8 .
Kircun R, Shormaker E I , Chovanes G I , Stephens H W . Epidural abscesst:s of t h e ccrvical spine: MR fi ndings in five cases. A1R. 1 992;1 58 : 1 145- 1 1 49. Lang 1 M , H ughes DG, J e n k ins JPR, e t al. M R im aging appearances uf cervical epidura l abscess. Clin Radiol. 1 995;50:466-47 1 .
Lexa FJ , Grossman Rl. M R sarcoidosis o f the brain and spint:: spedrum of manifestalions and radiographic response to steroid therapy. A.lNR 1 994: 1 5:973. Loke T K L , M a H TG , Chan CS. Magnetic resonance im aging uf tuberculous spinal i n fection. A lIslraias Nadiol. 1 997 ;41 :7 - 1 2.
Modic MT, Feigl in D I I, Piraino O W , et al. Vertebral us l l:lI m yc l i t is: assessment usi ng M R . Nadioiogy. 1 985;1 57:1 57 -1 66.
M uder RR, Lumish R M, Corsello GR. M yelopa t h y after herpes zoster. A rch Neurol. 1 983 ;40:445-446.
Nesbit G M . Mi ller G M , Baker G L, Ebersold MJ , Schei th auer BW. Spinal cord sarcoidosis: a new finding a t MR imaging with Gd-DTPA enha ncemenl. Radiology. 1989; 173:!G9-843. Post M J D , Quencer RM, Montalvo B M , et al. Spinal i n rection: evaluation with M R imaging a nd i n traoperative US. Radiology. 1988 ; 1 69:765-77 1 . Post M J D , Sze G , Quencer R M , e t a l . G adol i n i u m -enhanced MR i n spinal infection . .leA T. 1 990;1 4:721 -729.
l§£2
l N FLAM MATORY DISEASES OF THE SPINE Quem;er R M . Post M J D . Spinal cord lesions i n patients with A I DS. Neuroilllag eli" North AM. 1997:7:359-373. Rieger J . Hosten N . Sp in al cord sarcoidosis. Nf'II mmdinl. 1 994;36:627. Roze n b l i t A. Wasserman
E.
Marin
ML. et a1. I n fected aortic aneurysm and vertebral osteomy
elitis after i n t ravesical bacillus Calmeue-GlIerin therapy. AJ R. 1 996; 1 67:7 1 1 -7 1 3. Sadato N, Numaguchi Y. R iga l llo n t i D, et a1. Spinal epidural abscess with gadolini um enhanced
M R I ; serial
follow-up s t u di es a llli cli nical correlations. Neuroradiol. 1 ')')4;36:44-51 .
Sandhu FS. Dillon WP. Spinal cp i u ural abscess: evaluation with contrast-enhanced M R imaging. AJNR. 1 982: 1 2: 1087- 1 093. Schellinger D. Patterns of anterior spinal canal involvemem by neoplasms and i n fect i o ns . AJ NR. 1 996: 1 7:953-959.
Sharif
H.
Clark DC. Aabcu MY. ct a1. Granulomatous spinal i n fections: MR imaging.
Radiology. 1 990: 1 77: I 0 1 - 1 07.
Sze G, Sioctsky S. Broncn R , ",t a1.
MR
imaging of thc cranial meningie� with emphasis on
contrast enhancement and meningeal carcinomatosis. AJNR. Talpos D . Tien RD, Hesselink J R .
I 989; I O:<J65-'l75.
M agnctic resonance imaging of A I DS-related polyradicu
lopathy. Neurology 1 99 1 ;4 1 : 1 995-1 997. Thrush A. Enzman D R . MR i ma g i n g of i n fectious Thurnhcr
MM.
spo ndyl iti ,. A.lNlr 1 990: 1 1 : 1 1 7 1 - 1 1 80. MJD. Diagnostic imaging of i n fections and neoplasms with A I DS. Nellmifl/(/Ij Cii" Nllrth Am. 1 997:7:34 1 -357.
J inkins J R . Post
a!Tecting the spine i n patients
Vi olo n P. Patay Z. Braeckeveldt J,
et a1.
Atypical infectious complication of antcrior cervical
su rgery. Neuroradiol. 1 997;39:278-28 1 . Yumen N , Alper
H,
Zileli
M . e t a1.
Tuberculosis radiculomyelitis as a complication of
spondilodiscitis: M R demonstration. J Neuroradiul. 1 996:23:241 -244.
Section vm
Cervical Disc Disease
CERVICAL DISC D I S EA S E
I
Case 1 Clinical Presentation The patient is a 39-year-old male with a clinical history of 7 days of right neck, shoulder, arm, and hand pain and numbness in the C6 distribution. No history of tra uma.
A
B
Radiologic Findings Midsagittal short TR image in the cervical spine (Fig. A) reveals very slight narrowing of the intervertebral disc space at the C5-6 level (arrow). Midsagittal long TR image (Fig. B) reveals slight disc space narrowing and a small bulging disc at the C5-6 level (arrow).
I TEACHING ATLAS OF SPINE IMAG I NG
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I TEACH I N G ATLAS OF SPINE IMAGING Radiologic Findings (continued) Right para sagittal short TR image (Fig. C) rcveals a moderately large soft tissue mass that arises from thc intcrvertebral disc and projects poste riorly into the vertebral canal (arrow). Curvilinear posterior displ ... cement of the cervical spinal cord is visible at this level. There is compromise of the low sign ... 1 intensity subarachnoid space. The C7 vertebral body is identified with 7. Right parasagitlal intermediatc TR image (Fig. D) reveals a decre...setl signal i ntensity soft I issue mass that encroaches upon the cervical vertebral canal. Right parasagittal long TR image (Fig. E) reveals the soft tissue signal intensity mass projecting posteriorly [rom the intervcrtebral disc sp... ce, compromising the vertebral canal and causing curvilinear indental ion upon thc cervical spinal cord. Axial gradient echo image at the C5-6 level (Fig. F) reveals a large soft tissue Illass on the right side I h
Diagnosis Large hern iated disc at the C5-6 level on the right side.
Differential Diagnosis •
herniated disc
•
tumor
Discussion PEARLS •
•
u rgery can be confidently performed based upon the M R I finding . Because herniated discs may occur at more than one level, evaluation should be made for the possibility of a disc herniation at additional levels.
Herniated cervical discs are most common at the C5-6 level. In this patient. t he disc is hcrniated to the right of the midline. Because of the far latcral position of the disc, the m idsagittal image is normal. The curvilinear line seen in Figure G is the dura, which is displacetl posteriorly. The lateral position of the herniated disc results in encroachment upon the intervertebral foramen at this Icvel. The nerve roots of the spinal cord exit at the C5-O level <'Ind rcsult in the ntdicular pain in this patient. Magnetic resonance imaging ( M RI) is the procetlure of choicc for evaluation and accurately reflects the anatomic changes that arc present. Gradient echo images are used bccause they cause the cercbrospinal fluid 1 0 appear bright and are scnsitive to magnetic susccptibil ity artifact; therefore, they can
«
CERVICAL orsc D IS EASE
PITFALLS •
Care must be taken to accurately identify the side and level of the herniation, so an accurate urgical approach ean be planned and executed.
allow better di fferentiation between the bone and the signal intensity of the disc material. The appearance is very typical of an uncomplicated herniated disc. The soft tissue density mass arises at the level of the intervertebral disc and is associ ated with narrowing of the disc space. This fi nding does not suggesl a tumor. There is also straightening of the cervical spi ne on the sagittal view, a ti nding that is seen in association with a herniated disc. Straightening of the spine with loss on the normal cervical lordotic curve is well demonstrated in Figure A. These changes can also be seen with plain film evalua tion. In the correct clinical setting it is possible to predict a herniated intervertebral disc with a high degree of certainty based on the plain fi lm findings.
I TEACHING ATLAS OF SPINE IMAGING
Case 2 Clinical Presentation The patient is a 40-year-old female with a clinical history or right C6 radiculo pathy, pai n, and weakness.
A
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Radiologic Findings Midsagittal short TR image in the cervical region (Fig. A) reveals reversal of the normal lordotic curve. There is narrowing of the intervertebral disc at the C5-6 level (arrow) with slight anterior as well as posterior bulging of the disc at this level. There is curvi linear indentation of the cervical spinal cord.
PEARLS •
•
Surgery can be performed bascd on the magnetic resonance imaging (MRI) findings because MRI accurately renects the anatomic deformities. The long TR images should be carefully evaluated [or the presence of abnormal signal intensity in the pinal cord. These changes are thought to be secondary to vascular compromise or possibly direct trauma to the spinal corel.
PITFALLS •
•
Computed tomographic (Cf) scanning in association with myelography can be used for diagnosis; however, MRI has proved to be an accurate method to evaluate cervical disc disease. cr is more sensitive than MRJ for the identification of small bony osteophytes and so lDay be performed in conjunction with MRJ for evaluation of bony encroachment. M yelography a nd postmyelography also may be used for more complete evaluation.
1.§l4
Right parasagittal short TR image (Fig. B) reveals a soft tissue mass that projects posteriorly into the vertebral canal at the C5-6 level (arrow). There is curvilinear indentation upon the cervical spinal cord. The C6 vertebral body is iJentified with 6. Right parasagittal long TR image (Fig. C) reveals a soft t issue m ass en croachi ng upon the cervical vertebral canal at the C5-6 level. The spinal cord is compressed and displaceJ laterally toward the left side out of the plane of i maging. Axial gradient echo image at the C5-6 level (Fig. D) reveals a high signal intensity soft tissue mass on the right side (arrow). The normal high signal intensity cerebrospinal fluid is obliterated. There is effacement of the right, anterior margin of the cervical spinal cord and obliteration of the interverte bral foramen on the right side.
Diagnosis Right-sided herniated in tervertebral disc at the C5-6 level.
Differential Diagnosis •
herniated disc
•
tumor
Discussion The appearance is very typical of a herniated cervical disc. The C5-6 level in the most common level of a herniateJ cervical disc. The radicular pain is secondary to the mechanical compression of the nerve roots as they exit from the intervertebral foramen. The loss of lordotic curve and narrowing of the i ntervertebral disc are changes that can be appreciated on the plain fi lm evaluation; these findings can be utilized to predict the possible presence of a herniated d isc. The appearance does not suggest a tumor. The soft tissue mass arises from the in tervertebral disc and is herniated both anteriorly and posteriorly. [n general, progressive wea kness is a more typical clin ical presentation for a herniated disc, while neck pain and radiculopathy are more typical presenta tions for a patient with a herniated disc.
•
CE R V ICAL
D I SC DISEASE
I
Case 3 Clinical Presentation The patient is a 45-year-old left-handed female with sudden onset of severe pain and weakness in the left arm after playing tennis.
A
B
Radiologic Findings Midsagittal short TR image (Fig. A) reveals straightening of the spine. There is a bulging disc at the C4-5 level with encroachment upon the cervical subarachnoid space. There is also disc prominence at the C5-6 level with slight encroachment upon the cervical subarachnoid space. The C5 vertebral body is identified with 5.
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CERVICAL DISC D ISEASE
Radiologic Findings (continued) Midsagittal long TR image (Fig. B) reveals that the uisc at C5-6 appears more prominent than the disc at the C4-5 level. Note the slight anterior disc hcrniation at the C5-6 level. There is slight loss of intervertebral disc height at the C3-4, C4-5, and CS-6 levels. There is no abnormal signal within the cervical spinal coru. Long streaks of increased signal intensity within the spinal cord are secondary to truncation artifact. Parasagittal TIW image (Fig. C) reveals evidence of a far lalerally placed soft tissue mass at the C5-6 level (arrow). There is encroachment upon the cervical subarachnoid space. Ax ial gradicnt echo image (Fig. D) reveals bulging of the disc at the C4-5 level. There is slight encroachment upon thc ccrvical subarachnoid space and slight compression of the cervical spinal cord. Axial gradient echo image at the C5-6 lcvel (Fig. E) reveals definite encroach ment upon the cervical subarachnoid space. The normal high signal intensity epidural fat in the intervertebral foramen at the CS-6 level of the left side (arrow) is obliterated. There is a double signal intensity area where the disc extends beyond the posterior margin of the vertebral body (arrowheads). There is slight effacement of the left lateral margin of the cervical spinal coru.
Diagnosis PEARL •
areful evaluation of the parasagittal images are very helpful in the accurate diagnosis of a laterally herniated disc in the cervical region.
rITFALL •
Computed tomographic (Cf) scanning wilh myelography will demonstrate failure of filling of the nerve root sleeve at the level of the herniation on the myelogram and an extradural defect by CT scanning; however, accurate interpretatiou of the noninvasive MRI 'can will preclude Ihe use of myelography for diagnosis in most case .
Left lateral herniated disc at the C4-5 level.
Differential Diagnosis •
herniated disc
•
schwannoma
Discussion The midsagillal images in this case appear almost normal, or suggest only a small abnormality of thc disc at the C4-S level. However, close evaluation of the parasagittal images reveals the presence of a soft tissue mass encroaching upon the subarachnoid space. The axial images are also subtle and revcal the soft tissue mass obliterating the epidural fat on the left side. The normal high signal in tensity of the epidural fat provides the perfect contrast material when using magnetic resonance imaging ( MRI). The herniated disc also obliterates the high signal intensity fat in the intervertebral foramen, as seen on Figure E. Because the nerves m ust exit via these foram ina, a herniated disc will lead to severe radicular pain. The possibility of a schwannoma at the C5-6 level is a consideration; however, the broad base arising from the intervertcbral disc space favors a herniated cervical d isc.
r TEACHING ATLAS OF SPINE I M AGING
Case 4 Clinical Presentation The patient is a 43-year-old female with a history of neck pain.
A
Radiologic Findings Axial postenhancement with iodinated contrast material computed tomo graphic (CT) scan (Fig. A) reveals a low density curvibnear area projecting behind the intervertebral disc space at the C4-5 level. A peripheral high density margin surrounds this structure. The subarachnoid space is compro mised, and the cervical spinal cord is slightly indented .. Incidentally, there is also enhancement of the carotid arteries and j ugular veins
Diagnosis Herniated midline and left paracentral cervical disc at the C4-5 level.
Differential Diagnosis
53 8
•
herniated disc
•
epitlur
CERVICAL DISC D I SEASE
PEARLS •
•
Herniated discs may be seen even in asymptomatic patients. Therefore, care must be taken to interpret the presence of a herniated disc in the c1inicaJ setting of thc patient's symptom . While cr scanning can be used for the evaluation and diagno i of herniated cervical discs, M RI is the more accurate and les inva ive method.
PITFALLS •
A small epidural absccss could
have a similar appearance, so correlation should be performed with the clinical setting of the patient's presentation. •
Discussion Prior to thc dcvclopment of magnetic resonance imaging (MRI), various methods were attempted to identify herniated cervical discs. One of these methods was the use of cr canning in association with contrast enhance ment. The cervical venous plexus is very vascular and therefore enhances with contrast infusion. In this case, the venous plexus appears as a curvilinear area of increased density surrounding the relatively low density herniated disc. In those patients with a pure soft herniated disc that is not associated with osteophyte formation, this method is a useful tool, particularly if M RI is not available or the patient is not able to undergo MRl. Herniated discs in the cervical region may be in the midline, off to one side (in which case they are termed paracentral), or far laterally placed. Herniated discs that are off the midline may cause encroachment upon the nerve roots as they exit in the intervertebral foramen. The remote possibility of an epidural abscess is a consideration. However, the abnormality is centered at the level of the intervertebral disc, and the absence of a clinical history of fever or pertinent clinical setting such as drug abuse makes this diagnosis unlikely. MRI is the procedure of choice for the evaluation of herniated cervical discs; however, in some patients a myelogram with postmyelogram CT scan ning may be necessary to better define the anatomic location of a disc.
cr scanning may be used for diagnosis; however, it is bcst perfornled with thc use of an in fusion of contrast material. Therefore. MRI is recommended as the procedun! of choice for evaluation because MRI in this clinical setting does not require the use of contrast material.
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TEACH I N G ATLAS OF SPINE IMAG I N G
Case 5 Clinical Presentation The patien t is a 37-year-old female with a history of a motor vehicle accident wi th a whiplash injury.
A
B
Radiologic Findings Sagittal long TR image (Fig. A) reveals a s m all herniated disc at C4-S and CS-6 and disc bulges at C6-7 and C7-T1 . An oval area of increased signal intensity is j ust superior to the herniatcd disc at the C4-S level (arrow). There is an terior prominence of the disc at the C4-5 level and reversal of the curve of the cervical spine. Sagittal short TR image obtained approximately 4 months latcr (Fi g . B) reveals an increase in the disc space narrowing at C4-S and C5-6. There is a sm aIJ oval area of decreased signal intensity that projects at the level of the midbody of the C4 vertebra (arrow). The C4 vertebral body is idcntified with 4.
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TEACH I N G ATLAS OF SPINE I M A G ING
Radiologic Findings (continued) Sagittal long TR image (Fig. C) reveals that the small area of decreased signal intensity now appears as a focal area of increased signal i ntensity (arrow). There is intervertebral disc space na rrowing at multiple levels and encroachment upon the subarachnoid space at multiple levels. Axial short TR i m age (Fig. D) reveals the area of decreased signal intensity in the right side of the cervical spinal cord (arrow). This presumably repre sents an area of myelomalacia. These areas are thought to be secon dary to cither repeated trauma or vascular compromise. Axial gradient echo image obtained j ust above the level of the disc at the C4-5 level (Fig. E) reveals the decreased sign al in tensity of an osteophyte projecting from the posterior margin of the vcrtebral body (arrowheads). There is slight compromise of the cervical subarachnoid space at this level. Axial short TR image at the C4-5 level (Fig. F ) reveals a small right sided herniatcd disc (arrow). This results in compromise of the subarachnoid space at this level and flattening of the cervical spin al cord.
Diagnosis Degenerative changes with osteophyte formation and trauma resul ting in myelomalacia.
CERVICAL D ISC D ISEASE
PEARL •
Magnetic resonance imaging (MRT) is the ideal method for initial evaluation of these patients. MRI also aids in evaluating the presence of a hematoma following trauma. Initially these patients may do well clinically only to develop symptoms at a I.ater date, so MRI is tbe ideal method for follow-up.
PITFALL •
Myelograpby and postmyelography cr scann ing will not generally reveal these areas of myelomalacia. If a syrinx cavity fonns, delayed cr scanning approximately 8 hours following a myelogram may reveal tbe concentration of contra, t material within a syrinx cavity.
Differential Diagnosis •
myelomalacia
Discussion At the time of initial trauma, this patient presumably sustained a contusion of the spinal cord li t the C4 level secondary to the bony osteophyte. Over Lhe succeeding 4 months, this area of contusion or edema progressed to an area of focal myelomalacia or a small syrinx cavity. Although the exact cause of these areas of myelomalacia is uncertai n, one theory is that they are secondary to direct trauma to the spinal cord or secondary to vascular compromise. In some cases, these areas of initial increased signal intensity revert to normal , while in other patients, they progress to areas of myelo malacia. Small syrinx cavities may also form. The tiny syriTLX c.:aviLy seen here could have been a pre-existing lesion, b ut the proximity to the osteophyte and the herniated disc are more suggestive thaL the tiny cavity is related to the disc.
I TEA
H ING ATLAS OF SPINE I M AGING
Case 6 Clinical Presentation The patient is a 72-year-old female with a history of neck pain and numbness. The patient was in an automobile accident approximately 1 year prior to this study.
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CERVICAL DISC D ISEASE
Radiologic Findings Sagi llal shorl TR image (Fig. A) reveals that the odontoid processes are displaced posterior to the anterior arch of the Cl verlebral body. The anterior arch of Cl appears as an oval area of increased signal i n tensity (large white arrow). There is a mottled, lower than normal signal intensity mass posterior to the arch of Cl and anterior to the odontoid process. The spi n al cord at the level of the cervicomedullary j unction (black arrowhead) is markedly compressed. At the C3-4 level, a large herniated disc projects posteriorly into the verlebral canal and narrows the spinal cord at the C3-4 level (small while arrow). The C3 verlebral body is identitied by 3. Midsagittal long TR image (Fig. B) reveals anterior displacemen l of the posterior arch of Cl (long black arrow) rel alive lo the spinous process of C2 (s) . The poslerior displ acement of the odontoid process and the anterior displacement of the posterior arch of C2 result in a severe stenosis at this level (double black arrows). The spinal cord is markedly compressed at this level. There is a lso marked canal compromise at the C3-4 and C4-S levels secondary to prominent intervertebral discs at both of these levels. The CS vertebral body is identified with S. Parasagittal long TR image (Fig. C) reveals more marked prominence of the intervertebral disc at the C3-4 Level off loward the right side (white arrow). The spinal cord al the level of the cervicomeduUary junction is m arkedly compressed and exhibits a tiny focal area of increased signal i n tensity within the spinal cord (black arrow). The odontoid process is displaced posteriorly and superiorly. SagiLtal reconstruction image of the cervical spine (Fig. D) reveals the anterior arch of Cl (large white arrow). There is an oval shaped area- of increased density posterior to the arch of Cl . The distance be lween t he posterior arch of Cl and the odontoid process is markedly narrowed (douhle white arrows). There is an oSleophyle lhal arises from the posterior margin of the C3 verlebral body and extends into the vertebral canal (black arrow) al the C3-4 level. There is a small posterior osteophyte at the C4-S level and anterior and posterior osteophytes at the C6-7 level. The C7 vertebral body is identified with 7. Axial short TR image (Fig. E) reveals posterior displacement of the odontoid process (0, with straight arrow) relative to the anterior arch of the Cl vertebral body (curved arrow) . The osteophyte projects behind the anlerior arch of Cl and appears as a rounded area of increased signal intensity. Axial com puled lomographic (CT) scan at the level of C2 (Fig. F) reveals that the odontoid process is displaced posteriorly away from its normal anticipated position behind the anterior arch of Cl (A). The bony osteophyte seen in the sagittal reconstruction image projects behind the anlerior arch of Cl . The odontoid process is identified w i th O. Axial long TR i mage at the level of the C3-4 intervertebral disc (Fig. G ) reveals a large decreased signal intensity mass t h a t projects posteriorly into the vertebral canal and markedly narrows the cervical vertebral canal. The spinal cord (arrow) is compressed into to a crescent shaped slruclure posteri orly in the vertebral canal. Postmyelogram axial CT scan at the level of C3-4 (Fig. H) reveals a large osteophyte that markedly encroaches upon the vertebral canal (solid arrow). The spinal cord is compressed posteriorly into a crescen t shape (open arrow).
5£1
I TEA
H I NG ATLAS OF S P I N E IMAGING
Diagnosis Rheumatoid arthritis with C I -2 dislocation; herniated disc at the C3-4 and C4-5 levels.
PEARLS •
•
MRI i the procedure of choice for the evaluation of rheumatoid arthritis. In addition to static images, images can also be obtained u ing hort TR images in flexion and extension views to reveal the amount of motion at the Cl-2 level alld to determine the effect upon the cervical spinal cord.
PITFALLS •
•
These patients are a difficult management problem bec::lUse of the multilevel abnormali ties and because of the longstanding nature of the subluxation with compression atrophy of the cervical spinal cord. Care must be taken clinically when attempting to manipulate these patients because the patients themselves assume a position that is comfortable for them. Manipulation of the head and neck in a stressful way that is uncomfortable may have dire neurological consequences, including quadriplegia.
Differential Diagnosis •
rheumatoid arthritis
•
pseudogout
Discussion The patient had a known history of rheumatoid a rthriti . The soft tissue mass posterior the anterior arch of C I is pannus formation related to the rheumatoid arthritis. Laxity of the t ransverse and cruciate ligaments which normally hold the odontoid process in close proxim ity to the posterior arch of Cl is also associated with rheumatoid arthritis in this patient. The relative posterior displacement of the odontoid process and C2 vertebral body as compared to the relative anterior displacement of the Cl vertebral body and t he skull base results in a severe stenosis of the vertebral canal. This n arrowing is visible on the CT scan (Fig. D); however, the magnetic reso nance imaging (MRI) scan better reveals that this stenosis is even more severe than appreciated by the CT scan because the additional soft tissues can be seen by MRI as compared to CT scanning (see Fig. C). In addition the patient also has a large hern iated disc and accompanying osteophyte at the C3-4 level. The sagittal MRI scan also reveals a herniated disc at the C4-5 level (Fig. C). Note that the CT scan better demonstrates the bony abnormalities, while MRI is superior in identifying the soft tissue abnormalit ies and the relationship of the spinal cord to the surrounding bony and soft tissue abnormalities. Calcium pyrophosphate deposition disease (pseudogout) could have a simi lar appearance; however, patients with rheumatoid arthritis generally have a more typical clinical presentation with involvement of the joints of the ex tremities. The patient did not develop quadriplegia with the marked compression of the spinal cord because the changes occurred over a prolonged period of time. When the compression happens very slowly, the spinal cord is allowed to atrophy without catastrophic clinical symptoms. On the other hand, rapid development of spinal compression would result in quadriplegia.
CE RVICAL DISC DISEASE
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Case 7 Clinical Presentation The patient is a 54-year-old male with l ongstanding neck stiffness and recent acute neck pain .
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I TEACH I NG ATLAS OF S P I N E lMAGING
c
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Radiologic Findings Lateral view of the cervical spine from the d igital image obtained at the time of computed tomographic (Cf) scanning (Fig. A) reveals posterior and superior displacement of the odontoid process (0) relative to the ante rior arch of Cl. The large white arrow identifies the base of the odontoid process. Neither the anterior arch nor the posterior arch of Cl are well visualized. There is failure of segmentation (fusion) between the vertebral bodies and spinous processes of C2 through C4 (small while arrows). The black arrow identifies the posterior margin uf the foramen magnum. Sagillal sbort TR image of the cervical spine (Fig. B) reveals that the Cl vertebral body is not seen. The posterior arch of the Cl vertebral body is fused and incorporated into the occipital bone at the skull base. The anterior arch of the Cl vertebral body (a) is fused to the inferior aspect of the clivus. There is widening of the space between tbe odon toid process and the anterior a rch uf the Cl vertebral body. The odontoid process is displaced posterior itnd superior to its normal a nticipated position. Anterior osteophytes are visible at the C4-5, C5-6, and C6-7 levels. Tbere is loss of anterior vertebral body height at the C7 level. The C3 vertebral body is identified with 3. Sagitta l long TR image of the cervical spi ne (Fig. C) reveals a ventral indentation upon the subarachnoid pace at the C4-5 level. The vertebral canal is narrowed to 5 mm at this levcl . There is a small "streak-like·'
CERVICAL D I SC DISEASE
I
Radiologic Findings (continued) area of incre(lsed signal intensity within the cervical spinal cord at the C5 level (arrow). Axial short TR image at the C4-S level (Fig. D) reveals (In intcrmediate area of soft tissue promi nence at the C4-5 level which is largcst the right side and extends to thc midline (open arrow). There is compromise of the subarachnoid space and compression of the cervical spinal cord (0) on the right sidc. The afferent (long thin black arrow) and efferent (short thin black arrow) nerve roots of the cervical spinal cord are well demonstrated. The nerve root ganglion is also seen (It the level of the i n tervertebral foramen latcral to the afferent (lnd efferent nerve roots (while arrow). The flow void of the vertebral artery is seen in the foramen transversaria (sharI solid black arrow). The afferent nerve is carrying impulscs toward the spinal cord while the efferent nerve is carrying ncrvc impulses away fr0111 the spinal cord.
PEARL •
The vertebral body and spinous process fusion is generally well demon trated by plain 111 m evaluation. In this case, the fusion between the vertebral bodies is well demonstrated on the MR images.
PITFALL •
These patients may be diffi cult to manage because of the multiple congenital anomalies.
Diagnosis Atlantoaxial fusion; Klippel- Fei! anomaly; right-sidcd herniated disc at the C4-S level.
Differential Diagnosis •
atlantoaxial fusion
•
Klippel-Fcil anomaly
Discussion The Cl vertebral body is completely fused to the skull base. This anomaly is called atlantoaxial fusion, (lnd it is a congenital anomaly. In addition, there is laxity of the transverse and cruciate l igaments that fix the odontoid process to the anterior arch of C I . Th is allows the odontoid process to migrate superiorly and posteriorly. This migration results in marked compro mise of the foramen magnum and compression of the cervical spinal cord at the level of the foramcn magnum. The Klippel-Feil anomaly is also a congenital derorm ity witl l fusion of multiple cervical vertebral bodies. This fusion or the vertebral bodics causes limitation of motion of the cervical spine in the upper ccrvical region. This limitation translates the stress to the adjaccnt intervertebral e1isc, in this case C4-S, which is j ust below (or above in some cases) the fused vertebral body segments, resulting in a herniated disc (It t he C4-S level. This translation of stress call also be seen in patients who have had surgical fusion between the veltcbral bodies; herni(lted discs may be seen abovc and/or below the level of the fusion. Fusion of the vertebral bodies following a surgical proccdu re would result in the obl i teration of the intervertehral disc spaccs.
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I TEACHING ATLAS OF SPINE IMAGING Note that the cervical spinal cord is compressed on the right side, but is also rota tetl away from the right side and toward the left side. This rotation of the spinal cord is significant and should be noted when it is present. Magnetic resonance ( MR) scanning is performed with the patient in the supine position, which al lows the cervical spi nal cord to be displaced posteriorly away from the posterior margin of the vertebral bodies. I n reality the spinal cord is probably resting against the po ·terior margi n o f the vertebral bodies and therefore is displaced a nti rotated when there is a laterally placed herniated disc or laterally placed osteophyte. The large a nterior osteophytes are remi niscent of those seen in diffuse idiopathic skeletal hyperostosis (DISH).
1 [)5?
•
CERVICAL DISC DISEASE
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Case 8 Clinical Presentation The patient is a 74-year-old male with progressive myelopathy.
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CERVICAL D ISC DISEASE
I
Radiologic Findings Sagittal short TR i mage (Fig. A) reveals increased signal intensity spikelike areas that have the appearance of large osteophytes projecting posteriorly i n to the vertebral canal. These arise from the i n ferior endplates of C3, C4, m : d CS . There are very large anterior osteophytes at all tbese levels as wcll. The spinal cord is compressed and straightened from the C2 level through the Co level. There arc patchy areas of increased signal intensity within the ccrvical spinal cord at C2-C4 (arrows). There is compromise of the subarachnoid space anteriorly. The C3 vertebral body is itlt!ntified with 3. Sagittal intermediate TR image (Fig. B) reveals a herniated d isc at the C3-4 level that projects into the cervical canal. There is an area of increased signal intensity within the cervical spinal cord at this level (black arrows). The cervical vertehrlll canal is markedly narrowed in anteroposterior diameter at this level. Extending inferiorly below the C3-4 level is a ridgelike aretl of decreased density that extends from C3 through C7 (shorl while arrows). There is mild anterior displacement of TI on T2 (curv ed white arrow). Sagittal long TR image (Fig. C) again reveals the increased signal intensity within the cervical spinal cord at. the C3-4 level (arrow). The subarachnoid space from C3 through C7 is compromised. There is curvilinear indentation upon the cervical spinal cord at C3-4, C4-S and CS-6. Axial gradient echo image at the C3-4 intervertebral disc level (Fig. D ) reveals a oft tissue mass (open arrow) projecting posteriorly in to the verte bral canal and marked compression of the cervical spinal cord (curved arrow). There is a rounded area of increased signal i n tensity within the spinal cord ventrally (long thin arrow). The subarachnoid space is essentially completely obliterated at this level. Axial gradient echo image at the level of CS (Fig. E) reveals a platelike area of decreased signal intensity projecting behind the vertebral body (arrow). The subarachnoid space is obliterated at this level, and the cervical spinal cord is displaced posteriorly.
Diagnosis PEARLS scan n ing or cr in conj unction with myelography may be necessary for complete evaluation of the abnormality.
Herniated disc at C3-4; posterior longitudinal ligament ossification.
. cr
•
Sagittal and axial long TR images, in which the cerebrospinal fluid appears as increased signal intensity, hould be obtained because it is easier to identify the decreased signal intensity of the calcified! ossified posterior longitudinal l igament.
Differential Diagnosis •
posterior longitudinal ligament ossification
Discussion Posterior longitudinal ligament ossification is a disease of older individuals. Thc posterior longitudinal ligament is located along the posterior margins of the cervical vertebral bodies and extends from one vertebral body to I he nexl . Tbis ligament may either calcify or ossify. This calcification/ossification is easily demonstrated by computed tomographic (CT) sca nning, but may be more difficult to identi fy by magnetic resonance imaging (MRl). The partial volume effect on the M R images obtained in the sagittal plane
I TEACHl
G ATLAS OF SPI 'E IMAGING
PITFALL •
The full extent of the abnormality may not be demonstrated by MRI.
decreases the ability of MRI to demonstrate this abnormality. However, the diagnosis may be suspected because of secondary changes, such as interruption of the subarachnoid space and spinal cord compression. The axial images are also helpful [or demonstration of changes in the posterior longitudinal ligament. The appearance is very typical of the d i agnosis. The cause of the increased signal intensity within the spinal cord seen on the sagittal short TR image in Figure A is uncertain. It could be related to hemorrhage, or mure. likely to increased protein content within t he spinal cord.
•
CERVICAL D I S C D I S E ASE
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Case 9 Clinical Presentation The patient is a 6H-year-old female with neck pain and limitation of motion.
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I TEACHfNG ATLAS OF SPINE IMAGING
D
E
CER V I CAL D I SC DISEASE
Radiologic Findings Sagittal short TR image of the cervical spine (Fig. A) reveals a dense ridgelike area of marked decreased signal in tensity behind the cervical vertebral bod ies of C2 through C4. The spinal cord is displaced markedly posteriorly and compressed at the C2 through C4 levels. There are a nterior osteophytes at C4-5, C5-6, C6-7, and C7-Tl . There is loss of the normal cervical lordotic curve. Sagittal long TR image (Fig. B) reveals that the area of decreased signal intensity seen in Figure A remains decreased signal in tensity on the long TR image. The spinal cord is compressed to a "ribbonlike" structure. There is mild hulging of the intervertebral disc at the C4-5 level. Sagittal reconstruction image of a computed tomographic (CT) scan (Fig. C) reveals the dense linear, laminated appearing area of calcifica tionl ossification posterior to the vertebral bodies of C2 through C4. There are large bridging osteophytes anteriorly at the C4-5 level. The cervical vertebral canal is narrowed to 4 mm in the anteroposterior dimension. Axial gradient echo image at the C3 level (Fig. D) reveals a pancake-shaped area of decreased signal intensity projecting posterior to the vertebral body (arrow). The spinal cord (5) is markedly flattened i n to a curvilinear con figu ration posteriorly in the vertebral cana 1. PEARL The marked compression of the spinal cord is sufficiently severe that any area of increased sign al intensity present in the pinal cord may not be vi ualized. •
Axial CT scan at the same level as Figure 0 (Fig. E) reveals the laminated appearing areas of calcification/ossification projecting posterior to the verte bral bodies. The vertebral canal is markedly compromised.
Diagnosis Posterior longitudinal ligament calcification/ossification.
PITFALL • Both cr and MRl may be necessary for complete evaluation. In this patient, there is excellent correlation between the CT scan and the MR scan; however, posterior longitudinal ligament calcifica tion is often not well demonstrated by MRI and is generally better demonstrated by CT scanning. MRI, on the other hand, demonstrates the exact relationship between the spinal cord and the surrounding bony structures; this relationship is not demonstrated by CT scanning.
Differential Diagnosis •
posterior longitudinal ligamen t ossification
Discussion Posterior longitudinal ligament ossification is nicely demonstrated by the CT scan in this patient. The laminated nature of tbis type of calcification is well demonstrated by the CT scan. The overhanging edges of the ossified areas are also well demonstrated in this case. These appear as areas of intermediate signal intensity by short TR magnetic resonance imaging (MRI) or linear areas of increased signal i ntensity by long TR MR images. CT scanning is unable to directly demonstrate the appearance of the cervical spinal cord. MRl h as the advantage of being able to directly visualize the spinal cord and its relationship to the surrou nding vertebral canal. MRl thus allows for direct noninvasive visualization of the anatomic position of the spinal cord.
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SPINE I M A G I N G
O n e o f the uirrIcult management issues with a patient with such severe changes is that the anterior spinal artery is anatomical ly located along the anterior aspect of the cervical spinal cord. Therefore, this type or posterior longitudinal ligament ossification may result in compression of the anterior spinal artery and compromise ur the pyramidal tracks, causing both upper and lower extremity weakness. Because these changes are frequently long standing, the ossified ligament may actually invaginate into the spinal cord, mllk ing surgical removal of this difficult to inlpossible; attempts at remuval may actually interrupt or further compromise the blood supply to the spinal cord and result in severe neurological deficit.
CERVICAL DISC DISEASE
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Case 10 Clinical Presentation The patient is a 49-year-old female with a history of recent surgery for disceetomy at the C4-S and CS-6 levels.
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Radiologic Findings Sagittal short TR i mages (Fig. A) in the cervical region reveal that bony fusion plug have been placed at the level of the intervertebral discs at the C4-5 and C5-6 levels (arrows). At the C5-6 level, there is a cleft of decreased signal intensity that probably represents an area of gas accumu lation. The bony plugs extend slightly posterior to the posterior m argins of the vertebral bodies. There is slight straightening of the cervical spine and loss of the normal cervical lordosis. The C3 vertebral body is identifieLi with 3. Sagittal postcontrast infusion short TR image (Fig. B) reveals enhancement of the bony fusion plugs at hoth the C4-5 and the C5-6 levels (arrows). The C5 vertebral body is identifieLi with 5.
Diagnosis PEARL •
MR I is the ideal method of evaluation of the postoperative patient.
Recent surgery for disc removal at the C4-5 and C5-6 levels with bony fusion plugs in place.
Differential Diagnosis •
PITFALL •
Tf injury to the spinal cord occurred at the time of surgery, the area of increased signal intensity may be seen in the cervical spinal cord on long TR images. Therefore. long TR images should be obtained in these patients for complete evaluation.
�2
bony fusion plugs
Discussion The magnetic resonance imaging (MRI) study reveals that there is no migra tion of the bony fusion plugs, which enhance on the postinfusion study. Ideal ly, the plugs should not extend posterior to the posterior margin of the vertebral body. MRJ provides the ideal method for follow-up of these patients. Surgical complications include anterior slippage or migration of the bony fragments out of the intervertebral disc space. Posterior migration into the vertebral canal may also occur but is less common. Posterior migra tion of the bony plug would jeopardize the cervical spinal cord. Note the mild prevertebral soft tissue swelling hecause of the recent surgery.
CERVICAL DJSC D I S EASE
Case 11 Case Presentation The patient is a 56-year-old male with increasing weakness in the upper extremities bilaterally, and numbness in the upper and lower extremities bilaterally. Weakness on the left is greater than on the right.
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B
Radiologic Findings Sagittal short TR image (Fig. A) reveals a large herniated disc at the C34 level. There is marked extension into the cervical vertebral canal, obUtera lion of the subarachnoid space anterior to the spinal cord , and compression of the cervical spinal cord. There is straightening of the cervical spi ne. Incidentally noted are postoperative changes w i th fusion between the C5, C6, and C7 vertebral bodies. There is fO(.;(l1 reversal of th e curvc of the cervical spine at this level and n arrowing of the interspi nous distance at the C3-4 level (black arrow) and wideni ng of the interspinous distance at the C2-3 level (arrowhead).
I TEACHING ATLAS OF SPI ' E IMAGING
c
D
CER V I CA L DISC D ISEASE
E
Radiologic Findings (continued) Sa gi ttal long TR image (Fig. B) reveals the herniated disc at the C3-4 level. There is marked compromise of the vertebral canal at th is level. There is an area of i..ncreased signal intensity in the midportion of the cervical spinal cord at the C4 level (arrow) secondary to cervical encephalomalacia. Axial short TR image (Fig. C) reve als the large midline herniated disc at the C3-4 level (arrows). The spinal cord is markedly compressed posteriorly in Lo a curvilinear flattened structure. Axial long TR image ( Fig. D) reveals the l a rge herniated disc (long arruw) in the midline. The spinal cord is displaced posteriorly and exhibits bilateral areas of in creased signal intensity (short arrows). Axial short TR image below the level of the disc (Fig. E) reveals bilateral areas of decreased signal intensity with the lateral portions of the compressed cervical spinal cord. These represent either areas of syri nx formation or areas of cervical spinal cord encephalomalacia (arrows).
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I TEACH I NG ATLA
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Diagnosis Ll rge, midline herniated disc at the C3-4 level; postoperative changes with fusion at the C5-6 and C6-7 levels.
Differential Diagnosis PEARLS Note the widening of the interspinous distance between 6 and C7 spinous processe . This is because of the reversal of the curve of the normal cervical lordosi .
•
•
MRI is the procedure of choice for the evaluation of the presence of myelomalacia and syrinx cavity formation.
PITFALL •
It is not possible to di fferentiate with absolute certainty between myelomalacia and a syrinx cavity.
566
•
herniated disc
Discussion Following fusion of the cervical spinal vertebr,,1 hodies, herniation of a cervical disc j ust above or j ust below the level of the fusion frcqucntly occurs. This appears to be because the stress is translated to the levels above or below the fusion. In this patient, thcre is a very old fusion between the C5-6 and C6-7 vertebral bodies. Marked cord compression is visible at the C3-4 level secondary to the herniated soft disc. There is "Iso prominence of the posterior elements, which cause dorsal encroachment upon the cervical subarachnoid space as seen in Figure B. The resulting myelomalacia appears as an area of increased signal intensity. The cause of the increased signal intensity could be secondary to direct trauma and resulting edema, myelo malacia. or even a small syrinx cavity. The decreased signal in tensity areas identified in Figure E suggest that these are small syrinx cavities. The changes seen in th is patient are those that may typically occur in a patient with it previous pinal surgery. Herniated discs occur above and below the fusion levels because stress is translated to these levels when there is fusion between the vertebral bodies.
CERVICAL DISC D I S EASE
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Case 12 Clinical Presentation The patient is a 42-year-old m
A
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I TEACHI N G ATLAS OF SPINE I MA G I N G
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CER VlCAL D ISC D lSEASE
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Radiologic Findings Sagittal short TR image of the cervical spi ne (Fig. A) reveals straightening of the spine. Postsurgical change with obliteration of the in tervertebral discs space is visible at the C4-S level (arrow). There is slight retrolisthesis of C4 on CS and prominence of the intervertebral disc at thc C4-S level. Sagittal short TR image postcontrast (Fig. B) reveals enhancem ent of the inferior end plate of the C 6 vertebral body (straight arrow). The bony fusion plug between the C4 and CS vertebral bodies is enhanced (curved arrow). The re is also compromise of the suba rachnoid space behind the vertebral bodies of C4 and CS, and curvi li near compression of the spinal cord from C3 through CS. Sagittal long TR image (Fig. C) reveals a rounded area of increased signal intensity within the cervical spinal cord at the C4-S level (arro w).
PEARLS •
•
It is nol uncommo n fOT degenerative changes to occur at a level above or below the level of a previous cervical spine fusion. This occurs because the fusion at one level causes the stress to be translated to a different level. These bony fusion plugs often reveal enhancement postinfusion, although tbe exact reason for this is unclear. An inflammatory process is a consideration; however, there is no associated soft tissue swelling, and the patient did not h ave a febrile clinical course.
PITFALL •
Multilevel spinal fusion causes m arked limitation in a patient, and the patient is at a markedly increased risk in the event of an automobile accident or any other cause of a "whiplash" type of injury.
Axial gradient echo i mage (Fig. D) reveals a barlike area of decreased signal inlensity at the C4-5 level in the midline and extendi ng to the righ l side (arrows). There is compromise of the increased signal intensity cerebrospinal fluid at th is level.
Diagnosis Postoperative changes with fusion at C4-S; bony osteophyte at the C4-S level with compromise of the subarachnoid space; area of myelomalacia at the C4-S level.
Differential Diagnosis •
postoperative changes secondary to fusion
•
bony osteophyte
•
myelomalacia
Discussion The postoperative changes are secondary to a fusion between the C4 and C5 vertebral bodies. A bony osteophyte remains at the C4-5 level, and there is an area of myelomalacia (cord softening) at the C4-5 level secondary to repeated trauma of the herniated disc. Degenerative changes are visible at the C6-7 level. The a rea of myelomalacia occurred either because of direct trauma from the herniated disc, which was present before surgery, or because of direct injury to the spinal cord at the time of surgery. The anterior spinal artery is located along the midline in the anterior aspect of the spinal cord and is therefore at risk from a herniated disc or su rgery. Note that at the C4-5 level the cervical spi nal cord is compressed slightly on the right side and displ aced slightly toward the left side of the vertebral canal. There is also a mildly bulging dise at the C6-7 level in this patient.
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I TEACH ING ATLAS OF SPINE I MA G I N G
Case 13 Clinical Presentation The patient is a 44-year-old male who originally presented with a history of neck pa i n (lnd a herniated disc, and was treated with discectomy and a nterior cervical fusion. The patient presents for follow-up.
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CERVlCAL DISC D ISEASE
D
I
I TEACH ING ATLAS OF SPINE I MAGING Radiologic Findings Sagittal short TR image ( Fig. A) reveals localized degenerative change at the C5-6 level. There is a large osteophyte arising from the inferior end plate of C5 that projects posteriorly into the vertebral canal. This obl iterates the cervical subarachnoid space at this level. Although tll e suharachnoid space is compromised, there is no compression of the spinal cord. There is a mild retrolisthesis with posterior displacement of c::5 relative to C6 and disc space narrowing at the C5-6 level. There is decreased signal intensity within the C5 vertebral body. The C4 vertebral body is identified with 4. Sagittal short TR image (Fig. B) following urgery with placement of a fusion plug of bone (p). There is now reversal of the curve of the cervical spine at the level of the previous surgery. The anterior, inferior corner of the fusion plug extends into the superior end plate of -the C7 vertebral body (arrow). The posterior superior corner of the hone plug projects posteriorly into the vertebral canal. The bone pl ug and the marrow within the adjacent vertebral bodies appear a decreased signal intensity. The osteophyte arising [rom the inferior end plate of C5 demonstrated in Figure A is still present on the follow-up study. Sagittal short TR image obtained approximately 6 months later (Fig. C) reveals that the fusion plug bas begun to incorporate and fuse with the vertebral body of C7. The large osteophyte on the inferior end plate of C5 remains (short arrow). There is marked compromise of the cervical subarachnoid space and curvil inear posterior displacement of the cervical spinal cord. There is focal reversal of the curve of the spine at this level and widening of the interspinous distance between the spinous processes of C6 and C7 (long arrows). Also note the acute forward angulation of the odontoid process relative to the body of C2. The patient sustained a fracture (now healed with deformity) of the odontoid process following trauma between the two studies. Sagittal short TR image a fter the in fusion of contrast material (Fig. D ) reveals enhancement of the vertebral bodies o f C 5 , C6 a n d C7. The interspi nous distance is widened. Sagittal long TR image (Fig. E) reveals · the decreased signal intensity of the C5-6 and C7 vertebral bodies. There is a large posterior osteophyte at the C5-6 level with marked compromise of the vertebral canal. There is no abnormal signal intensity within the cervical spinal cord. Streaks of increased signal intensity within the spinal cord are truncation artifact (arrows).
PEARL •
Comparison with plain films and eval uation of serial studies is vital for the correct evaluation of these images.
Diagnosis Degenerative change in the cervkal spine with subsequent postoperative changes.
Differential Diagnosis •
degenerative changes
•
discitis and osteomyelitis
CERVICAL DISC O rSEASE
PITFALL The final images, iJ viewed without the benefit of comparison with the initial studies, would be difficult to interpret accurately. The postoperative changes would be mistaken for severe degeneraLive changes. A h istory of t ra u ma i also vital to fully evaluate the findings.
Discussion
•
There is decreased signal intensity in the C5 vertebral body as seen in Figure A, and these changes are related to sclerosis secondary to the degenerative changes. FoUow-up studies continue to reveal a large osteophyte arising from the C5 vertebral body; there was inadequate removal of the bon y osteophyte from the inferior end plate of the C5 vertebral body at the t ime of surgery. Because incorporation and fusion o f the bone plug appe
I TEACH ING ATLAS OF SPINE IMAGlNG
Case 14
f
Clinical Presentation The patient is a 55-year-old female with a history of tingling in the arms when she moves her head from side to side.
A
l.?L4
CERVICAL
DISC D I SEASE I
B
c
I TEACHI
G ATLAS or SPINE I MA G I NG
D
E
CERVICAL D I SC D I SEASE
Radiologic Findings Sagittal short TR image (Fig. A) reveals a small oval area of decreased signal intensity in the central portion of the cervical spinal cord at the C4-5 level. There is reversal of the curve of the cervical spinal cord at the C5-6 level and slight compression of the cervical spinal cord at the C5-6 level secondary to a bulging herniated disc. The Cn vertebral body is identi fied with 6. Sagittal intermediate (Fig. S, left) and long TR (Fig. E , right) images reveal a larger area of increased signal intensity in the cervical spinal cord, which extends frum C3 through C5-6. The herniated cervical disc is now seen I II beLLer advantage. Anterior herniation of the disc can also be seen at the C5-6 level. The C6 vertebral body is identified with 6. Axial short TR image (Fig. C) reveals a right-sided intermediate signal intensity soft tissue mass (white arrow). The spi nal cord is rotated away from the herniated disc. The afferent nerve root is seen in the subarachnoid space (black arrow). Axial short TR image (Fig. D) reveals the central location of the a reil of decreased signal intensity (arrow). Axial gradient echo image (Fig. E) reveals an etrea uf increased signal intensity in the central portion of the spinal cord (arrow).
Diagnosis R ight-sided herniated nucleus pulposus at C5-6 and resulting myelomalacia.
PEARL •
Follow-up examination may be helpful for more complete evaluation in this patient.
PITFALL •
An area of myelopathy (previously called myelitis) m igh t h ave a similar appearance. MRI of the brain to evaluate for the presence of areas of increased signal intensity secondary to demyelination m ight also be h elpful for more complete evaluation.
Differential Diagnosis •
herniated disc
•
myelomalacia
Discussion The midsagittal image in Figure A also reveals anterior prominence of the intervertebral disc at the C5-6 level. The axial image (Fig. C) better demonstrates the presence of the herniated d isc on the right side with compression of the spinal cord. This probably is not as well demonstrated on the sagittal images because of the partial volume effect and the finite limitation of the thinness of the sagittal i mages, which obscures demonstra tion of the focal lateral herniated disc. The area of decreased signal intensity within the spinal cord seen on the short TR images is thought to represent an area of myelomalacia secondary to the herniated disc. The exact cause of this is u ncertain but is thought to be secondary to direct trauma or vascular comprumise. This could also represent a small syrinx cavity and differentiation between the two is not always possible. An area of myelo ma lacia not related to the herniated disc is also a consideration but appears less likely.
577 1
TEACHING ATLAS
OF
SPINE I M AG ING
a syrinx cavity associated with a spinal cord tumor is a consideration, a posti n fusi()n sl udy should be performed. Spinal cord tumors exhibit enhance ment in the majority of cases; therefore, iJ enhancement i demonstrated, the possibi lity of a tumor would be a strong consideration.
1f
In the correct clinical setting, an area of dcmyelination in association with acute disseminated encephalomyelitis might be a consideration, but seems unlikely in this patient.
�8
CERVICAL DISC DISEASE
I
Case 15 Clinical Presentation The patient is a 62-year-old male with a h istory of discectomy and fusion. The patient now presents wi th upper extremity weakness.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals postoperative changes with a fusion between the 05 and C6 vertebral bodies (wide arrow). A long area of decreased signal intensity within the cervical spinal cord extends from the
5121
I TEACHING ATLAS OF SPINE I M A G ING Radiologic Findings (continued) C5-6 level through the Tl-2 level (thin arrow at (7). The C4 vertebral body is indicated by 4. Axial gradient echo image at the C6 level (Fig. B) reveab a rounded area of increased signal intensi t y within the right side of the cervical spinal cord (arrowhead). There is also an increase in the amount of bone formation surrounding the vertebral body, resulting in encroachment on the interverte bral foramen on the right side (arrow) .
Diagnosis Postoperative changes; cervical spinal cord syrinx.
Differential Diagnosis •
syrinx cavity
•
spondylosis
•
spinal cord tumor
Discussion
PEARLS •
•
Correlation should be performed with any preoperative MR scans if they are available as the syrinx cavity could have been present preoperatively. The remote possibility of a spinal cord tumor with a cystic component is a consideration, and a postcontra t study would reveal an area of enhancement in this clinical setting.
PITFALL •
If the patient did not have a preoperative MR sca n, the yrinx cavity could h ave been present preoperatively and not appreciated.
The cause of the syrinx cavity is unclear. The syrinx cavity was not present preoperatively. One hypothesis is that trauma to the spinal cord by the herniated disc was present prior to the surgery for spinal fusion. A second is that di rect trauma to the cervical spinal cord during surgery with resulting vascular compromise progressed to myelomalacia and then to a syrinx cavity. The hypertrophic changes seen in Figure B are secondary to osteophytes surrounding the uncinate processes of the vertehral body. The hypertrophic changes result in encroachment upon the vertebral foramen and may cause radicular pain. The normal foramen is filled with increased signal intensity fat; in most cases, the individual afferent and efferent nerve roots can be seen. A commonly used term for degenerative changes of the spine is cervical spondylosis. Spondylosis is an inclusive term that includes a number of changes that may be associated with degenerative changes i n the spine. This term often includes a combination of di c space narrowing, hypertrophic huny osteophytes surrounding the uncinate processes, and hypertrophic osteophytes arising from the vertebral budy end plates either anteriorly or posteriorly. The term tends to imply bony changes rather than herniation of the intervertebral discs. It hould also be noted that individual degenerative changes or a combination of these changes will be more significant in a patient with a congenitally small vertebral canal than in a patient with a congenitally large vertebral canal. Because computed tomography (CT) is more sensitive than magnetic reso nance imaging (MRI) for evaluation of bone, CT is recommended for deter mination of t he a mount of bone encroachment by osteophyte formation prior to surgery. This best performed in conjunction with myelography so that contrast material outli nes the suba rachnoid space.
CERVICAL D ISC D I SEASE
I
Case 16 Clinical Presentation The patient is a 72-year-old male with limitation of motion of the cervi cal spine.
A
Radiologic Findings Lateral view of the cervical spine (Fig. A) reveals large anterior osteophytes that extend from C 4 through Tl. Vertebral body height and intervertebral disc space height are well preserved. There had been m , extensive laminec tomy. and the spinous processes are surgically absent from C4 through T l .
I TEACHING ATLAS OF SPINE I M A G IN G
•
B
c
Radiologic Findings (continued) Sagittal short TR image of the cervical spine (Fig. B) reveals the large, contiguous, anterior oSleophytes (arrowhead), which extend from C4 through Tl . The spinous processes of C4 through Tl are surgically absent. The subarachnoid space is preservcd, and there is no cncroachmcnt upon the cervical spinal cord. The C7 vertebral body is identified with 7. Axial shon TR image (rig. C) reveals the marrow tilled, la rge anterior osteophYle (arrowheads) al the Co level.
Diagnosis Diffusc idiopathic skeletal h ypcrostosis (DISH).
Differential Diagnosis •
DISH
•
degeneralive osleophytes
CERVICAL D I SC D I SEASE
PEARL •
These changes may actually be related to degenerative changes although stud ics suggest that D ISH may actually be a separate disease.
PITFALL •
evere degenerative changes with osteophyte formation may have a similar appearance but do not meet these diagnostic criteria.
Discussion The definition of DISH includes three specific criteria: 1 . Calcification and ossification anteriorly and laterally extending over a minimum of four contiguous vertebral bodies with or without pointed excrescences at the i n tervening vertebral body-intervertebral disc junc tions. 2. Preservation of intervertebral disc height and relative absence of degener ative disc disease. 3. Absence of apophyseal joint bony ankylosis and sacroili{lc erosion, sclero sis or i ntra-articular osseous fusion. These criteria have been chosen to eliminate other diagnostic considerations. Some believe that D ISH may actually be extensive degenerative changes, and some patients with DISH may also have degenerative changes in the spine. DISH may also involve other bony structures, but the exact nature of these other changes has not yet been elucidated. In general, these patients are elderly and do not complain of pain in association with the abnorm ality.
TEA C H I N G ATLAS OF SPINE IMAGi G
Suggested Readings Brown. B M . Schwartz R H . Frank E. Blank N K . Preoperative evaluation of cervical radiculo pathy and myelopathy by surface-coil M R imaging. AlNR.
1 98i1;9:!l59-i166.
Czerviunkc LF, Daniels DL. Wehrli FW, et al. Magnetic susceptibility artifacts in gradie111recalled echo M R imaging. AlNR. 1 988;9: 1 1 49- 1 155.
Enzmann
DR, Rubin J B . Cervical spine: M R imaging with a partial flip angle, gradient
refocused pulse sequence. Radiology. 1 988; 1 66:467-472.
Enzmann
D R , Rubin J B , Wright A . Cervical spine MR imaging: generating high-signal CSF
in sagittal and axial images. Radiology. 1 987; 1 63:233-23K Karasick
MV,
Schweitzer
ME. Vaccaro A R .
Complications
of cervical
spine
fusion:
imaging
features. A.IR. 1 997; 1 69:869. Kulkarni M V . Narayana PA. McArdle CI:I, et al. ( :ervical
spi ne
MR
imaging u s ing m u ltislic<.!
gradient echo imaging: comparison with cardiac gated spin echo. Magn Reson Imaging. 1 988;6:5 1 7-525.
Luetkehans TJ, Coughlin BF. Weinstcin MA. Ossi fication of ligament
diagnosed by
the
pusteriur lungi t ud i n a l
M R . AlNR. 1 987:8:924-925.
McAfee PC, Regan JJ, Bohlman
HH.
Cervical
cord compression
frolll
ossifl ca t iu n
uf the
posteri o r lungitudinal ligam<.!nt i n nOll-orientals. 1 BOlle laint Slirg ( B r ) . 1 987:69:569-575. Modic MT, Masaryk TJ, Mulopulos GP, Bundschu h
C. Hans
JS, Buh 1nHI11 H.
radiculupathy: prospective evaluation wi t h surface coil M R imaging,
anu
CT
<.!rvical
with metrizamiuc.
metrilumide myelography. Ratiiolol{Y. 1 986; 1 6 1 :573-579.
Muuic MT, M asaryk TJ . Ross JS, et al. Cervical raciiculopathy: value
of oblique
MR imaging.
Radiology. 1 987;163:227-231 .
Resnick D,
G. Diagnosis of Balle alld loint Company; 1 988.
iwayama
W . O . Saunders
Disorders. 2 nd cd. Philadelphia. Pa:
Tsuruda JS, Norman D, Dillon W , et al. Three-dimensional graident-rccallcd MR imaging as a screening tool for the diagnosis of cervical radiculopathy. AlNI<. 1 \18\1; 1 0:1 263- 1 27 1 . Tsuruda JS, Remley K. Effects of magnetic usc.eptibility art i facts and motion in evaluating the cervical neural foramina on 3 D FT gradient-echo MR imaging. AlNR 1 99 1 : 1 2:237-241 . Widder DJ.
MR
imaging of ossificatiun uf the posterior longitudinal ligament. Al R.
1 989: 1 53: 1 94- 1 95.
Yamashita Y, Takahashi
M,
M a tsunu Y , ct al. Spin a l cord cum pression due to ussiflcation
of ligaments: MR imaging. Radiology. 1990;175:843-848. Yousem D M , Atlas SW,
Go!uberg HI. et ,Ii.
Degenerative narruwing uf the cervical spine
neural foramina: evaluation with high-resolution 3DFT gradient-echo MR imaging. AlNR. 1 99 1 ; 1 2:229-236.
584
Section IX
Thoracic Spine
THORACIC SPINE
I
Case 1 Clinical Presentation The patient is a 54-year-old male with severe mid thoracic spine pain.
B
587 1
I
TE A C H I N G ATLAS OF SPINE IMAGTNG
c
D
THORAr:Ir: SPINE
E
Radiologic Findings M idsagittal short TR image of the thoracic spine (Fig. A) reveals an acute kyphosis of the thoracic spine. At tbe T6-7 level, there is intervertebral disc space narrowing and a ventral soft tissue mass anterior to the spinal cord t hat displaces tbe spinal cord posteriorly. Wiuening or the subarachnoid space is visible above and below the sort tissue mass. There is a questionable increase in signal intensity within the spinal cord just above the level or the sort I issue m
Diagnosis Herniated intervertebral disc at the T6-7 level.
I TEACH ING ATLAS OF SPI N E I M A G I NG PEARL •
Computed tomographic scanning might be useful in this case to evaluate tbe presence of calcification in the intervertebral disc at the T6-7 level. Nonetheless. even if the disc is calcil1ed, this probably would not change the surgical treatment or approach.
PITFALL •
Great care m ust be taken to iden tify the exact level of the abnormal disc so that surgery of the appropriate level can be planned.
Differential Diagnosis •
herniated disc
•
meningioma
•
Schwan noma
Discussion The markedly decreased signal intensity of thc hcrniated disc is consistent with a call:i lied disc. Herniated thoracic discs are typically calcified. There is marked posterior displacement of the thoracic spinal cord by the herniated uisc. Thc increased signal i ntensity within the �pinal cord is secondary to edema within the cord. The widening of the subarachnoiu space suggests that this mass is actually an intradural rather than an extradural mass. However, because of the appearance of an intradural process, meningioma certainly could be a strong diagnostic consideration. A schwannoma is also a consideration as schwannomas may be solitary lesions. Schwannomas may also be hemor rhagic and so could result in this low signal intensity appearance. However, the fact that the lesion is centered at the level of the i ntervertebral disc and has a mush room like appearance arising from the level of the intervertebral disc m akes meningioma and schwan noma less likely uiagnostic considerations. Note also the marked disc space narrowing and decreased signal intensity of the intervertebral disc at the T6-7 level which would be consistent with a herniated disc. Note also accentuation of the dorsal kypho sis at the level of the herniated disc.
F )90
•
THO R A C I C S P I N E
I
Case 2 Clinical Presentation The patient is a 57-year-old male with a history or left-sided chest the m idthoraeie region.
A
pain i n
_ _________���_L-__________ ___ B
�____��__... C
I TEACH[NG ATLAS OF SPINE IMAGING Radiologic Findings computed tomographic (CT) scan at the T6-7 level using soft tissue after a thoracic myelogram (Fig. A) reveals an oval-shaped h i gh density mass in the left side of the vertebral canal (arrow). The spinal cord is compressed, d isplaced posteriorly, and rotated away from the left side. The subarach noid space is compressed. Ax i a l
window widths
Axial CT scan at the T6-7 level using bone window width tech nique (Fig. B) reveals calcification of the intervertebral disc at the T6-7 level (arrows). There is an u m b i l i cated, oval, high density mass anteriorly on the left side. There i s compression of the subarach noid space, a nd the spi n a l cord is compressed, rotated away, and displaced t o the right.
PEARLS •
•
Thi mass arises at the level of the intervertebral disc and is associated with a calcified intervertebral disc, which trongly favors the diagnosis of a calcified herniated disc. Index images should be obtained such that the exact level of the abnormality can be identified.
PITFALL •
A calci fied meningioma might be a diagnostic consideration i n this patient; however, this mass is extradural rather than intradural, and this does not favor a meningioma.
592
Axial CT scan taken just below the level of Figure B again (Fig. C) reveals the umbilicated, oval high density mass in the anterior aspect of the vertebral canal displacing the sp i n a l emd posteriorly and toward the right side. There is complete obliteration of the subarachnoid space anteriorly on the left side at this level.
Diagnosis Calcified, herniated intervertebral disc at the T6-7 level.
Differential Diagnosis •
herniated disc
•
meningioma
•
osteochondroma
Discussion The appearance is typical of a calcified, herniated intervertebral disc. Note that there are patchy areas of increased density in the posterior aspect of the lung on the right side cons is te n t with a patchy pneumon i a . In t h e absence of calcification within the i n tervertehral disc, diagnostic considerat ions would also include meningioma o r osteochondroma .
THORACIC SPINE
I
Case 3 Clinical Presentation The patient is a 54-year-old female with adenocarcinoma or unkn own pri mary with new onset of weakness of the lower extremities.
A
B
5211
I TEACHING ATLAS OF SPINE I M AGING Radiologic Findings Axial co m p u tt:!u tomographic (CT) i magc at thc T8-9 (Fig. A) reveals an o va l area of increased dcns ity to the left of the midline ventral to the spinal cord. The spinal cord is displaced posteriorly and compressed on the left side. Axial CT image at the T8-9 level with bone window width tec hnique ( Fig. 8) reveals calcification of t he intervertebral ui�c (arrow). The h i gh de ns i ty mass seen in Figure A is aga in seen anterior to the spinal co rd.
PEARLS •
•
The herniated disc is the obvious finding in thi case; however, evaluation of the more peripheral portions of the images reveals the large pleural effusion. G reat care must be taken to determine the exact level of the abnormality so that the correct level may be app roached surgically.
PITFALL •
The urgical approach to such a densely calcified disc may be di mcult and may result in a more pronounced neurological deficit than was present beroft:! surgery.
Diagnosis Herniated, calcified intervertebral disc at t he Tt}-9 level.
Differential Diagnosis •
herniated disc
•
meningioma
• osteochondrom a
Discussion The appearance is typical of that seen with a herniated disc. The disc is calcified, and a portion of thc nucleus pulposus is displaced posteriorly i n t h e left side o f t h e vertebral canal. Meningioma o r oste oc hond roma could be diagno tic considerations; however, t ht:!y a re unlike ly becausc of the presence of calcification within the intervertebral disc and the level of the abno rmality. If the herniated disc is lateral ized, the side of t he abnormality should be clea rly identified so t ha t if surgical removal is planned the correct side can be approached.
Note a l so that there are large pleural effusions bil ate ra lly . Althoug h the study is directed toward the vertebral column, it is impo rtant to evaluate the areas adjacent to the vertebral column within the fi cld of view so that lung masses or abnormalities such as the pleural effusion seen in this p at it:!n t will not be overlooked.
1�94
TH O RA C I C S P I N E
I
Case 4 Clinical Presentation The patient is a 13-year-old male with midthoracic pain and mild lower extremity weakness .
._ A
I
TEA C H I NG ATLAS
OF
S P I N E I M A G IN G
D
E
1 596
THO R A C I C S PI N E
Radiologic Findings Axial computed tomographic ( CT) slice at the level of the C6-7 intervertebral disc (Fig. A) reveals d en se , s li gh tly irregularly m argi nated calcification of the i n tervertehral disc in the region of the nucleus pulposus (*). The calci fication extends posteriorly in the midline and then off to the left side (arrow) into the intervertebral canal in the epidural space. Axial CT scan at the level of the superior end plate of the C7 vertebral body ( Fig. B) reveals a rou nded area of increased density projecting in the an terior left side of the vertebral ca nal. There is a small internal area o f low density (arrow). Axial CT scan usi ng bone w indow widths at the same level as Figure B ( Fig. C) reveals the oval area of high density in the anterior lateral portion of the vertebral canal with a central area of low density (large arrow). There is faint calcification in the midportion of the i n tervertebral disc (small arrow). A xial CT scan usi ng bone window widths at the level of the TI-8 interverte bral disc ( Fig . D) reveals dense amorphous calci fication of the interverte bral disc.
Midsagittal reconstruction image of the t h o raci c spine using bone window wid ths ( Fig. E) reveals dense calcification of the intervertebral discs at both of these levels. In addition, there is an area of dense, slightly inhomogeneous calcification that extends from the level of the intervertebral body of T5-6 through the level of the midbody of the T7 vertebral body. There is moder ately severe narrowing of the vertebral canal. The an ticipated posi tion of the thecal sac is displaced posteriorly (arrows). The To vertebral body is identified with 6.
5�
I TEAC H I N G ATLAS
OF
SPINE I MA G I NG
Left parasagittal reconstruction of the spine with bone window widths (Fig. F) identifies by number the levels of the individual cr images as they were obtained in the axial plane. The dense inhomogeneous calcification is again seen project ing posteri or to the vertebral bodies at T5, T6. and 17 . The calcifica t ion is sl igh tly denser along the perip heral m argin .
PEARL •
The spine should also be evaluated for the presence or absence of the norm al number of vertebral bodies as well as for tbe presence of transitiona l vertebrae.
PITFALL •
Digital localization images in botb the an teroposterior and lateral projections will allow the best localization of these abnormal discs. These images should be clearly labeled as the to level of the slices so that the correct level can be identifi ed.
Diagnosis Calcified, herniated intervertebral disc at the T6-7 level with compromise of the vertebral canal in the midline and on the left side.
Differential Diagnosis •
herniated disc
•
ochronosis
Discussion The appearance of dense intervel1ebral disc calcification is unusual in a patient of 1 3 years of age. Calcified intervertebral discs are common in older patients, and calcification is a typical end resu l t of a degenerated thoracic disc. The thoracic vertebr(ll c(lnal is the narrowest portion of the vertebral canal, and encroachment upon the vertebral canal typically ca u ses symptoms because the spinal cord is confined in this small space. The spinal cord is approx imately 1 .0 cm in size; therefore, narrowing of the vertebral canal belo w th is size results in spinal cord compromise . Note that there is narrowing of the intervertebral disc space at the T6-7 level because the nucleus pulposus has migrated out of the intervertebral disc space and into the vertebral canal. Although thi pa t ient had lower extremity wcakness. it was elected to follow rather than operate on this herniated disc. Over time, the herniated portion of the disc has gradually decreased in size and become compressed against the posterior margin of the vertebral bodies. Ochronosis (alkaptonuria) may result in calcification of the intervertebral discs; h owever, there was no history of ochronosis in this i ndividual. Alkapto nouria is an inherited disease which results in the excretion of homogentisic acid in the urine which subsequently turns very dark after standing for a period of time. The darkened mesenchmyal t issues in middle age appear blue through the skin, and degenerative joint changes occur. In the spine, this results in intervertebral disc calcification and l arge osteophyte formation. However, these changes typically occur in middle age.
THORACIC S P I
E
I
Case 5 Clinical Presentation The patient is a 17-year-old female with an elevated hematocrit and recent onset of an unsteady ga it.
A
Radiologic Findings Postcontrast sagittal short TR image ( Fig. A) reveals multiple rounded, densely enhancing lesions in the subarachnoid space dorsal to the spinal cord (black arrows). There is also faint serpiginous areas of enhancement along the dorsal aspect of the thoracic spinal cord (whire arrows). The spinal corel is displaced anteriorly and flattened slightly at the T7 level (7) .
I
T E A C H I N G ATLAS OF SPI N E I M AG ING
B
c
THORACIC S P I N E
I
Radiologic Findings (continued) Axial short TR image in the axial plane at the level of the 17 vertebral body (Fig. B) reveals a round, densely enhancing lesion in the subarachnoid space dorsal to the spinal cord (arrow). Coronal short TR image of the brain (Fig. C) reveals two small, rounded areas of enhancement in the left cerebellar hemisphere (arrows).
PEARLS •
•
Angiography reveal a densely enhancing mass with enlarged draining veins. The cerebellar hemangioblastomas are typically cystic with a densely enhancing solid component. Angiography may mimic the appearance of an arteriovenous malformation. This disease is also aS$Oeiated with renal cell carcinomas.
l>ITFALLS •
•
Because of the multiplicity of Ie ions, 'uccessful surgical treatment may not be possible. These tumors may have a cystic component and may mimic the appearance of a cystic spinal cord tumor such as astrocytoma.
Diagnosis Von Hippel-Lindau disease with m ultiple cerebellar hemangioblastomas and spinal cord hemangioblastomas.
Differential Diagnosis •
multiple hemangioblastomas
•
multiple abscesses
•
metastases
Discussion The imaging findings and clinical presentation are typical of von Hippel Lindau disease. The densely enhancing lesions arc mUltiple hemangioblasto mas of the cerebellum and the spinal cord. These spinal cord hemangioblasto mas are most common in the thoracic spine. Hemangioblastomas of the spinal cord may be intramedullary or extramedullary, in which case the tumor has a pial attachment. These tumors are very vascular and will reveal a dense blush when evaluated with angiography. The differential diagnosis would include the possibility of mUltiple metasta 'e ' to the cerebellum and the spinal subarachnoid space. Primary tumors would include malignant melanoma, lung cancer, or lymphoma. However, the clinical presentation with an elevated serum hematocrit strongly favors the diagnosis of von Hippel-Lindau disease and mulliple hemangioblasto mas. Presentation is uncommon in the first two decades of life. Von Hippel Lindau disease is one of the neurocutaneous diseases; therefore, patients may also have retinal angiomas. Multiple vascular metastases could also have a similar appearance but are less likely in this clinical setting.
6QlJ
I
TEA CI-H N G ATLAS or spr N E I M A G I NG
Case 6 Clinical Presentation The patient is a 73-year-old male with a history of bilate ral lower extrem ity paralysis following aortic aneurysm repair.
A
B
Radiologic Findings The patient had a normal magnetic resonance study of the thoracic spinal cord immediately after the onset of symptoms, 3 days prior to the pres ent study. Precontrast sagittal short TR image (Fig. A) reveals diffuse increase in the size of the tho racic spinal cord. The thoracic subarachnoid space is almost completely obl iterated. There is diffuse mottli ng of the marrow within the vertebral bodies at multiple levels w ith small foca l areas of increased sig nal intensity.
c
D
E
I
TEA CH I N G ATLAS OF SPINE I M AG I N G
G
Radiologic Findings (continued) Postcontrast sagittal short TR image (Fig. B) reveals questionable patchy areas of enhancement (arrows), but no large focal area of enhancement. Sagittal long TR image in the lower thoracic region (Fig. C) reveals a longitudinal, multilevel area or increased sign al intensity within the central portion of the distal thoracic spinal cord (arro ws). Left parasagittal short TR image (Fig. D) reveals that the thoracic aorta is enlarged in size and demonstrates a lobulated, thickened wall (arrows).
THORACIC SPINE
I
Radiologic Findings (continued) Ldt parasagittal long TR image (Fig. E) reveals variable signal intensity within the dilated thoracic aorta (A). There are also [ocal areas of relative narrowing in the lower thoracic aorta (cu.rved arrows). There is also a loculated area of variably increased signal intensity adj acent to the thoracic spine (black arrows). Axial short TR i mage at the level of 1'7 (Fig. F) reveaJs an area of decreased signal intensity in the right side of the spinal cord (white arrow). There is a left-sidell pleural effusion (open. arrow) and an oval area of decreased signal intensity in the left paraspinal region (black arrow), as well as a variable signal intensity soft tissue mass that extends lateral to the spine on the left side. The dilated aorta projects anterior and to the left of the vertebral column. Post contrast axial short TR image (Fig. G) reveals an oval area of enhance ment within the right side of the thoracic spinal cord (white arrow). The left-sided pleural effusion is again seen (open arrow).
PEARL •
Because the initiaJ scan may be normal, repeat magnetic resonance scanning may be necessary for complete evaluation in a patient who ha ' sudden on.et of symptoms.
PITFALL •
Transverse myelopathy (myelitis) would be a diagnostic consideration in another clinical setting.
Diagnosis Thoracic spinal cord ischemia and presumell i nfarction.
Differential Diagnosis •
aneurysm
•
ischemia
•
transverse myelopathy
Discussion The blood supply of the distal spinal cord arises from the a rtery of Adamkew icz, which typically originates from the lefl ninth intercostal artery, although it may arise h igher or lower and may a rise from the right side. This arterial blood supply to the spinal cord may be interrupted at t he time of aneurysm repair; it may also be interrupted with aortic dissection or even atherosclero sis o[ the aorta. The fact that the in1aging was normal immediately fol lowing the onset of symptoms and is abnormal 3 days later favors the diagnosis of an ischemic event. The enhancement is similar to that seen in the brain when there is an infarct. When there is surgery for an aortic aneurysm, there may be i n terruption of thc arterial trunk which supplies thc spinal cord. This resulLs in ischemic changes to the spinal cord. If therc is not sufficient collateral circulation from other sources, this may result in infarction of the spinal cord. This has occurred in this case. The occurrence uf spinal cord i nfarction is very dependent upon the existing blood supply to thc cord and the ability to establish collateral blood supply. In the older patient, there is frequently
(ffi
TEACH fNG ATLAS OF SPINE I M A G I N G
existing atherosclerotic or arteriosclerotic changes in the blood vesse ls, which obviously compromises the blood supply to the spinal cord. Elderly patients may experience transient ischemic events involving the spinal cord in the same way that patients m ay have transient ischemic events of the brain . Spined cord ischemia and resulting infarction may also occur in patients who have a dissection of the lIortll. Cord ischemia occurs beca use there is abrupt interruption of the blood supply to the spi n al cord as II res ult of the d issecti on. This patient has a thoracic aortic aneurysm that exhibits a thickened and il1'egular wall. There is a left-sided pleural effusion (open arrow i n F and G), probably secondary to both fluid and hemorrhage, combi ned with post operative changes. The left paraspinal fluid collection (black arrow in F) is consistent with a loculated co llection of fluid. In the absence of a history of aortic aneurysm dissection or recent surgery. the diagnosis of spi nal cord infarction is less obviolls. In these cases, the diagnosis of i n fllrction or ischemic cha nges in the spinal cord becomes a d i agnosis of exclusion. The imaging appearance may mimic transverse myelopathy (myelitis). The variable signal intensity seen within the aorta in Figures C and D is secondary to flow-related e nhancement because of turbulent flow of the blood within the aneurysm . The mottled signal intensity within the vertebral bod ies is secondary to osteoporosis and focal areas of fat deposition.
16 06
TH O RACIC SPINE
Case 7 Clinical Presentation The patient is an 81 -year-old male with a history of i ntermittent gait distur bance and sudden onset of lower ex tremity weak ness .
A
B
Radiologic Findings Postcontrast sagittal sbort TR im age in th e lower thoracic regi on (Fig. A) reveals multiple irregular l inear areas of enh ancement in the lower thoracic spine (small black and white arrows) . The spinal cord is mildly enlarged th roughout its visualized course. There is a faint, rounded a rea of increased signaJ i ntensity within the vertebral body of T9 (large white arrow) . The p recontrast images revealed a mildly enlarged spinal cord . Sagittal lo ng TR image ( Fig. B) reveals a large a re a of increased signal intensity within the cen tral portion of the thoracic spinal cord. The area or increased signal intensity within the T9 vertebral body is better seen on the long TR image (arrow).
6QZl
I TE.ACHlNG ATLAS OF S P I N E IMAGING
c
D
Radiologic Findings (continued) Postcontrast sagittal short TR image at the level of the conus medullaris (Fig. C) reveals a central area of enhan cement in the distal spinal cord (open arrows). There are also areas of enhancement within Ihe central portions of the lumbar vertebral bodies (black arrows). The L4 vertebral body is identi fied with 4. Sagil lal long TR image at the level of the conus medullaris (Fig. D) reveals an area of increased signal in tensity within the central portion of the distal thoracic spimi l cord (solid arrows). I ncidentally noted is minimal bulging of the intervertebral discs at the L3-4 and LS-S I levels (open arrows).
Diagnosis Probable spinal cord ischemia with areas of enhanccment.
Differential Diagnosis
!6Ue
•
spinal cord ischemia
•
transverse myelopathy
•
spinal cord tumor
•
intramedullary inflammatory process
THORACIC SPI N E
PEARL •
The i m aging finding should also be correlated with th e evaluation of the cerebrospinal fluid. This would reveal an elevated protein and decreased glucose in the presence of infection.
PITFALLS •
•
There is no known treatment for tra nsv ers e mye lopa t h y or for ischemic ch anges within the spinal cord. Follow-up scans m ight be helpful for more complete evaluation, particularly if the diagnosis is in doubt at the time of initial evaluation.
Discussion T he p atient is an el d erl y p atient with in termittent symptoms followed by sudden onset of more definite symptoms. The abnormal areas within the distal spinal cord most li k e ly represent areas of ischemia with areas of enhancement. Transverse my elopa t h y (myelitis ) could also have a s im i l ar appearance and is a d iag n ostic consid erati o n.
The area of increased s ig nal i n tensity within the vertebr a l body of T9 is a h e m angi o ma. The enhancement within the vertebral bo dies is enhancement of the basivertebral venous p lexus , which is part of B atson's p lex us (black arrows in Fig. C). Spinal cord t um o r is n ot a likely d iag nosi s because of the p attern of diffuse enhancement. An intra medullary in fl am m at ory process could have a sim ilar appearance, and should be correlated with the a nalysis of the cerebrospi nal fluid.
I
TEACHING ;\ TL;\S OF SPINE I M A G I N G
Case 8 Clinical Presentation The patient is a healthy 16-year-old male who experienced the sudden onset of paraplegia.
A
lQlO
THO R A c r c S P I N E
B
-...,;
=...
D
c
E
I
I
TEA CHING ATL A S
OF
SPINE I M AGING
H
lQl2
THORACIC SPt
E
Radiologic Findings Sagittal short TR image in the midthoracic spine (Fig. A) reveals a 1 .2-cm oval area of i ncreased signal intensity that projects posterior to the midbody of the T7 vertcbral body (arrow). Sagittal short TR image in the lower thoracic, upper lumbar region (Fig. 8) reveals wideni ng of the distal spinal cord at the level or the conus. The signal cord exhibits mottled signal intensity with multiple small dotlike areas o r increased signal intensity with a faint halo of dccrcased signal intensity surrounding (X) them. There is a lobulatcd area of increased ignal intensity dorsal to the thecal sac in the lower thoracic and upper l umbar region. This mass encroaches upon the distal thoracic and upper lumbar vertebral ca nal (black arrows). There is also � small, elongated, sl ightly lobulatcu area or increased signal intensity behind the vertebral body or L4 «()pen arrow) and patchy areas of illdefined increased signal intensity within the thecal sac
(white arrows). Midsagittal and parasagittal long TR images in the lower thoracic and upper lumbar regions (Figs. C and D) reveal variable increased and decreased signal i n tensity areas within the entire visualized vertebral canal. In addition, thcre arc multiple internal areas of serpiginous decreased signal intensity. Parasagittal short TR image in the upper lumbar region (Fig. E) rcveals a dilated curvilinear vascular structure adjacent to the veltcbral body (arrow). Axi�1 short T R image at the level of T1 2 (Fig. F) reveals a crescentic shaped area of increased signal intensity with a central area of decreased sign�l intensity dorsal to the spinal cord and within the thecal s�c (arrow). The spinal cord is compressed and flattened and displaced anteriorly.
PEARLS •
•
The artery of Adamkewicz typically arises from the i ntercostal artery on the l eft side at approximately the T9 level, but may arise from the midthoracie region through the lower lumbar region. There(ore, angiography may need to be perrormed of the entire lengtb of the spinal cord if necessary to i dentify the blood supply to a vascular malformation. Magnetic resonance angiography has been attempted iJl the evaluation of the presence of a vascular mal(ormation; however, angiography is necessary for complete evaluation.
Axial short TR image at the level of L3 (Fig. G) reveals a stellate-shaped arca of i ncreased ignal i ntensity within the central portion or lumbar thecal sac. The nerve roots of the cauda eq uina are displaced laterally around this area of increased signal intensity. Digital �ngiogram of the left 1'12 i ntercostal artery (Fig. H) reveals an elongated arterial vessel (A-arrow) that initially courses ceph�l�d, and then makes a sharp reversal of course (curved black arrow) to flow inferiorly. This vessel supplies an area or blush and is accompanied by an enlarged early draining venous structure (white arrows).
Diagnosis Spin�1 cord arteriovenous malformation with subarachnoid hemorrhage and spinal cord ischemia.
Differential Diagnosis •
hemOiThagic tumor (unlikely)
•
post-traumatic hemorrhage (unlikely)
I TEACH I N G ATLAS OF SPI
E IMAG I N G
PITFALL Angiography of multiple vessels
Discussion
•
is nccc sary for complete evaluation in these patients. Care must be taken at the time of angiography that the catheter tip does not occlude the entire blood vessel and result i n an ischemia of the distal spinal cord.
The ca tastrophic clinical presentation in this patient favors a vascular event such as hemorrhage. There is a small rocal area of bloocl that projects anterior to the spi nal cord in the m i cl t huracic region. This blood is in the metabolic ph(lse o f methemoglobin (lncl is thererore increased signal intensity on the short T R images. The entire distal thoracic and lumbar ve rtebral canal is fil1eu with blood in v a rying stages of metabolism from deoxyhemoglobin to methemoglobin The serpiginous areas of decreased signal intensity seen in Figures C a nd D are dilated draining veins flowing away rrom the malforma tion. The parasagittal image i n Figure E reveals an enlargeu draining vein flowing away from the malformation. .
The artery supplying the arteriovenous malform(ltion i n this case arises from the left i ntercostal artery; it is the artery or Adamkewicz. which is the major vascular supply to the distal spinal cord. Treatment or these patients includes di rect surgical intervention with identi lication ancl occlusion of the supplying artery to the arteriovenous malforma tion. Occlusion of this supplying vessel may also be via interventional tec h niques with coils or glue to occlude the vessel that suppl ies t he arteriovenous malformation.
The appearance and cl i nical presentation are typical of an arteriovenous malrurmation of the sp i nal cord.
•
THOR ACIC SPINE
Suggested Readings A l varez
0,
Roque CT. Pa mpa t i M. M u l t i level thoracic disc herniations: CT and MR s t udi es .
I Cumpllt Assist Tu m og r. 1988:12:650. Andersen
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Wil loughby
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the
con us
medu Uaris.
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1 987 :21 :470-474. Berenstein A , La sjau n i a s P. Endovascular treatment of s pine a n d sp i n a l cord lesions. I n : Surgical Nt:llro-A nKioKraphy. B l; r l i n : Springer-Verlag; 1 992; 5 : 1 -85.
Bhole R, Gi l me r RE. B l u m berg s Psychiatry.
Two-level thoracic disc herniation. Cnn Orthop. 1984 ; 1 90:1 30.
PC, Byrne R. Hypotensive cen tra l infilrction of the sp in a l cord. I Nellrol Neurosurg 1980;43:75 1-753.
Bowen BC, DePrima S, Pa l tany PM, et ill. MR a n g i og mph y of normal i n t radu rill ve ss e ls of the thora colu mb ar spine . AlN R. 1 996; 1 7 :483.
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p, St ein B M . Spinal cord arteriovenous J 983;59:471-478.
component. I Neurosurg.
m al forma t ion s wi t h s i g n i fi ca nt i n t ram edu l l a r y
Djindjicll1 R . Clinical s ymp tu m a t ol ogy a n d n a t u ra l hist o r y of arteriovenous m a l formation of the s pin a l
cord: a st u d y of the clinical aspects ami progn usis. based on l50 cases. In: Pia HW, Djindjian R, eds. Sp inal Angiomas: Advan ces in Diagnosis and Therapy. New York. N Y : Springer-Verlag; 1 978:48-83. Dj i ndj i a n R. Neur or ad i ologi cal examination of sp i na l co rd a n gioma s . In: Vinken PJ , Bruyn
GW. c ds . Vascular Diseases of the Nervous System, Part Jl. Handbook of Clinical Neurology. V o l . 1 2 . Amsterdam: Nort h -Holland; 1972. 631-643. Djindjian R. Angiographie
de
la Moelle Epiniere. Paris: Masson Edit.; 1 1)70.
Domm isse G F. The a r te r ies , a rt eriol e s , a nd ca p i l l a rie s of the spin a l cord. S u rg i ca l g u i de l i n es
in the pre vent i on o f pos to pe ra t i ve p a ra p l egi a . A nn R Call Surg t:ngl. 1 1)80;62:369-376.
Dommisse GF. The hlood sup ply of the sp i na l cord. I BOlle loinr Surg (Bt). I 974:56B:225-235 . Do ppma n J L, Di Chiro G , O m m aya A K . Se lectiv e A rteriography of r h e Spinal Cord. S t . Louis, Missouri: W a rre n H. Green; 1 969.
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mations
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A sso u line E , et al. M R
i m a g i n g of spi n a l cord arteriovenous m a l for
study of 34 cases. AINR. 1988:9:933-838.
Elliott JP, Szilogyi DE, H a ge m a n H T, et al. S p in a l cord i schem ia: seco n d ary to surgery of I n: Bernard VM, Towne JB, eds. Complicariolls ill Vascular Surgery. New York, N Y : Gru n e & St m t to n ; I I)H5: 24 1 -:1 1 0.
the abdom i na l aorta.
Fra ncavilla TL. Powers A , Dina T. Hugo V. MR imaging Compllr Assisr Tomogr. 19S7; 1 1 : 1 06:1- 1 OM. Gueguen B, M e rl a n d
of thoracic disc herniations. I
]1, Riche MC, Rey A. Vascu l a r malformation of
t h e spinal cord:
i n t rat h eca l perimed ullar y arteriovenous fistulas fed by me du l l a r y arteries. Nellrology. 1987;37:969-979. H urth M. Houdart R. Djindjian R. Rey A. Dj i ndj i a n M. Arte riovenous malformations of the s pi n a l cord. Prog Neurol SlIrg. 1 978;9:238-266.
Kendall DE. Log ue V. Spin a l c p idu r a l il ngi o m at o u s m a l for ma ti o ns dr ai ni n g i n t o i n t ra t hecal
veins. Nel/roradiol. 1977; 1 3 : 1 8 1 -189.
Kulkarni MV. B ur ks D O , Pr i ce A C, et al. Di a gno s i s of s pi nal arteriovenous malformation
ill a pregnant patie n t by M R i m aging. I Cu mpll t A�sist Tumogr. 1 985;9: 1 7 1 - 1 73 . Masar yk
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R oss JS,
Modic M T ,
R u ff R L , Selman WR, Ratcheson RA. Ra dicu l o meningeal
vascular malformations of t h<..: s pi n c : MR i m a g i ng . Radiology. 1987 ; 1 64:845-849.
Masca\chi M. B i anchi Me, Q u i l i ci N, et al. M R an g i ogra ph y of sp in al vascular malformations. AINR. 1995;16:289-297.
Merland JJ, Reizine D, Laurent /\, et al. Embolization of t he sp i n a l cord vascular lesions. In:
Viiiuda F,
Halbach VV. Dion J E , e d s. intcrvcnlional NCliroradiology: Endovasclilar
Therapy of the Central N erv uus System. Ncw York. NY: Raven Press; ] <)92: 153- 1 67 .
Parilcl P M , R o dcs ch G , B a l c r i a u x D , e t a l . Gd-DPT A-enhanced M R i n t ho rac i c disc hernia tions. Ne/l ruradiul. 1989;31 :75-79. Provenzale JM, Tien RD , Fe l sberg GJ, H a c ie n - B ey L. Spinal dura l a rt erio v en ou s fis t u la : d emu nstra t io n us i n g phasc co nt ra st MR a n R caga n TJ , Thom as J E , Colby M Y . Chronic p r ogre s sive radiation myelopathy. lAMA .
1968:203 : 1 28-132.
TE ACHING ATLAS OF SPINE IMAGING Resnick D , Niwayama G . Intravertebral disc herniations: cartilaginous (Schmorrs) nodes. Radiology. 1 9 78; 1 26:57-65.
Riche MC, Reizine D , Melki JP, Me r land JJ . Classification of spinal cord malformations. Radial Med.
1 985 ;3 : 1 7-24. EH,
R osemblum B, Oldfield
Doppman JL, Di C h i ro G. Spinal arteriovenous m a l rormations:
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fi st ula a n d intrad u a l A VMs i n
81 patients. J NeuruslIrx.
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Ryan RW, L a l l y J F, Kozic Z. Asymptomatic ca l c i lied herniated thoracic discs: CT recogni tion. AJNR. 1 988;9:364-365.
Ter we y B , Becker H, Thron AK, Vah ldiek G. Gadol i n i u m-DPTA e n h ance d MR i maging of spinal dural arteriovenous
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Van Duym FC van A, van Wiechcn Pl
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of calcified n ucleus pulposus i n
the
Section X
Lumbar Discs
LUMBAR DJ CS
I
Case 1 Clinical Presentation The patient is a 37-year-old female with a clin ical history of back pain, ex t remity pain, and numhness.
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals what appears to be a moderately IlHge soft tissue mass projecting behind the intervertebrlll J isc at the L4-5 level. Sagittal long TR image (Fig. B) reveals tilllt the soft tissue fragment is much larger than is apparent on the short TR image. There is essentially complete o b li tera t ion of the subllrachnoid space at this level. In addition, there is decreased signal intensity of the in tervertebral discs at L3-4 (arrow).
B
I
TEACHING ATLAS OF SPI N E I M A G I N G
....___ . ....1
C
L U M B A R D ISCS
�EARLS •
The evaluation of degen era tive disc disease should include the usc of loog TR images. The long TR ima ges duplicate the lateral view of t he m yel ogra m with the ce re brosp i n a l fl u i d now appearing increased signal i nten ity on the MR images and high de nsity on the myel ogram i mages . The long TR ima ges also allow the identification of decreased sign a l intensi ty disc which may be the source of back p a i n even in th e patient who does not have a h ern i ated
disc. •
Beca use of the posterior longitudinal liga m en t , herniated discs occur only rarely in the midline; herniations occur more commonly off to the righ t or left ·ide.
Radiologic Findings (continued) Axial short TR image at the level of thc intcrvcrtebral disc (Fig. C) revea l a midline and sli gh t left paraccntral h e rni a t ed disc (arrow) which causes curvilincar distortion of the t heca l sac. Axial short TR i mage j us t below the level of the intervertebr
Diagnosis Large herniated disc at the L4-S level. Degenerated d i scs at the L3-4 a n d LS-S l levels.
Differential Diagnosis •
herniated disc
Discussion PITFALLS ·
•
cr better demonstrates the area of bone fracture from the vertebral body if this is presen t. With cr imaging, a very large hern ia ted disc may comp let el y obliterate the vertebral canal. The re s u l tin g homogeneous density of the disc may mimic the appearance of the normal thecal sac and r esult in the failure to appreciate the presence of a large herniated
disc.
The herniated po rt i on of the disc can be seen project i n g behind t h e pos t er ior ma rgi ns of th e vertehral bodies of L4 and LS . Tn Figure D, the decre ased si gn al in te ns ity midline and sli gh t l y pa race ntra l mass is caused by a sma l l avulsion fracture from the posterior ma rgin o f th e vertebral body. This fracture occurs from the force of the herniation which is located adja ce nt to the pos terior margi n of the vertebral bod y . Th is fracture fragment is easily demonstrated by co m puted tom ogra phic (CT) scanning, which is sensitive to b on e d e nsi ty , but is difficult to demonstrate wi th ce rt a i n ty by m agn etic resonance (MR) scanni n g.
The decreased si gna l i ntensi ty of the L3-4, L4-S, and LS-S l i n tervertebral discs is consistent with degen e ra tion and dehydration of these discs. Patch y areas of decreased si gna l intensity within the intervertebral discs area consis tent with vacuum dege nera t i ve change or areas of calcification of the disc.
I TEACHING ATLAS OF S P I N E IMAG I NG
Case 2 Clinical Presentation The patient is a 35-year-old male with sudden onset of low back and right leg pain.
622
B
LU M B A R DISCS
I
c
D
Radiologic Findings Multiangle images for evaluation of the lumbar intervertebral discs (Fig. A ) . Multi angle slices are obtained in addition to routine parallel slices through the lumbar spine. These slices should include the symptomatic levels and/or the lowest three intervertebral disc levels, as well as any other abnormal appearing level. There is a soft tissue prominence at the L4-5 level (arrow). The third lum bar vertebral body is identified with T. Sagittal short (Fig. B, left) and long (Fig. B, right) TR images reveal a herniated disc at the L4-5 leve1. The short TR i m age reveals that the disc has herniated and extruded below the level of the disc at the L4-5 level.
TEACHING ATLAS OF SPINE I M A G I G
Radiologic Findings (continued) The curvilinear arrow (left) identifies the dircction of the disc as it herniates below the disc level. The long TR i mage on the right reveals the herniated elisc as decreased signal intensity and projecti ng below the level of the intervertebral disc (arrow).
PEARLS •
•
•
Hern iated d iscs may occur at any level of the vertebral column. However, when a disc berniation occurs at an unusual level uch as the lower thoracic or upper lumbar region or at an unusual location such as medial to the vertebral pedicle, the disc may be m istaken for a schwannoma or even a metastatic deposit. Although unusual, discs m ay even migrate to a location dor al to the thecal sac. Rarely, a herniated d isc may pierce the dura and rest i nside of the thecal sac. Such an intrathecal disc is unusual, but when presen l , mimics the appearance of a schwannoma, neurofibroma, or even a meningioma or drop metastasis.
PITFALL •
If a herniated, equestered disc is closely applied to the posterior margin of the vertebral body, it m ay be difficult to identify. In a patient w i th positivc signs and symptoms it i helpful to perform both MR and cr. I t may b e necessary t o perform ' cr after the i nstillation of contrast material in the subarachnoid space.
\624
Axial short TR i mages just above (Fig. C, [eJi) and at the level of thc intervertebral disc level (Fig. C, right) reveal the herniated midline disc projecting just above the level of the disc (left, open arrow) and in the midline and slightly off tow(t rcl the right (right, arrow). The herniated disc obl iterates the ant erior epidural i ncreased signal intensity fat (arrow on right) and extends beyond the margin of thc vcrtcbral body. Just below the level of the intervertebral disc, a large fragment of I he herniated nucleus pulposus (Fig. D) projects on the right side (thick arrow). The disc fragment obliterates the epidural fat, displaces the thccal sac postcri orly, and compresses it. The disc also encroachcs upon thc normal nerve root in the lateral recess. The normal ncrvc root sleeve can be seen on the left side (thin arrow). A small rounded area of decreased signal intensity projects just posterior to the vertebral body (open arrow) .
Diagnosis Herniated, extruded elisc.
Differential Diagnosis •
herniated disc: Thc appcarance is typical of a herniated disc.
Discussion Herni ated discs can migrate superior to or, more commonly, infcrior to the level of the i ntervertebral disc. Therefore, i m(tging sl iccs should not be confined just to the level of the i n tervertebral disc, but should extend above and bclow the level of the disc. A good rule to follow for imaging is to i nclude tbe levels from one vertebral pedicle to the next. I n general. imaging should include parallel contiguous slices begin ni ng at the level of the mid body of L3 and extending i nfcriorly to tbe level of the midbody of S l . These images are accompanied by angled slices that extend through the individual intervcrtcbral discs. These should be anglcd in such a way that the slices parallel the angle of the i ntervcrtcbral disc. This is illust rated in Figure A. The small area of decreascd signal i ntensity posterior to the vcrtcbral body in Figure D is thc flow void of the anterior, internal vcrtcbral view. The more rcccnt addition of helical computed tomographic (CT) scanning allows more rapid evaluation of the spine than was previously possible. Because of this, imaging of the spine may now conveniently include all of the intervertebral discs i n the lumbar region. This is particularly helpful in cases of spinal stenosis, wherc it is recommended that all lumbar intcrvcrtc bral discs should be cvaluated.
LUM B A R
DI SCS
Case 3 Clinical Presentation The patient is a 38-year-old male with sudden onset of left leg pain and low back pain .
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals two small areas of decreased signal intensity in the po terior portions of the intervertebral disc at the L2-3 level (long arrows). There is
I TEACH I NG ATLAS OF SPINE IMA G J N G
D
LU MBAR D ISCS
E
Radiologic Findings (continued) Parasagittal long TR image (Fig. C) reveals that the soft tissue mass at the LS-S l level appears more prom inent laterally than in the midline. The nerve root of the cauda equina appears as a stringlike area of decreased signal i ntensity which follows a curvilinear course arou nd the soft tissue mass at the LS-Sl level (curved arrow) . Axial short TR im age (Fig. D) reveals a norm a l appearing interverteb ral disc configuration at the L3-4 level. The normal nerve can be seen surrou nded by high signal intensity perineural fat (arrow). Axial short TR image (Fig. E) reveals a soft tissue mass that obli terates the n ormal high signal intensity epidural fa l at the LS-Sl level i n the midline and off toward the left side (arrows).
Diagnosis La tera lly herniated disc at the LS-Sl level.
Differential Diagnosis •
herniated disc: The appearance is typical of
a
herniated
disc.
627 1
I TEACHING ATLAS OF S P I N E I M AG I NG PEARLS •
•
In this patient, the conspicuity or the disc is much greater on the long TR images than in the hort TR i mages. In addition, the intervertebral disc appears relatively normal on tbe short TR images but reveals definite decreaoed signal intensity o n the long T R i mages reflccting the presence of los' of hydration of thc disc and early degencrative cbanges.
Long TR images should be obtained in patients being evaluated for a possible herniated disc.
PITFALL •
The decreased signal intensity of the intervertebral disc at tbc L2-3 level could also be secondary to calcification. cr (computed tomography) is much more sensitive to the presence of calcification than magnetic resonance. cr also allow more ready differentiation bctween calcification and vacuum degenerative changes.
Discussion In addition to a large herniated disc at the LS-S1 level, there arc dcgenerated discs at all four or the lowest i ntervertebral di c lcvels. This is reflected as decreased signal intensity of the intervertcbral disc on the long TR images because of loss of fluid. The smal l areas of decreased signal intensity in the intervertebral disc at the L2-3 level (Fig A) represent small areas o r vacuum degenerative change within the in tervertebral disc. The posterior displace ment of thc nerve root seen in Figure C is similar to that which would be scen myelographically.
L UMBAR DISCS
Case 4 Clinical Presentation The patient is a 29-year-old male with severe low back and left leg pa in.
A
B
Radiologic Findings Right parasagittal short TR image of the lumbar spine (Fig. A) reveals minimal prominence of the i ntervertebral disc at the LS-Sl level but is otherwise normal. Left parasagittal short TR image (Fig. B) reveals an intermediate signal intensity, soft tissue mass at the LS-Sl level. The mass is laterally positioned and is surrounded by increased signal intensity perineural fat. There is also a mild prominence of the in tervertebral disc at the L4-S level.
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•
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Radiologic Findings (continued) PEARLS •
•
The normal perineural and epidural increased signal intensity fat provide an excellent contrast m aterial in MRI. By computed tomographic (CT) evaluation, the fat is low density and is also useful for diagnosis; however, MR provides more contrast than cr, and the conspicuity of the epidural fat signal intensity is more readily demonstrated by MR than by CT. Note that when using the long TR fast spin echo technique the
normally h igh signal remains high signal intensity, whereas when using the standard, rouLine long TR i mages, the normal high signal intensity fat becomes lower in signal intensity.
PITFALLS •
•
It is important to determine the laterality of a herniated disc so that a proper surgical approach can be planned. there are abnormal discs at two or more levels, they should be clearly reported so that surgery may be performed at all levels of involvemenl. if
Midsagillal long TR image with fast spin echo tech nique (Fig. C) reveals that the intervertebral disc at the L4-5 level appears decreased signal intensity (arrow). There is narrowing of the intervertebral disc at the L5-S I level. Left parasagittal long TR image with fast spin echo technique (Fig. D ) reveals t h e moderate sized disc at the L4-5 level (arrow) and thc large soft tissue mass at the L5-S 1 level. There is disc space narrowing at and decreased signal intensity of the L4-5 and L5-S1 i ntervertebral discs. Axial short T R images just above (Fig. E, leji) and at the level of the intervertebral disc of L5-S1 (Fig. E, right) reveal the le(t lateral soft tissue mass. There is obliteration of the normal nerve root and high signal intensity epidural fat on the left side by a large soft tissue mass (white arrow, right image). The normal right nerve root sleeve is identified on the right and is surrounded by high sign al intensity perineural fat (white arrow, left image). At the level of the intervertebral disc (right), the normal root can be seen on the right side. There is a soft tissue density mass on the left side which obliterates the normal epidural high signal intensity fat (right image, white arrow). On the left side, the nerve root can be seen to be com pressed and displaced posteriorly (right image. black arrow). Note the normal lemon shape of the L-5 vertebral body.
Diagnosis Large left paracentral herniated disc at L5-S I a nd a moderately sized disc at the L4-5 level.
Differential Diagnosis •
herniated disc: The appearance is typical of a herniated disc
Discussion Herniated discs are most common at the L 4-5 and L5-S1 levels. In this patient, there are abnormal discs at both of these levels. The magnetic resonance (MR) findings of effacement of the thecal sac. compression of the nerve root sleeve, and posterior displacement of the nerve root reflect the findings that are seen by myelography.
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Case 5 Clinical Presentation The patient is a 46-year-old male with l eft leg pain.
A
B
Radiologic Findings Sagi ttCl I short TR image (Fig. A) reveals disc space narrowing at L4-S. There is also what appears to be a bulging disc at the LS-Sl level. Sagittal long TR image better (Fig. B) reveals the herniated discs at L4-S
(straight arrow). There is decreased signal intensity of the lowest two l u mbar intervertebral discs. There is also an oval-shaped soft tissue, intermediate signal intensity mass behind the vertebral body of LS (curved arrow) that was not visible on the short TR images. There is also prominence of the LS-Sl intervertebral disc.
LUMBAR
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Radiologic Findings (continued) Midsagittal short TR image postcontrast (Fig. C) reveals a faint, slightly higher than normal cerebrospinal fluid signal intensity mass projecting be hind the vertebral body of LS (arrow). Parasagittal short TR image postcontrast (Fig. D) reveals enhancement of one of the nerve rootlets of the cauda equina (short solid arrows). There is also a soft tissue density mass that projects behind the vertebral body of LS. The thecal sac is essentially completely obliterated at this level; however, t he large size of the soft tis ue mass so completely obli terates the canal that its presence is difficult to appreciate. There also appears to be enhancement anterior to the soft tissue mass beh ind LS (curuetl arrow). This enhancement may actually be the epidural venous plexus. The i ntravertebral portions of Batson's plexus are also enhanced (open arrow). Axial short TR image at the level of the LS vertebral body (Fig. E) reveals a left sided soft tissue mass (long arrow). The mass obliterates the epidural fat. There is obliteration of the nerve root sleeve at this level. The nerve root sleeve can be seen on the right side surrounded medially by normal high signal i ntensity epidural fat (sharf arrow). Postcontrast (right) axial short TR image at the same level as Figure E (Fig. F) reveals peripheral enhancement surrounding the soft tissuc mass (arrow). Axial long TR image at the level of the midbody of LS (Fig. G) reveals the soft tissue mass along the left side of the thecal sac (large arrow). There is obliteration of the epidural fat and displacement of the thecal sac toward the right side (small arrow). Pre- (Fig. H, left) and postcontrast (Fig. H, right) axial short TR images at the level of L2 reveal enhancement of the nerve root of the cauda equina on the left side (arrows).
PEARLS •
•
Herniated disc fragments may migrate either superiorly or inferiorly. A mass lesion, such as a schwannoma, is not a likely diagnosis because there is no central enhancement. Contra t enhancement is generally not performed for the evaluation of a patient with a possible herniated dise who has not had previous surgery. On the other hand, contrast material should be used in any patient who h a had previous surgery.
Diagnosis Herniated, sequestered disc with nerve root enhancement. The herniated disc probably arose from the L4-5 intervertehral disc space level and mi grated inferiorly as there is more marked narrowing of the i ntervertebral disc at the L4-S level than at the LS-S1 level.
Differential Diagnosis •
herniated disc: The appearance seen in this case is typical of a herniated disc.
Discussion The use of contrast material is not usually utilized in patients with a herniated disc who have not had previous surgery. Therefore, it is nol. known what
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PITFALL Dense, fibrotic scar may reveal only peripheral enhancement and may not reveal central enhancement. Likewise, a chroni ca lly herniated disc fragment may be so affected by ingrowth of capiUaries tha,t the herniated di c m ay enhance homogeneously and mjrriiC the appearance of scar formation. Therefore, while differentiation between disc and scar can generalJy be made based on enhancement characteristics, it i not a lways possible. However, surgery may be indicated on a focal area of •
fibrosis.
percentage of patie n ts wo uld exh ibit nerve root enhancem ent postc o n tras t in the presence of a herniated disc. The presence of enhancement p rob a b ly represents a neuritis or irritation of the nerve root by the herniated disc. Enhancement of the nerves of the cauda equina may occasionaUy be seen even in the absence of a herniated disc. The cause is not certain but is p resum ably related to an irritation of the nerve.
L U M I3 A R
D I SCS
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Case 6 Clinical Presentation The patient is a 45-year-old male with a history of previous L5-S1 discectomy ror hern iated disc, now presenting with severe left lower extremity pain.
A
B
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PEARLS •
•
•
The use of contrast enhancement allows better definition of the extent of the di'c herniation. The enhancement is thought to be secondary to granulation tissue which surrounds the herniated djsc and develops because of reaction to the disc. Magnetic resonance is the ideal m ethod for follow-up of patien ts with recurrent herniated discs. arachnoiditis is a clinical consideration in the postoperative p atient, contrast material shou ld be used. The study may reveal clumping of the nerve roots of the cauda equina or adherence of the nerve roots to the peripheral margins of the thecal sac. These areas may occasional ly reveal enhancement postcontrast.
If
Radiologic Findings Sagittal short (Fig. A, left) and long (Fig. A, righ t) TR images reveal a very . large , intermediate signal in tensity, soft tissue mass the L5-S1 level. The mass can be seen extrudi ng posteriorly i nto the vertebral ca nal (arrows). There is disc space narrowing at this level and sl ightly decreased signal intensity on the adjacent vertebral body end plates. There is posterior bulging of the posterior margin of the thecal sac because there is a postoperativc pseudomeningocele. High signal i n tensity fat (F) secondary to the previous su rgery is seen dorsally at the L5 level ( righI, arrows). Pre- (Fig. B, left) and postcontrast (Fig. B, righ t) sagittal short TR images reveal a rim of enhancement around the perip heral margin of the soft tissue mass. Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal the large soft tissue mass which extends posteriorly into the vertebral canal. There is compression of the cerebrospinal fl u id con taining thecal sac and complete obliteration of the epidural fat at this level. There h as been a bilateral complete laminectomy; thcreforc, thc lamina of the vertebral body is not seen on either side. On postcontrast enhancement (right), a well-defined peripheral rim of enha ncement can be seen outlining the large soft tissue mass (arrow). It is the absence of the vertebral la mina that allows the dura to b ulge posteriorly and creates the pse udomeni ngoce1e.
Diagnosis Large recurrent herni ated disc fragment with peripheral enhancement.
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LUM B A R DISCS
PITFALLS •
•
In a chronically herniated disc, the capillary ingrowth may extcnd through tbe herniated fragment and result in homogeneous enhancement. This homogeneous enhancement may then have the appearance of scar tissue rather than a herniated disc. Scar tissue en hances homogeneously in most cases. Occasionally, when there is a chronic retracted scar, tbere may be only peripberal enbancement of tbe scar. Therefore, clinical h istory and clinical correlation are very important for diagnosis. A final combination is tbat of a herniated disc plus the presence of scar formation witb any possible enbancement pattern.
Differential Diagnosis •
large recurrent herniated disc: A large recurrent disc herniation is uncommon following surgery because a large portion of the nucleus pulposus is removed at the time of surgery.
Discussion Tn general, contrast material is not used in the diagnosis of a herniated disc. However, when contrast material is used, it may help to better define the margin of the herniated disc. As in this case, the peripheral rim of enhancc ment defines the uuter margin of the herniatcd disc and defines the separa tion between the disc and the thecal sac. In general. only the peripheral margin of a disc exhibits cnhancement. When there is scar tissue present following surgery, there is generally homogeneous enhancement of the scar tissue. Thus, contrast enhancement is recom mended in all cascs where there has been previous surgery. The decreased signal intensity of the vertebral body end plates adjacent to the intervertebral disc is secondary to edema of the bone marrow. Th is therefore becomes increased signal intensity on the long TR images. On the axial images (Fig. q. there is increased signal intensity sort tissue dorsally to the thecal sac; this occurs because at surgery t he epidural spacc is filled with fat.
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Case 7 Clinical Presentation The patient is a 31 -year-old female wi th low back pain radiating to the left leg and into the left foot. The patient is status post lumbar l ami nectomy.
A
B
Radiologic Findings S agi ttal short TR image of the lumbar spine (Fig. A) reveals a soft tissue de nsity mass that projects behind the L5 vert ebral body (arrow). Sagitta l short TR image postcontrast (Fig. B) reveals a curvilinear line of enha ncement surrounding the soft tissue density mass (arrow). The L4 vertebral body is identified with FO.
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F
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H
Radiologic Findings (continued) Left parasagittal short TR image (Fig. C) reve(t ls a sort tissue density mass projecting behind the vertebral body or LS (arrow). Sagittal short TR image (t rter contrast enhancement (Fig. D) reveals a dense rim of enhancement surrounding the soft tissue m ass behind the LS vertebr(tl body (lon.g arrow). A tiny area of decreased signal intensity is seen dorsally in the vertebral canal (short arrow). Axial short TR image at the LS-S [ level ( Fig E) reveals a sort tissue density mass that obliterates the norm(t l epidural fat and displace the thecal sac posteriorly (arrow). .
Axial short TR image after contrast enhancement (Fig. F) reve(t ls a lobulated (tTea of enhancement surrounding the soft tissue masses (straight arrow). There is also enhancement lateral to the thecal sac (curved arrow) that is secondary to postoper(tl ive scar formation. There is slight medial displace ment of the t hecal sac at this level. Pre- (Fig. G, left) and postcontrast (Fig. G, right) (txial short TR images reveal enhancement of soft tissue anterior (right, short arrow) and dorsal to thc thecal sac (right, 101114 arrow). Pre- (Fig. H, left) and postcontrast (Fig. H, right) axial short TR images reveal concentric rings of enhancement surrounding the soft tissue density mass in the anterior epidural space on the left side (right arrow).
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PEARL The postcontrast scan is very helpful in differentiating between the herniated disc and the enhancing scar . It is very possible that this sequestered disc fra g men t although p re sent was not identified and removed at the time of the initial surgery.
Diagnosis
•
,
" Recurrent herniated disc wh ich has migra ted b eh i n d the L5 vertebral body.
Differential Diagnosis , •
epidural venous plexus. A prominent epidural venous plexus could pussibly have a similar appearance.
Discussion PITFALL A prominent epidural venous p l e xu s may give a similar appearance on the sagittal ima ges so the presence of a herniated disc m ay not be app reciated, p articularly if contrast material is not used. •
,
l2!4
In addition to the recurrent herniated discs, there is also a small amount of p os t s u rgical scar formation that enhances after the infusion of contrast material. While the patient could have a recu rrent h erni ated disc, it is also possible that the original herniated disc was not actually removed at the time of the original surgery. A disc which has migrated away from the level of the intervertebral disc is sometimes difficult tu locate at the time of surgery unless a concerted effort is made to find such a disc. The short arrow in Figure D identifies a small area of magnetic susceptibility a rt i fac t s econdary to a small piece of metal related to the p rev ious surgery. These small retained metallic pieces may not be visible by pl a in spine radiography.
L U M B A R DISCS
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Case 8 Clinical Presentation The patient leg.
is
a 66-year-old m an with back pain extending down the right
A
B
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PEARLS •
•
An accurate description of this type of migrated disc should be provided so that an adequate urgicaJ approach may be planned, the disc fragment identified at the level of the vertebral pedicle and removed. Patients
with laterally herniated di cs typically have severe radicular pain because the disc compresses the nerve root in the region of the lateral recess (in this case) or in the region of the intervertebral foramen.
PITFALL •
A synovial cyst could have a similar appearance, but these are typically associated wiLh in terfacet degenerative changes and are positioned more posteriorly and laterally. The absence of interfacet degenerative changes is also not in favor of the diagnosis of synovia 1 cy ·t.
Radiologic Findings Sagittal long TR image (Fig. A) reveals a rounded soft tissue density mass on the right side which appears decreased signal intensity (white arrow). The mass is at the anticipated level of the pedicle of the vertebral body of L3. There is slight disc space narrowing at the intervertebra l disc level of L2-3. Axial short TR image at the level of the L2-3 i n ter verteb ra l disc (Fig. B) reveals a normal appearing disc (left). The nerve root can be seen j ust posterolateral to the disc surrounded by high signal intensity fat on the right side (small arrow, left image). The n e x t image (right) is obtained just below the disc level and reveals a faint area of sl i g h t ly increased signal intensity just medial to the ped icle and superior articulating facet on the right side in the region of the lateral recess (long white arrow, righl image). There is obliteration of the epidural fat. Note the faint cleavage plane between the cerebrospinal fluid in the thecal sac and the soft tissue mass (open arrow).
Diagnosis Herniated disc, probably arising from the L2-3 level . Surgically proved.
Differential Diagnosis •
schwannoma or neurofibroma: A schwannoma or neurofibroma could have a similar appearance.
Discussion The hernia ted disc fragment has migrated in feriorly to re st in the region of the Itlteral recess. The disc fr a g m en t is "seq uestered " from the main portion of the disc. A postcontrast study could be helpful in a case such as this and would potentially reveal enhancement around the peripheral m argin of the disc. A schwannoma or neurofibroma would be expected to reveal homogeneous enhancement postcontrast. The location is somewhat di fficult to approach at the time of surgery.
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Case 9 Clinical Presentation The patit:nt is a 40-year-uld male who developed low back and severe right leg pain upon lifting a heavy object.
A
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c
D
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E
Radiologic Findings Sagittal short TR image (Fig. A) reveals a bulging disc at the L4-5 level which interrupts the normal anterior, epidural , increased signal intensity adipose tissue. The anterior margin of the disc is also prominent and projects anterior to the vertebral bodies (arrow). Left parasagittal short TR image at the level of the intervertebral foramenae (Fig. 8) reveals that there is obliteration of the normally increased signal fat in the i n tervertebral foramen at the L4-5 level (curved arrow). The normal intermediate signal intensity dorsal root g
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Radiologic Findings (continued) Axial short TR image just below the level of the intervertebral disc (F ig. E) reveals the normal dorsal root ga ng lio n on the right side (while arrow G). On the left side, there is oblitera tion of the normal increased signal i n tensity fat s u rro undi n g the nerve root gangl ion and compression of the ga nglion into an oval-shaped mass (open arrow).
PEARLS Clinical evaluation is p artic ula rly important in these patients because t h ey generaJ ly h ave evere ra dicular p ain . •
•
M ye lography m ay not reveal these lateral l y herniated discs because the herniated portion of the disc is sufficiently lateral that it does not lead to deformity of the thecal sac.
PITFALL •
F a r la terally hernia led discs may be difficult to appreciate, p a lticu l a r ly if the p a rasagittal i mages at the level of the intervertebral foramen are 110t examined closely. The axial images may not cl ea rl y depict laterally hernia ted discs, and these laterally p osit io n e d discs are easily overlooked because they are rel a t i v e ly distant from the vertebral canal.
Diagnosis Left latcrally herniated disc at the L4-S level with encroachment on the intervertebral foramen.
Differential Diagnosis •
la terally herniated disc: Although the appearance is typical of a far laterally herniated disc, the presence of such a djsc may not be appreciated.
Discussion The m idsa gitt al images may appear d ece p t iv el y normal in the presence of a l a te ra l ly hern ia ted disc. Close eval uation of the intervertebral foramen is necessary to rule in o r out the p res e n ce of a laterally herniate d disc. Because the sagittal images progress from one side to the other, the laterality of the herniated disc can be determined. The side-to-side progression of the sagi tlal slices is determined by the m an ufactu rer or the equipment and can be used to predict t he side of an abnormal ity. Tn the presence of a he r niat ed disc, the myelographic signs of a her niated disc are: 1.
Po st eri or displacement of the nerve ro ot .
2. Inte rr up ti o n of nerve root sleeve fill ing. These myel o gr a ph ic changes are re fl e c ted in the magnetic resonance (MR) scan as p osteri o r d ispla ce me n t of t h e nerve root (a s seen on the right in Fig. B) and i nt errupt ion of nerve root sleeve filling ( as seen on the left i n Fig. B ) . 3. There is n erve root co m pre s sio n , also seen i n Figure B where t he nerve is compressed by th e herniated disc.
4. Another myel o grap h i c sign is curvilinear deviation or compression of t he thecal sac. This is seen by MR on the left in Figures B and D where the t heca l sac is effaceu and c om p re sse d al on g the left side by th e large hern i a te d disc. There a re also other findings in this case. On the right side at the LS-Sl l eve l , there appear to be two conjoined nervc roots exiting together. These are seen together on the left ide in Figure B a nd as two individual rounded low s ign a l intensity structures on the right in Figure B. The d orsal root gangli on is also seen more lat er ally and is s urr o u n de u by pe rin eu ra l high signal i ntensity fat.
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Case 10 Clinical Presentation The patient i a 74-year-old male with chronic low back pain with recent exacerbation of the back pain.
A
B
Radiologic Findings Sagittal short TR image of the lumbar spine (Fig. A) reveals prom inence of the intervertebral tlisc at the L2-3 level (black arrow). There is also prominence u f the disc at the L4-5 level (curved while arrow) and an oval shapetl area of increased signal intensity that projects behind the vertebr(ll botly of L4 (straight while arrow). R ight parasagittal short TR image (Fig. 8) reveals that there is a slightly lobulated area of decreased signal i ntensity behind the vertebral body of L4 (arrows).
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Radiologic Findings (coluinued) Left
para sa gitta l short TR image (Fig. C) rev eals an ova l -sh apeu area of increased signal intensity that projects behind the vertebral body of L4. There is also dorsal encroach ment upon the t heca l sac by a soft tissue mass
(curved Ilrmw). Sagittal i nte r media te TR image of the lumbar spine (Fig. D) reveals promi nence of the intervertebral disc at the L4-5 level (while arrow) and an area of variable signal intensity projecting pos te ri or to the vertebral body of L4 (open arrow). The intervertebra l uisc at L2-3 protrudes in t o the vertebral canal. There is a decreaseu s ig n al intensity soft tissue mass that encroaches upon the dorsal aspect of the thecal sac at the L4-5 level (curved arro w). Axial long TR image at the level of th e m idbody of L4 (Fig. E) reveals a m ush room-shaped area of d ecrea sed sign al intensity that projects beh ind the vertebral body of L4. This is capped by a crescentic area of incre aseu signal intensity (arrow). The thecal sac is compressed posteriorly anu toward the left side. The nerve roots of the cauda eqllina can be seen within the thecal sac. Axial short TR image at the L2-3 level (Fig. F ) reveals a midline and left paracentral prominence of the disc that encroaches upon the intervertebral foramen on the left side (curved arrow). There is slight prominence of the ligamentu m flavllm bilaterally (open arrow on left side).
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PEARLS •
•
•
The ligamentum fiavum does not actually "hypertrophy." Rather, the l i gam e n tum flavum i s normally stretched between the l amin ae of the vertebral bodies and therefore thinned. However, when there is disc space narrowing and degenerative changes of the interfacet joints, this results in closer approximation of the laminae and i nc r ea s ed fullness of the ligamentum fi a vu m . The appearance is un usual for a herniated disc, which is not usually associated with hemorrhage. If
surgery is not performed early in the course of the patient's illness, a follow-up scan m ay be helpful for more complete evaluation.
Diagnosis Midline he rn iate d disc at the L2-3 leve l ; l a r ge extruded hernia ted disc wi th a se qu es te re d fragment at t h e L4-S.
Differential Diagnosis •
•
hematoma: metastatic
A
hematoma from
•
He m orrhag e is unusual in association with a herniated disc.
have a similar appearance.
disease: Metastatic disease could also be a
consideration
but is
less likely.
Discussion The hern i a t ed disc at the L4-S level has extruded super i orly from the level o f t he intervertebral disc. There is a n area of i ncreased s i g n al i n te ns i ty hemorrhage along the dorsal aspect of the hern iated d isc. There continues to be evidence of a herniated disc at the L4-S level ; however, the majority of the nucleus pulposus has been extruded s u perio r ly. The decreased s i g n al in t e n si ty structure seen in Figure D is the ligamentum fl a vu m which is "hypertrophied" and encroaches upon the d orsal aspect of t h e thecal sac There is m arked com pressio n of the thecal sac a\ t h is le vel resulting in a spinal stenosis. .
There is a l s o a he rn i a Led d isc at the L2-3 level. The disc is predominantly in th e midl ine; h o weve r a po rt i o n of the disc extends laterally into the l ef t inLervertebral foramen. ,
PITFALL
any source could
L U M B A R D I SCS
Case 11 Clinical Presentation The patient is a 1 9-year-old male with low back pain.
A
B
Radiologic Findings Sagittal short TR image of the lumhar spine ( Fig. A ) reveals a minimal forward displacement of L4 on L S , a grade 1 spondylolisthesis. There is bulging of the disc at the L4-S level. The normal basivertebral venous p lexu s is seen in the mid portion of the lumbar vertebral body (arrow ) . Sagittal long TR image of the lumb
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Radiologic Findings (continued) Parasagittal short TR image (Fig. C) reveals an interruption of the pars interarticularis (shorr arrow). The superior articulating facet is seen above the level of t he break (5) and the inferior a rticulating facet (i) is seen below the level of the break. There is bulging of the L4-5 disc which encroaches on the inferior
armw). Axial short TR image (Fig. D) at the L3-4 Ievel through the normal in terver tebral disc. The interfacet joint is norlllal (open arrow). The superior articlI lating facet (5) is in norlllal apposition with the normal inferior articulating facet (i). Axial short T R image at the L4-5 level (Fig. E) reveals irregularity of the bony structures. There is widening of the space between the bony structures
(arro w-L).
Diagnosis G rade 1 spondylolisthesis secondary to bilateral spondylOlysis at the L4-5 level.
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•
Spondylolysis is generally more common in younger patients. In the older patient, the changes of spondylolisthesis are generally secondary to interfacet degenerative changes without a spondylolysis. Tn many patients, i t is not possible to identify the spondylolysis on the MR images. The sagittal MR images are ideal for the identification of small degrees of spondylolisthesis.
PITFALLS •
·
Attempts may be made to stabiHze the amount of forward or reverse slipping by utilizing metaUic fixating devices to maintain the relationship between t he vertebral bodies. cr canning or plain spine films may reveal the spondylolysis if i t is not visible by MR imaging.
Differential Diagnosis •
sponuylolisthesis: A spondylolisthesis may he present even without a spondylolysis; however, if there is no spondylolysis, there are typically interfacet degenerative changes. Common in older patients, interfacet degenerative changes are unusual in a young patient.
Discussion Metgnetic resonance imaging (MRl) is the ideal method for evaluation of subtle changes related to spondylolisthesis. In this patient, there is slight but defin ite forward displacement of L4 on L5. ThereFore. the reason for this displacement m ust be iden tified. The axial image (Fig. D) reveals the normal interfacet joint, while the axial image (Fig. E) actual ly reveals the pars intera rticularis, and the space between t he bone fragments actually represents the spondylolysis (arrow L). This break in the pars interarticularis results in instability of the spine and allows the vertebral body to slide forward on the vertebral body below. Th is furward sli ppage is the spondylolisthesis. The instability of the spine results in distortion of the intervertebral disc and creates a pseuuobulging disc at the L4-5 level. However, these changes cause mild degenerative changes in the disc, loss of hydration, and decreased signal intensity. When there is a spondylolisthesis, the intcrfaect joints and the pa rs inte rartieularis should be evaluetteu very closely. The pars interarticularis may be seen on plain film evaluation, on computed tomogretphic scans, and with careful evaluation of this anatomic area on petrasagittal images. The combination of the e changes and the bulging disc resu lts in interverte bral foramenal narrowing with encroachment upon the lower aspect of the intervertebral foramen by the bulging disc. MR is an excellent method of evaluating this change beefl use the increased signal intensity fat in the intervertebral foramen is an excellent contrast m aterial. I n general, the interfacet joint is positioned at approximately a 45 degree angle. while the pars interarticularis defect is at an almost horizontal projec tion. However, in some cases, particularly when there is more marked for ward displacement of one vertebral body on the next, the interfacet joint and the ddect i n the pars interarticularis may be almost supe rimposed. ThereFore, careful evaluation m ust be made of the im ages in multiple planes.
LUMBAR D I SCS
Case 12 Clinical Presentation The patient is a 44-year-old male with a history of pain in left bUllock which radiates down the left leg.
A
B
Radiologic Findings Sagi t t il l short TR image (Fig. A) reveals forward displacement of L5 on S l . The single arrow identifies t h e posterior i n ferior corner of the L 5 vertebral body. The two arrows identify the amount or rorward disp(;.\cement of L5 on Sl which is approximately 8 Illlll. There is widening of the epidural space behind the vertebral body of L 5. This widened epidural space is fil led with increased signal intensity fat. There is also a bulging dise at the L4-5 level. There is marked prom inence of the disc at the LS-SJ level. The LS vertebral body is identified. Parasagittal short TR image a t the level of the i n terfacet joi nts (Fig. B) reveals an interruption in the pars interarticularis a t the L5 level (open nrrow). The inferior articulating facet of the L4 vertebral body (i) proj ects dorsal to the superior articulating facet of the LS vertebral body (s). There
I TEACHING ATLAS OF SPINE I MAGING
D
c
Radiologic Findings (continued) is discontinuity between the superiur articulating facet of L5 and the inferior articulating facet of L5 . Axial short TR image a l t.he levcl of the pars defect (Fig. C) reveals sclerosis of the adjacent vertebral bodies which appear as decreased signal intensity. The superiur articulating facet projects anterior ( open arrow), while t he i nferiur articulating facet projects posteriorly (o[len arrow wirh box). Ax ial short TR image at the level of I he interfacet joint (Fig. D) reveals bony sclerosis and resulting decreCised signal i n tcnsity of the inferior articu lating facet on the left side (open arrow). The area of the spondylolysis is seen on the right side (h/ack arrow) on the same image and a lso reveals sclerosis with resulting 'decreased signal intensity surrounding the bones structures. Note that the interfacet joint is wider than the arca of the pars interarticularis defect. In some cases I he appeCira nce of these two areas is very similar.
Diagnosis Bilateral spondylolysis and gradc
I
spondylolisthesis.
Differential Diagnosis •
spondylolysis Clnd spondylolisthesis: The appearance is Iypical spondylolysis with spondylolisthesis.
of
a
LU M B AR D ISCS
PEARLS •
•
When there is spondylolysis, close evaluation should be made for the presence of spondylolysis. It may be necessary to perform a co mp u te d to m ogr ap hi c scan or plain sp ine images if further evaluation is needed. There is not t yp i caUy a herniated disc in these patients, but rather a " pseudobulging" disc because the s pond ylolist hesi s distorts the normal appearance of the intervertebral d is c.
PITFALL •
It is not always possi ble to identify the presence of sp ondylo l ysis on m agneti c r eso nan ce i magi ng. However, when tbere is a spondy l o li sth es i s, a spondylolysis should be r u l e d i n or out. Therefore, correlation should be made with plai n film evaluation or CT scanning.
Discussion The cause of sponuylolysis is un known , b u t it is t h ou ght to be related to trauma in some cases. The break, or " lysis," of the pars i n te r a r ticu l ar i s results in forward di splacem e n t of one vertebral body upon th e next. The dura of t he thecal sac is firm and d o es not adhere to the posterior margi n of the vertebral body b u t rem ains p oster ior ly placed . This results i n an enlarged ep idu r al space an terior to the thecal sac. This enlarged space fills with a d ip o se lissue which appears increased s ignal int ens i ty. Th e interverte bral disc appears p romi ne n t because the an terior d is place m en t of one verte bral hody on th e next resul l s in a "pseudobulging" disc as the d isc is unable to remain normal in co nlour. A pr act ica l method of gradi ng spondylol isthesis is to consider a forward s li p of one vertebral body on the other of 25% or less of the wiuth of the vert eb ra l bo d y as grade I, 25 to 50% s l i pp a g e of one verteb ral body on the next as grade 2, 50 to 75% sl ippage of one vertebral body on the next as grad e 3, and greater that 75% slippage as grade 4. A l though there are other methods, t hi s one is p rac ti ca l and easily used on a d ay-t o - d ay basis. The s l i p pag e may be either forward (anterolislhesis) or posteri or (retrolysthesis) .
Because there is i n terru p ti on of the pars inlerarticularis, the poslerior el e ments of the vertebral body are independent from the an te rior structures. Therefore, there i s not forward displ acement of the posterior e l e m en ts . There is u sually disc space n a rro wi n g in association with s po nd y l o ly si s a n d sp on dyl olisthe si s because the facet i nst ab i l i ty results in we a k en i ng of the disc and u lti ma t e l y loss of d isc he i gh t .
I
T E A C H J N G ATLAS OF S P I N E
I MA G I N G
Case 13 Clinical Presentation The p atie n t
is a 32-year-old male with a history of many years of low back
pain.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals marked forwanl d i s pla ce ment of the L5 vertehral hody rela tive to the S I vertehral hody. The pos terior inferior corner of the L5 vertebral body is displaced an terior to the anterior superior corner of the S1 vertebral body (a/'/'ow). The Sl vertebrae is deformed, and the superior end plate is rounded. The i n te rv e rtebral disc is markedly abnormal with both anterior and posterior promi nence of the disc. The epidural fat is markedly widened behind the ver t ebral body of L4 and L5
(arrowhead).
LUMBAR DISCS
c
D
I
I TF.ACl l l NG ATLAS OF S P I N E I M A G I NG
E
Radiologic Findings (continued) Sagittal long TR image (Fig. B) reveals that the epidural rat behind the vertebral bOllies of L4 and L5 now appears decreased signal intensity (arrow head). The i ntervertebral d isc at L5-S I appears prominent both anteriorly and posteriorly. There is encroach ment upon the vertebral canal and a resulting spinal stenosis. Axial short TR image at t h l! level or the L5 vertebral body ( Fig. C) reveals tllat the disc (small arrow) projects posteriorly to the vertebral body of L5 (large arrow). There is i ncreased signal intensity soft tissue surrounding the thecal s(tc. Axial short TR image at the level or the superior end plate of the S I vertebral body (Fig. D ) reveals that the thecal sac is compressed. Posteriorly the S I vertebral body i s visual ized while a n teriorly the L5 vertebral body i s visual ized. The thecal sac is compressed (arrow). Axial short TR image at the L4 level, just superior to the L5-S 1 intervertebral disc, (Fig. E) reveals an enlarged, rat-fil led epidural space that is well demon strated as seen in Figure A (triangle) as an area of decreased signal intensity. The nerves are demonstr(t t ed on either side. surrounded by pe rineural Fat (arrows). The widened an terior, epidural fat (also seen in Figure A) is {l lso seen (arrowhead).
LUMBAR DISCS
PEARL •
Ma gnetic resonance (MR) is th e procedure of choice for the evaluation o( spon dylolisthesi s.
Diagnosis Grade 4 spondylolisthesis.
Differential Diagnosis PITFALLS •
[(
the spinal stenosis is sufficiently severe and myelogra ph y is performed, contrast ma terial may not be a h l e to migrate to the distal end of the thecal Sac. In general m yel ograp hy is not necessary i( MR evaluation is available. ,
•
The pseudobulging elisc does not requi re surgery.
•
spondylolisthesis: The appearance is typica l spondylolisthesis.
of
a congenital
Discussion This d e formi ty is a congenital deformity. 1t is assoc ia t ed with an i nc rea sed lordosis on physical examination. The in tervertehr
I TEACH ING ATLAS OF SPIN E I M A G I
G
Case 14 Clinical Presentation The patie nt is a 63-year-old female with a long history of low back pain.
A
B
Radiologic Findings Sagittal short TR image of the lumbar spine (Fig. A) reveals a soft tissue density mass that projects behind the lower border of the vertebral body of L4 (arrow). Midsagittal long TR image (Fig. B) reveals that the soft tissue mass appears decreased signal intensity (arrow). Thcre is a slight anterolisthesis of L4 (4) on L5.
1 666
LUMBAR D I SCS
c
D
I
I TEACH ING ATLAS OF SPI
E IMAGIN G
E
Radiologic Findings (continued) Parasagittal long TR image (Fig. C) reveals that the soft tissue mass ( arrow) is slightly larger and obliterates essentially all of the lumbar vertehral cana\. There is decreased signal intensity of the intervertebral d isc at the L4-5 level. Axial short TR image (Fig. D) reveals the soft tissue mass in the dorsal. left lateral aspect of the vertebral canal. The theca l sac is displaced forward and compressed anteriorly ami tow(t n.l the right side (arrow). Axial long TR image (Fig. E) reveals that the soft tissue mass has a decreased signal intensity peripheral rim and an increased signal intensity central portion (arrow).
Diagnosis Synovial cyst.
Differential Diagnosis •
herniated disc: Very rarely, a herniated disc may migrate to a location dorsal to the thecal sac. In that case, contrast enhancement may reveal a peripheral rim of enhancement surrounding the herniated disc fragment.
L U M B A R D ISCS
PEARL A herni ated disc is not likely in
Discussion
•
this case because the mass is posterior to the thecal sac rather than anterior to the thecal sac. Synovial cysts are always associated wi th interfacet degenerative changes such as those seen here.
PITFALL •
Attempts have been made to aspirate the fluid contents of these cysts; however, they are generally removed surg ically.
Synovial cysts a re n uid-filled cystic lesions and m a y h ave a calcified or hemorrhagic component. Th i s calci fication presumahly results in the de creased signal in tensity seen h ere. Synovial cysts are associated with inter facet degenerative changes. Note that in this case there is widening of the interfacet joints laterally and cuppi ng of one facet around the other. In addition to the development of the synovial cyst, there is a spondylolisthesis with the forward d isplacement of L4 on the L5 vertebral body. The spondy lolisthesis is secondary to the interfacet degene r ative ch a nges which res ult in uown ward slipping or one facet joint on the ot her, loss of intervertebral disc height, and forward displace m ent of one vertebral body on the next. Note that in Figure A there is di ffuse increase in the sign al int e n s i ty of the marrow or all the visualized ve rtehral bodies. T h is is secondary to osteoporo sis and an increase in the amount of fat that i s p resent in the marrow of the vertebral bodi es.
I TEACH ING ATLAS OF SPINE I M A G I N G
Case 15 Clinical Presentation The patient is a 73-year-old male with a clinical history of previous surgery for a lumbar disc.
A
B
Radiologic Findings Sagittal short TR image (Fig. A) reveals a grade 1 an terolisthesis (anterior spondylolisthesis) with forward displacement of LS on Sl. There is also disc space narrowing at the LS -S l level. There is retrolisthesis (posterior spondylolisthesis) with posterior displacement of L2 on L3 and L1 on L2. The normal dorsal epidural fat at the L4 level (arrow) is obliterated, and a rounded, intermediate soft tissue mass projects into the vertebral can a l a n d t h e thecal sac a t t h e L4-S level. There are anterior osteophytes at mul tiple levels (shorr while arrows). The S1 vertebral body is identified with S.
LUMBAR DI SCS
c
o
I
I
TEACH I N G ATLAS OF SPINE IMAGI N G
Radiologic Findings (continued) Sagittal long TR image (Fig. B) again reveals the soft tissue mass which now appears as decreased signa l intensity wi th an increased sign al intensity rim and a peri pheral surrounding rim of decreased signal intensity. The nerve roots of the cauda equina are displaced anteri orly by this m(lSs. There is near complete obliteration of the thecal sac at this level. There (I re bulging discs at T12-Ll, Ll-2, and L2-3 w i th encroachment upon the hi g h signal intensity cerebrospinal fluid. The L 5 vertebral body is identified with 5 . There i s decreased signal intensity of all of the visualized intervertebral discs. The patient hau a previous lamin ectomy at the L4 and L5 level; the spin ous processes are not seen. Axial short TR image at the level of the L3-4 intervertebral disc (Fig. C) reveals the soft tissue mass encroaching upon the lefl uursal aspect uf the vertebral canal (straight arro w ) . The thecal sac is displaced forward and compressed in a curvilinear fashion ( curved arrow ) . There is i rregularity of the inter facet joint bilaterally ( open arrows ) . The supe rior and i nfe rior facets on the r ight are decreased in signal intensity as compared to the left side. Axial short TR image at the level of the vertebral pedicle at L4 (Fig. D) reveals the inferior aspect of the rounded mass (arro w) . The interfacet joint reveals irregularity of the inferior a rticu la ting facet anti an increase in the surroun ding soft tissue adj acent to the interfacet joint.
PEARL •
Syn ov ial cysts may occasionally appear bright on short TR images because of hemorrhage. They may also calcify; calcification is best seen by compu t e d tomographic sca nnin g
Diagnosis Synovial cyst arising from the left interfacet join t at the L3-4 level.
Differential Diagnosis •
dense scar formation secondary to the previous surgery.
•
an epidermoid.
•
tissue introduced into the vertebral canal by a spinal tap.
.
PITFALL •
Att empts have been ma de obliterate these cysts by aspira ting the fl uid wi thin the cyst. This has met with varying degrees of success. Generally these cysts are treated surgi cally with total rem oval .
Discussion Synovial cysts are most common at the L4-5 level where they are associated with degenerative changes of the interfacet joints and arise from the synovial lining of the i nterfacet jOint. They are typically cystic and m ay occasion ally be hemorrhagic. They are easily differentiated from herniated discs because they arise dorsally rather than ve ntral ly. They result in a variable, but ge nerally severe, spinal sten osis with variable obliteration of the thecal sac and compression of the nerve roots of the cauda equina. Because they are cyst ic synovial cysts typically appear as increased signal intensity on long TR images. ,
Typ ically, patients have a long history of low back pain .
LUMBAR D I SCS
I
Case 16 Clinical Presentation The patient is an 80-year-old man with weakness in the legs and numbness in the feet.
A
B
I
TEACH I N G ATLAS OF S P IN E I M A G I NG
•
c
D
lQ{4
L U M BAR DISCS
Radiologic Findings Sagittal short TR i mage of the lumbar spine (Fig. A) reveals a very faint soft tissue signal intensity mass that projects into the dorsal aspect of the thecal sac at the L3-4 level (long arrow). There is a slight compressi o n fracture of the superior end plate of the L3 vertebrnl body. There is mottled signa l intensity involving the L5 (open arrow), S 1 (while arrow) and S2 vertebral bodies. Sagittal lo n g TR image ( Fig. B) reve
PEARLS Radionuclide bone scannillg is very useful in the eval u
•
•
A radiograph of the pelvis reveals increased density of the pelvic inlet with Paget's disease. Pl ain films of the spine reveal a typical appearance of Paget's disease.
Diagnosis Spinal stenosi at the L3 4 level seco n da ry to hypertrophy of the ligamen tum flavum and encroachment upon the dorsal aspect of the vertebral canal. Incidental Paget s disease of the lumbar pine at the L5, Sl , and S2 levels, as well as the sacral alae and the iliac crests. .
-
'
'
Differential Diagnosis •
bone infarcts
•
areas of focal fibrosis
•
metastatic disease is a remote possibility
Discussion Ligamentum flavum hypertrophy is relate d to a nd associated with i n ter facet degenerative ch
"
"
6 / tll
I TEACHING ATLAS OF SPI N E IMAG I N G PITFALL •
Paget's disease may have a wide variety of appearances and may be mistaken for metastatic disease. Therefore, comparison should be made with the plain films as well as the radiolluebde scans.
. phied . ' This change results i n encroachment upon the central canal and cen tral canal spinal stenosis .
ii
P
«
L U M I3 A R DI SCS
Case 17 Clinical Presentation The patient is a 55-year-old female with 6-week
�_--,,-",, !..-:lL
history of
right leg pai n .
..._�
_ _
A
B
I
I
TE A C H I N G ATLAS OF SP I N E I M AGING
Radiologic Findings Axial computed tomographic (CT) scan at the level of L4-5 performed postmyelogram with the bone window width technique ( Fig. A) reveals a diffusely bulging disc that extends anterior to the vertebral body and toward the left side (white arrows). The small black arrows mark the margin of the vertebral body. There is a large osteophyte arising from the superior arLicul aLing facet on the right side (large black arrow). Th is ostcophyte encroaches upon the uorsal right side of the vertebral canal. There is marked compression of the thecal sac at this level . On the left side, there is slight widen ing of the interfacet joint (apen arrow) with n u iu i n the joint space. Axial CT scan (Fig. B) using bone window width technique at a level sligh t l y below the level in Figure A. There is slight prominence of the ligamenLum flavum on the Jeft side at the L4-S level (arrow). There is resulting curvil inear encroachment upon the contrast-filled thecal sac on the left sidc.
PEARLS •
CT is more sensitive for the evaluation of bony osteophytes, while MR can readily diagnosis the compromise of the lateral recess and central spinal canal.
•
Areas of stenosis are always associated with loss of epidural fat, and MR is excellent in the iden tification of epidural fat.
PITFALL m a y not identify areas of vertebral canal encroachment and may not be able to differentjate between bony versus soft tissue or areas of calcification. cr scanning is very sensitive to areas of bone fom1ation or areas of calcifica tion.
• MR
Diagnosis Diffusely bulging disc, largest on the left side; lateral recess stenosis on the righ t ide.
Differential Diagnosis •
degenerative changes: The appearance is typical of degenerative changes with degenerative changes in the intervertebral elisc and hypertrophic bone formation. CT scanning may reveal small bony osteophytes that are not visible by magnetic resonance (MR) scann ing.
Discussion The lateral recess is a portion of the subarticular canal. The location of the lateral recess is between the superior articulating facet and the posterior margin of the vertebral body . W hen osteophytes arise from the articula ting facet, th ey encroach upon the lateral recess of the vertebral canal. The nerve of the cauda equina arises from the thecal sac and courses through the late ral recess j ust before it exits via the intervertebral canal. Therefore, the nerve can be compressed by an osteophyte at the level of the lateral recess; this results in severe radicular pain. The enlargemen t of the ligamentum f1avum results in encroachment upon the dorsal aspect of the vertebral can al and a cen tral spin al canal stenosis. There is narrowing of the interfaeet joint on the right side with small degenerative cysts in the inferior articula ting facet as well as increased density with i n the facets secondary to bony sclerosis. The small oval areas of decreased density in the intervertebral d isc are secondary to small areas of vacuum degenerative cha nges. There is also encroach ment upon the interverLehral foramen on the left side by the bulging disc which results in intervertebral foramenal stenosis.
LUM B A R D I SCS
Case 18 Clinical Presentation The patient
is
a ll
RO-year-old female with a long h istory of back pain.
A
I
TEACHTNG ATLAS OF SPINE I MA G 1 N G
Radiologic Findings Axial computed tomograph ic (CT) scan using soft tissue wi ndow width technique (Fig. A) reveals diffuse low dcnsity of the intervertebral disc secondary to vacuum degenerative changes. The disc is bulging beyond the margin of the vertebral body (white arrows). There is a large osteophyte a rising from the superior a rticulating facet which encroaches upon the lateral recess (Long black arrow). The posterior m argi n of t he vertebral body is identified hy the arrowhead. There is thicken ing of the ligamentum tlavum
(open arrow).
PEARLS •
Spinal stenosis may involve a single level, but typically involves multiple levels.
•
myelograpby is performed and contrast material can not be identified below the level of a severe stenosis, the post myelogram CT scan may also identify contrast in the lower thecal sac. In addition, if contrast material is not identified in the thecal sac im mediately postmyelogram, the patient may be restudied with a delayed CT scan following a 1 or 2 hour delay prior to rescanlling. If
PITFALLS •
•
Tbe vacuum degenerative cbanges are better demonstrated by CT than by MR. If a myelogram is performed, tbe presence of a severe spinal stenosis may block the flow of contrast material inferior to the level of stenosis. In tbi' case, MR is definitely advan tageous for evaluation.
l@O
Axial CT scan (Fig. B) using bone window width technique at the same level as Figure A. The superior articulating facet and posterior margin of the vertebral body (white arrowheads) identify the lateral recess. There is a small area of cystic degenerative change involving the inferior articulating facet (white arrow-o). There is cupping of the su perior articulating facets around the in ferior articulating facets ami narrowing of the in terfacet j oi nt (while arrow-J) on the right side. Th ere is an area of curvilinear calci fication anterior the vertebral hody (open arrow).
Diagnosis Spi nal stenosis wit h vacuum degenera t ive changes of the intervert ebnt l disc.
Differential Diagnosis •
degenerative changes: The appearance is typical of degenerative changes in the intervertebral disc and interfacet joints.
Discussion There is di ffuse bulging of the disc. There are vacuum degenera tive changes of the intervertebral disc. The re is lateral recess stenosis on t he left side secondary to an osteophyte arising from the superior articulating facet and central canal stenosis secondary to hypertrophy of the ligamentum tl avum on th e left side. There are bilateral interfacet degenerative ch anges. No epidural fa t is seen because of the degenerative changes of the facets and the bulging disc. This absence of fa t is typica l l y seen in pa tient with spi nal stenosis. The evaluation of spinal stenosis should include CT images of the lower thoracic region through the entire lumbar vertebral canal. CT may also be performed following myelography. Magnetic resonance (MR) im aging may a lso be usetI for eva l uation of spi nal stenosis antI is atIva ntageous because it also reveals areas of spondylol isth esis. MR also has the advantage of not req uiring the instillation of con trast material.
LUMBAR
D I SCS
I
Case 19 Clinical Presentation The patient is a 62-year-old male with low back pain and bilateral lower extrem ity pa i n. The pain improves when the patient bends forward.
A
B
6Jill
I
TEACHING ATLAS OF SP I N E IMAG ING
Radiologic Findings Sagittal short TR image using the tech nique of magnetic resona nce (MR) myelography (Fig. A) reveals dorsal encroachment upon the thecal sac at the L4-S level (arrow). There is also a low signal intensity dorsa l soft tissue m ass that encro (1 c hes on the dorsal aspect of the thecal sac extending from the level of L4-5 superiorly to the level of L3-4. Decreased signal i n tensity of the L4-S disc and posterior promi nence of the intervertebra l disc at the L3-4, L4-S, and LS-S1 levels also are visible. of the MR myelogra m (Fig. B) reveals bilateral encroach ment upon the thecal sac (arro w). Th e re is a lso less severe bilateral encroachment upon the thecal sac at thc L3-4 level.
Posteroanterior s ho rt TR im age
PEARL •
T he
use of this technique allows a three-dimensional evaluation of the lumbar thecal sac.
Diagnosis Spinal stenosis at the L4-5 and L3-4 levels with bulging discs at L3-4, L4-5, and LS-Sl .
Differential Diagnosis PITFA LL •
Although these images m ay be reformatted into various planes, the images are degraded i n p l an es other than the plane in which the images were originally obtained.
•
metastatic disease
•
an epidural abscess or hematoma
Discussion MR-myelograpby is a technique that involves collecting multiple very thin slices i n a sing le pla ne and reformatting these images such that they mimic the appeara nce of a contrast myelogram. In this example, the images were initially obtained in the sagittal plane. Followin g this, the slices were re Cormatted in the anterorposterior (AP) pla n e . This explains why the sagi tta l images appear better den ned and l ess degraded than the AP i m age s. There is hypertrophy of the ligamentum ftavum which results in dorsal encroachment upon the subarachnoid space. The cereorospinal fluid in the s u ba rachno id space appcars increased signal i n te n s i ty and m i m i cs the appearance of the lateral and AP views of a myelogram. The technique of MR-myelography can be used with any level of t he spinal col umn and may compliment a myelogram . Surgery may be performed based upon these findings. MR-myelograpby should be used in conj u nction with routine MR scan ning so that a more accurate diagnosis can be made. MR-myelography may also be used in conjunction wi th cr scanning of the lumbar spine.
�2
LUM B A R DISCS
Suggested Readings Ackerman SJ, Steinberg EP. Bryan RN. B e n Debba M. Long OM. Persistent low back pain in p
add-on?
Radiology.
I 'N7:203:533-538.
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Bangert B A . Modic MT. Ross J S. et al. Hyperintellse tlisks un TI -wcightctl MR images: correlation with calcification. Radiology. 1 995: 1 95:437-443. Boden SO. Davis DO, Dina TS, et al. Abnormal magnetic resunance scans
of
thc lumbar
spine in as ympt o matic subjects. J /Jolle Joilll SlIfg I 990:72A :403-408.
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I. Brarile A, Passariello R. Lumbar disk herniation:
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postoperative lumbar spine patient.
Byrd SE. Cohn M L. Diggers SL, H u ntington
cr.
Locke G E. Charles M F. The radiographic
evaluation of the symptomatic pustoperativ(; IUlllbar spill" pati,,"t. SpifIC. 1 985: I 0:652-61i I . Chappell P M , Glover G H . Enzmann D R . Contrast on T2-weighted images of the lumbar �pine u�ing fast spin-echo and gated eonventiunal 1 995;37: 1 83 - 1 Hh.
�pin-ccho sell llcnces. NCllforadiol.
Chcng XG . Brys P. Nijs J . et al. Radiological prevalene" uf lumbar i ntcrvertcbral disc calcification i n the elderly: autop�y �tudy. Skeleral RadioI. 1 996:25:23 1 -235. Cohn EL. Maurcr EJ, Keats TE. et a1. Plain fi l m evaluation of degenerative tlisk tlisease at the lumbosacral junction. SkelelUl I?arliol. 1 997:26: I li l - 1 /iii.
Council un Sei(;ntifie A ffairs. Magnctic resonance imaging of the central nervous system: report of the panel on magnetic resuna nce imaging. Crisi G, Carpcggiani
.lA MA.
P, Trevisan C. Gadolinium-enhanced
1 98R:259: 1 2 1 1 - 1 222.
nerve roots in lumbar disk hernia
tion. AJNI<. 1 993: 1 4: 1 379- 1 392. Edelman R. Shoukimas G , Stark D. High-resol ution surface-coil imaging of lumbJr disk
disea�e. A.lIi.
1 985: 1 44: 1 123- 1 1 29.
Enzmann D R, DeLaPaz RL. Rubin JB. Magnetic Resonance of the Spine. St. Louis: M o�by, 1 990:225-23 1 . Erkintalo MO. Salminen J J , Alancn A M . Paajanen H E K . Kormano MJ. Development of degenerative changes in the l u m bar intervertebral disk: results of a prospective MR imJging 51 udy i n adolescents with and without luw-bllck pai l l . Rlldiulugy. 1 995: 1 %:529-533.
Goldberg A. Soo M , Deeb Z. Dc�cnerative disease of tbe lumbar spine: role of cr-myelogra phy in the MR era. Ciill III/aging. 1 99 1 : 1 5:47-55. Grcnier N, Kressel "Y, Schieblcr M L. G rossman R I . Isthmic spondylolysis of the lumbar spine: MR imaging at 1 .5T. Radiology. 1 989: 1 70:489-493. Hasegawa T. An HS. Haughton V M .
owicki B H . Lumbar foraminal stenosis: critical heights
uf the i ntervertebral discs and foramina. J
Balle Juint SlIfl!.
1 995:77:32-3K
Hemminghytt S. Daniels DL. Williams A L. Haughton VM. I n traspinal synovial cysts: natural hbtory and diagnosis by cr. Rndiolo!:y. 1 \182:1 45:375-376. Hergan K. Amann T. Vonbank
H, ct al. M R-myclography:
comparisun WIth conventiunal
myelography. EliI' I Radiol. 1 996;2 1 : 1 96-200. Hickey OS. Aspden R M , Hukins resonance
images from normal
O W L. and
Jenkin� .!P R. I sherwood I. Analysis uf magnetic degenerate
lumhar
intervertebral
discs.
Spille.
1 986; 1 1 :702-70R.
Howling SJ. Kessel D. Case report: acute radiclliopathy clue to hacmorrhaglc lumbar synuvial cysts. Ciin Radiol. 1 997:52:73 74.
683 1
TEACHI N G ATLAS OF SPI N E I M A G I N G I l ueftle M , Modic MT, Ross J S . e t al. Lumbar spine: postoperative M R imaging with Gd DTPA. Radiu/uKY. 1 9S8: 1 67:8 1 7-824. Hwang G-J . S u h J-S. Na J - B . et al. Contrast enhancement pattern and frequency of previously unoperated lumoar d iscs on M R I . l M R /. 1 997;7:575-57K Ibrallim MA. JesmanowicL A. Hyde JS. et al. Contrast enh�ncell1ent of nor m al intervertebral disks: time and dose dependence. AlNR. 1 994: 1 5: 4 1 ,) . I toh R . M urata K . Kamata M, e t al. Lu m bosacra l
nerve 1"00t enhancement w i t h disk herniation
on contrast-enhanced M R . AINN. 1 996; 1 7 : 1 61 9- 1 625. J ackson DE J r. Atlas SW. Mani J R. Norman D. I nt r"�pinal ,ynovial cysts: M R imaging. Radi%
g.\'. 1 98,): 1 7U:527 -5JO.
J i n k i n s J R . Malthes.JC, Sener RN. Vcnkatappan S, Ra uch R. Spondylolysis. spondylolisthesis, and a ssociat e d nerve roOl entraplllent i n the lumbosacral spine : MR evaluation. Alii. I 'in; 1 59: 799-803.
J i n kins J R. Osborn
AG, Garrett 0 J r.
Hunt S, Story JL. Spinal nerve enhancemcnt w i t h Gd
DTPA: MR correlation with the postoperative lumbosacra l spine. AlNR. 1 993; 1 4:383-394. J inkins J R. M R of enhancing nerve roots in the unopera t ed lumbosacral spine. AlNR.
1 993;14: 1 93-202. Johnson OW, Farnum G N , Latchaw R E. Erba SM. MR imaging of the pars interarticularis. A/Ji. 1 9H9; 1 52:327-332.
Kent DL. H a ynor
UR.
Larson EB. Dcyo R A . DiagnLl,b of lumbar spinal stenosis in adults:
a meta analysis of the accuracy of Lafforgue PF, Ch�gnaud
CJ.
CT.
MR. and myelography. AlR. 1 991; 1 58: 1 1 35-1 144.
Daver L M H . et al. I ntervertebral disk vacuum phenomenon
secondary t o vertebral collapse : prevalence and significance. Radi%
gy. 1 994; I 93:853-t>58.
Lane J I , K o eller KK, Atki n son J LD. E n hanced lumbar nerve roots in the spine without prior surgery: radiculitis or radicular veins? AlNR. 1 994: 1 5 : 1 3 17- 1 325. Liu SS. Williams KD. D rayer BP. Spetzler RF. Sonntag VK. Synovial eysts of the lumbar spinc : diagnosis by MR imaging. AlNR. 1 989: 1 0: 1 239- "1242. McPhee B . Spondylolisthesis and spondylolysis. In: Youmans JR. ed. Neurologic� 1 Surgery . vol. 4, Milette PC, Fontaine S, Lepanto L. et "I. Clinic�1 impact uf eontrast-enhanced MR imaging reports i n patients with previou, lumbar disk su rgery . /llR. 1996: 1 67:2 1 7-223. Modic M . M�,�ryk T. Boulllphrey F, Goorm a sti c M . Bell G . L u m b a r herniated d i s k disease and canal stenosis: prospective evaluation by surface coil M R,
CT, and
myelograpby. AlN!?
1986:7:709-7 17. Modic MT, Massaryk TJ. Ross JS. Carter JR. Imaging or degenerative disk disease. Nadi%
gy.
1 988: 1 68: 1 77- 1 86. Modic MT. Steinberg PM, Ross JS, Masaryk TJ. Carter J. Degenerative disk disease: assess ment of changes in vertebral hody marrow with M R I . Narii%
gy. 1 988: 1 66: 1 93- 1 99.
Modic MT, Weinstein MA, Pavlicek W, Boumph rey F, Starnes D, Duchesneau PM. Magnetic resonance
imaging of the
cervical
,pille:
tcchnical
�\1t1 d inical
observations.
AfR.
1 983; 1 4 1 : 1 129- 1 1 36; AlNR. 1 984 ;5' 1 5-22. Nguyell CM, An H, Ho K-C. et a l .
U tility
of high-dose contrast enhancement for detecting
recurrent herniated i ntervertebntl disks. AlNR. 1 994; 1 5 : 1 29 1 - 1297. Nowicki B H , Haughton V M . &hmidt TA, et al. Occult lumbar lateral spinal stenosis i n neural foramen subjected t o physiologic loading. A lNR. 1 996:17:1 605- 1 6 1 4 . Patel S . Sanders W . Synovial cyst o f the cervical spine: case report and review of the literature. AlNR. 1 988;9:602-603.
Ouint OJ. Hyperintense disks on TI -weighted M R images : are they i m portan t"? Radi%
f!.Y·
1 995: 1 95:325-326. Reul J, G i evers B , Weis J, ct al . Assessment of the narrow cervical spinal canal: prospective comparison of M R I , myelography and CT-myelography. Neuroradio/. 1 995:37: 1 87- 1 9 1 . Rodziewicz
G,
Kaufman B . Spetzler RF. Diagnosis o f sacral perineurial cysts by nuclear
magnetic resonance. SlIrg Neuro/. 1 984;22:50-52. Ross JS, Masllryk TJ. Schrader M. et al. M R imaging of t h e postoperative
assessment with gadope metate dimeglumine. /llNN. 1 990; 1 1 :77 1 -776.
l umbar
sp i ne :
Ross JS. Modic MT, Masaryk TJ. Curter J. Marcus RE, Bohlman H. Asse ssmen t of extradural degenerative disease with Gd-DTPA-cnhaneed MR imaging: correlation wi t h surgical and pa t hologic findings. AlNR. I 'iH9; I O: 1 243- 1 249.
L U M B A R D I SCS
Ross JS, Mouic MT. Ma saryk 1'.1,
Carter J,
Marcus RE, Bohlman H. Assessment of extradural
degenerative uisea,e with Gd-DTPA-enhanced MR imaging : correlation with surgical and pathologica l findings. AlR. 1 990: 1 54: 1 5 1 - 1 57. Ross JS. Mouie MT, Masaryk TJ. Tears of the ,onulus fibrosus: assessm ent with Gd-DTPA enhanced MR imaging. AlNR. 1 989; 1 0: 1 25 1- 1254. Ross JS, Zepp R, Modic MT. Posto p erative lumbar spine : enhanced MR evaluation of the intervertehral disk. A.lNR. 1 9911; 1 7 :323-33 1 . S a l o S. Paajanen I
r,
A l a n e n A . D i s c degeneration of pediatric patient s in l u m b a r M R I .
Pediarr Hadin/. 1 \195:25: 186- 1 89.
Schellinger D,
Manz
HJ,
Yidic B, et al.
Disk fragment migration. Radiulugy.
I ll'll);
175:83 1 -H3n.
Seidenwu rlll DJ , Lilt A W. Natural history of lumbar spine disease. (Comment) /?adiology_ 1 995; 1 95:323-324.
Sether LA. Y u S, Haughton V M , Fischer M E. I n tervertebral disk: normal age-re lated changes in MR signal intensity . Radiology. 1 \I\lIl;1 77:3R5-388.
Silbe rgleit
R,
Gebarski SS.
B runherg JA. McGillicudy J. Blaivas M. Lumbar synovial cysts: CT, M R , and pathologic lin d i ngs. AlNR. 1 990: 1 1 :777-779.
correlation w i th myelographhic,
Si lverman CS, Lenchik L, Shimkin PM, et al. Value of M R i n differentiating subligam e ntous from supraligamentous lumbar disk herniations. AlNH. 1 \1\1 5 ; 1 6:57 1 -579. Steinberg E, Anderson G, Stei nwachs D. Erickson J , Fahey M, Hynes D . rinancing magneti c resonance imaging in an era of prospe ctive payment: issues and options. W ashington . D.C.: Health I ndustry M a n u facturers Association. J u ne 1 986. Tahas .1 . Deeb
Z.
D i agnosis of sacra l perineurial cysts hy computed tomography. 1 ComplII
Tomgr. I \lX6;1 O:255-259.
Tarim' I M.
Perineurial cysts of the spinal nerve roots . A n'Ii NI'lIrol P.'ychin/ry. 1 938:40: 1067-
1 074.
Tarlnv
1M.
Spinal perineurial anu menin geal
I 970:33:R33-R43.
cysts . .I Nell ",I NC/lros/lrg J>sycltiarry.
Tartaglino LM. Flanders A E, Vinitski S. Friedman DP. Metallic ar1ifaets on MR images of the
postoperative spine: reduction with fast sp i n e -ec h o techniq ues. RadiululIY. 1994:1 90:565-.'\(1).
Teplick J G , Haskin M E. Spontan e ous regression of herniateu n ucleus pulposus. A.lNII . 1 985;6:33 1 -335.
Tyrrell PNM, Davies M, Evans N , et al. Signal chang"s i n t he int c rvertehral eliscs on M R I of t h e thoracolumbar spine in an kylosing spondylitis . Cilll Radiul. 1 9':15;50:377-383. Ulmer J L, Elster A D, Mathews VP. Allen A M . Lumbar spondylosi s : reactive marrow changes seen in
adjacent
pedicles on M R i m ages . AlR. 1' )1)5 : 1 04:429-433.
Ulmer J L, Mathews YP, Elster AD. et al . MR imaging of lumbar spondylolysis: t h e im p or tance of ancillary observa tions . Al R. 1 997: 1 69:233-23\1.
Ulmer JL, Mathews VP. Elster AD, et al . Lum bar spondylolys is without spondylolisthesis: recognition of isolated posterior dement subluxation on sagittal MR. AlNR. 1 995 ; 1 6: 1 393I 3l)X.
Wagner M, Sether LA. Yu S. Ho PSI'. H aughton V M . Age changes in the lumbar interverte
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r,
Kitchcner P. Spinal imaging: will M R I replace myelography? Spine.
1 9RR: 1 3:65-68.
Wiltse LL. Rothman SLG . Spondylolisthesis: classificat ion, diagnosis. anu natural history. S�I/Iin Spine S/lrg. 1989;1 :78-94.
Yu
S. Haughton
Yu
S,
VM, H o PSP, Sether LA, Wagner M, Ho KC. The progressive anu regressive
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Kc' Wagner Nadio logy.
degenerated lumbar i ntervertebral uisks.
M. Criteria for classifying normal and 1 9R9; 1 70:523-526.
Yu S, Haughton V M , Sether LA , Wagner M. The an n ulus fi b rosus in bulging iJltervertebral disks. Hadiology. 1 988: 1 69:761 -763. Yu S, Sether LA, Ho PSP, Wagner M, Haughton Y M . Tears of the annulu . fibrosus: correla tion between M R anu pathologic fi ndings in cadavers. A.lNR. 1988:9:367-370.
68�1
Section XI
Miscellaneous
M I SCELLA N EOUS
I
Case 1 Clinical Presentation The patient is a 29-year-old female with 3 weeks of decreased pain a m1 temperature sensation below the T3 level on the right and T4-5 on the left.
A
B
Radiologic Findings Sagittal long TR i m ages of the cervical spi nal cord ( Fig. A) and the thoracic spinal cord (Fig. 8) reveal three areas of increased si g n a l intensity (arrows). The l o we r most lesion in the distal thoracic spinal cord appears to be associ ated with slight edema and resulting widening of the sp in a l cord. -
6891
I TEACH I N G A
T LA S OF SPINE I M AG I N G
•
C
D
M I SCELLANEOUS
I
E
691
I
TF.AO l i NG ATLAS
OF SPINE IMAGING
Radiologic Findings (continued) Sagittal short TR image postcontrast (Fig. C) reveals a small area of enhance ment (arrow) at the C4 Icvcl corresponding to the area of increased signal intensity seen in Figure A . Axial short TR image postcontrast (rig. D ) reveals H sm
Diagnosis Multiple sclerosis of the hrain and spinal cord.
PEARLS •
•
Imaging should correlate with the patient's clinical symptoms and the laboratory analysis of the cerebrospinal fluid for an increase in oligoclonal bands o f abnormal protein. In a patient with abnormal imaging of the spin
PITFALLS Although uncommon, demyelinating plaques may bc seen in the spinal cord when none are seen ill the brain. •
•
Altbough a spin al cord tumor is unlikely, if it is a considerll t ion, follow-up is helpful for complete evalui;l.tion.
Differential Diagnosis •
•
multiple sclerosis spinal cord tumor
•
metastatic diseHse
•
acute dessiminated encephalomyelitis (ADEM)
Discussion Thc pcriventricular areas of increased signal intensity lire typical of and consistent with the demyelinating plaques of multiple sclerosis; therefore, multiple sclerosis appears to be the most likely diagnosis. The enhancing plaque in the pons is unusual in the patient with multiple sclerosis. In the spinal cord, the gray matter is in the central portion of the spinal cord. while the white matter is in thc peripheral portion of the spinal cord. Therefore, the areas of demyelinating plaque formation are typically seen in the later
•
MISCELLANEOUS
location and the widespread multiplicity of the lesions make this diagnosis unlikely. Similarly. metastatic uisease may also occur within the intramedul lary space; however, it is uncommon, and multiple lesions would be very rare. Another possibility could be th
6931
I TEACI l i N G ATLAS OF SPINE IMAGING
Case 2 Clinical Presentation The patient is a 1 6-year-old femClIe with (I c1ill ical h istory of right leg tingli ng Clnd right cyc blurring.
A
B
Radiologic Findings Sagittal short TR image postcontrast (Fig. A ) reveals multiple patchy areas or cnh ancement throughout thc thoracic spinal cord (arrows). The seven l h thoracic vertebrae i s identified w i l h TI .
M I SCELLANEOUS
C
D
I
I TEACHING ATLAS OF SPI
E IMAGING
E
M ISCELLA EOUS
G
Radiologic Findings (continued) Sagittal lung TR image (Fig. B) reveals multiple patchy areas of increased signitl intensity throughout the visualized spinal cord (straight arrows). C.urvi l inear areas of decreased signal intensity are seen in the suh;.mtchnoid fluid dorsal to the spinal cord (curued arrows). Axial long TR image (Fig. C) reveals an are
697
I
TEACHING ATLAS OF SPINE 1 M A G ING
PEARLS •
•
Correlation should be performed with cerebrospinal fluid evaLuation. Fo llow -up would be helpful for evaluation for progression or regression of the abnormality.
PITFALL •
O cca si o n a lly multiple m ay have a similar appearance. The diagnosis of metastases would be unlikely in a 16-year-old patient but could be a consideration in an older p a t ient .
metastases
Diagnosis Multiple sclerosis of the brain and spinal cord .
Differential Diagnosis •
mul tiple sclerosis
•
acute disseminated encephalomyelitis (ADEM)
Discussion The magnetic resonance imaging appearance of the brain is typical of multi ple sclerosis, although the age of 16 years is u n us ual l y young. The i nvolve ment of the corpus call osum is typical and strongly favors a diagnosis of m u l t ipl e sclerosis. Multi ple sclerosis affects the white matter of the centra l nervous system, and the white matter is also present in the arcuate fibers, which are white matter tracts that extend from one gyrus to the next. These pl a q ues of m u l tip l e sclerosis result in de m ye l ina t i on of the fihers. The a reas o f decreased signal i n tensity seen in the suharachnoid space dorsal to the spinal cord arc secondary to areas of flow-rclatcd enhancement, which are secondary to flow of cerebrospinal fluid in the subarach n oid space (Fig.
B, curved black arrows) . ADEM (post-infectious encephalomyelitis) is also a strong diagnostic con sideration in this patient because multiple sclerosis i s uncommon in a patient as young as 16 years of age. 1f ADEM is a co n s id eration, follow- up scans are necessary (or c ompl e te ev a l uati o n.
M ISCELLA NEOUS
I
Case 3 Clinical Presentation The patient is a 37-year-old female with paralyzed lower extremities and a history of op ti c neuritis.
A
B
699 1
c
700
D
E
M ISCELLA N EOUS
I
F
Radiologic Findings S
Diagnosis Probable multiple sclerosis.
7iLU
I TEA CHING ATLAS OF SPI. E I M AGING PEARLS Multiple sclerosi is more common in women than men, favoring the diagnosis of multiple sclerosis in this patient.
•
Follow-up examination would be very helpful for complete evaluation of this patient.
•
MRl of thc brain would also bc helpful because the presence of the typical areas of increased signal intensity in a periventricular anti deep white m atter distribution strongly favor the d iagnosis of multiple sclcrosis.
•
•
Corrclation should also be madc with analysis of thc cerebra pinal fluid.
PITFALLS •
•
Because thc treatment may bc different depending upon the diagnosis, it is important to attempt to make an accurate diagno is in a case such as this. Biopsy of the spinal cord may make the patient clinically worse, so it is prudent to follow the patient with MRT with contrast enhancement to evaluate thc progre ion of thc di easc.
702
Differential Diagnosis •
multiplc sclerosis
•
acute disseminated encephalomyclitis (ADEM)
•
idiopathic transverse myelopathy
•
Devic's disease
•
syrinx cavity
Discussion Based on the imaging appearance and clinical correlation with other tests, mul tiple sclerosis is the most l ikely diCignosis; other possibilities such as ADEM or idiop
«
M ISCELLANEOUS
I
Case 4 Clinical Presentation The patient is a 26-year-old female with a clinical history of right :I ' I" m ptl in and leg numbness.
A
B
/UJI
I TEACHING ATLAS OF S P I N E I M A G I N G
c
D
MISCELLANEOUS
E
Radiologic Findings Sagittal short TR image postcontrast (Fig. A) rcvcals an area of enh ancement in the ventral aspect of the spinal cord at the C2-3 level . Note t hat the enhancement exhibits an elongated ring or oval-shaped appearance. Th e C2 vertebral body is identified with 2. Sagittal short TR image postcontrast (Fig. B) reveals a second area of enhancement at the level of CS-6 (arrow). Sagittal long TR image (Fig. C) reveals an oval area of increased s ignal i n tensity in the ventral aspect of the spinal cord at the C2-3 level. The l inear area of decreased signal intensity dorsally at the C5 Icvel is an artifact
(arrow). Pre- (Fig. 0 , left) and postcon t rast (Fig. D, right) a x ial short TR images at the C2-3 level reveal an area of slight prom inence of the ventral aspect of the spi nal cord on the right side (left, open arrow). This area exhibits faint hypointcnsity. After the infusion of contrast , there is enhancement of the area of low signal intensity (right, arrow). Axial short TR image (Fig. E) reveals a rounded area of decreased signal i n tensity on the right side of the cervical spinal cord (arrowhead). There is a bilobed area of enhancement in this same area after the i nfusion of contrast material (right, arrow).
Diagnosis Multiple sclerosis of the spinal cord.
I
TEACH I NG ATLAS
OF S P I N E
IMAG ING
PEARLS •
•
Magnetic resonance imaging (MRI) evaluation of the brain would be very heJpful.
PITFALLS
•
•
multiple sclerosis
•
postinrectious encephalomyelitis
•
syrinx cavity
If there are areas of increased
signal intensity typical of multiple sclerosis plaques, this would confirm the diagnosis.
•
Differential Diagnosis
Biopsy is rarely performed in cases such as this. so the diagnosis generally is made based on clinical presentation and imaging findings. S arcoidosis of the spim ll cord could also have a simi lar appeltram;e. Therefore, tbe M R appearance should be correlated with cerebrospinal fluid evaluation.
Discussion The lateral location of the areas of enhancement in the spinal cord are consistent with lesions of the white matler. The grlty matter forms the central portion of the spinaJ cord and can be seen as ,m X-shaped area of decreased signal intensity. This is best seen on the right image of Figure E (arrow). The age of the patient is compatible with multiple sclerosis, which is more common in women tban men. The lack of a history of previous vaccination or viral illness also favors the diagnosis of multiple sclerosis rather than postinfectious encephalomyelitis. The circular/oval area of enhancement is also more typical of an area of demyelination, while a spinal cord tumor would be more masslike and would not be confined tn a white matter distribution. The marked edema of the spinal cord almost has the appearance of a syrinx cavity.
MISCELLANEOUS
I
Case 5 Clinical Presentation The patient is a 22-year-old female with blurred vision and upper extremity tingling.
A
_........ .
B
7�
I TEACH I N G ATLAS OF SPI
E IMAGING
PEARLS •
•
•
Not all plaques of multiple sclerosis exhibit enhancement on the postcontra t study. Thc clinical history of blurred vision is significant in this patient because multiple sclerosis commonly a [[ects the visual pathways. The patchy enhancement is not in favor of the diagnosis of a spinal cord tumor, but rather is a more typical finding in transverse myelopathy (myelitis).
PITFALL •
MRI of the brain should be performed to aid in better substantiating the diagnosis of multiple sclerosis.
Radiologic Findings Sagittal short TR images in the cervical region pre- (Fig. A, lefl) and postcon trast (Fig. A, right) reveal that the precontrast study appears within normal limits. There is a questionable area of enhancemen t in the dorsal aspect of the spinal cord at the C2 level (right, arrow). The st udy otherwise appears within normal limits. Sagillal i n termediate TR image (Fig. B) reveals multiple patchy areas of increased signal intensity throughout the cervical spinal cord region (arrow heads).
Diagnosis Mul tiple sclerosis of the spinal cord.
Differential Diagnosis •
mUltiple sclerosis
•
acute disseminated encephalomyeliti (ADEM)
Discussion The patient was known to have a diagnosis of multiple sclerosis, and magnetic resonance imaging (MR I ) of thc brain reveals multiple deep white matter and periventricular areas of increased signal consistent with the typical demyelinating plaques of multiple sclerosis. The appearance of the spinal cord is typical of the plaques of multiple sclerosis. No enhancement is seen in this patient; however, the plaques are seen as areas of increased signal intensity on the longer TR images. In another setting, ADEM (postinfectious encephalomyelitis) should be considered as a possible diagnosis.
M I SCELLA N E O U S
Case 6 Clinical Presentation The patient is a 48-year-old female with upper extremity proximal wea kness and back and shoulder pain .
A
Radiologic Findings Pre- (Fig. A, left) and postcon trast (Fig. A, right) sagittal short TR i mages reveal that the cervical spinal cord is diffusely enlarged throughout its visual ized length. In add ition, there is a streaklike area of low signal intensi ty within the central portion of the spinal cord that begins at the level or the midbody of C2 and extends inferiorly through C4. After the infusion of contrast (right), there is dense, irregular, and i nhomogeneous enhancement throughout the cervical spinal cord.
I TEACHING ATLAS
OF
SPINE IMAGING
B
c
Radiologic Findings (continued) Sagittal short TR image postcontrast in the thoracic region (Fig. B) reveals a small area of enhancement in the dorsal aspect of the spinal cord at the level of T8 (solid arrow). A small and less d istinct area of enhancement is more superiorly placed (open arrow). Axial short TR image postcontrast (Fig. C) reveals a dense patchy enhance ment in the dorsal aspect of the spinal cord (arrow) in the midline, extending off to the Ie ft side.
Diagnosis Transverse myelitis of unknown
1229
cause.
M I . CELLAN EOUS
PEARL •
Multiple sclerosis may present with an appearance similar to idiopathic transverse myeliti . An MR scan of the brain may be helpful in these cases; when the typical appearance of multiple sclerosis is identified i n the brain, the diagnosis o r multiple sclerosis involvement of the spinal cord is more secure.
PITFALL •
Biopsy or a spinal cord lesion may result in an increased neurologic deficit, so a conservative m anagement course is usually followed with evaluation w i th additional MR scans following a suitable period of med ical m anagement or when there is CI sudden change in the cl inical condition of the patient.
Differential Diagnosis •
transverse myelitis
•
paraneoplastic syndrome
•
spinal cord tumor
•
intramedullary metastases
Discussion The patient also had a h istory of m ultiple sclerosis; however. the brain magnetic resonance (MR) scan was within normal limits. Demyelinating plaques may be seen in the spinal cord in patients with mUltiple sclerosis when the brain scan is normal. However, it is much more common to have an abnormal brain MR scan when the spinal cord is abnormal. Patients may also have signs and symptoms of a spinal cord myelopathy and have a normal MR scan of the spinal cord. Paraneoplastic syndrome may also present with the appearance of transverse myelopathy/myelitis. Spinal cord tumor is unli kely in this case because the patchy nature of the enha ncement is not in favor of the diagnosis of tumor. Also, tumor is unlikely to reveal areas of intervening normal spinal cord tissue. The possibility of intramedu llary metastases from a primary tumor outside the central nervous system (e.g., breast or l ung cancer or melanoma) or from within the central nervous system (e.g., rrom a pinealoma or ependymoma of the brain or spinal cord) are also considerations because of the mul tiple lesions but are actually uncommon and arc therefore less likely.
71 1
I
TEACHING ATLAS OF SPI N E I MAG I N G
Case 7 Clinical Presentation The patient is a 43-year-old previously healthy male who presented with a I-week history of progressive upper extrem ity weakness and lack of coordi nation. The patient also had neck pain. Two weeks prior to onset of symp toms, the patient had received a vaccination for hepatitis B.
A
712
B
M I SCELLANEOUS
I
C
D
7 1 31
I
TEACHING ATLAS OF SP IN E IMAGING
E
Radiologic Findings Sagittal short TR image (Fig. A) reveals a central area of decreased signal intensity in the central portion of the spinal cord that extends from the level of C2 through the level of C5 (arrow at C3-4) . The spinll l cord is normal. in size throughout its length. Sagittal long TR image (Fig. B) reveals an arell of increased s ignal intensi ty that extends from the medulla i n feriorly through the level of C5-6 ( arro w
heads) . Axial long TR image (Fig. C) reveals a central area of increased signal intensity (arrow). Sagittal short TR image postcontrast (Fig. D) reveals a dense arell of en h ancement in the dorsal aspect of the spinal cord that extends from the lower medulla th rough the level of C3-4 (arrows) . The margin of the area of enhancement reveals an irregular edge. Axial short TR image postcontrast (Fig. E) reveals a wedge-shaped area of enhancement in the dorsal aspect of the sp inal cord . The area of enhance ment extends sl ightly more toward the left th lln toward th e right side ( arrow ) .
Diagnosis Postimmunization transverse myelopathy (" myelitis").
Differential Diagnosis •
transverse myelopathy
•
M I SCELLANEOUS
PEARLS •
•
The clinical history of a vaccination or viral illness is vital for accurate evaluation of the images. Spinal cord infarct with enhancement is a consideration in this paticnt; however, infarction is more typically seen in older age group patients and is often seen in association with congestive beart failure.
PITFALL •
This illness may a lso mimic the presentation of m ultiple sclerosis and the patient should be evaluated for this possibility. Magnetic resonance imaging of the brain would be belpful for more complete evaluation.
Discussion This disease is also known as acute disseminated encephalomyelopathy (ADEM). Transverse myelopathy following immunization is rare. Similar changes may occur in the brain where it is called acute disseminateu encepha lomyelitis. These changes are not truly an i nt"la mmatory process but are secondary to an antibody-antigen reaction. The body makes antibodies against the antigen of the hepatitis immunization product; however, the antibody mistak es the normal myelin in the brain and spinal cord for the antigen, and demyelination results. The clinical presentation is approxi mlltely 2 weeks following the imm unization. This process may also occur rollowing viral illness such as an upper respiratory infection or the common cold. Therefore, the clinical history should include inq u iry about these possi bilities. The areas of enhancement are thought to he secondary to acute demyelin ation. The clinical course in this illness is highly variable. Recovery may occur; however, this illness may al 0 progress to severe neurological deficit or even death . Idiopathic transverse myelopathy would also have a si milar appearance, and while quadriplegia may occur following immuni�at ion ror hepatitis B virus, it is very rare. The patchy, irregularly marginated areas of increased signal intensity within the vertebral bodies of C4 and C6 are secondary to areas of fat deposition within the marrow of the vertehrlll body and are of no clinical significance.
71 5
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Case 8 Clinical Presentation The patient is a 53-year-old fem ale who developed lower extremity weakness 2 weeks following a second vaccination against hepatitis B virus.
A
Radiologic Findings Pre- (Fig. A, left) and postcontrast (Fig. A, right) sagittal short TR images reveal enJargemen t of the distal end of the spinal cord. There is also increased signal i n tensity w ithin the enlarged portion of the spinal cord on the postcon trast study (right) arrow). Incidentally noted i s disc space narrowing a t the LS-S1 level with Schmorl 's nodule deformities in the adjacent vertebral body end plates. There is also i ncreased signal in tensity in the vertebral bodies adjacent to the degenerated disc. Posterior osteophytes are en croaching upon the vertebral canal, i ndenting the thecal sac, and widening the epidural rat above and bclow the bulging disc at L5-S l .
MISCELLANEOUS
I
B
c
Radiologic Findings (continued) Axial long TR image (Fig. 8) reveals incre(lsed signal intensity within central portion of the spinal cord.
the
Pre- (Fig. C, left) and postcontrast (Fig. C, right) axial short TR images reveal patchy enhancement in the spinal cord (right, arrow).
7J2.1
I
TEACHING ATLAS OF SPI N E I M A G I N G
PEARLS •
The term myelitis should be repl aced wi lh the tenn
myelopathy.
Diagnosis Postvaccination encephalomyelopathy (acute disseminated cncephalo mye lopathy) secondary to vaccination.
• •
Follow-up evaluation with magnetic resonance i maging is helpful and is the ideal noninvasive method to follow the response to treatment.
Differential Diagnosis •
transverse myelopathy
•
primary spinal cord tumor
•
spinal cord infarction
PITFALLS •
•
Follow-np is necessary for complete evaluation of this p atient. The administration of steroids may decrease the enhancemen t that is seen postinfusion, so correlation of the images should be made with the clinical treatment.
Discussion The patient received a vaccination for hepatitis B and experienced no symp toms. The patien t received a second vaccination approximately 2 weeks prior to this study, following which she developed lower extrem ity weakness. This history is typical of patients with transverse myelopathy associated with a viral illness such as an upper respiratory iJl ness or after vaccination. The clinical course is highly variable; these patients may do well, or they may progress to permanent neurological deficit or even death. Transverse myelopathy (myelitis) following vaccination is actually an anti body-antigen reaction. Following vaccina tion with a foreign an tigen, the patient develops antibodies against the foreign antigen . The antibodies " m is take" the normal nervous system tissue for the foreign antigen. This results in an antibody-antigen reaction in the patient, resulti ng in symptoms. The increased signal i n tensity in the vertebral body end plates is secondary to transformation of the bone marrow from red marrow to fatty white marrow. This is seen adjacent to degenerated intervertebral discs. The differential diagnosis incl udes a primary spinal cord tumor. A follow up scan m ay aid to differentiate this diagnosis. Spinal cord infarction could ha ve a similar imaging appearance, al though the clinical history would be di fferen t in the case of cord infarct. Spinal cord infarcts are typically seen in older pati ents who have arteriosclerotic vascular disease or in patients who have had surgery for abdominal aortic aneurysm or aortic dissection in which there is interruption of the blood supply to the spinal cord .
M lSCELLAN EOUS
Case 9 Clinical Presentation The patient is a 58-year-old female with a history of bilateral lower extremity weakness and n umbness. The patient also has a history of optic n euritis.
A
B
Radiologic Findings Sagittal short TR image precontrast (Fig. A) reveals that the thoracic spi nal cord in the midthoracic region appears larger than normal in size. Short TR image postcontrast (Fig. B) reveals patchy enhancement of the midthoracic spinal cord extending over approximately four vertebral body levels (arrows).
7221
I TEACH1NG ATLAS OF SPINE IMAGING
D
c
E
no
M lSCELLA EOUS
Radiologic Findings (continued) Axial short TR image postcontrast ( Fig. C) reveals a slightly irregularly marginated, very thick rimmed, rounded area of enhancement in the left side of the thoracic spinal cord (arrow). Axial short TR image uf the spinal cord at the luwer end of the area of enhancement (Fig. D) reveals a rounded area of dense en hancement in the dorsal left side of the spi nal cord (arrow). Sagittal short TR image of the brain (Fig. E) reveals a defect in the cerebral cortex and an accompanying defect in the corpus callosum (arrow).
PEARLS •
•
Correlation with brain imaging is very helpful for more complete eval uation and to confirm the diagnosis of multiple sclerosis. The clinical history is significant in this patient because of the presence of optic neuritis, which is a common presenting complaint in patients with multiple sclerosis.
Diagnosis Transverse myelitis, most li kely secondary to multiple sclerosis.
Differential Diagnosis •
multiple sclero is
•
spinal cord tumor
•
idiopathic transverse myelopathy
Discussion PITFALL •
Follow-up may be necessary in a patient such as this. Biopsy is often not performed because biopsy may m ake the patient's .ymptoms worse.
A spinal cord tumor could have similar appearance. However, the abnormal appearance of the brain is more in (avor of the diagnosis of multiple sclerosis. The remainder of the brain images reveal additional areas of increased signal intensity in the brain. The (l natomic locatiun uf the area of enhancement i n the dorsal aspect o f the spinal cord definitely favors a demyelinating process. I d iopathic tra nsverse myelopathy might also be a consideration. Transverse myelitis has many causes, including multiple sclerosis, sarcoidosis. and para neoplastic syndrome. Transverse myelitis may also occur following a viral illness or vaccination.
111 1
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Case 10
•
Clinical Presentation The patient is a 1 5-year-old previously healthy male with a o-month h istory of chronic leg weakness. The patient is now wheelchair-bound.
A
Radiologic Findings Sagittal short TR postcontrast image (Fig. A) reveals faint patchy areas of enhancement of the upper thoracic spinal cord (arrows). The spi nal cord is otherwise normal in size and configuration. Sagittal long TR image (Fig. B) reveals a long area of increased signal intensity within the central portion of the lower cervical and upper thoracic spinal cord (arrow). Follow-up image with smaller field of view (Fig. C) reveals the definite enhancement of the lower cervical and upper thoracic spinal cord (arrow). The cord is ot herwise of normal size.
MISCE L L A N E O U S
B
PEARL •
Transverse myelitis may be idiopathic, secondary to multiple sclerosis, part of the paraneoplastic syndrome, or a manifestation of acute disseminated encepbalomyelitis
I
c
Diagnosis Transverse "myelitis," cause unknown.
Differential Diagnosis •
multiple sclerosis
•
intramedullary infection
•
spi nal cord infarct
•
acute disseminated transverse myelitis
Discussion These changes could be related to multiple sclerosis, but thcrc was no history or cerebral symptoms, and the brain magnetic resonancc study was normal. Although this does not rulc out multiple sclcrosis, it makes the diagnosis lcss l i kely.
I TEACHING ATLAS OF SPINE I MAGING PITFALLS The initial imaging findings in this patient. using body coil imaging and a wide field of view, did not initially demonstrate the abnormality. Therefore, in a patient with definite clinical symptoms, additional imaging with a small field or view directed at the area of interest is certainly warranted. •
•
The administration of systemic steroids may decrease the amount of vi ' ible enhancement, so i maging findings should be correlated with the clin ical treatment.
1 124
A lthough rare. the possibility of an intramedullary infection with an organ i m such as Mycobaclerium Illberclllosis is a consideration, and the imaging findings should be correlated with analysis of the cerebrospinal fl uid. In an older patient, the diagnosis of spinal conJ inraret should be considered. particularly in the presence of other symptoms or atherosclerotic or a rterio sclerotic vascular disease. Acute disseminated transverse myel itis is also a trong diagnostic consider ation in this patient, even in the absence of a history of recent vaccination or viral illness.
•
M rSCELLANEOUS
Case 11 Clinical Presentation The patient is a 53-year-old male with a history of e sop h ageal cancer who w as previously treated with radiation therapy. The pa t ie nt has a 2-week history of increased tingling in the lower thoracic area.
A
B
Radiologic Findings Sagittal s h ort TR postcontrast image ( Fig. A) re v e a l s an a pp rox i matel y l -cm oval area of enhancement in th e midthoracic spinal cord (arrow). There is 00 deformity of the cord. Al l the vertebral bodies are diffusely increas e d in signal intensity secondary to p revio us radiation th e ra p y to a mediastinal mass. There is a Schmorl 's nodule deformity in the superior end pl ate of one of the lower tho r acic vertebral bodies (S) . S agiLL a l lo n g TR image (Fig. B ) reveals an area of increased sig n al in tensity in the midthoracic region (arrmv) that extends over approximately two vertebral body segments. This area is at the level of the previous area of enhancement.
7�
I TEACH ING ATLAS OF S PI N E I M AG ING
c
Radiologic Findings (continued) Axial long TR image (Fig. C) reveals the central area of increased signal inten ity within the thoracic spi nal cord (black arrow). The mediastinal mass is seen projecting anterior to the vertebral column (white arrows).
Diagnosis Postradiation changes in thc spinal cord and the vertebral bodies.
Differential Diagnosis •
postradiation changes
•
transverse myelitis
•
multiple sclerosis
•
•
pinal cord ischemic change intramedullary metastatic dcposit
MISCELLANEO US
PEARLS •
A normal brain magnetic resonance (MR) Scan would mitigate against the diagnosis of mUltiple sclerosis.
Discussion Transverse myelitis associate d with paraneoplastic syndrome could also give a similar appearance. However, the history of radiation and the changes in the vertebral bodies make postradiation changes a more likely diagnosis. Multi ple sclerosis is un likely as there were no other lesions or compati ble symptoms. ,
•
T h e index of suspicion is high for radi ation change when the patient has a history of receiving radiation and the anatomic location of the abnormality is within the radiated field. Radiation change m ay occur early after radiation treatment, while radiation necrosis is typically not seen unti l after 9 months following radiation.
An area of s p inal cord ischemic change could also have a sim i lar appearance. However, this patient is relatively young for a diagnosis such as s pina l cord infarct. Allho ugh an intramedullary metastatic deposit is also a consider ation , lhe l ack of mass effect does not favor this diagnosis.
PITFALLS •
The radiation dose to this patient s mediastinal mass was 5,000 gy (50 RADS), wIllch is below the level anticipated to cause radiation necrosis. This mitigates against the diagnosis of radia tion necrosis; however, the changes are still consistent with radiation changes without radjation necrosjs. '
•
Radiation change is generally a diagnosis of exclusion. If a disease process such as metastasis is suspected, foUow up evaluation with MRI lo determine if the lesion enlarges over a period of time is war ran ted .
7E1
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TEACH ING ATLAS OF S P[NE IMA G I N G
Case 12 Clinical Presentation The patient is a 53-year-old female who received previous thoracic radiation for hilar lymphadenopathy because of metastases.
A
B
Radiologic Findings Sagittal short TR image precontrast infusion (Fig. A) reveals an area of i ncreased signal in tens ity within the spinal cord at the T2-3 level (arrow). There are superior end plate compression fractures of Tl and T3 (arrow heads) . The marrow within the visualized thoracic vertebral bodies appears di ffusely increased in si gn a l in tensity.
M ISCELLANEOUS
� _ _ _ _....
c
I
D
Radiologic Findings (continued) Sagittal short TR image postcontrast (Fig. B) reveals an oval area or enhance ment i:lt the level of, and surrounding the area of, increased signal seen in Figure A (arrow). The T6 vertebral body is identi fied with 6. Axial short TR image postcontrast (Fig. C) reveals a ring of enhancement within the ventral lateral aspect or the spinal cord at the T2-3 level (arrow). Parasagittal short TR i mage at the level of the hilum (Fig. D) reveals a bilobed m
Diagnosis Postradiation change with enhancemenl or the spinal cord.
Differential Diagnosis •
radiation change
•
multiple sclerosis
•
paraneopl(lstic syndrome with transverse " myeli tis"
I
TE A C H I N G ATL A S OF SPI N E IMA G I N G
;PEARLS •
•
The enhancement in the white matter of the spinal cord favors a demyelinating process rather than a spinal cord tumor. The lack of m ass effect is strongly in favor of a demyehnating process.
PITFALLS •
•
Follow-up m ay be necessary for compl ete evaluation. Correlation s hould also be made with cerebrospinal fluid evaluation to rule out the presence of oligoclonal bands, which may be seen in multiple sclerosis.
lZlo
Discussion The mass in the hi lar region is a pri mary lung cancer. Within the radi a tion treatment field, there is radiation effect upon the spi nal cord with demyelin ation and consequent enhancement. The enhancement is presumed to be secondary to the advancing margin of demyelination of the white matter secondary to radiation effect even in the absence of rad iation necrosis. The previous radi at ion treatment has resulted in an increased amoun t of fat within the marrow of the vertebral bodies, and consequently they appear as increased signal intensity. The vertebral bodies are weakened because of the radiation change, and I his has resulted in m ul tiple compression fractures secondary to this osteoporosis. Multiple sclerosis would h ave a similar appearance on imaging. However, the history is n ot compatible witb the diagnosis of multiple sclerosis.
M ISCELLAN EOUS
I
Case 13 Clinical Presentation The patient is a 46-year-old diabetic male with non-Hodgkin's lymphoma with possible meningeal carcinomatosis.
A
B
Radiologic Findings Axial short TR image postcontrast at the level of the pontomedullary j unc tion (Fig. A) appears within normal limits. There are no abnormal arcas of enhancement. Long TR image at the level of the junction between thc lower pons and the medulla (Fig. B) reveals multiple, variable sizcd areas of increased signal i ntensity in the medulla (arrows). The scan i otherwise normal.
I TEACH ING ATLAS OF SPINE IM A G l l G PEARLS •
•
The h istory of mantle radiation is important in this patienl. Tn addition, the time from treatment to symptoms would be compatible with the diagnosis of "radiation effect" in the absence of radiation necrosis. The imaging findings in this patient are very subtle and close eval uation to the lowest slices is important for complete evaluation.
PITFALL •
Other diseases, such as spinal cord infarction, could have a imilar appearance. Multiple sclerosis could also have a 'imilar appearance; however, the clinical history is not in favor ot' this diagnosis. Radiation effect is a diagnosis of exclusion, and other diagno tic considerations should be ruled out. FoUow-up is also belpful for more complete evaluation.
Diagnosis Postradiation change.
Differential Diagnosis •
postradiation change
•
metastases
Discussion This patient with non-Hodgki n 's lymphoma had received radiation of the neck, chest, and axillary nodes. The symptoms began approximately 9 months after treatment. The areas of abnormal signal intensity are presum ably areas of demyelination secondary to the patient's radiation treatment. M eningeal carcinomatosis would be anticipated to show areas of enhance ment of the meninges; this was not present in this patienl. l n traparenchymal areas of metastases from non-Hodgkin's or Hodgk in's lymphoma are rare but may occur. However, metastases generally exhibit areas of enhancement; no enhancement was seen in this patient. Although the patient is diabetic, a condition that results in small vessel infarcts, the magnetic resonance pattern of i ncreased signal i ntensity is not typical for vascular lesion. The history of diabetes is non-contributory in this patient relative to the imaging findings.
MlSCELLANEOUS
Case 14 Clinical Presentation The patient is a 73-year-old female with weight loss and tenderness uf the lumbar spine. There was left leg weakness with decreased sensation.
A
Radiologic Findings Anteroposterior view of the lumber spine (Fig. A) reveals a small amount of retained pantopaque in the very distal end of the thecal sac, which appears as i ncreased density and exhibits a fluid level . Sagittal short TR image (Fig. B) reveals that the retained pantopaque ap pears as an area of increased signal intensity in the lower end of the distal thecal S(lC (arrow).
7 33 1
I TEACHING ATI .AS OF S P I N E I M AGING
D
c
E
MISCELLAN EOUS
Radiologic Findings (continued) Sagittal intcrmcdiate TR image (Fig. C) re:!ve:!als chemical shift artifact sur rounding the retained pantopaque. There is a halo of increased signal supc rior to the pantopaque (small arrow) and a streak or de:!cre:!ase:!d signal anterior to the ran lopaque. Also present is a herniated disc at the L4-L5 levd
(large arrow). Sagittal long TR image:! (Fig. D) reveals that the retained pantopaque appears as decreased signal intensity. The herniated disc at the L4-5 level is well demonstrated. There is slight encroachment upon the high signal iJl lensity cerebrospinal fluid. Note the normal decreased signal intensity cleft within the intervertebral discs at thc normal levels (arrnw) . Axial short TR image (Fig. E) reveals the retained pantopaque in the dependent portion of the lumbar thecal sac (arrow). The nerve root sleeves can also be identified lateral to the thecal sac and surrounded by increased signal intensity perineural fat.
PEARL •
Plain spine films will usually demon trate areas of retained pantopaque. There may also be retained droplets of pantopaque within the cranial vault. The use of pantopaque has been discontinued sincc thc development of water soluble contrast material.
PITFALL •
lnereased-signal-intensity retained oily pantopaque can be mistaken for blood in the methemoglobin phase of metabolism. However. pantopaque will become decreased signal intensity on long TR images, while methemoglobin will appear as increased signal i ntensity on long TR images.
Diagnosis Retained pantopaque; herniated disc at L4-5.
Differential Diagnosis •
retained pantopaque
Discussion Reporls have been published t hat link pantopaque with arachnoiditis especially when there is associated hemorrhage or blood in the subarach noid space. However, no direct cause and effect has been conclusively proven . and essentially all of these patients with pantopaque myelograms have also had spi nal surgery. Panlopaque, an oi l-based contrast material, appears as increased signal intensity on short TR images and decre:!ased signal intensity o n long TR images.
7�
I TEACHI N G ATLAS OF SPI N E IMAGING
Case 15
•
Clinical Presentation The patient is a 49-ycar-old male with a history of previous surgery for spi nal cord epcndymoma.
A
B
Radiologic Findings Anteroposterior view of the lower l umbar regions (Fig. A) reveals laminec tomy changes at the L3 and L4 levels. There is a metallic suturc projecting just medial to the right pedicle at the L4 level (arrow). Thcre are multiple small droplets of high density pantopaque contrast material and one large droplet in the lower end of the thecal sac. Sagittal short TR image (Fig. B) reveals a long l aminectomy that extends from L2 superiorly through the thoracic region. There is no normal appearing spinal cord remaining. The spinal cord remnant is a thin irregular strand of neural tissue (arrowheads) that floats in the di lated thecal sac. In the lower lumbar region, the ncrve roots of the cauda equina are th ickened and mattcd together. There is a streak like area of increascd signal intensity within these nerve roots.
1 / 36
M ISCELLANEOUS
c
D
Radiologic Findings (continued) Sagittal long TR image (Fig. C) rcvcals the dilated thecal sac in the lower thoracic region secondary to surgery and the developmcnt of a postoperativc pseudomeningocele with outpouching of the dorsal aspect of the thecal sac into the laminectomy site. The remaining strands o[ neural tissue appear as irregular bands of decreased signa\. The matted nerve rootlets of the cauda equina arc scen as a cordlike structure in the lower lumbar thccal sac. Axial short TR image (Fig. D) reveals the flattened, scatTed, matted nerve rootlets of the cauda equina (arrow).
Diagnosis Extensive postoperative changes with scarring and adhesions of the nerve roots of thc cauda equina.
737
I TEACH I NG ATLAS
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S P I N E IMAGING
PEARLS •
•
Follow-up studies may be helpful for complete evaluation; tumor would be expected to progress, while arachnoiditis would remain stable. Although no mass lesions are seen, rather streaky areas arc more con istent with scar formation are visible.
PITFALL •
While attempts have been made to urgically release adhesions, these attempts are generally unsuccessful and are not recommended. In a patient with such severe distortion of the normal anatomy, a follow up examination is certainly warranted for more complete evaluation, particularly as there i no known t reatment for arachnoiditis.
Differential Diagnosis •
postoperative changes
•
arachnoiditis
Discussion In cases such as this where there are extensive postsurgical changes, the presence or absence of remaining tumor may be impossihle to determine. Postcontrast images shuuld be obtained to identify any areas of enhancement as this would indicate a recurrent tumor. However, areas of arachnoiditis may also show enhancement. Enhancement in areas of arachnoiditis are highly variable.
•
M ISCELLAN EOUS
I
Case 16 Clinical Presentation The patient
is a 67-year-old
male with severe low back pain.
A
...._ .. . 8
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I TEACH I N G ATLAS OF SPINE I M A G I NG
•
c
D
V'10
M1SCELLANEOUS
PEARLS •
•
A po tcontrast scan may also be perfOlIDed and may occasionally reveal areas of enhancement with adhesions within the area of scar rormation. In patien t· in whom the area of nerve root adhesion is masslike. the possibility or drop metastases is a con ideration. However. this is less likely when there are postoperative changes and no history of a primary tumor.
PITFALLS •
•
The changes related to arachnoiditis may be very subtle in some patients, so careful evaluation o[ the scans must be perrormed. In rare cases, the magnetic resonance scan may be entirely normal even when there is arachnoiditis present. In these patients, a repeat myelogram with postmyelogram computed tomographic scanning may be necessary ror complete evaluation and demonstration of the typical changes seen with adhesive arachnoiditis.
Radiologic Findings Sagittal short TR image (Fig. A) reveals total laminectomy at L3 and L4 and a partial laminectomy at the L5 level. The spinous processes have been replaced by increased signal intensity fat (arrowheads). The spinal cord appears as a olid structure extending to the level of L3. At thc L3 level, the nerve roots or the cauda equina are malted and distorted. There is a large, plaquelike area of matted, distorted nerve rootlets fi lling the distal thecal sac (arrow). The anterior, irregular extensions of the nerve material is presumed to be areas where the neural structures are adherent to the anterior margin of the thecal sac. The nerve rootlets of the cauda equina are also tethered posteriorly in the lumbar region from L3 i n reriorly. Axial short TR image at the level of the kidneys (Fig. B) reveals the distorted neural tissue in the thecal sac (arrow). Axial long TR image in the upper lumbar region (Fig. C) reveals the irregu larly marginated spinal cord positioned posteriorly in the thecal sac and adherent to the posterior margin of the theca l sac (arrow). Axial long TR image at the Ievcl of the cauda equina (Fig. D) reveals that the nerve roots are matted together and displaced anteriorly and toward the left side (black arrow). In addition. there arc multiple nerve roots matted together and adherent to the po terior margin of the thecal sac (while arrow).
Diagnosis Postoperative adhesive arachnoiditis.
Differential Diagnosis •
arachnoiditis
•
drop metastases
•
meningeal carcinomatosis
Discussion The remote possibility or drop metastases or meningeal carcinomatosis is a consideration. However, there is no history of a primary tumor either within or outside of the central nervous system . The history of prcvious surgery and the evidence of a laminectomy are strongly in favor of arach noiditis. Arachnoiditis seems to be related to the presence or blood in the subarachnoid space and may occur in any patient who has had surgery. Surgery has been attempted to lyse adhesion. ; however. surgery is not found to be successful for treatment of arachnoid adhesions. Adhesive arachnoiditis may also appear as an "empty tube" with all the nerve roots of the cauda equina adherent to the walls of the thecal sac; therefore, they
I TEACH ING ATLA
OF S P I N E I MAGING
Case 17 •
Clinical Presentation The patient is a 36-year-old female who complained of severe headache and back pain following spinal anesthesia for childbirth. A blood patch had been attempted without success.
A
B
Radiologic Findings Sagittal short TR image in the lumbar region (Fig. A) reveals an elongated area or increased signal intensity dorsal to the thecal sac in the lower lumbar region (arrow). Sagittal long TR i mage (Fig. B) reveals a thin black line (arrows) along the anterior margin of tbe area of increased signal intensity seen in Figure A. This area remains i ncreased signal intensity on the long TR image. Axial short TR image at the level of L5 (Fig. C) reveals a semilunar area of increased signal i nten ity in the dorsal left side of the thecal sac (arrow).
MISCELLANEOUS
I
c
PEARLS •
•
Magnetic resonance imaging (MRI) is the procedure of choice for t he evaluation of areas of hemorrhage and can be used both for diagnosis and follow-up. If surgery is contemplated, the surgical approach can be planned based on the MR images because they accurately reflect the clinical situation.
PITFALL •
Pantopaque retained fOUowing mye lography could have a 'imilar appearance. However, pantopaque would be expected to accumulate in the dependent portion of the thecal sac. The history is also helpful [or eval uation of this patient.
Diagnosis Epidural hematoma.
Differential Diagnosis •
epidural hematoma
•
epidural lipoma
Discussion It is uncertain if the epidural hematoma is sccondary to the i nitial spinal anesthesia, epidural anesthesia, or blood patching procedu re, as either could lead to this appearance. The b lack line seen in Figure B is the an teriorl y displaced posterior margin o f the dura. There is also decreased signal inten sity on the intervertebral disc at the L4-5 level and a small hern iation of the disc into the vertebral canal. The differential diagnosis based on the short TR images could also suggest an epidural lipoma; however, the clinical setting and the increased signal i ntensity of the mass on the long TR im age is more consistent with an epidural hematoma.
I TEACHING ATLAS
OF
S P I N E I M A G I NG
Case 18
•
Clinical Presentation The patient is a 32-year-old male w i th A I DS ( acqui red immunodeficiency syndrome) who now presents with lower extremity loss of reflex, decreased sensation, and loss of movement. The patient experienced an episode o( Pneumocystis carinii pneumonia 6 months prior to this admission.
A
Radiologic Findings Axial postin[usion computed tomographic (CT) image through the upper lumbar region ( Fig. A) reveals a high-density rounded mass in the right dorsal aspect of the vertebral canal (open arrow). The low-density thecal sac is compressed and deformed to a semilunar configuration (solid arrow ) .
M ISCELLANEOUS
B
c
Radiologic Findings (continued) Sagittal short TR image of the lumbar spine (Fig. B) reveals numerous curvilinear areas of increased signal intensity interspersed with intermediate and slightly decreased signal intensity sort tissue material t h roughout the l umbar vertebral canal. The thecal sac is displaced anteriorly and markedly compressed. The nerve roots of the cauda equlna cannot be seen. The marrow within the vertebral bodies is diffusely decreased in signal intensity. Sagittal long TR image (Fig. C) reveals that the material within the vertebral canal appears variably increased and decreased in signal intensity.
Diagnosis Multi level epidural hematoma in the l umbar region.
I TEACHING ATLAS OF SPINE I MA G I NG PEARLS Epidural hematoma may also occur spontaneously in patients who are taking coumadill or have bleeding dyscrasias for other reasons.
Differential Diagnosis
•
•
The presence of an epidural hematoma is difficult to evaluate Oil cr i mages, and magnetic resonance i maging (MRI) is much more accurate for tbis type of evaluation.
PITFALLS Surgery may be attempted in these patients; however, blood may also accumula te in the thecal sac, and removal may not be pos ible. •
•
Because prolonged spinal cord compression from a process uch as an epidural hematoma may result in devastating neurologic consequences, rapid evaluation with MRI is necessary for evaluation. Treatment may be performed based upon the MR images.
•
epidural hematoma
•
metastatic tumor
•
epidural empycma
Discussion The cr evaluation is nonspecific and could be consistent with metastatic tumor or epidural empyema; a chloroma could also have a similar appear ance. The mottled signal intensity within the vertebral canal is consistent with hematoma of varying ages. The normal epidural increased signal intensity fat is completely obliterated in this patient. The cause ur the hematoma in this patient was not known. The diffuse low density of the ma rrow within thc vcrtebral bodies is typical of the findings that may be seen in the AIDS patient and is secondary to an increased amount of iron deposition. This is a result of more rapid cell turnover in the AIDS patient. This low density marrow may also be seen in patients who have had multiple blood transfusions, wh ich also result in an increased cell turnover and increased iron deposition in the reticuloendo thelial system of the bone marrow. The increased iron creates a paramagnetic effect and the resulting decreased signal intensity. Evaluation hould be made of the entire spine if surgical removal is contem plated or attempted.
MISCELLANEOUS
Case 19 Clinical Presentation The patient is a 37-year-old female with upper extre m ity weakness.
A
Radiologic Findings Sagittal short TR image (Fig. A) reveals an elongatet.!, triangu lar shaped. increased signal intensity mass along the dorsal aspect of the spinal cord. The mass extends from the superior end plate of C3 to the inferior endplate of C4. The normal lordotic curve of the cervical spine and the spinal cart.! is reversed. There is a faint decreased signal intensity line along the anterior margin of the mass (black arrow). There had been a previous lami nectomy. Incidentally noted are moderately severe degenerative changes with both anterior and posterior osteophytes at m ultiple l evels in the cervical spine. There is decreased signal intensity within the marrow of the C6 vertebral body.
B
I TEACHING ATLAS OF SPINE I M A G I N G
•
C
Radiologic Findings (continued) Sagittal long TR image (Fig. B ) reveals that the mass now appears relatively decreased in signal intensity. The mass continues to exhibit a decreased signal intensity border anteriorly (black arrow). There is an area of decreased signal intensity dorsal to the area of increased signal intensity that extends from C2 through C7 (while arrows). Axial short TR image ( Fig. C) reveals a slightly irregularly marginated increased signal intensity mass along the dorsal right side of the spinal cord. The cord is curved around the anterior margin or the mass (white arrows). The midline decreased signal intensi ty dekct in the muscle of the dors
Diagnosis Spinal cord lipoma.
Differential Diagnosis •
spinal cord lipoma
•
spinal cord tumor
M tSCELLANEO S
PEARLS •
•
The possibility of the increased ignal intensity being secondary to methemoglobin is a con ideration; however, methemoglobin would become increased signal intensity on the long TR images. In addition, chemical shift artifact is typically associated with adipose tissue and not with a hematoma. Fat suppres ion images may also be obtained to demonstrate that the signal intensity becomes decreased when using this technique.
PITFALL •
Discussion In addition to the lipoma of the spina l cord, there are postsurgical changcs in the cervical spine and the incidental findings of degenerative changes in the spine. The l ipoma itself is congenital. The appearance of decreased signal intensity in the longer TR image is consistent with lipoma. Note that the linear decreased signal intensity border along the anterior aspect of the lipoma is secondary to chemical hift art i fact. Lipomas are more common in the lumbar region and are typically seen in the clinical setting of the Chiari malformation. However, small lipomas may occur in the filum terminale and be seen even in asymptomatic patient . The parient had a previous laminectomy with partial removal of the mass. The decreased signal intensity area dorsal to the lipoma (Fig. B ) is secondary to scar formation. Complete removal of a lipoma that is intimately associated with the spinal cord is usually not possible. The reversal of the curve or the spine may occur following a wide lam incctomy. A spinal cord tumor is not likely because tumors are not elongated, and the increased signal intensity would reflect the presence of extensive hemor rhage, in which case the patient would present with devastating cl inical symptoms, which were not present in this patient.
Iinical hi tory is important in a case such as this where hemorrhage could also be a diagnostic consideration. The long hi tory in thi patient i s not in favor of hematoma, as patients with hemorrhage exhibit a catastrophic prese ntation.
1 49 \
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Case 20 Clinical Presentation The patient is an obese 55-year-old femak who presents with low back pain.
A
B
Radiologic Findings PEARLS •
•
The clinical hi 'tory was helpful in thi ' patient because it further substantiated a diagnosis of epidural lipomatosis. However. even in the absence of a h istory of steroid treatmen.t , the diagnosi would remain the arne.
MRI with use of a fat suppression technique would also aid in making the identification of fat because the adipose tissue will then appear as decreased signal intensity. while blood will remain as increased signal intcnsity.
Sagittal short TR image (Fig. A) reveals diffuse increased signal intensity soft tissue dorsally throughout the lumbar spine and anteriorly at the L4Sl levels. There is diffuse encroachment upon the thecal sac, which is com pressed (arrow al LS). Incidentally noted are anteriorly bulging discs at multiple levels; there are small posterior bulges of the discs. Ax ial short TR image (Fig. B) reveals a marked increase in the amount of epidural fat surrounding compressing the thecal sac (arrow).
Diagnosis Epidural lipomatosis.
Differential Diagnosis •
epidural lipomatosis
•
epidural hematoma
M I SCELLANEOUS
FITFALL •
An epidural hematoma could have a similar appearance because blood in the methemoglobin p hase appears as increased si gna l i ntensi ty H owever, there was n o history of trauma or blood dyscrasia in t his patient. Surgery can be attempted in patients with epidural l ipomatosis; however, the degree of success is variable. .
Discussion E pi dura l lipomatosis has a variety of ca uses. Additional hist ory reveals t ha t th i s pa t ient had been on long ter m steroid trcatment. which has been s hown to result in epidural li po m atosis . Othcr causes of idiopathic epidural l ipo matosis a re exogenous obesity and C ush in g s disease, which results in in crcascd endo ge no us steroid production. Magnetic resonance imllging (M R I) provides an ideal method of evalua ti o n of this conuition because fat is an excellent contrast material. Becliuse epiuural lipomatosis ma y involve m u lti ple levels, magnetic resonllnce imaging (MRI) is an ideal m et hod of eva l uati on . -
'
E pidural hematoma could a lso have a similar appearance. However, in patients with hemo rrhage, the clinical hi s tory is of a ca t astro phic presentation r(lther than prolonged back pain.
I TEACHING ATLAS OF SPI N E I M A G I
G
Case 21
•
Cl1nica1 Presentation The paticnt is a 56-year-old male with known thlllllssemia and new weakness in thc right arm and numbness in the right leg.
A
Radiologic Findings Pre- (Fig. A , left) and postcontrast (Fig. A, right) coronal short TR images reveal a smoothly marginated paraspinal mass projecting along the left side of the spine in the mid thoracic regiun. There is an intermediate-sized soft tissuc mass opposite the larger left-sided mass (right, arrow) . There are 1I1s() multiple smaller soft tissue masses along the right side of the pine in the paraspinal region (left, arrows). All these areas exhibit mild enhancement postcontrllst (right). Therc is a small rounded area of decreased signal inten sity with in the upper portion of the mass on the left side (right, arrowhead).
MlSCELLA EOUS
I
B
C
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I TEAC H I N G ATLAS OF SPI N E I M A(JJ NG
J 1
D
E
Radiologic Findings (continued) Coronal short TR preinfusion image slightly more posterior than Figure A (Fig. B) reveals multiple additional rounded areas of intermediate signal intensity on the left side of the spine. The pleural margin is displaced laterally in a curvilinear fashion around these masses. There is a rounded area of decreased ignal intensity (arrowhead) that projects above the mass. A small oval area of increased signal intensity i visible at the level of the inferior end plate of one of the lower thoracic vertebral bodies (arrow). Axial short TR image postcontrast (Fig. C) reveals a large lobulated, smoothly marginated mass on the left side. The smaller right-sided area of enhancement is again seen (arrow). Both exhibit mild, inhomogeneous enhancement. There is no encroachment upon the spinal cord or verte bral canal. Sagittal short TR image in the lumbar region ( Fig. D) reveals that the marrow of the vertebral bodies is unirorm ly slightly decreased signal inten sity. Otherwise, the spinal con.l is normal in size and configuration, a m.l there is no encroachment on the vertebral can a l . Incidentally there is a grade I spondylolisthesis with rorw1t n.l displacement of L5 on Sl (white arrows mark the posterior m a rgins of the vertebral bodies). Sagittal long TR image (Fig. E) reveals ui rruse uecreased signal intensity throughout the marrow of the lumbar vertebral bodies without
M ISCELLANEOUS
PEARLS •
•
The clinical history is important in making a diagnosis of eXlramedullary hematopoiesis. The magnetic resonance appearance of multiple rounded area of oft tissue masses adjacent to the spine is pathognomonic of the diagnosi of extramedullary hematopoiesis.
PITFALL •
Without a history, diagnostic considerations would include mul tiple metastases or possibly multiple neurofibromas or schwannomas. Other diagnostic considerations are very unlikely in thi clinical setting and with this typical imaging appearance.
Diagnosis Extramedullary hematopoiesis.
Differential Diagnosis •
extramedullary hematopoiesis
•
metastases
Discussion The multiple paraspinal soft tissue masses represent areas of extramed ullary hcma topoiesis. Thjs appearance is typical and pat hognomonic of the appear ance of extramedullary hematopoiesis. This is seen typically in patients with thalassemia and occasionally in patients with sickle cell anemia. Thcrc was no evidence of cord compression in this patient, so the cause of the patient's symptoms is unknown. The rounded areas of decreased signal intensity a re areas of flow void because of blood vessels. Multiple metastases might be a clin ical consideration in this patient; however. the patient was not known to have a primary tumor. In addition, there is no evidence of bony destruc tive change. In the lumbar region, the marrow appears as decreased signal intensity because there is increased deposition of iron in the marrow econdary to rapid cell turnover because of the patient's underlying discase. Therefore. the marrow remains as decreased signal intensity on the long TR images. The decreased signal intensity is secondary to paramagnetic e ffect.
755
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Case 22 •
Clinical Presentation The patient is a 25-year-old male presenting with low b ack pain who is being evaluated to rule out osteo mye li t is. The pa ti en t has a prosthetic left hip made from titanium.
A
B
Radiologic Findings Sagittal short TR image in t he l umb(lr region (Fig. A) reveals a biconcave appearance of m u l t i ple vertebral bodies. There are also varying deg ree s of compression fractures involving multiple vertebral bodies. The ma rrow of t he vertebral bodies exhibits mottled areas of increased and decreased s i g nal intcnsity. Sagittal long TR image (Fig. 13) reveals expansion of the i ntervertebral discs because of the biconcave deformity of the vertebral bodies. There are mul tiple vertical areas of increased signal intensity of varying size involving multiple vertebral bodies.
M I SCELLA EOUS
Diagnosis Sickle cell anemia with multiple bone in farcts .
Differential Diagnosis
PEARLS •
•
Patient.! with metallic hip, shoulder, or other joi n t prostheses may b e safely evaluated with MRI. Although images may be degraded in one imaging plane, they are often satisfactory in another imllging plane. The choice of scanning sequence is also significant. Grauient echo image are most susceptible to magnetic susceptibility artifact, followed by fast spin echo long TR images, routille long TR images, and short TR images. Imaging should be planned accordingly .
l'ITFALL •
M RI of metallic devices results in mild heating of the metal of any metallic prosthesis. However, the heating is not sufficient to cause tissue damage, and the heat is rapidly dissipated from the metalUc device.
•
sickle cell anemia
•
myelofibrosis
•
metastatic disease
Discussion Sickle cell anemia typically results in the biconcave deformity or the vertehrlll bodies seen in this patient. Bone infarcts, which appear as areas of decreased and increased signal intensity within the marrow of the vertebrae, arc com mon in patients with sickle cell anemia. The areas of infarction may be associated with an increase in fat deposition, and this appears as increased signal intensity. There may also be ueposition of iron , which appears as decreased signal intensity. The edema resulting from either the compression fractures or the infarcts appears as increased signal intensity on the long TR images. Infections are more common in patients with sickle cell anem ia than the general population, although this paticn t doe not exhibit cvidcnce of an inflammatory process. The patient had 1I hip replacement beclluse of infarction of the femoral head related to the sickle cell anemill. The metallic hip prosthesis is not a contraindication to magnetic resonance imaging (MRT). The M R images that include the prosthcsis may be degraded by artifact; however, the imagcs obtained distant from the metallic prosthesis will not be degradcd. Sickle cell anemia is an inherited gene for abnormal a-globin chain subunit of adult hemoglobin. Sickle cell anemia may be homozygous or heterozy gous. The disease is seen in black persons of African or African-American ancestry. The disease results in 1I sickle-shaped red blood cel l. The heterozy gous state for hemoglobin S (sickle cell trait) apparently confers a hiologic advantage against infcction with falciparum malaria. Areas of myelofibrosis could result in a similar imaging appearance; however, myelofibrosis would not result in the biconcave appearance of the verte hral bodies.
I TEACI I I NO ATLAS OF SPINE I MAGI '0
Case 23
«
Clinical Presentation The patient is a 58-year-old male who complains of left hand weakness. The patient has end stage renal disease with an abnormal protein electrophoresis.
A
B
Radiologic Findings Lateral plain spine radiograph (Fig. A) reveals hypertrophic spurs at multiple levels of the cervical spine. The degenerative changes are disproportionately severe for a patient of 58 years of age. There is sbght retrol isthesis of C3 on C4. There is disc space narrowing at C3-4. C5-6. and C6-7.
M I SCELLANEOUS
I
Radiologic Findings (continued) Sagittal short TR image of the cervical spine in thc same patient (Fig. B ) reveals disc space narrowing with a bulging disc a t the C3-4 level that indents the subarachnoid space. There is also disc space narrowing at C5-6 and C6-7. There is irregularity of thc end plates adjacent to the narrowed discs. Posterior osteophytes result in mild encroachment upon the subarachnoid space.
PEARLS •
•
Clinical history here i very helpful for diagnosis. Amyloid deposition may also be seen in patients with chronic multiple myeloma.
Diagnosis Amyloidosis secondary to chronic renal fa ilure with {32 microglobul inemia.
Differential Diagnosis •
chronic renal failure
•
multiple myeloma
PITFALL •
In the absence of a h istory of amyloidosis with (32 microglobuLinernia, degencrative changes secondary to osteoarthlitis could have a similar appearance.
Discussion Amyloidosis with increase in {32 m icroglobulin results in acceleration of the degenerativc changes in the cervical spine. Amyloidosis may a lso occur in patients with multiple myeloma. Amyloidosis is progressive, and although treatment is supportive, it is usually ineffective. The clinical history is vital to accuratc diagno is because without an appro priate clinical h istory the changes could be attributed to si mply dcgenera tivc changes. ,
7im
I TEACHING ATLAS OF SPINE I M A G I N G
Case 24 •
Clinical Presentation The palienl is a 67-yellr-old male with a history of polio as a child, long term back pain, and gradually progressive scoliosis and proximal muscle weakness.
A
B
M ISCELLAN EOUS
I
D
c
E
761
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•
G
M ISCELLA EOUS
I
H
J
7�
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K
Radiologic Findings Sagittal short TR images of the upper cervical (Fig. A), mi dcervical (Fig. B), lower cervical (Fig. C), and upper thoracic (Fig. D) regions reveal that because of a very severe scoliosis, there is visualization of the spinal cord in only very short segments (arrows). It is impossible to confirm or rule out the presence of a spinal cord tumor or encroachment upon the spinal cord. Sagittal long TR i m age at the level of the cervicomedullary j unction (Fig. E) reveals the spinal cord at the level of the foramen magnum. There is marked curvilinear deformity of the spi nal cord at all levels; as a conse quence, the spi nal cord is never well demonstrated. Sagittal long TR image at the midcervieal region (Fig. F) reveals that a short segmen t of the spin al cord is seen in the deformed vertebral canal (arrow). Axial short TR images (Fig. G) reveal a bone spur that arises from the lateral masses or facet joints and encroaches upon the dorsal aspect of the vertebral canal and compresses the spinal cord (left, arrow). There is also anterior encroachment upon the spinal cord (right, while arrow) . The verte bral a rteries appear as areas of flow void (right, black arrows). Sagittal short TR images utilizing the spine straigh tening program (Figs. H-K) allow the images to be reformed, so the vertebral bodies and spinal cord appear ( 0 have a normal relationship to one another. Although there
M ISCELLANEOUS
Radiologic Findings (continued) is still evidence of a minor scoliosis of the spine, the spinal cord is readily identified. There is still demonstrable evidence of encroachment on the spimtl cord in the upper cervical region in Figure T (arrow).
PEARL •
In institutions where a reformatting program is not available, mul tiplanar imaging may al low demonstration of tbe pinal cord in a sufficicnt fashion that cord compres ion can bc ruled out.
PITFALL •
Myelography with postmyelograpby computed tomography (Cf) may also be used for beller evaluation of the patient with scoliosis. However, even Cf may not allow exact evaluation of the distorted anatomy.
Diagnosis Scoliosis with dorsal em:ruHchment secondary to degenerative changes, no tumor. Secondary to poliomyelitis; postpol io syndrome.
Differential Diagnosis •
idiopathic scolioses
Discussion When there is a severe scoliosis, exact evaluation of the spinal cord and the surrounding structures cannot be performed . The scoliosis correction program allows reformatting of the images and allows ready evalu<Jtion of the spinal cord. This program modifies the original images via a computer reformatting program to el iminate the appearance of a scoliosis. Poliomyelitis (acute anterior poliomyelitis) is a disease that destroy the motor neurons of the spinal cord (anterior horn cells). It is a viral illness that is acquired orally. Previously common, it is now rare and has been almosl completely eradicated by vaccination. The disease attacks specific neuronal populations, and the affected cells undergo sequential degenerative change followed by cell death. The disease preferentially a ffects the motor neuron cells of the lower brain ·tem a nd the spinal cord. The muscles supplied by these neurons subsequently become flaccid because of lack of enervation and atrophy with fatty replacement of the m uscles, which occurs rapidly and is not reversible. The postpolio syndrome is characterized by progressive weakness of the m uscles many years after the in itial infection . This initial infection may be subclinica l. Therefore, imaging is usually performed on a patient older than 45 years of agc and most likely in patients in their 50s to 70s. Patients with such severe atrophy are generally presumed to have had polio and are not pre enting in the clinical setting of the postpolio syndrome. This syndrome is often (Issociated with back pain .
7 6b
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Case 25 Clinical Presentation The patient is a 66-year-old female with back pain and progressive scoliosis.
A
Radiologic Findings Axial short TR image at the L4 level (Fig. A) reveals that aLL the paraspinal m uscles of the back have been replaced by increased signal i ntensity fat. There is no normal appearing muscle remaining. The left psoas muscle is markedly atrophic (black arrow-p ) . The right psoas muscle is not seen. The gluteal muscles are also absent and replaced by increased signal intensity fat. There are also degenerative changes involving the interfacet joints bilat erally. The changes are worse on the right than on the left.
PEARL •
changes of fatty muscle in filtration are very marked in this patient but occur i n varying degrees in di fferent patients.
The
Diagnosis Post polio syndrome.
Discussion Clinical history revealed th at the patient had polio as a child. The pat ient was expe rienci ng increasing back pain and a progressive scoliosis, a history
M lSCELLA EOUS
PITFALL •
In any older patient, an attempt hould be made to elicit a history of polio in childhood. However, even in the absence of a positive history of polio, the magnt:tic resonance imaging appearance in this patient is typical of the postpolio patient, and the disease i then pre umed to have been ubclinical.
typical of the postpolio syndrome. There is almost complete absence of the muscles at the level visual ized. Extensive fatty infiltration of the muscles occurs because of the lack of enervation. This denervation is set:omlary to loss of the anterior horn ceUs related to the polio vi rus. The degenerative changes in the spine are related to the scoliosis a n d additional stress on the in terfacet joints. In occasional cases, i nact i v ity and prOlonged bed rest may result in some m uscle atrophy, but thc changes are not as extensive as those seen in th i s pa t i e n t .
The imaging appearance is typical for the postpolio syndrome; however, the ehangcs arc usually not as severe as seen in this patient. I n some p a tien t s, the atrophy may be very subtle, and it is frequently asymmetric and occasion ally affects only one side.
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Case 26 Clinical Presentation The patient is a 47-year-old male who had previous su rgery for a " cyst" of the thoracic spinal cord.
A
768
B
c
M I SCELLANEOUS
I
D
E
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I TEACH I N G ATLAS OF SPINE I M A G I N G Radiologic Findings Sagittal short TR image of the thoracic spinal cord (Fig. A) reveals an area of focal atrophy of the spinal cord at the level of previous surgery (white arrow). The spinous proee ses of the spine are surgically absent. The other two arrows identify the Tl and T6 vertebral bodies . Sagittal lon g TR i mage of the thoracic spine (Fig. B) revea l s a V -sha ped area of variable signal intensity at the level or previous surgery in the dorsal aspect of the thoracic subarachnoid space; this extends to the level of focal cord atrophy. The Tl vertebral body (long arrow) is identified with T-l .
Axial short TR image at I he level of focal cord atrophy (Fig. C) reveals that the spinal cord is triangu l ar in shape and displaced anteriorly adj a cent to the anterior margin of the subarachnoid space (arrow). The spinous processes are surgically absent at this level, and there is increased signal intensity fat dorsal to the thecal sac.
A xi a l postm yelogram comp u l ed tomographic (Cf) imagc at the same level as Figure C (Fig. D) reveals the irregular spinal cord configuration with close approximation of the spinal cord to thc posterior margin of the verte bra l body (black arrow). A high density surgical clip is present dorsally on the left side of the spine (white arrow). The spinous process is absent at this level.
PEARLS •
•
Pre- and postcontrast multiplanar imaging with MRI should be performed in a pati ent with this history to rule out tumor or "cyst" recurrence. If tumor is present, areas of enhancement would be anticipated. rr the diagnosis of postoperative change with scarring is in doubt, a follow-up examination will be helpful for complete eva l u a lion .
PITFALL •
Without re-operation the exact n ature of the tri angular shaped area of variable signal intensity seen i n Figure B cannot be absolutel y evaluated. However, repeat surgery in a patient uch as this risks causing the development of even greater sy mptoms.
Lateral reconstruction image of the thoracic spine (Fig. E) mimics the ap pearance or the short TR ma gnetic resonance (MR) image with focal nar rowing of the thoracic spinal cord (arrow). The spinous processes are surgi cal ly absent. Therc is slight dilatation of the thecal sac at this level with outward bulging into the laminectomy site.
Diagnosis Postoperative change with rocal atrophy of the spinal cord and anterio r tethering of the cord to the posterior margin of the vertebral body.
Differential Diagnosis •
postoperative change
Discussion This patient presumably had a dorsal arachnoid cyst removed at the time of the previous surgery. There i now an area of focal atrophy or the spinal cord, probably secondary to vascular com promise or di rect cord trauma related to the surgery. It is also possible that the patient had a spinal cord tumor removed rather than a cyst. The triangular shaped area of variable signal intensity seen iJ1 Figure B is probably a thin area of scarri n g and prominence of the arachnoid layer related to the surgery. The decreased signal inte n sity areas are relaled to deposition hemosidcrin related to thc previous surgery. Note I hat the M R scan is remarkably simil ar to t he postmy elogra m cr scan. However, MRI is noninvasive and allows convenient multiplanar imaging. MRI is the procedure or choice for evaluation in a patient such as this.
•
M I S C E LLAN EOUS
I
Case 27 Clinical Presentation The patient is a 27-year-oLd male with back pain.
A
B
Radiologic Findings Sagittal long TR image in the thoracic region (Fig. A) reveals multiple small curvilinear end plate deformities. There is sl ight accentuation of the normal dorsal kyphosis. Small curvilinear areas of decreased signal intensity in the cerebrospinal fluid dorsal to the spinal cord are visible in the m idthoracic region (arrow). Sagittal short TR image in the lumbar region also (Fig. B) reveals multiple curvilinear defects in the end pl ates of the vertebral bodies.
7111
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TEA CHI N G ATLAS OF SPINE IMAGING
PEARLS •
These end plate h erni ations are typically seen in young patien ts such as a thle te s who sustain repea ted axial loading inju ries
,
,
Diagnosis Multiple end plate herniations of the intervertebral discs, called Schmorl's node deformities.
.
•
While not of pathologic significan ce these end pJate herniations may be the source of back p a in and should be reported when th ey are i dentified on plain films or other ima gin g studies.
Differential Diagnosis
,
PITFALLS •
•
The se end plate disc herniations may be associated with such symptoms as back pain. The
flow void of the fluid should not be mi taken for a disease process such as an arteriovenous malformation. cerebrospinal
LZL2
•
end pl ate herniations
Discussion These curvilinear defects in the vertebral end plates are secondary to hernja tion of the intervertebral disc into the vertebral body. The disc hern i ates directly i nto the vertebral end plate rather than poste riorly inlo the vertebral canal through a tear in the annulus fibrosus. The appearance is very typical of a Schmorl's node deform ity. Enhancement has been reported in associa tion with these Sch morl's nodes. The curvilinear areas of decreased signa l intensity seen dorsal to the spinal cord in Figure A are areas of flow void secondary to moving cerebrospi nal fluid.
M ISCELLAN EOUS
I
Case 28 Clinical Presentation The patient is a 37-year-old male with a history of sudden onset of p'araplegia that gradually cleared over the following 48 hours.
A
Radiologic Findings Sagittal short TR image (Fig. A) rcveals bilobcd area of decreased signa l intensity in the anterior aspect of t h e spinal cord in t h e mjd-thoracic re gion (arrow).
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I TEACH ING ATLAS OF S P I N E I M A G I NG
B
c
7 74
MISCELLANEOUS
Radiologic Findings (continued) Sagittal long TR image (fig. B) reveals that the area of decreased signal intensity in the thoracic spi nal cord appears more prominent than o n the short TR image (arrow). Axial long TR image (Fig. C) reveals a rounded area of decreased signal intensity in the right, dorsal, and lateral aspect of the spinal curd (arrow).
PEARLS •
•
The appearance is typica l of a cavernous angioma. These lesions may be multi ple and may also be seen in the brain. The clinical presentation is typically progressive with a spin al cord tu m or but onset is typically rapid and i associated with devastating neurologic symptom in a patient with a cavernous angioma.
Diagnosis Cavernous a ngio ma of the spinal cord with hemorrha ge .
Differential Diagnosis •
cavernous angioma
•
spinal cord ependymoma
•
hemorrh agic metastasis
,
Discussion PITFALL •
A n gi ogra ph y would not reveal an abnormality i n th is p at ient as these lesions are angiographically occult.
The history of acute onset of symptoms is consistent with a catastrophic event such as might occur with a vascular malformation. The areas of de creased signal in tensity are consistent with areas of hemosiderin deposition. These areas are more prominent on the long TR images because the long TR images are more susceptible to magnetic susceptihil ity artifact. The appearance of the areas of hemosiderin deposition seen in association with cavernous a ngio mas is typically slightly irregularly m argin a ted with a periph eral margin that fades into the normal tissues. Spinal cord epend ymoma may also be associated with areas of hemorrhage; however, in those cases, the hemorrhage is seen within a larger mass that typica lly shows areas of enhancement. In addition, the areas of hemosiderin deposition are generally amorphous with a better defined rim than that seen in patie n ts with cavernous angiomas. Remote considerations could also include a hemorrhagic metastasis from a primary tumor such as malig nant melanoma.
TEACH L N G ATLA S OF SPINE IMAGING
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Clin
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Adriani J, Naragi M. Paraplegia associated with epid u ral anesthesia. Southern Med
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Boden G . Ra diation myelitis of the cervical spinal cord. ilr Brown
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Radiol. 1948;21 :464-469.
E, Virapongse C, Gregorios l B . MR imaging of cervical spi nal cord infarction.
leA T.
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Campi A , Filippi M, Comi G, et al. Acute transverse myelopathy: spinal and cra nial MR study with clinical follow-up. AJNR. 1 995; 1 6: 1 1 5 - 1 23 . Casselman J W, Jolie E, Dahaene 1, Meeus L. St.-Jan AZ. Gadol in ium -en h a nced MR imaging of i n farction of the anterior spinal cord. Al N H.. 1 991 ;1 2:561 . Castillo M, Carrier D A , Smith J K . Spinal cord i n farction after solitary rib fracture. Eme rgency Radiol. 1995:2:105.
Chen C.l . Fang W, Chen C M . Nan
YL. Spontaneous spinal epidural hematomas with repeated
remission and relapse. Neuroradiol 1 997;39:737-740. Chen
0, Ro LS. Central gadolinium enhancement o f an acute spontaneous spinal epidural
haematoma. Neuroradiol. 1996;38: S 1 14-S 1 1 6 . Choi KH, Lee KS, Chung S O , et a!. Idiopathic transverse myelitis: MR characteristics. AJNR. 1 9%;1 7 : 1 1 5 1 - 1 1 60.
Dibbern DA. Jr, Loevner LA, Liebermlln AP, et 111. MR of thoracic cord compression caused by epidural extramedullary hematopoiesis i n myelodyspl astic syndrome. AJNR. 1 997;1 8 : 363 -366.
Doppman .I . Epidural lipomatosis. Radiology. 1 989; 17 1:58 1 -582. Edwards MK, Farlow MR, Stevens
Jc. Crllnial M R i n spinal cord MS: diagnosing patients
with isolated spinal cord symptoms. ANJR. 1986;7 : 1 003- 1 005. Fo rtuna A, Ferrante L, Acqui M, e t al. Spinal cord ischemia diagnosed by M R I : case report and review of the literature. J Nell roradiol. 1 995;22: 1 1 5-122. Fowler M . Williams R, Alba J . B yrd C. Extra-adrenal myelolipomas compared with extramed ullary hematopoietic tumors. A m
1 Sit/X
Palhol. 1 982;6:363-374.
Gouliamos AD, Plataniotis GA, Michalopoulos ES, et al. Case report: magnetic resonance imaging of spinal cord compression i n thalassaemia before and after radiation treatment. Clin Radiol. 1 995;50:504-505.
Grossman R I , Gonzalez-Scarano F, Atlas SW, Faletta S, Silberberg D H . M ultiple sclerosis: gadoli n i u m enhancement in MR imaging. Radiology. 1986;161 :721 -725. Hittmair K, Mallek R, Prayer D , et al. Spinal cord lesions i n pat i e n ts w i t h mul tiple sclerosis: comparison of MR pulse sequences. A.TNR. 1996;1 7:1555- 1 565. Holtas S. Basibuyuk N, Fredriksson K. MRI i n acute transverse m yel opathy. Nell roradiol. 1993;35:221 -226.
Hol t as S, Heil ing M, Lonnto[t M. Spontaneous spinal epidural hematoma: findings at M R i111ilgi ng and cinical corre lation. Radiology. 1996;1 99:409-4 1 3 . Honig LS, Shercmata W A . Magnetic resonance imaging o f spinal cord lesions i n m u ltiple sclerosis.
1
Nellrol Neurosurg Psychiatry. 1 9H1,I;:"i2:459-4fi6.
Johnson CE, Sze G. Benign lumbar arachnoiditis: MR imaging w i th gadopentetate di111eglum ine. A.I N R. 1 990;11 :763-770. Kader S, Kalisher L, Schiller A. Extramedullary hematopoiesis i n Paget's disease of bonc. A.II?. 1 977;1 29:493-495.
Kornreich L, Dagan
0, G r unehaum M. M R [ ll1 acute poliomyelitis.
Nellroradiol. 1996:38:
371 -372.
Krag D, Reich S. Heterotopic bone marrow ( myelolipoma) of the medi ilsti n u m . Ches/. 1 972;61 :514-5 1 5 .
Lau S K , Chan C K , Chow YY. Cord compression d u e t o extramed u l l ary hematopoiesis i n a patient w i t b thalassemia. Spine. 1 994;1 l):24fi7-2470. Liou RJ, Chen CY, Choul TY, et a1. Hypoxic-ischacmic i nj u ry of the spinal cord in systemic shock: M R I . Neuroradiol. 1996;38: S 1 8 1 - S 1 83.
�6
•
MISCELLAN EOUS Luyendij k W, et a l . S p i n al wrel (';omprt:ssion d ue to t:xtramedullary ht:matopoicsis i n homozy gous t h alassemia. I Neurosurg. 1 975;42:2 12-2 16.
a NijdlOlt OJ. Barkhuf F, Castelijns JA,
Lycklama
t:l al. Comparison of two M R sequences
(or the detection of multiple sclerosis lesions i n the spi nal cord. AINR. 1 996; 1 7 : 1 533- 1 538 . Lycklama
a Nijeholt OJ. Barkhof F, Scheltens P, et a l . M R of the spinal cord in multi ple
sclerosis: relation to c l i n ica l subtype and disability. A.lNR. 1 997 ; 1 8: 1 04 1 - 1 048. M a n n KS, Yue CP, Chen KI I, et al. Paraplegia due to extramedulla ry hematopoiesis i n t h a l assemia . .I Neumsurg. 1 9R7 ;66:938-940. Maravi l l a KR. Weinreb J C, Suss R, N u n n a l l y RL. M agnetic resonance demonstration of m u l tiple sclerosis plaques in the cervical cord. A.I R. 1 985 ; 1 44:38 1 -385 . Markus
IB, Franchetto AA, Fairbrother J. Magnetic resonance imaging a n d computed
tomography of hyperacute spi nal epidural hematoma. CUfwd Assoc Radiol .l. 1994;45:391 . M u lder DW, Rosenbaum R A , Layton D D . Late progression of poliomye l itis or forme
fruste
amytrophic lateral sclerosis? Mayo Clin Proc. 1 972;47:756-761 . Papavasiliou C, Oouliamos A, V l ahos L, et a l .
cr and M RI of symptomatic spinal i nvolve
ment b y ext ramed u l l a ry hematopoiesis. Clirt Radiol. 1 990:42:91 -92.
Kim SJ , J u n g SM, e t al. M R I in presumed cervical a n terior spinal artery territory
Suh DC,
infards. Sze
Neururadiul. 1996;38:56-58.
O. Kawamura Y, Ncgishi C, ct al. Fast sp i n -e cho MR imaging of the cervical spine: of t:chu train It:ngth a n d ccho spacing on imagc contrast and quality. A.lNR.
influence
1993:14:1203 - 1 2 1 3.
Tartagl i n o LM, Croul SE, Flanders AE, et al. I d iopathic acute t ransverse myelitis: M R imaging fi n d ings . Radiology. 1 996;20"1 :661-669. Tartagliano LM, Friedman DP, Flanders AE, Lublin F D , Knobler RL, Lei m M . Multiple sclerosis i n the spinal cord: MR appearance and correlation w i t h clinical parameters. Radiol ngy. I lJlJ5;1 lJ5:725-732.
Tartagl i n o LM, Heim a n - Patterson T, Friedman DP. et al. M u l tiple sclerosis i n the spinal cord: M R appea rance and correlation with c l i n ical parameters. Radiology. 1 995 ;1 95:725 -732. Tartaglino LM, Heiman -Patterson T, Friedman DP, et al. MR i magi ng i n a case of postvacci nation myelitis. A.INR. 1 995 ;1 6:581 -582. Thielen K R, Miller OM. M u l tiple sclerosis of t he spina l cord: magnetic resonance appearance. lCA T. 1 996;20:434-438.
Thorpe JW, K idd D, Moseley I F, e t al. Serial gadoliniu m-enhanced M R I of the bra i n a n d s p i n a l corel i n early relapsing-remitting m ultiple sclerosis. Neurology. 1 996;46:373-37!:;. Wt:instuck-Outtman
B, Ross JS, Ransohoff R M . U n usual long-standing Gd-DPTA enha nce
ment in a chronic progressive mydopathy. lCAT. 1 995;1 9:649-65 l . Wit:bt: S, Lec
DH, Karlik SJ, et a l . Serial cran ial and spinal cord magnetic resona nce imaging
in multiple sclerosis. Ann Neural. 1 992;32:643-650. Yuh WTC, Marsh E E, Wang AK, ct al. MR of spinal cord an d vert ebra l body
i n rarction.
AINR. 1 992;1 3 : 1 45 - 1 54.
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Section XU
Unknowns
UNKNOWNS
I
Case 1 Clinical Presentation The patient is an 87-year-old female with a 3-month history of back pain, with a recent 3 -hour episode of confusion and difficully with speech .
A
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Radiologic Findings (Fig. A) Sagittal short TR image of the lumbar spine. (Fig. B) Sagittal long TR image of the lumbar spi ne.
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Radiologic Findings (continued) (Fig. C) Sagittal short TR images posteontrast. (Fig. D) Axial short TR image postcontrast at the L3 vertebral body level.
PEARLS •
•
In an older patient with spondylolisthesis, it is unlikely that the slippage i secondary to a spondylolysis. but rather is more likely secondary to interfacet degenerative changes. These interfacet degenerative changes often result i n secondary loss of i ntervertebral disc height. Hypertrophy of the ligamentum f1avwu then results and consequently spinal stenosis. For confirmation of the diagnosis, a a-guided biop y is helpful.
(Fig. E) Axial short TR images pre- (left) and postcontrast (righl) at the level of the L3 vertebral body. (Fig. F) Axial short TR images pre- (left) and postcontrast (right) at the intervertebral disc level of L3-4.
Diagnosis Discitis with vertebral osteomyelitis at the L3-4 level and severe spinal stenosis.
Differential Diagnosis •
discitis
•
degenerative changes
•
metastatic disease
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PITFALLS •
•
A CT-gujded biopsy may successfully yield a diagnosis of an inflammatory process; however, an organism m ay not be identified because these patients are frequently treated with antibiotics prior to the aspiration. However, the biopsy will identify inflammatory cells and rule out the presence of malignant cells. If contrast material bad not been used in this p atient, it mi. g ht have been assumed that the loss of disc height was secondary to degenerative changes and not because of a discitis. The increased signal intensity within the disc is typical of an infected di c, but not typical of degenerative changes where, because of loss of hydration, the disc is generally decreased signal intensity on the long TR images.
Discussion The sagittal short TR image (Fig. A) prior to the i nfusion of contrast mate rial reveals that the intervertebral disc at the L3-4 level is indistinct a nd there is low signal intensity i nvolving the lower half of L3 and upper half of L4 secondary to edema . There is also an anterolisthesis of L3 on L4 and L4 on L5. Increased signal intensity of the in tervertebral disc is apparent at the L3-4 level. This appearance is typical of the changes seen in patients with discitis. There is dense enhancement of the i ntervertebral disc and adj acent vertebral bodies on the postiniusion studies (Figs. C to F). The arrows in Figure C define the limit of the area of enhancement. There is also enhancement of one of the nerve roots of the cauda equina as seen in Figure D (arrow). This enhancement represents an irritation of the nerve root because of a type of neuritis. In Figure E, the anterior soft tissue com ponent is seen to enhance (right, arrowheads). There is also a scalloped area of en hancem ent in the anterior epidural space behind the vertebral body of L3 wh ich encroaches upon the thecal sac. This can also be seen in Figures C and D. In Figure F, the enhancement of the posterior portion of the intervertebral d isc can be seen (right, short white arrows); the hypertrophied ligamentum flavum can also be seen (right, long white arrow). There are in terfacet degenerative changes with cupping of one facet around another (left, black arrow). The hypertrophied ligamentum ftavum can be identified at the lowest three intervertebral d isc levels as curvilinear areas of decreased signal intensity in Figure B. The curved arrow identifies the ligamentum ftavum at the L34 level. The i nvolvement of the intervertebral disc and the two adjacent vertebral bodies is typical of a discitis. The decreased signal intensity and the e nhance m en t reflect the fact that there is also involvement of the vertebral bodies with osteomyel i tis. Th is can be confirmed with a CT-gu ided needle aspiration of the i ntervertebral disc space; this also may allow the identification of the organism that is causing the d iscitis. Thus, the appropriate antibiotic may be instituted. There is multilevel spondylolisthesis in this patient secondary to multilevel interfacet degenerative changes. These interfacet degenerative changes re sult in forward slipping of one vertebra on the next with consequent "hyper trophy" of the l igamentum ftavu m . Hypertrophy is actually a misnomer, as the enlargement of the ligamentum ftavum is secondary to the lack of traction and resulting stretching thinning of the normal ligamentum ftavum. Without the infusion of contrast material and the resulting enhancement, it is possible that the marked disc space n arrowing and low signal i n tensity of the adjacent vertebral bodies co uld be secondary to degenerative changes. Therefore, if there is doubt regarding the diagnosis or if the patient has an elevated erythrocyte sedimentation rate or other signs of an inflammatory process, a postcontrast study is imperative. Metastatic disease usually does not involve the in tervert.ebri:ll disc space , and therefore, metastases is not a likely diagnostic consideration in this patient.
t
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Case 2 Clinical Presentation The patient is a 47-year-old female with paralysis of the extremities.
B
A
Radiologic Findings (Fig. A) Sagittal intermediate signal intensity image of the cervical spine. (Fig. B) Sagittal long TR image of the cervical spine.
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Radiologic Findings (continued) (Fig. C) Sagittal short TR image postcontrast. (Fig. D) Axial long TR image. (Fig. E) Pre- (left) and postcontrast (right) axial short TR image. (Fig. F) Pre- (left) and postcontrast (right) axial short TR image.
Diagnosis Epidural and prevertebral abscess.
Differential Diagnosis •
epidural and prevertebral abscess
•
herniated disc
Discussion
PEARLS •
•
Additional h istory in this patient revealed that there was a history of intravenous drug abuse. Spinal abscesses may also be seen in patients who are diabetic, immunosuppressed, or have autoimmunodeficiency syndrome (AIDS). In the AIDS patient, infection may occur witb Mycobacterium avium inrracelllllarae. An abscess may also be seen in any patient who has a septicemia from any source, such as bacterial endocarditis.
PITFALL •
A tumor such as a meningioma might be a remote consideration, but is less likely than an i nflammatory process.
The intermediate TR image (Fig. A) reveals slight disc space narrowing at the C4-5, C5-6, and C6-7 levels. There is also anterior disc prominence a t both o f these levels. The spinal cord i s edematous and reveals a long area of i ncreased signal intensity above and below the lesion (straight white arrows in Fig. 8). The subarachnoid space is obliterated throughout the length of the cervical canal. The spinal cord is visible as distinct from the subarachnoid space in the upper thoracic region (arrow). The long TR image (Fig. 8) reveals a semilunar area of increased signal in tensity posterior to the intervertebral d isc at the C5-6 level. There is a concentric rim of decreased signal intensity surrounding this arca and a semilunar area of increased signal i ntensity anterior to the disc at the C56 level (curved arrow). There is also a very long area of increased signal intensity within the spinal cord that extends uperiorly to the level or C2 and inferiorly to tbe level of T3. The T2 vertebral body is iden tified with 2. Postinrusion (Fig. C) there is an elongated oval-shaped area of enhancement posterior to the vertebral bodies at the C5-6 level (short solid arrow) . The central area of decreased signal in tensity (long solid arrow) is the abscess cavity and is secondary to pus and necrotic debris. The vertebral hody enJplates are indistinct at the C5-6 level (open arrow). The long TR image in the axial plane (Fig. D) reveals similar findings with an area of increased signal intensity in the prevertebral space that extends i nto the vertebral canal posterior to the vertebral body. This area compresses the spinal cord posteriorly. There is also an oval-shaped abscess in the prevertebral space (white arrow) . The axial images reveal similar changes. I n Figure E, the absence of the normal decreased signal intensity surrounding thc thecal sac is also noted (left, arrow). There is enhancement in the prcvertebral space (right, arrow). There is also peripheral enhanecmcnt surrounding a n a rea or decreased
•
UNKNOWNS
signal intensity anterior to the spinal cord similar to that seen in Figure C. The spinal cord is markedly compressed and displaced posteriorly. In Figure F, the precontrast study (left) again reveals ubliteration or the subarachnoid space, while the postcontrast study (right) reveals the de creased central portion of the abscess cavity (lower arrow) within the verte bral canal. There is also a decreased signal intensity cavity seen anterior to the vertebral body (anterior arrow). Herniated disc is unlikely because the pattern of enhancement is typical of an abscess.
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Case 3 Clinical Presentation The patient is 1I 16-year-old female with a new onset of psychosis ( hearing voices, emotional l abi l ity, paranoia) and upper extremity weakness.
A
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c
Radiologic Findings (Fig. A) Axial long TR image at the level of the upper cervical spinal cord. (Fig. B) Axial long TR image of the brain at the level of the lateral ventricles. (Fig. C) Axial postcontrast image at the level of the lateral ventricles.
Diagnosis M ultiple sclerosis of the brain and spinal cord.
PEARL •
The clinical history would also be helpful in the case, particularly a history of a recent viral illnes or vaccination. If vasculitis is a diagnostic consideration, angiography is necessary for complete evaluation.
Differential Diagnosis •
multiple sclerosis
•
acute disseminated encephalomyelitis (ADEM)
•
infarct
•
vasculitis
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PITFALL •
The diagnosis may not be po sible on a single evaluation. Therefore. follow-up becomes vital for complete evaluation.
Discussion The images of the brain a re consistent with a diagnosis of mul Liple sclerosis. There are mUltiple deep white matter and periventricular areas of increased signal in tensity as seen in Figure B. These affect the corpus callosum as well. In Figure C, there are areas of enhancement which are ring shaped. solid, and partially ring shaped. Many of these areas of enhancement do not correspond to t he areas of increased signal inte nsi ty seen in Figure B. There is a lso a rounded area or increased signal intensity in the dorsal aspect of the spinal cord in Figure A. This is consisten t with a multiple sclerosis plaque in the spinal cord . Correlation should be made with the analysis of the cereb rospinal fluid, and follow-up is necessary for complete evaluation. ADEM could have a similar appearance. An infarct could also h ave a similar appearance, but would be unlikely in a 16-year-old patient. Consideration should also be given to the possibility of a vasculitis (vasculopathy), as this may result in areas of vessel spasm and resul ting ischemia.
•
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Case 4 Clinical Presentation The patient is a 47-year-old male with
a
h istory of lower extremity tingling.
A
B
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Radiologic Findings (Figs. A and B) Pre- (left) and postcontrast (right) sagittal i mages of the lumbar spine. The L4 vertebral body is identified with 4 (Fig. A). •
Diagnosis Neurofibromatosis type 2 (NF2) with multiple schwannomas.
Differential Diagnosis PEARLS •
•
•
The clinical history is vital in this patient. An excel lent method for remembering the abnorma1ities associated with NF2 is to use the mnemonic MISME: Multiple-Inberited Schwannoroas-Meningiomas Ependymomas (spinal cord). (Attributed to James Smiriniotopoulus, M.D.) Correlation should be made with an aJysis of cerebrospinal fluid for more complete evaluation and to rule out the presence of malign ant cells.
PITFALL An i n itia l discovery of multiple schwannomas is h ighly unusual
with muJtiple schwannomas
•
NF2
•
multiple metastases
•
inflammatory process
Discussion Additional h istory in this patient is the fact that she had a history of NF2. The slightly thickened nerve roots of the cauda equina can be seen in the lumbar thecal sac (Fig. A, lcft, arrow). There are multiple rounded and oval shaped areas of enhancement which arise [rom the distal spinal cord and the nerve roots of the cauda equina (Figs. A and B, right, white and black arrows). Also presen t is disc space narrowing at the L5-S 1 level with areas of increased signal intensity involving the adjacent vertebral bodies. There is also a slight retrolisthesis of L5 on Sl. Incidentally, there is moderately severe disc space narrowing at the L4-5 intervertebral disc level . There is i ncreased signal intensity of the vertebral marrow of the adjacent vertebral bodies because the marrow changes from red to "white" marrow. The white m arrow con tains an i ncreased amount of adipose tissue and so appears as increased signal intensity. A hern iated disc at the L4-5 level projects posteriorly into the vertebral canal.
•
in a patient of 47 years of age. It should be noted that patients with neurofibromatosis m ay not have the ty p ic al clinical stigmata.
[i94
Multiple metastases with "drop" metastases is a strong diagnostic consider ation in this p atient. Primary tumors of t he central nervous system which develop drop metastases include p inealoma or glioblastoma in an adult, and medullobl astoma, ependymoma, or pinealoma in a ch ild; primary tumors outside of the central nervous system include lung cancer, breast cancer, melanoma, and lymphoma. An in flammatory process is a possibility but unlikely, as these patients are very ill and typically have severe back pain .
Case 5 Clinical Presentation The patient is a 48-year-old female with diffuse spine pain.
A
B
Radiologic Findings (Fig. A) Sagittal short TR i m age of the lumbar spine. (Fig. B) Sagittal long TR image of the l umber spine.
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c
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UN KNOWNS
Radiologic Findings (continued) (Fig. C) Sagittal short TR image postcontrast enhancement. (Fig. D) Pre- (lefL) and postcontrast (right) axial short TR images at the level or L3.
PEARLS •
•
It may be necessary to correlate these magnetic resonance findings with radio nuclide bone scan result . For a final diagnosis, it may be necessary to perform a bone biopsy. This can be performed with computed tomographic guidance if n ecessary. If multiple myeloma is a diagnostic consideration, correlation should be made with results of serum protein electrophoresis.
PITFA LL In a patient with diffuse bony involvement, a normal appearillg vertebral body is not available for comparison. It may occasionally be necessary to perform a coronal image, which i ncludes the femoral bone or ilium wi th normal bone marrow, so that a comparison can be made with the vertebral column. In addition, when there is a "disc reversal " sign, the vertebral body, which is normally higher in signal intensity than the intervertebral disc because of tbe fatty bone marrow, becomes lower in signal intensity. Therefore, the intervertebral disc becomes relatively increased ignal i nten ity, and a "reversal" of the normal relationship between tbe two structures is seen. •
Diagnosis Di rruse osteolytic and osteoblastic metastases involving all the visualized bony structures.
Differential Diagnosis •
metCistCises
•
multiple myeloma
•
sickle cell disease
•
myelofibrosis
Discussion The sCigittal short TR image (Fig. A) reveals the "disc reversal" sign with the in tervertebral disc appearing higher in signal intensity than the mCirrow in the vertebral body. This reflects the diffuse replacement of the normally high signal intensity fat-filled marrow with decreased signal intensity meta static disease. The long TR image (Fig. B) reveals only faint areas or de creased signal intensity within the marrow or the vertebral bodics. The vertebral body of L3 (arrow) is slightly expanded. The postcontrast sagittal image (Fig. C) reveals diffuse enhancement of the mCljority or the marrow with multiple patchy areas of irregularly marginated decreased signal intensity throughout multiple vertebral bodies. The axial short TR image (Fig. D ) reveals diffuse decreased signal intensity preinrusion (left) and diffuse bomogeneous enhancement postcontrast (right). Note that there is a circumferential rim of enha ncement that surrounds the vertebral body and that the vertebral pedicles arc decreased signal intensity prein fusion. The spinous processes are mottled signal intensity in Figure to diffuse involvement with metastatic disease.
/\
secondary
Care must be taken when evaluating a patient with dirruse homogeneous changes in the vertebral bodies. The scan in Figure A appears normal except for the disc reversal sign. Likewise. the long TR image appears almost normal except for subtle alterations in the marrow signal intensity. The postcontrast image (Fig. C) reveals that the osteolytic metastatic deposits enhance, while the osteoblastic metastatic deposits remain decreased signa l intensity. The axial images reveal a thin rim of tumor extending outside
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of the vertebral body. Involvement of the vertebral pedicle is typical of metastatic disease. A diffuse marrow process such as m ultiple myeloma could have a similar appenrance, ns could entities stich as sickle cell disease with or without bone infarcts. Myelofibrosis is also a diagnostic consideration. However, the cli nical presentation is generally very helpful in ruling i n or uut these various diagnostic considerations.
•
U NKNOWNS
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Case 6 Clinical Presentation The patient is an 81-year-old male who presented to the emergency room because he was unable to walk.
A
B
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c
D
Radiologic Findings (Fig. A) Sagittal short TR i m age of the l umbar spine. (Fig. B) Axial short TR i m age of the lumbar spine.
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(Fig. C) Axial short TR image of the spine. (Fig. D) Sagittal short TR image of the spine after reformatting utilizin g the spine straightening technique.
Diagnosis Epidural hematoma, cause unknown.
Differential Diagnosis •
epidural hematoma
•
lipoma
•
chloroma
•
posttraumatic hematoma
Discussion PEARLS •
•
•
The spine-straightening technique was helpful in this case to more accurately define the extent of the accumulation. The cause of bleeding in this patient must be determined. It is possible that the patient is medicated witb anticoagulants or has a blood dyscrasia which results in abnormal areas of hemorrhage. MR is the procedure of choice for evaluation and should be obtained as an emergency. Emergent surgical evacuation of the hematoma is probably indicated in a case such as this.
PITFALL •
Computed tomograph ic (CT) scanning or myelography with the use of postmyelographic cr would not provide ao accurate diagnosis of tbe abnormality in thi case.
An elongated area of increased s ignal intensity is dorsal to the thecal sac in the lumbar region extending from the level of Ll through the midbody of L3. The signal intensity is increased and is consistent with the presence of an area of subacute hematoma formation. A second area of intermediate signal intensity is superior to the area of increased signal intensity that extends from the level of the superior end plate of Tl l through the inferior end p late of T12. The normal low signal i ntensity of the subarachnoid space is obliterated, and there is compression of the spinal cord from the level of the superior end plate of Tl l through the midbody of L3. At surgery, these represented areas of hemorrhage. The more superior area is acute hemorrhage while the more inferior, increased signal intensity area is second ary to subacute hemorrhage. The axial images (Figs. B and C) reveal a lentiform area of increased signal intensity dorsal to the thecal sac which compresses the thecal sac and the spinal cord. In Figure C, the area of i ncreased signal i n tensity appears more crescentic in appearance. The image with straightening of the spine (Fig. D) reveals that the hematoma is actually larger than is apparent in the unstJaightened sagittal image (Fig. A) . A large antedor osteophyte at the L2-3 level is seen on the sagi ttal images and also projects anteriorly and toward the left side on the axial image in Figure C. Magnetic resonance imagi ng (MRT) is the procedure of choice for evaluation of the abnormality i n th is case because it rapidly and noninvasively identifies both the abnormality and the anatomic location of the lesion. A l though lipoma is a diagnostic consideration, the location is very uncom mon in an older individual. A focal area of accumulation of leukemic cells is a remote possibility. A posttraumatic hematoma is a lso a consideration, and history should be obtained regarding the possibility or a spin al tap or steroid injection resulting in hematoma forma tion.
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Case 7 Clinical Presentation The patient is a 65-year-old male with a history of m any years of low back pain.
A
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B
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Radiologic Findings (Fig. A) Lateral plain view of the thoracolumbar spi ne. (Fig. B) Axial computed tomographic (CT) scan at the level of TI l .
PEARL •
In an older male, metastatic prostate cancer is the most common metastatic lesion. It is not uncommon to find diffuse osteoblastic metastases even when there is no history of known prostate cancer.
PITFALL • Because it is not possible to differentiate osteoblastic [rom osteolytic metastases with certainty, it may be necessary to obtain plain spine :film and/ or a CT scan to d.ifferentiate between the two.
Diagnosis Diffuse osteoblastic and osteolytic metastases from prostate cancer.
Differential Diagnosis •
metastases
•
gastrointestinal tumors such as carcinoid tumors
•
multiple myeloma in the clinical setting of POEMS (Polyneuropathy-Organomegaly-Endocrinopathy-Myeloma) (M-protein) and skin changes
Discussion The most common primary tumor that leads to osteoblastic metastases is prostate cancer. The lateral view of the spinal column (Fig. A) reveals both osteoblastic as well as osteolytic metastases involving all of the vertebral bodies. Incidentally noted arc surgical clips from a previous card i ac surgery. The axial CT scan (Fig. B) reveals diffuse sclerosis of the Tl l vertebral body. There is expansion of the vertebral body with bone formation and encroachment upon the vertebral canal and destruction of the cortex of the vertebral body. Magnetic resonance (MR) is the procedure of choice [or the evaluation of possible spinal cord compression because it provi des the most accurate evaluation of the location, amount, and type of abnormality. However, it is generally not possible to differentiate osteoblastic from osteolytic metastases with MR imaging. This is because the marrow generally appears as increased signal in tensity secondary to the presence of fat. Therefore, when this fatty marrow is replaced with tumor, the marrow appears as decreased signal in tensity.
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Case 8 •
Clinical Presentation The patient is a 25-year-old male with type 2.
a
history of k nown neurofibromatosis
A
Radiologic Findings (Fig. A) Sagittal short
T R i m age
postcontrast in the lumbar spine.
Diagnosis Multiple schwannomas and postoperative changes with laminectomy anu tethering o f the spinal cord posteriorly at the T1 2-L l level.
�4
UNKNOWNS
PEARL •
The p at i e n t who h as been successfully o p e ra t ed for a spinal cord lesion may later develop recurrent symptoms because of dors a l tet be rin g of the spinal cord by scar formation. Tills sca r may form because w hen the dura is opened, scar d e velops a n d t h e sp in al cord is p ul l ed dorsa ll y and becomes attached t o the po i nt where the dura is opened.
PITFALL •
If o n e abnormality is identified, in this case the m ult iple schwannomas, care sh ou ld be taken to evaluate the presence of a d ditional abnormalities at other l eve ls. It is p ru d e nt to evaluate the entire vertebral column for complete ev alu ati on .
Differential Diagnosis •
•
m ul ti p le schwannomas drop metastases: An additional d i agn ostic consideration includes drop metastases; however, in this clinical setting, this d i agn osti c consideration is unlikely.
Discussion Patients with neurofibromatosis type 2 may have multiple spinal cord or cauda equin a schwannomas. This p a t ie n t had previous surgery for removal of a large schwannoma at the Ll level. F ol lowin g this surgery, there is evidence of a l a m i n ecto m y defect with surgical absence of m ul t ipl e spinous processes (rom Tl 1 thr o ug h L2. In addition, the spinal cord is d isp laced po ster io rly at the T12-L 1 l e vel and is attached to t he dorsal aspect of the th ecal sac se co n dar y to scar ro r m at io n .
I TEAC:I I I
G ATLAS OF SPIN E I M A G I N G
Case 9 Clinical Presentation The patient is a l 4-year-old female who su ffered a fall while skiing, and when evaluated in the emergency room because of neck pain, was found to have 11 palpable left neck mass.
A
Radiologic Findings (Fig. A) Pre- (left) and postcontrast (righl) sagittal short TR images of the cervical pine. (Fig. B) Parasagittal short TR image postcontrast. ( Fig. C) Pre- (Ie/I) and postcontrast (right) axial fat saturation images.
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•
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Radiologic Findings (continued) (Fig. D) Pre- (top) and postcontrast (bottom) axial short TR images at the same level as Figure C. (Fig. E) Pre- (left) and postcontrast (riRlll) sagittal short TR images of the cervical spine at the level of the palpable m ass.
Diagnosis Desmoid tumor (unrelated to the recent trauma).
PEARLS •
•
Magnetic resonance imaging with multi planar m i aging and contrast enhancement is the procedure of choice for evaluation. A ngiography may be necessary to evaluate the possibility to neovascularity and to determine the relationship or the tumor to the vascular bundle.
PITFALL •
The clinical history of trauma suggest the possibility that this Ie ion could represent an acute hematoma. However, the pressure erosion and expansion of the i ntervertebral foramen is not consistent with an acute lesion, but is consistent with a longstanding slow-growing lesion.
Differential Diagnosis •
desmoid tumor
•
rhabdomyosarcoma
•
hemorrhagic schwannoma
•
lymphoma
Discussion There is a lobulated mass in the leFt side of the neck which extends down to the level of the intervertebr(]1 roramen. This tumor was present prior to the recent trauma, but only became apparent at the time or exa m ination. The decreased signal intensity of the mass seen in Figures C and E is related to the dense fibrous tissue. No hemorrhage was noted at the time of surgery. The mass expands the intervertebral foramen, as seen in Figure E, and extends to the level of the thecal sac. There is effacement of the leh lateral, anterior margin of the thecal sac; there is pressure erosion of the po terior margin of the vertebral body secondary to the longstanding nature of this process. The vertebral artery is seen as an area or now void and is displaced anteriorly by the mass (Fig. E, arrow). The diagnosis of desmoid (fibrous {Ulnor) is unusua l and could not be anticipated by the imaging appearance.
I TEAC H I NG ATLAS OF SPINE I MA G I NG
Case 10
•
Clinical Presentation The patient is a 29-year-old male with a history of progressive upper and lower extremity weakness.
A
B
UN KNOWNS
c
Radiologic Findings (Fig. A) Sagittal short TR i m age. (Fig. B) Sagittal long TR image. (Fig. C) Axial short TR image.
Diagnosis Chiari I malformation, postoperative changes in the posterior fossa , syrinx cavity.
PEARLS •
•
The magnetic susceptibility artifact is lightly more prominent on the long TR imllge thlln on the other imaging sequences. If the possibility of an associated tumor is a diagnostic consideration, a postinfusion study should be obtained fOT complete evaluation. Most tumors enhance on the postinfusion study.
Differential Diagnosis •
Chiari
•
cervical spinal conJ tumor
]
malformation and postoperative changes
Discussion This patient had a previous decompression of the posterior fossa for relid of a Chiari T malformation. The patient initially did well, but then returned with increasing symptoms. The sagittal short (Fig. A) and long (Fig. B) TR images reveal a loculated syrinx cavity in the cervical spinal cord. This cavity extends into the upper thoracic region. There are postllpenl tive changes i n the posterior fossa with absence of t h e i n ferior portion of t h e occipital bone.
I TEACHI
G ATLAS OF SPlNE I MAGING
PITFALL •
The syrinx cavity is q uite prominent; the postsurgical change. are subtle and therefore easily overlooked. A history of surgery would be helpful for better evaluation of the magnetic resonance images; however, careful evaluation will allow identiJkation of the typical postsurgical changes.
There is also a magnetic susceptibility lI rtifact at the level of the anticipated location of thc posterior margin of the foramen magnum from a metallic surgical clip. The posterior arch of Cl has a lso been removed. On the long TR imllge ( Fig. B), rounded and curvilinear areas of decreased signal i ntensity appear within the cavity secondary to areas of flow void because of motion of the cerebrospinal fluid withi n the syrinx cavity. Th is appearance of internal areas of flow void hlls sometimcs bcen used as a predictor that the patient will respond to shunting of the syrinx cavity. It is thought that these areas of now void a re secondary to transmitted hellrt beat and respiration from the fourth ventricle through the foramen of Ma gendie/opex of the fourl h ventricle into the central canal of the spi nal cord. The spinal cord is enlarged throughout its length secondllry to the syrinx cavity, and the normal subarachnoid space has been almost completely oblit erated. A cervical spinal cord tumor with an associated syrinx cavity is a diagnostic consider(l tion; howcver, there is no evidence or history of a tumor.
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UNKNOWNS
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Case 11 Clinical Presentation The patient is a 74-year-old male with a history of many years of uppcr and lower extremity discomfort.
A
Radiologic Findings (Fig. A) Sagittal short TR image. (Fig. B) M idsagittal short TR image postinfusion.
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I TEACHING ATLAS OF SP1N E IMAGING Radiologic Findings (continued) (Fig. C) Parasagittal short TR image postinfusion. (Fig. D) Axial long TR i mage at the level of C4-S. (Fig. E) Pre- (lOJ!) and postcontrast (bottom) axial short TR images at C4-S. (Fig. F) Postcontrast coronal short TR image of the cervical spine. (Fig. G) Postcontrast coronal short TR image at the level of the lateral mass. (Fig. H) Postcontrast coronal short TR image at the level of the vertebral artery.
PEARL •
The multiplanur imaging ability of magnetic resonance allows the accurate evaluation of the changes seen in this patient. A 'ingle plane, such as the sagittal view, gives the appearance that there is diffuse enlargement of the spinal cord. However, the spinal cord is actually compressed, and the multi ple dumbbell tumors compress the spinal cord and make it appear enlarged.
PITFALL •
I n this case, the clinical history i very helpful in the evaluation of the image .
Diagnosis Neurofibromatosis type 1 with plexiform neurofibromata at aU levels in the cervical spine.
Differential Diagnosis •
neurofibromatosis type 1 with plexiform neurofibromata
•
diffuse metastases
•
plexiform neurofibroma
•
inflammatory process
Discussion Additional history revealed that the patient was known to have neurofibro matosis type 1 . The finding of such extensive cha nges of neurofibromatosis type 1 with multiple level plexiform neurofibromata is unusual in a patient of this age. In this patient, there is the spurious appearance of marked expansion of the cervica l spinal cord on thc sagittal short TR image (Fig. A). The midsagittal postcontrast image (Fig. B) demonstrates a mass with an intradural appearance behind the intervertebral disc space at the Cl -2 level. There are also multiple additional ill-defined areas of enhancement at all levels in the vertebral canal. The parasagittal short TR image postcon trast (Fig. C) reveals multiple linear and patchy areas of enhancement. These areas of enhancement represent thc cnhancing peripherlll portions of the bilateral plexiform neurofibromata. In Figure D, the i ncreased signal intensity neurofibromas are seen in the vertebral canal, compressing the cervical spinal cord into a triangular-shaped structure. There are also areas o r increased signal intensity in the region of the nerve roots of the bnll:h ial plexus as they exit via the intervertebral fo ramen. In Figure E, the neurofibromas appear to be isointense and to exhib i t a thick wall of peripheral enhancement. No definite enhancement is seen surrounding the intracanalicular component of the tumors.
816
•
UNKNOWNS
The coronal postcontrast image at the level of the spinal cord (Fig. F) reveals rounded areas of enhancement at all levels of the spine (It Ihe origin of the nerve roots. The spinal cord is markedly compressed loward the midline. Multiple areas of enh(lncemenl along the lateral margins of the spinal cord are seen in Figure F, which was taken (II the level of the ventral aspect of the spinal cord. In Figure G, taken at the level of the vertebral artery, the plexiform neurofi bromas can be seen j ust lateral to the vertebral column bil(lterally. There is enhancement of all of these lesions. These multiple neurofibromata follow the course of the nerves of the brachial plexus and project between the anterior (lnd m iddle scalenus muscles. The sagitt(l l images alone suggest that the diagnosis could be a process such as diffuse metastases. However, the multiplanar i maging is much more in favor of t he diagnosis of a plexiform neurofibroma. An i nflammatory process would be unlikely in this patient.
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I TEACHI
G ATLAS OF SPI NE I MAGING
Case 12 Clinical Presentation The pCltient is a 69-year-old male with a history of left groin pain.
A
Radiologic Findings (Fig. A) Sagi ttal short TR image of the lumbar spine. (Fig. B) Midsagittal long TR image.
B
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Radiologic Findings (continued) (Fig. C) Parasagittal long TR image. (Fig. D) Axial short TR image at the level of L2.
PEARLS • In the absence of a split spinal cord , lh is lesion co uld be mistaken for a posttraumatic or spontaneous hematoma; therefore, a gradient echo imaging sequence should be used to differentiate beLween these two lesions. •
it is very unusual to identify tills type of extensive congenital abnormality in a patient of 69 years of age. Magnetic resonance imaging is the ideal method to diagnose and evaluate the complex nature of this abnormality. No further diagnostic examinations are neces ary in this patient.
(Fig. E) Axial long TR image at the level of L3. (Fig. F) Axial fat saturation image al the level of L3. (Fig. G) Axial fat satura tion im age at the level of L2 (same as Fig. D).
Diagnosis Lipoma at the L2 level with tethered spina l cord and diastematomyelia.
Differential Diagnosis •
lipoma, tethered spinal cord, diastematomyelia
•
hematoma
Discussion There is a lobul aled lipoma at the level of the L2 vertebral body. The spinal cord is pul led inferiorly and appears as a solid structure on the sagittal images (Figs. A to C); the split nature of the tethered cord is well demonstrated on
I TEACHING ATLAS OF SPINE I MAGING PITFALLS •
•
Thcre may also be an associated syri nx cavity with these patients, so evaluation should be performed of the entire length of the spi nal cord. Other diagnostic procedures, such as myelography or computed tomographic scaruUng with or without myelography, would not providc an accurate diagnosis in thi ca e. Myelography could potentially be dangerous in this patient because of the low-lying pinal cord.
the axial images (Figs. E, F) . The findings of a lipoma. tethered spinal cord and split spinal cord is very unusual in a patient of this age. This fi nding would bc anticipated in a newborn or young child. The normal spinal cord, cnds at the level of the inferior end plale of Ll or superior end plale of L2. In this patient, the spinal curd extends down to the level of L4. The lipoma appears as increased signal intensity on the short TR images (Figs. A and D) and as decreased signal intensity on the long TR images (Figs. B and C) and on thc fat suppression image (Fig. G) . The vertebral canal is expanded secondary to the longstanding nature o f this proccss and because there i s spinal dysraphism with incomplete spinous proccsscs in the midlumbar region. These changes are best demonstratcd in the axial images. In Figure F, the spi nal cord is acl ua\ly a nodular area of tissuc which is slightly higher in signal than the suppressed fat of the lipoma and is closely applied to the lipoma along its anterior margin. Note that there is chcmical shift artifact with a superiur rim of increased signal intcnsity on the upper margin of the lipoma and a decreased signal intcn ity rim along the inferior margin of the mass. This chemical hift artifact occurs in the frequency encoding direction. The appearancc is typical of that seen with a lipoma in any part of the body. Hematoma is a possible diagnosis. However, the fat saturation reveals that the lipoma actually becomes dccreased signal intensity; had this m ass actually been a hematoma, it would have appeared increased signal intensity on the fat saturation images.
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UN KNOWNS
Case 13 Clinical Presentation The patient is an I S-year-old female with polycythemia and symptoms of visual disturbance with head haking and poor responsiveness lasting a few minutes.
B
A
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D
Radiologic Findings (Fig. A) Lateral view of the upper cervical spine and the skull base. (Fig. B) Sagittal short TR i mage of the posterior fossa and the upper cervi cal spi ne. (Fig. C) Sagi ttal long TR image of the posterior fossa and the upper cervi cal spine. (Fig. D) Axial computed tomographic (CT) scan at the level of the u pper cervical spin e and foramen magnum.
PEARLS •
•
Rheuma t oi d
arthritis may also re ult in Cl-2 subluxation; however, there is overgrowth of the pannus when the patient h as rheumatoid ar t hritis . In some patien ts, Cl-2 subluxation may b e identified Oil the h e a d CT scan; this abnormality should be sought when reviewing a head CT scan on a patient with Dow n syndrome.
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Diagnosis Cl-2 subLuxation i n associ ation with Down syndrome.
Differential Diagnosis •
Cl-2 subluxation
•
posttraumatic dislocation
Discussion The p ati e nt had polycythemia in association with cyanotic congenital heart disease; the typical abnormality is an atrial septal defect. The episodic shak ing spells were thought to be secondary to seizures.
UNK NOWNS
PITFALL •
Care must be taken when manipulating tbe spine in patients so tbat no damage occurs to the spinal cord.
There is an association of Cl -2 subluxation with Down syndrome. The subluxation is secondary to rclaxation of thc tra nsverse and crueiate liga ments that transfix the odontoid proccss to the anterior arch of Cl. This ligamentous laxity causes posterior and upward displacement of the odontoid process which results in widening of the space behind the anlerior arch of Cl . The posterior displacement of Ihe odontoid process causes posterior displacement of the upper cervit:al spinal cord and compression of the spinal cord al the level of the C I vertebral body. The long TR image (Fig. C) better reveals the compromise of the subarach noid space surrounding the upper cervieal spinal cord. If spinal cord compres sion is present, the study may rcvcal increased signal intensity within the spinal cord on the long TR images. Magnetic resonance imaging ( M R I ) may also b e obtained using short TR images w i t h Ihe patient in nexion and extension. These views are helpful because I here may be cord compression in one position when none is seen in other position. The CT scan at the level ufthe foramen magnum (Fig. D) reveals the rounded odontoid process as it projects superiorly into the foramen magnum (arrow). Patients with Down syndrome may participate in athlctic games sllch as the Special Olympics. It is prudent (and frequently required) to evaluate the upper cervical region prior to allowing participation in athletic games 10 determine if there is Cl-2 subluxation. If there is Cl-2 subluxation, injury to these individuals at the time of trauma can be life threatening. A posttraumatic dislocation could be possible; however, there is no cvidence of soft tissue swelling and no history of trauma in this patient.
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TEACHING A T LA S OF S P I NE I MA G ING
Case 14
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Clinical Presentation The patient is a 53-year-old m ale with lower back pain a nd severe right sided radicular pain. The patient also has a history of previous surgery for a herniated disc.
A
B
Radiologic Findings (Fig. A) Sagittal short TR image. (Fig. B) Sagittal long TR image. (Fig. C) Right parasagitta I sho r t TR image. (Fig. D) Left parasagittal short TR i mage. (Fig. E) Pre- (left) and postcontrast (right) axial short TR images at 3 level.
t h e L2-
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F
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Radiologic Findings (continued) ( Fig. F) Pre- (left) and postcontrast (right) axial short TR i magcs at the level of L3-4. (Fi g . G) Pre- (left) and postcontrast (right) axial short TR images at the level of L4, j ust above the L4-S disc. (Fig. H) Pre- (left) and post co n trast (right) axial short TR images at the level of L4-S .
PEARL •
The para agitlal images readily demonstrate the intervertebral foramen. When there is
cncroachment on the foramen by a herniated disc, there is obliteration of the h igh signal i nten sity fat in the lower portion of the foramen. This is seen in this patient in Fig ure C. Patients with la terally h er n i a ted d i scs ty pically have very severe ntdicular p ai n because the disc compresses the nerve at the level of thc intervertebral foramen.
Diagnosis Large far laterally herniated disc at the L3-4 level; small midline herniatcd disc at L4-S level.
Differential Diagnosis •
herniated disc
Discussion The sagittal short TR images reveal a sl ight posterior prominence of the thecal sac in the low l umbar region secondary to the previous laminectomy. The lone TR image reveals the intervertebral disc prominencc at the L3-4 and L4-S levels. Si g nifica n tl y there is obliteration of thc perine u ral fat in
8 29
I TEACHING ATLAS OF S P I N E I MAGING PITFALLS •
•
A note of eautioo: A far laterally herniated disc is easily overlooked at the time of interpretation. These patients generally have severe radicular pain becau e of nerve compression. The surgical approach to these laterally placed discs is occasionally difficult and sometimes requires a lateral approach.
Because of the atypical location, a laterally heroiated disc may occasionally be misdiagnosed as a schwannoma.
the lower portion of the intervertebral foramen at the L3-4 level on the right side; this is best demonstrated on the parasagittal short TR image (Fig. C). The axial short TR images at the L2-3 level reveal a normal intervertebral disc with posterior concavity of the disc corresponding to the posterior margin of t he vertebral body. The normal nerve can be seen surrounded by perineural fat in the region of the i n tervertebral foramen. The short TR axial i mages at the U-4 level (Figs. I' and G) which are j ust above and at the level of the intervertebral t.Iisc reveal the far laterally herniated disc. The normal high signal intcnsity fat in the intervertebral foramen is obliterated. The nerve is displaced posteriorly and laterally by the herniated disc. There is effacement of the thecal sac along its right anterior margin. Far laterally herniated discs are uncommon and therefore these changes are also uncommon and may be easily overlooked. At the L4-5 level (Fig. H ) , the short TR images reveal the m idline herniated disc with indentation upon the thecal sac. There is also postoperative change with removal of the spinous process at this level. The appearance is typical of a herniated disc, however, the far laterally herniated disc may oot be appreciated unless proper attention is paid to the intervertebral foramenae.
•
UNKNOWNS
I
Case 15 Clinical Presentation The patient is an 86-year-old-female with severe lower back and pelvic pain.
A
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Radiologic Findings (Fig. A) Sagittal short TR image of the lower lumbar spine, sacrum, and coccyx. (Fig. B) Sagittal short TR image postcontrast of the sacrum and coccy geal area. (Fig. C) Axial short TR image at the level of the pelvis. (Fig. D) Axial short TR image at the level of t he pubic symphysis.
Diagnosis Chordoma of the distal lumba r spine, iliac crest, sacrum, and coccyx.
PEARL •
magnetic resonance imaging (MRI) is the procedure of choice for evaluation. Multiplanar imaging is neces ary, but may be the only imaging tbat i needed prior to treatment. MR is the ideal method for foUow-up evaluation. The relationships between the vertebral column, the cauda equina. and the pelvic structures are readily identified.
Differential Diagnosis •
chordoma
•
sacral teratoma
•
metastatic disease
Discussion The short TR images in the sagittal plane (Figs. A and B) reveal a large decreased signal i ntensity mass that has invaded the sacrum at the level of C2 and has completely replaced the coccyx with decreased signal intensity tumor. The lowest two sacral/coccygeal segments reveal increased signal
U NKNOWNS
PITFALL •
If a l umbar spine MR scan is performed, the image may not extend sufficien Lly in feriorly to evaluate the sacrum and coccyx. Therefore, when low back pain is present, it is important to be aware of the level of the pain.
I
in tensity and additional history revealed that the patient had previous radia tion therapy for treatment of chordoma. The axial images (Figs. C and D) reveal a lobulated variable ignal intensity mass that occupies the entire left side of the pelvis (Fig. C). At the level of the pubic symphisis, the study reveals a variable signal intensity lobulated mass that has replaced the entire left iliac bone and extends to the m idline in the region of the spine. In Figure S, there is irregular, inhomogeneous enhancement of the mas in the pelvis. The bladder is seen as an oval-shaped area of increased signal intensity because it is fi lled with gadolinium which settles in the dependent portion of the bladder because it is heavier than u rine. The visualized loops of bowel are d iJ a l e d , probably because of partial obstruction by the pelvic mass. Sacral teratoma is a possibility in a child. Metastatic disease can be identified in an older patient even without a history of a known primary I umor; primary tumors include breast, lung, or renal cancers.
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I TEACHING ATLAS OF SPINE IMAGING
Case 16 Clinical Presentation The patient is a 32-year-old female with upper and lower extremity weakness of sudden onset.
B
A
Radiologic Findings (Fig. A) Sagittal short TR i mage of the cerviciil spine. (Fig. 8) Sagittal intermediate signlll i n tensity image. (Fig. C) Sagittal long TR image of the cervical spine. (Fig. D) Axial hort
TR
image of the cervical spine at the level of C6.
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Radiologic Findings (continued) (Fig. E) Axial long TR image at the level of CS-6. (Fig. F) Axial gradient echo image at the level of C6.
PEARLS •
•
The appearance is very typica 1 of a cavernous angioma, which exhi bits a central appearance of increased signal intensity with a peripheral margin of decreased signal intensity that has a poorly defined outer margin . T h e decreased peripheral margin is thought to be secondary to subclinical areas of hemorrhage with resulting staining of the surrounding tissue with hemosiderin . Angiography will n o t reveal a va cular blush in cases of cavernous angioma as they are angiographically occult.
Diagnosis Cavernous angioma of the spin al cord.
Differential Diagnosis •
intramedullary hematoma
•
ependymoma
Discussion The short TR image in the sagittal plane (fig. A) reveals an oval-shaped ring of decreased signal intensity in the central portion of the cervical spinal cord at the C6 leve l . The i n termediate and long TR images (Figs. B and C) reveal that the lesion now appcars as a rather thick-walled oval of decreased signal intensity with a small central area of decreased signal intensity along the dorsal margin. In addition, small streaks of decreased signal intensity cxtend superior and i nferior to the mass.
UNKNOW
PITFALL •
When gradient echo imaging is used for evaluation, the magnetic susceptibility artifact will res uIt in the spurious appearance of the lesion being larger than it actualJy 1s.
S
The axial short TR i mage reveals the mass in the dorsal aspect of the spinal cord (Fig. D). The spinal cord is slightly prominent and bulges dorsally at this level. At the CS-6 level (Fig. E), which is at the upper m argin of the mass, it appears as a rounded area of decreased signal intensity in the left dorsal portion of the cord . The axial gradient echo image at the level of C6 (Fig. F) reveals that the lesion again appears as decreased signal i ntensity but now appears to occupy the entire diameter of the spinal cord . This spuriously enlarged appearance is because the gradient echo images are more susceptible to the magnetic susceptibility artifact than the long TR images and the short TR images are the least susceptible to magnetic susceptibility artifact. The appearance is typical of a cavernous angioma (previously called an occult vascul ar m alformation). The decreased signal in tensity areas are sec ondary to deposition of hemos iderin which is thought to arise from small hemorrhages or leakage of blood cells into the tissue. These lesions typicaUy exhibit the increased signal intensity central portion which is seen here. The lesion was successfully removed surgically. Intramedullary hematoma is unlikely in the absence of an underlying lesion such as a cavernous angioma. Ependymomas of the spinal cord may be associated with areas of hemosideri n deposi tion and so may be a diagnositic consideration. However, ependymomas typically exhibit enhancement on the postinfusion study.
I TEA C H I N G ATLAS OF SPINE I M A G I N G
Case 17
•
Clinical Presentation Metallic plate and postoperative change in the cervical spine.
A
Radiologic Findings (Fig. A) Sagittal short TR image of the cervical spine. (Fig. B ) Sagittal intermcdiate TR im(lge of the cervical spinc.
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I TEACH I N G ATLAS OF SPI
E IMAGING
•
E
Radiologic Findings (continued) (Fig. C) Sagittal long TR image of the cervical spine. (Fig. D) Pre- (left) and postcontrast (right) Clxial short TR images of the cervical spine at the level of C6. (Fig. E) Axial gradient echo image at the level of C6.
PEARL •
Comparison with plai n film evaluation would demonstrate the presence of the metallic fixating plate and confirm the d iagnosis of these postoperative changes. Magnetic resonance imaging with its capability for multiplanar imaging will generally allow evaluation of the pinal cord and surrounding subClrachnoid pace. 10 this patient, the spinal cord and normal appearing subarachnoid pace are well demonstrated in the hort TR images in the sagittal (Fig. A) aod axial (Fig. D) planes.
Diagnosis Metallic fusion plate and fixating screws.
Differential Diagnosis •
metallic fixation device, with resulting artifacts
Discussion The patient had previous surgery for removal or herniated discs at the C5level and at the C6-7 level. At the time or surgery, fusion plugs were put in placc, and a metallic fixating plate was utilized to hold the fusion plugs i n place. The metaUic plate caused magnetic susceptibility artifact. On the various sagittal images (Figs. A to C), there is progressively greater degrada tion of the images with the longer TR images.
(]
UN KNOWNS
PITFALL •
lL is important to be aware of the artifacts generated by metallic devices so that these artifact are not rni taken for a true abnormality.
The pre- and postcontrast axial short TR images (Fig. D) reveal a wedge shaped area of decreased signal intensity anterior to the spine with a periph eral rim of i ncreased signal intensity on the left side. After the in fusion of contrast, the high signal intensity l inear artifact surrounds the wedge-shaped artifact. The gradient echo image (Fig. E) is severely degraded by the susceptibility artifact and gives the spurious appearance of marked encroach ment on the vertebral canal. Dotl ikc areas of increased signal intensity i n the anteriur subarachnoid space on the sagittal intermediate and long TR images (Fig. B and C) are also artifactual. The appearance is typical for postoperative changes with metallic fixating devices in place; however, various scanner artifacts may mimic a less marked metallic device artifact.
I TEACHI
G ATLAS OF SPINE I MAG ING
Case 18
•
Clinical Presentation The patient is a 35-year-old female with a hi tory of modified radical mastec tomy, chemotherapy, and bone marrow transplant, now presenting with new onset of low back pain.
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Radiologic Findings (Fig. A) Sagi ttal short TR image. (Fig. B) Sagittal intermed iate TR image. (Fig. C) Sagittal postcontrast image. (Fig. 0) Pre- (left) and postcontrast (right) axial short TR images.
Diagnosis Diffuse bony metastases with pathologic fractures of T10, Ll, and L2 and a metastatic deposit in the right lobe of the liver.
Differential Diagnosis •
PEARLS In a patient with known cancer, careful evaluation may reveal subtle abnormalities as seen in this case . Subtle compression fractures should not be ignored, but carefully correlated with other findings. •
•
•
Correlation with magnetic resonance findings with other imaging, such as body imaging for the evaluation of the liver, is helpful for arriving at a final diagnosis. Radionuclide bone scanning may be necessary for complete evaluation.
PITFALL •
When ali the vertebral bodies are abnormal, there are no normal vertebral bodies available for comparison, alld identification of abnormalities is difficult.
diffuse metastases
Discussion The abnormalities in this patient are subtle. Cursory eval uation would poten tially overlook the abnormalities that are present. On the sagittal short (Fig. A) and intermediate (Fig. B) TR images, the compression fractures of the T10, Ll , and L2 are apparent. Tn addition, on the postcontrast image (Fig. C), there is actually diffuse enhancement of the marrow of the vertebral bodies at ali levels. Close inspection of the T10, L1, and L2 vertebral bodies reveal that the pattern of enhancement is not homogeneous, but rather is somewhat hetero geneous, more so than in the remaining vertebral bodies. There is no en croachment on the vertebral canal. The axial short TR images through the level of the TIO vertebral body (Fig. D) revea l a rounded, approximately 1 .8-cm rounded area of low density in the right lobe of the liver j ust l ateral to the hemidiaphragm (left). On the left in Figure D, there is mottled signal intensity in the marrow of the vertebral body secondary to the metastases, and decreased signal intensity tumor in the pedicle of the vertebral bodies bilaterally. Involvement of the vertebral pedicle is typical of metastatic disease. On the axial short TR images post contrast (right, in Fig. D ) , the TIO vertebral body also reveals the inhomogeneous pattern of enhancement within the marrow of the vertebral body secondary to the metastatic deposits. The linic metastases enhances and is no longer visible. It is possible that this study could (inappropri ately) be considered diffuse metastases from another t umor pri mary with metastases, such as multiple myeloma, which could have a sintilar appearance. However, metastases Lo the liver would be unusual with multiple myeloma.
•
UNKNOWNS
I
Case 19 Clinical Presentation The patient is a 65-year-old man with a history of recent onset of low back pain .
A
B
Radiologic Findings (Fig. A) Sagittal short TR image. (Fig. B) Sagittal long TR image. (Fig. C) Sagittal short TR image postcontrast. (Fig. D) S agittal short TR image postcontrast with fat suppression tech ni que.
I
TEACHING ATLAS OF SPINE IMAGI N G
c
D
E
U N KNOWNS
I
F
Radiologic Findings (continued) (Fig. E) Pre- (left) and postcontrast (right) axial short TR images at the level of TI L (Fig . F) Pre- (left) and postcontrast (right) axial short TR i m ag es at the level of the midbody of TI l .
Diagnosis Metastatic cancer i nvolving the metastllses.
T1 1
and
L4
ver te b ra l bodies with epidural
Differential Diagnosis PEARL Fat suppressio n images are useful for evaluation of areas of enhancement which are difficult to id en t ify on the standard short and long TR images.
•
an unusual p rese ntati on of multiple myelom a
•
metastases
•
Discussion Additional history in this patient re vell ls that he has a history of renal cell carcinoma. There is decreased signal in t e n si ty metastases i nvolving the L4 ve r te br a l body (Fig. A). T h i s is associated with a cjrcumferential area of
8�
TEACHING ATLAS OF SPT N E IMAGING
PITFALL •
In a patient wi.th metllstases, the entire vertebral column should be evaluated for other areas of compromise of the spin al cord so that treatment may be directed appropriately.
enhancement surrounding the thecal sac at the L4 level (Figs. B and D). There is enhancement behind the L3 vertebral body and behind the L4 vertebral body with posterior displacement of the thecal sac at these levels. The circumferential enhancement is better demonstrated in Figure D than in the other images. There is also an irregular rim of enhancement sur rounding the L4 metastasis which is faintly visible in Figure B and better seen in Figure D. There is also a rounded area of metastatic disease in the TI l vertebral body which appears signal intensity on the short TR images, increased signal intensity on the long TR images, and to enhance postcon trast. The axial images at the level of the vertebral pedi cle reveals extension of the decreased signal intensity tumor into the pedicle on the right side. This finding is very consistent with metastatic disease. Also i ncidentally noted is an area of epidural encroachment upon the dorsal aspect of the thecal sac at the TI2-LI level which is an area of osteophyte formation or possibly an epidural metastasis.
UN KNOWNS
I
Case 20 Clinical Presentation The patient is a 3-year-old male with a progressive scoliosis.
B
A
Radiologic Findings (Fig. A) Sagiual short TR prcinfusion magnetic resonance (MR) scan of the lower cervical and thoracic spine. (Fig. B) Sagittal short TR preinfusion MR racic regions.
scan
of the cervical and tho
I TEACHI N G ATLAS
OF
SPJ N E IMAGING
•
c
850
D
E
U N KNOWNS
G
I
I TEACH ING ATLAS or SPINE I M AG ING Radiologic Findings (continued) (Fig. C) Sagittal short TR preinfusion MR scan of the thoracic region. (Fig. D) Sagittal long TR image in the upper thoracic region. (Fig. E) Postcontrast sagittal short TR image of the lower cervical and thoracic spine. (Fig. F) Postcon trast axial short TR image at the T4 level. (Fig. G) Postcontrast axial short TR image at the TlO level.
Diagnosis PEARLS •
•
The entire length of the spinal cord should be evaluated to determine the length of the tumor and the associated syrinx cavily. In addition, the distal lumbar thecal sac hould be evaluated to rule out the presence of metastatic disease in the thecal sac. The presence of low signal intensity hemosiderin seen in the long TR images (Fig. D) within the tumor mass favors the diagnosis of ependymoma.
PITFALL •
Surgical removal of a lesion uch as this is difficult because there is extensive involvement of the spinal cord and total removal is essentially impossible without creating severe neurologic deficit.
�2
Spinal cord ependymoma with an associated syrinx cavity
Differential Diagnosis •
spinal cord astrocytoma
•
spinal cord ependymoma
•
spinal cord ganglioglioma
Discussion There is a large, sausage-shaped mass in the mid- and upper thoracic region that is associated with a syrinx cavity above and below the mass. The syrinx cavity extends from the level of the C2 vertebra through the upper margin of the mass at the T2 level and is again visible from the inferior margin of the tumor at the T6 level and extends through the distal end of the spinal cord. The mass itself also exhibits a peripheral margin of decreased signal intensity. The areas of decreased signal intensity are consistent with areas of deposition of hemosiderin. The syrinx cavity contains h igh protein content and therefore appears as increased signal intensity on the long TR image. There is dense enhancement of the tumor after the infusion of contrast material. The area of enhancement can be seen filling the entire spinal cord at the T4 level (Fig. F). In the lower thoracic region, the cystic cavity is demonstrated (Fig. G). The peripheral walls of the cystic cavity do not enhance because they are not i nvolved with the tumor.
•
UN KNOWNS
I
Case 21 Clinical Presentation The patient is a 52-year-old male with a clinical history of left-sided weakness; there also was a history of acute myeloid leukemia.
B
A
Radiologic Findings (Fig. A) Sagittal short TR i mage in the lumbar spine.
(Fi g R) Sagittal intermediate TR image .
in
the lumbar spi ne.
8�
I TEACHING ATLAS OF SPI IE IM AGING
I
c
E
D
UNKNOWNS
I
G
Radiologic Findings (continued) (Fig. C) Sagittal long TR image in the lumbar spine. (Fig. D ) Postcontrast sagittal fat suppression image in the l umbar spine. (Fig. E) Sagittal long TR i mage of the thoracic spine. (Fig. F) Postcontrast sagittal short TR image of the thoracic spine. (Fig. G) Postcontrast axial short TR image of the thoracic spine.
Diagnosis Leukemic infiltrate of the bone marrow; lepto meningeal carcinomatosis.
Differential Diagnosis •
multiple myeloma
•
metastases from another primary
Discussion The short (Fig. A) and intermediate (Fig. B) TR images reveal diffuse abnormal signal i n tensity throughout the marrow of the vertebral bodies with multiple small rounded areas of decreased signal intensity. The in termediate
I TEACHI NG ATLAS OF SPI NE I MAGING PEARL •
Clinical history i very helpful in the evaluation of this patient.
PITFALL •
This patient h a s a rapid progression of symptoms and was imaged several time within a short period of time. The initial images did not reveal meningeal carcinomatosis, although the subsequent studies were grossly abnormal. The fat suppression images in this patient obliterated the p resence of the bone lesions.
signal intensity sagittal images in the lumbar region (Fig. B) do not add significantly to the diagnosis; bowever, the long TR image reveals that the nerve roots of the cauda equina appear somewhat thickened in the mid lumbar region (Fig. C). The fat-suppressed postcontrast image (Fig. D) reveals prominent enbancement of the distal spinal cord and the nerve roots of tbe cauda equina. The areas of abnormal signal intensity within the marrow are no longer visible and the areas within the vertebral bodies do not exhibit demonstrable enhancement postinfusion. The sagittal long TR image of the thoracic region (Fig. E) reveals increased signal intensity within the central portion of the thoracic spinal cord. The postcontrast short sagittal TR image (Fig. F) at the same level reveals diffuse enhancement of the spinal cord and surrounding subarachnoid space. This finding is consistent with intramedullary cancer as weU as meningeal carcino matosis. The postcontrast axial short TR image (Fig. G) revettls the enhance ment within the subarachnoid space as well as within the central p0l1ion of the spinal cord. Incidentally noted are bilateral pleural effusions, which are slightly larger on the right side tban on tbe left. Although fat suppression postcontrast images are helpful in this cllse to diagnose the presence of meningeal carcinomatosis and intramedullary spread of tumor, was not helpful in the evaluation of the bony metastases. Metastases from another pIimary such as prostate carcinoma is unlikely because the meningeal component is not likely in a patient with prostate cancer.
"
U N KNOWNS
I
Case 22 Clinical Presentation The patient is a 37-year-okl male with progressive neurologic deficit.
A
B
Radiologic Findings (Fig. A) Postcontrast sagittal short TR i mage of the cervical spine. (Fig. B) Postcontrast parasagittal short TR image of the cervical spine.
851
I TEACHI N G ATLAS OF S P I
E I MAG I NG
•
c
1 858
D
UNKNOWNS
I
E
Radiologic Findings (continued) (Fig. C) Postcontrast sagittal short TR image of the thoracic spine. (Fig. D) Postcontrast sagittal short TR image of the brain. (Fig. E) Postcontrast parasagittal short TR i mage of the brain.
Diagnosis von Hippel-Lindau syndrome with multiple spinal and cerebral hemangio blastomas.
Differential Diagnosis •
•
multiple hemangioblasloma (in the patient with von Hippel-Lindau disease) multiple schwannomas of the spine and multiple cerebral meningiomas (in the patient with neurofibromatosis type 2)
Discussion The patient has multiple enhancing m asses measuring less than 1 cm through out the cervical and thoracic spinal cord. Postsurgical changes are visible
I TEACH I N G ATLAS OF SPINE I M A G I PEARL •
The clinical history is important in this patient.
PITFALL •
In the absence of sufficient history, it is important to evaluate the presence of postsurgical changes.
G
in both the cervical (Figs. A and B) and thoracic spine areas (Fig. C) where the patient previously underwent laminectomy. Areas of decreased signal intensity in the soft tissues dorsally in the cervical region are secondary to the magnetic susceptibility artifact that is seen following surgery. The patient previously underwent occipital craniectomy; the fourth ventricle is enlarged secondary to surgery in the posterior fossa for removal of a cerebellar hemangioblastoma . The brain has multiple enhancing lesions of varying sizes (Figs. 0 and E), which are located in the region of the midbrain and the suprasellar cistern and along the i nterhemispheric falx.
•
U N KN O WNS
I
Case 23 Clinical Presentation The patient is a 47-year-old female with acute myelogenous Le u kemia.
A
Radiologic Findings (Fig.
A)
Pre- (left) and postcontrast
(right)
sagitta] short TR images of th e
cervical spine.
8�
I TEACH I N G ATLAS OF SPINE IMAGI 'G
•
B
862
c
U KNOWNS
I
D
E
Ri:]
I TEACH1NG ATLAS OF SPINE IMAGING
•
G
s
H
I
I TEACHING ATLAS OF SPINE I MAGING
J
Radiologic Findings (continued) (Fig. B ) Sagittal intermediate TR image of the cervical spine. (Fig. C) Pre- (top) and postcontrast (bo/LOm) axial short TR i mages of the lower cervical spine. (Fig. D) Pre- (LOp) and postcontrast (bottom) axial short TR images of the upper thoracic region . (Fig. E ) Axial intermediate (left) a n d long (right) T R images o f t h e brain. (Fig. F) Postcontrast axial short TR image of the brain. (Fig. G) Postcontrasl coronal shon TR image of the brain at the level of the frontal horns of the lateral ventricles. (Fig. H) Postcontrast coronal short TR i mage of the brain at the level of the occipital horns of the lateral ventricles. (Fig. 1) Axial postcontrast axial short TR image of the brain with attention to the bony calvarium. (Fig. J ) Axial pre- (left) and postcontrast (right) hort TR image with atten tion to the bony calvarium.
UNKNOWNS
PEA RLS A ractionuclide bone scan might be helpful in a case such as this to identify the exact extent of the disease.
Diagnosis
•
•
In the axial image in the lower cervical region, the nerve roots of the brachial p lexus are rucely outlined by high signal intensi ty fat on the right side and a re surrounded by tumor on the left side (Fig. C).
Diffuse leukemic infiltrate of the marrow of the vertebral column; gran ulo cytic sarcoma (chloroma) of the soft tissues of the neck; dural based menin gea l metastases; hony calvari um metastases ('1) chloroma.
Differential Diagnosis •
•
•
PITFALL •
B iopsy may be necessary for complete evaluation in a case such as this.
multiple myeloma diffuse metastases (breast cancer in a female patient, prostate cancer in a male) lymphoma
Discussion The visualized portion of the vertebral column is diffusely abnormal. The marrow within the vertebral bodies is diffusely decreased in signal intensity and there is reversal of the signal intensity between the intervertebral disc and the marrow within the vertebral bodies. There is a soft tissue mass in the upper thoracic region at approxi mately the T3-4 level that is visible on the pre- and postcontrast sagittal images (Fig. A). This mass is associated with destruction of the spinous processes of the in volved thoracic vertebrae. A dense thick wall of enhancement is visible. The intermediate signal i nte nsity i m age (Fig. B) reveals that the expanded spinous process appears as increased signal intensity with a peripheral rim of decreased signal intensity cortical bone. The axial images (Figs. C and D) reveal the mass lateral to the vertebral col u mn at this level with extension into the vertebral can al and enhancement of the dura and epidural space, and with destruction of the lateral mass of the vertebral bodies at these l evels. There is compromise of the subarachnoid space, but no displacement of the spinal cord. There is a dural-based enhancing metastasis involving the falx in the parietal region and a second lesion in the right posterior parietal regio n. Both of th ese lesions exhibit surrou nding edem a. There are also multiple enhancing lesions with in the bony calvarium, shown in the right frontal region (Fig. I) and the left occipital bone (Fig. J).
8�
TEACHING ATLAS OF SPINE I M A GI NG
Suggested Readings Akansel G, Haughton V M . Papke RA, Censky S. D i ffusion i n to human intervertebral disks studied with MR and Gadoteric.lul. AJNR. 1 997;18:443-446. rlarkhof F, Scheltens P. Frequiu STFM. et al. Relapsing-remit t i ng multiple sclerosis: sequen tial enhanced MR imaging versus clini<;al Ondings i n c.letermilling disease activity. AJR. 1 '>92; 1 51): 1 04 1 - \ 047.
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1998;l9:
587-588.
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Dailey A , Tsuruda J. Filler A. Maravilla K, Goodkin R. Khot M. Magnetic r<;sonanec neurography of peripheral m:rve degelleration and regeneration. Lallcer. 1 997;350: 1 22 1 - 1 222. Friess H M . Wasenko JJ. MR of staphylococcal myelitis of the cervical spinal cord. AJNR. 1 997: 1 8:455-458.
Gasparoui R , Ferraresi S, Pinelli L, e t al. Three-dimensiunal MR myelography of traumatic injuries of the brachial plexus. A.lNR. 1 997 ; 1 8:1733- 1 742. Gerwig W. Presacral cystic tumors. Ann SI/rg. 1 954; 1 40:81 -85. Gupta RK. Mehta VS, Banerji AK, Jain RK. MR evaluation of brachial plexus injuries. Nellroradiology. 1 989;31 :377-381 .
Hayes
e.
Tsuruda J. Mathis C, MaraviJla K. Kliot M, Filler A. Brachial plexus: M R imaging
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CT
five years after myelo
graphic diagnosis of lumbar disk herniation. Acla Radial. 1991 ;332:2RCi-2Xl). Ibrahim MA, I laughton V M , Hyde JS. Enhancement of i ntervertebral disks with gadolinium complexes: comparison of a n ionic and noniunic medium i n a n animal model. AJNR. 1 994;15: 1 907 - 1 9 10.
Ibrahim M A . Jesmanowicz A . Hyde JS. Estkowski L. Haughton V M . Cont rast enhancement uf normal i n tervertebral disks: time and dose lkpenc\ence. AJNR. 1 994; 1 5:4 1 9-423. J inkins JR, Reddy S, Leite CC, Bazan I I I C. Xiong L. M I{ of parenchymal spinal curd siglHlI change as a sign of active advancement in clinically progressive posttraumatic syringomyelia. AJNR. 1 998: 1 9:1 77 - 1 82.
Kermode A G , Thompson AJ, Tofts P. e t al. Breakdown of the blood-drain barrier precedes symptoms and other M R I signs of new lesions i l l multiple sclerosis: pathogenic and clinical implications. Hrabl. 1 990;1 1 3: 1 477- 1 489. Kidd D, Thorpe JW, Thompsull AJ, et aJ. Spinal cord M R I using m ul t i -array cuils and fast �pin echo: findings in multiple sekrosis. Neurology. 1 l)93;43:2632-2637. Krudy GA. MR myelugraphy using heavily T2-weighted fast spin-echu pulse sequence with fat presaturation. AJR. 1992; 1 59: 13 1 5- 1 320. Lee RR. MR imaging and cervical spine injury. Radiology. 1 996;20 1 :6 1 7-6 1 8. Lemire RI . Graham CE, Beckwith J B . Skin-cov<;l cc.I sacrococcygeal m asses
in
i n fants alld
childr<;n. J Pl'liiarr. 1 99 1 ;79:948 954. Lipper M H , Goldstein J H , Do H M . Rrown-Sequard syndrome of the <;ervica spinal cord after chi ropractic manipUlation. AJNR. 1 998;11}: 1 349 - 1 352. Maravilla KR. Buwen Be. Imaging or the peripheral nervous system : evaluation of peripheral neuropathy and plexupathy. AJNR. I YYK; l 9: 1 0 1 1 - 1 024. M aravilla K R , Wcinreh JC, Suss R, Nunnally RL. Magnetic resonance demonstration of multiple sclerosis plagues in the cervical cord. AJNR. 1984;5:685-689. Matsumuto S, Hasuo K, Uchino A, et al. M R I of i n tradural-extramedullary spinal neurinomas and meningiomas. Clin III/aging. 1993;"1 7:46-52.
•
UNKNOWNS
Melhem ER, Benson M L , Beauchamp
J , et al. Cervical spondylosis: t h ree-dimensional
gradient-echo MR with magnetization transfer. A.lNR. 1 996;17:705-7 1 1 . Melhem ER. Israel D A , Eustace S. J ara H. MR of the spine with a fast T1 -weighted fl u i d atlen uated inversion recovery sequence. A.I N I? 1 997 ; 1 8:447-454. M urp hey F , Hartung W , Kirklin JW. Myelographic demonstration of avulsing i nj u ry o f t h e brachial plexus. A.I H.. 1 947;5R: I 02-105. Naidich TP , McLone DG, H a rwood-Nash DC. Arachnoid cysts, paraverterbral meningoce1es, and perineurial cysts. I n : Newton TH , Potts EG, eds. Mudern NellroradiuloXY, I: Compllted Tomography uJ the Spine and Spinal Cord. San Anselmo, Californ i a : Clavadel Press; 1 983.
Naidich TP, McLone DG, H arwood-
ash DC. Spinal dysraphism. I n : Newton TH. POlts
EG, eds. Mudem Neuroradiulogy, I : Comp u ted Tomography of the Spine alld Spinal Co rd.
San A n selmo, California: Clavadel Press; 1 983. Na tional I n s titute of Health Consensus Development Conference. Neurofibromatosis. Arch Nellrol. 1988;45:575-578.
Nesbit G M , Forbes GS, Scheithauer BW, O kazaki
H. Rodriguez M. Mu ltiple sclerosis:
histopathologic and M R a n d/or CT correlation in 37 cases at biopsy, and three cases at
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North R B , Campbell IN, J a m es CS, et al. Failed back surgery syndrome: 5-year follow-up in 102 patients uJl dergoing repeated operation. Neurosurgery. 1 99J ;2l):6l);) -69(). Ottery FD , Carlson .I Comput A ss
ist
RA ,
Gould H, Weese J L. Retrorectal cyst-hamartomas: CT diagnosis .
Tomogr. 19X6;I ():260-263.
Papadatos 0, A l brecht S , M o h r G, del Carpio-O'Donovan R. Exophytic pri m i t i ve neuroec todermal tumor of the spinal corel. AJNR. 1 998; 1 9:787-789. Peacock SJ, S h rosbree R D , Key AG. A review of 450 stabwounds of the spinal cord. S Afr Med .l. 1 977;5 1:961-964.
Provenzale J M , Barboriak DP, G aensler E H L, Robertson R L, Mercer B . Lupus-related myel itis: serial MR findi ngs. AJNR. 1994;1 5 : 1 9 1 1 - 1 91 7 . Q uekel LG B A , Certeege C W M . The "dural tail sign"
in M R I of spinal meni ngiomas . .I
Comput Assist Tomogr. 1 995 ; 1 9:890-892.
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H, et al. MRI o f anterior spinal artery syndrome of the
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J 998;1 9 : 1 025- 1 033. Trop I , Roy D, Raymond J, Roux A, Bourgouin P, Lesage J. Cranioeervical dura l fistula associated with cervical myelopathy: angiographic demonstration of normal venous drainage of the thoracolumbar cord does not rule out diagnosis. AJNR. 1998:19:583-586. Watters MR, Stears J C, Osborn AG, e t al. Transdural spinal cord herniation: imaging and clinical spectra. AJNR. 1 998:1 9: 1 337- 1 344. White SJ, Hajnal J V , Young lR, et <11. Usc of fluid-attenuated inversion recovery pulse sequences for imaging the spinal cord. Magn Res Med. 1 992;28:153- 1 62. Wiebe S, Lee DH. Karlik SJ, et aL Serial cranial and spinal eurd magnetic resonance imaging in multiple sclerosis. Ann Neu ro l. 1 992;32:643-650.
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WH ,
R ubio A . Ce rvical spinal meningioma w i t h u n usual
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•
Index A
cauda cquina nt'rvc nJUts. lI1alled nnll lclhcrcd,
Abdominal aorta
lallllL1t:ctomv al I J, 1 .4, L.' and, 739, 741
:
nt!rve ronls l1latter�d and atlhcrcnl 10 thecal �ac.
soft tissues masses around
In metastatic osleohlastlc prostate cancer, 34�, 343 Abdominal aorta now vouJ
Adolc'\Cenl
lumbar. 44 A bsccss( es) epidural; paraspinal and psoas muscle, 491 -�97 multiple von Hippel-Lindau disease with cerebellar and "pi·
nal hem angioblastomas uer'lUS, 599-f,() I pre,fertebral, 785· 7X9
desmoid tumor in. 806-809 multiple sclc.:rosi� of brai n and spinal cord in. 790-792 neurofibl omatosi s type I in with muillple ple�iform neurofihromas, 225-229
pilocyst ic astrocytoma In. 164- 1 66
Ir:"t nsver'iC m yelopa th y in, cause unknown, 722-724
Agcnesis
rClropharyngeill, 4tJX-502 Acute disscminutl!d cnccphulomyclopathy (ADEM).
SI't' a/so Transverse myelopathy (myelitis)
astrocytoma of distal spinal cord
versus,
23.1-234
mUltiple sclerosis versus. 692. 693, 7111) of brain. 79 1 . 797.
of brain aLld splIlal corti. 69X
coccygea l. 90-92. 1 00 0 l O I mcningomyelocele. tet her d cord a n d . 1'){)_iJ2
e
si n us tracl. spinal dysraphlsm. tcthcrctl l:Urd, IIK)- I O I
,acral. 1 00 - 1 0 1 . 1 02 - 1 03 cUl lgt:n i t
wilh filum Icrminalc lipoma and lo.....er·than-normal
postvaccination, 7 1 6 7 1 8 axia l long TR Image, 7 1 7
a"'I"\ :-.hnrt TR IInage'i, pre- a m I post con t ril s l , 7 1 7
dl'tlc space lIu rrowing i n , L5·S I , 716. 7 1 8 ol:>tcuphytc encroachment o n vertebral canal in. 716. 7 1 R s,1gillal �hort TR images. 7 1 6 . 7 1 8
spmal cord. 93-96 in IICOllutC, 77, 78, 79 ..in us trac1. spinal dysr3phism. tethered cord. 100-101 tethered cord. horseshoe kldnt:y i:llld, 102- 1 03 A I DS. lumbar �p\l1C in. slJgittal short TR image. 42
Schmorl'... nodule dcfurmltit:� i n . 7 1 6. 7 1 8 spinal cord enlargement i l l . 7 1 6 . 7 1 S thecal sac indenlation i n . 7 1 t) , 7 1 R Acute disseminated tr:tnJo;vcrJo;e myelopnthy tr;.II1 IlVer.;"e myelopathy vers"s, 723, 724
Acule lymphocytic leukemia illlihrutc in murrow of vertebral bodies. 455, 456-457 correlati on with rad ion uclide bone Jo;ca n in. 457 disc reversal sign i n , 457
nerve roots of cauda equina m. 455. 456-457 infiltrate in marrow of V!;: I h::bral bodies and meningeal carcinomatosis. 455-457
axial shorl TR image, prei n fullion. 456-457 Il:tgitlal long TK Image. 456-457 'iagl llal short TR i m agc�, 455
Air. III vertebral canal. post epi dural calhetcr place ment. 309, 3 1 1
p
A l ka ton
uri a. ,,"Pi' Ochronosis (alkaplOnuritl)
Am yloi dru i ls
brcust cunccr metastatic to C2 vertebral bod y with cord
(3,
compression uersus,
385
e
muillple my loma verSILS, 391 !'ccondary to chronic renal failure wilh
L lC LlJiu , 758 759
chloroma secondary to, 377-379 leukemic infiltrate in marrow. mctasta�es in theWiI sac. meningeal carcinomato�is in. 443 446 Acutc mveloid leukemia Icukt:n ic infihmte in bone marro w and leptomenin
;
geal carcinomatoslJo; and. 853-856 ADEM. See Acutt: di�selllilliited cllccphalomyciopathy ( A D EM)
{3� microglobi
seconda ry to end'itttge rcnal d isease with
(31 microglo-
hulincmia dISC space narrowing. C3-4. C5·6. C6·7. 758 759 hypertrophic spurs, multiple cervical. 75t) osteophytes in. 75H-75� sagittal shon TR Ima�e. Ct:rvicnl. 759 Angiugraphy for desmoid tumor, 809 spin;!1 cord arteriovenous m.Llformation. 6 1 3 . 6 1 4 Annulu.'i librosus. lumbnr disc. axial long T R image .
49 Antcrior sC<1 lcnus muscle. in neurofibromatosIs type I . 2 1 8 . 233
A de nocarcinom ll
nlctaslatlc. ulerine IIxlal :-.hnrt TR imllges. 354. 355 with bone destruction and spinal cord compression. 1�1-1�6 hone erosion in. T5 vertebral bod'll . 353. 355
b
comprcssion fracture in. T4 verte ral body, 3:U. 355 kyphosis in. thoraCIC. ]S3-J55
paras pinal mas� In. 354-355 �dgltlal f�IH.Uppl c�M::d image. ro�lconlr:I"'I, 114-355 l'Idglitlil �h(tft TR linage" 15] :;55 mt:1:tst.ltIC wllh hone dC'itruclioJl lind �J.lLIlHl cord com·
prc,:-,ulJJ. 3.'13 356 Atlcllupilthy. para\pinnl "'l'(,lln(\;lry 10 non · l l od.\.tki n · s lylllph l lm n 14X-:\4CJ Adhcslvc arachmllditi� ('T-i.\IoSlstcd lIIyclogrum in. 741 M R �un in. 741 pO'Hlaminectomy, 739-74 1
e
axial long TR i mag . al caudd. C4uiLla, 740 741
e
axial long rR linage. u pp l hllllbar. 739. 74 1 axial �lmrt TR IIl1iJgC. kidney level, 7]�. 74 1
Anterolisthesls traumatic C4 Oil C5 with herniated disc, 2H(I-2HX axial long TR image. C4-5 level. 2H7-2H8 nervI! root cOlllpresslon at intcrvcrtc1u HI foralllcn I n . 2Hb. 287-'288 Joiagl ital lulIg TR image. 286 l:>dgill
adht:sive. postlaminectomy, 731:J-74 I . See a/w A tlhc sive ar
chan gcs with �urring and 'Idhesions of
cauda equina nerve roots
versus.
arlcriovt:nuu::, malfonllillion of. 6 1 3. 6 1 4 blood supply t o "pinttl o rd. 11()5
c
origin of. (113 ArtIculating fal.:cdl:> lumbar a�lal short '1 K image. 45, 46 lumbar. JlJfcrior axial long TR image. 50
lumh;lr. inferior and superior
axial CT image, 57 A l t i f,lct(s) chemic,,1 �hifl Si't! Chcmical shift artifact
magnctic susceptibility. See Magn e tic sUl:>cept i hil L' ty ar tifact
Assault i nju ry disloc
of ccrvical spinal (:Ortl. 143 descrip1ion of. 143-144 of distal spinal cord. 233-234 sagittal inlt:f1nt:diate TR imagt!. di ta l 'ipina l cord. 234 sagittal short I'K imagc. cunu� II1ctlulluri�. 23.3 234
<;
cpendymoma ue"�f'S. 140 t:pt!ndyJlJoma with syri n x cavity Ui'r'ill.�, X52 with neurohhroma of dur�al ro01 gunglion. 1 4 1 - 144 axial long TR image. 142 143 axial short TR i m age . 142- 1 43 Silg,tlal long TR image
with microgiobulinemia characterization of. 759
lateral plain film. 758
A,utc lIIyclogCIIOU� leukemia
cerebellar. 7 1 cervical vertebral. 7 Artcry of Adamklcwlcz
741J-74I �aglll
aJtlal short TR iJnuge. 46
Arnold Chiari malformallon SI'I' ( 'hl:lfl malr(\nnali()I1 Arteries
739. 741
737, 738
C4-5 Ihrough C7. 1 43 �u gitta l l:>hort TR im age, 1 4 1 , 143 in nCLLrofihrnml'll osis Iype 2 ;uml short TR imHgcs. 168-171 cervicul spinal cord in. 167. 168. 170 lo rdosi s reverll�1 i n . cervical. 16K 170 mcdulla i n . 168. 170 sugillal long TR i m ag s. 168. 170 �agitlal "hon TR i mages. 1 67. 168. 17U spinal cord. 167- 1 7 1 tho racIC spi na l cord i n , 168. 170 pilocytic astrocYlOma uersus. 166 sarcoidosis of ccntral nervous sy�tt!1II Ulmus, 5 1 X �pinal cord mt!tastasis Ul!rsu.o., 1 5:\
e
sy ri n x i n . 143 Atlantoaxial fusion. 549-552 definition and pathophYSiology of. 551 A t lantott'Xial fllsion: Klippcl-Fcll anomaly: tl i ,1: ht! l n i a-
tion at C4-5. 549-552 uxial short TR image. C4·5. 550-55 1 ccrvical spinal cord cOI\lprC�slolI lII. 550-551 CI postcrior arch fusluLI with occipit;J1 bont:. ,4() ,,0 CI vertebral fusion with skull haJo;t:. 54�-55t). 55 1 fusion of vcrtcbral bodlcs and �pilluu� pHlCe�se�. C2·C4. 549-550 Klippcl-Fcil anomaly m. 54\)-5511 lateral vicw ot ccrvlcal �pm!;: from CT �can digital Imagt:. 5 IQ 5511 odontoid process dlspl;lcement Ill. 5511 osteo phytes at C4·5. ('5·6. C6·7. 54� 550. j�2 sagittal long TR imagt: of cervic.;;'11 � llJ Ilt! . 550 551 sagittal short T R Image 01 t.:ervlc
Atlanto-occipital fusion
inddental lo ('4 on C5 Iracture di,IOI.:illLnll. 291 Automobile a(,t,;ident Chance fracture in, 275
871
TEACHING ATLAS OF S P I N E I M A GING (tolui"uetl)
Automllhilc
mc.ial short TR imag�. pvstmfuMun of ccrVlcothora
renal cell cancer metao..,( atic to lung and thoracid lumhar vertt!hme Ver!i/H, 375
cic j un ction. 459 axial short Tit i mage .1t eervlcothoracic ju nction.
Brachial plcxu'i
fat :..a tUJ ati un MR !ttudie�
with rollover. 272-275 A xi;)l images Bugled am..l parallel slices. 2l)
459
in llIetnsl:1lic di5ease . .361 In met:lo;talic hreast cancer. 3SR-15'1. :lflfl-:lfd
marrow uf vcrlL:brul bodies in. 458-459
nu rJ lHlI anatomy or. 359. 361
sagill
sagi ttal short TR image. lower thoracic. 45R-459
{'cho gradient advantages of. 556 grl1dicl1t.ccho. 2l) l ong TR. 19
plcxi fo rm neurofibroma:.. alung. 213. 2 1 5 Ilrnchlfl l P\cXl11; nerves. axial short T R image, ccrvical.
short TR. 2Y
BI Bi n
sagillal short TR imagcs. lower thoraCIC. 45X-,tW
�(lgllll1l �hurt TR images. upper thOl /lCIC. 45S-459 ml!tastlltic 10 vertebral body IlId rrLJW al1J :..pi nHI L· pi.
14. 1 5
e1urnl sp
chloroma in, 379
multiple ",Ierosis 0[. 6H�-nq3, n'l4-6Q8. 790-792
B Oacten:mICl. In di,lhetc., mellitus patient I!pld u ral llh..ccs!'o.cs: p,mlspinal and psoas muo;cles ah·
�cc�c:-. ill. 491 -497 Basi vertebral vennu,," p lexus. 6
eeo;"es, 410-4 1 1
to "pinal
parasagittal short TR i mage. 3S. 39 intravcrtchral portion axial short TR 1I11age. pOSICOnlrHst. 48 lumbar axial CT im;1gc posl1l1yclngrHm. 5f! midsagit t al short TR i m age, JU. 3 1 lumbHf int nI Yc l t\.:l i rui portion
axial short TR image. pre· and postcontrast. 44 i n thoracic spm�1 cord ic;chcmia. 609
ljatson\ pie XU" III t h ora dc ilpinal cord ischemia. b09 B ,l Itc rcd pt::r�n. hangman's fracture di:..lucati un C2 on
C3 with dio;c hcrni
Biup�y C'T'guidcll In hrC
Hl
01000. morrl gc around thoracic s pi n el l corli. 309. 3 1 2 leakage with fr:lct u re dio;localion L1-2 spmous pro· cess and dUral tear. 2X2-283
lumbar regiull epidural and i n tra t hcC<11 . 1 1 2 Bone
poMcrior fossa Chiari I m a fonn a liull with foca l syrinx Breast cancer
i
sHgiltal short TR i m ages. 4 12-413 uers/ls.
.
70
I lorner's syndrome m. 461 with involvcment of vertebral bodies and brachial
metastatic w i t h vertebral involvement and adenopa thy, ]57-]59
plcKu>, 3fJO-36 I meta"tatlc
bJachiul plcxus nerve root displacement in. 35R 359
hr<1chitll plcxm; nerve root in, 360-36 1
('2, ( 'h, ('7 vcrtebral bodies. 357. 35X
compression fracture, 1'1. 357. 35'1
compression fracture wnh retropulsion of TI vcrte·
eurullul short TR image, 360-36 1 to C2 vertebral body with cord compre
bral bod)', 357. 359 parasagittal short TR images, 358 359 sagittal short TR Images. 1)7, 35R-359
involvement of vertebral bodies ,lnd bfilchial
plexus. 360-361 kyphosi s in. T4 level. 360 361 with ostc:ohlastic and osteolytic deposi ts through out bone: l....: rcbru l carcinumutosis. 461 -4t>3 rdl OpulMun o f T4 ve nebral body into vcrteblal ca· nal, 3{,()-36 1
soft Iissue mass m. 35H-359
TI-2 k\'el. 357, 358-359 with o�tt:oblastie and ostoolYlic depOSits tili oughout bone; cerehml carcinomatosis. 461 -463 axial short rR images of brain. 462 cl.1lvariulll in. 462 leptomeninges in. 462 marrow of vertebral bodies in, (') . ('7, T I . T2,
sagmal �hnrt TR images . 360-361
:.. p ilHll �ord di�pluccment and comprt::..si un in.
461 -462 �agi wi l iong TR imagt:. CT. T I . n. 461 -462
3/iO 361 sl1h"rachnoid space compromise in, :1O(l-:lh l to vcrtcbntl body marrow and spinul cpidurul space. 458-460 with vertebral involvement suharachnoid space compromise in, 35X-359 metastatic cervical wtth ustcobll:lstic meULStusl.!�. 4 1 0-4 1 1
sagittal short TR i mage, C5, T I . 461 -462 osteoblastic metast
with soft Iissue epidural component (lnd cord com· presslun, 4 12-413 uMeoblastic metastatic with so ft tissue component and pathologic fractures. 4 1 7-420 itXlal short TR i mages, 41 '1-420
ploton denslty and sagillal long T R images. 4 1 0-4 1 1
cr-guidc d bone biopsy in. 42U fractures through LJ. L4 and L1 vel tcbml bodies.
sagillal short T R imuges. cervical. 4 10-4 1 1
irradmted. 338. 3:W lung ca n ce r met:lo;tao;i� to. 386-388
4 18-420
mcll.1s tl1 tie t o bone
Bone hrll1sc comp;m�un with compuctcd trabecular bone. 338. 339 :..c1cro�is. 469 vcnehml uer.w.'t
inte rfacet joint involvement, 4 1 7 i nte rspmouo;; li gamen t in, 420
with spinal men in geal carcinomatosis. 439 442 me\;l
mtervertebral formncn in. 4 1 8 . 4 1 9 . 420 p.na:"
sion. 383-385 I1xial short TR image, 384-385
necrotic tumor in. 383, 385 neurologic evaluation in. 385 odontoid proces� m. 3X3, 3X5
COl tical. on C'T �ca n . 366 In mlJitiple myeloma C'T st,;ulIl Ii ng for. 396
Bone ma rrow. Set' Marrow Bone metil"tao;cs an d �pi na l n u:n in gcul carcinom
sagiltal long I'I{ Image. 440-44 1 sagittal short TR illlagt:. 43{). 441
verSIlS,
[or.men, 4 1 R, 4 1 9, 420 radionuclide scanni ng in. 420 ::.ugittul short TR image. lower Cl!lvical and upper
cervical cord com pressi on . 384-385 lamina expansion in. 385
pOMru diu t ion . 338. 339 Bone destruction c:llvarillm i n l Jl u ltlplc myeloma. 3CX>. 391
1§L2
disc rcverl
mewstatic
now \loid /lxiul short TR image. poStL:oll lrllst. 48
Done tu mor primary colon carcinulIld II1di1�tash
C7 through '1'4. 412-411
437-
in me m nge:l l carcinomatosis. 431 -412 Brail1 tumur
en t ran ce :-.ugi tlal long TR image. 4 1 sagi tltl l "hort T R image. 4U
See al.w Hc
ponent. and spillal cord cumpression. 412-413 axial shurt TR IIlJ
Urain i magmg i n g liobla:.. HJmit mulufufIllI.:. ce rebral recurrent With drol> met'lstm;;cs i.l Ild Illcnillgeal carcinomato::.i::.,
pathologic fracture pOlcmiul, 385 sagittal long TR image, 384�3RS sagi tt
of Ci on C2.
ilxiul short TR i ma ges. 334. 336
soft tissue metaslases. 4 1 8-420 sp i n ous processes and. 4 1 7 . 4 I X-419 vertebral body involvement in, 4 1 9-420 post treatment mctastatic depos it. right lobe of liver, 843. 844 pathologic fraclUres of T1D, L 1 , L2. 822. 842 post treatment bony metastases with pathologic fnu;· tun;:..
Jors:'11 roOI ganglion in. 334. 336 e x p;msion of vertebral body. 333. J:l4, :no
marrow of vertebral bodies in. 843. 844 �1gi l l
latera l pluin film of lumbar spm�. 33 1 . ))5. 337
po:..t trc.H ment bony nletastases wlth pa thulugi c fruc· l ures. l ID. L I . L2
332. 336 sagillal interrnediatt:/long TR imagl!!> . 333. 336 ,"gillal plain film. 33 1 . 335. 3]7 sagittal postcontrast short I'K Ima�e. 332. 336 sagittal short TR im agt: uf lumlJar �pine. 332. 336 subarachnoid space encroachme nt . ,,2, ,�fl
seco nda ry men ingeal carClnomiltosls in, 429-432
pedicle in. 334. 3)6, 337 r�t ropulsion of vertebral body inlll vertchnll cflnal.
technetium hone scan. anterior and posterior
V1CWS. 334, 336 368
Ihor
metastatic tu vcrtt:bral body m.:lfrow and spinal epi dural space. 115f(-4fln
�nd metastatic deposit In liver. R42-X44 with vertebral Involvement und aJcllul'lIthy. 357-359
c Calcium pyrophu�p hatc dcposition discl.lse (pseudo· gout) breast C
uerS/lS.
385
INDEX
rheumatoid arthritis with hernittted discs at C3-4. C4-5 levels versus. 548
Otlvurium
CervIcal cancer
radIcular p.lin in
pu�tradiotion change� in. 338-339
cau"e of. 537
in rheumatoid arthritIS. See ullder Kheumatold ar-
axial short TR im
destruction in multiple myeloma. 390. 391. 3Qfl
osteophyteo;;
inner and ollter table or
sagittal shurt TR image L2 end plate thruugh '
cervical spine. 5 metastuscs tu. 861 -S67 i n ulultiple myelonl,t. 389 391 Carcinomatosis. spinal and cerebral meningeal. second ary 10 breast cancer, 429-432 CarolH.! nnery now void ur external. 250-251
thritis i n Chiari Mlalformation axial short rK Image. 61}
f'crvical disc herniation. 503-566
edema uf
C4-5
in sarcoldo�is. ) 16-517
with atluntoaxial fu�ion and Klippel Fcil anomaly. 54Q-��2
i n tram.ver"c mycJopatllY, 709 with traumatic eompre"'siUll fracture. 271
case I: ['5-6 level. nght side
in neurofibromatrwio; type I. 2 1 9 , 22..1
aXIal gradient-echo images. C,)-6. 529-530
plexirorm neurolibromas and. 2 1 3, 2 1 5
bulging dise in. C5 6, 527
Caudu equina nerve roots
Cervicnl spinal COld
saclum, 338-339 Schlllorl ' s node. Ll vertehr:ll hody. JJX-33t)
glioma ufo 149-150 i n nletastntic colon carCUloma. 202. 2(M in neurnllh romatosis type 2 with astrocytoma. 167.
ccrvical spinnl cord displacement in. 528, 5}()
1f>X. 170
in anterior sncrnl myelomeni ngocele, 88
dura in. 52�-�'H{)
axial cr image
pilUl,:yslic astrocytuma ill. 164-1 6()
gradlcnt-echo iUlllgCS in. ratiunale ror. 530-531
post pilocytic astrocytoma removHI, 1St)
in dorsai lispeet thecal sac, 57
loss uf ccrvicld lordotic curvc in. 528. 531
i n o;.lrcoidosls. 5 1 t!-51K
pustmyclogram. 56
narrowing of di<;c space 111, 527
syrinx In. 57Y-580
obliteration or i n tervertebral foramen m. 529-530
tumor or
nxial long TR image. 49. 55 long TR image or, 52
plain IHm r\!udin� and. 531
lumhar
right interMlediateflong parasagittal TR images.
M R myelogram. t h rce-dimen�ionaL 61
postoperative changes with scarring and adheslono;, 7>6-738 I n thecal sac para�aglllul lung TR image, 59 Caudal rt:gres.<;lnn syndrome inrant. 90 �acrum and coccyx 111. t)7. 98 �aglllul !:>hort TR iUlUgc. 98
wilh tethered CUI d and vertebral anomalies. 97 (}<)
cervical disc hcrnllHion Ut'f\'U.'i, 530. 534 Chian I malformallon with po�topcrahve changes.
,2M, 530
�yrinx cavity ver.\II.l. 81 1
soft tIssue encroachment on vertcblUl canal in. 528.
Cervical �pine CI-2 disloc
530 spinal cord compression in. 52Q-530
111
Down's �yndrullic. 133-134
silharachnoid space eomproml'ic in. 528. 530
cuntri.l�t muterial ill. 3
vertebral canal compromise i n . 528. 530
dc:generativc changes and post discecwmy changes hony fusion plug� in. 570. 57 1 . 572
aXial gradient-echo image. C5�6 levcl. 533-534
cr i n conjunction with lordnllc curve loss
m.
MK
intcrspinou� �pace in. 571 -572. 573
imaging ror, 534
loss of 10ldotic eurve in. 571 -572. 573
532. 534
in neonate. 1 03
mitisagittul short TR image, 532. 534
ndontoid process in. posuraumalie. 571 -572
with lethered cord :lnd vertebral anumulics. fJ7-99
plain IiIIll and. 534
osteophyte ,n_ 570. 57 1 . 572. 573
radicular pain With. 514
right parasagittal long TR image. 533-:i34
retruh�thc�ls in. C5-6. 571
sagittal long TR image. ;71 -572
right pnrasagittal shorl TR image. 532. 534
sagittal short TR ima�es, pre- and poslsurgicul.
anteroposterior HllIJ lateral plalll film. 97 Cavernous angiuma
of cervical spinal cord. 834-X37 Hxial grHlhent echo image. Ct!. 836. 837 axial long Til image. l·5-6. 836. 837 axial �hort TR i m age. C6. X34-835. 837 hemosiderin deposition in. K37 magnetic susCepllhlllty
572
570. 57 1 . 572. 573
truuma to spinal cord and. 534
sdt:lo�is in. 570. 573
vascular compromise and, 534
suh:lr:lchnoid space compromise 111. 57 1 . 572. 573
case 4: C4·5 midlille nnd len lateral
truncation artifact Ill. 571 -572
cervical vcnous plexus in. 539 case 4: C4·5 midline and left pantcentral. 53M-539 aXial ('''I' Image. postcontraM. 538
vcrtcbnll canal comproMlise in. 571
572
degenerative changeo; secondary to fusion at C4-S. 51\7-51\9
subarachnuid space compromise in. 538 0-4 with posterior longitudinal ligament msification.
chunges with dbc protrusivlI .It C6-7 level. 567. �"l) myclomalclcia. 567. 569
553-"�
oSleophyte at ('4-5 with SUhiwlchnoid space com-
axi;!1 gradient echo Imugcs. 554-555
promise. 567. 569
displaecl11ent or �pinal cord at C5. 554 555 ubliteration or subnrachnoid space in, 5:)4-555
rctmli... thesls uf C4 un C5. 567. 569
osteophytes in. 553, 555
sagiltal long TR image... 5tlX-)69
sagittal lung TR iMlagc. 774 775
sagittal intermediate TR image. 553. 555
sagittal o;hort TR IMl"ge�. 567. 561}
�i.tgittal s.hort TR illlo.lge. 771
sagittal long TR image. 554-555
SPlllHI cord eompre�sH.1n . C3·C5. 567. 569
axial long rl R i Mlage. 774-775
Cerebellar a rtery, in Chidfl I m,lIrormatioll. 7 1 CcrchelJar tonsils I n l'lmJrl II malfornwtion ill neonate. 79
downward displttccmcnt of. 111
Chlan malfonnutum. 67. 68. 70
III Chi.m I lllilifurmation. 7 1 . 7fl herniation or i n Chian II malformation. 80-82 In Chian I I I nmlfurmatlon. 87 Cerchellum
glioma of. 1 4l}-150 piloc)'lic aSIrlX:YlUnm in. 155. 1 58. 159
Ccrcbrospinal nuid i n Chlari Ilwlfornmtion aXlal shurt TJl il1lagc. 68-69 in diffcrcntiutlon or met;.1�tntic from inHamm:unry dis e;'lsc. '1.W effect on
uf hcurt beat and Ic�plration. 356 l,l-4 long TR imagc. 53 L:\ hmg TR image uf, :;;2 le:lk. with rraeture dl...lllcution L 1 ·1 �plllUtl" rrocc:,� und dural t c: i.l 1 . 2X2 283 lumh;n mido;agittal lnng I'K Imagc. standard spin·echo tech niquc . •lJ
thurucic now·rclated enh;lI1ccment or on uxial 'I K UlUlge. 23 �l.Igilti.l1 IUllg TR image. 2 1 . 22 sagittal �hurt TR image. 211
subarachnuid space compromise i n . 567. "itiQ
sagittal short TR image. 553. 55�
spinal cord compression i n . C2-C6. 553. 554. 555
subarachnoId space comprOllllse in. 553. 554. 55)
T I on TI displ:lccment. 553. 555
diffu�c Idiopathic skeletal hyperostosIS of. 5KO-583 axiHI short TR image. 5K2 lateral plain Jilm. SRI
u::.tcophytes C4 Ih rough Tl . 5tH. 5X2
vertebral cHnal narrowing 111, 553. 555
po<;t laminectomy, 5 X I -5S3
C4-5 level. "5-537
SHgittal short I K image. 5M2
anterior herniation at CS-6. 535. 537 aAi.1I gradient-echo image. C4-5. CS..(,. :;30-537
ullHging selluellCt!� i n . 3-4
c�rvieal o;pinal cord compression In. 536-537
midsagittal short TR image. �
encroachment on �ubarachnoid space. 535. 536-537
normal anatomy. 3 - 1 5
intc:rvertebral disc heigh I lo,� at 0-4, ( '4·5. CS-6.
uxial. 8 . 14. 1 5 coronal. 7
53,. �17
mido;agiHal. Y
mldsagiHal lung TR image. 535. 537
p
l1Tid�l.lgittal short TR imHgc. 535
sagittal. 5 . tl . 10 . L 1
oblilcration of epidural rat. 536-537
nucleus pllipnsus herniatIon at C5-6 with myelo-
parasagittal images fur lateral hcrnil.1lion. 537
parasngittal TIW image. 536-537
malaCia. 574-578 anlcl iUI herniation at C�-6, "i7�. 577
C5-6 level
axial grttdicnl echo Ima�c. 576-577
commonality of, 530
aXial slum TR imagc::,. 575. �7n. 577
right side. 527-53 1 . 532-534 midline at C3-4 secondary to surgIcal fusion at C5-o and C6-7. 563-566
cm:t:ph(llllmyelitis and. lIi .....cminated wllh dcmyclin.lImn. ;78 100doilc curvc rr,;vcl�ill lJl. "74. 577
axial long rl R image. 564-565. 5M
M RI of hrain in. 577
nxial �hul t TR images. 564. "iM, 566 enccphalomill:lcia in. 564. 565
myclolllalocia m. 574. 577
mcchanl�m ill. 566
)o.;lglttal intermedldte TR imO\gc. 575. 577
mycluJlmlacia i n , 566
�agittal short TR Imilgl!. �M. 577
sagimtl long TR image. S64-56�
!
sagittal shun TR image. 563
relnled. 578
spinal curd compression in. 5M-.%5. 566
po�t dl'iccctomy/surgical fu�ion changes
spinal cord displacement 111. 564-565
,tXlal gnldicnt echo IlllUg ..· at C6. 5�O
svrinx lormution in. 565. 566
my�lugnll1l with postlllyelogram IT scan i n _ 534. 536. 539
m.
:\70-573
ClJse 2: C5·6 levd. right side. 532 534
Ul'rsw'
MRI
cervical syrinx in. 579 ��O
(''I' wilh myelography in. 5HO
81lJ
TEACH I G ATLAS OF SPIN E I MA G I N G I «('(III/IfillI'd)
epidural fal m. 7X
Cervical "Pi ll:
oOiiteopllytc encroachment on vertebral (onum:lI.
,7')_,XII
Clivu:-.. 5
ill illfant
degener:l livc changes in postoperative. 249. 2� 1
uxinl short TR image. 8 1 -82
"agittfll Oiihort Tit image. C;·j) through T I -2.
579-580
cerebellar tonsillar herniation ill. 80. 82 lumhar vertcbral canal in. 8 1 -82
postoperative changc� C5-6 through TI-2 post disccctomy and surgical fusion. 579-5� sagittal long nl image. h
Coccygeal agenesis. in inrant. 90 92
sagittal long Tit illlagt:, 8 1 -82
Coccyx
sagittal sholt TR illlage. 80. 8 1 . 82 tcthered cord Ill, X I -R2
vcrtehlal bOllie� of
vcrtebral malformauon 10. � 1 -�2
po:itsurglcal chan�cs with melallic plale and screws.
344-346
with meni ngomyelocele. <;acral agenesis, 77-79 sugittal short TR Imagc, ccrvical spine. 77 meningomyelocele in. 78. 79
ChHmbcrlHin's line. 5
wilh multiple ahnormalitics, 80-82
CIIUIlCC fr::lcturc
phltybasia of skull hase. 77
characterii'ation of. 275 Uenl(",
27'i
with lipoma. L2 levd. 822 sagittal mlennetlwle IOtcn�ity lumhar image. 43
to spillal wrll. 202. 204 spinal cord lIisplacement in. 2 0 1 , 204 splll,,1 corel in, 202, 204
ct:rvical. 77
to suhcutancous tissue of forearms. 448
lumbar. 77. 78 C'hiari I I I lOalformalinn, Xh-X7
Chian lIIalforllwtiun axial sllorl TR illlugc
\0 medulla. 202. 2()4 pi.lfHsagittal TR images. 2U3. 205
sagittal short 1 R images, cervical. 2UI. 204
vertebral canal !O
with retained Pantop:l.quce, 734 73<;
3XIOI short TR images. 202. 204 axi(ll TR image. 204-205
sagittal long TR image, 202, 204
thoracic lumbar syrinx in. 77-78
Chcmical shirt artifact
IIH.:tCl�tatic. 201 -205
postcontrast scan for. 448
tethered cord in, 78. 79
compression fracture in auto accident
ill c.1 udal regression syndrome. 97. 98 Colon carcinoma
wnh meni ngnmyelocele and sacral agenesis
in rdocy�tic astrocYlnma. 164. 166
chordoma Involving. 831 -X33 incolHplt!le lIevcluplllcut uf
meninguct:lt: ill, 7X, 79
Ccrvicomedull:lfY junction
in chordoma. postoperative metastatic. 2.)1-214
meningomyelocele 10. X I-X2
sl\gittal ShOft TR ilTla�c. 5 metastase\ tn, 144-1411
fUSIon with odonloid process midsagittal short TR image. 9
II It:tal-ot
Ctlrpus callosum agenesis in, 87
:Ixial level ..hort TR image, C2. 447-448
ecrcbrubpin,d ntlid in, 68-69
1I11,!lIIl1gocell! in. occipilul. 87
correlation with cerehrospinal fluid analysis. 448
cervic'll spinal cord in, 68-69
Illcllingocnccphalocele in. 87
stlgittul shun TR image. lumbar, 447-44H
formncn nwgnum in, 68-69
m neonMe, X6-87
Illctllstntic to TI2 with bone expansioll aud cord COI1l
witli focal syrillx cavity, 67-70
�yringohydromyelia in. 87
hydromyelia in. 70
syrinx cHvity in
Lhcrmltte's sign in, 70 spinal cord cvaluation in, 73 with �ylillx cavity cervic..11 ,lOd thoracic, 71
pression, 367-368 axial short TR image, 367-]oR
cervical. 86
73
involvement of ribs and transverse procc..s 10,
367-368
Child cytomegalovirus radlcuhtis 10. 5 1 9-521
lumbar vertebral bodies in. 368
dia�tt:lJlatolllycliu iu. 1 1 5- 1 18. 1 19- 1 2 1
.sagIttal .short TH. Images, 3tl7-3OX
evaluation 01. 711
glioma i n . 1 4 9 1 50
fucal . b7-70
ml!dullohlflstoma in, 44X-450. 5C17-508
postoperativc changes with shunt tube placement.
meningltib postcntniolomy with arachnoid adhc!Hons
X3-X,
�ort h�bUC ma�s, paraspi nul urea, 367-368
or T7 vcrtcbrul body. 278. 280
in. 503 506
thoracIc, 74-76
menintoccle/myelomeningocele in
Iype I
anterior !;(Icra l. 88-89
and postcraniotomy meningitis with arachnuill llll� he.sions, 503-506 Chiari I O1alformatlon dcfmcll . 10, 70 diagnobib of
MR inwging
(IN.;m
c 1 iniC:l I . 70
vertehral body frag�ents at C2. 293. 2% ( 'nmpres�ion fracturc(s)
Child abuse. fall from couch. 289-291 Chloroma (granulocytic sarcoma)
benign osteoporotic
L3. L4. L5. 182-183
in brain. 379
multiple. 324-325
definition or. ]79
T4 and T 1 2 . 320-321
epidural ht:matoma
with local syrlllx
spinal cord compression. 367 368
Comminuted fracture
mUltiple l1\yeloma
verMIS,
Ul'rStlS,
801
403
secondMY to 'Icllte myelogenous leukemia. 377-379 aXial l'hnrt TR image, T4, 378
comminuted of Ttl vertehral body. 27X, 2XO
LI with distraction of inte rfucet Joinb, L I -2 Il.:vl.:1. 272 275 L I with spinal cord hemalOma, 2R4-2RoC:i
fmnw /r'IHIP
"xiHI short TR ilOngc !It L3, 378-379
alCial short TH. Image, 2H4-2Re;
uescending aorta, 378
rt!lropublull LI vCrlcbral body into vcrtebral canal.
Klippcl�Feil anomaly in. 1 1 2- 1 1 4
p.uusagittal short TR images. 377-37X
·mgittnl long TR image. 284-285
with lower cervical alld tliori'tcil: �)'nn). axial short TR i mage. 72
paruspinal mass at L3. 379
·mgittul short TR image. 284-2M5
with deformity of posterior fossa. 1 22- 1 24
sagittal short -I R image. 7 1 -72 surgical trcatm!:nt or. 73 postoperative changes in posterior fossa. 810 8 1 2 and pmtoperatlve ehange� in poslenor fo�sa. syrinx cavity. 8\0-8 1 2
ilxial ..hort T R image. � I I cerehrn!<.pin:d nuid now void in. 810. 81 L 8 1 2
2X4 285
lumhar thecal �ac in. 379
paraspinal masses. 378 soft tissue mass at TJ·T4 and T6-TR. 377-:n� or sort tissues or neck. H6 1 -867
in multiple myeloma. 392-394 secondary to osteoporosi�
charaetcri7..ation of. 25 1 distal lumbar �pllle, iliac crest. sacrum, coccyx. axial short TR image, pelvIs. �31 -X32. �33
silgittal lollg T R iOlugc. 810-81 1
a).ial �hort TR iOlagl!. pubic symphysis. 832. 833
s:-1gittal short TR image. 8 1 O-RI I
at S2. 832
spinal coru enl argement in. H I 2 syrinx cuvity i n . 8 1 0. 8 1 1 . 8 1 2
sagittal short TR images. 320 sagittal short TR illlag�. lumbar/tllomcic.
833
magOl.:tlc su�ccpllbihty artifact in. 8 1 1 . 8 1 2
suburuchuoid spacl: obliteration m. 8 1 2
lumbar spine. 272-275 multiple. 322-323
in spinal cord. 379 Chordoma
831
<;I)inul cord compression in. 284-285
U. lA, L, vertebral bodies. 1 8 2 - 1 83
sagIttal short TR Images. R31 -H32. R33 wlthm L3 vertebral body. 256-257 lig:nnelltum flavum hypertrophy in. 256
324 1'4. Tb. '17. TIU. 324-325 T4. TID. Ti l . 322-323 1'4 and T12. 320-321 lraumatlc axial sllort TR illlages. 270-271
syringohydronlyelia i n , 79. R5
osteophYles in, 250
of L2 verteb,,1 bod),. 269-271
witli syrinx cavity
su�ilHiI short TR image. L2·Sl. 256
sagittal short and long TR images. 269
postoperative. 8 1 0 - 8 1 2 w i t h .syrinx cavity. C2-C6
axial short rR Image, X3. X5
cerebellar tUIl�ib III. 85
post shunt tulle plact:l1lenl. R:'\. He; sagittal long 'I H. 100age. X4. K5
sagittal �hort TR imagt:. X3. 85
with thoracic �yrinx. 74-70
axial shurt TR Imagc. 75-70
l-o
purnsugillul long TR image. 273-274 ..agiUal long TR image. 272. 274 sagittal short TR image. 272
axial short TR image. 254 agittal short TR image. 253-254 recurrent postoperative. 249-252 axial short TR image. 25U-25 I jugular v�in flow void in. 250-25 1
cervical �pm:\1 cord evailialinn nnd. 7h
s.agittal intermediate TR image. 250 25 I
�aglttal long 1 H. Image, 74-75
sagittal short TH. Images, 24Y. 251
cerehellar tonsils In, 7l)
defined. 71.) dysrnphblll
SHcntl sacral llIyelomeningocele sacral teralom(l
IJPn'(LS.
Vl'rSIU, 89
infant, 2h2
Chromc renal I
,-IXHlI long T R images, 273-274
with postoperative changes. 249-252 pnstnperative metas.tatic. 253-255
ccrebrosplllal fluid now voill ll1. 74 75
Mlgitli.d �hlJlt TR illuige. 74-75 , ( hlnri II lI1alfonn�ltion
wltll �plllal cord edema. 269-271
traumatic. L 1 . and distraction of L I ·2 interracet joints
�ccollllClry !unyl oidosis In, 758�759
COlltra�t enhancement. indications ror. 2\) ("nnlm�t material adipo� tissue as. 29 in cervical spinc. 3
rnrpll� callosum agenesis. in CllIari I I I nwlfmmation.
X7 Corticill bonc dcstrucllon. CT scnsltivlty ttl. 360 Coulllndin �eondary epidural hemaloll1(1
lN UEX C6 radiculopathy. pain, wCHk nes�. 527-53 1 . 532-534 f'ruclah! hg;lmcnts. cervical, sugittul long
TR
image. J3
Cytomegalovirus (CMV) nldiculitis. 5 1 9-521
anterupmkTHJl lIlydoglam. l i S. 1 1 7 axial cr mydngram. 1 1 6- 1 1 7
in child. " '- I I X
axinl �hon TR image, postcontrast. 520-521
hemlcords m . l i S. 1 1 6-1 1 7
cerchro"pinal l1uid analysis in. 521 scan of braln. 520-521 sagittnl shon TR image. postcontrasl. 5 1 9
thccl.II ::'I.IC ill. 1 1 5. I l tl, 1 1 7 spinal cord in. 1 2 1
C"I
atrophiC asymmetric. 123-124
lower thoracic/upper lumbar cnhanCCIllClll on, 519
syri ngomyclUl with. 1 1 8 thecal sac in. 1 2 1
vertebral body, deformed T JO and 'I'l l . 1 2 J - 1 24 Diffuse idiopathic skeletal hYPl!rostusl� (DISH). cri teria
o
[or. 583
Degcncrative changes in choruoma. recurrent postoperative. 24Q, 25 1 discitis with vertehral osteomyc l itls. L3-4. anu spinul stenoSIS
uer.m.f,
7X I
Intcrfacct JOll1t synoYlal. tl70-672 synovial cysts with, 661,1. 672 III Intervertebral uisc LA-S di"c bulge with lateral recess stenosIs
nil mcningc<11 metastases: hony calvarium mc tastases uersus, 867
I
uer.moS,
67R pusttruuOlU axii]1 gradient echo image, 541 -542 axial shon images, 541 -542 eervical lordotic curvc loss in. 540 cervical subarachnoid space compromise. 54 1 . 542
TR
dise hcrniatlOn at C4-5, C5-6 amJ L1iM': bulge at C6-7. C7-T I . 530 cncroachment on subarachnoid space. 541 -542
MRI
evaluation of hematoma. 543 myelomalacia in, 54 1 542. 543 o::.teophyte projection in. 541 -542 sagittal long TI{ 1Il1agc ... 540. 541 -S42 !'iaglttal short TR imugc. 540 �ylinx cavity Ill. 543 Degenerative di"c discase changes in. 1 8 1 - I R3 uiscilis ua�j/(.\, 469 Deoxyhemoglobi n, 3 1 1 . .1 1 7 . .111,1 Dermoid cyst. sacral myelomcnlngocele uersw. 89 Dermoid tumor cnudal regression syndrome with tethered cord and vertchral anomalies U€fSIU, 99 eharactcrization (,r. 264 low spinal cord and, 263-265 sagittal TI W image distal spinal cord at L2.J. 263-264 soft tissue mass. 263-264 spinol cord, 263-264 Desmoid tumor. 806-809 in adolescent. 806-809 angiography in. H<)iI axial fat saturation image!). prc· and postcontrnsl.
806-807 axial short TR images. XOX-X()iI dense Ilhrou" tissue Ill. 806. 807. 808 hcm
�)'l inx COWlty, (,hi�rI I malformation. 1 1 5-1 1 8 anteropostenor abdollllllal film. t22. 1 24 with atrophic �pinal cord and other anomalies.
TR
S<Jglttal shurt TR illlugc. 1 1 9. 1 2 1 , 122 hcmicords In asymmetnc. I 23 - 1 24 with lipoma, 8 1 8-822 lIlid!!
post hrca"t cancer treatmcnt. 842-844 leukemic inhltwtc 111 bune Ilwrrow With granul(J('.ytic sarcoma (chloroma) of neck: du
J)cgcncnlllvc changes with ostcophyte formation
122 1 24 aXial short TK IIn
Diffuse meta!!ta!!c� bony with palhnlogic fracture�. ' 1 1 11. L I . anLl L2
neurofibromatosis type wilh plexiform IIt:: urofibro· mas in cervical spine uerSIlS, 8 1 6 . X I ? Diplomyelia. uerslls hemicords. 1 1 7 Disc degeneration. See also Dlse herniatiull disci lis
uerSII.)',
469
cvaluatiull of long images in, 621
TR
a t L1·4 and L5·S1 levels. 619-621 vaCUUlll Ue.rSIIS calcification cr differentiRtion in, 62X
Oi'\C disease. Spe also Disc hcrniation cervical imaging sequences in. 3 long TR images in, 29 Oisccctomy C4·S and C5·6 with bony fusiun plug�, 561 562 complications of. 562 loss of lordosis with, 561 -.'562 postope rative evaluation of. 562 recurrent hernillted L1isc fragment following. tl37-tl3Q sagittal �hort TR images. prc- and pmlcontrast. 5hl Sfi2 Oi'\C I"ragmcnt
midlinc and left paract:ntraJ. 53K-539 right-sided. 54Y-552 C5·6 1cv
u('r:m!J',
788. 789
left parm;cntml. 629-6:\ 1 1I11rilthecai UI::.<: in. tl24 1.2-3. 1145-114(, mlLllmc. 05 1 -654 L3-4. X26 830 I A-5. " 1 �-b2 1 . 826-X]0 latcnll with Cllcru[]chmelll on inl crvertebral foramen. M7-6511 mIdline. K2X. 830 Palltllpl.l4UC" retention in. 733 73S pOSI epidural hlnck • .1(1{-.-307 lateral cuutiull in. 830 Imeral 1 ,1-4. X2h-X:\O
Si:lglltHI ::.hurt TR imng,-'. 828-829. 830 thecal sac prominence in. M2tl, X29 lateral 1 3-4 and midhne L4·5. 826-830 axiul �hort TR images. L2·3 pre· and postcontrast. 826 827. 8311 "xiill short imag�s. L3·4 pre- and postcontrast.
TR
828-829 axial shorl image\;, 1..4 pre- and postcontrast. X2X-X29
TR
829 left parasagittal short TR image. 826-827 righl purasaglual short TR image. 826-827 sagittal long TR image. 826-827 "agittal short image. 826-827
TR
recurrent migruwry post lumbar laminectomy. 640-644
axial shon TR image. LS-S I . 64 1 . b4J axial shoTt images. prc- anu po::.lcontr.I!!t. 642,
TR
643 disc herniation
uerSIl.�
scar on postcontra:.t �can.
644
magnetic ::.u::.ccptibility artifact in. 04�. M4 para::.agittal short T R image. M I. M3 sagittal '>hort TR image, posteontrast. 64 1 . 643 �glttal short T R images. 640 S<.:ar furmatioll in. 642-643, 644 soft ti-.sue mil"S behind epidural <.;pace anLl. 643 soft tissue mass behind L5 vertebrlll body. 640. 64 1 . 643 lhccl.Il sac displacement in. 64 1 . 642. 643 recurrent post discectomy. 637-tl31J arachnoiditis and, 638 axial short TR Image�. 638 clinical correlation in, 639 contrast enhancement in. b3� cdema of bone marruw ill, 639 imaging for. 638 p!!eudomeni ngocele in, ro�toperatlYc. 637, 63X sagi llal long lmagt::. 637-638
MR
rR
sagittal �hort TR image. 6J7-6�M UeHI/S scar IIssue. 639 soft tls::.uc nta�� at L5-S I . 637 63M thcQiI ::.ac bulging in, 637-tl3R. tl:W thecal sac compression m . 638 vertebral budy cndplutl!s in, 637 63ft 619 Oi:-te h�lght. lumhar, midsagilt(11 short TR Image. 30 Disc herni,lIion. S('P fllso lJisc L1cgcllcnllillll: Disc diseallc cait.:lficUliull in. 592 C2-C3 Ieycl in hattcred person. 294. 296. 297 in hnngrnun's fracture at C2·3. 292-297 C3-4 level. 563 566 and po.,terior longitudinal ligament ossification. 553-556 C3·4 and C4-5 levels. 544-548 C4-S Icvcl left lateral. 535-537
myelographic signs or. 650 nerve cncroachn)(:nt in. JH parasagittal short image. 3� postillmincctomy. �26-830 po"tnperativc changcs with fusion at C5-6 and C6-7 Ic'cls. 563-566 recurrent with migration behind L:5 vertebral body.
TR
6-10-644
synovial cyst U('rS/lJ. lumbar. 668. 669 T6·7 level. 587-590 with calcification. 591 -592 with calcification and vertebral canal compromise. 595-S98 T8-9 levcl with calcificatlon. 593-594 traumatic C4-, level. 21!6-288 C5·6 level. 302-305 with traumatic anterolisthe!ii l:-t. ( '4 on C5. 286-2AA Disc hcrniation fragmcnt rccurrcnt with peripheral cnhancC!ment. ()37 -6JIJ sequestercd at L4-5 level. 651 -654 with nervc root enhancement. ClJl-b3Cl Di"c infection. postope rative wOUI1J in fection with draining sinus tract and. 480-482 DI<;cili.. IIPrWS degcncrative disc uisease. 469 anLl cpiLlurul und paraspinal abscesses anna di"placcmcnt in. 4M-48S Hxial sh�)r\ TR imugel,. prc- and postcontrast. 484 4X5 nX1:d �hort TH imll�c". T4. 484- 485 ehl.!�t x-ray Ill. 486 Cl' guided tlSpinllinn hiopsy in. 485 in mtravcnous drug ahu::;.cr with pulmonary tubcrcu· lu::.is. 4M3 4R6 kyphosi" :l1 I 1--4 level. 4KJ In\s 01 vertebnll hody IIcight in. 483 .r\1) (·O!JII(·lerilll1l fII/)('rclIl()\·i\·-a,,�nciatcd. �3-486 rara"plnlll mas., in. 4K4-4XS prevertdmli "uft l i,\;ue n1:l\". f'2-Ttl, 4X3. 4�4-..u:;5 Mlgillal ::.hlll"l TR image'i. '13·4 level. 4X3. -4X5 t h l!cal 'ille eOlnprc......ion i n . 4K4 4:-\5
8 / bl
TEACH I NG ATLAS OF SPINE IMAGING Discitls (Co/II;'IUn}) III intravenous dru� abuser. 477-479. 487-490 with pulmollary tuherculosis. 483-486 with L1-4 \ierlchral ostenmyelitis and spinal stenosis. 7XI -7X4 M R 1111i1�ing UUS/IS phl in film and CI cvaluatlOll ilL 4(,1) nrgani"nl'" in. 4SQ-490 Mycoh{/crrr;w/l species rn. 475. 47<.) Pseudomonas aeruguw.m 111. 475 and ostcomycllti::, cervical spine dc:genc:rative clwnges :Inct post disccc lomy ch:mgel\ I}I'n'It!I, 57U-573 with para�pmal cxh:nl)1un ;:I1Id vertebral osteomyelitis. 477 479 axi,,1 �hort TR im
di...placcment of spinal cord in. 477 encroachment on epidural spacl!. 477 gallium scanning and. 479 LI and L2 loss of height in, 477 L I end plate destruclion in, 477 lumbar thecal sac I n , 47R radlvnudiuc :-'cU1l11ing 111H ..I. 479 sagittal short TR im age, 477 sagill'll short 1'1{ imtlge, postcontrasl, 477-47X Ilostopcnmvc with wound infeclion and drainrng SlI1U� trllCI. 480-482 tlxiul �hort TR images, 481 huttcrny configuration of disc. 4W-4�1 cr-guided aspiration biopsy with culture m. 482 extension of innamllll.1tiull intv inll.:rvcrtcbrul foraminae, 480 481 inflammation of prcvertchrnl sort tissue component in. 4/l0-4X I L'i-SI lh� cxpilnsioll 10. -481 p<1ra..agiIlA I "horl TR images. 480-48 1 !l.agltlal �hort TR Images. 4XO-481 thccnl M.IC cvmpression in. 480-481 p"..llrau111atic with pSOAS and other absce�ses. 470-476 tlorta displacement in. 473-474 uxilll intermediate TK image:.,. 473-474 axial short TR inli:lgt!!'!. 472. 474. 475 cauda equina nerve root!'! in, 47'i CT'-guidcd hlOpsy 111. 47:) cr scan. 472, 474 degenerative ui�c disc:1sc V('nllS, 475 linal pl<1in lihn. 470 f".\,n11 01 L1-4 hodics, 476 hltcrul "llJil1 111m, 473-474 L3-4 dbc projeclion into vertebral canal. 47 1 . 474 I J verlcbml body end plate in. 470. 474 metastases versl/S. 475 ofCsel of L1 relative to L4 in. 4 7 1 . 474 paraspinal sort tissue mass. 4711. 474 plain film. 470. 474. 475 prevertebral ab�cehh in. 470. 474 psoas 111u�dt! i.lb�ct!!'!". 472. 474. 475 sagillal intermediate TR il1l:lge. 471. 474 saglllal long TK unagc. 47 1 . 474 sagittal hhurt TR image", pre- and postcontrast. 470. -\74 and secondary cpldur,11 and pamspinal abscess. 4ll.l-4i«i
M,:culll .!ary to rctropharyngcal abscess. 498-502 with soft lis"IIC componcnt and dcstruction of venc bml body tnd phll�. 467-469 IIbuvminnl aorlic ane urysm displacement in. 4h7-4hX lT at L1-L4 inlerverlebral disc. 460. 4b7--4OX CT·guidcd biopsy in. 468. 469 degenermlve changes in interfacet joinl" in, 467-468 osteophyte, .t L5. 467-468 pl.in Him. L2.L5. 467-468. '169 psoas muscle evaluatIOn tn. 4bM soft tissue l11a�)) 111. 468 spinal scicrosilll ill. L3-(I. 4117 46g, 469 spinal stenosis 111. L.1-4. 4b7-4oX and vertebral ostcomyehtih: lJilutt..:rul P))uus. cpiduflii. para�pincll iih))cc�)oc)" 4:>:7 490 with vertt!hral ll!l.h!Omyeiiti... 1 .3-4, :Ind spinal stenosis. 7XI -7X4
876
anternlisthe"i". L1 o n 4 a n d L4 o n 5. 782. 784 aXial short TR image. L3 prc- and postcontrasl. 7R2-7�3 uxinl short TR images. L�-4. 7SJ cauda equina nt!rvt! rovt i n . 782. 784 cr·guided biopsy in, 7X4 versus d�gt:neratlvc change" in, 7S4 degenerative Chi11lges in. interfacet. 783. 7X4 h�mncntu111 nllvum hypertrophy and. 7M ! . 7MJ. 7M !->l1gittul lun g TR image. lumbar. 781 "agittal short TR image. lumbar. 7MI sagittal sh0l1 TR image. lumbm poslcontrast. 782-7XJ spondylohsthe!l.ls 111. secondary 10 degenerative changed. 784 V(,r.\I1.\ !,!plIlldylolisthesis. 783 with vertchral osteomyelitis: psoas and epidural ab '«:es"cs, lumbar through thoracic "pine, 4�7-49() axial short Til. image. postcontrast. 48H-4S9 cauda equina nerve root comprchsion in. 487. 489 fat-suppn:sst:d �agillal short TR image. 488-489 L4-5 dbc space narrowing, 487. 489 L4 inferior end plate in. 487. 489 L5 lIuperior end plate in, 487. 489 lumbar thecal sac compression. 4X7, 4MI) organisms in. 489-490 paraspinal ab))ct:�))cS, 488-489 psoas lllullIcie Abscesses, 488-489 sagillal imermcdiate TR image. 487-489 sagIttal short TR image, 487-489 DISC mi�ration. 635 i1l1uging slices ror. 623. 624 Disc(,) cervical aXial short TR Image, C4, R lumbar axml long TR imugc. 49. 55 L3-4. long TR image. 53 midsagillal long TR image. standard spin-cehn tech nique. 33
sagittal short TR image. 4U pediatric. 24. 25 projection into i11lcrvcrtcbral fora men parns�gillal short TR imagc. 18 niSI-{ fI('i' niffu"e idiopathic skeletal hyperostosis (DISI I)
DIslocation C I -2 in rheumatoid arthntls, 544-548 C5 on C6 with llucl1l.1l ligalnel1t disruption and disc herniation, 302-305 � xi a l CT ..c;IO, 1H4 axilll short 1'R images. 303-304 latcrIIl pin in film of eervir;aI spine. 302 sagittal intennedjate and long TR images. 303 304 posttraumatic Down's syndrome wilh C I -2 suhluxalion versus. X24, X25 UlstractlQn uf L I -2 interfacci joints with oolllpre�sion fmcture of L1. 272-274 Dorsal root gangHon cervical axinl short TR image. 15 pilmsnglttal short TR image. 12 lumbar axial long TR imttge, 54 ax Ja I shmt T K image, 40 a:<J:11 short TR image, prc- and post In fusion . 5 1 cOlol1al ..hurt T R image, 36 par:1sagilwl short TR image. 37. 38 normtll short TR image. postinfusion. 14. 1 5 Dowager's h u m p . 325 Down's syndrome in adolescent. 133-134 with C I -2 dislocatIon. congenilal hCilrt di<;Ci.I'>C, atrial septal delect. 133-134 latt!ral VH!W ur l:ervieal spine. 133 )).Jgittal short TR image. 1' 13 CI-2 di..lncation in. 1J3-134 l' 1 -2 sublux�tlion in. 823-825 IIxiul cr sClin. upper cervical �plnc allLl fVI ameli magnum. 823-824 cervical spinal cord compression and dlsplrtcement in. 82.'5 lateral plal11 111111. upper cervical splnc Hill .! skull b.,". 823-824
odontoid process projection into fonmlen magnum, X2.1-824. 825 sagittal long TR image, pO"lerior foslIa and upper cervical )opine, X23-X24 hagillal hhurt TR image, posterior rosS! and upper ccrvicll l spine, 823-824 sub�rachnoid space compromlsc in. 823-824, 825 nrnp metastases from cerebral glioblasloma Ill ultiforme, 433-438 from germinoma. 451-4-)4 from medul lohlastoma, 449-450 With mcningcal carcinomatosis gliubhlslomn multiforme. recurrenl ccrcbflll, versus, 438 meningioma ver.ms in 57-year-old female, 1 88 myxopttpillttry ependymoma verfril low thoraeic-uppcr lumbar. 191 neurvlibrvmulOsis type 2 with schwannomas. postop erative changes. tethered curd verSIlS, 129 ncurofibromatosis Iype 2 with schwannomas verSIU, 794
postlan1lnectomy adhesive amchnoiditis UUS/IS. 741 from recurrent cpcndymuma nXlal shurt TR images. 199-200 sogitlUl shorl TR images. 198. 200 from recurrent ependymoma versus medulloblastoma, 200 from recurrent poslerior fossa ependymoma. 198-200 lrolll recurrem posterior fossa medulloblastoma C I SC <1ns. postinfusion. 449-450 �ugittnl short TR image. 449-450 �chwannoma versllS. 177. 183 Dumbbell·shaped tumors. 127. 217-224 Duplication cyst of rect um. sacral myelomeningocele IWr.W.'i. Xl) Dura u�trocylOma in. 1 68. 170 meningeal metastascs in . 861 -8(,7 Dural tear. with cerebrospinal nuid leakage. in fracture dislocation of Ll-2 spinolls proce"ses, 2R2-283 Dy"raphlslll 10 agenesis and tethercd cord. 1 00- 1 0 1 in ChiHri I I mulfonnation. 78. 79. 80-82 in ncomltc. 100-101
E Encephttlomyelltill, postinfectious. mulliple sclerosis verW� 706 Enc:eph lomyclopathy. post\'a,r;11latiol1. 7 16-7 1 :-1 End plale herniations. o f diM;. 771 -772 End plates. verlebral. cervical. 5 Ependymoma, 137-140 astrocytnmtt ttnd neurolibroma of dorsal root gangliun ver."'u. 143. 144 u�trucytoma of distal spinal cord versu.\. 2J3-234 a�trocytoma versus. 1 7 1 axial long TR image. 139 axial short TR imttge. ("1 po"leontra"t, l3X, 139 at C3. 137. 13�, 1 4ll cavernous angiuma uf -.:pillul c:vrd VcrSIIS, 837 dilated Virchow Robin spaces and. 195-197 gliom:l of cervical spinal cord and cerebellum versu.f, 1,0
�
intramedullary in neurofibromatOSIs type 2. 236, 239, 240 lumbar with hemorrhagic deposits, 197 lOagitt'll "hlln TR im:lges. 195 With Virchow-Robin spaces in brain. 1% rncta-.:tntic Licposils from. 1%. 197 metA"talic spread of. 163 myxopapillary lumbar, 189- 1 9 1 . See ul.m MYXOpllplll'lf)' epen dvmoma will; ht!murrhagt:. 192-194 schwAnnoma versuS. 177 in neurolibromatosis type 2. 129. 235-240, 241 -245 pilocystic aSlfocYloma verSlil, 1 66 postopcrath'e, C I -7. 1 6 1 - 163 axilll short TR lIuages. 162-163 cystic area in. 1 6 1 . 163 sagittal short TR images. 1 0 1 . ((11
I N D EX rccurrcnt postenur fU!:Isa. 1 98-200 drop metastasis from. 1 98-200 sagillal long TR image. 137. 139 sagittal short TR image
Cl-5. 1 37, 139 postcontrast, 137, 139
spinal coru cavernous angioma of spinal cord with hemorrhage f)('rsw;, 775 po�tuperati\'c changes. 1 6 1 - 1 63 �urgery for. postoperative ch;mgcs following. 736-73X
"'pinal cord metastasis uerlUS. 153 !:Iuhar,tlchnoid space compromise. 137, 139
with syrinx cavHy, 849-X52 a\;l(ll �hurt TR image. T4. 851 -852
.. ial short TR image. TIO. 851 -852 s
R52 sagittal short TR imuge. lower cervical and thoracic spine. 849
<;'1gittal short TR Image. lowcr cervicallthoracir.: spine PO!:ltt:olltraM, 850. 852 sagittal short TR linage, thoracic spine. 850. X52 syrinx. C2·T6 and dl�tal end of spinal oord. �50, 851 -852
Epidennoid tumor post spinal tap. 264 �chwannoma at L3 ven'us, 183 synovial cyst at left L3·4 interfacet joint ver.�u.�, fl72 Epidu ral abscess. 4X7-4l)(). 785-789 ccrvical dISC herniatiun. at C4·5 levt!l vcrsw., 538. 539
in diabctc!:I mellitus patient. 49 1 . 492, 4Q4. 4t)C;, 4%. 497 mult ilevel anterior unu posterior. 49 1 - 497 sccolllJdry to letropharyngcal abscess, 49X-502 postoperatIve disc !Ofcction ver.ws. 482 postopcruttve ubcitis with wound infection and drain· inK :.. i nus tract vt'rSfiS. 482 secondary 10 ui�itis. 483-486 sccondary to retropharyngeal abscess. 498-502 axial short TR image, midcervical fXlSlcontrast. 4'1'1, 501
aXial �hurt TR image. upper ccrvie
cerVIcal sptnul cord co1l1prc::,::,iOll in. 498. 499, 500 501 ('2·3 to C7 enhancement. 5tJ l degenerative changc� HI ccn ical spine. 498 parasugittal TR image. postcontrast. 499. 501
prevcrtcbral soft tissue mass. C2·C7. 498. 4W. 501. 5U2 sagitlul short TR Image, postcontrasl. 498. 501 !:iagil1al TI W image of cervicnl spine. 498 l rachea displacement ill. 41)& I:.piuurnl nbscess: paraspinal and psoas muscles ab· SCCSSCII 11xtal shurt TR images epidural abscess. 494. 4qfl
lumhar region. 4�. 4% pnruspinal muscle::,. 494. 4% postcontraliil , ccrvical Sllin:.l1 curu, 495-496 prel.'Ontrast at C2. 494. 496 p::,oas muscle. 494. 496 at Tfi, 492, 4%
cercbroopinal fluid and, 497 cervical spinal cord displacement and comprcssion in, 492. 495 in dillbctes meIHtus patient with bacteremia. 491 -4':17 epidural abscess. 49 1 . 492. 495, 4%. 497 laminectomy for. 497 meninges in. 491 sngittal short TR images lumbar, 491 lumbar subarachnoid space, 41) 1 , 497 meninges on. 491 thecal sac in. 491 Ihoracic, 492, 495 IiOft H:'!:Iue loUSS in
at 0·5 level. 492. 495 in subarHchnoid space oblttcmtiun. 492. 495 subunlcltrtoid space in soft lissue obliteration of, 4�. 41)5 thecal '>HC in, 491 . 495-4\}(}
Epldurtll nnd prcvcrtcbral abscesses. 785-789 axial long TR image. 786. 788 pre\,crtebrnl "bscess on. 7R7, 7Xl) axial short Tn. imagc
epltluml ubsccss on. 787. 789
prevcrtcbral abscess on. 7X7. 7�N spin"l cord compression antl uisplm:cmcnt un. 787.
sagittal short TR images, 3 1 7-318 ...uharachnoid "ipace compression tn. 31K
thuracic with blow III thecal "'[.Ie: air in vertebral <::10:11,
308-3 1 2 Epidural hfXlma. epiduntl hematoma
versus,
743
axial short TR images. pn!· and postcontrast.
Epidural lipolOatu::,is. 750-751 axial short TR image, 750 climcal hlSlory in. 750 disc LJulgltlg ill. ll1ultipk. 750
..agittal short TR Illlage. pusu.:ontrast
EPIUUI<11 metastases in lung cnnCN. 386-38X WIth 'I'l l
789 subarachnoid space obliteratIon nn, 787. 7Xt)
787-788 sagittal intermediate TR image. 785 disc space narrowing 011. C4·5. C5·6. 6--7. 7X5. 789 spinul cord �UCllli:l ull. 785. 789 sagittal long TR inhlgc. cervical, 785. 78(}. 7XX abscess cavIty at C5·6. 785. 789 Epidural catheter placement axial short TR images lumbar r..:giull, 3 1 0-3 1 1 thecal sac at kidney level. 309, 3 1 1
epidural hemaloma; blood i n thecal �ae. uir in verte· bral canal. 308-3 1 2 sagittal short T R image air in verlehral e.mal, 3 1 1 - 3 1 2 lowcr thorm.:ic und lumbar region. 308. 3 1 1 osteophytes i n lumbar region. JOX, : n I thoracic region, 309, 3 1 1
Epidural fat in Chiati I malformation with focal syrinx. 72 jn Chiari 11 malformation in m:onate, 78 lumbar axial "ihorl TI{ imagc, 45
idiupathic. causes of. 751 sagittal "ihl lrt TR image. 7511 thccul \ttc wmprcssion in. 750
Epidural venous plexus cervical normal. 1 0 uisc fragment. recurrent migratory post lumbar lami· neclOmy versus, 644 lumbar midsagittal shurt TR imagc. 3 1 Esophagus axi�1 short TR Image, 1 5
canCCr of. postraumliun changes anu, 725 727
Ewing\ sarcoma met(lstatic bone UerSHJ :,uft tb!:lue compunt:nt Ill, 370 compl t!!:Ision fracture. 1'8, J69 myelography in, )70 sagittal short rR images. 369-370 !:Iuft ti��ue epidural mass. T2. 369 :nn
splOal cnrd compression at '1"'2. TX, 361J-370 SptnOUlii process expansion. 1'2. 369 tUulliplc 1IIyeloma with infiltration of venehral body m a rrllw and ...oft tissue mass u('rS/Il', 406
nl1ds;tgittul lung TR image. ::,tiJnuard spin-ccho tech nique. 33
mid�gittal �hort TR image, 30. 34 l:.pidural hCllmlOllHl. 742-743 C.1use unknown. 799-SO I
F
axial short Til. image. lumbar. 71)9-800 axntl !:Ihort TR image. spine. 8OO-RO I hemorrhage in. 799-800. MOl o�teophytc in. L2-3. 8OO-SO I
F:tccl.... hilateral perched. 300-301
lcchnillue. 800-801 spillul cord compression. TI I · L 1
alion enhancement 10. 62 "'at hune marrow postradiation. JJ<,I
�i.l gittul short TR image. lumh:lr, 799-XOO sngittJI ...hoTt TR image. spine with rdormatting
79Q-R(�). 801 suhurachnoid space obhtcrution, T I I ·L3. 799-800. 801 thecal sac compression in. 79tJ-BOO. 801
epidural lipomatosis
f)erSUS,
in hungman's (racture. 2<J7 lumbar region. 744-74(,
750. 751
axial cr post infusion. 744 marrow of vertebral bodies in, 744-745. 746 sagittal long TR image, 744-745 sagittal short TK imHge, 744-745 thecal sac compression in. 744, 745
methemoglobin phase in, 306, 3 1 1 in multiplc myclornu. 407-409 with pleural effusions in multiple myelomil. 407-409
post epidural block. 306 307 axial short TR image, 3Ob-307 sagittal lung TR tnHlgt:. lumbar, 306-307 sugittal short TR image, lumhar, 306-307
post epidural catheter plaet:m(,!nt. 309. 3 1 1 . 3 1 2 post spinal anesthe�ia. 742-743 axial short TR image, LS. 742-743 displacement of dura in. 742. 743 sagittal long TR image. 742 s..1gittal short TR image, lumbar. 742
small. 306-307 spontaneous secondary to COllmadin therapy. lumbar. 313-;\16. 3 1 7-3IY. 746 axial short TR image. L2. 3 1 4-.1 1 5 axial short T R Image. I I level. 3 1 5 sHgittal short T K Image. 3 1 3 !:Iagittul short TR image with straigh tening algo rithm . 3 14-3 1 5 spinHI ennui compronltse in. 3 1 6 thecal "'
... all frum sitting )XJ!:Iitiull. 269 271 Fa�t !:Ipin echo technique. rapid :Icquisition With r�lax
as contrast agent. 356
IJt cnd of clivus. 1 3 thoracic. 20 Fat saturation technique usc of c..:rvical. 4 MR imaging of brachial plexus. 3f11 rat·suppre'i�i(lll IOhort TR images. 337 Filum tcnnlllak axial C'T image postmyelogram. 56 midsagill�l long TR imagc
in distal L!nu uf thecal sac. 32 Filum terminale lipoma sacral agenesis with. 93-96
tcthercu curu with, 1 04 - 1 06 Fle:\ion injury hangman 's fracturl! in. 2fJ2-297 pcrchcll f,lcets from. bilateral. 300-JOI Foramen magnllm
!O ('Iuan II malformation. 80-82 ill Clliuri malformation aXliIl shnrl TR image. hK-(llJ high Signal intensity fat arca anu. 9 miu!:luKlItal short TR image. 9 sagitlal long TR image. 1 3 sagittal shurt T R image. 5 . 1 0 Furamen o f Magendic. in pilocyllC ast rocytoma. 164. lfifi
Foram!Oa trunsversarium ccrvicI.11 coronal long TR image. 7 pHruMlgittlll short TR image. I I vt!rtcbral nrlery in. I I FraclLtre dislocation C4 on C5 with scol iosis and posltrllumatic syrinx ca\'· ilv. 2XI)-291 curonal !:Ihurt TR image. 290 291 ....ugil t1l1 midline reconst ruction i'rom cr scan. 2'XI-29I S
87 7 1
TEACH I NG ATLt\S OF SPINE I M A <1 I N G rrClcturc disloCdllOIl (01ll';I/Iwtl) hang.man·� ( .! 011 l'J \Iollh dbc hl.!rniation. 29:!-297 axidl C'T :-.1...111.... 21)). 2% axidl :-.hurt I'R image ... . 2(),,-Nn lah:rctl cervic al rlmn hi m. 292. 2% pmd�II�lltal lung TR il1lllgc. 294. 296 �agittal long TR imilgc. 2C)4. 2Q6 saglttal lllldlmc n:cnn<;lruction from cr scan. 292. 2%
s,lgittal ... hort 'I'll image, 294 . 296 �plnal cord cnmprc"�ion in, 294. 29(;, 297 :-.uhm :u.:hllllill spucc c:ompn.:ssion in. 295-2% uf L 1 ·2 "'pinol1'i processes with dural tear nnd cacbrospmal flUid leak age. 2H2-2R3 '16-7 with cord contusion and !1ara�pii1al hematoma,
276-2K I
l.IIlIcropo:o,tcrior plain film, thoraCIC. 276. 27Y ,1'
hematoma 111, 277. 21-;11 plL:ural CffW.. llIlI'" ill. 277, 2X() retrupubion. vcrtehrlll hudies into cerebral " l l1al. 27fi. 277. 279
�aglttlll lon!!. 'I I{ imagc. 277. 279 ...agittld ... hUlt TR image, 276. 279 ...yrinx cavity development in. 280 I--nu.:ture'i, S/'I' a/.\() Comminutcd fract u re: ( 'ofllprt!ssion fHIt.:tllrc�: OdonlOid frncturc(:.,) p:ltlHlll lglC III IIlctastutu: disease. 397-3YX ill o...tclJbl'l"tiL' disl.'::lsc. 4 1 7-420 FU'ilnn C4·S. o'ilcophyte formation wllh suhar
G Gl.l ngho�homa, L:pL:lldYll11llll11 wilh :.,yrinx ctlvity versus. X52
Ga�trninte ...linal tumor.;.. (J"itcohla"ilie and ostcolytic metaslaM.:.... o/'r.\'/I\·. pnl\lIHic. R03 Germinuma with drnp meta ...t;I"e" and spinal meningeal carcinoma\II!o!i�. 45 1 -454 axiul intcrn1('diatc TR image. pint:al gland, 453-454 (I,<wl long TR image. pineal gland. 453-454
4JA
coronal loihort TR llnngt!. hnnn. 414. 437 distal thecal :'dC tn. 4.15. 4.16-437 �del11a in, 4.14. 437 importance of pO'itinlllslon �can. 41S left frontal lohc In. 434, 437 L5- I IIltervertebral disc herniation in. 433. 4}fi-437
lumbar theelll �ae 111. 435, 437 ill pcdi
878
port!nccph�dy in po',;!operative. 434. 437 !o!agltlal long TR image. lumbar. 436-437 �a�lttal slHm TR images. lumbar. 433. 435. 437 Glioma 01 cervical 'ipin:!I cord and cerebellum. 149 11(l sHglltal TIW image. postcontrasl. 1 4IJ- 150 !'.aglll�d TIW image C2-6. 149-15U in child. 14Q-I:C;O Gluteal mu"dcs, postpolLo. 7M Gmllit.:nt ccho images. magm:tic sU�Lephhihty of. 346 rinlnillocytic sarcoma. S,'" Chloroma (gmnulncytic :.,u n.:omu) Guillain-Barrc syndrolllt:. Cyh)lllt:�cllu\,lru::, cr bruin 'ican comparison wilh, 52 1
H l l angman'� fracture .\,,1:' (I/oin II"dt'r Fracture dislocation C2 on ('3 wllh dLsc herniation. 292-297 ut!/lnitiol1 1Jf. 21)7 l Ieadache, in germinoma with drop metastase:., and !)pi nal memngeHI carcinomatosis. 451 -454 Hellll.lligiubll.lstumtl cerebellar axial 'ihnrl T R image. 258-259 lesion·u:.,sociatcd. 259 cerebral, 857-860 of ccrvical spinal cord sagittal short 'I I{ image, 25X-25IJ glioma of cervical :.,pinal curd
t::d::.t:: . 258-259 in von I l ippel·Lindau tli�ea�e cerebellar. 5W-blIl spinal COld, 25R-259. 599-601 I lemangioma. in T i l vt!rtt!'hral hody. 2(iY, 271 Hematoma, .\ee a/.w I:.pH.lurClI hematoma chlorullHl Vef1I1.\. 379 lipoma. L2 level with tethered "pinal cord and diastc matcllnveha Vl'r.\'II\·, 82 1 , K22 L2-3 midlm� dl\e ht.:rlllHtiun .... ith seq uestered frag ment L4 5 :Jnd hemorrh
lllldlUlnhar bilatcrnl. 310-3 1 1 . 3 1 2 with T6 and n fractures. 277. 280 posl traumatic epidural hematoma venllS, XUI 'Wrt tlssul' with cervical spinal cord injury. 305 spmal cord with LI compn:�:.,ion fradurt:. 284-285 Hcmatopoiesis extramedullary. 752-755 axial short TR illlagt:. pu�tcontra:.,t, 753-754 characterization of, 755 clinical history and. 755 condnions aS50clatcd with. 755 coronal short TR images. pre- :Jnd pO"lcontrast. 752. 75.1 -754 flow void art:a:., in. 752, 753-754 marrow in lumbar region, 754. 755 sagiltal long TH Image. 754 sagltlal l!hort TR lllla�e. lumbar, 7.14 spondylolisthesis in. LS-S1, 754 I lemicords ill diastt:lllatumydia, 1 1 5, 1 1 6- 1 1 7. 1 2 1 . 123-124 diplomyelia Vl'rw/S. 1 1 7 I-temophilla. spontllnCOUS cpidurnl ht.:matoma versus, 319
I lemorrhage. Sf'I' (Itm Blood with ht:manglubla:.,tonm. 259 po:.,ttraul11atic spinal cnrd artenovenous malrormation with subarachnoid ht:lllorrhagc uer.ms, 6 1 3 o f schwannoma, 177 spontaneous epidural hematoma uerslIS, 319 subacute lipoma verslIS. % I lemnrrhaglc intarcl. eighth cranial n�rvc. bilatcral acou:.,tldllluitipic st.:hwl.lnnomas versus. 132 Hel110rrhClgic tumor. "pinal cord arteriovenous malfor· mation with sllharachnoid hcmorrhage verSIlS, 613
Ht:mosidcrin. 3 1 1
Hemosiderin depo:.,itiOlI with cavernou� angioma. &37 With ht!'m
HepHtiti:., B vaccination. transverse myclopathy rOl low. iog. 7 12-7 1 5. 7 1 6-718 I-tila!' Iymphadenupathy. postrodiution changes and. 728 7]0
I lorseloihoe kidnev. 102-103 Hydromyeha, in Chiari malformation, 70 Hyperustol!is. difrusc idiopathIC skeletal. 5tH -5X3
Idlnpathlc tnmwcrse myclopathy multiple o.,clerosis uersus. 702 tru nsversc myclopathy postlmmuOlZatlOn uersus. 7 1 5 !linc crest. chordoma mvolvin�. 831 -833 100aging :.,t:4Ut:lll,;t:<; axial gradit!'nt t!'cho. 29 axial o;hClrt and long TR, 2Q cerVical flll-salUrated. 4 sagittal short and long "I K. 29 tmp .... rforatt: anus. l!acml agcm:sis with filum terminale lipoma in, 93-96 Inrant coccygeal .1gene'ii'i in, 90-92 M. IlIherCli/osis meningitis With pneumonitls In t.:.... rt.:brospinal flUid analysis and, 5(»<; meninges in. 507-5UR sagittal short TR images, 507 508 subar:lchnoid "pace below (5 in. 507-508 vertehnll hody end platcs in. 507-508 menmgomycloccle in. 90-92 pncumonitb and meningttis tn. 507-508 l!8cral teratoma ill. 260-262 calcification in, 260. 261 �agittal TIW image. 260-261 sagillal T2W image. 261 thecal sac in, lumbar, 260-261 telh�rr.:d eord in. 90-92 I nfurct bone marrow. 756-759 hemorrhagic. cranial nerve, 132 lllultiple �clerosis versus, 79 1 , 792 Inferior vcna cava flow void, axial short TR image. 46 Inllam malOry disease lung cancer with bony and epidural mctllstl.lseS uer
sus. 388
meta�tatic breast Co.1.ncer with adenopathy vtr.fllS. 359 Inflammatory mcningitis. bacterial. meningeal carcino mato'iis VI'rSUS, 4�2 I nllllmmatory process hrcast cancer metastatic to C2 vcrtt:hral body with cord comprt:s�lon verlUS. 3S5 drop lllctastase::. from recurrent posterior fOSS.l medul loblastomrt uers"s, 4�O M),('oh(wt('riwn tu ber('fl/o";,� versus sarcoidosis. 5 1 5 neurotihromatosis type I with plexiform neurofibro mal! in cervical spine verSUl·. Slt), 8 1 7 ncurolibromatosis type 2 with schwannomas Ul'fSIIS, 7Q4
Intcrfacct joint fluid, axial long TR inwge, 55 I n tcrfacet jOlnt(s} cervical para�a�iltal �hort TR iluagc. 1 2 degenerative changes in lumbar Ol'd al long TR image, 54 lumbar uxial short TR image. 46 thoracic and lumbar MVl.vbudcTlW" tuberclliosis in. 5 1 2- ) l � Interv�rtehral diSCS. Spp Disc(s) Intcrvertebral torarnen luntbar pLlrnsllgi tlal short TR image. 37. 38 in neurofibromatosis type 1 with multiple plexiform and dumbbell-shaped tumors cervical. 219. 22:l In neurolihromatosb type 1 with multiple plt.:xiform ncurolibrulnu�
•
I N D EX cervical. 2 12 . 213. 2 1 5. 2 1 6 lumbar: 2 1 4. 2 1 5
parasagitlal short T R Image. I I
T5-6 ano T6-7 renal cell cancer metastasis to. 372 Intramedullary enhancing le�ions. neurofibromatosis type I with m u l ti pl e ple x i fo rm neurofibromas ver >1'S, 2 1 6 Intra medulla ry i nfect i on . t rans ver se m yelo p ath y versus. 723, 724 Intrameuullary innammatory proc ess. s pi na l curu isc h emia with areas of enhanc�",�nt ver>IIS, 60l! I ntramedullary metastas�s. transverse my el itis versus. 711 Intramedullary metastatic de posi l , post radi a t i on
Leptomeninge al carcinomatosis, 429 432, 853-856 Leukemia. See alw Acute lym p h ocytic leukemia; Acute m ye l ogenou s l eu ke mi a mu l t ipl e m yeloma with l11 u rrow i n vo lvemen t verSltS. 394 Leukemic inliltrate in bone marruw with bony c�lv�rium metastases. 865. 866. 867 wit h du ra l meningeal metastases. 864. 866, 867
with gra nulocy tic sarcoma (ch loroma) of neck; dunil m e nin ge al met as t a,� , axial short TR images. cervical. 862. 866, 867 axia l short TR i m a ges, upper th oracic. X63. 866 coronal s h ort TR Image, brain post contrast, 864. 8b6 mass lateral to v ert ebm l column in. 862, 863.
ChllllgCS ill s pilla l coro amI ve r tebra l bodies versus.
8(,6. R67 radionuchde sC
726. 727 I nt ramed ulla ry tumor, cervical. imaging seq u e nc e s in, 3
sagi tt a l intermediate TR images. cervical. 862. 866
I ntrave nous drug abuse, di scit i s in. 483-4l!6. 4X7-4YO
sag i t t a l short TR images. cervical, R61
J
soft tissue mass i n, T3-4. 86 1 , 867
subarachnoid space compromise in. 862, 863. 866. 867
J ugu l a r vei n
now void. 250-25 1
nornull short TR i ma ge . pustinfusion. 1 4
with granul oc y t i c sa rc oma (ch lo roma ) of neck; d u
ral me n i nge al metastases; buny calvarium m e tastases. 861 -867
K Kidnev cor� nlll short TR i m a ge. 36
horseshoe in sacral age nesis with tethered cord. 102- \03 les ions in in sac ral agt:III;:::, i�. 96 Kl i pp e l- Fe il anomaly. 54Q 552 with Chiari I m u l ro rm a ti on, Icthered cord. lipoma. sac ral agen es is. 1 1 2- 1 1 4 lipuma a n u. 1 1 2 sacral agenesis and. 1 1 2 s agi ual intermediate T R i mage . T H . 1 1 3 s agi tta l short TR i ma ge. 1 1 2 fusion of Tl -TI and T6-1'7 . 1 1 2- 1 1 3 s agitt al short TR image, lumbar. 1 1 1 Ch i ari 1 malformalion-associated. 1 1 2- 1 1 4 de scrip ti on of. 551 K y p h osis
dorsal
with osteoporoti c com p ress io n fractures. 325 L..3 -4 level in discitis with epi dura l and para spi nal abscesses. 483 l h oracie
in adenocarcinoma. me t as ta t ic uterine. 353-355 normal. 20 s econdar y to osteo poros is . 320 T4 level in m e tastati c breast cancer, 360-361
L Lamina. cervica l , axial short TR image. 1 5 Lumineetomy completc hi late ral w i t h di sce ctomy recurrent herniated d is c fragment following. 637-639 indication of p re v ious in chordoma. recurren t pos toperati ve . 250-251 lumbar post operative recurrent ilerniated disc migration behind L'i vertebral b ody. 640-644 postopera llve adheSive arachnoiditis unu, 739-741 postop�nltive challge, w i t h . IR2-183. 736. 804-805 postsurgical clips and, ccrvicnl a n d t h oraci c. 857. 85lJ-Xo() syn ovi al cy st fol luwi ng , 670-672 ul ry nge u l vent ricl e . s�gi tt al short TR image. \0 Lat e ra l reee<s L4-S . s t e nos is of, 677-678 lumbar n rti eul u ti ng face.t -vertebral booy axia l long TR ima ge. 50 Leiomyosarcoma re c lal sacral myelomeningocele vcrjUS. 89
and le p to me n in ge a l carcinomatosis, 1<53-850 axial short TR imagc. th orac i c posteontrast, 855 cauda equina nerve root, i n . 854-855. 856 clinical history in, 856 d ista l sp inal cord i n , 856 marrow of ve r t eb ral bodies i n . 1:153. X55 pleural dfusions in. bilateral. 856 sagit t �1 fat u pp re ss iul l IllIag�. lumbar, fur m eni n ge al carcinomatosis. 854-855, 856 sa gitt al intermediate 1'K image, lumhar spine. 853 s agit t a l l o ng TR image. lumb�r spine. 854-855 sagittal long TR image, thoracic. 1154-1155 sagittal long TR image, thuracic pustcontrast. 854-855 TR i ma ge , lumhllr spine. 853
sagi tt a l short
wi th metastases in thecal s ac and meningeal
carcinomatosis, 443-446 in bone marrow wi t h bony calvarium metastases �xial intermediatel10ng TR im age s. brain, X63, X60
ax ia l short TR im age, bony calvarium. 865, 866 a x ial
short TR image, brain postcontra,t. 864, 866
throughout visualized marrow
axial long TR image, 444-445 cauda equina nerve roots in, 445, 446 with fracture LI vertebral body, and metastases in thecal sac. meningeal ca rcinomatos is . 443-446 s agi tt a l and parasagittal long T R images, 443-444, 445 , agitt a l short TR image, 443, 445
sagi tt a l short TR image, postcontrast, 445 in vertebral body marrow and men ingeal carcinomatosis. 455-457 in vertebral column marrow. 861-867
I . h e rm ine ·s sign. in Ch i ar i malformation. 70 Ligam e ntum flavum axial sho rt TR image. 46 lumhar disc bulge and, L4-5 with lateral recess steno sis, 677-678 Ligamentum Bavum hy pe rtroph y characterization of, 675-676
in discitis with vertebraJ oste omye li t is . L..3-4, ano spi nal sten osis , 78 1 , 783. 784 i n lumba r d i sc he rni ation L2-3 m i dl in e with fragment sequcstcrcu al L4-5, OS2. 653, 654 , p i n a l stenosis wi t h , 673, 675. 676 and vacuum degenerative changes of lumbar disc. 67'1-680 Lipulllu. Sec ulsu Epidural l ipo m a caudal reg ressi on .yndrome with tethered cord and vertebral anum a li es versus, 99 epiuurul h cm o to ma versus. SOl of liIum term ina le
" c ra l agenes is with, 93-96
,
tet hercd cord with, 104-106 L2 level with tethered cord and diastematomyelia , 11111-1122 axial fat saturation i mage.
U. 820-82 1
axial lo ng 1'R i m age. L3. 820-821 ax ial short TR i m a ge. L2. 8 1 9 . 821 c h em ical shilt artifact in, l!20, 822 dinical h is tury in, 8 1 6 danger of m yelogra ph y in. 822 dys ra ph i.m in. 822 lipoma, L2, 1:1 1 8. 8 1 9. 821 m idsa gi t tal lo ng TR i mag� r ar a. a gi t1 a l long TR image. 8 1 9. 82 1 sa g it tal short TR image. l umha r, R I X s pin ous processes i n. I Ocom p le t e miulumbar. 822 tethered �pinal curd. 820, 82 1-822 tethered cord with. 109- 1 1 1 Lumbar di sc aXial short
TR image. 4 5
conspicuity of lo n g UNSIIS short TR i m a ges in. 628 m igra ti on or L-2 to l a t e ra l recess. 646 and sequestration at L4-S. 632-636 Lu mhar disc hulge L4-5 wit h lateral recess stcnosis on ri gh t . 677-678 axial CT scans at L4-5 post m ye l og ra rn with bone window width technique. 677-678 int e rverteb r al foraminal stenosis. 078 ligamentum navum prominence in, 677-678 osteophyte i n . 677-678 Lumba r di sc h e rn ia t i on L2- 3 with di.c Iragmelll migration. 645-646 axial short TR i m a ge . L2-3. 645-646 s ag i tt al long TR image. 645-646 L2-3 m idline w i t h fragm en t seques tra t i on at L4-5, 651 -654 axial lung TR image. L4 miubouy_ 652-653 3-'( i al short TR il1l ag� . L2-3. 653 cauda equ i na nerve roots w i t h i n t h eca l ,ae, 652-653 disc p rom in � nc� at L2·J. L4-5. 652 hemorrhage along dursal aspect i n , /\5 1 . 652-653. 654 le ft parasagi t t al sbort TR image. 652-653 l i ga me ntu m flavum hypertrophy i n . 652. 653. 654 righl pa ras a gi t ta l short 1'R image . 65 1 sagi tt al IOtermediate TR image. 652-653 sagittal short TR im age. 65 1
sof1 tis,ue ma s.� encroachment on thecal sa c .
652-653 sp i n al stenusis in. 652-653. 654
su pe r io r e x t ru si on of n u cleus p u lpos u, in. 654
t h eca l sac compre ss ion in. 652-653. 054
L2-3 m igra ti on to lateral recess. 640 L4-5 axial silo rt TR images . 623 624 epidural fat obliteration in. 623-624 evaluation with multi -an g lc images, 623, 624 extrw,iun ano UII ,agi tt a l long TR image, 623-624 nerve roo t compression in. 648-649. li50 nerve roOl encroachment in. 623-624 poster ior d is pl aeem e n l of nerve root in. 648-649. 650
s a gi tta l short TR image in, 622
t h eca l SHe com pr essi on in. 646. 648. 64\!. 65U thecal sac displacement/compression in. 623 -624 IA·� wilh disc degene ration at U-4 and L5-S I . 0 1 Y-621 avulsion fracture i n . 620-621 ax i a l short TR images. 620-621 CT for avulsion fracture in. 621 uorsal root ganglion in intervertebral fo ra m,," . 620-621 obliteration of s uh a r ac h no id space m. 0 1 9 sagittal long TR i ma g�. 619 sagittal silort TR image. 619 th eca l sac com press io n m. 112(1-021 L4-5. disc migratIOn and sequestratiun in, 632-636 axial �hllrt 1'R images at L2. 634-635 axial short 1'R image' ," L'i. 633. 635 Bat,on's plexus e n h a ncem e nt in. 633. 635 �auua "4uill[l ne rv e roOl e n h a ncem e n t and. 634635. 636 ep i dura l venous p lexus in. 633. 635 L4-5. Icft lateral. with encroachment on intervertebral fommen, 1i47-1i50 axial sho rt TK im ages . 648. 649. 650 clillical evaluation in, 650 conj oined nerve roots in, 047, 650
87 9 1
TEACHING ATLAS OF S P I E I M AG I NG Lumbar disc hcrnmtiull
(l'tJIuimu:d)
axial short TR im:lge. upper lumbar. 387-388 evalualJnn of epidural fat and ccrcbrosplnal fluid.
dor�al ruot ganglion in. 649-650 fat ohlilcmlioll in, MX-MIJ
388 murrow of vertebral bodies in. 386. 388
MR imnging uerslIs myelography in. 650 oblitcrrHlon or roramen in. MX-MIJ sagittal shoT! TR image. 647. 649
sngittal long TR image of thoracic spine, 3X6. 3&�
pleural effllsion in. 387-388
expansion of. 164, 1M In child
thoracic spinal l'ul d cUlnpl t$sion in. 387 388 vertebral pedicle.! involvement in, 1�7-JR8
culun Ci.1I1CCr metastatic to subarachnoid space
nerve root sleeve ohhieralllln at 1...5 . 633. 635
aXial short I'K ImiJ�es. �63. 364. 365
parasagiltal short I K \llli-lgC, PUSlcuntnlsl, 633. 635 sagltlal llJllg TR l i nage. (,]2
bone dcstrucllull in. 364. 365 clJe!!t cr ucr!ms plain film i n . 366
sagltlnt �horl TR image. 012
CT
sort IISlo,UI! rna!'>'; hchmd L5. 632. 633. 635 thecal �ac ubllteratiun lit L5. 633. 635
pediclc cxpansion mto tht!("i:11 sal,; in. 363. 365 posteroanteriur and lat�ral plain films, 362, 365 sagittal short TR images. J61. 1M soft lissue mas.'\ Ill. 3M-365
retrolisthesls and. 025 sagittal long rR Ilnag!.!. 625
Illmhar, enlarged uersu.i
calcification in.
1>21
L5-S I lind L4-5 uxilll shon TR image. L5·S I . 630-63 1 .. xinl shon TR images. 630-631 commonality or. 631 compression of ncrve root sleeve in, 630-63 1 determinatiun of lalt:fiJlity in, 631 epidural fat and. 631 fd:-.t !'!pin echo technique uersus long TR images for. 1>3 1 left para�..gilllJl lung TR image. fast spin echo tech· nilille. hJO flJ I nlldsagTlI;ll long TR image. fast spin ccho tech· nique. 630-63 1
thecal sae crfacement in. 63 1 Lumbar disc migration and seqlll!�lr;won IA-5, fl32-b3b Lumbar spine chordoma involvJll�. K31 -833 comtJrc��ioll fnlcturc�. 272 275 Iidical cr scanning of, 624 infant ilxinl short '1'1{ image. 9 1 -92 long Til imagc. 90. 92 :,ugillnl short TR image. 90 lymph node enlargement �gittal short TR image. 42 normal anatomy. 29-b4 axial cUlIlput�d lOl1logmphy, 56-5� axial long TR imagc. o;,
880
recurrent posterior fossa With multiple drop metastu scs, 449-450 Melanoma. bre.!ast lanCt!r. lIIt:tastatie with oSlcoblastic compre&.ion
411
hreast cancer. mctastatic with osteoblastic Jllt:tastase�. uersus,
prevertehral IJlmhar axial short TR Images, prc· and postcontrast. 44 leukcmic infiltrate i n bone marrow with granulocytic sarcoma (chloroma) of neck; du ral meningeal metasta,\es; bony calvarium me 807
413
from c�rt:hral ghoblastoma multiforme with drop JIletasta�cs, 429-432 cOlltrusl enhancement in. 29 cytomegalovirus radiculitis versus. 521 from di ffuse bone metastases. 4J9-442 epidural absce"s
/len-uS,
4()h
imaging of. cuTltra�t e n hanced. 3
lumbar spmc i n sagittdl short T R image. 4 2 meningeal carcinomatosis uU.ms, 432 multiple myeloma wllh marrow involvement 394
uerSIl5.
Meningeal c1:lrclnomatosis
cerebral. 461 463 secondary to hreast cancer, 433-438
Lymphoma
lrum leukemiC illriltrute. 443-446 ill velH:bral body marrow. 455-457 uerstu.
vertebral metaStases secondary to non-I-Iodg kin'" lymphoma, 349
U('rSIIS
nerve root displacement in. 630-631 parasagittal short TR images, leftlright. b29
soft Ilssue mass at L5-S I . 630-031
po�tcri(lf fo..."" Wil h drop metastases. 44Y-4,')(}
epidural component and spinal cord compression
puratrachcal ill ml!lastatic renal cell C,lnccr, 171 -37fl
uer.ms,
meningitiS wllh tJlH!umonitis uersus.
5U7-508
sagittal short TR Image. 42
tastases
lIliJerruJosis
mel<J�tulic to sub�lrachnnid space. 450
metaslases. �pidural component and '\pinal cord
Lymph node(,) enlarged secondary to non-Ilodgkin's lymphoma, 347-349
sagittal short TR image. 625 vacuum degener
unSII.\"
448 M.
"enn
spinal cord displacement in. 363, 365
epidural rat obliteration in. 627 parasagillal long TR image, fl26-h27
diffuse u�h':l)hlastlc metastases in. 423
with drop metastases
wilh (I-guided biopsy, }64-1h.'l ( '3 vertebral body marrow and height 10. 363, 365
with disc degeneration. 628
Medullohlastoma
sagittal short TI{ 1Il1age of thorm;ie �PlJle, 386. 388
metastatic with Iling nodules on chest cr. 362-366
L5-S I . luteflii. 625 - 628 axial short TR images. 627 cauda cquina nerve root displacement 111. 627. 628
I n mcta:,tutk colon carcinoma. 202. 204 in pilocytic astrocytoma cystic lesion i n . 155. 15H
I!.!II paf!l�agJlt.. 1 �horl TR image. at intervt:rtt:bral fUTullIcn. 647, 648, 649
L'\·SI disc prominence ill. 632 mids(lgittal short TR imagt:. 633. hI')
Medulla
M.
IlIbt>rminsis
men i ngitis with pneumonitis
versus.
SIIX meningitis postcra niotomy wah arachnuid adhesion:, uersus.
506
Mycobaclerium luberculosis without sarcoido"is
uer
sus. 5 1 1 postlamineetomy adhesive arachnoiditis
M
uerSIiS.
74 1
postradli.lIion change in non-Hodgkin's lymphoma
Magnetic resonance imaging (MRI), contrast material for, 3 MagnelTe reSl)naOl.:e (MR) myelography adjunctive tu M R nnd cr scanning. 682 ilpplicution of. 682 descriplion of, t.X2 fa"l spin-eeho. 62 rapid aquisition with relaxatiun �llhaJiCellleJlt. 62 thrce-dimensionc.1 of lumbar spine. 61 uersu..\' myelography, 02 three-dimensional gradient echo-pulse. 62 Magnetic resununcc (MR) study lumbnr spine fast Ul'rSIlS '\tandard spin-echo tcchnique. 32 standard spin-ccho. 33 Mugnl.!tic susceptibility artifact in Chiari I malformation with postoperativl! changes in posterior fossa. syrinx cavHy. 8 1 1 . 8 1 2 in chordoma. recurren t postoperative. 252 in disc fragment. recurrent migratory post IlImhnr laminectomy. 643. 644 in grad ient echo image in cavernous angioma, 837 fruJII Illctullic implants. 345-346 with metallic fusion plate and fixating scrcws post dis ccctomy C5-6, C6-7, 838, 839, 840, 841 post laminectomy in von Hippel-Lindau 5oyndrome with multi ple spi nal and cerebral hemangioblastomas. 857. 859,
860 Marrow edema of with disc fragment, h3Y infarction 01 JO brt:ast CClIlCCr. 461 -462 in �ickle cell anemi(l, 756-757 multiple myelom
lIU',
vcr·
732
sHfcoidosis of central nervous system
uerM
..... .
secondary to breast cancer, 429-43 1 . 411-43X axial short TR Images, 4311, 432 cauda equma nerve roots in, 429. 430. 432 cerehral meni nges in. 43 1 -432 coronal shurt TR images of brain. 431-432 JIlcta�tutic deposit in L4 vertebra. 429. 432 primary tumor search in. 432 primary tumor types in. 432 sagittal short TR images, 429, 432 spinill and cervical lcptomeninges in. 432 spmal from drop metastases, 451 -454 secondary to breast cancer, 433-438 Meni ngeal metastases. dural. 861 -867 Meningioma(s) metastatic colon carcinoma uerllM, 205 in neurofibromatosis type 2. 12Y, 2.15-240. 241 -245 '\chwannoma
uer.iU.f.
179
spinal in ncurofibroillatosis type 2, 238, 239, 24n T8-9 disc hernialion with calcification in adenocarci noma paticnt
Ul!r.iIIS.
594
Tfl·7 disc herniation with calcification
ver)·UJ.
592
thoracic axial short TR image postcontrast, IJoW-IX5 sagittal short TR images. I R4-1 X5 spinal cord compression with, 185 thoraC1C diSC hl!rnialion uersus, T6·7, 590 JJl 57-ye(Jf-uld female, 186-188 uxial cr scan, 186, lAA axial pOSlmyelogram cr scan. 1 87-188 Imeral view o f myelogram. 186. 188 sagittal rcconstruclion view of postlllyelogrnm (1' scan, 187-188 Meningitis. 491 -497 bone metastases and spinal nlt:JlillgcHI c
441
chcmical wltli arachnoid adhesion...
•
INDEX axial short TR i mages. Tl i pre - and postcontrast,
epid u ral abscess verSIIS, 496, 497 infective
1:\46-847
gliob lasto m a multiforme, recurrent cerebral with men ingeal carcinumatusis versus, 438
wilh hone window widths. 390
cpidural cncroachment on Lhecal sac, TI 2-Lt , o,teophyte formation in, 847-848
innammatory. 432
sagittal long TR image, 845
postcraniolOmy with arachnoid adhesions. 503-506. 504-506 axial short TR I mage. L4. 5U5-506 axia l short TR Image, 1'9, 504. 506
sagitlal shon TR image, LA, 845
axial shon TR, 408-409
axial shon TR image. 408-409
t h ecal sac a t L4, 847-848
meninges of brain in. 503, 505-506 saginal short TR images, lower thoracic and upper lumbar. 504. 506
s y r in x cavity in, 504, 506
hemangiobla"omas VPrsus, 599-601
ante rosacral
choruumas with postoperative changes uersus. 25 1 de rmoi d tumor uerSIIS, 264 osteo blastic and osteolytic, 4011 -463 signal intensity of marrow ver.<".. tumor, 337
MR imaging versus myelogra phy of, 89
i
Metas ta t c disease. See also O st e ob l astic mctastatie dis
in Ch ia ri II m a l formation
ease; Osteulytic and os teob lastic metastases
i n nconate. 78. 79
breast or prostate
occipital
in elliari 1 I I m alformat i on , 87
M eningoencep h a loce le, in Chiari III ma lform ation . 87
multiple myelom a uerSIlS, 409. 4 1 6 chordoma: distal lumbar sp i ne, il i ac creSl , sacr u m , colon carcinoma melastasis uerSIIS, 368
in Chiari II malformation, 77-79
cumprcs,iULl fn,cturc, 321 , 323
in neunate. 78. 79
discitis with vertebral osteomyelit i s. U-4. and spi nal
congenital. 90-92
slenosis versus, 781
in infant. 90-92
U-3 midline disc herniation with sequestered frag
tethered cord , coccygeal agenesis and, 90-92
me nt at L4-S verStL'. n54
M etallic fusion plale and fixating screws
lung cancer with bony anu e piuu r al mctastases uer-
cervical spine post disce ct om y CS-6. C6·7.
epid u ral faL and. 407. 409 epidural hematoma. 407. 409 sagittal short TR image, cervical and upper tho
racic, 407, 409 spi nal cord di splace.m ent and com press i o n in. 407.
409 with inliltration of v"rtehral hody and soft tissue ma ss
cum pre",;i un fractures in. 408-409 with infiltration o f vertebral body marrow with soft
coccyx I}l'rs"s, X32, K33
Meningomyelocele
axial short TR I m age. lumbar, 4UX-4UlJ com pression fracture i n . 408-409
pleural effusions, 40X-409
Melastatic deposit(s)
neurofibromatosis type 2 verSIlS, 230 232
Men ingocele
axial long TR image. lumbar. 408-409
sagittal short TR image. post contrast with (at sup-
von H ippel-Linda u disease with cerebellar and spi nal
cerebrospi nal fluid culture in. 506
pre "i u n fradures. 392-394 epidural hematonlll and pleural effusions in. 407-409
sagittal short TR i m age, postcontrast, X45-R46 pression technique, 845-846. 847
cauda e4uina lIerve roOlS in, 504, 505-506
description of, 403 with diffusc Illarrow IIlvolvement and mUltiple com
847-848
M. luberculosis with pneumon itis. 507-508
CT sca n in, 3%
tissue mass, 404-406 compression fracture of L5 vertebral hody, 404 degenerative ch anges at multiple levels. 404 extension into dursal paras pi nal muscles. 406 marruw uf ve rtebral buuics a nd. 404 os teo phyt es in, 404 sagi u al short TR images. 404
sofl l i ssue tumor, L3 level, 404. 405-406
with involvement of spine and bony calva ri um . 389-391 antt!ropostt:riur plain film of spine, 389-390. 391
axial grauie nt echo image. C6. 840
388 mu l t iple sclerosis versO/s, 692. 693
axial short TR images, C6 p re- and postcontra st.
versus osteogenic carcinoma. 337
CT brain scan poslinfusion, 390
rrom primary tumor, 205
cr scan with bone window width. 390
thyroid
ucgenerativc changes with osteophytes at e5. C6.
838-1:\4 1
�'IL'J,
839-840. 84 1 comparison with plain Ii I m , X411 magnetic susceptibility arLifact in, 838, 839. 840. 84 1 sagit t al intenneuiate TR image. cervical spine. 838. sagittal long TR imagc. cervical spine, 839-840. 841
M I SME. See Multiple inherited schwannoma. meningi
anu metastasc� to vertehral buuie s anu spinu us pru ce,scs. 344-346
M R inwging effect on. 346 po,ts urgical changes in. 344-346
amcrolisthesis uf C4 un C5 wi th herniated disc. 286-288
from another primary
I�ukeillic inllltn'te ill hUl l e marrow and le ptom enin geal carcinomatosis versus. 855. 856 ca ncers si milar to. 3501 diffuse
neurofibromatosis typc I with plexi rurm neuro fibromas in cervical spine verms, 8 1 6. 8 1 7
with pathologic fractures post breast cancer Ire�l
ej ecti o n at high speed, 282-283
Hexion injury wi th
fra ct u re di s luca t ion
llxial short TR image. lower thoracic/lumbar. 282-283 dural tear with cere brospi nal fluidlblood leakage,
u
sagittal long TR image lower. thoracic/lumbar,
fractures uf T I O. Lt , L2. 842-844
difruse vertebral body with co mpression (racture at
282-283 sagittal short TR image, lower thoracic/lumbar.
n, 397-391\
282-283
clinical hi.lOry in. 398 compression (racture o( T6. 397 radionuclidc bone scan and. 398 s agi tt al reco n st ru ction i mage. t h oracic s pine.
Multiple in herit ed schwannoma, meningioma. ependy moma (MlSME). 239, 794-795. See also Neuro fibrommosis Iype 2 Multiple myeloma. 395-396
397 -398
versus am yloidosi s. 39 I
sagillal short TR i m ages. 397
soft tissue component eXlensiun into T6 vcrtebral canal. 397 at end of thecal sac. 443-445
with verte bral. Tll and L4, 845-ll4S
With
hem
orrhage
mening�al d u ral. 861 -867 MYClJl){IClerillln tuberculosis versus sa rco ido sis, 5 1 5
po't raui a tion changes, T1X-339 Ti l anti l A venebral bodies with epidural metasta axial short TR i m ages . T i l midbody pre- and post
radionudide hune scan currelatiun wilh. 391 with granulocylic sarcoma (chloroma) of neck: du tastases uersus. 867 leukcmic infiltrate in ma rrow and l e pt o meningeal car cinomatusis versus. 855, 856
with marrow involvement and com pression fract u res. 392-394 axi�1 shon TR image. 395-396 clinical cuns iu e ra t ions in, 396 cum pres s ion fractures, L I and LA ve rte b ral bully. 395 with disc proLrusion. lumbar, 395 m arrow involvement, 395. 3%
sagittal shurt T R i m age. 395
sagittal shon TR image, postcontrast. 393-394
sagittal short TR image. I horacic. 392, 393-394 ,uharachnoid space compression in. 395-396 transverse process in, lumbar, 395-396 m�tastuses to vertebral bodies with com pression fracturc verslll', 398 metastases versus, 344-346 metastatic lung cancer uerSIiS, 366
metastal1c osteublastic pruslate ea rci n um a uerSllS, 4 1 6 usteu blas t ic m , d osteulytic metastases versus, prostatic, 803 osteohl�stic metastatic prostate cancer versus. 352
axial short TR image
oSleolytie and ost eo blast ic mctastases verms. di ffu se:.
thoracic spinal cord compression in. 403
lung. 386-31ll!
pedicle at L3 level. 311lJ-3l)(J leu kemic infiltrate in marrow
amyloidosis ill. 759
With bony involvement and wru cum prcssion from
epidural
contrast . 847
toma, 284-285
L J -2 spino s processes, 282-283
diffuse bo n y
ses. 845-848
com pression (racture o( Ll with spinal cord hem�
282-283
ment , 842-844
C7. 389-390 expansion of frontal bone. 390 m arrow of vertehral hodies. 3X9-3l)()
ral meningeal metastases: bon y calvarium me
type 2
Motorcycle accident, fracture dislocation Tn-7, wi o h Motor veill cle acci dent
accuracy of M R imaging and. 337
verst"", 775
oma. ependymoma (MISME): Neu rofi b roma tosi,
cord cnntu.•ion and paraspinal hematoma, 276-281
MCHlswsis(es)
caverno us angioma of spinal cord
kin's lymphoma, 349 Methemoglobin, 3 1 1 . 3 17, 319
sagitt al short TR image, cervical spine, X3X
in es. 6. and 7 verLc hral hodies
h e mor rh ag ic
traumatic com p ress i on fracture versus, 271 versus vertebral metastase. secondary to non-I-Iodg
84 1
With
versO/s renal cell carcinoma. 382
bone destruction in bony c�lvariLlm. 390 . 391
suft tissu e mass, 402 406 axial short TR images, pre- and poslcontrast. 405-4U6 fat infiltratiun of paraspi no us muscles. 405-406 parasagitta l short TR image. postcontrast. 405-406 breast cancer with osteoblastic and osteolytic deposits throughout bone; cerebral carcinomatosIs verSI/S. 463 calvarium destruction ill. 390, 391 characterizatio n of, 39 1 with compression fr�ctures al '1'12, L I , L2, L3, LA. L5. 392. 393-394
797. 798 pleural effusions in. bilateral bloody. 408-409
po tsurgical changes with metallic implants and meta s tases uerslIs, 346 with rapid prugrt!"iun. 399-401 axial shO,1 TR images . LA pre- and po�tcolllrast, 401 com prc" ion fraclures al Ll . LA. L5. 399-400 marrow of vc rteh r al bodies in. 400-40l
paraspi na l mass in. 401
pedicle expansion in, 4()()-401 retropUlsion of Ll component into v�rtcbral canal. 399-400
sagittal lu n g TR im age. 400 40 I
TEACH I N G ATLAS OF SPINE IMAGI G (commitI'd )
Multiple myc10nm s(lgittal silO! t TR illl�lgt:'), 3l)Q�400
:\xi,,1 short TR images postcontra:-.t. 1 90 sagittal short T R images postcnntrast. IXl) lumbor
M),cobll(lerilllll avill'" illJracelllllarc
spinill corel dlsphtcement In. 3W-4(X) renal cell cancer metastatic to lung and thoracicllum· har verlehrac vaSIH', 375 �agillal long TR imttgc
inflammatory process of metastatic brea�t versus. 385 MycubuLiI!Tl lOII J,,!;crclllu.\i!) withuut sarcoido<;is �IU. SO'-J 5 1 1
ucr
lowcr cervical uncJ upper thoracic spine. 402
MYI.;uIJIIL'lcrillt/l
N
PIICllIIlUllitis nnLl meningitis with. 507-508
TR
schwannoma in, 1 80 I � I
infl:unlllatory process or. 385 in interfacet joints. thoracic and lumbar. 5 1 2-5 1 5 Rxial short 515
spmal cord cOlllprcsloIlOn
T R images.
pre- and postcontrasL 5 1 3.
cerebrospinal fluid analy:-.is ill, 5 1 5
frum sufi tissue compollent. 3')4 with thoracic vertebral body marrow involvement. J�1-JQ4 unusual presentation of, 845-848 with vertebral body marrow infillration and !loft ti�· sue mass. 404-406 Multiple myeloma, '''olyneuropathy. Organomegaly. I:.n· docrinopathy. Myeloma. Skm changt!:-. (POEMS) ostcoblastic metastatic prostate cancer
,"bt'fm/osis
in di:-'cllis. 4X5
sagittal shorl image po�tconlrast. 402-403 thoracic spinal cord compression on. 402 403
uerms,
352
Multiple sclerosis blurred vision in. 707, 7UX or bram. 6H\I-t193. 790-792 bnlill alld :-.pilHII cord. 689 693. 694 698 in adolcsccnl. (;<)4 6<)8, 790-792 RrClIlltc lihcr� in, 6%, 697. 698 aXial FLA I R image. brain. 697 axial long TR image. brain. 695. 697. 698 axial long TR illlage. brain at lateral ventricles. 691 -692. 790. 791 axial long TR mtage. central spmal conI. 695. 697. b98 axidl long TR image. upper cervical spinal cord. 790 7QI axial �hort I'R Image. brain. 6%-697 .axial !'!hort TR illlugc. hmin pre- and postcontrast. 691 692 axial short
TR image. posteontrast C4. 6W. 692
ccrebrospinal Ouid i.m aly:-.is in. 692. 792
l:crvical cord findings in. 692-693 corpu� callosum in. 695. 697. 698. 7c}(1. 71.)2
edema i n . spinal cord. 699. 70 1 . 702
front,,1 horll of Iilteral vcntrid� in. 700 -70 1 . 700 pcriventricular areas of brain tn. 6Q2 plaque in spinal cord in. 7�1. 71.)2 preventncular area lit. 697
correlation with neuroradiologic imaging. 5 1 � ('T.guided needle iI<,;plnHion with culture in. 5 1 5
aXial long I K image. 700-701 :-.agiltal lulIg TR illlage. C I through C7. ftl)l), 701 sagiWll lihort TK inwge. ccrvlc:'1 1 sptne. t1l)9, 701 sagittal short I I{ ima)::cs. mid- amJ upper cervical. 700 701 scx dlrrcrenee in. 702, 7()fl 'p,"al cord. �X9-6�3. 694-698. 703-706. 707-708. 7'lO-792 axiul ..hort TR imRgc.. 70S, 706 :lxial l
TR
TR
meningitis and. 506
t�thert!d cord. :-.acral agenesis. horseshoe. pelvic kid-
without sarcoidosis, 5t)l.)-5 1 1
aXial shorl ' 1 K imag�, 510-51 1 t.:c:rvic:al �pillal cord compression in. 5 1 0 5 1 1
5 1 0 -5 1 1 medulla narrowed at craniocervical junction. 509 ,'gill.l long TR image. 510-51 1 sagittal shon TR image. 509-5 1 1
sagittal short TR tmage. postcontra:-.t, 510-5 1 1 subarachllold :-.pace i n . 5 1 0-5 1 1 upper cervical cord to C2 in. 5 1 0-5 1 1 Myelitts
See
transver)'c. alsu Tran:-.verse myelopathy (myelitis) po:-.tilll llluni7.at . ion , 7 1 2 - 7 1 5 secondary If) multiple sclerosis, 7 19-721
or unknown caUM:, 709-7 1 1 . 722-724 Myclufibrosis, bre;:\st cancer with osteoblastic and osteo lytic deposits throughout bone; cerebral carcinoma tosis ver'iUS, 463 osteolytic and osteoblastic metastases 797. 798
vemlS.
diffuse.
M R imugillg ill rClml cell cancer metastatic to l u n g and thoracicl Illmhar vertehrae. 376
MK �canning verSIlS fur IIH.:ningioma. 185 in osteohlastic metalitatic prostate canccr. 352 for postsurgical changcs with metallic plate and ...crews. 346 Myelography with pO�lmyelogram cr scan. utrsus
M R I . for cervical disc herniation. 534. 536. 539 Myclumalaci�t from C5-6 disc herniation. 574-578 from degeneration with osteophyte formatHJII and trauma. 540-543 degenerative changes with osteophyte fornmllnn Iwr· SitS. 543 post C4·5 fUSion and ostt:ophyk fOllllatlun. 567 569 Myelonteningocele anterior sacral. KH-X\J
(h�cal so"'c �xtenslon in. KH ( 'llIan II malturmahon !1I1l.!. 77-79. �-R2 sacr;t\
uer�IIS.
vpr\'/iS,
757
sRgltlal long TK Iml:l.gc, 88 :-.agIWt\ !lhoJt TR im
715
anterior. 88 8t1 CT <;canning in, �9 tethered cun.! ulld lipoma with. 1 09- 1 1 1 Myxopapillary ependymoma derllloid tumor VeTSIIS, 264 luwer t llurm.:ie-upper lumbar. 189-1<) 1
raphi:-.m. tt:th�r�L1 cord ill, 100-101 ney in. 1 0 2 - 1 03
TR
Nerve. lumhar, coronal short image. 36 Nerve ruots. L3-4. long TR imagc. 53 Ncunll roramen. axial short TR image. 60
cervical spinal cord widening in. 509 leptomeninges surrounding cervical spinal cord.
"ast. 703. 705. 706 sagittal short TR i ntagcs. cervIcal pn.:· dnd PO:-.tCOII·
white matter i n . 697. 698
long TR image. 94-95
pneumonitis and meningitis with. 507-508 sarcoidosis of central nervous system verslls. S I R transverse myelopathy versus. 724
706 sagittal �hort TR images. Cl-J and C5-6 pmtcon·
"ast. 707-708 spinAl cord findings in. 692 transverse myelitiS lJersmi. 7 1 1
TR imagc of skull, 86
short TR Image. at tntervertehral dISC of LA-5, 1.)5
cervical or lumhar tap and. 370
prubable. 697 702. 699 702 axial mtermedlate TK Image. 70(1-701
cele. 1:IJ7 sllgittal short
sacral and coccygeal agenests, :-.inus tract. spinal dys
lJer:ms
bodies ver.'lIl'). 726. 727 postradiation changes with sptnal cord enhancement lJef.WS. 721.). 730
Chiari 1 1 1 malformation Yo ith occipital mcningocclc/meningocncephaln.
s!lgitta l intenncdiate TR image. 93. 95 sagittal shon image. 93. 95
:-.ugittal short TR images. 5 1 3. 5 1 5 temporal bone involvement and. 5 1 5
sickle cell anemia with multiple bone infRrcts
MR imaging of brain m. 7112 postradiation changt:s in :-.pinal COld and vertehral
axial short TR image. 94-95
radionuelidc bone scan in, 5 1 5
.rea. 5 1 3. 5 1 5 pamliRgittal �hort TR image, postcontrast. 514-515
Myelography in Itlc:ta:-.tatic Ewillg's sarcoma spinal cord enm· pression
cervical spinal cord ill imaging sequenc� in. 3
saerlll agcnesis with ilium tenninale hpoma Ill, 93-96
para:-.agmal �hort TR illlage. lumbar paraspinal
sagiltal long TR image. 69-1. 697 �gittal short TR image. postcontrast C4. 690, 6t12 suharaehnoid IlUid in, 694. 697
Neon;ltc
Chiari 11 malfonnation with meningomyelocele. sacral agenesis. 77-79
sagittal short TR image. thoracic spinal cord . 694 cerehro:-.pinul fluid analysis in. 702. 706
1l)4
lIIeUt:-.ta:-.es r nlln, 1 94
in inf,lIl1
cpiduf;l\ mass on, 402 thoracic spinal cord displacement. 402
transverse myc.:lopathy
with hemorrhagic arl!a�. IQ2 sagittal :-.hort TR Images, 1 1.)2
in di!
�agi lll.1l short TR image dctz,L'nen\livc changes in cervical spine. 402
TR
axial short TR IIll
Myco/}(U'/rrium species
Neuroblastoma. diffuse osteoblMtic metastases in. 421 Neurofibroma. 1 4 1 - 1 44.
Sep
aL'Io Plexiform neuro-
fibroma of dOJM1,1 root ganglion bilaterally, 1 4 1
144
dlUp llIetastasi:-. vcrsi/s. 200 dumbhell :lppe4lrRnce of enlarged lymph nodes
vaSlls.
349
L2·3 dISC herniation with (ragment migration 1>46
u�r�m.
schwannomR vas/IS, 177. 179 Tarlov cyst vusus. 61 Nl:u rofibromatosis with bilateral acoustic schwannolllils. Ill eni nginm(ls. and spinal cord ependymomas. 241 -245 aXial loIhort TR Image. 242, 244 coronal :-.hort TR images, 244-245 magnetic �usceptibility artifact. 241 pnrasRgittal short TR image. 242. 244 sagittRI long TR image, 242. 244
sllgittul TI W images. 24 1 . 244 bilateral acoustic schwannomas in. 242. 244. 245
cent ral Set> Neurofibromatosis type 2 Illcningiontas in. 242. 244
peripheral form. See Ncurufibrulll.at�i� type I Neurolibromatu:-.is t)'lX! 1 . 239 d:-.tl Ocytom
Vt'fSIIS.
233 234
axl1.ll posteontrast image. midhunterus. 126-127 congenital. 125- 1 27 plexifonn neurofibroma tn. 125. 127 eoronul short TR image. chest and thoracic spille. I '. 1 27 long "1'[( image, 126-127 with multiple plexifonn neurofibromas. 2 1 1 -216. 225-229 in adolescent patient. 225-229 at all Icvels. 225-229 axial image. up�r lumbar region. 227. 229 brac1ual plexus in. 2 1 3 . 2 1 5 spmRI cRnal sort lIssue masses I n , 225. 228 with multiple plcxifonn IIcul Ufibrumas mld dumhlwl l · :-.hapt:L1 tUIllOrs. 2 1 7 224 anterior sC:llcnlls muscle, 2 1 X, 223 Cilrottd artery flow voiLl, thoracic inlet. 2 1 9. 223 fXr\'ie�11 region, 2 1 7 . 2 1 8. 2 1 Q , 223. 224 globes of orhit and. 222, 22-1 imcrvertchral foramina in. cervical. 2 1 9. 223 left subclllvil.ln vl:in flo,,", void in. thoracic inlet. 2 1 9. 223 I U lIlbar region, 220. 22 1 . 222. 22]-224 right subclavl3n vein Ilow vOILi. thorat:lc ililet. 2 1 9 . 223 spinal cord compression
m.
220. 22 ! . 223
spinal cord displacentent tn. 220. 22J
INDEX supraclavicular region in. 2 1 7 , 223 trachea in, 2 1 9 , 223 with multiple spinal neurofibromata and plexiform neurofibroma on right brachial plexus. 1 25 with plexiform neurofibromas. cervical spine. 81 3-817 axial long TR image. C4·5, 8 1 4. 816 axial short TR image. (,A·S, pre· and postcontrast, 8 1 5 -8 1 6 bilateral, 814, 8 1 5. 816, 817 brachial plexus nerve roots in. 814, 8 1 b cervical spinal cord expansion i n . 8 1 3 . 8 1 6 coronal short T R image, cervical postcontrast, 8 1 5- 8 1 6 coronal short TR image, cervical spine post con trast, 1l15-8 1 6 corooal short TR image. vertebral artery postcontraS!, X I S -R I 6 mass a t C I -2 level, 813. 8 1 6 midsagittal short TR image. postinfusion. 8 1 3 parasagillal short TR image, postinfusion, 8 1 4, 8 1 6 sagillal short T R image. 813 spioal cord com pres. ion in, 81.�-XI6, 8 1 7 with plexiform neurofibromata in cervical spine. 8 1 3-817 short TR image, supraclavicular. 125. 1 27 Neurofibromato,i, type 2 astrocytoma in. 167- 1 7 1 axial short TR Image pre- and postwntrast, 1 30- 1 3 1 with bilateral acoustic schwannomas, 241 -245 with cerebral meningiomas and acoustic schwannomtls. 238. 239 characterization of. 1 32 dclinition of. 129 descript ion of. 239 with meningiomas and ependymomas. 241 -245 with multiple schwannomas, 793-794 with plexiform neurolibromas. 230-232 with plexiform neurufibromas in intervertebral foramina. 'tcmocleidomastoid muscle, intradural space axial short TR images. C5, 23 1 -232 cervical aod thoracic. 230-232 ,agittal short TR images. 230. 232 sagillal shon TR image lumbar. postcontrasl. 1 1 1 sagillal T1W image falx ccrcbri on. 238-239 with schwannomas. 7Y4-7Y5 With schwannomas. lumbar spine caud�1 equina nerve roots in. 793-794 cerehrospinal fluid analysis in. 794 clinical history and, 794 disc herniation io. L4-5. 793. 794 retrolisthesis in. L5 on S I . 793. 794 sagillal images. 793-794 with schwan nom as, postoperative changes. tethered cord, 128-129 spinal cord tethering in, postoperative. 12X-12'1 with spinal schwannoma. meningioma. and ependy moma, 235-240 axial T I W image. cauda equioa region. 238-239 sagillal TI W image of cervical and thoracic spine. 235, 216, 237, 239 sagillal T I W image of thoracic and upper lumhar subarachnoid space, 2.16, 237, 239 Non-Hodgkin's lymphoma postradiation change in. 731 732 vertebral metastases and lymph node eolargement ill, 347-349 ahdominal aorta tlow void and. 347, 349 axial short TR image, 348-349 epidural enhancement, 348-349 marrow in L3 and LA vertebral bodies. 348-349 parasagillal short TR image. 347-34R, 14'1 ,aglll>]1 short T R Image. lumbar. 347. 349 ,agillul short T R images. 347. 349 soft ti"ue masses. 34K-:W) thecal suc in. 347-34R Nllcleus plliposu�. lumbar dISC. axial loog 1'1{ image, 49
o Ochronosis (alkaptonuria) calcified T6-7 herniated di,c lI('rSIIS, 598 characterization of. 59M intervertebral disc calcification i n . 598
Odontoid fracture(s) meciicolegal prohlems and. 29Y old. 298-291} postlraumatie, 298-299 type I. 299 type 1 1 . 298-2'1'1 sagillal long TR image. 298-299 sagillal short TR image. 298-299 type 1 1 1 , 299 Odontoid process. 5 coronal long TR image. 7 degenerative changes in. 249. 25 1 in Down's syndrome dislocatio� of, \:l3-134 subluxation of, 133-134 midsagitlal short TR image, 9 sagittal long TR image. 6 sagittal short TR image. 5 Optic neuritis multiple sclerosis and. probable. 699 702 and transverse myelopathy secondary to multiple scle rosis. 7 1 9-721 Osteoarthritis. amyloido,is in. 759 Osteoblastic and osteolytic metastases from prostate cancer axial cr scan, T1 1 , 802-803 lateral plain film. thoracolumbar spine. 802-803 sclerosis. T i l vertebral body. 802-803 Osteoblastic metastatic deposits breast cancer metastatic to vertebral body marrow and ,pinal epidural space verSIlS. 460 diffuse. 460-463 in prostate cancer. 350-352 cervical and upper thoracic. 350-35 1 lumbar, 350-351 sagillal short TR images. 350-351 .aginal short TI{ im ages post scoliosis correction program, 350-351 scoliosis in. 350- 351 Osteohlastic metastatic disease in breast cancer, 410-4 1 1 . 4 1 2 -4 1 3 M R image correlation with plain film. 4 1 1 osteoblastic mctastatic prostalc cancer verslis. 152 diffuse in prostate eaoccr. 350-351 . 795-798 from known primary osteogenic sarcoma. 42 1 -423 with multiplc pathologic fractures. 4 1 7-420 in primary osteogenic carcinoma, 421-423 axial short TR tmages, 422-423 compression fract ures of L t . L3. L4 vertebral bod ies. 421 L5 vertebral hody encroachment on subarachnoid space. 421 radionucliue scanning in, 423 retropulsion of vertebral hody into vertebral canal. 422-423 sagillal long TR image, lumbar region. 422-423 sagillal short TR images. 421 from prostate cancer. 340-343, 350-352. 4 1 4-416. 802-803 re'pon,e to long TR sequences. 337 with soft tissue component in lowcr cervical region. 4 1 7 -420 Osteochondroma T6-7 disc herniation with calcification /lerSlIS, 592 TH-'1 disc herniation with calcificatIOn in adenocarci noma patient Vcr"IIS, 594 Osteogenic carcinoma. metastatic breast cancer ver.n"l, 137 Usleolytic and osteublustic metasta""s diffuse. 795-798 axial short TR images, pre- and post contrast. 796-7'17 bone biopsy in. 7<)7 coronal image in, 797 disc reversal sign in. 795. 797 marrow of vertebral bodies in, 71}5. 796. 797 radionuclide bone scan in. 7'17 sagittal lung TR image. lumbar, 795 sagittal short TR image. lumbar. 795 sagittal short TR image, lumhar postcontrast, 7Yb-7'17
spinal processes in. 795, 797 Osteolytic metastases brea�t cancer metastases in vertebral body marrow and spinal epidural 'pace verSlIs. 460
conversion to osteohlastic deposits, 420 di ffuse. 461 -463. 79�-7'1H response to long '1'1{ sequcnces, 337 Osteomyelitis C 5 a o d C 6 levels a n d retropharyngeal abscess, 498. 501 . 502 discitis and, 570-573 epidural ahseess verSllS. 502 at L3-4 and spioal st'lIlosis. 781 -784 vertebral. 487-490 discitis with. 477-47Y Osteophytes d iffuse idiopathic skeletal hyperostosis 580-582 end plates, <'5 and e6. 9
versus.
formation and chordoma. 249, 251 formation of and myelomalacia. 540-543 at L2-3 level. 338-339 post ("4-5 fusion, 567-561} Osteoporosis compression fractures i n kyphosis w i t h . 320, 325 Ll, LA. L5. IH2- I X1 thoracic. 320-325 in lumbar splll e synovial cyst aod. 666. 669 traumatic compression fract ure UfI'SIIS. 27 1
p Pagel's disease characterization of. 674-675 . 676 at L5. S1 . S2. sacral alae and Ihac crests. incidental. 675. 676 of lumbar spine. sacral alae. and iliac crests. 673-676 plain film in, 076 radionuchde bone scanning in, 675 Pantopa4ue". Sa Retained Pantopaque Paraneoplastic syndrome postradiation changes 1 0 spinal cord and vertebral
bodies verSlIs. 727 tran>verse myeliti, verslIs. 7 1 1 Pmaplegia. in �avernous angioma of spinal cord with hemorrhage. 773 -775 Paraspinal mass. postradiation changes versus, 339 Paraspinal muscles abscess of. 491-497 in diabetes mellitus patient. 493. 494. 491\ secondary to discitis. 4X3-486 postpolio. 766 Pathologic fracture, in metastatic disease from breast cancer, X42-844 vertcbral body, 397-398 in osteoblastic disease. 4 1 7-420 Pedicle. lumbar. coronal short TR image. 36 Pelvis, in neurolihromatosis type 1 with plexiform neu rofibromas. axial long TR image, 226. 229 Perched faeets from aCllle neck fte,ion injury. 300-301 compression o f nerve roollets in. 30 1 C4 011 C5 subluxatioll. 300 lateral plain film. 300 tre;,1 ment of. 30 I bow tie appearance of. 301 Pilocytic astrocytoma. 1 45- 148. 154 160 in adolescent, 164-11i6 axial short TR Image postcontras!. 147- 1 48 at tumor midportion. 147 - 148 axial short TR image. CZ. odontoid tip. 157- 1 58 axial short T R image. C l postcon t rast. 1 57- 1 58 C I ·3 axial short TR image. tip of odontoid. 1 57- 1 5 8 cystic lesIOn in medulla. 1 55. 158 cystic portion of tumor. 1 59 parasagittal lnng TR image, 1 55, 158 sagiltal long TR image. Cl-T!. 155. 158 sagillal short TR imag"'", 1 55. 158 spinal cord enlargement, 156. 1 5 8 subarachnoid space ohliteration in. 1 5 6 . 1 5 7 . 158 cen�cal spinal cord in, 164- 1 66 c11araeterization o f . 1 44 glioma of cervical spinal cord and cerehellum versus. 1 50
TEACHING ATLAS OF SPINE IMAGING with focal atruphy and tethering of thc spinal cord.
Pilocytic astrocytoma (contll/ued)
radionuclide bone scan i n . 4 1 6
76ll-770
mcdull� and, 1 64, 16(;
sagittal long T R image o f vertebral masses.
absence of spinous processes in. 7611, 769-770
postoperative
4 1 5-416
after arachnoid cyst removal, 768-770
axial TI{ images, 1 59 cervical spinal curd, 1 5'1, 1 60
axial post111yelogralll cr image. 76')-770
sagittal T R images, 1 59
axial short TR image. focal cord atrophy. 768, 770
tethered spinal cord, 1 60
IalCral reconstruction image. thoracic spine, 76')-770
.agillal long T R image. 1 48
sagill
sagittal long TR images, 1 1i5 - 1 66
sagittal long TR i1l1ag�, thoracic, 768. 770
cerebrospinal Iluid in, 343
sagittal short TR image
sagittal short TR image. thoracic, 768, 770 scarring nf arachnoid layer in. 71iX. 770
incidence of. 343
midthoracic, 146, 148 postculltrast, 146, 1 48 syrinx i n . 147. 148 SlIgittal short TR imagtl. cervical. 145, 1 47 sagillal short TR images, 1 64 , 1 M Pincalocytoma. germinoma with drop 454
me tastases versus,
Pinealoma colon cancer metastatic to subarachnoid space versus, 448 with drop metastases M. wbercu/osis meningitis with pneumonitts versus,
507-5IJ8 meningeal carcinomatosis from. 438 Pineoblastoma. germinoma wit h drop metastases versus. 454 Plasmacytoma culon carcinoma metastasis versus, 361': mUlliple myelumu verj'r;s, 39 1
renal cell m�tastatic carcinoma ve,.,'LV, 382
Pleural effusion in fracture dislocation 1'1i-7 with cord contusion and paraspinal hema toma. 277. 280 in lung cancer with bUllY and �pidural metastases and cord compression. 387-31<8 in multiple myeloma, 407-40'1 in thoracic di.c hermation
T8-9 wllh ealeilication in adenocarcinoma patient. 594
in thoracic spinal cord ischemia and infarct ion. 604605. 606 Plexiform neurolihroma in cervical spine. 81 3 -X 1 7 i n neurofibromatosis type 1 . 1 25 - 1 27, 2 1 1 -2 1 6. 217223, 225-229 in neurofibromatosis type 2, 230-232 on right bfllchial plexus. 1 2 5 Pneumonitis, a n d meningitIs with Mycobllrtl'Tiltlll ,"ber
..:V,
CII/O.
507-508
POEMS. See Multiple m ye loma . Polyneuropathy. Or ganumegaly, Enduerinopathy. My�loma. Skin changes Poliomyelitis. See aiso POSt polio syndrome characteri7ation of. 765 postpolio syndrome and. 766-767 Pulyeytbcnllu. with visual uisturbance and head shaking Down's syndrome with C I -2 subluxation with. 823-R25 Polypoid defect. at end plate of L3 vertebral budy. 1 82- 1 83 Postcrior longitudinal ligament calcification/ossification of, 557-560
ant erior spinal anery compression and, .'160
axial cr scan at C3. 55R-559
axial gOldient echo image at C3, 558-559
cr and M R I in, 559 cr dcmonstration of. 'i57, 55') disc hulge at C4-5. 557. 55')
inva�inatlOn of spinnl cord in. 560 lurdotic curve 10" in, cervical, 557. 559 m;Jnagement issu�s in. 560 l"teophytcs at ('4-5, C5-O. C6-7 with. 557. 559 spinal cord compression in, C2-C4. 557. 559 ossificatiun of characterization of, 553. 555
CT ver.I·IIS MRI for. 555-556
tYPIcal appearance of. 556 P,"toperative changes cervical spine. with metallic implants
C.'i-C7. 344-346
aXIal short TR images. C5. Cl. 345-346 sagittal shurt TR image. 344-346
lymph nodc involvement in. 343
spinal cord displacement in. 768. 770
with para-aortic lymph node involvement, 340-343
triangular shapcd ar�a, 768. 770
sagittal intermediate short TR im ages, thoracic
with scarring and adhesions of cauda equina nerve
spine. 34'1, 343
roots, 731i-738
sagittal long TR image. 342-343
adh",iuns in. 736, 737, 738
sagittal short TR image, lumbar spine, 341. 343
anteroposterior plain film. lower lumbar. 736 axial short TR image. 737
soft tissue masses aruund abdumlllal aorta. 342.
laminectomy L2 through thoracic region. 736
spinal cord compression in. 342. 343
sagittal shon TR images, 34tl, 34 1 , 343
laminectomy L3 and LA. 736
343
L3 and LA levels, 736
truncation artifact in sagittal 10llg TR image. 342,
pseudomeningoeele in. 737 sagittal long TR image, 737 ,agillal ,hort TR image, 736 thecal sac dilation. lower thoracic, 737 Postpolio syndrome, 766-71i7 characterization of, 71i5 dcgenerative changes in spine and. 766-767
343 usteoblastic and ustcolytie metastases in, 802-803 Protein electrophoresis. in mUltiple myeloma, 401 Pseudomonas aerugil1osa.
abscess uf. 4') 1 -497 bilateral. 470-476. 487-490
absence of muscles in, paraspinal. psoas. gluteal. 766 aXIal short T R image, L4, 766
paraspinal muscles loss in. 766
progressive scoliosis in, 766-767
scolio.i, with dors�1 encro�chment secondary to de generative changes in, 760-765 Postradiation changes, 731-732. See a/so Radiation necrosis i n cervical cancer, 338-33') as diagnosis of exclusion, 727 lumbar vertebra. 368 in non-H odgkin's lymphoma, 731-732 axial long TR image. lower pons-meduUa junc tiun. 73 1 , 732 axial short TR image. pontomedullary junction postcont rast, 731 in spimll cord and vertcbral bodies, 725-727 axial long T R image. thuracic spillul cord. 726 mediastinal mass in, 726 sagittal short TR images, midthoracic. 725 Schmorl's node deformity in. 725 with spimll cord enhancclTlcnt. 728-730 axial ,hort TR image. postcontrast. 728- 729
in posttraUmatic discit is. 475
Psoas muscle
in diabetes mellitus patient, 494. 496
axial short TR image, 45, 4Ii coronal short TR image, 36 post polio. 766
R Radiatioll necrosis, 727 Radiculitis. cytomegalovirus, 519-521 Radionuclide bone scan in acute lymphocytic leukemia infiltratc, i n marrow of vertebral bodies, 457 i n bone evaluation for back pain. 366 in hreast cancer metastatic with osteobla.lic metastases. epidural component, and spinal curd compression, 4 1 1 osteoblastic 111etastatic, 420 in disci tis, with paraspinnl extension and vertehral osteomyelitis, 479 indications ror. 271 in leukemic infiltrate in marrow. 867 in metastases. di ffuse vertebral body wil h compres sion fractUre at TIi, 391l
end plate compression rractures of TI and TI, 728,
in multiple myeloma with mvulvcmcnt of spine and
730 imaging correlation with cerebrospinal fluid analy-
in oSleoblaslie metastases. 4 1 1 , 4 1 fi. 420. 42:1
sis, 730 marrow of thoracic vertebral bodies in, 728. 730 parasagittal short TR image, hilar. 728-729 sagittal short TR image, posteontrast, 728-729 sagittal short TR imagc, precontrast. 728 spinal cord at TI-3 in, 728 ventral lateral spinal cord in. TI-3. 728-729
Postsurgical changes. Spe Postoperative changes
Prusta te cancer
diffuse metastases secondary to osteoblastic lesions in, 350-3)2 metastatic leukemic infiltrat� in marrow of vertebral hodies with meningeal carcinomatosis versus, 457 metastatic breast cancer with osteublastic mctastases and epidural cumponent vcrs"" 4 1 3 metastatic lung cancer versus, 388 multiple myeloma verSlLI', 401 ,chwannuma ven'us, 1 8 1 metastatic o<1eoblastic, 4 1 4-4 1 6 axial short T R Image postcuntrast, 4 1 b cauda �4uina cumpression i n , 4 1 4, 4 1 5 -4 1 1i Cf-guided bone biopsy i n , 4 1 6 t -r scanning for differentiation between ,uft tissue and hony metastas�s, 416
Cf scanning versus MR imaging in, 4 1 6
bony calvarium. 391
in osteolytic and osteoblasllc metastases. 7,}7 in prostate cancer, metastatic osteublastic. 4 1 6 i l l prostate cancer, osteoblastic metastatic. 4 16 R A R E (rapid acquisition with relaxation enhancement) (fast spin-ccho) sequences, 62
Renal cell carcinoma, metastatic to C3 vertebral body with cord compression, :I80-JIl1, 380-3X2
�xial short TR image. :Ill I laminae in, 381
sagittal short TR images. 380
spinous proceS' expansion in, :IXO, 3111 suharachnoid space obliteratIOn in. 3llO, 381 treatment of. 381 tumor replacement of vertebral body marrow in, 381l, 3XI -3X2 vertebral body artery now vuid in. 380-381 metllstatie to lung and thomcidlumbar vertehr�e. 3 7 1 -37/i articulatmg facels at T6, 372 "xial shon TR images. 373 clinical hi.tory i n diagnosiS of, 375-376 inferior aniculatmg facet expansiun, 373 mass at T6 epidural space, 371 M R imaging versus ruyelography in, 371i p�rasagittal images, 374-375 parasagittal short TR image, 372
epidural fat a t 1.2-3, 4 1 4
pedicle expansion at T6, 372. 373
epidural space in, 414 fat saturation postcontrast study in, 416
sagillal short T R image. 37 1
sagittal long TR image, 37 1
spinuu, processes, 344-345
fracture of L3 vertehral hody. pathOlogic. 4 1 4
sort t issue mass. 37 I
subluxation c.'I on C6. 344-345
L3 vertebral body retropulSIOn. 4 15-4 1 6
soft tissue mass. right lung. 373
f
I N DEX �I)ft ti!!!lIIC rcplucemc n t or pcdlck anll IIlf..:riur m tH.: ulaling face l. 374-375 meHlstatic to Ti l . L4. 845-84R. See aLw muler Meta sUIIIC Cl.lnccr von Hippel-Lind.1U disease in. 601 Retai ned Pa ntopaque an tcropostcrior plai n film. lumbar. 733. 735 a rac hnoidit i s and. 735 :lxittl short TR image. 734-735 chemicul shift artiract and. 734-735 disc herniation at L4-5 and. 733 735 sagil1l1l intermediate TR imttge. 734-735 sagillill long TR Image cc rebrospi n al Ouid ill. 734-735 sagittal short TR i mage. 731 on short Ver,flL'i long Imagc!!, 735
I'H.
in Ihecal sac. 733. 734-735
Retropharyngeal dbscess, with vertebral osteomyelitis. C5 and C6 levels. 49X. SIll. 502 Rheumatoid a rthri tis
C2
bn:a!!t canccr metastatic to vertebral body with cord compression VtrSIIS, 385 with C I -2 dlslocmion Duwn'!! syndrome with C I -2 disiocatiull veT!ms. 134 with C I -2 dislocation. disc he rn iat i on at C3·4. C4-S. �44-.�4X !lxiill CT imuge at Cl. 546-547
I'H.
I mage , C3-4 level. 544 . 547. 54X
Scuicilus muscle(s) anterior a nd m idd le
axial short TR Image . 1 5
pa rasagi ltal shurt T R image. I I Sca r rUllllat i oll. synov ia l cyst at left L3-4 i n terfacet joint uersu't. fl72
Schlllorl's node deformi ty. 77 1 -772 ill acute dissclllinutcd encephalomyt!lupathy. PO!!tV
thoracic. 2 0 Sehwannomtt, 175- 1 77 bilateral acoustic
ill nCUl oflbromatosis. 242. 244 in neurofibromatosis type 2. 129. 1 30- 1 3 2 cerviettl di�c he rn i ation . left lateral. a t C4·5 level. 537
chordoma: tlistul lumbar spine. sacrum . F.:Ut.:l:VX Vl'r.\'IU. 832. 833 . SI1crum
i n caudal regresSion syndrome, 97, 9R
i n rant, 9 1 -92 neonate. 95 Sarcoidosi s m bra in . 5 1 central nervous system. 516-518 axial shon TR image, postcontrast. 5 1 6-5 1 7 cerviCllI spinlll cord edema i n . 516-517 M R imaging correlation with chest x·roy. 5 1 8 pituitury stalk i n . 5 18 sngittlll short TR images. 516-517 slIharueh noid space comprom ise in, 5 1 6 cerVical spinal cord involvement 10. 5 1 6- 5 1 8 mUltiple sclerosis
Vt'TSllj.
706
MY('oh"rler;um IlIberculosi5 vt!r.�us, 5OY-51 1
o f spinlll mcninges. 5 1 8
lOX MR idclltitication of. lOR
sUQ!ical d isM.:ct i un for. lOB with low lumbar sk i n di m ple. 92 i n neonate, I OCl- I O I tel hcr\!d cord with. 107- I OX Sort tis!!uc tumor, chloroma uersus. 37lJ Spi nal canal, a i r in. 308-3 1 2 Spinal cord arteriovenous malformtttion With suharach noid hemor rhage and curd i!!chcmia, 610-614 astrocytoma uf. 233-234 iOierruptio n of. fl05 chluroma in. 379 evaluation of
hemorrhagic, 177 lIc::'lIlold tumor ucrstls. 806-809 isolated. T6
focili lltrophy and anterior tethel ing postoperative. 768-770
coronal short TR imagc. 178-179 sagi ttal silort TR imagl.-'S. 178- 179 12·3 dise herniation with fragment mi grat ion verSIIS. 646 l"mhar. 175-177 postmye logram CT SCiJll. L:urulwl reconslruction. 176-177 176-177 LJ. 1 82- 1 83 with osteoporosis imd postoperat ive clumges. 182-IX3 sagittal short TR image. 182-183 1ll!.:ll i n giuma versus, 185 in 57-yea r-old female, IRR mUltiple myeloma and, IMO-181 sllgi ttal short TR images. L2-L3. 180 1 8 1 m u lliple spi nal . 130- 132 in neurofibromtttosi1\ type 2. 236-239. 240
TH.
791. 798 in infant. 1 07
eavernuus Hngiuln H ur. 773-775. 834-837
m ul t i ple spmal wi t h m ul liple (..'crcbral me n ingi om as
sagi ttal short TR imagc, 93. 95
osteolytic and o!!lr!ohl
d i sc herniation ver.'iU.�} lateral. 830
sagittal !!hort TR imHgcs. 176-177
ltoiJgi ttal !!hort TR i mage. 100. 103 Sacml tt!ratoma v�.
sligi ttal long TR imagl:, lumbar, 756 sagi tt al shurt TR image. lumbar. 756
dorsal root ganglion enhun ccrncn t versus, 5 1 drop metastasis uersus. 200 dumbbell appeamnce of, 179
spi nal cord comprc��ion at cervicomedullary Junc tion. 544. 547
Sacral agF.:n!.:::.i !!. 1 00- 1 0 1 . 102-103 with fi lum term in ale lipoma, Q3-96 aXial �horl i mage. L4. U·5. 94. 95
with multiple bone inrarcts. 756 757 marrow or vertehral hodie1\ Ill. 75h
blood supply to
postmyelogra m cr scan, 1\ttglllal rceon�truction.
s
with hone i n ra rcts. 756-757 dmructcril.1It ion or. 757
chaructcri zat i on or. 177 d!.:nnoid tumor vtmms. 264 disc rragmen t versus, sequestered, 635
spmal canal cumpromise at 0-4. C4-5 i n . 544. 547 !!p i llal corti compression at C3-4. 546-547
�pillul F.:urll F.:Uln p ress ion in. slow Ufmus nlpid devcl opmcnt of, �48 )itcnmi� of vertehral canal i n. 545. 547. 54� �uhluxutiol1 with compressiull atruphy ur cel vicnl spinal cord in, 548 chordomas with postoperative cha nges versus, 251 M R I procedure or choice in. 548
Shunt tube. i n syrinx cavity. 85 Sickle cell di�ett�c
von Hipped-Lindau synd rome with mult iple spinall cerebral hemangiohlaslomas verSIU, 859 in neurolihromatosis type 2, 235-240. 793-795. See ellso Ncurofibromatos is type 2. 230-232
with plex i rorm neurofibromas axial short TR images. 231 -232 sagittal short TR i mages. C2 a nd upper thuruciF.:, 230. 232 with post lam inectomy changes and "pin;lI Cflrd teth ering. TI2-Ll. 804-8115 laminectomy defect m. 805 sa gi ttal short TR illlage, lumbnr po<;tconlm�t, 804-805 spinous process absence, 805 Tarlov cyst uerSlU. 6 1 thoracic disc herniation versus, TfI-7, 5t}() Scoliosis with dorsal encroachment secondary to degenerative changes. 760-765 axial 1\hort TR images, 762, 764 degcncrative cilanges in, 762. 764 sdgillal lo n g TR images, mid cervical. 762. 764 sagittal short TR i mages, lower cervical. uppcr thurade, 761, 764 �lIgilllll short TR images. reformatted wilh scolio<;i� correction program. 763. 7M-7h5 ... agittal short TR images. upper and nudccrvi clii. 760. 764 vertebral arteries i n . 762, 764 in fracture dislocation of C4 on CS. 2M'J-291 in ostcob last i c metastatic lIcpusits III prost:llc ca ncer, 350-351 reformat correction program tor, 352
in Chi,lri I malrorma t i on. 73
inte rnal se pt a t i ons in Chillri I malformatioll with rocal syrinx. 72. 73. 76 lipo ma of. 747-749 lower-than-normal With sacral agellc!!is with filum terminale lipoma, 93 96 Illul tiple sclerosis in . o.�9-693. 694-69M. 703-71)0. 707-708. 7lJO-792, See all'o Wider M ul t iple scle ru!!i!! lIornUl I lumhnr. midsagittal long TR imnge, stttndard spinecho techn i que. 33 midsagittal short TR IIl1
ped iatric. sagittal short TR image, 24 thoracic. 20 thoracic. sagittal long TR II nug\!, 21 postrall iation Changes in. 725 727 term i nat ion of coronal short 'I I{ i mage <11 LI. 35 at IIlferior cndplatc of L2. 93. 95 midsagittal short TR i motge. 30 Spinal cord ttrteriovenou.... malformat ion With subaruchnoid hemorrhage a nd �pill.. 1 cord iM:hcmia. 6 1 0-614 in adolesceOl. 610-614 ttxial short TR image. L1. h 1 2-h13 axial short TR i mage. T12. 612-613 cauda equina lIerve roots in. 6 1 2 613
di gita l a ngiogmm of left TI2 intercostal artcry. 612-613 m i dsagitta l hmg TR IllIuges. lo.....c r thoracic. upper lumbar. 6 1 1 . 613
Ifl ldsagi llal long 1'H. Images. uppcr lumbar. 61 1 . tl l ) parasagntal shurt T R illluge. upper l u mbar . 6 1 1 . 613
sttgittal �hort T R image, midthoracie. 610. 6 1 3 . 6 1 4 spmal curd compn:ssiull i n . 612-613 thecal sac in. 6 1 1 . 613 treatment of, f.14 vem draining malformation. 6 1 1 . 6 1 3. 6 1 4 vertebral canal i n . 6 1 1 . 6 1 3 Widening o f distal spinal cord i n . 6 1 1 . h l J Spmat cord comprr..:ssion rruUl bune destruct ion in metastatic a de nocn rcinomtt . 1�1-1�f. from bony and epidu ral lung metastuscs. 386-388 in brcust cancer. mt:ta!!tdtlF.:. 3R3 385, 4 1 2 4 1 3
in colon cancer. with T I 2 bone expa n�i on , 167-368 from C2 vertebral body meltl�ln�i�, 3X3-3R5
rrom C3 vcrtc bral body metast .lsIS, 380-382 from epid ural component in nmtast:uie hrc:-\st cancer. 4 1 2- 4 1 3 evaluation for sagi tta l long TR image. 342. )41
TEA CH I G ATLAS OF S P I N E I M AGING (CVlltillued)
Spinal cord compressiun MR imaging
uersm
cyslic degenerallve change
in mull'plc myeloma with �ufl ti� ... uc IIIU!)S. -102-403
al T1 in Ewit1g'� �'lrCull1a. 369 370
in uterine adenocarcinom(l. melaslallc. 353-356
with traulllatic compressitln fracture. 271 acule ui:-'SClII lIltllt!d �lIccphalo\1lyclop:.lIhy
aSl rocylom:1 o f dlslal spinel! cord transvcrst.: myelupathy
uer�'U\',
Spillal curd ischemia, 607 609
verSIIS,
versus,
718
233-234
7 1 5. 72), 724
VI'WIS.
726, 727
III �pil1ul curd ,Irlcriu\'cnous malformation. 610-614 Spinal cnrd lipoma. 747-749 aXial shon 'I I{ Im
posl lam ineclomy. 747
thcC<11 sac displacemcnticompression in. 67 1 -672 thcel" sac oblileralion in. 670. 672
normal. 20
lumh1'lr "ipine
Spondylolistht!sis
antcrolisthesls of L4 In. 666. ()(YJ axiul long TR image. 668
grade I. 655 65�
axial short TR image. 667-6tlR
L2 on U. 1 8 1
oSlcoporosi� ill. 666. 669
mldsagitlal long TR Image. 666
655-658
axinl long TR image. 152-153 axial �h(lrl TR image. pre- and POStCOlllril.SL 152-153
axial shorl TR image. L3-4. 656-657 axial short TK 1I1U1ge. U-5, 657 pl.l ra�lIgitt
sngiltul shorl TR images. 1 5 1 . 1 5 3
pars inlcrarl1culari" inlerruplion in, 656, 657. 65H
Spinal cord lumor(s)
p,cllc\nhulpc encroachment on intcrvcrtebral rora-
chordoma. 24fl-257
men. 656. 657
dermoid. 263-264
Migitllli iong TR image. 655, 658
hemangioblastoma. multiple
sagittal shorl TR image. 655. 658
i n von I lippcl·Lmdau d,'ic
<;pondylolysis in, 657, 65K
inlradural. 175-205
parasagitlal long TR im(lge, M7-tt6X
sagittal short TR Image. 666
Ihecal sac displacement and compression in. 667-668 spinal slenosls and. 672 Syringohyllrulllyt:lla
i n Ch13ri I malfornwlion, 79, R5 i n Chiari I I I mallormil.lton, R7
Syringonlyt:hu. lIiaslcmawlllyciia-llssocialed. 1 1 8 Syrinx cavity, 810 8 1 2 benign pllncytlc astrocytomu
L4 leve!. 664
245
580
L5 Yencbral body. 663-664. 665 SI superior cllLi plale, 663-664, 665
epiuural f:ll in. 6£12, 663-664. 605
primary acute dls�emmrHed cncellhalomyelopathy
uersus,
71�
�acral teratoma. 260 262 spinal cord i"ichenw\ wtlh (lreas uf enha nccmelll va· 608. 609
�pinal cord liponH\ ut'rs"s, 74R, 74() tran"iverse myellli"i IJI'r,\'IU, 71 1 transverse tnyc\upulily secundary l11ullipl.... sclerosis uenlU', 721
epidurrtl .o;pace enlargement in. 662. 663-664 nl.!rVCh al L4 level, �Irclehed. 664. 665 p�cllliobulging disc, 662. 663. 664. 665 sngill1ll long TR image, 662, 664
cerVIcal, 57lJ-580
\1\ Clliari I I I m a l formation. 86
evall1alion of. 76
Spondylolysis bilalcral. L4-5 level. 655-658 bilaleral and grade I spondylohsthesls. 659-660 axial �hort TR Illlage al illtcrfaCl! Joim. 660, 661
Spinal Imllinar hne. :) Sptnal sle nOSls. 677-678 wilh c.:ervical spinal cord injury. 305
C5 from a n lcroli"ilhesis <...'4 on C5, 291
cvalurtllon of lumbar
cr of lunlhar and lower thoracic vertebral canal in. 6XO
M R imaging for spondylolisthesis i n . 680
helical CT scanning in. 624
1 .3-4 fmm osteomyelills. 781 -784 L3-4 �c\:undary 10 ligamentum flavum hyperlrophy/en cro:lchmcm on vcrlchral canal. 673-676 axial short I'R Il\1ugc�. L5 and S I vertebral bodies, 674 675 axi .. 1 shorl TK \llHl�eS, L5 vcncbntl body
Pagct'� lIi�I.!!I�c al LS. S I . S2. incidenlal. 673. 675 incldcnwl, fl73. fl75
sagillill long TR imugc, 673. 675 �agilllli �h(lrl TR image. (,,7\ 670Ci
IA 5 and I ,-4 wtlh hlliging discs at L3-4. L4-5. LSS I . 081 -6X2
t!l1crmlcllllh.:nl on ..ubanlchnoid "pace, 68 1 -682 encroachment on Ihecal suc wilh. 68 1 -682 h�Unlt.:lllulll novum hYIX'rlrophy in. 681 -682
pu�l�ro
with vacuum L1cgenemlive c11(lng�s of lumbar disc. 67Y-6X11
axial cr �an with tissue bone widlh Icchnique, 67Y-(,Xll aX1iI1 <"':1 hcun wtth lI::.sue WII IUOW width lechnique.
Imaging sequcnces in. 4 in Chiari I malformalion. 7 1 in Chiari malformalion. 83-85 in child. 1 ().! - I 06 lIccomprcssion of. cervical posloperative follow-up. 83-85 diastemalomvelia-associated. 122-124 . distal cord lelhered cord with filum lerminale lipol11l1 wilh,
s(lgillal short TR image, 662 �pinlll stcnusis In. 662. 664. 665
axial �horl TR imnge al pars defeci . 660 dbc prominence tn. Ll)-S I . 659, fill c1isplacemem of L5 on S I in, 659
epldurul SpliCC enlurgemenl In. 659. 66 1
1 04- 1 06 evalualion for i,l
multiple scleroSIS
661 sagillal short TR image. 659. 661
Ul'rSIlS.
702, 706
�pillal \:urLi ependymoma remoyal
un"lLf,
1M
respon� 1 0 shunl tube placemenl M R evalualion of, 85 Ihoral,;ll: a:
659-660. 661
pseudobulging disc in. L4-S i, 659. fill
hiari I malformation. 70
posttraumatic
pmflsagi llal short T R image at inlerfacel joinls. pars interarlicularis interruption at L5. 659-660,
1 46. 148
I n fraclllrc di"loc(ltion of C4 on C5. 289-21J 1
axial shorl TR image
postope ralive chilnges PO"'I di..ceclomy with spmal fu
uersw'.
C4
Spondylol isthesis. grade 4. 662-665
171
muiliple scleroM� U£'rSliS. b1J2. 708
111 ,
�"gillal lollg TR image. 670. 672 s(lgillill shorl TR image. 670
Ihoracic
secondary 10 bilaleral spondylosis al l.A+5.
from leiomyosarcoma. 1 5 1 -153
Pagel's discn ..e
g
sagittal long TR Image. h
inlcrfacet joint changes anLi. 658
140
n"urofibroi11
reI ruirsl IrcslS, L2 un U and Ll on L2. 670
axial shorl TR image. 46
Spondylolislhesis. grade I
Spinal cord metaslasis
intramedullary. 137
i r regularily of i n ferior Mliculating facel in. 671 -672 oslcnphylc<; in, h70
lumhar
659-661
'i4lgillal shurl TR i mage. 7-47 ver'i/U.
c1i)'c :-.pacc narrowing in, L5·S 1 , 670 t!pldurul fut oblilcrution in. 670
Illidsugittal shurt TR image. 34
�cont.Jary 1 0 bilaleral spondylolysis. 655 65K
":lgiHal long TR image. 747-748
1886
cauda t!quina ne rve rools diliplacemenl in. 670. 672
gmde 4, M2-M5
oSlcophylc� with. 747
679 6HO
bUlging ui,,,,, . T I 2· L J . L J -2. L2-3. 670. 672
�Clgiltal shorl TR image, 10
�cconll"ry 10 lIegcllcrutivc changes. 182-183
degenertt livc ch.mges and. incidental. 747
SII.'I.
671 -672
anlerior
cungt!nital. 749
672
axial short TR imttge. vertchrrtl pedicle ill 1...4.
normill short TR ima e . poslrnfusion. 14
poslmumliol1 change... in spinal cnrd and vcrlchral
Uer,\'IH.
axial shorl TR il ilage. L1A, 671
ligamt!lllum navum hypertrophy in. 679 6.P.O Spinous processe'i
L�
Spinal cord 1I1farcll01l
sion
anlerolrsthesis t n . anlerior, b70
I11cla�la�c� 10, 344-3-46
wilh epiuul'al am.! prevcrtcbral abscesses. 78:'i. 789
cpendymnm!\
fOY-OS{)
cerVical
Spinal cord edemCi
hndlcs
111 .
inh:rfaccl Joint narrowlllg i n . 679-680
olhc:r 111t:lhods for. 376
�gittal shurl TR image. 74-75 Ihomcic-Iumhilr i n Chmri II malformation. 77-78 I l aumalic injury and, 280
sclero:iis in, 660 definilion of. 580 postopcrative changes posl disceclomy with :-.pil1al fu sion
lIers"s.
580
Sternocleidomasloid muscle plexiform neurollhroma"i in. 230-232 soft tIssue masseh itl llt:urofibromat05is Iype 2, 231 �212 Subarorchnoid space. cnloll cancer meta�Ulsis 10. 447-44H
SutKlrtviall vcill�. righl and left. in neurofihromAlosis Iype I. 219. 223 Suhl'lxillion t ' 1 - 2 11\ Down's syndromc. 823-825
C'2 on Cl. 2<)4. 2% (',' nn (''1, 300 t'.I UI1 C6. 304
postsu rgica l . 344-345 Synovial cy<;1. flM-669 ealcllie!.lliun of. 672 ehuraeterization of. 669 Vf'rsus
herniated discs. 672
inlcrfacel dcgenerative changc� with. 669 al L3·-4 inlerfacel juint. 670�672
T T;:lrlov cy<;IS dclllllltun uf, 61 Teraloma de"icription of. 262 malignu ill pUlcmial of, 262 ....'crnl, 260-262 caudal regression syndrome with tethered COlLI al iLi verlebral anomalies
uersIIS.
99
i n inrnm. 260-262
'iacral agenesis wilh filum lipoma suer,,1 myelomeni ngocele
utr
uer.)n\.
%
11$, 89
Tcth
con�cniwL 90-92. 100- 1 0 1 wilh m u m Icrminale lipoma. syrim: of dist(ll cord, expanded lumbar canal. 1U4- I UU IrPOl11u. myelomclli ngocele and. 109- 1 1 1 .. inu" Irael. 1(}7 -lOR I n infant. YO-':.12
,
I N DEX Ilucleus pulposus displacement in. 59·1 pleural effusions in. 594
with lipoma at L2. 8 I M-K22 amJ myelumeningocele. 1 09 I I I lower thoracic And upper IlIInhar in ncuroflbromatO!m; type 2. 128. 12\1 meningomyclocele. coccygeal agenesIs uIllJ . 90-92 tn neonate. IUO- I O I . 103 postlamincctulIIY. 163 postoperatIve. 768-770 post pilocytie a"trocytomA removul, 1 60
sacral agenesis. horseshoe kidney and. 102-1 (J) secondary to surgcry. 129
T I 2·L 1
post lamilleetomy. 804-805
Tethered cord . lipoma. myelomeningocele in infant parasagiUal image. left side, l I D-I I I parasugittal l mage. right side. 1 09- 1 1 0 Sl1g1ttal intermediate signal intensity image. ..agiual short
TH
image. I OY- I I O
Tethcrcd cord . sacral agene!)is. hUl3cshoe pchic kidney neonatal s
TR image.
103
Tethercd cord and �inu!) tract in inf... nt. 107-108 stlgittal short TH image. 107 TcLhered cord wuh filum terminale lipuma. syrinx of dIstal cord. expanded lumbar vertebral canal. 1 04 1 06 axial �holl T R image. 1 04 . 1 06 chemicnl .;;hift artifact i n . 1 06 in child. 104-100 "ngittal long TR image, 106
,agittal short '1 H image. 104. lOb vertebral canal cxpansioll in. 1 05 - 1 06 Thecal sac long TR image of. 52 lumbar axial cr images. 56. 57 myelogram. thrce-dimensional. 6 1
MR
parasagittal long
TR image. 59
metastasis to i n acute 11lyelogcnous leukemm. 443-445 from Icukemic infiltrate, 443-446 tenmnatu}IJ of 1IIidsagittai short tlHnncic
TR
ill111g�. 34
blood in. 308-3 1 2 Thor"cic disc hernwtion n·7. 587-5,}0 aXIal !)hort TR images. T5-6 and T6-7. 588. 58t) caklli":l.Itioll of. 5<xJ
CT "canning for calcification in. 590 kyphosis alld. S87-�XX, �90 midllagittal Inng "' H image. SM7-5K8 midsagittal short
TR imag�. 51:0-588
mu.shroum·�haped ma!i� in. 5R7 588. 589 pafi1�agitI<11 long TR image. 5AA-589 �pinal cord compr�sion in. 5X9 ,pinal emd displtlcemcnt in. 587-588. :;89 Th-7 with calclhcilliun. 591 -592 aXH11 CT sCiUl bcl"w T6 7. 591 -592 t1xiClI CT scan pO'it1l1yc1ogram u"ing hone width technique, )91 -592 axial cr scan pustmyclogram u!)ilig soft tissue win dow wIdths. 591 -592 T6-7 with compromise of vertehral cAnal. 5Q� ,.)�X in adole
axial CT scan at supenor end plate of T7. 595, 597
aXIal cr scan uSl11g bUlle window willlh�. 595. 597 uxiul cr scan u�ing bone window width" at T7-8. 596-597 nxinl cr shce, �95, 597 cnlcificatJon uf di!)c in. 595. 596. 597. 598 left parw.agittal reconstruction of spine with bone window widths. 597-59R midsagittAl reconstruction imagc using bone will dow widths. 596-597 vcrtcbrul ennal compromise in, 595. 596. 597 TB-9 with calcification in adenocarcinomA patient. 591-594 clxial cr image. TM·9, 593-594 axial cr image with bone winduw technique. 593 -.\'14
""gittal �hllrt TR image. lower medulla throllgh
593 594
C3-4 poMcontrast. 713-714 postradidtiull dwnges i n �pl1H11 cord and vellehral bollles U!"sus, 726 secondary tn multiple sclerrn as. 7 1 9-721
Thur acic 'ipinal corll a,trncytoma in. l ftX, 170 hemangioblastomas in. 599-601 bchemia and I'r e�ul1led infarction in. 602-606 midsagittal long TR image
axial short TR images. thor11l.:ic spinal ":old. 720-721
Ht L1 vcrtehral hodv. 32
6
brain imaging correlation with spinal Imaging in.
multiph.: sc1cru�l� in. 94 Thoracic !)pinill cord infarction, post aortic aneury"m re
With areas uf enhancement. 607-608 IWllumgioma ill T9 vertebral body. 608. 609 incidental disc protrllsion at LJ-4 and I �-S l . 60H wilhin lumbar vertebral bodies. brn:S
!)agillal long
TR Image. medulla throu�h C5-6. 712.
714 �
721 cerebrlll corlex ddl!et ill, 720-721 l c inical history in. 721
pair. 602 606 Thoracic 'irmal cord ischemia
stnus tract. 107-108
I I (}" I I I
sagittal long
�pllHiI curd displacement and compr..:�ion in.
TR image. 607 TR
corpul; callosum defect in. 720-721 optic neuntis in. 721 sagittal short image. bnnn. 720 721
TR
sagittal short TR imtlges. thortiCIC spinal cord. 7 1 \1 spinal cord Ischemia with ar..:as of enhuncem�nt ucr·
�us. 60S. 609
sagittal long image at conus medullaris, h08 "agittal short image. posteuntnlst. 607
thoracic sp1l1al cord ischemm and infarction
TR
urr.fjj�,
60'\
sagittal �hurt TR image at conul; medullaris. 1)08 spinal cord enlargement in. om
of unknown CHUS":. 709-7 1 1 axial �hurt image. po.;;tcontra'it. 7 1 0
TR
cervIcal 'irmAI cord edema i n , 709
infarction from. 606
sagittal 'ihort TR image, thorllcic postcontl!1�t. 7 1 0 saglltal short images. pre- a n d postcontmst, 709
trallsh!nl In elderly palu;:nt, 605-606
TR
ThoracIc �l1illlll cord ischemia and infarction axial short TR image. 604-005
Trauma anterolil;thesls of C4 on ('5
poslcontrast. 604--ft(IS len pllrasagitlal long image. 603. 605
TR
wlth h..:rniatcd dlSC al C4-5 level. 286-288 ,,:ulIlprcssion fracture in
left parnsagillal !)hort TR image. 603 604 pa r.'pinal fluid collection in. 604-('()�. 606
with cord ede ma, 2fi�-27 1 1 . 1 . 272-275
pleural effusion in. b04-605. ft()6
LI with dlstmction of interfalXt juints. 272-275 L1 with sp11lal cord hematoma. 2>t4-2X5 multiple. ]22-323
POSt aorhc aneurysm rcprur. 602-606 sngittal lung image. 603-604 sagittal short TR images
TR
ostcoporosls-relatcd. 324-325 T4 and '1' 1 2 . osteoporosis-related. 320-321 di"location of ('5 on C6 in with nuchal ligament dl�ruption nnd hefiliation of
postcontrast, 602. 604 precontrast. 602 si811al illtensity variation in secondary to flow-related, 603. 605. 600
C5·C6 disc. 302-305 cpidural hem
!lIgnal mtensity within vertebral bodies
!)c..:onllary to osteoporosis, 606 �ub3raehnoid space ohlitcfAtion in. 602
with hlooo m thecal sac. aIr in I,Icrtebral l:illllll. 30�- 3 1 2
Ihm<'lcic aorta in
i l l l1lillthorncic region. ( 'nl1m'ldinrelated . 3 1 7-:1 1 9
enlargcmcnl of. 603-604. 605 narrowing uf lower, 603. 605
spmltaIlCtlUs. 3 1 3-31(,
Thoracic spine
nt:xion in with frilcture dislocation L 1 -2. 2K2-2X�
di:;:,tal i n Chi
Ir:.lcture dislocahol1 ill
norlllal anatomy. 1 7-25. 1 9-25 axial Im:lge". 1 9
C4 on C5. �colimis anll posttraumatic syrin-.: cavity
eonlri.lst enhancement of, 1 9
('2 on C3 with herniated diSC. 292-297
associated WIth. 2RQ-291
aXIal long TR image. 23
L1 ·2. 2M2-283 T6-7 With cord contusion alld pnrn'ipinal hematoma. 276-281
imaging of. 1 9 pedi;lIric. 24. 25 <;}Igittal long Image. 2 1 . 22. 25 sagittal short image. 20. 24
TR TR
odontoid fractures in. 2\)K-2\19 pcrdu!d fi.lct:ts from
nlOTacic vertebrae renal cell cancer metastasis to. 371 -376
bildh!ral. 300-301 TUnlor(s) cervIcal cer,ical disc herniation. (';-6 level. nght 'ilde \'II,\'. 53tl
'I'onsillar ectopia defined. 70 sagittal short TR image. 10 Tr<'lchca. in neurofibromatosls type 1 , 219. 223 TnmsverM: hganlents cervical sagi ttal long TR image. 1 3 Tr8nSVer�l! ll1yelitis. See Transverse myelopathy (my r;:i1ti,)
Tran�vero;c myelopathy (myelitis). See (liso A..:utl! di�semlnlltcd encephalulllyelopathy
(ADEM)
acute di.;;seminated encephalomyelopathy C'-\II"e.'; o f , 72 1 . 723
""'.\'IIS,
718
calise unknown. 722-724 111 adolescent. 722 724 correlation of illlilgmg with climcal 11I�tury, 724 sagittal long TR Imilges, cervical
pustimmunlzatiun, 7 1 2-715
TR
axial long image. 713-714 axial short TR image. postcontrast, 714 clinical cnurse of, 7 1 5
U(',
Ima}!,lIIg �l!quence!) (l1111 contr:lst material in, 1 spinal l:uHI contra<;t enhancenlent 1T1. 29
u I JIlClnl.lte process ..:el vical :I):ial short TR lI11i1ge. 14 coronal long 1IIlHge. 7 ..:crvical. C4 :lxial short TR image. 8
rR
nonnal short TR mUlgc. postillfu!-JlOn. 14
v Vagus ncrve. neurufibroma uf. 212, 2 1 t) Vascular insult. Chiari I malfornHuion with focal �ynl1),. [)t!r.fIj,�, 70 Vllsculitis. mUltiple sclerosis Ut:".HI.'!.. 7Q I , 7Q2 Venous plexus. cervical vertebr:l1 hody, .;ngittal short TR image. 1 0
TEACHING ATLAS OF SPI
E I MA G I N G
Venous pl exus flow void coronal short TR image. 36 Ventriculitis, ccrebrHI. cytomegalovirus radicul i tis ver· SII.\', 52 1 Vertebral anomalies, diastematomyelia ver'lLI. 1 2 1 Vertebral a rt e ries eervical , 7 in foramen transversarium. I I VertebrHI body cervical, 7 dorsal root ganglion. L5 long TR image of. 52 endplates of lumbar sagittal intermediate intensity image, 43
Ll
axial short T R image, 60 spinal cord termination at, 35 lumbar parasagiUal ,hort TR image, 39 s�gitt�l long TR image, 41 midsagit tal short TR image, L4 and L5. 3 1 normal pediatric sagi ll a l short TR image, 24 postradiation changes in, 725-727 Ve rtehra l body height l um ha r mitlsagitt'tl short TR image. 30 sagitta l short TR image. 42 Vertchral can a l
in Ch ia ri I mal formation with focal synnx. 72
spinal and ce rebra l. 857-860
expa nsion of in pil ocystic astrocytoma, 164. 1 06 tissue i n from spinal tap synovial cyst at left L3-4 interfacet joint verSIIS, 672 Vertebral me tasta,e,. See 111m IIlIder Non·Hodgkin's
spinal cord, 258-259 typical I1nding� in, flOI Von Hippel-Lindau syndrome with multiple �pinal and cerebral hemanglohla�tnmas, 857-860
Iymphunm
magnetic sllsceptihility a rtifact in, 857, 859. 860
and lymph nodc cnlargcmen t . 347-349
pa ra, agil 1 a l short TR image, brain postcon trast.
Vertehral pedicle
859
Illmhar
parasagitta l short TR i mage , cervical spine, 857 post IHminectomy clip' in, cervical and thoracic.
axial cr image postmyelogram. 51\ axial short TR image, 47
R57, 859-860 postoperative changes in. from occipital craniec
axial short TR image. postwntnt,t, 48 10
m etas ta t ic disease, 337
tomy. 860
Virchow-Robin spaces
sagittal short TR image , brain postcO,.lrast,
axial short TR image of brain, 196
858-859
dilated, 195-197
,agi llal short TR i mage, cervica l spine, 857
Von Hippcl-Lindau disease with cerehcllar and spinal hemangioblastomas, 599-601
sagittal short TR image. thoracic spine. 858-859 Von Recklinghau,en', uise,tsc. See Neurolibromatosis, typt.: I
in adolescent patient, 599-601 axial short TR image. n. 600-601 cerebellar, 600-60 I coronal short TR imagc. brain. 600-601 sagittal short TR image. postcontrast. 5Y<J spinal cord displacement in, 599 subarachnoid space lesions in, 599, 600 60 I hemangioblastoma in, 599-601 multiple, 258-259
w Wallerian degeneration spinal cord ependym oma removal versus, 164 Whiplash injury degenerativ., c hanges with osteophyte formation post trauma, 541-543
t
