neuro -radiology
DESCRIPTION
Neuro -Radiology. SPINE. Raj Reddy Neurosurgery Prince of Wales Hospital. Objectives. R eview spine anatomy on X- ray, CT and MRI A pproach to interpretation of imaging Differential diagnoses for common spine lesions. Imaging Modalities. Basic Imaging Types. X-ray - PowerPoint PPT PresentationTRANSCRIPT
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NEURO-RADIOLOGY
RAJ REDDYNeurosurgery
Prince of Wales Hospital
SPINE
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Objectives
Review spine anatomy on X-ray, CT and MRI Approach to interpretation of imaging Differential diagnoses for common spine
lesions
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Imaging Modalities
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Basic Imaging Types
X-ray CT (Computed Tomography) MRI (Magnetic Resonance Imaging) Angiography
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X-ray
Limited Use Evaluation of:
Bones (fractures) Calcification
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Computed Tomography
http://fitsweb.uchc.edu/student/selectives/TimHerbst/intro.htm
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Computed Tomography (CT)
Tomography Imaging in sections, or slices
Computed Geometric processing used to reconstruct an
image Computerized algorithms
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Computed Tomography
Uses X-rays Dense tissue, like bone, blocks x-rays Gray matter weakens (attenuates) the x-rays Fluid attenuates even less
A computerized algorithm (filtered backprojection) reconstructs an image of each slice
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CT Image Formation
X-ray detectorX-ray
X-ray tube
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CT Image Formation
Backprojection
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CT Image Reconstruction – 6 Slices
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CT Image Reconstruction – 12 Slices
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CT Image Reconstruction – Final
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Magnetic Resonance Imaging
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What is MR?
Not an X-ray, electromagnetic Electromagnetic field aligns all the
protons in the brain Radiofrequency pulses cause the
protons to spin Amount of energy emitted from the spin
is proportional to number of protons in the tissue
No ferromagnetic objects
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Angiography
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Angiography
Real time X-ray study Catheter placed through femoral artery is
directed up aorta into the cerebral vessels Radio-opaque dye is injected and vessels are
visualized Gold standard for studying cerebral vessels.
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Angiography
AP Right ICA Lateral Right ICA
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Angiography
AP Right Vertebral
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Planes of Section
Axial (transverse) Sagittal Coronal Oblique
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Anatomy
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Radiographic Anatomy
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Cervical Spine – AP View
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Cervical Spine – Lateral View
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Cervical Spine – Open-Mouth (Dens) View
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Cervical Spine – Oblique View
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Lumbar Spine – AP View
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Lumbar Spine – Lateral View
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Approach to Xrays
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Approach to Spine Imaging
A – adequacy/alignment
B – bone
C – cord/canal/cartilage
D – disc
E – extras
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C7-T1
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Alignment
1. prevertebral 2. anterior spinal 3. posterior spinal 4. spino-laminar
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Cartilage Predental Space
should be no more than 3 mm in adults and 5 mm in children
Increased distance may indicate fracture of odontoid or transverse ligament injury
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Cartilage Disc Spaces
Should be uniform
Assess spaces between the spinous processes
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Soft tissue Nasopharyngeal space
(C1) - 10 mm (adult) Retropharyngeal space
(C2-C4) - 5-7 mm Retrotracheal space
(C5-C7) - 14 mm (children), 22 mm (adults)
Extremely variable and nonspecific
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CT Anatomy
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CT
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MRI Anatomy
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Compartments of the Spinea. Intradural, intramedullaryb. Intradural, extramedullaryc. Extradural, extramedullary
a. c.b.
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…
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Pathology
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Spine Pathology
Trauma Degenerative disease Tumors and other masses Inflammation and infection Vascular disorders Congenital anomalies
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Trauma
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Evaluating Trauma Fracture – plain film / CT Dislocation – plain film / CT Ligamentous injury – MRI Cord injury – MRI Nerve root avulsion – MRI
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To x-ray or not to x-ray? 13 million trauma
patients at risk for cervical spine injury
very low incidence of cervical spine fracture
In alert and stable trauma patients:
x-rays performed on 69% CT performed in 5% acute injury in 2.6% stabilization in 2.2%
Stiell IG et al. The Canadian C-Spine Rule versus NEXUS in Patients with Trauma. N Engl J Med. 2003.
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NEXUS C-Spine Rules
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Canadian C-Spine Rules (CCR)
Stiell IG. The CCR in Alert and Stable Trauma Patients. JAMA. 2001.
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Which one is better?NEXUS Pro: easy to use Con: poor sensitivity and
specificity (90.7% and 36.8%)
Con: more x-rays (67%)
CCR Pro: great sensitivity and specificity (99.4%
and 45.1%) Pro: less x-rays (55.9%) Con: more difficult to remember and use
Stiell IG et al. The Canadian C-Spine Rule versus NEXUS in Patients with Trauma. N Engl J Med. 2003.
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Plain film findings may be very subtle or absent!
Anterolisthesis of C6 on C7
(Why?)
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CTFractures of C6 left pedicle and lamina
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CT – 2D Reconstructions
Acquire images axially…
…reconstruct sagittal / coronal
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26M MVA
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Vertebral body burst fx with retropulsion into spinal canal
2D Reformats
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Vertebral Artery Dissection/Occlusion Secondary to C6 Fracture
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Hyperflexion fx with ligamentous disruption and
cord contusion
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Nerve root avulsion
Axial Coronal Sagittal
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Degenerative Disease
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Degenerative Disc (and Facet Joint) Disease
Foraminal stenosis
Thickening/Buckling of Ligamentum
Flavum
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Degenerative Disc (and Facet Joint) Disease
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Degenerative Disc (and Facet Joint) Disease
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Lumbar Spinal Stenosis
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Lumbar Spinal Stenosis
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Lumbar Spinal Stenosis
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Lumbar Spinal Stenosis
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Lumbar Spinal Stenosis
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Lumbar Spinal Stenosis
Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis
Note the trefoil shape of stenotic spinal canal
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Lumbar Spinal Stenosis
Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis
Note the trefoil shape of stenotic spinal canal
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Foraminal StenosisNeural
foramen
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Cervical Spinal Stenosis
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MRI - Degenerative Disc Disease
20-40 36% have degenerated disc 50 85-95% have degenerated disc 60-80 98% have degenerated disc <60 20% have asymptomatic disc herniation
Age:
Conclusion: Abnormal findings on MRI frequently DO NOT relate to symptoms (and vice versa) !
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MRI – Herniated Disc Levels 85-95% at L4-L5, L5-S1 5-8% at L3-L4 2% at L2-L3 1% at L1-L2, T12-L1 Cervical: most common C4-C7 Thoracic: 15% in asymptomatic pts. at
multiple levels, not often symptomatic
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Annular
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Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Protrusion Extrusion Extrusion
Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Protrusion Protrusion w/migration
Protrusion w/migration +
sequestration
Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
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Abnormal Disc
Bulge
Symmetric Asymmetric
Herniation
Broad-based Focal
Extrusion Protrusion
Sequestered Migrated Neither
> 180º< 180º
< 90º90º–180º
No waistWaist*
Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
*(In any plane)
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Central Disc Protrusion
![Page 107: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/107.jpg)
L5-S1 Disc Extrusion Into Lateral Recess with Impingement of R S1 Nerve Root
L-S1DiscR-S1
![Page 108: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/108.jpg)
Schmorl’s Nodes
![Page 109: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/109.jpg)
Cervical Radiculopathy
![Page 110: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/110.jpg)
Lumbosacral Radiculopathy (Sciatica)
Important: A herniated disc at (e.g.) L4-5 may impinge either the L4 or L5 nerve roots!
![Page 111: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/111.jpg)
L5-S1 Disc Extrusion Into Lateral Recess with Impingement of R S1 Nerve Root
L-S1DiscR-S1
![Page 112: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/112.jpg)
Spondylolysis / Spondylolisthesis
![Page 113: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/113.jpg)
Confusing “Spondy-” Terminology
• Spondylosis = “spondylosis deformans” = degenerative spine
• Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.)
• Spondylolysis = chronic fracture of pars interarticularis with nonunion (“pars defect”)
• Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects
• Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)
![Page 114: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/114.jpg)
Tumors and Other Masses
![Page 115: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/115.jpg)
Extradural = outside the thecal sac (including vertebral bone lesions)
Intradural / extramedullary = within thecal sac but outside cord
Intramedullary = within cord
Classification of Spinal Lesions
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Herniated disc Vertebral hemangioma Vertebral metastasis Epidural abscess or hematoma Synovial cyst Nerve sheath tumor (also intradural/extramedullary)
Neurofibroma Schwannoma
Common Extradural Lesions
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Nerve sheath tumor (also extradural) Neurofibroma Schwannoma
Meningioma
Drop Metastasis
Common Intradural Extramedullary Lesions
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Astrocytoma Ependymoma Hemangioblastoma Cavernoma Syrinx Demyelinating lesion (MS) Myelitis
Common Intramedullary Lesions
![Page 119: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/119.jpg)
Classification of Spinal Lesions
Extradural IntramedullaryIntraduralExtramedullaryDuraCord
![Page 120: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/120.jpg)
Extradural: Vertebral Body Tumor
![Page 121: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/121.jpg)
Extradural: Vertebral Metastases
T2 (Fat Suppressed) T1 T1+C (fat suppressed)
![Page 122: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/122.jpg)
Extradural: Vertebral Metastases
T2 (Fat Suppressed) T1 T1+C (fat suppressed)
?
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Vertebral Metastases vs. Hemangiomas
Hemangiomas (Benign, usually asymptomatic, commonly incidental):
Bright on T1 and T2 (but dark with fat suppression) Enhancement variable
Metastases:
Dark on T1, Bright on T2 (even with fat suppression) Enhancement
![Page 124: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/124.jpg)
Vertebral Hemangiomas
![Page 125: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/125.jpg)
Diffusely T1-hypointense marrow signal may represent widespread vertebral metastases as in this patient with prostate Ca
This can also be seen in the setting of anemia, myeloproliferative disease, and various other chronic disease states
Extradural: Vertebral Metastases
![Page 126: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/126.jpg)
Extradural: Epidural Abscess
![Page 127: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/127.jpg)
Extradural: Nerve Sheath Tumor(Schwannoma)
![Page 128: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/128.jpg)
Intradural Extramedullary: Meningioma
![Page 129: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/129.jpg)
Intradural Extramedullary: Meningioma
![Page 130: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/130.jpg)
Intradural Extramedullary: Nerve Sheath Tumor(Neurofibroma)
![Page 131: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/131.jpg)
Intradural Extramedullary: “Drop Mets”
T2 T1 T1+C
![Page 132: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/132.jpg)
Intradural Extramedullary: “Drop Mets”
![Page 133: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/133.jpg)
Intradural Extramedullary: Arachnoid Cyst
T2 T1
![Page 134: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/134.jpg)
Intramedullary: Astrocytoma
![Page 135: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/135.jpg)
Intramedullary: Astrocytoma
![Page 136: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/136.jpg)
Intramedullary: Cavernoma
![Page 137: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/137.jpg)
Intramedullary: Ependymoma
![Page 138: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/138.jpg)
Seen with:• congenital lesions
• Chiari I & II• tethered cord
• acquired lesions• trauma• tumors• arachnoiditis
• idiopathic
Intramedullary: Syringohydromyelia
![Page 139: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/139.jpg)
Seen with:• congenital lesions
• Chiari I & II• tethered cord
• acquired lesions• trauma• tumors• arachnoiditis
• idiopathic
Intramedullary: Syringohydromyelia
![Page 140: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/140.jpg)
Confusing “Syrinx” Terminology
• Hydromyelia: Fluid accumulation/dilatation within central canal, therefore lined by ependyma
• Syringomyelia: Cavitary lesion within cord parenchyma, of any cause (there are many). Located adjacent to central canal, therefore not lined by ependyma
• Syringohydromyelia: Term used for either of the above, since the two may overlap and cannot be discriminated on imaging
• Hydrosyringomyelia: Same as syringohydromyelia
• Syrinx: Common term for the cavity in all of the above
![Page 141: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/141.jpg)
Infection and Inflammation
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Infectious Spondylitis / Diskitis
Common chain of events (bacterial spondylitis): 1. Hematogenous seeding of subchondral VB2. Spread to disc and adjacent VB3. Spread into epidural space epidural abscess4. Spread into paraspinal tissues psoas abscess5. May lead to cord abscess
![Page 143: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/143.jpg)
Infectious Spondylitis / Diskitis
T2 T1 T1+C T1+C
![Page 144: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/144.jpg)
Infectious Spondylitis / Diskitis
![Page 145: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/145.jpg)
Pyogenic Spondylitis / Diskitis with Epidural Abscess
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T1
T2
![Page 150: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/150.jpg)
T1 + C
Spinal TB (Pott’s Disease)
• Prominent bone destruction• More indolent onset than pyogenic• Gibbus deformity• Involvement of several VB’s
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Spinal TB (Pott’s Disease)
• Prominent bone destruction• More indolent onset than pyogenic• Gibbus deformity• Involvement of several VB’s
![Page 152: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/152.jpg)
Transverse Myelitis
Inflamed cord of uncertain cause Viral infections Immune reactions IdiopathicMyelopathy progressing over hours to weeksDDX: MS, glioma, infarction
![Page 153: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/153.jpg)
Multiple Sclerosis
Inflammatory demyelination eventually leading to gliosis and axonal loss
T2-hyperintense lesion(s) in cord parenchyma
Typically no cord expansion (vs. tumor); chronic lesion may show atrophy
![Page 154: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/154.jpg)
Multiple Sclerosis
Inflammatory demyelination eventually leading to gliosis and axonal loss
T2-hyperintense lesion(s) in cord parenchyma
Typically no cord expansion (vs. tumor); chronic lesion may show atrophy
![Page 155: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/155.jpg)
Cord Edema
As in the brain, may be secondary to ischemia (e.g. embolus to spinal artery)
or venous hypertension (e.g. AV fistula)
![Page 156: Neuro -Radiology](https://reader035.vdocuments.us/reader035/viewer/2022081419/56816514550346895dd790e2/html5/thumbnails/156.jpg)
Spine Imaging Guidelines1. Uncomplicated LBP usually self-limited, requires no imaging
2. Consider imaging if: • Trauma• Cancer• Immunocompromise / suspected infection• Elderly / osteoporosis• Significant neurologic signs / symptoms
3. Back pain with signs / symptoms of spinal stenosis or radiculopathy, no trauma:
Start with MRI; use CT if:
• Question regarding bones or surgical (fusion) hardware
• Resolve questions / solve problems on MRI (typically use CT myelography)
• MRI contraindicated
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4. Begin with plain films for trauma; CT to solve problems or to detail known
fractures; MRI to evaluate soft-tissue injury (ligament disruption, cord contusion)
5. MRI for sx of radiculopathy, cauda equina syn, cord compression, myelopathy
6. Fusion hardware is safe for MRI but may degrade image quality; still worth a try
7. Indications for IV contrast in MRI:
• Tumor, infection, inflammation (myelitis), any cord lesion
• Post-op L-spine (discriminate residual/recurrent disk herniation from scar)
8. Emergent or scheduled? Emergent only if immediate surgical or radiation therapy
decision needed (e.g. cord compression, cauda equina syndrome)
9. Difficult to image entire spine in detail; target study to likely level of pathology
10. CT chest/abdomen/pelvis includes T-L spine (no need to rescan trauma pts*)* If image data still on scanner (24-48 hours)
Spine Imaging Guidelines