Introduction to Neuroimaging spine. John J. McCormick MD

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1 Introduction to Neuroimaging spine John J. McCormick MD

2 Neuroanatomy

3 Netter drawings

6 Radiographic Anatomy

7 Cervical Spine

8 Cervical Spine Oblique View

9 Cervical Spine Dens View

10 Thoracic Spine

11 Lumbar Spine

12 MRI Anatomy

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

17 Evaluating Trauma Fracture Dislocation Ligamentous injury Cord injury Nerve root avulsion

18 Plain films may be very subtle or absent

19 A 28 year old man who was 5 feet 9 inches and 16 stone was playing rugby as a number 8. He ran head first into a tackle, causing an axial compression injury to his neck. This caused immediate, dull pain over the whole of his neck. He attempted to continue playing but found that merely running exacerbated the pain considerably. He later noticed the pain localising to the whole axial area along with his head feeling heavy and loose. He self treated with a soft collar for two days, before presenting to the accident and emergency (A&E) department, by which time the pain was persistent in the sub-occipital area. At no stage did he have any neurological symptoms. Examination showed painful neck movements, with pronounced reduction of range in all directions.

26 Burst fracture

39 Tumors and Other Masses

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

41 Common Extradural Lesions Herniated disc Vertebral hemangioma Vertebral metastasis Epidural abscess or hematoma Synovial cyst Nerve sheath tumor Neurofibroma Schwannoma

42 Common Intradural Extramedullary Lesions Nerve sheath tumor (also extradural) Meningioma Drop Metastasis

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

45 Extradural: Herniated disc

48 Extradural: Hemangioma

49 Extradural: Vertebral Metastasis

50 Extradural: Epidural Abscess

51 Extradural Meningioma

52 Intradural Extramedullary: Meningioma

53 Intradural extramedullary

54 Intrradural Extramedullary: Neurofibroma

55 Intradural Extramedullary: Drop Mets Endolymphatic Sac

56 Intradural Extramedullary: Arachnoid Cyst

57 Intramedullary: Astrocytoma

58 Astrocytoma with Syrinx

59 Hydromyelia

60 Intramedullary: Syringohydromyelia Seen with: Congenital lesions chiari I & II tethered cord Aquired lesions trauma tumors arachnoiditis Idiopathic

61 Confusing Syrinx Terminology Hydromyelia: Fluid accumulation/dilatation within central canal, therefore lined by ependyma Syringomyelia: Cavitary lesion within cord parenchyma, of any cause. 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

62 Infection and Inflammation

63 Infectious Spondylitis/ Diskitis Common chain of events (bacterial spondylitis): Hematogenous seeding of subchondral VB Spread to disc and adjacent VB Spread into epidural space Spread into paraspinal tissues May lead to cord abscess

64 Pyogenic Spondylitis / Diskitis with Epidural Abscess

65 Acute Osteoporosis Compression May look similar to pyogenic infection Clinical context

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

67 Inflamed cord of uncertain cause Viral infections Immune reactions Idiopathic Myelogathy progressing over hours to weeks DD: MS, glioma, infarction Transverse Myelitis

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

69 Cord Edema May be secondary to ischemia (eg embolus to spinal artery) Venous hypertension (eg AV fistula) Aortic aneurysm

70 Congenital

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