Introduction to Neuroimaging spine John J. McCormick MD
Neuroanatomy
Netter drawings
Radiographic Anatomy
Cervical Spine
Cervical Spine Oblique View
Cervical Spine Dens View
Thoracic Spine
Lumbar Spine
MRI Anatomy
Spine Pathology Trauma Degenerative disease Tumors and other masses Inflammation and infection Vascular disorders Congenital anomalies
Evaluating Trauma Fracture Dislocation Ligamentous injury Cord injury Nerve root avulsion
Plain films may be very subtle or absent
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.
Burst fracture
Tumors and Other Masses
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
Common Extradural Lesions Herniated disc Vertebral hemangioma Vertebral metastasis Epidural abscess or hematoma Synovial cyst Nerve sheath tumor Neurofibroma Schwannoma
Common Intradural Extramedullary Lesions Nerve sheath tumor (also extradural) Meningioma Drop Metastasis
Common Intramedullary Lesions Astrocytoma Ependymoma Hemangioblastoma Cavernoma Syrinx Demyelinating lesion (MS) Myelitis
Extradural: Herniated disc
Extradural: Hemangioma
Extradural: Vertebral Metastasis
Extradural: Epidural Abscess
Extradural Meningioma
Intradural Extramedullary: Meningioma
Intradural extramedullary
Intrradural Extramedullary: Neurofibroma
Intradural Extramedullary: Drop Mets Endolymphatic Sac
Intradural Extramedullary: Arachnoid Cyst
Intramedullary: Astrocytoma
Astrocytoma with Syrinx
Hydromyelia
Intramedullary: Syringohydromyelia Seen with: Congenital lesions chiari I & II tethered cord Aquired lesions trauma tumors arachnoiditis Idiopathic
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
Infection and Inflammation
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
Pyogenic Spondylitis / Diskitis with Epidural Abscess
Acute Osteoporosis Compression May look similar to pyogenic infection Clinical context
Spinal TB (Pott s Disease) Prominent bone destruction More indolent onset than pyogenic Gibbus deformity Involvement of several VB s
Inflamed cord of uncertain cause Viral infections Immune reactions Idiopathic Myelogathy progressing over hours to weeks DD: MS, glioma, infarction Transverse Myelitis
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
Cord Edema May be secondary to ischemia (eg embolus to spinal artery) Venous hypertension (eg AV fistula) Aortic aneurysm
Congenital