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how to read spine mri

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how to read spine mri

  1. 1. HOW TO READ SPINE MRI QM
  2. 2. BASIC • T1 images weighted toward fat • T2 images weighted toward water • Dark on T1- and bright on T2-weighted images  Water, cerebrospinal fluid, acute hemorrhage, soft tissue tumors • Other tissues showing similar intensity on both T1- and T2-weighted images: – Dark: cortical bone, rapid flowing blood, fibrous tissue – Gray: muscle and hyaline cartilage – Bright: fatty tissue, nerves, slow flowing (venous)blood, bone marrow Imaging and special studies, Miller review of orthopaedic
  3. 3. MID-SAGITAL How do you tell which sagittal image represents the true mid- sagittal cut? Simply scroll through the images until you find the one that has the largest looking spinal canal
  4. 4. PARA-SAGITAL you start to see the traversing nerve roots show up (red arrows) the horizontal dimensions of the vertebral canal get progressively smaller. In fact, once you hit the beginning of the intervertebral foramen (a.k.a. neuroforamen) zone (as we will see below) you can no longer see any vertebral canal.
  5. 5. The parasagittal region is very important for looking for potential pain generators. For example, lumbar disc herniations typically occur in the paracentral zone and are visualized on para sagittal cuts. Symptomatic facet joint cysts are also typically found in the paracentral zone, only they are found more posteriorly positioned as compared to a disc herniation.
  6. 6. para-sagittal zone / lateral recess that demonstrates a moderate-sized disc herniation (red arrows) If you look closely, you can also see the herniation touching one of the traversing nerve roots and even pushing it a little bit off course (green arrow). This is sometimes called "tenting."
  7. 7. FORAMINAL-SAGITAL he foraminal-sagittal region, which is typically represented by only one slice, demonstrates some new anatomy that includes the exiting nerve roots (and sometimes even their accompanying blood vessels). Figure 4 is a foraminal-sagittal cut that demonstrates the boundaries of the right neural foramen (pink circle) quite nicely: The roof and floor are created by the pedicles (P) (the strongest part of the vertebra) of the vertebra above and below, respectively. The posterior boundary is created by the superior articular process of the vertebra below, and the anterior boundary is created by the disc and vertebral body (VB)
  8. 8. AXIAL
  9. 9. Figure 5 is a real disc-level T2-weighted axial MRI image in which I have outlined the disc, (white) the thecal sac, (green) and the posterior arch (yellow). I have also colored the left neural foramen red and marked the right side of the image. *It is important to note that all MRI and CT axial images, whether they be on disk or film, are reversed with regard to sidedness—anything on the right of the image is in reality on the left. This is because we are really looking up from beneath the slice and not down from above.
  10. 10. The Inspection Algorithm 1.Inspect the Disc 2.Inspect the Neural Foramina and Thecal Sac 3.Inspect the Posterior Arch
  11. 11. Inspect the Disc • Prominent/bulging? Focal herniation? • Central? Paracentral? Far lateral? • Annulus tear?  hyperintensity
  12. 12. Inspect the Neural Foramina and Thecal Sac • Foramen open or stenosis? • By what structure? narrowed anteriorly by osteoarthritic thickening of the posterolateral vertebral body, by a posterolateral disc herniation, or by a bulging disc narrowed posteriorly by osteoarthritic thickening of the superior articular process
  13. 13. Inspect the Neural Foramina and Thecal Sac Normally the thecal sac should be symmetrically shaped into a shield-like configuration (figure 7) with the lumbar nerve roots visible and lined-up along its periphery
  14. 14. Inspect the Posterior Arch • Although CT is the gold standard for detecting fractures of the posterior arch, sometimes they are still visible on MRI. • Therefore, carefully inspect the posterior arch for signs of cortical disruption (breaks in the outlines of the wishbone)
  15. 15. Quiz • T1/T2? • Disc/ bony Level? • Disc? Prominent/bulg? Focal stenosis (central, paracentral, far lateral)? • Neural foraminal? Thecal sac? Narrowed anteriorly or posteriorly? By what structure? • Posterior arch? Lig flavum thickening? Fracture? Facet conditions?
  16. 16. Quiz • T1/T2? • Disc/ bony Level? • Disc? • Neural foraminal? Thecal sac? • Posterior arch?
  17. 17. Quiz • T1/T2? • Disc/ bony Level? • Disc? • Neural foraminal? Thecal sac? • Posterior arch?
  18. 18. • It is a T1-weighted image. You should have also noted that the posterior arch is abnormal. Specifically, ligamentum flavum (LF) (which is usually barely seen) has greatly hypertrophied (second) and has compressed the posterolateral corners of the thecal sac. so what is this condition called? Central stenosis.
  19. 19. Quiz • T1/T2? • Disc/ bony Level? • Disc? • Neural foraminal? Thecal sac? • Posterior arch? Lig flavum thickening? Fracture? Slip of facet joint?
  20. 20. • The presence of a fairly hyperintense (white) flattened teepee-like defect in the disc (remember, this should be black), which is indicative of a massive bilateral annular tear within the annulus
  21. 21. NEXT …
  22. 22. The evaluation of an MRI study steps : 1. Determination of which conventional and specialized MRI pulse sequences are available for review 2. Evaluation of T2-weighted images for recognition of areas of increased T2-weighted signal that are not expected or physiologic 3. Evaluation of T1-weighted images for improved detection of anatomic detail and correlation of the alteration in local and regional anatomy on the T1-weighted images with areas of increased signal intensity on the T2-weighted images 4. Evaluation of specialized MRI pulse sequences that may be specific to the region or disease process that is being evaluated 5. Correlation of the above imaging information with the patient’s history, physical examination, and laboratory
  23. 23. WHAT THINGS TO EVALUATE • Alignment • Bone • Ligaments • Intervertebral Discs • CSF • Spinal Cord • Roots and Foramina • Extraspinal tissue
  24. 24. 1. Alignment
  25. 25. 2. Bone • Vertebral body fracture • Posterior element fracture • Destruction due to infection or tumor • Edema • Degenerative change
  26. 26. 3. Ligaments • Normal ligaments should have low signal intensity on all pulse sequences
  27. 27. 4. Intervertebral disc • The outer annulus  hypointense on T2- weighted images • The inner annulus (fibrocartilage and a high proportion of type II collagen) and nucleus pulposus (proteoglycan matrix and type II collagen)  hyperintense on T2-weighted images and hypointense on T1-weighted images
  28. 28. • Disc herniations also classified by the location as the following: – Central (compression of the medial portion of the spinal cord) – Posterolateral (compression of the lateral portion of spinal cord and nerve root) – Lateral (compression of the nerve root only)
  29. 29. 5. CSF • CSF  low signal intensity on T1-weighted images and high signal intensity on T2- weighted images • T2-weighted images provide a myelographic appearance that allows for the detection of spinal stenosis
  30. 30. 6. Spinal Cord • Sagittal T2-weighted images provide a myelographic effect that allows for the evaluation of spinal cord morphology and the presence of extrinsic compression
  31. 31. Spinal Stenosis • The term spinal stenosis describes the compression of the neural elements in the spinal canal, lateral recesses, or neural foramina
  32. 32. • Foraminal stenosis may be caused by a disc herniation or uncovertebral or facet joint hypertrophy. • Central canal stenosis is most often caused by: – Disc bulge or herniation – Uncovertebral joint osteophyte formation – Ligamentum fl avum hypertrophy – Facet arthrosis – Thickening, calcifi cation, or – ossification of the posterior longitudinal ligament or other structures
  33. 33. 7. Roots and Foramina • The nerve roots have intermediate signal intensity and are surrounded by high signal intensity fat on T1-weighted images and by high signal intensity CSF on T2- weighted images.
  34. 34. Other Pathologic Conditions • Tumors Spine tumors are categorized by their anatomic location • Extradural • Intradural–extramedullary • Intramedullary
  35. 35. CERVICAL SPINE • Sagittal Images The T1-weighted and T2-weighted sagittal images should be reviewed first to evaluate the spinal anatomy
  36. 36. CERVICAL SPINE • Axial Images Cervical spine anatomy and anatomic pathology are well visualized on axial T1- weighted images; T2-weighted images have good CSF-to-cord contrast which allows evaluation of spinal cord or nerve root compression
  37. 37. THORACIC SPINE • The anatomic structures in the thoracic spine are unique in that the ribs form two additional articulations with the vertebrae: – the costocentral joint (between the vertebral body and the rib head) and – the costotransverse joint (between the transverse process and proximal rib).
  38. 38. LUMBAR SPINE • Sagittal Images The T1-weighted images are best used for shows the full profile of the sacrum and most of the lumbar vertebral bodies, spinal cord, and cauda equina The bright signal from CSF on T2-weighted images provides a myelographic eff ect
  39. 39. LUMBAR SPINE • Axial Images the degree of contribution of the three primary contributors to spinal stenosis (disc pathology, facet arthropathy, and ligamentum flavum hypertrophy) should be noted
  40. 40. case • A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis
  41. 41. • Figures A and B show the axial and sagittal sequences of a T2-weighted MRI of the lower lumbar spine. A large L5/S1 para-central disc herniation is seen that has migrated cephalad
  42. 42. THANK YOU
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    May. 28, 2021
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