Imaging of back pain

The British Institute of Radiology

J Teh, MRCPFRCR, , , A Imam, MRCSFRCR, , , and C Watts, FRCR,
Radiology Department, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK
DOI: http://dx.doi.org/10.1259/imaging/51081048
Published Online: March 05, 2014

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Abstract
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Back pain results in a huge socio-economic burden.

Most cases of back pain do not require imaging.

The presence of red flags should prompt early imaging.

MRI is the modality of choice for imaging back pain.

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Nearly half the adult population in the UK suffers from back pain, lasting at least 24h at some time every year [1].
Approximately five million people consult their general practitioner with back pain annually. The impact of back pain
on society is considerable and is associated with an enormous economic burden. It was estimated that the direct
healthcare cost of back pain in the UK in 1998 was 1632 million whereas the costs from informal care and loss of
production was 10668 million [2]. Low back pain most commonly affects the 3050 year age group, with the
prevalence peaking during the sixth decade [1]. Young people are more likely to have brief, acute episodes of back

pain, whilst chronic pain tends to occur in older people. There is an equal sex distribution. This review summarizes
the aetiology, clinical presentation and radiological investigation of back pain.

When to image
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There are many causes of back pain with a complex inter-relationship between anatomical, pathological and
psychological factors leading to the eventual clinical presentation. A careful history and physical examination remains
the mainstay of initial assessment of back pain. Imaging is not necessary in most cases of back pain because of the
high rate of spontaneous remission within 68weeks. Furthermore, the use of early imaging does not appear to alter
management in most patients [3, 4]. There are, however, certain features or red flags that should suggest serious
pathology and prompt early imaging (Table1).
The Royal College of Radiologists has drawn up guidelines for the investigation of back pain [5] (Table2). The
application of these recommendations will depend on many factors including local expertise, financial resources and
availability of MRI. It is increasingly recognized that plain radiographic evaluation of back pain in the absence of
trauma is of limited value, as degenerative changes are very common and sinister pathology may easily be missed
[6].
Broadly speaking, there are four main clinical scenarios:

1.
Acute non-specific back pain, which usually resolves spontaneously within 68 weeks.
2.
Chronic back pain without sinister features. A very common situation that is usually
related to degenerative disease.
3.
Back pain with sciatica. A condition usually caused by disc prolapse.
4.
Possible serious pathology or cauda equina syndrome. This group encompasses various
conditions such as tumour, infection and inflammatory disorders.

Of these conditions, the first two do not usually warrant imaging. In patients suffering from sciatica, the cause is
usually a prolapsed disc, and those who have had a failed period of conservative therapy may require imaging. In
patients with possible serious pathology, urgent specialist referral and imaging are both indicated.

Conditions causing back pain

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The physical causes of back pain can be divided into mechanical conditions such as disc disease and nonmechanical conditions, such as infection, inflammation or malignancy (Table3). There are also conditions which do
not involve the spine, such as abdominal aortic aneurysms and urological conditions that may present with back pain
(Figure1). Due to the complexity of the bony, ligamentous, muscular and neural elements of the back, a specific
anatomical diagnosis often cannot be made. Even when radiological investigations show an abnormality, the positive
findings may not necessarily relate directly to the back pain [7]. Close clinico-radiological correlation is therefore
required.
Of the first 1000 MRI studies carried out in lieu of plain radiographs for low back pain in our institution, 80% showed
degenerative or normal spines, whereas 20% showed other pathology [6]. Figure2 presents the conditions found in
the 200 patients with a pathological cause.

MRI sequences
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If the patient warrants evaluation of persistent back pain or suspected serious pathology, a limited MRI is
recommended rather than plain radiographs [6]. This examination should include a sagittal T1 weighted and a short
tau inversion recovery (STIR) sequence. The T1 weighted sequence is of particular value in evaluating spinal
anatomy and bone marrow, whereas the STIR sequence is useful for depicting the discs, inflammatory changes,
bone marrow oedema and the spinal canal. Axial images are not routinely obtained, as the investigation is not
performed for evaluating neural compression. As the purpose of the investigation is to exclude a sinister cause for the
symptoms, it is important to endeavour to perform the MRI in a short timeframe, preferably within 2 weeks.
For patients with sciatica the cause is usually disc disease and, if specialist referral is being made, we would
recommend an MRI scan with sagittal and axial T1 and T2 weighted sequences. This is discussed in a separate
chapter.

Other imaging modalities

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In certain situations plain radiographs, CT or scintigraphy may be used as an alternative to MRI to evaluate the spine.
For example, if patients are unable to undergo MRI, CT may be a useful alternative. If bony metastases are
suspected, scintigraphy may be an appropriate first line investigation.

Infection
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Spondylodiscitis accounts for 24% of cases of osteomyelitis [8, 9]. Men are affected more often than women. Spinal
infections can broadly be categorised into three age groups: Group 1 comprises babies less than 1 year, typically
presenting with septicaemia. Group 2 comprises children with localized discitis, a condition which often runs a benign
course. Group 3 is the largest and comprises adults, particularly the elderly and immunocompromised, who present
with back pain and fever. The reasons for the more benign presentation in children compared with adults may be due
to differences in the infecting organisms, the immune status and the greater vascularity of the endplates [10].

The spinal column is surrounded by a dense vascular network, with the anterolateral subchondral region of the
vertebral body adjacent to the endplates being particularly well vascularized [11]. This area is often the starting point
for haematogenous infections. From here spread into the adjacent disc, vertebra and soft tissues may occur. Spread
to the adjacent endplate may occur across the disc or via the peripheral vascular anastamosis. Pathogens that
produce proteolytic enzymes, such as Staphylococcus aureus, spread rapidly into the disc with loss of disc height
and disc herniation [9, 12]. Pathogens such as Mycobacterium tuberculosis that do not produce proteolytic enzymes
tend to spread more slowly, often sparing the disc until late in the disease process.
There are three main routes for acquiring spinal infection:

Haematogenous route. This is the most common route for acquiring spinal infection. The
elderly, immunocompromised, diabetics and intravenous drug users are particularly at risk.

Spread from adjacent infection. This usually occurs due to pelvic, pleural and
retropharyngeal infections.

Direct inoculation. This tends to be iatrogenic, occurring as a complication of discography

(1%) or spinal surgery (313%) [13]. Direct trauma may also lead to infection.

Patients usually present with localized back pain and fever [14]. Neurological symptoms may arise from cord
involvement secondary to vertebral collapse or epidural abscess formation. The inflammatory markers and white cell
count may be raised. Ultimately, however, the diagnosis of spinal infection relies heavily on imaging.

Imaging of spondylodiscitis
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Imaging allows confirmation of spondylodiscitis and helps guide biopsy. Although plain radiography, CT and
scintigraphy can all be used to diagnose spondylodiscitis, MRI provides the highest sensitivity and specificity [15].
Pyogenic infection
In the acute phase of infection, there may be little or no radiographic abnormality. With spread into the disc, there is
rapid diminution of disc space, with loss of definition of the vertebral endplates, followed by progressive vertebral
destruction. The plain radiographic findings include narrowing of the disc space, vertebral endplate demineralization
and convexity of the paraspinal lines. There may be vertebral collapse and associated new bone formation (Figure3).
MRI provides good visualization of the vertebral bodies and discs, as well as the paraspinal regions
[12, 16]. T1weighted sequences provide excellent anatomical detail. On T1 weighted images, the findings include low
signal in the disc and adjacent vertebral bodies, with poor delineation of the disc-endplate interface. Typically, the
affected portions of the vertebrae and disc will enhance following intravenous gadolinium. On
corresponding T2 weighted and STIR images there is increased signal within the disc and adjacent endplates with
loss of the intranuclear cleft (Figure4). As the infection advances, there is progressive endplate destruction and
irregularity (Figure5).

MRI provides excellent delineation of epidural disease and assessment of mass effect on the cord [9, 17, 18].
Epidural abscesses and phlegmons appear as extradural masses, which are typically isointense or hypointense to
the cord on T1 weighted images and hyperintense on T2 weighted and STIR sequences. A phlegmon is inflammatory
tissue without a fluid or pus component, whereas abscesses have a fluid component. Most epidural abscesses occur
ventrally, adjacent to the level of infection. Homogeneous enhancement of an epidural mass suggests a phlegmon,
whereas rim enhancement suggests an abscess. Epidural abscesses may be difficult to detect without intravenous
contrast as the adjacent cerebrospinal fluid may have similar signal intensity on all sequences (Figure6).
Paraspinal collections have been reported in 53.5% of cases of pyogenic vertebral osteomyelitis [19]. MRI allows the
depiction of paraspinal abscesses in relation to the retroperitoneum and the aorta and vena cava. Often abscesses
track along the iliopsoas muscles (Figure7).
The imaging findings may appear to worsen even if the patient has improved clinically [16]. The return to fatty marrow
signal in the endplates and a decrease in contrast enhancement are good signs of healing. The persistent uptake of
contrast at the site of initial infection may, however, be encountered for months after treatment has commenced. The
late sequelae of spondylodiscitis include loss of disc height, vertebral collapse and sclerosis, kyphoscoliosis and
interbody fusion.
Tuberculous infection
On imaging, the features of pyogenic and tuberculous spondylodiscitis may be indistinguishable, but there may be
pointers that indicate tuberculous infection [20]. Tuberculous osteomyelitis tends to involve the anterior endplate of
the vertebral body with infection spreading behind the anterior longitudinal ligament to the adjacent vertebral body
(Figure8). Initially, disc involvement is limited, compared with vertebral body involvement. Large paravertebral
abscesses may develop which appear disproportionate to the degree of vertebral body involvement. Epidural
collections may result in compression of the thecal sac (Figure9). Bony destruction may lead to vertebral collapse
and an angulated kyphosis or gibbus deformity. Patients with tuberculous spondylodiscitis tend to have a longer
clinical course, greater thoracic involvement, greater spinal deformity and more paraspinal masses and neurological
deficits than patients with pyogenic infection [19].
Differential diagnosis and pitfalls
There are several conditions that can mimic spinal osteomyelitis and discitis on imaging:

Degenerative spine with type 1 Modic change [21]. Inflammatory type end plate changes
may be seen with degenerative disc disease, with low signal on T weighted images and
high signal on the STIR sequence. Usually in this situation, the intervening disc is of low
signal on all sequences (Figure10).
1

Spinal neuroarthropathy, arising from conditions such as diabetes or syringomyelia, can

result in radiographic features indistinguishable from infection. On MRI the disc usually
demonstrates low signal on all sequences [22].

The spondyloarthropathy of chronic haemodialysis may be mistaken for infection [23, 24].
Biopsy may be required to exclude infection.

Inflammatory spondyloarthropathy, such as ankylosing spondylitis (AS), with a

pseudoarthrosis may mimic infection [25]. Extension of the fracture into the posterior
elements occurs with a pseudoarthrosis, allowing differentiation from infection.
Pars interarticularis defects: spondylolysis
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Patients with spondylolysis have pars interarticularis defects of the neural arch. The L5 level is most commonly
affected, followed by the L4 level. The condition affects males more than females, and may be congenital or acquired.
Congenital forms occur with conditions such as hypoplastic pars and spina bifida [26, 27]. Acquired pars defects
usually arise due to recurrent microtrauma resulting in stress fractures. This occurs particularly with repeated flexionextension activity seen in sports such as weight-lifting, gymnastics and cricket [28].
Although spondylolysis is commonly asymptomatic, it may cause severe disabling pain in some patients. During
adolescence and in adults, back pain often occurs after sporting activity. The pain may become sciatic in nature and
radiate into the lower limbs or buttocks if there is associated spondylolisthesis, which is the forward slip of a vertebral
body with respect to the vertebral body below.
Imaging of spondylolysis and spondylolisthesis
Thin section (3mm or less), high resolution MRI may be used as the primary investigation for evaluating the pars
[29, 30]. In our experience sagittal images are usually sufficient, although some authors advocate imaging in more
than one plane [31]. On MRI, spondylolysis has a variable appearance that depends on how acute the lesion is.
Patients with an acute stress reaction have increased signal on STIR and T2 weighted images in the pars indicating
marrow oedema (Figure11). On T1 weighted images, corresponding decreased signal is seen. Patients with a defect
or fracture of the pars have discontinuity of the cortex that is seen best on contiguous sagittal T1 weighted images
(Figure12). With chronic pars defects, reactive sclerosis may lead to decreased signal on T1 and STIR sequences.
Patients with spondylolysis may have an abnormally wide spinal canal (the wide canal sign). This may even occur in
the absence of a spondylolisthesis as the posterior elements can displace without anterior slip of the vertebral body
[32] (Figure13). There are important collateral findings that may be encountered in patients with spondylolysis
and spondylolisthesis, including disc degeneration, exit foraminal stenosis and associated nerve root compression
[33, 34] (Figure14).
Multislice CT using thin (12mm) sections allows excellent evaluation of pars defects and can also elucidate those
cases that are equivocal on MRI or plain radiographs [30]. The use of reverse gantry imaging has largely been
superseded by multislice CT with the ability perform reformats in any plane. On axial images, a pars defect can be
identified by virtue of the absence of a complete bony ring, with a linear lucency extending through the pars above the
level of the facet joint. Pars defects are, however, most easily identified on sagittal reformats (Figure15). CT has
limited ability to detect stress reactions in the pars that have not progressed to a complete fracture.
In many institutions, plain radiographs remain the first line of investigation for suspected pars defects. On lateral plain
radiographs of the lumbosacral junction spondylolysis appears as a linear lucency in the pars (Figure16).
Flexion/extension views can provide information regarding instability [35]. The lucency seen in the pars on oblique
radiograph has been termed the collar on the neck of the Scottie dog (Figure17). The contralateral pedicle may be
sclerosed and dense. It is important to emphasise that if plain radiographs are negative or equivocal, further imaging
with MRI or CT may be warranted.

Bone scintigraphy, particularly with single photon emission computed tomography (SPECT) is more sensitive than
plain radiographs for the diagnosis of acute pars defects, but is less specific [30, 31]. Scintigraphy is particularly
useful for demonstrating symptomatic defects as increased activity is seen with an acute stress response or a healing
reaction [36]. In chronic defects, there may be no increased uptake. Usually additional imaging with MRI or CT is
required for further evaluation when a bone scan is positive.

Primary neoplasms of the spine

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Primary osseous tumours of the spine are rare, accounting for 39% of primary skeletal neoplasms [37, 38]. They are
rarely confused with metastases and myeloproliferative disorders, which tend to be multiple. Patients present with
localized back pain that may be associated with neurological symptoms and other red flags such as night pain. The
development of a painful scoliosis should always alert the clinician to the possibility of an underlying neoplasm. Any
bone neoplasm can affect the spine, but this section shall only cover the more common lesions.
Imaging evaluation
Plain radiographs and CT are the best techniques for the characterization of cortical lesions and tumour
mineralization. MRI is the best technique for staging, allowing assessment of the degree of marrow, soft tissue and
cord involvement. Scintigraphy is a sensitive technique for identifying lesions, but tends to be non-specific. The
morphology and location of the lesion, and whether it primarily involves the posterior elements, are important factors
in determining its nature. The patient's age is another important consideration. For example, primary neoplasms of
the spine are more common in the lumbar and thoracic regions than the cervical region. Osteoid osteomas and
osteoblastomas typically present as mineralized lesions involving the posterior elements in a young adult.
Aneurysmal bone cysts usually present as expansile lesions of the posterior elements with fluidfluid levels.
Chordomas most often present as a midline destructive lesion of the sacrum in an elderly patient.
Benign lesions
Haemangiomas
Haemangiomas are the most common benign lesions of the vertebral body and rarely involve the posterior elements.
Several levels may be involved. Haemangiomas are usually discovered incidentally and tend not to be clinically
important. Histologically, they are comprised of blood vessels interspersed with fat, smooth muscle, fibrous tissue and
thrombus [39]. On plain radiography, vertebral haemangiomas demonstrate prominent vertical trabeculae, due to
reinforcement of trabeculations along lines of stress. On axial CT small punctuate foci, representing the trabeculae,
are seen within the vertebral body [40], which has been called the polka-dot sign. On MRI, the classic appearance is
of a well-defined fat-containing lesion, which is of high signal on T1 weighted images and high signal on T2 weighted
images (Figure18). Occasionally, haemangiomas in the thoracic spine may expand and become symptomatic,
sometimes leading to neurological compromise. On T1 weighted images these atypical haemangiomas normally lack
fatty signal [41].
Osteoid osteoma
Osteoid osteomas are benign lesions that are comprised of a small (less than 2cm) vascular nidus that is surrounded
by reactive bone. Around 10% of osteoid osteomas affect the spine, typically involving the posterior elements in a
patient in their second to third decade [42, 43]. Patients classically present with localized back pain that is worse at
night and relieved by aspirin or non-steroidal anti-inflammatories. A painful scoliosis may develop. On plain
radiography, osteoid osteomas may be difficult to detect, but occasionally a small radiolucent nidus may be seen, with
some surrounding sclerosis. If associated with a scoliosis, the nidus lies at the concavity of the curve. CT is the
technique of choice for confirming the presence of an osteoid osteoma, which appears as a small lucent lesion

surrounded by sclerosis with variable central mineralization [43, 44] (Figure19). On MRI, osteoid osteomas can have
a variable appearance, sometimes making detection problematic [45]. Usually the nidus is of low/intermediate signal
on T1 weighted sequences, and of increased signal on T2 and STIR sequences, with surrounding soft tissue oedema
[42] (Figure19b). Surrounding marrow oedema can make the nidus difficult to identify. Scintigraphy is an excellent
modality for localizing osteoid osteomas, with marked increased uptake seen within the nidus, which is surrounded by
a halo of less intense uptake from surrounding reactive sclerosis (Figure19c).
Osteoblastoma
Osteoblastoma is a benign lesion with a predilection for the spine that shares many features with osteoid osteomas.
Nevertheless, they represent a distinct clinical entity. Osteoblastomas occur in young adults, presenting with a dull
localized pain that is relieved by anti-inflammatories [46]. Patients presented with neurological symptoms in 29% and
with scoliosis in 47% of cases in one large series [47]. Typically, the posterior elements are involved, sometimes with
extension into the vertebral body. On plain radiographs and CT osteoblastomas appear as expansile lucent lesions,
usually greater than 2cm in diameter, with variable amounts of mineralization which may be multifocal [46,47]. The
margins of the lesion tend to be geographical with a scalloped or lobulated appearance. There may be cortical
destruction with an associated soft tissue mass extending into the adjacent tissues or spinal canal (Figure20a). The
MRI features are dependent on the degree of mineralization that is present [48]. On T1 weighted images, the lesion is
of low to intermediate signal. On STIR and T2 weighted images, the lesion is of intermediate or high signal (Figure
20b). There may be extensive perilesional oedema. Scintigraphy demonstrates intense focal increased uptake in the
lesion (Figure20c). The key features that favour osteoblastoma over osteoid osteoma are the larger size at
presentation (>2cm), multiple foci of mineralization and the presence of a soft tissue mass.
Giant cell tumour (GCT)
Giant cell tumours of the spine occur in the third and fourth decades, affecting women more than men. Most GCTs
affect the sacrum with the thoracic, cervical and lumbar spine affected in decreasing order [49]. The vertebral body is
usually involved with the lesion growing eccentrically. An important feature is the ability of the lesion to grow across
the sacroiliac joint (SIJ) or cross a disc space. Plain radiographs and CT demonstrate an expansile lytic lesion without
mineralization [50], with a thin cortical margin at the edge of the lesion (Figure21a). Secondary aneurysmal bone cyst
formation can occur, leading to fluidfluid levels (Figure21b). MRI may demonstrate areas of low signal on
both T1 and T2 weighted sequences due to high haemosiderin content [51]. This is distinct from most other neoplasms
that affect the sacrum which tend to demonstrate high signal on T2 weighted sequences.
Aneurysmal bone cyst (ABC)
Aneurysmal bone cysts are benign bone lesions that tend to occur in patients below the age of 20 years with pain
being the main symptom [52]. In the spine, they typically involve the posterior elements, most commonly affecting the
cervical or thoracic spine. It has been postulated that ABCs may occur due to altered haemodynamic flow, with the
lesion appearing histologically as multiloculated blood filled spaces which are not lined by endothelium [53]. Plain
radiographs and CT demonstrate an expansile lesion surrounded by a thin rim of cortex (Figure22a). The hallmark of
the lesion is the presence of fluidfluid levels which can be demonstrated on both CT and MRI [54, 55] (Figure22b).
These occur due to sedimentation of blood products, and the signal characteristics will reflect the various
components. For example, the presence of methaemoglobin gives rise to increased signal on both T1 and T2weighted
sequences. It should be noted that secondary ABC formation can occur with a variety of bone tumours including
osteosarcomas, GCTs and osteoblastomas. Usually these lesions contain a significant soft tissue component allowing
differentiation from primary ABCs [56, 57].
Malignant lesions
Chordoma
Chordomas are malignant lymphoproliferative bone tumours that arise from notochord remnants [58]. They have a
predilection for the sacrococcygeal region (up to 60%) and the basisphenoid [59]. The lesions tend to affect middle-

aged and elderly patients, with the incidence in men higher than in women. With sacral lesions, patients present with
chronic pain that may be associated with neurological and bladder or bowel symptoms due to local pressure effects.
On plain radiographs and CT, chordomas appear as lytic lesions with a large associated soft tissue mass, arising in
the midline. Amorphous calcification is seen in up to 90% of cases affecting the sacrococcygeal region on CT [60].
The lesion is usually very locally invasive and may extend across a disc or the SIJ. Extension along the nerve roots is
common. The local staging of chordomas is best achieved on MRI [61, 62]. On T1 weighted images, the lesion tends
to be of intermediate to low signal, with high signal seen on T2 weighted or STIR sequences reflecting the high water
content. Heterogeneous enhancement is usually seen following contrast (Figure23).
Chondrosarcoma
Chondrosarcomas represent up to 12% of primary neoplasms of the spine [63]. Rarely, they may arise from
malignant transformation of an osteochondroma. Patients present with pain, with up to 50% having neurological
symptoms. On plain radiographs and CT, they appear as lytic lesions which contain matrix calcification. They tend to
involve the posterior elements, but they may also involve the vertebral body. On MRI, chondrosarcomas are of low to
intermediate signal on T1 weighted sequences and of high signal on T2 weighted sequences (Figure24). The lesion
may contain foci of low signal matrix calcification on all sequences [64]. Soft tissue extension with cord compression
may be seen.
Lymphoma
Spinal involvement in lymphoma may be due to primary involvement of the vertebral body or secondary spread from
paravertebral lymph nodes. The imaging findings are variable, a dense sclerotic vertebral body (ivory vertebra) is a
classical plain radiographic finding, but some lesions are purely lytic. On T1 weighted sequences the affected
vertebral body returns low or intermediate signal, with intermediate to high signal seen on T2 weighted sequences
[65, 66]. Epidural infiltration and an associated soft tissue mass are common findings. There may be contiguous
vertebral body involvement (Figure25). With intravenous gadolinium, there is usually avid enhancement of the
involved tissues.
Osteosarcoma
Osteosarcomas rarely occur in the spine accounting for around 5% of primary malignant spinal neoplasms [67].
Typically, they affect the vertebral body and are densely mineralized, although lytic lesions may occur. On MRI the
mineralization is manifest as foci of low signal on both T1 and T2 weighted sequences [68]. The prognosis is extremely
poor due to the high incidence of metastases (Figure26).

Differentiation of benign from malignant collapse

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Benign vertebral collapse may result from osteoporosis or trauma, or benign lesions such as haemangiomas and
eosinophilic granulomas. Malignant vertebral collapse may be due to metastases or primary neoplasms.
Differentiating benign from malignant collapse may be very difficult both clinically and radiologically, particularly in
elderly osteoporotic patients who have a history of malignancy. Reaching the correct diagnosis has important
implications for treatment and prognosis.
Plain radiographs, CT and scintigraphy can be used to assess vertebral collapse, but the technique of choice is MRI.
In our institution, sagittal T1 and STIR sequences are performed. The STIR sequence is preferred over a
conventional T2 fast spin echo sequence as it confers increased lesion conspicuity. The differentiation of benign from
malignant vertebral collapse relies on the marrow signal characteristics and the morphology of the collapsed vertebra.

Features of a malignant vertebral collapse

Marrow signal
On T1 weighted sequences there is typically complete replacement of the fatty marrow resulting in diffuse low signal
throughout the vertebral body, with involvement of the posterior elements [6971]. Occasionally, there may be
incomplete marrow replacement. On T2 and STIR sequences, there is corresponding isointense or high signal, which
may be either homogeneous or heterogeneous. Following intravenous contrast there may be diffuse or patchy
enhancement on a T1 fat-saturated sequence (Figure27a).
Morphology
Several features are considered suspicious for malignant compression fractures.
1. 1. A convex posterior bulge involving the whole of the posterior cortex due to retropulsion of tumour has
been shown to have a sensitivity of 70% with a specificity of 94% [69] (Figure27b).
2. 2. Involvement of the pedicles judged by abnormal signal or change in morphology has been shown to have
a sensitivity of 80% and a specificity of 94% [69] (Figure28).
3. 3. The presence of an epidural or paraspinal soft tissue mass has been shown to have a sensitivity of 80%
and specificity of 100% [69], but it should be recognized that traumatic fractures can produce mass like
haematoma (Figure29).
Features of a benign vertebral collapse
Marrow signal
The marrow signal changes encountered in benign vertebral collapse depend on the age of the fracture. Acute
osteoporotic collapses (less than 2 months old) typically show a band-like area of low signal adjacent to the collapsed
endplate on T1 weighted sequences, with corresponding high signal on T2 weighted or STIR sequences. Usually there
is at least one area of normal fatty marrow signal seen within the vertebral body. On T2 weighted and STIR sequences
there may be a linear low signal fracture line seen adjacent to the collapsed endplate. Focal areas of very high signal
adjacent to the endplate on STIR sequences has been described as the fluid sign, which is seen in benign fractures
[72]. The marrow signal change following a benign collapse may persist for up 24 months and then gradually returns
to normal over time. Old osteoporotic fractures may therefore demonstrate abnormal morphology without any signal
abnormality (Figure30).
Morphology
The retropulsion of a posterior corner fragment into the spinal canal is a highly specific sign (100%) of a benign
collapse. Typically the posterior superior corner is involved [69] (Figure31).
On plain radiographs the presence of an intravertebral vacuum cleft indicates avascular necrosis (Kummell's disease)
and therefore suggests a benign process [73]. On T1 and T2 weighted sequences, the vacuum cleft is of low signal.
Occasionally, on T2 weighted sequences, high signal may be seen within the cleft as fluid can replace the gas.

Diagnostic pitfalls
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Multiple myeloma

Patients with multiple myeloma frequently have compression fractures that have the appearance of osteoporotic
collapse. Only a small proportion of compression fractures in multiple myeloma have the appearance of malignant
collapse [74]. Multiple myeloma should therefore always be considered in the differential for non-traumatic vertebral
compression fractures that have a benign appearance.
Acute trauma
Acute trauma may result in diffuse low signal on T1 weighted images with an associated paraspinal mass or
haematoma [71]. Although the appearances may mimic a malignant collapse, the history of trauma is usually
forthcoming.
Sacral insufficiency fracture
On sagittal images a sacral insufficiency fracture results in bone marrow signal change in contiguous sacral
segments, which may be mistaken for an infiltrative process. An oblique coronal sequence through the sacrum allows
confirmation of an insufficiency fracture (Figure32).

Equivocal findings
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Although MRI can help differentiate benign from malignant vertebral collapse, the findings may be equivocal, in which
case several options are available.

Supplementary imaging can be performed. On CT, cortical destruction or pedicular

involvement may be seen in cases of malignant collapse [75]. Whole body scintigraphy
may show other skeletal lesions indicating metastases. Furthermore, FDG-PET scanning
may have potential value for differentiation between osteoporotic and pathological
vertebral fractures, as acute osteoporotic collapse tends to have no pathologically increased
FDG uptake [76]. Several researchers have successfully used diffusion-weighted MRI to
help differentiate benign from malignant vertebral collapse [7779]. This technique
measures random motion of free water protons. Diffusion is hindered in densely packed
cells (i.e. tumour) resulting in high signal.

In elderly patients or patients in whom the index of suspicion is low, a follow up MRI scan
can be performed in 68 weeks. This should be sufficient time for findings to have
improved if osteoporotic collapse has occurred. In malignant collapse, the findings would
be expected to worsen.

Vertebral biopsy can be performed. In younger patients and those with a high index of
suspicion for malignancy, early biopsy is advocated.
Seronegative spondyloarthropathy
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The seronegative spondyloarthropathies are a group of multisystem inflammatory conditions linked by a variety of
genetic, clinical and radiological features. Included in this group are ankylosing spondylitis, inflammatory bowel
disease, psoriatic arthritis, Reiter's syndrome and reactive arthritis [80, 81]. A small number of patients cannot be
neatly classified into one of these entities and they are referred to as having undifferentiated spondyloarthropathy
[82]. The pathogenesis of spondyloarthropathies is poorly understood, but immune mediated mechanisms involving
human leukocyte antigen B27 (HLA-B27), genetic and environmental factors are thought to have key roles [83].
The most common age group affected are the second to third decades with 1020% presenting before the age of 16
years, but patients in their 50s may also present after a longer, milder disease course. Spondyloarthropathies are
more common in men, in the case of ankylosing spondylitis the ratio of men to women is around 3:1. In women,
ankylosing spondylitis is milder and runs a more indolent course [84].
Inflammation at the insertions of ligaments, tendons, or joint capsules to bone, which is termed enthesitis, is the
hallmark of spondyloarthropathy [85]. This process is characterized by bony oedema and erosions, followed by bony
proliferation and eventually ankylosis. The disease process results in synovitis, leading to sacroiliitis and
costovertebritis. Inflammation of fibro-osseous junctions at syndesmotic joints leads to changes at the intervertebral
discs, SIJ ligaments, manubriosternal joint and pubic symphysis. The diagnosis of spondyloarthropathy is based on
both clinical and radiological grounds [86].
Imaging modalities
The seronegative spondyloarthropathies share common clinical and radiological features with characteristic patterns
of involvement of the SIJs, spine, and peripheral joints. Although plain radiographs are the often the first line of
imaging investigation, they are insensitive for demonstrating the early changes of enthesopathy and sacroiliitis. Other
imaging modalities, including scintigraphy, CT and MRI, allow better visualization of inflammatory changes at the SIJs
and axial skeleton. Of these, MRI is the most sensitive and specific as it directly visualizes changes in the synovium,
articular cartilage and subchondral bone [87]. The sensitivity of MRI for assessing disease activity also allows
objective assessment of therapeutic response to novel biological agents such as infliximab and etenercept [88, 89].
This section will review these modalities and emphasise the role of MRI.
The main sub-types of spondyloarthropathy
Ankylosing spondylitis
AS is the most common of the spondyloarthropathies and presents as insidious onset low back or buttock pain, with
morning stiffness. The diagnosis of AS is made using either the Rome or the modified New York criteria [85, 86]
(Table4). These use radiological and clinical parameters to make a diagnosis of AS. There are no specific laboratory
tests for AS, but HLA-B27 gene is present in 9095%. Up to 70% of patients with active disease have a raised Creactive protein (CRP) and erythrocyte sedimentation rate (ESR), although these are not accurate reflections of
disease activity.
The characteristic feature of the AS is sacroiliitis. The upper two-thirds of the SIJ is fibrous and the inferior third is
synovial. The synovial part of the joint develops erosions earlier than the upper fibrous part, but the whole joint is
eventually involved. The iliac aspect is initially involved due to the thinner fibrocartilage and due to degenerative clefts
and splits which may allow inflammatory tissue penetration.
Psoriatic arthropathy
Up to 40% of patients with psoriasis will develop arthritis, commonly an asymmetrical oligoarthritis, which is
associated with HLA-B27 in 50%. Sacroiliitis is usually bilateral and symmetrical [90]. The sacroiliitis in psoriatic

arthropathy develops less joint space loss and ankylosis than AS. The paravertebral ossification that develops tends
to be bulky, making it easy to differentiate from the thin marginal ossification of AS.
Reiter's syndrome (reactive arthritis)
Reiter's syndrome is a triad of urethritis, uveitis and arthritis occurring almost exclusively in males [91]. It is
associated with HLA-B27 in 7580%. It causes a polyarthritis similar to psoriatic arthropathy, but typically affects the
distal lower extremity more commonly than the hands. Bilateral sacroiliitis is seen in 3050% of cases and is usually
asymmetrical, unlike in AS when it tends to be bilateral and symmetrical.
Enteropathic arthropathy
Enteropathic spondyloarthropathy is seen in ulcerative colitis (UC), Crohn's disease, Whipple's disease, post-infection
with Salmonella, Shigella, and Yersinia, and is associated with HLA-B27 in 75%. The radiological findings are
indistinguishable from AS [92].

Imaging of sacroiliitis
Section:
Choose

On plain films initially there is blurring of the subchondral bone and irregular marginal erosions of the SIJs resulting in
pseudowidening. In the later stages there is sclerosis, joint space narrowing and eventually joint fusion. These
changes can be graded using the New York Grading system [93]: Grade I, suspicious; Grade II, evidence of erosion
and sclerosis; Grade III, erosions, sclerosis and early ankylosis; and Grade IV, total ankylosis (Figure33).
CT and MRI both demonstrate subchondral sclerosis and erosions better than plain radiography [94, 95]. MRI offers
the best visualization of cartilage and subchondral bone oedema allowing earlier detection of sacroiliitis than CT or
scintigraphy [94, 9698] (Figure34).
In our institution we use coronal oblique T1 weighted sequence with fat suppression and a STIR sequence. In
equivocal cases, intravenous gadolinium is administered as it has been shown to increase the sensitivity of MRI for
detection of erosions [99, 100]. On T1 weighted images the posterior ligamentous portion of the joint contains adipose
tissue and focal low signal areas of connective tissue [101]. Focal marrow defects, insertion pits, can be seen at the
attachments of the ligamentous portion. On STIR images, the high signal synovial joint is clearly demonstrated
between low signal periarticular tissues. The cartilage thickness varies from 45mm posteriorly to 23mm
anteroinferiorly. Erosions, irregularity of the joint space, sclerosis, periarticular fat accumulation and fusion are the
main MRI features of sacroiliitis. Erosions are best appreciated on T1 weighted fat-saturated sequence as
hypointense subchondral lesions. These appear hyperintense on STIR images. Subchondral oedema is best
appreciated on the STIR sequence (Figure35). Subchondral sclerosis manifests as low signal on all sequences.
Periarticular bone marrow fat accumulations may be seen as non-enhancing low signal areas on T1 fat saturated and
STIR sequences (Figure36). Once ankylosis has occurred, bone marrow signal is seen to cross the SIJ, obliterating
the cartilage.
If there is unilateral disease with prominent oedema in the soft tissues and marrow adjacent to the affected joint,
infection should be considered.

Imaging of the spine

Section:
Choose

The imaging features of AS in the thoracolumbar spine arise due to enthesitis and progress in a continuous fashion,
usually starting at the thoracolumbar and lumbosacral junctions and eventually involving the whole spine. The spine
is particularly affected at the discovertebral junction, the apophyseal joints, the costovertebral joints, the posterior
ligament attachments and the atlantoaxial articulation. At the discovertebral junction there are many changes
including osteitis, syndesmophyte formation, erosions, disc calcification, osteoporosis and disc ballooning.
Early radiographic signs include squaring of the vertebral body secondary to the inflammatory osteitis [102]. Erosions
(osteitis) at the superior and inferior margins of the vertebral bodies occur at the site of attachment of the anterior
longitudinal ligament and are called Romanus lesions (Figure37). These cause loss of the normal concavity of the
vertebral body resulting in squaring seen most clearly in the lumbar spine where the vertebral bodies are more
concave than in the thoracic spine which is squarer. Once the Romanus lesion is sclerosed it is seen as a shiny
corner on the plain film. In the early active phase on MRI they are low signal on T1, high on T2 and STIR, and
enhance post-intravenous gadolinium [103] (Figure38). In the post-active phase, the Romanus lesion on MRI can be
both high signal on T1 and T2 sequences (with no enhancement) due to accumulation of fatty marrow, or low signal on
these sequences indicating marginal osteosclerosis. The presence of syndesmophytes in the spine is one of the
characteristic findings in spondyloarthropathy [102]. A syndesmophyte is a vertically orientated paravertebral
ossification. Syndesmophyte formation initially occurs at the annulus fibrosis. However, in advanced disease, the
anterior longitudinal ligament becomes involved resulting in spinal fusion, giving the bamboo spine appearance on
plain radiographs. Ossification of the supraspinous and interspinous ligaments give rise to the dagger sign, which is
a dense line running cranio-caudally along the vertebral bodies in the midline (Figure39). Other causes of
paravertebral ossification include osteophytes associated with osteoarthritis, undulating ossification which is seen in
diffuse idiopathic skeletal hyperostosis (DISH) and non-marginal paravertebral ossification seen in psoriatic arthritis
and Reiter's syndrome. Osteophytes can generally be differentiated from syndesmophytes as they run horizontally as
opposed to vertically, are triangular in shape and arise away from the discovertebral junction. Non-marginal
paravertebral ossification is seen away from the vertebral body and intervertebral disc.
Erosions at the discovertebral junction were first described by Andersson in 1937 [103, 104]. Andersson lesions have
been classified into three types; Type I involves the central portion covered by the cartilaginous endplate, Type II
involves the peripheral portion which is not covered by endplate, and Type III involves the whole discovertebral
junction. Type III lesions occur in advanced disease and are typified by destruction and reactive sclerosis of the
adjacent endplates. These changes are seen as hyperintense discovertebral endplate changes on STIR
and T2weighted images, and low signal on T1 weighted images, with enhancement post-intravenous gadolinium
(Figure38).
Disc calcification may occur in association with adjacent syndesmophytes and apophyseal joint ankylosis. Disc
calcification can also occur with other conditions such as DISH and juvenile chronic arthritis. Osteoporosis may lead
to ballooning of the disc giving the appearance of fish vertebra. Disc calcification can be high signal on
both T1 andT2 weighted sequences [105].
Erosions, sclerosis and ankylosis may occur at the costovertebral and costotransverse joints. In the early phase of
inflammation plain radiographs are normal, but MRI can demonstrate high signal STIR and T2 weighted sequences
(Figure40). Ankylosis at the costovertebral joint results in reduced chest wall movement and can be associated with
thickening of the posterior ends of the ribs.
The fused spine is at risk of fracturing with minimal trauma. The most common sites of fracture are the cervical and
thoracolumbar spine [106], with those at the thoracolumbar region often being recognized late. Fractures of the fused
spine resemble Chance fractures, either passing through an ossified disc or through the vertebral body (Figure41). If
a fracture is suspected, CT is an excellent modality for demonstrating the break in the bone cortex; however, MRI
gives more information regarding soft tissue and spinal cord injury. Healing of these fractures is generally good with
appropriate immobilization, but fibrous ankylosis and subsequent pseudarthrosis may occur [107]. Pseudarthrosis is
considered a subgroup of the Andersson lesion and normally occurs at the thoracolumbar junction. The radiographic
and CT changes may resemble infectious discitis [25] (Figure42). On MRI there is increased signal on T2 weighted
and STIR sequences at the pseudarthrosis [108, 109]. With a chronic pseudarthrosis there may be low signal

on T2 weighted images indicating fibrosis. Extension across the anterior and posterior elements is the key feature that
allows differentiation from infectious discitis (Figure43).
Section:
Choose

Figure 1. Abdominal aortic aneurysm. T1 weighted sagittal image demonstrating an abdominal aortic aneurysm
(arrowheads) in a patient with low back pain.

Figure 2. Causes of low back pain in 200 patients with significant pathology from a cohort of 1000 patients who underwent
limited MRI for low back pain in lieu of plain radiographs [6].

Figure 3. Pyogenic spondylodiscitis. Plain radiograph demonstrating vertebral destruction and collapse (arrow), with loss of
definition of the endplates and involvement of the adjacent vertebral bodies.

Figure 4. (a) Pyogenic spondylodiscitis. Sagittal T1 weighted image demonstrating loss of end-plate definition and fatty
marrow signal at L3/4. (b) Sagittal short tau inversion recovery (STIR) image demonstrating end-plate oedema and high
signal in the L3/4 disc.

Figure 5. Pyogenic spondylodiscitis. (a) Sagittal T1 weighted and (b) short tau inversion recovery (STIR) images
demonstrating loss of normal marrow signal and endplate destruction at L2/3.

Figure 6. (a) Pyogenc spondylodiscitis. Sagittal T1 weighted image demonstrating altered marrow signal with loss of
definition of the endplates (white arrowheads) and cord compression (black arrow). (b) Sagittal T1 weighted image following
intravenous gadolinium demonstrating a large abscess with an enhancing rim.

Figure 7. Psoas abscess. Axial T2 weighted image demonstrating a high signal collection in the right iliopsoas muscle in a
patient with spondylodiscitis.

Figure 8. Tuberculous vertebral osteomyelitis. (a) Sagittal T1 and (b) T2 weighted images demonstrating an abscess tracking
deep to the anterior longitudinal ligament (arrows) and early involvement of the anterior inferior endplate of L3 (arrowhead).
Note that disc signal is maintained.

Figure 9. Tuberculous spondylodiscitis. Sagittal T2 weighted image demonstrating early destruction of the anterior superior
endplate of S1. There are tracking abscesses deep to the anterior (arrowheads) and posterior (arrow) longitudinal ligaments.

Figure 10. Modic Type 1 endplate changes. Sagittal short tau inversion recovery (STIR) sequence demonstrating high signal
endplate changes at L3/4 adjacent to a low signal degenerate disc. There is also retroperitoneal lymphadenopathy
(arrowheads) in this patient with lymphoma.

Figure 11. L5 pars defect. Sagittal T2 weighted image demonstrating bone marrow oedema in the L5 pedicle (arrow)
indicating stress change, with a low signal line across the isthmus of the pars interarticularis (arrowhead) representing the
defect.

Figure 12. L5 pars defect. Sagittal T1 weighted image demonstrating a low signal line across the pars representing the
defect.

Figure 13. Bilateral L5 pars defects with a 50% spondylolisthesis at L5/S1. There is a wide canal sign (arrow).

Figure 14. L5 exit foraminal stenosis due to spondylolytic spondylolisthesis. Sagittal T2 weighted image demonstrating
severe stenosis of the exit foramen (arrowheads). The normal exit foraminae at other levels are indicated by arrows. Note
the degenerate L5/S1 disc.

Figure 15. (a) Bilateral L5 pars defects. Axial CT demonstrates irregular defects in the neural arch bilaterally. (b) CT sagittal
reformat demonstrates an L5 pars defect (arrow).

Figure 16. L4/5 pars defects. Lateral radiograph demonstrating a break in the pars at L4/5 with a grade 1spondylolisthesis.

Figure 17. L4/5 pars defects. An oblique radiograph demonstrates the collar on the Scottie dog sign.

Figure 18. Vertebral haemangiomas. There are well defined lesions of increased signal on both (a)T1 and (b) T2 weighted
images in the L2 and L5 (arrows) vertebral bodies.

Figure 19. (a) Osteoid osteoma. Axial CT demonstrates an expanded lesion involving the posterior elements with a lucent
nidus (arrowhead) containing a small focus of mineralization. (b) Osteoid osteoma. Sagittal short tau inversion recovery
(STIR) image demonstrating a high signal lesion containing a low signal focus. (c) Osteoid osteoma. Technetium 99m MDP
isotope bone scan in the equilibrium phase demonstrating marked increased uptake in the region of the right lamina at L4.

Figure 20. (a) Osteoblastoma. Sagittal CT reformat demonstrating an expansile lucent lesion in the posterior elements with
central mineralization. Note the size of the lesion compared with the osteoid osteoma in Figure 19a. (b) Sagittal short tau
inversion recovery (STIR) image demonstrating an intermediate/high signal mass involving the posterior elements (arrows).
(c) Scintigraphy demonstrates a solitary focus on intense uptake in the thoracic spine.

Figure 21. (a) Giant cell tumour of the sacrum. Axial CT demonstrates an expansile lytic lesion that crosses the sacroiliac
joint to involve the ilium. The arrows point to a thin cortical rim that illustrates the expansile nature of the lesion. (b) Giant cell
tumour of the sacrum. Sagittal T2 weighted image demonstrating an eccentric mass lesion with secondary aneurysmal bone
cyst formation (arrow).

Figure 22. (a) Aneurysmal bone cyst. CT sagittal reformat demonstrating a lytic lesion affecting the spinous process of C5.
(b) Aneurysmal bone cyst. Sagittal short tau inversion recovery (STIR) image demonstrating a multiloculated high signal
lesion affecting the spinous process of T5. The cysts are too small to demonstrate clear fluidfluid levels.

Figure 23. (a) Chordoma of the sacrum. Sagittal T1 weighted image demonstrating a large mass of heterogeneous signal
arising from the sacrum (arrowheads), with involvement of all sacral segments. There is infiltration into the spinal canal. (b)
Sagittal T2 weighted image demonstrating a heterogeneous high signal mass. There is massive distension of the bladder
(arrows). (c) Axial T2 fat saturated image at the level of the hips demonstrating a large lobulated infiltrating mass arising from
the midline in the sacrum.

Figure 24. Chondrosarcoma. Sagittal T2 weighted image demonstrating an expansile mass arising from the posterior aspect
of the L3 vertebral body with compression of the thecal sac.

Figure 25. (a) Lymphoma. Sagittal short tau inversion recovery (STIR) image demonstrating high signal throughout the T5
vertebral body with involvement of the adjacent vertebrae. (b) Axial T2weighted image demonstrating a paravertebral soft
tissue mass (arrow) in addition to a separate pulmonary lesion (arrowheads).

Figure 26. Osteosarcoma. Sagittal (a) T1 and (b) short tau inversion recovery (STIR) images demonstrating infiltration of
contiguous vertebral bodies via the basivertebral plexus. The foci of low signal on both sequences indicate foci of dense
mineralization.

Figure 27. (a) Metastatic collapse. Sagittal T1 weighted image demonstrating complete replacement of the fatty marrow
signal of L3. (b) Metastatic collapse. Sagittal short tau inversion recovery (STIR) image demonstrating a posterior convexity
of the collapsed L3 vertebral body.

Figure 28. Pedicular involvement in metastatic disease. Sagittal T1 weighted image demonstrating replacement of the fatty
marrow signal in the left L5 pedicle.

Figure 29. Soft tissue mass in metastatic disease. Sagittal short tau inversion recovery (STIR) image demonstrating a large
soft tissue mass (arrows) adjacent to the collapsed L3 and L4 vertebral bodies.

Figure 30. (a) Acute osteoporotic collapse at L3. Sagittal T1 image demonstrating a band-like area of low signal at the
superior endplate of L3 (arrows). There is collapse of the T12 vertebral body with normal marrow signal indicating old
osteoporotic collapse. (b) Corresponding sagittal short tau inversion recovery (STIR) image demonstrating high superior
endplate signal at L3 (arrows) in conjunction with a thin low signal subchondral fracture line. Note the normal marrow signal
in the T12 vertebral body.

Figure 31. Corner retropulsion in osteoporotic collapse. Sagittal short tau inversion recovery (STIR) image demonstrating
posterior corner retropulsion (arrow) with osteoporotic collapse. There is multilevel degenerative disease.

Figure 32. (a) Sacral insufficiency fracture. Sagittal short tau inversion recovery (STIR) image demonstrating bone marrow
oedema (arrows) in the sacrum. Notice that there is no loss of height. (b) Coronal oblique STIR image demonstrating the
presence of a sacral insufficiency fracture (arrows).

Figure 33. Sacroiliitis. Plain radiograph demonstrating early erosions and sclerosis (Grade II changes) at the left sacroiliac
joint (arrows) and minimal changes at the right sacroiliac joint.

Figure 34. Sacroiliitis. CT demonstrating early erosions and sclerosis at the left sacroiliac joint only.

Figure 35. (a) Sacroiliitis. Coronal oblique short tau inversion recovery (STIR) image demonstrating subchondral bone
marrow oedema (arrow). (b) On the corresponding T1 fat-saturated image, the small subchondral erosion is better
demonstrated (arrow).

Figure 36. (a) Burnt out sacroiliitis. Coronal oblique short tau inversion recovery (STIR) image demonstrating minor
subchondral oedema at the left sacroiliac joint. (b) On the corresponding T1 fat-saturated image there is marked low signal
change on either side of the sacroiliac joints bilaterally, indicating fatty marrow accumulations.

Figure 37. Ankylosing spondylitis. Plain radiograph of the thoracic spine demonstrating squaring of the vertebral bodies
(Romanus lesions) with early ossification of the anterior longitudinal ligament.

Figure 38. (a) Ankylosing spondylitis. Sagittal short tau inversion recovery (STIR) image demonstrating high signal
Romanus lesions at multiple levels at the anterior corners of the vertebral bodies (arrowheads). There are also
enthesopathic changes at the posterior corners of the vertebral bodies. There is a discovertebral lesion in the lower spine
(Andersson lesion) (long arrow). (b) Corresponding T1 weighted image demonstrating low signal Romanus lesions.

Figure 39. (a) Bamboo spine in ankylosing spondylitis. Plain radiograph demonstrating syndesmophyte formation across the
discs giving the bamboo spine appearance. (b) Dagger sign in ankylosing spondylitis. Plain radiograph demonstrating
ossification of the interspinous and supraspinous ligaments giving rise to the dagger sign (arrowheads). Note that there is
fusion of the sacroiliac joints in this patient with Paget's disease of the pelvis.

Figure 40. Costovertebritis. Sagittal short tau inversion recovery (STIR) image demonstrating increased signal at the
costovertebral junctions (arrows) indicating costovertebritis.

Figure 41. Chance type fracture through a fused spine. Plain radiographs demonstrate a fracture traversing the disc and
posterior elements (arrows).

Figure 42. (a) Pseudoarthrosis. Plain radiograph demonstrating endplate irregularity and sclerosis (arrowheads) in a patient
with a bamboo spine. (b) Corresponding CT with sagittal reformat demonstrates the fracture extending through the
posterior elements allowing differentiation from infectious discitis.

Figure 43. Pseudoarthrosis. Sagittal T2 weighted image demonstrating endplate irregularity, subchondral oedema and high
signal in the disc (arrow). There is a fracture extending into the posterior elements indicating a pseudoarthrosis (arrowhead).

Table 1. Red flag features of low back pain

Table 1.Red flag features of low back pain

Table 2. Royal College of Radiologists' guidelines for the

investigation of low back pain [5]

Table 2.Royal College of Radiologists' guidelines for the investigation of low back pain [5]

Table 3. Causes of back pain

Table3of 4
Table 3.Causes of back pain

Table 4. Modified New York criteria for ankylosing spondylitis

(AS)

Table 4.Modified New York criteria for ankylosing spondylitis (AS)

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