Some Issues in Spine Imaging: DR Greg Cowderoy

Some issues in spine imaging
Dr Greg Cowderoy
• Radiation exposure: is it important?
• Role of X-ray, bone scan and other modalities
• CT vs MRI for back pain
• Guidelines for imaging of low back pain
• Imaging appearances of disc herniation and spinal st
• The young athlete with back pain
• Indications for vertebroplasty
• A few cases
• Imaging appearances of disc herniation and
spinal stenosis
• A few cases
CT radiation dose
• Background average 2-3 mSv/year
– Natural background 85%
– Medical 14%
– CT 40-67% of medical
• CT use increased by 600-820% over 20 years
from mid-80s
– Plateaued/ decrease more recently
CT dose reduction strategies
• Only use CT where appropriate (US, MRI)
• Scan parameters: pitch, kvp, mAs
– Paediatrics
– Built-in protocols
– Automatic tube current modulation
– Iterative image reconstruction
• Minimize phases
– No pre-contrast for trauma, oncology follow-up
• Minimize coverage
– L3 to S1 in most cases
Radiation doses
Imaging test Effective CXRs Background Flying hours

dose (mSv) exposure
CXR 0.02 1 3 days 4
Lumbar X-ray 1.5 75 6/12 300
Lumbar CT 2-10 100-500 8/12 - 3 years 400 - 1800
Bone scan 6 300 2 years 1200

CT risk controversies
• Validity of linear, no threshold model
• Variable literature
– Increased cancer risk in some
– Beneficial effect of low level radiation in others
• Children more radiosensitive and at greater risk
for decades
• Triple risk secondary tumours
– Leukaemia 50mGy
– Brain tumour 60mGy
• Lancet 2012;380:499-505
spinal stenosis
• A few cases
Imaging modalities
• Radiographs (X-rays)
• Scintigraphy (bone scan)
• CT
• MRI
Radiographs
What you see
• Bony anatomy and

alignment
• Disc height
Radiographs
What you see Disadvantages
• Bony anatomy and • Radiation

alignment • Nonspecific
• Disc height – OA changes in most
adults
• Insensitive
– No direct visualisation
of neural and other
nonbony structures
Bone scan
What you see
• Bone pathology
– Osteoblastic activity
Bone scan
• Bone pathology • Radiation

– Osteoblastic activity • Very nonspecific
• Relatively poor
anatomical resolution
– (Improved with
SPECT; SPECT/CT)
– No direct visualisation
of neural and other
nonbony structures
SPECT-CT
SPECT-CT
SPECT-CT
SPECT-CT
SPECT-CT
SPECT-CT
CT
What you see

alignment
• Cross sectional view
of spinal canal and
foramina
• Disc, thecal sac,
nerve roots
CT
• Bony anatomy and • Nonspecific

alignment – Most adults have
• Cross sectional view ‘findings’
of spinal canal and • Poor visualisation of
foramina individual neural
• Disc, thecal sac, structures and disc
nerve roots anatomy
• Radiation
MRI
What you see

alignment
• Bone pathology
• Multiplanar view of
spinal canal and
foramina
• Disc: hydration and
structure
• Neural structures:
cord, nerve roots
MRI
• Bony anatomy and • Nonspecific

alignment – Most adults have
• Bone pathology ‘findings’
• Multiplanar view of • Availability

spinal canal and • Expense
foramina – Rebate
• Disc: hydration and
structure
• Neural structures:
cord, nerve roots
GP rebatable MRI: children
GP rebatable MRI: adults
spinal stenosis
• A few cases
T1
T2
T2 T1
MRI: T1
– Fat bright
• Bone marrow
– Bone cortex black
– Anatomy
MRI: T2
– Bone cortex black

– Anatomy
– Fluid bright
– Fat bright
• Bone marrow
– Oedema bright
• Difficult to
differentiate
MRI: STIR or T2FS
– Fat ‘saturated out’
• Bone marrow black
– Fluid bright
– Differentiate oedema
from marrow
T1 T2 STIR
T1 T1FS-Gd
MRI: T1FS-Gd
– Fat ‘saturated out’
• Bone marrow and other
fat black
– Non-fat T1 bright
• Haemorrhage
• Movement
• Enhancement
 Pathology
 Veins
 Nerve root ganglia
T1FS-Gd
spinal stenosis
• A few cases
Ineffectiveness of imaging for
nonspecific LBP
• Favourable natural Hx
– Most improve by 4 weeks; unaffected by imaging
• Nonspecificity: loose association between findings
and symptoms
– ‘Abnormalities’ or normal aging?
• Potential harms:
– Radiation
– ‘Labelling’
– Incidental findings
Ann Intern Med 2011;154:181-190
Degenerative changes on imaging
• Ubiquitous and nonspecific
Age (yr)
Imaging Finding
20 30 40 50 60 70 80
Disk degeneration 37% 52% 68% 80% 88% 93% 96%
Disk signal loss 17% 33% 54% 73% 86% 94% 97%
Disk height loss 24% 34% 45% 56% 67% 76% 84%
Disk bulge 30% 40% 50% 60% 69% 77% 84%
Disk protrusion 29% 31% 33% 36% 38% 40% 43%
Annular fissure 19% 20% 22% 23% 25% 27% 29%
Facet degeneration 4% 9% 18% 32% 50% 69% 83%
Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%
Brinjikji AJNR 2015;36:811

Appropriate imaging for back
pain
• Clinical presentations: classification into 3 broad
categories
1. Nonspecific low back pain
2. Back pain associated with radiculopathy
3. Back pain associated with a specific cause requiring
prompt evaluation
Back pain categories
1. Nonspecific (mechanical) low back pain
– Acute: < 12 weeks
– Chronic: > 12 weeks
– Ligament/ muscle strain/ tear
– Intervertebral disc degeneration
– Osteoarthritis
– Facet joints
– SI joints
– Spondylolysis/ spondylolisthesis
2. Back pain associated with radiculopathy
a) Unilateral acute nerve root compression (sciatica)
– Leg pain >> back pain
– Disc herniation
a) Unilateral chronic nerve root compression
– Disc herniation or spinal stenosis
a) Bilateral chronic nerve root compression
– Spinal stenosis
– DD vascular claudication
a) Bilateral acute nerve root compression = ‘cauda equina
syndrome’
Cauda equina syndrome
• Bilateral acute nerve root compression
– Massive disc protrusion/ sequestration
• Sudden onset bilateral leg pain
• Saddle anaesthesia
• Rapidly progressive or severe neurological
deficits
– Motor deficits at >1 level
– Faecal incontinence
– Urinary retention
3. Back pain associated with a specific cause requiring
prompt evaluation
− Cauda equina syndrome
− Cancer
− Vertebral infection
− Vertebral compression fracture
− Ankylosing spondylitis (inflammatory
spondyloarthropathy)
LOW BACK PAIN GUIDELINES
Diagnostic triage ‘Red Flags’
• Cauda equina syndrome
1. Non-specific LBP • Known 10 tumour
2. Radiculopathy • Weight loss
• Severe symptoms, not
3. Specific LBP settling
• ‘Red flags’
• Fever
• Recent infection or Sx
• Osteoporosis
• Steroid use
• Non-mechanical pain
• Child*
1. Focused Hx and examination to place patients
into 1 of 3 categories
2. No imaging for nonspecific LBP
3. Imaging for LBP + severe or progressive
neurological deficits OR risk factors for specific
cause
4. Imaging for LBP and radiculopathy if candidates
for surgery or epidural injection
• American College of Physicians & American
Pain Society Recommendations
– Ann Intern Med 2007;147:478-491
• Choosing Wisely Australia
– www.choosingwisely.org.au
• National Institute for Clinical Excellence (NICE)
UK
• ACR Appropriateness Criteria
www.imagingpathways.health.wa.gov.au
Diagnostic work-up
Possible cause Imaging Additional studies
Nonspecific LBP None None
Radiculopathy MRI (CT)
Cauda equina MRI
Cancer MRI for known 10 ESR
X-ray for other eg wt loss
Staging: bone scan; PSMA
Vertebral infection MRI ESR, CRP
Vertebral compression # X-ray
MRI pre vertebroplasty
Ankylosing spondylitis X-ray, incl pelvis (MRI) HLA-B27; ESR, CRP
Ann Intern Med 2007;147:478-491

spinal stenosis
• A few cases
NOMENCLATURE
• Consistent
• Reflect common usage where appropriate
• Surgically relevant
• ‘Able to visualize over the phone’
• 2 morphological characteristics:
– Nature of disc pathology
– Location
• Able to add further descriptors
– Neural structures
– Clinical context
• www.asnr.org/spine_nomenclature/reporting
• Spine Journal 2014;14:2525-2545
Annular tear/ fissure
• Annular fissure = degeneration
• Annular tear: outdated
– When ‘tear’ obvious result of trauma use the term
‘rupture’
• Annular high intensity zone (HIZ)
– Not synonymous with ‘fissure’
– Does not imply trauma
– Does not imply pain generator
Disc bulge
• Extension of disc tissue beyond intervertebral
disc space = displacement of annulus
• >25% circumference (>900)
• Relatively short distance, <3mm
• Normal at L5/S1
Herniated disc
• Localised displacement of disc material beyond
intervertebral disc space (ie disrupted annulus) OR break in
vertebral end plate (Schmorl’s node)
• ‘Localised’ = <25% circumference (<900)
– No longer divide into ‘broad based’ and ‘focal’
• ‘Herniation’ or ‘protrusion’
• Disc between but not beyond osteophyte OR adaptive to
subluxation/ listhesis is NOT herniation
• ‘HNP’ not accurate
– Herniation may include NP, cartilage, annulus, bone
• ‘Rupture’ tends to refer to trauma/ acute event
• ‘Prolapse’ and ‘bulging disc’ outdated
Protrusion vs extrusion
• Based on appearance
• Extrusion = greatest distance in any
plane between edges > base
OR
• Protrusion: contained
• Extrusion: uncontained = ruptured PLL
• Presence or absence of containment
more clinically relevant:
– Surgical approach
– Prediction of resorption
Sequestered disc
• Extruded disc material that has no continuity
with the disc of origin
• = free fragment
• Migrated disc:
– Disc material displaced away from site of extrusion
T1
T2 T2
Location of herniation
• Anatomic system that correlates with surgery
• Landmarks, transverse plane:
– Sagittal and coronal planes at centre of disc
– Medial edge of articular facet
– Medial, lateral borders of pedicles
• Locations, transverse plane:
– ‘Central’ = midline
– ‘Right central’ & ‘left central’ =
paracentral/ posterolateral
– ‘Subarticular’ = lateral recess
– ‘Foraminal’
– ‘Extraforaminal’ = far lateral
– ‘Foraminal’
– ‘Foraminal’
– ‘Foraminal’
– ‘Foraminal’
Volume: degree of canal
compromise
• X-sectional area at site of maximal narrowing
• ‘Mild’: <1/3
• ‘Moderate’: 1/3 – 2/3
• ‘Severe’: > 2/3
• Correlation with fluid around cauda and
‘crowding’ of neural structures
• Other descriptors such as compression of
specific neural structures
Mild Moderate Severe
Modic 1
T2 T1
• Vascularised bone marrow
• Oedema
• Overlap with inflammatory
changes
Modic 2
• Proliferation of fatty tissue
• Most common form T2 T1
Modic 3
• Sclerotic bone T2 T1
• Long standing
degenerative change
Nomenclature: summary
• No consensus for cervical and thoracic
• Cannot date disc pathology without serial
imaging
• Definitions based on morphology and pathology
• No implication of aetiology
• No distinction between symptomatic and
asymptomatic findings
spinal stenosis
• A few cases
Pars protocol
 LBP in 40% children and adolescents 12F
 Structural causes 12-26%
 Pars defect = spondylolysis
 Common cause
 Pars interarticularis (interarticular
part) = weakest part of neural arch
 Often accelerated by athletic
activity
 2 key concepts:
 Spectrum of pars pathology
 DD: other causes of pain
Pars pathology
 Developmental deficiency
 Asymmetry of posterior elements: laminae and facet
joints
 Traumatic fracture: uncommon
 Stress injury
 Chronic repetitive low grade trauma
 Oedema early
 Sclerosis or fracture/ defect later
Pars stress injury
 Lumbar, esp L5
 Often bilateral
 Spondylolisthesis
 Disc pathology
 Unilateral defect →
contralateral stress
 Symptoms:
 Often asymptomatic
 LBP
 Hamstring tightness
 Increased by activity
Imaging of LBP in children
 Radiography  Radiation dose in
 CT children
 SPECT/ SPECT-CT  Triple risk secondary
 RadioGraphics 2015;35:819-834 tumours
 MRI  Leukaemia 50mGy
 Brain tumour 60mGy
 Lancet 2012;380:499-505
Imaging of LBP in children
Radiography CT SPECT-CT MRI

Defect
•Recent +/- + + +
•Old +/- + + +
Stress
•Oedema - - + +
•Sclerosis + + + +
Spondylolisthesis + + + +
Disc changes
•Dehydration - - - +
•Narrowing/ end- + + + +
plate deformity
T1
GE FS
STIR T2
T1 GEFS STIR
11F gymnast, back pain
Fracture + oedema = acute

T1
18M
LBP
STIR
Fracture, corticated, no oedema = chronic

T1 GEFS STIR
16F Unilateral LBP
Incomplete defect + oedema = acute stress reaction/

partial defect
T1 STIR
15M Bilateral pars defects, assess healing at 6 months

T1 STIR
Oedema resolved, right unhealed, left healed

LBP in children: DD
 Pedicle fracture
 Unilateral
 Vertical
 Often contralateral pars
 Spinous process avulsion
 Stress fracture
 Transverse process
 Spinous process
 Sacrum
T2
LBP in children: DD
 Disc degeneration
 Discitis
 Tumour eg osteoid osteoma
T1
17F Left LBP, acute on chronic
T1 GEFS T2
Multiple findings:
Left pars defect + oedema
Degenerate discs L4/5, L5/S1
Muscle tear or denervation left multifidus
spinal stenosis
• Vertebroplasty
• A few cases
Percutaneous vertebroplasty
Indications
• Painful crush fracture
– Osteoporosis
– Acute: 4-6 weeks
• Malignant crush fracture
– +/- biopsy
• Haemangioma
– Galibert Neurochirurgie 1987;33:166-8
Patient selection = key to
success
• Back pain
– Sudden onset
– May radiate anteriorly
– NOT sciatica
– Mechanical
– Restricted activity
– Poor sleep
• Local tenderness
• Imaging
24/3/2012
24/3/2012 16/12/2011
Imaging techniques
• MRI:
– Confirm presence of crush fracture
– Confirm that crush fracture is acute
– Diagnose other acute levels
– Integrity of spinal canal
– Accurately localise level
MRI
2
2
T1 STIR
Needle placement: Thoracic
Needle placement: Lumbar
Cement injection
Post procedure care
• Lie prone for 20 minutes
• Bed rest for 2-3 hours
• Discharge if well
– Post-sedation instructions
– Rest 24 hours
– Mobilize according to pain
• Advise re muscle pain
• Follow-up phone call(s)
Complications: rare
• Mild fever; nausea for 24 hours
• Rib fracture
• Foraminal leak
• Spinal canal leak
• Venous emboli
My results
• Audit of first 250 patients, 2001 to 2006
• Complete or near complete response
– No or minimal pain
– Good return of activity level
– 83.0 %
• Moderate response
– Still suffer pain, though noticeably reduced
– Some return of activity, though still restricted
– 12.0 %
• No response
– 5.0 %
Percutaneous vertebroplasty
Keys to success
• Patient selection
– Early referral
– MRI
• High quality fluoroscopy
– Accurate needle placement
– Cement injection
• Nursing care
– Cement preparation
– Patient care: pre and post
MBS funding September 2005
So, what happened?
• Buchbinder NEJM 2009;361:557-68
– Multicentre, randomized, double blind
– Vertebroplasty vs placebo ‘sham’ procedure
– N = 78: 38 vertebroplasty, 40 sham
– No difference in pain scales or quality of life
• MJA (Editorial) 2009;191:476-7
– ‘Percutaneous vertebroplasty is not an effective
treatment for acute osteoporotic vertebral fractures’
• Patient selection
– Up to 12 months pain
• Recruitment
– Majority of eligible
patients not recruited
• Technique
– Up to 3ml cement
– Stopped injection if
leaking
MBS funding withdrawn 2011
Where are we now?
• Uncommon in most places
• Ongoing studies
– Clark Lancet 2016;388:1408-1416
– ‘Vertebroplasty is superior to placebo for pain
reduction in acute osteoporotic spinal fractures of less
than 6 weeks' in duration. These findings will allow
patients with acute painful fractures to have an
additional means of pain management that is known
to be effective’.
• Included in appropriateness guidelines in UK
and USA
• No Medicare rebate
• Our cost: 1200 + day bed about 700
spinal stenosis
• Vertebroplasty
• A few cases
• 68M
• Sudden onset bilateral leg pain and weakness
• Urinary retention
• Dx: Cauda equina syndrome
• Cause: massive sequestration
• Other causes:
– Tumour
• Primary of lower cord: ependymoma
• Primary of nerve: BPNST
• Primary of dura: meningioma
• Primary of vertebral body: chordoma, giant cell
tumour
• Secondary
– Trauma
Cauda equina syndrome
T2
30M 60F 70M

T2 T1 T1FS con
T1 T1FS con
30M
T2 T1 T1FS con
T1 T1FS con
60F
T2 T1 T1FS con
T1 T1FS con
70M
T2 T1 T1FS con
76M CRC
• 62 year old male
• Severe low back pain of rapid onset
• Febrile and unwell
• 4 weeks ago underwent abdominal surgery for
perforated diverticulitis
T2 T1 T1FS con
T2 T1FS con
• 45 year old male
• 2 weeks post discectomy L4/5
• Recurrent bilateral leg pain
T2 T1
T2
T2
T1FS con
T1FS con
• Dx: recurrent disc:
– Central herniation + huge sequestration virtually filling
the spinal canal
• Note peripheral enhancement pattern
• DD: fibrosis
• 51 year old female
• Left sciatica
– Intermittent pain and paraesthesia
T2 T1 T1FS con
What is the most likely diagnosis?
1. Massive disc sequestration

2. Discitis complicated by abscess
3. Synovial cyst
4. Benign peripheral nerve sheath tumour
T2 T1 T1FS con
• Dx: benign peripheral nerve sheath tumour
(BPNST) of left L3 nerve root
– Many clinicians use the term ‘neuroma’
• Pathologically imprecise term
– Most are benign
• Schwannoma or neurofibroma
• Difficult (impossible) to differentiate on imaging
– BPNST is probably the best terminology
– Associated with NF1 and ‘NF2’ (MISME)
• 66 year old female
• Severe lower back pain on and off for years
• More recent (2 months) development of right
sciatica
What is the most likely diagnosis?
1. Massive disc sequestration

2. Discitis complicated by abscess
3. Synovial cyst
4. Benign peripheral nerve sheath tumour
L4/5
• Severe OA of facet (zygoapophyseal) joints
• Round heterogeneous lesion projecting into right
spinal canal
• Note: close relationship to facet joint
• Dx: synovial cyst
Synovial cyst lumbar facet joint
• Fairly common
• Key is relationship to degenerate facet joint
• Density may vary from pure cyst to varying levels of
calcification and heterogeneity
• Usually present clinically with intractable sciatica
• May respond to aspiration and steroid injection, but
usually treated surgically
T2 T1
T2 T1

Some Issues in Spine Imaging: DR Greg Cowderoy

Uploaded by

Copyright:

Available Formats

You might also like

Some Issues in Spine Imaging: DR Greg Cowderoy

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Some Issues in Spine Imaging: DR Greg Cowderoy

Uploaded by

Copyright:

Available Formats

Some issues in spine imaging

Imaging test Effective CXRs Background Flying hours

CXR 0.02 1 3 days 4

Lumbar X-ray 1.5 75 6/12 300

Lumbar CT 2-10 100-500 8/12 - 3 years 400 - 1800

Bone scan 6 300 2 years 1200

• Bony anatomy and

• Bony anatomy and • Radiation

• Bone pathology • Radiation

• Bony anatomy and

• Bony anatomy and • Nonspecific

• Bony anatomy and

• Bony anatomy and • Nonspecific

• Multiplanar view of • Availability

– Bone cortex black

Disk degeneration 37% 52% 68% 80% 88% 93% 96%

Disk bulge 30% 40% 50% 60% 69% 77% 84%

Disk protrusion 29% 31% 33% 36% 38% 40% 43%

Annular fissure 19% 20% 22% 23% 25% 27% 29%

Facet degeneration 4% 9% 18% 32% 50% 69% 83%

Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%

Brinjikji AJNR 2015;36:811

Ann Intern Med 2007;147:478-491

Radiography CT SPECT-CT MRI

11F gymnast, back pain

Fracture + oedema = acute

Fracture, corticated, no oedema = chronic

16F Unilateral LBP

Incomplete defect + oedema = acute stress reaction/

15M Bilateral pars defects, assess healing at 6 months

Oedema resolved, right unhealed, left healed

30M 60F 70M

1. Massive disc sequestration

1. Massive disc sequestration

You might also like