MRI Lumbosacral Spine for DDD

Made Easy for Master Trainees

Spine Instructional Course 2019

Mun-Keong Kwan
Professor of Spine Unit
Department of Orthopaedic Surgery,
University of Malaya, Kuala Lumpur,
Malaysia
 Overview
• Introduction
• MRI in Lumbar Spine
– Basic Principles
– Usage of MRI
• Do and Don’t
• Conclusion
 Overview
• Introduction
• MRI in Lumbar Spine
– Basic Principles
– Usage of MRI
• Do and Don’t
• Conclusion
 Magnetic Resonance Imaging
• MRI has revolutionized the management of
spinal pathologies.
 Thank You

• 1946: Discovery of
NMR Spectroscope
Felix Bloch
• Early 1980s: 1st Human
MRI scanner became
available

Edward Purcell
http://www.nobelprize.org/nobel_prizes/physics/laureates/1952/bloch-bio.html
Diagnosis
Diagnosis
Diagnosis
Jackpot!
Surgical Option
Surgical Decision
Surgical Decision
Surgical Decision
Surgical Decision
 Overview
• Introduction
• MRI in Lumbar Spine
– Basic Principles
– Usage of MRI
• Do and Don’t
• Conclusion
Anatomy
 Zone Concept

L4

L5
 Central Canal

L4

L5
 Lateral Canal

L4

L5
 Subarticular

L4

L5
 Foraminal

L4

L5
 Extraforaminal

L4

L5
 Zone Concept

L4

L5
 Zone Concept

L4

L5
 Zone Concept

L4

L5
 Zone Concept

L4
Exiting L4

L5
 Zone Concept

L4
Exiting L4

L5
 Zone Concept

L4
Exiting L4

L5 Trasversing L5
 Zone Concept
Dorsal Root
Ganglion L4
L4

L5
 Zone Concept

L4

L5
Lateral View
 Zone Concept

L4

L5
Lateral View
 Zone Concept

L4

L5
Lateral View
 Zone Concept

L4

L5
Lateral View
 Zone Concept

L4

L5
Storey 3 = Pedicle level
 Storey 3 = Pedicle level

L4 Pedicle
Storey 3 = Pedicle level

L4 Nerve
Root
 Storey 3 = Pedicle level

L5 Nerve
Root
 Zone Concept

L4

L5
Storey 2 = Foraminal level (i.e. visualizing the dorsal root
ganglion of the exiting nerve root)
Storey 2 = Foraminal level (i.e. visualizing the dorsal root
ganglion of the exiting nerve root)
Storey 2 = Foraminal level (i.e. visualizing the dorsal root
ganglion of the exiting nerve root)

L5 Nerve
Root
 Zone Concept

L4

L5
Storey 1 = Disc space level (i.e. visualizing the
traversing nerve root)
 Storey 1 = Disc space level (i.e. visualizing the
traversing nerve root)

L5 Nerve
Root
Storey 1 = Disc space level (i.e. visualizing the
traversing nerve root)

L4 Nerve
Root
Storey 1 = Disc space level (i.e. visualizing the
traversing nerve root)

No neural structure in the

foraminal area
 Zone Concept

L4

L5
Central Level = to visualize central stenosis
 Zone Concept

L4

L5
Subarticular Level = to visualize traversing nerve
root
 Zone Concept

L4

L5
Pedicle Level = to visualize Dorsal Root Ganglion
of the exiting nerve
Common Error
Report: Exit nerve root compression
 Zone Concept

L4

L5
Best slice to visualize foraminal
stenosis
 Overview
• Introduction
• MRI in Lumbar Spine
– Basic Principles
– Usage of MRI
• Do and Don’t
• Conclusion
4 types of prolapsed disc

McCullough JA: 1994

Protrusion
Extrusion/ Sequestration
Differentiate Axilla vs Shoulder Disc
Axilla Disc
Shoulder Disc
Foraminal Disc
Far Lateral Disc
Lateral Canal Stenosis
Central Stenosis
Nerve Root Compression
 Nerve Root Compression

Trapped
Type
Nerve Root Compression
Nerve Root Compression
Nerve Root Compression
Nerve Root Compression
Nerve Root Compression

Escaped
Type
Synovial cyst
Central Flavum Cyst
 Overview
• Introduction
• MRI in Lumbar Spine
– Basic Principles
– Usage of MRI
• Do and Don’t
• Conclusion
Don’t accept Poor Quality Images
Lumbarization of S1
Beware of Conjoint Nerve Root
MIS TLIF
MIS TLIF
MIS TLIF
Do Look at the Edge of the Images
 Lumbar – look at the
Thoracolumbar Junction
 Thoracic – Look at the
Cervicothoracic Junction
Spine – Look at the Brain
Brain Tumor
Don’t assume Pain from Spine
Neck Pain
Low Back Pain
Conclusion
 MRI has revolutionized the
management of spinal pathology
A basic MRI knowledge is required
for a sound surgical decision.
Thank You