Diagnostic Imaging: Spine 4th Edition

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 FOURTH EDITION

s oR
e ro M

i
ii
 FOURTH EDITION

Jeffrey S. Ross, MD
Consultant
Neuroradiology Division
Department of Radiology
Mayo Clinic in Arizona
Professor of Radiology
Mayo Clinic College of Medicine
Phoenix, Arizona

Kevin R. Moore, MD
Pediatric Radiologist and Neuroradiologist
Primary Children’s Hospital
Salt Lake City, Utah

iii
 Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC IMAGING: SPINE, FOURTH EDITION ISBN: 978-0-323-79399-5

Copyright © 2021 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2015.

Library of Congress Control Number: 2020941756

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedication
Blessed is the one who finds wisdom,
And the one who gets understanding.
– Proverbs 3:13
JSR

Once again, I have the great fortune to work with Dr. Jeffrey Ross and the
excellent editorial and production staff at Elsevier, who spend countless hours in
the background attending to the many tiny details that distinguish an excellent
book. Although they frequently work in anonymity, the importance of these
team members is difficult to overstate. We are deeply indebted to them. I would
also like to acknowledge (and thank!) my wife and colleagues, who directly
or indirectly have supported the devotion of many hours’ time committed to
completing this project.
KRM

v
vi
Contributing Authors

Nicholas A. Koontz, MD
Sara M. O’Hara, MD, FAAP
Usha D. Nagaraj, MD

vii
viii
 Preface
Welcome to the 4th edition of Diagnostic Imaging: Spine. Five years have passed since
the 3rd edition, and 16 years have flown by since the 1st edition was published in 2004.
This edition is a complete refresh with many new images, new categories of disease
(such as CSF leaks), new diagnoses, new art, and updated text and references. The same
wonderful formatting is present, with individual diagnoses capable of standing alone, but
with a logical integration within the larger sections. The Key Facts box retains its visual
prominence at the beginning of each diagnosis, allowing for a quick scan of the most
important bullet points when time is critical and attention spans are short. The text format
remains in the hallmark Diagnostic Imaging bulleted form that allows a large amount of
important information to be displayed in an easy-to-use and inviting layout. Prose text
chapters are included for the introduction to major sections, which are color coded, and
the use of tables allows quick scanning for important data and measurements.

Our coauthors and the staff at Elsevier are amazing to work with, and we have been
extremely fortunate to interact and learn from such a fantastic team. We hope you find
this edition useful, not only as a reference, but as an essential component in your daily
practice and in your care of patients.

Jeffrey S. Ross, MD
Consultant
Neuroradiology Division
Department of Radiology
Mayo Clinic in Arizona
Professor of Radiology
Mayo Clinic College of Medicine
Phoenix, Arizona

Kevin R. Moore, MD
Pediatric Radiologist and Neuroradiologist
Primary Children’s Hospital
Salt Lake City, Utah

ix
x
Acknowledgments
LEAD EDITOR
Nina I. Bennett, BA

LEAD ILLUSTRATOR
Richard Coombs, MS

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Terry W. Ferrell, MS
Megg Morin, BA
Kathryn Watkins, BA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ILLUSTRATIONS
Lane R. Bennion, MS
Laura C. Wissler, MA

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

xi
xii
 Sections

SECTION 1:
Congenital and Genetic Disorders

SECTION 2:
Trauma

SECTION 3:
Degenerative Diseases and Arthritides

SECTION 4:
Infection and Inflammatory Disorders

SECTION 5:
Neoplasms, Cysts, and Other Masses

SECTION 6:
Peripheral Nerve and Plexus

SECTION 7:
Spine Postprocedural Imaging

xiii
 TABLE OF CONTENTS

80 Lipomyelomeningocele
SECTION 1: CONGENITAL AND GENETIC Kevin R. Moore, MD and Usha D. Nagaraj, MD
DISORDERS 84 Lipoma
CONGENITAL Kevin R. Moore, MD and Jeffrey S. Ross, MD
88 Dorsal Dermal Sinus
NORMAL ANATOMICAL VARIATIONS Kevin R. Moore, MD
92 Simple Coccygeal Dimple
4 Normal Anatomy Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 94 Dermoid Cyst
10 Measurement Techniques Kevin R. Moore, MD
Jeffrey S. Ross, MD 98 Epidermoid Cyst
16 MR Artifacts Kevin R. Moore, MD
Kevin R. Moore, MD
22 Normal Variant ANOMALIES OF CAUDAL CELL MESS
Kevin R. Moore, MD 102 Tethered Spinal Cord
26 Craniovertebral Junction Variants Kevin R. Moore, MD
Kevin R. Moore, MD 106 Segmental Spinal Dysgenesis
30 Ponticulus Posticus Kevin R. Moore, MD and Jeffrey S. Ross, MD
Kevin R. Moore, MD 110 Caudal Regression Syndrome
32 Ossiculum Terminale Kevin R. Moore, MD
Kevin R. Moore, MD 114 Terminal Myelocystocele
34 Conjoined Nerve Roots Kevin R. Moore, MD and Jeffrey S. Ross, MD
Kevin R. Moore, MD 118 Anterior Sacral Meningocele
38 Limbus Vertebra Kevin R. Moore, MD
Kevin R. Moore, MD 122 Sacral Extradural Arachnoid Cyst
42 Filum Terminale Fibrolipoma Kevin R. Moore, MD
Kevin R. Moore, MD 126 Sacrococcygeal Teratoma
44 Bone Island Kevin R. Moore, MD and Sara M. O'Hara, MD, FAAP
Kevin R. Moore, MD
46 Ventriculus Terminalis ANOMALIES OF NOTOCHORD AND
Kevin R. Moore, MD VERTEBRAL FORMATION
CHIARI DISORDERS 130 Craniovertebral Junction Embryology
Kevin R. Moore, MD
50 Approach to Chiari 136 Paracondylar Process
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
56 Chiari 1 138 Split Atlas
Kevin R. Moore, MD and Usha D. Nagaraj, MD Kevin R. Moore, MD
60 Complex Chiari 140 Klippel-Feil Spectrum
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD
62 Chiari 2 144 Failure of Vertebral Formation
Kevin R. Moore, MD and Usha D. Nagaraj, MD Kevin R. Moore, MD
66 Chiari 3 148 Vertebral Segmentation Failure
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD
ABNORMALITIES OF NEURULATION 152 Split Cord Malformation
Kevin R. Moore, MD
68 Approach to Spine and Spinal Cord Development 156 Partial Vertebral Duplication
Kevin R. Moore, MD Kevin R. Moore, MD
76 Myelomeningocele 158 Incomplete Fusion, Posterior Element
Kevin R. Moore, MD and Usha D. Nagaraj, MD Kevin R. Moore, MD

xiv
 TABLE OF CONTENTS
160 Neurenteric Cyst 258 Burst C2 Fracture
Kevin R. Moore, MD and Usha D. Nagaraj, MD Jeffrey S. Ross, MD
262 Hangman's C2 Fracture
DEVELOPMENTAL ABNORMALITIES Jeffrey S. Ross, MD
164 Os Odontoideum 266 Apophyseal Ring Fracture
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
168 Lateral Meningocele 270 Cervical Hyperflexion Injury
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
172 Dorsal Spinal Meningocele 276 Cervical Hyperextension Injury
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
176 Dural Dysplasia 280 Cervical Burst Fracture
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
284 Cervical Hyperflexion-Rotation Injury
GENETIC DISORDERS Kevin R. Moore, MD
180 Neurofibromatosis Type 1 286 Cervical Lateral Flexion Injury
Kevin R. Moore, MD Jeffrey S. Ross, MD
184 Neurofibromatosis Type 2 288 Cervical Posterior Column Injury
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
188 Schwannomatosis 290 Traumatic Disc Herniation
Kevin R. Moore, MD and Nicholas A. Koontz, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
190 Achondroplasia 292 Thoracic and Lumbar Burst Fracture
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
194 Mucopolysaccharidoses 296 Facet-Lamina Thoracolumbar Fracture
Kevin R. Moore, MD Kevin R. Moore, MD
198 Sickle Cell Disease 298 Fracture Dislocation
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
202 Osteogenesis Imperfecta 300 Chance Fracture
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
206 Tuberous Sclerosis 306 Thoracic and Lumbar Hyperextension Injury
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
210 Osteopetrosis 308 Compression Fracture
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
212 Gaucher Disease 312 Lumbar Facet-Posterior Fracture
Kevin R. Moore, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
214 Ochronosis 314 Sacral Traumatic Fracture
Kevin R. Moore, MD Kevin R. Moore, MD
216 Connective Tissue Disorders 318 Pedicle Stress Fracture
Kevin R. Moore, MD Jeffrey S. Ross, MD
220 Spondyloepiphyseal Dysplasia 322 Sacral Insufficiency Fracture
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD

SECTION 2: TRAUMA CORD, DURA, AND VESSELS

326 SCIWORA
VERTEBRAL COLUMN, DISCS, AND Kevin R. Moore, MD
PARASPINAL MUSCLE 330 Posttraumatic Syrinx
226 Fracture Classification Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 334 Presyrinx Edema
232 Atlantooccipital Dislocation Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 338 Spinal Cord Contusion-Hematoma
236 Ligamentous Injury Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 344 Central Spinal Cord Syndrome
240 Occipital Condyle Fracture Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 348 Traumatic Dural Tear
244 Jefferson C1 Fracture Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 352 Traumatic Epidural Hematoma
248 Atlantoaxial Rotatory Fixation Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 356 Traumatic Subdural Hematoma
254 Odontoid C2 Fracture Jeffrey S. Ross, MD
Jeffrey S. Ross, MD

xv
 TABLE OF CONTENTS
358 Vascular Injury, Cervical
Jeffrey S. Ross, MD
SPONDYLOLISTHESIS AND SPONDYLOLYSIS
364 Traumatic Arteriovenous Fistula 478 Spondylolisthesis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
366 Wallerian Degeneration 482 Spondylolysis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
486 Instability
SECTION 3: DEGENERATIVE DISEASES Kevin R. Moore, MD and Jeffrey S. Ross, MD
AND ARTHRITIDES
INFLAMMATORY, CRYSTALLINE, AND
DEGENERATIVE DISEASES MISCELLANEOUS ARTHRITIDES
370 Nomenclature of Degenerative Disc Disease 490 Adult Rheumatoid Arthritis
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
374 Degenerative Disc Disease 496 Juvenile Idiopathic Arthritis
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
380 Degenerative Endplate Changes 502 Spondyloarthropathy
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
384 Degenerative Arthritis of Craniovertebral Junction 508 Neurogenic (Charcot) Arthropathy
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
388 Disc Bulge 512 Hemodialysis Spondyloarthropathy
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
392 Anular Fissure, Intervertebral Disc 514 Ankylosing Spondylitis
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
396 Cervical Intervertebral Disc Herniation 520 CPPD
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
402 Thoracic Intervertebral Disc Herniation 526 Gout
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
406 Lumbar Intervertebral Disc Herniation 528 Longus Colli Calcific Tendinitis
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
412 Intervertebral Disc Extrusion, Foraminal
Jeffrey S. Ross, MD SCOLIOSIS AND KYPHOSIS
416 Cervical Facet Arthropathy 532 Introduction to Scoliosis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
420 Lumbar Facet Arthropathy 536 Scoliosis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
424 Facet Joint Synovial Cyst 540 Kyphosis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
430 Baastrup Disease 542 Degenerative Scoliosis
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
434 Bertolotti Syndrome 546 Flat Back Syndrome
Jeffrey S. Ross, MD Kevin R. Moore, MD
436 Schmorl Node 548 Scoliosis Instrumentation
Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
440 Scheuermann Disease
Jeffrey S. Ross, MD and Kevin R. Moore, MD SECTION 4: INFECTION AND
444 Acquired Lumbar Central Stenosis INFLAMMATORY DISORDERS
Jeffrey S. Ross, MD
448 Congenital Spinal Stenosis, Idiopathic INFECTIONS
Kevin R. Moore, MD 554 Pathways of Spread
454 Cervical Spondylosis Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 558 Spinal Meningitis
460 DISH Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 562 Pyogenic Osteomyelitis
464 OPLL Kevin R. Moore, MD
Jeffrey S. Ross, MD 568 Tuberculous Osteomyelitis
470 Ossification Ligamentum Flavum Kevin R. Moore, MD
Jeffrey S. Ross, MD 574 Fungal and Miscellaneous Osteomyelitis
474 Retroodontoid Pseudotumor Jeffrey S. Ross, MD
Jeffrey S. Ross, MD

xvi
 TABLE OF CONTENTS
578 Osteomyelitis, C1-C2
Jeffrey S. Ross, MD
SECTION 5: NEOPLASMS, CYSTS, AND
582 Brucellar Spondylitis
OTHER MASSES
Jeffrey S. Ross, MD and Kevin R. Moore, MD NEOPLASMS
584 Septic Facet Joint Arthritis
Jeffrey S. Ross, MD INTRODUCTION AND OVERVIEW
590 Paraspinal Abscess
Jeffrey S. Ross, MD 678 Spread of Neoplasms
594 Epidural Abscess Jeffrey S. Ross, MD
Jeffrey S. Ross, MD EXTRADURAL
600 Subdural Abscess
Jeffrey S. Ross, MD and Kevin R. Moore, MD 682 Imaging of Metastatic Disease
604 Abscess, Spinal Cord Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 688 Blastic Osseous Metastases
608 Viral Myelitis Jeffrey S. Ross, MD
Jeffrey S. Ross, MD and Kevin R. Moore, MD 692 Lytic Osseous Metastases
612 HIV Myelitis Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 696 Hemangioma
616 Syphilitic Myelitis Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 700 Osteoid Osteoma
618 Opportunistic Infections Kevin R. Moore, MD
Jeffrey S. Ross, MD and Kevin R. Moore, MD 704 Osteoblastoma
622 Echinococcosis Jeffrey S. Ross, MD and Kevin R. Moore, MD
Jeffrey S. Ross, MD 708 Aneurysmal Bone Cyst
626 Schistosomiasis Jeffrey S. Ross, MD and Kevin R. Moore, MD
Jeffrey S. Ross, MD 712 Giant Cell Tumor
630 Cysticercosis Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 716 Osteochondroma
Jeffrey S. Ross, MD and Kevin R. Moore, MD
INFLAMMATORY AND AUTOIMMUNE 720 Chondrosarcoma
DISORDERS Jeffrey S. Ross, MD
724 Osteosarcoma
634 Acute Transverse Myelopathy
Jeffrey S. Ross, MD and Kevin R. Moore, MD
Jeffrey S. Ross, MD
728 Chordoma
638 Idiopathic Acute Transverse Myelitis
Jeffrey S. Ross, MD and Kevin R. Moore, MD
Jeffrey S. Ross, MD and Kevin R. Moore, MD
734 Ewing Sarcoma
642 Multiple Sclerosis
Jeffrey S. Ross, MD and Kevin R. Moore, MD
Jeffrey S. Ross, MD
738 Lymphoma
646 Neuromyelitis Optica Spectrum Disorder
Jeffrey S. Ross, MD
Jeffrey S. Ross, MD
744 Leukemia
650 Myelin Oligodendrocyte Glycoprotein Autoantibody
Jeffrey S. Ross, MD and Kevin R. Moore, MD
Myelitis
748 Plasmacytoma
Jeffrey S. Ross, MD
Jeffrey S. Ross, MD
652 ADEM
752 Multiple Myeloma
Kevin R. Moore, MD
Jeffrey S. Ross, MD
656 Guillain-Barré Syndrome
756 Neuroblastic Tumor
Jeffrey S. Ross, MD and Kevin R. Moore, MD
Kevin R. Moore, MD
660 CIDP
760 Langerhans Cell Histiocytosis
Jeffrey S. Ross, MD
Kevin R. Moore, MD
664 Chronic Recurrent Multifocal Osteomyelitis
764 Angiolipoma
Jeffrey S. Ross, MD
Jeffrey S. Ross, MD and Kevin R. Moore, MD
666 Grisel Syndrome
Jeffrey S. Ross, MD INTRADURAL EXTRAMEDULLARY
668 Paraneoplastic Myelopathy
768 Schwannoma
Jeffrey S. Ross, MD
672 IgG4-Related Disease/Hypertrophic Pachymeningitis Jeffrey S. Ross, MD
774 Melanotic Schwannoma
Jeffrey S. Ross, MD
Jeffrey S. Ross, MD
776 Meningioma
Jeffrey S. Ross, MD

xvii
 TABLE OF CONTENTS
782 Solitary Fibrous Tumor/Hemangiopericytoma 858 Intracranial Hypotension
Jeffrey S. Ross, MD Jeffrey S. Ross, MD and Kevin R. Moore, MD
786 Neurofibroma 862 Fast CSF Leak/Meningeal Diverticulum
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
790 Malignant Nerve Sheath Tumors 866 Fast CSF Leak/Ventral Dural Tear
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
794 Metastases, CSF Disseminated 870 Slow CSF Leak/CSF Venous Fistula
Jeffrey S. Ross, MD and Kevin R. Moore, MD Jeffrey S. Ross, MD
798 Paraganglioma 874 Idiopathic Spinal Cord Herniation
Jeffrey S. Ross, MD Jeffrey S. Ross, MD
INTRAMEDULLARY VASCULAR
802 Astrocytoma
Jeffrey S. Ross, MD and Kevin R. Moore, MD VASCULAR ANATOMY AND CONGENITAL
806 Ependymoma LESIONS
Jeffrey S. Ross, MD and Kevin R. Moore, MD 878 Vascular Anatomy
810 Myxopapillary Ependymoma Jeffrey S. Ross, MD
Jeffrey S. Ross, MD and Kevin R. Moore, MD 884 Persistent First Intersegmental Artery
814 Hemangioblastoma Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 886 Persistent Hypoglossal Artery
820 Spinal Cord Metastases Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 888 Persistent Proatlantal Artery
824 Primary Melanocytic Neoplasms/Melanocytoma Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD
826 Ganglioglioma VASCULAR MALFORMATIONS
Jeffrey S. Ross, MD 890 Spinal Dural Arteriovenous Fistula (Type 1)
Jeffrey S. Ross, MD
NONNEOPLASTIC CYSTS AND TUMOR 896 Spinal Cord Arteriovenous Malformation (Type 2)
MIMICS Jeffrey S. Ross, MD
900 Complex Spinal Cord Arteriovenous Malformation
CYSTS (Type 3)
828 CSF Flow Artifact Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 904 Spinal Perimedullary Fistula (Type 4)
830 Meningeal Cyst Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 908 Conus Arteriovenous Malformation
836 Perineural Root Sleeve Cyst Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 912 Posterior Fossa Dural Fistula With Intraspinal
840 Syringomyelia Drainage
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
916 Spinal Epidural Arteriovenous Fistula
NONNEOPLASTIC MASSES AND TUMOR Jeffrey S. Ross, MD
MIMICS 920 Cavernous Malformation
844 Epidural Lipomatosis Jeffrey S. Ross, MD
Kevin R. Moore, MD
846 Normal Fatty Marrow Variants VASCULAR MISCELLANEOUS
Kevin R. Moore, MD 924 Spinal Artery Aneurysm
848 Fibrous Dysplasia Jeffrey S. Ross, MD
Kevin R. Moore, MD 926 Spinal Cord Infarction
850 Calcifying Pseudoneoplasm of Neuraxis Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 930 Subarachnoid Hemorrhage
852 Kümmell Disease Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 934 Spontaneous Epidural Hematoma
854 Hirayama Disease Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 940 Subdural Hematoma
Kevin R. Moore, MD and Jeffrey S. Ross, MD
CSF LEAK DISORDERS 944 Superficial Siderosis
856 Introduction and Overview of CSF Leak Kevin R. Moore, MD and Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 948 Hematomyelia/Nontraumatic Cord Hemorrhage
Kevin R. Moore, MD and Jeffrey S. Ross, MD

xviii
 TABLE OF CONTENTS
952 Bow Hunter Syndrome 1040 Peripheral Neurolymphomatosis
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD
954 Vertebral Artery Dissection 1042 Hypertrophic Neuropathy
Kevin R. Moore, MD and Jeffrey S. Ross, MD Kevin R. Moore, MD and Jeffrey S. Ross, MD

SYSTEMIC DISORDERS SECTION 7: SPINE POSTPROCEDURAL

IMAGING
SPINAL MANIFESTATIONS OF SYSTEMIC
DISEASES POSTOPERATIVE IMAGING AND
COMPLICATIONS
960 Osteoporosis
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1048 Surgical Approaches
964 Paget Disease Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1052 Normal Postoperative Change
968 Hyperparathyroidism Jeffrey S. Ross, MD
Kevin R. Moore, MD 1058 Postoperative Spinal Complications
970 Renal Osteodystrophy Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1064 Myelography Complications
972 Hyperplastic Vertebral Marrow Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1068 Vertebroplasty Complications
976 Myelofibrosis Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1072 Failed Back Surgery Syndrome
978 Bone Infarction Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1076 Recurrent Disc Herniation
980 Extramedullary Hematopoiesis Jeffrey S. Ross, MD
Kevin R. Moore, MD 1080 Peridural Fibrosis
984 Tumoral Calcinosis Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1084 Arachnoiditis/Adhesions
988 Sarcoidosis Jeffrey S. Ross, MD
Kevin R. Moore, MD and Jeffrey S. Ross, MD 1090 Arachnoiditis Ossificans
994 Hemophilic Pseudotumor Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 1092 Accelerated Degeneration
996 EBV-Associated Smooth Muscle Tumor Jeffrey S. Ross, MD
Jeffrey S. Ross, MD 1096 Postoperative Infection
998 Subacute Combined Degeneration Jeffrey S. Ross, MD
Kevin R. Moore, MD 1100 Pseudomeningocele
Jeffrey S. Ross, MD
SECTION 6: PERIPHERAL NERVE AND 1106 Postsurgical Deformity
PLEXUS Jeffrey S. Ross, MD

PLEXUS AND PERIPHERAL NERVE LESIONS HARDWARE

1004 Normal Plexus and Nerve Anatomy 1110 Metal Artifact
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1010 Superior Sulcus Tumor 1114 Occipitocervical Fixation
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1014 Thoracic Outlet Syndrome 1116 Plates and Screws
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1018 Muscle Denervation 1120 Cages
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1020 Brachial Plexus Traction Injury 1122 Interbody Fusion Devices
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1024 Idiopathic Brachial Plexus Neuritis 1126 Interspinous Spacing Devices
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1028 Traumatic Neuroma 1130 Cervical Artificial Disc
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1032 Radiation Plexopathy 1134 Lumbar Artificial Disc
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD
1036 Peripheral Nerve Sheath Tumor 1138 Hardware Failure
Kevin R. Moore, MD and Jeffrey S. Ross, MD Jeffrey S. Ross, MD and Kevin R. Moore, MD

xix
 TABLE OF CONTENTS
1144 Bone Graft Complications
Jeffrey S. Ross, MD
1148 rhBMP-2 Complications
Jeffrey S. Ross, MD
1152 Heterotopic Bone Formation
Jeffrey S. Ross, MD

POST RADIATION AND CHEMOTHERAPY

COMPLICATIONS
1156 Radiation Myelopathy
Kevin R. Moore, MD and Jeffrey S. Ross, MD
1160 Postirradiation Vertebral Marrow
Kevin R. Moore, MD
1164 Anterior Lumbar Radiculopathy
Kevin R. Moore, MD

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FOURTH EDITION

Ross
Moore

i
 SECTION 1

Congenital and Genetic Disorders

Congenital

Normal Anatomical Variations

Normal Anatomy 4
Measurement Techniques 10
MR Artifacts 16
Normal Variant 22
Craniovertebral Junction Variants 26
Ponticulus Posticus 30
Ossiculum Terminale 32
Conjoined Nerve Roots 34
Limbus Vertebra 38
Filum Terminale Fibrolipoma 42
Bone Island 44
Ventriculus Terminalis 46

Chiari Disorders
Approach to Chiari 50
Chiari 1 56
Complex Chiari 60
Chiari 2 62
Chiari 3 66

Abnormalities of Neurulation
Approach to Spine and Spinal Cord Development 68
Myelomeningocele 76
Lipomyelomeningocele 80
Lipoma 84
Dorsal Dermal Sinus 88
Simple Coccygeal Dimple 92
Dermoid Cyst 94
Epidermoid Cyst 98

Anomalies of Caudal Cell Mess

Tethered Spinal Cord 102
Segmental Spinal Dysgenesis 106
Caudal Regression Syndrome 110
Terminal Myelocystocele 114
Anterior Sacral Meningocele 118
Sacral Extradural Arachnoid Cyst 122
Sacrococcygeal Teratoma 126
Anomalies of Notochord and Vertebral Formation
Craniovertebral Junction Embryology 130
Paracondylar Process 136
Split Atlas 138
Klippel-Feil Spectrum 140
Failure of Vertebral Formation 144
Vertebral Segmentation Failure 148
Split Cord Malformation 152
Partial Vertebral Duplication 156
Incomplete Fusion, Posterior Element 158
Neurenteric Cyst 160

Developmental Abnormalities
Os Odontoideum 164
Lateral Meningocele 168
Dorsal Spinal Meningocele 172
Dural Dysplasia 176

Genetic Disorders
Neurofibromatosis Type 1 180
Neurofibromatosis Type 2 184
Schwannomatosis 188
Achondroplasia 190
Mucopolysaccharidoses 194
Sickle Cell Disease 198
Osteogenesis Imperfecta 202
Tuberous Sclerosis 206
Osteopetrosis 210
Gaucher Disease 212
Ochronosis 214
Connective Tissue Disorders 216
Spondyloepiphyseal Dysplasia 220
 Normal Anatomy
Congenital and Genetic Disorders
Imaging Anatomy
There are 33 spinal vertebrae, which comprise 2 components:
A cylindrical ventral bone mass, which is the vertebral
body, and the dorsal arch.
7 cervical, 12 thoracic, 5 lumbar bodies
• 5 fused elements form sacrum
• 4-5 irregular ossicles form coccyx
Arch
• 2 pedicles, 2 laminae, 7 processes (1 spinous, 4 articular,
2 transverse)
• Pedicles attach to dorsolateral aspect of body
• Pedicles unite with pair of arched flat laminae
• Lamina capped by dorsal projection, called spinous
process
• Transverse processes arise from sides of arches
The 2 articular processes (zygapophyses) are diarthrodial
joints.
• Superior process bearing facet with surface directed
dorsally
• Inferior process bearing facet with surface directed
ventrally
Pars interarticularis is the part of the arch that lies between
the superior and inferior articular facets of all subatlantal
movable elements. The pars are positioned to receive
biomechanical stresses of translational forces displacing
superior facets ventrally, whereas inferior facets remain
attached to dorsal arch (spondylolysis). C2 exhibits a unique
anterior relation between the superior facet and the
posteriorly placed inferior facet. This relationship leads to an
elongated C2 pars interarticularis, which is the site of the
hangman's fracture.
Cervical
The cervical bodies are small and thin relative to the size of the
arch and foramen with the transverse diameter greater than
the AP diameter. The lateral edges of the superior surface of
the body are turned upward into the uncinate processes. The
transverse foramen perforates the transverse processes. The
vertebra artery resides within the transverse foramen, most
commonly starting at the C6 level.
C1 has no body and forms a circular bony mass. The superior
facets of C1 are large ovals that face upward, and the inferior
facets are circular in shape. Large transverse processes are
present on C1 with fused anterior and posterior tubercles.
The C2 complex consists of the axis body with dens/odontoid
process. The odontoid embryologically arises from the
centrum of the 1st cervical vertebrae.
The C7 vertebral body shows a transitional morphology with a
prominent spinous process.
Thoracic
• Thoracic bodies are heart-shaped and increase in size
from superior to inferior
• Facets are present for rib articulation, and laminae are
broad and thick
• Spinous processes are long, directed obliquely caudally
• Superior facets are thin, directed posteriorly
• T1 vertebral body shows complete facet for capitulum of
1st rib and inferior demifacet for capitulum of 2nd rib
• T12 body has transitional anatomy and resembles upper
lumbar bodies with inferior facet directed more laterally
4
Lumbar
The lumbar vertebral bodies are large, wide, and thick and lack
a transverse foramen or costal articular facets. The pedicles
are strong and directed posteriorly. The superior articular
processes are directed dorsomedially and almost face each
other. The inferior articular processes are directed anteriorly
and laterally.
Joints
Synarthrosis is an immovable joint of cartilage and occurs
during development and in the 1st decade of life. The
neurocentral joint occurs at the union point of 2 centers of
ossification for 2 halves of the vertebral arch and centrum.
Diarthrosis is a true synovial joint that occurs in the articular
processes, costovertebral joints, and atlantoaxial and sacroiliac
articulations. The pivot-type joint occurs at the median
atlantoaxial articulation. All others are gliding joints.
Amphiarthroses are nonsynovial, movable connective tissue
joints. Symphysis is a fibrocartilage fusion between 2 bones,
as in the intervertebral disc. Syndesmosis is a ligamentous
connection common in the spine, such as the paired ligamenta
flava, intertransverse ligaments, and interspinous ligaments.
An unpaired syndesmosis is present in the supraspinous
ligament.
Atlantooccipital (AO) articulation is composed of a
diarthrosis between the lateral mass of atlas and occipital
condyles and the syndesmoses of the AO membranes.
Anterior AO membrane is the extension of the anterior
longitudinal ligament (ALL). The posterior AO membrane is
homologous to the ligamenta flava.
Atlantoaxial articulation is a pivot joint. The transverse
ligament maintains the relationship of the odontoid to the
anterior arch of atlas. Synovial cavities are present between
the transverse ligament/odontoid and the atlas/odontoid
junctions.
Disc
The intervertebral disc is composed of 3 parts: The
cartilaginous endplate, the anulus fibrosis, and the nucleus
pulposus. The height of the lumbar disc space generally
increases as one progresses caudally. The anulus consists of
concentrically oriented collagenous fibers, which serve to
contain the central nucleus pulposus. These fibers insert into
the vertebral cortex via Sharpey fibers and also attach to the
anterior and posterior longitudinal ligaments (PLLs). Type I
collagen predominates at the periphery of the anulus, while
type II collagen predominates in the inner anulus. The normal
contour of the posterior aspect of the anulus is dependent
upon the contour of its adjacent endplate. Typically, this is
slightly concave in the axial plane, although commonly at L4-
L5 and L5-S1, these posterior margins will be flat or even
convex. A convex shape on the axial images alone should not
be interpreted as degenerative bulging.
The nucleus pulposus is a remnant of the embryonal
notochord and consists of a well-hydrated, noncompressible
proteoglycan matrix with scattered chondrocytes.
Proteoglycans form a major macromolecular component,
including chondroitin 6-sulfate, keratan sulfate, and hyaluronic
acid. Proteoglycans consist of protein core with multiple
attached glycosaminoglycan chains. The nucleus occupies an
eccentric position within the confines of anulus and is more
dorsal with respect to the center of the vertebral body. At
 Normal Anatomy
birth, ~ 85-90% of the nucleus is water. This water content
gradually decreases with advancing age. Within the nucleus
pulposus on T2-weighted sagittal images, there is often a
linear hypointensity coursing in an anteroposterior direction,
the intranuclear cleft. This region of more prominent fibrous
tissue should not be interpreted as intradiscal air or
calcification.
Anterior Longitudinal Ligament
The ALL runs along the ventral surface of the spine from the
skull to the sacrum. The ALL is narrowest in the cervical spine
and is firmly attached at the ends of each vertebral body. It is
loosely attached at the midsection of the disc.
Posterior Longitudinal Ligament
The PLL runs on the dorsal surface of bodies from the skull to
the sacrum. The PLL has a segmental denticulate
configuration and is wider at the disc space but narrows and
becomes thicker at the vertebral body level.
Craniocervical Ligaments
The craniocervical ligaments are located anteriorly to the
spinal cord and occur in 3 layers: Anterior, middle, and
posterior. Anterior ligaments consist of the odontoid
ligaments (apical and alar). The apical ligament is a small,
fibrous band extending from dens tip to basion. Alar
ligaments are thick, horizontally directed ligaments extending
from the lateral surface of dens tip to anteromedial occipital
condyles. The middle layer consists of the cruciate ligament.
The transverse ligament is a strong horizontal component of
the cruciate ligament extending from behind the dens to the
medial aspect of C1 lateral masses. The craniocaudal
component consists of a fibrous band running from the
transverse ligament superiorly to the foramen magnum and
inferiorly to C2. Posteriorly, the tectorial membrane is the
continuation of PLL and attaches to the anterior rim of the
foramen magnum.
Vertebral Artery
The vertebral artery arises as the 1st branch of the subclavian
artery on both sides. The vertebral artery travels cephalad
within the foramen transversarium (transverse foramen)
within the transverse processes. The 1st segment of the
vertebral artery extends from its origin to the entrance into
the foramen of the transverse process of the cervical
vertebrae, usually the 6th. The most common variation is the
origin of the left vertebral artery from the arch, between the
left common carotid and the left subclavian arteries (2-6%).
The vertebral artery in these variant cases almost always
enters the foramen of the transverse process of C5. The 2nd
segment runs within the transverse foramen to the C2 level.
Nerve roots pass posterior to the vertebral artery. The 3rd
segment starts at the C2 level where the artery loops and
turns lateral to ascend in the C1 transverse foramen. It then
turns medial, crossing on top of C1 in a groove. The 4th
segment starts where the artery perforates the dura and
arachnoid at the lateral edge of the posterior occipitoatlantal
membrane, coursing ventrally on the medulla to join with the
other vertebral artery to make the basilar artery.
Vertebral Column Blood Supply
Paired segmental arteries (intercostals, lumbar arteries) arise
from the aorta and extend dorsolaterally around the middle
of the vertebral body. Near the transverse process, the
segmental artery divides into lateral and dorsal branches. The
Congenital and Genetic Disorders
lateral branch supplies dorsal musculature, and the dorsal
branch passes lateral to the foramen, giving off branch(es) and
providing major vascular supply to bone and vertebral canal
contents. The posterior central branch supplies disc and
vertebral body, while the prelaminal branch supplies the inner
surface of the arch, ligamenta flava, and regional epidural
tissue. The neural branch entering the neural foramen
supplies pia, arachnoid, and cord. The postlaminar branch
supplies musculature overlying lamina and branches to bone.
Nerves
• Spinal nerves are arranged in 31 pairs and grouped
regionally: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and
1 coccygeal
• Ascensus spinalis is apparent developmental rising of
cord related to differential spinal growth
• Course of nerve roots becomes longer and more oblique
at lower segments
• C1 nerve from C1 segment and exits above C1
• C8 nerve from C7 segment and exits at C7-T1
• T6 nerve from T5 segment and exits at T6-T7
• T12 nerve from T8 segment and exits at T12-L1
• L2 nerve from T10 segment and exits at L2-L3
• S3 nerve from T12 segment and exits at S3 foramen
Meninges are divided into dura, arachnoid, and pia.
Dura is a dense, tough covering corresponding to the
meningeal layer of the cranial dura. The epidural space is filled
with fat, loose connective tissue, and veins. The dura
continues with spinal nerves through the foramen to fuse
with the epineurium. Cephalic attachment of the dura is at the
foramen magnum and the caudal attachment at the back of
the coccyx.
Arachnoid is the middle covering, which is thin, delicate, and
continuous with cranial arachnoid. The arachnoid is separated
from the dura by the potential subdural space.
Pia is the inner covering of delicate connective tissue closely
applied to the cord. Longitudinal fibers are laterally
concentrated as denticulate ligaments lying between
posterior and anterior roots and attach at 21 points to dura.
Longitudinal fibers are concentrated dorsally as the septum
posticum, attaching the dorsal cord to the dorsal midline dura.
Selected References
1. Gailloud P: Spinal vascular anatomy. Neuroimaging Clin N Am. 29(4):615-33,
2019
2. Shanechi AM et al: Spine anatomy imaging: an update. Neuroimaging Clin N
Am. 29(4):461-80, 2019
3. Griessenauer CJ et al: Venous drainage of the spine and spinal cord: a
comprehensive review of its history, embryology, anatomy, physiology, and
pathology. Clin Anat. 28(1):75-87, 2015
4. Fardon DF et al: Lumbar disc nomenclature: version 2.0: recommendations
of the combined task forces of the north american spine society, the
american society of spine radiology, and the american society of
neuroradiology. Spine (Phila Pa 1976). 39(24):E1448-65, 2014
5. Santillan A et al: Vascular anatomy of the spinal cord. J Neurointerv Surg.
4(1):67-74, 2012
6. Modic MT et al: Lumbar degenerative disk disease. Radiology. 245(1):43-61,
2007
7. Battie MC et al: Lumbar disc degeneration: epidemiology and genetics. J
Bone Joint Surg Am. 88 Suppl 2:3-9, 2006
8. Grunhagen T et al: Nutrient supply and intervertebral disc metabolism. J
Bone Joint Surg Am. 88 Suppl 2:30-5, 2006
9. Haughton V: Imaging intervertebral disc degeneration. J Bone Joint Surg
Am. 88 Suppl 2:15-20, 2006
5
 Normal Anatomy
Congenital and Genetic Disorders

Atlas

7 cervical vertebral bodies

Axis

12 thoracic vertebral bodies

Transverse process
5 lumbar vertebral bodies

Iliac wing

5 fused sacral vertebral bodies

Sacral ala
4 coccygeal bodies

Brachial plexus

C8 root exiting at C7-T1 level

Thoracic intervertebral discs

Intercostal nerves

T12 root exiting at T12-L1 level

Lumbar intervertebral discs

L4 root exiting at L4-L5 level

Lumbosacral plexus
Sacral nerve roots

Sciatic nerve

(Top) Coronal graphic of the spinal column shows the relationship of 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 coccygeal
bodies. Note the cervical bodies are smaller with the neural foramina oriented at 45° and capped by the unique C1 and C2 morphology.
Thoracic bodies are heart-shaped, with thinner intervertebral discs, and are stabilized by the rib cage. Lumbar bodies are more massive
with prominent transverse processes and thick intervertebral discs. (Bottom) Coronal graphic demonstrates exiting spinal nerve roots.
C1 exits between the occiput and C1, while the C8 root exits at the C7-T1 level. Thoracic and lumbar roots exit below their respective
pedicles.

6
Normal Anatomy

Congenital and Genetic Disorders

(Left) Sagittal graphic of CVJ
shows: 1) Ant. atlantooccipital
membrane, 2) apical lig., 3)
ALL, 4) cruciate lig., 5)
tectorial membrane, 6)
transverse lig., 7) post.
longitudinal lig., and 8) post.
atlantooccipital membrane.
Red star is the basion; blue
star is the opisthion. (Right)
Posterior view of CVJ shows:
1) Sup. cruciate ligament, 2)
cruciate lig., 3) odontoid ant.
to cruciate lig., 4) atlantoaxial
jt., 5) accessory atlantoaxial
lig., 6) inf. cruciate lig., 7)
transverse lig., 8) alar lig., and
9) atlantooccipital jt. Red star
is the basion.

(Left) Graphic shows the

cervical vertebra from above.
Vertebral body is broad
transversely, central canal is
large and triangular in shape,
pedicles are directed
posterolaterally, and laminae
are delicate. Lateral masses
contain the vertebral foramen
for passage of vertebral artery
and veins. (Right) Mid-C5 body
at the pedicle level shows
transverse foramina are
prominent ſt, encompassing
the vertical course of vertebral
artery. The anterior and
posterior tubercles st give rise
to muscle attachments in
neck.

(Left) Graphic shows the

thoracic vertebral body from
above. Thoracic bodies are
characterized by long, spinous
processes and transverse
processes. Complex rib
articulation includes both
costotransverse joints ſt and
costovertebral joints st. Facet
joints are oriented in the
coronal plane. (Right) Image
through the pedicle level of
the thoracic spine shows the
coronal orientation of the
facet joints ﬈ are well
identified. The pedicles are
thin and gracile with adjacent
rib articulations.

7
 Normal Anatomy
Congenital and Genetic Disorders

(Left) Graphic shows the

lumbar body from above.
Large, sturdy lumbar bodies
connect to thick pedicles and
transversely directed
transverse processes. Facets
maintain oblique orientation,
favoring flexion/extension.
(Right) Lateral 3D scan of the
lumbar spine shows large
bodies joined by thick
posterior elements with the
superior and inferior articular
processes angled in lateral
plane. Transverse processes jut
out laterally for muscle
attachments. Pars
interarticularis form a junction
between articular processes.

(Left) Coronal oblique view of

the lumbar spine shows the
typical Scotty dog appearance
of the posterior elements. The
neck of the "dog" is the pars
interarticularis ﬈. (Right)
Oblique 3D exam of the
lumbar spine shows surface
anatomy of Scotty dog:
Transverse process (nose) ﬇,
superior articular process (ear)
ſt, inferior articular process
(front leg) st, and intervening
pars interarticularis (neck) ﬈.
Pedicle that forms the "eye"
on CT reconstructions is
obscured.

(Left) Cut-away graphic shows

the lumbar vertebral bodies
joined by disc and anterior ﬈
and posterior ﬊ longitudinal
ligaments. Paired ligamentum
flavum ﬇ and interspinous
ligament st join posterior
elements with the midline
supraspinous ligament ﬈.
(Right) Graphic shows spinal
cord and coverings: 1) Dura
mater, 2) subdural space, 3)
arachnoid mater, 4)
subarachnoid space, 5) pia
mater, 6) ant. spinal artery, 7)
epidural space, and 8) root
sleeve.

8
 Normal Anatomy

Congenital and Genetic Disorders

Medullary branches Posterior spinal arteries

Anterior spinal artery

Posterior radiculomedullary
artery
Artery of Adamkiewicz

Ventral branch of segmental

artery
Anterior radiculomedullary
artery

Postcentral branch to
vertebral body Muscular branch

Intercostal artery (segmental

supply) Dorsal ramus

Intercostal artery

Intercostal artery
Posterior branch of segmental
artery

Anterior spinal artery

Pia mater
Ventral radiculomedullary
artery
Postcentral branch to
vertebral body
Radiculomedullary artery
Medullary arteries
Dorsal radiculomedullary
Dura mater artery

Subdural potential space

Epidural space

Muscular branch

Posterior spinal arteries

(Top) Oblique axial graphic of the thoracic spinal cord and arterial supply at T10 shows segmental intercostal arteries arising from the
lower thoracic aorta. The artery of Adamkiewicz is the dominant segmental feeding vessel to the thoracic cord, supplying the anterior
aspect of the cord via the anterior spinal artery. Adamkiewicz has a characteristic hairpin turn on the cord surface as it first courses
superiorly, then turns inferiorly. (Bottom) Axial graphic shows the anterior and posterior radiculomedullary arteries anastomosing with
the anterior and posterior spinal arteries. Penetrating medullary arteries in the cord are largely end-arteries with few collaterals. The
cord watershed zone is at the central gray matter.

9
 Measurement Techniques
Congenital and Genetic Disorders
Terminology
Radiographic measurement techniques, skull base
craniometry, skull base lines
Pathology-Based Imaging Issues
This chapter provides a broad summary of the varied
measurement techniques used for evaluating the spine. The
main focus for the reader should be the tables and the
multiple schematics that define the variously named lines and
angles. These summarize the classic measurement techniques
for the skull base, rheumatoid disease, and some of the most
commonly used measurements for assessing trauma. The rest
of the measurements defined below are a mixture of
miscellaneous measurements and those that do not translate
well into a table (i.e., equations).
Torg-Pavlov Ratio
• Diameter of canal:width of vertebral body (initially
defined on plain radiographs of the subaxial spine)
The practical utility of this measurement is controversial. Less
than 0.80, as seen on the lateral view, is considered to be
cervical stenosis, and such a small canal potentially increases
risk for cord injury.
Maximum Canal Compromise (%)
• = 1-(Di/[(Da+Db)/2]) x 100%
AP canal diameter at the normal levels (immediately above
and below the level of injury) and at the level of maximum
compromise are defined. The measurement of normal levels is
taken at the midvertebral body level. Di is the AP canal
diameter at the level of maximum injury, Da is the AP canal
diameter at the nearest normal level above the level of injury,
and Db is the AP canal diameter at the nearest normal level
below the level of injury.
In spinal cord injury patients, midline T1 and T2 MR provide an
objective, quantifiable, and reliable assessment of cord
compression that cannot be defined by CT alone.
Maximum Cord Compression (%)
• = 1-(di/[(da+db)/2]) x 100%
AP cord diameter at the normal levels immediately above and
below the level of injury and at the level of maximum cord
compression is defined. di is the AP cord diameter at the level
of maximum injury, da is the AP cord diameter at the nearest
normal level above the level of injury, and db is the AP cord
diameter at the nearest normal level below the level of injury.
If cord edema is present, then measurements are made at the
midvertebral body level just above or below the extent of the
edema where the cord appears normal.
Cobb Measurement of Kyphosis
Lines are drawn to mark the superior endplate of the superior
next unaffected vertebral body and the inferior endplate of
the inferior next unaffected vertebral body, which are then
extended anterior to the bony canal. Perpendicular lines are
then extended, and the angle between the 2 perpendicular
lines is measured.
Tangent Method for Kyphosis
Lines are drawn along the posterior vertebral body margin on
the lateral view of the affected body and the next most
superior body that is unaffected. The angle between these 2
vertically oriented lines is measured.
Centroid
10
Also called the geometric center of the vertebral body, this
measurement is defined by drawing diagonal lines between
opposite corners of the body, with the centroid at the
intersection.
Apical Vertebral Translation
Lateral displacement of the apex of the coronal curve is
relative to the center sacral vertical line (CSVL) on AP plain
film. The apical vertebral translation (AVT) is the horizontal
distance between the centroid of the apical body and the
CSVL.
Sagittal Balance
Sagittal alignment is defined on the lateral view using a C7
plumb line. The distal reference point is the posterior superior
aspect of the sacrum. There is a positive number if C7 plumb
line falls anterior to the reference point, and a negative
number if it falls posterior to the reference.
Selected References
1. Chang DG et al: Traumatic atlanto-occipital dislocation: analysis of 15 survival
cases with emphasis on associated upper cervical spine injuries. Spine (Phila
Pa 1976). 45(13):884-94, 2020
2. Le Huec JC et al: Sagittal balance of the spine. Eur Spine J. 28(9):1889-905,
2019
3. Martinez-Del-Campo E et al: Computed tomography parameters for
atlantooccipital dislocation in adult patients: the occipital condyle-C1
interval. J Neurosurg Spine. 24(4):535-45, 2016
4. Riascos R et al: Imaging of atlanto-occipital and atlantoaxial traumatic
injuries: what the radiologist needs to know. Radiographics. 35(7):2121-34,
2015
5. Andreisek G et al: Consensus conference on core radiological parameters to
describe lumbar stenosis - an initiative for structured reporting. Eur Radiol.
24(12):3224-32, 2014
6. Karpova A et al: Reliability of quantitative magnetic resonance imaging
methods in the assessment of spinal canal stenosis and cord compression in
cervical myelopathy. Spine (Phila Pa 1976). 38(3):245-52, 2013
7. Radcliff KE et al: Comprehensive computed tomography assessment of the
upper cervical anatomy: what is normal? Spine J. 10(3):219-29, 2010
8. Rojas CA et al: Evaluation of the C1-C2 articulation on MDCT in healthy
children and young adults. AJR Am J Roentgenol. 193(5):1388-92, 2009
9. Angevine PD et al: Radiographic measurement techniques. Neurosurgery.
63(3 Suppl):40-5, 2008
10. Bono CM et al: Measurement techniques for upper cervical spine injuries:
consensus statement of the Spine Trauma Study Group. Spine (Phila Pa
1976). 32(5):593-600, 2007
11. Furlan JC et al: A quantitative and reproducible method to assess cord
compression and canal stenosis after cervical spine trauma: a study of
interrater and intrarater reliability. Spine (Phila Pa 1976). 32(19):2083-91,
2007
12. Pang D et al: Atlanto-occipital dislocation: part 1--normal occipital condyle-C1
interval in 89 children. Neurosurgery. 61(3):514-21; discussion 521, 2007
13. Pang D et al: Atlanto-occipital dislocation--part 2: the clinical use of (occipital)
condyle-C1 interval, comparison with other diagnostic methods, and the
manifestation, management, and outcome of atlanto-occipital dislocation in
children. Neurosurgery. 61(5):995-1015; discussion 1015, 2007
14. Bono CM et al: Measurement techniques for lower cervical spine injuries:
consensus statement of the Spine Trauma Study Group. Spine (Phila Pa
1976). 31(5):603-9, 2006
15. Fehlings MG et al: The optimal radiologic method for assessing spinal canal
compromise and cord compression in patients with cervical spinal cord
injury. Part II: results of a multicenter study. Spine (Phila Pa 1976). 24(6):605-
13, 1999
16. Rao SC et al: The optimal radiologic method for assessing spinal canal
compromise and cord compression in patients with cervical spinal cord
injury. Part I: an evidence-based analysis of the published literature. Spine
(Phila Pa 1976). 24(6):598-604, 1999
17. Harris JH Jr et al: Radiologic diagnosis of traumatic occipitovertebral
dissociation: 1. Normal occipitovertebral relationships on lateral radiographs
of supine subjects. AJR Am J Roentgenol. 162(4):881-6, 1994
18. Harris JH Jr et al: Radiologic diagnosis of traumatic occipitovertebral
dissociation: 2. Comparison of three methods of detecting occipitovertebral
relationships on lateral radiographs of supine subjects. AJR Am J
Roentgenol. 162(4):887-92, 1994
19. Powers B et al: Traumatic anterior atlanto-occipital dislocation.
Neurosurgery. 4(1):12-7, 1979
 Measurement Techniques

Congenital and Genetic Disorders

Common Craniovertebral Junction Measurements
Measurement
Chamberlain
(palatooccipital) line
McGregor (basal) line
McRae line
Wackenheim clival line
Fischgold digastric line
Fischgold bimastoid line
Anterior atlantodental
interval
Atlantooccipital joint
space
Atlantoaxial joint space
Definition
Posterior hard palate to opisthion
Posterior hard palate to lowest point of
occipital bone
Basion to opisthion
Dorsum sellae to tip of clivus
Connects 2 digastric fossae
Connects tips of mastoid processes
Posterior aspect of anterior C1 arch to
anterior margin odontoid process
Line from midpoint of occipital condyle
to C1 condylar fossa
Line defining midpoint of C1-C2 joint on CT in adults: < 3.4 mm; CT in
coronal view
Normal Abnormal
< 2.5 mm of dens above line Dens > 2.5 mm above line
Tip of dens < 4.5 mm above line Tip of dens > 4.5 mm above line
Entire dens below line < 19 mm
Entire dens ventral to line Dens bisects line
Entire dens below line Dens bisects line
Tip of dens 3 mm below to 10 mm Tip of dens > 10 mm above line
above line
Plain films in children: < 4-5 mm; Plain films in children: > 4-5 mm; plain
plain films in adults: Males < 3.0 films in adults: Males > 3.0 mm,
mm, females < 2.5 mm; sagittal CT females > 2.5 mm; sagittal CT
reformats in children: < 2.6 mm; reformats in children: > 2.6 mm;
sagittal CT in adults: Both males sagittal CT in adults: Both males and
and females < 2.0 mm females > 2.0 mm
Plain films in children: < 5 mm; CT in Plain films in children: > 5 mm; CT in
children: < 2.5 mm; CT in adults: 1.5 children: > 2.5 mm
mm
CT in adults: > 3.4 mm; CT in children: >
children: < 3.9 mm 3.9 mm

Rheumatoid Arthritis Measurements

Measurement Definition Normal Abnormal
Ranawat Distance between center of C2 pedicle and < 15 mm in males, < 13 ≥ 15 mm in males, ≥ 13 mm in females
transverse axis of atlas measured along axis of mm in females
odontoid process
Redlund-Johnell line Distance between McGregor line and < 34 mm in males, < 29 ≥ 34 mm in males, ≥ 29 mm in females
midpoint of caudal margin of C2 mm in females
Clark stations Dividing odontoid process into 3 parts in Anterior ring of atlas is Anterior ring of atlas is level with middle 1/3
sagittal plane level with 1st station (2nd station) or caudal 1/3 (3rd station)
Posterior atlantodental Horizontal distance from posterior dens to Smaller is worse and relates to potential
interval anterior aspect of C1 lamina or ring neurologic deficit
Space available for cord AP diameter on sagittal MR between dorsal > 13 mm SAC < 13 mm then decompression in RA
and ventral dura patients considered
Spinal canal diameter Horizontal measurement from posterior On plain films < 14 mm, canal stenosis
vertebral body to spinolaminar line warrants MR for further evaluation

Craniovertebral Junction Trauma Measurements

Measurement Definition Normal Abnormal
Basion dental Basion to superior aspect of odontoid process < 12-12.5 mm in children on plain films, < > 12 mm (Harris measurement)
interval 10.5 mm in children on sagittal CT, < 8.5
mm in adults
Basion axial Distance between basion and line drawn along 0-12 mm on plain films Highly variable and not
interval posterior cortical margin of C2 recommended as primary
diagnostic method
Powers ratio Ratio of distance between basion and C1 < 1.0 > 1.0 (anterior dislocation only);
posterior arch divided by distance between posterior dissociation or vertical
opisthion and midpoint of posterior aspect of distraction could be missed with
anterior C1 arch (BC/OA) normal value
Summed Sum of bilateral distances between midpoint of CT in adults: < 3.0 mm Condylar sum ≥ 3 mm most
condylar occipital condyle and C1 condylar fossa sensitive CT sign of
distance atlantooccipital dislocation

11
 Measurement Techniques
Congenital and Genetic Disorders

(Left) Sagittal graphic of

craniocervical junction shows
the Wackenheim clival line
(red) extending tangent to the
normal odontoid position. The
line is drawn from the dorsum
sellae to the tip of the clivus.
(Right) Sagittal graphic of the
craniocervical junction shows
the Chamberlain line (red)
drawn from the posterior hard
palate to the opisthion and
McGregor line (yellow) drawn
from the posterior hard palate
to the lowest point of the
occipital bone.

(Left) Sagittal graphic of

craniocervical junction shows
lines comprising the Powers
ratio (BC/OA), where normal is
< 1. BC = basion to C1
posterior arch, OA = opisthion
and midpoint of the posterior
aspect of anterior C1 arch.
(Right) Sagittal graphic depicts
the Lee method. BC2SL and
C2O should just intersect
tangentially with the
posterosuperior aspect of the
dens and the highest point on
the atlas spinolaminar line
respectively in normal state.
Deviation suggests
atlantooccipital dislocation
(AOD).

(Left) Sagittal graphic shows

basion dental interval (BDI) in
red, which should be < 12-12.5
mm in children on plain films
and < 8.5 mm in adults on CT.
Black lines define basion axial
interval (BAI) ſt extending
from basion to line extended
along posterior margin of C2,
which should be < 12 mm on
plain films. C1-C2
spinolaminar line is shown in
purple (< 8 mm in adults).
(Right) Sagittal graphic shows
atlantodental interval (green)
and spinal canal diameter
(red).

12
Measurement Techniques

Congenital and Genetic Disorders

(Left) Sagittal CT
reconstruction in AOD shows
widening ſt of the BDI > 8.5
mm in this adult. Note the
normal Wackenheim line
relationship. (Right) Sagittal
CT reconstruction in AOD
shows widening of the C0-C1
junction ſt with anterior
subluxation of the condyle.
Condylar fragment is present
in the joint space st. Note the
normal C1-C2 relationship ﬇.

(Left) Sagittal STIR MR in AOD

shows widening of BDI with ↑
T2 signal ſt from alar and
apical ligament rupture. Note
also prevertebral edema st
and posterior interspinous
ligament disruption ﬉.
Posterior epidural hemorrhage
﬇ contributes to
subarachnoid space
narrowing. (Right) Coronal CT
in AOD shows widening of the
C0-C1 joint space ﬇, which
should be ~ 1.5 mm. Bilateral
symmetric avulsion fractures
off of the condyles are present
st. Condylar sum ≥ 3 mm is
the most sensitive CT sign of
AOD.

(Left) Sagittal graphic shows

the maximum canal
compromise measurement. Di
is the AP canal diameter at the
level of maximum injury, Da is
the AP canal diameter at the
nearest normal level above
the level of injury, Db is AP
canal diameter at nearest
normal level below level of
injury. (Right) Sagittal graphic
shows maximum cord
compression measurement. di
is AP cord diameter at level of
maximum injury, da is AP cord
diameter at nearest normal
level above injury, db is AP
cord diameter at nearest
normal level below injury.

13
 Measurement Techniques
Congenital and Genetic Disorders

(Left) Sagittal graphic shows

Redlund-Johnell line (red)
defined by distance between
McGregor line (yellow) and
midpoint of caudal margin of
C2 body. (Right) Sagittal
graphic shows Ranawat
measurement as the distance
between the center of C2
pedicle (purple) and transverse
axis (yellow) of the atlas
measured along the axis of the
odontoid process.

(Left) Graphic shows the 3

Clarke stations for measuring
basilar impression in RA. If
anterior ring of C1 is level with
the 2nd or 3rd station, then
basilar impression is present.
(Right) Sagittal graphic shows
2 different measurements:
McRae line (yellow) is defined
from basion to opisthion, and
the dens should be below this
line. Length of McRae should
be > 19 mm. Lower
measurement shows
measurements of Torg-Pavlov
ratio, which is the diameter of
canal (red) to width of
vertebral body (black). Normal
is > 0.8.

(Left) Coronal CT shows

Fischgold digastric line
(yellow) connecting the 2
digastric fossae (normal when
dens below the line), and
Fischgold bimastoid line (red)
connecting the mastoid
processes (abnormal if tip of
dens > 10 mm above line).
(Right) Sagittal CT shows
upward translocation of
odontoid with Wackenheim
clival line and Chamberlain
line grossly abnormal in this
patient with RA. Odontoid is
eroded with thinned pencil tip
appearance. Note markedly ↑
atlantodental interval.

14
Measurement Techniques

Congenital and Genetic Disorders

(Left) Sagittal graphic shows
Cobb angle method for
cervical kyphosis. Lines are
drawn along superior endplate
of cephalad unaffected body
and inferior endplate of
caudal unaffected body
(yellow). The angle of
perpendiculars (red) from
these lines is considered Cobb
angle (white). (Right) Sagittal
graphic shows posterior
vertebral body tangent
method. Lines extend from the
posterior body at fractured
level and superior unaffected
level. Distance can be
measured (red) or angle of
lines determined.

(Left) AP view shows Cobb

measurement. Lines are drawn
(yellow) along end vertebrae,
which are upper and lower
limits of curve tilting most
severely toward concavity.
Perpendiculars are drawn
from the endplate lines (red)
with angle measurement
(white). (Right) AP radiograph
shows measurement of overall
coronal plane balance by the
distance (yellow) from C7
plumb line (white) to central
sacral vertical line (CSVL)
(black). Positive displacement
is to the right, negative to the
left.

(Left) AP radiograph shows

measurement of apical
vertebral translation (AVT).
Distance (arrowed line) from
centroid of apex of curve
(yellow) is measured relative
to CSVL (black). (Right) Lateral
radiograph shows
measurement of sagittal
balance. Horizontal
displacement measured from
plumb line extended from
centroid of C7 (black line) to
posterior superior margin of
the sacrum (yellow). Positive
balance when line is anterior
to reference point.

15
 MR Artifacts

KEY FACTS
Congenital and Genetic Disorders

TERMINOLOGY ○ Normal marrow T1 hypointensity at high field strength (≥

• MR imaging artifacts that simulate disease 3.0 tesla)

IMAGING TOP DIFFERENTIAL DIAGNOSES

• Artifactual "pseudolesion" is usually bizarre or nonanatomic • Syringohydromyelia
in appearance or distribution • CSF drop metastases
○ May be detected anywhere in spine • Aneurysm or arteriovenous malformation
• Common artifacts • Spinal cord hemorrhage
○ Truncation (Gibbs) artifact • Marrow infiltration or replacement
○ Phase ghosting artifact CLINICAL ISSUES
○ Motion artifact • Artifact location often unrelated to clinical findings
○ CSF flow artifact • Exception is susceptibility artifact in cases of hemorrhage,
○ Chemical shift artifact metallic foreign body, or medical devices
○ Wraparound artifact (aliasing)
○ Susceptibility artifact DIAGNOSTIC CHECKLIST
○ Zipper artifact • Always consider MR artifacts when confronted with bizarre
○ Gradient warping artifact imaging findings
○ Fat-saturation failure ± inappropriate water saturation

(Left) Sagittal STIR MR

demonstrates linear T2
hyperintensity ſt within the
lower thoracic spinal cord
extending to the conus,
representing motion artifact
from abdominal wall
movement. The appearance is
suspicious for artifact because
it continues to the conus tip,
which is unusual with true
syringomyelia. (Right) Axial
T2WI FS MR demonstrates
prominent periodic ghosting
artifact ﬇ of the thecal sac
ſt propagated across the
image in the phase direction.

(Left) Sagittal T2WI MR

obtained for CSF drop
metastasis surveillance shows
bizarre intradural T2
hypointensity ſt, representing
marked CSF pulsation artifact
in the thoracic spine. (Right)
Axial T2WI MR (imaging
surveillance for CSF drop
metastases) confirms
intradural low signal intensity
CSF pulsation artifact ſt.
Correct interpretation as
artifact is possible by
recognizing that this low
signal intensity does not
resemble either a normal
anatomic structure or typical
drop metastasis.

16
 MR Artifacts
TERMINOLOGY
Abbreviations
• Specific absorbed radiation (SAR), radiofrequency (RF)
Synonyms
• Phase ghosting, Gibbs artifact, blooming artifact
Definitions
• MR imaging artifacts that simulate disease
IMAGING
General Features
• Best diagnostic clue
○ Artifactual "pseudolesion" is usually bizarre or
nonanatomic in appearance or distribution
• Location
○ May be detected anywhere in spine
– Appearance depends on artifact type
• Size
○ Variable
• Morphology
○ Bizarre appearance that seems nonphysiological or
nonanatomical
– MR is very prone to imaging artifacts
– Fortunately, most are pretty unique in appearance,
readily identified if reader is aware of their existence
○ Compare with CT motion artifacts, which often simulate
spine fractures or congenital anomalies on reformatted
images
MR Findings
• Truncation (Gibbs) artifact
○ Mathematical artifact related to truncation of
computational series used during Fourier transformation
of K-space data
– Not possible to calculate infinite series when
reconstructing raw data
– Mathematical equation is "truncated" or shortened to
reflect practical necessity of sampling finite, rather
than infinite, number of frequencies
○ May be detected in both phase and encoding directions,
although more conspicuous in phase direction, because
fewer samples usually obtained
○ Occurs at high contrast interfaces, producing alternating
light and dark bands that may mimic lesions
○ In spine, may artifactually widen or narrow spinal cord or
mimic syrinx
○ Decrease artifact conspicuity by increase number of
phase-encoding steps or decrease field of view (FOV)
• Phase ghosting artifact
○ Periodic replication of structure along line in phase-
encoding direction
○ Ghost artifacts, in particular, occur whenever there is
periodic motion within FOV
– Examples include blood flow in vessels, CSF
pulsations, cardiac, and respiratory motion
○ Like many artifacts, phase ghosting is more conspicuous
in phase-encoding direction, because sampling times are
much slower than in frequency encoding direction
Congenital and Genetic Disorders
– Thus, these artifacts are propagated in phase direction
regardless of motion direction
• Motion artifact
○ Voluntary or involuntary patient movement (random) or
pulsating flow in vessels (periodic)
○ Detected in phase-encoding direction
○ May simulate pathologic intramedullary or intradural
lesion
– Usually recognizable as artifact but may render study
limited or nondiagnostic for cord pathology
○ If motion is nonperiodic (e.g., bowel peristalsis), ghosting
will not occur, but generalized image degradation will be
apparent
○ Address with patient instruction, respiratory
compensation, sedation, faster scanning
• CSF flow artifact
○ Subset of periodic motion artifact
○ Dephasing of protons due to CSF motion may simulate
intradural blood, disc herniation, CSF metastasis, or
intramedullary lesion
○ Flow compensation techniques can decrease artifact
conspicuity
• Chemical shift artifact
○ Protons precess at slightly different frequencies in fat
compared to water
– Difference in proton precessional frequency between
water and fat at 1.5T is 220 Hz
○ Spatial misregistration of fat and water produces overlap
that causes additive bright band at lower frequency
range and subtractive dark band at higher frequency
range
○ Can be useful to confirm presence of macroscopic fat
• Wraparound artifact (aliasing)
○ Occurs when dimensions of imaged object exceed FOV
○ Seen in both frequency and phase-encoding directions,
although much more conspicuous in phase-encoding
direction
○ May also be identified in slice-select direction on 3D
sequences because of additional phase-encoding
direction
○ Increasing FOV and number of phase-encoding steps
helps reduce artifact in phase direction, as does use of
"no-phase-wrap" software
○ Aliasing in frequency direction may be abolished by
oversampling above Nyquist frequency
• Susceptibility artifact
○ Metal or blood products disrupt local magnetic field
homogeneity, produce signal void or image distortion
○ Common in postoperative instrumented spine
○ New metal-insensitive pulse sequences help reduce
artifact
○ Can be used to advantage to diagnose hemorrhagic or
calcified lesions
– e.g., cavernous malformations, spinal cord
hemorrhage
• Zipper artifact
○ Family of similar-appearing artifacts most commonly
occurring in phase-encoding direction
○ Produced by RF noise related to scanner equipment,
scan parameters, or extrinsic noise (TV or radio channel,
flickering fluorescent room light, patient monitor, etc.)
17
 MR Artifacts
Congenital and Genetic Disorders
○ Usually easy to identify as artifact but may obscure
important findings or create confusing "pseudolesion"
• Gradient warping artifact
○ Image distortion at edges of large FOV studies (> 30 cm)
caused by gradient distortion
○ May be be addressed with gradient distortion correction
(GDC)
• Fat-saturation failure ± inappropriate water saturation
○ Frequency selective RF ("fat-saturation") pulse frequency
chosen to saturate fat spectral peak center frequency
○ Magnetic field inhomogeneity alters fat center
frequency so that fat-saturation pulse frequency no
longer overlaps fat spectral peak → fat-saturation failure
○ If fat-saturation pulse frequency inadvertently overlaps
water spectral peak → inappropriate water suppression
• Normal marrow T1 hypointensity at high field strength (≥
3.0 T)
○ Problem arises because of technical parameter changes
needed to acquire T1-weighted images at high field in
reasonable time without SAR issues
○ Inversion recovery T1WI sequences less SAR intensive
than T1 SE sequence, commonly used in 3.0T spine
imaging
– Marrow signal relatively hypointense compared to
appearance on SE T1WI, simulates pathologic marrow
infiltration
Imaging Recommendations
• Protocol advice
○ Minimize artifacts using appropriate parameters, flow
compensation, saturation bands, adequate sedation, or
comfort measures, etc.
DIFFERENTIAL DIAGNOSIS
Syringomyelia
• True dilation of central spinal cord canal, without
(hydromyelia) or with (syringomyelia) underlying cord injury
and myelomalacia, eccentric cavitation
• Does not usually extend entirely to conus; may be
sacculated
• Simulated by truncation artifact or phase ghosting
CSF Drop Metastases
• Will usually be detectable in at least 2 planes
• Mimicked (or obscured) by CSF pulsation artifact
• Swap phase and frequency if needed to confirm as not
artifact
Aneurysm or Arteriovenous Malformation
• Phase ghosting permits diagnosis of patent flow within
vessels or tissue based on periodic ghost artifact
• Absence of this artifact in technically satisfactory MR exam
indicates slow flow or thrombosed lesion
Spinal Cord Hemorrhage
• Cavernous malformation, posttraumatic spinal cord
hematoma, neoplasm
• Mimicked by phase ghosting, RF leak, motion artifact
• Use gradient-recalled echo (GRE) imaging to capitalize on
susceptibility artifact, confirm blooming of hypointense
signal in hemorrhagic lesion
18
Marrow Infiltration or Replacement
• Marrow replacement or ablation, fibrosis
• Hematopoietic neoplasms, marrow replacement, or
ablation diseases, osteopetrosis
• Mimicked by use of T1 FLAIR technique for T1WI at higher
field strengths (≥ 3.0T)
• Results in lower normal marrow signal intensity than seen
on spin-echo T1WI sequences
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Artifact location often unrelated to clinical findings
○ Exception is susceptibility artifact in cases of
hemorrhage, metallic foreign body, or medical devices
Natural History & Prognosis
• Not applicable
Treatment
• Not applicable
DIAGNOSTIC CHECKLIST
Consider
• Artifacts often have characteristic appearance,
recognizable if imager is aware of and considers artifact
Reporting Tips
• Always consider MR artifacts when confronted with bizarre
imaging findings
○ If MR artifact cannot be excluded, consider true
pathology
○ Clinical context always crucial to avoid failure to consider
important pathologic differential considerations
SELECTED REFERENCES
1. Chiang IC et al: Benefits and pitfalls of iterative decomposition of water and
fat with echo asymmetry and least-squares estimation (IDEAL) imaging in
clinical application of the cervical spine MR. Clin Radiol. 74(1):78.e13-21,
2019
2. Jungmann PM et al: Advances in MRI around metal. J Magn Reson Imaging.
46(4):972-91, 2017
3. Lee YH et al: Fat-suppressed MR imaging of the spine for metal artifact
reduction at 3T: comparison of STIR and slice encoding for metal artifact
correction fat-suppressed T2-weighted Images. Magn Reson Med Sci.
15(4):371-8, 2016
4. Zaitsev M et al: Motion artifacts in MRI: a complex problem with many partial
solutions. J Magn Reson Imaging. 42(4):887-90, 2015
5. Mohankumar R et al: Pitfalls and pearls in MRI of the knee. AJR Am J
Roentgenol. 203(3):516-30, 2014
6. Motamedi D et al: Pitfalls in shoulder MRI: part 1--normal anatomy and
anatomic variants. AJR Am J Roentgenol. 203(3):501-7, 2014
7. Motamedi D et al: Pitfalls in shoulder MRI: part 2--biceps tendon, bursae and
cysts, incidental and postsurgical findings, and artifacts. AJR Am J
Roentgenol. 203(3):508-15, 2014
8. Dagia C et al: 3T MRI in paediatrics: challenges and clinical applications. Eur J
Radiol. 68(2):309-19, 2008
9. Fries P et al: Magnetic resonance imaging of the spine at 3 tesla. Semin
Musculoskelet Radiol. 12(3):238-52, 2008
10. Shapiro MD: MR imaging of the spine at 3T. Magn Reson Imaging Clin N Am.
14(1):97-108, 2006
11. Elster AD et al: Questions and Answers in Magnetic Resonance Imaging. St.
Louis: Mosby. 123-47, 2001
MR Artifacts

Congenital and Genetic Disorders

(Left) Axial T2WI MR in a
patient with a tethered spinal
cord shows classic chemical
shift artifact ﬇, confirming
the presence of fat within the
filum. The pattern of
alternating hyper- and
hypointensity confirms that
frequency direction is AP.
(Right) Axial T2WI MR depicts
prominent chemical shift
artifact in the thecal sac ﬇
and nerve root sleeves ſt
reflecting presence of water
(CSF in root sleeves) and fat
(epidural) within adjacent
voxels. Frequency direction is
right to left.

(Left) Coronal T2WI MR

demonstrates artifactual wrap
of back fat ſt onto the
thoracic spine. Such artifacts
could be diminished by
increasing the field of view
(FOV), at the cost of spatial
resolution, unless the number
of phase-encoding steps is also
increased. (Right) Axial T1WI
MR depicts propagation of
respiratory motion ſt through
the abdomen and spine as well
as phase wrap of the abdomen
behind the back ﬇.

(Left) Sagittal T2WI MR shows

marked signal loss and image
degradation in the upper
thoracic spine, reflecting
attempted MR imaging with
the incorrect spine coil
elements turned on. There is
also a prominent zipper
artifact ſt running in the
craniocaudal direction. (Right)
Sagittal T1WI MR reveals
marked distortion of the
inferior frontal lobes and
facial soft tissues reflecting
severe metallic dental brace
artifact.

19
 MR Artifacts
Congenital and Genetic Disorders

(Left) Sagittal T1WI MR

(suprasellar
craniopharyngioma,
postoperative) performed for
spinal surveillance with known
CSF craniopharyngioma
dissemination shows a
metastatic lesion ſt anterior
to the pons. (Right) Sagittal
T1WI C+ FS MR (suprasellar
craniopharyngioma, known
CSF metastases) demonstrates
a prominent band of
susceptibility artifact ﬇ 2° to
inhomogeneous fat
saturation, unfortunately
nearly completely obscuring
known CSF metastasis ſt.

(Left) Sagittal T1WI MR shows

severe radiofrequency
interference artifact creating
horizontal stripes across the
image-producing mild image
degradation. Note also the
incomplete zipper artifact ſt
at the inferior margin of the
image center. (Right) Axial
T2WI MR of the thoracic spine
demonstrates a prominent
zipper artifact ſt in the upper
center of the image. Like most
zipper artifacts, this does not
seriously compromise the
diagnostic quality of the exam.

(Left) Sagittal T1WI MR in an

uncooperative, delirious
patient shows severe motion
artifact that markedly
degrades the image quality
and renders it nondiagnostic.
It is important not to try to use
these images in a diagnostic
attempt because artifact may
either simulate or obscure a
lesion. (Right) Axial T1WI C+
FS MR shows severe motion
artifact running in the AP
direction reflecting respiratory
movement of the abdominal
wall. There is also periodic
phase ghosting of the aorta
ſt.

20
MR Artifacts

Congenital and Genetic Disorders

(Left) Axial T2WI MR depicts
periodic phase-encoding
artifact from the thecal sac
simulating lesions in the liver
ſt and spleen ﬇. The spacing
between the thecal sac and
the artifactual ghosts is
precisely the same distance, a
characteristic finding with
periodic phase ghosting
artifact. Recognizing this
assists in making the diagnosis
of artifact. (Right) Axial T2WI
MR shows periodic phase
ghosting from the thecal sac
and spinal cord simulating
bilateral renal lesions ſt.

(Left) Sagittal T1WI MR

demonstrates gradient
warping artifact of the lower
thoracic spine. This artifact is
characterized by image
distortion ſt at the edges of
large FOV studies (especially >
30 cm) caused by gradient
distortion. (Right) Sagittal
T2WI MR depicts unacceptable
phase ghosting artifact ſt
that mimics cervical
syringohydromyelia in this
case arising from failure to
place an anterior saturation
band in front of the cervical
spine.

(Left) Axial T1WI C+ FS MR

shows inhomogeneous fat
suppression using chemical
fat-saturation technique with
bright areas of fat-suppression
failure ſt as well as dark
areas of inappropriate water
saturation ﬇. (Right) Axial
T1WI C+ FS MR shows
complete failure of chemical
fat-saturation technique,
compounded by unwanted
inappropriate water
saturation that nullifies all
water signal. This artifact is
commonly encountered when
imaging complex shapes, such
as the cervicothoracic
junction.

21
 Normal Variant

KEY FACTS
Congenital and Genetic Disorders

TERMINOLOGY CLINICAL ISSUES

• Normal anatomic variations that simulate pathologic
conditions
IMAGING
• Multiplanar MR best for soft tissue evaluation
• Radiography, bone CT most useful for bone anatomy
TOP DIFFERENTIAL DIAGNOSES
• Traumatic or degenerative vertebral subluxation
• Transverse process fracture
• Vertebral segmentation and formation anomalies
• Vertebral hemangioma
• Intervertebral disc herniation
• Nerve sheath tumor
• Posterior spinal dysraphism
• Caudal regression spectrum
• Discovered incidentally when patient is imaged for other
indications
○ Patient asymptomatic, or presenting symptoms do not
match location of finding
• Normal life expectancy, no incremental morbidity
• May lead to unnecessary diagnostic tests or treatment if
not recognized as normal variant
DIAGNOSTIC CHECKLIST
• Many normal variants are common and readily recognized
by experienced observers
• Some are uncommon and may not be recognized as normal
variant, require high index of suspicion to correctly
diagnose
• Consider normal variant within differential diagnostic
considerations when unexpected finding is detected

(Left) Sagittal bone CT in a

young pediatric patient
demonstrates slight apparent
subluxation of C2 on C3 ſt.
All other spinal lines are
normal, particularly the
posterior spinolaminar line ﬇
from C1 to C3, confirming
pseudosubluxation. (Right)
Anteroposterior cervical
radiograph shows unusual
elongation of the C7
transverse processes ſt. In
some patients, draping of the
lower brachial plexus trunk
over the C7 transverse process
may produce a clinical brachial
plexopathy.

(Left) Anteroposterior cervical

radiograph demonstrates
small bilateral rudimentary C7
cervical ribs ſt. Downward
angulation of the adjacent
transverse processes
distinguishes these from
hypoplastic T1 thoracic ribs.
(Right) Sagittal T1WI MR
along the plane of the medial
aspect of the L5 pedicle shows
a vertically oriented root ſt
spanning the L5 disc level due
to a conjoined nerve root. This
vertical orientation of the
exiting inferior root is typical,
along with the more
horizontal course of the
superior root.

22
Another random document with
no related content on Scribd:
to say, would necessarily startle the reading public with some
explanation so extraordinary that his scientific views would cause a
real hegira to the unexplored fields of psychology. Well, he does
startle us, for to all this he quietly observes: “Recourse was had to
marriage to bring to a stop these disorders of the
Convulsionaires!”[607]
For once des Mousseaux had the best of his enemy: “Marriage, do
you understand this?” he remarks. “Marriage cures them of this
faculty of climbing dead-walls like so many flies, and of speaking
foreign languages. Oh! the curious properties of marriage in those
remarkable days!”
“It should be added,” continues Figuier, “that with the fanatics of
St. Medard, the blows were never administered except during the
convulsive crisis; and that, therefore, as Dr. Calmeil suggests,
meteorism of the abdomen, the state of spasm of the uterus of
women, of the alimentary canal in all cases, the state of contraction,
of erethism, of turgescence of the carneous envelopes of the
muscular coats which protect and cover the abdomen, chest, and
principal vascular masses and the osseous surfaces, may have
singularly contributed toward reducing, and even destroying, the
force of the blows!”
“The astounding resistance that the skin, the areolar tissue, the
surface of the bodies and limbs of the Convulsionaires offered to
things which seem as if they ought to have torn or crushed them, is
of a nature to excite more surprise. Nevertheless, it can be
explained. This resisting force, this insensibility, seems to partake of
the extreme changes in sensibility which can occur in the animal
economy during a time of great exaltation. Anger, fear, in a word,
every passion, provided that it be carried to a paroxysmal point, can
produce this insensibility.”[608]
“Let us remark, besides,” rejoins Dr. Calmeil, quoted by Figuier,
“that for striking upon the bodies of the Convulsionaires use was
made either of massive objects with flat or rounded surfaces, or of
cylindrical and blunt shapes.[609] The action of such physical agents
is not to be compared, in respect to the danger which attaches to it,
with that of cords, supple or flexible instruments, and those having a
sharp edge. In fine, the contact and the shock of the blows produced
upon the Convulsionaires the effect of a salutary shampooing, and
reduced the violence of the tortures of hysteria.”
The reader will please observe that this is not intended as a joke,
but is the sober theory of one of the most eminent of French
physicians, hoary with age and experience, the Director-in-Chief of
the Government Insane Asylum at Charenton. Really, the above
explanation might lead the reader to a strange suspicion. We might
imagine, perhaps, that Dr. Calmeil has kept company with the
patients under his care a few more years than was good for the
healthy action of his own brain.
Besides, when Figuier talks of massive objects, of cylindrical and
blunt shapes, he surely forgets the sharp swords, pointed iron pegs,
and the hatchets, of which he himself gave a graphic description on
page 409 of his first volume. The brother of Elie Marion is shown by
him striking his stomach and abdomen with the sharp point of a
knife, with tremendous force, “his body all the while resisting as if it
were made of iron.”
Arrived at this point, des Mousseaux loses all patience, and
indignantly exclaims:
“Was the learned physician quite awake when writing the above
sentences?... If, perchance, the Drs. Calmeil and Figuier should
seriously maintain their assertions and insist on their theory, we are
ready to answer them as follows: ‘We are perfectly willing to believe
you. But before such a superhuman effort of condescension, will you
not demonstrate to us the truth of your theory in a more practical
manner? Let us, for example, develop in you a violent and terrible
passion; anger—rage if you choose. You shall permit us for a single
moment to be in your sight irritating, rude, and insulting. Of course,
we will be so only at your request and in the interest of science and
your cause. Our duty under the contract will consist in humiliating
and provoking you to the last extremity. Before a public audience,
who shall know nothing of our agreement, but whom you must
satisfy as to your assertions, we will insult you; ... we will tell you that
your writings are an ambuscade to truth, an insult to common sense,
a disgrace which paper only can bear; but which the public should
chastise. We will add that you lie to science, you lie to the ears of the
ignorant and stupid fools gathered around you, open-mouthed, like
the crowd around a peddling quack.... And when, transported beyond
yourself, your face ablaze, and anger tumefying, you shall have
displaced your fluids; when your fury has reached the point of
bursting, we will cause your turgescent muscles to be struck with
powerful blows; your friends shall show us the most insensible
places; we will let a perfect shower, an avalanche of stones fall upon
them ... for so was treated the flesh of the convulsed women whose
appetite for such blows could never be satisfied. But, in order to
procure for you the gratification of a salutary shampooing—as you
deliciously express it—your limbs shall only be pounded with objects
having blunt surfaces and cylindrical shapes, with clubs and sticks
devoid of suppleness, and, if you prefer it, neatly turned in a lathe.”
So liberal is des Mousseaux, so determined to accommodate his
antagonists with every possible chance to prove their theory, that he
offers them the choice to substitute for themselves in the experiment
their wives, mothers, daughters, and sisters, “since,” he says, “you
have remarked that the weaker sex is the strong and resistant sex in
these disconcerting trials.”
Useless to remark that des Mousseaux’s challenge remained
unanswered.
 CHAPTER XI.
“Strange condition of the human mind, which seems to require that it should long
exercise itself in Error, before it dare approach the Truth.”—Magendie.
“La verité que je defends est empreinte sur tous les monuments du passé. Pour
comprendre l’histoire, il faut etudier les symboles anciens, les signes sacrés du
sacerdoce, et l’art de guerir dans les temps primitifs, art oublié aujourd’hui.”—
Baron Du Potet.
“It is a truth perpetually, that accumulated facts, lying in disorder, begin to
assume some order if an hypothesis is thrown among them.”—Herbert Spencer.

A nd now we must search Magical History for cases similar to

those given in the preceding chapter. This insensibility of the
human body to the impact of heavy blows, and resistance to
penetration by sharp points and musket-bullets, is a phenomenon
sufficiently familiar in the experience of all times and all countries.
While science is entirely unable to give any reasonable explanation
of the mystery, the question appears to offer no difficulty to
mesmerists, who have well studied the properties of the fluid. The
man, who by a few passes over a limb can produce a local paralysis
so as to render it utterly insensible to burns, cuts, and the prickings
of needles, need be but very little astonished at the phenomena of
the Jansenists. As to the adepts of magic, especially in Siam and the
East Indies, they are too familiar with the properties of the akasa, the
mysterious life-fluid, to even regard the insensibility of the
Convulsionaires as a very great phenomenon. The astral fluid can be
compressed about a person so as to form an elastic shell, absolutely
non-penetrable by any physical object, however great the velocity
with which it travels. In a word, this fluid can be made to equal and
even excel in resisting-power, water and air.
In India, Malabar, and some places of Central Africa, the conjurers
will freely permit any traveller to fire his musket or revolver at them,
without touching the weapon themselves or selecting the balls. In
Laing’s Travels among Timanni, the Kourankos, and the Soulimas,
occurs a description by an English traveller, the first white man to
visit the tribe of the Soulimas, near the sources of the Dialliba, of a
very curious scene. A body of picked soldiers fired upon a chief who
had nothing to defend himself with but certain talismans. Although
their muskets were properly loaded and aimed, not a ball could strike
him. Salverte gives a similar case in his Philosophy of Occult
Sciences: “In 1568, the Prince of Orange condemned a Spanish
prisoner to be shot at Juliers; the soldiers tied him to a tree and fired,
but he was invulnerable. They at last stripped him to see what armor
he wore, but found only an amulet. When this was taken from him,
he fell dead at the first shot.”
This is a very different affair from the dexterous trickery resorted to
by Houdin in Algeria. He prepared balls himself of tallow, blackened
with soot, and by sleight of hand exchanged them for the real bullets,
which the Arab sheiks supposed they were placing in the pistols. The
simple-minded natives, knowing nothing but real magic, which they
had inherited from their ancestors, and which consists in each case
of some one thing that they can do without knowing why or how, and
seeing Houdin, as they thought, accomplish the same results in a
more impressive manner, fancied that he was a greater magician
than themselves. Many travellers, the writer included, have
witnessed instances of this invulnerability where deception was
impossible. A few years ago, there lived in an African village, an
Abyssinian who passed for a sorcerer. Upon one occasion a party of
Europeans, going to Soudan, amused themselves for an hour or two
in firing at him with their own pistols and muskets, a privilege which
he gave them for a trifling fee. As many as five shots were fired
simultaneously, by a Frenchman named Langlois, and the muzzles
of the pieces were not above two yards distant from the sorcerer’s
breast. In each case, simultaneously with the flash, the bullet would
appear just beyond the muzzle, quivering in the air, and then, after
describing a short parabola, fall harmlessly to the ground. A German
of the party, who was going in search of ostrich feathers, offered the
magician a five-franc piece if he would allow him to fire his gun with
the muzzle touching his body. The man at first refused; but, finally,
after appearing to hold conversation with somebody inside the
ground, consented. The experimenter carefully loaded, and pressing
the muzzle of the weapon against the sorcerer’s body, after a
moment’s hesitation, fired ... the barrel burst into fragments as far
down as the stock, and the man walked off unhurt.
This quality of invulnerability can be imparted to persons both by
living adepts and by spirits. In our own time several well-known
mediums have frequently, in the presence of the most respectable
witnesses, not only handled blazing coals and actually placed their
face upon a fire without singeing a hair, but even laid flaming coals
upon the heads and hands of by-standers, as in the case of Lord
Lindsay and Lord Adair. The well-known story of the Indian chief,
who confessed to Washington that at Braddock’s defeat he had fired
his rifle at him seventeen times at short range without being able to
touch him, will recur to the reader in this connection. In fact, many
great commanders have been believed by their soldiers to bear what
is called “a charmed life;” and Prince Emile von Sayn-Wittgenstein, a
general of the Russian army, is said to be one of these.
This same power which enables one to compress the astral fluid
so as to form an impenetrable shell around one, can be used to
direct, so to speak, a bolt of the fluid against a given object, with fatal
force. Many a dark revenge has been taken in that way; and in such
cases the coroner’s inquest will never disclose anything but sudden
death, apparently resulting from heart-disease, an apoplectic fit, or
some other natural, but still not veritable cause. Many persons firmly
believe that certain individuals possess the power of the evil eye.
The mal’occhio, or jettatura is a belief which is prevalent throughout
Italy and Southern Europe. The Pope is held to be possessed—
perchance unconsciously—of that disagreeable gift. There are
persons who can kill toads by merely looking at them, and can even
slay individuals. The malignance of their desire brings evil forces to a
focus, and the death-dealing bolt is projected, as though it were a
bullet from a rifle.
In 1864, in the French province of Le Var, near the little village of
Brignoles, lived a peasant named Jacques Pelissier, who made a
living by killing birds by simple will-power. His case is reported by the
well-known Dr. d’Alger, at whose request the singular hunter gave
exhibitions to several scientific men, of his method of proceeding.
The story is told as follows: “At about fifteen or twenty paces from us,
I saw a charming little meadow-lark which I showed to Jacques.
‘Watch him well, monsieur,’ said he, ‘he is mine.’ Instantly stretching
his right hand toward the bird, he approached him gently. The
meadow-lark stops, raises and lowers his pretty head, spreads his
wings, but cannot fly; at last he cannot make a step further and
suffers himself to be taken, only moving his wings with a feeble
fluttering. I examine the bird; his eyes are tightly closed and his body
has a corpse-like stiffness, although the pulsations of the heart are
very distinct; it is a true cataleptic sleep, and all the phenomena
incontestably prove a magnetic action. Fourteen little birds were
taken in this way, within the space of an hour; none could resist the
power of Master Jacques, and all presented the same cataleptic
sleep; a sleep which, moreover, terminates at the will of the hunter,
whose humble slaves these little birds have become.
“A hundred times, perhaps, I asked Jacques to restore life and
movement to his prisoners, to charm them only half way, so that they
might hop along the ground, and then again bring them completely
under the charm. All my requests were exactly complied with, and
not one single failure was made by this remarkable Nimrod, who
finally said to me: ‘If you wish it, I will kill those which you designate
without touching them.’ I pointed out two for the experiment, and, at
twenty-five or thirty paces distance, he accomplished in less than
five minutes what he had promised.”[610]
A most curious feature of the above case is, that Jacques had
complete power only over sparrows, robins, goldfinches, and
meadow-larks; he could sometimes charm skylarks, but, as he says,
“they often escape me.”
This same power is exercised with greater force by persons known
as wild beast tamers. On the banks of the Nile, some of the natives
can charm the crocodiles out of the water, with a peculiarly
melodious, low whistle, and handle them with impunity; while others
possess such powers over the most deadly snakes. Travellers tell of
seeing the charmers surrounded by multitudes of the reptiles which
they dispatch at their leisure.

Bruce, Hasselquist, and Lemprière,[611] testify to the fact that they

have seen in Egypt, Morocco, Arabia, and especially in the Senaar,
some natives utterly disregarding the bites of the most poisonous
vipers, as well as the stings of scorpions. They handle and play with
them, and throw them at will into a state of stupor.“In vain do the
Latin and Greek writers,” says Salverte, “assure us that the gift of
charming venomous reptiles was hereditary in certain families from
time immemorial, that in Africa the same gift was enjoyed by the
Psylli; that the Marses in Italy, and the Ophiozenes in Cyprus
possessed it.” The skeptics forget that, in Italy, even at the
commencement of the sixteenth century, men, claiming to be
descended from the family of Saint Paul, braved, like the Marses, the
bites of serpents.”[612]
“Doubts upon this subject,” he goes on to say, “were removed
forever at the time of the expedition of the French into Egypt, and the
following relation is attested by thousands of eye-witnesses. The
Psylli, who pretended, as Bruce had related, to possess that faculty
... went from house to house to destroy serpents of every kind.... A
wonderful instinct drew them at first toward the place in which the
serpents were hidden; furious, howling, and foaming, they seized
and tore them asunder with their nails and teeth.”
“Let us place,” says Salverte, inveterate skeptic himself, “to the
account of charlatanism, the howling and the fury; still, the instinct
which warned the Psylli of the presence of the serpents, has in it
something more real.” In the Antilles, the negroes discover, by its
odor, a serpent which they do not see.[613] “In Egypt, the same tact,
formerly possessed, is still enjoyed by men brought up to it from
infancy, and born as with an assumed hereditary gift to hunt
serpents, and to discover them even at a distance too great for the
effluvia to be perceptible to the dull organs of a European. The
principal fact above all others, the faculty of rendering dangerous
animals powerless, merely by touching them, remains well verified,
and we shall, perhaps, never understand better the nature of this
secret, celebrated in antiquity, and preserved to our time by the most
ignorant of men.”[614]
Music is delightful to every person. Low whistling, a melodious
chant, or the sounds of a flute will invariably attract reptiles in
countries where they are found. We have witnessed and verified the
fact repeatedly. In Upper Egypt, whenever our caravan stopped, a
young traveller, who believed he excelled on the flute, amused the
company by playing. The camel-drivers and other Arabs invariably
checked him, having been several times annoyed by the unexpected
appearance of various families of the reptile tribe, which generally
shirk an encounter with men. Finally, our caravan met with a party,
among whom were professional serpent-charmers, and the virtuoso
was then invited, for experiment’s sake, to display his skill. No
sooner had he commenced, than a slight rustling was heard, and the
musician was horrified at suddenly seeing a large snake appear in
dangerous proximity with his legs. The serpent, with uplifted head
and eyes fixed on him, slowly, and, as if unconsciously, crawled,
softly undulating its body, and following his every movement. Then
appeared at a distance another one, then a third, and a fourth, which
were speedily followed by others, until we found ourselves quite in a
select company. Several of the travellers made for the backs of their
camels, while others sought refuge in the cantinier’s tent. But it was
a vain alarm. The charmers, three in number, began their chants and
incantations, and, attracting the reptiles, were very soon covered
with them from head to foot. As soon as the serpents approached
the men, they exhibited signs of torpor, and were soon plunged in a
deep catalepsy. Their eyes were half closed and glazed, and their
heads drooping. There remained but one recalcitrant, a large and
glossy black fellow, with a spotted skin. This meloman of the desert
went on gracefully nodding and leaping, as if it had danced on its tail
all its life, and keeping time to the notes of the flute. This snake
would not be enticed by the “charming” of the Arabs, but kept slowly
moving in the direction of the flute-player, who at last took to his
heels. The modern Psyllian then took out of his bag a half-withered
plant, which he kept waving in the direction of the serpent. It had a
strong smell of mint, and as soon as the reptile caught its odor, it
followed the Arab, still erect upon its tail, but now approaching the
plant. A few more seconds, and the “traditional enemy” of man was
seen entwined around the arm of his charmer, became torpid in its
turn, and the whole lot were then thrown together in a pool, after
having their heads cut off.
Many believe that all such snakes are prepared and trained for the
purpose, and that they are either deprived of their fangs, or have
their mouths sewed up. There may be, doubtless, some inferior
jugglers, whose trickery has given rise to such an idea. But the
genuine serpent-charmer has too well established his claims in the
East, to resort to any such cheap fraud. They have the testimony on
this subject of too many trustworthy travellers, including some
scientists, to be accused of any such charlatanism. That the snakes,
which are charmed to dance and to become harmless, are still
poisonous, is verified by Forbes. “On the music stopping too
suddenly,” says he, “or from some other cause, the serpent, who had
been dancing within a circle of country-people, darted among the
spectators, and inflicted a wound in the throat of a young woman,
who died in agony, in half an hour afterward.”[615]
According to the accounts of many travellers the negro women of
Dutch Guiana, the Obeah women, excel in taming very large snakes
called amodites, or papa; they make them descend from the trees,
follow, and obey them by merely speaking to them.[616]
We have seen in India a small brotherhood of fakirs settled round
a little lake, or rather a deep pool of water, the bottom of which was
literally carpeted with enormous alligators. These amphibious
monsters crawl out, and warm themselves in the sun, a few feet from
the fakirs, some of whom may be motionless, lost in prayer and
contemplation. So long as one of these holy beggars remains in
view, the crocodiles are as harmless as kittens. But we would never
advise a foreigner to risk himself alone within a few yards of these
monsters. The poor Frenchman Pradin found an untimely grave in
one of these terrible Saurians, commonly called by the Hindus
Moudela.[617] (This word should be nihang or ghariyāl.)
 When Iamblichus, Herodotus, Pliny, or some other ancient writer
tells us of priests who caused asps to come forth from the altar of
Isis, or of thaumaturgists taming with a glance the most ferocious
animals, they are considered liars and ignorant imbeciles. When
modern travellers tell us of the same wonders performed in the East,
they are set down as enthusiastic jabberers, or untrustworthy writers.
But, despite materialistic skepticism, man does possess such a
power, as we see manifested in the above instances. When
psychology and physiology become worthy of the name of sciences,
Europeans will be convinced of the weird and formidable potency
existing in the human will and imagination, whether exercised
consciously or otherwise. And yet, how easy to realize such power in
spirit, if we only think of that grand truism in nature that every most
insignificant atom in it is moved by spirit, which is one in its essence,
for the least particle of it represents the whole; and that matter is but
the concrete copy of the abstract idea, after all. In this connection, let
us cite a few instances of the imperial power of even the
unconscious will, to create according to the imagination or rather the
faculty of discerning images in the astral light.
We have but to recall the very familiar phenomenon of stigmata, or
birth-marks, where effects are produced by the involuntary agency of
the maternal imagination under a state of excitement. The fact that
the mother can control the appearance of her unborn child was so
well known among the ancients, that it was the custom among
wealthy Greeks to place fine statues near the bed, so that she might
have a perfect model constantly before her eyes. The cunning trick
by which the Hebrew patriarch Jacob caused ring-streaked and
speckled calves to be dropped, is an illustration of the law among
animals; and Aricante tells “of four successive litters of puppies, born
of healthy parents, some of which, in each litter, were well formed,
whilst the remainder were without anterior extremities and had hair
lip.” The works of Geoffroi St. Hilaire, Burdach, and Elam, contain
accounts of great numbers of such cases, and in Dr. Prosper Lucas’s
important volume, Sur l’Heredité Naturelle, there are many. Elam
quotes from Prichard an instance where the child of a negro and
white was marked with black and white color upon separate parts of
the body. He adds, with laudable sincerity, “These are singularities of
which, in the present state of science, no explanation can be
given.”[618] It is a pity that his example was not more generally
imitated. Among the ancients Empedocles, Aristotle, Pliny,
Hippocrates, Galen, Marcus Damascenus, and others give us
accounts quite as wonderful as our contemporary authors.

In a work published in London, in 1659,[619] a powerful argument

is made in refutation of the materialists by showing the potency of
the human mind upon the subtile forces of nature. The author, Dr.
More, views the fœtus as if it were a plastic substance, which can be
fashioned by the mother to an agreeable or disagreeable shape, to
resemble some person or in part several persons, and to be
stamped with the effigies, or as we might more properly call it,
astrograph, of some object vividly presented to her imagination.
These effects may be produced by her voluntarily or involuntarily,
consciously or unconsciously, feebly or forcibly, as the case may be.
It depends upon her ignorance or knowledge of the profound
mysteries of nature. Taking women in the mass, the marking of the
embryo may be considered more accidental than the result of
design; and as each person’s atmosphere in the astral light is
peopled with the images of his or her immediate family, the sensitive
surface of the fœtus, which may almost be likened to the
collodionized plate of a photograph, is as likely as not to be stamped
with the image of a near or remote ancestor, whom the mother never
saw, but which, at some critical moment, came as it were into the
focus of nature’s camera. Says Dr. Elam, “Near me is seated a
visitor from a distant continent, where she was born and educated.
The portrait of a remote ancestress, far back in the last century,
hangs upon the wall. In every feature, one is an accurate
presentment of the other, although the one never left England, and
the other was an American by birth and half parentage.”
The power of the imagination upon our physical condition, even
after we arrive at maturity, is evinced in many familiar ways. In
medicine, the intelligent physician does not hesitate to accord to it a
curative or morbific potency greater than his pills and potions. He
calls it the vis medicatrix naturæ, and his first endeavor is to gain the
confidence of his patient so completely, that he can cause nature to
extirpate the disease. Fear often kills; and grief has such a power
over the subtile fluids of the body as not only to derange the internal
organs but even to turn the hair white. Ficinus mentions the
signature of the fœtus with the marks of cherries and various fruits,
colors, hairs, and excrescences, and acknowledges that the
imagination of the mother may transform it into a resemblance of an
ape, pig, or dog, or any such animal. Marcus Damascenus tells of a
girl covered with hair and, like our modern Julia Pastrana, furnished
with a full beard; Gulielmus Paradinus, of a child whose skin and
nails resembled those of a bear; Balduinus Ronsæus of one born
with a turkey’s wattles; Pareus, of one with a head like a frog; and
Avicenna, of chickens with hawks’ heads. In this latter case, which
perfectly exemplifies the power of the same imagination in animals,
the embryo must have been stamped at the instant of conception
when the hen’s imagination saw a hawk either in fact or in fancy.
This is evident, for Dr. More, who quotes this case on the authority of
Avicenna, remarks very appropriately that, as the egg in question
might have been hatched a hundred miles distant from the hen, the
microscopic picture of the hawk impressed upon the embryo must
have enlarged and perfected itself with the growth of the chicken
quite independently of any subsequent influence from the hen.
Cornelius Gemma tells of a child that was born with his forehead
wounded and running with blood, the result of his father’s threats
toward his mother “ ... with a drawn sword which he directed toward
her forehead;” Sennertius records the case of a pregnant woman
who, seeing a butcher divide a swine’s head with his cleaver,
brought forth her child with his face cloven in the upper jaw, the
palate, and upper lip to the very nose. In Van Helmont’s De Injectis
Materialibus, some very astonishing cases are reported: The wife of
a tailor at Mechlin was standing at her door and saw a soldier’s hand
cut off in a quarrel, which so impressed her as to bring on premature
labor, and her child was born with only one hand, the other arm
bleeding. In 1602, the wife of Marcus Devogeler, a merchant of
Antwerp, seeing a soldier who had just lost his arm, was taken in
labor and brought forth a daughter with one arm struck off and
bleeding as in the first case. Van Helmont gives a third example of
another woman who witnessed the beheading of thirteen men by
order of the Duc d’Alva. The horror of the spectacle was so
overpowering that she “suddainly fell into labour and brought forth a
perfectly-formed infant, onely the head was wanting, but the neck
bloody as their bodies she beheld that had their heads cut off. And
that which does still advance the wonder is, that the hand, arme, and
head of these infants were none of them to be found.”[620]
If it was possible to conceive of such a thing as a miracle in
nature, the above cases of the sudden disappearance of portions of
the unborn human body might be designated. We have looked in
vain through the latest authorities upon human physiology for any
sufficient theory to account for the least remarkable of fœtal
signatures. The most they can do is to record instances of what they
call “spontaneous varieties of type,” and then fall back either upon
Mr. Proctor’s “curious coincidences” or upon such candid
confessions of ignorance as are to be found in authors not entirely
satisfied with the sum of human knowledge. Magendie
acknowledges that, despite scientific researches, comparatively little
is known of fœtal life. At page 518 of the American edition of his
Precis Elementaire de Physiologie he instances “a case where the
umbilical cord was ruptured and perfectly cicatrized;” and asks “How
was the circulation carried on in this organ?” On the next page, he
says: “Nothing is at present known respecting the use of digestion in
the fœtus;” and respecting its nutrition, propounds this query: “What,
then, can we say of the nutrition of the fœtus? Physiological works
contain only vague conjectures on this point.” On page 520, the
following language occurs: “In consequence of some unknown
cause, the different parts of the fœtus sometimes develop
themselves in a preternatural manner.” With singular inconsistency
with his previous admissions of the ignorance of science upon all
these points which we have quoted, he adds: “There is no reason for
believing that the imagination of the mother can have any influence
in the formation of these monsters; besides, productions of this kind
are daily observed in the offspring of other animals and even in
plants.” How perfect an illustration is this of the methods of scientific
men!—the moment they pass beyond their circle of observed facts,
their judgment seems to become entirely perverted. Their deductions
from their own researches are often greatly inferior to those made by
others who have to take the facts at second hand.
The literature of science is constantly furnishing examples of this
truth; and when we consider the reasoning of materialistic observers
upon psychological phenomena, the rule is strikingly manifest. Those
who are soul-blind are as constitutionally incapable of distinguishing
psychological causes from material effects as the color-blind are to
select scarlet from black.
Elam, without being in the least a spiritualist, nay, though an
enemy to it, represents the belief of honest scientists in the following
expressions: “it is certainly inexplicable how matter and mind can act
and react one upon the other; the mystery is acknowledged by all to
be insoluble, and will probably ever remain so.”
The great English authority upon the subject of malformation is
The Science and Practice of Medicine, by Wm. Aitken, M.D.,
Edinburgh, and Professor of Pathology in the Army Medical School;
the American edition of which, by Professor Meredith Clymer, M.D.,
of the University of Pennsylvania, has equal weight in the United
States. At page 233 of vol. i. we find the subject treated at length.
The author says, “The superstition, absurd notions, and strange
causes assigned to the occurrence of such malformations, are now
fast disappearing before the lucid expositions of those famous
anatomists who have made the development and growth of the
ovum a subject of special study. It is sufficient to mention here the
names, J. Muller, Rathke, Bischoff, St. Hilaire, Burdach, Allen
Thompson, G. & W. Vrolick, Wolff, Meckel, Simpson, Rokitansky, and
Von Ammon as sufficient evidence that the truths of science will in
time dispel the mists of ignorance and superstition.” One would think,
from the complacent tone adopted by this eminent writer that we
were in possession if not of the means of readily solving this intricate
problem at least of a clew to guide us through the maze of our
difficulties. But, in 1872, after profiting by all the labors and ingenuity
of the illustrious pathologists above enumerated, we find him making
the same confession of ignorance as that expressed by Magendie in
1838. “Nevertheless,” says he, “much mystery still enshrouds the
origin of malformation; the origin of them may be considered in two
main issues, namely: 1, are they due to original malformation of the
germ? 2, or, are they due to subsequent deformities of the embryo
by causes operating on its development? With regard to the first
issue, it is believed that the germ may be originally malformed, or
defective, owing to some influence proceeding either from the
female, or from the male, as in case of repeated procreation of the
same kind of malformation by the same parents, deformities on
either side being transmitted as an inheritance.”
Being unsupplied with any philosophy of their own to account for
the lesions, the pathologists, true to professional instinct, resort to
negation. “That such deformity may be produced by mental
impressions on pregnant women there is an absence of positive
proof,” they say. “Moles, mothers’ marks, and cutaneous spots as
ascribed to morbid states of the coats of the ovum.... A very
generally-recognized cause of malformation consists in impeded
development of the fœtus, the cause of which is not always obvious,
but is for the most part concealed.... Transient forms of the human
fœtus are comparable to persistent forms of many lower animals.”
Can the learned professor explain why? “Hence malformations
resulting from arrest of development often acquire an animal-like
appearance.”
Exactly; but why do not pathologists inform us why it is so? Any
anatomist who has made the development and growth of the embryo
and fœtus “a subject of special study,” can tell, without much brain-
work, what daily experience and the evidence of his own eyes show
him, viz.: that up to a certain period, the human embryo is a fac-
simile of a young batrachian in its first remove from the spawn—a
tadpole. But no physiologist or anatomist seems to have had the
idea of applying to the development of the human being—from the
first instant of its physical appearance as a germ to its ultimate
formation and birth—the Pythagorean esoteric doctrine of
metempsychosis, so erroneously interpreted by critics. The meaning
of the kabalistic axiom: “A stone becomes a plant; a plant a beast; a
beast a man, etc.,” was mentioned in another place in relation to the
spiritual and physical evolution of man on this earth. We will now add
a few words more to make the idea clearer.
What is the primitive shape of the future man? A grain, a
corpuscle, say some physiologists; a molecule, an ovum of the
ovum, say others. If it could be analyzed—by the spectroscope or
otherwise—of what ought we to expect to find it composed?
Analogically, we should say, of a nucleus of inorganic matter,
deposited from the circulation at the germinating point, and united
with a deposit of organic matter. In other words, this infinitesimal
nucleus of the future man is composed of the same elements as a
stone—of the same elements as the earth, which the man is
destined to inhabit. Moses is cited by the kabalists as authority for
the remark, that it required earth and water to make a living being,
and thus it may be said that man first appears as a stone.
At the end of three or four weeks the ovum has assumed a plant-
like appearance, one extremity having become spheroidal and the
other tapering, like a carrot. Upon dissection it is found to be
composed, like an onion, of very delicate laminæ or coats, enclosing
a liquid. The laminæ approach each other at the lower end, and the
embryo hangs from the root of the umbilicus almost like a fruit from
the bough. The stone has now become changed, by
metempsychosis, into a plant. Then the embryonic creature begins
to shoot out, from the inside outward, its limbs, and develops its
features. The eyes are visible as two black dots; the ears, nose, and
mouth form depressions, like the points of a pineapple, before they
begin to project. The embryo develops into an animal-like fœtus—
the shape of a tadpole—and like an amphibious reptile lives in water,
and develops from it. Its monad has not yet become either human or
immortal, for the kabalists tell us that that only comes at the “fourth
hour.” One by one the fœtus assumes the characteristics of the
human being, the first flutter of the immortal breath passes through
his being; he moves; nature opens the way for him; ushers him into
the world; and the divine essence settles in the infant frame, which it
will inhabit until the moment of physical death, when man becomes a
spirit.
This mysterious process of a nine-months formation the kabalists
call the completion of the “individual cycle of evolution.” As the fœtus
develops from the liquor amnii in the womb, so the earths germinate
from the universal ether, or astral fluid, in the womb of the universe.
These cosmic children, like their pigmy inhabitants, are first nuclei;
then ovules; then gradually mature; and becoming mothers in their
turn, develop mineral, vegetable, animal, and human forms. From
centre to circumference, from the imperceptible vesicle to the
uttermost conceivable bounds of the cosmos, these glorious
thinkers, the kabalists, trace cycle merging into cycle, containing and
contained in an endless series. The embryo evolving in its pre-natal
sphere, the individual in his family, the family in the state, the state in
mankind, the earth in our system, that system in its central universe,
the universe in the cosmos, and the cosmos in the First Cause:—the
Boundless and Endless. So runs their philosophy of evolution:

“All are but parts of one stupendous whole,

Whose body Nature is; and God the Soul.”

“Worlds without number

Lie in this bosom like children.”

While unanimously agreeing that physical causes, such as blows,

accidents, and bad quality of food for the mother, effect the fœtus in
a way which endangers its life; and while admitting again that moral
causes, such as fear, sudden terror, violent grief, or even extreme
joy, may retard the growth of the fœtus or even kill it, many
physiologists agree with Magendie in saying, “there is no reason for
believing that the imagination of the mother can have any influence
in the formation of monsters;” and only because “productions of this
kind are daily observed in the production of other animals and even
in plants.”
In this opinion he is supported by the leading teratologists of our
day. Although Geoffroi St. Hilaire gave its name to the new science,
its facts are based upon the exhaustive experiments of Bichat, who,
in 1802, was recognized as the founder of analytical and
philosophical anatomy. One of the most important contributions to
teratological literature is the monograph of G. J. Fisher, M. D., of Sing
Sing, N. Y., entitled Diploteratology; an Essay on Compound Human
Monsters. This writer classifies monstrous fœtal growths into their
genera and species, accompanying the cases with reflections
suggested by their peculiarities. Following St. Hilaire, he divides the
history of the subject into the fabulous, the positive, and the scientific
periods.
It suffices for our purpose to say that in the present state of
scientific opinion two points are considered as established: 1, that
the maternal, mental condition has no influence in the production of
monstrosities; 2, that most varieties of monstrosity may be
accounted for on the theory of arrest and retardation of development.
Says Fisher, “By a careful study of the laws of development and the
order in which the various organs are evolved in the embryo, it has
been observed that monsters by defect or arrest of development,
are, to a certain extent, permanent embryos. The abnormal organs
merely represent the primitive condition of formation as it existed in
an early stage of embryonic or fœtal life.”[621]
With physiology in so confessedly chaotic a state as it is at
present, it seems a little like hardihood in any teratologist, however
great his achievements in anatomy, histology, or embryology, to take
so dangerous a position as that the mother has no influence upon
her offspring. While the microscopes of Haller and Prolik, Dareste
and Laraboulet have disclosed to us many interesting facts
concerning the single or double primitive traces on the vitelline
membrane, what remains undiscovered about embryology by
modern science appears greater still. If we grant that monstrosities
are the result of an arrest of development—nay, if we go farther, and
concede that the fœtal future may be prognosticated from the
vitelline tracings, where will the teratologists take us to learn the
antecedent psychological cause of either? Dr. Fisher may have
carefully studied some hundreds of cases, and feel himself
authorized to construct a new classification of their genera and
species; but facts are facts, and outside the field of his observation it
appears, even if we judge but by our own personal experience, in
various countries, that there are abundant attainable proofs that the
violent maternal emotions are often reflected in tangible, visible, and
permanent disfigurements of the child. And the cases in question
seem, moreover, to contradict Dr. Fisher’s assertion that monstrous
growths are due to causes traceable to “the early stages of
embryonic or fœtal life.” One case was that of a Judge of an Imperial
Court at Saratow, Russia, who always wore a bandage to cover a
mouse-mark on the left side of his face. It was a perfectly-formed
mouse, whose body was represented in high relief upon the cheek,
and the tail ran upward across the temple and was lost in his hair.
The body seemed glossy, gray, and quite natural. According to his
own account, his mother had an unconquerable repugnance to mice,
and her labor was prematurely brought on by seeing a mouse jump
out from her workbox.
In another instance, of which the writer was a witness, a pregnant
lady, within two or three weeks of her accouchement, saw a bowl of
raspberries, and was seized with an irresistible longing for some, but
denied. She excitedly clasped her right hand to her neck in a
somewhat theatrical manner, and exclaimed that she must have
them. The child born under our eyes, three weeks later, had a
perfectly-defined raspberry on the right side of his neck; to this day,
when that fruit ripens, his birth-mark becomes of a deep crimson,
while, during the winter, it is quite pale.
Such cases as these, which are familiar to many mothers of
families, either in their personal experience or that of friends, carry
conviction, despite the theories of all the teratologists of Europe and
America. Because, forsooth, animals and plants are observed to
produce malformations of their species as well as human beings,
Magendie and his school infer that the human malformations of an
identical character are not at all due to maternal imagination, since
the former are not. If physical causes produce physical effects in the
subordinate kingdoms, the inference is that the same rule must hold
with ourselves.