SPINE_ANATOMY,_Traumatic,_Inflammatory,_Neplastic_Diseases_of_the.pdf

Spine anatomy

1. Basic
imaging the spine
Godwin I. Ogbole MD
Neuroradiology
UCH Ibadan

2. Anatomy

6. Radiographic Anatomy
Plain x-ray
CT
MRI
CTA/MRA

7. Cervical Spine –AP View

8. Cervical Spine –Lateral View

9. Cervical Spine –Oblique View

10. Cervical Spine –Open-Mouth (Dens) View

11. Lumbar Spine –AP View

12. Lumbar Spine –Lateral View

13. MRI Anatomy
Source: CW Kerber and JR Hesselink, Spine Anatomy, UCSD Neuroradiology

19. Source: CW Kerber and JR Hesselink, Spine Anatomy, UCSD Neuroradiology

24. Spine Pathology
Trauma
Degenerative disease
Tumors and other masses
Inflammation and infection
Vascular disorders
Congenital anomalies

25. Trauma

26. Evaluating Trauma
Fracture–plain film / CT
Dislocation–plain film / CT
Ligamentous injury–MRI
Cord injury–MRI
Nerve root avulsion–MRI

27. Cervical Spine Injuries

28. Plain film findings may be
very subtle or absent!
Anterolisthesis of
C6 on C7
(Why??)

29. CT
Fractures of C6 left
pedicle and lamina

30. CT –2D Reconstructions
Acquire images axially…
…reconstruct sagittal / coronal

31. 26M MVA

32. Vertebral body burst fx with
retropulsion into spinal canal
2D Reformats

35. Vertebral Artery Dissection/Occlusion
Secondary to C6 Fracture

36. Hyperflexion fx with
ligamentous disruption and
cord contusion

37. Nerve root avulsion
Axial Coronal Sagittal

40. Jefferson Fracture
Burst Fx of C1

42. Type II Dens Fracture

43. C3 Left Pedicle Fracture

48. L1 Burst

52. Summary _Trauma
Basic anatomy is key
Review in multiple window
May need more than one modality to confirm diagnosis

53. SPINAL
TUMOURS

54. OUTLINE
INTRODUCTION
CLASSIFICATION
ROLE OF RADIOLOGIST
IMAGING MODALITIES
IMAGING FINDINGS

55. INTRODUCTION
Tumors of the spine are important due to their
potentially devastating clinical effects and
challenging radiographic appearance.
In establishing the differential diagnosis for a spinal
lesion, location is the most important feature, but
the clinical presentation and the patient‟sage and
gender are also important

56. CLASSIFICATION OF LESIONS
Spinal tumors are subdivided according to their point of
origin
Intramedullary,
Extramedullary –Intradural
Extradural
Epidural

58. classification

59. ROLE OF THE RADIOLOGIST
MAKE THE DIAGNOSIS
DELINEATE THE EXTENT / STAGE AND LEVEL OF
AFFECTATION
MANAGE THE COMPLICATIONS
FOR INTERVENTION
FOLLOW UP

60. IMAGING MODALITIES
Magnetic Resonance Imaging.
Computed Tomography.
Plain Radiograph of the Spine.
Radionuclide (RNI) Scan
Plain Radiograph of the Spine.
Single photon Emission Computed Tomography (SPECT).
Positron Emission Tomography (PET).

61. Intramedullary tumors
Rare, accounting for about 4-10 percent of all central
nervous system tumors.
Intramedullary tumorsinclude
1. Gliomas (ependymomas, astrocytomasand gangliogliomas)
and
2. Nonglial tumors(such as hemangioblastomas, lymphoma
and metastases)

62. EPENDYMOMA

63. EPENDYMOMA

64. EXTRA DURAL TUMUORS
METASTASES.
Spinal metastasis is the most common tumor of the spine..Multiplein 90 % of cases.
In adults, the most common primary tumorsare adenocarcinomas of lung, prostate
and breast.
In children, most vertebral metastases arise from neuroblastoma and Ewing‟s
sarcoma.
Thoracic > lumbar > cervical spine.The metastatic foci mostly involve the posterior
elements.Mostspinal metastases are lytic.
Densely sclerotic metastases are typical for prostrate and rare cancers such as
carcinoid tumors.
Metastases to spine generally present as T1-hypointense and T2-hyperintense
lesions that replace normal marrow.Mostmetastases enhance.

65. METASTASES
MRI may be helpful to differentiate between an osteoporotic and a neoplastic
compression fracture.
The latter tends to show complete replacement of the fatty marrow in the
vertebral body and a possible soft tissue component that extends beyond the
bone.
Osteoporotic compression fractures may only demonstrate a band of
marrow
replacement representing edema.
Gradual return to the normal fatty marrow on follow-up.
Diffusion weighted imaging may be helpful in differentiating benign
osteoporotic

66. METASTASES

67. MULTIPLE MYELOMA
Multiple myeloma (MM) is a malignancy characterized by monoclonal proliferation of
malignant plasma cells.
Nearly always, the disease is systemic, but occasionally it may be isolated
(plasmacytoma).
In most patients, plasmacytoma is the initial manifestation of the disease and MM
develops in most of the cases 5 to 10 years after the initial diagnosis.
MM is most common primary neoplasm of spine with the majority occurring in the
thoracic and lumbar spine.
Most patients are men, 60 years of age or older.
Plasmacytomas are expansile lytic masses Mthatmay extend into the epidural
space; as with other tumors of the spine, they mayundergopathologic fracture.
On plain film or CT, they usually appear as focal lytic lesions, but often the disease
may
present innocuously, appearing only as diffuse osteopenia

68. MULTIPLE MYELOMA
In general, abnormalities are identified as hypointensities on T1WI,
hyperintensities on STIR images and enhancement on gadolinium-enhanced
images.
These imaging features are not pathognomonic for MM and may also be
seen in other diseases that affect the marrow.

69. MULTIPLE MYELOMA

70. LYPMHOMA
Lymphomas demonstrate intense enhancement and may narrow the spinal
canal, resulting in compression of the spinal cord.
Paravertebral soft-tissue masses occur consistently.
Gouge defects of the anterior border of the vertebrae are frequently the
result of
erosion by lymph nodes.

71. LYMPHOMA

72. HEMANGIOMA
Vertebral body hemangiomas are the most common primary bone tumor and are found in over
10 percent of population.
They are composed of thin-walled vessels lined by endothelial cells infiltrating the
medullary cavity between bone trabeculae.
They are most commonly found in 4
TH
-6
TH
decades with slight female
predominance.
They may be solitary (70%) or multiple (30%).
The most common locations are the thoracic, lumbar and cervical regions.
Most of the hemangiomas arise in the body of the vertebra, but may also involve the
pedicles.
The majority of hemangiomas that involve bone are discovered incidentally in
asymptomatic patients.
Some hemangiomas enlarge and become
symptomatic during pregnancy.

73. hemangioma
At radiography, vertebral hemangiomas classically have a coarse, vertical,
trabecular pattern (corduroy appearcne), with osseous reinforcement
(trabecular thickening)adjacent to the vascular channels that have caused bone
resorption.
At CT, the thickened trabeculae are seen in cross section as small punctate
areas of
sclerosis, often called the „polka-dot‟ appearance.
The presence of high signal intensity on T1 and T2WI is related to the amount
of adipocytes or vessels and interstitial edema, respectively.
Fatty vertebral hemangiomas may represent inactive forms of this lesion,
whereas low signal intensity at MR imaging may indicate a more active lesion
with the potential to compress the spinal cord

74. HAEMANGIOMA

75. SOLITARY LESIONS -Aneurysmal Bone Cyst.
Represents fewer than 1 percent of all primary bone tumors.20% are located in the spine,
particularly in the cervical and thoracic regions, where the posterior elements are typically involved.
The peak incidence is in the second decade of life with a slight female predominance.
Patients complain of back pain and neurologic symptoms resulting from encroachment on the spinal
canal.
Pathologically, ABC often has a characteristic appearance consisting of multiloculated blood-filled
spaces, which are not lined by endothelium and, therefore, do not represent vascular channels
Solid components are usually in septations and are composed of fibrous tissue, reactive bone and
giant cells.
Radiographs of spinal ABCs generally show marked expansile remodeling of bone centered in the
posterior elements, although extension into the vertebral body is frequently seen.
Spinal ABC, similar to GCT and chordoma, may extend into adjacent vertebral bodies, intervertebral
disks, posterior ribs and paravertebral soft tissues

76. ANEURYSMAL BONE CYST
CT and MR imaging may reveal multiple fluid-fluid levels reflecting hemorrhage with
sedimentation, a characteristic feature of this tumor.
These lesions often have a soft-tissue attenuation or low-signal-intensity rim on
CT and MR images (all pulse sequences), respectively, that corresponds to an intact,
thickened periosteal membrane.
Gadolinium enhancement of these lesions on MR images is usually seen within the
rim and septations, rather than the cystic spaces.
The presence of fluid-fluid or hematocrit levels is suggestive, but not pathognomic
of ABC and have also been reported in giant cell tumors, chondroblastoma,
fractured simple cyst, fibrous dysplasia and malignant fibrous histiocytosis.

77. ANEURYSMAL BONE CYST

78. CONCLUSION
Plasmacytoma/multiple myeloma and lymphoproliferative tumors are the most
common malignant primary spinal tumors.
Hemangioma is the most common benign tumor of the spine. Although rare,
leiomyoma/leiomyosarcoma and spindle cell tumors can occur in the spine.
Imaging plays an important role in early diagnosis.
CT is useful to assess tumor matrix and osseous change.
MR is useful to study associated soft tissue extension, marrow infiltration, and
intraspinal extension. However, radiologic manifestations of these tumors need
to be correlated with the age, sex, location, and presentation to arrive at a close
differential diagnosis that can help the clinician for treatment planning.

79. Infectious &
Inflammatorydisease
of the spine

80. OUTLINE
INTRODUCTION
DIFFERENTIALS /AETIOLOGY
ROLE OF RADIOLOGIST
IMAGING MODALITIES
IMAGING FINDINGS

81. INTRODUCTION
Spinal infectionsare clinically important and may be
life-threatening.
Patients may present
back pain,
fevers or neurological deficit with prior instrumentation,
spinal injections
implant,
iv drug use and immunosuppression as risk factors.

82. Pathology
3possible anatomical spaces may be affected in spinal infections-
disk-endplate complex: producingdiskitis-osteomyelitis
facet joints: producing septic arthritis
epidural space: producing anepidural abscess

83. DIFFERENTIALS
1-Spondylodiskitis
2-Spinal T.B. (Pott’s Disease)
3-Osteomyelitis (Bacterial Spondylitis)
4-Abscess (Epidural and subdural)
5-Arachnoiditis
6-Guillain-Barre Syndrome
7-Sarcoidosis
8-Multiple Sclerosis
9-Neuromyelitis Optica
10-Acute Transverse Myelitis
11-Meningitis
12.-Chronic Inflammatory Demyelinating Polyneuropathy
13.-Others -Syphilis , fungal Infections ,Paget Disease and Vit B12
deficiency.

84. ROLE OF THE RADIOLOGIST
MAKE THE DIAGNOSIS
DELINEATE THE EXTENT / STAGE AND LEVEL OF AFFECTATION
MANAGE THE COMPLICATIONS
INTERVENTION
FOLLOW UP

85. IMAGING MODALITIES FOR SPINAL
INFECTION
Plain Skull Radiograph.
Plain Radiograph of the Spine.
TransfontanelleUltrasound.
Computed Tomography.
Magnetic Resonance Imaging.
Radionuclide (RNI) Scan.
Single photon Emission Computed Tomography
(SPECT).
Positron Emission Tomography (PET).

86. IMAGING MODALITIES
Conventional radiographs are usually the initial imaging(low sensitivity and specificity)
The sensitivity of CT is higher while it lacks of specificity.
Conventional CT has played minor role for the diagnosis of early spondylitis and disc space
infection and for follow-up
MRI is as sensitive, specific and accurate as combined nuclear medicine studies and the method
of choice for the spondylitis.
Low signal areas of the vertebral body, loss of definition of the end plates and interruption of the
cortical continuity, destruction of the cortical margins are typical on T1WI whereas high signal of
affected areas of the vertebral body and disc is typical on T2WI.

87. Spondylodiskitis
-Spine infections may progress from spondylitis →
diskitis
→epidural abscess →cord abscess
-Infective spondylitis usually involves extradural
components of the spine such as posterior elements ,
disks (diskitis) , vertebral body (osteomyelitis) &
paraspinous soft tissues

88. IMAGING FINDINGS
Plain Radiography :
-Insensitive to the early changes of diskitis/osteomyelitis with normal
appearances being maintained for up to 2-4 weeks
-Thereafter disc space narrowing and irregularity or ill-definition of
the vertebral endplates can be seen
-In untreated cases , bony sclerosis may begin to
appear in 10-12 weeks
CT findings are similar to plain film but more sensitive to earlier
changes
-Additionally surrounding soft tissue swellingcollections and even
epidural abscesses may be evident

89. RIGHT-Lateral x-ray of discitis , L1-L2 disc height loss , endplate sclerosis &
Indistinct endplates
MIDDLE-Old Spondylodiskitis
LEFT-Spondylodiskitis L2-3

90. Spondylodiskitis

91. Spondylodiskitis
T1W
T2W T1W+C

92. T1+C shows L1-L2 spondylodiskitis with epidural abscess

93. Nuclear Medicine :
A bone scan may be used to demonstrate
increased uptake at the site of infection and
are more sensitive than plain film and CT ,
however lack specificity

94. TB SPINE

95. CT & MRI :
Cross-sectional imaging is required to better assess the extent of involvement
and particularly for the presence of an epidural component and cord compression
, MRI is the modality of choice
for this, with CT with contrast being a distant second
-Features include irregularity of both the endplate and anterior aspect of the
vertebral bodies with bone marrow edema and enhancement seen on MRI
-The collections are typically well circumscribed with fluid centers and well
defined enhancing margins

96. TB SPINE

97. TB SPINE

98. TB SPINE

99. TB SPINE

101. TB SPINE

102. TB SPINE

103. ARACHNODITIS

104. ARACHNODITIS

105. ARACHNODITIS

106. summary
Always important to understand the anamonyof any region
Choose appropriate modality
Describe lesion well
Consider differential diagnosis
The role of a radiologist in diagnosis and therapy emphasized

107. Thank you