Objectives

Spinal Imaging Interpretation For The NonNon-Radiologist

Damon Spitz, M.D. Department of Radiology New England Baptist Hospital Boston, MA

o Describe the available spinal imaging

modalities and their common clinical indications o Assess the pros and cons of each modality o Illustrate the typical appearance of normal spinal anatomy as well as common pathologic findings

Jules slide?
o Wood o Bone It is bone

Clinical Indications
o Persistent back or neck pain o Radiculopathy o Spinal stenosis (neurogenic claudication) o Myelopathy o Trauma o Post surgical. Is the hardware placement

appropriate? Is there evidence of osseous fusion? Is there a recurrent disc herniation? o Infection o Tumor/Metastasis

Location
o Cervical Spine o Thoracic Spine o Lumbar Spine o Sacrum

Modalities/Menu
o Radiography (X(X-ray) Frontal and lateral views Oblique views or flexion and extension views o Magnetic Resonance Imaging (MRI) With or without intravenous gadolinium o Computed Tomography (CT) Multislice helical CT with multiplanar reconstructions

Modalities/Menu (Contd)
o Myelogram With CT scan to follow (CT Myelogram) o Nuclear Medicine (Bone Scan) With or without SPECT

Anatomy: Lumbar Spine Axial Plane

X-ray -- Lumbar -- Lateral View

X-ray -- Lumbar -- Frontal View

X-ray -- Lumbar -- Oblique View

Spondylolysis(Pars Defect)

X-ray -- Cervical -- Lateral View

X-ray -- Cervical -- Frontal View

X-ray -- Cervical -- Oblique View X-ray -- Cervical -- Odontoid View

Magnetic Resonance Imaging (MRI)

Newer ShortShort-bore MRI

Magnetic Resonance Imaging (MRI)

o Excellent for evaluation of soft tissue

Magnetic Resonance Imaging (MRI)

o How does MRI Work? Place patient in a strong magnetic field (the bore) and then we transmit radiowaves into the patient and receive radiowaves from the patient. We use the radiowaves to construct an image. o Different types of images: Main types are T1 and T2 Weighted

structures: disc, ligaments, nerve roots, dural sac and spinal cord o Excellent in disc herniations (primary and recurrent), tumor, metastasis, and infection o Limited in the evaluation of fusion and hardware placement

images

Magnetic Resonance Imaging (MRI)

o Creates different types of images T1 Weighted Weighted FLUID IS DARK T2 Weighted Weighted FLUID IS BRIGHT Inversion recovery or fat suppressed images Very sensitive for fluid or edema Intravenous contrast (Gadolinium) enhanced imaging Used in PostPost-operative patients and patients with question of infection and abscess, or tumor.

MRI -- Sagittal Plane

T1

T2

MRI -- Fat Suppression

Good for detection of edema. Valuable for imaging patients with: -recent trauma -infection -spondylolysis -compression fracture -tumor

MRI -- Normal Axial PlanePlane-Lumbar Spine

MRI Normal T2 Axial Lower Thoracic Spine

MRI -- Small Disc Herniation

MRI--? MRI---?

MRI -- Large Disc Herniation

MRI Spinal Stenosis

MRI --Tumor --Tumor

MRI -- Metastasis

MRI -- Metastasis

MR -- Synovial Cyst

MRI -- Cervical Spine

T1

T2

MRI -- Cervical Spine Axial

MRI
Safety

MRI Safety
o No ionizing radiation

Computed Tomography (CT)

Computed Tomography (CT)

Conventional (Non(Non-helical) CT

Helical CT

Helical CT

Helical CT-CT-- Reconstructions

Computed Tomography (CT)

o CT is the best tool for evaluating the

Computed Tomography (CT)

o Helps to differentiate between disc o o o o

osseous anatomy in multiple planes o Excellent for the evaluation of the presence of osseous fusion in post surgical patients. Evaluation of hardware o Complimentary to myelography

material, calcification, and bone Valuable in evaluation of spondylolysis Availability Rapid examination times Does involve exposure to ionizing radiation

Computed Tomography (CT) Spinal Stenosis

Computed Tomography (CT) Fusion Evaluation

CT in Complex Post Surgical Patients

Computed Tomography (CT) Axial Plane -- Spondylolysis

Computed Tomography (CT) Spondylolysis

Computed Tomography (CT) Spondylolysis

Computed Tomography (CT) Spondylolysis -- Sag. Recons

Myelography
o Radiologist injects iodinated contrast

material into the thecal sac (spinal canal)

o Multiple XX-rays are taken often with the

patient standing and with extension and flexion o CT scan is performed after the injection

Myelography
o Excellent in the evaluation of spinal

Myelography -- Spinal Stenosis

stenosis patients o Evaluates for instability -- dynamic compression on nerve roots o Valuable in post operative patients with hardware in place o Often utilized in patients who cannot undergo MRI

CT Myelogram

Nuclear Medicine -- Bone Scan

o Patient is injected intravenously with a

radiotracer (Technetium 99m labeled MDP) o This tracer is absorbed by the osteoblastic cells in the body (cells that make new bone) o We are then able to image the patient with a special camera (Gamma camera) o Bone Scan shows osteoblastic activity

Nuclear Medicine -- Bone Scan

Nuclear Medicine -- Bone Scan

o Bone scans are commonly used in the

evaluation of bone metastasis

o Also used for Stress fractures (spine -- spondylolysis) Compression fractures Arthritis Infection Prosthesis loosening

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Nuclear Medicine -- Bone Scan

o Scan usually covers the entire skeleton o Does involve ionizing radiation o Although it is a test that is sensitive for

Bone Scan with SPECT

o SPECT stands for

active bone remodeling, the findings are often not specific to one disease process o When imaging spinal disorders SPECT imaging is often added

Single photon emission computed tomography o SPECT SPECT

Bone Scan with SPECT

Bone Scan - Compression Fracture

Bone Metastasis

Sacral Insufficiency Fracture

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Conclusions
o Variety of different modalities for patients

with spinal disorders. Radiography, MRI, CT, myelography, and nuclear medicine o Selection of test depends on the individual patient and clinical indication o Each imaging modality has strengths and weaknesses

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