Radiology of Lumbar Spine by Jeff Berger DO

Crash Course:
Imaging of Lumbar
Spine
Jeffre S. Berger, DO
April 4, 2014
AOCPMR Midyear Meeting
Format
First 20 minutes: Review of X-ray

interpretation
Second 20 minutes: MRI anatomy, slice by
slice
Last 10 minutes: Characterization of disc
herniations
GOAL: Understand how to apply and
recognize normal radiographic anatomy
Anatomy by Expectation (Bogduk, 2005)
Radiologic images are

projections of same
anatomy
Image simply confirms
what you expect should be
in particular position
AP vs. Lateral views
AP View
Pedicles at each side of

vertebral bodies
Verify true AP by center
position of spinous process
and equal interpedicular
distance
Interpedicular distance
estimates transverse width
of spinal canal
Lateral View
Demonstrates spinal
curves
Better delineates individual
vertebral bodies and
intervertebral spaces
Distance between
posterior vertebral body
(anterior border) and
spinolaminar line (posterior
border) represents sagittal
diameter
Normal AP Lumbar diameter 15 to 27mm

Stenosis < 11.5mm (Slipman, 2007)
Slipman, 2007
Mean AP diameter 25-30mm (Nirvan, 2005)
Vertebral
Bodies
(Bogduk, 2003)
pedicles
(Bogduk, 2003)
Facet Joints
(Bogduk, 2003)
Facet joints
Draw pair of lines in sagittal plan, across

diameter of each circle
Upper lumbar facets in the sagittal plane
Lower lumbar facet joints in oblique plane
Difficult to visualize in AP view
Lamina
(Bogduk, 2003)
spinous processes
(Bogduk, 2003)
Transverse Process
Long
Short
Thick
(Bogduk, 2003)
www.stryker.com
(Bogduk, 2003)
anterior elements
(Bogduk, 2003)
posterior elements
(Bogduk, 2003)
Anatomic elements
pedicles
vertebral bodies
articular facet joints
margins of the laminae
spinous processes
transverse processes
www.depts.washington.edu
Anatomic elements
pedicles
vertebral bodies
spinous processes
L1
L2
L3
L4
L5
Anatomic elements
pedicles
vertebral bodies
spinous processes
L1
L1
L2
L1
L2
L3
L1
L2
L3
L4
L1
L2
L3
L4
L5
Anatomic elements
pedicles
vertebral bodies
spinous processes
L1 iaps
L2 sap
L2 sap
L2 iaps
L3 sap
L3 sap
L3 iaps
L4 sap
L4 sap
L4 iaps
L5 sap
L5 sap
L5 iaps
S1 sap
S1 sap
Anatomic elements
pedicles
vertebral bodies
spinous processes
www.stryker.com
Anatomic elements
pedicles
vertebral bodies
spinous processes
L1
L2
L3
L4
L5
www.stryker.com
Anatomic elements
pedicles
vertebral bodies
spinous processes
L1
L2
L3
Long
L4
Short
L5
Thick
Posterior
Elements
L1
L2
L3
L4
L5
Anterior
Elements
L1
L2
L3
L4
L5
Posterior
Elements
L1
L2
L3
L4
L5
Anterior
Elements
L1
L2
L3
L4
L5
Posterior
Elements
L1
L2
L3
L4
L5
Anterior
Elements
L1
L2
L3
L4
L5
www.stryker.com
SAP
L1
Pedicle
IAP
L1
L2
L1
L2
L3
L1
L2
L3
L4
L1
L2
L3
L4
L5
L1
L2
L3
L4
L5
S1
facet joint
facet joint
spinous processes
L1
L2
L3
L4
L5
Anatomic elements
vertebral bodies
pedicles, laminae,
superior and inferior
articular processes
transverse process
spinous process
www.drgarymellick.com
Anatomic elements
vertebral bodies
pedicles, laminae,
articular processes
transverse process
spinous process
L1
L2
L3
L4
L5
Anatomic elements
vertebral bodies
pedicles, laminae,
articular processes
transverse process
spinous process
L1
L2
L3
L4
L5
Facet joints
Neural Foramina
Anatomic elements
vertebral bodies
pedicles, laminae,
articular processes
transverse process
spinous processes
L1
L2
L3
L4
L5
Anatomic elements
vertebral bodies
pedicles, laminae,
articular processes
transverse process
spinous processes
L1
L2
L3
L4
L5
Oblique Views
Commonly used for interventional

procedures
Hub view
Objects appear to move in direction
OPPOSITE to the direction X-ray beam
rotated
Oblique Views
B
A
A
D
C
0.5
0
30o
0.25
0.85
0.63
PA View
30 degree right rotation

(Bogduk, 2003)
Squaring Off
AP view of a lumbar spine segment does not

necessarily provide a perpendicular view
Lumbar lordosis varies the inter-segment angle
Tilting the X-ray beam to reduce the elliptical

margins of vertebral body into straight lines
Vertebrae take on a more square shape
Squaring Off
Vertebral Body
Pedicle
Spinous Process
Lamina
Superior and Inferior
Articular Process
Transverse Process
(Bogduk, 2003)
45 degree Right Rotation
Vertebral Body
Pedicle
Spinous Process
Lamina
Superior and Inferior
Articular Process
Transverse Process
(Bogduk, 2003)
Vertebral
Bodies
Pedicles
Inferior Articular Process
Superior Articular Process
Transverse Process
MRI Basics
T1-weighted images radio receiver listens early

during decay
Short TR, Short TE

Fat is white with excellent soft tissue discrimination
Anatomical Information
T2-weighted images radio receiver listens late

during decay
Long TR, Long TE

Sensitive to increased water white, fat is gray
Pathology
TR = Repetition Time
Sequence
TR
TE
T1WI
<1,000 msec
<45 msec
T2WI
>2,000 msec
>60 msec
Erkonen, 2005
TE = Echo Time
Sequences
STIR = Short T1 Inversion

Recovery
FLAIR = Fluid Attenuation

Inversion Recovery
Pulse sequence with

specific timing to suppress
signal from fat
suppresses water signal
Proton Density Weighted

Image
minimize T1 and T2
excellent anatomical info
Saggital Views
Paramedian
Midline
Transpedicular
Midline Sagittal View
Intersects:
Vertebral bodies and discs

Vertebral canal
Laminae and spinous
processes posteriorly
Conus medullaris at L1
Cauda equina
Dural sac at all segmental
levels.
DOES NOT intersect:
facet joints
pedicles
CSF
nerve roots of cauda

equina
L1
L1-2 disc
L1 lamina
L2
ligamentum flavum
L2-3 disc
L3
L3-4 disc
L4
L4-5 disc
L5
L2 lamina
ligamentum flavum
L3 lamina
ligamentum flavum
L4 lamina
L5 lamina
L5-S1 disc
(Bogduk, 2003)
Aorta
(Bogduk, 2003)
http://members.cox.net/injections/images/esi_images/sag_t2.jpg
Paramedian View
Intersects:
DOES NOT intersect:
Vertebral bodies & discs

Vertebral canal
Laminae posteriorly
Cauda equina
Facet joints
Pedicles
Transverse processes
Spinous processes
MAY intersect
lateral conus medullaris
Paramedian View
Vertebral bodies and discs
appear to have narrower AP
diameters with paramedian
view compared to midline scan
Right Paramedian
Left Paramedian
L1
L1 pedicle
L1-2 disc
L2
L1 iap
L1-2 zj
L2-3 disc
L3
L2 iap
L2-3 zj
L3-4 disc
L4
L4-5 disc
L5
L5-S1 disc
L3 iap
L3-4 zj
L4 iap
L4-5 zj
L5 iap
L5-S1 zj
(Bogduk, 2003)
Transpedicular View
Intersects:
Lateral vertebral body

Pedicles
Intervertebral foramen
Spinal Nerves
Facet joint
DOES NOT intersect:
Spinous Process
Transverse Process
Nucleus Pulposus
Cauda Equina
Right Transpedicular
Left Transpedicular
dural sleeve
epidural fat
spinal nerve
L1
L1-2 disc
L2
L2 sap
L2-3 disc
L3
L3-4 disc
L3 sap
L4 sap
L4
L4-5 disc
L5 sap
L5
L5-S1 disc
(Bogduk, 2003)
L1 spinal nerve
L2 spinal nerve
L3 spinal nerve
L4 spinal nerve
L5 spinal nerve
(Bogduk, 2003)
Far Lateral View
Intersects:
Transverse Processes
DOES NOT intersect:
Everything else
Interpretation of Axial View
Vertebral canal of the

lumbar spine contains:
Conus medullaris terminates at L1-2

Cauda equina
Dural sac - terminates at S2
Lumbar spinal nerves,
passing to the intervertebral
foramina
http://www.chirogeek.com
Anatomy: Spinal Nerve
Spinal Nerve
Nerves about to leave at next level lie ventral and lateral

Nerves leaving at lower levels lie dorsally and medially
Exiting spinal nerve lies
Intervertebral foramen contains:
Below pedicle
Behind inferior border vertebral body
ABOVE the disc, not behind it.
spinal nerve
terminal dorsal and ventral roots
Distal to intervertebral foramen spinal nerves divides

into larger ventral ramus and smaller dorsal ramus
L5-S1
L4-5 disc
AP lumbar spine
Conus medullaris
L1-L2
Cauda Equina
Dural Sac
dural sac
Bogduk, 2003
dural sac
dorsal root
ventral root
Bogduk, 2003
dural sac
dorsal root
ventral root
dural nerve-root sleeve
Bogduk, 2003
dural sac
dorsal root
ventral root

dorsal root ganglion
Bogduk, 2003
dural sac
dorsal root
ventral root

dorsal root ganglion
spinal nerve
Bogduk, 2003
Determining axial slice level
Anatomy: Quadratus Lumborum
Anterior to lateral 2/3 of

Extends laterally beyond
transverse process
Extends from 12th rib to
iliac crest and iliolumbar
NOT PRESENT BELOW
L5 TRANSVERSE
PROCESS
www. fotosearch.com
Anatomy: Psoas Major
Anterior to medial 1/2 of

Extends in front of
anterolateral vertebral bodies
and discs
Narrow at upper lumbar levels
Increasingly wider at lower
levels
Fibers from lower levels are

added to muscles
http://www.scipion.hr/
Anatomy: Diaphragm Crura
Arise at upper lumbar levels

Left crus descends to L3
Right crus descends to L2
Anatomy: IVC
Travels to right of
vertebral bodies
Formed at L5 level via
two common iliac veins
May be displaced
forward by the right Crus
Anatomy: Aorta
Travels to left of
vertebral bodies
Bifurcates at L4 into 2
common iliac arteries
Right renal artery
arises at L2 level,
passes to right behind
IVC
Quadratus lumborum
Lies laterally, anterior to transverse process
quadratus
lumborum
quadratus
lumborum
dural sac
& nerves
Psoas Major
Lateral to the vertebral body, anterior to quadratus

lumborum
psoas
psoas
quadratus
lumborum
quadratus
lumborum
dural sac
& nerves
Crura
Anterolateral corners of the vertebral body

right
crus
left
crus
psoas
psoas
quadratus
lumborum
quadratus
lumborum
dural sac
& nerves
Aorta lies to left of vertebral body

right
crus
left
crus
psoas
psoas
quadratus
lumborum
quadratus
lumborum
dural sac
& nerves
IVC to right of vertebral body

IVC
aorta
right
crus
left
crus
psoas
psoas
quadratus
lumborum
quadratus
lumborum
dural sac
& nerves
Anatomic Relations
Below L5, 4 vessels anterior to spine
2 common iliac arteries

2 common iliac veins
Between L4 and L5, 3 vessels

Inferior vena cava
Anatomic Relations
Aorta at levels L1 to L4
IVC at levels L1 to L5
Left crus to L2, right crus to L3
Psoas at all levels
Below L5 replaced by common iliac veins
Both crura at L1
Below L4 aorta is replaced by common iliac arteries
small at L1, growing to maximum size at L5
Quadratus Lumborum starts at L1, absent

below transverse process of L5
L1-L2
Will the left crus be present?
yes
no
Will the right crus be present?
yes
no
Will the aorta be present?
yes
no
If not, will the common iliac arteries be present?
yes
no
Will the inferior vena cava be present?
yes
no
If present will it be displaced by the right crus?
yes
no
Will the quadratus lumborum be present?
yes
no
Will psoas be present?
yes
no
Will psoas be large?
yes
no
Will iliac crests be present?
yes
no
IVC
L1-2
right
crus
psoas
quadratus
lumborum
aorta
left
crus
psoas
quadratus
lumborum
L2-L3
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
L2-3
IVC
aorta
left
crus
psoas
quadratus
lumborum
psoas
quadratus
lumborum
L3-L4
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
L3-4
IVC
psoas
quadratus
lumborum
aorta
psoas
quadratus
lumborum
L4-L5
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
Common iliac arteries
L4-5
IVC
psoas
psoas
quadratus
lumborum
quadratus
lumborum
longissimus
L5-S1
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
L5-S1
common iliac veins
common iliac arteries
psoas
psoas
Neural Relations
Transpedicular
Subpedicular
through pedicle
below pedicle, above disc
Transdiscal
through disc, below vertebra
transpedicular
subpedicular
transdiscal
transpedicular
subpedicular
transdiscal
L1
vertebral
body
L3 nerve roots
about to emerge
pedicle
transverse process
L2
vertebral
body
L3
L3 nerve roots
lamina
L4
L5
spinous process
L3 ventral
ramus
facet joint
(Bogduk, 2003)
spinous process
Transpedicular
Subpedicular
Transdiscal
(Bogduk, 2003)
L3-L4 Transdiscal
Central Region
Directly behind disc

PLL thickest
Paracentral Zone
Lateral to central
PLL thinner
Between medial facet joint and

medial pedicle
Foraminal Zone
Schematic representation of the anatomical "zones" identified on axial

images. The anterior zone (not illustrated) is delineated from the extraforaminal zone by an imaginary coronal line in the center of the
vertebral body. (Adapted from Wiltse LL, Berger PE, McCulloch JA. A
system for reporting the size and location of lesions of the spine. Spine
1997;22:1534-1537)
Herniations frequent
Subarticular Zone
Herniations less common
Within intervertebral foramen

Between medial and lateral
edges of pedicle
5-10% herniations
Site of dorsal root ganglion
Central Region
Directly behind disc

PLL thickest
Paracentral Zone
Lateral to central
PLL thinner
Between medial facet joint and

medial pedicle
Foraminal Zone
Coronal drawing illustrating the main anatomical "zones" and "levels".

(From Wiltse LL, Berger PE, McCulloch JA. A system for reporting the
size and location of lesions of the spine. Spine 1997;22:1534-37)
Herniations frequent
Subarticular Zone
Herniations less common
Within intervertebral foramen

Between medial and lateral
edges of pedicle
5-10% herniations
Site of dorsal root ganglion
IVC displaced from vertebral column

Psoas small and thin
Quadratus Lumborum attenuated
Kidneys bilaterally
Bilateral Crura
L1 Subpedicular
IVC
Aorta
Right Crus
Left Crus
Psoas
Psoas
QL
QL
nerve
roots
dural
sac
L1 spinal
nerve
L1-2 Transdiscal
IVC
Aorta
Left Crus
Right Crus
NP
Psoas
Psoas
QL
QL
L2 sap
L1-2
facet
L1 iap
IVC close to vertebral column

Right Crus absent
Psoas narrow
Quadratus Lumborum flares laterally
L2 Subpedicular
IVC
Aorta
Right Crus
Psoas
Psoas
QL
QL
L2 exiting nerve
nerve
roots
L2 exiting
nerve
L3 nerve
root
L3 nerve
root
L2-3 Transdiscal
Aorta
IVC
NP
Psoas
Psoas
QL
QL
L3 sap
L2-3
facet
L2 iap
Psoas substantial with prominent anterior margin

IVC and Aorta present
Quadratus Lumborum present
Vertebral body and pedicles present
L3 Transpedicular
IVC
Psoas
Aorta
Psoas
QL
Transverse
Process
Pedicle
L3 Subpedicular
IVC
Aorta
Psoas
Psoas
QL
QL
L3 nerve
root
L4 nerve
root
nerve
roots
L3 nerve
root
L4 nerve
root
L3-4 Transdiscal
IVC
Psoas
Aorta
NP
Psoas
QL
QL
L4 sap
L3-4
facet
L3 iap
Psoas large, bulges anterior and lateral

Aorta bifurcating into common iliacs
Quadratus Lumborum present
Vertebral body, pedicles, transverse
processes present
L4 Transpedicular
Common Iliac A.
IVC
Psoas
Psoas
QL
QL
Transverse
Process
Pedicle
L4 Subpedicular
Common Iliac A.
Common Iliac V.
Psoas
Psoas
QL
QL
L4 nerve
root
L5 nerve
root
nerve
roots
L4 nerve
root
L4-5 Transdiscal
CIA
CIV
Psoas
Psoas
QL
QL
L5 sap
L4-5
facet
L4 iap
Psoas large
Absent Quadratus Lumborum
2 common iliac veins
Iliac crest present
L5 Transpedicular
CIA
CIV
Psoas
Psoas
Transverse
Process
Pedicle
L5-S1 Transdiscal
CIA
CIV
Psoas
Psoas
Iliacus
S1 sap
L5-S1
facet
S1 iap
S1
Sacroiliac Joint
Sacroiliac Joint
Definitions
Herniated disc: best general term to denote

displacement of disc material beyond
intervertebral disc space. The term includes discs
that may properly be characterized by more
specific terms, such as "protruded disc" or
"extruded disc." Avoid using term herniated
nucleus pulposus.
Disc Bulge: Greater than 50% of the
circumference of the disc and extends a relatively
short distance, usually less than 3 mm, beyond
the edges of the apophyses
Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine
Radiology, and American Society of Neuroradiology, 2003
Degenerative disease or changes of

maturity?
30% of 30 year olds have radial fissures

40% of 40 year olds have disc bulging
Definitions
Protruded Discs: greatest distance, in any plane,

between the edges of the disc material beyond
the disc space is less than the distance between
the edges of the base in the same plane.
Focal: Protrusions with a base less than 25% (90

degrees) of the circumference of the disc.
Broad-based: If disc material is herniated so that the
protrusion encompasses 25% to 50% of the
circumference of the disc.
Definitions
Extruded Discs: Any one distance between the edges of the

disc material beyond the disc space is greater than the
distance between the edges of the base measured in the
same plane
Sequestrated: subtype of "extruded disc" but, by definition,
can never be a "protruded disc." No continuity between
herniated disc material and parent disc. Disc material that is
displaced away from the site of extrusion, regardless of
continuity, may be called "migrated," a term which is useful
for the interpretation of imaging studies because it is often
impossible from images to know if continuity exists.
References
Nirvan AB, Pensi CA, Patel JP*, Shah GV & Dave RV. A study of inter-pedicular distances of the
lumbar vertebrae measured in plain antero-posterior radiograph in GujaratisJ.Anat.Soc. India 54
(2) 1-9 (2005)
Bogduk N. Radiographic Anatomy of the Normal Lumbar Spine. San Francisco: International
Spinal Intervention Society; 2003.
Bogduk, N. Clinical Anatomy of the Lumbar Spine and Sacrum. 4th ed. Elsevier Inc. 2005.
Weyreuther, M. et al. MRI Atlas Orthopedics and Neurosurgery: The Spine. Springer. 2007.
Lufkin, R. et al. MRI of the Spine. 2nd ed. Lippincott Williams and Wilkins. 2000.
Berquist, T. MRI of the Musculoskeletal System. 5th ed. Lippincott Williams and Wilkins. 2006.
Fast, A. et al. Navigating the Adult Spine: Bridging Clinical Practice and Neuroradiology.
Demos. 2007.
www.stryker.com
www.injuryupdate.com
Slipman C. et al. Interventional Spine: An algorithmic approach. Elsevier Inc. 2008.
Erkonen, W, Smith W. Radiology 101: The basics and fundamentals of imaging. Lippincott,
2005.
Czervionke, L. Pocket Atlas of Normal Spine MRI. Lippincott, 2001.

Radiology of Lumbar Spine by Jeff Berger DO

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Crash Course:

First 20 minutes: Review of X-ray

Anatomy by Expectation (Bogduk, 2005)

Radiologic images are

AP vs. Lateral views

Pedicles at each side of

Normal AP Lumbar diameter 15 to 27mm

Mean AP diameter 25-30mm (Nirvan, 2005)

Draw pair of lines in sagittal plan, across

Difficult to visualize in AP view

Commonly used for interventional

30 degree right rotation

AP view of a lumbar spine segment does not

Lumbar lordosis varies the inter-segment angle

Tilting the X-ray beam to reduce the elliptical

Vertebrae take on a more square shape

45 degree Right Rotation

Inferior Articular Process

Superior Articular Process

T1-weighted images radio receiver listens early

Short TR, Short TE

T2-weighted images radio receiver listens late

Long TR, Long TE

STIR = Short T1 Inversion

FLAIR = Fluid Attenuation

Pulse sequence with

suppresses water signal

Proton Density Weighted

Midline Sagittal View

Vertebral bodies and discs

DOES NOT intersect:

nerve roots of cauda

DOES NOT intersect:

Vertebral bodies & discs

lateral conus medullaris

Lateral vertebral body

DOES NOT intersect:

Far Lateral View

DOES NOT intersect:

Interpretation of Axial View

Vertebral canal of the

Conus medullaris terminates at L1-2

Anatomy: Spinal Nerve

Nerves about to leave at next level lie ventral and lateral

Intervertebral foramen contains:

Distal to intervertebral foramen spinal nerves divides

dural nerve-root sleeve

dural nerve-root sleeve

dural nerve-root sleeve

Determining axial slice level

Anatomy: Quadratus Lumborum

Anterior to lateral 2/3 of

Anatomy: Psoas Major

Anterior to medial 1/2 of

Fibers from lower levels are

Anatomy: Diaphragm Crura

Arise at upper lumbar levels

Lies laterally, anterior to transverse process

Lateral to the vertebral body, anterior to quadratus

Anterolateral corners of the vertebral body

Aorta lies to left of vertebral body

IVC to right of vertebral body

Below L5, 4 vessels anterior to spine

2 common iliac arteries