Introduction to

Neuroimaging

spine

John J. McCormick MD

Neuroanatomy

Netter drawings

Radiographic Anatomy

Cervical Spine

Cervical Spine

Oblique View

Cervical Spine

Dens View

Thoracic Spine

Lumbar Spine

MRI Anatomy

Spine Pathology

• Trauma

• Degenerative disease

• Tumors and other masses

• Inflammation and infection

• Vascular disorders

• Congenital anomalies

Evaluating Trauma

• Fracture

• Dislocation

• Ligamentous injury

• Cord injury

• Nerve root avulsion

Plain films may be very subtle or

absent

• A 28 year old man who was 5 feet 9 inches and 16 stone was playing rugby as a number 8. He ran head first into a tackle, causing an axial compression injury to his neck. This caused immediate, dull pain over the whole of his neck. He attempted to continue playing but found that merely running exacerbated the pain considerably. He later noticed the pain localising to the whole axial area along with his head “feeling heavy and loose”. He self treated with a soft collar for two days, before presenting to the accident and emergency (A&E) department, by which time the pain was persistent in the sub-occipital area. At no stage did he have any neurological symptoms.

• Examination showed painful neck movements, with pronounced reduction of range in all directions.

• Burst fracture

Tumors and Other Masses

Classification of Spinal Lesions

• Extradural: outside the thecal sac

(including vertebral bone lesions)

• Intradural/ extramedullary: within the

thecal sac but outside cord

• Intramedullary: within cord

Common Extradural Lesions

• Herniated disc

• Vertebral hemangioma

• Vertebral metastasis

• Epidural abscess or hematoma

• Synovial cyst

• Nerve sheath tumor

– Neurofibroma

– Schwannoma

Common Intradural Extramedullary

Lesions

• Nerve sheath tumor (also extradural)

• Meningioma

• Drop Metastasis

Common Intramedullary Lesions

• Astrocytoma

• Ependymoma

• Hemangioblastoma

• Cavernoma

• Syrinx

• Demyelinating lesion (MS)

• Myelitis

Extradural: Herniated disc

Extradural: Hemangioma

Extradural: Vertebral Metastasis

Extradural: Epidural Abscess

Extradural Meningioma

Intradural Extramedullary:

Meningioma

Intradural extramedullary

Intrradural Extramedullary:

Neurofibroma

Intradural Extramedullary:

“Drop Mets”

Endolymphatic Sac

Intradural Extramedullary:

Arachnoid Cyst

Intramedullary: Astrocytoma

Astrocytoma with Syrinx

Hydromyelia

Intramedullary: Syringohydromyelia

• Seen with:

– Congenital lesions

chiari I & II

tethered cord

– Aquired lesions

trauma

tumors

arachnoiditis

– Idiopathic

Confusing “Syrinx” Terminology

• Hydromyelia: Fluid accumulation/dilatation within central canal, therefore lined by ependyma

• Syringomyelia: Cavitary lesion within cord parenchyma, of any cause. Located adjacent to central canal, therefore not lined by ependyma

• Syringohydromyelia: Term used for either of the above, since the two may overlap and cannot be discriminated on imaging

• Hydrosyringomyelia: Same as syringohydromyelia

• Syrinx: Common term for the cavity in all of the above

Infection and Inflammation

Infectious Spondylitis/ Diskitis

• Common chain of events (bacterial

spondylitis):

– Hematogenous seeding of subchondral VB

– Spread to disc and adjacent VB

– Spread into epidural space

– Spread into paraspinal tissues

– May lead to cord abscess

Pyogenic Spondylitis / Diskitis with

Epidural Abscess

Acute Osteoporosis Compression

• May look similar to pyogenic infection

• Clinical context

Spinal TB (Pott’s Disease)

• Prominent bone

destruction

• More indolent onset

than pyogenic

• Gibbus deformity

• Involvement of

several VB’s

Transverse Myelitis

• Inflamed cord of uncertain cause – Viral infections

– Immune reactions

– Idiopathic

• Myelogathy progressing over hours to weeks

• DD: MS, glioma, infarction

Multiple Sclerosis

• Inflammatory

demyelination eventually

leading to gliosis and

axonal loss

• T2 hyperintense lesions

in cord parenchyma

• Typically no cord

expansion (vs. tumor);

chronic lesion may show

atrophy

Cord Edema

• May be secondary to

ischemia (eg embolus

to spinal artery)

• Venous hypertension

(eg AV fistula)

• Aortic aneurysm

Congenital