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Spinal Imaging InterpretationSpinal Imaging Interpretation

For The NonFor The Non--RadiologistRadiologist

Damon Spitz, M.D.Damon Spitz, M.D.

Department of RadiologyDepartment of Radiology

New England Baptist HospitalNew England Baptist Hospital

Boston, MABoston, MA

ObjectivesObjectives

oo Describe the available spinal imagingDescribe the available spinal imaging

modalities and their common clinicalmodalities and their common clinicalindicationsindications

oo Assess the pros and cons of eachAssess the pros and cons of each

modalitymodality

oo Illustrate the typical appearance of normalIllustrate the typical appearance of normal

spinal anatomy as well as commonspinal anatomy as well as common

pathologic findingspathologic findings

Jules slide?Jules slide?

oo WoodWood

oo BoneBone

It is boneIt is bone

Clinical IndicationsClinical Indications

oo Persistent back or neck painPersistent back or neck pain

oo RadiculopathyRadiculopathy

oo Spinal stenosis (neurogenic claudication)Spinal stenosis (neurogenic claudication)

oo MyelopathyMyelopathy

oo TraumaTrauma

oo Post surgical. Is the hardware placementPost surgical. Is the hardware placementappropriate? Is there evidence of osseousappropriate? Is there evidence of osseousfusion? Is there a recurrent disc herniat ion?fusion? Is there a recurrent disc herniation?

oo InfectionInfection

oo Tumor/MetastasisTumor/Metastasis

LocationLocation

oo Cervical SpineCervical Spine

oo Thoracic SpineThoracic Spine

oo Lumbar SpineLumbar Spine

oo SacrumSacrum

Modalities/MenuModalities/Menu

oo Radiography (XRadiography (X--ray)ray)

Frontal and lateral viewsFrontal and lateral views

Oblique views or flexion and extension viewsOblique views or flexion and extension views

oo Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)With or without intravenous gadoliniumWith or without intravenous gadolinium

oo Computed Tomography (CT)Computed Tomography (CT)

Multislice helical CT with multiplanarMultislice helical CT with multiplanar

reconstructionsreconstructions


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Modalities/Menu (Contd)Modalities/Menu (Contd)

oo MyelogramMyelogram

With CT scan to follow (CT Myelogram)With CT scan to follow (CT Myelogram)

oo Nuclear Medicine (Bone Scan)Nuclear Medicine (Bone Scan)

With or without SPECTWith or without SPECT

Anatomy: Lumbar SpineAnatomy: Lumbar Spine

Axial PlaneAxial Plane

XX--rayray ---- LumbarLumbar---- Lateral ViewLateral View

XX--rayray ---- LumbarLumbar---- Frontal ViewFrontal ViewXX--rayray ---- LumbarLumbar---- Oblique ViewOblique View

Spondylolysis-(Pars Defect)


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XX--rayray ---- CervicalCervical ---- Lateral ViewLateral View XX--rayray ---- CervicalCervical ---- Frontal ViewFrontal View

XX--rayray ---- CervicalCervical ---- Oblique ViewOblique ViewXX--rayray ---- CervicalCervical ---- Odontoid ViewOdontoid View

Magnetic Resonance ImagingMagnetic Resonance Imaging

(MRI)(MRI)Newer ShortNewer Short--bore MRIbore MRI


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(MRI)(MRI)

oo Excellent for evaluation ofExcellent for evaluation ofsoft tissuesoft tissue

structures: disc, ligaments, nerve roots,structures: disc, ligaments, nerve roots,dural sac and spinal corddural sac and spinal cord

oo Excellent in disc herniations (primary andExcellent in disc herniations (primary and

recurrent), tumor, metastasis, andrecurrent), tumor, metastasis, and

infectioninfection

oo Limited in the evaluation of fusion andLimited in the evaluation of fusion and

hardware placementhardware placement


(MRI)(MRI)

oo How does MRI Work?How does MRI Work?

Place patient in a strong magnetic field (thePlace patient in a strong magnetic field (thebore) and then we transmit radiowaves intobore) and then we transmit radiowaves intothe patient and receive radiowaves from thethe patient and receive radiowaves from thepatient. We use the radiowaves to constructpatient. We use the radiowaves to constructan image.an image.

oo Different types of images:Different types of images:

Main types areMain types are T1 and T2 Weightedimages


(MRI)(MRI)

oo Creates different types of imagesCreates different types of images

T1 WeightedT1 WeightedFLUID IS DARKFLUID IS DARK

T2 WeightedT2 WeightedFLUID IS BRIGHTFLUID IS BRIGHT

Inversion recovery or fat suppressed imagesInversion recovery or fat suppressed images

Very sensitive for fluid or edemaVery sensitive for fluid or edema

Intravenous contrast (Gadolinium) enhancedIntravenous contrast (Gadolinium) enhancedimagingimaging

Used inUsed in PostPost--operative patientsoperative patients andandpatients with question ofpatients with question ofinfection andinfection and

abscess, or tumorabscess, or tumor..

MRIMRI ---- Sagittal PlaneSagittal Plane

T1 T2

MRIMRI ---- Fat SuppressionFat Suppression

Good for detection of

edema. Valuable for

imaging patients with:

-recent trauma

-infection

-spondylolysis

-compression fracture

-tumor

MRIMRI ---- NormalNormal

Axial PlaneAxial Plane--Lumbar SpineLumbar Spine


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MRI Normal T2 Axial LowerMRI Normal T2 Axial Lower

Thoracic SpineThoracic Spine

MRIMRI ---- Small Disc HerniationSmall Disc Herniation

MRIMRI------?? MRIMRI ---- Large Disc HerniationLarge Disc Herniation

MRI Spinal StenosisMRI Spinal Stenosis MRIMRI ----TumorTumor


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MRIMRI ---- MetastasisMetastasis MRIMRI ---- MetastasisMetastasis

MRMR ---- Synovial CystSynovial Cyst MRIMRI ---- Cervical SpineCervical Spine

T1 T2

MRIMRI ---- Cervical Spine AxialCervical Spine Axial

MRIMRISafetySafety


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MRI SafetyMRI Safety

oo No ionizing radiationNo ionizing radiation

Computed Tomography (CT)Computed Tomography (CT)Computed Tomography (CT)Computed Tomography (CT)

Conventional (NonConventional (Non--helical) CThelical) CT Helical CTHelical CT


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Helical CTHelical CT Helical CTHelical CT---- ReconstructionsReconstructions

Computed Tomography (CT)Computed Tomography (CT)

oo CT is the best tool for evaluating theCT is the best tool for evaluating the

osseous anatomy in multiple planesosseous anatomy in multiple planes

oo Excellent for the evaluation of theExcellent for the evaluation of the

presence of osseous fusion in postpresence of osseous fusion in post

surgical patients. Evaluation of hardwaresurgical patients. Evaluation of hardware

oo Complimentary to myelographyComplimentary to myelography


oo Helps to differentiate between discHelps to differentiate between disc

material, calcification, and bonematerial, calcification, and bone

oo Valuable in evaluation of spondylolysisValuable in evaluation of spondylolysis

oo AvailabilityAvailability

oo Rapid examination timesRapid examination times

oo Does involve exposure to ionizingDoes involve exposure to ionizing

radiationradiation


Spinal StenosisSpinal Stenosis


Fusion EvaluationFusion Evaluation


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CT in Complex Post SurgicalCT in Complex Post Surgical

PatientsPatientsComputed Tomography (CT)Computed Tomography (CT)

Axial PlaneAxial Plane ---- SpondylolysisSpondylolysis


SpondylolysisSpondylolysisComputed Tomography (CT)Computed Tomography (CT)

SpondylolysisSpondylolysis


SpondylolysisSpondylolysis ---- Sag. ReconsSag. Recons MyelographyMyelography

oo Radiologist injects iodinated contrastRadiologist injects iodinated contrast

material into the thecal sac (spinal canal)material into the thecal sac (spinal canal)

oo Multiple XMultiple X--rays are taken often with therays are taken often with the

patient standing and with extension andpatient standing and with extension and

flexionflexion

oo CT scan is performed after the injectionCT scan is performed after the injection


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MyelographyMyelography

oo Excellent in the evaluation of spinalExcellent in the evaluation of spinal

stenosis patientsstenosis patientsoo Evaluates for instabilityEvaluates for instability ---- dynamicdynamic

compression on nerve rootscompression on nerve roots

oo Valuable in post operative patients withValuable in post operative patients with

hardware in placehardware in place

oo Often utilized in patients who cannotOften utilized in patients who cannot

undergo MRIundergo MRI

MyelographyMyelography ---- Spinal StenosisSpinal Stenosis

CT MyelogramCT MyelogramNuclear MedicineNuclear Medicine ---- Bone ScanBone Scan

oo Patient is injected intravenously with aPatient is injected intravenously with aradiotracer (Technetium 99m labeledradiotracer (Technetium 99m labeledMDP)MDP)

oo This tracer is absorbed by the osteoblasticThis tracer is absorbed by the osteoblasticcells in the body (cells that make newcells in the body (cells that make newbone)bone)

oo We are then able to image the patient withWe are then able to image the patient witha special camera (Gamma camera)a special camera (Gamma camera)

oo Bone Scan showsBone Scan shows osteoblasticosteoblastic activityactivity

Nuclear MedicineNuclear Medicine ---- Bone ScanBone ScanNuclear MedicineNuclear Medicine ---- Bone ScanBone Scan

oo Bone scans are commonly used in theBone scans are commonly used in the

evaluation of bone metastasisevaluation of bone metastasis

oo Also used forAlso used for

Stress fractures (spineStress fractures (spine ---- spondylolysis)spondylolysis)

Compression fracturesCompression fractures

ArthritisArthritis

InfectionInfection

Prosthesis looseningProsthesis loosening


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Nuclear MedicineNuclear Medicine ---- Bone ScanBone Scan

oo Scan usually covers the entire skeletonScan usually covers the entire skeleton

oo Does involve ionizing radiationDoes involve ionizing radiation

oo Although it is a test that is sensitive forAlthough it is a test that is sensitive for

active bone remodeling, the findings areactive bone remodeling, the findings are

often not specific to one disease processoften not specific to one disease process

oo When imaging spinal disordersWhen imaging spinal disorders SPECTSPECT

imaging is often addedimaging is often added

Bone Scan with SPECTBone Scan with SPECT

oo SPECT stands forSPECT stands for

Single photonSingle photonemission computedemission computed

tomographytomography

oo SPESPECTCT

Bone Scan with SPECTBone Scan with SPECT Bone ScanBone Scan -- Compression FractureCompression Fracture

Bone MetastasisBone Metastasis Sacral Insufficiency FractureSacral Insufficiency Fracture


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ConclusionsConclusions

oo Variety of different modalities for patientsVariety of different modalities for patients

with spinal disorders. Radiography, MRI,with spinal disorders. Radiography, MRI,CT, myelography, and nuclear medicineCT, myelography, and nuclear medicine

oo Selection of test depends on the individualSelection of test depends on the individual

patient and clinical indicationpatient and clinical indication

oo Each imaging modality has strengths andEach imaging modality has strengths and

weaknessesweaknesses

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