Dr. M.

Samy, MD

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List of contents:
Vertebral Column Anatomy
Spine MRI Protocol
Chapter 1: Spinal Extradural Lesions
Chapter 2: Spinal Subdural Extramedullary Lesions
Chapter 3: Spinal Intra-Medullary Lesions
Chapter 4: Myelopathy
Chapter 5: Cauda Equine Lesions
Chapter 6: Spinal Dysraphism
Chapter 7: Scoliosis

Sources:
Diagnostic imaging of spine
Primer of diagnostic imaging
Radiopedia
Radiology assistant
Radiographic journal
MRI Master

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 Vertebral Column Anatomy

C1 vertebra

C2 Vertebra

Cervical vertebrae

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Dorsal vertebrae

Lumbar Vertebrae

Neural Foramen

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 Eye = Pedicle
Nose = Transverse process
Ear = Superior articular process
Foreleg = Inferior articular
process
Neck = Pars interarticularis
Body = Lamina

Sacrum & Coccyx

Ligaments

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Cranio-cervical Junction

Chamberlain line extending from hard palate to opisthion.

McGregor line extending from hard palate to base of occipital bone.
Basilar impression:
Odontoid tip ≥ 5 mm above Chamberlain line defines basilar impression.
odontoid tip ≥ 7 mm above McGregor line defining basilar impression.

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Arterial Supply
Dorsal thoracic aorta => segmental (intercostal) a. => Dorsal branch =>
Radiculomedullary a.
=> Ventral radiculomedullary a. => Anterior spinal artery
=> Dorsal radiculomedullary a. => Posterior spinal artery

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 Spine MRI Protocol
Sagittal T1 FOV= 35 cm
Sagittal T2 Slice thickness = 4mm
Axial T1 Slice gap = 0.4 mm (10%)
Axial T2

Sagittal post contrast T1 FS

Axial post contrast T1 FS
Sagittal:
// center of vertebral body + spinous process + spinal cord
Cover the spine from the lateral border of Rt transverse process to the
lateral border of the Lt transverse process.

Axial:
Multi block multi angle
// intervertebral disc

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MR Myelography
Heavily T2 WI (single shot TSE)
3D MIP reconstruction
Advantages:
 Non invasive
 No contrast injection
 No radiation exposure
Pre-surgical evaluation of:
 Nerve root compression
 Thecal sac deformity
 Foraminal stenosis
 Spinal canal stenosis
Post-operative evaluation of:
 Thecal sac compression by epidural scar / recurrent disc

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 I. Spinal Extradural Lesions

Vertebral Column Extradural space

1) Trauma 1) Epidural hematoma
2) Spondylitis / Spondylodiscitis 2) Epidural / Subdural abscess /
(Pyogenic – Granulomatous) empyema
3) Inflammatory (RA – AS) 3) Epidural lipomatosis
4) Degenerative 4) Epidural arachnoid cyst
5) Neoplastic 5) Vascular malformation

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 A. Vertebral Column Fracture
i. Cervical Fracture
Mechanisms of Spinal Injury
1) Hyperflexion 2) Hyperextension 3) Axial Compression

4) Rotation 5) Lateral Stress 6) Distraction

Prevertebral space:
at C2 < 7 mm.
at C3 and C4 < 5 mm.
at C6 it is wider due to esophagus
and cricopharyngeal muscle
< 22 mm in adults
< 14 mm in children
In children younger than 24 months
there can be physiologic widening
of the prevertebral space during
forcefull expiration ([Link]).

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Jefferson Fracture
Burst fracture of C1 ring
Lateral displacement of both articular masses.

Dens Fracture
Type I Type II Type III
Fracture in superior tip Fracture at base of Fracture at base of
of odontoid. odontoid. odontoid + body of
axis.
Unstable Unstable Stable
Relatively rare most common type Rare

Hyperflexion injuries Hyperextension injuries:

Hyperflexion sprain Hyperextesnion sprain
Flexion teardrop fracture Extension teardrop fracture of C2.
Wedge fracture Wedge fracture.
Unilateral facet dislocation C1 anterior arch avulsion fracture.
Bilateral facet dislocation. C1 posterior arch fracture.
Anterior subluxation Hyperextension on top of
Clay Shoveler’s fracture. spondylosis.
Hangman’s fracture.

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A. Hyperflexion injuries:
1) Hyperflexion Sprain
Injuries to the soft tissues of the spine without fracture.
Stable injury.
Edema in posterior paraspinal ms + Inter-spinous + Supra-spinatous lig.
Edema in lower C and upper T - vertebrae = bone bruise.
± Lower C- disc extrusion
± Spinal cord edema

2) Flexion Teardrop Fracture

 Unstable injury.
 Posterior ligament disruption
 Anterior compression fracture of the vertebral body
 Avulsion of the anterior aspect of inferior end plate of C6.
 Posterior part of vertebral body is displaced backward into spinal canal

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 3) Unilateral Facetal Dislocation
Unilateral superior facet slides over the inferior facet and becomes locked.
Mostly stable.
Anterior subluxation of the upper vertebral body
Edema in posterior paraspinal ms + Inter-spinous + Supra-spinatous lig.
Edema in lower C and upper T - vertebrae = bone bruise.
± Lower C- disc extrusion
± Spinal cord edema
Bow tie sign
Inverted Humburger sign

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 4) Bilateral Facetal dislocation
Bilateral superior facet slides over the inferior facet and becomes locked.
Unstable.
Anterior subluxation of the upper vertebral body
Edema in posterior paraspinal ms + Inter-spinous + Supra-spinatous lig.
Edema in lower C and upper T - vertebrae = bone bruise.
± Lower C- disc extrusion
± Spinal cord edema

Double inverted hamburger

sign

5) Clay Shoveler’s Fracture.

Lateral view:
Spinous process fracture

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B. Hyperextension Injuries:
1) Hangman's Fracture
 Most common cervical spine fracture
 Unstable fracture
 Traumatic spondylolisthesis of C2 vertberal body
 Bilateral C2 pars interaticularis fractures
 Anterior dislocation of C2 vertebral body

2) Extension Teardrop Fracture

3) Hyperextension in preexisting spondylosis

'Open mouth fracture' = widening of the anterior part of the disc +
narrowing of the posterior part of the disc
± Spinal cord edema

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Atlantoaxial instability
Type I: rotation about dens without translation.
Type II: rotation and anterior translation 3-5 mm.
Type III: rotation and anterior translation more than 5 mm
Type IV: posterior dislocation of C1 behind dens (rare, fatal).

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 ii. Thoraco-Lumbar Injury
Classification:

Denis => 3 Column Classification

Spinal stability is dependent on at least two intact columns.

When two of the three columns are disrupted => Instability.

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1) Morphology

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 2) Posterior Ligamentous Complex

CT features:
 Widening of the interspinous space.
 Avulsion fractures or transverse fractures of spinous processes
 Widening or dislocation of facet joints.
 Vertebral body translation or rotation.
MRI features:
Definite: 3 points
Loss of normal low signal intensity of the ligamenta flava or
supraspinous ligaments on T1 and T2.
Indeterminate: 2 points
Edema without clear rupture; high signal intensity of the interspinous
ligaments or along the facet joints on T2 SPIR or STIR.

3) Neurological status:

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 iii. Soft Tissue Injury
Muscle strain.
Spinal cord compressive myelopathy / edema / contusion / Transection /
Syrinx / Herniation.
Epidural-subdural hematoma.
Meninges (pseudo meningeocele).
Vessels (dissection, thrombosis, tear, pseudo aneurysm, AV fistula).
Prevertebral soft tissue.

Vertebral Artery Dissection

Coronal MRA => Diffuse Narrowing Axial T1 FS => crescentic
of vertebral artery hyperintense intramural hematoma
+ significantly narrowed flow voids
(arrows).

Spinal Cord Contusion

Imaging findings:
Ill defined intramedullary zone
T1: Low signal
T2/STIR: High signal
+C: No enhancement
T2*: Susceptibility artifact

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 Vertebral Compression Fracture
Benign Malignant
Non-neoplastic: Metastasis
Osteoporosis (and its causes) Multiple myeloma /plasmacytoma
Trauma
Infection Lymphoma
Paget's disease (lytic phase) Leukemia
Sheuermann’s disease. Langerhans cell histocytosis
Sickle cell anaemia
Congenital non-fractural vertebral
deformities

Benign Tumors:
Haemangioma
Giant cell tumour
Aneurysmal bone cyst
Grading of Vertebral Collapse:
Grade 1: height loss < 25% of original height
Grade 2: height loss 25% - 50%
Grade 3: height loss 50% - 75%
Grade4: height loss > 75%
Fracture Patterns
(a) Normal vertebral body

(b) Wedge fracture

(c) Biconcave fracture

(d) Crush fracture

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Osteoporotic Vertebral Collapse

Acute / Subacute Stage (<3m):

Edema and hemorrhage obscures the normal fatty marrow within the
vertebral body
Edema & fluid signal:
T1 WI: Hypointense
T2WI : Isointense to hyperintense
STIR: Hyperintense
+C: Marked diffuse homogeneous or
patchy heterogeneous enhance.
Fracture line:
Single horizontal line // Endplate
Non-enhancing low signal line on T1
& T2 surrounded by marrow edema
Intravertebral Vacuum Cleft Sign Intra-vertebral fluid sign:
Plain X-ray: radiolucent, linear, and T1: Low signal
horizontally oriented T2 WI & STIR: markedly
All pulse sequences: Low SI (signal void) hyperintense (equivalent to
GRE: Magnetic susceptibility effects that of CSF)

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 Patterns of edema signal:

 Band like signal:

Considered specific for osteoporotic collapse.
Most prominent adjacent to fracture line &
gradually dissipates towards opposite endplate
Partial preservation of normal fat marrow.
 Diffuse signal:
Homogenous / Heterogeneous
Posterior vertebral body cortex:
 Preserved normal concave posterior cortex
 Retropulsion = Posterior-angulated fragment of the postero-superior or
postero-inferior vertebral body is highly characteristic of benign collapse
Paraspinal mass:
Thin circumferential paraspinal soft tissue rim.
Epidural mass:
Epidural extension is rare.
Chronic benign fractures
Within 3 months => Normal conversion back to fatty marrow.
T1: linear hypointense horizontal signal may persist, representing compact
bone and/or marrow replacement by fibrosis
T2: Return of SI from hyperintense to isointense is strong evidence of a
nonmalignant collapse

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 Vertebral Compression #
Acute Benign Malignant
Pattern  Fracture line  Diffuse homogenous
 Band like edema signal  Diffuse heterogeneous
 Intra-verteberal vacuum  Salt & pepper
cleft sign (micronodular)
 Intra-verteberal fluid sign  Multifocal patchy areas
Chronic (3m) Restoration of normal fatty Signal intensity remain
marrow by time unchanged or progress
Posterior  Preserved concave Posterior vertebral body
vertebral  Retropulsion = Posterior- convexity
body cortex superior angulated
fragment
Pedicle - +++
Paraspinal Thin circumferential rim +++
mass
Epidural _ +++
mass
T1+C FS Homogenous / heterogonous enhancement
It can’t be relied upon to distinguish
osteoporotic from metastatic fracture.
DWI Iso – Low signal High signal
ADC High signal Low signal
Chemical Edema & hemorrhage on-top Replacement of normal fatty
Shift MRI of normal fatty marrow => marrow by tumor tissue =>
suppression of signal on out of No suppression of signal on out
phase images of phase images

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 B. Degenerative Spine Disease
Northamerican Society of Spine (NASS), American Society of Spinal Radiology (ASSR)
and American Society of Neurorradiology (ASNR) => Disc Classificatoin:
A) Normal intervertebral disk.
B) Congenital or developmental disc alteration.
C) Traumatic/degenerative disc pathology:
1) Annular tear
2) Disc Degenerative:
i. Spondylosis deformans.
ii. Intervertebral osteochondroses.
3) Disc Herniation: Protrusion - Extrusion
D) Infectious/Inflammatory.
E) Neoplastic.
F) Morphological variant of uncertain significance.
Normal Disc
Nucleus pulposus:
Central high T2 signal
Anulus fibrosus:
Peripheral low T2 signal
Hyaline cartilage (vertebral side)
Fibrocartilage

Congenital or Developmental Disc Alterations

include both the congenital abnormal discs and morphological changes
secondary to adaptation to abnormal growth of the spine (scoliosis,
spondylolisthesis).
Annular Tear

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Degenrative Spine Disease (DSD) = Spondylosis
Disc Degeneration:
Result from replacement of the hydrophilic glycosaminoglycans
within the nucleus polposus with fibrocartilage
 High T2 signal = Spondylosis Deformans
 Disc height = Intervertebral Osteocondroses
Intra-discal gas = Vaccum phenomena
Vertebral endplate degeneration:
Modic Vertebral endplate marrow degenerative changes
Type I marrow edema Low signal T1+ high signal T2
Type II fatty conversion High signal T1+ Low signal T2
Type III bone sclerosis Low signal T1+ Low signal T2
Osteophytes (Anterior ± Posterior)
Erosive osteochondrosis
Ligamentum flavum: Hypertrophy / Calcification / Ossification
Facet joint arthropathy: Narrowing of joint space – Hypertrophy –
Osteophytes – Synovial cyst
Spondylosis Deformans = Loss of Intervertebral Osteocondroses =
high T2 signal + Preserved height Loss of high T2 signal + decreased
disc height

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Sequale of degenrative Disease
1) Disc Bulge / Herniation
2) Stenosis: Spinal canal / Lateral neural recess / Neural foramen
3) Instability = Spondylolisthesis
 Disc Bulge
Disc material 'circumferential' displacement (50-100%) beyond the edges of
the ring apophyses
Symmetrical Disc Bulge Asymmetrical disc bulge

 Disc Herniation
Disc material displacement (< 50%) of the disc circumference.
Direction of disc herniation
Posterior => Intraspinal Cephalocaudal => Schmorl’s nodule
Anterior => Elevates anterior Intravertberal disc herniation =>
longitudinal ligament Limbus vertberae
Focal Disc Herniation Broad Based Disc Herniation
<25% of the disc circumference 25-50% of the disc circumference

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 Disc Protrusion Disc Extrusion
Distance between the edges of the Distance between the edges of the
disc herniation < distance between disc herniation > distance between
the edges of the base. the edges of the base.

Disc Migration Disc Sequestration

Displacement of disc material away from Displaced disc material has lost
the site of extrusion, regardless of completely any continuity with the
whether sequestrated or not. parent disc

 Axial localization of herniated disc

Central: Since PLL (posterior longitudinal ligament) is thickest in this region,
the disc usually herniates slightly to the left or right of this central zone.
Paracentral or lateral recess: most common.
Foraminal: disc to herniate into the intervertebral foramen.
Extraforaminal or lateral: Disc herniations in this region are uncommon.

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  Levels of Nerve Compression
1) Lateral neural recess
2) Neural foramen
3) Extra-foraminal
4) Spinal canal
1) Lateral Neural Recess Stenosis
Caused by
a) Paracentral disc herniation
b) Ligamentum flavum hypertrophy
c) Facetal arthropathy
d) Synovial cyst
Left paracentral disc herniation is seen comressing the left nerve root in
its lateral rtecess

Right synovial cyst is seen compressing the right nerve root in its lateral
recess.

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 2) Neural Foramen Stenosis
Caused by:
a. Foraminal disc herniation with upward migration
b. Facet arthropathy
c. Spondylolisthesis

3) Extraforaminal Nerve Compression

Lateral disc herniation compresses the extraforaminal part of the nerve.

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 4) Spinal Canal Stenosis
sagittal mid-diameter of the spinal canal
< 13mm => Relative stenosis
< 11mm => Absolute stenosis
Causes:
Most common => Degenerative:
1) Bilateral facet arthrosis / Synovial cyst
2) Disc bulge
3) Ligamentum flavum hypertrophy
4) Spondylolisthesis
Less common
 Congenital / Developmental: Short thick pedicles - Thick laminae - Large
articular facets - Narrow inter-laminar angle
 Trauma: Spinal injury and epidural hematoma
 Infection: Spondylodiscitis or epidural abscess
 Neoplastic: Bone tumors
Location: Lumbar is most common site
Axial Image => Trefoil appearance of lumbar spinal canal

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  Spondylolisthesis
Slippage of vertebrae anteriorly or posteriorly relative to one below
Anterior = Anterolisthesis
Posterior = Retrolisthesis
Causes:
1) Degenerative => Facetal arthropathy with sliding of the facets.
2) Isthmic = Lytic = Spondylolysis => Pars interarticularis break
3) Congenital
4) Post-traumatic
5) Pathological
6) Iatrogenic
Grading:
Grade I: 0-25%
Grade II: 26-50%
Grade III: 51-75%
Grade IV: 76-100%
Grade V: >100%

Post-operative Complications = Failed Back Syndrome

1. Scar tissue (epidural and perineural scar tissue enhances after contrast
injection)
2. Recurrent disc herniation
3. Lateral neural recess / neural foramen stenosis
4. Diskitis
5. Arachnoiditis (adhesion between the quada equina nerve roots)
6. Epidural abscess or hematoma
7. Pseudomeningocele

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Facetal Arthropathy
Degenerative facet joint disease
Imaging Findings:
 Osseous facet overgrowth => "Mushroom cap" facet appearance
 Narrowed joint space + Intra-articular gas ("vacuum phenomenon")
 Irregular articular surface + Marginal osteophytes
 Foraminal compromise

Facet Joint Synovial Cyst

Synovial cyst formed from degenerative facet joint
Location: Lumbar spine (L4/5 = 70 – 80%)
A well-defined postero-lateral extradural cyst
 Communicating with the facet joint
 Encroaching on the lateral neural recess
 Exerts mass effect on the posterolateral aspect of the thecal sac
Imaging findings:
Content of the cyst:
Clear fluid (Low T1 & High T2)
High proteinaceous content / Hemorrhage (High T1 & Low T2)
Surrounded by low signal rim

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Schmorl’s Node
Craniocaudal intravertebral disc herniation
Age: Adolescents and young adults
Sex: M > F
Location: T-8 to L1 region most common
Imaging findings:
Well defined focal defect in the vertebral endplate filled by disc
Well corticated margins
Adjacent bone marrow: Low T1+High T2/STIR + Enhancement (Acute phase)

Scheurmann Disease
Juvenile thoracic kyphosis
Multiple Schmorl nodes => Vertebral body wedging => Kyphosis
Undulation of endplates secondary to extensive disc invaginations
Disc spaces narrowed, with greatest narrowing anteriorly
> 3 levels

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Limbus Vertebrae
Caused by herniation of a portion of the nucleus pulposus underneath the
ring apophysis before its fusion to the body => Ring apophysis stays
separate from the main body
Location:
Most commonly affects the antero-superior corner of vertebral body.
Seen mostly in mid-lumbar spine
Imaging Findings:
Triangular fragment of bone at antero-superior corner of a vertebral body
Sclerotic margins to fragment
Sclerotic margin of adjacent vertebral body

Nuclear Impression
Notochord persistance
Smooth concave defect at posterior
1/3 of the vertebral body
No clinical significance

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DISH = Diffuse idiopathic skeletal hyperostosis
Common condition characterized by enthesopathy = bone proliferation at
sites of tendinous and ligamentous insertion of the spine
Age = Elderly patients (>50y).
Location: cervical and thoracic spine
Imaging Features:
 Florid, flowing ossification of anterior longitudinal ligament along the
anterior or anterolateral aspects of at least four contiguous vertebrae
 Preserved disc spaces
 No sacroiliitis or facet joint ankylosis
Associations:
Enthesopathies => “Whiskering” at the sites of tendinous insertion:
o Pelvic involvement
 Iliac crests
 Ischial tuberosities
 Iliolumbar ligaments
 Lesser trochanter
o Deltoid tuberosities of humerus
o Olecranon spurs
Ossification of the
 Achilles tendon
 Plantar aponeurosis
 Triceps tendon

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OPLL = Ossification of Posterior Longitudinal Ligament
Elderly males
Location: Midcervical (C3-C5) > mid-thoracic (T4-T7)
Sagittal image => Posterior flowing ossification extending over multi-levels
Axial image => Characteristic "upside down T" or "bowtie" configuration

Ossification of Legamentum Flavum

Pathogenesis: Hydroxyapatite (HAD) or calcium pyrophosphate deposition
(CPPD) in ligament => calcification, ossification
Thin curvilinear "calcification" ventral to lamina
"V-shape" on axial images

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Baastrup Syndrome
Results from adjacent spinous processes in the lumbar spine rubbing
against each other and resulting in focal midline pain and tenderness
relieved by flexion and aggravated by extension
=> kissing spines = Close contact of adjacent spinous processes
=> Enlargement, flattening and reactive sclerosis of apposing interspinous
surfaces.
=> Interspinous bursa formation => Postero-central epidural cyst =>
Posterior compression of the thecal sac

Bertolotti’s Syndrome
Lumbosacral transitional vertebrae (LSTV) + Low back pain in young people
1) L4/5 disk, spinal canal, and posterior element pathology
2) Degeneration of anomalous articulation between LSTV and sacrum
3) Facet joint arthrosis contralateral to unilateral fused or articulating LSTV
4) Extraforaminal stenosis secondary to broadened transverse process

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 C. Infectious Spondylitis & Discitis
An infection of one or more components of the spine:
 Vertebrae
 Intervertebral discs
 Paraspinal soft tissues
 Epidural space
Causative Organism
Pyogenic Granulomatous
Staphylococcus aureus (80%) Tuberculosis
Streptococcus Fungi (Histoplasmosis, Aspergillosis),
Pseudomonas Leprosy
Escherichia coli Parasites
Salmonella: in patients with
sickle cell anemia.
Predisposing factors:
o Chronic medial illness:
o Diabetes mellitus
o Liver cirrhosis
o kidney failure
o Intravenous drug abuse
o Conditions that suppress the immune system.
o Post-traumatic
o Post-operative
o Post-spinal intervention
Route of infection
1. Hematogenous dissemination from extraspinal focus of infection
2. Mucous/cutaneous source
3. Contiguous spread from adjacent abscess
4. Direct inoculation through trauma or interventional procedures

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 1) Pyogenic Spondylodiscitis:
Age: 5th – 6th decade
Sex: M:F = 2:1
Causative organism:
o Staphylococcus aureus (80%)
o Streptococcus – Pseudomonas - Escherichia coli
o Salmonella: in patients with sickle cell anemia.
Predisposing factors:
 History of recent primary infection: Urinary- Respiratory-Skin infection.
 Instrumentation (catheterization, cystoscopy).
 Diagnostic (myelography, discography), therapeutic (irradiation), or
surgical procedures (bowel, urinary, or back surgery).
 Immunocompromised patients
Routes of infection:
1) Hematogenous spread (arterial and venous).
2) Spread through a contiguous source of infection.
3) Direct implantation.
4) Post-operative infection
Site: L > T > C
MRI Disc Opposing Vertebral endplate
Narrowing of disc Irregularity of vertebral endplate
T1 Low signal Low signal
T2 High signal High signal
+C Peripheral enhancement Patchy enhancement

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 2) Tuberculous Spondylodiscitis / Spondylitis

Causative organism: Mycobacterium TB

Mode of infection: Hematogenous spread from 1ry in lung or GU system
Site: Thoracolumbar junction: most frequent site
Patterns of vertebral involvement:
a) Paradiscal = Endplate = Subchondral:
It is the most common pattern of spinal T.B.
It is adjacent to intervertebral disc leading to narrowing of disc space.
It is either caused by destruction of subchondral bone or by direct
involvement of the disc.
b) Anterior = subperiosteal = Subligamentous:
Pus spreads over multiple vertebral segments, stripping the periosteum
& anterior longitudinal ligament from anterior surface of vertebral bodies
with preserved discs.
c) Central:
Centered on vertebral body
Disc is not involved → can’t be distinguished from Mets or lymphoma.
Vertebral collapse → vertebra plana appearance
d) Posterior element = Adenexal:
Rare
Bone erosion + associated abscess
Imaging features:
 Vertebral body destruction & fusion => Gibbus deformity
 Vertebrae: areas of abnormal bone marrow signal (low T1 & High T2)
 Spread of infection to adjacent vertebrae through disc affection
 Spread of infection to distant vertebrae through subligamntous spread +
Skip normal regions
 Paravertebral soft tissue lesion / Psoas abscess
 Epidural abscess / granulation tissue
 Spinal cord compression by:
o Vertebral body collapse / Sublaxation / Dislocation
o Epidural pus & granulation tissue.

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 Pyogenic TB
Rapidly progressive Slower
Less collapse Marked collapse
Paravertebral abscess Small / No +++
Epidural abscess Small / No +++
Subligamentous spread No +++

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 3) Brucellosis
Incidence: Endemic in midevest US
Aetiology:
Ingestion of unpasteurized milk => Organism penetrate lymphatics from
GIT → RES => Granulomatous inflammatory reaction as T.B.
Brucellosis TB
Site Lower lumber Thoracolumber
Vertebrae Preserved height Destruction / Collapse
Disc Preserved Destroyed
Deformity Rare Gibbus deformity
Paraspinal Rare +++
abscess
Epidural Rare +++
abscess
Subligamentous Rare +++
spread

4) Aspergillus-induced Spondylitis
Saprophytic fungus in immunocompromised patients.
Spinal osteomyelitis, discitis low signal on T2 and STIR
Similar to the proposed mechanism for signal hypointensity in fungal
sinusitis

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 5) Actinomycosis
Anaerobic organism found normally in mouth flora
Disseminates from oral cavity in immunocompromised patients => Bones of
mandible + Spine + Ribs => Sinus tract formation
6) Hydatid
The thoracic spine is most common
Multiloculated , multiseptated T2WI hyperontense ( bunch of grapes )
No enhancement
Disc is spared

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Septic Facetal Arthritis
Rare
97% Lumbar region
Unilateral
Single level
Aetiology:
 Staphylococcus aureus most common
 Bacteremia from an extra-spinal primary source
Imaging findings:
Inflammatory changes in the facet joint
Bone erosions of the opposing articular surfaces of the facet joint
Subchondral bone marrow edema
Paraspinal soft tissue inflammation / edema / enhancement / abscess
Intraspinal epidural inflammation / edema / enhancement / abscess

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Epidural Abscess / Empyema
Aetiology: Hematogenous spread 2ry to infection from septic focus.
Phlegmon stage: thickened inflamed with granulation tissue & embedded
microabscesses.
Abscess stage: collection of pus.
Imaging findings:
Intraspinal extradural lesion => Blockage of normal CSF flow
± Associated spondylodiscitis
T1: Low signal
T2: High signal
+C:
Phlegmon => Diffuse enhancement
Abscess => Marginal enhancement

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Subdural Abscess / Empyema
Intradural extramedullary ring-enhancing fluid collection on
Location: Thoracolumbar region most common
Causative organism: Staphylococcus aureus most common
T1: Low signal
T2: High signal
+C:
Phlegmon => Diffuse enhancement
Abscess => Marginal enhancement
Sagittal T1+C FS Axial T2 Axial T1+C FS

Paraspinal Abscess
Location => Periverteberal space: Imaging Features:
 Prevertebral space T1: Low signal
 Paravertebral soft tissue T2: High signal
• Psoas +C:
• Iliacus Phlegmon => Diffuse enhancement
• Posterior paraspinous ms Abscess => Marginal enhancement

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 D. Vertebral Tumors
Classification of vertebral tumors by Location:
Anterior = Vertebral Body Posterior = Neural arch
Single Multiple Single Multiple
Hemangioma Hemangioma ABC Metastasis
Bone islands Bone islands Osteoblastoma
Chordoma Metastasis Osteoid osteoma
Giant cell tumor Multiple Myeloma Osteochondroma
Osteosarcoma Lymphoma
Ewing sarcoma Leukemia
LCH
Paget
Plasmacytoma

Classification of spinal tumors by Tissue of origin:

DD: Ivory Vertebrae

Children Adults
Lymphoma Paget
1ry Osteosarcoma 2ry Osteosarcoma
Osteoblastic Metastasis Osteoblastic metastasis

52
Hemangioma
Most common spinal tumor.
F>M
L & D > C & S spine. Multiple in about 1/3 of cases.
Dilated, blood-filled, vascular spaces in a stroma containing large amounts
of adipose tissue
X-ray: "Corduroy sign" Axial CT: “polka-dot” appearance=
Sparse, thickened bone trabeculae

MRI => 2 patterns:

a) Large proportion of fat => b) Large proportion of vessels +
High T1 + High T2 edema => Low T1 + High T2

Aggressive Hemangioma:
Hemangioma extending into the pedicles and posterior elements, causing
expansion and breaking through the vertebral wall into the epidural space.
During pregnancy

53
Aneurysmal Bone Cyst
Benign expansile bone lesion
Age: Young patients 80% < 20 years of age
D>L>C>S
Posterior elements are most commonly affected.
Expansion into the vertebral body
Imaging Findings:
Well defined expansile lytic lesion
Blood filled cystic spaces with fluid / fluid level
MRI: Variable signal
+C: No / Marginal enhancement

Giant Cell Tumor

The spine is the 4th most common location of GCT.
Sacrum>D>L>C spine
Usually affects the vertebral body.
Expansile lytic lesion.
Extension into the posterior elements and paraspinal soft tissues and
associated vertebral collapse are often apparent.
No involvement of the adjacent intervertebral disks and vertebrae
No evidence of mineralized matrix.
54
Vertebral Chordoma
Rare low grade malignant tumor Location:
Arise from notochordal remnants Sacrococcygeal (60%)
Age: Adults > 30y Sphenooccipital (25%)
Spine (especially C2) (15%)
Radiological Features: CT: Amorphous calcifications.
Vertebral body expansile / T1: Low signal + areas of hemorrhage
destruction / erosion / remodeling. T2: very high signal (Bubbly-like) +
Epidural + perivertberal soft tissue Cord edema
components => +C: Moderate heterogeneous
“collar button” or “mushroom” enhancement
appearance and a “dumbbell” shape

55
  Osteogenic Lesions
1) Enostosis (Bone Island)
14% in spine
Frequently involve the periphery of the
vertebral bodies
Spare the central area
MRI => Low signal on all pulse sequences

2) Osteoid Osteoma
Age: 2nd and 3rd decades
Sex: M>F 2–3:1.
Benign osteoblastic lesion
L > T > C > S.
Postrerior neural arch
Nidus of osteoid tissue < 1.5cm
surrounded by sclerotic reactive bone
surrounded by bone marrow edema
+ve bone scintigraphy
3) Osteoblastoma
Age = 2nd and 3rd decades
M > F = 2:1.
Originate in the posterior neural arch
Locally aggressive => Extend to the vertebral body
Lesion > 2cm
Osseous expansion
Soft-tissue components + Multifocal calcified / ossified matrix

56
 4) Osteosarcoma
4% of all osteosarcomas involve the spine
2ry Osteosarcoma:
Peak prevalence occurs during the 4th decade of life.
Radiation therapy and Paget disease
Sclerosing osteoblastic OS
Matrix mineralization
Ivory vertebrae
Telangiectatic OS
Fluid filled hemorrhagic cystic spaces
Thick, solid nodular tissue surrounding the cystic spaces
Matrix mineralization
More aggressive growth pattern

 Cartilage Forming Tumors

1) Osteochondroma
M> F
Solitary – Sporadic
C>T&L
Atlantoaxial region
Posterior neural arch
Tip of spinous or transverse process
Central area => Cancellous bone =>
Fatty marrow (high T1&T2)
Peripheral rim => Cortical bone =>
Low signal rim
Thin cartilaginous cap < 1cm
2) Chondroblastoma
Chondroblastoma is a benign cartilaginous tumor
Young adults
Involves vertebral body and posterior arch
Chondroid matrix

57
 3) Chondrosarcoma
nd
2 most common primary malignant tumor of the spine in adults
Age = 30-70y
Vertebral body (15%), posterior element (40%), or both (45%)
Large destructive mass
Chondroid matrix

58
Hematopoietic, Reticuloendothelial, Lymphatic Tumors
1) Eosinophilic Granuloma
Children (5-10Y).
D> L & C spine
Complete or incomplete vertebral
collapse => Vertebra plana
Preservation of adjacent
intervertebral disc.

2) PLASMACYTOMA
A solitary bone plasmacytoma (SBP) may involve any bone, but it has a
predisposition for the red marrow - containing axial skeleton.
Age: 4th to 6th decades
Sex: M > F
Imaging Findings:
Solitary expansile lytic lesion
Thinning and destruction of cortex
Bubbly/trabeculated appearance
'Mini-brain' appearance = curvilinear low signal areas within lesion
‘Soap-bubble’ appearance = multicystic purely lytic lesion
T1 : hypo- to isointense
T2 : iso- to hyperintense to muscle
T1 C+ : variable enhancement

59
 3) Lymphoma
A) Primary:
Originates in bone with no evidence of disease elsewhere for at least 6
months after diagnosis
< 5% of all malignant bone tumours, 93% older than 20 years
B) Secondary:
spread through haematogenous dissemination from nodal disease
(majority of cases)
Patterns:
 Epidural lymphoma: enhancing epidural mass
 Osseous lymphoma: bone destruction (“ivory vertebra”, rare)
 Leptomeningeal lymphoma: smooth nodular pial enhancement.
 Intramedullary lymphoma: poorly defined enhancing mass.
Plain X-ray:
Sclerotic (Ivory vertebra) > Mixed lytic and sclerotic > Lytic pattern
MRI:
T1: Low signal
T2: Variable signal
+C: Homogenous contrast enhancement
Epidural Lymphoma Vertebral Lymphoma Intramedullary Lymphoma

4) LEUKEMIA
Leukemia is the most common malignancy in childhood
Plain X-ray: Multiple compression fractures
MRI:
T1: Low signal
T2: High signal
+C: Abnormal enhancement

60
Sickle Cell Anaemia
Hereditary (autosomal recessive) haemoglobin abnormality resulting in
anemia, deformed (sickle) red cells which occlude blood vessels.
Imaging Features:
Hematopoietic marrow:
T1: Low signal
T2: Intermediate signal

Paget’s Disease (Osteitis Deformans)

chronic metabolic disorder of abnormal bone remodelling in adult skeleton,
in which there is overactive osteoclasts and osteoblasts
Sex: Males > females.
Age > 55 y.
3 phases:
1. Active osteolyic phase
2. Mixed blastic lytic phase
3. Inactive quiescent phase
X-ray:
 “Picture frame” vertebra: coarse and sclerotic peripheral trabecular
pattern and central osteopenia.
 Ivory vertebra
MRI Features:
A) Fibrovascular marrow in active phase:
T1: Heterogenous predominantly hypointense
T2: Hyperintense.
T1+C: Post-gadolinium enhancement

B) Fatty marrow in mixed phase:

T1 & T2: Hyperintense

61
Metastatic Disease
Metastases are the most common vertebral tumors
Osteolytic Metastasis Osteoblastic Metastasis
Bronchogenic Prostate carcinoma
Breast Breast cancer
Thyroid Lymphoma
kidney carcinoid tumors
Colon Mucinous adenocarcinoma
Neuroblastoma (in childhood) Pancreatic adenocarcinoma
Bladder carcinoma,
Neuroblastoma,
MULTIPLE MYELOMA
A malignant plasma cell disorder that usually affects the bone marrow.
Most common primary bone tumor
10% of hematologic malignancies.
The hallmark of MM is the detection in blood and/or urine of a monoclonal
protein (M protein) produced by the abnormal plasma cells
Ages : 40 – 80y Location:
Sex: M > F 1. Vertebrae in 66% of patients.
2. Ribs (45%)
3. Skull (40%)
4. Shoulder (40%)
5. Pelvis (30%)
6. Long bones (25%)

Patterns of Infiltration:
1) MRI may be normal
2) Focal (Multifocal ) lesions
3) “Salt and pepper” = Micronodular
4) Diffuse homogenous
5) Diffuse heterogeneous

62
Diffuse Homogenous marrow involvement
T1: diffuse STIR: diffuse +C: diffuse
homogenous low Homogenous high homogenous
signal signal enhancement

Diffuse Heterogeneous marrow involvement

T1 & T2: diffuse heterogeneous areas of low and +C: Heterogeneous
high signal enhancement

63
Salt-and-pepper pattern:
T1: Micronodular foci STIR: Microndular foci +C: Micronodular
of low signal of high signal enhancing foci

Focal (Multifocal ) lesions

T1: Multifocal patchy STIR: Multifocal patchy +C: Multifocal patchy
areas of Low signal areas of high signal areas of
heterogeneous enh

64
 E. Epidural Space Lesions
 NON Enhancing Lesions
1) Epidural Hematoma
Extravasation of blood into the epidural compartment of the spine.
Etiology
 Spontaneous in 1/3: Pressure elevation in vertebral venous plexus
 Instrumentation: Epidural anesthetic - Nerve block - Facet joint injection
- Lumbar puncture
 Spinal vascular malformation
Imaging features:
Eccentric, multilocular or inhomogeneous multi segmental collection.
Encasing or displacing cord or cauda equine.
MR signal depends on age
+C: NO / marginal enhancement

65
 2) Epidural Abscess / Empyema
Aetiology: Hematogenous spread 2ry to infection from septic focus.
Phlegmon stage: thickened inflamed with granulation tissue & embedded
microabscesses.
Abscess stage: collection of pus.
Imaging findings:
Intraspinal extradural lesion => Blockage of normal CSF flow
± Associated spondylodiscitis
T1: Low signal
T2: High signal
+C:
Phlegmon => Diffuse enhancement
Abscess => Marginal enhancement

3) Epidural Lipomatosis
Abundant epidural fat in mid-thoracic and distal lumbar spinal canal
 Association with long term exogenous epidural steroid injection
 Excessive endogenous steroid production
• Cushing disease
• Hypothyroidism
• General obesity
• Idiopathic

66
 4) Epidural Arachnoid Cyst
MRI: CSF like signal
+C: No enhancement
DWI: Facilitated diffusion

5) Disc Sequestration
Displaced disc material has lost completely any continuity with the parent
disc

67
 6) OPLL = Ossification Posterior Longitudinal Ligament
Elderly males
Location: Midcervical (C3-C5) > mid-thoracic (T4-T7)
Sagittal image => Posterior flowing ossification extending over multi-levels
Axial image => Characteristic "upside down T" or "bowtie" configuration

7) Ossification of Legamentum Flavum

Pathogenesis: Hydroxyapatite (HAD) or calcium pyrophosphate deposition
(CPPD) in ligament => calcification, ossification
Thin curvilinear "calcification" ventral to lamina
"V-shape" on axial images

68
Hirayama Disease
The cord is markedly thinned and demonstrates high T2 signal between
C5/6 and C6/7 and consistent with myelomalacia.
In neutral position: The canal is capacious + No cord compression is present
In flexion position:
The posterior wall of the dural canal displaces anteriorly from C5 to T2
Epidural space filling with intermediate to high T2 signal material (thought
to represent engorged epidural venous plexus).

Idiopathic Spinal Cord Herniation

Herniation of the cord (arrow) through a ventral dural defect into the right
anterior epidural space.
Continuous CSF flow is seen within the dorsal subarachnoid space (white
arrowhead).

69
 II. Spinal Intradural Extramedullary Lesions
Benign Tumours
 Spinal Schwannoma (1st common 30%)
 Spinal Meningioma (2nd common 25%)
 Spinal Neurofibroma
 Spinal Paraganglioma
 Myxopapillary Ependymoma
Malignant Tumours
 Spinal leptomeningeal metastases
Cysts And Benign Tumour-like Lesions:
 Lipoma
 Epidermoid Cyst
 Dermoid Cyst
 Neuroenteric Cyst
 Arachnoid Cyst
 Cystic Schwannoma
 Subdural Empyema
Spinal Vascular Malformations

70
 Spinal Schwannoma Spinal Meningioma Spinal Neurofibroma
A. Spinal Subdural Extramedullary Tumors

1st most common 2nd most common

Benign tumor arising from the Benign tumor of the meninges. Benign peripheral nerve tumor
Schwann cells of the nerve
sheath. Age: Middle age group Age: Middle age
Sex: F > M M=F
NF-II = Schwannoma + Meningioma + Ependymoma Multiple => NF-I
Sausage shaped = align along Well defined hemispherical 3 types:
axis of the cord + extend over meningeal based lesion Localized > Diffuse – Plexiform

71
several levels. Rare foraminal extension
Dumbbell shape = extend along
the neural foramen Well defined dumbbell shape
CT: Hypodense CT: Hyperdense +/- calcifications X-ray/CT:
T1: Low signal T1: Iso -Low signal Enlarged neural foramen
T2: High signal +/- Cystic changes T2: Iso - High signal Thinning of pedicle
+C: Moderate heterogeneous +C: Moderate Homogenous Posterior scalloping of VB
enhancement + enhancement + Meningeal tail T1: Low signal
+ Non-enhancing cystic T2: Target sign = Peripheral high
component + Central low signal
+C: Heterogeneous / Target
Spinal Schwannoma
Well defined intraspinal subdural extramedullary lesion
Sausage shaped lesion
T2: High signal + +C: Moderate heterogeneous enhancement
Cystic changes + Non-enhancing cystic component

Spinal Meningioma
Well defined intraspinal subdural extramedullary lesion
Hemispherical dural based lesion
No foraminal extension
T2: Iso - High signal +C: Moderate Homogenous enhancement
+ Meningeal tail

72
NF-I
Well defined dumbbell shape lesions
Intradural 75%
Extradural 15%
Dumbbell 15%
Imaging Findings:
Enlarged neural foramen
Thinning of pedicle
Posterior scalloping of VB
T1: Low signal
T2: Target sign = Peripheral high + Central low signal
+C: Heterogeneous / Target

73
Intradural Spinal Capillary Hemangioma
Rare benign vascular tumor
Imaging findings:
T1: Low signal
T2: Very high signal
+C: Homogenous enhancement

74
 B. Spinal Subdural Extramedullary
Cyst & Tumor Like Lesions
Lipoma
Epidermoid Cyst
Dermoid Cyst
Neurenteric Cyst
Arachnoid Cyst
Subdural Empyema

Intradural Spinal Lipoma

T1: High signal T2: High signal STIR: Loss of T1+C FS: No enh
signal

Spinal Epidermoid Cyst

Non neoplastic epithelial inclusion lesion
Pathology: Filled with desquamated cells and keratinceous debris
Location: Intradural extramedullary
Imaging findings:
T1: Low signal
T2: High signal
+C: No enhancement
FLAIR: mild high signal
DWI: Distinguishes epidermoid (hyperintense) from arachnoid cyst
(isointense to CSF)

75
Spinal Dermoid Cyst
Congenital or acquired ectodermal midline inclusion cystic lesion tumors.
20% of all intradural tumors seen during the first year of life.
20% of those lesions are associated with a dermal sinus tract.
Pathology: Filled with = Lipid + Cholesterol + Desquamated cells
Location: Intradural extramedullary – Lumbosacaral region
Complication:
Dermoids and epidermoids => Rupture => Chemical meningitis.
Imaging findings:
Well defined spherical / multilobulated lesion
Midline / near midline
T1: High signal T1+C FS: Loss of the high signal
No enhancement

76
  Arachnoid / Meningeal Cysts
Type I = Extradural + No Nerve Root
Type IA: Arachnoid cyst
Type IB: Meningeal cyst
Type II = Extradural + Nerve Root involved
Tarlov cyst
Type III = Intradural Arachnoid Cyst
Type I = Intraspinal Extradural Arachnoid cyst

Type IB = Sacral Meningocele

77
Type IB = Traumatic Pseudomeningocele.
arise after a severe traction injury.
The dura and arachnoid walls of the root sleeve are torn.
The enclosed nerve roots may or may not be torn

Type 2: Perineurial cysts or Tarlov cysts

Extradural Meningeal Cysts Containing Neural Tissue

Type III = Spinal Intradural Arachnoid Cyst

T1: Low signal T2 / STIR: high signal

78
  Dural Ectasia
Ballooning or widening of the dural sac especially in the lumbar region
which can result in posterior vertebral scalloping
associated with herniation of nerve root sleeves
Associations
 Marfan Syndrome
 Neurofibromatosis Type 1
 Ehlers-Danlos Syndrome
 Ankylosing Spondylitis
 Osteogenesis Imperfecta

79
 C. Leptomeningeal Enhancement
 Leptomeningeal Metastasis = Carcinomatosis meningitis:
A) Primary CNS neoplasm:
 PNET (Medulloblastoma)
 Ependymoma
 Choroid plexus papilloma / Ca
 Glioblastoma
B) Primary neoplasm outside CNS:
 Lung
 Melanoma
 Breast
 Leptomeningeal Infiltration:
 Lymphoma
 Leukemia
 Leptomeningeal Inflammation:
o Infections: Bacterial – Fungal - Viral meningitis
o Granulomatous: TB – Sarcoidosis
Myelography or CT / MRI Myelography → 4 Patterns:

 Nodular or plaque like deposits intimal related to conus & cauda equine
 Focal, discrete lumbosacral mass lesion
 Clumping & crowding of diffusely thickened lumber nerve roots
→Striated myelographic appearance
 Root sleeve obliteration.
MRI:

 Single or multiple nodular enhancing subarachnoid lesions

 Focal or diffuse abnormal subarachnoid enhancement along pial
surface of spinal cord.

80
81
 D. Spinal Vascular Lesions
Modified Classification of Spinal Vascular Lesions:
Spetzler et al; 2002
 Neoplastic Vascular lesions:
o Hemangioblastoma
o Cavernoma
 Spinal aneurysm
 AVF
o Extradural
o Intradural: Ventral - Dorsal
 AVM
o Extradural
o Intradural
 Intramedullary
 Compact
 Diffuse
 Conus medullaris
Spinal Hemangioblastomas
Intramedullary tumor and lie adjacent to the pial surface
Highly vascular lesions
The arteries and veins associated with a hemangioblastoma can enlarge
and simulate an AVM.
The syrinx associated with some intramedullary hemangioblastomas can
simulate an astrocytoma
T1: isointense
T2: Hyperintense + Multiple signal voids
T1+C: Intense enhancement
T2*: Low signal hemosiderin

82
Spinal Cavernoma
Rare: 5% of intramedullary lesions in adults, 1% in children
Subarachnoid hemorrhage is very rare
Imaging findings:
Well defined lobulated lesion
T1: Mixed high + low signal = popcorn
T2: Mixed high + low signal + Low signal hemosiderin rim
T2*: Blooming artifact
+C: No enhancement
Angio: Negative
No edema / No mass effect / No flow voids

Spinal Cord Aneurysm

Rare
Presented with subarachnoid hemorrhage and sudden-onset low-back pain

83
Spinal AVF & AVM
Type I: Dural AVF (most common)
Type II: Glomus AVMs
Type III: Juvenile AVMs
Type IV: Intradural AVF

Type I: Dural AVF (most common)

Radiculomeningeal Fistula
The most common type (60%)
Single AV connection within the dura of the nerve root sheath
Results in dilated arterialized coronal venous plexus
Mean age: 50y
Sex: M>>>F
Majority: thoracic and thoracolumbar
Imaging Findings:
Serpentine vessels on cord surface
Nidus in neural foramen shows focal enhancement
Arterial supply arises from dural branch of radicular artery
Venous drainage => Intradural veins => Cord pial veins
Enlarged cord + Flame like central edema

84
Type II (Glomus AVMs)
Tightly packed nidus of dysmorphic arteries and veins in direct
communication without capillary bed; over a short segment of spinal cord.
The nidus may be completely or partially intramedullary.
Location: Usually at the cervicothoracic junction
 Tl WI: Large cord, heterogeneous signal (blood products), flow voids
 T2WI: Cord hyperintense (edema, gliosis, ischemia) or mixed (blood)
 STIR :Shows flow voids, edema within cord
 T2* GRE: More sensitive to blood by products of AVM hemorrhage
 Tl C+: Variable enhancement of nidus, cord, vessels

Type III (Juvenile AVMs)

Intramedullary + Intradural + Extradural + may involve soft tissue and bone.
Large complex nidus, multiple feeding vessels; may be intramedullary and
extramedullary and even extraspinal

85
Type IV (Intradural AVF)
Direct connection between an intradural artery and vein in the
subarachnoid space without a definable nidus

86
 III. Spinal Intra-Medullary Lesions
= Non- Compressive Myleopathy
A. Demyelinating/Inflammatory: MS–ADEM–NMO–TM–SCD–Radiation–
Sarcoidosis.
B. Infection: Schistomiasis = Bilharziasis
C. Vascular: Infarction – Vasculitis – Vascular malformations
D. Tumors: Astrocytoma–Ependymoma–Hemangioblastoma–Metastasis.

87
 A. Inflammatory Causes of Myelopathy:
1) MS
2) ADEM
3) NMO = Neuromyelitis optica
4) ATM = Acute Transverse myelitis
5) SCD = Subacute Combined Degeneration
6) Radiation
 Short or long segment involvement
Short segment Long segment
MS Transverse myelitis
Neuromyelitis Optica
Vascular
SCD

 Location of involvement on Transverse image

MS => Triangular in shape dorsally or laterally
SCD => Dorsal parts
Ischemia => Anterior parts.
Transverse myelitis and Neuromyelitis optica => whole cord.

88
 1) Multiple sclerosis (MS)
 Most common demyelinating disease.
 Immune-mediated inflammatory demyelinating disease.
 F>> M. Middle age
 Brain lesions:
o Periventricular – Subcortical (U-fibers) – Centrum semiovale –
Corona radiate – Internal capsule.
o Cerebellar white matter – Temporal lobes – Corpus callosum –
Cerebellum – Brainstem.
o Dawson Fingers: Ovoid lesions perpendicular to the ventricles.
 Spinal cord lesions:
o Cervical cord is most commonly affected
o Short segment < 2vertberal segments
o <50% of cross section area of spinal cord
o Peripheral portion of the spinal cord
o Triangular shape
o Lateral – Dorsal

89
Spinal cord atrophy => Primary Diffuse abnormalities => primary and
progressive MS (PPMS) secondary progressive MS

2) Neuromyelitis Optica (NMO) = Devic Syndrome

Is autoimmune demyelinating disease
F >>> M
Diagnostic criteria:
 Optic neuritis
 Spinal lesions:
o Transverse myelitis > 3 segments
o Full transverse diameter
 No evidence of sarcoidosis, SLE or Sjogren syndrome
 No brain lesions.

90
 3) Acute Disseminated Encephalomyelitis (ADEM)
is an inflammatory demyelinating disease of the CNS
Post viral infection or vaccination (1 – 4 w).
Young children
Monophasic in 90%
Anti-MOG IgG test is positive and supports the diagnosis.

4) Subacute Comined Degenration = Vitamin B12 Defeciency

Vit B12 deficiency:
Malabsorption
Pernicious anemia - Gastric bypass
Strict vegetarians
Selective degeneration of the dorsal column &/or lateral spinal columns
T2 high signal of the posterior column
No enhancement

91
 5) Acute Transverse Myelitis (ATM) =
Viral / Idiopathic Transverse Myelitis
Acute inflammatory disorder of the spinal cord resulting in motor, sensory
and autonomic dysfunction.
M > F. Adult age group
Causes:
o Idiopathic
o Post – viral infection: HSV – herpes Zoster – CMV – EBV – Influenza.
o Post – vaccination: Rabies
o Systemic autoimmune disease / Collagen vascular disease eg: SLE –
Sarcoidosis – Sjogren syndrome
o Paraneoplastic syndrome
Spinal cord involvement:
o Thoracic spinal cord most common
o > 4 vertebral segments
o > 50% of cross sectional area of spinal cord.
o Central portion of spinal cord
o Whole cord involvement in transverse section
o Focal cord enlargement.

92
 6) Radiation Myelitis
Spinal cord shows intramedullary hyperintense T2 signal, which is localized
in the radiation field

Radiation Necrosis
 Rare complication of spinal
irradiation
 Acute necrosis within spinal cord
 Mass lesion with a necrotic center
and enhancing rim

7) Sarcoidosis
Noncaseating granulomatous disease of spine and spinal cord
Imaging Features:
Leptomeningeal enhancement
Intramedullary mass-like enhancement
Sagittal T2 Sagittal T1+C

93
 B. Infectious causes of Myelopathy: Bilharziasis
CNS infection from parasitic trematodes (blood flukes) of Schistosoma
Location: Thoracic cord, conus
Imaging findings:
Myelopathy
Conus edema + enhancement

94
 C. Vascular causes of Myelopathy
1) Spinal Arterial Infarction
Aetiology:
Atherosclerotic - DM – HTN
Abdominal aortic aneurysm (AAA) surgery - stenting

High T2 signal + Restricted DWI.

Axial => typical snake-eye appearance can be seen

95
 2) Vasculitis
The images are non-specific with multiple focal lesions
DD: MS

3) Spinal AVF
The most common vascular malformation of the spinal cord is dural AVF.
It consist of an abnormal connection between the artery and the veins,
which can lead to increased venous pressure and predisposes the cord to
ischemia and less commonly to hemorrhage.
High T2 signal in the lower thoracic cord + surrounding dilated vessels

96
Summary 
Non-Compressive Myelopathy
 Short Segment => MS
 Long segment:
Anterior => Vascular occlusion
Posterior => SCD
Central => ATM
+ Optic neuritis => NMO
+ Vascular Malformation => Dural AVF
+ Leptomeningeal enhancement => Sarcoidosis
+ Radiation => Radiation myelitis

97
Intramedullary Hematoma:
Aetiology:
1) Trauma
2) Vascular malformation
3) Coagulopathy
4) Amyloid angiopathy
5) Infarction
6) Metastasis
7) Abscess
8) Viral infection (HSV, CMV)
Stage T1 T2
Hyperacute Diamagnetic Intracellular Iso High
<6 hrs Oxy-Hb
Acute Paramagnetic Intracellular Iso Low
1-2 days Deoxy-Hb
Surrounded Surrounded
by by
peripheral peripheral
zone of high zone of high
T2 (edema) T2 (edema)
Early Paramagnetic Intracellular High Low
subacute Met-Hb
2-7 days Surrounded Surrounded
by by
peripheral peripheral
zone of high zone of high
T2 (edema) T2 (edema)
Late Paramagnetic Extracellular High progressing from
subacute Met-Hb central to peripheral
1-4 weeks

Chronic Ferromagnetic Hemosiderin Low Low

98
 Spinal Astrocytoma Spinal Ependymoma Spinal Hemangioblastoma
2nd most common spinal cord Most common spinal cord 3rd common spinal cord tumor
tumour overall tumor overall overall
Most common spinal cord Most common spinal cord 5% of intramedullary tumors
D. Intramedullary Tumors

tumor in children tumor in adults

Children > Adults Adults > Children Middle age
Association => NF-I Association => NF-II Association => VHL
3 Types: 3 Types:

99
Fibrillary (Grade II) Myxopapillary (Grade I)
Anaplastic (Grade III) Cellular (Grade II)
GBM (Grade IV) Anaplastic (Grade III)
Thoracic > cervical Cellular => Cervical > Thoracic Thoracic > Cervical
Myxopapillary => Conus
medullaris / Cauda equine /
Filum terminal
Eccentric Ill defined Central well defined Highly vascular lesion
expansile lesion expansile lesion Signal voids
Long segment (6 VB) Focal segment (4 VB) Hemosiderin cap sign
Intratumoral cystic component 3 types of cysts
 1) Spinal Ependymoma
Central lesion => Symmetrical cord expansion
T1: Low signal
T2: High signal + Peritumoral edema + Cysts + Low signal hemosiderin rim.
+C: Heterogeneous enhancement
3 types of ‘‘cysts’’:
1) Intratumoral cysts
2) Caudal or rostral cysts
3) Reactive dilatation of the central canal.
Intratumoral haemorrhage => “cap sign” (T2 hypointense haemosiderin
rim) => Subarachnoid hemorrhage => Superficial siderosis
(DD: Spinal AVF – Hemangioblastoma – Cavernoam)
Inferior Hemosiderin Caudal Cyst
Cap Sign:

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 2) Spinal Astrocytoma
Eccentral lesion => Cord expansion
T1: Low signal
T2: High signal + Peritumoral edema + Intratumoral Cysts
+C: Heterogeneous enhancement

3) Spinal Haemangioblastoma
Highly vascular lesions
T1: isointense
T2: Hyperintense + Multiple signal voids
T1+C: Intense enhancement
T2*: Low signal hemosiderin

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 4) Metastasis
Incidence: Rare
A) 1ry CNS tumors:
 PNET / Medulloblastoma
 Glioblastoma
B) 1ry tumors outside CNS:
 Lung Ca
 Breast Ca
 Melanoma
 Colorectal Ca
 Renal Ca
Location:
 Cervical > thoracic > Lumbar
MRI:
 Single / multiple lesions
 Intramedullary / Superficial lesion
 T1: Low
 T2: High
 Gd: enhancement

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Spinal Cord Cavernoma

Spinal Cord Lymphoma

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Syringohydromyelia
 Congenital: Chiari I & II - Tethered cord
 Acquired lesions: Trauma – Tumors
 Idiopathic
 Hydromyelia = Fluid accumulation / dilatation within central canal
 Syringomyelia = Cavitary lesion within cord
 Syrinx = Syringohyromyelia = Terms used for either of the above

Spinal Cord Arachnoid Cyst

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 Compressive Myelopathy Non-
Compressive
Myelopathy
Extradural Subdural Intramedullary
Extramedullary
Myelopathy

Vertebral column Extradural Space

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1) Neoplastic 1) Vascular 1)Neoplastic 1)Demyelinating /
2) Traumatic 2) Traumatic 2)Cysts & Tumor like Inflammatory
3) Degenerative 3) Infection lesions 2) Vascular
4) Infection 4) Cysts / Lipomatosis 3) Spinal vascular 3) Infection
& Tumor like lesions Malformations 4) Tumors
 Cauda Equina/ Filum Terminale Lesions
Arachnoiditis
Causes:
 Infection: T.B. – Puogenic
 Trauma
 Surgery (Failed back syndrome)
 Subarachnoid hemorrhage
 Spinal anesthesia
 Reaction to radio-opaque contrast.
MRI:
 Clumping of nerve roots in center of the thecal sac
 Nerve roots adherent to thecal sac peripherally => Empty sac sign
 Soft tissue mass obliterating subarachnoid space + Gd enhancement =
intrathecal pseudomass.
 Irregular margins of thecal sac.
Empty sac sign Clumping Intra-thecal adhesions

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Guillain-Barre Syndrome
Autoimmune post-infectious or post-vaccinial acute inflammatory
demyelination of peripheral nerves, nerve roots, cranial nerves.
Motor weakness that can progress to total paralysis over a period of days
to weeks.
Monophasic course
Recovery is generally favorable in those patients that survive.
T1+C: Diffuse enhancement of the cauda equine
Nerve roots are enlarged; not nodular

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Chronic Inflammatory Demyelinating Polyradiculoneuropathy =
CIDP
Chronic acquired, immune-mediated demyelinating neuropathy
characterized by relapsing or progressive muscle weakness +/- sensory loss
Causes => Idiopathic
Associations:
Connective tissue disease, diabetes mellitus, IgG or IgA monoclonal
gammopathy, hepatitis C infection, Sjogren syndrome, inflammatory bowel
disease, human immunodeficiency virus (HIV), and lymphoma
Location
Spinal nerve roots and peripheral nerves (extraforaminal > intradural)
Lumbar> cervical, brachial plexus,
thoracic/intercostal > cranial nerve
T2: Enlargement + hyperintensity of spinal nerve roots or plexi
+C: Mild / Moderate enhancement
Bilateral symmetric enlargement Diffuse thickening and
and hyperintensity of cervical nerve hyperintensity of thoracic
roots and brachial plexus (arrows). nerve roots and paraspinal
intercostal nerves.

Thickening and enhancement of ventral and dorsal cauda equina nerve

roots (arrows).

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Cauda Equina/ Filum Terminale Lesions
 Myxopapillary Ependymoma
 Spinal Nerve Sheath Tumours
o Spinal Schwannoma
o Spinal Neurofibroma
 Spinal Lymphoma / Leukaemia
 Lipoma of Filum Terminale
 Metastasis
Myxopapillary Ependymoma
Most common tumours of the conus medullaris and filum terminale.

Filum Terminale Fibrolipoma

Fat signal along the filum terminale
Normal position of the conus medullaris
No evidence of tethered cord

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 Spinal Dysraphism
A group of spinal congenital anomalies involving Cord – Spine – Meninges
Aetiology: Defective closure of neural tube

Radiological Findings:
Vertebral Anomalies Cord & Meninges
1) Coronal cleft v. 1) Tethered cord.
2) Sagittal cleft v. 2) Diastomatomyelia
a. Hemivertebrae 3) Syringohydromyelia.
b. Butterfly v 4) Meningocele
3) Block vertebrae 5) Myelocele
4) Transitional vertebrae 6) Myelomeningocele
5) Spina Bifida
6) Sacral agenesis / Caudal
regression syndrome
7) Bony spur
Developmental Cysts: Spinal Lipomas
1) Arachnoid cyst 1) Lipomyelocele
2) Dermoid 2) Lipomyelomeningocele
3) Epidermoid 3) Filum terminale lipoma
4) Neuroenteric cyst 4) Intradural lipoma
5) Tarlov cysts
Associations: Cutaneous abnormalities:
 Chiari II malformation  Dorsal dermal sinus
 Hydrocephalus.  Lipoma
 Hemangioma
 Hairy patch.

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 Congenital Vertebral Anomalies
1) Coronal Cleft Vertebra

Due to failure of fusion of 2

ossification centers.

Lateral view => linear or oval

radiolucent defect

2) Sagittal Cleft Vertebrae:

A) Butterfly Vertebrae:
Due to failure of fusion of the lateral halves of the vertebral body because
of persistent notochordal tissue between them.

B) Hemi vertebrae:
results from a lack of formation of one half of a vertebral body
 Dorsal hemivertebra: classically results in a kyphosis
 Lateral hemivertebra: classically results in a scoliosis
 Ventral hemivertebra (extremely rare): results in the lordosis

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 3) Block Vertebrae
Most common C5/6, C2/3, L4/5
Complete fusion = Vertebral body + posterior neural arch
Partial fusion = Vertebral body only
Maintained vertebral body height
Smooth concave anterior vertebral margin
Rudimentary disc
Association: Klippel-Feil-Syndrome

DD: Surgical – Juvenile idiopathic arthritis

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 4) Lumbosacral Transitional Vertebrae (LSTV):
a) Sacralization of L5 vertebrae
Small or abscent ribs of D12
Large transverse process of L5
Redumintary L5/S1 disc
Castellvi Classification
Type I: Type II: Type III:
Elongated & dysplastic Pseudoarticulation of Complete fusion of
transverse process. the transverse process transverse process and
and sacrum sacrum

Bertolotti syndrome:
association between LSVT + low back pain
5) L4/5 disk, spinal canal, and posterior element pathology
6) Degeneration of anomalous articulation between LSTV and sacrum
7) Facet joint arthrosis contralateral to unilateral fused or articulating LSTV
8) Extraforaminal stenosis secondary to broadened transverse process
b) Lumbarization of S1 Verteberae
Free floating transverse process of S1 .
May form pseudo-arthrosis with ileum => Degenerative disease => Low
back pain
5) Spina Bifida:
Failure of fusion of neural arch of verteberae.
6) Caudal Regression Syndrome:
Agenesis of of caudal spine:
Cocccyx – Hemisacrum – Whole sacrum – Variable number of lumbar V.
Association with VACTERL and Currarino triad syndromic complexes

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Clinical presentatioin:
GIT: Imperforate anus
GU: Neurogenic bladder
Genital: Malformed genitalia
LL: Motor deficit > Sensory deficit

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115
 I. Open Spinal Dysraphism
1) Myelocele: neural placode flush with the skin
2) Myelomeningocele: neural placode protrudes above the skin
3) Hemimyelocele: Myelocele + Diastematomyelia
4) Hemimyelomeningocele: Myelomeningocele + Diastematomyelia
1) Myelocele
Neural tube closure defect.
Spina bifida aperta.
Not covered by skin.
Neural placode (arrow) flush with skin surface.
No expansion of underlying subarachnoid space.

2) Myelomeningocele (98%):
Neural tube closure defect.
Spina bifida aperta.
Not covered by skin.
Neural placode protrudes above the skin.
Expansion of underlying subarachnoid space.

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 II. Occult Spinal Dysraphism
A) Covered by skin + Subcutaneous mass:
1) Lipomyelocele: Placode-lipoma interface within spinal canal
2) Lipomyelomeningocele: Placode-lipoma interface outside spinal canal
3) Meningocele: herniation of CSF filled sac lined by dura
4) Terminal myelocystocele: terminal syrinx herniating into posterior
meningocele
5) Myelocystocele: dilated central canal herniating through posterior spina
bifida
1) Lipomyelocele
Placode–lipoma interface (arrow) within spinal canal

2) Lipomyelomeningocele
Myelomeningocele (nueral placode) + covered by lipoma that is contiguous
with dorsal subcutaneous fat.
Placode–lipoma interface (arrow) lies outside of spinal canal due to
expansion of subarachnoid space

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 3) Meningocele
Herniation of a CSF-filled sac lined by dura and arachnoid mater.
The spinal cord is not located within a meningocele but may be tethered to
the neck of the CSF-filled sac.
Posterior meningoceles herniate through a posterior spina bifida
Most common in lumbar or sacral regions.
but also can occur in the occipital and cervical regions
Occipital Cervical Lumbar

Anterior meningoceles are usually presacral in location

Cervical Presacral

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 4) Terminal Myelocystocele
Herniation of large terminal syrinx (syringocele) into a posterior
meningocele through a posterior spinal defect
 The terminal syrinx component communicates with the central canal
 The meningocele component communicates with the subarachnoid
space.
 The terminal syrinx and meningocele components do not usually
communicate with each other

5) Myelocystocele
A nonterminal myelocystocele occurs when a dilated central canal
herniates through a posterior spina bifida defect.
Myelocystoceles are covered with skin and can occur anywhere
Most commonly seen in the cervical or cervicothoracic regions

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 II. Occult Spinal Dysraphism
B) Covered by skin + NO Subcutaneous mass:
i. Simple Dysraphic State
1) Intradural lipoma
2) Filar Lipoma / Fibrolipoma
3) Tight filum terminale
4) Persistent terminal ventricle
5) Dermal sinus
1) Intradural Lipoma
 Lipoma contained within dural
sac.

 No open spinal dysraphism is

present.

 most commonly lumbosacral in

location

 Usually present with tethered-

cord syndrome
2) Filar Lipoma
Fibrolipomatous thickening of the filum terminale
T1: hyperintense strip within a thickened filum terminale
Filar lipoma can be considered a normal variant if there is no clinical
evidence of tethered-cord syndrome

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 3) Tight Filum Terminale
Hypertrophy and shortening of the filum terminale.
The condition causes tethering of the spinal cord and impaired ascent of
the conus medullaris
4) Persistent Terminal Ventricle
 Persistence of small, ependymal
lined cavity within the conus
medullaris.

 No enhancement

5) Dermal Sinus
An epithelial lined fistula that connects neural tissue or meninges to the
skin surface.
It occurs most frequently in the lumbosacral region
Associated with spinal dermoid at level of cauda equina or conus medullaris
Associated with hairy nevus, hyperpigmented patch, capillary hemangioma
Clinically: Patients present with midline dimple
Complications: Meningitis and abscess

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 ii. Complex Dysraphic States
Disorders Of Midline Disorders Of
Notochordal Integration Notochordal Formation
 Dorsal enteric fistula  Caudal agenesis
 Neurenteric cyst  Segmental spinal dysgenesis
 Diastematomyelia
1) Dorsal Enteric Fistula
An abnormal connection between the skin surface and bowel.
2) Neurenteric Cyst
A more localized form of dorsal enteric fistula.
lined with mucin-secreting epithelium similar to GIT
typically located in the cervicothoracic spine anterior to the spinal cord

3) Diastematomyelia
Separation of the spinal cord into two hemicords
2 hemicords => Symmetrical or asymmetrical
Septum => Bony / Cartilagenous / Fibrous
Type 1: 2 hemicords + 2 individual dural tubes + separated by an osseous or
cartilaginous septum
Type 2: Single dural tube containing 2 hemicords + intervening fibrous
septum

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 4) Caudal Agenesis
Total or partial agenesis of the spinal column.
associated with the following:
Anal imperforation, genital anomalies, renal dysplasia or aplasia,
Pulmonary hypoplasia, or limb abnormalities.
2 types:
Type 1: High position and abrupt termination of the conus medullaris.
Type 2: Low position and tethering of the conus medullaris

5) Segmental Spinal Dysgenesis

 Segmental agenesis or dysgenesis of the thoracic or lumbar spine
 Segmental abnormality of the spinal cord or nerve roots
 Congenital paraparesis or paraplegia
 Congenital lower limb deformities.

 Tethered Cord Syndrome

Low conus medullaris below L2
Associated with:
 Short thick filum terminal
 Intradural lipoma
 Diastomatomyelia
 Meningocele

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 Scoliosis
Classification of Scoliosis
 Idiopathic (70 - 80 % of all cases)  Neuromuscular
o Poliomyelitis
 Nonstructural scoliosis o Cerebral palsy
o Postural scoliosis o Syringomyelia
o Compensatory scoliosis o Muscular dystrophy
 Transient structural scoliosis o Amyotonia congenita
o Sciatic scoliosis o Friedreich's ataxia
o Hysterical scoliosis  Neurofibromatosis
o Inflammatory scoliosis  Mesenchymal disorders
 Trauma o Marfan's syndrome
o Fractures o Morquio's syndrome
o Irradiation o Rheumatoid arthritis
Surgery o Osteogenesis imperfecta
o Certain dwarves
Congenital Scoliosis:
 Failure of formation
o Partial failure of formation (wedge vertebra)
o Complete failure of formation (hemivertebra)
 Failure of segmentation
o Unilateral failure of segmentation (unilateral unsegmented bar)
o Bilateral failure of segmentation (block vertebra)

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Failure of formation Failure of Segmentation

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