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Despite evidence to the contrary, the public, and clinicians, often believe that low back pain (LBP) diagnosis and management are enhanced through the use of imaging such as MRI and CT. In the USA alone, nearly $6 billion is spent on spinal MRI scans annually, stretching limited resources. We have previously discussed1 how imaging rates for LBP may be safely reduced and aligned with guidelines,2 using methods such as clinician decision support to ‘shape the path’.3 Nevertheless, reducing imaging rates for LBP is difficult. There may be additional value in gaining a better understanding of the decision-making processes, and motivations, of referring clinicians. There is considerable variation in imaging referral patterns between clinicians, with variation the greatest for LBP presentations not involving trauma or radiculopathy (the majority of people with LBP). This suggests clinician factors, in addition to system factors, contribute to the variation. Many clinicians are aware of, and broadly agree with, recommended clinical …

A 73-year-old woman presented with acute lower back pain and right sensory radicular L4 syndrome. Spinal MRI showed a cranially shifted T2-hypointense mass suspicious for disc herniation in the L3/4 segment with compression of the right nerve root L4 (figure 1). Due to atypical morphology, CT was performed and disclosed an intraspinal epidural gas bubble mimicking disc herniation on MRI (figure 2). In association with coexisting intravertebral vacuum disc phenomenon (figure 2B), it appears likely that the gas gained access to the epidural space after annulus fibrosus rupture.1 Vacuum disc phenomenon results from the accumulation of gas (mostly nitrogen) within the crevices of the disc as it degenerates.1

To evaluate the incidence and pattern of spinous process fractures (SPFs) in patients with osteoporotic compression fractures (OCFs) of the thoracolumbar spine.Spinal MRI or CT of 398 female patients (age range 50-89 years, mean age 70 years) who had OCFs in the thoracolumbar spine were retrospectively reviewed. The incidence, location and imaging results for the SPFs were evaluated.Of the 398 patients who had thoracolumbar OCFs, 14 (3.5%) had SPF. In six patients with single compression fractures, the SPF occurred at the level just above the vertebral compression fracture. In six out of seven patients with multiple continuous compression fractures, the SPF occurred just one level above the uppermost level of the compression fracture. The remaining one patient who had thoracolumbar spinal fixation at T12-L2 with continuous compression fractures in T12-L5 had a SPF in L2. In one patient who had multiple compression fractures in discontinuous levels (fractures at T10 and L1, respectively), the SPF occurred at T12. The directions of the fractures were vertical or oblique vertical (perpendicular to the long axis of the spinous process) in all cases.In the presence of an OCF in the thoracolumbar spine, a SPF was found in 3.5% of cases, and most of the fractures were located just one level above the compression fracture. Therefore, in patients who have OCF, the possibility of a SPF in the level just above the compression fracture should be considered.

Study design Report of a high dysplastic developmental spondylolisthesis in two identical twins of two unrelated families. Objective To investigate the multifactorial etiology of developmental spondylolisthesis. Summary of background data Multiple studies have suggested an association between a high pelvic incidence and the presence of isthmic spondylolisthesis. Other studies suggest a genetic background for spondylolysis and a pattern of inheritance of susceptibility to spondylolysis and spondylolisthesis. Heterozygous cartilage-derived morphogenetic protein-1 (CDMP-1) mutation has previously been associated with spondylolysis and severe spondylolisthesis. Methods Two identical female twins presented with a developmental spondylolisthesis. Pelvic parameters, lumbar lordosis and grade of spondylolisthesis were calculated on a lateral standing spine radiograph. MRI is performed to confirm a high dysplastic developmental spondylolisthesis. Blood sample of these four individuals were analyzed for the presence of a CDMP-1 mutation, a cartilage-specific member of the TGF-b superfamily of secreted signaling molecules that plays a key role in chondrogenesis, growth, and patterning of the developing vertebrate skeleton. Results PI, SS, PT, LL, and SI are significantly greater in all of these patients in comparison with the general population. Spinal MRI confirms a high dysplastic developmental spondylolisthesis in both twins. Mutation analysis of the two coding exons of CDMP-1 did not reveal any mutation in all four individuals. Conclusion To our knowledge, this is the first report of a high dysplastic developmental spondylolisthesis in identical twins. The presence of a high dysplastic developmental spondylolisthesis in two identical twins shows the convergence in etiology of different factors such as genetics, maturation, critical age, female sex, high pelvic incidence. Although we cannot confirm that CDMP-1 mutation plays a key role in the etiology of spondylolysis/spondylolisthesis, neither can we rule out that CDMP-1 problems may be an etiology for at least a subpopulation of patients. However, the presence of a developmental spondylolisthesis in two sets of identical twins still suggests a genetic susceptibility to spondylolysis and spondylolisthesis.

Isolated leptomeningeal recurrence of melanoma is rare, occurring in 2% of patients with central nervous system involvement secondary to melanoma. The optimal treatment of leptomeningeal carcinomatosis (LMC) in melanoma has not yet been determined and remains a major challenge. We report a melanoma patient who presented with isolated LMC in the form of a new-onset weakness of the lower limbs, paresthesia of the left hand and foot, lumbago and headache. A lumbar puncture and spinal MRI confirmed LMC. The patient was treated with temozolomide 75 mg/m(2)/day on a 4 weeks on/2 weeks off schedule. After an initial transient clinical deterioration, the patient showed a complete radiological response as well as a dramatic improvement in quality of life. The encouraging clinical response reported here suggests that dose-intensified temozolomide might have significant activity in the treatment of leptomeningeal dissemination of melanoma and may be a valid treatment option for patients who have not been previously exposed to this agent. Moreover, this treatment regimen is extremely well tolerated and obviates the need for repeated intrathecal administrations of chemotherapeutic agents, which are often not well tolerated by patients who have significant co-morbidities due to their disease. As illustrated in this case, response to temozolomide may occur in a delayed manner, highlighting the importance of following temozolomide treatment long enough before determining that it is inefficient in a given patient.

OBJECTIVE Magnetic resonance imaging (MRI) is the most popular follow-up study for patients who have undergone spinal surgery. However, the image quality often becomes poor because of artifacts from metal implants and/or from failed fat suppression, which obscure diagnosis. Iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) is a new fat suppression method that is less affected by inhomogeneity of the magnetic field. Here, we compared postsurgical spinal MRI with IDEAL versus chemical shift selective saturation (CHESS). METHODS For 35 patients who had spinal surgery, we examined T2-weighted fast spin-echo sagittal images of the spine with both IDEAL and CHESS. Two radiologists evaluated the degrees of fat suppression and spinal canal projection from 0 (least/worst) to 2 (most/best). RESULTS Fat suppression and spinal canal scores for IDEAL were statistically higher than those for CHESS (P < 0.05). CONCLUSIONS Iterative decomposition of water and fat with echo asymmetry and least-squares estimation is clinically useful for postoperative spinal MRI.

Guillain-Barré syndrome diagnosis is based on clinical presentation and supportive diagnostic testing. In its early stage, no single, reliable diagnostic test is available. However, a finding of nerve root enhancement on spinal magnetic resonance imaging may be useful. We evaluated the frequency of nerve root enhancement on spinal magnetic resonance imaging in children with Guillain-Barré syndrome. At a single tertiary pediatric center, we conducted a retrospective chart review of children with Guillain-Barré syndrome who had complete spinal or lumbosacral spinal magnetic resonance imaging with gadolinium administration from January 2002-January 2009. Twenty-four consecutive patients were identified. Spinal nerve root enhancement with gadolinium was present in 92% (22/24) of children with Guillain-Barré syndrome on initial spinal magnetic resonance imaging (95% confidence interval, 0.745-0.978). This finding increased to 100% of patients, after two patients underwent repeat spinal magnetic resonance imaging that did reveal nerve root enhancement. Patterns of enhancement were variable, but involved the thoracolumbar nerve roots in all patients. Enhancement of nerve roots with gadolinium on initial spinal magnetic resonance imaging was frequently present in these children with Guillain-Barré syndrome. Spinal magnetic resonance imaging is a sensitive diagnostic test and should be considered an additional diagnostic tool in select cases.

Rationale: Subacute combined degeneration (SCD) of the spinal cord has been reported to have distinctive characteristics on magnetic resonance imaging (MRI), such as an “inverted V sign”, a “pair of binoculars sign”, and a “dot sign”. We report a 3-point sign as a novel MRI characteristic, expanding the spectrum of imaging signs for SCD. Patient concerns: A 64-year-old female vegetarian presented with a 3-month history of progressive numbness and weakness in the lower extremities. Diagnosis: Laboratory examination showed a reduced serum vitamin B12 level. Spinal MRI showed hyperintensity within the posterior and lateral columns (appearing as a three-point sign) on T2-weighted imaging. Thus, the patient was diagnosed with SCD. Interventions: The patient was treated with intravenous cyanocobalamin and oral vitamin B12. Outcomes: After a follow-up period of 5 months, the symptoms were significantly improved. Lessons: Clinicians should be aware of this atypical MRI pattern, which may facilitate an early diagnosis.

In the past decade, fat-suppression MRI techniques have been increasingly used for the assessment of axial-SpA. Indeed, newly proposed classification criteria have suggested the inclusion of fat-suppression MRI for the evaluation of the SI joint in inflammatory back pain (IBP) of suspected axial-SpA. However, recent data on the whole spine have identified certain MRI spinal lesions to be highly diagnostic of axial-SpA; that the SI joint can be spared in axial-SpA; and that IBP may originate in the lumbar spine rather than SI joint. Therefore, it is proposed that MRI of the whole spine and not just the SI joint should now become a routine part of the assessment of axial-SpA. Not only is spinal MRI of great diagnostic utility in axial-SpA but there is also increasing evidence to suggest that it can play a significant role in the management, in particular directing anti-TNF therapy in AS, and also it may be prognostically useful in axial-SpA. With the wider availability, improving technology and falling cost of MRI, and the difficulty that clinical assessment of axial-SpA poses, especially in early disease, there is now a strong case for the use of whole-spine MRI in the diagnosis and management of axial-SpA.

Recognizing syndromes which mimic ALS is crucial both to avoid giving this diagnosis erroneously and since there may be appropriate treatments. We report a 63-year-old woman diagnosed with possible ALS five years ago based on upper and lower motor neuron signs with typical electrophysiology and normal cranial MRI. At reassessment, spinal MRI revealed a cervicothoracic cyst with cord compression that was successfully treated neurosurgically. Histopathology confirmed an arachnoid origin as suspected from MRI. Spinal cysts may mimic ALS and need to be thoroughly excluded by appropriate imaging.

PURPOSE: The standard for the detection and localization of spinal dural and perimedullary AV fistulas has been digital subtraction angiography. The purpose of this study was to correctly locate dural AV fistulas using high-resolution (hr), contrast-enhanced (ce) MRA at 3 T or at least to estimate the site within a range of two to three segments. As a result, the radiation exposure, contrast dose and risk of complications were able to be reduced. METHODS: Five patients with typical clinical symptoms and the characteristic signs in spinal MRI were examined at 3 T (GE Signa Excite HD). Hr, ce MR angiography and a time-resolved sequence (TRICKS) were compared and correlated with the subsequent DSA and the operation record with respect to the site of the fistula. In addition, the amount of contrast agent and the number of selectively catheterized segmental arteries in DSA were analyzed. RESULTS: In all patients, a dural AV fistula was able to be demonstrated by hr, ce MRA, and the side and the segmental level of the point of the fistula were correctly predicted and confirmed in subsequent DSA as well as in the operation record. In time-resolved MRA the determined location was correct in one of the five cases. In the remaining 4 cases no definitive mapping was possible. CONCLUSION: In hr, ce MRA at 3 T the localization of the point of the fistula in a spinal AVF is highly reliable so that the radiation time and the amount of contrast medium can be reduced. Hr, ce MRA is superior to the time-resolved sequence (TRICKS).

The purpose of our study was to evaluate spinal MR images for extraforaminal disk herniation with or without foraminal disk herniation to determine the reliable MRI findings.Thirty-five patients with extraforaminal with or without foraminal disk herniation confirmed at radiculography or surgery between March 2005 and July 2007 underwent spinal MRI. We assessed the morphologic features of the disk, changes in nerve root thickness, epidural fat obliteration surrounding the nerve root, and displacement of the nerve root in the foraminal and extraforaminal zones.Mixed disk herniation was found in 23 patients, and purely extraforaminal herniation was found in 12 patients. Focal eccentricity of the disk contour was identified in 32 patients (91%). Change in the nerve root thickness was found in 30 patients (86%). The nerve roots were displaced in 22 patients (63%), and the original location was maintained in nine patients (26%). Differentiation between the disk and the nerve root was poor in four of the 35 patients (11%). Obliteration of the epidural fat surrounding the nerve root was present in all patients.The presence of extraforaminal with or without foraminal disk herniation should be ascertained on the basis of the following MRI findings: focal eccentricity of the disk contour, obliteration of epidural fat surrounding the nerve root, change in the thickness of the nerve root, and displacement of the nerve root.

PURPOSE: Magnetic resonance imaging (MRI) has become a valuable tool for diagnosing and monitoring multiple sclerosis (MS). The high sensitivity for the detection of hyperintense lesions in T 2-weighted scans contributes substantially to diagnosis. The initial lesion number or lesion volume stands for an increased probability of further accumulation of lesion burden, an earlier conversion to clinically definite MS and progression of disability in the next 5 - 15 years. This diagnostic and prognostic information gained from MRI early in the disease course lead in 2001 to a revision of the diagnostic criteria. MATERIALS AND METHODS: For the first time MRI criteria were defined in addition to the clinical and paraclinical criteria using the clinical terms for dissemination with respect to space and time. In particular, the defined MRI criteria are based on lesion number and location, the appearance of new lesions and lesion enhancement using contrast agent. RESULTS: Reliable detection and description of older and new lesions in the disease course by MRI represents subclinical disease activity which can substitute the clinical confirmation of a relapse leading to an earlier diagnosis. This places importance on the assessment of the subclinical disease activity in sequential MR scans requiring a standardized and reproducible approach to minimize variability despite different MR scanners. CONCLUSION: This review provides an updated proposal for the approach and management of cranial and spinal MR scans in patients with MS. We describe the influence of variables which cannot be standardized (scanner, field strength, manufacturer and software) and outline potential pitfalls of clinical MR imaging in MS resulting from a non-standardized approach. This updated proposal for slice positioning, sequences and documentation is a result of a consensus process targeting systematic and standardized use in clinical MR evaluations of MS.

Rationale and Objectives This study evaluates utilization trends of emergency department (ED)-ordered magnetic resonance imaging (MRI) examinations in an adult academic medical center over a 5-year period (2001–2005). Materials and Methods MRI examinations from the ED-ordering location were identified by searching the radiology information system (RIS). Overall MRI volume and ED patient encounters were also assessed during the same period. Each examination was assessed by type of examination, examination completion time, and primary and secondary clinical indications by reviewing the RIS and medical record. Results During the study period, 1,900 ED-ordered MRI examinations were performed on 1,020 patients. During the same period, 62,823 total MRI examinations were performed, and the total ED patient volume was 420,840. ED-ordered MRI volume increased 391% over the study period (125 to 614 examinations/year), whereas total MRI volume increased only 38.9% and ED patient volume in our institution actually decreased by −9%. MRI examinations of the brain, magnetic resonance angiography of the head and neck, and spinal MRI were the most commonly ordered tests. Clinical indications were analyzed. Peak times of ED-ordered examination completion were between 4:00 PM and 11:00 PM. A total of 15.5% of examinations required overtime or callback of MRI technologists for completion. Conclusions Multiple reasons are suggested that may increase utilization (perceived need for diagnostic certainty, as well as medico-legal and patient-driven factors). Whether this increase in MRI utilization resulted in improved patient outcomes is unclear and should be studied further. Implications for radiologist coverage and resident training are discussed.

Resume Introduction Les myelites aigues de Lyme representent 4 a 5 p. 100 des cas de neuroborreliose. Seuls 8 cas ayant fait l’objet a la fois d’une etude du liquide cephalo-rachidien et d’une IRM medullaire ont ete decrits dans la litterature. Nous rapportons ici 3 nouveaux cas. Methode Dans une serie de 45 patients atteints de neuroborreliose diagnostiques en 8 ans entre le 1er janvier 1997 et le 31 decembre 2004, 3 avaient un tableau de myelite aigue. Nous en avons analyse les caracteristiques cliniques, biologiques et radiologiques. Observations Ces 3 patients avaient tous une atteinte motrice, sensitive et sphincterienne a des degres divers. Chaque patient avait aussi une atteinte extra-medullaire : fievre et cephalees pour l’un, paralysie faciale peripherique unilaterale pour le second et hemorragie meningee pour le dernier. Il existait une pleiocytose d’intensite variable de 10 a 520 globules blancs par mm3. La serologie de Lyme etait positive dans le liquide cephalo-rachidien dans les 3 cas. L’index de synthese intrathecale anti-Borrelia burgdorferi etait positif ou intermediaire. L’IRM medullaire retrouvait un hypersignal de plus de 3 metameres de haut pouvant etre transverse, posterieur ou centro-medullaire. L’evolution sous antibiotherapie specifique pendant au moins 3 semaines etait favorable pour les 3 cas. Conclusion Ces 3 cas ainsi que les autres decrits dans la litterature montrent la diversite des tableaux clinico-radiologiques de myelite aigue de Lyme : myelite transverse, posterieure ou centrale. Ainsi, une serologie de Lyme dans le liquide cephalo-rachidien doit etre systematiquement pratiquee dans les myelites aigues etendues, en particulier en zone d’endemie.

Background: Spinal TB (sTB) incidence is increasing globally, often presenting at a late stage with neurological morbidity; spinal MRI is increasingly used to monitor disease progression. National guidelines recommend 6 months of chemotherapy, however optimal treatment duration is unclear. Aims: To investigate presenting symptoms, treatment duration and role of spinal MRI in management of patients with sTB attending a tertiary referral centre. Methods and Results: Clinical records of 48 patients with sTB were studied retrospectively from 2007-2014. Mean age of onset was 38.6 years, mean symptom duration before diagnosis 9.8 months; most of the delay (8.5 months) was due to late referral. Mean treatment duration was 10.5 months; there was no correlation between number of vertebral lesions and treatment duration(p=0.9270). 98% of patients had a spinal MRI scan; 2.7 repeat scans were performed/person. MRI scans often corresponded to patients' symptoms – 67% of patients reported symptoms after 6 months of therapy and 22% at the end of treatment; MRI showed spinal abnormalities in 87% and 16% respectively. Conclusions: Education to increase awareness of sTB symptoms may reduce delay in diagnosis. Treatment duration is often guided by MRI and was frequently longer than recommended by current guidelines. Further guidance in the use of MRI in sTB management is needed. . | | Number(%) | || | Sex | Male: 30(63) | | Origin | UK: 6(15) | Africa: 20(52) | Asia: 10(26) | Other: 3(7) | | Time in UK(years) | ≤5: 9(38) | >5: 15(62) | | Symptoms | Back pain: 43(90) | Constitutional: 24(50) | Neurological: 24(50) | | Vertebral region | Cervical: 2(4) | Thoracic: 9(19) | Lumbar: 16(34) | Sacral: 3(6) | >1 region: 17(36) | | Treatment length(months) | ≤6: 7(15) | 6-9: 11(23) | >9: 30(62) | Cohort demographics

TNFα inhibitors are currently the only class of biological agent that has proven to be effective in the treatment of patients with ankylosing spondylitis and/or spondyloarthritis (SpA). These agents have been shown to control inflammatory pain of the axial skeleton, peripheral clinical manifestations, certain extra-articular manifestations as well as systemic and spinal MRI inflammation. Conversely, they are unable to slow radiographic progression in the spine. Since around 20–30% of patients with SpA are considered as nonmajor responders to TNFα inhibitors, there is a need for alternative therapies. Biological agents that target IL-1, IL-6, B cells and costimulatory pathways are not effective in SpA. Conversely, novel biological agents blocking IL-23 or IL-17 are promising in SpA, especially secukinumab, an anti-IL-17A monoclonal antibody.

Background: The impact of new asymptomatic spinal cord lesions (a-SL) in multiple sclerosis (MS) course is poorly characterized. Objective: The objective of this research paper is to assess the prognostic value of a-SL in predicting MS course. Methods: Relapsing–remitting MS patients who received serial MRI (brain and spinal) at baseline (t1) and within 12 to 36 months (t2) during clinical stability, and had a follow-up (t2–t3) ⩾24 months were included. Relapses and disability progression were evaluated between t2 and t3. Results: Of 413 consecutive screened MS patients, 103 patients (65 females, median age 43 years) were included. After a median t1–t2 interval of 17 (IQR 13–26) months, 25.2% and 43.7% patients had ⩾1 new a-SL (a-SL+) and asymptomatic brain lesions (a-BL+), respectively. Relapse risk between t2 and t3 (median interval: 42 (IQR 32–57.5) months) was significantly increased in a-SL+ and/or a-BL+ vs a-BL– and a-SL– (HR = 2.31, 95% CI = 1.13–4.72, p = 0.02). No differences in the risk of disability progression were found in a-SL+ and/or a-BL+ vs a-SL- and a-BL–. Conclusion: a-SL occur in one-quarter of clinically stable RRMS, and combined with a-BL contribute significantly in predicting future disease course.

This paper describes a fully automatic system for obtaining the standard Pfirrmann degeneration grading of individual intervertebral spinal discs in T2 MRI scans. It involves detecting and labeling all the vertebrae in the scan and then learning a regression from the disc region to the grading. In developing the regression function we investigate a spectrum of support regions which involve differing degrees of segmentation of the scan: our intention is to ascertain to what extent segmentation is necessary or detrimental in obtaining robust and accurate measurements. The methods are assessed on a heterogeneous clinical dataset containing 1,710 Pfirrmann-graded discs, from 285 symptomatic back pain patients. We are able to predict the grade to \(\pm 1\) precision at 85.8 % accuracy. Our novel method proposes new image features that outperform previous features and utilizes techniques to improve robustness to MR imaging variations.

Acute transverse myelitis (ATM) is commonly para-infectious. Recurrent ATM occurs in connective tissue diseases (CTD), infective myelitis and idiopathic inflammatory demyelinating disorders (IIDD) including multiple sclerosis (MS) and neuromyelitis optica (NMO). Previous studies might include NMO and idiopathic recurrent transverse myelitis (IRTM) as MS. The aim was to study the outcome of patients after a first attack of idiopathic ATM. Idiopathic ATM patients over a 6-year period were retrospectively studied. Known causes of myelopathy were excluded. Among 32 patients studied, 20 (63%) had single ATM attack upon follow up for 39-93 months, three developed recurrent ATM related to CTD (two systemic lupus erythematosus and one anti-Ro antibody positive) and nine (28.1%) developed recurrent neuroinflammation compatible with IIDD. Among IIDD patients, three had NMO, two restricted variant of NMO, three IRTM and one classical MS. NMO, its variant and IRTM had mean spinal MRI abnormality of 3.7, 2.1 and 3.9 vertebral segments respectively while non-recurrent ATM had 1.6 vertebral segments. Four (80%) of the five patients with NMO or its variant had poor neurological prognosis versus only one (5%) of non-recurrent ATM patients. IRTM patients had advanced mean onset age, 62 years vs. 43 years for non-recurrent ATM patients. In IIDD patients presenting with ATM as first attack of neuroinflammation, NMO and its variant (56%) were most frequent, then IRTM (33%), with classical MS (11%) the rarest. As long-term treatments for NMO are different from MS, early recognition of NMO and its variant is important for prevention of serious neurological deficits.

Identifying spinal injuries in trauma patients with altered mental status can be difficult. CT scanning and clinical examination are the basis of our spinal clearance, but screening “trauma protocol” spinal MRI is used to exclude occult injuries. We sought to evaluate the sensitivity of CT scanning for spinal injuries compared with our MRI protocol. Ninety-seven patients underwent MRI cervical spine trauma protocol during 2004. Twenty-nine patients were obtunded, 29 had neurologic symptoms, and 39 had spine pain. MRI confirmed the initial CT findings without new injuries in 83 cases. MRI reclassified fractures as degenerative changes in 12 cases. In 2 cases, the MRI identified new injuries: one a stable partial ligament tear, the second a T7 Chance fracture with ligamental disruption requiring operative fixation. There was no morbidity or mortality documented in obtaining the MRI studies. Overall negative predictive value of CT scanning of the spine was 98 per cent, the positive predictive value was 78 per cent, and the sensitivity and specificity was 94 per cent and 91 per cent, respectively. CT scanning of the cervical and axial spine is sensitive for spinal trauma but not specific. MRI trauma protocol should be reserved for cases when initial CT scanning is suggestive of traumatic injury.

Purpose To ascertain the suitability of vertebrae adjacent to spinal bone lesions as a signal intensity reference on MRI, and compare the MR spectroscopic appearance of vertebral body compression fractures due to malignant tumor infiltration, bone weakening (e.g., osteoporosis), and/or minor trauma. Materials and Methods Twenty-five patients with spinal compression fractures underwent routine spinal MRI with an additional 1H MRS study protocol to assess the percent fat fraction of the compressed vertebrae as well as the adjacent bony environment. Peak areas for water and total lipid were calculated from short-TE single-voxel 1H MR spectra using the LCModel analyzing tool. Results There were consistent water-only patterns in the fractured vertebra suggesting either near complete marrow replacement by malignant tissue or local edematous fluid/hemorrhage within the marrow spaces. However, the adjacent vertebrae showed a wide range of patterns from a dominant lipid signal to the inverse of a pronounced water level. These results far exceed the normal variation expected based on age and sex. Conclusion The results suggest that the adjacent vertebrae may not be an accurate reference, especially in diffusion-weighted imaging (DWI), because of the large difference between the two compartments. Furthermore, in the case of gradient-echo measurements, the in-phase vs. opposed-phase effects are significant. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Background: Low back pain is a common complaint among adults, worldwide. Lumbar canal stenosis is frequently diagnosed as a cause for low back pain. In this study we evaluate morphometric measures using MRI sections to predict the occurrence of lumbar central canal stenosis. Settings and Design: One hundred and fifty four lumbar spinal MRI sagital and axial section images, 77 males and females each were evaluated from the Department of Radiology, Kasturba Medical College, Mangalore, Manipal University. The study design was a prospective study. Materials and Methods: Various measurements were taken and two constant ratios were calculated. The Canal Body Ratio and the Ratio between the area of the dural sac and the vertebral body was evaluated. Statistical analysis: Unpaired t-test analysis was conducted using SPSS software. Results: A canal body ratio less than 0.6 from L1 to L3 levels and less than 0.5 at L4 and L5 levels were found. The ratio between area of dural sac and vertebral body was found to be a constant at 0.2 at all levels. It was found that maximum central canal stenosis occurred at the L5 lumbar vertebral level in 15.6% males and 13% females. This was followed by stenosis at the L4 and L3 lumbar vertebral levels with 5.1% males having stenosis at both levels and 3.9% and 5.1% females in L4 and L3 lumbar levels respectively. Conclusion: These morphometrical findings of the lumbar vertebrae could be of use in evaluating the possible cases of lumbar canal stenosis.

This is a case report of Chiari type 2 (C2) malformation associated with a thyroglossal duct cyst. A 3-month-old female patient with myelomeningocele was examined with cranial and spinal MRI. The imaging protocol included T1- and T2-weighted sequences. MRI revealed typical findings of C2 malformation and a thyroglossal cyst located at the base of the tongue. We hypothesize that occurrence of C2 malformation and the thyroglossal cyst is not totally independent, but instead, their association shown in the present case may be related to incomplete embryonic development. However, further studies and research are needed in order to prove this hypothesis.

Maple syrup urine disease (MSUD) is a rare metabolic disease affecting the neural tissue. While the brain abnormalities present on MRI are well known, spinal imaging features have not been studied. We herewith report an unusual finding of enlarged Virchow Robin spaces in brain and novel spinal cord changes in two biochemically diagnosed cases of MSUD. To the best of our knowledge, spinal MRI findings in cases of MSUD have not been previously reported. Knowledge of spinal MRI findings may be useful in diagnosis of this rare disorder.

Intraspinal schwannoma is a rare neoplasm in pediatric patients; cellular schwannoma is an unusual histological subtype of schwannoma. A six-month-old infant with an epidural dumbbell cellular schwannoma presented with progressive weakness of his arms and legs. A spinal MRI revealed an epidural mass from C5 to T4, and a complete surgical resection was achieved after laminotomy and facetectomy. The patient experienced a gradual neurological improvement and was still healthy without recurrence at the latest follow-up. The diagnosis of cellular schwannoma was confirmed on immunohistological examination.

We experienced 6 patients with paralysis due to cervical mechanical compression last year at our hospital. One patient had multiple sclerosis. He displayed sudden symptoms which improved and deteriorated. He also showed high T2 lesion in MRI. Another patient sustained spinal infarction. She also suddenly caused symptoms and showed high T1 and T2 lesion in spinal MRI. One patient had alcholic neuropathy. We believe that these diseases can be differentiated by physical examination, MRI, and various other examinations.

Aim To evaluate spinal magnetic resonance imaging (MRI) examinations using a combination of two-dimensional (2D) and three-dimensional (3D) MRI sequences for diagnosis of drop metastases. Materials and methods Fifty-five paediatric patients with primary brain tumours were evaluated for drop metastases at initial presentation using spinal MRI including sagittal 2D T1-weighted (W) contrast-enhanced (+C), axial 3D T1W+C volumetric interpolated breath-hold (VIBE), and sagittal 3D T2W SPACE (Sampling Perfection with Application optimised Contrasts using different flip angle Evolutions). Results The MRI false-negative rate was 4%, and cerebrospinal fluid (CSF) false-negative rate was 16% ( p= 0.07). The 3D T1W+C VIBE increased the number of drop metastases detected in 42% of patients. Drop metastases were more conspicuous in 25% of patients on 3D T2W SPACE. Conclusion Spinal MRI examinations including 2D and 3D sequences demonstrate characteristics that may improve radiological diagnosis of drop metastases.

We describe an extracardiac finding of syringomyelia in CMR study of a patient who was being investigated to exclude an infiltrative cause for presumptive cardiogenic syncope. Extension of a syrinx to involve the sympathetic structures in the intermediolateral column of the spinal cord can lead to well-recognised autonomic disturbances including Horner's syndrome. Autonomic control of the heart has also been shown to be impaired in patients with syringomyelia. We investigated a 20 year old man presented with a history of recurrent syncope triggered by pain, micturition and defaecation. The cardiac MRI findings were normal, however close inspection of the scout images was suggestive of a lower thoracic spinal cord syrinx - a finding later confirmed by dedicated spinal MRI. Subsequent neurological investigations were essentially normal. We suggest that syringomyelia-induced disruption of sympathetic fibres in the thoracic spinal cord is a plausible, but rare mechanism of syncope.

Spontaneous intracranial hypotension is an important cause of new daily persistent headaches in young and middle-aged individuals. The diagnosis is made based on low cerebrospinal fluid pressure with characteristic findings upon brain and spinal magnetic resonance imaging (MRI). We present the case of a 15-year-old boy with spontaneous intracranial hypotension. Although his brain MRI was normal, his lumbar spinal MRI showed clustering of the nerve roots characteristic of arachnoiditis. Radionuclide cisternography revealed an epidural leak, which was treated with an epidural blood patch. The patient reached a near-full recovery within 24 h, and the lumbar spinal MRI findings mimicking arachnoiditis disappeared.

In the previous chapter we discussed imaging methods that use relatively standard techniques available on most clinical MRI scanners. In this chapter we focus on cutting edge techniques for spinal MRI.

A 45-year-old man had subarachnoid hemorrhage (SAH) which was confirmed by lumbar puncture, since it was negative on head computed tomography. The result of neurological examination was normal. Following pan-cerebral angiography and cranial magnetic resonance imaging (MRI) failed to find out the cause of bleeding. The whole spinal MRI revealed an intradural-extramedullary mass lesion at the upper thoracic level which was consistent with cavernous malformation after surgery. When patients presented with SAH of no spinal symptoms, the diagnosis of an intradural-extramedullary cavernous malformation is challenging. A whole spinal workup should be considered in a patient with spontaneous SAH when bleeding from intracranial origin is carefully excluded.

Objectives: The objective of this presentation is to point out some diagnostic clues and presentations of MR myelograms in routine spinal MRI which may help radiologists and clinicians with better detection or description of spinal and extra-spinal pathologies. Patients and Methods: We collected more than 100 cases of spinal MRI from teaching files of five institutions during the past 10 years. All patients presented with symptoms and signs related to spinal disorders. Results: Imaging evaluation of patients with the possibility of spinal disk disorders can sometimes be very challenging, as low back pain or pain in the thoracic and cervical regions which is usually caused by intervertebral disks abnormalities, could also be triggered by a wide spectrum of pathologies in neighboring structures. In this presentation, with a view to updating the current therapeutic and diagnostic approaches, we have categorized and classified these potential pain sources and other incidental findings in MR myelograms of a number of patients as below: 1) infections 2) kidney, bladder and prostate problems 3) cholelithiasis 4) pleural effusion or chest infections 5) ovarian cysts or cystic masses 6) tumors 7) nondiscogenic lesions such as spinal arachnoid or other developmental cysts 8) miscellaneous (e.g., ascites) 9) trauma Conclusions: In this educational presentation, we will present a large collection of pathologies in MR myelograms of a number of patients presenting with pain in and around spinal region who referred to us to rule out disk abnormalities. Awareness, understanding, and recognition of these presentations may permit the radiologists to play a significant role in avoidance of unnecessary medical and surgical interventions or unnecessary diagnostic evaluation procedures.

The authors compared the data of stroke patients who received thrombolytic therapy with nonthrombolyzed controls. Their findings show improved outcomes in patients with diabetes, previous strokes, or both. There is no justification for the exclusion of these patients from thrombolytic therapy. See p. 1866; Editorial, p. 1862 The authors evaluated the diagnostic utility of spinal MRI with T1- and T2-weighted subtraction analysis in 17 patients with spontaneous intracranial hypotension. Epidural collection of CSF was identified in all cases; therefore, invasive investigations were avoided. This MRI …

A 35-year-old woman was hospitalized due to impaired consciousness. Magnetic resonance imaging (MRI) revealed multiple parenchymal lesions in supra and infratentorial brain regions, which were considered responsible for her declining consciousness level. She was treated with intravenous methylprednisolone. Neurological symptoms improved and she was discharged. She was readmitted 14 months later due to intractable hiccups. A follow-up brain MRI revealed an abnormal signal near the area postrema in the dorsal medulla. Serum aquaporin-4 antibody levels were positive, but there were no visual manifestations or myelitis. Spinal MRI was negative for longitudinally extended transverse myelitis throughout the clinical course.

Cranial MRI has been shown to be a safe procedure in patients with a vagus nerve stimulator (VNS), but body MRI may cause overheating of the stimulator lead. Here we report a case of a patient with an implanted vagus nerve stimulator who required a cervical spinal MRI due to a rapidly progressive paraparesis. The spinal MRI was performed in a 1.5T scanner without complications showing a nearly complete compression of the spinal cord.

Background and purpose Pediatric multiple sclerosis (MS) clinical and incidence data have been reported for several countries but valid age dependent incidence data are not yet available. The true incidence of pediatric MS in Germany was estimated and the clinical characteristics at diagnosis according to the 2005 McDonald criteria are described. Methods Between 2009 and 2011 active prospective nationwide surveillance for MS in children and adolescents ≤15 years included all pediatric hospitals, MS centers and private practices specialized in MS. Data were adjusted for under-reporting by capture−recapture from an independent second source. Results The estimated incidence of pediatric MS was 0.64 per 100 000 person-years with clear increase from age group ≤10 (0.09/100 000) to 2.64 per 100 000 in age group 14−15 years. All had relapsing−remitting disease with polysymptomatic onset in half of the cases. Spinal MRI with positive findings in two-thirds of patients contributed to diagnosis. Conclusion Using an active prospective surveillance system and the McDonald criteria for first MS diagnosis the age-related incidence of pediatric MS in Germany was uncovered and is more common than in previous estimates. Thorough application of McDonald criteria and inclusion of spinal MRI data allowed for early diagnosis in almost 90% of cases.

Background: Spinal magnetic resonance imaging (MRI) finding of longitudinally extensive spinal cord lesions (LESCL) extending over three vertebral segments and involvements of spinal central gray matter have been reported in patients with neuromyelitis optica (NMO). Objectives: We aimed to review spinal MRI findings in NMO and multiple sclerosis (MS), and to determine whether the “bright spotty lesions” (BSLs) are a discriminative finding of NMO. Methods: For this study, 24 consecutive patients with NMO and 34 patients with MS were enrolled. BSLs were defined as very hyperintense spotty lesions on axial T2WI. We also studied the length, distribution, signal homogeneity, size, and presence of contrast-enhanced lesions. Results: BSLs were more frequently found in patients with NMO (54%) than in those with MS (3%; p < 0.01). LESCL were found in 67% of the NMO patients. BSLs were seen in 63% of the patients without LESCL. BSLs or LESCL were found in 88% of the NMO patients. Inhomogeneous lesions, transversally extensive lesions, and central lesions were more frequently seen in NMO than in MS. Conclusions: BSLs are a newly defined spinal MRI finding specifically seen in NMO. In combination with LESCL, BSLs can help differentiate patients with NMO from those with MS with higher sensitivity than LESCL alone.

Image exams are a fundamental tool in health care for decision making. A challenge in Content-based image retrieval CBIR is to provide a timely answer that complies with the specialist's expectation. There are different systems with different techniques to CBIR in literature. However, even with so much research, there are still particular challenges to be overcame, such as the semantic gap. In this paper, we presented a new spinal-image comparison method based on the perception of specialists during his/her analysis of spine lesions. We take advantage of a color extractor and propose a shape descriptor considering the visual patterns that the radiologists use to recognize anomalies in images. The experiments shown that our approach achieved promising results, testifying that the automatic comparison of images should consider all relevant visual aspects and comparisons' criteria, which are defined by the specialists.

Spinal hydatid cyst is an uncommon but serious condition. Intradural presentation is extremely rare. The case reported herein describes an unusual recurrent hydatidosis with progression of recurrence and spreading into intradural extramedullary field.

There are many traps in spinal MRI in part related to the technique but also due to the existence of anatomical variations, lesions which are difficult to confirm because of non-specific signs, and sometimes rare conditions.