Updates to Spinal MRI€¦ · 11/03/2020 · Chiropractic Management 43 June 14 2003 Feb 18 2004 Sequestered Fragment • Uncontained disc material –NOT connected to parent disc

Updates to Spinal MRI

1Warshel


Chad D. Warshel, D.C., DACBR

Associate Professor, NYCC

Director, MS in Diagnostic Imaging Residency

Chiropractic Radiologist, NYCC Diagnostic Imaging

www.nyccdi.com

Classification of Disc Pathology

• Originally published by ASNR in 2001

• Redesigned in 2014– Lumbar Disc Nomenclature: Version 2.0

– The Spine Journal 14 (2014) 2525-2545

Classification of Disc Pathology

• Normal

• Congenital/Developmental Variation

• Degenerative/Traumatic

• Infectious/Inflammatory

• Neoplastic

• Morphologic Variant of Uncertain Significance

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Normal

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• Morphologically normal– Irrespective of clinical issues

• No degenerative or adaptive changes

• Disc does not extend beyond bony margins

• The horizontal cleft– Small dark line in center of

the nucleus

– 2 considerations• Normal with aging

• Early degenerative changes

T1

T2

Normal

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• The horizontal cleft– Small dark line in center of

the nucleus



Normal




• The horizontal cleft– Small dark line in center of the

nucleus



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T2


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Congenital / Developmental Variants

• Discs that are altered as an adaptation to structural variants

• Conditions include:– Scoliosis

– Transitional segments

– Spondylolisthesis

– Hemivertebra

– Butterfly vertebra7

8C. Warshel Pathfile



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12http://www.scoliosisjournal.com/content/figures/1748-7161-3-3-4-l.jpg

http://orthoinfo.aaos.org/figures/A00423F02.jpg


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Degenerative / Traumatic

• Degeneration

• Annular fissures

• Herniation

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Degenerative Disc Disease

• Imaging findings– Decreased T2 nuclear

signal

– Loss of disc height

– Diffuse disc bulging

– Osteophyte formation



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Degenerative Disc Disease


Modic Changes

• Changes in marrow in response to degenerative changes

• Necessary to recognize, so that they are not confused with other pathologies

• Typical spinal marrow is cellular red marrow

• 3 types of change can occur

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Modic Type 1

• Type 1: ↓T1 ↑T2

– Replacement with fibrovascular tissue

– Edematous, acute, thought to be associated with Sx



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Modic Type 2

• Type 2: ↑T1 ↔T2– Fatty replacement or red marrow

– Considered chronic, not associated with Sx


Modic Type 3

• Type 3: ↓T1 ↓T2– Replacement of marrow space by bony sclerosis

– Signal approaches that of cortical bone


Modic Decision Tree

T1

T1 Bright: Type 2

T1 Dark: T2?

T2 Bright:Type 1

T2 Dark:Type 3

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Annular Fissures

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• aka – Annular tears

– High intensity zones (HIZ)

• DOES NOT necessarily represent a traumatic etiology

• M/C in the posterior disc

• 3 types– Transverse

– Concentric

– Radial ****• Only radial are important

Annular Fissures

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• Transverse – Involves the peripheral

annulus

– Represents an separation of disc insertion fibers (Sharpey’s fibers) at the cartilaginous endplate

– Can be seen as a vacuum cleft on plain film

– Rarely seen on MRI

– No clinical significance


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Annular Fissures

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• Concentric– Vertically oriented

separation between annular layers

– No evidence of symptoms

Annular Fissures

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• Concentric– Vertically oriented

separation between annular layers

– No evidence of symptoms

C. Warshel Pathfile

Annular Fissures

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• Radial – Longitudinal fissuring

extending from the nucleus through multiple layers of annulus

– Can allow for significant nuclear migration

– Considered to be associated with symptoms of discogenicpain

• Growth of vascularizedgranulation tissue in the tear

• Chemical and mechanical irritation to the outer (innervated portion) of the annulus


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Annular Fissures

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• Radial – Extending from the

nucleus through multiple layers of annulus

– Can allow for significant nuclear migration

– Considered to be associated with symptoms of discogenic pain

C. Warshel Pathfile

Intervertebral Disc Herniation

• Herniation is a general term– Displacement of disc material

beyond the normal disc margins by 2mm or more

• Good for clinical discussion, but non-specific

• Terminology has historically been imprecise

• ASNR standardized the nomenclature

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http://www.spineuniverse.com/1p/rauschning/1cervspine/cervs13.html

Disc Herniation Classification

• Morphology– Bulge: NOT a herniation**

– Protrusion

– Extrusion

– Sequestered Fragment

• Location– Central

– Subarticular (formerly paracentral)

– Foraminal

– Extraforaminal

• Neurologic involvement

30http://www.spineuniverse.com/1p/rauschning/1cervspine

/cer s13 html

Contained

Uncontained


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Disc Herniation Morphology

• Classification of disc herniation type requires viewing BOTH axial and sagittal images

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Disc Bulge

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• Frequently associated with degeneration– Disc looses height,

expands outward

• Disc extends beyond body margin generally less than 3mm

• Involves greater than 25% of the circumference C. Warshel Pathfile

Disc Bulge

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• Bulges can be– Symmetric

– Asymmetric


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Disc Protrusion

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• Focal extension of disc beyond the vertebral body margin

• The base is greater than the depth in both sagittal and axial dimensions

Protrusion

Protrusion

Disc Protrusion

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• Often ASx– 1/3-2/3 of the ASx

population has a protrusion

• Just because there is a structural lesion there do not have to be symptoms– Treat the patient,

not the MRI

C. Warshel Pathfile

Disc Extrusion

• Nuclear material not contained by the outer annular fibers

• Maintains continuity with the parent disc

• Base is narrower than the depth in either the sagittal or axial plane

• Acute extrusions may show high intensity on T2 and postcontrast T1 due to surrounding granulation tissue

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Disc Extrusion

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• Base is narrower than the depth

• MUST compare the axial and sagittal

• Disc material can look like a protrusion in one plane and an extrusion in the other– If either looks like an

extrusion, it is an extrusion NOT a protrusion

Disc Extrusion

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• Disc material can look like a protrusion in one plane and an extrusion in the other– If either looks like an extrusion, it is an extrusion NOT a

protrusion

Looks like an extrusion


Disc Extrusion

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protrusion


Looks like a protrusion


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Disc Extrusion

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protrusion

Looks like a protrusion


Disc Extrusion

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• Extrusions have been shown to reduce in size with time

• ~90% of extrusions with radiculopathy managed non-operatively with aggressive conservative management have been shown “to do well” (Kaplan)(from Saal SPINE 14(4) 431-437)

• Pain more likely from chemical causes than mechanical compression

C. Warshel Pathfile

Disc Extrusion

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Disc Extrusion with Chiropractic Management

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June 14 2003 Feb 18 2004

Sequestered Fragment

• Uncontained disc material– NOT connected to parent disc

• Can migrate in the spinal canal– Usually ~ 5mm

– Can migrate significantly • 2-3 levels

– Can affect multiple nerve roots

• Acute sequestration may have surrounding high T2 and postcon T1 signal from vascular granulation tissue

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• Can be very subtle and easy to overlook

• Examine the entire series, not just the midsagittal and the disc plane axials

• Sequestration makes minimally invasive spine surgery less than optimal, generally requires an open procedure

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47www.mypacs.net


48T1 PostCon w w/o FatSatwww.mypacs.net


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Disc Herniation Locations

• Location – Central

– Subarticular

– Foraminal

– Extraforaminal

• ~92% are central and subarticular– 4% foraminal

– 4% extraforaminal

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Disc Herniation Locations

• 90% of disc contour abnormalities occur at L4/L5 and L5/S1 in the lumbar spine and C5/C6 and C6/C7 in the cervical spine

• 1/3 – 2/3 of asymptomatic people have a disc abnormality on MRI

• Only 1 % of asymptomatic patients have a disc extrusion on MRI

Disc herniations and nerve roots

• Cervical disc herniations– Central, subarticular, and foraminal all hit the

exiting roots• e.g. C5/C6 subarticular hits the C6 root

• Lumbar disc herniations– Central and subarticular discs hit the

transiting nerve root in the lateral recess– Foraminal herniations hit the exiting roots

• e.g. L4/L5 subarticular hits the L5 rootbut L4/L5 foraminal hits the L4 root


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Neurologic Involvement

• Remember, a large enough disc herniation can effect MULTIPLE nerve roots

• Disc herniations can also have significant effect on the cord or cauda equina

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Intravertebral Disc Herniation

• Schmorl’s nodes– Usually occur during

the pubescent growth spurt

– Occasionally traumatic

– Imaging findings can distinguish the difference

– Typically ASx, unless acute

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56Image Source: M. Mestan Pathfile

Documents

Updates to Spinal MRI€¦ · 11/03/2020 · Chiropractic Management 43 June 14 2003 Feb 18 2004 Sequestered Fragment • Uncontained disc material –NOT connected to parent disc