Magnetic Resonance Imaging of the Spine 5

J. W. M. Van Goethem

Contents
5.1
5.1 Patient Positioning and Coils . . . . . . . . . . . 147 Patient Positioning and Coils
5.1.1 Positioning of the Patient . . . . . . . . . . . . . . 147
5.1.2 Coils . . . . . . . . . . . . . . . . . . . . . . . . . 147 5.1.1
5.1.3 Positioning of the Coil in Relation to the Patient 148 Positioning of the Patient
5.1.4 Patient Information . . . . . . . . . . . . . . . . . 149
5.2 Sequence Protocol . . . . . . . . . . . . . . . . . . 149 In magnetic resonance (MR) imaging of the cervical
5.2.1 General Guidelines . . . . . . . . . . . . . . . . . 149 and thoracic spine, patients are positioned supine, head
5.2.2 Localizer Images . . . . . . . . . . . . . . . . . . . 150
first. When imaging the lower thoracic spine, patients
5.2.3 Specific Types of Sequences . . . . . . . . . . . . 150
5.2.3.1 Degenerative Disc Disease . . . . . . . . . . . . . 150 can be positioned feet first if they are not too tall.
5.2.3.2 Postoperative Lumbar Spine . . . . . . . . . . . . 152 Otherwise, their feet may reach the end of the magnet
5.2.3.3 Postoperative Cervical Spine . . . . . . . . . . . . 153 bore before they are in the correct position. If the mag-
5.2.3.4 Nontumoral Medullary Lesions . . . . . . . . . . 154 net is open on both sides, this may not be a problem.
5.2.3.5 Intraspinal Tumoral Lesions . . . . . . . . . . . . 154 Children are positioned feet first for thoracic examina-
5.2.3.6 Vertebral Metastases . . . . . . . . . . . . . . . . 154 tions. We use a knee support for patient comfort, which
5.2.4 Sequence Parameters . . . . . . . . . . . . . . . . 155
in turn is favorable for the image quality since patients
5.2.5 Slice Thickness and Orientation . . . . . . . . . . 155
5.2.6 Saturation Zones . . . . . . . . . . . . . . . . . . 156
are less likely to move during the examination.
5.2.7 Special Sequences . . . . . . . . . . . . . . . . . . 157 MR imaging of the lumbar and sacral spine is best
5.2.7.1 Coronal Images . . . . . . . . . . . . . . . . . . . 157 performed with the patient in supine position and feet
5.2.7.2 Large FOV . . . . . . . . . . . . . . . . . . . . . . 157 first. This tends to diminish claustrophobic reactions.
5.2.7.3 Sequences with Fat Suppression . . . . . . . . . . 157 We do not use a knee support in imaging the lumbar
5.2.7.4 Out-of-Phase Imaging . . . . . . . . . . . . . . . 157 spine, since this reduces the lumbar lordosis and may
5.2.7.5 Ultrafast Imaging . . . . . . . . . . . . . . . . . . 158 lead to an underestimation of disc herniations. Only
5.2.7.6 MR Myelography . . . . . . . . . . . . . . . . . . 158
when patients are unable to remain motionless without
5.2.7.7 MR Angiography . . . . . . . . . . . . . . . . . . 158
5.2.7.8 Diffusion-Weighted Imaging . . . . . . . . . . . . 158 support of the legs, e.g., patients with substantial back
5.2.7.9 Functional Imaging . . . . . . . . . . . . . . . . . 158 pain, should a knee support be used. In any case, the
5.2.8 Contrast Media . . . . . . . . . . . . . . . . . . . 161 patient should be positioned as comfortably as possible
5.3 Clinical Examples . . . . . . . . . . . . . . . . . . 161
to minimize movement artifacts. On high field magnets
5.3.1 Degenerative Disease . . . . . . . . . . . . . . . . 161 with strong gradients, ear plugs or a headphone should
5.3.2 Herniated Disc . . . . . . . . . . . . . . . . . . . . 163 be provided to the patient.
5.3.3 Inflammatory and Infectious Lesions . . . . . . . 164
5.3.4 The Postoperative Lumbar Spine . . . . . . . . . 166
5.3.5 Spinal Tumors . . . . . . . . . . . . . . . . . . . . 166 5.1.2
5.3.5.1 Intramedullary Tumors . . . . . . . . . . . . . . . 166 Coils
5.3.5.2 Intraspinal Extramedullary Tumors . . . . . . . . 169
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 In general, two types of coils are used in spine imaging:
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . 172 linearly polarized (LP) and circularly polarized (CP)
coils. CP coils are constructed to generate more signal
148 J. W. M. Van Goethem

and, hence, provide images with a higher signal-to- not up to par with images generated with local coils.
noise ratio (SNR). Therefore, CP coils are preferred. Therefore, subtle lesions may be missed, e.g., smaller
Although all coils are designed to receive the signal disc herniations or intramedullary lesions as in multi-
generated by the patient during imaging, only certain ple sclerosis (MS). It is, therefore, preferable to perform
coils are also used to transmit the radiofrequency (RF) separate examinations of the cervical, thoracic, and/or
pulses used in MR imaging. These so-called send- lumbosacral segments of the spine in such cases.
receive coils tend to produce better images, since the RF
transmission is performed closer to the region of inter-
est. 5.1.3
Usually, one type of coil can be used for imaging the Positioning of the Coil in Relation to the Patient
thoracic and lumbar spine. It consists of a flat box
incorporated in a lumbar (or thoracic) support or When imaging the thoracic spine, it can be useful to
directly incorporated into the patient table. Depending attach one or more markers on the skin of the patient’s
on the type of coil and the manufacturer, these coils back prior to starting the examination. These markers
generate a maximum field-of-view (FOV) of 25–40 cm. simplify the problem of determining the examined lev-
A cervical spine (CS) coil is usually more raised so els afterwards, especially in a system in which it is not
that it provides better support for the patient’s neck. In possible to obtain large FOV (50 cm) localizer images
general, it is made of a lower and an upper part, where- with the body coil while the surface coil is already in
by the latter is fixed in position after the patient is place. The use of a console-operated table movement, if
placed on the lower part. The maximum FOV of these available, also facilitates this problem.
coils usually covers the craniocervical junction, the CS, When positioning patients in the cervical coil, one
and the cervicothoracic junction. Depending on the coil must try to place the coil relatively low down so that
design and the patient’s stature, imaging down to the cervico-thoracic junction is included in the images. To
first to sixth thoracic vertebra may be possible. Some minimize movement, a cervical collar can be used for
manufacturers also provide circular solenoid coils, cervical MR examinations. In patients with a very pro-
which can be placed around the neck. These coils tend nounced thoracic kyphosis and/or stiff CS, normal
to generate a smaller FOV. Flexible coils can be used in positioning in the cervical coil may be impossible.
patients who cannot be positioned in the normal cervi- Some coils allow imaging without the upper part
cal coil, e.g., patients with large neck collars or extreme attached, but one still has to pay attention to be sure the
thoracic kyphosis. distance between the coil and the neck is not too large.
If the magnet is equipped with phased-array spine It sometimes helps when cushions are placed under the
coils, they should be used since coil selection and patient’s buttocks and/or legs. In extreme cases, it may
patient positioning in relation to the coil are less criti- be necessary to allow the patient to lay his or her head
cal. The use of several phased-array coils simultaneous- on a pillow. In these cases, one can use a flexible or col-
ly allows for a larger FOV. Moreover, new software solu- lar-like coil or, if this is not available, the body coil. This
tions, known as parallel acquisition technique (PAT) may also be the case in patients with dyspnea, who are
and SENSE, permit a considerable reduction in acquisi- unable to lie completely flat.
tion time using phased-array coils in spine imaging For MR imaging of the lumbar spine without
with a large FOV. If phased-array spine coils are not phased-array coils, the center of the coil should be posi-
available and a very large section of the spine, or even tioned about 5 cm above the iliac crest (which is usual-
the entire spine, needs to be imaged, the built-in body ly at the L4–5 level). The conus medullaris and the
coil should be used. Depending on the homogeneity of sacrum should be included in the FOV. For all examina-
the magnetic field outside the magnet center and the tions, one should try to match the center of the region
length of the gradient coils, 45–50 cm of the spine may of interest to the center of the bore of the magnet.
be visualized (which is the complete spine in children
or small individuals). Indications for imaging the entire
spine without use of phased-array coils should be care-
fully monitored. If the body coil is used, image quality
and, in particular, contrast and spatial resolution are
 5 Magnetic Resonance Imaging of the Spine 149

5.1.4 their child inside the magnet, lying in prone position,

Patient Information head to head with the child. With anxious patients, it
can be helpful to leave a member of the nursing staff
Patients should be cleared for any MR imaging contra- inside the magnet room to calm the patient down when
indications before they enter the magnet room. They necessary. Anxiolytic medication can be beneficial in
should also be informed of the benefits and potential claustrophobic patients.
risks of MR imaging before the examination is per- MRI in patients with metallic or electronic implants
formed. In particular, before administering intravenous is discussed further below (see 5.2.3.2 The Post-
contrast products, informed consent (written or oral) operative Lumbar Spine).
should be obtained.
The scenario and length of the examination should
be explained in understandable terms. It is helpful to 5.2
keep the patient informed during the examination Sequence Protocol
about the length of each sequence. That way, swallowing
and movement can be minimized since patients will 5.2.1
have a better idea about the time they must keep still. General Guidelines
As with all MR examinations, the patient should be
instructed to lie as motionless as possible. Excessive In general, both sagittal and axial images are obtained
thoracic or abdominal breathing movements should be in spine imaging.
prevented when imaging that region. In imaging the CS, T1- and T2-weighted images (WI) offer different and
the patient must be instructed not to swallow or at least complementary information.
minimize swallowing during the measurements. Since On T2-WI, normal intervertebral discs are bright.
this is very hard for some patients, it may be useful to With aging, water loss occurs, the T2 relaxation time
leave enough time between measurements (more than shortens, and the discs gradually become darker
15 s) to allow the patient to swallow or cough. (degenerative disc disease or ‘black disc disease’).
When examining children, we allow a parent(s) to be However, with longer echo train lengths (ETL) (more
present in the magnet room. With young children echoes sampled after each 90° pulse), normal discs also
(<6 years), parents are sometimes placed together with become darker due to certain physical effects (Fig. 5.1).

Fig. 5.1A,B. Normal and ultrafast T2-

weighted images (WI) from the same vol-
unteer. A The routine turbo spin-echo
(TSE) sequence. B The ultrafast sequence
(see Tables 5.1 and 5.2 for the complete
sequence parameters). Notice the excellent
spatial resolution of both images (both
obtained with a 512 matrix). The ultrafast
sequence is noisier and darker in most
areas except cerebrospinal fluid (CSF), due
to lengthening of the echo train. This may
cause problems in accurately diagnosing
degenerative disc disease
150 J. W. M. Van Goethem

Therefore, in order to diagnose degenerative disc dis- of little importance and depends on the manufacturer
ease, sagittal T2-WI with a relatively short ETL are pref- of the system. The FOV of the localizers should be larg-
erable (e.g., 15). Sagittal T2-WI are also excellent to vis- er than the FOV of the images desired. The same coil
ualize the spinal cord and cauda equina nerve roots. (surface or body) should be used as the one to be used
Finally, spinal canal stenosis and impressions on the during the actual examination. The coronal localizers
thecal sac are most easily recognized on sagittal T2-WI. are positioned so that they intersect the spine.
One should be aware of the fact that turbo spin-echo When imaging the thoracic spine, extra-large FOV
(TSE) or fast spin-echo (FSE) T2-W sequences are not sagittal localizers using the body coil (or phased-array
effective in diagnosing marrow-infiltrating disease, coils) are useful to determine the exact levels to be
unless fat-suppression techniques are used. imaged. Sagittal sequences are positioned parallel to
Sagittal T1-WI are more sensitive than conventional the spine on coronal localizers. Axial images are posi-
nonfat-suppression TSE/FSE T2-WI in detecting bone- tioned on sagittal localizers, perpendicular to the spinal
marrow disease, e.g., degenerative endplate changes or canal, rather than parallel to the intervertebral disc
vertebral metastases, but short T1 inversion recovery space.
(STIR) or other fat-suppression T2-WI are also able to
increase the detection of certain bone marrow diseases.
Also, the difference between osteophytes and disc mate- 5.2.3
rial (with or without posterior disc protrusion) is usu- Specific Types of Sequences
ally better appreciated on T1-WI, especially in the CS.
The epidural fat tissue in the lumbar (and thoracic) The sequences used in MR imaging of the spine depend
spine is very bright on T1-WI and contrasts well with on the kind of pathology (expected to be) found.
the dural sac and the intervertebral disc. This is why
axial T1-WIs are preferred in the (thoraco-)lumbar 5.2.3.1
region. Since acquisition times are substantially short- Degenerative Disc Disease
ened with the newer techniques, we also use axial T2-
WIs in our standard imaging protocol of the (thoraco- In imaging patients with degenerative spinal disease,
)lumbar spine. This sequence allows excellent visualiza- sagittal T1 and T2-W SE or TSE sequences are used for
tion of the nerve roots in relation to other structures, all spine examinations. In the CS, axial T2-W GRE
especially the intervertebral disc. sequences are added, while in the thoracic and lumbos-
In the CS, there is no epidural fat tissue, but an epi- acral region, axial T1-W SE images are applied. In axial
dural venous plexus. To optimize contrast between the T2-WI, GRE sequences are preferable over SE sequenc-
dural sac and the intervertebral discs, axial T2-WIs are es since SE sequences, and especially TSE sequences,
preferred. These images are also useful in detecting tend to be severely degraded by cerebrospinal fluid
medullary disease. On conventional spin-echo (SE) and (CSF) flow artifacts. Also, as mentioned before, GRE
TSE T2-WI, it is difficult to differentiate osteophytes sequences are of value in differentiating between disc
from disc material. On gradient-echo (GRE) images, and bone, e.g., soft disc herniation versus osteophytic
these can usually be differentiated because bone is spur formation.
markedly hypointense and disc is hyperintense. For all axial and sagittal T1-WI, TSE is preferable
Moreover, the shorter echo time of gradient-echo T2-W over SE imaging since the imaging time is considerably
sequences in comparison to spin-echo sequences shorter. The slight blurring or loss in spatial resolution
reduces CSF-induced pulsation artifacts. is an acceptable penalty to pay for the shorter imaging
time (Fig. 5.2). In choosing a TSE T2-W sequence for
sagittal imaging, one should experiment with different
5.2.2 ETLs. If a long ETL is chosen (>10), the discs become
Localizer Images darker, the contrast with the vertebrae decreases, and
only the bright CSF stands out. An ETL should be cho-
After positioning the patient, mid-sagittal and coronal sen that is long, but with an acceptable remaining signal
localizer images (syn. scout images, survey images) are of the intervertebral discs to be able to differentiate
obtained. The type of sequences used for this purpose is between normal and degenerative discs (Fig. 5.1). Some
 5 Magnetic Resonance Imaging of the Spine 151

Fig. 5.2A,B. Turbo spin-echo (TSE) and

spin-echo (SE) T1-weighted images (WI).
Sagittal T1-WI from the same volunteer.
A The routine TSE sequence (see Table 5.1
for the complete sequence parameters).
B The SE sequence (TR 500, TE 15,
256 × 512, TA 4’19’’). The SE sequence has a
lower resolution in the phase direction
(anteroposterior) to partially compensate
for the longer acquisition time. Image con-
trast is very similar, but signal-to-noise
ratio (SNR) is clearly superior in the TSE
image. Therefore, there is no reason for
using SE T1-W sequences in normal spine
imaging

Fig. 5.3A,B. Cerebrospinal fluid (CSF) flow

compensation. Sagittal T2-weighted imag-
es (WI) of the mid-thoracic spine from
the same volunteer. A The routine TSE
sequence for the thoracic spine. B The
sequence without CSF-flow compensation
(actually the sequence used in the lumbar
spine) (see Table 5.1 for the complete
sequence parameters). The latter (B) is
slightly blurred, especially at the level of
the thoracic medulla, due to the non-com-
pensated up and downward movement of
the CSF (pulsating CSF in the read direc-
tion)

sagittal T2-W sequences are flow compensated; this obtained even if no pathology is discernible on the sag-
means they are specifically designed for imaging the ittal images. No examination of the CS is complete with-
(cervical and thoracic) spine by minimizing flow out axial images. In the lumbosacral or thoracic spine,
artifacts caused by the craniocaudal CSF pulsations. axial images should only be obtained at the level(s) of
If these sequences are available, they should be used the (most) affected discs (as seen on the sagittal T2-
(Fig. 5.3). WI). The thoracolumbar neural foramina are much
In the CS, axial images are usually positioned from more accurately displayed on sagittal images than on
C2 down to T1. Since the cervical neural foramina are axial images (Fig. 5.4).
not visible on sagittal images, axial images should be
152 J. W. M. Van Goethem

Fig. 5.4A–D. Foraminal stenosis. Foraminal

stenosis can be underestimated on axial
images. In this figure, three consecutive
axial images through the neural foramen
are depicted (B,C,D) and cross-referenced
on the parasagittal image (A). Note that
only the first of the axial images (B, right
upper quadrant) actually represents the
part of the foramen through which the
nerve roots pass. Anatomic relationships
in the neural foramen are much better
depicted on the sagittal image. The slight
deformity or compression of the nerve
sheath as seen on this image is not visible
on the axial images

5.2.3.2 ferentiate from the normal small amount of enhance-

Postoperative Lumbar Spine ment usually seen on fat-suppression images. In some
rare cases, fat suppression can be helpful in the diffe-
Additional axial SE T1-WI after intravenous gadolin- rentiation between postoperative blood and normal
ium injection should be obtained in patients after lum- epidural fat.
bar disc surgery. The postcontrast images should be Metallic implants used for spinal fusion are not a
obtained as quickly as possible after gadolinium injec- contraindication for MR imaging. However, superpara-
tion (sequence completed within 5–8 min after injec- magnetic materials, e.g., steel, will create severe suscep-
tion). The most important use of gadolinium is in dif- tibility artifacts (Fig. 5.5). TSE sequences are less sus-
ferentiating scar tissue from (recurrent or residual) disc ceptible than SE sequences, which in turn are less sus-
herniation, since the latter is generally accepted to be a ceptible than GRE sequences (Fig. 5.5). Also, shortening
possible indication for reintervention. Also, the evalua- the echo time and increasing the bandwidth of the
tion of enhancement of nerves, meninges, posterior spi- sequence lessens artifacts. If a particular region is not
nal facet joints (i.e., zygapophyseal joints), and perispi- interpretable due to artifacts, it may be worthwhile try-
nal soft tissues is important in some patients. Some ing to swap read- and phase-encoding directions.
authors also stress the usefulness of (T)SE T2-WI or Nonsuperparamagnetic metals, e.g., titanium, only pro-
fluid-attenuated inversion recovery (FLAIR) T2-WI in duce RF artifacts, which are smaller in size.
addition to or instead of T1-WI after gadolinium in the Spinal stimulators and other electronic implant
differentiation of recurrent disc herniation and epidu- devices in principle constitute an absolute contraindi-
ral fibrosis. cation for MR imaging. Some types of electronic
Fat suppression can be used to differentiate enhanc- implants, however, are ‘MR-compatible’. This should be
ing scar tissue from epidural fatty tissue in i.v. gadolin- checked with the manufacturer and the surgeon or cli-
ium-enhanced T1-WI of the postoperative spine. nician who implanted the device before the patient is
However, the detection of abnormal postoperative brought into the magnet room. In any case, these devic-
nerve root enhancement may be more difficult to dif- es have to be switched off before the MR examination.
 5 Magnetic Resonance Imaging of the Spine 153

Fig. 5.5. Susceptibility artifacts. Superparamagnetic metal

implants (e.g., stainless steel) cause severe susceptibility artifacts.
Although these spinal orthopedic implants are not a contraindica-
tion for MR imaging in general, they almost always exclude imag-
ing of the involved region. Note, however, that the disc spaces
above the fusion are not affected

Patients have to be carefully instructed to signal during

the examination when they have the impression the
device is turned on again, or in any case when they
sense something unusual.

5.2.3.3
Postoperative Cervical Spine

No additional sequences are necessary since the prob-

lem of epidural fibrosis is almost nonexistent in the CS.
As in the lumbar spine, one should be aware of the sus-
ceptibility artifacts on GRE sequences that may be
caused by metallic implants (Fig. 5.6). In these cases, SE
or, better, TSE sequences are preferred.

Fig. 5.6A,B. Radiofrequency (RF) artifacts. Nonsuperparamag- sequences are preferred over gradient recalled echo (GRE) sequenc-
netic metals (e.g., titanium) do allow imaging of the region of the es; compare the sagittal TSE T1-W sequence (A) with the axial
implants, since they only cause RF artifacts, which are smaller than GRE T2-W sequence (B). Therefore, in these cases, GRE sequenc-
susceptibility artifacts. However, note that SE and especially TSE es should be replaced by (T)SE sequences, also in the axial plane
154 J. W. M. Van Goethem

5.2.3.4 5.2.3.6
Nontumoral Medullary Lesions Vertebral Metastases

When looking for inflammatory (MS) or infectious In screening for vertebral metastases, one should per-
medullary lesions, one should perform axial GRE T2- form sagittal TSE T1- and T2-WI. In addition, a sagittal
WI (instead of T1-WI) in the thoracic spine. In addi- GRE so-called out-of-phase sequence should be used.
tion, the routine sagittal T1-W and T2-W sequences are This is a sequence with a specific echo time (TE) corre-
performed. Gadolinium-enhanced images may be use- sponding to the time it takes for water and fat protons
ful in suspected inflammatory and infectious lesions, to move exactly 180° out-of-phase. This time depends
especially in nonviral myelomeningitis. on the field strength of the magnet and is approximate-
For suspected ischemic medullary lesions, diffusion- ly 7 ms for a 1.5-T imager, and 11 ms for a 1.0-T
weighted imaging (DWI) is very useful, both in the machine. In the normal adult human, the medullary
detection and the differential diagnosis. Moreover, DWI bone of the vertebral bodies contains approximately
allows us to make an assumption about the age of an equal amounts of water and fat protons. In out-of-phase
ischemic lesion (hyperacute, acute, chronic). conditions, the signal of both will cancel out, leaving the
vertebrae completely black. In the case of vertebral
5.2.3.5 pathology, however, the signal will increase, and as
Intraspinal Tumoral Lesions such, vertebral metastases (or other lesions) will clearly
stand out (Fig. 5.7).
In addition to the normal imaging protocol, one should If a metastasis extends into the spinal canal or neu-
perform axial and sagittal TSE T1-WI after gadolinium ral foramen, additional axial T1-WI after gadolinium
injection. injection should be performed.

Fig. 5.7A–C. Vertebral metastases. Out-of-phase gradient-echo ses, causes an increase in signal, making the involved region clear-
(A), unenhanced (B), and gadolinium-enhanced (C) TSE T1- ly stand out (A). Therefore, this is a good sequence in the search
weighted images (WI). Out-of-phase sequences use an echo time for vertebral metastases. Also note that hypointense bone-marrow
(TE) that effectively cancels out water and fat signals by imaging lesions on the T1-WI (B) (such as most metastases) become less
at a time when protons of both are in opposed phases (180°). conspicuous after administration of gadolinium, since enhance-
Therefore, structures that contain equal amounts of both water ment of the lesions renders them isointense to the normal marrow
and fat are effectively black on these sequences. This is especially (C). Compare, for example, the contrast of the small metastasis
true for vertebral bone marrow in the adult patient. Any patholo- subjacent to the superior endplate of L1 (arrow)
gy of the bone marrow, as in this patient with vertebral metasta-
 5 Magnetic Resonance Imaging of the Spine 155

5.2.4 Since motion (respiration, movement, pulsatile

Sequence Parameters blood flow, CSF flow, etc.) usually causes artifacts in the
phase-encoding direction, it can be useful to swap the
Table 5.1 lists the standard sequence parameters for MR read-out and phase-encoding directions. In the lumbar
imaging of the CS, thoracic, or lumbar spine. All matric- spine, choosing phase encoding in the craniocaudad
es of images with a large FOV (lumbar spine) should be direction diminishes artifacts due to CSF pulsations
at least 512. On some newer machines, even 1024 (Fig. 5.8).
matrices are possible.
Rectangular field-of-views (RFOV) can be used to
shorten the imaging time. However, this can also be
achieved by decreasing the number of acquisitions, e.g., 5.2.5
a sequence with two acquisitions and 50% RFOV is Slice Thickness and Orientation
identical in imaging time and SNR to the same
sequence with one acquisition and no RFOV (100%). Standard slice thickness for sagittal sequences in the
RFOV, however, may cause infolding (or wrap-around) spine is 3–4 mm. One should use an uneven number of
artifacts. To avoid infolding artifacts in general, over- slices so that the middle slice is precisely centered on
sampling can be used. In the read direction, this can be the midpoint of the spinal cord. For axial slices, one can
achieved without lengthening the acquisition. In the use 3-mm to 4-mm slices in the neck and 4-mm to 5-
phase direction, oversampling linearly increases the mm slices in the lumbar region, since lumbar disc spac-
imaging time, but SNR also increases. For this reason, es are relatively thick and the foramina are large.
100% oversampling and one acquisition is equal to no Thicker slices, although generating a significantly bet-
oversampling and two acquisitions, both in imaging ter SNR, are unsatisfactory in depicting small disc her-
time and SNR. Therefore, we can state: niations due to partial volume effects.
쐌 These axial slices should be oriented perpendicular
4 acquisitions + 50% RFOV
쐌 to the spinal canal rather than parallel to the interverte-
= 2 acquisitions + 100% RFOV
쐌 bral disc. Usually, this does not make much difference
= 1 acquisition + 200% RFOV
쐌 except in the CS when the discs are angulated down-
(100% phase oversampling)
ward.
This occurs in both imaging time and SNR, but the lat- Coverage on the sagittal images should include the
ter solution prevents infolding artifacts. There may, neural foramina on either side. At least part of the adja-
however, be an advantage in obtaining more acquisi- cent anatomic region should be imaged, e.g., the conus
tions with RFOV, since image degradation by motion medullaris in imaging the lumbar spine or the cranio-
artifacts decreases when more averages are obtained. cervical junction in imaging the CS. It is not unusual for

Table 5.1. Suggested sequence parameters for standard MRI of the lumbar and cervical spine. Imaging of the thoracic spine can be done
using lumbar spine sequences

Region Sequence Plane No. of TR TE Flip Echo Slice Matrix FOV Band No. of Acq.
type slices (ms) (ms) angle train thickness (mm) width acq. time
length (mm) (Hz) (min:s)

Lumbar TSE T1 Sag 11 835 12 180 5 4 512×410 320×320 195 2 2:19

TSE T2 Sag 11 4000 136 180 15 4 512×308 320×320 130 1 2:34
TSE T1 Ax 3×5 570 14 180 7 4 512×308 230×230 130 2 2:34
TSE T2 Ax 3×5 4000 99 180 15 4 512×308 230×230 130 1 1:38
Cervical TSE T1 Sag 11 750 10 180 3 3 512×308 280×280 195 2 3:32
TSE T2 Sag 11 2900 102 180 15 3 512×308 280×280 191 2 2:47
GRE T2 Ax 19 960 27 30 – 3,5 256×220 200×200 195 1 3:30

Abbreviations: TR repetition time (ms); TE echo time (ms); Matrix (phase × frequency matrix); FOV field of view (mm); Acq acquisi-
tion(s)
156 J. W. M. Van Goethem

Fig. 5.8A–D. Sagittal T2- WI from the same

volunteer. A The sequence with swapped
phase and read directions (phase direction
craniocaudal). B The non-swapped
sequence. Swapping reduces blurring due
to artifacts from the pulsating cerebrospi-
nal fluid (CSF). Magnified views (C, D) of
the same anatomic region clearly show
blurring of the conus medullaris and the
nerve roots on the non-swapped image
(D). Do not use rectangular field-of-views
(RFOV) in combination with swapped
images since this will create infolding arti-
facts

a conus medullaris tumor to present clinically as a spins that lie outside the region of interest. They are
radiculopathy or low-back pain. extremely useful to eliminate motion-induced artifacts
arising outside the spine. If possible, all tissues in front
of the spine should be saturated. This diminishes the
5.2.6 phase-encoding artifacts caused by moving tissues in
Saturation Zones this region, e.g., breathing, swallowing, cardiac motion,
pulsating blood flow, etc. If the saturation is not effec-
Saturation techniques use a selective pulse that is tive enough, two smaller bands instead of one larger
applied to tissues either inside or outside the field of band can be used.
view. Their purpose is to excite (or saturate) moving
 5 Magnetic Resonance Imaging of the Spine 157

5.2.7
Special Sequences

5.2.7.1
Coronal Images

Coronal images can be useful in evaluating spinal scoli-

osis. Also, paraspinal extension of processes, such as
foraminal neurinomas, are more clearly depicted.
Finally, developmental anomalies, such as lumbosacral
transitional vertebrae (Fig. 5.9), craniocervical junction
abnormalities, or failures of segmentation and fusion
of vertebrae, are more readily assessed on coronal
images.

5.2.7.2
Large FOV

In some cases, the use of a large FOV can be helpful. In

particular, when screening or staging a patient with ver-
tebral metastases, an overview of the spine is sensible.
When phased-array coils are available, large segments
of the spine can be portrayed with excellent image qual-
ity. However, when phased-array coils are not available,
the body coil must be used, and the image quality will
be suboptimal. For vertebral metastases, this should not
Fig. 5.9. Transitional vertebra. A lumbosacral transitional vertebra
pose a major problem, but in screening for more subtle can be difficult to detect if only axial and sagittal images are
lesions, such as intramedullary lesions in MS, these acquired. This (para)coronal image clearly depicts the abnormal
large FOV images may give false-negative results. articulation of the left L5 transverse process with the sacrum and
the ilium, with formation of a pseudarthrosis (arrow)

5.2.7.3
Sequences with Fat Suppression
water and fat protons to progress 180° out of phase. In
In the CS, no intraspinal fat is present, and fat-suppres- these circumstances, objects consisting of equal
sion sequences are of limited use. In the lumbar spine, amounts of water and fat protons are hypointense
fat suppression can be used to differentiate enhancing (black) on MR images, since the contributions of water
scar tissue from epidural fat tissue in gadolinium- and fat protons to the overall signal intensity effective-
enhanced T1-WI of the postoperative spine. Never- ly cancel each other out. During adult life, vertebral
theless, the same result can be obtained by subtracting bodies consist more or less of equal amounts of water
pre- and postcontrast images without fat suppression. and fat. When a pathologic process disturbs this equi-
In some rare cases, fat-suppression techniques can be librium, the vertebrae will show areas of higher signal,
helpful in the differentiation between blood and fat. which clearly stand out in relation to the normal black
background. A frequently used indication involves
5.2.7.4 screening for vertebral metastases. One exception is
Out-of-Phase Imaging osteoblastic metastases, which remain dark on out-of-
phase images since they are already hypointense due to
Out-of-phase or opposed-phase images occur in GRE the lack of mobile protons (Fig. 5.7). Therefore, stan-
sequences when the TE equals the time needed for dard T1-WI should always also be obtained.
158 J. W. M. Van Goethem

5.2.7.5 5.2.7.7
Ultrafast Imaging MR Angiography

In some patients, it can be useful to shorten the imag- Magnetic resonance angiography (MRA) has limited
ing time in order to decrease motion artifacts (children, use in spinal imaging. Even arteriovenous malforma-
uncooperative patients, etc.) or to decrease the overall tions or fistulae are hard to image with MRA. Normally,
examination time (claustrophobic patients, monitored postcontrast T1-W sequences are sufficient (Fig. 5.12).
patients, etc.). In these cases, the sequence parameters
listed in Table 5.2 can be used. Although the acquisition 5.2.7.8
time is reduced to 1 min or less, these ultrafast sequenc- Diffusion-Weighted Imaging
es still produce high-quality images or even better
images with patient movement (Fig. 5.10). Imaging time Diffusion-weighted imaging (DWI) is a special tech-
is (or can be) further decreased by eliminating satura- nique using very strong magnetic gradients, effectively
tion zones. SNRs are substantially lower but still suffi- canceling signal from protons in free moving water, e.g.,
cient. CSF. Protons that are more restricted in movement, e.g.,
in intracellular water, still produce a measurable MR
5.2.7.6 signal. The spontaneous movement of protons is known
MR Myelography as ‘Brownian motion’ and results among others in diffu-
sion, hence the term DWI.
MR myelography can be helpful in addition to the nor- This technique is especially useful in detecting cyto-
mal imaging sequences. Although three-dimensional toxic edema, where there is cell swelling effectively
(3D)-TSE sequences have been proposed, they signifi- increasing the amount of intracellular over extracellular
cantly add to the total imaging time of the examination. water and thereby reducing water diffusion. Since ische-
Therefore, I prefer single-shot wide-slab T2-W mia produces cytotoxic edema very early on (after 1 h),
sequences with a very long echo train (Fig. 5.11). DWI is capable of the early detection of ischemic
Although these allow only one view of the thecal sac at lesions.
a time, their imaging time is very short, making it pos-
sible to obtain different views by running the sequence 5.2.7.9
in different orientations (one frontal view, one sagittal Functional Imaging
view, and two obliques). This sequence has the added
advantage of eliminating postprocessing (no maximal Functional imaging of the spine consists mainly of sem-
intensity projection is necessary). idynamic imaging. Flexion/extension imaging of the CS

Table 5.2. Suggested sequence parameters for ultrafast MR imaging of the lumbar and cervical spine. Imaging of the thoracic spine can
be done using lumbar spine sequences

Region Sequence Plane No. of TR TE Flip Echo Slice Matrix FOV Band No. of Acq.
type slices (ms) (ms) angle train thickness (mm) width acq. time
length (mm) (Hz) (min:s)

Lumbar TSE T1 Sag 11 835 12 180 5 4 512×205 320×320 195 1 0:35

TSE T2 Sag 11 3000 136 180 23 4 512×205 320×320 130 1 0:42
TSE T1 Ax 3×5 570 14 180 7 4 512×205 230×230 130 1 0:51
Cervical TSE T1 Sag 11 750 10 180 3 3 512×205 280×280 195 1 0:35
TSE T2 Sag 11 2900 102 180 23 3 512×205 280×280 191 1 0:41
GRE T2 Ax 12 610 27 30 – 4 256×120 200×200 195 1 1:03

Abbreviations: TR repetition time (ms); TE eche time (ms); Matrix (phase × frequency matrix); FOV field of view (mm); Acq acquisi-
tion(s)
 5 Magnetic Resonance Imaging of the Spine 159

Fig. 5.10A–C. Ultrafast imaging. A Sagittal

TSE T1-WI from the same volunteer. On
the left is the routine sequence [repetition
time (TR) 1350, echo time (TE) 15, echo
train length (ETL) 7, acquisition time (TA)
2 min 28 s], on the right, the ultrafast
sequence (TR 1270, TE 15, ETL 7, TA 53 s’,
see also Tables 5.1 and 5.2 for complete
sequence parameters). Notice the compar-
able spatial resolution of both images
(both 512 matrix), but the higher SNR of
the routine sequence on the left. B Routine
sagittal TSE T2-W sequence (TR 3000, TE
96, ETL 7, TA 4 min 19 s) in a patient with
considerable low-back pain. The image is
degraded by motion artifacts, and the
quality is unsatisfactory. C Ultrafast
sequence (TR 3200, TE 128, ETL 23, TA
1 min 7 s; see Tables 5.1 and 5.2 for the
complete sequence parameters) in the
same patient. Owing to the shorter imag-
ing time, the quality of the ultrafast
sequence is clearly better

is relatively easy to perform with fast sequences. The Dynamic imaging of the lumbar spine is more diffi-
first images are made with the head flexed forward. This cult because of the limited space available in the mag-
can be readily achieved by placing an inflated balloon net; this problem can be solved in two ways. The most
under the patient’s head. By letting air out of the bal- simple solution is to image the patient supine and
loon in small amounts, imaging can be performed in prone, thus simulating extension and flexion. Another
different positions between flexion and extension. This possibility is to use specially designed devices and/or
way, dynamic relationships between anatomic struc- balloons or to image the patient in lateral decubitus.
tures and pathology, e.g., herniated disc, can be These techniques are relatively cumbersome. Flexion-
assessed. Depending on the coil design, it can be neces- extension views of the spine have also been obtained
sary to switch the normal neck coil for a flexible coil or with the patient in sitting position with a special type of
to use the body coil. open interventional MR system (‘double-doughnut’
160 J. W. M. Van Goethem

Fig. 5.11A–C. MR myelogram. A Routine MR myelogram in a nor- metric nerve roots and sheaths. The sequence can be run in differ-
mal volunteer [repetition time (TR) 2800, echo time (TE) 1100, ent directions to obtain frontal, lateral, or oblique-view myelo-
echo train length (ETL) 240, TA 7 s]. In this example, a frontal view grams. B,C For comparison a 3D TSE T2-W sequence. This
MR myelogram (right) is obtained by placing the slice on a sagit- sequence has a markedly longer acquisition time but has the
tal image (left). Slice thickness should be adjusted to include the advantage of producing multiple views
complete dural sac and nerve sheaths. Excellent detail with sym-
 5 Magnetic Resonance Imaging of the Spine 161

5.2.8
Contrast Media

The use of contrast agents has been discussed in previ-

ous sections of this chapter. The most common indica-
tions for the use of intravenous gadolinium in the spine
are:
1. The postoperative lumbar spine, especially after dis-
cectomy (use of gadolinium obligatory)
2. Detection of small tumors, especially neurinomas
3. Imaging of tumors in general
4. MS and other inflammatory diseases

5.3
Clinical Examples

The MR imaging findings in some typical examples of

spinal pathology are demonstrated in Figs. 5.13–5.24.

5.3.1
Degenerative Disease
Fig. 5.12. Spinal AV malformation, gadolinium-enhanced T1-WI.
Notice the presence of multiple serpiginous blood vessels on the The most frequently encountered pathology in the
surface of the thoracic cord in this typical example. The small
blood vessels with slow flow enhance with gadolinium, and the spine is degenerative disease. Degenerative disc disease
medium-sized vessels with higher flow do not enhance and are is typified by dehydration of the intervertebral disc.
seen as areas of flow void. These gadolinium-enhanced images are This phenomenon is easily recognized on T2-W
typical and sufficient for making the diagnosis. High-quality MR
angiography images are difficult to obtain due to the small size sequences as black or dark discs. Secondary changes,
and tortuous course of these blood vessels such as reduced intervertebral space, osteophytic reac-
tions, and bulging disc, are also easily recognized.
Sometimes tears of the annulus fibrosus can be detect-
ed on T2-WI as a region of high signal intensity near
design). Newer machines allow standing weight-bear- the posterior margin of the disc (Fig. 5.13). These annu-
ing MR of the spine. These have the advantage of imag- lar tears typically enhance after intravenous gadolin-
ing the spine under physiological loading, and during ium injection.
bending and rotation. Other characteristic findings in degenerative disc
The term functional magnetic resonance imaging disease are alterations in the adjacent vertebral body
(fMRI) is also used for the detection of neuronal activ- endplates (Table 5.3.). These endplate changes were first
ity. Usually, a special MR technique, called blood oxygen categorized by Modic. Type I endplate changes repre-
level dependent (BOLD) imaging, is used to detect sent vascularized bone marrow and/or edema and are
minute changes in the blood level of deoxyhemoglo- seen as low-SI changes on T1-WI and high-SI areas on
bin due to neuronal activity and secondary autono- T2-WI. Type II changes represent more chronic altera-
mous blood flow adaptation. The technique is mostly tions with proliferation of fatty tissue and are bright
used in the brain, since susceptibility artifacts make both on T1-WI and T2-WI. Type III changes, also seen
it very hard to obtain useful images of the spinal on conventional radiographs and computed tomogra-
cord. phy (CT) images, represent dense, sclerotic bone and
are dark on T1-WI and T2-WI. Type I and II changes
162 J. W. M. Van Goethem

Table 5.3. Modic type changes of vertebral endplates in degenera-

tive disease (Modic et al. 1988)

Modic T1-SI T2-SI Represents

classification changes changes

I – + Vascularized bone
marrow and/or edema
II + + Proliferation of fatty
tissue
III – – Sclerotic bone

may enhance with gadolinium, but should not be con-

fused with inflammatory enhancement commonly seen
with disc infection.
Degenerative changes of the facet joints may play an
Fig. 5.13. Degenerative disc disease is characterized by T2-short-
ening of the disc and decreased intervertebral height (open important role in low-back pain, but may also cause
arrows), degenerative vertebral endplate changes, bulging disc, irradiating leg pain due to secondary foraminal steno-
and/or osteophytes. A radial tear of the annulus, which is found sis (Fig. 5.4). Foraminal narrowing, or foraminal pathol-
consistently with the other degenerative changes in the interverte-
bral disc, involves all layers of the annulus fibrosus. It may be ogy in general, is more accurately assessed on sagittal
detected by MR imaging as a band of high signal intensity on images than on axial images (CT or MRI) (Fig. 5.4).
T2-WI (arrow) In the CS, uncovertebral degenerative disease may
play an important role in irradiating shoulder or arm
pain due to secondary foraminal narrowing. In assess-
ing the cervical neural foramen, one should be aware of
the underestimation of the diameter (up to 10%) on MR
imaging because of chemical shift artifacts.

Fig. 5.14A,B. Sequestered disc. Sequestered

disc fragments can migrate upward (or
less frequently downward) behind the ver-
tebral bodies all the way up to the next
intervertebral space. As such, they may be
missed on axial computed tomography
(CT). Therefore, sagittal imaging is an
important advantage of MR imaging. The
contrast between the extruded disc frag-
ment and the surrounding epidural fat tis-
sue is better seen on T1-WI (A) than on
T2-WI (B) (arrows)
 5 Magnetic Resonance Imaging of the Spine 163

5.3.2 and 50% of the disc circumference. The presence of disc

Herniated Disc tissue ‘circumferentially’ (50%–100%) beyond the edges
of the ring apophyses may be called ‘bulging’ and is not
Herniated discs are more easily detected with MRI than considered a form of herniation, nor are diffuse adap-
with CT. First, MR imaging allows visualization of the tive alterations of the disc contour secondary to adja-
complete lumbar (or cervical or thoracic) spine in one cent deformity as may be present in severe scoliosis or
examination. Second, sagittal images also depict the spondylolisthesis.
spinal canal in between intervertebral disc spaces. It is Herniated discs may take the form of protrusion or
not unusual for a disc fragment to migrate (or extend) extrusion, based on the shape of the displaced material.
into the area behind the vertebral body (Fig. 5.14). Some Protrusion is present if the greatest distance, in any
of these migrated discs can be missed on CT if axial plane, between the edges of the disc material beyond
slices are limited to the intervertebral disc spaces exam- the disc space is less than the distance between the
ined. Third, the intrinsic tissue contrast is usually better edges of the base in the same plane. The base is defined
on MR. Especially the cervicothoracic and/or lumbosa- as the cross-sectional area of disc material at the outer
cral region can be hard to assess on CT due to beam margin of the disc space of origin, where disc material
hardening, especially in larger patients. displaced beyond the disc space is continuous with disc
The terms used to describe or classify bulging or material within the disc space. In the craniocaudal
herniated discs are somewhat ambiguous and some- direction, the length of the base cannot exceed, by defi-
times misused. Recently, a nomenclature project initiat- nition, the height of the intervertebral space. Extrusion
ed by the American Society of Spine Radiology has is present when, in at least one plane, any one distance
found wide acceptance among radiologists, clinicians, between the edges of the disc material beyond the disc
and surgeons (Table 5.4). In this nomenclature, hernia- space is greater than the distance between the edges of
tion is defined as a localized displacement of disc mate- the base in the same plane, or when no continuity exists
rial beyond the limits of the intervertebral disc space. between the disc material beyond the disc space and
The disc material may be nucleus, cartilage, fragmented that within the disc space. Extrusion may be further
apophyseal bone, anular tissue, or any combination specified as sequestration, if the displaced disc material
thereof. The term ‘localized’ contrasts to ‘generalized,’ has completely lost all continuity with the parent disc
the latter being arbitrarily defined as greater than 50% (Fig. 5.14). The term migration may be used to signify
(180°) of the periphery of the disc. displacement of disc material away from the site of
Localized displacement in the axial (horizontal) extrusion, regardless of whether it is sequestrated or
plane can be ‘focal’, signifying less than 25% of the disc not. Because posteriorly displaced disc material is often
circumference, or ‘broad-based’, meaning between 25% constrained by the posterior longitudinal ligament,

Table 5.4. Nomenclature of disc herniation

General
terminology Definition Specification I Specification II Definition

Bulging Displacement over

>50% of the periphery
of the disc

Herniation Localized displacement Focal (<25%) OR broad- Protrusion No extrusion

(<50% of the periphery based (25%...50%)
of the disc)

Extrusion Distance of the edge of the

herniated material>disc
heigth or hernia base

Sequestration (=special No continuity with parent

form of extrusion) disc
164 J. W. M. Van Goethem

images may portray a disc displacement as a protrusion 5.3.3

on axial sections and an extrusion on sagittal sections, Inflammatory and Infectious Lesions
in which cases the displacement should be considered
an extrusion. Herniated discs in the craniocaudal (ver- The most common inflammatory intramedullary
tical) direction through a break in the vertebral body lesions are seen in patients with MS. Most of these
endplate are referred to as intravertebral herniations. lesions are hard to detect on precontrast T1-WI, as are
Disc herniations may be further specifically MS lesions of the brain. On T2-WI, lesions are hyperin-
described as contained, if the displaced portion is cov- tense (Fig. 5.15) and can be quite large in the acute
ered by the outer anulus, or uncontained when any such phase. Sometimes, they also exhibit uptake of gadolin-
covering is absent. Displaced disc tissues may also be ium contrast, which is believed to be a sign of an active
described by location, volume, and content. lesion. An MRI examination of the brain and the com-

Fig. 5.15A–D. Multiple sclerosis. In this 24-year-old woman with

multiple sclerosis, sagittal TSE T2-weighted images (WI) (A), axial
gradient-echo T2-WI (B), and sagittal unenhanced (C) and gado-
linium-enhanced TSE T1-WI (D) were obtained. The signal
changes observed with intramedullary multiple sclerosis lesions
are comparable to those in the brain. The sagittal T2-WI shows
three hyperintense lesions; only one lesion manifests enhance-
ment (arrow, D). Note that multiple sclerosis can be seen on mag-
netic resonance (MR) imaging with lesions in the brain and/or the
spine. Therefore, when a presumptive diagnosis of spinal multiple
sclerosis plaques is made, MR examination of the brain should be
performed to confirm the diagnosis, by demonstrating typical
brain lesions
 5 Magnetic Resonance Imaging of the Spine 165

plete spinal cord should be performed to search for in location. Spondylodiscitis is frequently caused by
other lesions. Clinically, one-third of MS patients exhib- bacteria or tuberculosis (Fig. 5.17). Postoperative spon-
it spinal symptoms only. The cervical cord is twice as dylodiscitis can be difficult to diagnose in the early
likely to be involved as the lower levels. postoperative phase, since normal (inflammatory)
Spinal infections can be (intra-)medullary (Fig. 5.16), postoperative changes may resemble infectious pathol-
intraspinal or, more frequently, vertebral and/or discal ogy.

Fig. 5.16A–C. Tuberculous myelomeningitis. Tuberculous mye-

lomeningitis in a patient with an epidural morphine catheter for
pain release in a case of incurable pancreatic carcinoma. The sag-
ittal TSE T2-weighted image (WI) shows extensive medullary
edema (A). The sagittal (B) and axial (C) T1-WI after gadolinium
enhancement show a much smaller nidus of active inflammation
in the medulla and in the subdural space around the tip of the
catheter (arrow). Granulomatous changes in cases of tuberculous
or bacterial meningitis show marked enhancement after gadolin-
ium injection. Conversely, in patients with viral meningitis, mag-
netic resonance (MR) imaging findings are often normal. Myelitis
can be either infectious as in this case with extensive medullary
edema, or inflammatory, as for example in multiple sclerosis
166 J. W. M. Van Goethem

Fig. 5.17A,B. Spondylodiscitis.

Spondylodiscitis or disc space infection
with osteomyelitis. Note the substantial
signal changes both in the vertebral bodies
and in the intervertebral disc space. The
blurry margins of the vertebral endplates
on the T1-WI (A) and the high SI of the
disc space on the T2-WI (B) allow diffe-
rentiation with degenerative or postopera-
tive changes

5.3.4 5.3.5
The Postoperative Lumbar Spine Spinal Tumors

As mentioned earlier, MR imaging is capable of differ- 5.3.5.1

entiating postoperative epidural fibrosis and recurrent Intramedullary Tumors
disc herniation. This is important since the latter can be
an indication for reintervention. On postcontrast T1- Three primary intramedullary tumors are frequently
WI, herniated disc material shows no or minor encountered: astrocytoma, ependymoma, and heman-
enhancement (Fig. 5.18), while epidural fibrosis gioblastoma.
enhances intensely, especially in the first years after sur- The peak incidence of spinal astrocytomas is around
gery (Fig. 5.19). However, smaller disc fragments or the third and fourth decade, and they are most often
‘older’ recurrent herniated discs may progressively found in the thoracic cord. Clinical symptoms vary and
show more enhancement due to secondary inflammato- are sometimes very minor. Most often patients have
ry changes. motor changes with gait difficulties, but pain and blad-
It is important to note that when the intervertebral der disturbances are also possible. In children, some-
disc space narrows after discectomy, secondary forami- times a secondary scoliosis is found. The cord is often
nal stenosis may occur, causing irradiating pain without enlarged, and most cord astrocytomas are low signal on
recurrent herniation. T1, high signal on T2, and, contrary to brain astrocyto-
mas, show enhancement after gadolinium injection
(Fig. 5.20). After gadolinium injection, the delineation
of potential cysts is usually more apparent.
Cord ependymomas are usually found in older
patients, with a peak incidence around the fourth and
fifth decade. It is the most frequent tumor of the lower
 5 Magnetic Resonance Imaging of the Spine 167

Fig. 5.18A,B. Recurrent disc herniation. Axial T1-WI before (A) Fig. 5.19A,B. Postoperative epidural fibrosis. Axial T1-WI before
and after (B) gadolinium enhancement in a patient with a large (A) and after (B) gadolinium enhancement in a patient with post-
recurrent disc herniation. Differentiating postoperative recurrent operative epidural fibrosis. Compare with Fig. 5.18; epidural fibro-
disc herniation from epidural fibrosis is important, since the latter sis shows complete enhancement after contrast administration.
is no indication for surgical reintervention. When imaging is per- Nerve root enhancement can be seen in asymptomatic patients up
formed directly after gadolinium injection, disc material only to 6 months after surgery (curved open arrow). Thereafter,
shows peripheral enhancement (curved open arrow) enhancement of the nerve roots is considered abnormal, and a
sign of active nerve root damage

thoracic cord and conus medullaris, where they are usu- centrally located than cord astrocytomas. Cord ependy-
ally of the myxopapillary type. Clinically, patients with momas are usually hypointense on T1 and hyperintense
ependymomas more often present with back or neck on T2, but can be more heterogeneous than astrocyto-
pain and sometimes radicular pain, but bladder dys- mas due to areas of hemorrhage. Ependymomas show
function and gait problems are also encountered. These strong enhancement after gadolinium injection
lesions also show cord enlargement and tend to be more (Fig. 5.21).
168 J. W. M. Van Goethem

Fig. 5.20A–C. Spinal cord astrocytoma. Astrocytoma of the tho- nature, intramedullary astrocytomas nearly always enhance.
racic spinal cord: sagittal T2-WI (A), unenhanced T1-WI (B), and Often, there are associated cysts, but the cysts are usually not lined
gadolinium-enhanced T1-WI (C). Because of their infiltrative by tumor and do not require excision

Fig. 5.21A,B. Ependymoma of the conus medullaris. In this patient astrocytomas. On histopathologic examination, they are often sur-
with an ependymoma of the conus medullaris (myxopapillary rounded by a capsule. Ependymomas usually show intense and
type), sagittal T2-WI (A) and gadolinium-enhanced T1-WI (B) homogeneous enhancement. Ependymomas tend to be central
were performed. Ependymomas are usually better delineated than and are more frequently hemorrhagic than astrocytomas
 5 Magnetic Resonance Imaging of the Spine 169

Fig. 5.22A–C. Spinal hemangioblastoma. In this patient with a spi- large accompanying cystic lesion and edema. There is marked
nal hemangioblastoma, sagittal T2-WI (A), sagittal T1-WI (B), and swelling of the cord, and the lesion is very extensive, especially
gadolinium-enhanced sagittal T1-WI (C) were performed. The compared to the small enhancing tumor nodule.
typical pattern of this tumor is a small enhancing nodule with a

Finally, spinal hemangioblastomas are less common ed with neurofibromatosis, even when single. Nerve
than the two other types of intramedullary tumors. One sheath tumors are the most frequent intraspinal
out of three patients with spinal hemangioblastomas tumors, and they have a peak incidence around the
have von Hippel-Lindau syndrome. Spinal hemangio- fourth decade. Patients usually present with radicular
blastomas typically have associated cyst formation and pain. These lesions are most often markedly hyperin-
substantial cord edema. Strong enhancement of the tense on T2-WI, and iso- to hyperintense on T1-WI.
tumor nidus after gadolinium injection is always seen After gadolinium injection, there is homogeneous
in these tumors (Fig. 5.22). tumor enhancement.
Spinal meningiomas tend to be encapsulated and are
5.3.5.2 attached to the dura. They do not invade the spinal
Intraspinal Extramedullary Tumors cord, but displace it. They are usually anterior in the
cervical region and posterolateral in the thoracic
Two types of tumors are frequently encountered: neu- region. Only 3% of spinal meningiomas occur in the
rinoma (Figs. 5.23 and 5.24) and meningioma (Fig. lumbar region. Most patients are women, with a peak
5.25). incidence in the sixth decade. Generally, patients
Neurinoma, neurofibroma, neurolemmoma, and present with radicular, neck, or back pain.
schwannoma are various names for tumors that arise Meningiomas are hypo- to isointense on T1-WI, iso- to
from Schwann cells or nerve sheaths. Schwannoma, hyperintense on T2-WI, and show intense, homogene-
neurinoma, and neurolemmoma are synonyms. ous contrast enhancement.
Usually, neurinomas (Fig. 5.24) do not envelop the adja-
cent, dorsal sensory root, while neurofibromas
(Fig. 5.23) surround the nerve and are mostly associat-
170 J. W. M. Van Goethem

Fig. 5.23A–D. Neurofibroma. In this patient with a neurofibroma nal on T2-WI reflects the high water content of the tumor.
in the lumbar region, sagittal T2-WI (A), sagittal T1-WI (B), and Enhancement is usually homogeneous, although central fibrous
gadolinium-enhanced sagittal (C) and axial (D) T1-WI were per- portions may enhance less intensely. Tumors extending through
formed. Scalloping of the vertebral bodies and widening of the the neural foramen are typically dumb-bell-shaped as in this case
neural foramen are typical in nerve sheath tumors. The high sig- (D)
 5 Magnetic Resonance Imaging of the Spine 171

Fig. 5.24A,B. Intradural neurinoma. In this patient with a small enhanced T1-WI (B) were obtained. Smaller neurinomas may be
neurinoma of the cauda equina, axial T1-WI (A) and gadolinium- impossible to detect without gadolinium administration

Fig. 5.25A–C. Intradural extramedullary meningioma. In this 65- sixth decades. The lesions are hypo- to isointense to the spinal
year-old woman with a meningioma near the craniocervical junc- cord on T1-WI (B) and slightly hyperintense on T2-WI (A).
tion, the following imaging sequences are shown: sagittal T2-WI Intense and homogeneous enhancement is typical (C), and the
(A), sagittal T1-WI (B), and gadolinium-enhanced sagittal T1-WI presence of a dural tail indicates the dural-based nature of the
(C). From 60% to 80% of meningiomas are seen in middle-aged to tumor
elderly women. The average age at presentation is in the fifth and
172 J. W. M. Van Goethem 5 Magnetic Resonance Imaging of the Spine

Acknowledgements. I would like to thank Bavo Van Further Reading

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