The Lumbar MRI in Clinical Practice

“He who studies medicine without books sails an uncharted sea, but
he who studies medicine without patients does not go to sea at all.”

William Osler Canadian Physician, 1849-1919
The Lumbar MRI
in Clinical Practice
A Survey of Lumbar MRI for Musculoskeletal Clinicians
William E. Morgan
Bethesda Spine Institute LLC,
11117 Innsbrook Way
Ijamsville, Maryland, 21754
Copyright © 2013. Text by William E. Morgan, DC
All rights reserved. No part of this book may be reproduced in any form, or by
any electronic, mechanical, or other means without prior permission in writing
from the publisher.
Editor: Clare P. Morgan
All rights reserved
Copies of this eBook can be purchased through http://drmorgan.info/home/

Disclaimer
The views expressed in this book are those of the author and do not
necessarily reflect the official policy or position of the Department of the Navy,
Department of the Army, Department of Defense, nor the U.S. Government.
Nothing in the presentation implies any Federal/DOD/DON endorsement.
The information within this guide represents the views of the author at the date
of publication. Due to the rapid increase in knowledge, the author reserves the
right to update and modernize his views as science uncovers more information.
While every attempt has been made to verify the information, the author cannot
accept responsibility for inaccuracies or oversights. Any perceived disrespect
against organizations or individual persons is unintentional. The author makes
no guarantee or warranty pertaining to the success of the reader using this
material.
The Cost of Piracy
The ability to rapidly share information is part of what makes living in the
twenty-first century so extraordinary. So extraordinary that many people forget
that much of what is passed from person to person is protected by copyright.
Reproducing copyright-protected electronic literature is illegal and is, in a word,
stealing. Reproducing copyright protected material is morally wrong and is
illegal.
But more disturbing than the legality of piracy is the fact that doctors and
students continue to steal the intellectual property of others. When a doctor or
student bootlegs intellectual property, it costs them. It costs them their integrity;
it costs them their self-respect; and it costs them their shame. If you cannot
afford these costs, I would ask you to pay for the labor of others rather than
steal it. It is the right thing to do, and our patients deserve to be treated by
doctors who have retained their integrity.
Preface
While there are books written on the subject of systematic interpretation of lumbar
MRI, they are written from a radiologist’s perspective. This presentation seeks to
help practitioners who actually treat lumbar spinal conditions to understand how the
radiologist’s interpretation relates to their patients. This book is not intended to be a
replacement for using a radiologist; it is intended to magnify the effectiveness of the
practitioner-radiologist relationship. My background is not radiology, but manual
treatment of spinal conditions. I learned long ago the value and limitations of a
radiologist’s report. The value is in their expert interpretation, the ability to identify
pathology, injury, and anatomical variance. With the advent of computer-enhanced
imagery such as CT and MRI, the amount of data available to a radiologist has
increased exponentially. Because of this increase, the radiologist must decide what
information is important and what information is incidental. I have seen MRI studies
in which a ten-page report would not be sufficient to describe the specific findings.
The quality of MRI has improved so much that it is difficult to find images that are
totally unremarkable.
The knowledge gained in this book is not a replacement for the many years of
training and experience that create board certified radiologists.
This book is intended to be used within the safety net of a qualified radiologist.
The Physics of MR
“Never worry about theory as long as the machinery does what it's supposed to
do.”
Robert A. Heinlein, Waldo & Magic, Inc. (1950)
The physical science behind MRI was intentionally omitted from this manual. While I do
understand the importance of knowing the science behind this medium, I do not have
the inclination nor the background to discuss the physics of MRI in this book. I would
encourage those interested in knowing more about this aspect of MRI to delve deeper
into this subject through another author. This book will concentrate on the clinician’s
need to extract clinical data from the images, rather than learn how MRI works. I
would compare my approach to driving a car with no intricate knowledge of how the
engine works, as opposed to learning the mechanics and engineering theories of the
automobile before driving. In short, you can drive the car without understanding how
the engine works, and for our needs you can understand some diagnostic principles of
MRI (within the safety net provided by a qualified radiologist) without knowing the
detailed physics.
For those interested in understanding the physics of MR more fully, I recommend the
work of Joseph P. Hornak, Ph.D. who offers a free online eBook on the physics of MRI
at:
http://www.cis.rit.edu/htbooks/mri/
Contents
Chapter Page
1 The Clinician’s Perspective 1

2 Introduction to the Systematic Interpretation of the Lumbar MRI 9
3 Anatomic Atlas of the Lumbar Spine on MRI 24
4 Standardized Anatomic Reference Descriptions 46
5 Classification of Disc Derangements 54
6 Classification of Annular Tears 88
7 Gallery of Lumbar Disc Derangements 96
8 Spondylolysis and Spondylolisthesis 150
9 Spondylosis 180
10 Central Canal Stenosis 187
11 Fractures 202
12 Modic Changes on MRI: Vertebral Body Marrow Morphology 214
13 Lumbar Facets 224
14 Vertebral Hemangiomas 243
15 Conjoined Nerve Roots 249
16 Classification of Spinal Cord Tumors and Masses by Location 258
17 Perineural (Tarlovs) Cysts 268
18 Hematomas 276
19 Metastasis 283
20 Tumors: Schwannomas/Ependymoma 291
21 Inflammatory Joint Disease 297
22 Fat 303
23 Gadolinium Enhancement 323
24 Post-Surgical Findings 330
25 Arachnoiditis and Arachnoid Cysts 347
26 Incidental Visceral Findings 357
27 Other Assorted Findings on MRI 379
28 Upright MRI 394
29 Artifacts 400
30 Systematic Sequence of Interpretation 406
Appendix 410
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Introduction
Before beginning this book you should know my peculiar perspective on the duty of the
clinician to know the tools of his or her trade and why my perspective is so geared toward the
training of clinicians in the various diagnostic tools that they use to make clinical decisions.
When I had been in practice for about ten years, a young man was referred to my office with
neck pain and headaches. He had fallen and struck his head three months prior and
subsequently had been seen by five different physicians. Cervical spine X-rays along with
CTs of the head and cervical spine were taken at the time of injury, but the radiologist’s
reports were negative. I accepted this referral and the radiographic reports at face value and
began a treatment plan. Early in the care I sensed that something was not right with this
patient even though he was neurologically intact. I requested another set of x-rays,
something the insurance company balked at because it was not compliant with their
guidelines for care. I insisted and provided a compelling enough argument that the insurance
company acquiesced and authorized a second set of X-rays. Soon I received a call from the
radiologist, a friend of mine, who was very energetic on the phone. “Bill,” he said, “I read the
x-rays on the patient that you sent over this afternoon. He needs to be transported to the ER
in a rigid cervical collar as soon as possible. He has a hangman’s fracture of C2 and an
anterior dislocation of C2 on C3.”
We transported the patient to the ER of the hospital, but the orthopedic surgeon on call
refused to come down for a patient who had been injured three months prior. I never will
forget his words on the phone, “If his head hasn’t fallen off in the last three months, it’s not
going to fall off tonight.” Thank God he was right since I could not get a physician with
admitting privileges to admit this young man. He spent the night in the ER before being
admitted the next morning. The orthopedic surgeon was astounded at the sight of the new
images and was a little sheepish around me for some time after this event. The young man
subsequently received three corrective surgeries.
When we reviewed the original X-rays and CT scans, the fractures were clearly visible,
though the anterior dislocation was not. Another set of eyes or two may have been able to
spot the fractures and get this patient to the appropriate level of care sooner. Since that day I
have been committed to reviewing the actual images of my patients and not just the written
report. This book is intended to help you to be another set of eyes in screening those
images. It will also help you to understand what the radiologist is saying in his or her report.
William E. Morgan
The Clinician’s Perspective
1
Why Should a Clinician Study Lumbar MRI?
It has been said that a picture is worth a thousand words. I believe that this adage is true if
you understand what you are observing. The radiology report is an attempt to describe in
words what is seen in a radiographic image. This will work well for describing overt
pathology, injury, or obvious clinically significant findings. A picture is worth a thousand
words, yet the average radiologist report fails to have even a thousand words.
Radiologists are economical in the use of words in their reports, so by necessity the
radiologist must triage what findings reach the written report. With advanced imagery
technology such as CT and MRI, so much information is available that if a radiologist were
to describe everything visible in every slice of imagery, the report could conceivably be ten
to twenty pages long. A report of that length would be impractical for both the radiologist
and the requesting provider. As a result the radiologist must try to determine which findings
are clinically significant ,and then concisely pass these on to the requesting provider.
Prior to the innovation of MRI and CT, spinal specialists used clinical findings correlated to
X-rays and myelograms. (Myelograms use a contrast media and an X-ray to identify spinal
lesions.) When MRIs became available with their increased specificity and sensitivity, a
high percentage of the studies yielded the identification of disc herniation. This resulted in
an increase in the number of lumbar disc surgeries until it was determined that in many
people a disc herniation and other spinal lesions are considered an incidental finding. Just
because you find a derangement or anomaly, it does not mean that it is clinically significant.
Analyzing the patient history and physical examination along with an MRI will help to
determine the clinical relevance of a finding on MRI.
We can expect the radiologist to identify most pathology, diagnostic findings such as disc
derangements, and findings that have the potential of being clinically significant. What they
do lack, however, is first-hand knowledge of the patient.
Below is the description of a famous work of art. It is written from a detached point of view
that is uninformed about the people and events in the painting. It is accurate in every way,
but lacks sufficient background knowledge to clearly state what is happening.
Image Report
This painting appears to be an oil on plaster painting. This image demonstrates a

well-developed white male reclining on a green slope leaning on his right elbow. He
is nude and devoid of body hair. This man is located on the left side of the painting
and is looking at another older man on the right side of the painting. The man on the
left is casually reaching his left hand toward the older man. The older man has long
gray hair and a beard, but is well-muscled. The older man is surrounded by eleven
nude young children and is shrouded in a red cloth. He is wearing a shear short-
sleeved tunic. The older man is reaching his right arm with an extended index finger
toward the hand of the younger man.
The Lumbar MRI in Clinical Practice 2

Here is the painting that was described on the previous page. With a historical perspective
you may clearly see that image is the romanticized duplication of God reaching out to
Adam during Creation painted on the ceiling of the Sistine Chapel by Michelangelo di
Lodovico Buonarroti Simoni. While the description of this painting on the previous page
was accurate in every way, it lacked the historic and visual perspective that provides the
viewer with the immediate knowledge of the significance of the painting.
Figure 1:1. The Creation of Adam by Michelangelo di Lodovico Buonarroti Simoni 1512,
Sistine Chapel
It is my contention that the historical perspective is important in obtaining information of

clinical significance. Having watched many neurosurgical morning reports, it is quite
obvious that while they defer to the opinion of the neuroradiologist, the neuro-surgeons
connect their history and physical exam with their own interpretation of MRIs to obtain a
specific diagnosis. The MRI is a tool that should be in the hands of everyone who treats
the spine, and a clinician-radiologist collaborative team is far preferable to having two
distinct and non-conversing professions. That collaboration begins with the clinician
providing the radiologist with adequate historic and clinical perspective to help the
radiologist understand why the study was requested and progresses to the radiologist
correlating the radiographic findings to the clinical profile of the patient. For most cases
this level of communication is sufficient, but there will be times where only direct interaction
between the clinician and the radiologist will suffice. The radiologist may need more
clinical information or recommend another study or protocol to better visualize what the
clinician wants to see. The clinician may ask the radiologist to expound on the findings or
to elaborate on a nuance found in the image. The clinician-radiologist relationship should
be a healthy relationship built on clear communication.

What Makes it into a Radiology Report?
The amount of information to a radiologist on a

single MRI study is vast, that to attempt to
record all findings is not practical and would add
confusion to the average practitioner. What is
on a radiology report is most pathology and
most clinically significant findings, as deemed
significant by the radiologist, and a smattering of
other details that may be pertinent to the
requesting provider. This pyramid represents
the findings that are visible on MRIs. It shows
that the findings with less of a clinical impact are
more common, and the more clinically
significant findings are less common. Normal
findings and anatomical variants are on the
bottom while pathology and diagnostic findings
are at the top.
Figure 1:2.
The red inverted triangle represents what is

included in a radiology report. Since a report that
includes everything could consume an hour of
dictation and a ream of paper, the radiologist must
prioritize and economize what is reported. Of
course all pathology and diagnostically significant
findings should be included and most are included.
The radiologist will also include a smattering of
other findings that have potential significance:
coincidental findings, anatomical variants, and
the like. This book will not replace the radiology
report, and certainly every MRI should be
interpreted by a board certified radiologist.
But it will aid clinicians in expanding their
use of the lumbar MRI past the limitations
of a written MRI report.
Figure 1:3.

MRI Findings in Asymptomatic Patients
There have been several studies over the years that have found significant MRI
findings in asymptomatic subjects. Many of these findings on MR had previously
been considered to cause pain and infirmity. Jensen and associates performed
scans on 98 asymptomatic individuals. Of the 98 individuals without symptoms, only
36% had normal lumbar discs at every level, 27% had disc protrusions, 1% had an
extrusion, 52% had disc bulges at one or more levels, and annular tears were
present in 14%.
In another study performed by Boden et al., 67 people who never had lower back
pain received lumbar MRIs. Of those individuals younger than 60 years old, 20%
had a disc herniation, while those older than 60 had a herniation rate of 36%, and
21% had spinal stenosis.
Weishagupt studied 60 asymptomatic people between the ages of 20 and 50. In this
population, 62-67% had lumbar disc bulges or herniations, 32-33% had annular
tears, and 18% had disc extrusions.
These and other studies clearly demonstrate the need to correlate a patient’s clinical
presentation with the findings on lumbar MRI. Coincidental or incidental findings can
lead the practitioner on a grand wild goose chase while creating anxiety in the
patient. We need to be careful in discerning between findings that have clinical
implications and those findings which are merely incidental.

Balancing the Weight of Clinical and Radiographic Findings
Figure 1:4.
With the amount of detail that is visible on an MRI, it would be easy to get bogged down
with the incidental findings on an MRI. Just because there is a finding visible on MRI
does not mean that it is clinically significant. Herniated discs are often seen on MRIs of
patients with no clinical manifestation of the condition. The flip side of learning to read
MRI is that the sensitivity of this technology is so great that there can be too much
information. All radiographic findings must be correlated to history and clinical findings.
So I offer a word of warning to the non-radiologists: Do not jump to conclusions; most
MRI findings should be corroborated by the patient’s complaints and findings on clinical
examination. The exception is the finding of pathologies which may lie dormant clinically,
but still require intervention.

Radiologist
Spine
Specialist PCM
Figure 1:5.
This Venn diagram illustrates the relationships and knowledge overlap of radiologists, spinal
specialists, and primary care managers (PCM). The spine specialists and the radiologists
(particularly neuroradiologists) have an intersecting body of knowledge. The spine care
practitioner has some knowledge of radiology, and the radiologist has some knowledge of
spinal care procedures and diagnosis. The primary care manager will have some overlay of
knowledge, but it would be to a lesser degree. The PCM would be much more reliant on the
written report than someone who primarily treats spinal conditions.
What is not shared with the other providers is the radiologist’s in-depth knowledge of radiologic
diagnostics and interventions, the spine specialist’s in-depth knowledge of spinal conditions
and treatments, and the PCM’s broad base of medical knowledge. These three team members
are reliant on the others for providing optimal patient care.

Suggested Reading
Jensen et al. (1994). Magnetic resonance imaging of the lumbar spine in people
without back pain. New England Journal of Medicine, Jul 14;331(2):69-73.
Boden et al. (1990). Abnormal magnetic-resonance scans of the lumbar spine in

asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am.
1990 Mar;72(3):403-8.
Weishaupt et al. (1998). MR imaging of the lumbar spine: prevalence of

intervertebral disk extrusion and sequestration, nerve root compression, end
plate abnormalities, and osteoarthritis of the facet joints in asymptomatic
volunteers. Radiology. 1998 Dec;209(3):661-6.

Introduction to the
Systematic Interpretation
of the Lumbar MRI
9
Orientation and Sequencing of the Lumbar MRI
Without a systematic approach, endeavoring to

interpret MRIs would be a daunting task.
Efficient interpretation of the lumbar MRI entails
several components: identification of the
image orientation, the MRI image type (T2W,
T1W, fat suppressed T2W,etc.), the knowledge
of the anatomical structures (normal and
variants of normal), and the ability to identify
injury, abnormality, and pathology. This
chapter will introduce a simple system for
analyzing lumbar MRI studies.
Image Orientation
There are three planes of orientation that are
common in MRI studies: sagittal, axial, and
Figure 2:1. Sagittal view
coronal.
1.Sagittal Images- Sagittal images are
oriented in a lengthwise view allowing the
visualization of the entire lumbar spine in one
image. In some aspects the sagittal image
resembles a lateral lumbar X-ray. The
difference is that the sagittal image shows a
slice through the body at a particular anterior to
posterior slice. After identifying the sagittal
image, determine the left-right orientation.
2.Axial Images- Axial images reveal cross- Figure 2:2. Axial view
sectional anatomy of the spine and paraspinal
structures. In the axial image the structures
appear reversed. The structures from the left
side of the body will appear on the right side of
the axial image. This is easier to remember
and conceptualize if you envision the patient’s
feet being toward the viewer.
3.Coronal Images- Coronal images are full
length studies that show the left-to-right width
of the structures studied. These images are
usually only included in the spotting/orientation
views and are not commonly included in the
detailed bulk of the lumbar MRI studies.
Figure 2:3. Coronal view

Orientation of Axial Images
Anatomical
Orientation
of the Patient
Anatomical
Orientation in
Axial Imagery
Figure 2:4.
Figure 2:5.
It is important to remember that when viewing axial MRIs left and right are reversed. If a
structure is visualized on the right of the axial image, it is found on the left side of the patient.
You may notice that in the image above there is a simple cyst in this patient’s right kidney.
This is seen on the left side of the MRI (yellow arrow).

Image Orientation and Location Descriptors
Figure 2:6.
This diagram clearly illustrates the planes available in MRI: axial, sagittal, and coronal. It
also clarifies several other terms that are commonly used in anatomical, biomechanical,
and radiographic discussions. In describing locations seen on imagery, this
standardized terminiology will give more complete descriptions of location. There are
variations in the use of these descriptors. It is common to see cephalad rather than
cranial, or anterior and posterior rather than ventral and dorsal in reports, and transverse
rather than axial.
This schematic was adapted from NASA: Reference: 16, pp. III-78; NASA-STD-3000 260 (Rev A)
http://msis.jsc.nasa.gov/images/Section03/Image64.gif

Identifying Image Sequences
MRI studies typically include scout films which identify and label the slices. Understanding
how to use scout films to identify image locations is fundamental to interpreting MRI studies.
Figure 2:7. The scout image for

identifying the axial slices is a
sagittal film with lines through it.
These lines present each of the
axial images available for
viewing. This particular image
identifies and labels 30 different
axial slices. When viewing an
axial image, the level can be
identified by finding the
corresponding identifying
markers. These slices are
uniform and made horizontally,
regardless of the angles of the
vertebral anatomy.
Figure 2:8. For sagittal images the scout film is a

coronal film with lines through it. These lines
correspond to each of the sagittal images
available for viewing. This particular image
identifies and labels 15 different sagittal slices.
The key to viewing sagittal imagery is to know
which side of the spine you are viewing: left or
right.
In viewing MRI in an electronic format sequence,
identification is simplified by the use of scout lines
and linking images together and scrolling.

Figure 2:9. Uniform horizontal slices Figure 2:10. Slices along the disc
planes.
In most lumbar MRIs the axial slices will be
evenly spaced intervals (figure 2:9). Some
studies will emphasize special regions of
anatomy or a site of concern, such as the
site of an injury, degeneration, or disease; or
a study may be limited to the disc spaces
(figure 2:10). They may even be angled to
correlate to the angles of the vertebrae and
disc spaces. These spotting or scout films
indicate that the technician selected slices
through the disc spaces and through an area
of particular concern. The technician also
made sure that the slice angles aligned with
the anatomic variations of the lumbar
segments. Note that there are areas of the
lumbar vertebrae which are not visualized at
all.
Figure 2:11. Selective slices of anatomy
The red lines in the scout film of figure 2:11 of particular interest. Note the red
reveal large areas of the lumbar spine that bordered sections with no slices.
are not represented in axial imagery. This
study was particularly intended to visualize a
condition affecting the L3-4 vertebrae and
disc along with the intervertebral disc spaces
of the rest of the lumbar spine.

MRI Image Type
MRI image types enhance various tissue types differently. This allows the
differentiation of tissues by the specialist. The various types of MRI images are as
follows:
1. T1 Weighted Image: Water densities are dark, and fat densities are bright. T1WI
have greater anatomic detail than T2WI.
2. T2 Weighted Image: Water and fat densities are bright, while muscle appears
intermediate in intensity.
3. Fat Suppressed T2 Weighted Image: Water densities are bright, whereas fat is
suppressed and dark.
4. Intermediate T2 Weighted Image: Ligaments and cartilage are viewed as very
dark.
5. Gadolinium Enhanced T1 Weighted Image: Gadolinium is an injected contrast
media. It is used to identify pathology.
6. Fast Spin Echo (FSE): Frequently used in musculoskeletal imaging, FSE allows
quicker image acquisition of T2 weighed images. Fat is bright on T2 weighted images.
Marrow or subcutaneous pathology may not show up unless fat suppression is used.
7. FSE STIR (Short T1 Inversion Recovery): This image has a decreased signal
intensity (brightness) from fat and an increased signal from fluid and edema. It is
useful in identifying soft tissue and marrow pathologies.
8. Proton Density: Proton density uses a mixture of T1 and T2 images. It is
characterized by enhanced anatomical detail and poor tissue contrast.
9. Fat Saturation: Fat saturation employs a “spoiler” pulse that neutralizes the fat
signal without affecting the water and gadolinium signal. Fat saturation can be used
with T1 weighted images to distinguish a hemorrhage from a lipoma. When used with
FSE T2 weighted images, fat saturation can enhance marrow or soft tissue pathology.
10. FIESTA (Fast Imaging Employing Steady sTate Acquisition): This method of
image acquisition captures structures rapidly and provides high quality images of fluid-
filled structures.

Comparing T1 to T2 Weighted Images
MRI Image Characteristics

For practical purposes the most commonly utilized types of MRI images by non-radiologists
are T1 and T2 weighted images. T1 has greater anatomic detail, but T2 tends to be the
favored image type for observing the intervertebral disc and the spinal cord. The chart below
reflects the characteristics of each image type. These images highlight the characteristics of
T1 and T2 images.
Tissue T1 T2
Bone Neutral Neutral
Air Dark Dark
Fat Bright Light
Water Dark Bright
Figure 2:12. Tissue characteristics on MR with T1 and T2 weighted imagery.
Bone
CSF
(water
density)
Fat Fat
Air Air
Figure 2:13. T1W Axial Image Figure 2:14. T2W Axial Image
Note that some tissues are dark (low intensity signal) on both image types. These include:
gas, cortical bone, calcification, tendons/ligaments, and menisci.

How are T1 and T2 Weighted Images Alike?
For comparison purposes the two sagittal images have been placed side by side with
T1 on the left and T2 on the right. Note that on both images the vertebral bodies are a
neutral gray color, the muscles and ligaments are dark, air is black, and fat is light-
colored.
Figure 2:15. T1 Weighted Sagittal Figure 2:16. T2 Weighted Sagittal

Image. The green arrow points to the Image. The blue arrow points to
dark (hypointense) disc, the white arrow the hyperintense signal, indicative
points to the fat of the posterior recess, of a well-hydrated disc. The yellow
and the yellow arrow points to the fluid arrow points to the bright signal,
of the CSF. characteristic of fluid in the CSF.
How Do T1 and T2 Weighted Images Differ?
The difference is black and white. In T1 images water is black, while T2 images display
water as white. The blackness of water in a T1 image makes it more difficult to
differentiate the cerebral spinal fluid from the nerves, and likewise, the disc from the
contents of the central canal. However, the T1 image aids in discerning the details of
other anatomic structures.

Characteristics of T1 and T2 Weighted Images and Fluid-Filled Lesions
These two images are from a patient

with multiple benign renal cysts.
Note the large light colored ovoid
lesions in the kidneys in the T2
weighted image (figure 2:17). The
cysts are easy to distinguish from the
soft tissue of the kidneys.
In the T1 weighted image (figure
2:18) the water-density cysts are dark
and more difficult to distinguish from
the kidneys.
Fat is light-colored in both T1 and T2,
while muscles, ligaments, and
tendons are dark.
Figure 2:17. T2 weighted axial image reveals

multiple large renal cysts. These cysts are ovoid
and light-colored.
Figure 2:18. In this T1 weighted axial image the

renal cysts are dark.

Systematic Interpretation of the Lumbar MRI
There are several methods for systematically reviewing lumbar MRIs. This method
ensures that you cover the images in a logical manner. The next two pages expand on
how to analyze axial and sagittal sequences in detail. As you develop an eye for the
subtleties found in lumbar MRI, you will find that sticking to a systematic procedure of
observation will help you to avoid missing important findings.
Sequence of Systematic Interpretation

of Lumbar MRI Images
1. Verify patient identifiers and date of examination.

2. Confirm that the images and the studies are in order if using film
rather than digitized images.
3. View the sagittal T2 weighted images from left to right.
5. View and analyze the T2 weighted axial images from caudal to
cephalad.
cephalad.
7. Review your findings and compare to the radiologist’s report.
8. Determine if the radiographic findings are clinically significant or
coincidental findings.
9. Integrate collaborative MRI findings into patient care.

Sequential Analysis of Sagittal Images
1. Identify the left-right orientation. Sagittal images represent anatomic slices in a

vertical plane which travel through the body from posterior to anterior and divide
the body into right and left components. Scroll from left to right. If you are unable
to identify the orientation of the sagittal images, remember that the aorta is on the
left while the inferior vena cava is on the right. The aorta typically has a greater
girth and a more symmetrically round appearance.
2. Analyze the spine from a global view. Scan through the sagittal images and look
for larger, more obvious findings:
Alignment of the spine - Spondylolisthesis and retrolisthesis can be usually be
discerned on sagittal inspection. Scoliosis can be a little more difficult. On
sagittal imagery a scoliosis will present with partial views of structures and a
contorted view of the spinal canal and vertebral bodies.
Vertebral body shape- Identify endplate disruption, Schmorl’s nodes,
compression fractures, block vertebrae, and fusion.
Vertebral body content- Analyze for edema, tumors, fatty infiltration, and
hemangiomas.
Posterior elements- Evaluate the facets, the pars, the spinous processes, the
pedicles, and the lamina.
Endplates- Look for sclerotic changes and alterations in signal intensity as well
as disruptions or fractures of the endplates.
3. Intervertebral foramina:
The IVF should be a light-colored peanut-shaped image with a gray dot in the
middle. The light color is due to the fat that is in the foramina. When displaced,
the light-colored fat will alter in shape. The gray dot in the foramina is the exiting
nerve root.
4. The discs and the spinal canal:
Look for alterations in disc height. Increased disc height may occur with discitis.
Loss of disc height and reduced water content is indicative of degeneration. Disc
tears and derangements may also be observed in sagittal imagery. Note
disruptions of the thecal sac, the cauda equina, and nerve roots.
High intensity zones (HIZ) may be observed in T2 weighted images. These
bright-colored zones indicate the presence of disc tears, scarring, or
vascularization of the annulus.
The cord should terminate at about the level of L1. Increased signal (brightness)
on T2 weighted images may indicate cysts, tumors, syrinxes, or demyelination.

Sequential Analysis of Axial Images
1. Identify left and right. Axial images are backwards; structures seen on the left of
an axial image represent structures found on the right side of the patient.
2. Begin your analysis caudally proceeding cephalad. The sacrum will be easily
recognizable. Observe the S1 nerve roots. Look for perineural (Tarlovs’ cysts)
which occur most commonly at the S2 and S1 nerve roots.
3. As you scroll superiorly, observe the L5-S1 disc. Note the circumferential margin
of the disc and inspect it for derangement. Scroll past the disc to the L5 vertebra.
Note that L5 is commonly shaped like a lemon when viewed axially. Observe the
bony integrity of L5. Look for elongation of the central canal which may be
indicative of a spondylolisthesis.
4. The canal should be intact and not effaced. Look for effacement or disruption of
the thecal sac by discs, osteophytes, spondylosis, or other space-occupying
lesions.
5. Look at the lumbar discs and evaluate for tears, herniations, nerve compression,
and degeneration.
6. Identify the ligamentum flavum, and look for signs of hypertrophy and subsequent
stenosis.
7. Evaluate the posterior elements of the vertebrae. Look for pars defects, spina
bifida, facet hypertrophy, and overall posterior ring integrity.
8. Examine the retroperitoneal space.
9. In addition to examining the spinal structures, evaluate and note the paraspinal
muscles, multifidus muscles, iliopsoas muscles, the great vessels, and the
kidneys.
10. After scrolling up the lumbar spine, reverse directions and descend the spine to
follow the course of the nerve roots. Start cephalad and scroll (if using a
computer) caudally. If looking at film, move from slide to slide. Follow the
migration of the nerve rootlets from the cauda equina from their posterior central
location to the lateral anterior portion of the thecal sac and then leaving the sac
as traversing nerve roots.

Which Radiological Studies Should You Order?
Develop a relationship with your radiologist and be willing to consult with the radiologist
prior to ordering radiological studies. Explain the history and work with the radiologist to
determine the best study for each patient.
Trauma •Plain films may be used initially to determine if there is

an unstable injury or displacement
•Non-contrast CT
•MRI to evaluate cord integrity
Tumors MRI with contrast enhancement
Inflammation and Vascular MRI with contrast enhancement

Disorders
Scoliosis Plain-film X-rays unless pathology is suspected; then MRI
Congenital anomalies MRI without contrast enhancement
Infections MRI with contrast enhancement
Nerve Root Compression MRI
Spondylolisthesis •Plain film radiographs

•CT
•MRI if there is a need to evaluate neuronal involvement
Note: There is an inherent danger in using contrast enhancements. These risks

include allergic reaction, shock, and death.
CTs are less expensive than MRI and are the medium of choice for head and neck
trauma. CTs utilize significant doses of radiation and increase the risk of cancer.

Suggested Reading
Cramer G, Darby S (2013). Basic and clinical anatomy of the spine, spinal cord,
and ANS (third edition). Elsevier Mosby.
Marchiori D (2013). Clinical imaging: with skeletal, chest and abdomen pattern
differentials (third edition). Mosby.
Atlas SW. (2008). Magnetic resonance imaging of the brain and spine (forth
edition). Lippincott Williams & Wilkins.
Ross JS et al. (2010). Diagnostic imaging spine (second edition). Amirsys Inc.

Anatomic Atlas of the
Lumbar Spine on MRI
24
Anatomy
In addition to knowing the image orientation and MRI image type, it is important to have a
good foundation in the anatomy of the lumbar spine as viewed on MRI. This chapter will
review the lumbar anatomy as viewed in various sequences.
This sagittal T2 weighted image demonstrates typical vertebrae, intervertebral discs, and the
sacrum. The light-colored disc in a T2 weighted image is indicative of a healthy well-hydrated
disc. The light-colored zones in the nucleus pulposa appear brighter than the annular fibers.
The vertebrae remain neutral gray in color. A normal lumbar lordosis is visualized.
Vertebral
Bodies
Intervertebral Discs
Sacrum
Figure 3:1

Anatomy
This image, also a T2W sagittal slice, identifies the five lumbar vertebrae and the top three
sacral segments. The discs are identified by their adjoining vertebrae. The disc between L5
and S1 is called the L5-S1 disc. Sacral disc remnants are difficult to see on plain film X-rays,
but are often visible on MRI. This can result in confusion when using plain films to identify
structures found on MRI.
L1
L2
L3
L4 Sacral
Disc
Remnant
L5
S1
S2
L5-S1 Disc
S3
Figure 3:2.

Anatomy
Components of the intervertebral discs as viewed on a sagittal T2 weighted image. The
nucleus pulposa of the L4-L5 intervertebral disc is demarcated by a red dotted line. The
arrows indicate the location of the annulus fibers of the disc: the blue arrows indicate the
boundaries of the posterior portion of the L2-L3 disc, and the yellow arrows identify the
anterior portion of the annular fibers of L3-L4. Note on this T2 weighted image that the
nucleus is lighter in color than the annular portion of the discs. This is due the increased
hydration of the nucleus versus the annular fibers. As a disc ages and dehydrates, the entire
disc will appear dark on a T2WI.
Figure 3:3.

Normal Disc Appearance
Figures 3:3 and 3:4. The appearance of a normal disc on axial T2 weighted MR. The nucleus is
light in color (indicating normal fluid content), while the annular ring is dark. Figure 3:3 is the
same slice as figure 3:4, but with the margins of the nucleus pulposa denoted by a red dotted line.
Figure 3:5. This sagittal image shows

the level of the axial slice seen in
figures 3:3 and 3:4.
The Central Canal
Figure 3:6. Figure 3:7.

The central canal is outlined with a red dotted line in these sagittal and axial T2 weighted images.
Anatomy of an Axial Slice Through L5
L5 vertebral body
Deep abdominal fat
Iliopsoas muscle
Iliacus muscle
Ilium
Gluteal muscle
Subcutaneous fat Multifidus muscle
Figure 3:8. Erector spinae muscles
This image, a T2W sagittal slice through the level of L5, reveals the cross-sectional anatomy of this
plane. Recall that in T2 images water density is bright, fat is light-colored (but not as bright as
water), air is black, muscles are dark, and bone is a neutral gray.

Expanded L5 Axial Image
L5 vertebral body Thecal sac
L5 nerve exiting the L5-S1 foramina

L5-S1 facets
Cerebral spinal fluid (CSF) within

Nerve rootlets within the thecal sac the thecal sac
Figure 3:9.

Conus Medullaris
Figure 3:10. T2 weighted axial of the conus

medullaris (yellow arrow).
The conus medullaris is the terminal

end of the spinal cord. It typically
terminates at the level of T12 or L1, but
is occasionally seen terminating at L2.
Though the spinal cord terminates with
the conus medullaris, the spinal nerves Figure 3:11. T2 weighted sagittal image of the
lumbar spine showing a normal termination of
continue inferiorly within the thecal sac
the conus medullaris posterior to the vertebral
in the cauda equina. These dangling body of L1 (yellow arrow).
nerves resemble a horse’s tail, hence
the Latin description cauda equina
which literally translated is horse’s tail.

Spinal Nerves
The exiting nerve root expands into the dorsal root ganglion as it exits the intervertebral
foramina. The nerve roots are surrounded by fat from the point in which they exit the thecal
sac and transverse the foramina. Within the thecal sac, nerve rootlets (identified by blue in the
lower figure) are surrounded by cerebral spinal fluid (CSF) which is bright in color. These
nerve rootlets are known as the cauda equina.
Figure 3:12.
Figure 3:13.
Exiting nerve root

(the dorsal root
ganglion)
Nerve rootlets of the cauda equina

The Unique Shape of L5 on Axial Imagery
While not an ironclad landmark, the L5 vertebra can frequently be identified by its lemon
shape when viewed in an axial plane. These axial images characterize the appearance of the
L5 vertebra in an axial orientation.

Vertebral Anatomy
Superior
endplate
Foramina for
basivertebral vein
Inferior
endplate
Figure 3:18. Cross section of a lumbar vertebra.

Images adapted from Henry Gray (1821–1865). Anatomy of the Human Body. 1918.
Basivertebral vein
Inferior
endplate
Figure 3:19. T2 sagittal of a lumbar vertebra.

Axial Image of Sacrum
Left psoas muscle
Sacrum
S1 nerve roots
Right sacroiliac joint Left Ilium
Figure 3:20. Lumbopelvic anatomy on axial imagery.

Ligamentum Flavum
There are several ligaments that stabilize and support the spine. Of those the ligamentum
flavum is of particular interest to the clinician. It comprises the posterior boundary of the
spinal canal and normally appears as a “V” on axial slices (red arrows). On sagittal images
the ligamentum flavum is seen at the posterior of the spinal canal (yellow arrows).
Figure 3:21. Ligamentum flavum on T2 axial.
Figure 3:23. Ligamentum flavum on T2

sagittal image.
Figure 3:22. Ligamentum flavum on T2 weighted

axial image.

Sagittal Lumbopelvis
Posterior
Anterior
longitudinal ligament
Urinary bladder Gas density in the colon

Uterus
Figure 3:24. Lumbopelvic anatomy.

Normal Spinal Fat Distribution
Figures 3:25 and 3:26. Normal fat distribution within the spine. Epidural fat is located in the
posterior recess of the spinal canal. The white arrows identify normal epidural fat which appears
light in these T2WI.
The exiting nerve roots are surrounded by fat as it traverses

the IVF. Fat is light on both T1 and T2 weighted images.
Figure 3:27. T1 weighted axial image. Figure 3:28. T2 weighted axial image.
The nerves are surrounded by fat as they traverse the IVF. Note the water density of the CSF is
bright on T2 image and dark in the T1 image. Absence or displacement of the fatty tissue may be
clinically significant.
Anatomy from a Coronal Orientation
Liver Spleen
Right
kidney
Iliopsoas
muscle
Vertebral
body
Deep
Figure 3:29. Coronal anatomy abdominal
adipose
Longissimus muscle
Spinous processes Liver Kidneys
of the erector spinae
Quadratus lumborum
muscle
Image artifacts
Figures 3:30 and 3:31. Anatomy on coronal images.

Multifidus Muscles
The clinical significance of the multifidus muscles has become increasingly evident in
recent years, and clinicians are looking for better ways to observe this interesting muscle.
While coronal images are rarely used in most lumbar MRIs, they are useful in identifying
the multifidus muscles. Note that the multifidus fibers do not run longitudinally like the
erector spinae muscles (spinalis, longissimus, and iliocostalis), but rather obliquely from
the lateral side of the spinous processes to the mamillary processes of the lumbar spine
and the sacrum. In the lower lumbar and sacral region, the multifidi originate along the
spinous processes and insert into the aponeurosis of the sacrospinalis muscle, the
posterior superior iliac spine, and the posterior sacroiliac ligaments.
Figure 3:32. The multifidus muscles. Figure 3:33. The multifidus muscles on MRI.
The illustration on the left (figure 3:32) highlights the left multifidus muscles in red. The
coronal MR on the right (figure 3:33) provides a clear view of the multifidus muscles. Note the
oblique orientation of the multifidus muscles. Compare them to the longitudinal orientation of
the erector spinae muscles.
Image 1 adapted from Henry Gray (1821–1865). Anatomy of the Human Body. 1918.

Multifidus Muscle Characteristics
Figure 3:34. Schematic of multifidus location.

In axial imagery the multifidus lies in the laminar groove bordered by a fascial/adipose
boundary. The multifidus is typically a small flat muscle and subject to atrophy and fatty
infiltration. The illustration above (figure 3:34) demonstrates the location of the multifidus
in red. In the axial image below (figure 3:35) the location of the multifidus is
demonstrated in a T2WI within the red dotted lines.
Figure 3:35. T2W axial image denoting the location of the multifidus.

The Positional Relationship between the Erector Spinae and the Multifidus
M I
L
S
Figure 3:36. T2 weighted axial image with labeled muscles.
L I
M
S
Figure 3:37. Illustration of paraspinal muscles .
The posterior muscles of the spine can be seen on axial imagery and are separated by
fascial investment seen as the same intensity as adipose (figure 3:36).
The schematic (figure 3:37) identifies the location of these muscles:
M=multifidus, S=spinalis, L=longissimus, and I=iliocostalis.

The Anterior and Posterior Longitudinal Ligaments
Anterior Posterior
longitudinal longitudinal
ligament ligament
Figures 3:38 and 3:39. The posterior longitudinal ligament is located within the vertebral
canal and runs from the body of C2 to the sacrum. It lies posterior to the vertebral bodies
and intervertebral discs. The anterior longitudinal ligament lies along the anterior of the
vertebral bodies and discs. On sagittal MR these ligaments normally appear as a thin
line.
Posterior
Anterior longitudinal ligament
Figure 3:40. The ALL and PLL identified

on a T2 weighted sagittal image.

The Great Vessels
Abdominal aorta
Inferior vena cava
Figure 3:41. The great vessels of the abdomen.
The abdominal aorta is located on the left side of the body, (the right side of an MRI), and the
inferior vena cava is on the right side of the body (the left side of an MRI). The greater
pressure of the aorta helps to create a more circular inflated appearance, while the inferior
vena cava has a lower hydrostatic pressure and appears less inflated.

Suggested Reading
Marchiori D (2013). Clinical imaging: with skeletal, chest and abdomen

pattern differentials(third edition). Mosby.
Atlas SW. (2008). Magnetic resonance imaging of the brain and spine
(forth edition). Lippincott Williams & Wilkins.
Ross JS et al. (2010). Diagnostic imaging spine (second edition). Amirsys

Inc.

Standardized Anatomic
Reference Descriptors
46
Standardized Anatomic Descriptions
“There is no more difficult art to acquire than the art of

observation, and for some men it is quite as difficult to
record an observation in brief and plain language.”
William Osler, Physician, 1849-1919
Every specialty has its own lexicon that has special meaning within their
profession. This is fine when working within a given profession, but may confound
those from another profession. The language of healthcare is always evolving and
periodically contradictory and confusing. The condition known as Tarlovs cysts is
slowly ceding to the more descriptive term perineural cyst. The term HNP
(herniated nucleus pulposa) is now passé, replaced by the term herniated disc
(HD). Definitions evolve and change, but dissemination of the changes lags.
Periodically the various specialties join forces to identify words, diagnoses, and
descriptors with multiple or conflicting definitions, and through a consensus
process agree on a standardized definition. The combined task forces of the North
American Spine Society, the American Society of Spine Radiology, and the
American Society of Neuroradiology created a guideline for standardizing the
vocabulary between the various spine specialists. They published these guidelines
in the March 1, 2001 edition of Spine. I recommend that every spine practitioner
read and apply this article. While this work proposes a guideline to standardize
terms within the spine specialties, it will eventually become obsolete and will need
updating too. Most of the next three chapters rely heavily on this document.
Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology: recommendations of the
combined task forces of the north American spine society, American society of spine radiology, and American
society of neuroradiology. Spine, Volume 26(5).March 1, 2001.E93-E113
http://www.rsna.org/radlex/committee/ASSRDiscNomenclature.pdf

Figure 4:1. P-A view.
These schemactics represent common identifying vertebral landmarks of the spine as seen
on a P-A view with the posterior elements removed (figure 4:1) and on a lateral view (figure
4:2). Using these points of reference, a radiologist or spinal specialist will be able to
verbalize the findings on MRI into an easy to understand written report. For example, if you
were to read a report that read, “The L4-5 disc herniated posteriorly and superiorly into the
infrapedicle level,” you should be able to ascertain the location of the herniation.
Figure 4:2. Lateral view.

Figure 4:3.
In addition to the levels of anatomic reference, longitudinal zones are also used to describe
anatomic locations in the spine. The schematic above (figure 4:3) is a posterior view of two
spinal segments with the posterior elements removed. Below (figure 4:4) is a corresponding
axial view of a single vertebral segment. These schematics reveal the location of the
various anatomical zones: central canal zone, subarticular zone, foraminal zone, far lateral
zone, and extraforaminal zone. The term paracentral is less clear-cut and is being replaced
by more definitive phrases such as “right central” or “left central.” The schematic seen
below represents a coronal slice through the spinal canal and the pedicles.
Figure 4:4.

Image from
USAMDCS
FSH, TEXAS 78234-6100
THE CENTRAL NERVOUS
Figure 4:5. The spine. SYSTEM
SUBCOURSE MD0572 EDITION 1
The spine is composed of 24 vertebrae, the sacrum, and coccyx. The segments from
C2 to the sacrum have intervertebral discs. These discs are identified by the adjoining
vertebrae. In the lumbar spine there are typically five discs: the L1-L2 disc, L2-L3
disc, L3-L4 disc, L4-L5 disc, and the L5-S1 disc.
While there is an L1 vertebra and nerve root, there is no L1 disc. There is a T12-L1
disc, and an L1-L2 disc. Both vertebrae must be named in the identification of the disc.
Image from
USAMDCS
FSH, TEXAS 78234-6100
THE CENTRAL NERVOUS
SYSTEM

Image from
USAMDC
FSH TEXAS 78234-6100
THE CENTRAL NERVOUS SYSTEM
Figure 4:6.
Nerve roots are identified by the vertebral segments from which they exit the spinal column.
Cervical nerve 1 (C1) exits between the occiput and the C1 vertebra and the C2 nerve root
between C1-C2. The exception to this method of identification is the C8 nerve root which exits
between the C7 and T1 vertebrae (there is no C8 vertebra). The sequence of nerve root
identification continues from the T1 (the first thoracic) vertebra through the sacrum with the name
of the nerve root being the same as the superior vertebra. The T1 nerve root exits between T1
and T2; the T2 nerve root exits between T2 and T3 and so on.
The cord is enlarged in the cervical spine (see the cervical enlargement above) and in the lower
thoracic spine (called the lumbar enlargement). The spinal cord terminates at the lower portion
of L1 or upper portion of the L2 vertebra. There is some anatomical variation on the level of cord
termination. The termination of the cord is called the conus medullaris. From the conus
medullaris, the cauda equina extends down the remainder of the spinal canal.
The filum terminale (literally meaning the terminal thread) extends from the conus medullaris of
the spinal cord to the first segment of the coccyx. It is composed mainly of connective tissue.

Identifying Affected Nerve Roots
Figure 4:7. Paracentral herniation Figure 4:8. Lateral herniation
These schematics show the the relationship of the lumbar nerves as they descend and exit
the lumbar spine and sacrum. Note the exiting nerve roots are high and lateral as they leave
the spinal canal, whereas the descending nerve roots are more central. When there is a
paracentral herniation (figure 4:7), it typically affects the descending nerve root, not the
exiting nerve root. To affect the exiting nerve root, the herniation usually has a foraminal or
lateral component (figure 4:8).
Additionally, when there is a paracentral herniation, the nerve contacted usually has the
same name as the vertebra below the herniation. A paracentral herniation of the L5-S1 disc
usually affects the S1 nerve root.

Suggested Reading
Fardon DF, Milette PC. Nomenclature and classification of lumbar disc

pathology: recommendations of the combined task forces of the north American
spine society, American society of spine radiology, and American society of
neuroradiology. Spine, Volume 26(5).March 1, 2001.E93-E113.
differentials(third edition). Mosby.
Bogduk N. (2012). Clinical and radiological anatomy of the lumbar spine.

Churchill Livingstone.

Classification of
Lumbar Disc Derangements
54
Nomenclature and Classification of Lumbar Disc Lesions
Speaking the same language is foundational for optimized integrated spine care. Physicians
need to have a reliable set of terms and criteria that transcend the various specialty jargon.
Guided by the need to establish a standardized and universally acceptable classification
system for identifying lumbar disc pathology, an interdisciplinary task force created a
collective set of guidelines. Again we reference the guidelines that were presented in 2001
through the combined efforts of the North American Spine Society, American Society of Spine
Radiology, and American Society of Neuroradiology. All spine practitioners are encouraged
to read the original work of this task force located in Volume 26, Number 5, Spine 2001.
http://www.asnr.org/spine_nomenclature/discussion.shtml
Normal
The normal disc is defined as a hydrated disc that does not show signs of degeneration, loss
of disc height, dehydration, bony edema, or degenerative changes.
Figure 5:1. A normal axial image.

Classification of Lumbar Disc Derangements
Differentiating an Intervertebral Disc Herniation from an Intravertebral Disc Herniation

The intervertebral space is the region between two adjacent vertebral bodies. This space is
typically occupied by the intervertebral disc. The peripheral boundaries of the intervertebral
space is marked by the border of the vertebral body. An intervertebral herniation occurs when
disc tissue migrates outside of the intervertebral boundaries.
Intravertebral herniations occur when the disc migrates into the vertebral body. This usually
occurs with axial compression from trauma, excessive load bearing, or a reduction in the bony
integrity of the endplate and underlying cancellous bone. Longstanding intravertebral
herniations are usually considered a coincidental finding.
Intravertebral herniations are

those disc derangements which
extend into the vertebral
bodies.
The intervertebral disc space

lies between the vertebrae.
Intervertebral herniations
extend outward from between
the margins of the adjoining
vertebral bodies.
Figure 5:2. Intervertebral lumbar segments

Figure 5:3. Intravertebral
herniations occur when the disc
breaks through the vertebral
endplate of an adjoining
vertebra. This schematic shows
both an inferior and superior
intravertebral herniation. These
are commonly called Schmorl’s
nodes.
Figure 5:4. This sagittal T2

weighted image reveals a large
intravertebral herniation through
the inferior endplate of L1.

Axial Images
Axial schematics will be used for much of the remainder of this chapter to illustrate the
characteristics of intervertebral herniations. The schematics will be based on an oval
shape of the disc. This is not how the disc typically appears, but it aids in understanding
the concept of classifying disc derangements.
Figure 5:5. Intervertebral discs are not uniform in shape or symmetry.
Figure 5:6. For the sake of clarity we will treat the intervertebral disc as a symmetrical
oval as we describe the nomenclature of classifying disc derangements.

Classification Parameters of Intervertebral Disc Derangements
To simplify the classification of disc derangements the disc is reduced to a two dimensional
oval model that is divided into quadrants. Each 90° quadrant represents 25% of the total
circumference of the disc. Using axial MRI imagery and this simple guideline allows the
differentiation between broad-based and focal herniations, between symmetrical and
asymmetrical disc bulges, and between extrusions and protrusions of the disc.
Normal Disc
25 % 25 %
25 % 25 %
Figure 5:7. The normal disc.

Symmetrical Disc Bulge
25 % 25 %
25 % 25 %
Margins of a Normal Disc
Extent of Disc Bulge
Figure 5:8. Symmetrical disc bulge.
Disc bulges are categorized as disc migration (beyond the border of the vertebral
apophyses) of more than 50% (180°) of the disc circumference. Symmetrical bulging
discs have a symmetrical appearance of bulging between 50 and 100 percent of the
disc circumference. The above schematic depicts a symmetrical bulging disc. Disc
bulges are not considered a herniation. Herniations, by contrast, are disc derangements
which involve less than 50% of the circumference of the disc.

Symmetrical Disc Bulge
This axial T2 image reveals a nearly

uniform disc bulge extending out in
all directions. It involves 100% of the
circumference of the disc. In the
lower image the dotted line signifies
the boundary of the vertebra, and the Figure 5:9. Symmetrical disc bulge on T2W axial
solid line reveals the extent of disc image.
migration. This is a good example of
a symmetrical disc bulge.
Figure 5:10. Symmetrical disc bulge. This is the

same MRI slice as in figure 5:9 above, but the
boundaries of the vertebral bodies are demarcated
by a dotted line and the extent of the disc bulge is
represented by a solid line.

Asymmetrical Disc Bulge
25 % 25 %
25 % 25 %
Margins of a Normal Disc Extent of Disc Bulge
Figure 5:11. Asymmetrical disc bulge.
Asymmetrical disc bulges are categorized as disc derangements that are asymmetric, but
involve outward migration of disc material of at least 50% of the disc’s circumference.
Asymmetrical bulging discs have an asymmetrical appearance of bulging greater than
50% of the disc’s circumference. This schematic depicts an asymmetrical bulging disc.

Asymmetrical Disc Bulge
These images are of the same axial

T2 slice and they reveal an
asymmetric disc bulge. It is
categorized as a bulge rather than a
herniation since it occupies more
than 50% of the circumference of the
disc. In the bottom image the white Figure 5:12. Asymmetrical disc bulge on a T2W
arrows indicate the border of the axial image.
vertebra, and the yellow arrows point
to the margins of the asymmetrical
disc bulge.
Figure 5:13. Enhanced image of an asymmetrical

disc bulge on a T2W axial image. The white
arrows identify the boundary of the vertebra and
the yellow arrows, the boundary of the disc bulge.

Disc Herniation
Margins of a Normal Disc Disc Herniation
Figure 5:14. Schematic of a disc herniation.
Disc herniations are migrations of disc tissue more localized in appearance and occupying less
than 50% of the disc’s circumference. There are several subcategories of disc herniation.

Disc Herniation
Figure 5:15. This herniation affects less than 50% of the disc circumference, so it
would be labeled a herniation rather than a bulge.

Differentiating between a Focal and a Broad-Based Disc Herniation
25 % 25 %
25 % 25 % 25 % 25 %
25 % 25 %
Figure 5:16. A broad-based Figure 5:17. A focal disc herniation

herniation occupies 25-50% of the occupies less than 25% of the disc
disc circumference. circumference. Recall that a disc bulge
occupies more than 50% of a disc’s
circumference.

Broad-Based Disc Herniation
This broad disc herniation

involves more than 25%,
but less than 50% of the
circumference of the disc.
Thus it is classified as a
broad-based disc
herniation.
Figure 5:18. A broad-based herniation in a T2W axial

image.
25%
Figure 5:19. A broad-based herniation in a T2W axial

image. A broad-based herniation occupies 25-50% of
the disc circumference.

Focal Disc Herniation
This disc herniation clearly

involves less than 25% of
the circumference of the
disc; so it is classified as a
focal disc herniation.
Figure 5:20. A focal herniation in a T2W axial image.
25%
Figure 5:21. A focal herniation occupies less than 25% of the

circumference of a disc.

Differentiating between a Protrusion and an Extrusion
Disc Protrusion Disc Extrusion
Figure 5:22. A disc protrusion has a Figure 5:23. A disc extrusion has a
base wider than its tip. “waist” that is narrower than the tip.
A disc protrusion is wider at the base than it is at the tip. A disc extrusion mushrooms
out so that it will have a narrowed waist at the base as indicated by the arrows.

Disc Extrusion
Figure 5:24. Disc extrusion with a narrowed waist (red arrows).
An extrusion is demonstrated on axial imagery by either the narrowed waist that joins the
herniated portion of the disc with the rest of the disc or by the absence of a clear bridge
between the herniated portion and the main body of the disc. The red arrows indicate the
space between the vertebral body and the extruded disc.

Disc Extrusion
Figure 5:25. This T2 weighted sagittal image shows the characteristic waist of an extrusion.

Disc Protrusions
These T2W images depict

protrusions. Note that the base of
these herniations are wider that the
tips, and there is no narrowed waist.
Figure 5:26. Axial image of a herniation with its base

wider than its tip.
Figure 5:27. Axial image of a protruded disc.

Sagittal Views of Protrusions and Extrusions
Protrusion Extrusion Extrusion
Figure 5:28. Schematics of protrusion and extrusion.
Disc extrusions can be diagnosed in either the axial or sagittal planes. A protrusion is a
herniation that has a wide proximal base which narrows as it extends distally from the
center of the disc. An extrusion has an expansive herniation that widens after it leaves the
intervertebral space. Even if the herniation appears to have a wide base like a protrusion,
it is considered an extrusion if it expands along the vertebral body to a width wider than
that of the disc (see image on right). A protrusion does not exceed the cranio-caudal
boundaries of the intervertebral disc.

Clarification of Extrusion versus Protrusion
To further clarify the difference between a protrusion and an extrusion, axial and sagittal images
of the same disc herniation have been selected. On the axial image the disc herniation looks like
a disc protrusion (the base of the herniation appears wider than the tip). However, when you
view the same herniation from the sagittal orientation, you can see a narrowed waist of the disc
at the point that it exits the intervertebral space, and the disc expands out. A disc extrusion is
present when an expansion is visualized in either the axial or sagittal views or if a sequestered
fragment is present.
Figure 5:29. This axial image appears to be a Figure 5:30. This sagittal image of the same
protrusion (green arrow) as its base is wider herniation in figure 5:29 shows a narrowed
than its tip. waist (red arrows) making this an extrusion,
regardless of its appearance on axial imagery.

Sequestered Fragment
Disc Herniation
Margins of a Normal Disc

Sequestered Disc Fragment
Figure 5:31. Sequestered disc fragments have broken off and are no longer
contiguous with the rest of the disc.
Another category of disc extrusion is the sequestered fragment. A sequestered fragment

is the designation given to a disc derangement in which a portion of the disc breaks free
from the rest of the disc. Sequestered fragments can migrate from their mother discs.
They are considered a category of disc extrusions. Sometimes these are referred to as
“free fragments.”

Figure 5:32. A large sequestered disc fragment in the central canal of L5 displacing
and compressing the S1 nerve root.
Figure 5:33. The axial image from figure 5:32 is enhanced here. The red dotted line
outlines the sequestered disc fragment, and the blue line outlines the S1 nerve root..
This image contains a sequestered disc fragment that displaces and compresses the left
S1 nerve root. The bottom version of this MR slice highlights the sequestered disc
fragment with a circumferential red dotted line around it. The compressed nerve root is
identified by a solid blue line. Note the degree of swelling of the displaced left nerve root in
comparison to the right nerve root.

Contained versus Non-contained Herniations
Another identifier describing disc derangements is the relationship of the derangement to the
outer annulus and the posterior longitudinal ligament (PLL). The PLL lies over the posterior
vertebral bodies and the posterior portion of the disc. If the PLL and the outer annulus are
intact and contain the disc derangement, it may be categorized as a sub-ligamentous or
contained herniation. If the disc has violated the outer annulus, it is categorized as a non-
contained herniation. If the disc derangement disrupts and passes through the posterior
ligaments, it has been called an extra-ligamentous herniation. The current limitations of MR
often make it difficult to differentiate between ligamentous, contained ,and non-contained
herniations.
Sub-ligamentous and contained Extra-ligamentous and non-contained
Figure 5:34. A sub-ligamentous Figure 5:35. An extra-ligamentous

herniation does not violate the integrity herniation violates the integrity of the
of the ligaments, usually the posterior posterior longitudinal ligament. A non-
longitudinal ligament (red dotted line). contained disc derangement denotes
A contained disc derangement remains disc material escaping the confines of
enclosed within the annulus fibers. the annulus fibers.

Normal Axial Slice
Exiting
nerve root
Thecal sac
Facet joint
Figure 5:36. A baseline schematic of a normal axial image.
Figure 5:37. A baseline T2W axial image of a normal lumbar segment.

Central Disc Herniation
Figure 5:38. A schematic of a central disc herniation.
Figure 5:39. T2W axial image of a small, focal, central disc

herniation.

Paracentral Disc Herniation Displacing a Nerve Root
Figure 5:40. Axial schematic image of a paracentral disc herniation displacing an S1

nerve root.
Figure 5:41. Axial image of a paracentral disc herniation (green arrow) that contacts and
displaces the left S1 nerve root.

Nerve Root Compression
Figure 5:42. Schematic of a focal disc herniation compressing an S1 nerve root.
Figure 5:43. This axial MRI demonstrates a herniation (yellow arrow) that contacts and
displaces the S1 nerve root, compressing it against the bony posterior portion of the
spinal canal.

Anterior Disc Herniation
Figure 5:44. Schematic of an anterior disc herniation.
Figure 5:45. Sagittal image of a large Figure 5:46. Axial image of a large
anterior herniation (red arrow). anterior herniation (yellow arrow). This
is the same herniation seen in figure
5:45.
Anterior disc herniations do not compromise the spinal cord, thecal sac, or nerve roots,
but may be a source of pain and indicative of biomechanical failure.

Foraminal Disc Herniation
Figure 5:47. Schematic of a foraminal herniation.
Figure 5:48. Axial image of a foraminal herniation.
Herniations into the foraminal canal can compromise the exiting nerve roots. Even a
small herniation in the foraminal canal can cause significant nerve impingement.

Far Lateral Foraminal Disc Herniation
Figure 5:49. Schematic of a far lateral herniation.
Figure 5:51. Axial image of a far lateral

Figure 5:50. Axial image of a far lateral
herniation shown outlined with a red dotted
herniation.
line.
Far lateral herniations may contact and affect the exiting nerve root after it leaves the
intervertebral foramen. The image on the right outlines the circumference of this far lateral
herniation which is visualized in both images.

Volume Descriptors
Figure 5:52. Mild herniation. Figure 5:53. Moderate herniation.
These are the volume descriptors for the amount

of disc material herniated into the central canal
as observed on the axial image at the slice of
most severe compromise. A canal compromised
less than one-third is a mild herniation (figure
5:52), between one-third and two-thirds is
considered a moderate herniation (figure 5:53),
and over two-thirds is a severe herniation (figure
5: 54). This grading method can also be utilized
to describe foraminal involvement.
Figure 5:54. Severe herniation.

Volume Descriptors for IVF Involvement
Intervertebral
Foramina (IVF)
Figure 5:55. Normal/patent foramina Figure 5:56. Mild foraminal occlusion
Figure 5:57. Moderate occlusion Figure 5:58. Severe IVF occlusion
The descriptors for IVF occlusion are similar to the volume descriptors used for
notating the size of disc herniations. An IVF with less than one-third of the canal
occluded has a mild occlusion (figure 5:56), an occlusion that is between one-third
and two-thirds is considered moderate (figure 5:57), and over two-thirds is a severe
occlusion (figure 5:58).

Suggested Reading


Classification of
Annular Tears
88
Annular Tears
The term annular tear or annular fissure is used to categorize separation
between the annular fibers, avulsion of the fibers from the vertebral body, or a
tear through the fibers. A common misconception is that trauma is always
indicated by a tear. Annular tears may occur from trauma or over time as part of
a degenerative process. Some experts prefer the term annular fissure since it is
less implicative of trauma. There are three categorizations of annular tears:
radial tears, transverse tears, and concentric tears. Annular tears may be
clinically significant or may be asymptomatic coincidental findings. As with many
findings on MRI, just because a lesion is visible does not mean that it is clinically
significant.
Radial Tears
Radial tears begin centrally and progress outward in a radial direction. Radial tears
may precede the migration of the nucleus, resulting in a disc herniation.
Radial tears of the disc radiate

out in a radial direction from
the center of the disc .
Figure 6:1. Radial disc tears.

Annular Tears
Figures 6:2 and 6:3. Radial disc tears are denoted by yellow arrows in T2W sagittal images.
Radial Tears
These two T2 sagittal images demonstrate radial tears of the annulus of the disc between
L5 and the sacrum .

Transverse Tears
Transverse tears have also been called rim lesions. Transverse tears are horizontal
lesions that may involve the disc tearing away from the endplate. This lesion may
involve disruption of Sharpey’s fibers (the matrix of connective tissue that binds the disc
to the vertebral endplates) and the disc. Transverse tears appear to have a causal effect
in degenerative disc disease and the formation of osteophytic spurring. They are
typically small and limited to the joining of the annular attachments to the apophyseal
ring–the rim of the vertebra, hence the term rim lesion.
Apophyseal ring
Transverse tears from the

apophyseal rings
Figure 6:4. Transverse disc tears.

Transverse Tears
Figures 6:5 and 6:6. T2WI of an L5-S1 posterior transverse tear.

The two images above show a transverse annular tear from the superior endplate at the
posterior margin of the sacrum. The T2 weighted images above are from the same
patient. Below is an image from a different patient with a small tearing of the annulus
fibers from the superior apophyseal ring of the sacrum. Annular tears are well
demonstrated in T2 images and appear as high-intensity zones, thus appearing white in
T2 weighted images.
Figure 6:7. Transverse disc tear.

Concentric Tears
Concentric tears are a separation of the concentric annular bands that surround the
nucleus. Normally the outer third of the annulus is affected by concentric tears.
Incidentally, it is the outer third of the annular fibers that are the most richly innervated
and vulnerable to nociception.
Figure 6:8. Concentric disc tear.

Concentric tears separate bands of
the annular rings of cartilage.
They are characterized by high
intensity zones (white appearance)
on T2 weighted images. Most
concentric tears occur in the outer
portion of the disc.

Concentric Tears
Figure 6:9. Concentric disc tear in a Figure 6:10. Concentric disc tear in a
T2W sagittal image. T2W axial image.
The T2W images above are from the same patient and show a transverse concentric
tear involving the posterior portion of the L5-S1 disc. Below is an image from a different
patient with a lateral concentric tear. Most concentric tears occur in the outer rings of
the annulus.
Figure 6:11. Posterior lateral concentric disc tear in a T2W

axial image.

Suggested Reading

Schmorl G, Junghans H, “The human spine in health & disease”. New York:
Grune & Stratton, 1971.


Gallery of Lumbar Disc
Derangements
96
Gallery of Lumbar Disc Derangements
This chapter is composed of a gallery of various lumbar disc derangements and will
help unite the information provided in the last six chapters. As you view this pictorial
essay take a moment to consider the components of each disc herniation: the
vertebral level, the anatomical zone, and the type of derangement (tear, extrusion,
protrusion, bulge, intravertebral herniation, and so forth). In addition to identifying the
nomenclature and classification of the disc lesions, take time to familiarize yourself
with the other structures in each image. Of particular interest to clinicians is the disc
injury’s relationship to the cord, the cauda equina, thecal sac, and nerve roots.
Moreover, consider the impact of disc derangement on facets, muscles, ligaments,
endplates, vertebral bodies, the canal space, epidural venous plexus, sacroiliac joints,
and other anatomical structures. A disc herniation may be associated with facet
effusion, multifidus atrophy, bony edema of the vertebral bodies, facetal imbrication,
ligamentum flavum changes, posterior longitudinal ligament disruption, and other
anatomical and functional failures.
Additionally, take time to consider the potential clinical consequences of particular

disc injures: pain distribution, orthopedic-neurologic signs, and effects on other
anatomical structures. By viewing a variety of different derangements, you will begin
to gain familiarity of this topic and be more competent at discerning the nuances of
disc disease.
Figure 7:1. L4-L5 disc herniation with cephalad migration along the body of L4.

Comparing T1 and T2 Weighted Images of Disc Derangements
Figure 7:2. T1 axial at L4-5. Figure 7:3. T2 axial at L4-5, the same
slice as figure 7:2.
Figure 7:4. T1 sagittal of a Figure 7:5. T2 sagittal of the same

herniation at L4-5. herniation at L4-5 in figure 7.4.
T1 images have good anatomical detail, but contrast is reduced between the disc and the
cerebral spinal fluid in the thecal sac, making it more difficult to identify a disc herniation.
Because of this, it is easier to view a herniation on T2 images.
Most of the disc herniations in this chapter will be presented in T2 weighted format.

Caudal Sequestered Extrusion into the Sacral Canal
Figure 7:6. This T2 weighted axial image reveals Figure 7:7. This T2 weighted sagittal
a round circumscribed herniation (sequestered image shows a light-colored sequestered
disc fragment) descending into the sacral canal disc fragment descending into the sacral
and displacing the thecal sac and the S1 nerve canal along the body of S1.
root.
Figure 7:8. This axial image is a slice that Figure 7:9. A sagittal T1 weighted image
is cephalad to the slice in figure 7:6. The of a caudal herniation (green arrow) of
sequestered fragment is clearly seen. the L5-S1 disc.
These four images show a large L5-S1 sequestered extrusion that extends caudally into the central
canal of the sacrum following the left S1 nerve root and displacing the thecal sac. The light color of
this extrusion is indicative of high water content.

Foraminal Herniation
Figure 7:10. This T2 weighted axial image

reveals a right foraminal herniation of the L4-5
disc. Figure 7:11. This sagittal T2 weighted image
reveals a right foraminal herniation of the L4-5
These images reveal a foraminal herniation at
disc. Note the L4-5 disc extending upward into
L4-L5 with compression of the right L4 nerve
the IVF and compressing the exiting L4 nerve
root in a 69 year-old man. Also of note in the
root.
axial image is increased intensity within the
right zygapophyseal joint and atrophy of the
multifidus muscles. This focal herniation is an
extrusion and extends cephalad in the IVF,
contacting and compressing the exiting nerve
root.
Figure 7:12. Schematic of a right-

sided L4-5 foraminal herniation.

Foraminal Herniation with Zygapophyseal Effusion
Figure 7:13. This axial image displays a broad-based disc protrusion (yellow arrows)
that crosses the right IVF. Note the effusion within the right zygapophyseal joint
(green arrow).

Caudal Extrusion of the L4-5 Disc
Figure 7:14. L4-L5 inferior extrusion and possible sequestration.
Figure 7:15. An axial view of the extrusion along the body of

L5. Note the thecal sac displacement.

Regression of Disc Herniation
Figure 7:16. Large extrusion of the Figure 7:17. Follow-up MRI of the same
L4-5 disc. patient six months later. Note the
regression of the L4-5 disc herniation.
These images show the regression of a large extrusion of the L4-5 disc over a six month
period of conservative care. Figure 7:16 displays a huge herniation, but a second MRI taken 6
months later, figure 7:17, reveals a significant reduction in the mass of the herniation. Note the
bony edema of the adjoining vertebral bodies. Endplate disruption and bony edema of the
vertebral bodies will be discussed more fully in Chapter 12. Larger herniations are more apt to
regress than smaller herniations. Disc bulges tend not to regress in size. Axial images of this
patient are presented on the following page.

Regression of a Disc Herniation (continued)
Figure 7:18. Large extrusion of the L4-5 disc. Figure 7:19. Follow-up MRI of the same patient
Note the extent of thecal sac effacement and six months later. Notice the regression of the
displacement of the nerve rootlets. L4-5 disc herniation.
From an axial perspective figure 7:18 reveals the extent this disc extrusion occupied the central
canal, subarticular zone, and foraminal zone. Figure 7:19, taken six months later, clearly
demonstrates a profound reduction in the size of the herniation.

Extrusion and Post-Surgical Re-Herniation and Regression
Figure 7:20. Pre-surgery. Figure 7:21. Re-herniation two Figure 7:22. Regression of the
months post-discectomy. disc six months after the image
in figure 7:21 was taken.
This sequence of images show a sequestered extrusion of the L5-S1 disc extending inferiorly
into the central canal of the sacrum (figure 7:20). This patient was treated surgically with a
microdiscectomy. Two months after surgery, he re-herniated the L5-S1 disc, this time with
superior migration of the extruded disc along the posterior body of L5 (figure 7:21). He was
treated conservatively with chiropractic care, exercise, and modified work postures. A follow-
up MRI six months following the second herniation revealed what appears to be a “deflated”
herniation (figure 7:22). The herniation still extends superiorly along L5, but the mass of the
herniation is significantly reduced.

Focal Central Herniation
Figure 7:24. This T2W axial image of the

same patient reveals a focal herniation
arising from a broad-based herniation. Note
the herniation is between the S1 nerve roots.
Figure 7:23. T2W sagittal image

revealing a small extrusion of L5-S1.
These images reveal a focal extrusion on top of a broad-based protrusion of the L5-S1 disc.
The focal extrusion between the S1 nerve roots contacts both descending S1 nerve roots and
effaces the thecal sac.

Herniations with Annular Tears
Figure 7:25. This T2 weighted axial image Figure 7:26. This T2 weighted axial image
reveals a posterior concentric annular tear reveals broad-based herniation with a
of the L4-5 disc. posterior paracentral concentric annular tear.
Figure 7:27. This T2 weighted sagittal Figure 7:28. This sagittal image displays
image reveals a transverse annular tear a posterior transverse tear at the superior
of the anterior of L2-3 on the superior endplate of L4 (yellow arrow), a
L3 endplate. There is also a tear along concentric tear of the posterior L5 disc
the superior endplate of L4 affecting the (green arrow), and a small portion of a
posterior portion of that disc. transverse tear at the superior L3
endplate (red arrow).

Paracentral Herniation
Figure 7:29. T2W sagittal image Figure 7:30. T2W axial image showing a left para-
revealing desiccation of the L4-5 and central extrusion of the L5-S1 disc.
L5-S1 disc and an extrusion of the L5-
S1 disc.
These T2 weighted images reveal an L5-S1 paracentral disc extrusion displacing and
compressing the left S1 nerve root. Notice the levels of brightness and darkness in these images.
The extruded portion of the disc is light-colored, which on a T2WI indicates a high degree of water
content. In contrast, the L4-L5 disc is dark in color indicating reduced water content and
desiccation.

Paracentral Extrusion
Figure 7:31. Sagittal T2 weighted

image of an L4-5 extrusion.
Figure 7:32. Axial T2W images of a paracentral L4-

5 disc extrusion.

Broad-based Protrusion
Figure 7:34. Sagittal T2 weighted image of an

L4-5 extrusion.
Figure 7:33. Sagittal T2 weighted image

of an L4-5 protrusion.
Here we see a broad-based protrusion of the L5-S1 disc that distorts the left anterior portion of the
thecal sac and narrows both IVFs. The left IVF is particularly compromised.

Figure 7:36. This axial represents the slice

showing with the greatest herniation mass
at L5-S1.
Figure 7:35. Sagittal T2 image revealing a

relatively small L4-5 extrusion (yellow
arrow) and a larger L5-S1 herniation
(green arrow). The L5-S1 extrusion has a
Figure 7:37. This slice shows the
“hook” extending caudally from the main
caudally migrated portion of the L5-S1
herniation. disc seen in figure 7:35.
These three images show a large L5-S1 herniation (a focal herniation on top of a broad-based
herniation) with a portion of the disc descending caudally. This portion of the L5-S1 disc may
actually be a sequestered fragment that has not displaced. In figure 7:36 the thecal sac
effacement and nerve compression is worthy of note. In figure 7:37 the inferior portion of the L5-
S1 disc is clearly visualized displacing the left S1 nerve. Also of note is the disc extrusion and
desiccation at L4-5 seen in the T2 sagittal image.

Two Level Herniation
Figure 7:39. Focal paracentral extrusion at

L3-4 displacing the thecal sac.
Figure 7:38. Sagittal T2 image of L3-4 Figure 7:40. Broad-based herniation with a
(green arrow) and L4-5 (yellow arrow) strong left foraminal component at L4-5.
extrusions.
These three images show two herniations migrating toward each other. The L3-4 herniation is
seen on the sagittal image (figure 7:38) and axial image (figure 7:39). It extends inferior along
the posterior body of L4. The L4-5 herniation is visualized in figure 7:38 and figure 7:40. The
L4-5 herniation travels superiorly. Also notable in this series is the concentric annular disc tear
affecting the posterior fibers of the L5-S1 disc.

Herniation with Nerve Root Entrapment
Figure 7:41. This focal foraminal zone herniation of the L5-S1 disc (white arrow) entraps
and compresses the S1 nerve root (yellow arrow). Also of note in this T2W axial image is
the central canal stenosis and subarticular stenosis. Ligamentum flavum hypertrophy and
facetal hypertrophy contribute to the stenosis.

Broad-based Extrusion
Figure 7:42. Moderate broad-based extrusion of L5-S1

extending across both foramina favoring the right.
Figure 7:43. L5-S1 extrusion and L4-L5 protrusion. Figure 7:44. Sagittal T2WI of L4-5and L5-S1
herniations. L5-S1 is an extrusion.

Intravertebral Herniation
Intravertebral herniations occur when the disc breaks through the vertebral endplate of
an adjoining vertebra. This schematic shows both an inferior and superior intravertebral
herniation. These are commonly called Schmorl’s nodes.
Figure 7:45. Sagittal T2 weighted image Figure 7:46. Sagittal T2 weighted image from
showing an intravertebral herniation the same study showing another intravertebral
(Schmorl’s node) extending superiorly herniation extending superiorly into L4. Note
into T12. Note the halo of Modic 2 (see the bony edema surrounding this bony
chapter 12) changes around the lesion disruption.
and affecting the L2 and L3 vertebrae.

Herniation
Figure 7:47. Sagittal T2WI showing an extrusion and

degeneration of the L5-S1 disc.
Figure 7:48. Axial T2WI of a left-sided paracentral herniation

displacing the S1 nerve root and effacing the thecal sac.

Large Extrusion Projecting Inferiorly

reveals the large extrusion that occupies a
great portion of the central canal posterior to
the body of L5.
Figure 7:49. This sagittal image shows a huge

L4-5 extrusion (probably a sequestered fragment)
that projects inferiorly from the L4-5 disc space
along the vertebral body of L5.
From the axial image this herniation would be classified as being moderately large. The
sagittal view is needed to fully grasp the mass of disc material that herniated from the
L4-5 disc and descended along the body of L5. This herniation resulted in a left leg foot
drop, which resolved after surgery.

Figure 7:51. This axial image shows a sequestered fragment from the L5-S1 disc. The
sequestered fragment displaces the left S1 nerve root. The left S1 nerve appears inflamed.
Figure 7:52. This is the same axial slice as is displayed in figure 7:52, but with
demarcations. The sequestered fragment is denoted by a red dotted line, and the
yellow dotted line denotes the S1 nerve root .

Re-herniation Two Weeks Post Surgery
Figure 7:53. This image, taken two Figure 7:54. In addition to the re-herniation of
weeks after a discectomy, shows a L4-5, this T2 weighted image shows fluid
large re-herniation of the L4-5 disc collecting (bright on T2WI) posterior and to the
(the same segment and same side right of midline.
that had been operated on).
Figure 7:55. Sagittal T2WI showing the Figure 7:56. Sagittal T1WI showing the
L4-5 re-herniation (yellow arrow) and L4-5 re-herniation (yellow arrow) and
posterior fluid collection (green arrow). posterior fluid collection (green arrow).
This series of images taken two weeks following a discectomy reveals a re-herniation
of the L4-L5 disc and a pseudomeningocele (see page 335, chapter 24).

Regression of Disc Herniation (page 1 of 3)
Figure 7:57. This sagittal image shows a large Figure 7:58. This sagittal image of the same
L4-5 extrusion that projects inferiorly from the patient seen in figure 7:57 reveals significant
L4-5 disc space. regression of the L4-5 disc extrusion.
A series of seven images over the next three pages are taken from a patient who
presented with a large herniation that regressed significantly over a five month period.

Regression of Disc Herniation on Axial Images (page 2 of 3)
Figures 7:59 and 7:60. These axial images are from the same patient from the previous page.
These images reveal two axial slices of an L4-5 herniation.
Figure 7:61. This axial slice represents the largest remnant

visible of the L4-5 herniation from any image in the axial
series taken five months after the series represented in

Regression of Disc Herniation (page 3 of 3)
Figure 7:62. From this axial slice, the disc derangement looks like a free-floating
sequestered fragment. It represents the slice depicted by the green line in figure 7:63.
Figure 7:63. By correlating the axial images with the sagittal images, you will gain a
more conceptual view of the anatomy. Here we can see that the axial slice in figure
7:62 (green arrow) captures one portion of a larger caudal extrusion, not a
sequestered fragment. This concludes a seven image series.

Intravertebral Herniations
Figure 7:64. T1W sagittal image of a large Figure 7:65. T2W sagittal image of a large
intravertebral herniation through the inferior intravertebral herniation through the
endplate of L1 into the body of L1. inferior endplate of L1 into the body of L1.
Figure 7:66. A different T2W sagittal Figure 7:67. This axial T2WI image shows the
slice from the same patient shows the disc material that has herniated into the vertebral
halo of bony edema indicating that this body of L1.
injury is new and possibly a pain
generator.
Concentric Tear
Figure 7:68. Sagittal T2WI showing an extrusion and

degeneration of the L4-L5 (red arrow) and L5-S1 discs with
a posterior concentric annular tear at L5-S1(yellow arrow).
Figure 7:69. Axial T2WI of the concentric annular tear at

L5-S1(yellow arrow).

Concentric Tear
Figure 7:71. Sagittal T2WI showing a posterior

concentric annular tear at L4-L5.
Figure 7:70. Sagittal T2WI showing a

posterior concentric annular tear at L4-L5.

Paracentral Herniation
Figure 7:72. Sagittal T2WI showing an extrusion and degeneration at L4-

L5 (yellow arrow). Desiccation is also visible at L5-S1 (green arrow).
Figure 7:73. Axial T2WI showing a left paracentral disc herniation.

Small Central Herniation
Figure 7:74. Small central herniation.

Figure 7:75. Sagittal T2WI showing an extrusion of Figure 7:76. Axial T2WI showing an extrusion
the L5-S1 disc. A sequestered fragment sits on the of the L5-S1 disc.
extrusion like the cap of a mushroom.
Figure 7:77. Axial T2WI showing an Figure 7:78. Axial T1WI showing an
extrusion of the L5-S1 disc. extrusion of the L5-S1 disc.

Central Extrusion
Figure 7:80. T2W axial image of the same

disc derangement as seen in figure 7:79.
Figure 7:79. T2W sagittal image of a small L5-S1

extrusion with a concentric tear.

Figure 7:82. Left-sided paracentral extrusion

effacing the thecal sac (yellow arrow) and
displacing the left S1 nerve root (green arrow)
on a T2W axial image.
Figure 7:81. L5-S1 extrusion, degeneration,

and desiccation. The discs of the upper lumbar
vertebrae are light-colored in this T2WI
indicating hydration. The black disc of L5-S1
shows reduced hydration and desiccation.

Figure 7:83. Moderate paracentral herniation on top of a

broad-based herniation at L5-S1on a T2WI.
Figure 7:84. Two extrusions are visible

in this sagittal image: L4-5 (green
arrow) and L5-S1 (yellow arrow). The
upper discs appear well hydrated, but
L4-5 and L5-S1 are dark in this T2WI
indicating desiccation.

Broad-based Herniation and Extrusion
Figure 7:85. T2W axial image showing a broad-

based herniation at L5-S1.
Figure 7:87. T2W sagittal image of the

lumbar spine showing well-hydrated discs
from L1-L5 and a cephalad migrating
extrusion arising from L5-S1. Note the
black disc of the L5-S1 indicative of
desiccation.
Figure 7:86. T1W image of the herniation as it

extends cephalad along the body of L5.

Focal Herniation into a Large Central Canal
Figure 7:89. This image shows a focal disc

herniation on top of a broad-based
herniation. The herniation extends into a
very large central canal.
Figure 7:88. A degenerative disc with

degenerative endplate changes at L5-S1.
An extrusion exits from the L5-S1 disc into
a very large central canal. Note a small
hemangioma in the body of L3.

Focal Extrusion Compresses and Deforms the Thecal Sac
Figure 7:90. The T2W axial image shows a focal

extrusion compressing and deforming the thecal sac
and its contents.
Figure 7:92. The sagittal view of this

extrusion clearly shows deformation of the
thecal sac at L4-5 along with disc
desiccation at that level and a small
perineural cyst at the level of S2. This
image also demonstrates a clear view of
the conus medullaris terminating at L1.
Figure 7:91. This enlargement of the

sagittal slice from figure 7:92 shows the
boundary of the thecal sac (yellow
arrows).

Severe Herniation
Figure 7:93. A very large disc herniation at L5-S1. The

mass of the herniation occupies nearly the entire central
canal.
Figure 7:95. A very large disc

herniation at L5-S1.
Figure 7:94. Enlarged view of the sagittal from figure

7:95.

Large Central Lumbar Herniation
Figure 7:97. A very large disc herniation

(extrusion) at L5-S1.
Figure 7:96. A large disc herniation at L5-S1. The

mass of the herniation occupies a significant portion
of the central canal.

Sequestered Disc Fragment Following a Hemilaminectomy
Figure 7:98. A large disc herniation at L5-S1 along the sacrum and a sequestered fragment
(yellow arrow) in the central canal posterior to the body of L5. These images indicate that this
patient had previously had a right hemilaminectomy at L5-S1.
Figure 7:99. This axial image shows three distinct hues from the same disc. These hues
represent the fluid content of the derangement. The broad-based disc herniation is dark (green
arrows), the central portion of the herniation is neutral (yellow arrow), and the right foraminal
herniation is light (red arrow). The path of the surgeon is clearly visible along the right lamina
(white arrows).

Anterior Herniation
Figure 7:100. This T2W sagittal image Figure 7:101. This is a T1W sagittal
clearly shows a large anterior image of the same anterior herniation
herniation of L1-2. as seen in 7:100 and 7:102.
Figure 7:102. This T2W axial shows a broad

anterior herniation of L1-L2 extending to the
abdominal aorta.

Foraminal Herniation
Figure 7:104. The left L3-4 foramina is totally

occluded by this dumbbell-shaped foraminal
herniation.
Figure 7:103. The L3-4 foramina is

totally occluded by this foraminal
herniation.

Right Paracentral Herniation
Figure 7:105. This paracentral extrusion (green arrows) deforms the thecal sac (red dotted line)
and extends into the right foramina.
Figure 7:106. L4-5 extrusion (red dotted line) extending cephalad.

Multiple Disc Derangements
Figure 7:108. Note the horizontal radial

tear in the posterior L5-S1 disc (yellow
arrow), and the extrusion at L4-L5 extends
caudally along the posterior body (blue
arrow) of L5.
Figure 7:107. Disc derangements at L3-L4,

L4-L5, and L5-S1.
Figure 7:109. L4-L5 extrusion on axial

imagery (green arrow).

Post-Surgical Re-herniation and Spondylolisthesis
Figure 7:111. A disc herniation in an axial

T2WI (green arrow). Note the fatty
infiltration of the paraspinal muscles in this
elderly patient.
Figure 7:110. A large L4-L5 disc herniation at the

site of a previous surgery. Note the large canal in
this patient which extends down into the sacrum.
This T2W sagittal image also reveals a post-
surgical anterolisthesis of L4 on L5.

Large Central Lumbar Herniation
Figure 7:112. A sagittal view of a cephalad migration of an L4-L5 extrusion.
Figure 7:113. An axial view of the extrusion along L4.

Foraminal Protrusion
Figure 7:114. This axial (T2WI) reveals a foraminal herniation at L4-5.

Annular Tears
Figure 7:115. A crescent-shaped transverse

tear in the posterior portion of the L4-L5 disc.
Figure 7:116. Annular tears are visible at

multiple levels in this sagittal image (T2WI):
a concentric tear in the posterior portion of the
L5-S1 disc and transverse tears along the
posterior superior endplate of L4, and the
anterior superior endplate of L3.

Compressive Injuries
Figure 7:117. This image displays an intravertebral Figure 7:118. The compressive forces
herniation (Schmorl’s node) extending through the that caused the L2 intravertebral
superior endplate of L2. This injury was herniation visible in figure 7:117 also
symptomatic. caused the compression fracture seen in
this thoracic MRI.

Sequestered Fragment and Thecal Sac Displacement
Figure 7:120. The thecal sac is

displaced through a previous
laminectomy in this T2 axial image
(yellow arrow).
Figure 7:121. The thecal sac is displaced

through a previous laminectomy in this
T1 axial image (yellow arrow).
Figure 7:119. A sequestered fragment descends caudally

from the L4-L5 disc (yellow arrow). Note the intravertebral
herniation through the inferior endplate of L5 and the changes
in the L4 and L5 endplates. These images reveal a lumbar
surgery that had been performed at L4-L5.

Central L5-S1 Protrusion
Figure 7:122. Mild Central L5-S1 protrusion.
?
Figure 7:123. Mild Central L5-S1 protrusion.

Suggested Reading

Ahn SH, Ahn MW, Byun WM. Effect of the transligamentous extension of lumbar
disc herniations on their regression and the clinical outcome of sciatica. Spine.
2000;25:475–80.
Bozzao A, Gallucci M, Masciocchi C, Aprile I, Barile A, Passariello R. Lumbar

disk herniation: MR imaging assessment of natural history in patients treated
without surgery. Radiology. 1992;185:135–41.
Delauche-Cavallier MC, Budet C, Laredo JD, Debie B, Wybier M, et al. Lumbar

disc herniation. Computed tomography scan changes after conservative
treatment of nerve root compression. Spine. 1992;17:927–33.
Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K. The natural

history of herniated nucleus pulposus with radiculopathy. Spine. 1996;21:225–9.
Matsubara Y, Kato F, Mimatsu K, Kajino G, Nakamura S, Nitta H. Serial changes

on MRI in lumbar disc herniations treated conservatively. Neuroradiology.
1995;37:378–83.
Modic MT, Ross JS, Obuchowski NA, Browning KH, Cianflocco AJ, Mazanec DJ.
Contrast-enhanced MR imaging in acute lumbar radiculopathy: a pilot study of
the natural history. Radiology. 1995;195:429–35.
Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc
extrusions treated nonoperatively. Spine. 1990;15:683–6.
Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history
of massive lumbar disc herniation. J Bone Joint Surg Br. 2007;89:782–4.


Spondylolysis and
Spondylolisthesis
150
Types of Spondylolisthesis
Spondylolisthesis is a condition in which one vertebra slips anteriorly on the vertebra

below. While five types of spondylolisthesis have been identified, this chapter will
concentrate on the two most common types: degenerative and isthmic.
The various types of spondylolisthesis share the commonality of anterior vertebral
slippage, but have significantly different etiologies and clinical presentations. It is
important to be able to differentiate the difference and to be familiar with their
radiographic presentations. This chart clarifies the main differences between the
categories of spondylolisthesis:
Type of Pathology
Spondylolisthesis
Degenerative Facetal and connective tissue
degeneration leading to anterior listhesis
Isthmic Secondary to spondylolysis of the
affected pars interarticularis
Congenital Usually from hypoplasia of the S1 facets
Traumatic Resulting from an acute fracture that
may include structures other than the
pars interarticularis
Post surgical Surgical mishaps that progress or cause a
spondylolisthesis
Figure 8:1. Categories of spondylolisthesis
The most common types of spondylolisthesis encountered are degenerative and

isthmic, and most of this chapter will discuss these two. However, it is important for the
clinician to be aware of and familiar with the lesser known types. Thus, congenital,
traumatic and post-surgical spondylolistheses will be also be touched upon, but with
less detail. For these less common types of spondylolisthesis, a good working
relationship between the radiologist and clinician is important for categorization.

Meyerding Classification System
Figure 8:2. Grade I spondylolisthesis of L5 on S1 viewed on a lateral plain film radiograph.
MRI is not the preferred medium for viewing and identifying a spondylolisthesis. X-ray
(particularly weight bearing views) and CT are preferred to MRI for visualizing
spondylolisthesis. While spondylolysis and spondylolisthesis may be diagnosed and graded
on a lateral X-ray, the preferred image for identifying a spondylolysis is the oblique plain film x-
ray. MRI, however, is a valuable tool for determining the effect of spondylolisthesis on the soft
tissues of the spine and adjoining structures.
To categorize the degree of anterior slippage of a spondylolisthesis, the Meyerding

classification system was adopted. The Meyerding scale grades a spondylolisthesis
(regardless of the cause of the listhesis) on a scale of 1-4. Each number represents 25% of
the superior end plate of the vertebra or sacral segment below the level of listhesis. When the
posterior body of L5 slides forward up to 25% of the surface of the vertebra below, it is
classified as a Grade I, at 25-50% it is a Grade II, at 50-75%, a Grade III, and at 75-100%, a
Grade IV. If the vertebral body slides completely off of the segment below, it is called a
spondyloptosis.
Clinical note: If a spondylolisthesis exceeds grade I (greater than 25% anterior slippage), it
will have a spondylolysis. Degenerative spondylolisthesis rarely exceed 25% anterior
listhesis.

Comparing Isthmic and Degenerative Spondylolisthesis
An isthmic spondylolisthesis is characterized by pars interarticularis defect or stress

fracture (spondylolysis) that essentially splits the vertebra into two pieces.
In the degenerative variety of spondylolisthesis, the posterior elements of the vertebral
segments degenerate to the point in which they cannot prevent anterior listhesis
(slippage). This results in an anterior listhesis of the entire vertebral body along with the
posterior elements of the vertebra.
Figure 8:3. Isthmic spondylolisthesis

occurs after a bony insult occurs. A
stress fracture (though this terminology
has been disputed) of the pars
interarticularis, also known as a
spondylolysis, occurs as a result of
repeated stresses or microtrauma.
Figure 8:4. Degenerative spondylolisthesis

is by far more common in the general
population (though less common in younger
populations). Degenerative
spondylolisthesis occurs over time,
secondary to degenerative changes of the
facet joints, discs, and subsequent ligament
laxity.

Characteristics of a Spondylolisthesis in Sagittal Images
In addition to the primary radiographic findings of a pars interarticularis defect and

anterior listhesis of the vertebral body, there are secondary findings characteristic of
spondylolisthesis.
Figure 8:5. A normal spine will have will Figure 8:6. An isthmic spondylolisthesis may
have a continuous uninterrupted alignment have a separation of the two segments of the
of the vertebral segments vertebra. These segments may migrate in
opposite directions (red arrows).
Figure 8:5 shows a normal spine without anterior
listhesis. The red dotted line traces the posterior
longitudinal ligament and posterior vertebral
bodies revealing a normal lumbar lordosis.
Bilateral pars interarticularis spondylolysis literally
breaks the vertebra into two pieces. When a
spondylolysis progresses to a spondylolisthesis, it
is common for the vertebral body to travel anterior
and the posterior elements to list posterior (figure
8:6). In contrast, a degenerative
spondylolisthesis will have the entire vertebra
travel anterior (figure 8:7).
While an isthmic spondylolisthesis may expand
the central canal, a degenerative
spondylolisthesis will frequently contribute to a
stenosis of the central canal. This concept is Figure 8:7. Degenerative spondylolisthesis
expanded upon on the following page. has the entire vertebra moving anterior as a
unit. Degenerative spondylolisthesis will
not progress past 25%.

Conceptualizing the Effects of Spondylolisthesis on the Central Canal
Figure 8:8. This Figure 8:9. When a

schematic shows degenerative
the thecal sac spondylolisthesis
descending occurs, the thecal sac
through the spinal is distorted as it
canal in a normal follows the snaking
manner. central canal.
Figure 8:10. In degenerative spondylolisthesis the

vertebral arch is preserved causing a canal narrowing as
the alignment of the canal is compromised. This is often
compounded by the stenotic effects of degeneration and
ligamentum flavum hypertrophy. Degenerative
spondylolisthesis is often associated with a clinical
presentation characteristic of central canal stenosis. This
image depicts the compromised alignment of the two
adjoining vertebra from above. The canal appears
narrowed when viewed from above.
Figure 8:11. When a bilateral spondylolysis

is present, the vertebral arch is not
preserved. The two components of the
vertebra may open causing a widening of
the canal.
These images are an attempt to simplify the understanding of the effects of degenerative and
isthmic spondylolisthesis on the central canal of the spine. Simply put, degenerative
spondylolisthesis generally results in central canal stenosis, and isthmic spondylolisthesis
expands the central canal at the level of the lysis.

Characteristics of a Spondylolisthesis in Axial Images
The central canal of the lumbar spine is

typically oval shaped (figure 8:12). In an
isthmic spondylolisthesis with a defect
of the pars interarticularis, the body of
the vertebra moves anterior while the
posterior arch migrates posterior. This
elongates the canal into an anomalous
appearance (figure 8:13). Note the gap
between the posterior vertebral body
and the anterior thecal sac in figure
8:13.
Degenerative spondylolisthesis, by
contrast, is frequently characterized by
a reduction in canal size (figure 8:14).
Axial imagery can aid in identifying the
type of spondylolisthesis and its effects
on other structures.
Figure 8:12. Normal size central canal.
Figure 8:13. Elongated central canal. This finding Figure 8:14. Stenotic central canal. This
is characteristic of an isthmic spondylolisthesis. finding is characteristic of a degenerative
spondylolisthesis.

These T2W MRIs correlate axial images with sagittal images. These images clearly show
the central canal stenosis associated with degenerative spondylolisthesis (figures 8:15 and
8:16). This stands in stark contrast to the isthmic spondylolisthesis which is characterized by
the elongated canal visualized on the axial image (figures 8:17 and 18).
Figure 8:15. Sagittal image of a Figure 8:16. Sagittal image of an isthmic

degenerative spondylolisthesis of L4 on L5. spondylolisthesis of L5 on the sacrum. The
The entire vertebra has slipped forward. anterior and posterior elements travel in
opposite directions.
Figure 8:17. Axial image of degenerative Figure 8:18. This axial image of an isthmic
spondylolisthesis with severe central canal spondylolisthesis reveals an elongated
stenosis and facetal effusion. central canal as the vertebral elements
migrate away from each other.

Spondylolysis, Facetal Effusion, and a Resulting Synovial Cyst
Figure 8:19. A spondylolysis is visualized Figure 8:20. The same image as figure
(with the red circle) in this T2W sagittal. A 9:19 without denotations.
synovial cyst arises from the facet of L5-
S1 (yellow arrow).
This T2W image of a football lineman shows facetal effusion (hyperintense on T2) at L4-5, L5-
S1 with a synovial cyst extending posteriorly and caudally from the L5-S1 facet (yellow arrow).
The pars defect is identified with the red circle. The image on the right is the same image
without the markers. These findings correlate with his symptoms and history of pain and
traumatic lumbar extensions while playing football. Facet effusion can be an indicator of
reduced segmental stability in degenerative spondylolisthesis.

Wedging of a Vertebral Body Secondary to Isthmic Spondylolisthesis
Finding a wedged lumbar vertebra, particularly at L5, is associated with spondylolisthesis

secondary to spondylolysis. While it is not fully understood if this finding predisposes the
vertebra to lysis or if it occurs as a result of lysis and listhesis, experts are leaning toward
the thought that this trapezoid deformation occurs over time after the spondylolysis and
listhesis occur.
Figure 8:21. Trapezoid shape. Figure 8:22. The vertebra affected by the lysis has a
tendency to take on a trapezoid shape. This
phenomenon is not pathognomonic for an isthmic
spondylolisthesis, but is a point of reference that may
alert the clinician to a spondylolisthesis.

Characteristics of the IVF in Spondylolisthesis
Figure 8:23. The shapes of the lumbar Figure 8:24. The same T2W sagittal image
foramina are outlined by dotted lines. The as figure 8:23 without the markers.
red dotted lines show the normal peanut
shaped foramina of the IVFs from L1-L5.
The yellow dotted line shows the abnormal
shape of the IVF as found in an isthmic
spondylolisthesis.
The normal outline of an intervertebral foramina (IVF) tends to be shaped like a peanut.
Note the shape of the upper IVFs outlined in red in figure 8:23. In contrast, the L5-S1
IVF, outlined in yellow is contorted due to the anterior slippage of L5. This contortion is
representative of a reduction in the size of the IVF resulting in foraminal stenosis.
Figure 8:24 shows the same T2W sagittal image without the lines.

Bony Edema Secondary to Spondylolisthesis
Inflammatory and degenerative changes to the endplates and adjoining bone of the
vertebra frequently accompany spondylolisthesis. These secondary degenerative
changes are visible on MRI. The changes are named after the well-published
radiologist Michael T. Modic. Figure 8:25 is a schematic revealing the appearance
of Modic degenerative changes on MRI.
Bony edema and

sclerosis of the
cortical bone
Sclerotic thickening of
the vertebral endplate
Henry Gray (1821–1865). Anatomy of the Human Body. 1918.
Figure 8:25. Modic schematic .
Bony edema, disc degeneration, and sclerotic changes to the vertebral endplates
secondary to spondylolisthesis are clearly visible in figures 8:26 and 27.
Figure 8:26. T1W sagittal image. Figure 8:27. T2W sagittal image.

Pars Defect
Figure 8:28. Bony edema of the pars interarticularis (yellow arrows) is visible
on this T2 weighted axial image indicating a probable isthmic spondylolisthesis.
This T1W axial image reveals evidence of a pars defect. MRI reveals bony edema
and soft tissue changes, but does not reveal discrete injury to bone. X-ray and CT
are preferred for viewing bony injuries.

Characteristics of Spondylolisthesis
These images reveal what the anterior lip of

L5 looks like on axial imagery (figure 8:29)
as it extends past the margins of the
sacrum. Figure 8:30 is a selected sagittal
image of this patient. The blue line in figure
8:31 shows the level of the slice that was
used to create figure 8:29.
Incidentally the sagittal images display a
perineural cyst affecting the S2 nerve root.
Figure 8:29. This axial image shows a

“Napoleon hat sign.”
Figure 8:30. T2W sagittal supine image of Figure 8:31. This image shows the
the spondylolisthesis from figure 9:29. level of the slice taken to make the
image in figure 9:29.

Double Set of Zygapophyseal Joints
This axial image (figure 8:32) shows two sets

of zygapophyseal (facet) joints. This unusual
looking image is almost bizarre in
appearance. By analyzing the sagittal views
(figure 8:33) we can see that the L4-5 and
L5-S1 facets are approximated by the
anterolisthesis of L5 on S1. The red line
across the sagittal image of figure 8:34
shows the MRI slice that was used to
produce the axial image which is visualized
in figure 8:32. By following the red line we
can clearly see how the facets of L4-5 and
L5-S1 could appear on the same axial slice.
This finding underscores the importance of

comparing sagittal views with axial views to
gain a complete perspective of the lumbar Figure 8:32. Axial image of an L5 isthmic
spine. spondylolisthesis. This unusual image shows
four zygapophyseal joints.
Figure 8:33. T2WI of L5 on S1 isthmic Figure 8:34. The red line shows the level of axial
spondylolisthesis. imagery that would show four zygapophyseal
joints in one axial image (figure 8:32).

Disc Roll-up
Figures 8:35 and 8:36. L5-S1 spondylolisthesis with disc roll-up.
Another common finding in isthmic

spondylolisthesis is the “rolling up” or
“peeling” of the disc below the
listhesis and less commonly “rolling
down” of the disc above the
spondylolisthesis. This disc migration
can contribute to or cause a stenosis
of the IVF. Some radiologists call this
rolling up a “pseudo-bulge.”
Figure 8:37. Axial T2WI of the spondylolisthesis

disc roll-up shown on figures 8:35 and 8:36.

Disc Roll-up
Figure 8:38 and 8:39. The disc roll-up phenomenon that occurs with a spondylolisthesis has
unique characteristics on MRI The disc tends to stay anchored to the lower segment, but will no
longer stay in alignment with the vertebra that is listing forward.
Figure 8:40 and 8:41. In sagittal imagery of a spondylolisthesis, a line drawn along the posterior
body of the lower segment typically shows the disc to be in line with the inferior segment.

Disc Roll-up
Figure 8:42. On axial imagery of a spondylolisthesis, it is not uncommon for the appearance
of a pseudo-bulge or pseudo-disc herniation to be seen. Here is a pseudo-disc herniation of
the L5-S1 disc.
Figure 8:43. The phenomenon of a pseudo-bulge or pseudo-disc herniation occurs when

the axial image slice (blue line in the schematic) contains the rolled up portion of the disc
along with vertebra listing forward. By integrating axial and sagittal views, the clinician can
more fully understand what occurs to the disc in a patient with spondylolisthesis.

Disc Roll-up and Roll-down
Figure 8:44. Sagittal PD FSE Figure 8:45. Sagittal T1WI
Figure 8:46. Sagittal T2WI Figure 8:47. Off-center sagittal

T2WI slice from the same patient.
This series shows not only the L5-S1 disc rolling up, but the L4-L5 disc rolling down
following an L5 anterolisthesis.

Secondary Characteristics of Isthmic Spondylolisthesis
Figure 8:48 Sagittal T2WI reveals a Figure 8:49. Axial T1WI. Note the elongated
trapezoid shaped L5 and an L5 central canal.
anterolisthesis.
Figure 8:50. Axial T2WI revealing an Figure 8:51. Axial T2WI showing the
expansion of the central canal. migration of the L5-S1 disc as it “rolls up”
behind the body of L5.
These images of an isthmic spondylolisthesis reveal enlargement of the central canal,

anterolisthesis, a trapezoid shaped L5, and a “roll-up” of the adjoining intervertebral
discs.

Isthmic Spondylolisthesis with Synovial Cysts
Figure 8:52. Axial T2W image of an Figure 8:53. This axial T2W image of
isthmic spondylolisthesis show a the same patient shows another
synovial cyst arising from the inferior synovial cyst arising from the right L5-
portion of the right L5-S1 facet . S1 facet.
Figures 8:54-56. These sagittal T2 weighted images show three synovial cysts arising from the
facets adjoining an L5 on S1 spondylolisthesis.
A spondylolisthesis can place stress on facets and cause effusion. The excessive fluid
production (effusion) can result in a ballooning of the facet joint’s capsule creating synovial
cysts. When synovial cysts project posteriorly, they usually do not require intervention.
However, if the synovial cyst projects into the central canal, intervention may be indicated.
These images are all of the same patient whose L4-L5-S1 facets produced multiple synovial
cysts projecting posteriorly.

Degenerative Spondylolisthesis
Figure 8:57. Degenerative spondylolisthesis of L4 on L5.
Degenerative spondylolistheses can also manifest this rolling up of the disc. Given the
degeneration of the disc, anterolisthesis, facetal hypertrophy, and ligamentous buckling
and thickening, this phenomenon could be particularly contributory to creating central
canal and foraminal stenosis.

Figure 8:58. T2 weighted sagittal image Figure 8:59. A STIR sagittal image of
of a degenerative spondylolisthesis. the same patient.
Figure 8:60. Erosion of facets and disc Figure 8:61. Central canal stenosis.
roll-up on a T2W axial image.
In this case the facets of L4-5 eroded and degenerated to such an extent that they could
no longer function to restrain the anterior listhesis of L4 on L5. Though these images show
severe anterior listhesis, it should be noted that this patient was lying on her back while the
MRIs were taken. The following page has weight bearing flexion and extension views.
Weight bearing plain films or upright MRIs are preferred methods of viewing the degree of
listhesis (versus supine MRI images).

Figure 8:62. Plain film upright radiograph of the Figure 8:63. Plain film upright radiograph
lumbar spine in extension. of the lumbar spine in flexion.
Recumbent lumbar MRI may reveal some of the effects of spondylolisthesis, but it is not
the preferred medium for accessing degrees of listhesis or stability. Plain film radiographs
taken standing upright, standing in extension, and standing in extension are preferred
over recumbent MRI for determining degrees of listhesis and stability. Upright and
functional MRI are also valuable assessment tools.

Degenerative Spondylolisthisis
Figures 8:64 and 8:65. These two sagittal images display the characteristics that are
common in degenerative spondylolisthesis. The image on the left presents facetal
degeneration of the L4 facets. The image on the right shows anterolisthesis, disc
degeneration, disc rolling at the level of listhesis, and stenosis. Note that the posterior
vertebral elements of L4 have maintained a normal relationship with the vertebral body; they
have not come apart as is seen in most cases of listhesis secondary to spondylolysis.

Post-Surgical Re-Herniation and Spondylolisthesis
Figure 8:67. Post-surgical spondylolisthesis

of L5 and re-herniation of the L4-L5 disc on
a T2W axial image.
Figure 8:66. Post-surgical spondylolisthesis

of L5 and re-herniation of the L4-L5 disc on
a T2W sagittal image.

Upright, Functional, and Dynamic MRIs and Spondylolisthesis
One of the criticisms directed at using standard MRIs for evaluating spondylolisthesis is that
the patient is lying supine during the MRI. Lying supine will allow a mobile segment to settle
into a lower state of displacement. One study of 510 patients with lower back pain revealed
that supine MRI missed 18.1% of spondylolisthesis cases that were observed in dynamic
(flexion) MRIs. As more upright and functional MRI units are made available, this diagnostic
medium may replace the neutral/supine MRI for visualizing functional and anatomical
disruptions of the lumbar spine.
Figure 8:68. T2W sagittal image taken Figure 8:69. The same patient from
while lying recumbent in a conventional figure 8:68 was re-imaged in an upright
MR tube. (Image provided by FONAR MRI. This image clearly reveals an
Corporation and used with permission.) anterior listhesis of L3 on L4 that was not
visible on the recumbent MRI. (Image
provided by FONAR Corporation and
used with permission.)

Isthmic Spondylolisthesis with IVF Occlusion
Figure 8:70. Plain film radiograph. Figure 8:71. T2 weighted sagittal

showing significant disc rolling of the L4-5
and L5-S1 discs.
This case presents an isthmic spondylolisthesis in a patient with transitional anomalies of the
lumbosacral anatomy . Of particular interest is the amount of disc roll-up of the L5-S1 disc and
disc roll-down of the L4-L5 disc. The L5-S1 intervertebral foramina is almost completely
occluded.
Figures 8:72, 73, and 74. T2W axial revealing transitional anomalies of the lumbosacral
anatomy.

Isthmic Spondylolisthesis with IVF Occlusion
Figure 8:75. Disc rolling at mid- Figure 8:76. L5-S1 intervertebral

central canal. foramina occlusion.
These T2 weighted sagittal images show

the significant disc rolling above and
below the L5 vertebra. Figures 8:76 and
8:77 demonstrate severe IVF occlusion of
the L5-S1 IVF from the listhesis and the
L5-S1 disc.
Figure 8:77. L5-S1 intervertebral

foramina occlusion.

Suggested Reading
Antoniades SB, Hammerberg, KW, DeWald, RL. Sagittal plane configuration of the sacrum in
spondylolisthesis. Spine: 1 May 2000.Volume 25, Issue 9, pp 1085-1091.
Lattig F, Fekete Truncal flexion, Grob D, Kleinstuck FS, Jeszensky D, Mannion AF. Lumbar
facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis? Eur Spine
Journal. 2012 Feb; 21 (2):276-81. Epub 2011 Sep 20.
Meyerding HW: Spondylolisthesis. Surg Gynecol Obstet 54:371-377, 1932.

McPhee B: Spondylolisthesis and spondylolysis, in Youmans JR (ed): Neurological Surgery: A
Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical
Problems, ed 3. Philadelphia: WB Saunders, 1990, Vol 4, pp 2749-2784.
Sim GPG, Vertebral contour in spondylolisthesis. British Journal of Radiology (1973) 46, 250-
254 .
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Cramer G, Darby S (2013). Basic and clinical anatomy of the spine, spinal cord, and ANS
(third edition). Elsevier Mosby.
Marchiori D (2013). Clinical imaging: with skeletal, chest and abdomen pattern differentials
(third edition). Mosby.
Atlas SW. (2008). Magnetic resonance imaging of the brain and spine (forth edition). Lippincott
Williams & Wilkins.

Spondylosis
180
Spondylosis
Spondylosis is a term that literally interpreted from Latin means condition of the spine. It refers to
degenerative osteoarthritis of the spine. It is a broad, vague term that covers many findings. For
that reason it has more value in radiology reports than in clinical diagnosis. Spondylosis is
common and frequently present in patients without symptoms. It is characterized by hypertrophic
osteophytic changes, desiccation of the discs, loss of disc height, ligamentous instability, facetal
hypertrophy, facetal imbrication, and bony remodeling. This series of images shows a moderately
severe spondylitic lumbar spine. The dark disc spaces in these T2WI indicate a loss of hydration
(desiccation) of these discs. Disc bulges, hypertrophic facets, and thickening of the ligamentum
flavum all contribute to stenosis of the central canal, lateral recess, and the foramina.
Figures 9:1 and 9:2. T2W sagittal images of moderately severe spondylosis of the lumbar spine.

IVF Encroachment
Figure 9:3. T2 weighted sagittal image Figure 9:4. Another T2 weighted sagittal
revealing IVF encroachment of the L3-4, L4-5, image revealing IVF encroachment of the L4-
and L5-S1 segments. 5 and L5-S1 segments.
Spondylosis can result in intervertebral foraminal (IVF) encroachment/stenosis. These two

sagittal images show occlusion of lumbar IVFs resulting from degenerative osteophytes.

Spondylosis
Figure 9:5. Degeneration of intervertebral discs can cause slackening of the spinal
ligaments which can lead to degenerative spondylolisthesis. Note the anterolisthesis of
L3 and L4 and the retrolisthesis of L2.
Figure 9:6. The body responds to slackened ligaments by producing osteophytes as

seen particularly at the level of L4 and L5.
Spondylosis
Figure 9:7. Multiple levels of degeneration and disc bulges. L4 has a

degenerative spondylolisthesis.
Figure 9:8. Hypertrophic changes of the vertebral bodies and facets.

Spondylosis
Figures 9:9-14. Premature degenerative changes in a thirty-eight year-old athletic man. Note
the endplate changes, fatty infiltration of bone, the disc degeneration, IVF encroachment, and
osteophytic spurring.

Suggested Reading
Heithoff KB, Gundy CR, Burton CV, Winter RB, Juvenile discogenic disease. Spine.
1994 Feb 1;19 930 335-40.
Resnick D, Niwayama G, Guerra J et-al. Spinal vacuum phenomena: anatomical

study and review. Radiology. 1981;139 (2): 341-8.
Resnick D, Kransdorf MJ (2005). Bone and joint imaging. W B Saunders Co.
Cramer G, Darby S (2013). Basic and clinical anatomy of the spine, spinal cord, and
ANS (third edition). Elsevier Mosby.

Central Canal Stenosis
187
To fully understand what a central canal stenosis is, we need to understand what the central
canal is and what is normal. The central canal is the protective conduit that protects the spinal
cord and (from L1-L2 caudally) the cauda equina. The bony arch of the central canal usually
does not change size. Stenosis usually occurs at the levels of the intervertebral disc where
the disc bulges. Facet hypertrophy and ligament thickening can combine to narrow the
central canal. The length of the pedicles is important for maintaining adequate canal size.
Pedicles can be congenitally short or asymmetrical in length, contributing to stenosis.
Figure 10:1. The posterior border of the Figure 10:2. A transection of a vertebral
vertebral body along with the arch of the segment showing the canal’s position within the
pedicles and lamina comprise the bony portion vertebra.
of this protective conduit. The central canal is
outlined with a red dotted line.
Figure 10:3. A T2 weighted axial revealing a

widely patent central canal at L5.
Figure 10:4. A T2 weighted sagittal image of

a patent central canal traveling the length of
the lumbar spine.

Figure 10:5. Stenosis at the L2-3 disc

space. Note the congenitally narrowed
canal, ligamentum flavum hypertrophy,
and facetal hypertrophy.
Figure 10:7. Note that stenosis typically

occurs at the vertebral interspace where a disc
bulge, ligamentum flavum hypertrophy, and
facet hypertrophy combine to narrow the
central canal. Note the canal narrowing at L1-
L2, L2-L3, and L3-L4.
Figure 10:6. Even in patients with central

canal stenosis, the canal is usually patent at
the middle of the vertebral body.
In patients with stenosis the entire canal is usually not stenotic. Only the intervertebral region
where the combination of disc, facet hypertrophy, and ligamentum flavum hypertrophy or
enfolding combine to narrow the central canal. This can be compounded by a degenerative
spondylolisthesis.

Figure 10:8 and 10:9. Sagittal T2WI revealing a stenosis at the L2-L3 section of the canal
and a herniation at L5-S1.
Figure 10:10 and 10:11. Sagittal T2WI displays a stenosis at the L2-L3 level of the canal.
These images expose a lumbar stenosis at L2-L3 arising from a congenitally narrow canal,
ligamentum flavum hypertrophy, an L2-L3 disc bulge, and facetal hypertrophy.

Figure 10:12. Normal lumbar central canal. Figure 10:13. Lumbar stenosis of the central
This T2 weighted axial image clearly canal and lateral recesses secondary to facet
demonstrates a patent central canal. hypertrophy and ligamentum flavum
hypertrophy.
Spondylosis may result in degenerative stenosis. The combination of decreased disc height,
enfolding and thickening of spinal ligaments, and bony hypertrophy contribute to this slowly
progressing condition. The image on the left (figure 10:12) shows a widely patent central
canal, lateral recesses (subarticular zone), and intervertebral foramina. The exiting nerve
roots are suspended in a supple cradle of fat.
The image on the right (figure10:13) reveals a moderately severe stenosis that affects the
central canal, lateral recesses, and foramina. The point at which a narrowing of the canal
becomes a stenosis is imprecise and is usually left to the interpretation of the radiologist.

Figure 10:15. This T2W axial image

shows significant ligamentum flavum
hypertrophy and facet hypertrophy from
degeneration.
Figure 10:14. This T2W sagittal image shows

an L4-5 central canal stenosis that is caused by
the convergence of a disc bulge, disc
degeneration, degenerative spondylolisthesis of
L4 on L5, ligamentum flavum hypertrophy, and
facet hypertrophy.
Figure 10:16. Disc bulging at L4-L5

compounds the narrowing effects of the
hypertrophic changes of the ligamentum
flavum and the zygapophyseal joints.

A Case of Complicated Central Canal Stenosis
This case represents a “sampler pack” of comorbid conditions that contribute to this central
canal stenosis. This case compiles ligamentum flavum hypertrophy, a synovial cyst,
degenerative spondylolisthesis, disc bulging, facetal hypertrophy, and epidural lipomatosis to
narrow the central canal. Figures 10:17 to 10:25 are all images taken from the same case.
Figure 10:17. This T2W sagittal image reveals a stenosis of the central canal
caused by an accumulation of various factors. This image reveals a
degenerative spondylolisthesis, ligamentum flavum hypertrophy, facet
hypertrophy, an L4-L5 disc bulge, and a large synovial cyst at L4-L5.

A Case of Complicated Central Canal Stenosis (continued)
Figure 10:18. A facet that is inflamed and effused

(white arrow) can give rise to a synovial cyst (red
arrow). This synovial cyst occupies a significant
portion of the central canal.
Figure 10:19. Facetal effusion denoted by the white

arrow and spinal epidural lipomatosis denoted by the
red arrow.

Figure 10:20. Consolidation of the thecal sac with no

visible stenosis .
Figure: 10:21 Central canal stenosis from facet hypertrophy,

ligamentum flavum hypertrophy (yellow arrows), and a disc
bulge. The white arrow points to a facet effusion.

Figure 10:22. T2WI showing spinal epidural lipomatosis (excessive

fat deposition) encroaching into the central canal.
Figure 10:23. The adjoining axial slice reveals even more

encroachment/central canal stenosis. Additional fat posteriorly
contributes to the canal narrowing.

Figure 10:24. T2W sagittal image. The Figure 10:25. The yellow arrow points to a high
yellow arrow points to a synovial cyst that intensity zone (white on T2WI), probably
contributes to central canal narrowing. depicting an annular tear. The red arrows point
to increased fluid (effusion) in the interspinous
bursa.

Narrowed Central Canal from Enfolding of the Ligamentum Flavum
Figure 10:26. Redundant ligamentum flavum

combines with a disc bulge and facetal hypertrophy to
create a central canal stenosis visible in this T2
weighted axial image of the L2-L3 interspace.
Associate this image with the sagittal image in figure
10:27.
Figure 10:27. Redundant ligamentum
flavum in T2 weighted sagittal image.
Note the stenosis at L2-L3 and L3-L4.
A developmentally narrowed central canal, usually attributed to congenitally short pedicles,

predisposes a spine to develop a central canal stenosis as normal age-related degeneration
contributes to a narrowing of the canal. These age-related changes include ligamentum
flavum enfolding (redundant ligamentum flavum) and hypertrophy, facet hypertrophy, and
disc bulges.

Congenitally Narrowed Central Canal
Figure 10:28. Normal lumbar central canal. Figure 10:29. A congenitally small canal.
A developmentally narrowed central canal tends to produce stenosis symptoms earlier and with
a more profound clinical presentation than a more patent canal. A congenital canal tends to
have a more rapid onset of stenosis with less spinal degeneration. The difference between a
congenitally narrowed canal and a stenosis is that a stenosis refers to a focal narrowing of the
canal, whereas a congenitally narrowed canal is the generalized narrowing of the canal.
Shortened pedicles are frequently blamed for congenital narrowing of the canal.
Clinically, patients with congenital stenosis will report with multiple levels of stenosis, and they
present with symptoms at a younger age.
Figure 10:30. A congenitally narrowed Figure 10:31. A congenitally narrowed

central canal in a 32 year-old female. Her central canal in a 23 year-old male.
stenosis is compounded by space
occupying hypertrophy of the facets.
Figures 10:28, and 10:29 are copyright free images acquired through U.S. Department of Health and Human Services
Public Health Service National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 05–5282 September 2005.

Stenosis
Figure 10:32. Normal lumbar central canal. Figure 10:33. A congenitally narrowed
This T2 weighted axial image clearly shows central canal in a 32 year-old female. Her
a patent central canal. stenosis is magnified by space occupying
hypertrophy of the facets.
These two images show a contrast in central canal size. The image in figure 10:32 shows a
widely patent central canal with ample room for the spinal nerves of the cauda equina. In stark
contrast is the image in figure 10:33; it has a tight canal that has little room to spare for the
contents of the thecal sac.

Suggested Reading
Clark K. Significance of the small lumbar spinal canal: cauda equina compression
syndromes due to spondylosis. 2. Clinical and surgical significance. J Neurosurg 1969
Nov;31 (5):495-8.
Cramer G, Darby S (2013). Basic and clinical anatomy of the spine, spinal cord, and
ANS (third edition). Elsevier Mosby.
Atlas SW. (2008). Magnetic resonance imaging of the brain and spine (forth edition).
Lippincott Williams & Wilkins.
Bogduk N. (2012). Clinical and radiological anatomy of the lumbar spine. Churchill
Livingstone.

Fractures
202
Lumbar Fracture
Identifying the bony extent of spinal fractures is best done with computed tomography (CT),
though initial screening is frequently performed with plain film radiology. MRI is a good
adjunct to CT and plain film radiographs.
MRI has the advantage of clearly identifying soft tissue integrity or damage. It can also
provide insight into the degree of bony edema and the formation of epidural hematomas.
When a spine fractures, fragments of bone may be pushed backwards into the spinal canal
or cord. This is known as retropulsion. The retropulsion of bony fragments into the canal
and possibly even into the cord is a great concern in compression fractures of the spine.
Retropulsion is most clearly seen on CT, but the effect of a retropulsed fragment on soft
tissues such as the cord is more evident in an MRI.
The next few pages will present a gallery of images revealing common presentations of
vertebral fractures.

Compression Fracture
Figure 11:1. Compression fracture in a 91 year-old man seen on a T2W

sagittal image.
Compression fractures occur in healthy individuals who experience a traumatic event or more
commonly after petite trauma in osteoporotic patients, as seen in this MRI of a 91 year-old male.
Back pain is the most common symptom associated with compression fractures. Structurally an
increased spinal kyphosis frequently occurs. Compression fractures usually result in loss of
height. The pain of a stable compression fracture usually abates in 8-12 weeks.

Figure 11:2. Stable compression fracture of L1 with no retropulsion of bone

posteriorly. Endplate disruptions, intravertebral herniations (AKA Schmorl’s
nodes) and Modic changes within the cancellous bone (AKA trabecular or spongy
bone) of the L1 vertebra.

Contortion of the Aorta Secondary to Compression Fractures
Figure 11:3. Multiple level compression Figure 11:4. Buckling of the aorta (yellow
fractures. The reduction in spinal column height arrow) seen in axial.
of these fractures resulted in a buckling of the
aorta.
The loss of height attributed to compression fractures can lead to crowding of internal
structures. In this case of multiple fractures, the aorta is forced into a torturous contorted
path, the lungs and heart have lost chest space, and the bone fragments have migrated
posteriorly into the central spinal canal.

Compression Fractures and Retropulsion
Figures 11:5 and 11:6. Retropulsion of bony fragments of T12 compression fracture.
This image reveals a number of significant findings: compression fractures, post-surgical

changes, spondylolisthesis, endplate disruption, fusion, spondylosis, disc derangements
and degeneration, and cord effacement. While most compression fracture are stable and
do not endanger the spinal cord, this patient has a significant posterior displacement
(retropulsion) of bony fragments at T12. The fragments of T12 efface and displace the
thecal sac and the cord. This spine is not stable.

Burst Fracture
Figure 11:7. Burst fracture of L3 visualized on a Figure 11:8. T2 weighted sagittal MR

sagittal CT. image of an L3 burst fracture. Note the
integrity of the spinal canal is preserved.
Burst fractures or compression fractures in healthy non-osteoporotic patients are usually the result
of significant trauma. This patient experienced significant compressive forces that caused an L3
burst fracture.

Burst Fracture
Figures 11:9. Acute compression fracture of L2 with intrusion into the central canal.

Burst Fracture
Figures 11:10 and 11:11. Axial image of the compression fracture of L2 with bony retropulsion
into the central canal and cauda equina.
Figure 11:12. Coronal view of L2 fracture.

Figure 11:13. STIR (short inversion-time Figure 11:14. Another STIR sagittal slice of the
inversion recovery) sagittal image. Notice how same patient. This image shows the extent of
bright the body of L2 appears. This is due to the retropulsion into the central canal.
edema (fluid) at that level. The brightness of the
fracture at L2 also indicates it is recent.

Burst Fracture
Figures 11:15 and 11:16. Traumatic burst fracture of L1 (white arrow) with a compression
fracture. Note the bony edema in L1 and L2 and the hematoma posterior to the spinous
processes of L3 and L4 (yellow arrows). Also, take note of the retropulsion of the posterior
vertebral body of L1.
Figure 11:17. T2W axial image of the L1 fracture. Note the significant central canal
stenosis resulting from the retropulsion of bone posteriorly.

Suggested Reading
Lee IS, Kim HJ, Lee JS et-al. Dural tears in spinal burst fractures: predictable MR
imaging findings. AJNR Am J Neuroradiol. 2009;30 (1): 142-6.
Atlas SW, Regenbogen V, Rogers LF et-al. The radiographic characterization of

burst fractures of the spine. AJR Am J Roentgenol. 1986;147 (3): 575-82.
Shuman WP, Rogers JV, Sickler ME et-al. Thoracolumbar burst fractures: CT

dimensions of the spinal canal relative to postsurgical improvement. AJR Am J
Roentgenol. 1985;145 (2): 337-41.
Schoenfeld AJ, Dinicola NJ, Ehrler DM, Koerber A, Paxos M, Shorten SD, Bowers J,
Jackson E, Smith MJ. Retrospective review of biopsy results following percutaneous
fixation of vertebral compression fractures. Injury. 2008 Mar;39(3):327-33. Epub
2007 Sep 18.
Lavelle W, Carl A, Lavelle ED, Khaleel MA. Vertebroplasty and kyphoplasty.

Anesthesiol Clin. 2007 Dec;25(4):913-28.


Modic Changes on MRI:
Vertebral Body Marrow
Morphology
214
Modic Changes
Figures 12:1 and 12:2. Reactionary changes to the endplates and bony marrow are called
Modic changes. Notice the bright areas of the vertebral bodies circled in red .
Vertebral body edema is a common finding on MR imagery, but it is frequently absent from
radiographic reports. This may be due to the radiologist considering it clinically irrelevant.
However, the more practical consideration is that every finding on MR cannot be recorded,
and most practitioners do not want excessive details. Most practitioners want to know if there
is a need for surgical referral or a referral to an oncologist: (Is there neurological defect? Is
there a neoplasm?) Degenerative changes like bony edema may seem like unimportant
background noise to the busy clinician. However, recent studies have found that vertebral
marrow edema is clinically significant and can be progressive.
Michael T. Modic, MD, identified and published his findings on vertebral bony marrow changes
in the journal Radiology in 1988. Since that time these findings and his grading criteria have
born his name. Modic changes represent MR observations of vertebral marrow and endplate
changes. These changes have been linked to trauma, disc disruption, and degeneration.
More studies are currently underway to identify the clinical significance of this finding and to
fully understand its progression.
The vertebral body has an outer barrier of cortical bone that is particularly dense at the
vertebral endplates. Within this tough outer shell lies the subcortical marrow cavity. This
cancellous bone is less dense and is porous. It is normal for this porous bone to contain
marrow. The T1 and T2 weighted images will reflect the presence of normal marrow with a
supportive bony matrix. When edema is present in the marrow, it is characterized by an influx
of water content: T1 weighted images show loss of signal (hypointense signal in the marrow),
while T2 weighted images will demonstrate an increased (hyperintense) signal.

Modic Classifications on MRI
Modic Classifications T1WI T2WI
Type 1 Hypointense Hyperintense

Bone marrow edema and
swelling
Type 2 Hyperintense Isointense
Associated with ischemic or mildly
conversion of normal marrow hyperintense
to yellow fatty marrow
Type 3 Hypointense Hypointense
Believed to be representative
of subchondral bone
sclerosis
Figure 12:3. This chart categorizes the types of Modic changes seen on MRI.
Hypointense Isointense Hyperintense
Figure 12:4. Shades of gray. Interpreting findings on MRI is not always black or white. When
we use terms like hypointense or hyperintense, we are not saying that the image will be black or
white, but will tend toward darkness or lightness on a grayscale continuum.

Bone Morphology and Modic Classifications
Evidence emerging indicates there is a progressive nature to Modic changes. The bony
edema of type I Modic changes may progress to type II, and type II may progress to type III.

Type 1 Modic Characteristics
Image adapted from Henry Gray (1821–1865). Anatomy of the Human Body. 1918.
Figures12:6. Bony edema extending into the spongy subcortical bone.
The high water content of inflammation and edema is evident in type 1 Modic changes.
Type 1 changes are manifested as hypointense (dark) on T1 and hyperintense on T2
weighted images.
Figure 12:7. T1 weighted sagittal image Figure 12:8. T2 weighted sagittal image
revealing type 1 Modic changes. Fluid (bony revealing type 1 Modic changes. The edema
edema) is dark on T1. is light on T2WI.

Figure 12:9. Fatty infiltration extending into the spongy subcortical bone.
On T1 images, the fatty infiltration of Type 2 Modic changes will appear hyperintense, and
on T2 weighted images, they will appear hyperintense or isointense.
Figure 12:10. T1 weighted sagittal Figure 12:11. T2 weighted sagittal

lumbar image showing hyperintense lumbar image showing isointense or
signals arising form the adjoining mildly hyperintense signal from the
vertebral bodies and endplates of L5 adjoining L5 and S1 vertebral bodies
and S1. and endplates.

Figure 12:12. Sclerotic changes of the cortical bone and thickening of the vertebral
endplates.
T1 and T2 weighted MRI will manifest type 3 Modic changes with decreased signal or
hypointense. These findings can typically be correlated with sclerosis on plain film x-ray.
The images below demonstrate type 3 Modic changes in a patient with degenerative disc
disease of L5-S1 following an old discectomy.
Figure 12:13. T1 weighted sagittal lumbar Figure 12:14. T2 weighted sagittal

image showing hypointensity of the inferior lumbar image showing hypointensity of
L5 and superior S1 vertebral bodies and the inferior L5 and superior S1 vertebral
endplates. bodies and endplates.

Figure 12:15. T1 weighted sagittal lumbar Figure 12:16. T2 weighted sagittal lumbar
image showing hypointensity of the image showing hypointensity of the inferior
inferior L4 and superior L5 vertebral L4 and superior L5 vertebral bodies and
bodies and endplates. endplates.
These MRIs show a superior endplate fracture of L5 and the resulting Modic changes.
They show a similar gray appearance of the reactionary changes which indicates these
are type 3 Modic changes.

Reactionary Changes to an Acute Intravertebral Herniation
These T2 weighted MRIs show the reactionary halo of bony edema Modic 1 changes, following
an acute injury. This patient had retired from her sedentary lifestyle as an executive in her mid-
fifties and purchased a farm. While performing heavy lifting on her new farm she felt and heard
a pop in her back that was accompanied by pain. An MRI revealed a Schmorl's node
(intravertebral disc herniation) extending into the inferior endplate and vertebral body of L3.
These images also clearly show bony edema surrounding the fracture and even affecting the
superior endplate of L4.
Modic changes can help differentiate new injuries from old. Newer injuries are more likely to
have reactionary bony edema (Modic 1 changes).
Figure 12:17. This T2 weighted sagittal Figure 12:18 and 12:19. These T2 weighted sagittal
lumbar image was taken seven years lumbar images show both the intravertebral herniation
prior to the intravertebral herniation. and reactionary Modic 1 changes.
Figure 12:20. This T2 weighted axial lumbar

image shows both the clear margins of the
intravertebral herniation (yellow arrow) and the
hyperintense reactionary Modic 1 changes
encircling the injury.

Suggested Reading
de Roos A, Kressel H, Spritzer C, et al. MR imaging of marrow changes adjacent

to end plates in degenerative lumbar disk disease. AJR Am J Roentgenol
1987;149:531–34.
Braithwaite I, White J, Saifuddin A, et al. Vertebral end-plate (Modic) changes on

lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur
Spine J 1998;7:363–68.
Modic MT, Steinberg PM, Ross JS, et al. Degenerative disc disease:
Assessment of changes in vertebral body marrow with MR imaging. Radiology,
1988;166:193-9.
Modic MT, Masaryk TJ, Ross JS, et al. Imaging of degenerative disk disease.
Radiology 1988;168:177–86.
Modic MT, Ross JS. Lumbar degenerative disk disease. Radiology. 2007
Oct;245 (1): 43-61.
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changes: a systematic morphologic and epidemiologic evaluation. Skeletal
Radiol 2005;34:125–29.
Kjaer P, Korsholm L, Bendix T, et al. Modic changes and their associations with
clinical findings. Eur Spine J 2006;15:1312–19.
Kuisma M, Karppinen J, Niinimaki J, et al. A three-year follow-up of lumbar spine

endplate (Modic) changes. Spine 2006;31:1714–18.
Rahme R, Mousa R. The Modic Vertebral Endplate and Marrow Changes:

Pathologic Significance and Relation to Low Back Pain and Segmental Instability
of the Lumbar Spine. AJNR Am J Neuroradiol 29:838–42 _ May 2008 _
www.ajnr.org
http://www.ajnr.org/content/29/5/838.full

Lumbar Facets
224
Facet Contours and Orientation
Figures 13:1 and 13:2. These T2W axial images display asymmetrical facets and S-shaped
joint lines.
Facet anomalies are rarely reported on MRI reports. Usually the only ink the facets receive are
about degenerative changes or severe disruptions. But manual practitioners would benefit from
knowing more about the facets.
For this reason it is especially important for clinicians to be comfortable looking at facets and
analyzing them. This chapter will introduce the clinician to facet orientation, effusion, anomalies, and
hypertrophy, as well as synovial cysts arising from facets and other clinically significant aspects of
the lumbar facets .
Lumbar facet effusion has been identified as a sign of instability in degenerative spondylolisthesis.
These axial images show anomalous facets.
Figures 13:3 and 13:4. This image reveals asymmetrical facets with the left facet having
both coronal and sagittal components.

Anatomical Variants: Wrap Around Facet
Figure 13:5. This T2W axial image reveals facets that are circular in orientation.
Anatomists typically classify vertebral

facets as being either coronal or sagittal in
orientation. Occasionally a vertebra will
have asymmetrical facets with one
oriented coronal and the other oriented
sagittal. But there can be other
anatomical variants that may or may not
be clinically significant. Here we see
facets that are circular in configuration. It
is conceivable that this configuration could
affect interarticular motion and spinal
function.
Certainly a manual practitioner would be

interested in knowing the configuration of
the facet joints (also known as
zygapophyseal joints).
Figure 13:6. This schematic overlays the facets
and highlights the extent of the circular shape of
this intervertebral unit.

Asymmetrical Facets
Figure 13:7 Asymmetry of the L5-S1 facets revealed on axial CT.
Figure 13:8. Second axial image of patient with facet asymmetry.

These are CT axial images revealing asymmetry of the L5-S1 facets. The left facets (seen on the
right of this image) are sagittal, while the right are coronal.

Variations in Facet Anatomy
Figures 13:9 and 13:10. Axial T2WI of atypical facet joint anatomy.
Figures 13:11 and 13:12. Axial T2WI of atypical facet joint anatomy.

Hypertrophic Facets
Figures 13:13 and 13:14. Facet hypertrophy that wraps around the articulating
facet and limits joint motion.

Synovial Cyst Arising from Facet Effusion
These images show degenerative and asymmetrical facets contributing to a central canal
stenosis. The left L4-5 facet (seen on the right of the axial images) shows the white sign of
effusion. This effusion gives rise to the synovial cyst that extends into the central canal.
Figures 13:15 and 13:16. These T2W axial images show asymmetry of the facets, effusion,
which is seen as white fluid within the left facet (red arrow), and a synovial cyst bubbling out
from the facet capsule to occupy space within the central canal (yellow arrow).
Figure 13:17. Synovial cyst in sagittal Figure 13:18. The synovial cyst and joint
T2 is seen contributing to spinal effusion is less distinct in thisT1 axial
stenosis (yellow arrow). image.

Facetal Effusion
Figure 13:19. This T2W axial image clearly Figure 13:20. This T2W axial image reveals
reveals effusion of the right facet joints. effusion of the L4-5 facet.
Facet joint effusion is characterized by increased swelling and fluid accumulation within the
facet joint and has been correlated with back pain. Synovial cysts of the spine arise from
facets burdened with swelling and fluid accumulation. As the fluid accumulates, the
synovium of the facet may balloon out forming a synovial cyst. These cysts may or may not
be symptomatic. Spinal synovial cysts are more likely to cause symptoms if they occupy
space in the spinal canal or IVFs.
The presence of lumbar facet joint effusion is more prevalent in patients with lumbar
instability. This finding is clinically significant.

Facetal Effusion
Figures 13:21 and 13:22 clearly show a

significant degree of effusion of the L4-L5
facets. The axial of normal facets in Figure
13:23 is provided to show the difference
between normal and inflamed zygapophyseal
joints.
Figure 13:21. Facet effusion at L4-L5 in a sagittal T2 weighted image. Take note of the
shape and size of the IVF at this level compared to IVFs at other levels seen in this image.
Facet effusion can cause IVF encroachment.
Figure 13:22. Bilateral zygapophyseal joint Figure 13:23. Normal facets in a T2W axial.
effusion in a T2 weighted axial image.

Synovial Cyst
Figure 13:24. This T2W axial reveals a Figure 13:25. This T1W axial reveals a
synovial cyst (yellow arrow) that projects synovial cyst (yellow arrow). While difficult
posteriorly from the right zygapophyseal joint. to differentiate from muscle in T1 images,
Note the high intensity (white in this T2WI) of comparing T1 and T2 can differentiate
the synovial cyst. water from fat densities.
Figure 13:26. This T2W sagittal image Figure 13:27. This T1W sagittal image
reveals a synovial cyst (yellow arrow). reveals a synovial cyst (yellow arrow).

Effusion of the Facets with a Synovial Cyst & Pars Defect
Figure 13:28. This image shows effusion of the L4-5 and L5-S1 facets along with
a pars defect of the L5 pars. The L5-S1 facet effusion extends beyond the
margins of the facet joint as it balloons out into a posterior synovial cyst (yellow
arrow).

Synovial Cyst Protruding into the Central Canal and IVF
Figure 13:29. This T2W axial image reveals a synovial cyst (yellow arrow) that
projects anterior from the left facet joint. The cyst abuts and displaces a portion of the
thecal sac. This synovial cyst arises from a hypertrophic and degenerative left facet
joint (white arrow).

Facet Effusion
Figure 13:30. Effusion of the L4-L5

facet seen on T2W sagittal image.
Figure 13:31. A T2W axial of the

same patient. The facet joint is so
filled with fluid that it is significantly
gapped.

Facet Erosion and Degenerative Spondylolisthesis
One of the functions of the facet

joints is to prevent the anterior
displacement of one vertebra on
another. With severe facet
degeneration and erosion, the
restraining function of the facets
is negated. Without the restraint
of the facets, a vertebra will
migrate anterior, resulting in a
degenerative spondylolisthesis.
These images show severely
degenerated L4-L5 facets and the
subsequent degenerative
spondylolisthesis of L4 on L5.
Figure 13:32. A T2W axial showing severe degeneration

and erosion of the facet joints.
Figure 13:33. A T2W sagittal

image revealing a degenerative
spondylolisthesis that resulted
from facet erosion.

Facetal Effusion
Figures 13:34-36. These images show axial and sagittal T2W images with an L4-L5 left facet joint
effusion.

Effusion and Synovial Cysts
Figures 13:37 and 13:38. Severe facet joint erosion and effusion of the L4-L5 facet seen on T2W
axial image (yellow arrow). This case is further complicated by a broad disc bulge, ligamentum flavum
hypertrophy, and a synovial cyst in the central canal (figure13:39).
Figure 13:39. A synovial cyst within the central canal can be

clinically significant (T2W axial image).

Facet Joint Effusion
Figures 13:40 and 13:41. Facet joint effusion of L4-L5 seen on an axial T2WI on the left and T1WI
on the right.
Figure 13:42. Bilateral facet joint effusion as seen on a T2W axial.

Weight Bearing Facets
Figure 13:43. This T2W sagittal image shows Figure 13:44. Another “pillar” facet resulting in
severe L5-S1 facet degenerative changes. This facet degeneration and facet joint effusion.
patient’s anatomy appears to cause the L5-S1
facets to bear much of the axial compressive
force placed on the spine.
When facets project up from the sacrum like a pillar, they bear the weight of axial
compression. This leads to early degenerative changes and frustration in responding to
treatment.

Suggested Reading
Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, Mannion AF. Lumbar facet
joint effusion in MRI: a sign of instability in degenerative spondylolisthesis? Eur Spine J.
2012 Feb;21(2):276-81. doi: 10.1007/s00586-011-1993-1. Epub 2011 Sep 20.
Venkatanarasimha N, Suresh SP. AJR Teaching File: An Uncommon Cause of

Spinal Canal Stenosis.AJR 2009;193:S56–S58 0361–803X/09/1933–S56 © American
Roentgen Ray Society. SPINE Volume 32, Number 14, pp 1555–1560.
Rihn JA, Lee JY, Khan M, Ulibarri JA, Tannoury C, Donaldson WF, Kang JD. Does
Lumbar Facet Fluid Detected on Magnetic Resonance Imaging Correlate With
Radiographic Instability in Patients With Degenerative Lumbar Disease?
Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti PThe correlation between

exaggerated fluid in lumbar facet joints and degenerative spondylolisthesis: prospective
study of 52 patients. J Orthop Traumatol. 2011 June; 12(2): 87–91.
Berven S, Tay BB, Colman W, Hu SS. The lumbar zygapophyseal (facet) joints: a role in
the pathogenesis of spinal pain syndromes and degenerative spondylolisthesis. Semin
Neurol. 2002 Jun;22(2):187-96.
Pal GP, Routal RV. Mechanism of change in the orientation of the articular process of the
zygapophyseal joint at the thoracolumbar junction. J Anat. 1999 Aug;195 ( Pt 2):199-209.
Lakadamyali H, Tarhan NC, Ergun, TC, et al. STIR Sequence for Depiction of
Degenerative Changes in Posterior Stabilizing Elements in Patients with Lower Back Pain
Am. J. Roentgenol. 2008 191: 973-979 Am. J.
Cramer G, Darby S (2013). Basic and clinical anatomy of the spine, spinal cord, and ANS
(third edition). Elsevier Mosby.
Livingstone.

Vertebral
Hemangiomas
243
Hemangiomas
Hemangiomas are the most common benign neoplasm of the spine. Hemangiomas are
composed of dilated blood vessels that displace or erode bone. This disruption causes the
remaining trabeculae to thicken. That thickening gives the vertebra a corduroy appearance
on plain film radiographs.
Being able to discern the difference between malignant neoplasms and predominantly benign
findings such as hemangiomas is a valuable skill. Hemangiomas are common, so common
that it is easy to become complacent and flippantly identify all intravertebral findings as
hemangiomas. Being familiar with common incidental findings will add confidence to the
provider and help in identifying what is not normal. Keep in mind that it is the clinician
reviewing MRs with patients (versus the radiologist) who will be confronted with a startled
patient gawking at a large scary-looking hemangioma during a report of findings.
Figure 14:1. Axial T2WI with a

hemangioma in the L3 vertebral body.
Figure 14:2. Sagittal T2WI with a

hemangioma in the L3 vertebral body.

Hemangioma in the Vertebral Body of L4
Spinal hemangiomas are common. Because of this, most clinicians dismiss them without a
second thought, and in the vast majority of hemangiomas this would be acceptable.
Hemangiomas are benign, asymptomatic, and slow growing with no known tendency to
become malignant. Spinal hemangiomas are composed of a proliferation of vascular tissue.
This proliferation of vascular tissue can displace bone and in some cases create a risk for
compression fractures.
Occasionally other conditions are mistaken for hemangiomas. The differential diagnosis list
for hemangiomas includes metastatic cancer, Paget’s disease, lymphoma, prominent
basivertebral veins (a normal anatomical variant), and multiple myeloma.
Treatment of a hemangioma is rare. Observation is the most common management of this
finding.
Figure 14:3. Sagittal T1WI with a Figure 14:4. Sagittal T1WI with a
hemangioma in the body of L4. hemangioma within the vertebral body of L4.

Differentiating between Vertebral Body Metastasis and a Hemangioma
Any discussion about the differentiation between benign and cancerous lesions on MRI
should occur over the safety net provided by radiologists. Hemangiomas are a common
benign finding on lumbar MRI and are usually incidental and asymptomatic. Upon first
viewing of a large hemangioma on MR, a clinician may be taken back by the appearance
of this impressive looking lesion. Having confidence in the differentiation of these two
findings will expedite appropriate progression of care.
Lesion Type T1 T2 T2 with Fat

suppression
Hemangioma Bright Bright Dark
Metastasis Dark Bright Bright
Figure 14:5. This T1WI shows a Figure 14:6. Metastasis is seen at

bright hemangioma within the two levels, L1 and L4, in this T1WI.
anterior body of L4. Note the darkness of the entire
vertebral body of L4 in this T1WI.

Prominent Basivertebral Veins
Along with hemangiomas and other common inconsequential findings seen on MRI are
vascular foramina. Some images tend to have more pronounced variations of this normal
anatomical finding. Prominent basivertebral veins are normal variants that may draw
attention from an untrained eye.
Figure14:8. Normal vascular variant of

the basivertebral vein on a T2W axial
image.
Figure 14:7. Prominent appearance of the

basivertebral veins at every level in this T2W
sagittal image. This is a normal anatomical
finding.
Figure 14:9. This is the same MRI level

as seen in figure 14:8, but in a T1W
axial image.

Suggested Reading
Aksu G, Fayda M, Saynak M, Karadeniz A. Spinal cord compression due to

vertebral hemangioma. Orthopedics. Feb 2008. Vol 31. Issue 2.
Marchiori D (2013). Clinical imaging: with skeletal, chest and abdomen

pattern differentials(third edition). Mosby.
Hwang PM. Vertebral abnormality in a patient with suspected malignancy

Proc (Bayl Univ Med Cent). 2002 July; 15(3): 325–326.

Conjoined Nerve Roots
249
Conjoined Nerve Roots
Identifying conjoined nerve roots can be difficult for even

skilled radiologists, but since they are periodically left out of
radiology reports it is important that spine practitioners learn
how to identify the location and clinical significance of
conjoined nerves. Anchoring or tethering the nerve roots or
the cord into a position of lesion is one of the most
disturbing aspects of a conjoined nerve root. Though most
conjoined nerve roots will not be symptomatic, symptoms
may develop if the conjoined nerve tethers a nerve root into
the path of a herniation, stenosis, or other compressive
lesion.
The nerve roots normally exit the intervertebral foramina in
the upper 1/3 of the foramina. If a conjoined nerve tethers a
nerve root so that it exits the lower portion of the foramina, it
will be much more susceptible to the pressure of a disc
herniation, facet hypertrophy, or foraminal stenosis. This
can create a clinically significant complex for manual
Normal nerve root practitioners, surgeons, therapists, and pain practitioners.
configuration While conceptualizing conjoined nerve roots is best done in
coronal orientation, like in the schematics pictured, coronal
images are rarely available in MRI studies. Therefore,
relying on clues from axial and sagittal images is the best
Figure 15:1. way to identify this anatomical anomaly.
Samples of conjoined nerve root configurations
Figure 15:2.

Identifying Conjoined Nerve Roots on MRI
Asymmetry in the exiting nerve rootlets is an indication of possible conjoined nerve

roots. The nerve rootlets should appear to travel in symmetrical pairs. The left and
right side of the thecal sac should roughly mirror each other. Figure 15:3 shows a
group of several rootlets grouped together on the left side of the central canal (circled
in red). Figure 15:4 is a schematic of the axial image seen in figure 15:3.
Figure 15:3. T2W axial image showing asymmetry of the exiting nerve rootlets.
Figure 15:4. Schematic of the axial slice seen in Figure 15:3.

This T2W axial image reveals two nerves traveling in the same anterior sacral foramina.
Nerves sharing the same foramina is an indicator of conjoined nerve roots.
Figure 15:5. T2W axial image showing two nerves sharing the same anterior
sacral foramina (red circle).
Figure 15:6. Schematic of the axial image of the sacrum shown in figure 15:5.

Nerve roots normally exit through the upper portion of the lumbar foramina. Suspect
a conjoined nerve root if the nerve is located in the lower 1/3 of an IVF as seen in
both the sagittal MRI on the left and the schematic on the right at L5-S1. After
identifying a nerve exiting low in the IVF in a sagittal view, analyze the axial images
for evidence of anomaly.
Figures 15:7 and 15:8. T2W sagittal image and schematic showing an anchoring
of the L5 nerve root in the lower portion of the L5-S1 foramina (red circle). Note
that all of the other nerve roots exit through the upper 1/3 of the lumbar
intervertebral foramina (yellow arrows).

Normally a nerve root exits the IVF above the level of the disc ,in the upper 1/3 of the IVF.
This location prevents the nerve from being too vulnerable to compression from disc bulges,
herniations and degenerative hypertrophy. Conjoined nerve roots can anchor the nerve root
in the lower 1/3 of the IVF. This increases their likelihood of compromise and injury.
Figure 15:9. T2W sagittal image showing the Figure 15:10. This T2W sagittal image of the
right L4 nerve exiting at the bottom of the L4- same patient shows a foraminal disc
L5 IVF, The L3 nerve is also lower than protrusion entrapping the left L4 nerve root in
normal. the L4-L5 IVF.

Figure 15:11. T2W sagittal image and schematic showing an anchoring of the L4 nerve root
in the lower portion of the L4-L5 foramina.

Figures 15:12 and 15:13. These axial T2W images show two nerve roots exiting the same
foramina. This is highly suggestive of conjoined nerve roots.
MRI is certainly the most accurate and non-invasive diagnostic method for identifying
conjoined nerve roots. Conjoined nerve roots can pose significant clinical concerns and
complications. The occurrence rate in cadaver studies is approximately 8%. Clinically the
reporting rate is much lower. This condition is hard to diagnose and frequently is missed by
radiologists and clinicians.
L5 and S1 are the most common segments associated with this condition. There also seems
to be an increased rate of conjoined nerve roots in patients with other vertebral
malformations. These conditions include spina bifida, spondylolisthesis, and other posterior
vertebral defects.

Suggested Reading
Scuderi GJ, Vaccaro AR, BrusovanikGV. Kwon BK, BertaSC. Conjoined lumbar
nerve roots: A frequently underappreciated congenital abnormality. Journal of
Spinal Disorders & Techniques: April 2004 - Volume 17 - Issue 2 - pp 86-93.
Böttcher J, Petrovitch A, Sörös P, Malich A, Hussein S, Kaiser WA.

Conjoined lumbosacral nerve roots: current aspects of diagnosis.
European Spine Journal. March 2004, Volume 13, Issue 2, pp 147-15.
Lotan R, Al-Rashdi A , Yee A, Finkelstein J. Clinical features of conjoined

lumbosacral nerve roots versus lumbar intervertebral disc herniations
Eur Spine J. 2010 July; 19(7): 1094–1098.
Neidre A, Macnab I. Anomalies of the lumbosacral nerve roots. Review of

16 cases and classification. Spine. 1983;8 (3): 294-9.
Song SJ, Lee JW, Choi JY et-al. Imaging features suggestive of a

conjoined nerve root on routine axial MRI. Skeletal Radiol. 2008;37 (2):
133-8.
Mccormick CC. Developmental asymmetry of roots of the cauda equina at

metrizamide myelography: report of seven cases with a review of the
literature. Clin Radiol. 1982;33 (4): 427-34.

Classification of Spinal Cord
Tumors and Masses by
Location
258
Space Occupying Lesions, Tumors, and Masses
The identification, diagnosis, and classification of tumors and masses is best left to the
experts: radiologists. Having said that, all MSK practitioners should have a basic
understanding of the characteristics of space occupying lesions (SOL) and how they affect
the surrounding structures.
The location descriptors in this chapter describe SOL location in relation to the spinal cord,
cauda equina, and thecal sac. Spinal cord lesions fall into one of three categories:
extradural, extramedullary, and intramedullary. Extradural lesions are spinal lesions found
in the spine, but outside of the thecal sac. Intradural extramedullary lesions are found within
the thecal sac, but outside of the spinal cord. Intramedullary lesions are found within the
cord.
Extradural Lesions Extramedullary Intramedullary

Lesions Lesions
•Disc herniation •Schwannoma* •Ependymoma

•Metastasis to the •Neurofibroma* •Astrocytoma
vertebra •Hemangioblastoma
•Synovial cyst •Syrinx
•Hematoma •Demyelinating disease
•Abscess •Myelitis
•Schwannoma*
•Neurofibroma*
*Schwannomas and neurofibromas can be found intradurally and extramedullary. They are
not intramedullary lesions.

Location Classification of Spinal Tumors and Masses
Thecal Intradural Extradural

Sac
Cord Intramedullary Extramedullary
Figure 16:1. Space occupying lesions of the spine are categorized by their location
and relationship to the thecal sac and to the spinal cord.
Space occupying lesions of the spine are categorized by their location and relationship to the
thecal sac and to the spinal cord. Is the lesion within or outside of the cord? Is it in or outside
of the thecal sac? Is the lesion inside the thecal sac, but outside of the cord. These are the
location identifiers for space occupying lesions of the spine. Lesions within the cord are called
intramedullary lesions, cysts, or tumors. Lesions within the dura mata (the membrane of the
thecal sac) are intradural lesions. Those located outside the dura mata are called extradural
lesions, masses, cysts or tumors. Since the cord terminates high in the lumbar spine, there
will be few truly intramedullary lesions. We can see expansive lesions in the conus medullaris
and the filum terminale as well as in the caudal equina.

Intramedullary Tumors
Intramedullary
Figure 16:3. T2W axial image revealing an

ependymoma filling most of the central canal.
Figure 16:2.
Ependymomas are an example of an

intramedullary tumor. They are usually slow
growing benign tumors arising from the
epithelial lining of the spinal cord’s central
canal. These images show an expansive
ependymoma within the filum terminale.
Ependymomas are the most common
primary tumors of the spinal cord. As in this
case they most frequently occur in the lower
portion of the spinal cord or in the filum
terminale.
Figure 16:4. T2W sagittal image revealing an

ependymoma arising from the filum terminale.

Intramedullary Tumors and Masses
Intramedullary
These images display a

conus medullaris cyst. This
lesion is considered an
intramedullary cyst. The use
of FIESTA (Fast Imaging
Employing Steady sTate
Acquisition) imagery helps to
clearly visualize cystic lesions
of this type.
Figure 16:6. Sagittal T1 weighted

image showing the conus medullaris
cyst as a dark void.
Figure 16:5.
Figure 16:7. Axial FIESTA images Figure 16:8. Sagittal FIESTA image
revealing a conus medullaris cyst. revealing a conus medullaris cyst.

Intramedullary Tumors and Masses: Syrinx
Intramedullary
Figure 16:9. Figure 16:10. Syrinx in a thoracic spine

T2W sagittal image.
Cavities within the spinal cord can have a
significant clinical impact. The term syrinx
is used to describe a fluid-filled cyst within
the central canal of the spinal cord. The
CSF-filled cyst can expound outward,
compressing and damaging nerves.
These are rarely seen in the lumbar spine,
so a thoracic example is used here.
Figure 16:11. A T2W axial image shows

the expansiveness of this syrinx.

Intradural/Extramedullary Tumors and Masses: Lipoma
Intradural
Extramedullary
Figure 16:13. Axial T2 weighted image

showing a lipoma in the thecal sac.
Figure 16:12
An intradural lipoma has the

potential to create significant
adverse effects. This space
occupying lesion is an intradural
extramedullary mass which has the
potential to anchor the cord and
cause severe neurological
Figure 16:14. Sagittal T1 weighted image
impediment.
showing a large lipoma (yellow arrow) within
the thecal sac.

Extradural Tumors and Masses
Extradural
Figure16:16. This image displays an extradural

mass effacing the thecal sac.
Figure 16:15.
An extradural lesion is located

outside of both the dura and the
cord. It may or may not compress
or efface the thecal sac or cord.
Figure 16:17. This vascular anomaly of the

intervertebral vein is an extradural lesion.

Extradural Tumors and Masses
Extradural
Figure 16:19. A schwannoma enhanced with gadolinium.

Figure 16:18.
This schwannoma is an example of an extradural lesion.
An extradural lesion is located

outside of both the dura and the
cord. It may or may not compress
or efface the thecal sac or cord.

Suggested Reading
Börm W, Gleixner M, Klasen J. Spinal tumors in coexisting degenerative spine

disease--A differential diagnostic problem. Eur Spine J 2004;13:633-8.
El-Mahdy W, Kane PJ, Powell MP, Crockard HA. Spinal intradural tumours: Part I--
Extramedullary. Br J Neurosurg 1999;13:550-7.
Grimm S, Chamberlain MC. Adult primary spinal cord tumors. Expert Rev Neurother
2009;9:1487-95.
Hogen Esch RI, Staal MJ. Tumors of the cauda equina: The importance of an early
diagnosis. Clin Neurol Neurosurg 1988;90:343-8.
Yuh EL, Barkovich AJ, Gupta N. Imaging of ependymomas: MRI and CT. Childs
Nerv Syst. 2009 October; 25(10): 1203–1213.
Lee RR. MR imaging of intradural tumors of the cervical spine. Magn Reson Imaging
Clin N Am 2000;8:529-40.
Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic

imaging approach. November 2009 Radiology, 253, 297-316.
Livingstone.

Perineural (Tarlovs) Cysts
268
Perineural (Tarlovs) Cysts
Perineural cysts (aka Tarlov cysts, Tarlovs cysts, and Tarlov’s cysts) are fluid-filled
meningeal dilations of the posterior nerve root sheath, usually at the dorsal root
ganglion. They are commonly viewed in the sacrum but can also be observed in the
lumbar, thoracic, and cervical spine. Dr. Isadore Tarlov first described the presence
of perineural cysts in 1931 while studying the histology of the filum terminale at Royal
Victoria Hospital in Montreal. Since then, this finding has borne his name. Despite
its identification 70 years ago, scant scientific knowledge is available about this
condition. Studies have shown perineural cysts to be present in 4.6-9% of the
population. Although they are usually considered a coincidental finding on MRI and
predominantly asymptomatic, some authors have reported perineural cysts to be
symptomatic up to 20% of the time (1% of the total population, 20% of those with
perineural cysts) and could pose a challenge to both the patient and the clinician.
Radiography
The advent of advanced diagnostic imagery such as MRI and CT has resulted in more
frequent reports of perineural cysts. However, it is rare for any diagnostic imaging
procedure to be ordered for the sake of identifying a perineural cyst. Perineural cysts
are commonly found on MRIs taken for other diagnostic purposes.
On MRI, perineural cysts are typically seen as well-circumscribed and ovoid in shape.
They tend to exist as singularities and less often in clusters. T2 weighted MRI is the
preferred medium to view perineural cysts. In T2 weighted MRI, water density appears
white; in T1 weighted MRI, water density structures appear black and may be more
difficult for the less experienced eye to visualize. Perineural cysts can also be made
visible with computer tomography (CT), particularly when intrathecal contrast
enhancement is used. CT with enhancement is used to determine the degree of
communication between the perineural cysts and the thecal sac. Bony erosion caused
by perineural cysts can be identified on plain film radiographs, but this is not the
preferred medium for viewing this phenomenon.

What is a Perineural (Tarlovs) Cyst?
Nerve Root
Cerebral
Spinal
Fluid
Nerve Sleeve (CSF)
Figure 17:1. Schematic of the normal nerve Figure 17:2. Dilation of the nerve sleeve
root . filling with CSF.
Perineural cysts are fluid-filled meningeal dilations of the posterior nerve root
sheath, usually at the dorsal root ganglion. These schematics illustrate the normal
relationship of the dural sleeve and the nerves.
Figure 17:3. This image of the sacrum shows eight perineural cysts
clustered together like a cluster of grapes.

Characteristics of Perineural Cysts on MRI
This sequence of images demonstrates the characteristics of two large perineural cysts
affecting the dural sleeves of the S2 nerve roots. Note the high intensity of the
perineural dilation of the cysts in T2 and the low intensity of the cysts on T1. These
images also reveal significant bony erosion of the sacrum which weakens the integrity of
the sacrum.
Image adapted from Henry Gray’s Anatomy

of the Human Body. 1918.
Figure 17:4.. Large ovoid perineural cysts Figure 17:5. Schematic of the cyst.
affecting the sleeve of the S2 nerve root on
fat-suppressed T2 weighted image.
Figure 17:6. Axial fat-suppressed T2 Figure 17:7. T1 image of perineural

weighted image demonstrating two large cysts. Fat is hyper-intense while the
perineural cysts in the sacrum. perineural cysts are hypointense (black).

Multiple Cysts of the Perineural Tissues
Perineural cysts may be seen in clusters. They all appear like a cluster of grapes or like
bubbles. Multiple cysts may be seen at every level of the spine, but are most common in
the sacrum.
Figure 17:8. T2 weighted sagittal image Figure 17:9. T1 weighted sagittal version of the
revealing multiple expansive perineural cysts same sagittal slice.
causing erosion of the sacrum.
Image adapted from Henry Gray’s Anatomy of the Human Body. 1918.
Figures 17:10 and 17:11. These illustrations demonstrate the relationship of this expansive
cluster of cysts (left) and a normal cross-section of sacrum (right).

Typical Presentation of Perineural Cysts
The previous two pages presented perineural cysts that were noteworthy due to their
size or number. This page will demonstrate the typical presentation of a perineural
cyst. Typically they are solitary, seen in the sacrum and affecting the S2 (or less
likely the S1) nerve roots. They are ovoid in shape and well defined.
Figure 17:12. T1 weighted sagittal Figure 17:13. T2 weighted sagittal

image. image.
Figure 17:14. T2 weighted axial image.

Large Perineural Cyst Displacing the Thecal Sac
These images display a large perineural cyst which displaces the thecal sac at the
level of L2-3.
Figure 17:15. Sagittal T1W image. Figure 17:16. Sagittal T2W image.
Figure 17:17. T1W axial image. Figure 17:18. T2W axial image.

Suggested Reading
Langdown AJ, Grundy JR, Birch NC. The clinical relevance of Tarlov cysts. J
Spinal Disord Tech. 2005;18:29–33.
Paulsen RD, Call GA, Murtagh FR. Prevalence and percutaneous drainage of
cysts of the sacral nerve root sheath (Tarlov cysts) AJNR Am J Neuroradiol.
1994;15:293–297. discussion 298-299.
Seaman WB, Furlow LT. The myelographic appearance of sacral cysts. J

Neurosurg 1956;13;88-94.
Paulsen RD, et al. Prevalence and percutaneous drainage of cysts of the sacral
nerve root sheath (Tarlov cysts). AJNR 1994; 15:293,297.
Mummaneni PV, et al. Microsurgical treatment of symptomatic sacral Tarlov

cysts. Neurosurgery 2000; 47:74-79.
Bartels RH, van Overbeeke JJ. Lumbar cerebrospinal fluid drainage for
symptomatic sacral nerve root cysts: an adjuvant diagnostic procedure and/or
alternative treatment? Technical case report. Neurosurgery 1997; 40:861-865.
Patel MR, et al. Percutaneous fibrin glue therapy of meningeal cysts of the sacral
spine. AJR 1997; 168:367-370.
Voyadzis JM, e. Tarlov cysts: a study of 10 cases with review of the literature. J
Neurosurg (Spine 1) 2001;95:25-32.

Tarlov IM. Perineural cysts of the spinal nerve roots. Arch Neural Psychiatry.
1938;40:1067–74.
Prashad B, Jain AK, Dhammi IK. Tarlov cyst: Case report and review of literature
Indian J Orthop. 2007 Oct-Dec; 41(4): 401–403.

Hematomas
276
Paraspinal Hematoma
Trauma in the form of a blow, fall, or tearing of tissue can result in bleeding into the soft
tissues. Patients with increased bleeding tendencies may have hematomas without noting
trauma. This internal bleeding can result in the formation of a space occupying pocket of
blood, a hematoma. These images show a hematoma that appeared nine days prior in the left
paraspinal L3-4 region. Note the heterogenic appearance that is particularly evident in the T2
weighted images.
Figures 18:1 and 18:2. T2W axial image showing a hematoma in the left (right side in
these images) paraspinal muscles.
Figure 18:3. T1W axial image showing a Figure 18:4. T2W sagittal image showing a
hematoma in the left paraspinal muscles. hematoma in the paraspinal muscles.

Paraspinal Hematoma
Figure 18:5. Coronal image showing the hematoma in the left multifidus.
Figure 18:6. T2 fat-saturated axial image showing the hematoma in the left paraspinal muscles.

Right Iliacus Hematoma
Figure 18:7. T2 weighted image showing the hematoma in the right iliacus
designated by yellow arrows.
Figure 18:8. Coronal image showing the hematoma in the right iliacus
(yellow arrows).

Hematoma
Figure 18:9. Post-traumatic hematoma Figure 18:10. Post-traumatic hematoma

posterior to L4. Note the compression posterior to L4.
fracture of L1.
Figure 18:11. Post-traumatic

hematoma posterior to L4.

Suggested Reading
Wu JS, Hochman MG. Soft-tissue tumors and tumor like lesions: a systematic
Lee YS, Kwon ST, Kim JO, Choi ES. Serial MR imaging of intramuscular
hematoma: experimental study in a rat model with the pathologic correlation.
Korean J Radiol. 2011 Jan-Feb; 12(1): 66–77.

Metastasis
283
Metastasis
It cannot be overstated that clinicians should always have MRIs read by a board certified
radiologist. It is assumed that this book is not adequate instruction in itself for diagnosing
neoplasms. Always consult with your radiologist when there is a history of cancer or
when cancer is suspected.
If you believe that your radiologist may have missed a neoplasm, contact the radiologist
and discuss the images. Have the image identifiers available to share with the
radiologist.
Figure 19:1. T1 weighted sagittal image of Figure 19:2. This sagittal T1 fat sat image
vertebral body metastasis at L1 and L4. was taken after the administration of
gadolinium. Note how the appearance of
the metastatic disease is heightened by the
enhancing agent.

Metastases
Figures 19:3 and 19:4. T2W sagittal images of the lumbar spine show diffuse metastases and
bony disruption.
Neoplasms of the spine can arise as primary lesions from the spine or can metastasize from
another region of the body. The most common sites that cancer has metastasized to the spine
from includes the lungs, prostate, and breasts. If one tumor is found, it is termed metastasis; if
multiple tumors are found it is referred to as metastases. When cancer spreads to the spine,
the vertebrae become brittle. This often leads to compression fractures.

Characteristics of Metastases on Lumbar MR
Figure 19:5. T1 weighted sagittal image Figure 19:6. T2 weighted sagittal image.
revealing diffuse metastases of the lumbar
spine .
T1 T2 T2 with Fat suppression

Metastases Dark Bright Bright
Figure 19:7. Characteristics of metastases on T1,T2, and T2 with fat suppression.

Differentiating Fat in Bones from Bony Metastases
Figure 19:8. Fatty infiltration into the Figure 19:9. Metastases into the
vertebral bodies in this T2WI. vertebral bodies on a T2WI.
Fatty infiltration into bone can have a heterogeneous mottled appearance that may appear to
look like metastases, and metastases may appear to the clinician like fatty infiltration. On MRI
comparing T1, T2, and fat suppressed images will help to distinguish fat infiltration from
neoplasms (see figure 19:10). It is important to always defer to a trained radiologist for the
identification of pathology.
Differentiating Fat from Bony Metastases

T1 T2 T2 with
fat suppression
Fat Bright Bright Dark
Figure 19:10. Characteristics of fat and bony metastases on MRI.

Figure 19:11. Metastases of Figure 19:12. By selecting the Figure 19:13. This T1 fat sat
thyroid cancer to the vertebral proper MRI enhancements the image with gadolinium
bodies of L1 and L3 is visible cancer becomes more evident. enhancement further
on this sagittal T2 image. This T2 image with fat illuminates the extent of the
suppression helps to reveal metastases.
additional metastases.
When cancer is suspected, it is a good idea to communicate with a radiologist to ensure that the
most appropriate studies are requested. Certain MRI studies are very effective at illuminating
metastases. Compare these three images and the impact that the various image types have on
visualizing the cancer.

Figure 19:14. Metastasis of thyroid cancer to L1. Figure 19:15. Metastasis of thyroid cancer to
This large mass is visible on T2WI. L1. This T1 fat sat image with gadolinium
enhancement brings out the details of this
metastasis.

Suggested Reading

Guise TA, Mohammad KS, Clines G et-al. Basic mechanisms responsible for
osteolytic and osteoblastic bone metastases. Clin. Cancer Res. 2006;12 (20 Pt
2): 6213s-6216s.
Sebastian PR, Fisher M, Smith TW et-al. Intramedullary spinal cord metastasis.

Surg Neurol. 1981;16 (5): 336-9.
Beall DP, Googe DJ, Emery RL et-al. Extramedullary intradural spinal tumors: a
pictorial review. Curr Probl Diagn Radiol. 36 (5): 185-98.
Kalayci M, Cağavi F, Gül S et-al. Intramedullary spinal cord metastases:

diagnosis and treatment - an illustrated review. Acta Neurochir (Wien). 2004;146
(12): 1347-54.

Tumors: Schwannomas and
Ependymomas
291
Schwannoma
Schwannomas are benign nerve sheath tumors that are composed entirely of Schwann
cells. Since these tumors are benign, the major clinical impact arises from compression
of other tissues, particularly nerve tissue. Schwann cells are supportive of nerves and
encompass the axons. Schwannomas are extramedullary (outside the spinal cord)
neoplasms. These tend to arise in middle-aged adults with a male to female prominence
of 3:1 and may present with symptoms similar to those of herniated discs.
On MRI schwannomas are typically hypointense on T1 weighted images and

hyperintense and heterogeneous on T2 weighted images. Schwannomas are enhanced
with gadolinium.
The following two pages show the characteristics of a schwannoma in various MRI
orientations and image types.
Figure 20:1. Schematic of a Schwann cell.

Schwannoma Extending through the IVF and into the Iliopsoas Muscle
Figure 20:2. T2 weighted axial image Figure 20:3. Another T2 weighted axial image
showing heterogeneous expansion of a showing heterogeneous expansion of a
schwannoma into the left psoas. schwannoma into the left psoas.
Figure 20:4. T1 weighted axial image. The Figure 20:5. T1 weighted axial image with
Schwannoma is dark in color. gadolinium enhancement. The fat is
suppressed, but the kidneys and the
schwannoma shine bright.

Schwannoma Protruding through the Iliopsoas Muscle
Figure 20:6. Proton density sagittal image Figure 20:7. Post-gadolinium T1 weighted
of a schwannoma protruding through the sagittal image of a schwannoma protruding
iliopsoas muscle. through the iliopsoas muscle. Note the
high intensity of the tumor and the kidney.
Figure 20:8. T2 weighted sagittal image of Figure 20:9. T1 weighted sagittal image of
a schwannoma. a schwannoma.

Myxopapillary Ependymoma
An ependymoma is an intramedullary tumor that arises from the ependyma (glial tissue found
in the central nervous system). Ependymomas are the most common type of primary
neoplasms in the spinal cord and filum terminale (figures 20:10 and 11). The diagnosis of
spinal cord tumors is best left to the neuroradiologists. On finding an ependymoma, a
neurosurgical referral is appropriate.
These tumors arise mainly in the conus medullaris and filum terminale. Clinically they often
present in young adults, males more prevalent than females, and with a long history of lower
back pain. They are slow growing tumors.
This condition is treated surgically and, if indicated, with radiation therapy.
MRI studies should include images with and without enhancement (gadolinium). They
typically are isointense on T1, hyperintense (light) on T2, and are enhanced with contrast.
Figure 20:10. T2 axial image of a myxopapillary

ependymoma of the filum terminale.
Figure 20:11. T2 weighted sagittal image.

Suggested Reading
David P. Friedman et.al, Intradural schwannomas of the spine: MR findings with

emphasis on contrast-enhancement characteristics , 158:1347-1350, June 1992.
Taher El Gammali et.al, MR Myelography: Imaging Findings, AJR 1995;164:173-

177. J Neuroradiol. 2005 Jan;32(1):42-9.
De Verdelhan O, Haegelen C, Carsin-Nicol B, Riffaud L, Amlashi SF, Brassier G,

Carsin M, Morandi X. Service de Neuroradiologie, Fédération d'Imagerie
Médicale.
López J, Diaz DR, Medina YC, et al. Schwanoma intramedular cervical. Arch
Neurocien 2004;9:55-8.
Slooff JL, Kernohan JW, MacCarty CS. Primary intramedullary tumors of the
spinal cord and filum terminale. 1964.


Inflammatory Joint Disease
297
Inflammatory Joint Disease
Inflammatory changes in the spine can result from infection, rheumatologic conditions,
autoimmune disease, trauma, chronic irritation, or iatrogenic insult. While this section will
show a few signs of spinal inflammation, the chapter on Modic changes is another resource
for identifying bony edema.
Even though an entire chapter of this book is dedicated to vertebral body and endplate
inflammation and degenerative changes (see chapter 12), we need to include bony edema
within this discussion of inflammatory disease.
The high water content of inflammation and edema is evident in type 1 Modic changes.
Type 1 changes are manifested as hypointense (dark) on T1 and hyperintense on T2
weighted images. This is indicative of an acute reactionary process.
Figure 21:1. T1 weighted sagittal image revealing Figure 21:2. T2 weighted sagittal image
type 1 Modic changes. Fluid (bony edema) is dark revealing type 1 Modic changes. The edema is
on T1. light on T2WI.
Bony edema can be caused by infection, fracture, disc injury, or from a number of other sources.
It can be the first sign of a more serious condition. Type 1 Modic changes usually indicate an
active inflammatory process is going on. Understanding the characteristics of Modic changes will
help the clinician to know whether the condition is actively inflamed (Modic 1 changes) or has
reacted to the insult in a more chronic manner (Modic 2 and Modic 3 changes).

Psoriatic Arthritis of the Sacroiliac Joint
Figure 21:3. T1 weighted axial image of the Figure 21:4. T2 axial demonstrating bony
sacrum and sacroiliacs with fat saturation after edema and erosion of the sacral joint surface
receiving a contrast enhancement injection. and bone.
Bony edema, synovitis, joint effusion,

and joint and bone erosion are
characteristics of psoriatic arthritis that
can be seen on MRI. These MRI
features are shared with rheumatoid
arthritis and other inflammatory joint and
infectious diseases. Differentiating
between various inflammatory and
infectious joint diseases requires a
comprehensive clinical, laboratory, and
radiographic approach. Given the
dangers and aggressiveness of joint
infections, aggressive and emergent
measures should be employed when
infection is suspected.
Figure 21:5. T1 weighted axial image of the sacrum
and sacroiliacs. Note the bony edema which
appears dark in this T1WI.

Pyogenic Spondylitis and Discitis
Figure 21:6. T2 weighted sagittal image of a Figure 21:7. CT sagittal of the same patient
staphylococcus aureus infection of L1, L2, and revealing loss of disc height and bony erosion
the L1-2 disc. Note the marrow changes along of the endplates and vertebral bodies of L1 and
with endplate and disc disruption. L2.
Identifying infections of the lumbar spine requires the knowledge of symptoms, clinical
presentation, lab findings, and radiology. Staphylococcus aureus is the most common organism
involved in pyogenic spondylitis and discitis, but other organisms may also cause infections of
the spine. The T2 weighted sagittal MR image (figure 21:6) shows destruction of the affected
vertebrae, L1 and L2, along with the L1-2 disc, and erosion of the vertebral endplates and
vertebral bodies. The halo of a high intensity signal extends well into the vertebral bodies. The
CT (figure 21:7) reveals bony and disc destruction associated with infectious spondylitis and
discitis. Bone and disc destruction are the hallmarks of pyogenic spondylitis and discitis. This
diagnosis is a medical emergency and requires prompt and aggressive medical treatment.
Plain film spinal radiology will not display evidence of disc or bony infection until 7 to10 days
have passed from the onset of symptoms. Clinical presentation includes fever, chills, elevated
ESR, and leukocytosis. Patients at risk for discitis and infectious spondylitis include immune
depressed patients, trauma, recent surgery or dental work, and patients with systemic infections.

Facet Effusion
Figure 21.9. A T2W axial of the same patient. The

facet joint is so filled with fluid that the joint is
significantly gapped.
Figure 21:8. Effusion of the L4-L5 facet

seen on T2W sagittal image.
Fluid in a joint is indicative of inflammation. When facet effusion is present, it can be

caused by mechanical irritation or by an inflammatory process or disease. This can result
from a rheumatologic condition, trauma, infection, or disease.

Suggested Reading
McQueen F, Lassere M, Østergaard M. Magnetic resonance imaging in psoriatic

arthritis: a review of the literature. Arthritis Res Ther. 2006;8:207. doi:
10.1186/ar1934.

Fat
303
Fat
Recognizing fat and its characteristics is an essential skill set for anyone interested in
reading MRI. The characteristics of fat on T1 and T2 weighted images was discussed in
detail in a previous chapter. This chapter will highlight fat as a space-occupying lesion,
discussing the appearance of fatty lesions such as lipomas, fatty filum terminale, tethered
cord, fatty infiltration into bones, and epidural lipomatosis.
Fat is common, so we need to be able to identify fatty tissue and distinguish it from other
tissues. We also need to know when a fatty lesion is potentially dangerous. Lipomas are
common and benign and usually just an incidental finding on physical or radiographic
examination. However, they can produce profound symptoms if they are contained within
the spinal canal.
Figure 22:1. This large lipoma was removed from a forearm due to its
compression of the median nerve. Published with permission from Sebastian E
Valbuena, Greg A O'Toole and Eric Roulot through Creative Commons.
Sebastian E Valbuena, Greg A O'Toole and Eric Roulot: Compression of the median nerve in the
proximal forearm by a giant lipoma: A case report. In: Journal of Brachial Plexus and Peripheral
Nerve Injury 2008, 3:17 doi:10.1186/1749-7221-3-17 (Open Access Article, published under cc-by-
2.0)

Lipoma
Figures 22:2 and 22:3. These T2W sagittal images are slices taken lateral of midline and show the
investment of a fairly large lipoma (yellow arrows). This lipoma was easily palpated and had the
consistency of a rubbery mass. The subcutaneous fat and its network of supporting vessels can be
seen between the red arrows. The orange arrow points toward the deep visceral fat that surrounds
the internal organs.
Lipomas are a common benign neoplasm. Periodically their size, location, or number will be a
source of alarm to patients. Normally they are found in or around other fatty tissues. Use known
fatty structures as a point of reference for comparison of intensity and structure. If it is the same
color and consistency of other fatty structures, it is probably fat.

Lipoma
Figure 22:4. A large subcutaneous lipoma (yellow arrows) at the level of the right kidney.
Figure 22:5. The large lipoma from figure 22:4 without the arrows.

Lipoma
Figure 22:6. T1 weighted sagittal image of Figure 22:7. T1 weighted axial image of the
the thoracic spine revealing a paraspinal thoracic spine revealing a paraspinal lipoma.
lipoma.
Lipomas are benign fatty tumors that are typically of little clinical consequence. An MSK provider
will see thousands of lipomas in a career. Clinically, they are typically pain-free encapsulated
nodules of fat. Finding a tumor can cause a patient with a lipoma significant anxiety, and it is
important that clinicians are able to dispel the patient’s fears. Having a lipoma is not an
indication to order an MRI, unless its size and location cause significant symptoms or
impairment.
These images show a paraspinal lipoma in T1 weighted views. Note how the lipoma is invested
in the subcutaneous fascia and how circumscribed it appears. Lipomas may be quite large and
still be asymptomatic. Patients may request to have lipomas removed for cosmetic purposes. .

Lipoma in the Paraspinal Muscles
Figure 22:8. T2 weighted axial image of a Figure 22:9. T2 weighted axial image.
paraspinal lipoma.
Lipomas are rarely considered clinically

significant unless they place pressure on
adjoining tissue. As the name indicates,
lipomas are tumors of fatty material. These
benign tumors are the most common type of
soft tissue tumor. To identify a lipoma on MRI
it is best to compare T1, T2, and when
possible, fat-saturated images. The images
on this page reveal a lipoma that is located
deep below the paraspinal muscles. Because
lipomas are composed of fat, they will be
hyperintense on both T1 and T2 weighted
imagery and hypointense on fat-suppressed
imagery.
It is important to be able to differentiate
between this benign lesion and other more
ominous lesions.
Figure 22:10. T1 weighted axial image. Note the

tone of this lipoma is consistent with the
subcutaneous and visceral fat.

Lipoma of the Filum Terminale
Figure 22:11. This T1W sagittal image shows Figure 22:12. The fatty filum terminale is
the fatty filum terminale as hyperintense. more difficult to distinguish on this T2WI.
A fatty filum terminale is usually an incidental finding on MRI. However, when the lipoma is
large, it can cause a tethered cord syndrome that disrupts bladder and lower extremity
function. There is some evidence that even a small fatty terminale can contribute to clinically
significant conditions under the right circumstances. The characteristics of a fatty filum
terminale on MRI are as follows: T1- hyperintense (bright); T2- hyperintense; Fat Saturation-
saturated; Gadolinium- not enhanced.

Lipoma of the Filum Terminale
Figure 22:13. This T1W axial image clearly Figure 22:14. This T2W axial image shows the
shows the fatty filum terminale as a hyper- fatty filum terminale as a hyperintense white dot
intense white dot in the dark thecal sac. in the thecal sac.
Figure 22:15. MRI Characteristics of a Lipoma of the Filum Terminale
T1 T2 Fat Gadolinium
Saturation Enhancement
Bright Bright Saturated Not Enhanced
(hyperintense) (hyperintense)

T2 with Fat Saturation
Figure 22:17. T2 weighted fat saturated axial

image.
By comparing normal T2 images and T2 fat-saturated images, the clinician can differentiate
fatty structures from water density structures. In figure 22:16 a structure appears suspicious
for a large lipoma within the thecal sac of the sacrum. Large lipomas in the sacrum can cause
tethered cord syndrome, so it is important to be able to differentiate lipomas from other
lesions.
By suppression of the fat signal, we can differentiate water densities from fat densities.
Comparing these images, the lesion that is visible in figure 22:16 does not darken with fat
suppression in figure 22:17. Therefore, we can accept that this is a water density lesion, most
likely a perineural cyst.
While contemplating the composition of various structures, compare the composition of known
structures with that of the unknown. Look at known fat, water, and gas densities. Is your
unknown structure consistent with any of these densities? In these images we can see that
the questionable structure is similar to the water density seen in the urinary bladder. It is a
water density.

Tethered Cord
Figure 22:18 and 22:19. These T1 weighted axials reveal a large lipoma within the thecal sac.
Note that the CSF is dark in T1 weighted images. This is useful in differentiating fluid-filled cysts
from lipomas. Lipomas of this size frequently result in tethered cords as discussed in the previous
chapter.

reveals a large lipoma within the thecal sac.

Tethered Cord (continued)
Figure 22:21. This T2 weighted sagittal image Figure 22:22. This fat-suppressed T2
reveals a large lipoma within the thecal sac. This weighted image is useful to clarify that this
lipoma is an intradural extramedullary space space-occupying lesion is indeed a fat density.
occupying lesion. In fat-suppressed T2 weighted images, water
densities are bright, and fat densities are
suppressed (dark).
Lipomas of the filum terminale can become so enlarged that they anchor the cord and
create a tethered cord. Tethered cords can cause severe neurological damage.

Fatty Infiltration into Bone
Figure 22:23. T1 weighted axial image Figure 22:24. T1 weighted sagittal

showing fatty infiltration into the sacrum. image with fatty infiltration into the
sacrum.
Figure 22:25. T2 weighted axial image with Figure 22:26. T2 weighted sagittal
fatty infiltration into the sacrum. image with fatty infiltration into the
sacrum.
Fatty infiltration into the bone is a common benign finding on MR. These images show fatty
infiltration into the sacrum of a 41 year-old male. In addition to naturally occurring fatty
infiltration into bone, it may be sequelae of radiation exposure or treatment. Fatty
replacement of the normal marrow may also be part of degenerative changes (see chapter 12
on Modic Changes).

Spinal Epidural Lipomatosis
Figure 22:27. T2 weighted axial with epidural fat Figure 22:28. T1 weighted axial image.
deposits denoted by yellow arrows.
Epidural lipomatosis of the spine (excessive fat

deposition in the spinal canal) has been attributed
to steroid therapy, endocrinopathy, and
inconclusively to obesity. Idiopathic spinal
epidural lipomatosis is rare, but has been
documented. Spinal epidural lipomatosis can
cause back pain, nerve root impingement, and
cord compression. These images demonstrate
excessive fat deposition posterior to the vertebral
bodies and anterior to the spinal canal. Increasing
obesity in the developed world may contribute to
an increase in the occurrence of this condition, but
the increase in the prevalence of MRIs has also
been sited as a cause for increased diagnosis of
this condition.
Figure 22:29. T1 weighted sagittal image of the

same patient from figures 22:27 and 22:28. The
arrows point out the presence of excessive fat in
the anterior canal.

Spinal Epidural Lipomatosis (continued)
Figure 22:30. T2 weighted axial with Figure 22:31. T1 weighted axial revealing
epidural fat indenting the thecal sac. the “Y” sign of thecal sac compression
associated with epidural lipomatosis.
Epidural lipomatosis has been attributed to various compression findings on MRI including the
“Y” sign (figure 22:31). This is caused by the compression of the thecal sac into a trifid shape
of three lobes that looks much like a “Y” (Kuhn).

Epidural Lipomatosis
Figure 22:32. T1 weighted axial image

showing a significant encroachment of the
central canal by of epidural lipomatosis.
Figure 22:33. T1 weighted sagittal image

showing a significant encroachment of the
central canal by of epidural lipomatosis.

Epidural Lipomatosis
Figure 22:34. T1 weighted axial image Figure 22:35. T1 weighted axial image
showing a significant encroachment of the showing the “Y” phenomenon that is
central canal by epidural lipomatosis. indicative of epidural lipomatosis.
Figure 22:36. T2 weighted sagittal image Figure 22:37. T1 weighted sagittal image
showing a significant encroachment of the showing a significant encroachment of the
central canal with diffuse epidural central canal from epidural lipomatosis which
lipomatosis. is particularly evident by comparing water
densities and fat densities in T1.

Fatty Replacement of Muscle
barney
Figure 22:38. T1 weighted axial image showing fatty replacement

of the multifidus muscles.
Figure 22:39. T1 weighted axial image showing extensive fatty

replacement of the paraspinal muscles in an 80 year-old man.

Fat in Bones
Figures 22:40 and 22:41. The mottled appearance of fatty infiltration into the vertebral bodies is
clearly visible in these T2W sagittal images.
Fatty infiltration into the vertebral bodies is a common finding on MRI, especially with age.
These T2 weighted sagittal images reveal the botchy appearance of fat within the trabecular
bone (spongy bone). Compare areas of known fat with the consistency of suspected fat in the
spine. Matching the T1and T2 images will also be beneficial in determining if the light-colored
infiltration is fat or some other substance.

Differentiating Fat in Bones from Bony Metastases
Figure 22:42. Fatty infiltration into the Figure 22:43. Metastases into the
vertebral bodies in this T2WI. vertebral bodies on a T2WI.
Fatty infiltration into bone can have a heterogeneous mottled appearance that may appear like
metastases, and metastases may remind the clinician of fatty infiltration. On MRI comparing T1,
T2, and fat-suppressed images will help to distinguish fat infiltration from neoplasms (see figure
22:44). It is important to always defer to a trained radiologist for the identification of pathology.
Differentiating Fat from Bony Metastases

T1 T2 T2 with
fat suppression
Fat Bright Bright Dark
Figure 22:44.. Characteristics of fat and bony metastases on MRI.

Suggested Reading
T. Iizuka: Fatty Filum Terminale on MRI. The Internet Journal of Spine Surgery.
2007 Volume 3 Number 1.
Lisai P, Doria C, Crissantu L, Meloni GB, Conti M, Achene A. Cauda equina

syndrome secondary to idiopathic spinal epidural lipomatosis. Spine
2001;26:307-309.
Haddad SF, Hitchon PW, Godersky JC. Idiopathic and glucocorticoid-induced

spinal epidural lipomatosis. J Neurosurg 1991;74:38-42.
Kuhn MJ, Youseff HT, Swan TL, Swenson LC. Lumbar epidural lipomatosis: The
“Y” sign of thecal sac compression. Comput Med Imaging Graph 1994;18:367-
372.
Kumar K, Nath RK, Nair CPV, Tchang SP. Symptomatic epidural lipomatosis
secondary to obesity. J Neurosurg 1996;85:348-350.
Kurt E, Bakker-Niezen SH. Neurogenic claudication by epidural lipomatosis: a

case report and review of literature. Clinical Neurol Neurosurg 1995;97:354-357.
Alicioglu B, Sarac A, Tokuc B. Does abdominal obesity cause increase in the

amount of epidural fat? Eur Spine J. 2008 October; 17(10): 1324–1328.
Pinkhardt EH,Sperfeld AD. Is spinal epidural lipomatosis an MRI-based

diagnosis with clinical implications? A retrospective analysis. Acta Neurologica
Scandinavica. June 2008 Volume 117, Issue 6, pages 409–414.
Hadar H, Gadoth N, Heifetz M. Fatty Replacement of Lower Paraspinal Muscles:

Normal and Neuromuscular Disorders. AJR 141: 895-898,November 1983.

Resnick D, Kransdorf MJ. Bone and joint imaging. W B Saunders Co. (2005).
Robertson SC et.al, Idiopathic spinal epidural lipomatosis. Neurosurgery. 1997

Jul;41(1):68-74; discussion 74-5.
Selmi F et.al, Idiopathic spinal extradural lipomatosis in a non-obese otherwise

healthy man, Br J Neurosurg. 1994;8(3):355-8.

Gadolinium Enhancement
323
Gadolinium
Gadolinium is a contrast medium used commonly in the study of organs and disease. MRI
with gadolinium enhancement has some value in the examination of certain musculoskeletal
conditions. Gadolinium is administered to the patient through an IV injection. It is a
paramagnetic compound that has an increased intensity (brightness) on T1W images.
Gadolinium has an affinity for vascular tissue so it is used to differentiate between vascular
and avascular structures. A tumor that is vascular will enhance with gadolinium, but a
hematoma will not. Scar tissue, which is initially vascular granulation tissue, will enhance
with gadolinium, but intervertebral disc material typically will not.
Gadolinium is relatively safe when compared to other contrast media, which may be why it
is the most commonly used medium of enhancement. However, it does carry some risk.
Indications for Using Gadolinium Risks to Using Gadolinium
1. Previous spine surgery. Gadolinium will help 1. Allergic reaction

differentiate between (avascular) disc 2. Kidney damage. Gadolinium
material and fibrosis which is vascular. The is ultimately filtered through
disc material will not enhance, so it can be the kidneys. For this reason it
differentiated from scar tissue. is recommended that those
2. Differentiating between a solid and a cystic with renal disease not use
mass. A fluid-filled cystic lesion will not gadolinium.
enhance, but a vascular mass will. 3. Patients with nephrogenic
3. Determining if a tumor is vascular or systemic fibromatosis (NSF)
avascular. A lipoma will not enhance, but a should avoid gadolinium.
sarcoma will. 4. Pregnancy. Gadolinium is
4. Gadolinium use is preferred when ruling out contraindicated during
either a primary tumor or metastatic disease. pregnancy.
5. Osteomyelitis 5. Breast feeding mothers should
6. Abscess discontinue breast feeding
7. Bone cyst until the gadolinium has
8. History of cancer passed from their system.
Clinical note: When in doubt about using gadolinium or any contrast media, consult your
radiologist.

Figure 23:1. T1W axial image of a left- Figure 23:2. T2W axial image of a left-
sided paraspinal hematoma. sided paraspinal hematoma.
Figure 23:3. T1W axial image of a Figure 23:4. Schwannoma that extends
schwannoma extending into the left from the IVF into the left iliopsoas muscle
iliopsoas muscle. in this T2 axial image.
These images demonstrate two different

lesions that look similar on MRI. Figures 23:1
and 23:2 display a hematoma in the left
paraspinal muscles. Figures 23:3 and 23:4
are images of a schwannoma penetrating the
left iliopsoas muscle. Notice the lesions are
both hypointense in the T1 axials and then
hyperintense and heterogeneous in the T2
images. If you only had these MRI images
available, you might be at a disadvantage in
differentiating these two very different lesions.
The use of gadolinium enhancement (figure
Figure 23:5. Gadolinium enhances
23:5) aids in identifying the schwannoma.
the visualization of the Schwannoma
in this fat-suppressed T1 axial.

Scar tissue is enhanced by gadolinium. The images on these two pages show a patient with
surgical decompression surgery of the lumbar spine. Compare the pre- and post-gadolinium
images. The images below clearly show the affinity that gadolinium has for scar tissue. This
patient has significant post-surgical scarring in the right paraspinal muscles.
Figures 23:6 and 23:7. These axial images show an isointense signal in the right paravertebral
muscles (yellow arrow) which could represent fatty infiltration or scar tissue. The red arrow
points to the left paraspinal muscles which are normal.
Figures 23:8 and 23:9. These axial images were taken after the administration of gadolinium.
The hyperintense signal in the right paravertebral muscles (yellow arrow) indicates gadolinium
uptake into vascular tissue indicating this is scar tissue. The red arrow points to the normal left
paraspinal muscles.

Image 1. pregad T2
Figure 23:10. T2 weighted sagittal image of Figure 23:11. Post-gadolinium T1 fat sat
a post-surgical lumbar spine. sagittal of the same patient. Note the
enhancement of the discs (green arrows)
indicating increased vascularity and scarring
in the discs. Also note the posterior
paraspinal enhancement (within the red
circle) indicating post-surgical scarring.
Gadolinium aids in determining the content of a space-occupying lesion. After lumbar discectomy,
non-contrasted MRI (figure 23:10) showed space-occupying lesions that appeared to be re-
herniations of the discs at L3-L4 and L4-L5. The administration of gadolinium (figure 23:11)
revealed enhancement consistent with the vascularity associated with scar tissue. Gadolinium can
help differentiate between disc material and post-surgical scarring. In this case there is significant
scarring.

Figure 23:12. Post-gad T1 FS (the same slice as seen on figure 23:11, but
without the identifying markers) showing increased enhancement of the
posterior discs of L3-L4 and L4-L5.

Suggested Reading
Geraldes C, Laurent S. Classification and basic properties of contrast agents for

magnetic resonance imaging. Contrast Media & Molecular Imaging 4(1): 1–23.
doi:10.1002/cmmi.265. PMID 19156706.
Murphy KJ, Brunberg JA, Cohan RH. (1 October 1996). Adverse reactions to
gadolinium contrast media: A review of 36 cases. AJR Am J Roentgenol 167 (4):
847–9. doi:10.2214/ajr.167.4.8819369. PMID 8819369.
Penfield, Jeffrey G; Reilly, Robert F (2007). What nephrologists need to know

about gadolinium. Nature Clinical Practice Nephrology 3 (12): 654–68.
doi:10.1038/ncpneph0660. PMID 18033225.
http://www.ismrm.org/special/EMEA2.pdf
Grobner, T. (2005). Gadolinium - a specific trigger for the development of

nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis?.
Nephrology Dialysis Transplantation 21 (4): 1104–8. doi:10.1093/ndt/gfk062.
PMID 16431890.
Marckmann, P; Skov, L, Rossen, K, Dupont, A, Damholt, MB, Heaf, JG,

Thomsen, HS (2006). Nephrogenic systemic fibrosis: suspected causative role
of gadodiamide ysed for contrast-enhanced magnetic resonance imaging.
Journal of the American Society of Nephrology 17 (9): 2359–62.
doi:10.1681/ASN.2006060601. PMID 16885403.
Centers for Disease Control and Prevention (CDC) (2007). Nephrogenic

fibrosing dermopathy associated with exposure to gadolinium-containing contrast
agents--St. Louis, Missouri, 2002-2006. MMWR. Morbidity and mortality weekly
report 56 (7): 137–41. PMID 17318112.
Broome DR, Girguis MS, Baron PW, Cottrell AC et al. Gadodiamide-associated

nephrogenic systemic fibrosis: why radiologists should be concerned. AJR Am.
J. Roentgenol. 2007 Feb; 188 (2): 586-92.


Post-Surgical Findings
330
Post-Surgical Findings
Surgery alters the anatomy and integrity of the spine. Some post-surgical findings are
particularly important and will require clinical intervention. This chapter will uncover some
of the common findings seen in the post-surgical spine: pseudomeningoceles, paraspinal
scarring and adhesions, post-surgical cystic lesions, laminectomy, and surgical implants.

Hemilaminectomy
Figure 24:1. This T2W axial image shows a healing scar from a
hemilaminectomy.
Figure 24:2. This image is the same slice as figure 24:1 with the
surgical path shown by a red dashed line. The yellow oval shape
contains three cystic lesions along the surgical path.

Laminectomy
Figures 24:3 and 23:4. T2W axial image. Note the pocket of gas posterior to the thecal sac
(green arrow) and the light-colored fluid-filled pockets (yellow arrows). The gap left by the
laminectomy is defined by the red dotted lines.
Figures 24:5 and 24:6. T1W axial image. Note the pocket of gas posterior to the thecal sac
(green arrow) and the light-colored fluid-filled pockets (yellow arrows). The gap left by the
laminectomy is defined by the red dotted lines.
These images show several radiographic images following an L5 laminectomy. The path of the
surgeon is visible in all three images along with a gas pocket posterior to L5 that is dark in both
T1 and T2 weighted images. Fluid-filled pockets are also seen posterior to L5. These pockets
are dark on T1 weighted images and light on T2 weighted images.

Laminectomy
Figures 24:7 and 24:8. This is a T2W sagittal image of an L5 laminectomy. Note the path of
the surgeon through the subcutaneous fat (blue arrow), the absence of the L5 lamina and
spinous process (between the red dotted lines), and the air pocket in the void where the L5
spinous process had been (green arrow).
This image is a sagittal that corresponds to the axials seen on page 333.

Pseudomeningocele
Figure 24:10. T2W axial image.
Figure 24:11. T1W axial image.
Figure 24:9. This T2W sagittal image clearly

reveals a post-surgical pseudomeningocele.
Note the white-colored pouch of fluid posterior
to L4.
A postoperative pseudomeningocele is a
complication of spine surgery. This
unintended complication is essentially a
pouch of cerebrospinal fluid (CSF) that has
leaked into the paraspinal tissues. It appears
cyst-like on MRI.
Figure 24:12. T1 fat-saturated image.

Meningoceles and Pseudomeningoceles
Vertebrae Dura Mater
CSF CSF
Filled Filled
Pouch Pouch
Skin
Figure 24:13. Schematic of a meningocele. Figure 24:14. A pseudomeningocele may

A fluid-filled ballooning of the dura mater. look somewhat like a meningocele on MRI,
Meningoceles are commonly associated with though it is not retained within the meninges.
spina bifida deformations. It is contained within the surrounding soft
tissues.
A meningocele is a cyst-like collection of cerebral

spinal fluid (CSF) in a pouch contained within the
meninges and the dura mater. A meningocele is
frequently associated with spina bifida.
Meningoceles may be related to severe neurological
complications.
Pseudomeningoceles are abnormal accumulations

of CSF in the tissues surrounding the spine or brain.
Pseudomeningoceles are not contained within the
dura mater. Pseudomeningoceles may appear
following surgery or injury that has resulted in a CSF
leak. The leaking CSF deforms surrounding soft
tissues to create its own fluid-filled cavity that may
resemble a meningocele in appearance, hence the
name pseudomeningocele.
Figure 24:15. A post-surgical
pseudomeningocele observed in a
Seromas are pockets of serous fluid which may
sagittal T2 weighted image of the
weep from tissues following surgery. Seromas lack
lumbar spine.
the red blood cells seen in hematomas.

Post-Fusion Pseudomeningocele
Figures 24:16 and 24:17. These T2W sagittal images show a post-fusion pseudomeningocele
with its margins identified by the yellow pointers. The surgical screws appear as black voids and
are identified by the green pointers.
These T2 weighted sagittal images show
evidence of orthopedic fixation appliances
and evidence of fluid collections in the gap left
by a laminectomy. In figure 24:18 we can see
intradiscal devices (bone graft material) and a
large pseudomeningocele posterior to the
thecal sac. Note the displacement of the
paravertebral muscles posteriorly by the
expansion of the pseudomeningocele.
Figure 24:18. This image shows another sac of

fluid within the pseudomeningocele (orange
pointer), as well as the intervertebral placement
of cadaverous bone to stimulate fusion (blue
pointers). The outer margins of the pseudo-
meningocele is denoted by the yellow pointers.

Post-Fusion Pseudomeningocele (continued)
Figures 24:19-22. T2W axial images following surgical fusion surgery. The yellow arrows point to a
heterogeneous collection of fluids, probably a seroma with residual blood products. The green arrows
point to the metal screws that secure the vertebra and allow fusion to take place.
A seroma is a space-occupying pocket of serous fluid that can develop after surgery when serous
fluid weeps out.

Five Level Hemilaminectomy Discectomy
Figures 24:23 and 24:24. These T2W sagittal images are of a 45 year-old man who had lumbar
surgery five years prior. The surgery included five levels of hemilaminectomy and discectomy.
Note the extent of scar tissue in the soft tissues.

Post Hemilaminectomy
These images show the third disc extrusion of the L5-S1 disc. This herniation occurred
after two previous discectomies. This is not an uncommon occurrence. According to
investigators, re-herniation after surgery happens 9-25% of the time.
Figure 24:25. T2W sagittal image of Figure 24:26. Another T2W sagittal
a large extrusion at L5-S1. image of the same extrusion at L5-S1.
This image shows the extent of foraminal
occlusion of the left L5-S1 IVF by the
extrusion.
Figure 24:27. This T2W axial

image shows a focal extrusion
superimposed on a broad-based
herniation. This extrusion is
affecting the left IVF of L5-S1.

Right Hemilaminectomy Two Months Post-Surgery
Figure 24:28. T2W axial image of the Figure 24:29. T2W axial image showing
thecal sac displaced through the opening in the path of the surgeon on this patient two
the lamina which was created by the right months after a hemilaminectomy.
hemilaminectomy. Note the oblong shape
of the thecal sac.
Figures 24:30 and 24:31. T2W sagittal images Figure 24:32 T1W axial image showing
showing post-surgical changes in this post- the path of the surgeon on this patient
hemilaminectomy at two months. two months after a hemilaminectomy.
This series of images shows the MRI findings of a lumbar spine two months after a
right hemilaminectomy. The path of the surgeon is clearly visible in all of the
images. The axial images show the thecal sac being displaced into the gap in the
posterior right arch by the hemilaminectomy.

Displacement of the Thecal Sac through a Hemilaminectomy
T2WI T1WI
Figures 24:33 and 24:34. T2W and T1W sagittal images show post-surgical re-herniation,
and sequestered fragmentation arising from the L4-L5 disc.
T1WI
T2WI
Figures 24:35 and 24:36. These images reveal partial displacement of the thecal
sac through the hemilaminectomy (yellow pointer). Note the oblong appearance of
thecal sac.
This series of images shows the MRI findings of a lumbar spine after a left hemi-
laminectomy. The path of the surgeon is less visible on these images than those of the
previous page. The axial images show the thecal sac being displaced into the gap in
the posterior arch left by the hemilaminectomy. The sagittal images reveal a
sequestered disc fragment from an extrusion at L4-5.

Pre- and Post-Surgical Images of an Ependymoma
Figure 24:37. T2W axial image of an ependymoma.
Figure 24:39. T2W sagittal image of

a large ependymoma in the central
canal from L2-L4.
Figure 24:38. T2W axial image of diffuse ill-defined,

disrupted, post-surgical changes.
This series of images shows the MRI findings of a

lumbar spine after a large ependymoma was
removed from L2-L4. This tedious surgery
caused significant disruption of the paraspinal
muscles and posterior elements of the spine.
Figure 24:40. Post-surgical T2W sagittal
image showing extensive post-surgical
changes following the removal of the
ependymoma.

Re-herniation of L4-5 Two Weeks after a Discectomy

image shows the re-herniation
(extrusion) of the L4-5 disc.
Figure 24:41. T2W sagittal Figure 24:42. T1W sagittal

image of a large L4-L5 image of a large L4-L5
extrusion (yellow arrow). Note extrusion(yellow arrow). Note
the pocket of fluid posterior to the pocket of fluid posterior to
the spinous processes of L3 the spinous processes of L3
and L4 (red arrows). and L4 (red arrows).

image reveals the path of the
This series of images show the MRI findings of a lumbar surgeon (green arrows) and
spine two weeks following a right discectomy. These fluid accumulation in the
images display a large paracentral re-herniation that paraspinal soft tissues (red
occurred at the site of the previous surgery. Re- arrows).
herniations at the site of surgery occur between 9-25%.

Fracture with Surgical Implant
Figures 24:45 and 24:46. T2W sagittal image of a surgical Figure 24:47. Plain film
implantation of titanium hardware that was used to stabilize a radiograph of the same
fracture of T12. implant that is represented in
Because titanium is not a ferrous metal, titanium implants will only minimally impact
the quality of MR images. Ferrous implants are prone be influenced by the strong
magnet of the MRI and can create patient hazards as well as negatively influence
the quality of the MR image. Since titanium is not magnetic, it is not affected by the
strong magnet of the MRI and will appear as a void in the image.

Suggested Reading
Hu R, et al. A Population based study of reoperations after back surgery. Spine

1997;22:2265-2271.
Malter A., et al. 5-Year reoperation rates after different types of lumbar surgery.
Spine 1998;23:814-820.
Atlas S., et al. Surgical and nonsurgical management of sciatica secondary to

lumbar disc herniation: five-year outcomes from the Maine lumbar spine study.
Spine 2001;26:1179-1187.
Osterman H., et al. Risk of multiple reoperations after lumbar discectomy: a

population based study. Spine 2003;28:621-627.
Atlas et. al. Long-term outcomes of surgical and nonsurgical management of

sciatica to a lumbar herniation: 10 year results from the Maine lumbar spine
study. Spine 2005;30:927-935.


Arachnoiditis
and Arachnoid Cysts
347
Arachnoiditis
Misunderstood and underreported, arachnoiditis can result from routine medical

procedures and leave patients permanently incapacitated. Arachnoiditis is a
neuropathic malady that affects the arachnoid layer of the meninges. A more
severe type of arachnoiditis is adhesive arachnoiditis. Adhesive arachnoiditis
results in scarring and adhesions within the meninges. Additionally, it compresses
the nerve rootlets within the thecal sac and can cause nerves to adhere to one
another. While described as a rare condition, it has become evident to me that
there is no clear tracking method for this disease and many cases may go
undiagnosed. Since many doctors are not familiar with this condition, it may be
mistaken for other conditions such as disc extrusions, cauda equina syndrome,
failed back surgery, or multiple sclerosis.
Refractory pain is the predominant symptom of arachnoiditis. Other symptoms

include urinary and bowel dysfunction, sexual dysfunction, numbness, tingling,
loss of mobility, headaches, fatigue, and extremity pain and weakness. Since
there is no consistent pattern of symptoms for this malady, a correct diagnosis may
be difficult.
Treatment of arachnoiditis is difficult and frequently focused on pain reduction.

Spinal procedures (epidural injections, intrathecal injections, and surgery) may
cause or worsen this condition, so they are typically avoided. Medical
management is often limited to protracted use of opiates, antidepressants,
steroids, and other treatments intended to minimize pain. Since the degree of
symptoms may vary in severity, some patients with arachnoiditis may live relatively
normal lives and can be managed with interdisciplinary care: medical care,
chiropractic, psychology, and physical therapy. While none of these professions
can claim to cure or even help every case of arachnoiditis, any treatment that is
safe and may control the symptoms should be considered.
Causes
Three causes have been identified to induce arachnoiditis: Chemicals, trauma,

and infection.
Ironically most cases of arachnoiditis are attributed to iatrogenic causes. The

chemicals used in spinal injections are the leading iatrogenic cause of this
condition. The trauma of a lumbar puncture, spinal surgery, and injury can also
cause arachnoiditis. The chronic trauma of spinal stenosis and disc derangement
has also been cited to cause arachnoiditis.
Infection is another cause of arachnoiditis. Meningitis (viral, fungal, or bacterial)

can result in arachnoiditis.

Arachnoiditis
Radiographic findings
While plain film radiographs will not contribute to the diagnosis of arachnoiditis, magnetic
resonance images can reveal characteristic findings of arachnoiditis. On MRI, compression or
adhesion of nerve rootlets of the cauda equina may be visualized. The nerve rootlets of the
cauda equina will frequently be clumped in the anterior portion of the thecal sac in patients with
adhesive arachnoiditis rather than in their normal location which is more posterior.
As epidural steroid injections and percutaneous spinal procedures become more routine and
widely used, we can expect to see a rising number of these patients entering our offices.

Arachnoiditis
Figure 25:1. A schematic axial image of a Figure 25:2. This schematic depicts a
normal lumbar segment. Note the wide patient with arachnoiditis. The nerve
distribution of the nerve rootlets within the rootlets are adhered together in a blurred
thecal sac. mass.
Figure 25:3. A T2W axial image of a Figure 25:4. A T2W axial image of a
normal lumbar segment with divergent patient with adhesive arachnoiditis.
nerve rootlets. Note the clumping together of the nerve
rootlets of the cauda equina.

Arachnoiditis
Figure 25:5. Anterior clumping of the nerve Figure 25:6. Normal. This image displays the
rootlets of the cauda equina (yellow arrows) is normal distribution of nerve rootlets in the
indicative of arachnoiditis. This image is a slice upper lumbar spine. They are normally found
from the upper lumbar spine. in the posterior portion of the thecal sac in the
upper lumbar spine and migrate anteriorly as
they descend.
These images contrast the anterior

clumping together of the nerve rootlets of
the cauda equina (figure 25:5) as seen in
arachnoiditis with the normal anatomy of
the upper lumbar spine (figure 25:6) and
lower lumbar spine (figure 25:7).
Figure 25:7. Normal. This image displays the

normal spreading and anterior migration of the
nerve rootlets in the lower lumbar spine.

Arachnoiditis
Figure 25:8. T2 weighted Figure 25:9. This image is a Figure 25:10. Normal. This T2
sagittal image of a patient with duplication of figure 25:8. weighted sagittal image shows
arachnoiditis. This patient’s The yellow dotted line outlines the normal appearance of the
arachnoiditis began with an the conus medullaris and the cauda equina on MR. The
epidural injection intended to red arrows point to the cauda yellow arrows point to the nerve
reduce the pain of childbirth. equina clumped together in rootlets of the cauda equina.
the anterior portion of the Note the nerve rootlets are
spinal canal. The green normally found in the posterior
arrow points to the enlarged portion of the central canal and
post-partum uterus. migrate inferior and anterior
before exiting the intervertebral
foramina.
This series of sagittal images shows the anterior clumping of the cauda equina that is
characteristic of arachnoiditis. The significance of the enlarged post-partum uterus is that this
patient’s arachnoiditis arose after receiving epidural anesthesia for childbirth.

Arachnoiditis
Figure 25:12. A duplication Figure 25:13. Normal. This T2

Figure 25:11. T2 weighted
of 25:11. The yellow dotted weighted sagittal image shows
sagittal image of a patient
line outlines the conus the normal appearance of the
with arachnoiditis.
medullaris, the red circle cauda equina on MR. The
encloses a section of the yellow arrows point to the wispy
cauda equina that is nerve rootlets of the cauda
adhered together into one equina. Note they are separate
large clump, and the green and not clumped together.
arrow points to an L5-S1
disc herniation with a
concentric annular tear.
This series of sagittal images compares the appearance of a patient with adhesive arachnoiditis
(figures 25:11 and 25:12) and a normal lumbar spine (figure 25:13). Figures 25:11 and 25:12
show the clumped together presentation of the cauda equina. In comparison the nerve rootlets
of the cauda equina in figure 25:13 are wispy and separate.

Arachnoiditis
Figures 25:14-17. Adhesive arachnoiditis. This series of axial T2 weighted images shows the
characteristic adhesive clumping of nerve rootlets of the cauda equina.
Figure 25:18. Normal. For reference and

comparison, this T2W axial displays the
normal dispersed nerve rootlets of the cauda
equina (green arrows).

Spinal Arachnoid Cysts
Arachnoid cysts are uncommon findings in the spine. They are usually asymptomatic and
discovered incidentally. Arachnoid cysts are filled with cerebral spinal fluid contained within
arachnoid tissue. Though usually asymptomatic, arachnoid cysts can be clinically significant
and cause harm, including neurological compromise (paresis, numbness, bowel /bladder
dysfunction, etc.). They are normally congenital, but can be a result of trauma or surgery. The
use of gadolinium is helpful to differentiate arachnoid cysts from tumors.
Figure 25:19 and 25:20. These T2 weighted images show a hyperintense expansive lesion in
the lower lumbar spine and in the sacrum.
Figure 25:21 and 25:22. In these T1 fat sat images with gadolinium, the lesion did not enhance.
This ensured that it was not a vascular lesion like a tumor.

Suggested Reading
Aldrete JA. Clinical Diagnosis. In: Arachnoiditis: the silent epidemic, JA Aldrete
(ed.) Futuremed. Denver. 2000. pp 201-220.
Ribeiro C, Reis FC. Adhesive lumbar arachnoiditis. Acta Med Port. 1998
Jan;11(1):59-65.
Delamarter RB, Ross JS, Masaryk TJ, Modic MT, Bohlman HH. Diagnosis of
lumbar arachnoiditis by magnetic resonance imaging. Spine (Phila Pa 1976).
1990 Apr;15(4):304-10.
Struffert T, Brill G, Reith W. Lumbar arachnoiditis as differential chronic spinal

symptoms diagnosis]. Radiology. 2001 Nov;41(11):987-92.
Etchepare F, Roche B, Rozenberg S, Dion E, Bourgeois P, Fautrel B.

Post-lumbar puncture arachnoiditis. The need for directed questioning. Joint
Bone Spine. 2005 Mar;72(2):180-2.
DA Nelson, WM Landau. Intraspinal steroids: history, efficacy, accidentally, and

controversy with review of United States Food & Drug Administration Reports.
Neurosurgery/Psychiatry Review,2001
Moreira, Navarro et.al. Clinical and histological effects of the intrathecal

administration of MPA (Depo-Medrol) in dogs-animal trial. 2010 Pain Physician.

Lolge S, Chawla A, Shah J et-al. MRI of spinal intradural arachnoid cyst

formation following tuberculous meningitis. Br J Radiol. 2004;77 (920): 681-4.
Hamamcioglu MK, Kilincer C, Hicdonmez T et-al. Giant cervicothoracic

extradural arachnoid cyst: case report. Eur Spine J. 2006;15 Suppl 5 : 595-8.
Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott

Williams & Wilkins. (2007).


Incidental Visceral Findings
357
Incidental Visceral Findings
Lumbar MRIs will reveal much more than just musculoskeletal and nerve findings. Incidental
findings of all sorts will invariably present, from congenital anomalies and anatomical
variants, to cysts and pathology. This chapter is a limited collection of some of the more
common incidental findings that will be seen on lumbar MRI. Some of these findings may not
even warrant mention in a radiologist’s report. However, it is conceivable that some of these
findings may be clinically significant, even if the radiologist chooses not to mention them.
While we do not want to identify every incidental finding as being clinically significant, we
need to know what is common and asymptomatic and what is common and potentially
clinically significant.

Enteric Cyst
Figure 26:2. T2 weighted axial image of the

lumbar spine shows a small benign enteric
cyst. This finding is of limited concern save
for the fact the cyst abuts the abdominal
aorta.
Figure 26:1. T2 weighted sagittal image of the

lumbar spine shows a small benign enteric cyst.
Enteric cysts are usually benign. They are pockets of fluid created by an anomalous membranous
sac and typically lined with epithelium.

Simple Renal Cyst
Simple renal cysts are fluid-filled cysts

that may be caused by blocked renal
ducts. This benign finding is present in
more than 50% of those over the age of
50 and are increasingly common with
age. Simple renal cysts display the
characteristic water densities on MRI,
hypointense in T1WI and hyperintense
in T2WI. Simple cysts are considered a
coincidental finding and normally do not
require intervention.
Figure 26:3. Simple renal cyst in the inferior right

kidney is visible in this coronal view.
Figure 26:4. Simple renal cyst in the inferior right Figure 26:5. T2 weighted axial image of a large
kidney is visible in this axial T1 image. solitary simple renal cyst.

Multiple Renal Cysts
Figure 26:6. Coronal image of multiple large renal cysts.
Figure 26:7. Cysts outlined with red dashed lines.

Huge Renal Cysts
Figure 26:8. T1 weighted axial of large multiple renal cysts

bilaterally. The fluid in the cysts appears dark in color.
Figure 26:9. T2 weighted axial of large multiple renal cysts

bilaterally. The fluid content is light in T2.

Hypertrophic Heterogeneous Uterus
Figure 26:10. This image reveals an enlarged heterogeneous uterus which was
a coincidental finding on this T2 weighted axial image from a lumbar spine MRI.
This finding was not associated with any symptoms.

Hypertrophic Postpartum Uterus
Figure 26:12. T2 weighted axial image of a patient

with a postpartum hypertrophic uterus.
Figure 26:11. T2 weighted sagittal image of a

patient with a postpartum hypertrophic uterus.
This series of images shows the coincidental

finding of an enlarged (hypertrophic) uterus
in a patient who had just delivered a child.
This is a normal variant in postpartum
women. Figure 26:13. Coronal image of a patient with a
postpartum hypertrophic uterus.

Large Adnexal Hemorrhagic Cyst
Figure 26:14. T2 weighted axial image of a 5.6 Figure 26:15. T2 weighted sagittal image.
by 4.7 cm ovarian cyst (yellow arrow). Also a The green arrow points to the urinary bladder,
uterine fibroid is visible in the right uterine the yellow to an ovarian cyst, and the red to
fundus (red arrow). the darker region of the cyst that contains
blood components.
Figure 26:17. Coronal image revealing a

left-sided adnexal cyst.
The adnexal region of the pelvis is the anatomy adjacent to a woman’s uterus. The adnexal
region is composed of the ovaries, fallopian tubes, supporting ligaments and tissues, bowel, and
blood vessels. A large cyst can place pressure on the bladder or rectum causing secondary
symptoms.
The term adnexal cyst is a fairly nondescript term that does not identify the exact structures
involved, the size, or severity of the lesion. The adnexal cyst seen here is most likely an ovarian
cyst.

Uterine Fibroids
Figures 26:18 and 26:19. Fat-suppressed T2 weighted sagittal image of a patient with
multiple uterine fibroids (also known as leiomyomas or myomas).
Figure 26:20. Fat-suppressed

T2 weighted axial image of a
patient with multiple uterine
fibroids.

Uterine Fibroids
Figure 26:21. Enlarged uterus with diffuse Figure 26:22. In addition to the diffuse
multiple fibroids and fibrosis. fibrosis of the uterus and multiple fibroids,
this patient had a large uterine fibroid (yellow
arrows). The green arrows point to the
urinary bladder.

Heterogeneous Uterus
Figures 26:23 and 26:24. In addition to the L4-L5 disc extrusion, this patient also has an enlarged
heterogeneous uterus (yellow arrows) and fluid collection in the posterior cul-de-sac of the pelvis.

Hemorrhagic Ovarian Cyst
Figure 26:25. Coronal image revealing the Figure 26:26. Sagittal T2 weighted image
bright color of a left-sided ovarian cyst. showing a large hemorrhagic ovarian cyst.
Figure 26:28. Sagittal T2 weighted image of

the hemorrhagic ovarian cyst seen in figure
26:26 With red dotted line denoting the fluid
line.
A hemorrhagic cyst occurs when a benign fluid-filled
cyst fills with blood following the rupture of a small
blood vessel in the ovary. Note the fluid line in
figure 26:28. This denotes a separation of the types
of fluids in the cyst: cystic fluid versus blood. The
Figure 26:27. Sagittal T1 weighted image.
line is vertical because the patient is lying on her
back for the MRI.

Ovarian Cysts
Figure 26:29. Coronal image of fluid in the Figure 26:30. T2 weighted sagittal image
posterior cul-de-sac of the pelvis. reveals free fluid in the posterior cul-de-sac of
the pelvis indicated by the yellow arrow.
Figure 26:31. Coronal image of a right Figure 26:32. T2 weighted sagittal image
ovarian follicle (red arrow). Note the heavily revealing an ovary with multiple follicles, also
laden colon (white arrow) lying upon and referred to as a polycystic ovary.
effacing the urinary bladder (yellow arrow).
Incidental findings of fluid-filled ovarian cysts and fluid in the pelvis may not be particularly
uncommon findings in young women. Sometimes cysts and bowel contents are large enough to
place pressure on the bladder and cause a sense of urinary urgency.

Polycystic Ovaries
Figures 26:33 and 26:34. Polycystic ovaries found onT2 weighted sagittal images. Note the “string
of pearls” finding on the image on the right. The string of pearls appearance of follicles (cysts) is
characteristic of polycystic ovarian syndrome.
What is Polycystic Ovarian Syndrome?
Polycystic Ovarian Syndrome gets its name from the characteristic enlarged ovaries with
multiple small cysts around the outer edge of the ovary (or ovaries). The exact cause of
PCOS is not known; in fact, I question whether the polycystic portion of the disease is a
result of a more insidious underlying condition that results in ovarian disease and not the
other way around.
PCOS results in the ovaries producing too much androgen (hormones associated with
male characteristics). The symptoms commonly attributed to PCOS include obesity
(though about 50% of the patients with PCOS are not obese), excessive facial and body
hair, increased muscle size, reduced breast size, acne, and amenorrhea. Other effects
include fertility issues, insulin resistance, type 2 diabetes, hypercholesterolemia, infrequent
ovulation, and heart disease. Patients with PCOS are also at greater risk for hypertension,
sleep apnea, and fatty liver disease. PCOS affects 5-10% of women in their childbearing
years.
Diagnosis
The diagnosis of PCOS is difficult and probably should involve an interdisciplinary team.
PCOS may be diagnosed by the presence of excessive androgen activity, infrequent
ovulation, sporadic or absent menstrual cycles, and polycystic ovaries. Excessive
androgen activity can be accessed clinically and in the lab through testing levels of
androstenedione and testosterone. The ovaries can be visualized radiographically by
diagnostic ultrasound and MRI.

Gallbladder
Figure 26:35. Normal gallbladder. T2 weighted Figure 26:36. T1 weighted image of the same
axial image of a normal gallbladder. anatomy as 26:35, depicting a normal gallbladder.
The gallbladder is a small pear-shaped bladder that is nestled under the liver. It has a cyst-like
appearance in T2 weighted images, but may be hard to distinguish from the liver in T1 weighted imagery.
Figures 26:37 and 26:38. Gallstone (cholelithiasis). T2 weighted axial images of a gallstone. The
yellow arrow points to the light-colored fluid within the gallbladder. The green arrow points to the
dark-colored gallstone.

Hypoplastic Kidney
Figure 26:39. Hypoplastic right kidney (yellow arrow) identified as a coincidental finding on a
lumbar MRI. The normal-sized left kidney is identified by the green arrow.

Polycystic Liver and Kidney Disease
Figure 26:40. Coronal image of polycystic liver disease with renal

involvement. This patient had dozens of renal and liver cysts.
Figure 26:41. Axial image of polycystic liver disease with renal involvement.

Polycystic Liver and Kidney Disease
Figure 26:42. Numerous cysts of the kidneys and

liver in a T2 axial image.
Figure 26:43. Multiple benign cysts of the
kidneys and liver in a coronal image.
Figure 26:44. Multiple benign cysts of the kidneys Figure 26:45. Renal cysts visible in an axial T2
and liver in an axial image. weighted image.

Benign Cysts in Kidneys
Figures 26:46-49. Multiple benign cysts of the kidneys.

Kidney Transplant
Figure 26:51. Transplanted kidney anterior to

L5 and the sacrum in this T2W axial.
Figure 26:50. Transplanted kidney anterior to L5

and the sacrum in this T2W sagittal.
The dysfunctional or diseased kidneys are not

replaced when a transplant occurs. The
surgeon will leave the dysfunctional kidneys in
place and just insert the new kidney in the
abdomen near the bladder and new sources
of blood supply.
Figure 26:52. Transplanted kidney anterior

to L5 and the sacrum in this T2W sagittal.

Suggested Reading
Wang JG, Anderson RA, Graham GM 3rd, Chu MC, Sauer MV, Guarnaccia MM, Lobo
RA. The effect of cinnamon extract on insulin resistance parameters in polycystic
ovary syndrome: a pilot study. Fertility Sterility. 2007 Jul;88(1):240-3.
Hoeger, KM. Obesity and Lifestyle Management in Polycystic Ovary Syndrome.

Clinical Obstetrics and Gynecology. 2007; 50: 277-294.
Johns Hopkins News Release:

http://www.hopkinsmedicine.org/news/media/releases/physicians_have_less_respect
_for_obese_patients_study_suggests
Wilde S, Scott-Barrett S. Radiological appearances of uterine fibroids. Indian J Radiol

Imaging. 2009 August; 19(3): 222–231.
Tahvanainen E, Tahvanainen P, Kääriäinen H, Höckerstedt K. Polycystic liver and

kidney diseases. Ann Med. 2005;37(8):546-55.
Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic imaging
approach. November 2009 Radiology, 253, 297-316.

Other Assorted
Findings on MRI
379
Asymmetrical Iliopsoas Muscles
Not all radiographic findings that fit neatly into categories can make up an entire chapter.
This chapter will cover several small categories of MRI presentations. The theme of each
presentation will change from page to page. This page will focus on the asymmetry of the
iliopsoas muscles.
Figure 27:1. T2 axial image showing atrophy of the left iliopsoas muscle.
Figure 27:2. Another T2 axial image showing atrophy of the left iliopsoas
muscle.

Baastrup’s
Figure 27:3. This plain film radiograph Figure 27:4. T2WI demonstrates effusion in the
demonstrates the spinous processes interspinous bursa as a hyperintense signal.
abutting each other.
Baastrup’s disease (the use of the word disease is a misnomer as it is a condition not a disease)
is a condition known as kissing spinous disease. The spinous processes are enlarged to the
point at which they cause approximation or contact between the spinous processes. The
condition was named by Christian Baastrup, a Danish radiologist in 1933.
Anatomical, postural, and degeneration components may combine to contribute to this condition.
Baastrup’s may or may note be symptomatic.
The approximation of the spinous processes can be seen on plain film radiographs, but MRI will
show edema within the interspinous bursa. Note the hyperintense signal of the interspinous
bursa in this T2WI.

Baastrup’s
Figure 27:5. Normal. This MRI of a normal Figure 27:6. This MRI of a patient with
spine demonstrates the typical spacing Baastrup’s is presented to show the difference
between the spinous processes. of this condition next to a normal spine. In this
patient, degenerative disc disease and a
degenerative spondylolisthesis increase the
interspinal compression characteristic of this
condition.

Ligamentum Flavum Hypertrophy
Figures 27:7 and 27:8. T2 sagittal images showing hypertrophy of the ligamentum
flavum in a degenerative lumbar spine.
Figure 27:9. T2 axial image of hyper- Figure 27:10. This T2 axial image reveals a
trophy of the ligamentum flavum and relatively normal ligamentum flavum and
facets. facets.
Ligamentum flavum hypertrophy is an insidiously progressive finding that gradually

contributes to central canal stenosis. Ligaments appear dark in these T2 weighted images.

Neurogenic Bladder
Normal urination occurs through a complex neurological synchronization of muscle

contraction, muscle relaxation, reflexes, responsiveness, and consciousness. The
neurology of urination is complex and reliant upon coordination between sympathetic,
parasympathetic, and somatic nervous systems, and executive volition.
The two functions of the bladder are storage and voiding. Either of these can be affected
by neurologic compromise. While MSK practitioners frequently think of incontinence in
association with neurologic compromise, urinary retention is another condition that can
result. Either retention of urine or incontinence of urine can happen depending on the
location of the neurological insult.
Detrusor Hypertrophic
Muscle Detrusor
Muscle
X X
Figure 27:11. In normal voiding there is a Figure 27:12. In neurogenic urinary
coordinated contraction of the detrusor muscle retention the sphincters do not open and
and opening of the sphincters that allows urine is retained. The detrusor muscle
normal urination. contracts to overcome the resistance of the
sphincter. In time, the detrusor muscle will
hypertrophy to the point that the thickened
muscle can be recognized on MRI.
In a simplified explanation of urination, we can say that the urinary sphincters open and allow urine
to escape while the bladder’s detrusor muscle contracts to push the urine out of the bladder. In
patients with neurological incontinence, the sphincter does not appropriately retain urine flow, and
urine leaks out. In neurological urinary retention the sphincter does not open to allow urine to exit.
This may result in hypertrophy of the detrusor muscle which strains to push urine through a closed
sphincter.
Other urinary obstructions such as prostate hypertrophy, urethral obstruction, or cancer may also
result in detrusor hypertrophy.
While evidence of a neurogenic bladder may be evident on MRI, MRI is not the medium of choice
for making a diagnosis of neurogenic bladder.

Neurogenic Bladder
Figure 27:13. Chiari malformation

(downward displacement of the
cerebellar tonsils/hindbrain through the
foramen magnum).
Figure 27:15. Thickening of the detrusor muscle (red

arrows) of the bladder in this patient with a tethered cord
syndrome resulting from a lipoma anchoring the filum
terminale to the sacrum (yellow arrows). Neurogenic
urinary retention can cause a greatly distended bladder .
Figure 27:14. Chiari malformation is
diagnosed by measuring the extent of
downward displacement. This is done Lipomas of the filum terminale can become so large
by drawing a line from the ophisthion to that they anchor or “tether” the spinal cord. This can
basion (the anterior and posterior result in neurologic compromise. There is also a
margins of the foramen magnum) and greater likelihood of Chiari malformation, syrinx, and
measuring the distance from the line to syringomyelia in patients with a tethered cord.
the most inferior portion of the cerebellar
tonsils. Normally this should be less
than 3mm.

Neurogenic Bladder Syrinx
Figures 27:16 and 27:17. These two T2W images show the CSF-filled dilation of the
central spinal canal. These findings are consistent with a syrinx.
Figures 27:18 and 27:19. The sagittal image on the left reveals several central spinal canal
dilations. The axial image on the right shows the extent.
Dilation of the central spinal canal and filling with CSF is called a syrinx. A syrinx may result in a
syringomyelia (syrinx progression and damage to the spinal cord). This can result in significant
neurologic compromise including motor weakness, headaches, inability to distinguish hot or cold,
and other symptoms including neurogenic bladder. Syrinxes are caused by congenital
anomalies, trauma, spinal cord tumors, tethered cord, and Chiari malformations.

Neurogenic Bladder: Cervical Spondylotic Myelopathy
Figures 27:20 and 27:21. These two images (sagittal CT on the left and T2W sagittal MRI on the
right) show the effects of cervical spondylotic occlusion of the central canal. This can result in
myelopathy.
The most common cause of spinal cord pathology in patients over 55 is cervical spondylotic
myelopathy (CSM). CSM is caused by the slow progression of osteophytic spurs within the spinal
canal to the point that the spinal cord is compressed, producing myelopathy. The symptoms of CSM
progress slowly—so slowly that the gravity of this condition is often missed and/or attributed to other
age-related conditions.
The indistinct presentation of CSM leads to a broad number of potentially different diagnoses,
including spinal cord tumors, syrinx (with syringomyelia), ALS, MS, normal pressure hydrocephalus,
cerebral hemisphere disease, and peripheral neuropathy. It takes an alert clinician to identify when
spondylosis progresses to CSM. In addition to particular radiographic findings, the following
characteristic symptoms are attributed to CSM:
• gait spasticity
• upper extremity numbness and loss of fine motor control
• neck pain
• motor weakness in the extremities
• upper and lower motor neuron findings
• bowel and bladder signs
• Lhermitte’s sign (electrical shock with cervical flexion).

Conus Medullaris Cyst
Figure 27:22. This FIESTA sagittal image clearly Figure 27:23. This T2W axial image
shows a fluid-filled ovoid cyst at the conus displays the cyst as a hyperintense
medullaris. The cyst is hyperintense in this image. circular image.
There are many reasons that a cystic cavity

can form in the spinal cord. It might present
as an incidental finding, or it may cause
serious complications such as conus
medullaris syndrome or cauda equina
syndrome. Cystic cord lesions should be
evaluated by a neurosurgeon.
Comparing T1WI, T2WI, and fat-suppressed

images is useful in differentiating cystic
lesions from lipomas.
Figure 27:24.This T1W sagittal image

displays the cyst as a hypointense
(darkened) ovoid image.

Engorged Epidural Plexus
Figure 27:25. This image, taken with the patient at Figure 27:26. This image was taken after the
rest, shows minimal enlargement of the veins of patient exercised for 20 minutes riding a recumbent
the epidural plexus in a patient with agenesis of bike and then immediately entered the MRI tube.
the inferior vena cava. This image shows significant engorgement of the
epidural plexus with displacement of the thecal sac.
In the stenosis or absence of the normal inferior vena cava, blood flow may be diverted to the
epidural plexus. The epidural plexus may contribute to the transport of blood back to the heart from
the lower extremities. This has been reported to occur in cases of inferior vena cava thrombosis,
agenesis of the inferior vena cava, and in the occlusion of inferior vena cava flow from liver disease.
This phenomenon may displace the cauda equina or nerve roots and can be symptomatic.
In one study reviewing 9640 patients’ MRIs, Paksoy found that 13 patients had inferior vena cava
obstruction resulting in epidural venous engorgement. A busy practitioner could conceivably see
several of these cases in a career.

Large Non-Displaced Discs
Figure 27:27. T2 weighted sagittal image of Figure 27:28. T1 weighted sagittal image
large intervertebral discs. This is a normal of the large intervertebral discs.
variant.
These images show a normal variant: abnormally large disc height without displacement.

Intranuclear Cleft
Figure 27:29. This T2 weighted sagittal image shows

the normal variant of intranuclear clefts. This is a
normal sign of aging.
This T2 weighted sagittal image demonstrates lines through the intervertebral discs.
This is an early sign of aging (constant in those 30 years old and older). This is a
normal variant known as an intranuclear cleft.

Sebaceous Cyst
Figure 27:30. Sagittal T1 weighted image. Figure 27:31. Sagittal T2 weighted image.
Sebaceous cysts are not typically a

source of great concern to MSK
practitioners outside of being an
occasional source of pain and infection.
Nonetheless, a back pain specialist should
be able to discern the difference of this
common lesion from normal and from
more significant cystic lesions. These
images reveal a sebaceous cyst posterior
to the spinous process of L2.
Figure 27:32. Axial T2 weighted image.

Suggested Reading
Kamerath J, Morgan WE. Absent inferior vena cava resulting in exercise-induced

epidural venous plexus congestion and lower extremity numbness: a case report
and review of the literature. Spine (Phila Pa 1976). 2010 Aug 15;35(18):E921-4.
Paksoy Y, Gormus N. Epidural venous plexus enlargements presenting with

radiculopathy and back pain in patients with inferior vena cava obstruction or
occlusion. Spine (Phila Pa 1976). 2004 Nov 1;29(21):2419-24.
Aguila L APiraino DW, Modic MT, Et al. The intranuclear cleft of the
intervertebral disk: magnetic resonance imaging. Radiology April 1985 155:155-
158.
Fukuda K, Ozaki T, Tsumura N, Sengoku A, Nomi M, Yanagiuchi A, Nishida K,

Kuroda R, Iguchi T.Neurogenic bladder associated with pure cervical spondylotic
myelopathy: clinical characteristics and recovery after surgery. Spine (Phila Pa
1976). 2013 Jan 15;38(2):104-11. doi: 10.1097/BRS.0b013e318267af02.
Milhorat TH, Bolognese PA, Nishikawa M, Francomano CA, McDonnell NB,

Roonprapunt C, Kula RW. Association of Chiari malformation type I and tethered
cord syndrome: preliminary results of sectioning filum terminale. Surg Neurol.
2009 Jul;72(1):20-35. doi: 10.1016/j.surneu.2009.03.008.
Baastrup CI. Proc.spin. vert.lumb. und einige zwischen diesen liegenden

Gelenkbildungen mit pathologischen Prozessen in dieser Region. Fortsschritte
auf dem Gebiete der Rontgenstrahlen, 1933, 48:430-435.
Coleman LT, Zimmerman RA, Rorke LB. Ventriculus Terminalis of the Conus
Medullaris: MR Findings in Children. AJNR Am J Neuroradiol 16:1421–1426,
August 1995.
Lai SW, Chan WP, Chen CY, Chien JC, Chu JS, Chiu WT. MRI of epidermoid
cyst of the conus medullaris. Spinal Cord. 2005 May;43(5):320-3.

Chen CK, Yeh L, Resnick D et-al. Intraspinal posterior epidural cysts associated
with Baastrup's disease: report of 10 patients. AJR Am J Roentgenol. 2004;182
(1): 191-4.
Rutherford EE, Tarplett LJ, Davies EM et-al. Lumbar spine fusion and
stabilization: hardware, techniques, and imaging appearances. Radiographics.
27 (6): 1737-49.

Upright MRI
394
The Case for Upright MRI
Figure 28:1. T1 weighted sagittal Figure 28:2. T1 weighted sagittal image of the
image taken in supine position. Image same patient taken weight bearing. Instability of
provided by FONAR Corporation and L4 is clearly visible on a weighted view, but not
used with permission. visible on a supine image. Image provided by
FONAR Corporation and used with permission.
While lying supine may be comfortable for the patient and lends for a more stable study
with less motion artifacts, it also may inhibit the visualization of certain lesions. Lumbar
disc lesions, listhesis, ligament integrity disorders, stenosis, and stability disorders may
be better visualized in an upright or dynamic/kinetic image. The images on this page
show that an unstable L4 appears normal when viewed supine (figure 28:1), but it is
evident when viewed in a weight-bearing dynamic image (weight bearing in flexion).

Upright MRIs
Figure 28:3. T2 weighted sagittal image Figure 28:4. T2 weighted sagittal image of the
taken in supine position. Image provided same patient taken weight bearing. Instability
by FONAR Corporation and used with of L3 is clearly visible on a weighted view, but
permission. not visible on a supine image. Image provided
by FONAR Corporation and used with
permission.
Timing of the Image
One of the aspects of MRI that is rarely discussed is the time of day the study is taken.
The intervertebral disc has hydrodynamics that are time and position dependent. The
discs are hydrophilic and absorb water when lying down. Conversely, as the day
progresses with a person weight bearing, the discs lose hydration. This explains why
people are taller in the morning and shorter as the day progresses. It may also explain
why some spinal conditions are more symptomatic in the morning and regress as the day
progresses. A common complaint is that it is difficult to put shoes on in the morning, but
easy to take them off in the evening.
It may be better to take MRIs of suspected disc herniations in the morning than in the
later part of the day. Taking an MRI at the time and position of greatest pain may yield
the most valuable images.
Claustrophobia
Conventional MRI tubes are enclosed, confining and loud. This causes problems for
patients who are claustrophobic. Claustrophobic patients frequently are sedated to
acquire an MRI study. Upright MRIs are open and reduce the effect of claustrophobia.

Upright MRIs
Currently most MRIs are performed with the patient lying supine; while the supine position
is easy for putting a patient in a position that is stable and less apt to move, it may not be
the optimal view for visualizing particular spinal lesions such as spondylolisthesis.
Figure 28:5-7. In addition to allowing the patient to be upright for an MRI, some machines
allow the patient to be positioned in various postures. For some patients this would allow the
patient to have an image taken with reduced pain, but this feature can also be used to take an
image while in a provocative (painful or symptom producing) posture. Images provided by
FONAR Corporation and used with permission.
The premise behind the concept of upright MRI is that visualization of some lesions may be
position dependent. An intervertebral foramina occlusion may be evident in lumbar
extension, but invisible while supine. A disc herniation may be evident when visualized
while weight bearing and exacerbated in truncal flexion, but not visible or not as evident
when the patient lies supine. Some patients have conditions that are worse with particular
positions. By placing the patient in the position of provocation during an MRI study. it may
be possible to “capture” an image when the lesion is most visible.
Upright MRIs are gaining popularity, but most MRI tubes are still horizontal. To obtain an
upright MRI may require a purposeful effort on the part of the requesting provider.

Upright MRIs
Figure 28:8. Disc pressure is

affected by body position. Weight
bearing MRI allows the image to be
taken in the position that is most
provocative or the position of
increased disc pressure. Currently
most MRIs are taken with the
patient in the position that provides
the lower level of disc load: supine.
Image from TheLumbarDisc.com

Based on:
Nachemson A: The Load on Lumbar Disks in Different Positions of the Body, Clin. Orthop., 45:107-122, 1966

Suggested Reading
Hong SW, et al., Missed spondylolisthesis in static MRIs but found in dynamic
MRIs in the patients with low back pain. The Spine Journal, 7 (2007) p 69S.
Nachemson AL. Disc pressure measurements. January/February 1981 - Volume

6 - Issue 1, pp: 1-106.
Nachemson AL. The load on lumbar disks in different positions of the body, Clin
Orthop, 45:107-122, 1966.
http://www.fonar.com/pdf/Spine_Journal_UCLA_study.pdf

Artifacts
400
Artifacts
Artifacts are a common finding on MRI. An artifact is an alteration of the MRI images in a
manner that creates distortion. A detailed explanation of what causes these artifacts
would require a discussion about the physics of MRI. That discussion will not take place
in this book. This chapter will instead point out some common artifacts seen in MR and
provide a superficial description of what causes the artifact.
The three main categories of MRI artifacts are (1) patient-triggered artifacts, (2)
processing or signal-triggered artifacts, or (3) machine-generated artifacts.
Patient-triggered artifacts include motion artifacts, flow artifacts, and metal artifacts. A
blurred or distorted image from the patient moving during the procedure is called a motion
artifact. Variations in blood flow speed will alter the MR machine’s ability to achieve an
optimal image. Metal artifacts are distorted images caused by the presence of metal in or
near the patient. Ferrous metals will have the greatest impact on the quality of the MRI
image. This is one reason, along with safety, that titanium (a non-ferrous metal) is
preferred for surgical implantation.
Processing or signal-triggered artifacts include chemical shift artifacts, partial volume

artifacts, wrap around artifacts, and ringing artifacts (aka Gibb’s phenomenon). Chemical
shift artifacts occur at anatomical points of interface between fat and water.
Partial volume artifacts arise from variations the size of the anatomic structure versus the
size of the pixel used to depict the anatomic structure. Items smaller than the pixels that
represent them in the computerized image may appear distorted or be absent from the
image.
Wrap around artifacts occur when there is a spatial cartography error and portions of the
anatomy which should be viewed on one side of the image are visible on the opposite
side of the image. This is the result of corruption in the processing of the image.
Ringing artifacts are the production of a series of parallel lines of alternating high and low
intensity signals. This phenomenon occurs near sharply contrasted boundaries.
The subject of machine-generated MR artifacts is an escalating body of information.

There are many ways that the MR machine, hardware, other mechanical factors, and
radiofrequency waves can disrupt normal MRIs. Other than to introduce the concept that
there is a broad field of machine-generated artifacts, this book will not attempt to delve
into this subject.

Artifacts
Figures 29:1-4. Lumbar MRIs are subject to the appearance of various artifacts that may be
distracting and are of no clinical significance. These images show spiral distortion artifacts that
degrade the image quality, but are not clinically relevant.

Metal Artifacts
Figures 29:5 and 29:6. Post-surgical metallic artifacts. These transpedicular titanium
screws have a spider-like appearance in these coronal images.
Figures 29:7 and 29:8. Post-surgical metallic artifacts. These images show a metallic
artifact left by the surgical repair of fractures of T11, T12, and L1. The images from left to
right are a T1 weighted sagittal, a T2 weighted sagittal, and a plain film lateral lumbar
radiograph.

Artifacts
Figures 29:9 and 29:10. Motion artifacts. These two axial images show motion artifacts. The
patient moved during the study, degrading the diagnostic quality of the study.
Figure 29:11. Chemical shift artifact. Figure 29:12. This plain film lateral
Note the black line (yellow arrow) at lumbar radiograph reveals a surgically
the margin of the kidney and the implanted medical device, in this case
surrounding fat, as well as the white a spinal cord stimulator. This device
line (white arrow). Black line and contains ferrous metal and taking an
white line artifacts are created at MRI of this patient could prove to be
fat/water interfaces. disastrous.

Suggested Reading
Smith TB, Nayak KS. MRI artifacts and correction strategies. Imaging Med.
(2010) 2(4).
Erasmus LJ, Hurter D, Naudé M, Kritzinger HG, Acho S. A short overview of

MRI artefacts SA Journal of Radiology, August 2004.

Systematic Sequence of
Interpretation
406
Systematic Interpretation of the Lumbar MRI
After hundreds of pages of learning the details of what can be found in a lumbar MR,
looking a an MRI can be daunting unless you have system of review. At this point I would
like to reintroduce the system that we first purposed in Chapter 2. This system ensures
that you cover the images in a logical manner. The next pages expand on how to
analyze axial and sagittal sequences in detail. As you develop an eye for the subtleties
found in lumbar MRI, you will find that sticking to a system of observation will help you to
avoid missing important findings. With time you will become more and more proficient in
streaming through MRIs and be able to scan MRI without referring to these notes.
Sequence of Systematic Interpretation

of Lumbar MRI Images
1. Verify patient identifiers and date of examination.

2. Confirm that the images and the studies are in order if using film
rather than digitized images.
cephalad.
cephalad.
7. Review your findings and compare to the radiologist’s report.
8. Determine if the radiographic findings are clinically significant or
coincidental findings.
9. Integrate collaborative MRI findings into patient care.

Sequential Analysis of Sagittal Images
1. Identify the left-right orientation. Sagittal images represent anatomic slices in a

vertical plane which travel through the body from posterior to anterior and divides
the body into right and left components. Scroll from left to right. If you are unable
to identify the orientation of the sagittal images, remember that the aorta is on the
left (right in the MRI) and that the inferior vena cava lies on the right (left in the
MRI). The aorta typically has greater girth and a more symmetrically round
appearance.
2. Analyze the spine from a global view. Scan through the sagittal images and look
for larger, more obvious findings:
Alignment of the spine – Spondylolisthesis and retrolisthesis can be usually be
discerned on sagittal inspection. Scoliosis can be a little more difficult. On
sagittal imagery a scoliosis will present with partial views of structures and a
contorted view of the spinal canal and vertebral bodies.
Vertebral body shape – Identify endplate disruption, Schmorl’s nodes,
compression fractures, block vertebrae, and fusion.
Vertebral body content – Analyze the cortical bone for edema, tumors, fatty
infiltration, and hemangiomas.
Posterior Elements – Evaluate the facets, the pars, spinous processes, pedicles,
and the lamina.
End plates – Look for sclerotic changes and alterations in signal intensity. Also
look for disruptions or fractures of the endplates.
3. Intervertebral foramina:
The IVF should be a light-colored peanut-shaped image with a gray dot in the
middle. The light color is due to the fact that it is in the foramina. When
displaced, the light-colored fat will alter in shape. The gray dot in the foramina is
the exiting nerve root.
4. The discs and the canal:
Look for alterations in disc height. Increased disc height may occur with discitis.
Loss of disc height and reduced water content is indicative of degeneration. Disc
tears and derangements may also be observed in sagittal imagery. Note
disruptions of the thecal sac, the cauda equina, and nerve roots.
High intensity zones (HIZ) may be observed in T2 weighted images. These
bright-colored zones indicate the presence of disc tears, scarring, or
vascularization of the annulus.
The cord should terminate at about the level of L1. Increased signal (brightness)
on T2 weighted images may indicate cysts, tumors, syrinxes, or demyelination.

Sequential Analysis of Axial Images
1. Identify left and right. Axial images are backwards; structures that you see on
the left of an axial image represent structures found on the right of the patient.
2. Begin your analysis caudally proceeding cephalad. The sacrum will be easily
recognizable. Observe the S1 nerve roots. Look for perineural (Tarlovs’ cysts)
which occur most commonly at the S2 and S1 nerve roots.
3. As you scroll superiorly, observe the L5-S1 disc. Note the circumferential margin
of the disc, and inspect it for derangement. Scroll past the disc to the L5
vertebra. Note that L5 is commonly shaped like a lemon when viewed axially.
Observe the bony integrity of L5. Look for elongation of the central canal which
may be indicative of a spondylolisthesis.
4. The canal should be intact and not effaced. Look for effacement or disruption of
the thecal sac by discs, osteophytes, or spondylosis, or other space-occupying
lesions.
5. Look at the lumbar discs and evaluate for tears, herniations, nerve compression,
and degeneration.
6. Identify the ligamentum flavum, and look for signs of hypertrophy and subsequent
stenosis.
7. Evaluate the posterior elements of the vertebrae. Look for pars defects, spina
bifida, facet hypertrophy, and overall posterior ring integrity.
8. Examine the retroperitoneal space.
9. In addition to examining the spinal structures, evaluate and note the paraspinal
muscles, multifidus muscles, iliopsoas muscles, the great vessels, and the
kidneys.
10. After scrolling up the lumbar spine, reverse directions and descend the spine to
follow the course of the nerve roots. Start cephalad and scroll (if using a
computer) caudally. If looking at film, move from slide to slide. Follow the
migration of the nerve rootlets from the cauda equina from their posterior central
location to the lateral anterior portion of the thecal sac and then leaving the sac
as traversing nerve roots.

Appendix
410
Shades of Gray
Hypointense Isointense Hyperintense
Figure 1. Shades of gray. Interpreting findings on MRI is not always black or white. When we
use terms like hypointense or hyperintense, we are not saying that the image will be black or
white, but will tend toward darkness or lightness on a grayscale continuum.

Which Radiological Studies Should You Order?
Develop a relationship with your radiologist, and be willing to consult with the radiologist
prior to ordering radiological studies. Explain the history, and work with the radiologist to
determine the best study for each patient.
Trauma •Plain films may be used initially to determine if there is

an unstable injury or displacement
•Non-contrast CT
•MRI to evaluate cord integrity
Tumors MRI with contrast enhancement
Inflammation and Vascular MRI with contrast enhancement

Disorders
Scoliosis Plain films, unless pathology is suspected, then MRI
Congenital anomalies MRI without contrast enhancement
Infections MRI with contrast enhancement
Nerve Root Compression MRI
Spondylolisthesis •Plain film radiographs

•CT
•MRI if there is a need to evaluate neuronal involvement
Note: There is an inherent danger in using contrast enhancements. These risks include
allergic reaction, shock, and death.
CTs are less expensive than MRI and are the medium of choice for head and neck trauma.
They utilize significant doses of radiation and increase the risk of cancer.

MRI Image Type
MRI image types enhance various tissue types differently. This allows the
differentiation of tissues by the specialist. The various types of MRI images are as
follows:
1. T1 Weighted Image Water densities are dark; fat densities are bright. T1WI have
greater anatomic detail than T2WI.
2. T2 Weighted Image Water and fat densities are bright; muscle appears
intermediate in intensity.
3. Fat Suppressed T2 Weighted Image Water densities are bright; fat is suppressed
and dark.
4. Intermediate T2 Weighted Image Ligaments and cartilage are viewed as very dark.
5. Gadolinium Enhanced T1 Weighted Image Gadolinium is an injected
enhancement. It is used to identify pathology.
6. Fast Spin Echo (FSE) Frequently used in T2 weighted musculoskeletal imaging.
Allows quicker image acquisition. Fat is bright on T2 weighted images. Marrow or
subcutaneous pathology may not show unless fat suppression is used.
7. FSE STIR (Short T1 Inversion Recovery) Decreased signal intensity (brightness)
from fat and an increased signal from fluid and edema. This is useful in identifying soft
tissue and marrow pathologies.
8. Proton Density Proton density uses a mixture of T1 and T2 images. It is
characterized by enhanced anatomical detail and poor tissue contrast.
9. Fat Saturation Fat saturation employs a “spoiler” pulse that neutralizes the fat
signal without affecting the water and gadolinium signal. Fat saturation is used with T1
weighted images to distinguish a hemorrhage from a lipoma. When used with FSE T2
weighted images, fat saturation can enhance marrow or soft tissue pathology.
10. FIESTA (Fast Imaging Employing Steady sTate Acquisition) This method of
image acquisition captures structures rapidly and provides high quality images of fluid-
filled structures.

William E. Morgan practices in Bethesda’s Walter Reed
National Military Medical Center, the President’s Hospital. He
has been credentialed at five hospitals and serves as a
consultant to various United States government executive
health clinics in Washington, D.C., caring for government
leaders. He has served as a consultant to the White House,
the Veterans Administration, the U.S. Navy, and the U.S. Army.
Dr. Morgan holds faculty adjunct appointments at institutions of
higher learning: He is a professor for New York Chiropractic
College and assistant professor for F Edward Hébert School of
Medicine. Additionally he is on the Board of Trustees for
Palmer College of Chiropractic.
Dr. Morgan is the team chiropractor for the United States

Naval Academy football team. A veteran of military service, he
has served in Naval Special Warfare Unit One, Marine Corps
Recon, and in a Mobile Dive and Salvage Unit.
Dr. Morgan is a 1985 graduate of Palmer College of
Chiropractic-West. In addition to many other awards, he has
received the American Chiropractic Association’s Chiropractor
of the Year Award. He has also been featured on CCN.com
and has been interviewed by the Washington Post. William
Morgan has written dozens of
articles on integrated
medicine, chiropractic, and
health care. Dr. Morgan uses
MRI in an integrated clinical
setting on a daily basis and is
well suited to share this
knowledge in a practical and
engaging manner.
He can be contacted through

his website: DrMorgan.info
The Lumbar MRI in Clinical Practice is written for the
busy practitioner. It combines easy to understand
schematics, illustrations and explanations with an
exhaustive gallery of lumbar MRIs. This book will quickly
immerse the reader with practical applications. This
book is the perfect companion for any specialist or
resident who treats the lumbar spine:
•Physical Medicine and Rehabilitation Specialists
•Orthopedists
•Neurologists
•Neurosurgeons
•Chiropractors
•Physical Therapists
•Team Physicians
You will not get lost in the details with this manual, it does
not delve deeply into the details of MRI physics, but it
does tell you what you need to look for on a lumbar MRI
to make a difference in your patient’s care.
$75.00
USD

The Lumbar MRI in Clinical Practice

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“He who studies medicine without books sails an uncharted sea, but

he who studies medicine without patients does not go to sea at all.”

Copyright © 2013. Text by William E. Morgan, DC

Editor: Clare P. Morgan

All rights reserved

Copies of this eBook can be purchased through http://drmorgan.info/home/

Nothing in the presentation implies any Federal/DOD/DON endorsement.

Robert A. Heinlein, Waldo & Magic, Inc. (1950)

1 The Clinician’s Perspective 1

To return to this page from

This painting appears to be an oil on plaster painting. This image demonstrates a

The Lumbar MRI in Clinical Practice 2

It is my contention that the historical perspective is important in obtaining information of

The Lumbar MRI in Clinical Practice 3

The amount of information to a radiologist on a

The red inverted triangle represents what is

The Lumbar MRI in Clinical Practice 4

The Lumbar MRI in Clinical Practice 5

The Lumbar MRI in Clinical Practice 6

The Lumbar MRI in Clinical Practice 7

Boden et al. (1990). Abnormal magnetic-resonance scans of the lumbar spine in

Weishaupt et al. (1998). MR imaging of the lumbar spine: prevalence of

The Lumbar MRI in Clinical Practice 8

Without a systematic approach, endeavoring to

Figure 2:3. Coronal view

The Lumbar MRI in Clinical Practice 10

The Lumbar MRI in Clinical Practice 11

The Lumbar MRI in Clinical Practice 12

Figure 2:7. The scout image for

Figure 2:8. For sagittal images the scout film is a

The Lumbar MRI in Clinical Practice 13

The Lumbar MRI in Clinical Practice 14

The Lumbar MRI in Clinical Practice 15

MRI Image Characteristics

The Lumbar MRI in Clinical Practice 16

Figure 2:15. T1 Weighted Sagittal Figure 2:16. T2 Weighted Sagittal

How Do T1 and T2 Weighted Images Differ?

The Lumbar MRI in Clinical Practice 17

These two images are from a patient

Figure 2:17. T2 weighted axial image reveals

Figure 2:18. In this T1 weighted axial image the

The Lumbar MRI in Clinical Practice 18

Sequence of Systematic Interpretation

1. Verify patient identifiers and date of examination.

The Lumbar MRI in Clinical Practice 19

1. Identify the left-right orientation. Sagittal images represent anatomic slices in a

The Lumbar MRI in Clinical Practice 20

The Lumbar MRI in Clinical Practice 21

Trauma •Plain films may be used initially to determine if there is

Tumors MRI with contrast enhancement

Inflammation and Vascular MRI with contrast enhancement

Congenital anomalies MRI without contrast enhancement

Infections MRI with contrast enhancement

Nerve Root Compression MRI

Spondylolisthesis •Plain film radiographs

Note: There is an inherent danger in using contrast enhancements. These risks

The Lumbar MRI in Clinical Practice 22

The Lumbar MRI in Clinical Practice 23

The Lumbar MRI in Clinical Practice 25

The Lumbar MRI in Clinical Practice 26