Teaching Atlas of Spine Imaging (Teaching Atlas Series)

Teaching Atlas of Spine Imaging

Teaching Atlas of Spine Imaging

Ruth G. Ramsey Professor of Radiology Head, Section of Neuroradiology The University of Chicago Chicago, Illinois

1999

ew

York. Stuttgart

Thieme New York

333 Seventh Avenue New York. N Y

10001

Executive E d i tor: Jane E. Penn i ngton, P h . D . Editorial Assistan t : J i n nie Kim Editorial D i rector: Ave McCracken Devel opmental Ed itor: Kathleen P. Lyons Director, Production & Manufacturi ng: M ax i n e Lllngweil Production Editor: M ichek M u l l igan Marketing D i rector: Phyllis Gold Sales Manager: David Bertelsen Chief Financial Offteer: Seth S. Fishman Preside n t : B ri a n D . Scan l a n Cover Designer: Kevin KII II Compositor: B i -Comp, I nc. Pri n t er: Courier. I n c. Library of Congress Cataloging-in-Publication Data

Ramsey. R u th G . Teaching a tlas o f spine imaging / Ruth G . Ramsey. p . cm. I n cludes bibliographical references and i ndex.

ISBN 0-86577-778-0.-ISBN 3-13-115791-7 I. Spine-imaging-Allases. 2. Spine- I maging-Case studies. I . Tille. [ DNL M : 1 . Spinal Diseases-diagnosis atlases. 2. Spinal Diseases­ diagnosis cllse sludi es. 3. Spi ne-p athology Iltillses. 4. M a gnetic Resonance I maging aliases. WE ISR lS3t 1995J

RD76S.R36 1998 617.5'60754-de2 I D N LMIDLC for Library of Congress

98-27857 OP

Copyright © IlJ99 by Thieme M edical Publisbers. In c. This book. i ncluding all parts thereof, is legally protected by copyright. Any use, explo i t a t io n or commercializat ion outside the narrow lim its set by copyright legislation , without the publis her's consent, is illegal and liable to prosecution. This applies i n particular to photostat reproduction, copying, mimeographing or dupl ication of any kind, transla t i ng, preparation of microfilm, and electronic data processing and storage. Important note: Medical knowledge is ever-changing. As new research and cl i n ical experience broaden our knowledge, changes i n

trelltment and drug therapy m a y be required. The authors a n d editors of the material here i n have consulted sources believed t o be reliable in their efforts to provide inform a t ion thaI is complete and i n accord w i th the standards accepted at the time of publication. However, i n view of the possi blity of human error by the authors, editors, or publisher of t h e work herein. or changes in medical knowledge. neither the a u t hors, editors, publisher. nor any otber paI1y who has been involved in tbe preparation of this work, warrants that the information contained herein is i n every respect accurate or complete, and they arc not responsible for any errors or omissions or (or the results obtai ned from use of such informat ion. Readers are encouraged to confirm the information con t a ined herein with other sources. For example, readers are advised to check the product information sheet i ncluded i n the package of each drug they plan 10 administer to be certain that the informaiton con tai ned i n this puhlication is accurate and that Changes have not been made in the recommended dose or in the contraindications for admin istration. This recom mendation is of particular importance in connection with new or i n frequently used drugs. Some of the product names, p a tents, and registered designs referred to in this book are i n fact registered trademarks or proprietary names even though specific rderence to this fact is not always made i n the tex t. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by t h e publisher that it is in tbe publ ic domain. Printed i n the Un ited States of America 5 4 3 2 1 TNY I S B N GTV ISBN

0-86577-778-0 3-13-115791-7

For Michael, Thomas, and Timolhy­ thanks for all your understanding

Contents Pre face . . Acknowle dgments

xv xvi i

I. Normal Anatomy

A. Ce rvic a l spin e E xample 1 . Sagitt al Example 2. Midsagittal B. Thoracic spine E xample I. Sagittal short T R image E xample 2. Sagittal long TR image . E xample 3. Sagittal short TR image i n a pe di atric patie nt Example 4. Sagittal long TR image i n a pe diatric patie nt C. Lumbar spine Example 1. Mi dsagitt al short TR image s Example 2. Mi dsagit tal short TR image s Example 3. Coronal short TR images . Example 4. P arasagittal short TRun age s Example 5. N orma l pe diat ric lumbar spine E xa mple 6. Sagittal hort T R image s E xample 7. Axial short T Ri mage s . Example 8. Pre infusion and posti nfusion axial short TR image s Example 9. Long TR i mage s . . Example 10 . Axial long TRi mage s Example 1 1 . A xial compute d tomographyi mage s Example 12 . M ultiple T arlovc ysts .

5 9 20 22 24 25 03 34 35 37 40 42 45 51 52 54 56 58

O. Congenital

Case l . Case 2. Case 3. Case 4. Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case 1 I. Case 12. Case 1 3. Case 14. Case 1 5 . Case 1 6.

Chiari I mal[ormation with focal syrinx cavity Chiari [ malformation wi th lowe r ec rvical and thoracic syrin x cavity Chiari I malformation andt horacic syrulX . Chi ari type I [ ma l format ion wi th a lar ge meningomye loce el , s acral age ne is s . Chiari 1 1 malformation wi th me n ingomye loce el . dysraphic spine , ec er be llar ton sillar he rniation, et the er d coru, de forme d verte brae , a nde xpanueu forame n magnum Chiari I malformati on with syrinx cavity, postope rative change s with shunt tube place me nt . Chiari type III malformation A nte rior sacral mye lome ni ngoce el Te the er d cord. me ningomye loce e, l and coccyge al age ne sis Sacral age ne sis wi th filum et rminale lipoma and lowe r-than-normal spi nal cord Caudal er gre ssion syndrome with et the er d cord and multiple ve rte bral anomalie s . Partial sacral and coccyge al age ne sis, sinus tract, spinal dysraphi sm, et the er d spinal cord Tet he er d cord, sacral age ne is s, horse shoe, pe lvic kidne y . . Te the er d cord with filum et rminale lipoma, syrinx of the distal cord.e xpande d lumbar ve tre bral canal Te the er d cord, sinus rt act T ethe er d cord, lipoma, mye lome ningocele

67 71 74 77 08 83 86 88 90 93 97 01 0 01 2 104 107 109

�1E ACH I N G ATLAS Of' SPIN E I MA G I N G Case 17. Kl ipple-Feil an o maly associa ted with the Chiari I malformation, tethered cord, lipom a, sacral agenesis Case 1 8. D i astematomyelia, scoliosis, vertebral body . Case 19. Diastematomyelia . . Case 20. Diastematomyelia with atrophic spinal cord with two slightly asymmetric hemicords and an associated syrinx cavity, forme fruste of a Chiari I malformation with deformity of the posterior fossa Case 21. Neurollbromatosis type 1, multiple neurofibromata along the spine, a large plexiform neurofibroma along the course of the brachial plexus on the right arm Case 22. Neurofibromatosis type 2, with mUltiple schwannomas, postoperative changes, spinal cord tethering Case 23 . Bilateral acoustic schwannomas and m ultiple spinal schwannomas; small right internal auditory canal lipoma . Case 24. Down's syndrome with Cl-2 dislocation , congenital heart disease with atrial septal defect

112 115 119 122 125 128 130 133

10. Spinal Cord Tumors

A. Intramedullary Case 1. Ependymoma Case 2. Astrocytomas; neurofibromas of the dorsal root ganglion bilateraUy Case 3. Pilocytic astrocytoma . Case 4. Glioma of the cervical spinal cord and cerebellum, confirmed at surgery Case 5 . Spinal cord lesion, a metastasis from the patient's known leiomyosarcoma, confirmed at surgery . Case 6. Pilocytic astrocytoma, confirmed at surgery Case 7. Postoperative changes in a patient who had previous surgical removal of a spinal cord ependymoma . Case 8. Pilocytic astrocytoma, confirmed by biopsy Case 9. Astrocytoma, confirmed at surgery; tumor arose from within the spinal cord and grew in an exophytic fashion; soft tissue schwannomas B. Intradural Case 1. Schwannoma . Case 2. Isolated schwannoma Case 3. Schwan noma; multiple myeloma Case 4. Schwannoma at L3; osteoporosis; postoperative changes Case 5 . Men ingioma, confirmed at surgery Case 6. Meningioma . Case 7. Myxopapillary ependymoma Case 8. MyxopapiUary ependymoma with areas of hemorrhage Case 9. Ependym oma; dil ated Virchow-Robin spaces in the brain of unknown significance . Case 10. D rop metastasis from recurrent posterior fossa ependymoma Case 11 . Metastatic colon carcinoma . C. Neurollbromatosis Case 1. Neurofibromatosis type 1 with multiple plexiform neurofibromas Case 2. Neurofibromatosis type 1 with multiple plexiform and dumbbell-shaped tumors Case 3. Neurofibromatosis type 1 with m ultiple plexiform neurofibromas at all levels on the spine Case 4. Neurofibromatosis type 2 with plexiform neurofibromas in the intervertebral foramina, deep to the sternocleidomastoid muscle, and in the i ntradural space in the cervical and thoracic region Case 5. Probable nonenhancing low grade astrocytoma of the distal spinal cord Case 6. Neurofibromatosis type 2 with multiple spinal schwannomas, men ingiom as, and ependymomas, as well as cerebral meningiomas and acoustic schwannomas . Case 7. Neurofibromatosis with bilateral acoustic schwannomas, meningiomas, and spinal cord ependymomas

137 1 41 145 149 151 154 161 164 167 175 178 180 182 184 186 189 192 195 198 201 211 217 225 230 233 235 241

CONTENTS

D. Miscellaneous Case 1 . Chordoma, with postoperative chang es . Case 2. Metastatic chordomas: postsurg ical chang es Case 3. Chordoma within the vertebral body of L 3, confirmed at biopsy Case 4. M ultiple hemang ioblastomas in a patient with von Hippel-Lin dau disease Case 5. Sacral teratoma . Case 6. Dermoid tumor, low spinal cord (proved at surgery) . . .

249 25 3 256 258 260 263

IV. Trauma

Case 1 . Case 2. Case 3. Case 4. Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case 11 . Case l 2. Case ] 3. Case 1 4. Case] 5 . Case 1 6. Case 1 7. Case 1 8.

T raumatic compression fracture with spina l cord edema . Compression fracture of L 1 and distraction of the inteli acet jointsti t the L1-2 level . Fracture dislocation of T 6-7 with cord contusion and paraspinal hematom a formation . F lexion inj ury with fracture dislocation of the Ll -2 spinous proce. ses with tear in the dura and leakag e of cerebrospinal fl uid and blood into the soft tissue and muscles of the back Compression fracture of L l with spinal cord hematoma . T raumatic anterolisthesis of C4 on C5 with a traumatically herniated disc on the left side at the C4-5 level . Probably old fracture dislocation of C4 on C5 associa ted with a cs oliosis and formation of a posttraumatic syrinx cavity at C4; presumed child a buse Fracture dislocation of C2 on C3 ni a " hang man' s" type of fract ure with a traumatically herniated disc at the C2-3 level Old odontoid fracture; type 2 odontoid fracture Bilateral perched facets . Anterior dislocation of C5 on C6 with disruption of the nucal L gi ament and traumatic herniation of the intervertebral disc at the C5-o level . Small epidural hematoma Epidural hematoma; blood in the thecal sac: air in the vertebral canal in the lower thoracic reg ion Spontaneous epidural hematoma . . Spontaneous epidural hematoma in the m id thoracic reg ion secondary to coumtlu in treatment Benig n compression fractures of T4 and T1 2 secondary to osteoporosis Multiple compression fractures Multiple be nig n compression fractures secondary to osteoporosis

269 272 276 282 284 286 289 292 298 300 30 2 30 6 30 8 31 3 3] 7 320 322 324

V. Metastases

Case 1 . Case 2. Case 3. Case 4. Case 5 . Case 6. Case 7. Case 8. Case 9. Case 01 .

I solated metastatic breast carcinoma to the L3 vertebral body, proved at biopsy P ostradiation chang es . Metastatic osteoblastic prostate cancer within the bone marrow; multiple para-aortic lymph nodes also show sig ns of metastatic disease . Postsurgi cal chang es with placement of a metallic plate and multiple screws in the vertebral bodies at C5,6 , and 7; diffuse metastases to m ultiple vertebral bodies and spinous processes V ertebral metastases and mU ltiple patholog ically enlarg ed lymph nodes secondary to non-H odg kin' s lymphoma Diffu e metastases secondary to innumerable osteoblastic lesions related to the prostate cancer . Metastatic adenocarcinoma with bone des truction a nd spinal cord compression Metastatic breast cancer with vertebral body ni volvement and patholog ic adenopathy Metast atic breast cancer involving multiple vertebral bodies and the brachial plexus Metastatic lung cancer, b iopsy proved; mu ltiple additional lung nodules were present on the chest CT scan .

331 33R 340 344 347 350 353 357 360 36 2

TEACHING ATLAS OF S PlNE I MAGING

Case I I . M etastatic colon carcinoma to T 1 2 with bone expansion and cord compression Case 1 2. Metastatic Ewing' s sarcoma with cord compression at the T2 level . Case 1 3. Metastatic renal cell cancer to the rig ht lung and the vertebrae in the thoracic and l umbar reg ion and i nvolving the para tracheal lymph nodes . Case1 4. Chloroma, secondary to acute myelog enous leukemia Case 1 5. Metastatic renal cell carcinoma involving t he C3 vertebral body with cord compression Case 1 6. B reast cancer. metastatic to the C2 vertebral body with cord compression Case 1 7. Metastatic lung cancer with bony and epidural metastases and cord compression Case l 8. Multiple myeloma with i nvolvement of the spine and bony calvariam . Case 1 9. Multiple myeloma with diffuse marrow involvement and m ultiple pat holog ic compression fractures . Case 02 . Multiple myeloma . Case 21 . Diffuse metastases involving m ultiple vertebral bodies with a patholog ic fracture at T6 Case 22 . Mu lti ple myeloma with rapid prog ression . Case 23. Multiple myeloma involving the bony structures and forming a sort tissue mass dorsal to the spinal cord resulting in cord compression Case 24. Mu ltiple myeloma with di rfuse infi ltration of the bone marrow or the vertebral bodies and with a sof t tissue mass Case 25. Multiple myeloma; m ultilevel epidural hematoma predom inantly posteriorly, but also present an teriorly; bilateral bloody pleural effusions . Case 26. Metastatic h reast cancer with diffuse osteoblastic metastases . Case 27 . B reast cancer with osteoblastic metastases with soft tissue epidural component and spinal cord compression . Case 28. Metastatic osteoblastic prostate carcinoma Case 29. D iffuse osteoblastic metastatic disease with mild soft tissue component in the lower cervical reg ion and multiple patholog ic fr actures Case 03 . D i ffuse osteoblastic metastases from the patient's known primary osteog enic sarcoma

367 369 37 1 37 7 380 383 386 389 392 395 397 399 04 2 04 4 04 7 410 4J 2 41 4 417 42 l

VI. Carcinomatosis

C ase l . Case 2. Case 3. ase 4.

Case 5. Case 6. Case7 . Case 8. Case 9. Case10 .

Spinal and cerebral mening eal carcinomatosis secondaryt o breast cancer, with involvement of the leptomening es (pia and arachnoid) of the spine and brain; presumed metastatic deposit ni the inferior end plate of the L4 vertebrae Recurrent cerebralg lioblastoma multiforme with drop metastases and resulting men i ng eal carcinomatosis Diffuse bone metastases and spinal mening eal carcinomatosis . D iffuse leukemic infi ltrate throug hout the visualzi ed marrow, resulting in diffuse decreased sig nal within the marrow of the vertebral bodies; minimal patholog ic fracture of the L l vertebral body; metastases in the distal end of the thecal sac; mening eal carcinomatosis; polycystic disease of the kidney (incidentalfi nding ) Metastatic colon cancer in the subarachnoid space . Recurrent posterior fossa medulloblastoma with multiple drop metastases from medulloblastoma G erminoma with drop metastases and resulting spin al mening eal carcinomatosis L eukemic infi ltrate in the marrow of the vertebral bodies and mening eal carcinomatosis with enhancement of the nerve roots of the cauda equina . Metastatic breast cancer to the vertebral body marrow and the spinal epidural space Diffuse osteoblastic and osteolytic metastatic deposits throug hout the bony structures; cerebral mening eal carcinomatosis

42 9 433 439

443 447 449 451 455 458 461

VII. Inflammatory

Case

I.

D iscitis with soft tissue component a nd destruction of the vertebral body end plate

467

CONTENTS

Case 2. Case 3 . Case 4 . Case 5.

Discitis, following trauma with an unusual organ ism as the etiolog ic ag ent; bilateral psoas abscesses and an abscess surrounding the abdominal aorta . Discitis, i nvolving the intervertebral disc with paraspinal extensio n ; en hancement of the vertebral body reflects the prese nce of vertebral osteomyelitis P ostoperative wound infection with draining sinus tract and posto perative disc i ne[ ction; i nfl ammatory process exte nds into the soft tissues of the back and into the intervertebral foramenae bilaterally . . . . . Discitis and epidural and paraspinal abscess secondary to

Mycobacterium tuberculosis . Discitis, vertebral osteomyelitis; bilateral psoas abscesses; epid ural abscess extending f rom the lumbar region throug h the thoracic ps ine; bt ick-rimmed thoracic p araspin al muscle absce ss . . . . Case 7 . M ulti level anterior and posterior epidural abs cess, meningitis a n d mul tiple dorsal and paraspinal, and psoas muscle abscesses . . Case 8. Loculated, multilevel anterior and posterior epidural abscess seco ndary to retropharyngeal abscess; etiologic org anism was not cultured . Case 9. Chemical meningitis with arachnoid adhe sions . Case 01 . Probably pneumonitis and mening itis with Mycobacterium tuberculosis Case 1 . Mycobacterium tuherculosis without evide nce of sarcoidosis Case1 2. Mycobacterium tuberculosis in the interfaeet joints of the thoracic and lumbar regions . Case1 3. Cervical spinaL cord i nvoL vement with sarcoidosis Case1 4. Cytomegalovirus radiculitis

470 477 48 0 483

Case 6.

487 49 1 498 50 3 50 7 50 9 51 2 15 6 51 9

Vlll. Cervical Spine

Case 1 . Larg e he rniated disc at the C5-6 leve l on the right side Case 2. Rig ht-sided herniated i ntervertebral disc at the C5-6 level Case 3 . Left lateral hern iated disc at the C4 5 - level . . Case 4. H erniated midline andL eft paracentral cervical disc at t he C4-5 el vel Case 5. Deg enerative changes with osteophyte formation and trauma resulting in myelomalacia . Case 6. Rheumatoi d arthr itis with C1-2 dislocation ; hern iated disc at the C3-4 and C4-5 levels Case 7 . Atlantoaxialf usion: K lippel-Feil anomaly; right-sided herniated disc a t the . . . . C4-5 level . . Case 8. H erniated disc at C3-4 level; posterior longitudinal ligament ossification . Case 9. Posterior longitudinal l igament calcifi l c ltion/ossifi cation . . Case 01 . Recent surg ery F or disc removaL at the C4 -5 and C5-6 levels with bony fusion plug s in place Case 1 1 . Larg e midline herniated disc at C3-4; postoperative changes with fusion at the C5-6 and C6-7 levels . . . Case1 2. P ostoperative changes with fusion at C4-5; bony osteophyte at the C4-5 level with compromise of the suba rachnoid space; area of myelomalacia at the C4-5 level Case 1 3. Deg enerative chang e in the cervical spine with subse4 uent posto perative changes . Case1 4. Right-sided herniated nucleus pulposus at C5-6 and resulting m yelomalacia Case 1 5. Postoperative changes; ec rvical spinal cord syrinx Case 16. Dif uf se idiopathic skeL etal hyperostosis .

527 35 2 535 538 540 544 549 553 557 56 1 563 567 570 574 579 581

IX. Thoracic Spine

Case1 . Case 2. Case 3. Case 4.

H erniated intervertebraL disc at the T6-7 level Calcif ied, herniated intervertebral disc at the T6-7 level H erniated, calcifi ed intervertebraL disc at the T8-9 level Calcifi ed, herniated intervertebral disc at the T6-7l evel with compromise of the vertebral canal in the midline and on theL eft side . . Case 5. von Hippel-Lindau di sease with muL tiple cerebellar hemangioblastomas and spinal . . . . cord hemangioblastomas . .

587 59 1 593 595 599

�I

I TEACHING ATLAS OF SPINE IM AGING Case 6. Case 7. Case 8.

Thoracic spinal cord ischcmia and presumed infarction Probable spinal cord ische mia with are as of enhanceme nt Spinal cord arte riove nous malformation with subarachnoid hcmorrhage and spinal cord ischemia

06 2 06 7 610

X. Lumbar Disc

Case I .

Lu ge herniated d isc at the L 4 -S level; degenerated discs at the L3-4 and . . . LS-S 1 levels Hern ialed,e xtruded disc . Laterally herniated disc at thc LS-Sl leve l Large left paracentral herniated disc at the LS-S 1 and a mO derately size d disc at the L4-S level . . Herniated, sequestered disc with nerve root enhancement . Large recurrent herniate d disc fragm ent with peripheral enhancement . Recurrent herniate d disc which has migrated he hind the L S verte bral body Herniate d disc, probably arising fr om the L2-3 level; surgicall y prove d Left laterally he rniatcd disc at the L4-S el vel withe ncroachment on the i ntervertebral forame n M idline hern iatcd disc at the L2-3 el ve ;l large extrude d he rniated disc with a sequestereCl fragment at the L4-S . G rade 1 spondylolisthe si s secondary to bi lateral spondyloly. sis at thc lA -5 el vel Bilateral spondylolysis and grade1 spondyloU sthesis . G rade 4 spondyloU sthe sis Synovial cyst . . Synovial cyst arising from the left inte rfacet joint at the L3-4 level Spinal stenosis at the L3-4 lev el es condary to hypertrophy of theU g\\ me ntum f1 av um and encroachment upon the dorsal aspect of the vertebral canal; incide ntal Pagct'� dise asc of thc l umbar spine at the L 5 , S1 , and S2 el vels, as well as the sacral alae and the ili ac crests . Diffusely bulging disc, l arge st on the left side; lateral recess stenosis on the right side . . Spinal ste nosis with vacuum degene rative changes of the inte rvcrtcbral disc . Spinal sten os is at the L45 and L3-4 levels with bulging discs at L3-4, L4-5, and LS-S1 .

Case 2. Case 3. Case 4. Case S. Case 6 . Case 7. Case S. Case Y. Case 10 . Case 1. l Case 1 2. Case 1 3. Case 1 4. Case I S. Case 1 6.

..

Case 1 7. Case 1 8. Case 1 9.

61 9 622 62S 629 632 637 64 0 64S 647 65 1 65 S 6S9 662 666 670

673 677 6 79 6 18

Xl. Miscellaneous

Case I . Case 2. Case 3. Case 4. Case S. Case 6 . Case 7. Case 8. Case 9. Case10 . Casc 11. Case1 2. Case1 3. Case 1 4. Case I S. Case 1 6. Case 1 7. Case IS.

M ultiple sclerosis of the brain and spinal cord M ultiple � clerosis of the brain and spinal cord P robable mult i ple sclerosis . M ul ti ple sclerosis of the spinal cord . . M ul tiple sclerosis of the spinal cord . Transv erse mye litis of unknown cause . P ostimmuh zi ati on t ransverse myelopathy (mye litis) P ostvaccinatio ne ncephalomyelopathy (acute disse minate de ncephalomye lopathy) es condary to v accination . Transverse myeli tis, most lik ely secondary to multiple scle rosis Transve rse myelitis, cause unknown . Postradiation change s in the spinal cord and the vertebral bodies Postradiation change withe nhancement of the spinal cord . P ostradiation change . . Retained pantopaque: hernj ated disc at IA,S . Extensive postopcrativc change s with scarring and adhesions of the ne rve roots of the cauda eq uin a P ostoperative adhe sive arachnoiditis . . . . Epidural he matoma M ultile ve le pidur al hcmatoma in the lumbar e r g ion

689 694 699 70 3 70 7 07 9 17 2 716 17 9 722 72 5 728 73 1 733 736 739 742 744

CONTENTS

Case1 9. Case 20 . Case 21 . Case 22. Case 23. Case 42 . Case 25. Case 26. Case 27. Case 28.

Spinal cord lipoma . Epidural lipomatosis Extramedul lary hematopoiesis Sickle cell anemia with multiple bone i n fitrcts Amyloidosis secondary to chron ic renal failure with f32 microgloblinerrila Scoliosis with dorsal encroaclun ent secondary to degenerative changes, no tumor; secondary to poliomyelitis; postpolio syndrome . . Postpolio syndrome Postoperative change with focal atrophy of th e spi nal cord and anterior tethering of the cord to the posterior margin of the vertebral body M ultiple endplate herniations of the intervertebral discs called Schmorl's node deformities Cavernous angioma of the spinal cord with hemorrhage .

47 7 750 752 756 758 760 766 768 77 1 773

XII. Unknown Cases

Case1 . Case 2. Case 3. Case4 . Case 5. Case 6. Case 7. Case 8. Case 9. Case 10 . Case11 . Case 1 2. Case1 3. Case 14 . Case 1 5. Case 1 6. Case 17. Case1 8. Case1 9. Case 20 . Case 12 . Case2 2. Case 3 2 .

Index

Discitis with vertebral osteomyelitis at the L34 level and sevcre spinal stenosis Epidural and prevertebral abscess Multiple sclerosis of the brain and spinal cord Neurofibromatosis type2 with multi ple schwan nomits Diffuse osteolytic and osteoblastic metastases involving all the visualized bony structures . Epidural hematoma, cause un known D iffuse osteoblastic and osteolytic metastases from prostate cancer M ultiple schwannomas and postoperative changes with larrilnectomy and tethering of the spinal cord posteriorly at the T12-Ll level . Des moid tumor (unrelated to the recent trauma) . . Chiari I malformation, postoperative changes in the posterior fossa; syrinx cavity Neurofibromatosis type 1 with plexiform neurofibroma tit at all levels in the cervical spine . Lipoma at the L2 level with tethered spinal cord and diastematomyelia Cl-2 subluxation in assoeia tion with Down syndrome Large far laterally herniated disc at the L34 level; small midline herniated disc a t t h e L4 -5 level Chordoma of the distal lumbar spine, i liac crest, sacrum, and coccyx Cavernous angioma of the spinal cord . . . . Metallic fusion plate and fixating screws Diffuse bony metastases with pathologic fractures of TIO, Ll, and L2 and a metastatic deposit in the right lobe of the liver . Metastatic cancer involving the T11 and L4 vertebral bodies with epidural metastases Spinal cord ependymoma with an associated syrinx cavily . Leukemic infiltrate of the bone marrow; leptomeningeal carcinomatosis von Hippel-Lindau disease with multiple spinal and cerebral hemangioblastomas Di ffuse leukemic infiltrate of the marrow of the vertebral column; granulocytic 'arcoma (chloroma) of the soft tissues of the neck; dural based meningeal metastases; bony calvarium metastases (?) ch loroma .

781 785 790 793 795 799 �0 2 � 40 R06 180 18 3 81 8 8 23 8 26 83 1 83 4 838 48 2 48 5 84 9 853 857 86 1 87 1

Preface Teaching Atlas o/Spine Imaging, a collection of both classic and challenging cases. is formatted to reflect "real-life" presentations. These cases. the em­ phasis of which is not rare and unusual cases, but those seen in a busy practice regardless of the clinical settin g, begin with a brief clinica l presenta­ tion, followed by a series of images, and a section entitled Radiologic Find­ ings. The large form at of the vo lume allows life-size presentation of the images to simulate the clinical setting at the time of interpretation. Armed with the clinical presentation, the i mages, and the radiologic findings, the reader should be able to make a diagnosis. which is subsequently provided, along with the differential diagnosis and a brief discussion of the abnormality. The need for clinical correlation and relevance is repeatedly emphasized. The clinical information, often not included on the consultation request, i frequently the key to diagnosis. I n cases in which it is not possible to arrive at a diagnosis at the time of initial imaging evalua tion, follow-up images are provided as well. Practical guidelines to diagnosis and imaging, cal led pearls and pitfalls, are highlighted in the margins. Because the ability to evaluate abnormal anatomy req uires an understanding of normal anatomy, the first section of t he book evaluates the normal spine. The next nine sections-Congenital, Spinal Cord Tumors, Trauma. Metasta­ ses, Carcinomatosis. In flamm atory, Cervical Spine. Thoracic Spine, Lumbar Disc, and Miscellaneous Cases-address a wide variety of abnormalities that alTeet the vertebral column and the spinal cord. An up-to-date bibliography is included with each section. The final sect ion is devoted to unknown cases. The reader may use these cases for sel f-assessment by either using the given clin ical data or by using the i mages alone. These typical clinical cases cover a wide variety of clinical entities. Evaluation of the vertebral column and spinal cord has evolved from plain film evaluation to the use of computed tomography (CT). to CT in conjunc­ tion with myelography, and most recently to magnetic resonance (MR) imaging in conjunction with a variety of basic and sophisticated techniques. At present, MR imaging has essentially replaced ot her imaging methods for evaluation of the vertebral spinal column and spinal cord. Although these news modalities are better for diagnosing spine abnormalities, this technology requires a keen eye and solid understanding of how the various abnormaLities are imaged. It is my hope that this volume, developed as a response for an easy to use imaging guide for a variety o f abnormalities of the spine will be used by both new and experienced practitioners alike to diagnose these special patients.

Acknowledgillents The vast majority of the photography was performed by Mr. Harold Tyler, without whose help this book would have been very difficult. Special thanks to the Neuroradiology fellows as well, especially Rajiv Shah who a lways watched for i nteresting teach ing cases, Donna Bower Kim, Rohert Wank­ mul ler, V ivek Sehgal, and Sundeep Nayak. Thanks to Sharon Byrd for many of the pediatric cases. Thanks to the residents whose q uestions allowed me insight into what is complicated and diffi cult for them to understand about spine imaging. Thanks also to my clinical colleagues who suffered through all the teaching files that were made during the course of this project. Thanks to Anne Healy, who always pruvided the necessary technical assis­ tance and support, Margaret Caldwell my secretary, as well as the entire secretarial staff who pitched in when needed: Charlene Sheridan, Leslie Cleveland, Debbie Cop, and Evelyn Ruzik. The entire technology staff, who made certain that excellent images were obtained on all our patients. The film library staff also deserve special thanks for helping me to find the cases. I would certai nly be remiss if I did not mention tbe staff at Thieme Medical P ubl ishers, includi ng Hilary Evans, whu encouraged me to start this project; Jane Pennington for her excellent advice; Michele Mulligan for her patience and perseverance; Kathy Lyons, who listened to all the phone calls and shepherded all the images through the process; and their colleagues in the New York office. Thanks to Martin 1. Li pton, Chairman of the Department of Radiology, for his help and encouragement.

Section I

Normal AnatoDlY A. Cervical Spine

N ORMAL ANATOMY

I

Cervical Spine Evaluation of the normal cervical spine includes sagittal short and long TR images. Intermediate TR images in the sagittal plane may also be obtai ned. Axial images are obtained through any areas of interest using short TR sequences or sequences that result in increased signal intensity cerebrospi­ nal fluid. Contrast material is used in any patient who h as had previous surgery. Contrast material should also be used in patients who are being evaluated for a possible tumor in the cervical region, an inflammatory process or a process such as meningeal carcinomatosis, or demyelinating disease such as m ultiple sclerosis. The standard imaging sequences and pla nes may be modified in a variety of ways depending upon the clinical presentation and anatom ic area and level of interest. For various diseases, the following sequences are suggested: 1. Disc disease •

•

Sagittal short and long TR images: fast spin-echo sequences may be used . Axial short TR images or axial gradient-echo images: axial images should be obtained through all abnormal levels.

2. Intramedullary tumor •

Sagittal short and long TR images.

•

Sagittal short TR images postcontrast.

•

Axial short TR images precontrast and postcontrasL.

3. Cervical spinal cord multiple sclerosis •

Sagittal short and long TR images.

•

Sagi ttal short TR i mages postcontrast.

•

Axial short TR images precontrast and postcontrast.

•

Axial long TR images or gradient echo images.

4. Cervical spi ne tumor •

Sagittal short and long TR images.

•

Sagittal short TR images postcontrast.

•

Axial short TR images precontrast and postcontrast.

I TEACHING ATLAS OF SPI N E I M A G I NG 5. Cervical spine syrinx cavity with and without Chiari malformation •

Sagittal short and long TR images including the skull base.

•

Axial short TR images.

•

•

Sagittal and axial images should include the entire length of the syrinx cavity. The thoracic spinal cord should also be evaluated to determine the entire exten t of the syrinx cavity.

6. Cervical spine congenital maliormation •

Sagittal short and long TR images.

•

Axial short TR images.

•

Axial images with increased signal intensity cerebrospinal fluid.

•

Additional images as needed for evaluation of the abnormality.

•

Short TR images post contrast materi£ll

£IS

needed.

Additional imaging sequences, such as fat-saturated images in any plane, should be used as necessary. Many cases need to be evaluated on a case­ by-case basis. [n complic£l l ed cases, it is necessary to monitor the imaging and alter the sequences and the planes of imaging as necessary for complete ancl accurate evaluation .

NOR MAL ANATOMY

Example 1

A

(Fig. A) Normal cervical spine short TR sagittal image. The outer table and the inner table of the bony calvaria both appear as linear areas of decreased signal intensity. T he diploe of the ctcuphytc encroachment o n vertebral canal in. 716. 7 1 R s,1gillal �hort TR images. 7 1 6 . 7 1 8

spmal cord. 93-96 in IICOllutC, 77, 78, 79 ..in us trac1. spinal dysr3phism. tethered cord. 100-101 tethered cord. horseshoe kldnt:y i:llld, 102- 1 03 A I DS. lumbar �p\l1C in. slJgittal short TR image. 42

Schmorl'... nodule dcfurmltit:� i n . 7 1 6. 7 1 8 spinal cord enlargement i l l . 7 1 6 . 7 1 S thecal sac indenlation i n . 7 1 t) , 7 1 R Acute disseminated tr:tnJo;vcrJo;e myelopnthy tr;.II1 IlVer.;"e myelopathy vers"s, 723, 724

Acule lymphocytic leukemia illlihrutc in murrow of vertebral bodies. 455, 456-457 correlati on with rad ion uclide bone Jo;ca n in. 457 disc reversal sign i n , 457

nerve roots of cauda equina m. 455. 456-457 infiltrate in marrow of V!;: I h::bral bodies and meningeal carcinomatosis. 455-457

axial shorl TR image, prei n fullion. 456-457 Il:tgitlal long TK Image. 456-457 'iagl llal short TR i m agc�, 455

Air. III vertebral canal. post epi dural calhetcr place­ ment. 309, 3 1 1

p

A l ka ton

uri a. ,,"Pi' Ochronosis (alkaplOnuritl)

Am yloi dru i ls

brcust cunccr metastatic to C2 vertebral bod y with cord

(3,

compression uersus,

385

e

muillple my loma verSILS, 391 !'ccondary to chronic renal failure wilh

L lC LlJiu , 758 759

chloroma secondary to, 377-379 leukemic infiltrate in marrow. mctasta�es in theWiI sac. meningeal carcinomato�is in. 443 446 Acutc mveloid leukemia Icukt:n ic infihmte in bone marro w and leptomenin­

;

geal carcinomatoslJo; and. 853-856 ADEM. See Acutt: di�selllilliited cllccphalomyciopathy ( A D EM)

{3� microglobi­

seconda ry to end'itttge rcnal d isease with

(31 microglo-

hulincmia dISC space narrowing. C3-4. C5·6. C6·7. 758 759 hypertrophic spurs, multiple cervical. 75t) osteophytes in. 75H-75� sagittal shon TR Ima�e. Ct:rvicnl. 759 Angiugraphy for desmoid tumor, 809 spin;!1 cord arteriovenous m.Llformation. 6 1 3 . 6 1 4 Annulu.'i librosus. lumbnr disc. axial long T R image .

49 Antcrior sCdgill lumbar a�lal short '1 K image. 45, 46 lumbar. JlJfcrior axial long TR image. 50

lumh;lr. inferior and superior

axial CT image, 57 A l t i f,lct(s) chemic,,1 �hifl Si't! Chcmical shift artifact

magnctic susceptibility. See Magn e tic sUl:>cept i hil L' ty ar­ tifact

Assault i nju ry disloc
pathologic fracture pOlcmiul, 385 sagittal long TR image, 384�3RS sagi ttX. 170

in anterior sncrnl myelomeni ngocele, 88

dura in. 52�-�'H{)

axial cr image

pilUl,:yslic astrocytuma ill. 164-1 6()

gradlcnt-echo iUlllgCS in. ratiunale ror. 530-531

post pilocytic astrocytoma removHI, 1St)

in dorsai lispeet thecal sac, 57

loss uf ccrvicld lordotic curvc in. 528. 531

i n o;.lrcoidosls. 5 1 t!-51K

pustmyclogram. 56

narrowing of di6-738 I n thecal sac para�aglllul lung TR image, 59 Caudal rt:gres.hort TR iUlUgc. 98

wilh tethered CUI d and vertebral anomalies. 97 (}HC in, 491 . 495-4\}(}

Epldurtll nnd prcvcrtcbral abscesses. 785-789 axial long TR image. 786. 788 pre\,crtebrnl "bscess on. 7R7, 7Xl) axial short Tn. imagc

epltluml ubsccss on. 787. 789

prevcrtcbral abscess on. 7X7. 7�N spin"l cord compression antl uisplm:cmcnt un. 787.

sagittal short TR images, 3 1 7-318 ...uharachnoid "ipace compression tn. 31K

thuracic with blow III thecal "'[.Ie: air in vertebral '; hchmd L5. 632. 633. 635 thecal �ac ubllteratiun lit L5. 633. 635

pediclc cxpansion mto tht!("i:11 sal,; in. 363. 365 posteroanteriur and lat�ral plain films, 362, 365 sagittal short TR images. J61. 1M soft lissue mas.'\ Ill. 3M-365

retrolisthesls and. 025 sagittal long rR Ilnag!.!. 625

Illmhar, enlarged uersu.i

calcification in.

1>21

L5-S I lind L4-5 uxilll shon TR image. L5·S I . 630-63 1 .. xinl shon TR images. 630-631 commonality or. 631 compression of ncrve root sleeve in, 630-63 1 determinatiun of lalt:fiJlity in, 631 epidural fat and. 631 fd:-.t !'!pin echo technique uersus long TR images for. 1>3 1 left para�..gilllJl lung TR image. fast spin echo tech· nilille. hJO flJ I nlldsagTlI;ll long TR image. fast spin ccho tech· nique. 630-63 1

thecal sae crfacement in. 63 1 Lumbar disc migration and seqlll!�lr;won IA-5, fl32-b3b Lumbar spine chordoma involvJll�. K31 -833 comtJrc��ioll fnlcturc�. 272 275 Iidical cr scanning of, 624 infant ilxinl short '1'1{ image. 9 1 -92 long Til imagc. 90. 92 :,ugillnl short TR image. 90 lymph node enlargement �gittal short TR image. 42 normal anatomy. 29-b4 axial cUlIlput�d lOl1logmphy, 56-5� axial long TR imagc. o;, rminsis

men i ngitis with pneumonitis

versus.

SIIX meningitis postcra niotomy wah arachnuid adhesion:, uersus.

506

Mycobaclerium luberculosis without sarcoido"is

uer­

sus. 5 1 1 postlamineetomy adhesive arachnoiditis

M

uerSIiS.

74 1

postradli.lIion change in non-Hodgkin's lymphoma

Magnetic resonance imaging (MRI), contrast material for, 3 MagnelTe reSl)naOl.:e (MR) myelography adjunctive tu M R nnd cr scanning. 682 ilpplicution of. 682 descriplion of, t.X2 fa"l spin-eeho. 62 rapid aquisition with relaxatiun �llhaJiCellleJlt. 62 thrce-dimensionc.1 of lumbar spine. 61 uersu..\' myelography, 02 three-dimensional gradient echo-pulse. 62 Magnetic resununcc (MR) study lumbnr spine fast Ul'rSIlS '\tandard spin-echo tcchnique. 32 standard spin-ccho. 33 Mugnl.!tic susceptibility artifact in Chiari I malformation with postoperativl! changes in posterior fossa. syrinx cavHy. 8 1 1 . 8 1 2 in chordoma. recurren t postoperative. 252 in disc fragment. recurrent migratory post IlImhnr laminectomy. 643. 644 in grad ient echo image in cavernous angioma, 837 fruJII Illctullic implants. 345-346 with metallic fusion plate and fixating scrcws post dis­ ccctomy C5-6, C6-7, 838, 839, 840, 841 post laminectomy in von Hippel-Lindau 5oyndrome with multi ple spi­ nal and cerebral hemangioblastomas. 857. 859,

860 Marrow edema of with disc fragment, h3Y infarction 01 JO brt:ast CClIlCCr. 461 -462 in �ickle cell anemi(l, 756-757 multiple myelom46

u�r�m.

schwannomR vas/IS, 177. 179 Tarlov cyst vusus. 61 Nl:u rofibromatosis with bilateral acoustic schwannolllils. Ill eni nginm(ls. and spinal cord ependymomas. 241 -245 aXial loIhort TR Image. 242, 244 coronal :-.hort TR images, 244-245 magnetic �usceptibility artifact. 241 pnrasRgittal short TR image. 242. 244 sagittRI long TR image, 242. 244

sllgittul TI W images. 24 1 . 244 bilateral acoustic schwannomas in. 242. 244. 245

cent ral Set> Neurofibromatosis type 2 Illcningiontas in. 242. 244

peripheral form. See Ncurufibrulll.at�i� type I Neurolibromatu:-.is t)'lX! 1 . 239 d:-.tl Ocytom
Pagct'� lIi�I.!!I�c al LS. S I . S2. incidenlal. 673. 675 incldcnwl, fl73. fl75

sagillill long TR imugc, 673. 675 �agilllli �h(lrl TR image. (,,7\ 670Ci

IA 5 and I ,-4 wtlh hlliging discs at L3-4. L4-5. LSS I . 081 -6X2

t!l1crmlcllllh.:nl on ..ubanlchnoid "pace, 68 1 -682 encroachment on Ihecal suc wilh. 68 1 -682 h�Unlt.:lllulll novum hYIX'rlrophy in. 681 -682

pu�l�ro con�cniwL 90-92. 100- 1 0 1 wilh m u m Icrminale lipoma. syrim: of dist(ll cord, expanded lumbar canal. 1U4- I UU IrPOl11u. myelomclli ngocele and. 109- 1 1 1 .. inu" Irael. 1(}7 -lOR I n infant. YO-':.12

,

I N DEX Ilucleus pulposus displacement in. 59·1 pleural effusions in. 594

with lipoma at L2. 8 I M-K22 amJ myelumeningocele. 1 09 I I I lower thoracic And upper IlIInhar in ncuroflbromatO!m; type 2. 128. 12\1 meningomyclocele. coccygeal agenesIs uIllJ . 90-92 tn neonate. IUO- I O I . 103 postlamincctulIIY. 163 postoperatIve. 768-770 post pilocytie a"trocytomA removul, 1 60

sacral agenesis. horseshoe kidney and. 102-1 (J) secondary to surgcry. 129

T I 2·L 1

post lamilleetomy. 804-805

Tethered cord . lipoma. myelomeningocele in infant parasagiUal image. left side, l I D-I I I parasugittal l mage. right side. 1 09- 1 1 0 Sl1g1ttal intermediate signal intensity image. ..agiual short

TH

image. I OY- I I O

Tethcrcd cord . sacral agene!)is. hUl3cshoe pchic kidney neonatal s