General Spine

Huey-Jen, Lee, M.D.
Waseem, Bhatti, MD, Non ASSR Member
Azadeh, Esmaeili, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

Cysticercosis is the most common parasitic disease to affect the central nervous system however spinal involvement is rare. We present a case of intradural extramedullary spinal neurocysticercosis involving the entire spine with emphasis on the MRI findings.

Methods & Materials

A case report of a 49 year old man who presented with bilateral upper and lower extremity numbness and weakness. The initial clinical examination was suggestive of cerebral vascular disease or myelopathy. MRI examinations of the brain and spine were performed and a pathological specimen was obtained.

Results

The MRI brain examination revealed multiple lesions in the corticomedullary junction and in the foramen magnum manifested by isointense T1W signal intensity and hypointense T2W signal intensity. These lesions show ring enhanced after contrast administration. The MRI of the spine revealed multiple cystic lesions in the intradural extramedullary space extending from the foramen magna to the S2-S3 level. The spinal cystic lesions demonstrated multiseptated ring enhancement on the post contrast examination. There is diffuse meningeal enhancement through the entire spine. The patient underwent suboccipital craniotomy for removal of the cysts in the foramen magnum and upper cervical spine in order to decompress the mass effect on the medulla and obliteration of CSF flow. Histopathological analysis confirmed cysticercosis.

Conclusion

Neurocysticercosis can be a debilitating condition. The condition is more endemic to Brazil, Peru, Mexico, Korea, and India [1]. Cerebral cysticercosis is usually located at the gray-white matter junction or within the gray matter. The cysts can also be located in the ventricular system and subarachnoid space. The cysticerci often do not pass through the subarachnoid space at the cervical level due to size and the physiological sieve. Besides, the CSF reflux at the craniocervical junction propels the cysts away from the spinal canal. These are the possible reasons why spinal neurocysticercosis in the subarachnoid space is rare. The spinal cysticercosis accounts for only 1-5% of cases and most of spinal cysticercosis are found in the spinal cord. [2, 3, 4]. In those with spinal cysticercosis, concurrent intracerebral involvement is nearly 100% [2, 5].

Our case demonstrates no intracranial subarachnoid cystic lesion on the MRI examination at the time of presentation however the patient may have had intraventricular cysticerci in the past. The spinal invasion is likely due to ventricular cysticerci passing through the Foramen of Magendie or Luschka and migrating via gravity through the subarachnoid space. Recognition of the imaging appearance of these lesions will allow for further preoperative
characterization of this infection on MRI.

References/Financial Disclosures

Financial Disclosure: none.

References:

1. Barry M, Kaldjian LC. Neurocysticercosis. Sem Neurol 13:131â

Interventional Spine

Walter, S, Bartynski, MD
Hoang, M, Trang, DO, Non ASSR Member
Peter, C, Gerszten, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

The lumbar disk is innervated by two separate pain fiber groups: 1) level-specific somatic nociceptors return from the sinuvertebral nerve to the adjacent nerve root, 2) level-nonspecific sympathethic nociceptors return from the sinuvertebral nerve, grey ramus and anterior ramus to a network of paraspinal sympathetic ganglia that ultimately enter the spinal canal at L1 or L2. (1) Previous authors have noted that diskogenic pain may lateralize at provocation but little attention has been given to the patientâ

General Spine

Klaus, M, FRIEDRICH, M.D.
David, Stelzeneder, M.D., Non ASSR Member
Sabine, Goed, Non ASSR Member
Goetz, H, Welsch, M.D., Non ASSR Member
Tatjana, Paternostro-Sluga, M.D., Non ASSR Member
Siegfried, Trattnig, M.D., Non ASSR Member

Paper/Non-Mentor

Purpose

To investigate the relationship between T2 relaxation time measurements and standardized morphological scoring of disc degeneration in patients with low back pain.

Methods & Materials

Fifty-three patients (mean age, 39 years; age range, 15-64 years) with low back pain had 3T MR imaging of the lumbar spine including the following sequences: T1-FSE sagittal, T2-FSE sagittal and axial, multiecho-spinecho sagittal. All disc were scored according to the classification introduced by Pfirrmann et al.. The multiecho-spinecho sequence was used to generate T2 maps. Regions of interest (ROIs) were placed within the outermost 20% of the disc on two adjacent slices to measure T2 values in the anterior and posterior annulus fibrosus and within the space in between, which was defined as the nucleus pulposus. The ratio between annulus fibrosus and nucleus puplosus (T2 A-N-index) was calculated as follows: T2 A-N-index = T2 (annulus fibrosus) / T2 (nucleus pulposus).

Results

The 265 discs were scored as follows: I, 6 discs (2.3%); II, 153 discs (57.7%), III, 81 discs (30,6%), and IV, 25 discs (9.4%). The mean T2 value of the annulus fibrosus was 53+/-16ms ; the mean T2 value of the nucleus pulposus was 108+/-46ms. The following T2 A-N-index values were calculated for the Pfirrmann groups I to IV: I, 0.19+/-0.07; II, 0.47+/-0.14; III, 0.61+/-0.16; IV, 0.81+/-0.19 (image 1). The differences between the groups were highly significant (p<0.001).

Conclusion

MR T2 mapping of the intervertebral discs showed good differentiation between annulus fibrosus and nucleus pulposus in morphological intact discs, which decreases with increasing degeneration of the disc resulting in an increase of the T2 A-N-index.

References/Financial Disclosures

Magnetic resonance classification of lumbar intervertebral disc degeneration.
Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N.
Spine (Phila Pa 1976). 2001 Sep 1;26(17):1873-8.

Interventional Spine

Wade, H, Wong, DO FACR FAOCR
Sheri, Albers, DO FAOCR, Non ASSR Member

Paper/Non-Mentor

Purpose

To assess the efficacy of a new fluoroscopically guided minimally invasive lumbar decompressive procedure (MILD- Vertoss) to reduce the degree of central canal stenosis by removing ligamentum flavum and lamina through a percutaneously placed canula with bone and tissues sculpturing microtools as visualized by fluoroscopy and epidurography.

Methods & Materials

12 patients ranging in age from 59 to 88 each with a history of at least severely disabling neurogenic claudication from central canal stenosis and with a history of repeatedly unsatisfactory responses to Lumbar epidural steroid injections and/or other conservative measures were selected.Each procedure was performed with local anesthetic, moderate sedation, and under fluorosopic guidance.
Assessments were made by rating VAS scales and Oswestry Disability scales at the following intervals: Pre procedure, 1 week, 3weeks, 6 weeks, and 12 weeks post procedure.

Results

VAS pain scales with short distance ambulation preprocedurally averaged 8/10; post procedural VAS scales dropped initially to 3/10 and continued to drop to 2/10 by week 3, remaining so out to 12 weeks.
Oswestry disabillity scales preprocedurally averaged severely disabled and dropped rapidly to mild by week 2 post procedurally and remained so at 12 weeks.
Patients tolerated the MILD procedure well as performed with local anesthetic and conscious sedation.
There were no complications.

Conclusion

Fluoroscopically guided minimally invasive lumbar decompression (MILD) may offer an effective treatment for those patients who have become disabled by neurogenic claudication from spinal stenosis and who have failed less aggressive therapy such as epidural steroid injections, but do not want more aggressive open surgical options.

References/Financial Disclosures

Dr. Wong has been on the training faculty for Vertoss.
Dr. Albers has nothing to disclose.

General Spine

Lubdha, M, Shah, MD
Nicholas, Lazzaro, MD, Non ASSR Member
Richard, H, Wiggins, MD, Non ASSR Member
Ulrich, Rassner, MD, Non ASSR Member
Edward, Quigley, MD, PhD, Non ASSR Member

Paper/Non-Mentor

Purpose

To introduce a novel application of the real-time balanced steady state free precession (bSSFP) imaging for the evaluation of cervical spinal stenosis.

Methods & Materials

At our institution we have added bSSFP sequences to the degenerative cervical spine protocol (sagittal T1, T2, STIR and axial T2). The bSSFP parameters are as follows: field of view 280, phase anterior to posterior, phase 100, 10 mm slice, TR / TE 143.63 / 1.18, bandwidth 1395, temporal resolution 2 seconds, imaging time 2 minutes. All scans are performed on 1.5T or 3.0T MRI scanners with multi-channel head and neck coil. The patient is instructed to repeatedly flex and extend his/her head in a slow steady manner.

Results

Preliminary results suggest that the bSSFP images are vital in accurately demonstrating motion induced narrowing of the cervical spine in addition to statically visualized degenerative factors traditionally imaged (e.g. disc osteophyte complexes, ligamentum flavum redundancy, facet arthropathy). These sequences are supplementary to conventional MR sequences.

Conclusion

Static conventional MRI sequences can be suboptimal in demonstrating the positional causes of cervical spinal stenosis. This new application of bSSFP imaging reveals the dynamic factors previously unseen by utilizing currently available MRI scanners and software.

References/Financial Disclosures

No disclosures

General Spine

Sedat, Alibek, M.D.
Hubertus, Gloger, M.D., Non ASSR Member

Paper/Non-Mentor

Purpose

To study the value of a 3D T2w MR sequence in comparison to conventional 2D T2w sequences within a routine cervical and lumbar spine MR protocol with special focus on detectability of pathology (e.g. disc herniation, neuroforaminal or spinal stenosis) and scan time.

Methods & Materials

Istitutional review board apporval was obtained. A total of 30 patients (15 cervial, 15 lumbar spine MRIs) were examined with a routine sequence protocol approved by local medical authorities. The cervical spine protocol consisted of a sagittal T2w and T1w sequence (FOV 25×25 cm, Matrix 256×256, Slice Thickness: 3 mm, Gap: 0,3 mm), transverse T2w sequence and a coronal T2 STIR sequence (FOV 20×18 cm, Matrix 288×224, Slice thickness: 3 mm, GAP: 0,3 mm). The lumbar spine protocol consisted of a sagittal T2w, T1w and coronal T2 STIR sequence (FOV 30×30 cm, Matrix 512×256, Slice Thickness: 4 mm, Gap: 0.4 mm), and a transverse T2w sequence (FOV 24×24 cm, Matrix 384×256, Slice thickness: 4 mm, Gap: 0.4 mm). An additional 3D T2w sequence (CUBE: FOV 300×270 mm, Slice thickness 1,0 mm, Matrix 288×288) in sagittal orientation was used in all patients for study purposes. Two radiologists who were blinded for patient´s history retrospectively reviewed the images and compared detectability of pathologies in consensus. All 2D sequences were reviewed on a 2D DICOM viewer, 3D CUBE sequence was reviewed interactively on a 3D DICOM viewer.

Results

In all patients all MR sequences were performed succesfully and without significant motion artefacts. 3D CUBE sequence was equal in detection of all pathologies seen with conventional T2w/T1w sequences in routine protocols. Cervical spine: in 66,7% (n=10) of patients protrusion of a disc was depicted in the cervical spine. Disc extrusion, stenosis of unilateral neuroforamen, syrinx and dorsla displacement of anterior dura was seen in 6,7% (n=1) of patients. Lumbar spine: in 40% (n=6) of patients protrusion of a disc was depicted in the lumbar spine. Disc extrusion was seen in 26.7% (n=4), stenosis of unilateral neuroforamen was seen in 6,7% (n=1) of patients.
Total imaging time for conventional MR seuqences ranged between 14-17 minutes, 3D CUBE took about 4,5 minutes.

Conclusion

3D CUBE MR sequence seems to be feasible for use within a routine cervical and lumbar scan protocol. Detection of pathology is equal to conventional MR sequences. Given that medical authorities (esp. local insurance companies) accepted the use of this sequence, e.g. T2w sagittal and transverse sequence could be replaced and exam time could be saved without penalty in image quality.

Interventional Spine

Eric, M, Spickler, MD
Suresh, C, Patell, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

The ACGME and the radiology RRC require feedback mechanisms for trainees, both resident and fellow, which conform to the core competencies. We have created a series of multisource feedback forms and processes used during and after spine interventions which fullfill those requirements, and will describe them with this presentation.

Methods & Materials

We recognized the potential for using our busy spine intervention service as an effective clinical source for allowing trainee feedback from a variety of sources. Using the six core competencies as a basis, four feedback forms, including staff, allied professional (nurse/technologist), peer, and patient forms were created.

Results

For over a year, more than thirty trainees have been required to have five examples of each of the four forms completed and placed into their learning portfolios. This has created a rich data base for review of performance and self improvement through regular meetings with their program director.

Conclusion

Spine interventions bring many people into contact with trainees and are an ideal setting for providing multisource feedback. Our strategy has been very successful and gives excellent proof of evolving competency.

References/Financial Disclosures

acgme.org/rrc.diagnosticradiology

Interventional Spine

Walter, S, Bartynski, MD
William, E, Rothfus, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

The shape of the annular margin is a critical observation consistently used to characterize abnormality of the lumbar disk on CT and MR imaging studies. Abnormal disks also have internal features of annular derangement including radial annular defects (RD: radial annular tears, annular gaps) and annular degeneration (lamellar tears, annular fragmentation, peripheral annular tears.
The purpose of this study was to evaluate the correlation between disk margin shape and the features of internal disk derangement identified on post-diskogram lumbar CT in significantly painful disks encountered at provocation lumbar diskography.

Methods & Materials

Significantly painful disks were encountered at 207 levels in 140 patients (75 male, 65 female) studied by provocation lumbar diskography where intra-diskal lidocaine was administered to reduce the patientâ

Interventional Spine

Louis, A, Gilula, MD

Paper/Non-Mentor

Purpose

Introduction
Osteoporosis affects 27% of women over 65 years of age in the United States. Painful osteoporotic VCFâ

General Spine

Jeryl, C, Jones, DVM, PhD
Kenneth, H, Wong, PhD, Non ASSR Member
John, H, Rossmeisl, DVM, MS, Non ASSR Member
Karen, D, Inzana, DVM, PhD, Non ASSR Member
David, Geiger, DVM, Non ASSR Member
Rick, G., Sherry, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

Developmental malformation/malarticulation of the cranio-cervical region (CCMM) is a common cause of neck pain and neurologic dysfunction in small breed dogs such as Toy Poodles, Yorkshire Terriers, Chihuahuas, Pekingese, Maltese Terriers, Shih Tzus, and Cavalier King Charles Spaniels. [1-5] Static MRI studies often demonstrate more than one anomaly and the severity of MRI abnormalities does not consistently correlate with the severity of clinical signs. An improved technique for localizing and quantifying spinal cord injury would be of benefit for surgical planning in affected dogs. We have previously developed a positional CT technique for measuring flexion/extension changes in spinal relationships for dogs with lower back pain. [6] We have also developed a finite element analysis (FEA) technique for calculating stress (forces) and stretch/strain (deformation) in the spinal cord for human neurosurgery patients with instability of the upper cervical spine. In these patients, FEA identified spinal cord stress values that decreased following surgery for brainstem decompression. [7] This decrease was accompanied by a concordant decrease in neurological symptoms. The purpose of the study described in this report was to determine whether spinal cord stretch injury could be localized and quantified using positional CT and FEA in a dog with surgically-confirmed CCMM.

Methods & Materials

A 3-month old Maltese Terrier with neck pain and rear limb ataxia was evaluated using static MRI, positional CT, and FEA. Static MR images of the cranio-cervical region were acquired with the head extended relative the spine, using a 0.2 T MRI scanner. [VetMR, Esaote] Positional CT images of the cranio-cervical region were acquired using a 16-slice CT scanner [Aquilion, Toshiba]. The dog was positioned in lateral recumbency with the head extended relative to the spine, and isotropic CT images of the cranio-cervical region were acquired using 1 mm slice thickness. The head was then flexed relative to the spine and the scan was repeated. Mid-sagittal reformatted CT images of the spinal canal were created using image analysis freeware [OsiriX, v. 3.3.2], and the outline of the spinal canal was traced for flexion and extension scans. Outlines of the canal were digitized and input into a finite element analysis program, which computed the local tissue stress and stretch/strain based on the differences between flexion and extension.

Results

MRI demonstrated malformation/malarticulation of the atlanto-occipital and atlanto-axial junctions. (Fig. 1) The C2-3 vertebrae were fused. Ventral (anterior) displacement of the brainstem was seen at the level of the caudal (inferior) cerebellum and dorsal (posterior) displacement of the spinal cord was seen at the level of cranial (superior) C1. Positional CT images demonstrated a decrease in the angle between the basi-occipital bone and the C2 vertebra with spinal flexion versus extension. This created a fulcrum effect at the level of the C2 odontoid process. The degree of dorsal displacement of the C1 lamina relative to the foramen magnum increased with flexion versus extension. (Fig. 2) Finite element analysis from positional CT image data demonstrated that a peak stretch of 3.0 mm occurred in the dorsal portion of the C1-2 spinal cord when the spine was moved from extension to flexion. (Fig. 3) A color overlay of spinal cord stress ranges relative to a transverse slice of the C1-2 spinal cord demonstrated that the greatest stresses occurred in the mid-dorsal and mid-ventral portions. (Fig. 4) The dogâ