General Spine

Sri Preethi, Vagvala, MD
Meeta, Gajjar, MD, Non ASSR Member
Gleb, Gorelick, MD, Non ASSR Member
Surya, Nadimpalli, MD, Non ASSR Member

Poster

Purpose

Arteriovenous malformations of the spine are rare but clinically important entities. They require an accurate diagnosis as they can cause severe neurologic deterioration, potentially reversible myelopathy and even death if not recognized and treated appropriately. This educational exhibit will illustrate the various types of spinal arteriovenous malformations with emphasis on imaging and appropriate approaches to treatment.

Methods & Materials

1. Become familiar with the normal spinal cord vascular anatomy.
2. Review the anatomic and typical imaging features ( CT, MR, and spinal angiography) of each of the four types of spinal arteriovenous malformations.
3. Recognize the differences in epidemiology and clinical presentations of each of the four types of spinal arteriovenous malformations.
4. Review the current treatment options and prognosis.

Results

Arteriovenous malformations of the spine can be classified into four types: dural or peridural arteriovenous fistulas (Type I), spinal cord vascular malformations (Types II and III) and spinal cord arteriovenous fistulas (Type IV). MR is the imaging modality of first choice in suspected spinal vascular malformation and should be complemented by selective spinal angiography for proper categorization.

Dural AVF (Type I) occurs when a fistula develops between an arterial feeder to the venous circulation in the dural root sleeve. Dilated pial veins along the cord surface on MRI is a helpful distinguishing feature. Therapy is aimed at occluding the draining vein by embolization or surgical approach. Prognosis is good with early diagnosis and treatment, potentially preventing irreversible cord infarction.

Glomus AVM (Type II) consists of an intramedullary nidus, with feeding vessels draining into the coronal venous plexus. Compact segment of serpentine intramedullary flow voids on MRI can be a discriminating feature. It clinically presents with progressive myelopathy, often with periods of acute neurologic impairment, secondary to hemorrhage. Treatment involves initial embolization to reduce arterial steal and improve cord perfusion. Subsequent surgical removal of residual nidus is generally considered as recanalization can occur over time.

Juvenile AVM (Type III) are large, complex lesions, both intra and extramedullary in location with possible extraspinal extension, often arising from different cord levels. Given their size and vascular complexity, complete resection is generally not possible and prognosis is poor.

Perimedulary AVF (Type IV) occurs when fistulous connection is intradural but peri or extramedullary in location. Displacement of the spinal cord on MRI is a helpful distinguishing feature. Three subcategories have been recognized with appropriate different treatment approaches for each lesion.

Conclusion

Knowledge and recognization of the clinical and imaging features of spinal arteriovenous malformations is important in proper timely diagnosis and determination of appropriate treatment methods.

References/Financial Disclosures

1. Morris P. Practical neuroangiography. Philadelphia: Lippincott Williams & Wilkins; 2007: 373-378.
2. Krauss WE. Vascular anatomy of the spinal cord. Neurosurg Clin N Am. Jan 1999;10(1):9-15.
3. Krings T, Lasjaunias PL, Hans FJ, Mull M, Nijenhuis RJ, Alvarez H, Backes WH, Reinges MH, Rodesch G, Gilsbach JM, Thron AK. Imaging in spinal vascular disease. Neuroimaging Clin N Am. 2007 Feb;17(1):57-72. Review.
4. Krings T, Geibprasert S. Spinal dural arteriovenous fistulas. AJNR AM J Neuroradiol. 2009 Apr;30(4):639-48. Epub 2009 Feb 12.
5. Barrow DL. Intracranial Vascular Malformations. Park Ridge, Ill: American Association of Neurological Surgeons; 1990.

General Spine

Amish, H, Doshi, MD
Jonathan, Steinberger, MD, Non ASSR Member
Puneet, Pawha, MD, Non ASSR Member
Kapil, R, Desai, MD, Non ASSR Member
Thomas, P, Naidich, Non ASSR Member

Poster

Purpose

The educational exhibit will provide a review the spectrum of benign and malignant spinal bone tumors extending from the clivus to the sacrum. The exhibit will discuss bone tumors routinely seen in practice such as hemangiomas and metastatic disease, as well as, uncommon primary spinal bone tumors. The epidemiology, clinical symptoms and signs, and imaging characteristics of these tumors will be reviewed.

Methods & Materials

1. Review of bone tumors extending from the clivus to the sacrum
2. Review the imaging findings of these tumors and identify characteristics that differentiate tumors
3. Review the differential diagnosis of lytic spinal lesions, ivory vertebral body, vertebral plana

Results

Introduction

Tumors of the Clivus: Epidemiology, Clinical presentation, Imaging

Tumors of the Sacrum: Epidemiology, Clinical presentation, Imaging

Other Vertebral Tumors: Epidemiology, Clinical presentation, Imaging

Conclusion

There are a large number of bone tumors that occur in the spinal column from the clivus to the sacrum. This exhibit highlights the differences in these tumors based on location, epidemiology and imaging findings to help guide the radiologist to a narrowed differential diagnosis.

Interventional Spine

Rebecca, Wu, M.D.
Yun-An, Tseng, D.O., Non ASSR Member
Steven, Drexler, M.D., Non ASSR Member
Orlando, Ortiz, M.D., M.B.A., F.A.C.R., Non ASSR Member

Poster

Purpose

To review a series of consecutive image-guided percutaneous spine and paraspinal soft tissue biopsies with radiologic-pathologic correlation and present suggestions regarding sample acquisition in order to optimize pathologic evaluation and diagnosis.

Methods & Materials

A retrospective review of consecutive image-guided percutaneous spine and paraspinal soft tissue biopsies by a single operator was performed. A total of 83 cases from 2008 to the present were reviewed. Imaging guidance consisted of fluoroscopy or CT fluoroscopy.

All disc biopsies were performed with fluoroscopy and all cervical, sacral and rib biopsies were performed with CT guidance. Coaxial technique was utilized for all procedures in order to facilitate multiple lesion sampling (in order to increase specimen yield) when technically feasible and increase procedure efficiency and safety. 12-gauge trephine needles (Elson; Cook Inc.) were used for bone biopsy, 14- to 16-gauge cutting needles (Temno; Cook Inc.) were used for soft tissue cores, and 18- to 22-gauge needles were used for fine needle aspiration. All available pathology reports were reviewed for the pathologistsâ

General Spine

Christopher, A, Kidd, B. Eng
Rachael, L, Bosma, B. Sc, Non ASSR Member
Patrick, W, Stroman, Ph.D, Non ASSR Member

Poster

Purpose

Spinal cord functional magnetic resonance imaging (spinal fMRI) is the only non-invasive, in vivo means available to assess neuronal changes that occur as a result of injury. However, in order to achieve its clinical potential, characterization of the fMRI response in healthy subjects is needed to demonstrate the sensitivity and reliability of this technique. Previous studies have shown spinal fMRI capable of detecting a signal response corresponding to peripheral heating stimuli.1,2 More importantly, recent studies have indicated that the signal is correlated with the change in temperature, as opposed to the constant heat. Here we demonstrate the effects of changing the heating stimuli parameters on the functional responses in the spinal cord to determine the sensitivity of our method. We hypothesized that there would be a neuronal response corresponding to rising/falling of temperature with significantly stronger responses occurring in response to faster ramping stimuli, than slower heating stimuli.

Methods & Materials

Functional MRI studies of the spinal cord were acquired in healthy subjects using a signal enhancement by extravascular water protons (SEEP) fMRI protocol.1,2 To examine the neuronal activity thermal stimulation was applied in a block paradigm by means of a custom-made device to the anterior side of the right thumb targeting the C6 dermatome at a constant temperature of 44°C. Studies were conducted by applying stimuli with varying ramp speeds (2 or 9 sec), and durations (45 or 72 sec).

Results

Group analysis from all the participants was completed for each of the different stimulus protocols, with results showing areas of consistent neuronal activity appearing in the target activation region. As expected, stronger positive signal responses occurred when the shorter ramps were a part of the stimulus protocol. This effect is even greater when examining protocols that incorporate shorter ramps for heating compared to having brief cooling ramps. In contrast, when longer ramp speeds are applied for the heating there is a notable increase in negative responses.

Conclusion

The results demonstrate that with this method it is possible to detect differences in activity in the spinal cord in response to various varying stimuli. This has implications for the development of a practical clinical method for assessing spinal cord function by means of spinal fMRI.

References/Financial Disclosures

References
1. C.R. Figley and P.W. Stroman, Neuroimage, 44(2), 421(2009)
2. P. W. Stroman, et al., Magn Reson. Imaging 20(1), 1 (2002)

General Spine

Sedat, Alibek, MD
Hubertus, Gloger, MD, Non ASSR Member

Poster

Purpose

To study the value of a 3D T2w MR sequence in comparison to 2D T2w sequence for cervical/lumbar spine MRI with special focus on detectability of pathology and scan time.

Methods & Materials

IRB approved study, written informed patient consent available. A total of 30 patients (15 c-spine, 15 l-spine) were scanned on 1.5T MR scanner (HDXT, GE Medical) with sequence protocol approved by medical authorities/insurance companies (c-spine: sag T2 FSE/T1SE, tra T2*, cor T2 STIR; l-spine: sag T2 FSE/T1SE, tra T2FSE, cor T2 STIR) and additionally a sagittal 3D Cube (slice thickness: 1 mm) for c-/l-spine) was performed.
Images were reviewed retrospectively by two radiologists in consensus, both blinded for patient history with the question of detectability of pathology. 2D sequences were reviewed with a 2D DICOM viewer, the 3D Cube was reviewed on a 3D DICOM viewer in MPR-mode, interactively.

Results

All MR sequences were performed successfully without artefacts which lead to repetition of sequences or the complete exam. In l-spine exams n=6 (40%) disc protrusions, n=4 (26.7%) disc extrusions, n=1 (6,7%) stenosis of unilateral neuroforamen was found. In c-spin exams n=10 (66,7%) disc protrusions, n=1 (6,7%) disc extrusion, n=1 unilateral neuroforaminal stenosis, n=1 syrinx, n=1 dorsal displacement of anterior dura was found. Mean imaging time was 12 min 35 s for c-spine, while 3 min 37 s was necessary for 3D Cube sequence and 9 min 45 s for l-spine, while 4 min 41 s was needed for 3D Cube sequence. Regarding comparison of 3D Cube vs. T2/T1w imaging, all reported pathology was detected by readears in conventional as well as 3D sequence (n=25, 100%).

Conclusion

3D Cube sequence seems to be feasible technically for use within a routine c-/l-spine scan protocol, detection rates of pathology is equal to conventional MR sequences in our series.
If medical authorities (esp. local insurance companies) accepted the use of this sequence and MPR images, e.g. T2w sag/tra sequence could be replaced by 3D sequence, exam time could be saved without penalty in image quality. Further studies with special focus on quantitative assessment (e.g. SNR/CNR) with greater number of patients should be performed to confirm clinical value of initial results.

Interventional Spine

Orlando, Ortiz, MD, MBA
Allison, Rubin, MD, Non ASSR Member

Poster

Purpose

To illustrate the utility of a dual puncture technique to facilitate therapeutic lumbar epidural steroid injection

Methods & Materials

Several cases are demonstrated in which patients underwent fluoroscopy guided lumbar epidural steroid injection. In each case, the initial spread of contrast agent during epidurography into the lumbar epidural space was limited. In each case subsequent epidural steroid injection was not effective at alleviating back pain symptoms at 3 weeks. The procedure was then repeated using two separate puncture sites for epidural space access. Epidurography with a low osmolar nonionic contrast agent was performed to confirm a more satisfactory spread of contrast agent about the level of suspected pathology. This was followed by epidural steroid injection.

Results

Dual puncture lumbar epidural steroid injection was safely performed in all of the patients. Lumbar stenosis was present in 3 patients; post-surgical adhesions due to prior laminectomy were present in another patient. Each patient experienced a therapeutic benefit defined as greater than 3 point reduction in their numeric pain score.

Conclusion

Dual puncture interlaminar epidural steroid injection can be an effective technique in the management of patients with low back pain in situations where the distribution of medication into the epidural space may be compromised (due to stenosis, adhesions or anatomic variants in the epidural space) as demonstrated on epidurography.

References/Financial Disclosures

Ranson MT, Deer TR. Epidural injections for the treatment of spine-related pain syndromes. In Mathis JM, Golovac S (eds). Image-Guided Spine Interventions. 2nd edition. New York: Springer, 2010: 157-174
Financial Disclosures: O Ortiz â

General Spine

Joon Bum, Koo, M.D.
Jin Young, Lee, M.D., Non ASSR Member
Jeong Seok, Yeo, M.D., Non ASSR Member

Poster

Purpose

The purpose of this exhibit is to bony metastasis of HCC compared 18 F FDG PET CT with MR images. A 52 year old male was evaluated 18F FDG PET CT and follow up MRI after 2 month. Retrospectively reviewed subtle bony changes on PET CT without uptake, we were performed CT guided bone biopsy.

Methods & Materials

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Results

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Conclusion

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References/Financial Disclosures

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Interventional Spine

Sujin, Kim, DR
Joon Woo, Lee, Dr, Non ASSR Member
Heung Sik, Kang, Dr, Non ASSR Member
Mi Sook, Sung, Dr, Non ASSR Member
Ji Young, Hwang, Dr, Non ASSR Member

Poster

Purpose

Percutaneous vertebroplasty is one of the best therapeutic choices for many painful vertebral compression fractures that are secondary to osteoporosis, multiple myeloma, hemangiomas, and osteolytic metastasis. The purpose of this exhibit is to review what the radiologists basically need to know about percutaneous vertebroplasty.

Methods & Materials

Fluoroscopic images, preopearative MR images, and postoperative CT images were reviewed in the patients who were performed with percutaneous vertebroplsty at our hospital.

Results

1. To understand principle, indications, and contraindications of percutaneous vertebroplasty
2. To learn basic techniques for successful and safe percutaneous vertebroplasty
3. To review clinical results after percutaneous vertebroplasty
4. To show radiological findings of side effects and complications after percutaneous vertebroplasty

Conclusion

Percutaneous vertebroplasty could provide minimally invasive and relatively safe treatment, and significant pain relief, to properly selected patients with painful vertebral compression fractures

General Spine

GREGORY, E, PUNCH, MD
GREGORY, E, PUNCH, MD, Tripler AMC, Honolulu, Non ASSR Member
LYNNE, RUESS, MD, Nationwide Children’s Hospital, Columbus, OH, Non ASSR Member
RICARDO, BURGOS, MD, Tripler AMC, Honolulu, Non ASSR Member
MICHELLE, YOSHIDA, MS, Non ASSR Member

Poster

Purpose

Purpose: To describe the spectrum of MRI findings of lumbar paraspinal muscle atrophy and correlate with clinical history and other MRI findings to identify and illustrate the various causes of dennervation atrophy.

Methods & Materials

Material and Methods: Nine patients with MRI findings of paraspinal muscle atrophy were identified. The clinical history provided by the patient at the time of MRI and patient demographics were recorded. MRI findings were tabulated and illustrative images chosen for presentation.

Results

Results: Seven males and 2 females had a mean age of 38 years (range 17-75). Five of 9 patients had bilateral lumbar paraspinal muscle atrophy although it was symmetric in only 1. The associated abnormalities and etiologies included severe facet joint degenerative arthropathy either unilateral or bilateral, disc disease with compression, post rhizotomy, post laminectomy, gout and neoplastic compression of lumbar nerve roots.

Conclusion

Conclusion: Recognition of the spectrum of MRI findings of lumbar paraspinous muscle atrophy will alert the radiologist to various clinical entities that may not have been previously recognized.

References/Financial Disclosures

References:
1. Barker K, Shamley D, Jackson D. Changes in the Cross-Sectional Area of Multiï¬

General Spine

Rachael, L, Bosma, BSc.
Christopher, A., Kidd, B.Eng, Non ASSR Member
Patrick, W., Stroman, PhD., Non ASSR Member

Poster

Purpose

Diffusion tensor imaging (DTI) allows for the in vivo examination of the extent of damage to white matter microstructure which may enable the detection and diagnosis of subtle injuries or progressive changes and provide a means of monitoring the effects of therapeutic interventions (1). Despite its clinical potential, there are few studies that use this technique to explore the long-term changes in spinal cord structure after injury (2,3,4). The aim of this study was to characterize DTI indices, including fractional anisotropy (FA) and mean diffusivity (MD), during the chronic stages of spinal cord injury and to compare these indices with those from healthy controls. Furthermore, we aim to determine how anatomical measures relate to preserved function as measured by conventional clinical assessments (ASIA). We hypothesize that changes in diffusivity associated with structural alterations are a sensitive measure of the extent of the lesion and that there will be a strong relationship between structural integrity and sensory and motor function.

Methods & Materials

DTI data were acquired from patients with chronic cervical spinal cord injuries and healthy volunteers. Fractional anisotropy vs. mean diffusivity values were plotted and a k-means clustering method was applied to partition the data into three clusters. Clusters were attributed to white matter, grey matter and CSF. A t test was used to compare FA vs. MD distributions between the regions of the cord.

Results

Mean FA and MD values and ASIA scores are listed in Table 1. Compared to controls, all patients showed significant decreases in both the amount of restricted diffusion and in overall diffusivity, reflected by lower FA values and MD values respectively.

Conclusion

Results from this study further our understanding of the structural damage that results from spinal cord injury and how this damage relates to everyday functioning. These measures may be a valuable supplement to current clinical assessments and may provide greater insight to both physicians and patients in order to guide therapeutic efforts.

References/Financial Disclosures

1. LeBihan et al. Biophysical Journal. 1994; 66: 259-267
2. Shanmuganatha, K. et al. AJNR. 2008; 29: 655-659
3. Ellingson B.M. et al., AJNR. 2008; 29: 1279-1284
4. Ellingson B.M. et al. AJNR. 2008; 29: 1976-1982