Journal of Manipulative and Physiological Therapeutics

Volume 23 Number 7 September 2000

0161-4754/2000/$12.00 + 0 76/1/108819 2000 JMPT

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MRI of the Spine and Spinal Cord: Imaging Techniques, Normal Anatomy, Artifacts, and Pitfalls
Claude Pierre-Jerome, MD, PhD,a Arzu Arslan, MD,b and Svein Ivar Bekkelund, MD, PhDc

ABSTRACT

the appropriate combination of the sequences

takes advantage of the different tissue characteristics to discriminate the various bonyand soft-tissue structures of the spine.
Conclusion: MRI enables the imaging specialist to evaluate a large anatomic region
in multiple planes and can better examine
the spinal cord. (J Manipulative Physiol Ther
2000;23:470-5)
Key Indexing Terms: Magnetic Resonance
Imaging; Spine; Spinal Cord

Background: Magnetic resonance imaging

(MRI) is widely used to evaluate the spine and
spinal cord.
Objective: In this article, MRI of the spine is
discussed in terms of normal anatomy, standard and advanced imaging techniques, general
indications, limitations, and potential for the
future.
Discussion: Although MRI does not provide the
high bony detail possible with computed tomography,

INTRODUCTION
The analysis of magnetic resonance imaging (MRI) of the
spine requires a thorough knowledge of normal anatomy and
film-reading experience. The variety of structuresbones and
soft tissuesin the anterior and posterior aspects of the spine
account for the risk of misdiagnosis by general radiologists
and trainees. For these structures to be well-identified along
with their anatomic variants, the acquisition of high contrast
and spatial resolution images is indispensable. Therefore an
appropriate selection of image sequences and sequence parameters is necessary when the spine is examined with MRI,
which consequently reduces the risks of misinterpretation
among readers of MRI because diagnostic accuracy will
improve. The advent of the recent technical developments in
magnetic resonance myelography and magnetic resonance
diffusion weighting has enhanced the sensitivity of MRI as an
imaging modality. This article presents an overview of magnetic resonance imaging of the spine, with emphasis on the
technical possibilities, normal anatomy, variants, and pitfalls.

Department of Radiology, Ullevl Hospital, Oslo, Norway.

Department of Radiology, Ullevl Hospital, Oslo, Norway.
c
Department of Neurology, Troms University Hospital,
Troms, Norway.
Submit reprint requests to: Dr Clause Pierre-Jerome, Ulleval
University Hospital, MRI Section, Kirkeveien 166, 0407 Oslo,
Norway; cpierrejerome@netscape.net.
Paper submitted October 26, 1999.
b

doi:10.1067/mmt.2000.108819

DISCUSSION
Normal Magnetic Resonance Anatomy
MRI images the spine and spinal cord in a direct, multiplanar fashion. The brain stem, thecal sac, and spinal cord
are particularly well-seen on mid-line sagittal images. The
conus medullaris can be identified with midsagittal or
parasagittal images (Fig 1, Left). Alignment of the spine is
evaluated primarily in the sagittal plane.1
In T1-weighted images, the cortical bone of the osseous
structures of the spine has a low signal intensity (SI) that
contrasts with the moderately high SI of the bone marrow,
reflecting the fat in the medullary bone (Fig 1, Left). Bone
marrow has intermediate SI on T2-weighted images.2-4
Cerebrospinal fluid (CSF) and cortical bone are usually difficult to distinguish from each other on T1-weighted spinecho (SE) images, whereas on T2-weighted images the cortical bone and CSF in the subarachnoid space are easily
separated by the SI of CSF2,3,5 (Fig 1). Areas of increased SI
in T1-weighted images in vertebral bodies can occasionally
be seen throughout the spine as a normal variant. Another
normal variant is the cupids bow, which is seen as an
increased concavity of the end-plate, usually in lower lumbar vertebral bodies.6 The osseous spinal canal contains the
epidural space, dural sac, subarachnoid space, spinal cord,
and cauda equina. In T1-weighted images, fat in the epidural
space contrasts with the cortical bone of the vertebral body
and with the lower SI veins within the epidural fat (Fig 2).
The facet joints in the spine vary in appearance and orientation according to the vertebral level. The superior and inferior articular surfaces of the joints are lined by hyaline cartilage, which is seen as a thin hyperintense region in
T2-weighted images and particularly well-differentiated from
the subjacent bone with gradient-echo (GE) imaging (Fig 3,
Right).

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MRI of the Spine Pierre-Jerome et al

Fig 1. Midsagittal view. Left, T1-weighted fast spin echo (TR/TE: 500/12). Right, T2-weighted inversion recovery (TR/TE/TI:
2000/70/150) images. 1, Spinal cord; 2, conus medullaris; 3, anterior longitudinal ligament; 4, ligamentum flavum; 5, posterior epidural
fat space; 6, anterior epidural fat space; 7, intranuclear cleft; 8, basivertebral vein; 9, annulus fibrosus; 10, nucleus pulposus.
The main ligaments of the spine include the anterior and
posterior ligaments and the ligamentum flavum. The anterior longitudinal ligament has a low SI that is not easily distinguished from the cortical bone of the vertebra. The posterior
longitudinal ligament can be distinguished in midsagittal
images and better visualized in GE images. The ligamentum
flavum is identified as a broad band of low SI that fills the
space between adjacent laminae. Its low signal enables it to
be distinguished from the surrounding fat1,3 (Fig 1, Left).
The spinal cord can be differentiated from CSF on either
T1-, T2-, or T2*-weighted images. Differentiation of gray
from white matter structures is even better perceived on GE
and on some proton density images than on SE T1- and T2weighted images. The spinal cord normally terminates at the

L1 to L2 vertebral level. The relatively hyperintense conus

medullaris is readily separated from the less intense cauda
equina on T1-weighted images, which are not separable on
T2-weighted images. The nerve roots can be distinguished
from the surrounding fat as a linear low SI structure on either
T1- and T2-weighted images (Fig 2).
The intervertebral disks, which are thinner at cervical and
thicker at lumbar levels, are well-demonstrated on MRI. On
T1-weighted MRI, the annulus fibrosus and the nucleus pulposus in the disk have a moderate SI compared with low SI
of Sharpeys fibers in the periphery of the disk. On proton
density or T2-weighted images, fibrocartilage in nucleus
pulposus and annulus fibrosus has. high SI, and Sharpeys
fibers have low SI. A dark signal zone within the central

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Fig 2. Axial T1-weighted fast spin echo (TR/TE: 600/9) images through the L4 vertebra corpus (Left) and the L4-L5 disk (Right). 1,
Anterior longitudinal ligament; 2, psoas muscle; 3, nerve root; 4, epidural veins; 5, lamina; 6, cauda equina; 7, nerve exiting through
neural foramen; 8, facet joint; 9, epidural fat; 10, spinous process; 11, inferior articular process; 12, superior articular process.

A
B
Fig 3. Axial T2-weighted gradient echo (TR/TE/flip angle: 500/14/20) images through the C3 vertebra corpus (Left) and the C2-C3 disk
(Right). The disk is higher in signal compared with the vertebral body. Hyaline cartilage (arrow) lining the facet joints is well-appreciated.

high signal of the disk represents the fibrous plate in the

nucleus pulposus, which is a normal finding after the third
decade of life (termed the intranuclear cleft).6 In GE
imaging, the disk is much brighter compared with the adjacent hypointense vertebrae (Fig 3, Right). The disk substance
may herniate through the cartilaginous plate of the intervertebral disk into the body of the adjacent vertebra (Fig
4), or a Schmorls node, the pathogenesis of which may

be developmental (ie, a normal variant) or may be caused

by degenerative processes.7 General indications of MRI in
the spine and spinal cord are developmental disorders,
infectious and inflammatory processes, neoplastic disease, metabolic and endocrine diseases, trauma, degenerative diseases, demyelinizing diseases of the spinal cord,
vascular disorders, and arteriovenous malformations of
the spinal cord.

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Imaging Techniques
A phased-array spinal coil rather than a surface coil should
be used to improve spatial resolution. The minimum slice
thickness (usually 3 mm) and at least 192 phase-encoding steps
(192 256 matrix) should be used to minimize artifacts.8 The
standard protocols in our institution for certain common
pathologic conditions are summarized in Table 1. The traditional series includes axial and sagittal T1-weighted and sagittal
T2-weighted images with the SE, GE, or FSE technique.9 In
most cases, a combination of 3 SE techniques (short TR, long
TR/TE, and long TR/short TE) provides a diagnostic examination of the spine.2 Advantages of the routine T1-weighted
SE series are that they provide good anatomic detail of the
spinal column and the cord, separate from CSF and the
extradural structures; yield images with high SNR within a
relatively short examination time (4 to 6 min); supply additional
information about the vertebral body marrow and reactive
changes along the end plates in degenerative disease; and are
least susceptible to local field inhomogeneities.10 Axial T1weighted series have the additional advantages of better identification of the lumbar nerve roots within the thecal sac.2
Chemical shift MRI techniques improve the ability to discriminate SI alterations on T1-weighted images as being
related to replacement of fatty marrow and increased water
content caused by abnormal soft tissue.4
T2-weighted SE series is time-consuming and therefore
used when clinical suspicion of intramedullary disease or diskspace infection and osteomyelitis caused by the high sensitivity
to the higher water content of pathologic tissues.10,11 Today,
T2-weighted SE series is almost replaced by T2-weighted
short inversion time inversion recovery (STIR) sequences.
STIR appears especially useful for the evaluation of red marrow, where contrast between normal and infiltrated marrow is
greater than with either GE or T1-weighted images. STIR is
also extremely sensitive for evaluation of infections, including
soft-tissue extent. Limitations of STIR include artifacts, in particular motion artifact, that necessitate motion compensation at
high field strength. In addition, because of extreme sensitivity
to water content, STIR may overstate margins of a marrow
lesion. With these limitations in mind, STIR is an effective
pulse sequence for evaluation of marrow abnormalities.12
GE images are an important supplement to SE images.3,10
Low and intermediate flip angles are used for the cervicothoracic and lumbar spines, respectively.10,13 In addition
to the advantages of rapid acquisition times and the ability to
be used in a three-dimensional (3-D) mode, axial GE series
provide more information than the axial T1-weighted SE
studies of the cervical and thoracic spine, especially in the
evaluation of foraminal stenosis.10
Whereas nonenhanced T1- and T2-weighted series usually
localize the abnormality, gadolinium-diethylenetriaminepentaacetic acid administration provides greater diagnostic
specificity by the presence and absence of enhancement.14
Contrast enhancement is helpful to distinguish the tumor
nidus from the surrounding edema, intratumoral cysts and
necrosis, or adjacent syrinx; to provide some information of
tumor vascularity10,15; to differentiate neoplastic from

Fig 4. Sagittal T1-weighted image through thoracolumbar vertebral

level. Schmorls nodes in 3 consecutive disks. The lowermost disk
is normal.

inflammatory processes, especially important in otherwise

isointense widely spread lesions; and to distinguish postoperative
scar tissue from a nonenhancing recurrent disk protrusion.10
In magnetic resonance of the cervical spine with 3-D
Fourier transform (FT) GE sequence, there are drawbacks
because of increased sensitivity to magnetic field inhomogeneity, magnetic susceptibility differences, chemical shifts,
pulsatility, and motion artifacts as a result of long acquisition times.5,16 Turbo field-echo (FE) imaging with a flip
angle sweep at the beginning of every shot allows fast GE
imaging, thus reducing image artifacts.5,17 Preparation modules
including inversion and chemical shift preparatory pulses
have been coupled to a turbo FE sequence to improve tissue
contrast or to suppress specific tissues.5,18 The myelographic
effect in 3-D FT GE imaging can be improved by applying
an off-resonance magnetization transfer prepulse, but this
technique has a limitation in terms of signal loss from tissues
sensitive to magnetization transfer.5,19,20 Melhem et al5
achieved a 4-fold improvement in the myelographic effect
with coupling of magnetization transfer prepulse to a 3-D
FT multishot turbo FE sequence. T2-weighted SE techniques for evaluation of intrinsic spinal cord abnormalities
are superior to gradient-recalled, echo-based techniques and
magnetization transfer prepulsed 3-D FT turbo FE techniques. However because of the good myelographic effect,
the turbo FE technique is helpful in evaluation of spondylotic
disease.5,21

Artifacts
Chemical shift artifacts in the direction of frequency
encoding arise from the bone marrow and epidural and

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Journal of Manipulative and Physiological Therapeutics

Volume 23 Number 7 September 2000
MRI of the Spine Pierre-Jerome et al

Table 1. Standard protocol for MRI of spine routinely used in Ullevl Hospital
Pathology
Disc prolapsus, T2 FFE
Medullary compression trauma
Metastases TSE
Tumor
Infection
Syrinx
Degenerative spine TSE

Technique
Sag 8:26 am T1 TSE, sag T2 TSE, tra
Postcontrast sag and tra T1 TSE for postoperative patients
Sag T1 TSE, sag STIR T2, tra T1
Sag T1 TSE, sag T2 TSE, postcontrast sag, and tra T1 TSE
Sag T1 TSE, sag T2 TSE, postcontrast sag, and tra T1 TSE
Sag T1 TSE
Sag T1 TSE, sag STIR T1, tra T1, tra T2

Sag, Sagittal; tra, transverse; STIR, short inversion time inversion recovery.

intradural fat and tend to be more prominent with higher

field-strength units. This artifact can be minimized by
increasing the band width with fat-suppression techniques
or reversing the frequency encoding direction.8,22
Ghost artifacts in the direction of phase encoding are
induced by motion because of respiration, flowing blood,
CSF pulsation, and swallowing and tend to be more prominent with lower field strength and admission of contrast.
These artifacts can be reduced by increasing the number of
signals acquired, reversing the phase-encoding axis, applying
presaturation pulses, gating, and flow compensation and
gradient moment nulling.8,23,24
Magnetic susceptibility artifacts occur within the trabecular
bone or at bonesoft-tissue interfaces, and are more evident
with GE sequences. These artifacts can be minimized with
thin slice thickness, short TR and TE, and a small flip angle.8
Metal artifacts may arise from surgical implants, foreign
bodies, and clothing and tend to be larger in GE and more
prominent in conventional SE versus fast SE techniques.8,24
Saturation artifacts, phase wrap-around artifacts, truncation
artifacts, radio-frequency interference, and shading artifacts
occur because of improper protocol planning and can easily
be corrected.8

Pitfalls and Limitations

MRI exquisitely demonstrates spine pathology; however,
artifacts and normal anatomic variants can mimic significant
pathologic conditions. Care must be taken to evaluate the true
midline scan before diagnosing degenerative disk disease
because the parasagittal scan (caused by partial volume averaging of the nucleus pulposus and annulus fibrosus) may suggest disk degeneration. In the presence of spondylolisthesis,
an erroneous diagnosis of disk protrusion may be made.
When scoliosis is present, it should be identified on anteroposterior examination to avoid mistakenly interpreting central
canal abnormalities on parasagittal images.6 Because of
magnetic susceptibility artifacts, the bone may appear larger
than it really is, which can be misread as foraminal stenosis.
Areas of CSF or bone may appear thickened because of truncation artifact and may be misinterpreted as spinal cord
atrophy or compression.8 A limbus vertebra, which is a normal
variant, may be misdiagnosed as an avulsion fracture.
The cost of MRI is still the most important limitation to
its widespread use. Calcifications and cortical bone produce
no magnetic resonance signal, and this remains a potential

shortcoming of MRI when compared with radiographic

techniques.1 In addition, certain patients, such as patients
with cardiac pacemakers, ferromagnetic aneurysm clips, other
ferromagnetic implants, and intraocular metallic foreign
bodies, cannot be examined by MRI.10

CONCLUSION
MRI has been used for guidance of interventional procedures.26 Because of technical limitations, frameless magnetic resonance-guided procedures with conventional closed
magnets are being replaced by C-arm, open-configuration
magnets with in-room image-monitoring capabilities, which
allowed greater patient access and monitoring, more rapid
temporal resolution, short procedure time, and interactive
guidance of image acquisition.26,27 Future directions are
toward improving the speed of magnetic resonance-guided
procedures by using higher speed techniques such as keyhole imaging, singular valve decomposition, wavelet encoding, 29and echoplanar imaging.27-29 The Baur et al30 study
recently introduced diffusion-weighted MRI of the bone
marrow. Diffusion-weighted MRI reflects the free mobility
of water molecules in interstitial tissue expressed as the diffusion coefficient. Although this technique seems to be
promising, further studies with a wide series of patients are
necessary. Tomczak et al31 described magnetic resonance
epidurography with Gd-diethylenetriaminepentaacetic acid
as a new imaging tool. They achieved superior results compared with conventional and computed tomographic
epidurography. However because of high costs, this technique is presently not suitable for routine use. Functional
imaging, such as CSF flow studies, also may play a significant role in the near future.

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