Choy et al.

M u s c u l o s k e l e t a l I m a g i n g Te c h n i c a l I n n o v a t i o n
MRI of Thoracolumbar
Spine
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Axial Compression Frame for

MRI of Thoracolumbar Spine
Daniel S. J. Choy1 OBJECTIVE. Our objective was to present a method of performing thoracolumbar MRI
Gian Paolo Tassi2 with intervertebral disk pressure at 150 kPa without the patient being seated.
Richard B. Libes1 CONCLUSION. Spine MRI with compression is more physiologic and will produce a
Choy DSJ, Tassi GP, Libes RB higher yield than standard supine MRI.

ll MRI is performed on patients hardwood dowels. The patient and frame are then

A with suspected herniated disk dis-

Keywords: compression, lumbar spine, MRI, percutaneous
laser disk decompression, spine
DOI:10.2214/AJR.07.2033
Received February 8, 2007; accepted after revision
May 18, 2007.
1Laser Spine Center and Columbia University, 66 E 80th St.,
Suite 1A, New York, NY 10021. Address correspondence to
D. S. J. Choy (info@laserspinecenter.com).
2Casa di Cura Villa Anna, San Benedetto del Tronto,
Pescara, Italy.
AJR 2007; 189:11751178
0361803X/07/18951175
American Roentgen Ray Society
ease with the patient in the supine
position and is therefore nonphys-
iologic. Patients are generally most comfort-
able in the supine position and most uncom-
fortable in the standing or sitting position.
Nachemson and Morris [1] showed intradis-
kal pressure of the lumbar spine to average
1520, 100, and 150 kPa in the supine, stand-
ing, and sitting positions, respectively. Ide-
ally, then, patients with suspected herniated
disk disease should be imaged sitting, when
the intradiskal pressure is highest. In 1996,
Jolesz showed augmentation of disk protru-
sion during MRI in the sitting position com-
pared with one in the supine position (Jolesz
F, presented at the 1996 annual meeting of the
Laser Association of Neurosurgeons Interna-
tional) (Figs. 13). However, at the time, only
two MRI sitting scanners were available
worldwide, and they cost $5 million each.
To obtain the same physics benefits without
the expense, one of the authors designed and
built for $75 a wood compression frame that,
with a patient lying on the frame, would fit in
a standard MRI bore (Fig. 4). Its use is de-
scribed in the Materials and Methods section.
After 9 years of use, a more advanced, pro-
fessionally manufactured aluminum frame
with a pressure gauge was created (Fig. 5A).
The purpose of this article is to describe both
frames and their applications.
Materials and Methods
In the wood frame, the patient lies on the frame
with the knees flexed so that the axial dimension
from the shoulders to the feet is shortened by 4
inches (10 cm). The footplate is then fixed with
positioned in the MRI bore. MRI is performed
with the patients knees flexed (no compression),
then with the knees fully extended (axial com-
pression). This frame was used for more than 10
years in 143 patients.
In the aluminum frame, the patient lies on the
frame with the legs fully extended and the feet in
contact with the footplate. A shoulder harness
spreads the pressure over the shoulders and trape-
zius and is connected to the footplate with nondis-
tensible straps. Precompression MRI is performed.
Imaging under compression is achieved by a pump
mechanism shortening the distance between the
footplate and shoulder harness to raise lumbar in-
tradiskal pressure to 150 kPa.
MRI was performed on a 1.5-T unit (Signa, GE
Healthcare) using a standard surface coil. Sagittal T2
fast spin-echo sequences were obtained with and
without compression. The imaging parameters were
as follows: TR/TE, 4,000/170; 256 256 matrix; 4
signals averaged; 30-cm rectangular field of view;
and 5-mm slice thickness with a 1-mm gap. After ap-
plying compression, a sagittal fast spin-echo T1 se-
quence was performed to determine the superior off-
set required because of the patients change in
position. All other parameters remained the same.
A radiologist identified any bulging or herniated
disks and compared qualitatively the degree of pro-
trusion between compressed and noncompressed im-
ages. In addition, any change in the patients symp-
toms was recorded after the compression sequence.
Ten patients about to undergo percutaneous laser
disk decompression had 18-gauge needles inserted
into their L4L5 disks under aseptic conditions
with local anesthesia and C-arm monitoring. The
patient demographics were seven men, age range,
2764 years; and three women, age range, 3975
years. There were disk herniations of L4L5 in

AJR:189, November 2007 1175

 Choy et al.

plastic tubing 4 mm in diameter (Rilsan PA 11 DIN

74324 ATM 66; 2.8 mm in lumen diameter, Om-
nexus). Data were obtained with ascending and then
descending readings of intradiskal pressures at inter-
vals of 30 kPa from 20 to 230 kPa, and corresponding
footplate pressures were expressed in psi. Thus, it
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was possible to obtain two curves with each patient.

One of the authors (height, 162.6 cm; weight, 59
kg) volunteered for the first compression in the alu-
minum frame with 189 lb (85.91 kg) footplate pres-
sure (equivalent to 150 kPa in L4L5).

Results
Two models were fit to obtain estimates for
footplate pressure as a function of intradiskal
pressure. In the first model, footplate pressure
Fig. 1MR image in patient having symptoms Fig. 2MR image of patient in Figure 1 obtained 5 was fit as a quadratic function of the kPa
compatible with L5S1 disk herniation shows slight minutes later. Note increased protrusion of disk value. In the second model, the log10 of foot-
bulge (arrow) of L5S1 disk. (Reprinted with permission (arrow). (Reprinted with permission from Choy DSJ.
from Choy DSJ. Percutaneous laser disc Percutaneous laser disc decompression: a practical plate pressure was fit as a quadratic function
decompression: a practical guide. New York, NY: guide. New York, NY: Springer-Verlag, 2003:126127 [5]) of kPa value. For the second model, estimates
Springer-Verlag, 2003:126127 [5]) of the footplate pressure at the 150 kPa value
were back-transformed.
The following estimates were obtained for
Fig. 3Sitting MRI kPa equal to 150. For the area of interest, the
scanner (Flexview 8800,
GE Healthcare) with quadratic model appeared to fit somewhat
which image in Figure 2 closer to the observed means than the log10
was produced. model: The quadratic model estimate was
(Reprinted with
permission from Choy 189.4 and the 95% CI was 178.4200.3. The
DSJ. Percutaneous laser log10 model estimate was 199.0 and the 95%
disc decompression: a CI was 187.5211.2. The composite curves
practical guide. New
derived from the intradiskal and footplate
York, NY: Springer-
Verlag, 2003:126127 [5]) pressure study are seen in Figure 6.
Representative MR images of patients with
and without axial compression with the wood
frame are seen in Figures 7 and 8. The control
(noncompression) and compression MR im-
ages are shown. An increase of disk bulging
with compression can be seen. Testing the
aluminum frame in a GE Healthcare MRI ma-
chine (Flexview 8800) at 1.5 T produced no
effects on the T2 image.
With the wood frame (n = 143 patients), 70
(49%) patients reported exacerbation of back
or sciatic pain, and in 32 (22%), there was ob-
servable augmentation of disk herniation. In 48
(30%), there was an increase of symptoms
without a change in imaging. In 10 (7%), there
was an increase in imaging but no change in
symptoms, In 22 (15%), there were both an in-
crease in symptoms and an increase in imag-
ing. Six patients could not be compressed be-
Fig. 4First axial compression frame built of hard marine-grade plywood, with shoulder restraints and a movable cause of body habitus. In the 10 years of
footboard with hardwood dowel fixation. (Reprinted with permission from Choy DSJ. Percutaneous laser disc performing spine MRI under compression, no
decompression: a practical guide. New York, NY: Springer-Verlag, 2003:126127 [5])
neurologic complications occurred.
At 189-lb (85.91-kg) footplate pressure,
seven, L5S1 in two, and L3L4 in one. The pa- With the patient in the frame, a needle was filled our volunteers height (162.56 cm) shortened
tients heights ranged from 1.6 to 1.8 m, and with sterile saline and connected to an IC912/VI pres- by 1.3 cm (0.8%). No symptoms were re-
weights ranged from 58 to 73 kg. sure gauge (Eliwell-Invensys) with nondistensible ported. T1 and T2 images showed no change.

1176 AJR:189, November 2007

 MRI of Thoracolumbar Spine

Fig. 5Compression
Frame for MRI of
Thoraco-Lumbar Spine
(Steven Weiburg, Inc.).
A, Pressure gauge is
calibrated in kPa of disk
pressure.
B, Overall view of
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compression frame with

vest connected to
footplate to evenly
distribute pressure.

A B

Fig. 6Graph shows composite curves for observed means of intradiskal pressure
272.16 (kPa) and corresponding footplate pressure (kg). In lumbar disk, 150 kPa corresponds
to 189 lb (85.91 kg) of foot pressure. Black line = raw means, short dashed line =
226.80 quadratic model, long dashed line = log model.
Footplate Pressure (kg)

181.44

136.01

90.72

45.34

0
0 50 100 150 200 250
Intradiskal Pressure (kPa)

A B
Fig. 7Representative MRI of lumbosacral spine.
A and B, Sagittal T2 images obtained with wood frame. A was obtained without compression and B was obtained with compression. Marks indicate disk bulges.

Discussion
When herniated disk disease is suspected in
a patient, it is obvious that the optimal MRI
should be performed under conditions when
the patient experiences the most pain, and this
is either in the sitting or standing position. MRI
performed in the supine position, when the pa-
tient is most comfortable and the intradiskal
pressure is lowest, is nonphysiologic.
It has been our experience that many equiv-
ocal MRI examinations can be converted to
positive examinations with axial compres-
sion. Moreover, there is a bonus in that many
patients report exacerbation of their sciatic
pain. In this respect, the frame confirms the
origin of the patients pain as diskogenic.
Although the aluminum frame is new and
no extensive experience has been obtained

AJR:189, November 2007 1177


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Fig. 8Representative MRI of lumbosacral spine.
A and B, Sagittal images obtained with aluminum frame. A was obtained without compression and B was obtained with compression. Marks indicate disk bulges.
with it, it is superior to the wood frame in that,
based on in vivo data, we can obtain targeted
lumbar intradiskal pressures of 150 kPa. We
expect to obtain similar if not superior data
with this frame. The intradiskal pressures can
be achieved and are reproducible.
Shortening our volunteers height by 1.3 cm
with 189-lb (85.91-kg) footplate compression
with the aluminum frame represents a change
of 0.8%. This is within the range reported by
Kimura et al. [2] in patients axially loaded with
50% body weight. Probably contributing to
this shortening are compressive changes in the
knee, hip, and sacroiliac joints. It can be ex-
trapolated that intervertebral disk compression
contributes to total change. Axial compression,
by augmenting the image of disk protrusion
and reproducing the patients pain pattern, can
provide the spine surgeon with additional data
to justify an interventional procedure.
Our central thesis that axial spine compres-
sion during MRI can contribute to the overall
evaluation of the patient with suspected disk
herniation disease is confirmed by prior work
by Danielson et al. [3] and Hargens et al. [4].
1178
Choy et al.
A B
We dispute the use by Kimura et al. [2] of
50% of the patients body weight based on ca-
daver studies as a clinically meaningful com-
pression of the lumbar disks. We believe that
our actual measure of disk pressure in kPa
confers a greater degree of accuracy.
The second-generation aluminum compres-
sion frame with a pressure gauge has obvious
advantages over the original wood frame and
will now serve as our instrument of choice for
both thoracolumbar spine MRI and CT in pa-
tients with suspected herniated disk disease.
In conclusion, in our experience over a pe-
riod of 10 years, we have found axial com-
pression MRI of the thoracolumbar spine in
cases of suspected herniated disk disease to
be useful in generating more meaningful di-
agnostic data in terms of augmentation of disk
bulge and reproducing pain patterns. It has
been completely safe. There are sufficient sci-
entific and clinical bases for these results. The
new aluminum frame does not affect the MR
images. We believe all MRI and CT of the
spine in suspected herniated disk disease
should be performed with axial compression.
References
1. Nachemson A, Morris JM. In vivo measure-
ments of intradiskal pressure: discometry, a
method for determination of pressure in the
lower lumbar discs. J Bone Joint Surg Am 1964;
46:10771092
2. Kimura S, Steinbach GC, Watenpaugh DE,
Hargens AR. Lumbar spine disc height and
curvature responses to an axial load generated
by a compression device compatible with
magnetic resonance imaging. Spine 2001; 26:
25962600
3. Danielson BI, Willen J, Gaulitz A, Niklason T,
Hansson TH. Axial loading of the spine during CT
and MR in patients with suspected lumbar spinal
stenosis. Acta Radiol 1998; 39:604611
4. Hargens AR, Hutchinson KJ, Ballard RE, Mur-
thy G. Intervertebral disc: loaded on earth and
unloaded in space. In: Reed R, Rubin K, eds.
Connective tissue biology, vol. 7, Integration
and reductionism. London, United Kingdom:
Portland Press, 1998
5. Choy DSJ. Percautaneous laser disc decompres-
sion: a practical guide. New York, NY: Springer-
Verlag, 2003:126127
AJR:189, November 2007