Acta Radiologica

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Value of Perineural Edema/Inflammation Detected

by Fat Saturation Sequences in Lumbar Magnetic
Resonance Imaging of Patients with Unilateral
Sciatica

M. Şirvanci, B. Kara, C. Duran, E. Ozturk, O. Karatoprak, L. Onat, O. L. Ulusoy

& A. Mutlu

To cite this article: M. Şirvanci, B. Kara, C. Duran, E. Ozturk, O. Karatoprak, L. Onat, O. L. Ulusoy
& A. Mutlu (2009) Value of Perineural Edema/Inflammation Detected by Fat Saturation Sequences
in Lumbar Magnetic Resonance Imaging of Patients with Unilateral Sciatica, Acta Radiologica,
50:2, 205-211

To link to this article: https://doi.org/10.1080/02841850802620671

Published online: 09 Jul 2009.

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 ORIGINAL ARTICLE ACTA RADIOLOGICA

Value of Perineural Edema/Inflammation Detected by Fat Saturation

Sequences in Lumbar Magnetic Resonance Imaging of Patients with
Unilateral Sciatica
M. ŞIRVANCI1, B. KARA2, C. DURAN1, E. OZTURK3, O. KARATOPRAK4, L. ONAT2, O. L. ULUSOY2 &
A. MUTLU2
1
Department of Radiology, Faculty of Medicine, Istanbul Bilim University, Istanbul, Turkey; 2Department of
Radiology of Florence Nightingale Hospital; 3Department of Radiology, GATA Haydarpasa Teaching Hospital,
Istanbul, Turkey; 4Department of Orthopeadic Surgery; Kadikoy Florence Nightingale Hospital, Istanbul, Turkey

Şirvanci M, Kara B, Duran C, Ozturk E, Karatoprak O, Onat L, Ulusoy OL, Mutlu A.

Value of perineural edema/inflammation detected by fat saturation sequences in lumbar
magnetic resonance imaging of patients with unilateral sciatica. Acta Radiol
2009;50:205
211.
Background: Routine lumbar spine magnetic resonance imaging (MRI) may not show
any evidence of the cause of sciatica in some cases. The relationship between nerve root
compression detected on lumbar MRI and sciatica is also sometimes uncertain.
Purpose: To ascertain whether axial (and, when necessary, sagittal and coronal) short-tau
inversion recovery or fat-saturated T2-weighted MRI findings can be used to study the
level of sciatica in patients with a non-yielding routine MRI examination.
Material and Methods: A total of 215 patients with unilateral sciatica underwent MRI.
All patients were asked to complete pain drawing forms describing their pain
dermatomal distributions. Perineural edema/inflammation corresponding to the pain
location indicated by the pain drawings was sought on short-tau inversion recovery or
fat-saturated T2-weighted images.
Results: Routine MRI findings revealed that 110 of the 215 patients had nerve root
compromise related to the patients’ symptoms. Routine MRI could not ascertain the
cause of these symptoms in the remaining 105 patients. In 31 (29.5%) of these 105
patients, short-tau inversion recovery or fat-saturated T2-weighted magnetic resonance
images revealed perineural edema/inflammation surrounding the nerve roots related to
the pain locations indicated in the pain drawings.
Conclusion: Axial (and, when required, sagittal and coronal) short-tau inversion recovery
or fat-saturated T2-weighted magnetic resonance images may be helpful for revealing
additional findings in cases of unexplained sciatica in standard magnetic resonance
imaging. However, the value of this imaging may be not great enough to justify routine
use of these additional sequences to study the level of sciatica.
Key words: Fat saturation; lumbar spine; magnetic resonance imaging; pain drawing;
sciatica; short-tau inversion recovery
Mustafa Sirvanci, Mesa Avrupa Konaklari, K:1, No:A/9/6, Altunizade, 34662 Istanbul,
Turkey (tel. 90 (0216) 651 92 73, fax. 90 (0216) 651 92 74, e-mail. sirvanci@
ttmail.com/sirvancim@yahoo.com.tr)
Accepted for publication November 7, 2008

The pain mechanisms in sciatic patients with disc
herniation detected on magnetic resonance imaging
(MRI) are not fully understood (1). Routine MRI
examination for patients with sciatica with and
without low back pain frequently fails to discover
the source of sciatica. Other pain mechanisms that
cannot be shown by classical MRI may be respon-
sible for symptoms and signs in sciatic patients. In
order to overcome this problem, several contrast-
enhanced MRI studies have been performed (2
4).
Toyone et al. reported that contrast-enhanced MR
images showed an enhancement of the symptomatic
nerve roots under compression by lumbar disk
herniation in patients with unilateral sciatica (5).

DOI 10.1080/02841850802620671 # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
206 M. Şirvanci et al.
In lumbar spine MRI, short-tau inversion recov-
ery (STIR) or fat-saturated T2-weighted sequences
are not used routinely. The purpose of this study
was to assess the value of axial (and, when required,
sagittal and coronal) STIR or fat-saturated T2-
weighted MR images in the diagnosis of sciatica for
pain mechanisms other than nerve root entrapment.
Material and Methods
From October 2006 to September 2007, 242 patients
were referred for MRI of the lumbar spine with an
episode of pain radiating into the leg, clinically
diagnosed as sciatica. Patients with a history of
previous surgery of the lumbar spine or lumbar
epidural steroid injection were excluded. A total of
16 patients were excluded because of previous spinal
surgery or epidural steroid injection and persistent
radiculopathy. All patients underwent MRI exam-
ination of the lumbar spine. Before undergoing
MRI examinations, all patients completed pain
drawing charts. No assistance was provided, other
than an aid for correct indication of the side of
unilateral pain on the drawings. A total of 11
patients with unusual pain drawings not corre-
sponding to a specific dermatome distribution
were excluded. Thus, the study population consisted
of 215 patients. The sample of the study included
patients with unilateral sciatica both with and
without low back pain. Every patient recorded
his/her leg pain using a 10-point visual analog scale
(VAS), where 0 represents no pain at all and 10
unbearable pain. The average age of the study
population was 51.7 years (age range 23
83 years).
The patients included 126 (59%) women and 89
(41%) men. The period between the onset of
symptoms and the MRI examination ranged from
2 weeks to 3 years (mean 31.9 weeks). A total of 105
patients (49%) had acute pain for less than 2
months, and 110 patients (51%) had chronic pain
for a duration of more than 2 months.
Table 1. Scanning parameters for 1.5T magnet
Sequences TR, ms TE, ms TI, ms
Sagittal T1-weighted 500
750 17
19
Axial T1-weighted 500
750 17
19
Sagittal T2-weighted 4000
4500 100
110
Axial T2-weighted 4000
4500 100
110
Sagittal STIR 4600 67 130
Axial STIR 4600 67 130
Coronal STIR 4600 67 130
TR/TE/TI: repetition/echo/inversion time; ST: slice thickness; IG: interslice gap; FOV: field of view.
Acta Radiol 2009 (2)
In 155 patients, MRI of the lumbar spine was
performed using a 1.5T magnet (Sonata; Siemens,
Erlangen, Germany), and a total of 60 patients were
examined using a 3T system (Signa HD; GE
Healthcare, Milwaukee, Wisc., USA). The scanning
parameters for the 1.5T and 3T systems are given in
Tables 1 and 2, respectively. The axial series
consisted of slices oriented for each intervertebral
disc level from L1 to S1. A phased-array surface coil
was used in both MR systems.
The findings that were considered as causes of
sciatica were defined as following: a) nerve root
compromise (widened, compressed, or displaced
nerve root), b) annular tear or non-compromised
herniated nucleus pulposus (HNP) accompanied by
perineural edema. All MRI studies were retrospec-
tively assessed by two radiologists experienced in
spinal MRI. The assessment mainly focused on the
presence or absence of a compromised nerve root or
edema/inflammation surrounding the nerve roots
that was compatible with the patient’s symptoms.
STIR or fat-saturated T2-weighted images in all
three planes were read together with no preset
sequential order. Observers knew that the patients
had unilateral sciatica, but they were unaware of the
side of the pain or any other clinical findings
suggesting a specific level of nerve root compromise.
They were also unaware of the information pro-
vided by the pain drawings of the patients. The
relationship between the level of nerve root com-
promise or perineural edema and the nerve root or
roots indicated by patients’ pain drawings were
investigated. Lumbalization or sacralization was
noted on plain films in order to avoid discrepancies
in determining the level of nerve root compromise.
Kappa statistics were used to establish interrea-
der agreement for perineural edema/inflammation.
Consensus of the two radiologists was used as
needed. Means and standard deviations were calcu-
lated for the VAS pain scores, and we used a t test
to determine whether the difference between the
Number of
ST, mm IG, mm FOV, cm Matrix excitations
* 3 0.6 2810 320256 3
* 4 1.0 2010 320225 2
* 3 0.6 2810 320256 3
* 4 1.0 2010 320225 2
3 0.6 2810 256180 2
4 1.0 2010 256180 2
3 0.6 2810 256180 2
 STIR and Fat-Saturated MRI of Perineural Edema/Inflammation in Sciatica 207

Table 2. Scanning parameters for 3T magnet

Number of
Sequences TR, ms TE, ms TI, ms ST, mm IG, mm Matrix FOV, cm excitations

Sagittal T1-weighted FLAIR 3000 24 880 4 1.0 384288 3030 2

Axial T1-weighted 650 10
4 1.0 320256 1818 2
Sagittal T2-weighted 4100 85
4 1.0 384288 3030 4
Axial T2-weighted 4100 85
4 1.0 384256 1818 2
Sagittal fat-saturated FSE T2 4100 85
4 1.0 384192 3030 4
Axial fat-saturated FSE T2 4100 85
4 1.0 384256 1818 2
Coronal fat-saturated FSE T2 4100 85
4 1.0 384192 3030 4

TR/TE/TI: repetition/echo/inversion time; ST: slice thickness; IG: interslice gap; FOV: field of view; FLAIR: fluid-attenuated inversion
recovery; FSE: fast spin echo.

VAS scores of patients with or without MR A total of 31 (30%, 25 women and six men) of the
detection of the cause of sciatica was statistically 105 patients (14% of the total 215 patients) with
significant. Correlations between MR detection of sciatica unexplained by standard MRI sequences
the cause of sciatica and variables (sex and duration showed perineural edema/inflammation upon addi-
of sciatica) were evaluated by Pearson correlation tional STIR or fat-saturated T2-weighted se-
analysis. quences. Of these 31 patients, perineural edema/
The study was approved by the ethics committee inflammation was detected in 22 patients with the
of our institution, and institutionally approved 1.5T scanner and nine patients with the 3T system.
written informed consent was obtained from all The intraobserver consistency of the MRI diagnosis
patients. of perineural edema/inflammation was high (kappa
0.83). In three patients, perineural edema/inflam-
Results mation not corresponding to the patients’ symp-
toms was seen with additional sequences.
Routine MRI revealed that 110 of 215 (51%) The additional MR sequences increased the like-
patients had nerve root compromise compatible lihood of detecting a cause for unilateral sciatica
with patients’ pain drawings. Routine MRI identi- from 51% to 66% (141 of 215 patients), 44% to
fied disc herniation, disc-osteophyte complex, de- 64% (80 of 126 female patients), and 62% to 69%
generative hypertrophy or synovial cyst of a facet (61 of 89 male patients) for the total group, female,
joint, hypertrophy of the ligamentum flavum, or and male patients, respectively (Table 4). As a
degenerative spondylolisthesis as the causative fac- result, the discrepancy between the two sexes in
tor of nerve root compromise within a lateral recess finding a cause for sciatica with MRI disappeared
or neural foramen. While these findings corre- when additional MR sequences were used (chi-
sponded to the symptoms in these patients, routine square, P 0.05). The duration of sciatica had no
MRI of the lumbar spine did not reveal the cause of relationship with the likelihood of detecting its
patient pain in 105 of the 215 (49%) patients. In 21
Table 3. Relationship between finding a cause for unilateral sciatica
patients, there were findings of nerve root compro- with the standard MR imaging technique and patient sex
mise at single or multiple levels with no relation to
patients’ symptoms of sciatica. Standard MR
When the standard MRI technique is used, imaging
finding a cause for unilateral sciatica compatible No Yes Total
with a patient’s pain drawings is affected by that
patient’s sex. There was an association between Sex variable
Female Count 71 55 126
patient sex and the likelihood of detecting a cause % within sex variable 56% 44% 100.0%
that explained the complaint of unilateral sciatica Male Count 34 55 89
when the standard MRI technique was employed. % within sex variable 38% 62% 100.0%
Routine MRI revealed that 55 of the 126 (44%) Total Count 105 110 215
% within sex variable 49% 51% 100.0%
female and 55 of the 89 (62%) male patients had
nerve root compromise compatible with patients’ P0.009. No: no MR-detectable cause for sciatica was revealed by
pain drawings (Table 3). This discrepancy was standard MR imaging; Yes: an MR-detectable cause for sciatica was
statistically significant (chi-square, P B0.05). revealed by standard MR imaging.

Acta Radiol 2009 (2)

208 M. Şirvanci et al.
Table 4. Relationship between finding a cause for unilateral sciatica
with the standard MR imaging technique plus additional sequences
and patient sex
 Additional
MR
sequences
No Yes
Sex variable
Female Count 46 80
% within sex variable 36% 64%
Male Count 28 61
% within sex variable 31% 69%
Total Count 74 141
% within sex variable 34% 66%
P 0.443. No: no MR-detectable cause for sciatica was revealed by
standard MR imaging plus additional sequences; Yes: an MR-
detectable cause for sciatica was revealed by standard MR imaging
plus additional sequences.
cause after either standard MRI or additional
sequences (chi-square, P0.05).
The average VAS score for all 215 patients was
5.8 (range 2
10). The mean VAS score was 5.592.1
for the 110 patients with nerve root compromise
corresponding to patients’ symptoms and 6.291.9
for the 105 patients with sciatica unexplained by
routine MRI. The VAS score of the patients with
sciatica unexplained by standard MRI sequences
was statistically significantly higher than that of
patients with nerve root compromise corresponding
to patients’ sciatica. The average VAS score was
5.692.0 for the 141 patients with nerve root
compromise or perineural edema /inflammation
corresponding to patients’ symptoms and 6.192.0
for the 74 patients with sciatica unexplained by
routine MRI together with additional sequences.
This difference was not statistically significant.
Perineural edema/inflammation was due to a
lateral and posterolateral annulus fibrosus tear or
disc herniation in eight and five patients, respec-
tively. In one of these patients, STIR images showed
a full-thickness annulus fibrosus tear closely resem-
bling the finding seen in computed tomography
discography. This annulus tear was also associated
with a subtle perineural edema/inflammation sur-
rounding the adjacent nerve root, and both findings
could not be demonstrated in MR images per-
formed using the standard technique. Perineural
edema/inflammation was associated with subchon-
dral bone marrow edema adjacent to the endplates
(Modic type 1) and/or non-compressive disc-osteo-
phyte complexes in 12 patients. Perifacetal edema/
inflammation was found around nerve roots in six
patients after fat-saturated T2 or STIR imaging
Acta Radiol 2009 (2)
(Fig. 1). In all of these six patients, perifacetal
edema/inflammation was compatible with the pa-
tients’ pain drawings.
Discussion
Total
The lack of correlation between MRI findings and
clinical symptoms is frequent in the lumbar spine,
126 and results in the failure to explain sciatica in some
100.0% patients. Neural compromise caused by the her-
89 niated nucleus pulposus, rather than disc hernia-
100.0%
215
tion, has been generally understood to be the best
100.0% predictor for symptomacy (6, 7). Severe radicular
pain may also be caused by internal annulus
fibrosus tears without deformation of the outer
annular wall or neural compromise (8
10).
In this study, we sought to determine whether fat-
saturated T2-weighted or STIR images have the
capability to detect perineural edema/inflammation
possibly associated with non-compressive causes of
sciatica. Perineural edema/inflammation may be
associated with and indicative of nerve root irrita-
tion. Despite meticulous inspection of the epidural
space within the spinal canal, fat-saturated T2 and
STIR images did not show any clear-cut evidence
for inflammation associated with non-compressive
annular tears in our study population. Perineural
edema/inflammation was due to a lateral and
posterolateral annulus fibrosus tear or disc hernia-
tion in eight and five patients, respectively. In
routine practice, annular tear is accepted as a cause
of sciatica. However, in our study, annulus fibrosus
tear was encountered as a cause of sciatica only if it
caused perineural edema. Thirty-one of the 105
patients with sciatica unexplained by standard MRI
sequences showed perineural edema/inflammation
after additional STIR or fat-saturated T2-weighted
sequences were taken. Consequently, STIR or fat-
saturated T2-weighted MR images may help iden-
tify the cause of pain in some patients with sciatica
that is unexplained by standard MRI. However, the
number of patients who benefit from these addi-
tional sequences does not appear to be high enough
to suggest routine use. Additionally, if the above-
mentioned 13 patients with annular tear are en-
countered in the group of detectable cause for
sciatica, as revealed by standard MR imaging, the
number of patients who benefit from the additional
sequences falls from 31 to 18 patients. This is likely
due to the low sensitivity of fat-saturated T2 and
STIR images for this issue. This may also be caused
in part by the confusing effect of slow-flowing
vascular structures of the lumbar epidural venous
plexuses on fat-saturated T2 and STIR images. In a
 STIR and Fat-Saturated MRI of Perineural Edema/Inflammation in Sciatica 209

Fig. 1. A 37-year-old man presented with right sciatica accompanied by low back pain for 3 months. A. A right parasagittal STIR image
demonstrates bone marrow edema (arrow) within the inferior articular process of the right L5
S1 facet joint. B. Axial T2-weighted images at
the L5
S1 level reveal subchondral bone marrow edema of the right facet joint (arrow). C. A STIR image at the same level shows soft-tissue
edema (arrowheads) adjacent to the right L5 nerve root in addition to subchondral bone marrow edema (arrow) of the facet joint.

study similar to ours, Saifuddin et al. (11) used
gadolinium-enhanced lumbar spine MRI for the
same purpose and found that the inflammatory
changes associated with an annular tear directly
involved the nerve root in some cases. This could be
because contrast-enhanced images are more sensi-
tive than fat-saturated T2 or STIR images in
showing inflammation.
Several studies have shown that the nucleus
pulposus contains elements with the potential to
cause inflammation within the epidural space (12

14). This mechanism may also be at work in
paravertebral soft tissues, and paravertebral inflam-
mation may cause irritation of the nerve root in the
extraforaminal region well beyond the exit of the
neural foramen. In this location, the spinal nerve,
rather than the nerve root, may be affected. The
irritation of the spinal nerve likely takes place in the
medial part of the psoas muscle, where the spinal
nerve contributes to form the lumbar plexus (Fig. 2).
It is a well-known fact that the majority of
patients with degenerative diseases of the facet
joints do not have radiculopathy. However, nerve
root compression by a hypertrophied arthritic facet
joint with osteophytes has been considered to be
one of the causes of sciatica (15). A mechanism
other than mechanical stress may also contribute to
the generation of pain caused by inflammatory
cytokines released from the facet joints with
osteoarthritic changes and inflamed synovia (16).
It is thought that chemical factors produced in the
synovial cells of the facet joint may spread into the
epidural space and come into contact with a nerve
root (17). Thus, degenerative inflammation of

Acta Radiol 2009 (2)

210 M. Şirvanci et al.
Fig. 2. A 74-year-old woman with left sciatica and low back pain for 3 years. A. A coronal T2-weighted image without fat saturation shows
degenerative right scoliosis with lateral disc-osteophyte complexes more prominent on the left side. Note also subchondral bone marrow
changes at the L2
L3 level (arrow). B. An axial STIR image at the L2 vertebral body level demonstrates left paravertebral soft-tissue edema
(arrowheads) accompanying the large disc-osteophyte complex.
the facet joint (so-called ‘‘facet arthrosis syn-
drome’’) may cause radiculopathy by induction of
inflammation in adjacent tissues surrounding nerve
roots (16, 17).
There are only a few reports in the literature
discussing the advantages of using fat-saturated T2-
weighted sequences. In some cases, fat saturation
shows perifacetal soft-tissue edema/inflammation
that is otherwise not detected by standard non-fat-
saturated T2-weighted images (18). However, we
did not find any published observations regarding
the relationship between perifacetal soft-tissue
edema/inflammation and radiculopathy. In our
study group, we found perifacetal edema/inflamma-
tion around nerve roots in six patients after fat-
saturated T2 or STIR imaging. In all these six
patients, the perifacetal edema/inflammation was
compatible with the patients’ pain drawings. How-
ever, the sensitivity of these additional sequences to
detect subtle perifacetal edema/inflammation is not
known.
Our study shows that the possibility to find a
cause for unilateral sciatica with standard MRI is
lower in females when compared with males.
Fortunately, the additional fat-saturated MR se-
quences clearly increased the likelihood of detecting
a cause for unilateral sciatica from 44% to 64% in
female patients, but only from 62% to 69% in male
patients. However, the cause for these discrepancies
between the two sexes is not known.
A limitation of our study is that it is not known
whether additional findings detected by fat-satu-
rated T2 or STIR images have any contribution in
Acta Radiol 2009 (2)
the therapy of patients with sciatica. It is clear that
none of these patients are candidates for surgical
intervention. Investigation of the impact of these
additional findings on the non-surgical management
of patients is of interest. The present study, how-
ever, has a bias in reading the MR images for
perineural edema/inflammation because the readers
knew that the patients had unilateral sciatica.
In conclusion, STIR or fat-saturated T2-weighted
MR images may help identify the cause of pain in
some patients with sciatica that is unexplained by
standard MRI. Perineural edema/inflammation de-
tected by STIR or fat-saturated T2-weighted MR
images may contribute to more accurate diagnosis
in a limited number of cases. Chemical inflamma-
tion produced by nucleus pulposus leakage through
annular tears or facet joint osteoarthritis may be
shown by perineural soft-tissue edema/inflamma-
tion on STIR or fat-saturated T2-weighted MR
images. However, the percentage of patients who
benefit from the additional sequences does not
appear to be impressive enough to suggest routine
use.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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