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SRI ANDREANI UTOMO

NEURORADIOLOGY CONSULTANT
FORMAL EDUCATION BACKGROUND :
• Graduated from Faculty of Medicine, Airlangga University : 1984
• Obtained the specialist degree for Radiology, January 1997
• Obtained The Master Degree In Neurovascular Diseases, Paris Sud University and
Mahidol University, held on Thailand, November 2001- November 2002.
PRESENT POSITION and MEMBERSHIP
• Staff in Dept. of Radiology, Dr. Soetomo General Hospital, Faculty of Medicine,
Airlangga University, Surabaya, Indonesia.
• Foreign Relationship in Indonesian Radiological Society.
• Secretary of The Indonesian Society of Neuroradiology and Head and Neck
Radiology.
• Member of The Asian-Oceanian Society in Neuroradiology and Head & Neck
Radiology
• Member of The Asian Musculoskeletal Society.
• Member of Neuroradiology Team , Dr. Soetomo Hospital, Surabaya, Indonesia.
• Member of The Spinal Team(Pan Med Tulang Belakang) Dr. Soetomo Hospital,
Surabaya, Indonesia.
• Member of The Oncology Musculoskeletal Team (Pertumsi), Dr. Soetomo
Hospital, Surabaya, Indonesia.
• Member of Sport Team, Dr. Soetomo Hospital, Surabaya, Indonesia

SPINE MRI ANATOMY

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T1 WEIGHTED MRI

•  Ideal for evaluating structures

containing fat, subacute or chronic
hemorrhage, or proteinaceous
fluid, have high signal (bright)
•  Good for delineating anatomic
structures

T2 WEIGHTED MRI

Signal intensity is related to state of

hydration of the tissue
Any tissue rich in free or extracellular
water will be bright :
Cerebrospinal fluid, cysts, necrotic tissue,
fluid collections, intervertebral discs, and
neoplasms

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T2 FAT SAT

Everything contain Fat tissue will be

saturated to hypointense signal

IMPORTANT OF FAT SAT

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MRI
•  Mineral rich tissue (e.g. bone) contains
few mobile protons and demonstrates
low signal on all pulse sequences
•  Gas generates no MR signal
•  Spatial resolution determined by slice
thickness, field of view, and size of
matrices
•  Motion artifacts most common cause of
image degradation

MRI
•  Strength resides in excellent soft tissue
contrast, direct multiplanar imaging,
and absence of ionizing radiation
•  Major contraindication is presence of
any electrical device in the body, brain
aneurysm clips, some cochlear and
ocular implants some vascular filters,
and metallic fragments in the eye or
spinal canal

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MRI – LUMBAR SPINE

AXIAL VIEW

DISC
FACET JOINTS

LAMINA

MRI – LUMBAR SPINE AXIAL VIEW

THECAL SAC
NERVE ROOTS

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MRI – LUMBAR SPINE AXIAL VIEW

EXITING NERVE ROOTS

FORAMEN

MRI SPINE

•  Sagital T1W, T2FSE, T2 Fat Sat

•  Axial T1W, T2FSE
•  Axial GRE (Cervical)
•  MR myelography (Not rutine)
•  MRI + Contrast: Infection, tumor, diff
recidive HNP with cicatrix

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MRI SPINE

•  Axial: Endplate-discus-endplate
•  Sagital : From right parasagital/
foramen to left parasagital

MRI Cervical irisan axial T1FSE, T2FRFSE, irisan sagital T1FSE, T2FRFSE, T2 Fat
Sat, tanpa kontras, menunjukkan:
Alignment normal.
Tidak ada spondylolisthesis.
Kurve cervical normal.
Intensitas signal marrow corpus vert. cervicalis normal, tidak ada abnormal
hypointense ataupun hyperintense area, tidak tampak malignant bone marrow
replacement.
C2-3: Normal.
C3-4: Normal.
C4-5: Normal.
C5-6: Normal.
C6-7: Normal.
C7-Th1: Normal.
Canalis spinalis normal.
Tidak tampak central canal stenosis ataupun foraminal stenosis.
Ligamen longitudinalis posterior, anterior, lig. flavum, interspinous normal.
Tidak ada lesi intramedular.
Tonsila cerebelli letak normal, tidak ada Chiari malformation.
 
Kesimpulan: MRI Cervical normal.

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IMAGING OF CANAL STENOSIS

RELATED TO
DEGENERATIVE SPINE

SRI ANDREANI UTOMO

Department of Radiology, Dr. Soetomo Hospital
Faculty of Medicine, Airlangga University
Surabaya, Indonesia

OVERVIEW
Degenerative Spine

Spinal Stenosis

Spinal Stenosis Grading Scheme

Take Home Point

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Degenerative Spine
Includes degeneration:
•  Intervertebral disc.
•  Vertebral Bodies.
•  Synovial joint.
•  The fibrous articulations,
ligaments, sites of ligament
attachment to the bone.

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SYMETRIC & ASYMETRIC DISK BULGE

FOCAL & BROAD BASED DISK PROTRUSION

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DISK EXTRUSION

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Disk Extrusion

Subarticular Central-Subarticular

foraminal Extraforaminal

Disc Protrusion

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SPINAL STENOSIS
Central canal stenosis

Stenosis of the subarticular

or lateral recessus

Stenosis of the neural

foramina

CENTRAL CANAL STENOSIS

•  Hypertrophic changes
of osteoarthritis of the
apophyseal joints.
•  Thickening of the
ligamentum flavum.
•  Osteophytes arising
from the vertebral
bodies.
•  Disc contour
abnormalities.

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STENOSIS OF THE SUBARTICULAR OR LATERAL

RECESSES

Bone hypertrophy at the sites of the facet joints

STENOSIS OF THE NEURAL FORAMINA

1.  Hypertrophic changes and

osteophytosis involving the vertebral
body and articular process.
2.  Distortion intervertebral foramen
caused by degenerative
spondylolisthesis.

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STENOSIS OF THE NEURAL FORAMINA

HYPERTROPHIC
CHANGES AND
OSTEOPHYTOSIS
INVOLVING
VERTEBRAL
BODY AND
ARTICULAR
PROCESS

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Degenerative Spondylolisthesis Cause Spinal Stenosis

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Grading System for Canal

Stenosis

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CENTRAL CANAL STENOSIS

Cervical spine without compromise of Grade 1 stenosis

spinal canal.
Normal CSF space is visible around Obliteration of CSF space
spinal cord. exceeding 50% of arbitrary
No evidence of cord deformity or signal subarachnoid space at C4–5,
change within cord. C5–6, and C6–7 levels

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Grade 2 stenosis at C4–5 level Grade 3 cervical canal stenosis at C5–6

Spinal cord is compressed and deformed,
but spinal cord shows no signal changes.
Grade 1 stenoses were also seen at C5–6
and C6–7 levels
level.
Spinal canal is significantly narrow at C5–6
level, and signal intensity of spinal cord is
increased at corresponding level.

FORAMINAL STENOSIS

Grade 0

Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal

MRI of lumbar spine. Grade 0 (normal). Schematic diagram of sagittal cross section
through foramen shows relationships between foramen and surrounding structures.
NR = nerve root, V = vertebral body, D = intervertebral disk, LF = ligamentum
flavum, FJ = facet joint.

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Grade 1

Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI

of lumbar spine. Grade 1 (mild degree of foraminal stenosis). Schematic diagram
shows perineural fat obliteration surrounding nerve root in transverse direction
(arrows). There is narrowing of superior foraminal width due to disk space narrowing
and thickened ligamentum flavum. No evidence of morphologic change in nerve root
is seen.

Grade 1

Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of

lumbar spine. Grade 1 (mild degree of foraminal stenosis). Schematic diagram shows
perineural fat obliteration surrounding nerve root in vertical direction (arrows). There is
narrowing of foraminal height due to disk space narrowing and diskoosteophytic
protrusion in foraminal zone. No evidence of morphologic change in nerve root is
seen.

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Grade 2

Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of

lumbar spine. Grade 2 (moderate degree of foraminal stenosis). Schematic diagram
shows perineural fat obliteration surrounding nerve root in four directions (vertical and
transverse) (arrows) without morphologic change. There is narrowing of foraminal width
and height due to disk space narrowing, thickened ligamentum flavum, facet arthropathy,
and diskoosteophytic protrusion in foraminal zone. No evidence of morphologic change
in nerve root is seen.

Grade 3

Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of

lumbar spine. Grade 3 (severe degree of foraminal stenosis). Schematic diagram shows
nerve root collapse or morphologic change (arrows) due to severe disk space narrowing,
severe thickened ligamentum flavum, facet arthropathy and diskoosteophytic protrusion
in foraminal zone.

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Central canal
& Foraminal
stenosis

M 43, PAIN AT THE BUTTOCK

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Deg. Disk + Nerve

roots compression
Which one is
compressed?
Exiting or Traversing

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30 Y, M WITH BACK PAIN

T1W T2W

T1W T2W

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L4
L4
L4-5

L4
L5
L4

L5

L5 S1

S1

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L4-5

L5

TAKE HOME POINT

• Spinal stenosis caused by degenerative spine.
• Three types of spinal stenosis: Central canal, lateral
recessus and foraminal stenosis.
• In the evaluation of degenerative spine, multiple
anatomic sites need to be imaged, including the
intervertebral disk, spinal canal, spinal cord, nerve
roots, neural foramina, facet joints, and soft tissue
within and surrounding the spine.
• MRI grading system shows promise for Dx spinal
stenosis.

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