Contents

Introduction
Spinal pain overview
Diagnostic testing
Neuroimaging as a guidances for spinal
intervention
Conclusion
 Introduction
Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage or
described in terms of such damage.
(Mersky&Timble,1979)

According to the American Pain Society,

approximately 45% of all Americans seek
care for persistent pain at some point of
their lives.

Back pain syndromes substantively

contribute to the overall epidemiologic
prevalence and fiscal gravity of pain
disorders.
 A significant issue is the progression of
acute and subacute back pain to a
condition of chronicity.

Chronic spinal pain involves

heterogenous mechanism of peripheral
and central sensitization, frequently
produces a cognitive constellation in
excess of apparent organic pathology and
increases the need for multidisciplinary
management approaches.
Causes of Low Back Pain
Lumbar strain or sprain 70%
Degenerative changes 10%
Herniated disk 4%
Osteoporosis compression fractures
4%
Spinal stenosis 3%
Spondylolisthesis 2%

3/4/03 Steven Stoltz, M.D.

Causes of Low Back
Pain
Spondylolysis, diskogenic low back pain
or other instability 2%
Traumatic fracture - <1%
Congenital disease - <1%
Cancer 0.7%
Inflammatory arthritis 0.3%
Infections 0.01%

3/4/03 Steven Stoltz, M.D.

Red Flags
History of cancer Major Trauma
Unexplained Osteoporosis
weight loss Fever
Intravenous drug Back pain at rest
use or at night
Prolonged use of Bowel or bladder
corticosteroids dysfunction
Older age

3/4/03 Steven Stoltz, M.D.

 Complete medical history
Physical examination

DIAGNOSTIC TESTING
 An X-ray is generally the first imaging test a physician will order
Showing the condition and alignment of vertebrae
X-rays are useful for viewing vertebrae that may be affected by
the following :
Arthritis of the spine
Bone spurs
Spondylolisthesis
Fractures
Tumors
X-rays penetrate through soft tissue, they typically will not show
herniated discs, bulging discs, sciatica, pinched nerves or
disorders involving the spinal cord.
 CT uses essentially the same basic technology as plain-
film X rays, but taking various angles to create a cross-
section view of the spine and other bony structures.
CT is the best tool for evaluating the osseous anatomy
in multiple planes
Helps to differentiate between disc material,
calcification, and bone
Valuable in evaluation of spondylolysis
Best for bony changes of spinal or foraminal
stenosis
Also best for bony detail to determine:
- Fracture
- Malignancy
SW Wiesel study 1984 Spine:
- 36 % of asymptomatic subjects had
HNP at L4-L5
and L5-S1 levels

13
CT with myelogram:
Can demonstrate much better anatomical detail
than myelogram alone
Utilized for:
- Demonstrating anatomical detail in multi-level
disease in pre-operative state
- Determining nerve root compression etiology
of disc versus osteophyte
- Surgical screening tool if equivocal MRI or CT

14
 A myelogram is an imaging test that uses a contrast dye
injection and X-rays to develop images of the spinal canal
Excellent in the evaluation of spinal stenosis patients
Evaluates for instability dynamic compression on nerve
roots
Often utilized in patients who cannot undergo MRI
A CT scan and MRI scan may also be taken while the dye
is in system.
Myelogram:
Procedure of injecting contrast material into the spinal canal
with imaging via plain radiographs versus CT
In past, considered the gold standard for evaluation of the spinal
canal and neurological compression
With potential complications, as well as advent of MRI and CT, is
less utilized:
- More common: Headache, nausea / vomiting
- Less common: Seizure, pain, neurological change, anaphylaxis
Myelogram alone is rarely indicated
Hitselberger study 1968 Journal of Neurosurgery:
- 24 % of asymptomatic subjects with defects

16
MRI:
Best diagnostic tool for:
Soft tissue abnormalities:
Infection
Bone marrow changes
Spinal canal and neural foraminal contents
Emergent screening:
Cauda equina syndrome
Spinal cored injury
Vascular occlusion
Radiculopathy
Benign vs. malignant compression fractures
Osteomyelitis evaluation
Evaluation with prior spinal surgery

17
 MRI with Gadolinium contrast:
Gadolinium is contrast material allowing
enhancement of intrathecal nerve roots
Utilization:
- Assessment of post-operative spine---most frequent use
- Identifying tumors / infection within / surrounding spinal cord
- Diagnosis of radiculitis
Post-operatively can take 2-6 months for reduction of
mass effect on posterior disc and anterior epidural
soft tissues which can resemble pre-operative studies
Only indications in immediate post-operative period:
- Hemorrhage
- Disc infection

18
 The back is composed
of vertebrae, muscles,
ligaments,
intervertebral disc,&
nerves.
There are 7 cervical,
12 thoracic, 5 lumbar
& 5 coccygeal
vertebrae
Spinal cord has
cervical lordosis,
Thoracic kyphosis, &
lumbar lordosis
Spinal Pain Generators
VERTEBRAE
The periosteum of the
vertebral bodies and arches
are innervated by
unmyelinated nerve fibers
(Groen et al.,1990; Jackson et al.,1966;
Wyke et al.,1970)

ZYGAPOPHYSEAL
JOINTS
The periosteum of the
vertebral bodies and arches
are innervated by
unmyelinated nerve fibers
derived from the medial
branches of the dorsal rami
(Bogduk et al.,1982; Jackson et
al.,1966)
 LIGAMENTS INTERVERTEBRAL DISCS
The paraspinal ligaments Innervated by a plexus of
nerve fibers that weaves within
are differentially the outer connective tissue of
innervated by free nerve the annulus fibrosus and
endings (Jackson etal., continue with the innervation
of the vertebral periosteum.
1966; Wyke 1970) (Hirsh et al.,1963,Roofe 1940,
Yoshizawa et al.,1980)
 DURA & NERVE
ROOTS
Durameter is innervated by
a plexus of unmyelinated
nerve fibers from the
ruccurent meningeal
nerve. (Edgar&Nundy,1964,
Groen et al., 1988)
 MUSCLES
The muscles of the spine are extensively
innervated; the majority of the deep paraspinal
muscular is innervated by the medial branch of the
dorsal rami. Intermediate and superficial
musculature by the lateral branch of the dorsal
rami. (Bogduk et al.,1982; Cave, 1937)
Radiographic
Anatomy

ML Richardson, Univ. Of Washington

Cervical Spine AP View

ML Richardson, Univ. Of Washington

Cervical Spine Lateral View

ML Richardson, Univ. Of Washington

Cervical Spine Oblique View

ML Richardson, Univ. Of Washington

Cervical Spine Open-Mouth (Dens) View

ML Richardson, Univ. Of Washington

Lumbar Spine AP View

ML Richardson, Univ. Of Washington

Lumbar Spine Lateral View

ML Richardson, Univ. Of Washington

 MRI Anatomy

Source: CW Kerber and JR Hesselink, Spine Anatomy, UCSD Neuroradiology

 Excellent for evaluation of soft tissue
structures: disc, ligaments, nerve
roots,dural sac and spinal cord
Excellent in disc herniations (primary and
recurrent), tumor, metastasis, and infection
Limited in the evaluation of fusion and
hardware placement
 Creates different types of images
T1 Weighted FLUID IS DARK
T2 Weighted FLUID IS BRIGHT
Intravenous contrast (Gadolinium)
enhanced imaging :
Used in Post-operative patients and
patients with question of infection and
abscess, or tumor.
 MRI SAGITTAL PLANE
T1 T2 T1 T2

CERVICAL LUMBAL
Evaluating Trauma
Fracture plain film / CT
Dislocation plain film / CT
Ligamentous injury MRI
Cord injury MRI
Nerve root avulsion MRI
Plain film findings may be
very subtle or absent!

Anterolisthesis of
C6 on C7
Spondilolisthesis
 CT
Fractures of C6 left
pedicle and lamina
 CT 2D Reconstructions

Acquire images axially

reconstruct sagittal / coronal

 Computed Tomography
(CT)
Spondylolysis

Computed Tomography
(CT)
Fusion Evaluation
Vertebral body burst fx
with retropulsion into
spinal canal

2D Reformats
Compressed Degenerative
fracture vertebrae
 Hyperflexion fx with
ligamentous disruption and
cord contusion
Degenerative Disease
Low Back Pain
Most episodes of LBP are self
limited
These episodes become more
frequent with age
LBP is usually due to repeated
stress on the lumbar spine over
many years (degeneration),
although an acute injury may
cause the initiation of pain
Disc Degeneration
Physiology
With age and
repeated efforts,
the lower lumbar
discs lose their
height and water
content (bone on
bone)
Abnormal motion
between the bones
leads to pain
Degenerative Disc (and Facet Joint) Disease
Foraminal Thickening/Buckling of
stenosis Ligamentum Flavum
Degenerative Disc (and Facet Joint) Disease
Degenerative Disc (and Facet Joint) Disease
 Lumbar Spinal Stenosis

Disc bulge, facet hypertrophy and flaval ligament

thickening frequently combine to cause central spinal
stenosis
Lumbar Spinal Stenosis
Computed Tomography
(CT)
Spinal Stenosis
Lumbar Spinal Stenosis
Lumbar Spinal Stenosis
Lumbar Spinal Stenosis
 Lumbar Spinal Stenosis

Disc bulge, facet hypertrophy and flaval ligament

thickening frequently combine to cause central spinal
stenosis
 Foraminal Stenosis
Neural
foramen
MRI-Myelo
Cervical Spinal Stenosis
MRI - Degenerative Disc
Disease
Age:
20-40 36% have degenerated disc
50 85-95% have degenerated disc
60-80 98% have degenerated disc
<60 20% have asymptomatic disc
herniation

Conclusion: Abnormal findings on MRI frequently DO NOT

relate to symptoms (and vice versa) !!
 New England Journal of Medicine (February 2001)

3/4/03 Steven Stoltz, M.D.

MRI Herniated Disc
Levels
85-95% at L4-L5, L5-S1
5-8% at L3-L4
2% at L2-L3
1% at L1-L2, T12-L1
Cervical: most common C4-C7
Thoracic: 15% in asymptomatic pts. at
multiple levels, not often symptomatic
 Specificity /
Sensitivity
Diagnosis Test Sensitivity Specificity
Disc CT 0.90 0.70
Herniation MRI 0.90 0.70
CT Myelo 0.90 0.70

Spinal CT 0.90 0.80-0.95

Stenosis MRI 0.90 0.75-0.95
Myelogram 0.77 0.70

79
Disc Herniation
Physiology
Tears in the annulus
Herniation of nucleus
pulposus
Disc Herniation
Physiology
Compression of the
nerve root in the
foramen leads to pain
Annular
 Protrusion Extrusion Extrusion

Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
 Protrusion w/ Protrusion w/
Protrusion migration +
migration
sequestration

Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
 MRI Nomenclature: (PER NASS)

Anular fissure: Focal disruption of anular fibers in concentric, radial or transverse

distribution
Disc bulge: Circumferential, diffuse, symmetric extension of anulus beyond the
adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax anular
fibers
Disc protrusion: Focal, asymmetric extension of disc segment beyond margin of
vertebral end plates into the spinal canal with most of anular fibers intact
Disc extrusion: Focal, asymmetric extension of disc segment and / or nucleus
pulposis through the anular containment into the epidural space
Disc sequestration: Extruded disc segment that is detached from original with
migration into the canal
Disc degeneration: Irreversible structural and histiological changes in nucleus
seen on MRI T2WI images (commonly associated with bulge)

85
Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
 Abnormal Disc
< 180 > 180

Herniation Bulge
90180 < 90

Broad-based Focal Symmetric Asymmetric

Waist* No waist

Extrusion Protrusion

Sequestered Migrated Neither

*(In any plane)

Adapted from: Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the
North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology, 2001.
Central Disc Protrusion
L5-S1 Disc Extrusion Into Lateral Recess
with Impingement of R S1 Nerve Root

R-S1 Disc L-S1

Schmorls Nodes
Spondylolysis / Spondylolisthesis
 Confusing Spondy- Terminology

Spondylosis = spondylosis deformans = degenerative spine

Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.)

Spondylolysis = chronic fracture of pars interarticularis with

nonunion (pars defect)

Spondylolisthesis = anterior slippage of vertebra typically

resulting from bilateral pars defects

Pseudospondylolisthesis = degenerative spondylolisthesis

(spondylolisthesis resulting from degenerative disease rather
than pars defects)
Tumors and Other Masses
 Classification of Spinal Lesions

Extradural = outside the thecal sac

(including vertebral bone lesions)

Intradural / extramedullary = within

thecal sac but outside cord

Intramedullary = within cord

 Classification of Spinal Lesions

Extradural Intradural Intramedullary

Cord Dura Extramedullary
 Common Extradural Lesions

Herniated disc
Vertebral hemangioma
Vertebral metastasis
Epidural abscess or hematoma
Synovial cyst
Nerve sheath tumor (also intradural/extramedullary)
Neurofibroma
Schwannoma
Extradural: Vertebral Body Tumor
 Extradural: Vertebral Metastases

T2 (Fat Suppressed) T1 T1+C (fat suppressed)

MRI - METASTASIS
 Extradural: Vertebral Metastases

T2 (Fat Suppressed) T1 T1+C (fat suppressed)

 Vertebral Metastases vs. Hemangiomas

Hemangiomas (Benign, usually asymptomatic, commonly incidental):

Bright on T1 and T2 (but dark with fat suppression)

Enhancement variable

Metastases:

Dark on T1, Bright on T2 (even with fat suppression)

Enhancement
Vertebral Hemangiomas
 Extradural: Vertebral Metastases

Diffusely T1-hypointense
marrow signal may represent
widespread vertebral
metastases as in this patient
with prostate Ca

This can also be seen in the

setting of anemia,
myeloproliferative disease, and
various other chronic disease
states
Extradural: Epidural Abscess
 Common Intradural
Extramedullary Lesions
Nerve sheath tumor (also extradural)
Neurofibroma
Schwannoma

Meningioma
Drop Metastasis
Intradural Extramedullary: Meningioma
Intradural Extramedullary: Meningioma
Intradural Extramedullary: Nerve Sheath Tumor
(Neurofibroma)
Intradural Extramedullary: Arachnoid Cyst

T2 T1
 Common Intramedullary Lesions

Astrocytoma
Ependymoma
Hemangioblastoma
Cavernoma
Syrinx
Demyelinating lesion (MS)
Myelitis
Intramedullary: Astrocytoma
Intramedullary: Astrocytoma
Intramedullary: Cavernoma
Intramedullary: Ependymoma
 Intramedullary: Syringohydromyelia
Seen with:
congenital lesions
Chiari I & II
tethered cord
acquired lesions
trauma
tumors
arachnoiditis
idiopathic
 Intramedullary: Syringohydromyelia
Seen with:
congenital lesions
Chiari I & II
tethered cord
acquired lesions
trauma
tumors
arachnoiditis
idiopathic
 Confusing Syrinx Terminology

Hydromyelia: Fluid accumulation/dilatation within central

canal, therefore lined by ependyma

Syringomyelia: Cavitary lesion within cord parenchyma, of

any cause (there are many). Located adjacent to central
canal, therefore not lined by ependyma

Syringohydromyelia: Term used for either of the above, since

the two may overlap and cannot be discriminated on imaging

Hydrosyringomyelia: Same as syringohydromyelia

Syrinx: Common term for the cavity in all of the above

Infection and Inflammation
 Infectious Spondylitis /
Diskitis
Common chain of events (bacterial spondylitis):
1. Hematogenous seeding of subchondral VB
2. Spread to disc and adjacent VB
3. Spread into epidural space epidural abscess
4. Spread into paraspinal tissues psoas abscess
5. May lead to cord abscess
Infectious Spondylitis /
Diskitis

T2 T1 T1+C T
Infectious Spondylitis /
Diskitis
Pyogenic Spondylitis / Diskitis
with Epidural Abscess
T1

T2
Spinal TB (Potts Disease)

Prominent bone destruction

More indolent onset than pyogenic
Gibbus deformity
Involvement of several VBs

T1 + C
Spinal TB (Potts Disease)

Prominent bone destruction

More indolent onset than pyogenic
Gibbus deformity
Involvement of several VBs
Transverse Myelitis
Inflamed cord of uncertain cause
Viral infections
Immune reactions
Idiopathic
Myelopathy progressing over hours to weeks
DDX: MS, glioma, infarction
Multiple Sclerosis
Inflammatory demyelination
eventually leading to gliosis and
axonal loss

T2-hyperintense lesion(s) in cord

parenchyma

Typically no cord expansion (vs.

tumor); chronic lesion may show
atrophy
Vascular
Spinal AVM / AVF
 Patient is injected intravenously with a
radiotracer (Technetium 99m labeled MDP)
This tracer is absorbed by the osteoblastic
cells in the body (cells that make new
bone)
We are then able to image the patient with
a special camera (Gamma camera)
Bone Scan shows osteoblastic activity
 Bone scans are commonly used in the
evaluation of bone metastasis
Also used for :
Stress fractures (spine-spondylolysis)
Compression fractures
Arthritis
Infection
Prosthesis loosening
When imaging spinal disorders SPECT
imaging is often added
Bone Scan with SPECT (Single Photon
Emission Computed Tomography)
Compression Fracture
Bone Scan with SPECT - Metastasis
 There has been a marked increase in the use of spinal
interventional pain procedures over the last decade
The choice of image guidance remains a matter of
physician preference with Computed Tomography (CT)
guidance most common
The use of CT guidance for an interventional procedure was
initially reported in 1975 . Since then it has grown to
become the image guidance modality of choice for many
percutaneous interventions
 Advantages to CT guidance for certain spinal
interventional pain procedures :
Increased needle tip positioning accuracy
Provides greater anatomical detail that
facilitates accurate needle trajectory
planning
Monitoring and final placement

CT guided spinal intervention can be performed

using two main techniques conventional CT
or CT fluoroscopy (CTF)
 Conclusion
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
45% of Americans seek care for persistent pain at some
point of their lives, this requires multidisciplinary
management approaches. diciplin .
The back is composed of vertebrae, muscles, ligaments,
intervertebral disc & nerves.
Diagnosing spinal pain: medical history, physical
examination and diagnostic testing (x-ray, CT-scan, MRI,
Bone Scan, Myelography).
The choice of image guidance for spinal intervention
remains a matter of physician preference, Computed
Tomography (CT) guidance is the most common.
CT guided spinal intervention can be performed
using two main techniques conventional CT or CT
fluoroscopy (CTF)
Thank you
for your
attention