February 2007 SPINAL CASES SAJID BUTT CONSULTANT RADIOLOGIST RNOH AND HOLLY HOUSE HOSPITAL

February 2007 Elderly man with low back pain. No history of trauma

February 2007

 Insufficiency fractures are caused by the effect of normal or physiologic stress upon weakened bone.  The most common cause of insufficiency fracture is postmenopausal osteoporosis.  Bone scintigraphy and MR imaging are the imaging modalities of choice

February 2007  senile osteoporosis, pelvic irradiation, corticosteroid therapy, and rheumatoid arthritis  Management is conservative  healing is expected within 4 months

February 2007 Forty-year-old woman with low back pain radiating into the leg

February 2007

Spinal Osteomyelitis  Plain films may be normal for 8-10 days following infection  Increased signal intensity in the disk and vertebral body  Contrast enhancement  Soft tissue mass (inflammation, abscess)

February 2007  Staphylococcus aureus is the most common cause of spine infection in adults  Blood cultures are often negative, so the diagnosis is made by disc biopsy  Spine infections progress from spondylitis to diskitis to epidural abscess to cord abscess  On MRI staphylococcus infections can be detected early as isolated osteomyelitis  Destruction of the disc space implies pyogenic infection as opposed to tuberculous spondylitis which typically spares the disc.

February 2007 Man with lower extremity weakness and sensory deficit

February 2007

 Schwannoma  Meningioma: Isointense on T1 & T2, moderate enhancement, dural tail  Epidermoid/Dermoid: Follows CSF in signal intensity, no enhancement  Metastasis  Intradural disk herniation

February 2007 Actual diagnosis: Schwannoma  Most common intradural extramedullary spinal neoplasm  Associated with neurofibromatosis  Symptoms similar to disk herniation: Pain, radiculopathy, weakness, sensory loss  MR: T1 - iso/hypointense; T2 - hyperintense, enhances homo/heterogeneously

February 2007 Man with right-sided radicular symptoms

February 2007

Extradural mass:  Tumor schwannoma schwannoma neurofibroma neurofibroma meningioma meningioma arachnoid cyst arachnoid cyst metastasis metastasis  Degenerative bulging /herniated disc bulging /herniated disc sequestered nucleus pulposus sequestered nucleus pulposus synovial cyst/ganglion synovial cyst/ganglion  Inflammation epidural abscess epidural abscess  Vascular hematoma hematoma

February 2007 juxta-facet cyst  Very characteristic imaging findings allowing for accurate preoperative diagnosis.  Almost always associated with degenerative changes in adjacent facet joint.  Located posterolateral to nerve root.  Hemorrhage into cyst is common usually with acute aggravation of symptoms

February 2007 Adult with lumbosacral pain radiating down the left leg. Absent left quadriceps reflex

February 2007

 sequestered disk fragment  synovial cyst  epidural abscess  metastases

February 2007  90% of disk herniations in the lumbosacral spine occur at the L4-L5 or the L5-S1 level.  L4/5 disc problem, which root?

February 2007 Elderly male with neck pain after falling

February 2007

Ossification of the posterior longitudinal ligament (OPLL) Ossification of the posterior longitudinal ligament (OPLL)  Ossification of the posterior longitudinal ligament primarily effects Asian patients.  OPLL can result in spinal stenosis and put effected individuals at risk for cord contusion with minimal trauma.  OPLL can easily be distinguished from DISH and OLF by the location of the ossification directly posterior to the vertebral bodies. 20% of cases of DISH will be associated with OPLL.

February 2007