1. MRI SPINE /KNEE DR, P S H HETTIARACHCHI CONSULTANT RADIOLOGIST
ASIRI SURGICAL HOSPITAL
COLOMBO 5

2. TISSUE COLOURS Water and pathology: White on T2, dark on T1.
Pathology stays white on FLAIR, water doesn't

3. TISSUE COLOURS
Fat:
white on T1 and T2
dark on STIR and out of phase

4. TISSUE COLOURS
Hematoma: varying with time

5. TISSUE COLOURS Bone Marrow: normally fatty
white on T1
White on T2
replaced with edema or other pathology
(dark on T1)
Bone cortex, stones, and ligaments
dark on everything
Contusion is white

6. TISSUE COLOURS Tumor: hypervascular (neovascularity):
white with gadolinium

7. Approach to protocols T1 -MRI with dark fluid
T2 -MRI with white water, inflammation
cartilage is black
STIR- T2 with dark fat
Proton Density - cartilage is grey
can suppress the fat
Gadolinium enhanced - with fat suppressionT1
bright blood
dark fat
Pathology bright

8. Magnetic resonance imaging (MRI) of the spine
A noninvasive procedure to evaluate different types of tissue, including
the spinal cord
intervertebral disks
spaces between the vertebrae through which the nerves travel
distinguish healthy tissue from diseased tissue.

9. Magnetic resonance imaging (MRI) of the spine
The cervical, thoracic and lumbar spine MRI should be scanned in individual sections.
The scan protocol parameter like e.g. the field of view (FOV), slice thickness and matrix are usually different for cervical, thoracic and lumbar spine MRI, but the method is similar.

10. Magnetic resonance imaging (MRI) of the spine
The standard views in the basic spinal MRI scan to create detailed slices (cross sections) are
sagittal T1 weighted and T2 weighted images over the whole body part
transversal (e.g. multi angle oblique) over the region of interest with different pulse sequences according to the result of the sagittal slices.
Additional views or different types of pulse sequences like fat suppression, fluid attenuation inversion recovery (FLAIR) or diffusion weighted imaging are created dependent on the indication.

11. Indications:
Neurological deficit, evidence of radiculopathy, cauda equina compression
Primary tumors or drop metastases
Infection/inflammatory disease, multiple sclerosis
Postoperative evaluation of lumbar spine: disk vs. scar
Evaluation of syrinx
Localized back pain with no radiculopathy (leg pain)

12. Contrast enhanced MRI Delineate infections, malignancies
show a syrinx cavity
support to differentiate the postoperative conditions. After surgery for disk disease, significant fibrosis can occur in the spine. This scarring can mimic residual disk herniation.
Magnetic resonance myelography evaluates spinal stenosis and various intervertebral discs can be imaged with multi angle oblique techniques.

13. Cine series can be used to show true range of motion studies of parts of the spine.
Advanced open MRI devices are developed to perform positional scans in the position of pain or symptom (e.g. Upright™ MRI formerly Stand-Up MRI).

14. Contraindications
MRI systems use strong magnetic fields that attract any ferromagnetic objects with enormous force.
Caused by the potential risk of heating, produced from the radio frequency pulses during the MRI procedure, metallic objects like wires, foreign bodies and other implants needs to be checked for compatibility.
High field MRI requires particular safety precautions.
In addition, any device or MRI equipment that enters the magnet room has to be MR compatible.
MRI examinations are safe and harmless, if these MRI risks are observed and regulations are followed.

15. Safety concerns in magnetic resonance imaging include:
The magnetic field strength;
possible 'missile effects' caused by magnetic forces;
the potential for heating of body tissue due to the application of the radio frequency energy;
the effects on implanted active devices such as cardiac pacemakers or insulin pumps;
magnetic torque effects on indwelling metal (clips, etc.);
the audible acoustic noise;
danger due to cryogenic liquids;
the application of contrast medium;

16. MRI Safety Guidance
It is important to remember when working around a superconducting magnet that the magnetic field is always on.
Under usual working conditions the field is never turned off.
Attention must be paid to keep all ferromagnetic items at an adequate distance from the magnet.
Ferromagnetic objects which came accidentally under the influence of these strong magnets can injure or kill individuals in or nearby the magnet, or can seriously damage every hardware, the magnet itself, the cooling system.

17. MRI Safety Guidance
The doors leading to a magnet room should be closed at all times except when entering or exiting the room.
Every person working in or entering the magnet room or adjacent rooms with a magnetic field has to be instructed about the dangers.
This should include the patient, intensive-care staff, and maintenance-, service- and cleaning personnel, etc..

18. MRI Safety Guidance
Leads or wires that are used in the magnet bore during imaging procedures, should not form large-radius wire loops.
The patient’s skin should not be in contact with the inner bore of the magnet.

19. MRI Safety Guidance
The outflow from cryogens like liquid helium is improbable during normal operation and not a real danger for patients

20. MRI contrast
The safety of MRI contrast agents is tested in drug trials and they have a high compatibility with very few side effects.
The variations of the side effects and possible contraindications are similar to X-ray contrast medium, but very rare.
In general, an adverse reaction increases with the quantity of the MRI contrast medium and also with the osmolarity of the compound.

21. Cervical Spine 1 – Basic • Indications • Sequences • Optional
o Disc disease, pain, radiculopathy
• Sequences
o Sag T1 FSE/TSE
o Sag T2 FSE/TSE
o Ax T2 FSE/TSE
o Ax TOF GRE
• Optional
o Cor T1 FSE/TSE
o Cor T2 FSE/TSE
For scoliosis, tethered cord and Neurofibromatosis, add coronal

22. Cervical Spine 2 – with contrast
• Indications
Tumor, Infection, MS, Syrinx, Transverse myelitis
• Sequences
Sag T1 FSE/TSE
Sag T2 FSE/TSE
Ax T1 FSE/TSE
Ax T2 FSE/TSE
Sag T1 +C FSE/TSE FS
Ax T1 +C FSE/TSE FS
• Optional
Cor T1 FSE/TSE
Cor T2 FSE/TSE

23. Cervical Spine 3 – Trauma
• Indications
o Trauma
• Sequences
o Sag T1 FSE/TSE
o Sag T2 FSE/TSE
o Sag IR T2 FSE/TSE
o Ax IR T2 FSE/TSE
o Ax T2 FSE/TSE
Can add sag T2 GRE to r/o hemorrhage

28. Cervical Neurography (Brachial Plexus)
• Indications
Post radiation therapy, eval for mass lesions, entrapment, denervation
• Sequences
Sag T2 FSE/TSE Scout
Cor STIR
Cor T1
AX STIR
Ax T1
Cor T1 +C FS
Ax T1 +C FS
• Optional
Cor T2 FSE/TSE FS
Ax T2 FSE/TSE FS
Sag T1 +C FS

29. Cervical Neurography (Brachial Plexus)
Use the Cardiac or phased array Body coil rather than the spine coil
Cor images should be 3mm skip 0mm, Ax Images 4mm skip 1.5
FOV should be from C4 through T1
Use T2 FSE/TSE FS if STIR images fail
Can add flow suppression or sat bands above, below, and anterior
Post process thick slab MIPs of STIR images if possible

30. Thoracic Spine 1 - Basic • Indications • Sequences • Optional
Disc disease, pain, radiculopathy
• Sequences
Sag T1 FSE/TSE
Sag T2 FSE/TSE
Ax T1 FSE/TSE
Ax T2 FSE/TSE
• Optional
Cor T1 FSE/TSE
Cor T2 FSE/TSE

31. Thoracic Spine 2 – with contrast
• Indications
Tumor, Infection, MS, Syrinx, Transverse myelitis
• Sequences
Sag T1 FSE/TSE
Sag T2 FSE/TSE
Ax T1 FSE/TSE
Ax T2 FSE/TSE
Sag T1 +C FSE/TSE FS
Ax T1 +C FSE/TSE FS
• Optional
Cor T1 FSE/TSE
Cor T2 FSE/TSE

32. Thoracic Spine 3 – Trauma
• Indications
Disc disease, pain, radiculopathy
• Sequences
Sag T1 FSE/TSE
Sag T2 FSE/TSE
Sag IR T2 FSE/TSE
Ax T2 FSE/TSE
• Optional
Ax GRE
Cor T1 FSE/TSE
Cor T2 FSE/TSE
Can add Sag GRE to rule out hemorrhage

35. Routine L-Spine MRI Degenerative spine Sagittal T1 SE,
Sagittal T2 FSE,
angled axial PD/T2 FSE,
Angled T1 stacked axials L3 to S2.
No IV contrast.

39. L-Spine MRI Trauma L-Spine MRI Sagittal T1 SE, Sagittal FSEIR,
Axial T2 FSE with fat sat.
Target axials to abnormality.
No IV contrast.
Post-Op L-Spine MRI
Target axials to abnormality at level of surgery
IV contrast.
Can add Sag GRE to rule out hemorrhage

43. Osteomyelitis, Discitis
pre-contrast:
Sagittal T1 SE,
Sagittal T2 FSE,
Axial PD/T2 FSE,
contrast: Gd (0.1 mmol / kg to max of 20 cc)
post-contrast:
Axial T1 SE

44. Tethered Cord Sagittal T1 SE, Sagittal T2 FSE, Axial T1 SE , T2 FSE,
T10 to S2, using interslice gap as needed.
No IV contrast.

45. Spine Survey • Indications • Sequences • Optional • Comments
Metastases, Non-localized infection, acute myelopathy / cord compression
• Sequences
Sag T1 FSE/TSE
Sag T2 FSE/TSE
Ax T1 FSE/TSE
Ax T2 FSE/TSE
Sag T1 +C FSE/TSE FS
Ax T1 +C FS (region of interest)
• Optional
Cor T1 FSE/TSE
Cor T2 FSE/TSE
• Comments
sagittal images to determine where to obtain axial images

46. MRI KNEE
Common Indications
Knee pain
Knee instability
Knee mass

47. Otherwise schedule anytime.
First Ask
Is there a mass?______ When did you first discover the mass?_______________________
Does the problem relate to a recent injury? YES NO DATE_____________________
Where does the knee hurt ( FRONT - BACK - INSIDE - OUTSIDE )?
Have you had surgery on your knee? YES NO DATE__________________________
Have you had an x-ray?
If “mass” then schedule in early morning with Radiologist monitoring. Patient may need gadolinium
Otherwise schedule anytime.
Instruct patient to bring x-rays if available.

48. Patient Preparation:
· Fill out safety screening and clinical information form
· Vitamin E capsule on the site of symptoms and on any masses
· Measure distance left or right from centerline of magnet

49. Coil: Extremity. Slightly externally rotate the foot by about degrees to stretch the anterior cruciate ligament.
Pack some cushions around the knee to help it stay motion-free. A small cushion under the ankle helps to keep the leg straight.
Landmark: inferior region of patella.
Patient Positioning: Supine, feet first.

51. Series 1: Axial Proton Density
Series 2: Sagittal Proton Density
Oblique to the intercondylar notch
Include all of medial and lateral menisci. Subcutaneous fat medial and lateral to knee joint may be excluded. If more slices are required, increase TR.

52. Series 3: Coronal Proton Density
Oblique perpendicular to series 2.
If more slices are required, increase TR.
Keep TR > 3000 and ETL < 16
If there is bone abnormality or soft tissue mass then it may be necessary to increase FOV.
Series 4: Coronal T2 Fat Sat (same as series 3 above) 
Series 5: Optional Cartilage:
Usually cartilage is well seen on the proton density sequences (series 1-3). However this in patients with cartilaginous injuries, this extra sequence optimized for cartilage may be useful.
Do not film this sequence. It is viewed on the computer work station.

53. If there is a Solid Mass suspicious for CANCER:
then make sure there is a vitamin E capsule marking the site of the mass and perform dynamic 2D or 3D Gd MRA during the injection of single dose gadolinium followed by axial and either sagittal or coronal T1 fat sat spin echo sequences

54. If there is hemophilia or if PVNS is suspected:
Do a gradient echo sequence
Series 8: Optional Gradient Echo:
This sequence is useful for patient with hemophilia or PVNS
Make sure to cover all of the synovium