Spine

Spontaneous intracranial hypotension caused by spinal CSF leaks can be a frustrating diagnosis from both diagnostic and therapeutic standpoints. While the classic finding is an orthostatic headache which may be exacerbated with a cough, sneezing or valsalva, a wide variety of other symptoms can be attributed to the disorder including photophobia, imbalance, hearing abnormalities and mental status change. Underlying etiologies may be a dural tear from osseous spur or disc, meningeal diverticulum or CSF-venous fistula. Up to 1/3 of patients may have no aetiology defined. The workup of these patients may vary widely and can include multiple imaging modalities and strategies ranging from nuclear medicine, CT, MR, and myelography. Our workup includes an initial evaluation with contrast-enhanced brain MR and epidural blood patch X2. If the blood patch fails, then a complete spine MR is performed looking for an epidural fluid collection (fast leak). If a fast leak is discovered, then additional dynamic imaging is performed (either dynamic myelography or dynamic CT myelography). If no extradural fluid is identified (presumed slow leak), then routine CT myelography is performed. If this routine study is negative, then MR myelography is performed with attention to defining a CSF-venous fistula.

During the last decade, we attended an incredible improvement in spine biomechanics knowledge and powerful diagnostic tools, as well as the development of a new generation of “minimally invasive” devices and “covert surgery” procedures, that changed our mind about who, when and how to treat a patient affected by spine disease. The use of X-ray and/or CT-guided procedures give Radiologists a wide range of new possibilities in treating the spine, reducing the risk of side effects and complications in comparison to conventional “open” surgery, lowering the economic costs of the procedures as well as rehab time, avoiding the risk of general anesthesia, as the most of the procedures can be performed in mild sedation. Last, but not least, CT-X ray guided procedures allows significant cost reduction for the Health Care System, as smaller medical staff is needed, with no operating room occupation as well as beds/patients rate reduction, a must in our money-saving critic times. Interventional Radiology, however, cannot progress without an advanced knowledge of Diagnostic Radiology of the Spine, that is fundamental when a decisional route must be proposed to the patient. We will analyse all the most recent CT-guided technique in the treatment of tumours, degenerative and traumatic disease of the Spine, treated with fully CT-guided techniques in simple analogue-sedation.

Neck pain is a common problem with many possible causes. The facet joint and the uncovertebral joint are frequently involved in degenerative cervical spine disease. It is important to learn how to differentiate normal and asymptomatic changes that occur with age from abnormal findings that are causing neck and/or arm pain. I will demonstrate the use of plain film, CT, SPECT and MRI in diagnosing an offending uncovertebral or facet joint. Many of these offending joints can be targeted specifically, leading to easy and fast pain reduction in many patients with specific neck pain.

Degenerative changes of the cervical spine may be caused by mechanical overload or may occur during the ageing process. Patients with spinal stenosis may present with clinical symptoms ranging from neck pain to spastic paraparesis. Imaging is crucial in these cases in order to identify the cause of these clinical symptoms and to select the appropriate treatment option. Spinal stenosis is caused by certain pathological features that occur during the degenerative process, e.g. marginal osteophytes of the vertebrae, hypertrophy of the ligaments and intervertebral disc degeneration with herniation. Radiographs, CT as well as CT-myelography and MR imaging are the common imaging modalities used for the assessment of the severity of the spinal canal stenosis. Next to the assessment of soft tissue structures and osseous structures of the vertebrae, especially T2-weighted MR imaging is crucial for the assessment of signal changes within the myelon. One of the most important aspects assessed with MR imaging is the differentiation between signs of acute myelopathy and myelomalacia, caused by irreversible damage of the spinal cord. These aspects are of importance for the selection of the adequate treatment option, especially in order to decide between conservative or surgical treatment.

Imaging is a routine part of follow up for the postoperative cervical spine. A knowledge of the surgical techniques and/or the hardware used for cervical surgical and instrumentation procedures is very helpful in understanding the postoperative imaging appearances. A knowledge of the imaging modalities and when to use them is required. Ways to reduce metal artefact in imaging should be implemented. Radiography provides information on cervical spine fixation or metallic hardware placement. CT provides information on cervical spine alignment, hardware placement and integrity, and bone graft incorporation or complications. MRI is helpful for complications of surgery not directly related to hardware. These include signs of CSF leakage, pseudomeningocoele, epidural or other haemorrhage and infection. In the context of the degenerative cervical spine, MRI shows residual or recurrent disk osteophyte complex. Long-term sequelae of cervical spine fusion such as hardware failure, advanced degeneration, post laminectomy spondylolisthesis and epidural and other scar tissue are detected by follow up imaging. The entity of the failed back surgery syndrome needs to be considered with the postoperative cervical spine and what to look for in imaging it. The combination of understanding the surgical techniques used, using the correct imaging modality for the patient symptoms and having a systematic approach to the imaging evaluation, renders imaging of the postoperative cervical spine safe, practical and useful.

Spinal injuries to the spinal column or spinal cord are devastating for the patient, their family and costly for the society. Depending on the degree of trauma, the age and condition of the patient, clinical, and neurological symptoms different imaging strategies are suggested. Different imaging rules and schemes have been suggested where the degree of trauma and the patients symptoms play an important role in the imaging decision making. The presentation aims to focus on when and how to image and present the differences that can be seen in injuries between the pediatric and the adult population.

Despite its high sensitivity but low specificity, magnetic resonance imaging (MRI) is the modality of choice for diagnosis of spinal cord diseases. Spinal cord examination is one of the most challenging MR examinations from a technical, interpretative, and differential diagnostic standpoint. In practice, there are no satisfactory ways to distinguish among different forms of myelitis and neoplastic conditions when conventional MR sequences are used. In the last decade, several indications for diffusion-weighted MR imaging (DWI) and diffusion tensor imaging (DTI) in the spine have been reported. DTI could provide reliable postoperative evaluation and analysis for cervical spondylotic myelopathy patients. DTI has been proven useful for differentiation of ependymoma and astrocytoma of the spinal cord. This lecture will review advantages and disadvantages of the advanced MR sequences (such as DWI, DTI, Perfusion) when used for the spine. Possible pitfalls, helpful clinical information, and recognition patterns will be discussed.

The group of spondyloarthritides compromises a number of closely related rheumatic diseases with common clinical features: Ankylosing Spondylitis, Psoriatic Arthritis, Arthritis and Spondylitis related to inflammatory bowel disease, and Reactive Arthritis. Patients can also be grouped into two categories based on their predominant clinical presentation: axial or peripheral. Axial Spondyloarthritis is inflammatory arthritis primarily involving the sacroiliac joints and the spine. Presumably, the process of inflammation starts as enthesitis, mainly visible as bone marrow oedema at the insertion of ligaments or tendons into bone. However, bone marrow oedema is an unspecific feature and occurs amongst others frequently in the context of mechanical changes and degenerative processes of the axial skeleton. Imaging is an important component of the classification criteria for axial Spondyloarthritis. Conventional radiography is an essential part of the internationally accepted modified NY criteria for Ankylosing Spondylitis but visualises only the late structural changes of the inflammatory process after years. Magnetic Resonance Imaging can detect the early changes in up to four months after clinical onset. MRI of the sacroiliac joints has been integrated as a key diagnostic criterion of axial Spondyloarthritis according to the Assessment of SpondyloArthritis International Society (ASAS) in 2009.

Crystal deposition in the spine is unusual. The presentation varies from acute pain syndromes to subclinical disease usually detected as an incidental finding on cross-sectional imaging. The pathophysiology, clinical presentation and imaging appearances of crystal disease will be presented. Spinal gout, acute longus colli hydroxyapatite deposition and Crown dens syndrome resulting from either hydroxyapatite or pyrophosphate deposition will be described. Differentiating crystal disease from ligamentous ossification, degeneration and other deposition diseases such as amyloid will be discussed. Gout is a common inflammatory arthritis most commonly seen on men and post-menopausal women. The prevalence of gout is currently increasing over time. Spinal gout typically presents with localised pain, incidental lytic vertebral lesions usually detected on cross-sectional imaging or with symptoms resulting from neurological compromise. Spinal gout most commonly effects the posterior elements of the spine. Crowned dens syndrome results from crystal deposition around the odontoid peg of the cervical spine. It presents with acute neck pain and unless recognised often leads to misdiagnosis and inappropriate treatment. The deposition can be either pyrophosphate or hydroxyapatite crystals with both having identical imaging appearances. A similar clinical presentation is also seen in Acute calcific longus colli hydroxyapatite deposition. This is a rare cause of severe neck pain, dysphagia and odynophagia is often mistaken for other common causes of neck pain. Similar to crowned dens syndrome prompt recognition is important to prevent unnecessary imaging or treatment.

The diagnosis of spinal infections is often made by a combination of clinical symptoms and radiologic abnormalities. Magnetic resonance imaging is the main imaging modality for this diagnosis. Confirmation is based on histopathologic findings and/or identification of pathogens from biopsy specimens or blood cultures. Percutaneous biopsies are widely practiced in this indication, with the more accurate and safer guidance of computed tomography (CT). Two main types of percutaneous biopsies are available: fine needle aspiration biopsy and core needle biopsy. Specific techniques and approaches with varying needle systems are described for each spinal region. It is the procedure of choice in the definitive diagnosis of pathologic lesions of the spine.