Lumbar Spine Imaging: MRI
As per the American College of Radiology (ACR) Appropriateness Criteria.
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Glenn C. Gaviola and Nehal A. Shah
MR Imaging
Technique
Indications
• T1-weighted sequences: best for evaluation of epidural fat and differentiation from cerebrospinal fluid (CSF), and for evaluation of optimal targets for epidural steroid injections (On T1, fat is bright and hyperintense in signal intensity and CSF is dark and hypointense in signal intensity) (Fig. 27.1a); • T2-weighted sequences: best for evaluation of cord signal changes and surrounding soft tissue pathology; best for evaluation of the conus medullaris and cauda equina nerve roots given optimal contrast resolution between the CSF and the nerve roots, unlike T1-weighted images (Fig. 27.1b). • Fluid sensitive sequences (e.g., STIR or T2-weighted fat-suppressed): best for marrow edema and fractures; disc extrusions and hydration of the nucleus pulposus (Fig. 27.2);
As per the American College of Radiology (ACR) Appropriateness Criteria: • Low back pain complicated by radiculopathy or sciatica, cauda equina syndrome, neurogenic claudication, spinal stenosis or in patients with risk factors including osteoporosis, focal/progressive neurological deficit, >6 weeks symptom duration; age >70; suspected cancer, infection or immunosuppression; or history prior lumbar surgery; • Myelopathy, in particular, non-traumatic myelopathy, whereas CT is best for evaluating traumatic myelopathy; • IV contrast is preferred in suspected cases of cancer, infection, inflammation, or vascular causes of myelopathy; and in postoperative evaluation for recurrent disc herniations and scar;
G.C. Gaviola, MD • N.A. Shah, MD (*) Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected]
Evaluation • Degenerative disc disease (Fig. 27.3) which includes annular fissures, loss of disc hydration and disc height, disc bulging, Modic endplate changes of edema (type 1), fatty replacement (type 2) and sclerosis (type 3) and for evaluation of disc migration: • Disc herniation defined as localized or focal displacement of disc material beyond
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_27
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Fig. 27.1 (a) Sagittal T1-weighted MR image of the lower lumbar spine demonstrates the utility of T1-weighting in differentiating epidural fat (solid black arrow), which is hyperintense in signal intensity, versus cerebrospinal fluid in the thecal sac (dashed black arrow) which is hypointense in signal intensity. Note the L4–L5 disc bulge which effaces the epidural fat and makes a ventral impression upon the thecal sac resulting in focal spinal canal stenosis at this level (dashed white arrow). The cauda equina nerve roots are not well seen because they are of similar signal intensity relative to the CSF due to suboptimal contrast resolution.
(b) Sagittal T2-weighted MR image of the lower lumbar spine at the same level demonstrates the utility of how e
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