Spine MRI- Quality

Quantity QED!Dr W J Rennie

University Hospitals of Leicester

Leicester Royal Infirmary

winston.rennie@uhl-tr.nhs.uk

Layout

• MRI sequences/Planes

• Protocol Logic- Briefly Image Quality!

• Disc Herniation

• Common & Uncommon Pathologies

• Reporting-How I do it!

• Why Spinal MRI is different!

Investigations in Clinical

Medicine - to reduce the degree

of Uncertainty!

What is Truth?

-Pontius Pilate

John c18:v38

MRI Protocols- How I do it!

• 30 minutes per body part

• 10 minutes for patient

transfer/positioning

• 20 minutes - Sequences

• Longest Sequence X 2

• Remaining time -Any number

of sequences!

Beware the Localiser

• Spinal MRI planned from

pedicle to pedicle!

• Localisers are quick GRE

sequences prone to

susceptibility and signal void!

• What you see is not always

what is True!

MRI Sequences

• Short TE

• T2W

• Fluid Sensitive sequences

• Sagittal plane

• Transverse plane

MRI Sequences

• Short TE

• Saturation bands

• Slice thickness and

Interspace

• Most Important Plane and

sequence in Spine

MRI Sequences

• T2 W

• Look good but are less

important in the Spine

• Spinal Surgeon Sequence

• Sagittal Imaging - Important

Plane

MRI Sequences

• Fluid Sensitive sequences

• Inversion recovery

• Fat Saturation

• TI=150 on a 1.5 T MRI

MRI Sequences

• Transverse Plane

• Ax T1

• Ax T2

• Angled to the disc/pathology

Level

Uncertainty & Quality

Conflicts In MR Image

Quality

TIME SIGNAL

Compliance

Image

FOV

TR

Concatenations

TF/ ETL

TE

Slice Thickness

BW

Matrix

MRI Protocol Planning

• Time/Resolution/Compliance

• Lumbar Spine Std=30mins

• 20 mins for sequences

• STIR = 4 mins x 2 =8mins

• 12mins plan any number of

sequences you can fit!

• FOV & Slice Thickness

• TE and TR = Weighting

Pathology

Common Pathologies

• Disc

degeneration/dehydration

• Disc Bulge

• Disc Herniation

• Spinal Stenosis

https://www.spine.org/Documents/ResearchClinical

Care/Nomenclature.pdf

Disc Herniation Report

• Location

• Containment

• Morphology

• Volume

• Continuity

• Migration

• Composition

Disc Herniation

Disc Herniation

Axial Images T1

Pathology

Spinal haemangioblastoma

• Third Most common

intramedullary spinal

neoplasm

• 2-6% of all IM tumours

• Peak 3-4 decade

• 1/3 Von Hippel Lindau

Syndrome

• 50% T spine, 40% Cspine

• Associated Syrinx 50-100%

AJR 2000;174 (2): 377-82.

Radiographics. 20 (6): 1721-49.

Pathology

• Facet Synovial Cysts

• Common L4/5 level

• Radicular symptoms

• Treatment Percutaneous

Image guided rupture

Bureau NB et al. Radiology Oct 2001 Vol22(1)

Pathology

Dural AVF

Spinal Dural AVF

• 70% of all vascular

malformations

• 5-6 decades

• M>F

• 60% Spontaneous

• Insidious Onset of progressive

weakness

AJNR Am J Neuroradiol. 2005;26 (8): 1949-54.

J Neurosurg Spine. 2011;15 (5): 541-9.

Pathology

Adhesive Arachnoiditis

• Empty Theca Sign

• Nodular/ Clumping

• Post surgical

• Post infective

• Associated with a syrinx

• Maybe asymptomatic

J Craniovertebr Junction Spine. 2010 Jul-Dec; 1(2): 100–106.

Pathology

Myeloma

Pathology

Post Trauma

Vertebral Artery Dissection

• Rare but not uncommon in <40

• Post traumatic

• Fractures extend into the

foramen transversarium

• Can have a latent period 3-4

days

• lateral medullary dysfunction

Wallenberg’s Syndrome

• Assess intracranial Extension

Radiographics. 20 (6): 1687-96.

Pathology

Demyelination

• Primary

• Infective

• Toxic

• Metabolic

• Ischaemic

Pathology

Intradural Haemorrhage

1 week Later

Intradural haemorrhage

Pathology

AAA

AAA

SpA

SpA MRI Protocol

• Costovertebral

• Costo transverse

• Lateral vertebral

• Lateral TP

Rennie WJ, Dhillon SS, Conner- Spady

B,MaksymowychWP, Lambert RGW. Arthritis

Rheum. 2009 Sep 15;61(9):1187-93.

SpA Spine

• Wide coverage laterally-

Check localiser

• Cervico Thoracic

• Thoraco Lumbar

• SIJ

• T1 &STIR

• 40 min-Book knee or brain

next= 2 parts in 1 hour!

Spine- SpA

SpA- SIJ

SIJ- SpA

www.carearthritis.com/mriportal/

login/

MRI Course Self-paced Learner

Reporting

Reporting

• Always related to the clinical Information

Provided

• Many ‘findings’ are clinically irrelevant

• Correlate Clinical History

• Spinal MRI Confounding Bias!

• Complications Of Spine Surgery

How I do It

• There are five Lumbar type vertebrae

• The conus is normal in signal intensity and

terminates at T12/L1

• No cauda or radicular compressive lesion is

demonstrated

• The lumbar Lordosis is preserved

• No spinal or paraspinal mass demonstrated

Why Spinal Imaging is prone

to Confounding Bias!

• Best plane in Cross-

sectional Imaging!

• Best Sequence for

Pathology

• Clinical Information

not always relevant

• Standard Protocols

• Sagittal

• T1W images

• Clinical Information always

relevant

• Tailored protocols

Summary

• MRI sequences/Planes

• How to obtain high quality images

• Disc Herniation

• Common & Uncommon Pathologies/ SpA

• Reporting How I do it!

• Why Spinal MRImaging is Prone to confounding Bias!