Back pain results in a huge socio-economic burden.
Most cases of back pain do not require imaging.
The presence of red flags should prompt early imaging.
MRI is the modality of choice for imaging back pain.
Se$tion-
"early half the adult !o!ulation in the + suffers from 7a$; !ain, lasting at least 26 h at some time e<ery year =0>/ A!!ro&imately fi<e million !eo!le $onsult their general !ra$titioner ?ith 7a$; !ain annually/ The im!a$t of 7a$; !ainon so$iety is $onsidera7le and is asso$iated ?ith an enormous e$onomi$ 7urden/ It ?as estimated that the dire$thealth$are $ost of 7a$; !ain in the + in 0445 ?as @0 (2 million ?hereas the $osts from informal $are and loss of!rodu$tion ?as @01 5 million = 2>/ *o? 7a$; !ain most $ommonly affe$ts the (1 31 year age grou!, ?ith the!re<alen$e !ea;ing during the si&th de$ade = 0>/ :oung !eo!le are more li;ely to ha<e 7rief, a$ute e!isodes of 7a$;
!ain, ?hilst $hroni$ !ain tends to o$$ur in older !eo!le/ There is an e ual se& distri7ution/ This re<ie? summariDesthe aetiology, $lini$al !resentation and radiologi$al in<estigation of 7a$; !ain/
When to imageSe$tion-
There are many $auses of 7a$; !ain ?ith a $om!le& interErelationshi! 7et?een anatomi$al, !athologi$al and!sy$hologi$al fa$tors leading to the e<entual $lini$al !resentation/ A $areful history and !hysi$al e&amination remainsthe mainstay of initial assessment of 7a$; !ain/ Imaging is not ne$essary in most $ases of 7a$; !ain 7e$ause of thehigh rate of s!ontaneous remission ?ithin 5 ?ee;s/ Furthermore, the use of early imaging does not a!!ear to altermanagement in most !atients = ( , 6>/ There are, ho?e<er, $ertain features or red flagsG that should suggest serious!athology and !rom!t early imaging HTa7le 0 /
The Royal College of Radiologists has dra?n u! guidelines for the in<estigation of 7a$; !ain = 3> HTa7le 2 / Thea!!li$ation of these re$ommendations ?ill de!end on many fa$tors in$luding lo$al e&!ertise, finan$ial resour$es anda<aila7ility of MRI/ It is in$reasingly re$ogniDed that !lain radiogra!hi$ e<aluation of 7a$; !ain in the a7sen$e of
trauma is of limited <alue, as degenerati<e $hanges are <ery $ommon and sinister !athology may easily 7e missed= >/
Broadly s!ea;ing, there are four main $lini$al s$enarios-
1.Acute non-specific back pain !hich usually resol"es spontaneously !ithin #$% !eeks.
&.'hronic back pain !ithout sinister features. A "ery common situation that is usuallyrelated to degenerati"e disease.
(.Back pain !ith sciatica. A condition usually caused by disc prolapse.
).*ossible serious pathology or cauda equina syndrome. This group encompasses "ariousconditions such as tumour infection and inflammatory disorders.
#f these $onditions, the first t?o do not usually ?arrant imaging/ In !atients suffering from s$iati$a, the $ause isusually a !rola!sed dis$, and those ?ho ha<e had a failed !eriod of $onser<ati<e thera!y may re uire imaging/ In
!atients ?ith !ossi7le serious !athology, urgent s!e$ialist referral and imaging are 7oth indi$ated/
The !hysi$al $auses of 7a$; !ain $an 7e di<ided into me$hani$al $onditions su$h as dis$ disease and nonEme$hani$al $onditions, su$h as infe$tion, inflammation or malignan$y HTa7le ( / There are also $onditions ?hi$h donot in<ol<e the s!ine, su$h as a7dominal aorti$ aneurysms and urologi$al $onditions that may !resent ?ith 7a$; !ainHFigure 0 / ue to the $om!le&ity of the 7ony, ligamentous, mus$ular and neural elements of the 7a$;, a s!e$ifi$anatomi$al diagnosis often $annot 7e made/ 8<en ?hen radiologi$al in<estigations sho? an a7normality, the !ositi<efindings may not ne$essarily relate dire$tly to the 7a$; !ain = ) >/ Close $lini$oEradiologi$al $orrelation is therefore
re uired/
#f the first 0111 MRI studies $arried out in lieu of !lain radiogra!hs for lo? 7a$; !ain in our institution, 51 sho?eddegenerati<e or normal s!ines, ?hereas 21 sho?ed other !athology = >/ Figure 2 !resents the $onditions found inthe 211 !atients ?ith a !athologi$al $ause/
MRI sequencesSe$tion-
If the !atient ?arrants e<aluation of !ersistent 7a$; !ain or sus!e$ted serious !athology, a limited MRI is
re$ommended rather than !lain radiogra!hs = >/ This e&amination should in$lude a sagittal T 0 ?eighted and a shorttau in<ersion re$o<ery HSTIR se uen$e/ The T 0 ?eighted se uen$e is of !arti$ular <alue in e<aluating s!inalanatomy and 7one marro?, ?hereas the STIR se uen$e is useful for de!i$ting the dis$s, inflammatory $hanges,7one marro? oedema and the s!inal $anal/ A&ial images are not routinely o7tained, as the in<estigation is not!erformed for e<aluating neural $om!ression/ As the !ur!ose of the in<estigation is to e&$lude a sinister $ause for thesym!toms, it is im!ortant to endea<our to !erform the MRI in a short timeframe, !refera7ly ?ithin 2 ?ee;s/
For !atients ?ith s$iati$a the $ause is usually dis$ disease and, if s!e$ialist referral is 7eing made, ?e ?ouldre$ommend an MRI s$an ?ith sagittal and a&ial T 0 and T 2 ?eighted se uen$es/ This is dis$ussed in a se!arate$ha!ter/
Other imaging modalities
Se$tion-
In $ertain situations !lain radiogra!hs, CT or s$intigra!hy may 7e used as an alternati<e to MRI to e<aluate the s!ine/For e&am!le, if !atients are una7le to undergo MRI, CT may 7e a useful alternati<e/ If 7ony metastases aresus!e$ted, s$intigra!hy may 7e an a!!ro!riate first line in<estigation/
InfectionSe$tion-
S!ondylodis$itis a$$ounts for 2 6 of $ases of osteomyelitis = 5, 4>/ Men are affe$ted more often than ?omen/ S!inalinfe$tions $an 7roadly 7e $ategorised into three age grou!s- 9rou! 0 $om!rises 7a7ies less than 0 year, ty!i$ally!resenting ?ith se!ti$aemia/ 9rou! 2 $om!rises $hildren ?ith lo$aliDed dis$itis, a $ondition ?hi$h often runs a 7enign$ourse/ 9rou! ( is the largest and $om!rises adults, !arti$ularly the elderly and immuno$om!romised, ?ho !resent?ith 7a$; !ain and fe<er/ The reasons for the more 7enign !resentation in $hildren $om!ared ?ith adults may 7e dueto differen$es in the infe$ting organisms, the immune status and the greater <as$ularity of the end!lates =01 >/
The s!inal $olumn is surrounded 7y a dense <as$ular net?or;, ?ith the anterolateral su7$hondral region of the<erte7ral 7ody adKa$ent to the end!lates 7eing !arti$ularly ?ell <as$ulariDed =00>/ This area is often the starting !ointfor haematogenous infe$tions/ From here s!read into the adKa$ent dis$, <erte7ra and soft tissues may o$$ur/ S!readto the adKa$ent end!late may o$$ur a$ross the dis$ or <ia the !eri!heral <as$ular anastamosis/ Pathogens that!rodu$e !roteolyti$ enDymes, su$h as Staphylococcus aureus , s!read ra!idly into the dis$ ?ith loss of dis$ heightand dis$ herniation =4, 02 >/ Pathogens su$h as Mycobacterium tuberculosis that do not !rodu$e !roteolyti$ enDymes
tend to s!read more slo?ly, often s!aring the dis$ until late in the disease !ro$ess/
There are three main routes for a$ uiring s!inal infe$tion-
+aematogenous route. This is the most common route for acquiring spinal infection. Theelderly immunocompromised diabetics and intra"enous drug users are particularly at risk.
,pread from ad acent infection. This usually occurs due to pel"ic pleural andretropharyngeal infections.
irect inoculation. This tends to be iatrogenic occurring as a complication of discography/ ∼ 10 or spinal surgery /($1(0 2 1( 3. irect trauma may also lead to infection.
Patients usually !resent ?ith lo$aliDed 7a$; !ain and fe<er = 06 >/ "eurologi$al sym!toms may arise from $ordin<ol<ement se$ondary to <erte7ral $olla!se or e!idural a7s$ess formation/ The inflammatory mar;ers and ?hite $ell$ount may 7e raised/ +ltimately, ho?e<er, the diagnosis of s!inal infe$tion relies hea<ily on imaging/
Imaging of spondylodiscitisSe$tion-
Imaging allo?s $onfirmation of s!ondylodis$itis and hel!s guide 7io!sy/ Although !lain radiogra!hy, CT ands$intigra!hy $an all 7e used to diagnose s!ondylodis$itis, MRI !ro<ides the highest sensiti<ity and s!e$ifi$ity = 03 >/
Pyogenic infection
In the a$ute !hase of infe$tion, there may 7e little or no radiogra!hi$ a7normality/ With s!read into the dis$, there isra!id diminution of dis$ s!a$e, ?ith loss of definition of the <erte7ral end!lates, follo?ed 7y !rogressi<e <erte7raldestru$tion/ The !lain radiogra!hi$ findings in$lude narro?ing of the dis$ s!a$e, <erte7ral end!late demineraliDationand $on<e&ity of the !aras!inal lines/ There may 7e <erte7ral $olla!se and asso$iated ne? 7one formation HFigure ( /
MRI !ro<ides good <isualiDation of the <erte7ral 7odies and dis$s, as ?ell as the !aras!inal regions=02 , 0 >/ T 0?eighted se uen$es !ro<ide e&$ellent anatomi$al detail/ #n T 0 ?eighted images, the findings in$lude lo?signal in the dis$ and adKa$ent <erte7ral 7odies, ?ith !oor delineation of the dis$Eend!late interfa$e/ Ty!i$ally, theaffe$ted !ortions of the <erte7rae and dis$ ?ill enhan$e follo?ing intra<enous gadolinium/ #n$orres!onding T 2 ?eighted and STIR images there is in$reased signal ?ithin the dis$ and adKa$ent end!lates ?ithloss of the intranu$lear $left HFigure 6 / As the infe$tion ad<an$es, there is !rogressi<e end!late destru$tion andirregularity HFigure 3 /
MRI !ro<ides e&$ellent delineation of e!idural disease and assessment of mass effe$t on the $ord = 4, 0) , 05 >/8!idural a7s$esses and !hlegmons a!!ear as e&tradural masses, ?hi$h are ty!i$ally isointense or hy!ointense tothe $ord on T 0 ?eighted images and hy!erintense on T 2 ?eighted and STIR se uen$es/ A !hlegmon is inflammatorytissue ?ithout a fluid or !us $om!onent, ?hereas a7s$esses ha<e a fluid $om!onent/ Most e!idural a7s$esses o$$ur<entrally, adKa$ent to the le<el of infe$tion/ %omogeneous enhan$ement of an e!idural mass suggests a !hlegmon,?hereas rim enhan$ement suggests an a7s$ess/ 8!idural a7s$esses may 7e diffi$ult to dete$t ?ithout intra<enous
$ontrast as the adKa$ent $ere7ros!inal fluid may ha<e similar signal intensity on all se uen$es HFigure /
Paras!inal $olle$tions ha<e 7een re!orted in 3(/3 of $ases of !yogeni$ <erte7ral osteomyelitis = 04 >/ MRI allo?s thede!i$tion of !aras!inal a7s$esses in relation to the retro!eritoneum and the aorta and <ena $a<a/ #ften a7s$essestra$; along the ilio!soas mus$les HFigure ) /
The imaging findings may a!!ear to ?orsen e<en if the !atient has im!ro<ed $lini$ally = 0 >/ The return to fatty marro?signal in the end!lates and a de$rease in $ontrast enhan$ement are good signs of healing/ The !ersistent u!ta;e of$ontrast at the site of initial infe$tion may, ho?e<er, 7e en$ountered for months after treatment has $ommen$ed/ Thelate se uelae of s!ondylodis$itis in$lude loss of dis$ height, <erte7ral $olla!se and s$lerosis, ;y!hos$oliosis andinter7ody fusion/
Tuberculous infection
#n imaging, the features of !yogeni$ and tu7er$ulous s!ondylodis$itis may 7e indistinguisha7le, 7ut there may 7e!ointers that indi$ate tu7er$ulous infe$tion = 21 >/ Tu7er$ulous osteomyelitis tends to in<ol<e the anterior end!late ofthe <erte7ral 7ody ?ith infe$tion s!reading 7ehind the anterior longitudinal ligament to the adKa$ent <erte7ral 7odyHFigure 5 / Initially, dis$ in<ol<ement is limited, $om!ared ?ith <erte7ral 7ody in<ol<ement/ *arge !ara<erte7rala7s$esses may de<elo! ?hi$h a!!ear dis!ro!ortionate to the degree of <erte7ral 7ody in<ol<ement/ 8!idural$olle$tions may result in $om!ression of the the$al sa$ HFigure 4 / Bony destru$tion may lead to <erte7ral $olla!seand an angulated ;y!hosis or gi77us deformity/ Patients ?ith tu7er$ulous s!ondylodis$itis tend to ha<e a longer$lini$al $ourse, greater thora$i$ in<ol<ement, greater s!inal deformity and more !aras!inal masses and neurologi$aldefi$its than !atients ?ith !yogeni$ infe$tion = 04 >/
ifferential diagnosis and pitfalls
There are se<eral $onditions that $an mimi$ s!inal osteomyelitis and dis$itis on imaging-
egenerati"e spine !ith type 1 Modic change 2 &13. Inflammatory type end plate changesmay be seen !ith degenerati"e disc disease !ith lo! signal on T 1 !eighted images andhigh signal on the ,TIR sequence. 4sually in this situation the inter"ening disc is of lo!signal on all sequences /5igure 16 .
,pinal neuroarthropathy arising from conditions such as diabetes or syringomyelia can
result in radiographic features indistinguishable from infection. 7n MRI the disc usuallydemonstrates lo! signal on all sequences 2 &&3.
The spondyloarthropathy of chronic haemodialysis may be mistaken for infection 2 &( &)3.Biopsy may be required to e8clude infection.
Inflammatory spondyloarthropathy such as ankylosing spondylitis /A, !ith a pseudoarthrosis may mimic infection 2 &93. :8tension of the fracture into the posteriorelements occurs !ith a pseudoarthrosis allo!ing differentiation from infection.
Pars interarticularis defects! spondylolysisSe$tion-
Patients ?ith s!ondylolysis ha<e !ars interarti$ularis defe$ts of the neural ar$h/ The *3 le<el is most $ommonlyaffe$ted, follo?ed 7y the *6 le<el/ The $ondition affe$ts males more than females, and may 7e $ongenital or a$ uired/Congenital forms o$$ur ?ith $onditions su$h as hy!o!lasti$ !ars and s!ina 7ifida = 2 , 2) >/ A$ uired !ars defe$tsusually arise due to re$urrent mi$rotrauma resulting in stress fra$tures/ This o$$urs !arti$ularly ?ith re!eated fle&ionEe&tension a$ti<ity seen in s!orts su$h as ?eightElifting, gymnasti$s and $ri$;et =25 >/
Although s!ondylolysis is $ommonly asym!tomati$, it may $ause se<ere disa7ling !ain in some !atients/ uring
adoles$en$e and in adults, 7a$; !ain often o$$urs after s!orting a$ti<ity/ The !ain may 7e$ome s$iati$ in nature andradiate into the lo?er lim7s or 7utto$;s if there is asso$iated s!ondylolisthesis, ?hi$h is the for?ard sli! of a <erte7ral7ody ?ith res!e$t to the <erte7ral 7ody 7elo?/
Imaging of spondylolysis and spondylolisthesis
Thin se$tion H( mm or less , high resolution MRI may 7e used as the !rimary in<estigation for e<aluating the !ars=24 , (1 >/ In our e&!erien$e sagittal images are usually suffi$ient, although some authors ad<o$ate imaging in morethan one !lane =(0 >/ #n MRI, s!ondylolysis has a <aria7le a!!earan$e that de!ends on ho? a$ute the lesion is/Patients ?ith an a$ute stress rea$tion ha<e in$reased signal on STIR and T 2 ?eighted images in the !ars indi$atingmarro? oedema HFigure 00 / #n T 0 ?eighted images, $orres!onding de$reased signal is seen/ Patients ?ith a defe$tor fra$ture of the !ars ha<e dis$ontinuity of the $orte& that is seen 7est on $ontiguous sagittal T 0 ?eighted imagesHFigure 02 / With $hroni$ !ars defe$ts, rea$ti<e s$lerosis may lead to de$reased signal on T 0 and STIR se uen$es/Patients ?ith s!ondylolysis may ha<e an a7normally ?ide s!inal $anal Hthe ?ide $anal sign / This may e<en o$$ur inthe a7sen$e of a s!ondylolisthesis as the !osterior elements $an dis!la$e ?ithout anterior sli! of the <erte7ral 7ody=(2 > HFigure 0( / There are im!ortant $ollateral findings that may 7e en$ountered in !atients ?ith s!ondylolysisand s!ondylolisthesis, in$luding dis$ degeneration, e&it foraminal stenosis and asso$iated ner<e root $om!ression=(( , (6 > HFigure 06 /
Multisli$e CT using thin H0 2 mm se$tions allo?s e&$ellent e<aluation of !ars defe$ts and $an also elu$idate those$ases that are e ui<o$al on MRI or !lain radiogra!hs = (1 >/ The use of re<erse gantry imaging has largely 7eensu!erseded 7y multisli$e CT ?ith the a7ility !erform reformats in any !lane/ #n a&ial images, a !ars defe$t $an 7eidentified 7y <irtue of the a7sen$e of a $om!lete 7ony ring, ?ith a linear lu$en$y e&tending through the !ars a7o<e thele<el of the fa$et Koint/ Pars defe$ts are, ho?e<er, most easily identified on sagittal reformats HFigure 03 / CT haslimited a7ility to dete$t stress rea$tions in the !ars that ha<e not !rogressed to a $om!lete fra$ture/
In many institutions, !lain radiogra!hs remain the first line of in<estigation for sus!e$ted !ars defe$ts/ #n lateral !lainradiogra!hs of the lum7osa$ral Kun$tion s!ondylolysis a!!ears as a linear lu$en$y in the !ars HFigure 0 /Fle&ion.e&tension <ie?s $an !ro<ide information regarding insta7ility =(3 >/ The lu$en$y seen in the !ars on o7li ueradiogra!h has 7een termed the $ollar on the ne$; of the S$ottie dogG HFigure 0) / The $ontralateral !edi$le may 7es$lerosed and dense/ It is im!ortant to em!hasise that if !lain radiogra!hs are negati<e or e ui<o$al, further imaging?ith MRI or CT may 7e ?arranted/
Bone s$intigra!hy, !arti$ularly ?ith single !hoton emission $om!uted tomogra!hy HSP8CT is more sensiti<e than!lain radiogra!hs for the diagnosis of a$ute !ars defe$ts, 7ut is less s!e$ifi$ =(1 , (0 >/ S$intigra!hy is !arti$ularlyuseful for demonstrating sym!tomati$ defe$ts as in$reased a$ti<ity is seen ?ith an a$ute stress res!onse or a healingrea$tion = ( >/ In $hroni$ defe$ts, there may 7e no in$reased u!ta;e/ +sually additional imaging ?ith MRI or CT isre uired for further e<aluation ?hen a 7one s$an is !ositi<e/
Primary neoplasms of the spineSe$tion-
Primary osseous tumours of the s!ine are rare, a$$ounting for ( 4 of !rimary s;eletal neo!lasms = () , (5 >/ They arerarely $onfused ?ith metastases and myelo!roliferati<e disorders, ?hi$h tend to 7e multi!le/ Patients !resent ?ithlo$aliDed 7a$; !ain that may 7e asso$iated ?ith neurologi$al sym!toms and other red flags su$h as night !ain/ Thede<elo!ment of a !ainful s$oliosis should al?ays alert the $lini$ian to the !ossi7ility of an underlying neo!lasm/ Any7one neo!lasm $an affe$t the s!ine, 7ut this se$tion shall only $o<er the more $ommon lesions/
Imaging e"aluation
Plain radiogra!hs and CT are the 7est te$hni ues for the $hara$teriDation of $orti$al lesions and tumourmineraliDation/ MRI is the 7est te$hni ue for staging, allo?ing assessment of the degree of marro?, soft tissue and$ord in<ol<ement/ S$intigra!hy is a sensiti<e te$hni ue for identifying lesions, 7ut tends to 7e nonEs!e$ifi$/ Themor!hology and lo$ation of the lesion, and ?hether it !rimarily in<ol<es the !osterior elements, are im!ortant fa$torsin determining its nature/ The !atientLs age is another im!ortant $onsideration/ For e&am!le, !rimary neo!lasms ofthe s!ine are more $ommon in the lum7ar and thora$i$ regions than the $er<i$al region/ #steoid osteomas andosteo7lastomas ty!i$ally !resent as mineraliDed lesions in<ol<ing the !osterior elements in a young adult/
Aneurysmal 7one $ysts usually !resent as e&!ansile lesions of the !osterior elements ?ith fluid fluid le<els/Chordomas most often !resent as a midline destru$ti<e lesion of the sa$rum in an elderly !atient/
#enign lesionsHaemangiomas
%aemangiomas are the most $ommon 7enign lesions of the <erte7ral 7ody and rarely in<ol<e the !osterior elements/Se<eral le<els may 7e in<ol<ed/ %aemangiomas are usually dis$o<ered in$identally and tend not to 7e $lini$allyim!ortant/ %istologi$ally, they are $om!rised of 7lood <essels inters!ersed ?ith fat, smooth mus$le, fi7rous tissue andthrom7us =(4 >/ #n !lain radiogra!hy, <erte7ral haemangiomas demonstrate !rominent <erti$al tra7e$ulae, due toreinfor$ement of tra7e$ulations along lines of stress/ #n a&ial CT small !un$tuate fo$i, re!resenting the tra7e$ulae,are seen ?ithin the <erte7ral 7ody =61 >, ?hi$h has 7een $alled the !ol;aEdot signG/ #n MRI, the $lassi$ a!!earan$e isof a ?ellEdefined fatE$ontaining lesion, ?hi$h is of high signal on T 0 ?eighted images and high signal on T 2 ?eightedimages HFigure 05 / #$$asionally, haemangiomas in the thora$i$ s!ine may e&!and and 7e$ome sym!tomati$,sometimes leading to neurologi$al $om!romise/ #n T 0 ?eighted images these aty!i$al haemangiomas normally la$;fatty signal = 60 >/
Osteoid osteoma
#steoid osteomas are 7enign lesions that are $om!rised of a small Hless than 2 $m <as$ular nidus that is surrounded7y rea$ti<e 7one/ Around 01 of osteoid osteomas affe$t the s!ine, ty!i$ally in<ol<ing the !osterior elements in a!atient in their se$ond to third de$ade =62 , 6( >/ Patients $lassi$ally !resent ?ith lo$aliDed 7a$; !ain that is ?orse atnight and relie<ed 7y as!irin or nonEsteroidal antiEinflammatories/ A !ainful s$oliosis may de<elo!/ #n !lainradiogra!hy, osteoid osteomas may 7e diffi$ult to dete$t, 7ut o$$asionally a small radiolu$ent nidus may 7e seen, ?ithsome surrounding s$lerosis/ If asso$iated ?ith a s$oliosis, the nidus lies at the $on$a<ity of the $ur<e/ CT is thete$hni ue of $hoi$e for $onfirming the !resen$e of an osteoid osteoma, ?hi$h a!!ears as a small lu$ent lesion
surrounded 7y s$lerosis ?ith <aria7le $entral mineraliDation = 6( , 66 > HFigure 04 / #n MRI, osteoid osteomas $an ha<ea <aria7le a!!earan$e, sometimes ma;ing dete$tion !ro7lemati$ =63 >/ +sually the nidus is of lo?.intermediate signalon T 0 ?eighted se uen$es, and of in$reased signal on T 2 and STIR se uen$es, ?ith surrounding soft tissue oedema=62 > HFigure 047 / Surrounding marro? oedema $an ma;e the nidus diffi$ult to identify/ S$intigra!hy is an e&$ellentmodality for lo$aliDing osteoid osteomas, ?ith mar;ed in$reased u!ta;e seen ?ithin the nidus, ?hi$h is surrounded 7ya halo of less intense u!ta;e from surrounding rea$ti<e s$lerosis HFigure 04$ /
Osteoblastoma
#steo7lastoma is a 7enign lesion ?ith a !redile$tion for the s!ine that shares many features ?ith osteoid osteomas/"e<ertheless, they re!resent a distin$t $lini$al entity/ #steo7lastomas o$$ur in young adults, !resenting ?ith a dulllo$aliDed !ain that is relie<ed 7y antiEinflammatories = 6 >/ Patients !resented ?ith neurologi$al sym!toms in 24 and?ith s$oliosis in 6) of $ases in one large series = 6) >/ Ty!i$ally, the !osterior elements are in<ol<ed, sometimes ?ithe&tension into the <erte7ral 7ody/ #n !lain radiogra!hs and CT osteo7lastomas a!!ear as e&!ansile lu$ent lesions,usually greater than 2 $m in diameter, ?ith <aria7le amounts of mineraliDation ?hi$h may 7e multifo$al = 6 ,6) >/ Themargins of the lesion tend to 7e geogra!hi$al ?ith a s$allo!ed or lo7ulated a!!earan$e/ There may 7e $orti$aldestru$tion ?ith an asso$iated soft tissue mass e&tending into the adKa$ent tissues or s!inal $anal HFigure 21a / TheMRI features are de!endent on the degree of mineraliDation that is !resent =65 >/ #n T 0 ?eighted images, the lesion isof lo? to intermediate signal/ #n STIR and T 2 ?eighted images, the lesion is of intermediate or high signal HFigure
217 / There may 7e e&tensi<e !erilesional oedema/ S$intigra!hy demonstrates intense fo$al in$reased u!ta;e in thelesion HFigure 21$ / The ;ey features that fa<our osteo7lastoma o<er osteoid osteoma are the larger siDe at!resentation H 2 $m , multi!le fo$i of mineraliDation and the !resen$e of a soft tissue mass/
Giant cell tumour (GCT)
9iant $ell tumours of the s!ine o$$ur in the third and fourth de$ades, affe$ting ?omen more than men/ Most 9CTsaffe$t the sa$rum ?ith the thora$i$, $er<i$al and lum7ar s!ine affe$ted in de$reasing order =64 >/ The <erte7ral 7ody isusually in<ol<ed ?ith the lesion gro?ing e$$entri$ally/ An im!ortant feature is the a7ility of the lesion to gro? a$rossthe sa$roilia$ Koint HSIJ or $ross a dis$ s!a$e/ Plain radiogra!hs and CT demonstrate an e&!ansile lyti$ lesion ?ithoutmineraliDation =31 >, ?ith a thin $orti$al margin at the edge of the lesion HFigure 20a / Se$ondary aneurysmal 7one $ystformation $an o$$ur, leading to fluid fluid le<els HFigure 207 / MRI may demonstrate areas of lo? signal on
7oth T 0 and T 2 ?eighted se uen$es due to high haemosiderin $ontent = 30 >/ This is distin$t from most other neo!lasmsthat affe$t the sa$rum ?hi$h tend to demonstrate high signal on T 2 ?eighted se uen$es/
Aneurysmal bone cyst (ABC)
Aneurysmal 7one $ysts are 7enign 7one lesions that tend to o$$ur in !atients 7elo? the age of 21 years ?ith !ain7eing the main sym!tom = 32 >/ In the s!ine, they ty!i$ally in<ol<e the !osterior elements, most $ommonly affe$ting the$er<i$al or thora$i$ s!ine/ It has 7een !ostulated that ABCs may o$$ur due to altered haemodynami$ flo?, ?ith thelesion a!!earing histologi$ally as multilo$ulated 7lood filled s!a$es ?hi$h are not lined 7y endothelium = 3( >/ Plainradiogra!hs and CT demonstrate an e&!ansile lesion surrounded 7y a thin rim of $orte& HFigure 22a / The hallmar; of the lesion is the !resen$e of fluid fluid le<els ?hi$h $an 7e demonstrated on 7oth CT and MRI = 36 , 33 > HFigure 227 /These o$$ur due to sedimentation of 7lood !rodu$ts, and the signal $hara$teristi$s ?ill refle$t the <arious$om!onents/ For e&am!le, the !resen$e of methaemoglo7in gi<es rise to in$reased signal on 7oth T 0 and T 2?eightedse uen$es/ It should 7e noted that se$ondary ABC formation $an o$$ur ?ith a <ariety of 7one tumours in$ludingosteosar$omas, 9CTs and osteo7lastomas/ +sually these lesions $ontain a signifi$ant soft tissue $om!onent allo?ingdifferentiation from !rimary ABCs = 3 , 3) >/
Malignant lesionsChordoma
Chordomas are malignant lym!ho!roliferati<e 7one tumours that arise from noto$hord remnants = 35 >/ They ha<e a!redile$tion for the sa$ro$o$$ygeal region Hu! to 1 and the 7asis!henoid =34 >/ The lesions tend to affe$t middleE
aged and elderly !atients, ?ith the in$iden$e in men higher than in ?omen/ With sa$ral lesions, !atients !resent ?ith$hroni$ !ain that may 7e asso$iated ?ith neurologi$al and 7ladder or 7o?el sym!toms due to lo$al !ressure effe$ts/#n !lain radiogra!hs and CT, $hordomas a!!ear as lyti$ lesions ?ith a large asso$iated soft tissue mass, arising inthe midline/ Amor!hous $al$ifi$ation is seen in u! to 41 of $ases affe$ting the sa$ro$o$$ygeal region on CT = 1>/The lesion is usually <ery lo$ally in<asi<e and may e&tend a$ross a dis$ or the SIJ/ 8&tension along the ner<e roots is$ommon/ The lo$al staging of $hordomas is 7est a$hie<ed on MRI = 0, 2>/ #n T 0 ?eighted images, the lesion tends
to 7e of intermediate to lo? signal, ?ith high signal seen on T 2 ?eighted or STIR se uen$es refle$ting the high ?ater$ontent/ %eterogeneous enhan$ement is usually seen follo?ing $ontrast HFigure 2( /
Chondrosarcoma
Chondrosar$omas re!resent u! to 02 of !rimary neo!lasms of the s!ine = ( >/ Rarely, they may arise frommalignant transformation of an osteo$hondroma/ Patients !resent ?ith !ain, ?ith u! to 31 ha<ing neurologi$alsym!toms/ #n !lain radiogra!hs and CT, they a!!ear as lyti$ lesions ?hi$h $ontain matri& $al$ifi$ation/ They tend toin<ol<e the !osterior elements, 7ut they may also in<ol<e the <erte7ral 7ody/ #n MRI, $hondrosar$omas are of lo? tointermediate signal on T 0 ?eighted se uen$es and of high signal on T 2 ?eighted se uen$es HFigure 26 / The lesionmay $ontain fo$i of lo? signal matri& $al$ifi$ation on all se uen$es = 6>/ Soft tissue e&tension ?ith $ord $om!ressionmay 7e seen/
Lymphoma
S!inal in<ol<ement in lym!homa may 7e due to !rimary in<ol<ement of the <erte7ral 7ody or se$ondary s!read from!ara<erte7ral lym!h nodes/ The imaging findings are <aria7le, a dense s$leroti$ <erte7ral 7ody Hi<ory <erte7ra is a$lassi$al !lain radiogra!hi$ finding, 7ut some lesions are !urely lyti$/ #n T 0 ?eighted se uen$es the affe$ted<erte7ral 7ody returns lo? or intermediate signal, ?ith intermediate to high signal seen on T 2 ?eighted se uen$es= 3, >/ 8!idural infiltration and an asso$iated soft tissue mass are $ommon findings/ There may 7e $ontiguous<erte7ral 7ody in<ol<ement HFigure 23 / With intra<enous gadolinium, there is usually a<id enhan$ement of thein<ol<ed tissues/
Osteosarcoma
#steosar$omas rarely o$$ur in the s!ine a$$ounting for around 3 of !rimary malignant s!inal neo!lasms = ) >/Ty!i$ally, they affe$t the <erte7ral 7ody and are densely mineraliDed, although lyti$ lesions may o$$ur/ #n MRI themineraliDation is manifest as fo$i of lo? signal on 7oth T 0 and T 2 ?eighted se uen$es = 5>/ The !rognosis is e&tremely!oor due to the high in$iden$e of metastases HFigure 2 /
ifferentiation of benign from malignant collapseSe$tion-
Benign <erte7ral $olla!se may result from osteo!orosis or trauma, or 7enign lesions su$h as haemangiomas andeosino!hili$ granulomas/ Malignant <erte7ral $olla!se may 7e due to metastases or !rimary neo!lasms/
ifferentiating 7enign from malignant $olla!se may 7e <ery diffi$ult 7oth $lini$ally and radiologi$ally, !arti$ularly inelderly osteo!oroti$ !atients ?ho ha<e a history of malignan$y/ Rea$hing the $orre$t diagnosis has im!ortantim!li$ations for treatment and !rognosis/
Plain radiogra!hs, CT and s$intigra!hy $an 7e used to assess <erte7ral $olla!se, 7ut the te$hni ue of $hoi$e is MRI/In our institution, sagittal T 0 and STIR se uen$es are !erformed/ The STIR se uen$e is !referred o<er a$on<entional T 2 fast s!in e$ho se uen$e as it $onfers in$reased lesion $ons!i$uity/ The differentiation of 7enign frommalignant <erte7ral $olla!se relies on the marro? signal $hara$teristi$s and the mor!hology of the $olla!sed <erte7ra/
$eatures of a malignant "ertebral collapseMarro signal
#n T 0 ?eighted se uen$es there is ty!i$ally $om!lete re!la$ement of the fatty marro? resulting in diffuse lo? signalthroughout the <erte7ral 7ody, ?ith in<ol<ement of the !osterior elements = 4 )0 >/ #$$asionally, there may 7ein$om!lete marro? re!la$ement/ #n T 2 and STIR se uen$es, there is $orres!onding isointense or high signal, ?hi$h
may 7e either homogeneous or heterogeneous/ Follo?ing intra<enous $ontrast there may 7e diffuse or !at$hyenhan$ement on a T 0 fatEsaturated se uen$e HFigure 2)a /
Morphology
Se<eral features are $onsidered sus!i$ious for malignant $om!ression fra$tures/
0/ 0/ A $on<e& !osterior 7ulge in<ol<ing the ?hole of the !osterior $orte& due to retro!ulsion of tumour has7een sho?n to ha<e a sensiti<ity of )1 ?ith a s!e$ifi$ity of 46 = 4> HFigure 2)7 /
2/ 2/ In<ol<ement of the !edi$les Kudged 7y a7normal signal or $hange in mor!hology has 7een sho?n to ha<ea sensiti<ity of 51 and a s!e$ifi$ity of 46 = 4> HFigure 25 /
(/ (/ The !resen$e of an e!idural or !aras!inal soft tissue mass has 7een sho?n to ha<e a sensiti<ity of 51and s!e$ifi$ity of 011 = 4>, 7ut it should 7e re$ogniDed that traumati$ fra$tures $an !rodu$e mass li;ehaematoma HFigure 24 /
$eatures of a benign "ertebral collapseMarro signal
The marro? signal $hanges en$ountered in 7enign <erte7ral $olla!se de!end on the age of the fra$ture/ A$uteosteo!oroti$ $olla!ses Hless than 2 months old ty!i$ally sho? a 7andEli;e area of lo? signal adKa$ent to the $olla!sedend!late on T 0 ?eighted se uen$es, ?ith $orres!onding high signal on T 2 ?eighted or STIR se uen$es/ +sually thereis at least one area of normal fatty marro? signal seen ?ithin the <erte7ral 7ody/ #n T 2 ?eighted and STIR se uen$esthere may 7e a linear lo? signal fra$ture line seen adKa$ent to the $olla!sed end!late/ Fo$al areas of <ery high signal
adKa$ent to the end!late on STIR se uen$es has 7een des$ri7ed as the fluid signG, ?hi$h is seen in 7enign fra$tures=)2 >/ The marro? signal $hange follo?ing a 7enign $olla!se may !ersist for u! 2 6 months and then gradually returnsto normal o<er time/ #ld osteo!oroti$ fra$tures may therefore demonstrate a7normal mor!hology ?ithout any signala7normality HFigure (1 /
Morphology
The retro!ulsion of a !osterior $orner fragment into the s!inal $anal is a highly s!e$ifi$ sign H011 of a 7enign$olla!se/ Ty!i$ally the !osterior su!erior $orner is in<ol<ed = 4> HFigure (0 /
#n !lain radiogra!hs the !resen$e of an intra<erte7ral <a$uum $left indi$ates a<as$ular ne$rosis H ummellLs diseaseand therefore suggests a 7enign !ro$ess =)( >/ #n T 0 and T 2 ?eighted se uen$es, the <a$uum $left is of lo? signal/
#$$asionally, on T 2 ?eighted se uen$es, high signal may 7e seen ?ithin the $left as fluid $an re!la$e the gas/
Patients ?ith multi!le myeloma fre uently ha<e $om!ression fra$tures that ha<e the a!!earan$e of osteo!oroti$$olla!se/ #nly a small !ro!ortion of $om!ression fra$tures in multi!le myeloma ha<e the a!!earan$e of malignant$olla!se = )6 >/ Multi!le myeloma should therefore al?ays 7e $onsidered in the differential for nonEtraumati$ <erte7ral$om!ression fra$tures that ha<e a 7enign a!!earan$e/
Acute trauma
A$ute trauma may result in diffuse lo? signal on T 0 ?eighted images ?ith an asso$iated !aras!inal mass orhaematoma =)0 >/ Although the a!!earan$es may mimi$ a malignant $olla!se, the history of trauma is usuallyforth$oming/
%acral insufficiency fracture
#n sagittal images a sa$ral insuffi$ien$y fra$ture results in 7one marro? signal $hange in $ontiguous sa$ralsegments, ?hi$h may 7e mista;en for an infiltrati<e !ro$ess/ An o7li ue $oronal se uen$e through the sa$rum allo?s$onfirmation of an insuffi$ien$y fra$ture HFigure (2 /
&qui"ocal findings
Se$tion-
Although MRI $an hel! differentiate 7enign from malignant <erte7ral $olla!se, the findings may 7e e ui<o$al, in ?hi$h$ase se<eral o!tions are a<aila7le/
,upplementary imaging can be performed. 7n 'T cortical destruction or pedicularin"ol"ement may be seen in cases of malignant collapse 2 ;9 3. <hole body scintigraphymay sho! other skeletal lesions indicating metastases. 5urthermore 5 =-*:T scanning
may ha"e potential "alue for differentiation bet!een osteoporotic and pathological"ertebral fractures as acute osteoporotic collapse tends to ha"e no pathologically increased5 = uptake 2 ;# 3. ,e"eral researchers ha"e successfully used diffusion-!eighted MRI tohelp differentiate benign from malignant "ertebral collapse 2 ;; $ ;> 3. This techniquemeasures random motion of free !ater protons. iffusion is hindered in densely packedcells / i.e. tumour resulting in high signal.
In elderly patients or patients in !hom the inde8 of suspicion is lo! a follo! up MRI scancan be performed in #$% !eeks. This should be sufficient time for findings to ha"eimpro"ed if osteoporotic collapse has occurred. In malignant collapse the findings !ould
be e8pected to !orsen.
?ertebral biopsy can be performed. In younger patients and those !ith a high inde8 ofsuspicion for malignancy early biopsy is ad"ocated.
The seronegati<e s!ondyloarthro!athies are a grou! of multisystem inflammatory $onditions lin;ed 7y a <ariety ofgeneti$, $lini$al and radiologi$al features/ In$luded in this grou! are an;ylosing s!ondylitis, inflammatory 7o?eldisease, !soriati$ arthritis, ReiterLs syndrome and rea$ti<e arthritis =51 , 50 >/ A small num7er of !atients $annot 7eneatly $lassified into one of these entities and they are referred to as ha<ing undifferentiated s!ondyloarthro!athy=52 >/ The !athogenesis of s!ondyloarthro!athies is !oorly understood, 7ut immune mediated me$hanisms in<ol<inghuman leu;o$yte antigen B2) H%*AEB2) , geneti$ and en<ironmental fa$tors are thought to ha<e ;ey roles =5( >/
The most $ommon age grou! affe$ted are the se$ond to third de$ades ?ith 01 21 !resenting 7efore the age of 0years, 7ut !atients in their 31s may also !resent after a longer, milder disease $ourse/ S!ondyloarthro!athies aremore $ommon in men, in the $ase of an;ylosing s!ondylitis the ratio of men to ?omen is around (-0/ In ?omen,an;ylosing s!ondylitis is milder and runs a more indolent $ourse = 56 >/
Inflammation at the insertions of ligaments, tendons, or Koint $a!sules to 7one, ?hi$h is termed enthesitis, is thehallmar; of s!ondyloarthro!athy = 53 >/ This !ro$ess is $hara$teriDed 7y 7ony oedema and erosions, follo?ed 7y 7ony!roliferation and e<entually an;ylosis/ The disease !ro$ess results in syno<itis, leading to sa$roiliitis and$osto<erte7ritis/ Inflammation of fi7roEosseous Kun$tions at syndesmoti$ Koints leads to $hanges at the inter<erte7raldis$s, SIJ ligaments, manu7riosternal Koint and !u7i$ sym!hysis/ The diagnosis of s!ondyloarthro!athy is 7ased on7oth $lini$al and radiologi$al grounds = 5 >/
Imaging modalities
The seronegati<e s!ondyloarthro!athies share $ommon $lini$al and radiologi$al features ?ith $hara$teristi$ !atternsof in<ol<ement of the SIJs, s!ine, and !eri!heral Koints/ Although !lain radiogra!hs are the often the first line ofimaging in<estigation, they are insensiti<e for demonstrating the early $hanges of entheso!athy and sa$roiliitis/ #therimaging modalities, in$luding s$intigra!hy, CT and MRI, allo? 7etter <isualiDation of inflammatory $hanges at the SIJsand a&ial s;eleton/ #f these, MRI is the most sensiti<e and s!e$ifi$ as it dire$tly <isualiDes $hanges in the syno<ium,arti$ular $artilage and su7$hondral 7one =5) >/ The sensiti<ity of MRI for assessing disease a$ti<ity also allo?s
o7Ke$ti<e assessment of thera!euti$ res!onse to no<el 7iologi$al agents su$h as infli&ima7 and etener$e!t =55 , 54 >/This se$tion ?ill re<ie? these modalities and em!hasise the role of MRI/
The main sub'types of spondyloarthropathy An!ylosing spondylitis
AS is the most $ommon of the s!ondyloarthro!athies and !resents as insidious onset lo? 7a$; or 7utto$; !ain, ?ithmorning stiffness/ The diagnosis of AS is made using either the Rome or the modified "e? :or; $riteria =53 , 5 > HTa7le 6 / These use radiologi$al and $lini$al !arameters to ma;e a diagnosis of AS/ There are no s!e$ifi$ la7oratorytests for AS, 7ut %*AEB2) gene is !resent in 41 43 / +! to )1 of !atients ?ith a$ti<e disease ha<e a raised CErea$ti<e !rotein HCRP and erythro$yte sedimentation rate H8SR , although these are not a$$urate refle$tions ofdisease a$ti<ity/
The $hara$teristi$ feature of the AS is sa$roiliitis/ The u!!er t?oEthirds of the SIJ is fi7rous and the inferior third issyno<ial/ The syno<ial !art of the Koint de<elo!s erosions earlier than the u!!er fi7rous !art, 7ut the ?hole Koint ise<entually in<ol<ed/ The ilia$ as!e$t is initially in<ol<ed due to the thinner fi7ro$artilage and due to degenerati<e $leftsand s!lits ?hi$h may allo? inflammatory tissue !enetration/
"soriatic arthropathy
+! to 61 of !atients ?ith !soriasis ?ill de<elo! arthritis, $ommonly an asymmetri$al oligoarthritis, ?hi$h isasso$iated ?ith %*AEB2) in 31 / Sa$roiliitis is usually 7ilateral and symmetri$al = 41 >/ The sa$roiliitis in !soriati$
arthro!athy de<elo!s less Koint s!a$e loss and an;ylosis than AS/ The !ara<erte7ral ossifi$ation that de<elo!s tendsto 7e 7ul;y, ma;ing it easy to differentiate from the thin marginal ossifi$ation of AS/
#eiter$s syndrome (reacti%e arthritis)
ReiterLs syndrome is a triad of urethritis, u<eitis and arthritis o$$urring almost e&$lusi<ely in males =40 >/ It is
asso$iated ?ith %*AEB2) in )3 51 / It $auses a !olyarthritis similar to !soriati$ arthro!athy, 7ut ty!i$ally affe$ts thedistal lo?er e&tremity more $ommonly than the hands/ Bilateral sa$roiliitis is seen in (1 31 of $ases and is usuallyasymmetri$al, unli;e in AS ?hen it tends to 7e 7ilateral and symmetri$al/
&nteropathic arthropathy
8ntero!athi$ s!ondyloarthro!athy is seen in ul$erati<e $olitis H+C , CrohnLs disease, Whi!!leLs disease, !ostEinfe$tion?ith Salmonella' Shigella , and ersinia , and is asso$iated ?ith %*AEB2) in )3 / The radiologi$al findings areindistinguisha7le from AS = 42 >/
Imaging of sacroiliitisSe$tion-
#n !lain films initially there is 7lurring of the su7$hondral 7one and irregular marginal erosions of the SIJs resulting in!seudo?idening/ In the later stages there is s$lerosis, Koint s!a$e narro?ing and e<entually Koint fusion/ These$hanges $an 7e graded using the "e? :or; 9rading system =4( >- 9rade I, sus!i$iousN 9rade II, e<iden$e of erosionand s$lerosisN 9rade III, erosions, s$lerosis and early an;ylosisN and 9rade IO, total an;ylosis HFigure (( /
CT and MRI 7oth demonstrate su7$hondral s$lerosis and erosions 7etter than !lain radiogra!hy = 46 , 43 >/ MRI offersthe 7est <isualiDation of $artilage and su7$hondral 7one oedema allo?ing earlier dete$tion of sa$roiliitis than CT ors$intigra!hy = 46 , 4 45 > HFigure (6 /
In our institution ?e use $oronal o7li ue T 0 ?eighted se uen$e ?ith fat su!!ression and a STIR se uen$e/ Ine ui<o$al $ases, intra<enous gadolinium is administered as it has 7een sho?n to in$rease the sensiti<ity of MRI fordete$tion of erosions = 44 , 011 >/ #n T 0 ?eighted images the !osterior ligamentous !ortion of the Koint $ontains adi!osetissue and fo$al lo? signal areas of $onne$ti<e tissue = 010 >/ Fo$al marro? defe$ts, insertion !itsG, $an 7e seen at theatta$hments of the ligamentous !ortion/ #n STIR images, the high signal syno<ial Koint is $learly demonstrated7et?een lo? signal !eriarti$ular tissues/ The $artilage thi$;ness <aries from 6 3 mm !osteriorly to 2 ( mmanteroinferiorly/ 8rosions, irregularity of the Koint s!a$e, s$lerosis, !eriarti$ular fat a$$umulation and fusion are themain MRI features of sa$roiliitis/ 8rosions are 7est a!!re$iated on T 0 ?eighted fatEsaturated se uen$e ashy!ointense su7$hondral lesions/ These a!!ear hy!erintense on STIR images/ Su7$hondral oedema is 7esta!!re$iated on the STIR se uen$e HFigure (3 / Su7$hondral s$lerosis manifests as lo? signal on all se uen$es/Periarti$ular 7one marro? fat a$$umulations may 7e seen as nonEenhan$ing lo? signal areas on T 0 fat saturated andSTIR se uen$es HFigure ( / #n$e an;ylosis has o$$urred, 7one marro? signal is seen to $ross the SIJ, o7literatingthe $artilage/
If there is unilateral disease ?ith !rominent oedema in the soft tissues and marro? adKa$ent to the affe$ted Koint,infe$tion should 7e $onsidered/
The imaging features of AS in the thora$olum7ar s!ine arise due to enthesitis and !rogress in a $ontinuous fashion,usually starting at the thora$olum7ar and lum7osa$ral Kun$tions and e<entually in<ol<ing the ?hole s!ine/ The s!ineis !arti$ularly affe$ted at the dis$o<erte7ral Kun$tion, the a!o!hyseal Koints, the $osto<erte7ral Koints, the !osteriorligament atta$hments and the atlantoa&ial arti$ulation/ At the dis$o<erte7ral Kun$tion there are many $hangesin$luding osteitis, syndesmo!hyte formation, erosions, dis$ $al$ifi$ation, osteo!orosis and dis$ 7allooning/
8arly radiogra!hi$ signs in$lude s uaring of the <erte7ral 7ody se$ondary to the inflammatory osteitis =012 >/ 8rosionsHosteitis at the su!erior and inferior margins of the <erte7ral 7odies o$$ur at the site of atta$hment of the anteriorlongitudinal ligament and are $alled RomanusG lesions HFigure () / These $ause loss of the normal $on$a<ity of the<erte7ral 7ody resulting in s uaring seen most $learly in the lum7ar s!ine ?here the <erte7ral 7odies are more$on$a<e than in the thora$i$ s!ine ?hi$h is s uarer/ #n$e the Romanus lesion is s$lerosed it is seen as a shiny$ornerG on the !lain film/ In the early a$ti<e !hase on MRI they are lo? signal on T 0, high on T 2 and STIR, andenhan$e !ostEintra<enous gadolinium = 01( > HFigure (5 / In the !ostEa$ti<e !hase, the Romanus lesion on MRI $an 7e7oth high signal on T 0 and T 2 se uen$es H?ith no enhan$ement due to a$$umulation of fatty marro?, or lo? signal onthese se uen$es indi$ating marginal osteos$lerosis/ The !resen$e of syndesmo!hytes in the s!ine is one of the$hara$teristi$ findings in s!ondyloarthro!athy =012 >/ A syndesmo!hyte is a <erti$ally orientated !ara<erte7ralossifi$ation/ Syndesmo!hyte formation initially o$$urs at the annulus fi7rosis/ %o?e<er, in ad<an$ed disease, theanterior longitudinal ligament 7e$omes in<ol<ed resulting in s!inal fusion, gi<ing the 7am7oo s!ineG a!!earan$e on!lain radiogra!hs/ #ssifi$ation of the su!ras!inous and inters!inous ligaments gi<e rise to the dagger signG, ?hi$h isa dense line running $ranioE$audally along the <erte7ral 7odies in the midline HFigure (4 / #ther $auses of!ara<erte7ral ossifi$ation in$lude osteo!hytes asso$iated ?ith osteoarthritis, undulating ossifi$ation ?hi$h is seen indiffuse idio!athi$ s;eletal hy!erostosis H IS% and nonEmarginal !ara<erte7ral ossifi$ation seen in !soriati$ arthritisand ReiterLs syndrome/ #steo!hytes $an generally 7e differentiated from syndesmo!hytes as they run horiDontally aso!!osed to <erti$ally, are triangular in sha!e and arise a?ay from the dis$o<erte7ral Kun$tion/ "onEmarginal!ara<erte7ral ossifi$ation is seen a?ay from the <erte7ral 7ody and inter<erte7ral dis$/
8rosions at the dis$o<erte7ral Kun$tion ?ere first des$ri7ed 7y Andersson in 04() = 01( , 016 >/ Andersson lesions ha<e7een $lassified into three ty!esN Ty!e I in<ol<es the $entral !ortion $o<ered 7y the $artilaginous end!late, Ty!e IIin<ol<es the !eri!heral !ortion ?hi$h is not $o<ered 7y end!late, and Ty!e III in<ol<es the ?hole dis$o<erte7ral
Kun$tion/ Ty!e III lesions o$$ur in ad<an$ed disease and are ty!ified 7y destru$tion and rea$ti<e s$lerosis of theadKa$ent end!lates/ These $hanges are seen as hy!erintense dis$o<erte7ral end!late $hanges on STIR
and T 2?eighted images, and lo? signal on T 0 ?eighted images, ?ith enhan$ement !ostEintra<enous gadoliniumHFigure (5 /
is$ $al$ifi$ation may o$$ur in asso$iation ?ith adKa$ent syndesmo!hytes and a!o!hyseal Koint an;ylosis/ is$$al$ifi$ation $an also o$$ur ?ith other $onditions su$h as IS% and Ku<enile $hroni$ arthritis/ #steo!orosis may leadto 7allooning of the dis$ gi<ing the a!!earan$e of fish <erte7raG/ is$ $al$ifi$ation $an 7e high signal on7oth T 0 and T 2 ?eighted se uen$es = 013 >/
8rosions, s$lerosis and an;ylosis may o$$ur at the $osto<erte7ral and $ostotrans<erse Koints/ In the early !hase ofinflammation !lain radiogra!hs are normal, 7ut MRI $an demonstrate high signal STIR and T 2 ?eighted se uen$esHFigure 61 / An;ylosis at the $osto<erte7ral Koint results in redu$ed $hest ?all mo<ement and $an 7e asso$iated ?iththi$;ening of the !osterior ends of the ri7s/
The fused s!ine is at ris; of fra$turing ?ith minimal trauma/ The most $ommon sites of fra$ture are the $er<i$al andthora$olum7ar s!ine =01 >, ?ith those at the thora$olum7ar region often 7eing re$ogniDed late/ Fra$tures of the fuseds!ine resem7le Chan$e fra$tures, either !assing through an ossified dis$ or through the <erte7ral 7ody HFigure 60 / Ifa fra$ture is sus!e$ted, CT is an e&$ellent modality for demonstrating the 7rea; in the 7one $orte&N ho?e<er, MRIgi<es more information regarding soft tissue and s!inal $ord inKury/ %ealing of these fra$tures is generally good ?itha!!ro!riate immo7iliDation, 7ut fi7rous an;ylosis and su7se uent !seudarthrosis may o$$ur = 01) >/ Pseudarthrosis is$onsidered a su7grou! of the Andersson lesion and normally o$$urs at the thora$olum7ar Kun$tion/ The radiogra!hi$and CT $hanges may resem7le infe$tious dis$itis = 23 > HFigure 62 / #n MRI there is in$reased signal on T 2 ?eightedand STIR se uen$es at the !seudarthrosis = 015 , 014 >/ With a $hroni$ !seudarthrosis there may 7e lo? signal
on T 2 ?eighted images indi$ating fi7rosis/ 8&tension a$ross the anterior and !osterior elements is the ;ey feature thatallo?s differentiation from infe$tious dis$itis HFigure 6( /
Se$tion-
$igure () A7dominal aorti$ aneurysm/ T 0 ?eighted sagittal image demonstrating an a7dominal aorti$ aneurysmHarro?heads in a !atient ?ith lo? 7a$; !ain/
$igure *) Causes of lo? 7a$; !ain in 211 !atients ?ith signifi$ant !athology from a $ohort of 0111 !atients ?ho under?entlimited MRI for lo? 7a$; !ain in lieu of !lain radiogra!hs = >/
$igure +) Pyogeni$ s!ondylodis$itis/ Plain radiogra!h demonstrating <erte7ral destru$tion and $olla!se Harro? , ?ith loss ofdefinition of the end!lates and in<ol<ement of the adKa$ent <erte7ral 7odies/
$igure ,) Ha Pyogeni$ s!ondylodis$itis/ Sagittal T 0 ?eighted image demonstrating loss of endE!late definition and fattymarro? signal at *(.6/ H7 Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating endE!late oedema and highsignal in the *(.6 dis$/
$igure -) Pyogeni$ s!ondylodis$itis/ Ha Sagittal T 0 ?eighted and H7 short tau in<ersion re$o<ery HSTIR imagesdemonstrating loss of normal marro? signal and end!late destru$tion at *2.(/
$igure .) Ha Pyogen$ s!ondylodis$itis/ Sagittal T 0 ?eighted image demonstrating altered marro? signal ?ith loss ofdefinition of the end!lates H?hite arro?heads and $ord $om!ression H7la$; arro? / H7 Sagittal T 0 ?eighted image follo?ingintra<enous gadolinium demonstrating a large a7s$ess ?ith an enhan$ing rim/
$igure /) Psoas a7s$ess/ A&ial T 2 ?eighted image demonstrating a high signal $olle$tion in the right ilio!soas mus$le in a!atient ?ith s!ondylodis$itis/
$igure 0) Tu7er$ulous <erte7ral osteomyelitis/ Ha Sagittal T 0 and H7 T 2 ?eighted images demonstrating an a7s$ess tra$;ingdee! to the anterior longitudinal ligament Harro?s and early in<ol<ement of the anterior inferior end!late of *( Harro?head /"ote that dis$ signal is maintained/
$igure 1) Tu7er$ulous s!ondylodis$itis/ Sagittal T 2 ?eighted image demonstrating early destru$tion of the anterior su!eriorend!late of S0/ There are tra$;ing a7s$esses dee! to the anterior Harro?heads and !osterior Harro? longitudinal ligaments/
$igure (2) Modi$ Ty!e 0 end!late $hanges/ Sagittal short tau in<ersion re$o<ery HSTIR se uen$e demonstrating high signalend!late $hanges at *(.6 adKa$ent to a lo? signal degenerate dis$/ There is also retro!eritoneal lym!hadeno!athyHarro?heads in this !atient ?ith lym!homa/
$igure (() *3 !ars defe$t/ Sagittal T 2 ?eighted image demonstrating 7one marro? oedema in the *3 !edi$le Harro?indi$ating stress $hange, ?ith a lo? signal line a$ross the isthmus of the !ars interarti$ularis Harro?head re!resenting thedefe$t/
$igure (*) *3 !ars defe$t/ Sagittal T 0 ?eighted image demonstrating a lo? signal line a$ross the !ars re!resenting thedefe$t/
$igure (+) Bilateral *3 !ars defe$ts ?ith a 31 s!ondylolisthesis at *3.S0/ There is a ?ide $anal sign Harro? /
$igure (,) *3 e&it foraminal stenosis due to s!ondylolyti$ s!ondylolisthesis/ Sagittal T 2 ?eighted image demonstratingse<ere stenosis of the e&it foramen Harro?heads / The normal e&it foraminae at other le<els are indi$ated 7y arro?s/ "otethe degenerate *3.S0 dis$/
$igure (-) Ha Bilateral *3 !ars defe$ts/ A&ial CT demonstrates irregular defe$ts in the neural ar$h 7ilaterally/ H7 CT sagittalreformat demonstrates an *3 !ars defe$t Harro? /
$igure (.) *6.3 !ars defe$ts/ *ateral radiogra!h demonstrating a 7rea; in the !ars at *6.3 ?ith a grade 0s!ondylolisthesis/
$igure (/) *6.3 !ars defe$ts/ An o7li ue radiogra!h demonstrates the $ollar on the S$ottie dogG sign/
$igure (0) Oerte7ral haemangiomas/ There are ?ell defined lesions of in$reased signal on 7oth Ha T 0 and H7 T 2 ?eightedimages in the *2 and *3 Harro?s <erte7ral 7odies/
$igure (1) Ha #steoid osteoma/ A&ial CT demonstrates an e&!anded lesion in<ol<ing the !osterior elements ?ith a lu$entnidus Harro?head $ontaining a small fo$us of mineraliDation/ H7 #steoid osteoma/ Sagittal short tau in<ersion re$o<eryHSTIR image demonstrating a high signal lesion $ontaining a lo? signal fo$us/ H$ #steoid osteoma/ Te$hnetium 44m M P
isoto!e 7one s$an in the e uili7rium !hase demonstrating mar;ed in$reased u!ta;e in the region of the right lamina at *6/
$igure *2) Ha #steo7lastoma/ Sagittal CT reformat demonstrating an e&!ansile lu$ent lesion in the !osterior elements ?ith$entral mineraliDation/ "ote the siDe of the lesion $om!ared ?ith the osteoid osteoma in Figure 04a/ H7 Sagittal short tauin<ersion re$o<ery HSTIR image demonstrating an intermediate.high signal mass in<ol<ing the !osterior elements Harro?s /H$ S$intigra!hy demonstrates a solitary fo$us on intense u!ta;e in the thora$i$ s!ine/
$igure *() Ha 9iant $ell tumour of the sa$rum/ A&ial CT demonstrates an e&!ansile lyti$ lesion that $rosses the sa$roilia$ Koint to in<ol<e the ilium/ The arro?s !oint to a thin $orti$al rim that illustrates the e&!ansile nature of the lesion/ H7 9iant $elltumour of the sa$rum/ Sagittal T 2 ?eighted image demonstrating an e$$entri$ mass lesion ?ith se$ondary aneurysmal 7one$yst formation Harro? /
$igure **) Ha Aneurysmal 7one $yst/ CT sagittal reformat demonstrating a lyti$ lesion affe$ting the s!inous !ro$ess of C3/H7 Aneurysmal 7one $yst/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating a multilo$ulated high signallesion affe$ting the s!inous !ro$ess of T3/ The $ysts are too small to demonstrate $lear fluid fluid le<els/
$igure *+) Ha Chordoma of the sa$rum/ Sagittal T 0 ?eighted image demonstrating a large mass of heterogeneous signalarising from the sa$rum Harro?heads , ?ith in<ol<ement of all sa$ral segments/ There is infiltration into the s!inal $anal/ H7Sagittal T 2 ?eighted image demonstrating a heterogeneous high signal mass/ There is massi<e distension of the 7ladderHarro?s / H$ A&ialT 2 fat saturated image at the le<el of the hi!s demonstrating a large lo7ulated infiltrating mass arising fromthe midline in the sa$rum/
$igure *,) Chondrosar$oma/ Sagittal T 2 ?eighted image demonstrating an e&!ansile mass arising from the !osterior as!e$tof the *( <erte7ral 7ody ?ith $om!ression of the the$al sa$/
$igure *-) Ha *ym!homa/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating high signal throughout the T3<erte7ral 7ody ?ith in<ol<ement of the adKa$ent <erte7rae/ H7 A&ial T 2?eighted image demonstrating a !ara<erte7ral softtissue mass Harro? in addition to a se!arate !ulmonary lesion Harro?heads /
$igure *.) #steosar$oma/ Sagittal Ha T 0 and H7 short tau in<ersion re$o<ery HSTIR images demonstrating infiltration of$ontiguous <erte7ral 7odies <ia the 7asi<erte7ral !le&us/ The fo$i of lo? signal on 7oth se uen$es indi$ate fo$i of densemineraliDation/
$igure */) Ha Metastati$ $olla!se/ Sagittal T 0 ?eighted image demonstrating $om!lete re!la$ement of the fatty marro?signal of *(/ H7 Metastati$ $olla!se/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating a !osterior $on<e&ityof the $olla!sed *( <erte7ral 7ody/
$igure *0) Pedi$ular in<ol<ement in metastati$ disease/ Sagittal T 0 ?eighted image demonstrating re!la$ement of the fattymarro? signal in the left *3 !edi$le/
$igure *1) Soft tissue mass in metastati$ disease/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating a largesoft tissue mass Harro?s adKa$ent to the $olla!sed *( and *6 <erte7ral 7odies/
$igure +2) Ha A$ute osteo!oroti$ $olla!se at *(/ Sagittal T 0 image demonstrating a 7andEli;e area of lo? signal at thesu!erior end!late of *( Harro?s / There is $olla!se of the T02 <erte7ral 7ody ?ith normal marro? signal indi$ating oldosteo!oroti$ $olla!se/ H7 Corres!onding sagittal short tau in<ersion re$o<ery HSTIR image demonstrating high su!eriorend!late signal at *( Harro?s in $onKun$tion ?ith a thin lo? signal su7$hondral fra$ture line/ "ote the normal marro? signalin the T02 <erte7ral 7ody/
$igure +() Corner retro!ulsion in osteo!oroti$ $olla!se/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating!osterior $orner retro!ulsion Harro? ?ith osteo!oroti$ $olla!se/ There is multile<el degenerati<e disease/
$igure +*) Ha Sa$ral insuffi$ien$y fra$ture/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating 7one marro?oedema Harro?s in the sa$rum/ "oti$e that there is no loss of height/ H7 Coronal o7li ue STIR image demonstrating the!resen$e of a sa$ral insuffi$ien$y fra$ture Harro?s /
$igure ++) Sa$roiliitis/ Plain radiogra!h demonstrating early erosions and s$lerosis H9rade II $hanges at the left sa$roilia$ Koint Harro?s and minimal $hanges at the right sa$roilia$ Koint/
$igure +,) Sa$roiliitis/ CT demonstrating early erosions and s$lerosis at the left sa$roilia$ Koint only/
$igure +-) Ha Sa$roiliitis/ Coronal o7li ue short tau in<ersion re$o<ery HSTIR image demonstrating su7$hondral 7onemarro? oedema Harro? / H7 #n the $orres!onding T 0 fatEsaturated image, the small su7$hondral erosion is 7etterdemonstrated Harro? /
$igure +.) Ha Burnt out sa$roiliitis/ Coronal o7li ue short tau in<ersion re$o<ery HSTIR image demonstrating minorsu7$hondral oedema at the left sa$roilia$ Koint/ H7 #n the $orres!onding T 0 fatEsaturated image there is mar;ed lo? signal$hange on either side of the sa$roilia$ Koints 7ilaterally, indi$ating fatty marro? a$$umulations/
$igure +/) An;ylosing s!ondylitis/ Plain radiogra!h of the thora$i$ s!ine demonstrating s uaring of the <erte7ral 7odiesHRomanus lesions ?ith early ossifi$ation of the anterior longitudinal ligament/
$igure +0) Ha An;ylosing s!ondylitis/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating high signalRomanus lesions at multi!le le<els at the anterior $orners of the <erte7ral 7odies Harro?heads / There are alsoentheso!athi$ $hanges at the !osterior $orners of the <erte7ral 7odies/ There is a dis$o<erte7ral lesion in the lo?er s!ineHAndersson lesion Hlong arro? / H7 Corres!onding T 0 ?eighted image demonstrating lo? signal Romanus lesions/
$igure +1) Ha Bam7oo s!ine in an;ylosing s!ondylitis/ Plain radiogra!h demonstrating syndesmo!hyte formation a$ross thedis$s gi<ing the 7am7oo s!ineG a!!earan$e/ H7 agger sign in an;ylosing s!ondylitis/ Plain radiogra!h demonstratingossifi$ation of the inters!inous and su!ras!inous ligaments gi<ing rise to the dagger signG Harro?heads / "ote that there is
fusion of the sa$roilia$ Koints in this !atient ?ith PagetLs disease of the !el<is/
$igure ,2) Costo<erte7ritis/ Sagittal short tau in<ersion re$o<ery HSTIR image demonstrating in$reased signal at the$osto<erte7ral Kun$tions Harro?s indi$ating $osto<erte7ritis/
$igure ,() Chan$e ty!e fra$ture through a fused s!ine/ Plain radiogra!hs demonstrate a fra$ture tra<ersing the dis$ and!osterior elements Harro?s /
$igure ,*) Ha Pseudoarthrosis/ Plain radiogra!h demonstrating end!late irregularity and s$lerosis Harro?heads in a !atient?ith a 7am7oo s!ineG/ H7 Corres!onding CT ?ith sagittal reformat demonstrates the fra$ture e&tending through the!osterior elements allo?ing differentiation from infe$tious dis$itis/
$igure ,+) Pseudoarthrosis/ Sagittal T 2 ?eighted image demonstrating end!late irregularity, su7$hondral oedema and highsignal in the dis$ Harro? / There is a fra$ture e&tending into the !osterior elements indi$ating a !seudoarthrosis Harro?head /
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