Cauda equina syndrome

30M 60F 70M

T2

30M

T2 T1 T1FS con

T1 T1FS con

60F

T2 T1 T1FS con

T1 T1FS con

70M

T2 T1 T1FS con

T1 T1FS con

35M PBA T2 T2 T1

•  72 year old male •  Non mechanical back pain •  Known prostate Ca:

–  Raised PSA (20) –  Nodule on DRE –  +ve on biopsy

•  Staging investigations

What is the most appropriate imaging modality for the spine?

1.  Plain film 2.  CT 3.  Scintigraphy (bone scan) 4.  MRI

64F Breast Ca

T2 T1 T1FS con

76M CRC

T2

54M RCC

•  62 year old male •  Severe low back pain of rapid onset •  Febrile and unwell •  4 weeks ago underwent abdominal surgery for

perforated diverticulitis

What is the most likely diagnosis?

1.  Acute disc herniation 2.  Discitis/ osteomyelitis 3.  Crush fracture secondary to osteoporosis 4.  Metastatic cancer

What is the most appropriate imaging modality?

1.  Plain film 2.  CT 3.  Scintigraphy (bone scan) 4.  MRI

T2 T1 T1FS con

T2 T1FS con

•  37 year old male •  Low back and buttock pain, increasing over

several months •  Worse in morning; reduced by activity

What is the most likely diagnosis?

1.  Acute disc herniation 2.  Facet joint degeneration 3.  Inflammatory spondyloarthropathy 4.  Metastatic cancer

Seronegative spondyloarthropathies (SpA)

•  European Spondyloarthropathy Study Group (ESSG) Arthritis Rheum 1991;34:1218-1227 –  Ankylosing spondylitis –  Reactive arthritis –  Arthritis spondylitis with inflammatory bowel disease –  Arthritis spondylitis with psoriasis –  Undifferentiated spondyloarthropathy (uSpA)

•  Clinical features + HLA-B27 •  Rheumatoid factor –ve = seronegative

ANKYLOSING SPONDYLITIS

•  Chronic inflammatory disease, primarily affecting spine and sacroiliac joints

•  Osteitis: –  Bone erosions; sclerosis; ankylosis

•  Peripheral arthritis: –  Asymmetrical; lower limb

•  Enthesopathy: –  Plantar fasciitis –  Distal Achilles tendonosis and paratendonitis

DIAGNOSIS OF AS

•  Radiographic grading of sacroiliitis 0-4 Kellegren Atlas of Standard Radiographs in Arthritis, Oxford

1963 •  Grade 0 = normal •  Grade 1 = suspicious (mild blurring) •  Grade 2 = minimal sclerosis, some erosions •  Grade 3 = severe erosions, joint widening, partial

ankylosis •  Grade 4 = complete ankylosis

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Radiographic grading of AS •  Grade 0 •  Grade 1 •  Grade 2 •  Grade 3 •  Grade 4

Dx of AS: Modified New York criteria

•  Arthritis Rheum 1984;27:361-368 •  Clinical:

1.  LBP & stiffness > 3/12 improved by exercise 2.  ↓ motion lumbar spine sagittal and frontal 3.  ↓ chest expansion for age & sex

•  Radiological: –  Grade ≥ 2 bilateral –  Grade 3-4 unilateral

•  AS = 2/3 clinical + radiological

Problems with radiographic grading

•  May take years for radiographic changes to develop –  Early cases excluded from research and treatment

•  Most radiographic signs in AS reflect healing processes, not disease activity –  cf erosions in RA

•  Most radiographic signs in AS irreversible •  Radiographs do not detect inflammation

T2FS

T1 STIR

STIR

Response to DMARD eg infliximab

–  Braun Ann Rheum Dis 2002;61:iii51-iii60

•  45 year old male •  2 weeks post discectomy L4/5 •  Recurrent bilateral leg pain

What is the most appropriate imaging modality?

1.  Plain film 2.  CT 3.  Scintigraphy (bone scan) 4.  MRI

T2                                                                                                                        T1  

T2  

T1FS  con  

T2

T1FS  con  

•  Dx: recurrent disc: –  Central herniation + huge sequestration virtually filling

the spinal canal •  Note peripheral enhancement pattern •  DD: fibrosis

•  51 year old female •  Left sciatica

–  Intermittent pain and paraesthesia

T2 T1 T1FS con

What is the most likely diagnosis?

1.  Massive disc sequestration 2.  Discitis complicated by abscess 3.  Synovial cyst 4.  Benign peripheral nerve sheath tumour

T2 T1 T1FS con

•  Dx: benign peripheral nerve sheath tumour (BPNST) of left L3 nerve root –  Many clinicians use the term ‘neuroma’

•  Pathologically imprecise term –  Most are benign

•  Schwannoma or neurofibroma •  Difficult (impossible) to differentiate on imaging

–  BPNST is probably the best terminology –  Associated with NF1 and ‘NF2’ (MISME)

•  66 year old female •  Severe lower back pain on and off for years •  More recent (2 months) development of right

sciatica

What is the most likely diagnosis?

1.  Massive disc sequestration 2.  Discitis complicated by abscess 3.  Synovial cyst 4.  Benign peripheral nerve sheath tumour

L4/5

•  Severe OA of facet (zygoapophyseal) joints •  Round heterogeneous lesion projecting into right

spinal canal •  Note: close relationship to facet joint •  Dx: synovial cyst

Synovial cyst lumbar facet joint

•  Fairly common •  Key is relationship to degenerate facet joint •  Density may vary from pure cyst to varying levels of

calcification and heterogeneity •  Usually present clinically with intractable sciatica •  May respond to aspiration and steroid injection, but

usually treated surgically

T2 T1

T2 T1

Image interpretation: spine

•  Anatomy •  Cross sectional techniques:

–  CT –  MRI

•  Nomenclature of disc herniations and spinal stenosis

•  A few cases