Friday, June 11, 2010
Top: Coronal and axial T1-weighted MRI demonstrating parietal subcortical heterotopia (arrows).Bottom left: Coronal T2-weighted MRI demonstrating bilateral perisylvian polymicrogyria.
Bottom right: Coronal inverted T2-weighted MRI demonstrating abnormal signal changes (post-traumatic in nature) in the left parietal lobe involving the white matter.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=epi&part=ch12&rendertype=figure&id=ch12.f16
Thursday, June 10, 2010
MRI in two patients with symptomatic frontal lobe epilepsy.Left: Coronal FLAIR MRI showing focal cortical dysplasia in the supplementary motor area of the left frontal lobe. Note the tail extending down towards the frontal horn of the lateral ventricle. This patient was 60 years old and had had left SMA seizures for 7 years. All previous MRI studies were negative.
Right: Axial T2-weighted MRI showing an heterogeneous lesion in the left precentral area. The signal changes are consistent with haemosiderosis suggestive of a cavernous angioma.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=epi&part=ch12&rendertype=figure&id=ch12.f8
Axial proton density-weighted MRI showing left temporal lobe cavernoma in a patient with LTLE.(lateral temporal lobe epilepsy).http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=epi&part=ch12&rendertype=figure&id=ch12.f7
MRIs of two patients with mesial (right) and lateral (left) temporal lobe epilepsy due to dysembryoplastic neuroepithelial tumours (DNET). Left: Coronal FLAIR MRI showing a discrete ring-like lesion in the lateral aspects of the right middle temporal gyrus consistent with a small neoplasm. Pathology revealed a DNET.
Right: Coronal T1-weighted MRI showing a large DNET occupying the left hippocampal areas and adjacent mesial temporal lobe gyri and white matter.
Temporal lobe epilepsies comprise a heterogeneous group of disorders sharing the same topographical seizure onset (the temporal lobe), but often of diverse aetiology, age at onset, prognosis, and response to medical or surgical management. Anatomically they are broadly divided into those originating from the lateral or mesial regions of the temporal lobe (Figures 12.1 and 12.2). Mesial (or medial) is far more common (accounting for two-thirds of cases) than lateral temporal lobe epilepsy (LTLE). The most common of all is hippocampal epilepsy, which probably constitutes a disease with known pathology rather than a syndrome. Other causes of temporal lobe epilepsy, mesial or lateral, are benign or malignant tumours, viral and other infectious and parasitic diseases, cerebrovascular disorders, malformations of cortical development, trauma and other injuries
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=epi&part=ch12
vertebral osteomyelitis
Figure 1a: 65-year-old man with vertebral osteomyelitis due to Mycobacterium avium-intracellulare. Sagittal T1-weighted image shows hypointense lesion from L4 to L5, extending to the prevertabral region (arrows).
Figure 1b: 65-year-old man with vertebral osteomyelitis due to Mycobacterium avium-intracellulare. Sagittal T2-weighted image obtained at the same level as A shows very hyperintense areas in the extended region and in the L4-5 intervertebral disc. (arrows).
Figure 1c: 65-year-old man with vertebral osteomyelitis due to Mycobacterium avium-intracellulare. Sagittal T1-weighted image obtained after gadolinium injection at the same level as A shows Rim-like enhancement in the lesion (arrows).
Figure 1d: 65-year-old man with vertebral osteomyelitis due to Mycobacterium avium-intracellulare. Axial T1-weighted image obtained after gadolinium injection at the level of L4-5 shows Rim-like enhancement (arrows). http://www.google.com.eg/imgres?imgurl=http://www.ispub.com/ispub/ijra/volume_5_number_1_35/spinal_osteomyelitis_due_to_mycobacterium_avium_intracellulare_mr_findings/mr-fig1a.jpg&imgrefurl=http://www.ispub.com/journal/the_internet_journal_of_radiology/volume_5_number_1_35/article_printable/spinal_osteomyelitis_due_to_mycobacterium_avium_intracellulare_mr_findings.html&usg=__hY1KRxYmHDUvaR5cpFp0YaPN6ow=&h=708&w=356&sz=39&hl=en&start=1&sig2=SZXF1AKu5xi-IlsCKlZHUA&itbs=1&tbnid=7w3LCfOoM6nlBM:&tbnh=140&tbnw=70&prev=/images%3Fq%3Dvertebral%2Bosteomyelitis%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=PLIQTNOXN9WK_Abs06WtBA
-Osteomyelitis most often occurs as a result of trauma producing open wounds that allows the entry of bacteria into the body, as a result of surgical procedures, or as a result of bacteria circulating in the bloodstream—a condition known as bacteremia. Osteomyelitis of joints can affect their function by means of bone destruction and joint deformity.
http://www.jamesdisabilitylaw.com/back-injuries.htm
http://www.jamesdisabilitylaw.com/back-injuries.htm
kyphosis
T2 weighted sagittal MRI image demonstrating kyphosis of the lower thoracic spine.
Kyphosis is an abnormal degree of curvature of the thoracic spine (upper back) in the forward direction (flexion). Kyphosis may be congenital or may occur in post-menopausal osteoporosis with collapse of the anterior (front) part of vertebral bodies in the upper back.
In kyphosis, forward curvature of the spine up to 20 degrees is considered normal, and mild up to 40 degrees. Bracing is prescribed for angles over 40 degrees and balance can be impaired by kyphotic curves greater than 40 degrees. Curves of 50 degrees or greater can produce a significant restrictive breathing deficit and should have vital capacity tested with spirometry. As with scoliosis, extremely abnormal curves of 100 - 110 degrees or more can compromise cardiac function.
http://www.jamesdisabilitylaw.com/back-injuries.htm
In kyphosis, forward curvature of the spine up to 20 degrees is considered normal, and mild up to 40 degrees. Bracing is prescribed for angles over 40 degrees and balance can be impaired by kyphotic curves greater than 40 degrees. Curves of 50 degrees or greater can produce a significant restrictive breathing deficit and should have vital capacity tested with spirometry. As with scoliosis, extremely abnormal curves of 100 - 110 degrees or more can compromise cardiac function.
http://www.jamesdisabilitylaw.com/back-injuries.htm
scoliosis
http://www.google.com.eg/imgres?imgurl=http://www.hoei.com/caden/blog/pics/MRI2.jpg&imgrefurl=http://www.hoei.com/caden/blog/2009/02/01/mri-results.htm&usg=__Ae_AsGimDP-JBeQBBciSJF47_NA=&h=605&w=605&sz=57&hl=en&start=2&sig2=XGEEt4DzAkPbREGSIErMpg&um=1&itbs=1&tbnid=UoB1tcKhXJy4CM:&tbnh=135&tbnw=135&prev=/images%3Fq%3Dscoliosis,mri%26um%3D1%26hl%3Den%26sa%3DG%26rlz%3D1T4RNTN_enEG364EG364%26tbs%3Disch:1&ei=orYQTKPSLYyf_QbR7cjJBA
http://scoliosisworld.ning.com/profiles/profile/show?id=AndyMcCall-Scoliosis is a sideways curvature to the spine (see Figure 9 below), associated with pain but not neurological impairment.
-Scoliosis should be suspected with leg length discrepancies of 2.2 cm or greater.
-The abnormal spinal curve of scoliosis is measured on plain X-rays. The measurement is called a Cobb angle. Scoliosis may be considered present with abnormal curves greater than 10 degrees. Mild cases have angles less than 30 degrees.
-Angles of 20 degrees or less are usually produce no symptoms. Bracing is prescribed for angles over 20 degrees. Curves over 40 degrees may produce neurological abnormalities such as sensory loss and weakness. Small curves of less than 30 degrees in childhood are not likely to get worse during adulthood, while more severe curves may continue to progress. Surgery with permanent rod implantation and fusion is indicated with curves greater than 45 degrees.
-Claimants with curves 60 degrees or more require spirometry for restrictive lung disease (decreased vital capacity).
-Heart failure may occur from scoliosis when abnormal curves are markedly severe at 100 degrees or more.
-Scoliosis should be suspected with leg length discrepancies of 2.2 cm or greater.
-The abnormal spinal curve of scoliosis is measured on plain X-rays. The measurement is called a Cobb angle. Scoliosis may be considered present with abnormal curves greater than 10 degrees. Mild cases have angles less than 30 degrees.
-Angles of 20 degrees or less are usually produce no symptoms. Bracing is prescribed for angles over 20 degrees. Curves over 40 degrees may produce neurological abnormalities such as sensory loss and weakness. Small curves of less than 30 degrees in childhood are not likely to get worse during adulthood, while more severe curves may continue to progress. Surgery with permanent rod implantation and fusion is indicated with curves greater than 45 degrees.
-Claimants with curves 60 degrees or more require spirometry for restrictive lung disease (decreased vital capacity).
-Heart failure may occur from scoliosis when abnormal curves are markedly severe at 100 degrees or more.
spinal stenosis
Spinal stenosis is a narrowing of the space inside the bony spine (see Figure 7 below), which sometimes results in pressure on the spinal cord and peripheral nerve roots from the spinal cord. The Social Security Administration most commonly sees such cases in claimants who have severe osteoarthritis of the lower spine. Spinal stenosis can be worsened by bulging or herniated disks (HNPs) (see Figure 8 below) and spondylolisthesis.
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Figure 7: Spinal stenosis with a narrowing of the spinal canal.
Figure 8: Spinal stenosis caused by a herniated disk and osteoarthritis.
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Figure 7: Spinal stenosis with a narrowing of the spinal canal.
Figure 8: Spinal stenosis caused by a herniated disk and osteoarthritis.-Spinal stenosis most commonly involves the lower back, specifically the area somewhere between the 3rd lumbar vertebra and the beginning of the sacrum (L3-4, L4-5, and L5-S1 levels). Less frequently, the neck (cervical spine) may be involved with spinal stenosis; its presence in the upper back (thoracic spine) is rare.
-Spinal stenosis is one of many possible causes of damage to the spinal cord (myelopathy). Myelopathy may be irreversible. Surgical decompression of the spinal cord may be necessary for severe cases, but even after surgery symptoms may not improve.
-In addition to osteoarthritis, causes of spinal stenosis include congenital spinal deformities (scoliosis, kyphosis, or congenital skeletal dysplasias like achondroplastic dwarfism); acquired deformities such as post-traumatic spinal fractures; inflammatory spinal diseases like ankylosing spondylitis; or stenosis may be of unknown cause. Tumors or infection present possible reversible causes of lumbar stenosis.
-Spinal stenosis can be seen on imaging studies such as myelography, CT, and MRI scans. But myelography and CT scans can miss some types of stenosis.
spondylolisthesis
Spondylolisthesis is a slippage of vertebral bodies out of their normal position, usually a forward slippage of the 5th lumbar vertebra over the 1st sacral vertebra (L5-S1). More rarely, a type of spondylolisthesis called retrolisthesis involving the backward displacement of a vertebral body occurs. Most spondylolisthesis is seen in the lumbar spine (L1-L5/S1). This disorder can been seen on plain X-rays. It is significantly more likely to be seen on X-rays taken in the standing position than in those taken in lying position—with weight on the spine, slippage is more likely.
However, severe or even significant neurological abnormalities (sensory changes, reflex changes, muscle weakness or atrophy) are not to be expected in spondylolisthesis
Studies have shown that most individuals with spondylolisthesis, lead active lives with little, if any, adjustment for having this type of spinal abnormality. Spondylolisthesis is most likely to become limiting as a contributing factor for spinal stenosis in combination with other spinal disorders, such as severe osteoarthritis and severely bulging intervertebral discs.
http://www.jamesdisabilitylaw.com/back-injuries.htm#Degenerative_Disc_Disease_(DDD)
However, severe or even significant neurological abnormalities (sensory changes, reflex changes, muscle weakness or atrophy) are not to be expected in spondylolisthesis
Studies have shown that most individuals with spondylolisthesis, lead active lives with little, if any, adjustment for having this type of spinal abnormality. Spondylolisthesis is most likely to become limiting as a contributing factor for spinal stenosis in combination with other spinal disorders, such as severe osteoarthritis and severely bulging intervertebral discs.
http://www.jamesdisabilitylaw.com/back-injuries.htm#Degenerative_Disc_Disease_(DDD)
Lumbar strain refers to stress on the ligaments, muscles, and other soft tissues near the spine with resultant pain. There may or may not be underlying arthritis or DDD. Acute strain, associated with a particular lifting event, will almost always resolve in several months. If the pain is marked, there is associated muscle spasm and difficulty bending the back. When back pain continues for a prolonged period, orthopedists and other doctors tend to apply the diagnosis of “chronic lumbar strain,” if there is no other underlying identifiable abnormality that can be seen on imaging studies.
MRI is the study of choice for the diagnostic evaluation of arachnoiditis. T1-weighted MRIs may reveal an indistinct or absent cord outline due to the increase in the signal intensity of the surrounding CSF. T2-weighted MRIs may demonstrate CSF loculation and obliteration of the subarachnoid space or irregularly thickened, clumped nerve roots, which occasionally may be misinterpreted as a tethered cord or a thickened filum terminale. With more severe arachnoiditis, progression of nerve root clumping and leptomeningeal adhesions may lead to angular defects in the dural sac. Peripheral adherence of the nerve roots to the walls of the thecal sac produces the so-called featureless, or empty, sac.
Arachnoiditis is inflammation of some part of the arachnoid membrane that covers the spinal cord. It can produce severe chronic pain. Arachnoiditis may occur as a result of infection, but most commonly is seen after surgical procedures and use of contrast material to enhance visualization of structures with X-rays during myelography. Some people are more sensitive than others to contrast material. An MRI scan has about a 90% chance of showing this abnormality if it is present. A negative MRI scan for arachnoiditis is a strong argument that it is not present.
The most serious tumors of the spine arise from cancer that has spread to the spine from breast, colon, prostate, or other origin. Tumors can not only cause chronic pain, but result in spinal fractures as they destroy bone. The spread of cancer of any kind to the spine is a serious development that must also be considered under the listings dealing with cancer.
Wedge fractures are the most common fractures and occur most frequently at the midthoracic and thoracolumbar regions in both men and women. Crush fractures also have a higher tendency to occur in the midthoracic and thoracolumbar regions. Unlike other types of fractures, biconcave fractures are equally as likely to occur in lower lumbar vertebrae as at other spinal locations.http://www.google.com.eg/imgres?imgurl=http://www.osseon.com/media/images/Vertebral-Fracture-Variations3.0.jpg&imgrefurl=http://www.osseon.com/patient-education/vertebral-compression-fractures/&usg=__VBKQEcYm5Z0voYuy75MmsbPgzxg=&h=233&w=429&sz=26&hl=en&start=13&sig2=nffz1kCLgXT2wEnyjvwuhA&um=1&itbs=1&tbnid=S-Wzj-yIQ5BWcM:&tbnh=68&tbnw=126&prev=/images%3Fq%3Dvertebral%2Bfracture%26um%3D1%26hl%3Den%26sa%3DG%26rlz%3D1T4RNTN_enEG364EG364%26tbs%3Disch:1&ei=-ioQTIr0CY6g4Qai6tTtDA
figure:Lumbar spine radiograph (two projections): A compressed fracture can be seen in the the second lumbal vertebra (arrows), which is anteriorly narrowed in a wedge shape. Corresponding to the fractured lumbal vertebra, a gibbus can be observed.http://www.google.com.eg/imgres?imgurl=http://www.szote.u-szeged.hu/radio/trauma2/traum1c.gif&imgrefurl=http://www.szote.u-szeged.hu/radio/trauma2/a2trau1c.htm&usg=__HUujda7IJMPb9Eqv7ZDE3cSnoEY=&h=400&w=368&sz=77&hl=en&start=3&sig2=Xz4lK1numwMuX2-y1Srt9Q&um=1&itbs=1&tbnid=bZ-F0zykprtzUM:&tbnh=124&tbnw=114&prev=/images%3Fq%3Dvertebral%2Bfracture%26um%3D1%26hl%3Den%26sa%3DG%26rlz%3D1T4RNTN_enEG364EG364%26tbs%3Disch:1&ei=CSoQTPOPOdCI4QbF0tH_DA
Fractures of the bony spine are most commonly related to automobile or motorcycle accidents. There may be associated spinal cord injury. Traumatically fractured vertebrae are treated with a combination of surgical fusion and sometimes stabilization with metal rods.
figure:showed osteoporosis vertebral compression fracturehttp://www.google.com.eg/imgres?imgurl=http://www.pharmaweblog.com/wp-content/uploads/2008/09/vertebral-fracture.jpg&imgrefurl=http://www.pharmaweblog.com/%3Fattachment_id%3D518&usg=__UtM9aBSMFgnd1wCzjaxdAU18k_k=&h=925&w=617&sz=43&hl=en&start=3&sig2=WLsfYQXD4h75WvH2xXZrgA&um=1&itbs=1&tbnid=812x2OKpqU8IYM:&tbnh=147&tbnw=98&prev=/images%3Fq%3Dvertebral%2Bosteoporosis%26um%3D1%26hl%3Den%26sa%3DN%26rlz%3D1T4RNTN_enEG364EG364%26tbs%3Disch:1&ei=dicQTMO4MemP4gaDioT0DA
Osteoporosis
Osteoporosis is a metabolic disorder associated with decrease in the mass of bone. By far, most of the instances of osteoporosis seen by the Social Security Administration are in post-menopausal women. Osteoporosis may be confined to the spine, but other bones may be involved in those who have used corticosteroids. A collapse of vertebral bodies, especially in the upper back, is known as a compression fracture. Compression fractures are visible on plain X-ray or other imaging studies. If the fracture involves the anterior (front) part of a vertebral body more than the rest of the vertebra, the spine will tend to curve forward and result in the popularly known dowager’s hump.
Compression fractures are graded in regard to the percent of the vertebra that is compressed, compared to the normal height of the vertebra. Normal height is judged from adjacent vertebrae. Pain, loss of motion, and muscle spasm are most likely to be present at the time of fracture and in the healing period. Marked or multiple compression fractures are more likely to produce chronic pain.
Plain X-rays are much less sensitive than bone densitometry in determining the severity of osteoporosis. A normal appearance of bone on plain X-rays only rules out the most advanced osteoporosis. Plain X-rays are fine for determining the percentage of vertebral body collapse in compression fractures.
http://www.jamesdisabilitylaw.com/back-injuries.htm#Degenerative_Disc_Disease_(DDD)
Osteoporosis is a metabolic disorder associated with decrease in the mass of bone. By far, most of the instances of osteoporosis seen by the Social Security Administration are in post-menopausal women. Osteoporosis may be confined to the spine, but other bones may be involved in those who have used corticosteroids. A collapse of vertebral bodies, especially in the upper back, is known as a compression fracture. Compression fractures are visible on plain X-ray or other imaging studies. If the fracture involves the anterior (front) part of a vertebral body more than the rest of the vertebra, the spine will tend to curve forward and result in the popularly known dowager’s hump.
Compression fractures are graded in regard to the percent of the vertebra that is compressed, compared to the normal height of the vertebra. Normal height is judged from adjacent vertebrae. Pain, loss of motion, and muscle spasm are most likely to be present at the time of fracture and in the healing period. Marked or multiple compression fractures are more likely to produce chronic pain.
Plain X-rays are much less sensitive than bone densitometry in determining the severity of osteoporosis. A normal appearance of bone on plain X-rays only rules out the most advanced osteoporosis. Plain X-rays are fine for determining the percentage of vertebral body collapse in compression fractures.
http://www.jamesdisabilitylaw.com/back-injuries.htm#Degenerative_Disc_Disease_(DDD)
A herniated nucleus pulposus is the protrusion of the hard, cartilaginous center (nucleus) of an intervertebral disk through the outer fibrous tissue (annulus fibrosa) (see Figures 5 and 6 below). Many small HNPs will produce acute symptoms that improve with time. Injection of corticosteroid drugs in the area of the HNP can also help relieve inflammation and pain. Some claimants have a large HNP that presses on a spinal nerve root, and must have part of the HNP removed (discectomy, diskectomy).
figure 5
figure 6
figure 5
figure 6
Degenerative disc disease refers to dehydration and shrinkage of the intervertebral discs that cushion the vertebral bodies of the spine. DDD is common and causes no symptoms in many older individuals. Everyone over about the age of 50 has some degree of DDD, which may or may not be symptomatic and functionally limiting. Osteoarthritis of the spine is frequently accompanied by DDD, while DDD without associated OA is also common. DDD can be seen on X-rays, MRI, and CT scans of the spine. It appears as narrowing of the space between vertebral bodies. Symptomatic DDD occurs between the 5th lumbar vertebra and the 1st sacral vertebra (L5-S1).
Sometimes a combination of OA and DDD produces enough symptoms that surgical fusion is performed in the lumbar spine (lumbar fusion) or cervical spine (neck). This procedure is done in an attempt to stabilize the spine and decrease pain. The surgery requires taking strips of bone from the posterior (back) upper part of the pelvic bone and laying them over the vertebral bodies that need to be stabilized (see Figure 4 below). Bone is living tissue and will incorporate the vertebral bodies into one solid mass. Sometimes, the bone strips do not incorporate well and the surgical fusion partially or wholly fails. Some fusions involve only two vertebrae, but multiple vertebrae may also be fused.
http://www.google.com.eg/imgres?imgurl=http://wiki.cns.org/wiki/images/0/03/Degenerative_disc_disease.jpg&imgrefurl=http://wiki.cns.org/wiki/index.php/Degenerative_Disc_Disease&usg=__fc681vAyEjRSyV3xOL2_RWtQVJA=&h=384&w=250&sz=23&hl=en&start=2&sig2=eNZJ3d6V4k_7UAPLw7BM4Q&itbs=1&tbnid=nCqP2wdJCQgcsM:&tbnh=123&tbnw=80&prev=/images%3Fq%3Ddegenerative%2Bdisc%2Bdisease%26hl%3Den%26gbv%3D2%26tbs%3Disch:1&ei=xB8QTJPAGYuu4QbgjLnzDA
Sometimes a combination of OA and DDD produces enough symptoms that surgical fusion is performed in the lumbar spine (lumbar fusion) or cervical spine (neck). This procedure is done in an attempt to stabilize the spine and decrease pain. The surgery requires taking strips of bone from the posterior (back) upper part of the pelvic bone and laying them over the vertebral bodies that need to be stabilized (see Figure 4 below). Bone is living tissue and will incorporate the vertebral bodies into one solid mass. Sometimes, the bone strips do not incorporate well and the surgical fusion partially or wholly fails. Some fusions involve only two vertebrae, but multiple vertebrae may also be fused.
figure 4
http://www.jamesdisabilitylaw.com/back-injuries.htm#Degenerative_Disc_Disease_(DDD)
http://www.google.com.eg/imgres?imgurl=http://wiki.cns.org/wiki/images/0/03/Degenerative_disc_disease.jpg&imgrefurl=http://wiki.cns.org/wiki/index.php/Degenerative_Disc_Disease&usg=__fc681vAyEjRSyV3xOL2_RWtQVJA=&h=384&w=250&sz=23&hl=en&start=2&sig2=eNZJ3d6V4k_7UAPLw7BM4Q&itbs=1&tbnid=nCqP2wdJCQgcsM:&tbnh=123&tbnw=80&prev=/images%3Fq%3Ddegenerative%2Bdisc%2Bdisease%26hl%3Den%26gbv%3D2%26tbs%3Disch:1&ei=xB8QTJPAGYuu4QbgjLnzDA
http://www.google.com.eg/imgres?imgurl=http://boneandspine.com/wp-content/uploads/2009/08/lumbar-spondylosis-straightening-spine.JPG&imgrefurl=http://boneandspine.com/category/spine/back-pain-spine/&usg=__p2jiMTUwCXEi9IPhFpdnWDAT_vA=&h=406&w=528&sz=40&hl=en&start=10&sig2=vZk0bOotdF0nyfEplIx1Fg&itbs=1&tbnid=hoEUEnG1VYm3rM:&tbnh=102&tbnw=132&prev=/images%3Fq%3Dspondylotic%2Bspinal%2Bchanges%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=IhwQTKz8C-WL4ga10tD4DASome degree of osteoarthritis of the spine is common in middle-aged people, even if they are not aware of it. OA of the spine can take several forms. In ankylosis, parts of the spine are abnormally fused together as a result of bony overgrowth. For example, bony spurs can fuse vertebral bodies together. The peripheral nerves formed from the spinal cord exit the bony spine through recesses in vertebrae called intervertebral foramina (see Figure 2 below). Some of these foramina can become encroached by osteoarthritis and require surgical decompression. Vertebrae have contact points with other vertebra called facet joints (see Figure 3 below). Arthritis affecting these facet joints can be painful and limit the motion of the spine.
Tuesday, June 8, 2010
pre (a) and post (b) contrast sagittal T1 weighted images of the cervical spine showing a 2 cm predominantly low signal area in the anterior cervical spinal cord with patchy tubular enhancement and focal dural thickening consistent with AVM .http://www.google.com.eg/imgres?imgurl=http://www.ispub.com/ispub/ijra/volume_5_number_2_29/high_cervical_spinal_cord_vascular_malformation_masquerading_as_guillian_barre_syndrome_a_case_report/spine-fig2.jpg&imgrefurl=http://www.ispub.com/ostia/index.php%3FxmlPrinter%3Dtrue%26xmlFilePath%3Djournals/ijra/vol5n2/spine.xml&usg=__6WdViDjaXcnTq7Bkie8jDX6gOus=&h=592&w=931&sz=60&hl=en&start=3&sig2=t_W5FAD60isrT67Nh9Q8tw&itbs=1&tbnid=w2a4jZvmCvPr_M:&tbnh=93&tbnw=147&prev=/images%3Fq%3D,mr%2BIntra-medullary%2Bvascular%2Bmalformation%2B(AVM).i%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=kAsOTPmsLov-4AbSltD3DA
As the older names imply, spina bifida and cranium bifidum share a failure of bone fusion in the posterior midline of the skull (cranium bifidum) or the vertebral column (spina bifida). The result is a bony cleft through which the meninges and varying quantities of brain or spinal cord tissue protrude. In cranium bifidum, the neural herniation is termed encephalocele and can consist of brain parenchyma and meninges or only of meninges. These form the wall of a saclike cyst filled with cerebrospinal fluid (CSF). Posterior encephaloceles may contain only supratentorial structures, only posterior fossa structures, or both. In spina bifida, the herniation is called meningocele or meningomyelocele, depending on whether the meninges herniate alone or together with spinal cord parenchyma and nerve roots. The traditional names spina bifida and cranium bifidum are now less frequently used than in the older literature because of the recognition that the bony cleft may not be the primary defect in all cases, but instead that the pathogenesis may involve neural induction of mesodermal tissues in the dorsal midline, including leptomeninges, dura mater, and bone.
Spina bifida occulta is a minor fusion failure of the posterior vertebral arches unaccompanied by herniation of meninges or neural tissue. Spina bifida cystica collectively designates meningocele, meningomyelocele, and other cystic lesions (FIGURE). Similarly, in the head, cranium bifidum comprises meningocele, a herniation of meninges containing only CSF, and the more commonly occurring encephalocele, in which the sac contains neural and glial tissue. Rachischisis refers to a severe condition with an extensive defect of the craniovertebral bone with exposure of the brain, spinal cord, and meninges. Myeloschisis is another defect in the tissues over the lower spinal cord. Neural tissue is exposed at the surface as a flat, red lesion with a velvety appearance over the sacral region, without protruding as a myelomeningocele sac.
meningocele meningomyelocele
myelocystocele myeloceleDrawings of various forms of spinal dysraphic lesions (spina bifida cystica). A: Meningocele. Through the bony defect (spina bifida), the meninges herniate and form a cystic sac filled with spinal fluid. The spinal cord does not participate in the herniation and might or might not be abnormal. B: Myelomeningocele. The spinal cord is herniated into the sac and ends there or can continue in an abnormal way further downward. C: Myelocystocele or syringomyelocele. The spinal cord shows hydromyelia; the posterior wall of the spinal cord is attached to the ectoderm and is undifferentiated. D: Myelocele. The spinal cord is araphic; a cystic cavity is in front of the anterior wall of the spinal cord.
http://www.google.com.eg/imgres?imgurl=http://www.msdlatinamerica.com/ebooks/ChildNeurology/files/5fcff0a7a0e5332caecf1ba18773d10c.gif&imgrefurl=http://www.msdlatinamerica.com/ebooks/ChildNeurology/sid398771.html&usg=__ZgHjoeZbwMSVuUVd5qOmeAqge1Q=&h=480&w=405&sz=113&hl=en&start=9&sig2=MA-qBTVzVvIDsdkXFlSN1g&itbs=1&tbnid=n8KdUngJ4OqbcM:&tbnh=129&tbnw=109&prev=/images%3Fq%3Dspinal%2Bdysraphism,mri%26hl%3Den%26sa%3DX%26gbv%3D2%26tbs%3Disch:1&ei=jwUOTICOM5WL_AbryMXMDA
Severe medullary contusion opposite C5 and C6 vertebrae with cord edema extending upwards until the level of C2 with visibility of small area of medullary hemorrhage opposite the vertebral body of C6 and the spinal cord is swollen at the level of the injury. However, no evidence of cord rupture. Severe injury to the C5-C6 intervertebral disc which is torn with posterior displacement of the posterior portion and inferior displacement of the anterior portion along the anterior aspect of C6 vertebra.http://www.google.com.eg/imgres?imgurl=http://www.ispub.com/ispub/ija/volume_19_number_2/problems_faced_during_anesthesia_in_morbidly_obese_patient_with_cervical_injury_presented_for_fixation_in_prone_position/obese-fig1.jpg&imgrefurl=http://www.ispub.com/journal/the_internet_journal_of_anesthesiology/volume_19_number_2/article_printable/problems_faced_during_anesthesia_in_morbidly_obese_patient_with_cervical_injury_presented_for_fixation_in_prone_position.html&usg=__OmGkowHq0mz-qxFeb2ApKH0RqZc=&h=523&w=689&sz=41&hl=en&start=3&sig2=h5504esCWaa5V3l7gF6efw&itbs=1&tbnid=udqgkQ-3yBHf7M:&tbnh=106&tbnw=139&prev=/images%3Fq%3Dspinal%2Bcord%2Bcontusion,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=QAMOTOXFKtf__Qbtk8W6DA
Guillain-Barré syndrome. T1-weighted postcontrast axial MR image of the cauda equina shows smooth, diffuse enhancement of the lumbar nerve roots. There is preferential involvement of the ventral roots, which is very suggestive of Guillain-Barré syndrome.http://www.google.com.eg/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033208703963/gr2-midi.jpg&imgrefurl=http://imaging.consult.com/image/topic/dx/Brain%2520and%2520Spine%3Ftitle%3DGuillain-Barre%2520Syndrome%2520(Spine)%26image%3Dfig2%26locator%3Dgr2%26pii%3DS1933-0332(08)70396-3&usg=__-5VAeTBmiID2yMO0OvIRadhS8qA=&h=192&w=200&sz=5&hl=en&start=4&sig2=8BblKz_g9ujZriV7hNrVvw&itbs=1&tbnid=X0pR1IU0BYuPIM:&tbnh=100&tbnw=104&prev=/images%3Fq%3DGuillain-Barre%2Bsyndrome,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=gfINTO2eIYfs4gaay6XuDA
Guillain-Barré syndrome. T1-weighted postcontrast sagittal MR image of the cauda equina shows smooth, diffuse enhancement of the lumbar nerve roots. There is preferential involvement of the ventral roots, which is very suggestive of Guillain-Barré syndrome.http://www.google.com.eg/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033208703963/gr1-midi.jpg&imgrefurl=http://imaging.consult.com/imageSearch%3Fquery%3Dinflammatory%26resultOffset%3D161&usg=__HkM7G5qM2d5kS0ow9l_oQCgw5aw=&h=200&w=101&sz=3&hl=en&start=3&sig2=N3ZgsiePOtPb15-MRJoUgA&itbs=1&tbnid=DjQFenIsTV41PM:&tbnh=104&tbnw=53&prev=/images%3Fq%3DGuillain-Barre%2Bsyndrome,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=-fANTKLdOtL24Aam1OD3DA
Sunday, June 6, 2010
GBM in a 49-year-old man. A, Axial T2-weighted image demonstrates a large right heterogeneous hemorrhagic mass with areas of necrosis (black arrow). B, Axial susceptibility gradient echo image demonstrates variable low signal intensity within the tumor, which confirms the presence of the blood products (white arrow) C, Axial enhanced Tl-weighted image. Note second right frontal lobe-enhancing lesion representing multifocal involvement (open arrow). (Click to magnify figure)http://www.google.com.eg/imgres?imgurl=http://yassermetwally.files.wordpress.com/2010/03/25.jpg&imgrefurl=http://yassermetwally.wordpress.com/2010/03/27/devics-disease-neuromyelitis-optica/&usg=__bwARSdZRPmwbvsWh1BZ8nYu8ujA=&h=480&w=360&sz=25&hl=en&start=2&sig2=Qzc0hV_0HHk4G4wGPvfCPw&itbs=1&tbnid=4tgCxjSDsrxnIM:&tbnh=129&tbnw=97&prev=/images%3Fq%3Dspinal%2Bcord%2Bfungal%2Binfection,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=248LTM-NFMX44AawtMRf
Multifocal glioblastoma multiforme (GB). A, B,C,D Axial T2 and FLAIR images demonstrate multiple regions of increased signal abnormality including the right cerebellum, right temporal lobe, and left frontal lobe. Despite diffuse involvement, white matter signal abnormality cannot be traced to connect all the lesions. E,F, Axial enhanced Tl -weighted images show multiple discrete ring-enhancing masses. Imaging findings are indistinguishable from metastatic disease. (Click to magnify figure)http://www.google.com.eg/imgres?imgurl=http://yassermetwally.files.wordpress.com/2010/03/25.jpg&imgrefurl=http://yassermetwally.wordpress.com/2010/03/27/devics-disease-neuromyelitis-optica/&usg=__bwARSdZRPmwbvsWh1BZ8nYu8ujA=&h=480&w=360&sz=25&hl=en&start=2&sig2=Qzc0hV_0HHk4G4wGPvfCPw&itbs=1&tbnid=4tgCxjSDsrxnIM:&tbnh=129&tbnw=97&prev=/images%3Fq%3Dspinal%2Bcord%2Bfungal%2Binfection,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=248LTM-NFMX44AawtMRf
Glioblastoma multiforme. A, Axial FLAIR and T2-weighted images demonstrate a large right temporal lobe mass with extensive signal abnormality extending across the splenium of the corpus callosum. There is also significant mass effect with right uncal herniation. The right temporal horn is trapped (white arrow). B, Axial and coronal enhanced Tl-weighted images show thick irregular enhancement. (Click to magnify figure)http://www.google.com.eg/imgres?imgurl=http://yassermetwally.files.wordpress.com/2010/03/25.jpg&imgrefurl=http://yassermetwally.wordpress.com/2010/03/27/devics-disease-neuromyelitis-optica/&usg=__bwARSdZRPmwbvsWh1BZ8nYu8ujA=&h=480&w=360&sz=25&hl=en&start=2&sig2=Qzc0hV_0HHk4G4wGPvfCPw&itbs=1&tbnid=4tgCxjSDsrxnIM:&tbnh=129&tbnw=97&prev=/images%3Fq%3Dspinal%2Bcord%2Bfungal%2Binfection,mri%26hl%3Den%26sa%3DG%26gbv%3D2%26tbs%3Disch:1&ei=248LTM-NFMX44AawtMRf
Note that the lesions above do not enhance with contrast.ADEM (acute disseminated encephalomyelitis): an inflammatory, demyelinating disorder, primarily of children, typically occurs after an infection (often a URI) or vaccination. It often presents as encephalopathy and multifocal neurologic deficits. An LP may show a mild leukocytosis and elevated protein (as in this case), but may be normal. MRI is key to the diagnosis and shows subcortical white matter hyperintensity on T2, with basal ganglia, brainstem, and spinal cord also commonly affected. Enhancement is unusual and suggestive of infection. Accepted treatment is with high dose steroids, followed by an oral taper. Other experimental immunosuppresive therapies have been tried. Prognosis is generally good, with 60-90% having a complete recovery. Traditionally considered monophasic in nature, multiple episodes are often reclassified as multiple sclerosis.
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Saturday, June 5, 2010
Cervical spinal cord MRI in the sagittal plane of a 28-year-old woman with polyphasic neuromyelitis optica. (A) T1-weighted image showing thickening of the cord from C7 to T2 with patchy areas of subtle intraparenchymal hyperintensity. (B) T1-weighted image, post gadolinium contrast administration, showing several enhancing lesions from C7 to T2. (C) T2-weighted image showing a contingous area of increased signal intensity spanning from C6 to T3.
MRI (Magnetic Resonance Imaging) is the leading diagnostic tool used in determining SM. The MR imager takes pictures of body structures, such as the brain and spinal cord, in vivid detail. MRI Testing will show the syrinx in the spine or any other conditions, such as the presence of a tumor. MRI is safe, painless, and informative and has greatly improved the diagnosis of syringomyelia.What is syringomyelia?
Syringomyelia is a disorder in which a cyst forms within the spinal cord This cyst called a syrinx expands and elongates over time destroying the center of the cord Since the spinal cord connects the brain to the nerves in the extremities this damage may result in pain weakness and stiffness in the back shoulders arms or legs Other symptoms may include headaches and loss of the ability to feel extremes of hot or cold especially in the hands and disruption in body temperature SM may also adversely affect sweating sexual function and bladder and bowel control.
What causes Syringomyelia?
• Trauma to the spinal cord or congenital developmental problems of the brain and/or spinal cord may result in SM
o Spinal cord trauma such as a car accident or serious fall may manifest years later as SM
- OR -
o Congenital developmental problems, sometimes undetectable may result in syringomyelia
In either case the condition may lie dormant and undetected for months or years until a symptom or variety of symptoms become bothersome enough to warrant medical attention. Many people with SM are not diagnosed until mid-life.
What are the different forms of Syringomyelia?
Generally, there are two forms of SM. The disorder may be related to a congenital abnormality of the brain called Arnold Chiari malformation. A syrinx may then develop in the cervical region of the spinal cord; this is referred to as communicating syringomyelia. Some people with this form of the disorder also have hydrocephalus (water on the brain), a condition in which CSF accumulates in the skull, or arachnoiditis, in which a covering of the spinal cord is inflamed.
The second major form of SM occurs as a complication of trauma, meningitis, hemmorrhage or tumor. Here, the cyst or syrinx develops in a segment of the spinal cord damaged by one or more of these conditions. The syrinx may start to expand; this is sometimes referred to as noncommunicating syringomyelia.
Presumed spinal cord metastasis in a female patient known to have breast cancer. MRI shows:- Focal cord expansion with intramedullary enhancing mass,
- Thin enhancing rim along lower anterior cord surface and,
- Enhancing metastatic foci in the bone marrow.
Spinal cord metastases can be:
1-Intramedullary (within the cord): rare.
2-Pial (Superficial, along pial surface): in most of the cases.
Common primary CNS tumors: PNET/medulloblastoma and glioblastoma.
Common primary malignancy outside CNS: lung (70%), breast (11%), melanoma, kidney, lymphoma and leukemia.
Post contrast MRI demonstrates so called “sugar coating” or zuckerguss (German for sugar icing) of the lower portions of the spinal cord in keeping with leptomeningeal metastases.
MR findings in all intramedullary gliomas may be similar. T1WI typically demonstrates fusiform widening of the cord over one or several segments by a soft tissue mass that is iso or slightly hypointense to normal cord. T2WI demonstrates focal areas of increased signal within the enlarged cord segments that represents the tumor and surrounding edema. There is a frequent association of both intratumoral cysts and an adjacent syrinx with astrocytomas (38%) and ependymomas (46%). It is difficult to differentiate cystic tumor from a benign or adjacent syrinx on standard spin-echo sequences, since the signal may vary depending on the fluid characteristics. Gadolinium may help in this regard, as nearly all gliomas can be expected to enhance.
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