Presented by: Dr David Lisle — Radiologist Event: Bundaberg GP & Allied Health Education Day - 2015

1. 60F
T2 T1 T1FS con
T1 T1FS con

2. 70M
T2 T1 T1FS con
T1 T1FS con

3. 35M PBA T2 T2 T1

5. • 72 year old male
• Non mechanical back pain
• Known prostate Ca:
– Raised PSA (20)
– Nodule on DRE
– +ve on biopsy
• Staging investigations

6. What is the most appropriate
imaging modality for the spine?
1. Plain film
2. CT
3. Scintigraphy (bone scan)
4. MRI

10. 64F Breast Ca

11. T2 T1 T1FS con
76M CRC

12. T2
54M RCC

14. • 62 year old male
• Severe low back pain of rapid onset
• Febrile and unwell
• 4 weeks ago underwent abdominal surgery for
perforated diverticulitis

15. What is the most likely diagnosis?
1. Acute disc herniation
2. Discitis/ osteomyelitis
3. Crush fracture secondary to osteoporosis
4. Metastatic cancer

16. What is the most appropriate
imaging modality?
1. Plain film
2. CT
3. Scintigraphy (bone scan)
4. MRI

17. T2 T1 T1FS con

18. T2 T1FS con

20. • 37 year old male
• Low back and buttock pain, increasingover
several months
• Worse in morning; reduced by activity

21. What is the most likely diagnosis?
1. Acute disc herniation
2. Facet joint degeneration
3. Inflammatory spondyloarthropathy
4. Metastatic cancer

23. 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

24. ANKYLOSING SPONDYLITIS
• Chronic inflammatory disease, primarily affecting
spine and sacroiliac joints
• Osteitis:
– Bone erosions; sclerosis; ankylosis
• Peripheralarthritis:
– Asymmetrical; lower limb
• Enthesopathy:
– Plantar fasciitis
– Distal Achilles tendonosis and paratendonitis

25. 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

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

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

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

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

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

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

32. 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

33. 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

34. T2FS

35. T1
STIR
STIR

36. Response to DMARD eg infliximab
– Braun Ann Rheum Dis 2002;61:iii51-iii60

38. • 45 year old male
• 2 weeks post discectomy L4/5
• Recurrent bilateral leg pain

39. What is the most appropriate
imaging modality?
1. Plain film
2. CT
3. Scintigraphy (bone scan)
4. MRI

40. T2 T1

41. T2
T1FS con
T2

42. T1FS con

43. • Dx: recurrent disc:
– Central herniation + huge sequestration virtually filling
the spinal canal
• Note peripheral enhancement pattern
• DD: fibrosis

45. • 51 year old female
• Left sciatica
– Intermittent pain and paraesthesia

46. T2 T1 T1FS con

47. What is the most likely diagnosis?
1. Massive disc sequestration
2. Discitis complicated by abscess
3. Synovial cyst
4. Benign peripheral nerve sheath tumour

48. T2 T1 T1FS con

49. • 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)

51. • 66 year old female
• Severe lower back pain on and off for years
• More recent (2 months) development of right
sciatica

53. What is the most likely diagnosis?
1. Massive disc sequestration
2. Discitis complicated by abscess
3. Synovial cyst
4. Benign peripheral nerve sheath tumour

54. L4/5

55. • Severe OA of facet (zygoapophyseal) joints
• Round heterogeneouslesion projecting into right
spinal canal
• Note: close relationship to facet joint
• Dx: synovial cyst

56. 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

57. T2 T1

58. T2 T1

59. Image interpretation: spine
• Anatomy
• Cross sectional techniques:
– CT
– MRI
• Nomenclature of disc herniationsand spinal
stenosis
• A few cases