Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 3 – Spine

Chapter 3
Thomas H. Berquist
Douglas S. Fenton
Suggested Reading
Daffner RH. Cervical radiography for trauma patients. A time effective technique. AJR Am J Roentgenol 2000;175:1309–1311.
M, Moushine E, Theumann N, et al. Thoracolumbar spine fractures in
patients who have sustained severe trauma: Depiction with multidetector
row CT. Radiology 2003;227:681–689.
Witte RJ, Lane JI, Miller GM, et al. Spine. In: Berquist TH, ed. MRI of the musculoskeletal system, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:121–202.


Trauma: Cervical Spine—Basic Concepts
FIGURE 3-1 Disruptive hyperflexion injuries. (A) Mechanism (blow to the occipital region) that causes more posterior soft tissue injury compared with anterior compression. (B) Lateral radiograph shows widened interspinous distance (double arrow), subluxation of the facets (posterior arrowhead) and slight subluxation, and disc space widening (anterior arrowhead).


FIGURE 3-2 Compressive hyperflexion injuries. (A) Mechanism of injury with force transmitted to the anterior vertebral body. (B) Lateral radiograph demonstrates compression of C7 and T1 (arrow).
FIGURE 3-3 Disruptive hyperextension injuries. (A) Disruptive hyperextension injury with anterior distraction. The cord may be compressed. (B) Lateral radiograph shows anterior disc space widening and vertebral chip fracture (arrow).


FIGURE 3-4 Compressive hyperextension injuries. (A) Mechanism resulting in posterior compression and less anterior distraction. (B) Lateral radiograph demonstrating a vertical posterior arch fracture (arrow).
FIGURE 3-5 Flexion-rotation injuries. (A) Mechanism of injury. (B) Lateral radiograph shows a unilateral locked facet with subluxation and “bow-tie” configuration (lines) of the facets.


FIGURE 3-6 Vertical compression injuries. (A) Mechanism of injury. (B,C) Axial CT images of a burst fracture.


FIGURE 3-7 Instability. (A)
Lateral radiograph demonstrating the anterior (anterior longitudinal
ligament, body, and disc), middle (posterior body and disc and
posterior longitudinal ligament), and posterior (facet joints and
posterior ligaments) columns. When two columns are involved the injury
should be considered unstable. (B) Lateral view showing multiple column involvement with widened interspinous distance (double arrow), subluxation (black lines), and anterior disc space narrowing (arrowhead) caused by a disruptive hyperflexion injury.
Suggested Reading
Denis F. Spinal instability as defined by the three column spine concept in acute spinal trauma. Clin Orthop 1984;189:65–76.
Gehweiler JA, Osborne RL, Becker RF. The radiology of the vertebral trauma. Philadelphia: WB Saunders; 1980.
MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt
cervical spine injury: Plain radiograph or computed tomography scans. J Trauma 2003;55:222–227.
CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in
obtunded blunt trauma patients: Review of the medical literature. Radiology 2005;234:733–739.


Trauma: Cervical Spine—Atlanto-Occipital Fracture Dislocations
FIGURE 3-8 Atlanto-occipital dislocation. Lateral radiograph shows a huge prevertebral hematoma (arrows) with anterior dislocation of the occipital condyles (arrowhead). The patient did not survive.
Suggested Reading
Deliganis AV, Baxter AB, Hanson JA, et al. Radiologic spectrum of craniocervical distraction injuries. Radiographics 2000;20:S237–S250.
Hosalkar HS, Cain EL, Chin KR, et al. Traumatic atlanto-occipital dislocation in children. J Bone Joint Surg 2005;87A:2480–2488.


Trauma: Cervical Spine—C1 Fractures


FIGURE 3-9 Jefferson fracture. (A) Mechanism of injury for Jefferson fractures. (B) AP open-mouth odontoid view shows displacement of the lateral masses outward (arrows). (C) The extent of injury is best appreciated on the axial CT image.


Hyperextension injury C1. Lateral radiograph of the upper cervical
spine demonstrates an avulsion fracture of the anterior arch of C1 (arrow).
Suggested Reading
Harris JH, Mirvis SE. The radiology of acute cervical spine trauma. 3rd ed. Baltimore: Williams and Wilkins; 1996:340–366.
Jackson RS, Banit DM, Rhyne AL, et al. Upper cervical spine injuries. J Am Acad Orthop Surg 2002;10:271–280.


Trauma: Cervical Spine—Atlantoaxial Dislocations


FIGURE 3-11 (A)
Lateral radiograph of the upper cervical spine demonstrates anterior
subluxation of C1 on C2. Odontoid-C1 and posterior arch relationships (dotted lines). (B) Axial CT image demonstrates an anterior arch fracture (arrow) and avulsion (arrowhead) of the transverse ligament.


FIGURE 3-12 Rotary subluxation/fixation. Skeletal specimens with metal markers on the C2 facet demonstrating normal (A) and rotary fixation (B) of C1 on C2. Axial (C) and three-dimensional reconstruction images (D) show rotary fixation. The position of C2 (line). O, odontoid.
Suggested Reading
Fielding JW, Hawkins RJ. Atlantoaxial rotary fixation. J Bone Joint Surg 1977;57A:37–44.
Neumann U, Urbanski H, Riedel K. Posterior atlantoaxial dislocation without fracture of the odontoid. J Bone Joint Surg 2003;85A:1343–1346.


Trauma: Cervical Spine—Axis (C2)
Location Incidence (%)
Odontoid 41
Hangman’s 38
Anterior inferior body 13
Lamina, spinous process 8
Type Incidence (%) Complications
I, odontoid tip 8 None
II, odontoid base 59 Nonunion 54%–67%
Neurologic 20%
III, below odontoid 33 Nonunion in 40% if displaced >5 mm



FIGURE 3-13 (A) Odontoid fracture classification: Type I—odontoid tip; Type II—odontoid base, above accessory ligament and vascular supply (arrows); and Type III—extend into body below vascular supply. (B) Sagittal reformatted CT image of a Type II odontoid fracture not evident on radiographs. Coronal (C) and sagittal (D) reformatted CT images of a Type III odontoid fracture (arrows).
FIGURE 3-14 Hangman’s fracture with displacement of C2 on C3.


FIGURE 3-15 Anterior inferior body fracture of C2 (arrow).
Suggested Reading
Berquist TH. Imaging of orthopedic trauma. 2nd ed. New York: Raven Press; 1992:93–206.
Jackson RS, Banit DM, Rhyne AL, et al. Upper cervical spine injuries. J Acad Orthop Surg 2002;10:271–280.


Trauma: Cervical Spine—Lower Cervical Spine: Vertebral Arch Fractures


FIGURE 3-16 CT image of a facet fracture (arrow). There is also a fracture through the foramen transversarium (arrowheads).


FIGURE 3-17 Sagittal CT image of a C5 facet fracture (arrow).


FIGURE 3-18 Spinous process fracture at C7 (Clay shoveler’s fracture). (A) AP view shows a double spinous process (arrows). This is a helpful sign as the lower cervical spine is often difficult to visualize on the lateral view. (B) Lateral view shows the C7 spinous process fracture clearly in this case.
Suggested Reading
Berquist TH. Imaging of adult cervical spine trauma. Radiographics 1988;8:667–694.
Harris JH, Mirvis SE. The radiology of acute cervical spine trauma. 3rd ed. Baltimore: Williams and Wilkins; 1996:408–419.


Trauma: Cervical Spine—Lower Cervical Spine: Vertebral Body Fractures
Type Mechanism of Injury Comments
Chip fractures Hyperextension (anterior inferior body)
Hyperflexion (anterior superior body)
Usually stable
Teardrop fractures Hyperflexion neurologic injury Quadriplegia in 87%
Hyperextension C2 most common
Compression fracture Flexion-compression Look for posterior soft tissue injuries
Lateral wedge, uncinate process Asymmetric vertical compression
Burst fractures Vertical compression CT to assess spinal canal
CT, computed tomography.


FIGURE 3-19 Flexion compression injury with compression of C7 and an anterior chip fracture (open arrow). There is widening of the interspinous distance (arrow) indicating posterior ligament injury and instability.


FIGURE 3-20 Teardrop fractures. (A) Hyperextension teardrop of C4. Note the posterior arch fractures of C2 and C3 (arrows) indicating the mechanism of injury. (B) Hyperflexion teardrop fracture of C5 with compromise of the spinal canal (dotted lines) and posterior ligament tears (double arrow).


FIGURE 3-21 Burst fracture. Axial (A) and reformatted sagittal (B) CT images show the fragments (arrow) and narrowing of the spinal canal.


Suggested Reading
Berquist TH. Imaging of orthopedic trauma. 2nd ed. New York: Raven Press; 1992:93–206.
B, Waxmann K, Jones T, et al. Cervical spine clearance in blunt trauma:
Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179–183.


Trauma: Cervical Spine—Lower Cervical Spine: Subluxation, Fracture/Dislocation
FIGURE 3-22 Flexion distraction injury with posterior ligament tear at C5–C6. Flexion (A) and extension (B)
views show subluxation and widening of the interspinous distance and
facet joints with flexion that reduces with extension.
Treatment-posterior fusion.


FIGURE 3-23 Unilateral locked facet. (A) AP radiograph shows disc space asymmetry (arrow) at C4–C5 and rotation of the spinous process. (B) Lateral view shows subluxation, and the C4 facets form the “bow-tie” sign. (C) Oblique view shows the facet overlap (arrow).


FIGURE 3-24 Sagittally reformatted CT images of locked (A) and perched (B) facets (arrow).


FIGURE 3-25 Lateral radiograph demonstrates bilateral locked facets at C5–C6 with a chip fracture (arrow)
of C6. Subluxation with bilateral locked facets must be equal or
greater than 50%. Quadriplegia occurs in 72% of patients with this
Suggested Reading
Harris JH, Mirvis SE. The radiology of acute cervical spine trauma. 3rd ed. Baltimore: Williams and Wilkins; 1996:270–276, 291–304.
Scher AT. Anterior cervical subluxation. An unstable position. AJR Am J Roentgenol 1979;133:275–280.


Trauma: Thoracolumbar Spine—Basic Concepts


FIGURE 3-26 (A)
Lateral radiographs demonstrating the three columns proposed by Denis.
Anterior-anterior longitudinal ligament, anterior disc, and vertebral
body. Middle-posterior disc, body, and posterior longitudinal ligament.
Posterior-facet joints, ligamentum flavum, interspinous, and
supraspinous ligaments. (B) Lateral radiograph shows mild compression of L1 (arrow) with splitting of the neural arch (curved arrow) caused by hyperflexion distraction injury. Unstable with three-column involvement.
Suggested Reading
Denis F. The three-column spine and its significance in classification of thoraco-lumbar spinal injuries. Spine 1983;8:817–831.
HM, Kim HS, Suk KS, et al. Reliability of magnetic resonance imaging in
detecting posterior ligament complex injuries in thoracolumbar spinal
fractures. Spine 2000;25:2079–2084.
M, Moushine E, Theumann N, et al. Thoracolumbar spine fractures in
patients who have sustained severe trauma: Depiction with multidector
row CT. Radiology 2003;227:681–689.


Trauma: Thoracolumbar Spine—Hyperflexion Injuries



FIGURE 3-27 Anterior wedge fractures. Normal anterior and posterior cortical lines of the lumbar (A) and thoracic (B)
vertebral bodies. The lumbar vertebral body is concave anteriorly and
posteriorly, and the thoracic vertebral body is concave anteriorly and
straight posteriorly. Lateral radiographs of mild anterior wedge
fractures of T3 and T4 (C) and T12–L2 (D). Note the anterior buckling of the cortex in (D) (arrowheads).
FIGURE 3-28 Lateral wedge fractures. Asymmetric compression of L3 (A) (arrow) and T5 (B) (broken lines).


FIGURE 3-29 (A) Lateral radiograph demonstrating a Chance fracture (flexion-distraction injury). There is only mild compression (arrow) of L1. (B) AP radiograph clearly demonstrates the fracture through the posterior elements (arrows).
Suggested Reading
Rogers LF. The roentgenographic appearance of transverse or chance fractures of the spine. The seat belt fracture. AJR Am J Roentgenol 1971;111:844–849.
Vialle LR, Vialle E. Thoracic spine fractures. Injury 2005;36:S-B65–S-B72.
KB, Khanne G, Vaccaro AR, et al. Assessment of two thoracolumbar
fracture classification systems used by multiple surgeons. J Bone Joint Surg 2005;87A:1423–1429.


Trauma: Thoracolumbar Spine—Flexion-Rotation Injuries
FIGURE 3-30 Lateral radiograph demonstrating separation of the L4–L5 facet joint (arrow) secondary to a flexion-rotation injury.


FIGURE 3-31 CT image demonstrating facet separation and neural arch fractures.
Suggested Reading
Manaster BJ, Osborne AG. CT patterns of facet dislocation at the thoracolumbar junction. AJR Am J Roentgenol 1987;148:335–340.


Trauma: Thoracolumbar Spine—Vertical Compression Injuries
FIGURE 3-32 T12 burst fracture. (A) AP radiograph demonstrates widening of the interpedicular distance (lines mark pedicles T11 to L1). (B) Lateral radiograph shows vertebral compression and posterior cortical convexity (broken lines).



FIGURE 3-33 Lower thoracic burst fracture. Reformatted sagittal (A) and coronal (B) CT images demonstrate vertebral compression with outward displacement of fragments on the coronal image (arrowheads) and posterior displaced fragments on the sagittal image (arrow). Axial image demonstrates displaced anterior fragments and posterior extension into the spinal canal (open arrow).
Suggested Reading
Atlas SW, Regenbogen V, Rogers LF, et al. The radiographic characterization of burst fractures of the spine. AJR Am J Roentgenol 1986;147:575–582.
Petersilge CA, Pathria MN, Emery SE, et al. Thoracolumbar burst fractures: Evaluation with MR imaging. Radiology 1995;194:49–54.


Trauma: Thoracolumbar Spine—Hyperextension Injuries
FIGURE 3-34 Lateral radiograph demonstrating an anterior-inferior fracture of L2 (arrow) caused by hyperextension injury.
Suggested Reading
Berquist TH. Imaging of orthopedic trauma. 2nd ed. New York: Raven Press; 1992:93–206.
Roaf A. A study of the mechanism of spinal injuries. J Bone Joint Surg 1960;42B:810–823.


Trauma: Thoracolumbar Spine—Shearing Injuries
FIGURE 3-35 AP radiograph of a transverse shearing fracture dislocation (arrow) of the thoracic spine.



FIGURE 3-36 Posterior dislocation. (A) AP radiographs demonstrating prominent paraspinal soft tissue swelling (arrowhead). (B) Lateral radiograph showing posterior dislocation (arrow) in the midthoracic spine. AP (C) and lateral (D) radiographs after Harrington rod instrumentation with sublaminar wire augmentation.
Suggested Reading
Berquist TH. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:109–215.
Holdsworth F. Fracture and fracture-dislocations of the spine. J Bone Joint Surg 1970;52A:1534–1551.


Trauma: Thoracolumbar Spine—Minor Fractures
FIGURE 3-37 AP radiograph of the lumbar spine demonstrating multiple transverse process fractures (arrows).
Suggested Reading
Berquist TH. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992:93–206.




FIGURE 3-38 Flexion (A) and extension (B)
radiographs demonstrating anterior subluxation of L5 on S1. The degree
of subluxation is determined by dividing the lower vertebral endplate
into four equal segments. Subluxation is graded 1 to 4. In this case,
it is Grade 1 and reduces slightly with extension.


FIGURE 3-39 Flexion (A) and extension (B)
radiographs of Grade 1–2 spondylolisthesis that increases with flexion.
At this level, the subluxation is most commonly the result of facet
degenerative disease.
FIGURE 3-40 (A) Lateral radiograph demonstrating a pars defect at L5 (arrow) with slight subluxation of L5 on S1. (B) Lateral radiograph shows Grade 2–3 subluxation caused by a pars defect (arrow). There is associated degenerative disc disease (curved arrow).


FIGURE 3-41 Sagittal reformatted CT images (A, B) of bilateral pars defects (arrow).
Suggested Reading
Horowitch A, Peck RD, Thomas JC, et al. The Wiltse pedicle screw fixation system. Spine 1989;14:461–467.
McTimoney CA, Micheli LJ. Current evaluation and management of spondylosis and spondylolisthesis. Curr Sports Med Rep 2003;2:41–46.
Wiltse LL, Neuman DH, MacNab I. Classification of spondylosis and spondylolisthesis. Clin Orthop 1976;117:23–29.


Scoliosis: Basic Concepts
Scoliosis: Imaging


Lippman-Cobb measurement. Lines are configured along the endplate or
pedicles of the upper and lower vertebrae maximally directed to the
concave side. Where these cross measures angles for large curves (L).
Perpendicular lines are drawn to the endplate lines for smaller
curves(s). Angle L = angles.
Rotational measurement. Neutral is spinous process midline (S).
Positive is rotation of the spinous process to the concave side and
negative to the convex side graded 1 to 4.


FIGURE 3-44 Standing AP (A) and lateral (B) radiographs after reduction with rods and hooks.


FIGURE 3-45 Lateral radiograph with fractured Luque rods (arrow) after treatment with rods and sublaminar wires.
Suggested Reading
Busch CH, Kalen V. Three-dimensional computed tomography in assessment of congenital scoliosis. Skel Radiol 1999;28:632–637.
Helenius I, Remes V, Yrjonen T, et al. Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis. J Bone Joint Surg 2003;85A:2303–2309.
McAlister WH, Shackelford GD. Measurement of spinal curvatures. Radiol Clin North Am 1975;13:113–121.


Degenerative Disc Disease
Lateral radiograph of the lumbar spine demonstrates prominent
osteophytes and vacuum disc phenomenon at L2–L5 levels. There is loss
of the lumbar lordotic curve.


FIGURE 3-47 Type I endplate changes. Sagittal T1-weighted (A) and T2-weighted (B) images demonstrate decreased signal relative to marrow on T1-weighted (A) and increased signal on T2-weighted (B) images.



FIGURE 3-48 Type II endplate changes. Sagittal T1-weighted (A) and T2-weighted (B) images demonstrate increased signal relative to marrow on both T1- and T2-weighted sequences.


FIGURE 3-49 Type III endplate changes. Decreased signal (arrows) seen on both T1-weighted (A) and T2-weighted (B) images.
Suggested Reading
Modic MT, Steinberg PM, Ross JS, et al. Degenerative disc disease: Assessment of changes in vertebral marrow with MR imaging. Radiology 1988;166:193–199.


Disc Herniation
FIGURE 3-50 Disc bulge, protrusion, extrusion, and sequestration based on consensus terminology. (From

Witte RJ, Lane JI, Miller GM, et al. Spine. In: Berquist TH, ed. MRI of the musculoskeletal system. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:121–202.)


FIGURE 3-51 Lumbar disc bulge at L3–4. Sagittal T1-weighted (A) and axial (B) T2-weighted images demonstrate broad-based bulging of the posterior annulus (arrowhead). The normal disc contour at L3–4 would be slightly concave.


FIGURE 3-52 Lumbar disc protrusion at L4–5. Axial (A)
T2-weighted image demonstrates a focal left posterolateral disc
protrusion flattening the left ventral lateral aspect of the thecal sac
(arrow). On the sagittal image (B) there is a focus of increased T2 signal intensity in the posterior annulus (arrow) compatible with an annular tear.


FIGURE 3-53 Lumbar disc extrusion. T1-weighted image showing a lateral fragment (arrow) displacing the exiting L4 nerve root and probably contacting the L5 nerve root.


FIGURE 3-54 Lumbar disc sequestration. Sagittal T2-weighted (A) image demonstrates a rounded focal 1-cm region of soft tissue signal intensity posterior to the upper L5 vertebral body (arrows) separate from the parent disc. Axial T1-weighted (B) image demonstrates disc material in the left lateral recess of L5 (arrows).
Suggested Reading
JR, Whittemore AR, Bradley WE. Anatomic basis of vertebrogenic pain and
autonomic syndrome associated with lumbar disc extrusion. AJNR Am J Neuroradiol 1989;10:219–231.
D, Zanetti M, Hodler J, et al. MR imaging of the lumbar spine.
Prevalence of intervertebral disc extrusion and sequestration, nerve
root compression, end plate abnormalities and osteoarthritis of the
facet joints in asymptomatic volunteers. Radiology 1998;209:661–666.


Synovial Cysts
FIGURE 3-55 Synovial cyst. Axial T2-weighted (A) and postcontrast-enhanced T1-weighted (B) images showing a cyst extending from the L4 facet compressing the dural sac. Note the wall of the cyst enhances with contrast (B). (From

Witte RH, Miller GM. Spine. In: Berquist TH, ed. MRI of the musculoskeletal system. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:105–194.


Suggested Reading
Krauss WE, Atkinson JLD, Miller GM. Juxtafacet cysts of the cervical spine. Neurosurgery 1998;43:1363–1368.
R, Geborski S, Brunberg J, et al. Lumbar synovial cysts. Correlation of
myelographic CT, MR, and pathologic finding. AJNR Am J Neuroradiol 1990;11:777–779.


Infection (Infectious Spondylitis)


FIGURE 3-56 Discitis. Lateral radiograph shows loss of disc height and early endplate irregularity at L1–2 (arrow). Note the normal disc below.


FIGURE 3-57 Postoperative lumbar disc space infection and osteomyelitis. (A) Sagittal CT scout image shows rod and pedicle screw instrumentation L3–L5. The L2–L3 endplates (arrow) are indistinct. Sagittal T1-weighted (B) and T2-weighted (C) images demonstrate loss of the endplates (open arrows) and increased signal intensity (white arrow) in the disc on the T2-weighted image (C). Note the minimal metal artifact (black arrows).


FIGURE 3-58 Tuberculous spondylitis in the thoracic spine. Sagittal T1-weighted (A) and T2-weighted (B) images demonstrate disc space loss and vertebral compression with paravertebral soft tissue extension (arrows). Off-axis sagittal image (C) shows a large multiloculated paraspinal abscess.


Suggested Reading
Jung NY, Jee WH, Ha KY, et al. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol 2004;182:1405–1410.
Stabler A, Reiser MF. Imaging of spinal infections. Radiol Clin North Am 2001;39:115–135.




FIGURE 3-59 Ankylosing spondylitis. (A) AP radiograph or the lumbar spine and sacroiliac joints. Note the smooth symmetric syndesmophytes (arrows). (B) Lateral radiograph of the lower thoracic spine shows smooth ossification of the anterior longitudinal ligament.
FIGURE 3-60 Lateral radiograph of the cervical spine demonstrating marginal osteophytes at C6–7 and a nonmarginal osteophyte at C5 (arrow).


Psoriatic arthritis. AP radiograph of the lumbar spine demonstrating
prominent asymmetric upper lumbar osteophytes. There is also asymmetric
sacroiliac joint involvement.
FIGURE 3-62 DISH. Lateral view of the lumbar spine with prominent contiguous osteophytes and normal disc spaces.


Rheumatoid arthritis. Sagittal T1-weighted MR image shows the odontoid
projecting upward behind the clivus compressing the cord against the
arch of C1 (arrowhead).
Suggested Reading
Brower AC. Arthritis in black and white, 2nd ed. Philadelphia: WB Saunders; 1997:175–191.


Tumors and Tumorlike Conditions: Bone Lesions
FIGURE 3-64 Sagittal T1-weighted images of the lumbar spine in a patient with lung metastasis (A) and marrow involvement in a patient with multiple myeloma (B). Note the multiple of low signal intensity (arrows) in (A). There is marrow replacement with only a small amount of fatty marrow (arrows) in (B).


FIGURE 3-65 Aneurysmal bone cyst. (A) Lateral radiograph demonstrates a well-defined lytic area in the C3 spinous process (arrow). (B) CT image shows the extent of the lesion with bone expansion, blood attenuation levels, and compression (arrow) of the dural sac.


FIGURE 3-66 Spinal chordoma. (A)
Lateral radiograph shows sclerosis and compression of L1 (15% of
chordomas involve the spine, 50% involve the sacrum, 30% to 70% may
calcify). Sagittal T1-weighted (B) and T2-weighted (C) and axial contrast-enhanced image (D) demonstrate extension of tumor from L1 to L2 with extension around the dural sac.
Suggested Reading
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases, 5th ed. Philadelphia: Lippincott-Raven; 1996.


Tumors and Tumorlike Conditions: Soft Tissue Masses


FIGURE 3-67 Neurofibroma. Oblique radiographs of the cervical spine show normal foramina in (A) and marked expansion in (B) (arrow). Coronal MR image (C) demonstrates a large neurofibroma extending through the foramen and displacing the cord.


FIGURE 3-68 Ependymoma. (A) Proton density-weighted sagittal image shows a well-defined intradural mass separate from the conus (curved arrow). (B)
Large mass in a different patient arising from the filum terminale on
enhanced T1-weighted image. There is a second smaller metastatic lesion
(arrow) distally.
Suggested Reading
Weiss SW, Goldblum JR. Enzinger and Weiss’s soft tissue tumors. 4th ed. St. Louis: Mosby; 2001.
Witte RJ, Lane JI, Miller GM, et al. Spine. In: Berquist TH. MRI of the musculoskeletal system. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:121–202.


Congenital Anomalies
Congenital Anomalies: Spinal Dysraphism


FIGURE 3-69 Diastematomyelia. Sagittal (A) and axial (B, C) fast SE T2-weighted images demonstrate diastematomyelia (arrow) with splitting of the cord at L2–L3. There is associated tethered cord with the tip (open arrow) at the conus at L4. There is also syringohydromyelia at T12–L1 (arrowhead) and spina bifida occulta at L5 (white arrow).


FIGURE 3-70 Tethered cord with lipoma in a 14-month-old child. Sagittal T1-weighted image shows the conus as the L3 interspace (arrow) and an intraspinal lipoma (open arrows) that communicates with the subcutaneous fat.
Suggested Reading
Altman NR, Altman DH. MR imaging of spinal dysraphism. AJNR Am J Neuroradiol 1987;8:533–538.


Congenital Anomalies: Caudal Regression Syndrome
Sacral agenesis. Sagittal fast SE T2-weighted image showing sacral and
coccygeal agenesis with a tethered cord at L3–4 and central
syringohydromyelia (arrow).
Suggested Reading
Barkovich AJ, Raghavan N, Chuang S, et al. The wedge-shaped conus terminus: A radiographic sign of caudal regression. AJNR Am J Neuroradiol 1989;10:1223–1231.


Congenital Anomalies: Chiari Malformation
FIGURE 3-72 Type I Chiari malformation. Sagittal T1-weighted MR image showing the cerebellar tonsils below the foramen magnum (short black arrow) with a large syrinx (double arrows). (From

Witte RJ, Miler GM. Spine. In: Berquist TH, ed. MRI of the musculoskeletal system. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:103–194.



FIGURE 3-73 Type II Chiari malformation in a 14-month-old child. Sagittal T1-weighted images demonstrating hydrocephalus (A) with a small posterior fossa and downward herniation of the cerebellum and medulla (B).
Suggested Reading
El Gammal T, Marks EK, Brooks BS. MR imaging of Chiari II malformation. AJNR Am J Neuroradiol 1987;8:1037–1044.


Congenital Anomalies: Segmentation Anomalies
FIGURE 3-74 Butterfly vertebra. (A) AP radiograph of the spine demonstrating a butterfly vertebra at T10. (B) Axial CT image shows the midline segmentation of the vertebral body.


FIGURE 3-75 Klippel-Feil and Chiari Type I malformation. (A) Lateral radiograph of the cervical spine shows fusion of C2–C5. Sagittal T1-weighted (B) and T2-weighted (C) images in a different patient demonstrate approximately 15 mm of ectopia of the cerebellar tonsils through the foramen magnum (open arrows). Note the segmentation anomalies of C3–C5 (arrows) consistent with Klippel-Feil Syndrome and the basilar invagination (arrowhead).
Suggested Reading
Nokes SR, Murtagh FR, Jones JD III, et al. Childhood scoliosis. MR imaging. Radiology 1987;164:791–797.

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