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Head and neck radiology > Spine imaging > Flashcards

Spine imaging Flashcards

1
Q

results from compromise of the spinal cord itself, due to mechanical compression, intrinsic lesions or inflammatory processes loosely grouped under the term “myelitis”. classic symptoms include bowel and bladder incontinence, spasticity, weakness and ataxia

A

myelopathy

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2
Q

true or false: myelopathy often presents without a clear sensory level. In such cases screening of the cord from the cervicomedullary junction of the conus is required

A

true

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3
Q

true or false: spinal cord is less tolerant of injury than the brain due to the small diameter of the spinal canal, resulting in permanent paralysis

A

true

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4
Q

acute myelopathy is an emergency, because

A

after 24 hours of acute severe cord compression, chances of full recovery are significantly diminished

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5
Q

due to the impingement or irritation of the spinal nerves within the spinal canal, lateral recess, neural foramen, or along the extraforaminal course of the nerve

A

radiculopathy

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6
Q

most common cause of radiculopathy are

A

disc herniations, spinal stenosis, and in the cervical spine, uncovertebral joint spurring

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7
Q

cause of myelopathy

A

spinal cord compromise

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8
Q

typical disease processes in myelopathy

A

extramedullary disease; cord compression due to epidural mass effect, cervical spinal stenosis, intramedullary disease: tumor, inflammation, AVMs, SDAVFs

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9
Q

ataxia, bowel and bladder incontinence and babinski sign are neurologic findings in

A

myelopathy

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10
Q

accuracy of clinical localization of spinal level in myelopathy

A

poor

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11
Q

urgency of imaging in myelopathy

A

high significant deficits may occur if severe compression untreated > 24 hours

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12
Q

preferred imaging modality for myelopathy

A

MR

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13
Q

cause of radiculopathy

A

spinal nerve compromise

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14
Q

osteophytic spurring (esp cervical spine), disc herniations, lumbar spinal stenosis, extramedullary and paraspinous tumors and inflammatory processes compromising nerve root may present with

A

radiculopathy

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15
Q

weakness and diminished reflexes in specific muscle groups, dermatomal sensory deficits are seen in

A

radiculopathy

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16
Q

true or false: accuracy of clinical localization in radiculopathy is quite good

A

true

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17
Q

urgency for imaging of acute presentations of radiculopathy

A

low-short delay for conservative tx usually entails little risk

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18
Q

preferred imaging modality for radiculopathy

A

CT, especially with intrathecal contrast is still excellent, particularly in cervical spine

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19
Q

flexion and extension plain films are helpful for the assessment of

A

spine stability in spondylolisthesis

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20
Q

in nondegenerative disease, pay careful attention to the integrity of the ____ because its a frequent site of metastasis

A

pedicles

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21
Q

this imaging modality is used in complex postoperative cases and patients in whom MR is contraindicated due to incompatible implanted device

A

myelography in conjunction with CT

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22
Q

True or false: ionic contrast agents are absolutely contraindicated for myelography

A

true; as they can result in severe inflammation, seizures, arachnoiditis and even death

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23
Q

in myelography, intrathecal iodine should not exceed

A

3 g

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24
Q

preferred puncture site in myelography

A

midlumbar region, inferior to the posterior elements of L2 or L3

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25
Q

complications of poor needle placement in myelography include

A

subdural and epidural injection

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26
Q

intradural, intramedullary masses include

A

ependymoma, astrocytoma, hemangioblastoma, lipoma/epidermoid, syringohydromyelia, intramedullary AVM

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27
Q

intradural, extramedullary masses include

A

meningioma, schwannoma/neurinoma, neurofibroma, hemangiopericytoma, lipoma/epidermoid, arachnoid cyst, adhesions, drop/leptomeningeal mets, extramedullary AVM

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28
Q

degenerative causes of an extradural impression in the spinal cord

A

herniated disc, synovial cyst, osteophyte, rheumatoid pannus

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29
Q

nondegenerative causes of extradural impression in the spinal cord

A

metastasis, abscess, hematoma, primary tumor expansion or invasion, epidural lipomatosis

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30
Q

this MR sequence can help differentiate tumor from fracture zones

A

DWI– tumors show restricted diffusion

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31
Q

when both clinical and pathologic findings pinpoint a distinct spinal level, the term ____ may be used

A

transverse myelitis

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32
Q

most common spinal cord “inflammatory” disorder and by far the most freq cause of intramedullary lesions seen on MR

A

Multiple sclerosis

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33
Q

true or false: when spinal MS predominates, it tends to follow a progressive clinical course, as opposed to the relapsing/remitting pattern more characteristic with brain involvement

A

true

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34
Q

an autoimmune disorder affecting the spinal cord and optic nerves. the spinal cord lesions are longer than in MS, and the brain is often spared

A

Devic disease or neuromyelitis optica (NMO)

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35
Q

specific test of NMO is

A

NMO IgG antibody, which targets the aquaporin 4 protein of astrocytes

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36
Q

in this autoimmune condition, necrotizing arteritis leads to cord ischemia and injury

A

lupus erythematosus

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37
Q

these have less well-defined margins that discrete plaques of MS and may involve the cord over 4 to 5 VB segments

A

SLE lesions

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38
Q

collagen-vascular disease that can compromise the spinal cord, although the mechanisms are different. focal inflammatory change termed “pannus” destroys the transverse ligament of C1, allowing the odontoid to slide posteriorly relative to C1. this leads to cord compression, particularly in flexion

A

Rheumatoid arthritis

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39
Q

neurologic injury in RA is due to ______ rather than a primary intramedullary lesion. this then leads in time to myelomalacia

A

atlantoaxial instability

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40
Q

shows the classic “bamboo spine” due to extensive bridging of syndesmophytes across multiple vertebral bodies. spine is prone to fracture with even mild trauma due to loss of flexibility

A

Ankylosing spondylitis

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41
Q

this viral infection can cause cord swelling and enhancement, appearing as spinal levels corresponding to the dermatologic outbreak

A

Herpes zoster

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42
Q

this viral infection provokes an autoimmune reaction that can damage the cord, and is termed subacute sclerosing panencephalitis

A

measles

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43
Q

a progressive ascending motor weakness that affects more than one limb, but involves peripheral nerves rather than the spinal cord. this has been seen after vaccinations and evolves over a maximum of 4 weeks. often the spinal nerves enhance

A

acute inflammatory polyradiculoneuropathy (Guillain-Barre syndrome)

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44
Q

inflammatory conditions involving pia and arachnoid have a similar differential diagnosis whether they involve cerebral or spinal leptomeninges. this condition present as diffuse leptomeningeal granulomatous nodules which typically enhance

A

Neurosarcoidosis

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45
Q

most common cause of arachnoiditis are

A

iatrogenic

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46
Q

peak incidence of radiation myelitis is

A

6-12 months after initial tx

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47
Q

this peaks 6-12 months after initial radiation therapy tx, with affected areas demonstrating increased signal intensity on T2 with variable enhancement

A

Radiation myelitis

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48
Q

most common cause of spine infection in adults

A

staph aureus

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49
Q

cause of spine infection with sickle cell disease

A

Salmonella

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50
Q

true or false: in adults, the disc itself has a relatively poor blood supply, so primary infection is rare. in children however, arteries penetrate the growing disc, providing access for primary hematogeneous primary infection

A

true

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51
Q

once the arterial vessels on the disc from childhood involute, the most common spinal site of “seeding” is the

A

vertebral body, particularly near the end plates, which have the richest blood supply

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52
Q

osteolyelitis/discities complex is suspicous for

A

infection, unusual in neoplasms

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53
Q

it can be difficult, though to distinguish between degenerative endplate changes and early infection. this sign on DWI has been proposed as a useful discriminating sign

A

Claw sign

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54
Q

true or false: many epidural infections do not have the well-encapsulated “liquid” collections we associate with abscesses elsewhere in the body, and technically are better termed “epidural phlegmon”

A

true

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55
Q

true or false: epidural infections spread craniocaudally, extending as many as three to four interspaces away from any vertebral abnormality. such distanct extension is unusual with epidural tumor from metastatic neoplasms

A

true

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56
Q

this is typically due to direct hematogeneous seeding of the CSF, rather than contiguous spread of adjacent vertebral infection, unless there is a disruption of the leptomeninges on a congenital or acquired basis

A

meningitis

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57
Q

these are rare, and usually result of direct seeding of the cord from overwhelming sepsis

A

spinal cord abscesses

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58
Q

causes slow collapse of one or usually more vertebral bodies, spreading underneath the longitudinal ligament. result is acute kyphotic or “gibbus” deformity. this angulation, coupled with epidural granulation tissue and body fragments can lead to cord compression. unlike pyogenic infections, the discs can be preserved

A

Tb of spine or Pott’s disease

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59
Q

in late stages of spinal TB, large paraspinal abscesses without severe pain, frank pus, or fever, occur, leading to the expression of

A

“cold abscess”

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60
Q

number of vertebrae afftected in infectious process

A

usually atleast 2 vertebrae around an affected disc (pyogenic) or intact disc with subligamentous spread (Tb or fungus)

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61
Q

portions of vertebrae affected in infectious process

A

destruction greatest at endplates, posterior elements relatively spared. abnormal marrow signal centered around disc in osteomyelitis/discitis complex

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62
Q

marrow signal changes in infectious process

A

dec on T1, inc on T2, normal diffusion, abnormal marrow signal centered around disc in osteomyelitis/discitis complex

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63
Q

disc integrity in infectious process

A

pyogenic: disc involved and enhances; nonpyogenic: disc may be spared

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64
Q

epidural component in infectious process

A

granulation tissue (best seen post-gad), extends several levels above and below the affected vertebrae

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65
Q

True or false: discogenic vertebral sclerosis can mimic the osteomyelitis complex on T1 (but not on enhanced scans)

A

true

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66
Q

number of vertebrae affected and pattern in neoplasm

A

isolated or noncontiguous involvement common

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67
Q

portions of vertebra affected in neoplasm

A

irregular vertebral body involvement, pedicles typically affected, entire vertebra often infiltrated

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68
Q

marrow signal in neoplasm

A

dec on T1, inc on T2, restricted diffusion due to “marrow packing”, entire vertebral body usually infiltrated with pathologic compression fracture

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69
Q

disc integrity in neoplasm

A

spared (prostate cancer an exception)

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70
Q

epidural component in neoplasm

A

focal mass usually on at level of affected vertebra/e, lymphoma an exception, with more extensive epidural mass

71
Q

number of vertebrae affected and pattern in osteoporosis

A

several, showing loss of height to varying degrees

72
Q

portions of vertebral affected in osteoporosis

A

anterior wedge deformity of VB, posterior elements spared, portions of VB retain normal marrow even with acute compression fracture

73
Q

marrow signal in osteoporosis

A

T1 and T2 normal (unless with fx), diffusion may be increased at fracture plane, portions of VB retain normal marrow even with acute compression fracture

74
Q

disc integrity in osteoporosis

A

discs spared

75
Q

epidural component in osteoporosis

A

rare, unless acute fracture with hematoma, or retropulsion of fragments

76
Q

these fungal infections may mimic metastatic tumor in the spine

A

candida and aspergillus

77
Q

true or false: coccidiotomycosis, like TB, spares the disc

A

true

78
Q

true or false: blastomycosis like actinomycosis, can destroy the discs and ribs

A

true

79
Q

this viral infection destroys the anterior horn cells directly

A

poliomyelitis

80
Q

myelopathy is seen in this viral infection with vacoular changes in the spinal cord

A

AIDS

81
Q

this constitute 25% of all intraspinal lesions in adults, but are rare in children

A

meningioma

82
Q

aside from poliomyelitis, this condition also affects the anterior horn cells

A

amyotrophic lateral sclerosis

83
Q

two most common primary intramedullary tumors. both are expansile, low in signal intensity on T1, bright on T2, with variable enhancement. both have increased incidence in neurofibromatosis

A

astrocytomas and ependymomas

84
Q

primary intramedullary tumor that has longer cord segments favors

A

astrocytoma

85
Q

primary intramedullary tumor that has cysts and hemorrhage favors

A

ependymoma

86
Q

most common spinal cord tumor in adults. they can be divided into cellular (intramedullary) and myxopapillary (filum terminale) types

A

ependymomas

87
Q

true or false: spinal ependymomas are genetically and epidemiologically different from intracranial types

A

true

88
Q

these are slow-growing neoplasms arise from ependymal cells lining the central canal of the cord or ependymal cell rests along the filum

A

ependymomas

89
Q

tx for spinal ependymomas

A

resection

90
Q

spinal astrocytomas occur in the

A

cervical and upper to midthoracic cord

91
Q

in this intramedullary tumor, there is fusiform cord widening, hyperintensity on T2 and contrast enhancement often extend over several vertebral body segments

A

astrocytoma

92
Q

true or false: spinal astrocytomas have lower histologic grade than astrocytomas in the brain

A

true

93
Q

most common spinal cord tumor in children, with peak incidence in the third decade, younger than for ependymomas. they may be exphytic, and at times may even appear largely extramedullary

A

astrocytoma

94
Q

it occurs in the spine as well as the posterior fossa, both types have a high association with von Hippel-Lindau syndrome. these rare tumors, with their characteristic densely enhancing nidus, represent 2% of the intraspinal neoplasms. 40% are extramedullay and 20% are multiple. it may be mistaken for an AVM

A

hemangioblastomas

95
Q

how to differentiate AVM versus hemangioblastoms

A

intramedullary AVM typically do not show related cyst, cord expansion or a non-vascular enhancing nodule

96
Q

refers to dilation of the central canal of the spinal cord, which is lined by ependyma.

A

syringohydromyelia/hydromyelia

97
Q

a cavity outside the central canal lined by glial cells

A

syringomyelia

98
Q

criteria for a syrinx cavity

A

well-defined margins and its contents should follow CSF signal intensity

99
Q

if the “syrinx” borders are indistinct and the signal is brighter than CSF on T1 and darker than CSF on T2, you may be dealing with severe central cord edema or ____ which is related to obstruction of CSF flow

A

“presyrinx”

100
Q

most common intradural tumor in the thoracic region and represents roughly 25% of all adult intraspinal tumors. most common in women with an average age of 45

A

meningioma

101
Q

usual location of meningioma

A

extramedullary-intradural

102
Q

main differential in spinal meningioma, which often will extend out through a neural foramen, and lacks a broad dural base. they are also less vascularized than meningioma, so may undergo cystic necrosis and often extend out the neural foramina

A

schwannoma

103
Q

most common intraspinal masses

A

nerve sheath tumors such as schwannomas and neurofibromas

104
Q

spinal schwannomas usually originate from the

A

dorsal nerve roots

105
Q

frequent finding in spinal schwannomas in the cervical and thoracic regions

A

extension into the neural foramen

106
Q

part of this tumor will be intraspinal, and part will be extraspinal, with the waist at the often-expanded bony neural foramen, giving the classic “dumbbell” appearance

A

schwannoma

107
Q

spinal neurofibromas may show what associated finding in the spine

A

dural ectasia

108
Q

classic cause of spinal intradural-extramedullary metastases is

A

subarachnoid seeding of primary CNS neoplasms, typically medulloblastomas, ependymomas and germ cell tumors. tumor cells exfoliate into the CSF and “drop” down into the spinal canal, implant on pia, and grow into small nodules, giving rise to the term drop metastasis

109
Q

malignancy that has the highest rate of infiltration of the meninges of any non-CNS tumor

A

leukemia

110
Q

this can cause considerable inflammation, and patients can present with signs of meningeal irritation, leading to the term “carcinomatous meningitis”. they appear classically as multiple intradural nodules, usually adherent to the pial reflections, best seen after gadolinium

A

Leptomeningeal metastases

111
Q

differential diagnosis of thicekend leptomeninges includes

A

carcinomatous and infectious meningitis, postinfectious states such as Guillain-Barre, granulomatous diseases and inflammatory arachnoiditis in postoperative patients

112
Q

second most common cause of extradural mass, after disc herniations and other degenerative processes

A

neoplasm

113
Q

most common extradural masses are

A

metastases

114
Q

most metastases, like infection, reach the vertebrae via

A

arterial seeding

115
Q

prostate carcinoma may preferentially ascend to the lumbar region via

A

Batson venous plexus

116
Q

appearance of spinal metastasis in MR

A

low signal on T1, high SI on T2 and STIR, diffusion restriction, because of their higher water content as compared with fat

117
Q

this neoplasms can “stealthily” involve the spinal canal, infiltrating through the neural foramina

A

round cell tumors such as lymphoma in adults and neuroblastoma in children

118
Q

leukemia change the appearance of the vertebrae in a characteristic fashion

A

diffuse, even replacement of the marrow with tumor

119
Q

solid leukemic infiltrates aka ____, can involve the epidural space and cause cord compression

A

chloromas

120
Q

can present as a diffuse and homogeneous low signal in the spine on T1, but more typically shows multiple focal defects

A

multiple myeloma

121
Q

differential diagnosis for vertebral plana or totally collapsed vertebral body

A

solitary plasmacytomas, eosinophilic granuloma, leukemia and severe osteoporosis

122
Q

true or false: multiple myeloma are missed in technetium bonse scans because they are often “indolent” metabolically. MR is the screening of choice for myeloma patients

A

true

123
Q

this is a rare scenario wherein a patient who became paralyzed after major thoracic surgery, such as repair of a thoracic aortic aneuryms. this condition may be suspected

A

spinal stroke

124
Q

spinal stroke will appear what in MRI

A

just like brain infarcts, bright on T2 and DWI, followed by development of myelomalacia

125
Q

true or false: cavernous malformations of the spinal cord are more dangerous due to lack of plasticity, and even a small hemorrhage can be devastating

A

true

126
Q

intramedullary AVMs have a congenital nidus of abnormal vesels within the cord substance, which cause symptoms by hemorrhage or ischemia, because of ____

A

steal phenomenon

127
Q

they are congenital spinal AVMs that can grow as vessels dilate and typically present in young patients with hemorrhage, leading to acute paraparesis

A

Intramedullary AVMs

128
Q

this is a classic lesion of extramedullary AVM, with a direct connection between an artery and vein without an intervening nidus of congenitally abnormal vasculature

A

spinal dural arteriovenous fistula (SDAVF)

129
Q

SDAVF cause symptoms through venous hypertension and congestion of cord with edema due to this process

A

direct arterial inflow into the local venous system through the fistula, undamped by the resistance of a capillary bed, raises pressure within the coronal venous plexus draining the spinal cord which is valveless

130
Q

houses the vertebral artery

A

foramen transversaria

131
Q

true or false: spinal cord contusions may occur in the absence of spinal fractures, because of hyperflexion or hyperextension, resulting in myelopathy

A

true

132
Q

true or false: subdural hematomas are rare in the spine, while epidural hematomas are far more common

A

true

133
Q

most posttraumatic bleeding in the spine are arterial or venous?

A

venous

134
Q

most common site for root avulsion in the spine is

A

cervical spine, probably because of its wide range of motion during accidents

135
Q

nerves typically affected in cervical spine root avulsion

A

brachial plexus and upper extremities are typically affected

136
Q

one of the classic causes of nerve root avulsion at the cervicothoracic junction in newborns, which can result in an Erb palsy on the affected side

A

birth trauma, typically traction on the shoulder

137
Q

degenerated discs appear what on MR

A

low SI on T2

138
Q

annular fiber disruption are show in MR as

A

high SI on T2

139
Q

this has been associated with internal disc derangement , which may be a cause of axial back pain, and surgeons may perform discectomy with spinal fushion for tx of IDD

A

“high-intensity zone”

140
Q

defined as a localized or focal displacement of disc material involving less than 25% of the periphery of the disc as viewed in axial plain

A

disc herniation

141
Q

it involves greater than 25% of the circumference of the disc, and may result from disc degeneration, ligamentous laxity, or bony remodelling

A

disc bulge

142
Q

true or false: mild disc bulging at L5-S1 <2 mm is considered a normal variant

A

true

143
Q

defined as displaced disc material extending beyond less than 25% of the disc space, with the greatest measure in any plane being less than the measure of the base. it has a broad base at its origin, and does not extend above or below the level of the disc in the sagittal plane

A

disc protrusion

144
Q

defined as a herniation where the greatest measure of the herniated material is greater than the base at the site of origin. any disc herniation extending above or below the disc space level should be called this type of herniation

A

disc extrusion

145
Q

the presence of extrusion, as the name implies that there is an

A

annular disruption

146
Q

extrusion are subclassified as ____ if the displaced disc material has lost continuity with the parent disc

A

sequestration

147
Q

this term signifies displacement of the herniated disc material away from the site of the extrusion

A

migration

148
Q

location of disc herniation include

A

central, subarticular, foraminal, extraforaminal and anterior

149
Q

herniated discs in the craniocaudal direction through a gap in the vertebral body endplate are referred to as intravertebral herniation or

A

“Schmorl nodes”

150
Q

enroachment of the bony or soft tissue structures of the spine on one or more of the neural elements, with resulting symptoms

A

spinal stenosis

151
Q

classification of stenosis based on anatomy

A

central canal, lateral recess and neural foramen

152
Q

lateral herniation or bulge in L4-L5 disc affects what nerve root

A

L4

153
Q

posterior disc herniation or bulge in L4-5 affects what nerve root

A

L5

154
Q

most common cause of central canal stenosis is ____, this is also the most common cause of lateral recess stenosis

A

degenerative disease of the facets, with bony arthritis that enroaches on the central canal

155
Q

most common cause of neural foramen stenosis

A

DSD of the facets

156
Q

in the cervical spine, these joints develop degenerative spurs that narrow the foramina anteromedially. these joints are not present in the thoracic and lumbar spine

A

uncovertebral joints (which help stabilize the vertebrae)

157
Q

these are bony canals in which the nerve roots lie after they leave the thecal sac and before they enter the neural foramen

A

lateral recesses

158
Q

most common cause of enroachment on the lateral recesses

A

arthritic spurs of the superior articular facet from DJD

159
Q

these are defects in the bony pars interarticularis, and are found in up to 10% of asymptomatic indivduals, and can be seen on oblique plain films. they can be a source of low back pain and instability

A

spondylolysis

160
Q

neck of Scotty dog represents the

A

pars interarticularis

161
Q

imaging of choice to detect spondylolysis

A

CT

162
Q

on axial images through the midvertebral body, it appears as a break in the normally intact bony ring of the lamina

A

sponylolysis

163
Q

refers to forward displacement of one vertebral body on a lower one, occurs from either slippage of 2 vertebral bodies following bilateral spondylolysis or from DJD of the facets with slippage of the facets

A

spondylolisthesis

164
Q

spondylolisthesis is most common at what levels

A

L4-5 and L5-S1

165
Q

modic type: dark on T1, bright on T2

A

modic type 1- fibrovascular ingrowth (increased fluid)

166
Q

modic type: bright on T1, bright on T2

A

modic type 2- fatty change, chronic irritation

167
Q

modic type: dark on T1, dark on T2

A

modic type 3- sclerotic change (end stage)

168
Q

endplate marrow changes are categorized by

A

modic types

169
Q

spondylolisthesis is grades by

A

Meyerding grading scale

170
Q

is a common and often unrecognized source of back pain. facet synovitis may be associated with facet effusions. this can be treated with radiofrequency facet denervation of the medial branches of the sinuvertebral nerves, which supply the facet joints

A

facet disease

171
Q

synovial cyst may be a complication of

A

facet disease

172
Q

synovial cysts are most commonly seen in the

A

lumbar spine

173
Q

tx of synovial cyst

A

minimally invasive image-guided injection into the adjacent facet jpint or directly into the cyst, which may result in cyst rupture in up to one-third of cases

Head and neck radiology (15 decks)

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