MRI OF THE CERVICAL SPINE

[Pages:62]MRI OF THE CERVICAL SPINE

Michael Wilczynski, DO FAOCR Diagnostic Radiology Department Chair Franciscan St James Healthcare Chicago, IL

Donald Kim, DO Radiology Residency, St James Healthcare Abdominal Imaging Fellowship, UCSF

CLINICAL INDICATIONS

? Absent or reduced sensation on clinical examination ? Absent or reduced reflexes ? Muscle wasting ? Severe intractable arm pain where symptoms have been present for more than 6 weeks ? Cervical radicular pain persisting for greater than 6 weeks ? Axial neck pain persisting for greater than 3 months ? Reduced power on physical examination ? CNS Tumor, Infection, Inflamation ? Tumor of the meninges ? Congenital malformations of the spinal cord, including vascular malformations ? Spinal surgery follow up ? Trauma

CERVICAL RADICULOPATHY WORKUP

? Plain radiography

? Radiography of the cervical spine is usually the first diagnostic test ordered in patients who present with neck and limb symptoms ? More often than not, this study is diagnostic of cervical disc disease as the cause of the radiculopathy

? The American College of Radiology recommends plain radiographs as the most appropriate initial study in all patients with chronic neck pain

? Lateral, anteroposterior, and oblique views ? On the lateral view ? Look for disc-space narrowing, comparing the level above and below ? Typically, the cervical disc spaces get larger from C2-C6, with C5-C6 being the widest disc space in normal necks, and C6-C7 slightly narrower. ? Besides narrowing, look for subchondral sclerosis and osteophyte formation. ? On oblique views ? Look for foraminal stenosis at the level of the suspected radiculopathy, comparing it with the opposite foramina

CERVICAL RADICULOPATHY WORKUP

? Plain radiography

? Other views: ? An open-mouth view should be ordered to rule out injury to the atlantoaxial joint when significant acute trauma has occurred ? If C7 can not be properly seen, then a "swimmer's view" (supine oblique view, in which the patient's arm is extended over the head) ? The atlantodens interval (ADI) is the distance from the posterior aspect of the anterior C1 arch and the odontoid process. ? This interval should be less than 3 mm in adults and less than 4 mm in children ? An increase in the ADI suggests atlantoaxial instability, such as from trauma or rheumatoid arthritis. ? Flexion and extension (lateral) views can be helpful in assessing spinal mobility and stability

? Limitations ? Problems with both specificity and sensitivity exist

? Correlations of findings on plain radiographs and cadaver dissections have found a 67% correlation between disc-space narrowing and anatomic findings of disc degeneration

? However, radiographs identified only 57% of large posterior osteophytes and only 32% of abnormalities of the apophyseal joints that were found on dissection

NORMAL

CERVICAL RADICULOPATHY WORKUP

? CT of the Cervical spine

? CT scanning provides good visualization of bony elements and can be helpful in the assessment of acute fractures

? It can also be helpful when C6 and C7 cannot be clearly seen on traditional lateral radiographic views

? The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation.

? CT with contrast myelography

? Has an accuracy approaching 96% for diagnosis of cervical disc herniation ? The addition of contrast material allows for the visualization of the subarachnoid space and assessment

of the spinal cord and nerve roots

? Even with myelography, however, soft-tissue visualization with CT is inferior to that provided by magnetic resonance imaging (MRI)

NORMAL

DJD (also C2 fracture)

CERVICAL RADICULOPATHY WORKUP ? MRI

? The American College of Radiology recommends routine MRI as the most appropriate imaging study in patients with chronic neck pain who have neurologic signs or symptoms but normal radiographs.

? MRI has become the method of choice for imaging the neck to detect significant soft-tissue pathology, such as disc herniation

? MRI can detect ligament and disc disruption, which cannot be demonstrated by other imaging studies

? The entire spinal cord, nerve roots, and axial skeleton can be visualized

? MRI has been found to be quite useful in evaluating the amount of cerebrospinal fluid (CSF) surrounding the cord in the evaluation of patients with cervical canal stenosis, although the T2-weighted images tend to exaggerate the degree of stenosis.

? Although MRI is considered the imaging method of choice for the evaluation of cervical radiculopathy, abnormalities have also been found in asymptomatic subjects.

? In one study,

? 10% of subjects younger than 40 years, were noted to have disc herniations

? 20% of subjects older than 40 years, had evidence of foraminal stenosis and 8% had disc protrusion or herniation

? Therefore, as with all imaging studies, the MRI findings must be used in conjunction with the patient's history and physical examination findings.

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