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(BQ) Part 2 book Diagnostic imaging spine presentation of content: Infections, inflammatory and autoimmune disorders, neoplasms, nonneoplastic cysts and tumor mimics, vascular and systemic disorders, plexus and peripheral nerve lesions, spine postprocedural imaging,...and other contents.
PART IV SECTION Infections Pathways of Spread 564 Spinal Meningitis 568 Pyogenic Osteomyelitis 572 Tuberculous Osteomyelitis 578 Fungal and Miscellaneous Osteomyelitis 584 Osteomyelitis, C1-C2 586 Brucellar Spondylitis 590 Septic Facet Joint Arthritis 592 Paraspinal Abscess 598 Epidural Abscess 602 Subdural Abscess 608 Abscess, Spinal Cord 612 Viral Myelitis 616 HIV Myelitis 620 Syphilitic Myelitis 624 Opportunistic Infections 626 Echinococcosis 630 Schistosomiasis 634 Cysticercosis 638 Infection and Inflammatory Disorders: Infections Pathways of Spread Anatomy-Based Imaging Issues Spread of infection may occur along one of many different tracts, including direct extension, lymphatic spread, hematogenous spread, and along the cerebrospinal fluid pathways Direct extension, as its name implies, occurs when bone or soft tissue comes into contact with a directly adjacent infection leading to a soft tissue abscess or osteomyelitis For the spine, this route is typically seen adjacent to a decubitus ulcer where there is adjacent osteomyelitis An infection of the disc space can extend into the adjacent paravertebral soft tissues and produce psoas muscle abscesses Direct extension is also the mechanism for epidural abscess involvement cranial or caudal to the site of disc space infection This route can also be seen for an intramedullary spinal cord abscess where the infection occurs through congenital dysraphism or a dermal sinus tract Lymphatic spread is of limited importance in the spine relative to the much more commonly seen direct extension and hematogenous spread Lymphatic spread may be seen in cases of retroperitoneal node enlargement from pelvic or abdominal primary neoplasms Hematogenous Spread Hematogenous spread is the major pathway of infection spread to the axial skeleton Which route is more important (arterial or venous) is controversial The arterial route is classically more important for spread of spinal infection Vertebral bodies have areas that function physiologically in a similar manner to long bone metaphyses The metaphyseal equivalent bone occurs near the anterior longitudinal ligament and has an end-arteriole network making it susceptible to bacterial seeding These areas have distal nonanastomosing vessels that have slow flow, and occlusion of these vessels will lead to avascular necrosis In the vertebral bodies, segmental arteries usually supply two adjacent vertebral bodies and the intervening disc, giving the typical disc space infection patterns The venous route is classically through Batson plexus, which is a longitudinal network of valveless veins running parallel to the spinal column These veins lie outside of the thoracoabdominal cavity These veins communicate with multiple aspects of the venous system, including the vena cava, portal venous system, azygos system, intercostal veins, and pulmonary and renal veins Flow direction within the plexus is variable due to the variable intrathoracic and intraabdominal pressures The pharyngovertebral plexus serves the same physiologic purpose The contiguity of the cerebrospinal fluid spaces between the intracranial vault and the thecal sac allows for direct communication of neoplasm and infection Intracranial neoplasms may seed throughout the cervical, thoracic, or lumbar thecal sac Likewise, even distal neoplasms involving the caudal thecal sac may propagate cephalad and extend into the intracranial cerebrospinal fluid space Pathologic Issues Types of spinal infection can be divided into disc space infection/vertebral osteomyelitis, subdural empyema, meningitis, intramedullary cord abscess, and septic arthritis/facet joint involvement Disc space infection shows the typical pattern of low signal intensity on T1-weighted images involving the disc space proper and extending to the adjacent endplates Endplate irregularity is a typical feature T2 hyperintensity is generally present within the intervertebral disc in a nonanatomic pattern, with adjacent T2 hyperintensity extending to the vertebral bodies Contrast enhancement 564 tends to be irregular when it involves the intervertebral disc, with diffuse enhancement extending to the involved vertebral bodies Extension into the paravertebral soft tissues is an important aspect of disc space infections and should be evaluated via either fat-suppressed, post-contrast T1weighted images looking for enhancement of the paravertebral and psoas musculature, or on T2-weighted images looking for T2 hyperintensity It is important to comment not only on the level of involvement, but also on any instability or malalignment that may be present and whether there is extension into the paravertebral regions, epidural space, and psoas musculature Epidural Abscess and Meningitis Isolated epidural abscesses can occur without concomitant disc space infections, but they can be associated with indwelling spinal catheters or prior spinal instrumentation Uncommonly, these may occur as a result of hematogenous spread Meningitis typically manifests on post-contrast T1weighted images as linear enhancement along the pial surface of the cord or the roots of the cauda equina With fungal infection, a more nodular enhancement pattern can be seen, which mimics the appearance of neoplastic spread Spinal subdural empyemas are an uncommon manifestation of infection but may be seen in the setting of a severe disc space infection with adjacent extension into the epidural space Presumably this is the result of direct extension through the dura and infection of the subdural space Intramedullary spinal cord abscesses are uncommon but can occur via both the hematogenous route and by direct extension In adults, direct extension is the more typical mechanism In children, the typical mechanism is direct extension through a dermal sinus Septic arthritis/facet joint involvement may occur via hematogenous extension or by direct extension Early infection may only be identified by slight T2 hyperintensity involving the bone of the facets, associated with facet effusion Adult vs Pediatric The routes of pyogenic infection will differ between adults and children due to developmental differences In adults, the vertebral endplates become infected first, spreading to adjacent disc space and subsequently to the adjacent vertebral body, paravertebral tissues, and epidural space In children, vascular channels are present across the growth plate, allowing primary infection of the intervertebral disc with subsequent secondary infection of the vertebral body Disc space infections occur most commonly in the lumbar spine, followed by thoracic and cervical regions Risk factors are many but include age over 50 years, diabetes, rheumatoid arthritis, AIDS, steroid administration, urinary tract instrumentation, prior spinal fracture, and paraplegia Staphylococcus aureus is the most common organism Pseudomonas may occur in the setting of drug abuse Salmonella is the classic infection seen in sickle cell patients; however, S aureus is still the most common overall in this population Classification The Cierny and Mader classification of bone infection divides the pathology into four anatomic disease types and three host categories, yielding twelve clinical stages The four anatomic disease types are: (1) Early hematogenous or medullary osteomyelitis, (2) superficial osteomyelitis (contiguous spread), (3) localized or full thickness sequestration, and (4) diffuse osteomyelitis The three host classifications are: (A) Pathways of Spread The spinal tuberculosis classification of Mehta (2001) divides the disease into four groups: (1) Stable anterior lesions without kyphotic deformity are treated with anterior debridement and strut grafting, (2) global lesions with kyphosis and instability are treated with posterior instrumentation and anterior strut grafting, (3) patients who are at high risk if treated by transthoracic surgery are treated with posterior decompression and instrumentation, and (4) isolated posterior lesions can be treated with posterior decompression Clinical Implications Spinal involvement with infection represents 2-5% of all osteomyelitis sites Axial spine pain is the most common presentation This is progressive, although it can have a fairly insidious onset, producing pain without relief from rest Fever is variable, and may be present in < 50% of cases High-grade fever is present in < 5%, and motor and sensory deficits occur in 10-15% of patients Rarely, intramedullary abscess can present with motor or sensory neurological deficits Delay in diagnosing spinal infection is common Intramedullary abscesses are fatal in 8%, with persistent neurological deficits in over 70% Erythrocyte sedimentation rate is positive in more than 90% C-reactive protein is also elevated Blood cultures are positive with spinal osteomyelitis in 25-60% of cases Operative debridement with fusion may be necessary for a variety of reasons, including necessity to obtain a specific microorganism, abscess drainage, persistent neurological deficit, presence of spine instability and deformity, and failure of medical treatment Long-term intravenous antibiotics remain the first line of therapy if there is no acute or evolving neurological deficit A 6-week course of intravenous antibiotics is typical, which may also include an additional oral antibiotic regimen at the completion of the intravenous phase External spine immobilization and bracing may be used Recurrent bacteremia, paravertebral abscesses, and chronically draining sinuses are associated with relapse Chronic auto-fusion of the infected level with successful nonoperative treatment is a common outcome osteomyelitis, when the disc space is not yet involved, it may be difficult to exclude neoplastic disease, type I degenerative endplate changes, or compression fracture from the differential diagnosis using only MR Follow-up studies are usually necessary to further define the nature of the lesion Boden et al suggested that in the postoperative spine, the triad of intervertebral disc space enhancement, annular enhancement, and vertebral body enhancement leads to the diagnosis of disc space infection, with the appropriate laboratory findings, such as an elevated sedimentation rate However, there is a group of normal postoperative patients with annulus enhancement (at the surgical curette site), intervertebral disc enhancement, and vertebral endplate enhancement without evidence of disc space infection In postoperative normal enhancement, the intervertebral disc enhancement is typically seen as thin bands paralleling the adjacent endplates, and the vertebral body enhancement is enhancement associated with type I degenerative endplate changes This pattern should be distinguished from the amorphous enhancement seen within the intervertebral disc with disc space infection Selected References 10 11 12 Differential Diagnosis The primary diagnostic modality in the evaluation of epidural abscess is MR, which is as sensitive as CT myelography for epidural infection but also allows the exclusion of other diagnostic choices, such as herniation, syrinx, tumor, and cord infarction MR imaging of epidural abscess demonstrates a soft tissue mass in the epidural space with tapered edges and an associated mass effect on the thecal sac and cord The epidural masses are usually isointense to the cord on T1weighted images and of increased signal on T2-weighted images Contrast-enhanced MR is necessary for full elucidation of the abscess The patterns of MR contrast enhancement of epidural abscess include: (1) Diffuse and homogeneous, (2) heterogeneous, and (3) thin peripheral Enhancement is a very useful adjunct for identifying the extent of a lesion when the plain MR scan is equivocal, demonstrating activity of an infection, and directing needle biopsy and follow-up treatment Successful therapy should cause a progressive decrease in enhancement of the paraspinal soft tissues, disc, and vertebral bodies In the initial stages of vertebral Infection and Inflammatory Disorders: Infections Normal physiologic response, (B) locally or systemically compromised response, and (C) treatment of the osteomyelitis would be worse than infection itself 13 14 15 16 Duarte RM et al: Spinal infection: state of the art and management algorithm Eur Spine J 22(12):2787-99, 2013 Malghem J et al: Necrotizing fasciitis: Contribution and limitations of diagnostic imaging Joint Bone Spine 80(2):146-54, 2013 Go JL et al: Spine infections Neuroimaging Clin N Am 22(4):755-72, 2012 DeSanto J et al: Spine infection/inflammation Radiol Clin North Am 49(1):105-27, 2011 Celik AD et al: Spondylodiscitis due to an emergent fungal pathogen: Blastoschizomyces capitatus, a case report and review of the literature Rheumatol Int 29(10):1237-41, 2009 Hong SH et al: MR imaging assessment of the spine: infection or an imitation? Radiographics 29(2):599-612, 2009 Karikari IO et al: Management of a spontaneous spinal epidural abscess: a single-center 10-year experience Neurosurgery 65(5):919-23; discussion 923-4, 2009 Mylona E et al: Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics Semin Arthritis Rheum 39(1):10-7, 2009 Petruzzi N et al: Recent trends in soft-tissue infection imaging Semin Nucl Med 39(2):115-23, 2009 Posacioglu H et al: Rupture of a nonaneurysmal abdominal aorta due to spondylitis Tex Heart Inst J 36(1):65-8, 2009 Sobottke R et al: Treatment of spondylodiscitis in human immunodeficiency virus-infected patients: a comparison of conservative and operative therapy Spine (Phila Pa 1976) 34(13):E452-8, 2009 Thwaites G et al: British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children J Infect 59(3):167-87, 2009 Dai LY et al: Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine Eur Spine J 17(8):102734, 2008 Mehta JS et al: Tuberculosis of the thoracic spine A classification based on the selection of surgical strategies J Bone Joint Surg Br 83(6):859-63, 2001 Mader JT et al: Staging and staging application in osteomyelitis Clin Infect Dis 25(6):1303-9, 1997 Boden SD et al: Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space changes Radiology 184(3):765-71, 1992 565 Infection and Inflammatory Disorders: Infections Pathways of Spread (Left) Sagittal graphic shows lumbar disc space infection with vertebral body osteomyelitis with endplate destruction and marrow edema There are ventral and dorsal abscess collections (Right) Sagittal T1WI C+ FS MR in this case of disc space infection shows enhancement of L5 and S1 bodies ſt and intervertebral disc, with prevertebral and epidural phlegmon extension (Left) Axial T1WI C+ MR of a disc space infection shows inflammatory extension into the prevertebral space, psoas muscles, and dorsal spinal muscles Phlegmon extends into the ventral epidural space with thecal sac compression ſt (Right) Axial T2WI FS MR shows inflammatory extension into the prevertebral space, psoas muscles ſt, and dorsal spinal muscles (Left) Axial T1WI C+ MR shows disseminated coccidioidomycosis with diffuse bone and soft tissue involvement and adjacent paraspinal extension and extension into lung (Right) Axial T2WI MR in coccidioidomycosis shows huge paraspinal abscesses ſt There is effacement of the normal thecal sac within the spinal canal due to disc space infection and osteomyelitis 566 Pathways of Spread Infection and Inflammatory Disorders: Infections (Left) Sagittal graphic shows dermal sinus ſt extending from skin surface to conus, with conus abscess and extensive cord edema (Right) Sagittal T2WI MR in a patient with a cervical cord abscess and streptococcal endocarditis shows diffuse cord expansion, with a ring-shaped area of low T2 signal (abscess capsule) within the cord from C4 to C5C6 ſt (Left) Sagittal T1WI C+ MR with fat suppression shows extensive subdural empyema with peripheral enhancement ſt throughout the cervical spine and extending along clivus (Right) A septic facet joint is shown Axial T1WI C+ MR at L4-L5 shows extension of the infection to the right facet joint with diffuse facet bone enhancement and juxta facet soft tissue involvement (Left) Axial T1WI C+ MR shows direct extension of infection from mycotic aortic aneurysm ſt into the ventral vertebral body, producing bone destruction and osteomyelitis There is also direct extension of infection into psoas muscle st (Right) Axial CECT shows direct extension of infection from mycotic aortic aneurysm ſt into vertebral body and left psoas muscle st 567 Infection and Inflammatory Disorders: Infections Spinal Meningitis KEY FACTS IMAGING PATHOLOGY • MR ○ Diffuse, extensive subarachnoid enhancement ○ Smooth or irregular meningeal enhancement • Infection of CSF and meningeal coverings surrounding spinal cord • Associated findings ○ Spondylodiscitis ○ Spinal epidural abscess ○ Blocked CSF flow → increased pressure within cord → syringomyelia TOP DIFFERENTIAL DIAGNOSES • Carcinomatous meningitis ○ Focal or diffuse, sheet-like or nodular enhancement along cord or nerve roots • Sarcoidosis ○ Leptomeningeal + nerve root enhancement mimics spinal meningitis • Lumbar arachnoiditis ○ "Empty sac" sign with nerve roots adherent to periphery of thecal sac • Guillain-Barré syndrome ○ Inflammatory demyelination typically following recent viral illness (Left) Sagittal T1WI C+ MR shows diffuse mildly irregular leptomeningeal enhancement ſt No extradural or vertebral inflammatory changes are apparent Abnormal contrast agent enhancement is noted in only 55-70% of patients with proven infectious meningitis on contrast-enhanced MR images Contrast-enhanced MR is particularly insensitive to viral meningitis (Right) Axial T1WI C+ MR image reveals diffuse nerve root enhancement ſt (Left) Sagittal T1 C+ MR exhibits diffuse leptomeningeal enhancement ſt extending into the posterior fossa st (Right) Sagittal T2 MR reveals diffuse intramedullary hyperintensity st consistent with spinal cord ischemia complicating meningitis Inflammatory vasculitis acutely produces vascular compromise Vascular insufficiency secondary to arachnoiditis gives delayed complications, such as paraparesis, sensory loss, and urinary incontinence 568 CLINICAL ISSUES • Acute onset of fever, chills, headache, and altered level of consciousness DIAGNOSTIC CHECKLIST • Imaging often negative in early spinal meningitis ○ Positive in advanced bacterial meningitis or granulomatous infection • Intravenous gadolinium increases sensitivity in detecting meningeal disease Spinal Meningitis Synonyms • Infectious arachnoiditis Definitions • Infection of spinal cord leptomeninges and subarachnoid space IMAGING General Features • Best diagnostic clue ○ Diffuse, extensive subarachnoid enhancement • Location ○ All spinal segments involved • Size ○ Diffuse or focal • Morphology ○ Smooth or irregular meningeal enhancement ○ Diffuse cerebral spinal fluid (CSF) enhancement Sarcoidosis • Noncaseating granulomatous inflammation of spinal cord and its coverings • Protean imaging findings ○ Leptomeningeal + nerve root enhancement mimics spinal meningitis ○ Cord edema with focal intramedullary enhancement simulates myelitis • Concurrent systemic manifestations and elevated angiotensin-converting enzyme level help make diagnosis ○ Clinical CNS involvement in 5% of patients with sarcoidosis Lumbar Arachnoiditis • Commonly associated with prior surgery • Cauda equina typically involved • Clumped nerve roots forming central mass or multiple cords ○ ± mild nerve root enhancement • "Empty sac" sign with nerve roots adherent to periphery of thecal sac CT Findings Guillain-Barré Syndrome • CECT ○ Enhancing CSF ± meninges • Inflammatory autoimmune demyelination typically following recent viral illness • Ascending paralysis • Diffuse enhancement of conus and cauda equina ○ ± nerve root thickening (uncommon) MR Findings • T1WI ○ Increased CSF intensity ○ Indistinct cord-CSF interface ○ Irregular cord outline ○ Clumped nerve roots • T2WI ○ Obliterated subarachnoid space ○ Nodular or band-like filling defects in subarachnoid space ○ Complication of cord involvement: Hyperintense cord signal intensity (SI) – ± focal or diffuse cord swelling • T1WI C+ ○ Smooth or nodular leptomeningeal enhancement – May show homogeneously enhancing CSF ○ Smooth or nodular nerve root enhancement – ± segmental or focal intramedullary enhancement Imaging Recommendations • Best imaging tool ○ Axial and sagittal C+ T1WI – Positive in advanced bacterial meningitis or granulomatous infection • Protocol advice ○ MR contrast mandatory for detecting meningeal disease DIFFERENTIAL DIAGNOSIS Carcinomatous Meningitis • Primary CNS neoplasm • Metastatic lung, breast carcinoma, melanoma, lymphoma • Thickened, blurred nerve roots on T1WI and T2WI ○ Obliterated CSF • Focal or diffuse, sheet-like or nodular enhancement along cord or nerve roots Infection and Inflammatory Disorders: Infections TERMINOLOGY Intracranial Hypotension • From prior spinal trauma, diagnostic or interventional procedure, or spontaneous ○ Low opening pressure on lumbar puncture ○ Increased dural venous engorgement ○ Diffuse smooth meningeal thickening & enhancement • May see cerebellar tonsillar descent + effaced prepontine space in posterior fossa PATHOLOGY General Features • Etiology ○ Acute meningitis: Onset of symptoms < 24 hr – Almost always bacterial – Newborn: Group B Streptococcus, gram-negative bacilli, Listeria monocytogenes – months to 12 years: Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitides – Adults: Above, plus streptococci + staphylococci ○ Subacute meningitis: Symptoms develop in 1-7 days – Mostly viral (e.g., HIV-related CMV radiculomyelitis), some bacterial (e.g., Lyme disease) ○ Chronic meningitis: Fluctuating symptoms for > days – Tuberculosis – Syphilis – Fungal: Coccidioidomycosis, cryptococcosis, and aspergillosis ○ Mechanism of inoculation – Hematogenous dissemination from extraspinal focus of infection 569 Infection and Inflammatory Disorders: Infections Spinal Meningitis – Contiguous spread from adjacent spondylodiscitis, spinal epidural abscess – Direct inoculation through trauma or interventional procedures – Unexplained source of infection: Probably bacteria (meningococci) colonized in nasopharynx ○ Pathophysiology of bacterial meningitis – Initial acute inflammatory exudate in subarachnoid space – Toxic mediators potentiate inflammatory response – Increased permeability of blood-cord barrier – Influx of inflammatory cells – Spinal cord swelling and edema likely due to ischemia from vasculitis, venous congestion, &/or direct infection • Associated abnormalities ○ Spondylodiscitis ○ Spinal epidural abscess ○ Subdural empyema ○ Subarachnoid cysts – Fibrin deposition results in loculation of subarachnoid space ○ Myelitis ○ Cord abscess ○ Syringomyelia – Blocked CSF flow results in increased pressure within cord and subsequent central canal expansion Microscopic Features • Cellular debris, inflammatory cells, and microorganisms • Tuberculous meningitis ○ Small tubercles consist of epithelioid cells, Langhans giant cells, and foci of caseation • Loss of integrity of brain-CSF barriers, oxidative stress and S-100B (mediator of astrocytes activation/injury) ○ → contribute to severity and neurological complications of bacterial meningitis CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Acute onset of fever, chills, headache, and altered level of consciousness ○ Other signs/symptoms – Generalized convulsions – Neck stiffness – Paraparesis – Paresthesia – Gait disturbance – Urinary bladder dysfunction • Clinical profile ○ Milder symptoms with protracted course in tuberculous or fungal meningitis ○ No gender preference among adults ○ M:F = 3:1 in neonates • Epidemiology ○ Incidence of bacterial meningitis: 2-3 per 100,000 Natural History & Prognosis • Prognosis depends on severity of disease, causative pathogen, patient age and comorbidities ○ Mortality of bacterial meningitis (20-90%) – Depending on initial neurologic impairment and rate of progression – Chronic disabilities include paralysis, seizures, deafness, etc ○ Viral meningitis generally less severe – Full recovery within weeks in most cases Treatment • Bacterial meningitis presenting with normal CSF is uncommon ○ Incidence (0.5-12%) ○ "Normal" CSF in meningitis does not correlate with age of child or subsequently demonstrated organism – Related to duration of illness; incidence is higher when lumbar puncture (LP) is performed within 1st 24 hours of illness (before inflammatory response has developed) □ Repeat LP after 24-48 hours in clinically suspected cases □ Repeat LP in blood culture-positive cases if initial CSF is clear • CSF lactate level → distinguish bacterial infection where lactate is ↑ from nonbacterial (viral) meningitis ○ High sensitivity, specificity, and predictive values ○ Level on 1st LP has no prognostic value, but decrease of CSF lactate during treatment → good prognosis • Supportive care with hydration and pain management • Intravenous dexamethasone to decrease inflammatory reaction and brain/cord edema • Empiric intravenous antibiotics based on suspected organisms in each age group • Organism-specific intravenous antibiotics • Preventive oral antibiotics for close contacts of patients with Neisseria meningitides DIAGNOSTIC CHECKLIST Image Interpretation Pearls • Imaging often negative in early spinal meningitis • Increased CSF SI on T1WI with diffuse post-gadolinium enhancement suggestive of spinal meningitis SELECTED REFERENCES Demographics • Age ○ Newborns ○ Infants: Peak age 3-8 months ○ Adults: 20s; 60s • Gender 570 Bottomley MJ et al: Future challenges in the elimination of bacterial meningitis Vaccine 30 Suppl 2:B78-86, 2012 Cunha BA: Cerebrospinal fluid (CSF) lactic acid levels: a rapid and reliable way to differentiate viral from bacterial meningitis or concurrent viral/bacterial meningitis J Clin Microbiol 50(1):211, 2012 Edmond K et al: Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis Lancet Infect Dis 10(5):317-28, 2010 Hamed SA et al: Oxidative stress and S-100B protein in children with bacterial meningitis BMC Neurol 9:51, 2009 Spinal Meningitis Infection and Inflammatory Disorders: Infections (Left) Sagittal T1WI C+ MR shows diffuse abnormal enhancement of the cauda equina and distal cord surface ſt with central clumping of the nerves within the thecal sac The leptomeningeal enhancement is due to histoplasmosis (successfully treated with antifungal medication) (Right) Sagittal T1WI C+ MR shows extensive thickening of the dura with enhancement and diffuse epidural phlegmon st There is massive infection involving soft tissues , epidural space, and subarachnoid space ſt (Left) Sagittal T1 C+ MR reveals extensive leptomeningeal enhancement surrounding the spinal cord ſt There is enlargement of the 4th ventricle st due to severe coccidioidomycosis meningitis (Right) Diffuse T2 hyperintensity due to severe coccidioidomycosis meningitis extends inferiorly from the obex st to the T4 level ſt There is relative sparing of the cord periphery Extensive cervical cord edema (presyrinx) is related to marked hydrocephalus and 4th ventricular outflow obstruction (Left) Diffuse pial and cauda equina enhancement is due to meningitis Minimal enhancement outlines an epidermoid st There is a dorsal dermal sinus tract ſt in the low sacral region (Right) Thickening and enhancement of the cauda equina ſt is due to adhesive arachnoiditis A fibrinous exudate with minimal cellular infiltrate adheres to the arachnoid membranes and nerve roots Fibroblasts infiltrate the exudate and produce collagen bands Meningeal scarring can alter CSF flow dynamics st 571 Infection and Inflammatory Disorders: Infections Pyogenic Osteomyelitis KEY FACTS TERMINOLOGY • Bacterial suppurative infection of vertebrae and intervertebral disc IMAGING • Ill-defined hypointense T1 vertebral marrow with loss of endplate definition on both sides of disc • Loss of disc height and abnormal disc signal • Destruction of vertebral endplate cortex • Vertebral collapse • Paraspinal ± epidural infiltrative soft tissue ± loculated fluid collection • Follow-up MR ○ Should focus on soft tissue findings ○ No single MR imaging parameter is associated with clinical status TOP DIFFERENTIAL DIAGNOSES • Degenerative endplate changes (Left) Sagittal T1WI MR in a patient with a history of lumbar surgery shows findings of disc space infection at L4L5, with hypointense marrow, vertebral collapse, endplate erosion, disc space loss, and epidural phlegmon (Right) Sagittal T1WI C+ MR demonstrates enhancing vertebral bodies and intervening disc There is an epidural abscess ſt extending from L4-L5 to S1, consistent with pyogenic vertebral osteomyelitis Severe central canal narrowing is present at L4-L5 (Left) Sagittal STIR MR shows increased fluid in the retropharyngeal/prevertebral space ſt Marrow edema in C6 and C7 vertebral bodies is seen st There is fluid signal within the disc space with irregularity along the endplate cortical margins (Right) Sagittal T1WI C+ FS MR shows homogeneously enhancing epidural phlegmon at C6-C7 level ſt, causing mass effect on the cord C6 & C7 vertebral bodies exhibit avid homogeneous enhancement Note the prevertebral, enhancing soft tissues st, representing phlegmon 572 • Tuberculous vertebral osteomyelitis • Spinal neuropathic arthropathy PATHOLOGY • Predisposing factors ○ Intravenous drug use ○ Immunocompromised state ○ Chronic medical illnesses (renal failure, cirrhosis, cancer, diabetes) • Staphylococcus aureus is most common pathogen CLINICAL ISSUES • • • • Acute or chronic back pain Focal spinal tenderness Fever ↑ ESR, ↑ CRP, ↑ WBC INDEX - heterotopic bone formation vs., 1149 Myxopapillary ependymoma See Ependymoma, myxopapillary N Nasopharyngeal infection, in etiologies of atlantoaxial rotatory fixation, 269 Neoplasms/tumors - brachial plexus idiopathic brachial plexus neuritis vs., 995 neural tumors, superior sulcus tumor vs., 981 - cauda equina, arachnoiditis/adhesions vs., 1073 - cervical facet arthropathy vs., 447 - cysticercosis vs., 639 - epidural recurrent disc herniation vs., 1065 traumatic disc herniation vs., 313 traumatic epidural hematoma vs., 383 - failed back surgery syndrome vs., 1060–1063 - instability vs., 517 - intradural extramedullary, spinal cord abscess vs., 613 - intramedullary multiple sclerosis vs., 653 sarcoidosis vs., 673 schistosomiasis vs., 635 - intrathecal, arachnoiditis ossificans vs., 1079 - lumbar facet arthropathy vs., 451 - mass associated with arthritis, traumatic neuroma vs., 999 - Pancoast, idiopathic brachial plexus neuritis vs., 995 - with paramagnetic effects, filum terminale fibrolipoma vs., 43 - paraspinal abscess vs., 599 - peripheral nerve, metastasis, peripheral neurolymphomatosis vs., 1011 - plexus, primary and secondary, thoracic outlet syndrome vs., 985 - postoperative infection vs., 1085 - postsurgical deformity vs., 1101 - primary bone-producing, heterotopic bone formation vs., 1149 - primary melanocytic See Melanocytoma - recurrent, traumatic neuroma vs., 999 - sacral traumatic fracture vs., 339 - scoliosis vs., 230 - soft tissue, pseudomeningocele vs., 1089 - spinal cervical intervertebral disc herniation vs., 427 thoracic intervertebral disc herniation vs., 433 - spinal cord See Spinal cord neoplasms/tumors - spinal tumor, dural dysplasia vs., 173 - spread of, 690–693 anatomy-based imaging issues, 690, 692–693 clinical implications, 691 mechanisms of tumorigenesis, 690–691 metastatic disease and cell motion, 691 pathologic issues, 690–691 - thoracic, other than NSCLC, superior sulcus tumor vs., 981 Nerve(s) - acute direct trauma, ulnar neuropathy vs., 1019 - imaging anatomy, - palsy, femoral See Femoral neuropathy - stretch injury peripheral neurolymphomatosis vs., 1011 traumatic, hypertrophic neuropathy vs., 1013 Nerve entrapment - median nerve, 1026–1027 - suprascapular, idiopathic brachial plexus neuritis vs., 996 - ulnar See Ulnar neuropathy Nerve infiltration, femoral, neoplastic, femoral neuropathy vs., 1017 Nerve root sleeve cyst, brachial plexus traction injury vs., 991 Nerve roots - avulsion brachial plexus, idiopathic brachial plexus neuritis vs., 995 meningeal cyst vs., 838 perineural root sleeve cyst vs., 843 - conjoined, 34–37 differential diagnosis, 35 - physiological enhancement, Guillain-Barré syndrome vs., 665 - thick, CSF disseminated metastases vs., 799 - tortuous redundant, from spinal stenosis, dural arteriovenous fistula vs., 879 Nerve sheath tumors - brachial plexus traction injury vs., 991 - common peroneal neuropathy vs., 1029 - conjoined nerve roots vs., 35 - connective tissue disorders vs., 213 - dural dysplasia vs., 173 - facet joint synovial cyst vs., 455 - femoral neuropathy vs., 1017 - hypertrophic neuropathy vs., 1013 - lateral meningocele vs., 165 - lumbar intervertebral disc herniation vs., 437 - malignant, 794–797 differential diagnosis, 795 neurofibroma vs., 792 staging, grading, & classification, 796 - myxopapillary ependymoma vs., 815 - neuroblastic tumor vs., 765 - normal variant vs., 24 - perineural root sleeve cyst vs., 843 - peripheral, 1006–1009 benign, malignant nerve sheath tumors vs., 795 differential diagnosis, 1007 extramedullary hematopoiesis vs., 965 median neuropathy vs., 1027 staging, grading, & classification, 1007 - suprascapular neuropathy vs., 1023 - ulnar neuropathy vs., 1019 Neural (vertebral) arch fracture See Facet-lamina thoracolumbar fracture xix INDEX Neural foraminal stenosis, 235 Neuralgic amyotrophy See Brachial plexus, idiopathic neuritis Neurenteric cyst, 156–159 - anterior sacral meningocele vs., 117 - dermoid cyst vs., 93 - differential diagnosis, 157 - epidermoid cyst vs., 97 - staging, grading, & classification, 158 Neuritis - peripheral nerve sheath tumor vs., 1007 - traumatic neuroma vs., 999 - viral, common peroneal neuropathy vs., 1029 Neuroblastic tumor, 764–767 - differential diagnosis, 765 - Langerhans cell histiocytosis vs., 769 - schwannoma vs., 777–778 - staging, grading, & classification, 766 Neuroblastoma, cystic, anterior sacral meningocele vs., 117 Neurocysticercosis See Cysticercosis Neurofibroma, 790–793 - differential diagnosis, 791–792 - plexiform pseudomeningocele vs., 1090 radiation plexopathy vs., 1003 - schwannoma vs., 777 - spinal cord metastases vs., 825 - staging, grading, & classification, 792 Neurofibromatosis - atlantoaxial rotatory fixation vs., 269 - central, neurofibromatosis type vs., 177 Neurofibromatosis type 176–179 - chronic inflammatory demyelinating polyneuropathy vs., 669 - connective tissue disorders vs., 213 - degenerative scoliosis vs., 236 - differential diagnosis, 177 - staging, grading, & classification, 177–178 Neurofibromatosis type 180–185 - clinical issues, 182 - differential diagnosis, 181 - imaging, 181, 183–185 - neurofibromatosis type vs., 177 - pathology, 181–182 - staging, grading, & classification, 181–182 Neurogenic (Charcot) arthropathy, 540–543 - brucellar spondylitis vs., 591 - differential diagnosis, 541–542 - imaging, 541, 543 Neurolymphomatosis, peripheral, 1010–1011 - differential diagnosis, 1011 - imaging, 1011 Neuroma, traumatic, 998–1001 - differential diagnosis, 999 - imaging, 999, 1000–1001 - peripheral nerve sheath tumor vs., 1007 Neuromuscular disease, Scheuermann disease vs., 471 Neuromuscular scoliosis - degenerative scoliosis vs., 236 - scoliosis vs., 229 xx Neuromyelitis optica, 656–659 - acute disseminated encephalomyelitis vs., 661 - acute transverse myelopathy vs., 645 - differential diagnosis, 657 - idiopathic acute transverse myelitis vs., 649 - multiple sclerosis vs., 653 - paraneoplastic myelopathy vs., 687 - spinal cord infarction vs., 911 - viral myelitis vs., 617 Neuropathic arthropathy - gout vs., 557 - pyogenic osteomyelitis vs., 573 - scoliosis related to, 225 Neuropathic joint - hemodialysis spondyloarthropathy vs., 545 - tumoral calcinosis vs., 969 Neuropathic spine, scoliosis vs., 230 Neuropathy - diabetic idiopathic brachial plexus neuritis vs., 995 tibial neuropathy vs., 1031 - hypertrophic See Hypertrophic neuropathy - inherited demyelinating, chronic inflammatory demyelinating polyneuropathy vs., 669 - median, 1026–1027 - suprascapular, 1022–1025 - ulnar, 1018–1021 - vasculitic, Guillain-Barré syndrome vs., 665 Neuropraxia, 975 Neurosarcoidosis, paraneoplastic myelopathy vs., 687 Neuroschistosomiasis See Schistosomiasis Neurosyphilis See Syphilitic myelitis Neurotmesis, 975 Neurulation abnormalities, 64–99 - coccygeal dimple, simple differential diagnosis, 89 low midline, dorsal dermal sinus vs., 85 - dermoid cyst See Dermoid cyst - dorsal dermal sinus, 84–87 differential diagnosis, 85 simple coccygeal dimple vs., 89 - embryology, 64–66 congenital and developmental anomalies of unknown etiology, 66 imaging protocols, 64 nondysjunction, 64 notochordal anomalies, 66 premature dysjunction, 64 primary neurulation, 64 secondary neurulation, 64–65 spinal cord, 66 vertebral formation and segmentation, 65–66 - epidermoid cyst See Epidermoid cyst - lipomyelomeningocele See Lipomyelomeningocele Newborn, normal, osteopetrosis vs., 207 Niemann-Pick disease (NPD), Gaucher disease vs., 209 Nonunion, degenerative endplate changes vs., 411 Normal anatomical variations - bone island See Bone island - conjoined roots nerve roots, 34–37 - craniovertebral junction variants, 26–28 INDEX - filum terminale fibrolipoma, 42–43 limbus vertebra See Limbus vertebra MR artifacts See MR artifacts normal variant See Normal variant ossiculum terminale, 32–33 pathology-based imaging issues, 10 ponticulus posticus, 30–31 ventriculus terminalis, 46–49 differential diagnosis, 47 syringomyelia vs., 847 Normal variant, 22–25 - Bertolotti syndrome vs., 465 - differential diagnosis, 23–24 - imaging, 23, 25 Notochordal anomalies - craniovertebral junction embryology, 128–131 - diastematomyelia, 66, 148–151 - embryology, 66 - neurenteric cyst See Neurenteric cyst Nucleus pulposus, 4–5 O Obstetric complications, SCIWORA vs., 353 Occipital bone and skull base - anomalies, 128 - embryology, 128 Occipital condyle - congenital variation (3rd occipital condyle), odontoid C2 fracture vs., 275 - hypoplasia, 128 Occipital condyle fractures, 260–263 - atlantooccipital dislocation vs., 254 - classification, 246 - differential diagnosis, 261 - staging, grading, & classification, 262 Occipital encephalocele - isolated, Chiari malformation vs., 63 - syndromic, Chiari malformation vs., 63 Occipitoatlantal dislocation See Atlantooccipital dislocation (AOD) Occipitoatlantoaxial fixation See Occipitocervical fixation Occipitocervical fixation (OCF), 1110–1111 Ochronosis, 210–211 - CPPD vs., 552 - differential diagnosis, 211 Odontoid C2 fracture, 274–277 - atlantooccipital dislocation vs., 254 - classification, 246 - differential diagnosis, 275 - os odontoideum vs., 161 - osteomyelitis of C1-C2 vs., 588 Odontoid fracture - type I or II, ossiculum terminale vs., 33 - type III, burst C2 fracture vs., 279 Odontoid hypoplasia, pathology-based imaging issues, 129 OPLL See Ossification, posterior longitudinal ligament Opportunistic infections, 626–629 - differential diagnosis, 627–628 Orthograde degeneration See Wallerian degeneration Os odontoideum, 129, 160–163 - atlantoaxial rotatory fixation vs., 269 - differential diagnosis, 161 - odontoid C2 fracture vs., 275 - ossiculum terminale vs., 33 - periodontoid pseudotumor vs., 503 - staging, grading, and classification, 162 Osseous lymphoma, differential diagnosis, 747 Osseous metastases - blastic, 694–697 differential diagnosis, 695–696 myelofibrosis vs., 696, 961 osteopetrosis vs., 696 osteoporosis vs., 945 osteosarcoma vs., 695, 733 staging, grading, & classification, 696 tuberculous osteomyelitis vs., 579 - diffuse, sickle cell disease vs., 195 - lytic, 698–701, 945 Baastrup disease vs., 461 differential diagnosis, 699–700 osteoporosis vs., 945 staging, grading, & classification, 700 tuberculous osteomyelitis vs., 579 Ossiculum terminale - os odontoideum vs., 161 - persistent, 129 Ossiculum terminale persistens, odontoid C2 fracture vs., 275 Ossification - accessory ossification center(s) occipital condyle fractures vs., 261 sacral traumatic fracture vs., 339 - of disc, with fatty marrow, anular fissure of intervertebral disc vs., 423 - ligamentum flavum, 498–501 differential diagnosis, 499 - normal progression of, incomplete fusion of posterior elements vs., 155 - posterior longitudinal ligament, 494–497 cervical intervertebral disc herniation vs., 427 cervical spondylosis vs., 485 differential diagnosis, 495 disc bulge vs., 419 periodontoid pseudotumor vs., 503 staging, grading, & classification, 496 traumatic epidural hematoma vs., 383 - post-traumatic, Bertolotti syndrome vs., 465 Osteitis condensans ilii, ankylosing spondylitis vs., 547 Osteitis deformans See Paget disease Osteoarthritis See also Craniovertebral junction, degenerative arthritis of - C1-C2, osteomyelitis of C1-C2 vs., 587 - facet joint, septic facet joint arthritis vs., 593 - ochronosis vs., 211 - periodontoid pseudotumor vs., 503 - rheumatoid arthritis vs., 523 - sacral insufficiency fracture vs., 348 Osteoarthrosis See Craniovertebral junction, degenerative arthritis of xxi INDEX Osteoblastoma, 712–715 - aneurysmal bone cyst vs., 717 - differential diagnosis, 713–714 - fibrous dysplasia vs., 855 - giant cell tumor vs., 721 - osteochondroma vs., 725 - osteoid osteoma vs., 707 - osteosarcoma vs., 733 - periodontoid pseudotumor vs., 503 - scoliosis related to, 225 - staging, grading, & classification, 714 Osteocartilaginous exostosis See Osteochondroma Osteochondroma, 724–727 - Bertolotti syndrome vs., 465 - differential diagnosis, 725 Osteogenesis imperfecta, 198–201 - achondroplasia vs., 188 - congenita, thanatophoric dwarfism vs., 221 - connective tissue disorder, 213 - differential diagnosis, 199 - juvenile idiopathic arthritis vs., 529 - Scheuermann disease vs., 471 - staging, grading, & classification, 200 - tarda, dural dysplasia vs., 173 Osteoid osteoma, 706–711 - bone island vs., 45 - degenerative scoliosis vs., 236 - differential diagnosis, 707–706 - osteoblastoma vs., 713 - scoliosis related to, 225 - spondylolysis vs., 513 Osteolysis/resorption, rhBMP-2 complications vs., 1145 Osteomalacia, renal osteodystrophy vs., 955 Osteomyelitis - C1-C 586–589 differential diagnosis, 587–588 juvenile idiopathic arthritis vs., 529 - cervical, longus colli calcific tendinitis vs., 559 - chronic recurrent multifocal, 682–683 differential diagnosis, 683 staging, grading, & classification, 683 - Ewing sarcoma vs., 743–744 - fungal, 584–585 brucellar spondylitis vs., 591 clinical issues, 585 differential diagnosis, 585 imaging, 585 opportunistic infections vs., 627 tuberculous osteomyelitis vs., 579 - gout vs., 557 - granulomatous cysticercosis vs., 639 echinococcosis vs., 631 fungal osteomyelitis vs., 585 kyphosis vs., 233 leukemia vs., 753 opportunistic infections vs., 627 postoperative infection vs., 1085 - miscellaneous, 584–585 differential diagnosis, 585 opportunistic infections vs., 627 xxii - osteoid osteoma vs., 708 osteosarcoma vs., 733 periodontoid pseudotumor vs., 503 pyogenic, 572–577 Baastrup disease vs., 461 brucellar spondylitis vs., 591 CPPD vs., 551 differential diagnosis, 573–574 fungal osteomyelitis vs., 585 Langerhans cell histiocytosis vs., 769 leukemia vs., 753 opportunistic infections vs., 627 postoperative infection vs., 1085 tuberculous osteomyelitis vs., 579 - sacral, sacral insufficiency fracture vs., 347 - septic multifocal, chronic recurrent multifocal osteomyelitis vs., 683 - skull base extension, osteomyelitis of C1-C2 vs., 588 - tuberculous, 578–583 brucellar spondylitis vs., 591 clinical issues, 580 differential diagnosis, 579 imaging, 579, 581–583 pathology, 580 vertebral, pyogenic osteomyelitis vs., 573 - vertebral tuberculous, pyogenic osteomyelitis vs., 573 vertebroplasty complications vs., 1057 Osteopenia, in ankylosing spondylitis, 547 Osteopetrosis, 206–207 - blastic osseous metastases vs., 696 - differential diagnosis, 207 - myelofibrosis vs., 961 - renal osteodystrophy vs., 955 - sickle cell disease vs., 195 Osteophyte - anterior fragment, limbus vertebra vs., 39 - cervical intervertebral disc herniation vs., 427 - endplate, foraminal disc extrusion vs., 443 - large facet, foraminal disc extrusion vs., 443 - metal artifact vs., 1108 - posterior, apophyseal ring fracture vs., 287 - recurrent disc herniation vs., 1065 - thoracic intervertebral disc herniation vs., 433 Osteopoikilosis, bone island vs., 45 Osteoporosis, 944–947 - congenital, osteogenesis imperfecta vs., 199 - differential diagnosis, 945 - multiple myeloma vs., 761 - senile, hyperparathyroidism vs., 953 - staging, grading, & classification, 946 Osteoporotic compression fracture - blastic osseous metastases vs., 695 - Chance fracture vs., 323 - lytic osseous metastases vs., 699 - plasmacytoma vs., 757 Osteosarcoma, 732–735 - blastic osseous metastases vs., 695 - chondrosarcoma vs., 729 - differential diagnosis, 733 - echinococcosis vs., 631 INDEX - Ewing sarcoma vs., 743 - fibrous dysplasia vs., 855 - neurogenic (Charcot) arthropathy vs., 541 - staging, grading, & classification, 734 Ovarian cyst, anterior sacral meningocele vs., 117 P Pachymeningitis, hypertrophic - idiopathic, subdural hematoma vs., 925 - subdural abscess vs., 609 Paget disease, 948–951 - acquired lumbar central stenosis vs., 475 - blastic osseous metastases vs., 695 - cervical facet arthropathy vs., 447 - differential diagnosis, 949 - fibrous dysplasia vs., 855 - hemangioma vs., 703 - lumbar facet arthropathy vs., 451 - osteopetrosis vs., 207 - pedicle stress fracture vs., 343 - plasmacytoma vs., 757 - renal osteodystrophy vs., 955 - tuberous sclerosis vs., 203 Pancoast tumor See also Superior sulcus tumor - idiopathic brachial plexus neuritis vs., 995 Pantopaque, retained, arachnoiditis ossificans vs., 1079 Paracondylar process, 132–133 Paraganglioma, 802–805 - differential diagnosis, 803 - meningioma vs., 781 - myxopapillary ependymoma vs., 815 - staging, grading, & classification, 803 Parasitic infections - cysticercosis vs., 639 - echinococcosis vs., 631 - spinal cord infarction vs., 911 Paraspinal abscess, 598–601 - differential diagnosis, 599–600 - ligamentous injury vs., 257 Paraspinous abscess, pseudomeningocele vs., 1090 Paravertebral abscess - extramedullary hematopoiesis vs., 965 - traumatic dural tear vs., 379 Pars interarticularis - fracture (spondylolysis), lumbar facet-posterior fracture vs., 337 - imaging anatomy, - unilateral absent, osteoid osteoma vs., 707 Parsonage-Turner syndrome See also Brachial plexus, idiopathic neuritis - suprascapular neuropathy vs., 1023 Partial cord syndrome See Spinal cord syndrome, central Partial vertebral duplication, 152–153 Pathologic fractures - burst C2 fracture vs., 280 - due to tumor anterior compression fracture vs., 331 thoracic and lumbar burst fracture vs., 315 - lateral compression fracture vs., 335 - vertebral, Chance fracture vs., 324 Pedicle, unilateral absent, osteoid osteoma vs., 707 Pedicle stress fracture, 342–345 - differential diagnosis, 343 - osteoid osteoma vs., 707 - spondylolysis vs., 513 Pedicolaminar fracture-separation See Cervical hyperextension-rotation injury Pediculolysis See Pedicle stress fracture Penetrating spinal trauma, SCIWORA vs., 353 Peridural fibrosis, 1068–1071 - differential diagnosis, 1069 - imaging, 1069, 1071 - lumbar intervertebral disc herniation vs., 437 - recurrent disc herniation vs., 1065 Perineural lymphomatosis (peripheral neurolymphomatosis), 1010–1011 Perineural root sleeve cyst, 842–845 - aneurysmal bone cyst vs., 717–718 - conjoined nerve roots vs., 35 - connective tissue disorders vs., 213 - differential diagnosis, 843 - foraminal disc extrusion vs., 443 - neurofibroma vs., 791 - sacral extradural arachnoid cyst vs., 121 - schwannoma vs., 777 - staging, grading, & classification, 843–844 - traumatic neuroma vs., 999 Perineural vein, enlarged, ulnar neuropathy vs., 1019 Periodontoid pseudotumor, 502–505 - differential diagnosis, 503 Peripheral nerve sheath tumor, 1006–1009 - differential diagnosis, 1007 - extramedullary hematopoiesis vs., 965 - median neuropathy vs., 1027 Peripheral nerve tumor - benign or malignant traumatic neuroma vs., 999 - metastasis, peripheral neurolymphomatosis, 1011 Peripheral neurolymphomatosis, 1010–1011 - differential diagnosis, 1011 - imaging, 1011 Perivertebral venous plexus, cement, vertebroplasty complications vs., 1057 Peroneal neuropathy, common, 1028–1029 Phase ghosting artifact See MR artifacts Phlegmon - CSF leakage syndrome vs., 1095 - epidural traumatic disc herniation vs., 313 traumatic dural tear vs., 379 traumatic epidural hematoma vs., 383 - epidural, peridural fibrosis vs., 1069 - paravertebral, extramedullary hematopoiesis vs., 965 Physiologic motion, spondylolisthesis vs., 509 Pia, imaging anatomy, Pilonidal sinus - dorsal dermal sinus vs., 85 - simple coccygeal dimple vs., 89 Plantar muscles, isolated fatty atrophy of, tibial neuropathy vs., 1031 xxiii INDEX Plasmacytoma, 756–759 - aneurysmal bone cyst vs., 717 - chondrosarcoma vs., 729 - chordoma vs., 737 - differential diagnosis, 757 - staging, grading, & classification, 758 Plates and screws, 1112–1115 - cages vs., 1117 - cervical artificial disc vs., 1127 - interspinous spacing devices vs., 1113 - scoliosis instrumentation vs., 241 - staging, grading, & classification, 1113 Plexiform neurofibroma - pseudomeningocele vs., 1090 - radiation plexopathy vs., 1003 Plexopathy - lumbar, femoral neuropathy vs., 1017 - radiation, thoracic outlet syndrome vs, 985 Plexus and peripheral nerve lesions, 974–1033 - anatomy-based imaging issues, 974–975 - brachial plexus See Brachial plexus - clinical implications, 975 - common peroneal neuropathy, 1028–1029 - differential diagnosis, 975 - femoral neuropathy, 1016–1017 - high-resolution MR imaging protocols, 976 - hypertrophic neuropathy See Hypertrophic neuropathy - imaging anatomy, 974 - median neuropathy, 1026–1027 - muscle denervation, 988–989 - normal plexus and nerve anatomy, 974–979 - peripheral nerve sheath tumor See Peripheral nerve sheath tumor - peripheral neurolymphomatosis, 1010–1011 - radiation plexopathy, 1002–1005 - stretch injury, peripheral neurolymphomatosis vs., 1011 - superior sulcus tumor, 980–983 - suprascapular nerve entrapment, idiopathic brachial plexus neuritis vs., 995 - suprascapular neuropathy, 1022–1025 - terminology, 974 - thoracic outlet syndrome vs., 984–987 - tibial neuropathy, 1030–1033 - traction injury, radiation plexopathy vs., 1003 - traumatic neuroma, 998–1001 peripheral nerve sheath tumor vs., 1007 - ulnar neuropathy, 1018–1021 PNET (primitive neuroectodermal tumor), Ewing sarcoma vs., 743 Poliomyelitis, degenerative scoliosis vs., 236 Polyneuropathies - chronic, Guillain-Barré syndrome vs., 665 - chronic inflammatory demyelinating, 668–671 brachial plexus traction injury vs., 991 differential diagnosis, 669 hypertrophic neuropathy vs., 1013 lateral meningocele vs., 165 peripheral neurolymphomatosis vs., 1011 - chronic interstitial demyelinating neurofibroma vs., 791 - hereditary, Guillain-Barré syndrome vs., 665 xxiv Polyradiculoneuropathy - acute inflammatory demyelinating See Guillain-Barré syndrome - congenital hypertrophic CSF disseminated metastases vs., 799 neurofibromatosis type vs., 177 - subacute inflammatory demyelinating, Guillain-Barré syndrome vs., 665 Positional scoliosis, scoliosis vs., 230 Posterior column fracture See Facet-lamina thoracolumbar fracture Posterior element, incomplete fusion, 154–155 Posterior fossa dural fistula, with intraspinal drainage, presyrinx edema vs., 361 Posterior inferior cerebellar artery, low, persistent first intersegmental artery vs., 873 Posterior longitudinal ligament (PLL) - imaging anatomy, - ossification See Ossification, posterior longitudinal ligament Post-irradiation vertebral marrow, 1158–1161 - differential diagnosis, 1159 - imaging, 1159, 1161 Postoperative change, 1041–1045 Postoperative imaging and complications, 1036–1103 - accelerated degeneration, 1080–1083 - arachnoiditis/adhesions, 1072–1077 - arachnoiditis ossificans, 1078–1079 - CSF leakage syndrome See Cerebrospinal fluid leakage syndrome - deformity, postsurgical, 1100–1103 - failed back surgery syndrome, 1060–1063 - myelography complications, 1052–1055 - normal postoperative change, 1040–1045 accelerated degenerative, 1081 - peridural fibrosis, 1068–1071 recurrent disc herniation vs., 1065 - postoperative change, 1041–1045 - postoperative spinal complications, 1046–1051 - pseudomeningocele See Pseudomeningocele - recurrent disc herniation, 1064–1067 - surgical approaches, 1036–1039 - vertebroplasty complications, 1056–1059 Postoperative spinal complications, 1046–1051 - differential diagnosis, 1048 - imaging, 1047–1048, 1049–1051 Postoperative status, instability vs., 517 Post-polio syndrome, flat back syndrome vs., 239 Postprocedural imaging: hardware, 1106–1151 - cages, 1116–1117 differential diagnosis, 1117 interbody fusion devices vs., 1119 lumbar artificial disc vs., 1131 - cervical artificial disc, 1126–1129 differential diagnosis, 1129 interbody fusion device vs., 1119 staging, grading, & classification, 1127 - hardware failure, 1134–1139 - heterotopic bone formation, 1148–1151 rhBMP-2 complications vs., 1145 INDEX - interbody fusion devices See Interbody fusion devices - interspinous spacing devices, 1122–1125 - lumbar artificial disc, 1130–1133 interbody fusion devices vs., 1119 - metal artifact, 1106–1109 - occipitocervical fixation, 1110–1111 - plates and screws See Plates and screws - rhBMP-2 complications, 1144–1147 Post radiation and chemotherapy complications, 1154–1163 - post-irradiation vertebral marrow, 1158–1161 - radiation myelopathy, 1154–1157 Postsurgical instability See Deformity, postsurgical Presyrinx edema, 360–363 - differential diagnosis, 361 Presyrinx state See Presyrinx edema Primitive neuroectodermal tumor (PNET), Ewing sarcoma vs., 743 Proatlantal artery - intersegmental persistent first intersegmental artery vs., 873 persistent hypoglossal artery vs., 875 - persistent, 876–877 differential diagnosis, 877 Proatlas segmentation abnormality, paracondylar process vs., 133 Prolapsed disc See Disc herniation Pronator syndrome See Median neuropathy Prosthesis, VB See Cages Prosthesis failure See Hardware failure Protruded disc See Disc herniation; Disc protrusions Pseudoachondroplasia, achondroplasia vs., 187 Pseudoarthrosis - accelerated degeneration vs., 1080–1083 - bone graft complications vs., 1141 - degenerative endplate changes vs., 411 - failed back surgery syndrome vs., 1060–1063 - instability vs., 517 Pseudogout See Periodontoid pseudotumor Pseudomeningocele See also Trauma, dural tear - avulsion, 990–993 - CSF leakage syndrome vs., 1095 - meningeal cyst vs., 838 - postoperative, 1088–1093 differential diagnosis, 1089–1090 imaging, 1089, 1091–1093 myelomeningocele vs., 73 peridural fibrosis vs., 1069 Pseudoneoplasm, calcifying See Tumoral calcinosis Pseudopannus, CPPD vs., 551 Pseudosubluxation - Hangman's C2 fracture vs., 283 - spondylolisthesis vs., 509 Pseudotumor, degenerative arthritis of CVJ vs., 415 Psoriatic arthritis - ankylosing spondylitis vs., 547 - DISH vs., 491 Pycnodysostosis - osteopetrosis vs., 207 - tuberous sclerosis vs., 203 Pyogenic abscess - cysticercosis vs., 639 - schistosomiasis vs., 635 Pyogenic infections - facet joint See Facet joints, septic arthritis - neurogenic (Charcot) arthropathy vs., 541 - osteomyelitis See Osteomyelitis, pyogenic Q Quadrilateral space syndrome, idiopathic brachial plexus neuritis vs., 995 R Radiation complications - degenerative scoliosis vs., 236 - fibrosis, superior sulcus tumor vs., 981 - hemangioma vs., 703 - myelopathy, 1154–1157 differential diagnosis, 1155 imaging, 1155, 1157 presyrinx edema vs., 361 spinal cord infarction vs., 911 spinal cord metastases vs., 825 - myopathy, muscle denervation vs., 989 - neuritis/myositis, idiopathic brachial plexus neuritis vs., 995 - plexopathy, 1002–1005 differential diagnosis, 1003 staging, grading, & classification, 1003 - post-irradiation vertebral marrow, 1158–1161 - radiculopathy after, Guillain-Barré syndrome vs., 665 - scoliosis vs., 230 Radicular (meningeal) cyst, lateral meningocele vs., 165 Radiculopathy - anterior lumbar, 1162 differential diagnosis, 1163 imaging, 1163 - cervical idiopathic brachial plexus neuritis vs., 995 median neuropathy vs., 1026–1027 suprascapular neuropathy vs., 1023 - chronic, Hirayama disease vs., 859 - postradiation anterior lumbar radiculopathy vs., 1163 Guillain-Barré syndrome vs., 665 - tibial neuropathy vs., 1031 Reactive arthritis, DISH vs., 491 Reactive arthropathy, ankylosing spondylitis vs., 547 Recombinant human bone morphogenetic protein (rhBMP-2) complications, 1144–1147 - differential diagnosis, 1145 Recurrent extrusion See Disc herniation, recurrent Recurrent protrusion See Disc herniation, recurrent Reiter arthritis See Reactive arthritis Renal osteodystrophy, 954–955 - blastic osseous metastases vs., 696 xxv INDEX - differential diagnosis, 955 - hyperparathyroidism vs., 953 - imaging, 955 - osteopetrosis vs., 207 - sickle cell disease vs., 195 Retinoid therapy, spondyloarthropathy vs., 535–536 Retropharyngeal abscess, longus colli calcific tendinitis vs., 559 Retropharyngeal tendinitis, calcific, periodontoid pseudotumor vs., 503 Rheumatoid arthritis - adult, 522–527 atlantooccipital dislocation vs., 254 CPPD vs., 551 degenerative arthritis of CVJ vs., 415 differential diagnosis, 523 periodontoid pseudotumor vs., 503 staging, grading & classification, 524 - ankylosing spondylitis vs., 547 - C1/C2 subluxation, odontoid C2 fracture vs., 275 - gout vs., 557 - juvenile See Juvenile idiopathic arthritis - measurement techniques, 11 - osteomyelitis of C1-C2 vs., 587 - septic facet joint arthritis vs., 593 - spondyloarthropathy vs., 535 Ribs, hypoplastic or accessory, lumbar facet-posterior fracture vs., 337 Rickets, renal osteodystrophy vs., 955 RIF (radiation-induced fibrosis) See Radiation, plexopathy RIP (radiation-induced plexitis) See Radiation, plexopathy Risser index, for scoliosis, 224 Rotary subluxation See Atlantoaxial rotatory fixation (AARF) Rotator cuff tear - idiopathic brachial plexus neuritis vs., 996 - suprascapular neuropathy vs., 1023 Ruptured disc See Disc herniation S Sacral agenesis See Caudal regression syndrome Sacral fracture - insufficiency fracture, 346–349 differential diagnosis, 347–348 - metastases, sacral insufficiency fracture vs., 347 - traumatic, 338–341 differential diagnosis, 339 osteoporosis vs., 945 sacral insufficiency fracture vs., 347 Sacral meningocele, anterior See Meningocele, anterior sacral Sacral plexus, imaging anatomy, 974 Sacrococcygeal teratoma, 65, 124–127 - anterior sacral meningocele vs., 117 - chordoma vs., 737 - differential diagnosis, 125 - staging, grading, and classification, 126 - terminal myelocystocele vs., 113 xxvi Sacroiliac joint - degenerative change, Bertolotti syndrome vs., 465 - disruption/dislocation, sacral traumatic fracture vs., 339 Sacroiliitis - in ankylosing spondylitis, 547 - infectious, spondyloarthropathy vs., 535 - sacral insufficiency fracture vs., 348 Sarcoidosis, 672–677 - differential diagnosis, 673 - hypertrophic pachymeningitis vs., 861 - schistosomiasis vs., 635 - spinal cord metastases vs., 825 - spinal meningitis vs., 569 - staging, grading, & classification, 674 - syphilitic myelitis vs., 625 Sarcoma - cervical facet arthropathy vs., 447 - osteogenic giant cell tumor vs., 721 osteoblastoma vs., 713–714 - soft tissue, peripheral nerve sheath tumor vs., 1007 - superior sulcus tumor vs., 981 Scheuermann disease, 470–473 - differential diagnosis, 471 - lateral compression fracture vs., 335 - scoliosis vs., 230 Scheuermann kyphosis - anterior compression fracture vs., 331 - kyphosis vs., 233 Schistosomiasis, 634–637 - differential diagnosis, 635 - staging, grading, & classification, 636 Schmorl node, s See also Scheuermann disease - anterior compression fracture vs., 331 - apophyseal ring fracture vs., 287 - bone island vs., 45 - differential diagnosis, 467 - lateral compression fracture vs., 335 - limbus vertebra vs., 39 - lytic osseous metastases vs., 699–700 - staging, grading, & classification, 468 Schwannoma, 776–779 - cystic, idiopathic spinal cord herniation vs., 371 - cysticercosis vs., 640 - differential diagnosis, 777–778 - foraminal disc extrusion vs., 443 - hemangiopericytoma vs., 787 - meningioma vs., 781 - neurofibroma vs., 791 - nonsyndromic, neurofibromatosis type vs., 181 - paraganglioma vs., 803 - with paramagnetic effects, filum terminale fibrolipoma vs., 43 - staging, grading, & classification, 778 SCIWORA (spinal cord injury without radiological abnormality), 352–355 - differential diagnosis, 353 Sclerotic island See Bone island Scoliosis, 224–231 - compensatory vs., 230 INDEX - congenital vs., 229 degenerative scoliosis vs., 236 - degenerative, 234–237 differential diagnosis, 235–236 - differential diagnosis, 225, 229–230 - due to syndromes, kyphosis vs., 233 - iatrogenic vs., 230 - idiopathic vs., 229 adult, degenerative scoliosis vs., 235–236 - imaging, 229 postoperative, 225 protocols, 225 role of advanced imaging, 224 - instrumentation, 240–243 differential diagnosis, 241 flat back syndrome vs., 239 - measurement of, 224 - morphology of curvature, 224 - neuromuscular vs., 229 degenerative scoliosis vs., 236 - positional vs., 230 - post-traumatic, inflammatory, or neoplastic, degenerative scoliosis vs., 236 - radiology reporting, 224 - Risser index, 224 - surgery See Scoliosis, instrumentation - terminology, 224 - treatment, 224 Screws See Plates and screws Seat belt fracture See Chance fracture Secondary degeneration See Wallerian degeneration Segmental instability See Instability Segmental spinal dysgenesis, 104–107 - clinical issues, 106 - differential diagnosis, 105 - imaging, 105, 107 - pathology, 105–106 - staging, grading, and classification, 106 Senile ankylosing hyperostosis See Diffuse idiopathic skeletal hyperostosis (DISH) Senile osteoporosis, hyperparathyroidism vs., 953 Sensory and autonomic neuropathy, hereditary See Hypertrophic neuropathy Sensory neuropathy, hereditary See Hypertrophic neuropathy Septic facet joint See Facet joints, septic; Facet joints, septic arthritis Septic meningitis, myelography complications vs., 1053 Sequestered disc See Disc herniation Seromas, rhBMP-2 complications vs., 1145 Seronegative spondyloarthropathy See Spondyloarthropathy, seronegative Shear injury, Chance fracture vs., 323 Shock, electrical, SCIWORA vs., 353 Sickle cell disease, 194–197 - bone infarction secondary to, 963 - differential diagnosis, 195 - Gaucher disease vs., 209 Simple bone cyst, aneurysmal bone cyst vs., 718 Simple coccygeal dimple See Coccygeal dimple, simple Skeletal hyperostosis, asymmetrical See Diffuse idiopathic skeletal hyperostosis (DISH) "Slipped" disc See Disc herniation Slipped vertebral apophysis See Apophyseal ring fracture Soft tissue inflammation, rhBMP-2 complications vs., 1145 Soft tissue sarcoma - malignant nerve sheath tumors vs., 795 - neurogenic (Charcot) arthropathy vs., 541 - peripheral nerve sheath tumor vs., 1007 Soft tissue tumor, pseudomeningocele vs., 1089 Solitary fibrous tumor See Hemangiopericytoma Space syndrome, quadrilateral, idiopathic brachial plexus neuritis vs., 995 Spacing devices See Interspinous spacing devices Spina bifida aperta See Myelomeningocele Spina bifida cystica See Myelomeningocele Spinal arteries - aneurysm, 908–909 - imaging anatomy, 866–867 Spinal cord - abscess, 612–615 differential diagnosis, 613 - cavernous malformation central spinal cord syndrome vs., 375 spinal cord contusion-hematoma vs., 365 - central T2 hyperintensity, superficial siderosis vs., 929 - contusion-hematoma, 364–369 differential diagnosis, 365 subacute combined degeneration vs., 679 - duplicated, diastematomyelia vs., 149 - embryology, 66 - expansion, post-traumatic syrinx vs., 357 - hemorrhage coagulopathy with, nontraumatic spinal cord hemorrhage vs., 933 MR artifacts vs., 18 nontraumatic clinical issues, 933 differential diagnosis, 933 imaging, 933, 934–935 - herniation, idiopathic See Spinal cord herniation, idiopathic - imaging, 103 - injury without radiological abnormality (SCIWORA), 352–355 - peripheral T2 hypointensity in dural fistula, superficial siderosis vs., 929 - tethered, 100–103 caudal regression syndrome vs., 109 clinical issues, 102 differential diagnosis, 101 filum terminale fibrolipoma vs., 43 - transient dilation of central canal, ventriculus terminalis vs., 47 Spinal cord herniation, idiopathic, 370–373 - differential diagnosis, 371 - meningeal cyst vs., 837 Spinal cord infarction, 910–913 - acute disseminated encephalomyelitis vs., 661 - acute transverse myelopathy vs., 646 xxvii INDEX - central spinal cord syndrome vs., 375 - contusion-hematoma vs., 365 - differential diagnosis, 911 - idiopathic acute transverse myelitis vs., 649 - nontraumatic spinal cord hemorrhage vs., 933 - paraneoplastic myelopathy vs., 687 - presyrinx edema vs., 361 - radiation myelopathy vs., 1155 - sarcoidosis vs., 673 - spinal cord abscess vs., 613 - subacute combined degeneration vs., 679 - viral myelitis vs., 617 - Wallerian degeneration vs., 397 Spinal cord neoplasms/tumors - acute transverse myelopathy vs., 646 - cervical spondylosis vs., 485 - cystic syringomyelia vs., 847 ventriculus terminalis vs., 47 - dural arteriovenous fistula vs., 879 - hemorrhagic, melanocytoma vs., 829 - hypervascular hemangioblastoma vs., 819 spinal cord abscess vs., 613 - idiopathic acute transverse myelitis vs., 649 - intradural/extramedullary hemangioblastoma vs., 819 melanocytoma vs., 829 with prominent vascular supply conus arteriovenous malformations vs., 897 type (glomus-type) AVM vs., 885 type (juvenile type) AVM vs., 889 type (perimedullary) AVF vs., 893 - intramedullary cavernous malformation vs., 905 hemorrhage from, spinal artery aneurysm vs., 909 sarcoidosis vs., 673 subarachnoid hemorrhage vs., 915 type (glomus-type) AVM vs., 885 type (juvenile type) AVM vs., 889 type (perimedullary) AVF vs., 893 - neuromyelitis optica vs., 657 - post-traumatic syrinx vs., 357 - spinal cord infarction vs., 911 Spinal cord syndrome - anterior, in spinal cord contusion-hematoma, 366 - central, 374–377 differential diagnosis, 375 in spinal cord contusion-hematoma, 366 - posterior, in spinal cord contusion-hematoma, 366 Spinal cord trauma - central spinal cord syndrome, 374–377 differential diagnosis, 375 in spinal cord contusion-hematoma, 366 - contusion-hematoma, 364–369 differential diagnosis, 365 imaging, 365 staging, grading, & classification, 365–366 subacute combined degeneration vs., 679 - penetrating, SCIWORA vs., 353 xxviii Spinal dysgenesis, segmental, 104–107 - clinical issues, 106 - differential diagnosis, 105 - imaging, 105, 107 - pathology, 105–106 - staging, grading, and classification, 106 Spinal dysraphism - closed (occult) caudal regression syndrome vs., 109 incomplete fusion of posterior element vs., 155 myelomeningocele vs., 73 tethered spinal cord vs., 101 - open See Myelomeningocele - posterior, normal variant vs., 24 Spinal epidural hematoma (SEH), 383 Spinal epidural lymphoma, extramedullary hematopoiesis vs., 965 Spinal fusion surgery, for scoliosis, 241 Spinal manifestations of systemic disease, 944–971 - bone infarction, 962–963 bone island vs., 45 - extramedullary hematopoiesis, 964–967 - hyperparathyroidism, 952–953 osteoporosis vs., 945 primary, renal osteodystrophy vs., 955 renal osteodystrophy vs., 953 - hyperplastic vertebral marrow, 956–959 - osteoporosis See Osteoporosis - Paget disease See Paget disease - renal osteodystrophy See renal osteodystrophy - tumoral calcinosis, 968–971 Baastrup disease vs., 969 differential diagnosis, 969 lumbar facet arthropathy vs., 451 Spinal meningeal cyst, extradural, pseudomeningocele vs., 1089 Spinal meningitis See Meningitis Spinal nerve root See Nerve root Spinal stenosis - acquired congenital spinal stenosis vs., 479 lumbar central, 474–477 - arachnoiditis/adhesions vs., 1073 - arachnoiditis ossificans vs., 1079 - congenital, 478–483 differential diagnosis, 479 staging, grading, & classification, 479 - inherited, congenital spinal stenosis vs., 479 Spinal "transitional" degenerative syndrome See Accelerated degeneration, postoperative Spinal veins, imaging anatomy, Spine - abnormal motion See Instability - anatomy, s See also Normal anatomical variations images, 6–9 imaging anatomy, 4–5 measurement techniques, 10–15 - aplasia, medial, segmental spinal dysgenesis vs., 105 - congenital anomalies, SCIWORA vs., 353 - congenital fusion, juvenile idiopathic arthritis vs., 529 - epidural empyema See Epidural abscess INDEX - fusion surgery See Plates and screws instability See Instability instrumentation See Plates and screws measurement techniques, 10–15 trauma See Spinal cord trauma tumor cervical intervertebral disc herniation vs., 427 dural dysplasia vs., 173 thoracic intervertebral disc herniation vs., 433 Spinous process impingement syndrome See Baastrup disease Split atlas, 134–135 - differential diagnosis, 135 Split cord malformation See Diastematomyelia Spondylitis - ankylosing See Ankylosing spondylitis - brucellar, 590–591 differential diagnosis, 591 tuberculous osteomyelitis vs., 579 Spondyloarthropathy, 534–539 - differential diagnosis, 535–536 - seronegative connective tissue disorder, 213 CPPD vs., 551 degenerative disc disease vs., 405 degenerative endplate changes vs., 411 gout vs., 557 hyperparathyroidism vs., 953 rheumatoid arthritis vs., 523 - staging, grading & classification, 536 Spondyloarthropathy of hemodialysis, 544–545 - degenerative disc disease vs., 405 - degenerative endplate changes vs., 411 - differential diagnosis, 545 - imaging, 545 - osteomyelitis of C1-C2 vs., 588 - pyogenic osteomyelitis vs., 573–574 Spondylocostal dysostosis, thanatophoric dwarfism vs., 221 Spondylodiscitis, lytic osseous metastases vs., 700 Spondyloepimetaphyseal dysplasia, spondyloepiphyseal dysplasia vs., 217 Spondyloepiphyseal dysplasia, 216–219 - achondroplasia vs., 187 - differential diagnosis, 217 - mucopolysaccharidoses vs., 191 - sickle cell disease vs., 195 - staging, grading, & classification, 217 - tarda, Scheuermann disease vs., 471 - thanatophoric dwarfism vs., 221 Spondylolisthesis, 508–511 - accelerated degeneration vs., 1082 - axis, traumatic See Hangman's C2 fracture - in degenerative scoliosis, 235 - differential diagnosis, 509 - imaging, 509, 511 - isthmic, postsurgical deformity vs., 1101 - staging, grading, & classification, 510 Spondylolysis, 512–515 - accelerated degeneration vs., 1081 - differential diagnosis, 513 - pedicle stress fracture vs., 343 - primary cervical, Hangman's C2 fracture vs., 283 - unilateral, osteoid osteoma vs., 707 Spondylometaphyseal dysplasia, spondyloepiphyseal dysplasia vs., 217 Spondylosis See also Disc disease, degenerative - cervical, 484–489 - DISH vs., 491 - OPLL vs., 495 Spontaneous dissection, cervical vascular injury vs., 389 Staphylococcal pneumonia, superior sulcus tumor vs., 981 Stenosis, spinal See Spinal stenosis Stress fracture - calcaneal, tibial neuropathy vs., 1031 - lamina, osteoid osteoma vs., 707 - pedicle, 342–345 differential diagnosis, 343 osteoid osteoma vs., 707 spondylolysis vs., 513 - sacral traumatic fracture vs., 339 Subacute combined degeneration, 678–681 - differential diagnosis, 679 - Wallerian degeneration vs., 397 Subarachnoid hemorrhage, 914–917 - differential diagnosis, 915 - filum terminale fibrolipoma vs., 43 - staging, grading, & classification, 916 - superficial siderosis vs., 929 Subarticular recess stenosis, 235 Subaxial cervical spine injury classification, 247, 248 Subdural abscess, 608–611 - differential diagnosis, 609 - subdural hematoma vs., 925 - traumatic subdural hematoma vs., 387 Subdural effusion, postoperative spinal complications vs., 1048 Subdural hematoma, 924–927 - differential diagnosis, 925 - spontaneous epidural hematoma vs., 919 - subdural abscess vs., 609 - traumatic, 386–387 differential diagnosis, 387 Subdural hemorrhage - postoperative spinal complications vs., 1048 - subarachnoid hemorrhage vs., 915 - superficial siderosis vs., 929 Subluxation - atlantoaxial rotatory See Atlantoaxial rotatory fixation (AARF) - C1/C2, rheumatoid arthritis, odontoid C2 fracture vs., 275 - cervical spine physiologic, juvenile idiopathic arthritis vs., 529 vertebral pseudosubluxation, imaging, 23 - nontraumatic atlantoaxial See Grisel syndrome - pseudosubluxation Hangman's C2 fracture vs., 283 spondylolisthesis vs., 509 - rotatory, C2-C3, Hangman's C2 fracture vs., 283 - vertebral cervical vertebral pseudosubluxation, imaging, 23 xxix INDEX traumatic or degenerative, normal variant vs., 23 Superficial siderosis, 928–931 - differential diagnosis, 929 Superior sulcus tumor, 980–983 - differential diagnosis, 981 - staging, grading, & classification, 982 Suprascapular nerve entrapment, idiopathic brachial plexus neuritis vs., 996 Suprascapular neuropathy, 1022–1025 - differential diagnosis, 1023 Surgical approaches, 1036–1039 Surgical instrumentation, failure of, scoliosis related to, 225 Symphysis, Synarthrosis, Syndesmosis, Synovial chondromatosis, tumoral calcinosis vs., 969 Synovial cyst - conjoined nerve roots vs., 35 - facet joint, 454–459 differential diagnosis, 455–456 meningeal cyst vs., 837 perineural root sleeve cyst vs., 843 septic facet joint arthritis vs., 593 - periodontoid pseudotumor vs., 503 - recurrent disc herniation vs., 1065 - tumoral calcinosis vs., 969 Syphilitic myelitis, 624–625 Syringohydromyelia See Syringomyelia, post-traumatic Syringomyelia, 18, 846–849 - central spinal cord syndrome vs., 375 - cervical spondylosis vs., 485 - cysticercosis vs., 639 - differential diagnosis, 847 - dural dysplasia vs., 173 - MR artifacts vs., 18 - nontraumatic post-traumatic syrinx vs., 357 presyrinx edema vs., 361 - post-traumatic, 356–359 acute transverse myelopathy vs., 646 astrocytoma vs., 807 differential diagnosis, 357 presyrinx edema vs., 361 Wallerian degeneration vs., 397 - radiation myelopathy vs., 1155 - spinal cord contusion-hematoma vs., 365 - ventriculus terminalis vs., 847 Syrinx See Syringomyelia Systemic lupus erythematosus - acute disseminated encephalomyelitis vs., 661 - bone infarction secondary to, 963 - nontraumatic spinal cord hemorrhage vs., 933 T Takayasu arteritis, cervical vascular injury vs., 390 Tarlov cyst See Perineural root sleeve cyst Tarsal tunnel syndrome See Tibial neuropathy TCS See Tethered cord syndrome xxx Telangiectatic osteogenic sarcoma, aneurysmal bone cyst vs., 717 Tendon tear, muscle denervation vs., 989 Tenosynovitis, median neuropathy vs., 1026–1027 Terminal myelocystocele See Myelocystocele, terminal Tethered cord syndrome, 65 Tethered spinal cord, 100–103 - caudal regression syndrome vs., 109 - differential diagnosis, 101 - filum terminale fibrolipoma vs., 43 - postoperative spinal complications vs., 1048 Thalassemia, sickle cell disease vs., 195 Thanatophoric dysplasia, achondroplasia vs., 187 Thoracic and lumbar hyperextension injury, 328–329 - differential diagnosis, 329 Thoracic outlet syndrome (TOS), 984–987 - differential diagnosis, 985 - median neuropathy vs., 1027 Thoracic spine - imaging anatomy, 4, 866 - intervertebral disc herniation, 432–435 differential diagnosis, 433 - surgery, in childhood, scoliosis related to, 225 - surgical approaches, 1036–1037 - tumors, other than NSCLC, superior sulcus tumor vs., 981 Thoracic spine fractures - anterior compression fracture, 330–333 clinical issues, 332 differential diagnosis, 332 imaging, 331 pathology, 332 - burst fracture, 314–317 clinical issues, 316 differential diagnosis, 315 imaging, 315 pathology, 315–316 thoracic and lumbar hyperextension injury vs., 329 - lateral compression fracture, 334–335 differential diagnosis, 335 imaging, 335 - low thoracic distraction fracture, thoracic and lumbar hyperextension injury vs., 329 - thoracolumbar fracture classification, 247 facet-lamina, 318–319 Thoracolumbar fracture, classification, 247 Thoracolumbar Injury Classification and Severity Score (TLICS), 247 Thoracolumbar injury severity score, 248 Thrombosis - inferior vena cava, CSF leakage syndrome vs., 1095 - jugular vein, CSF leakage syndrome vs., 1095 Tibial neuropathy, 1030–1033 - differential diagnosis, 1031 - imaging, 1031, 1032–1033 Tonsil herniation, acquired, Chiari malformation vs., 53 Tonsillar displacement below foramen magnum, Chiari malformation vs., 53 Torg-Pavlov ratio, 10 INDEX Torticollis - Grisel syndrome vs., 685 - muscular, atlantoaxial rotatory fixation vs., 269 Total lumbar disc replacement (TLDR) See Lumbar spine, artificial disc Traction neuropathy, suprascapular neuropathy vs., 1023 Transverse ligament, calcification of See Periodontoid pseudotumor Transverse myelitis See Myelitis, transverse Transverse process fracture, normal variant vs., 23 Trauma - arteriovenous fistula, 394–395 differential diagnosis, 395 - atlantoaxial rotatory fixation vs., 269 - craniovertebral junction variants vs., 27 - disc herniation, traumatic, 312–313 - dural tear, 378–381 differential diagnosis, 379 - epidural hematoma, 382–385 differential diagnosis, 383 traumatic dural tear vs., 379 traumatic subdural hematoma vs., 387 - fracture dislocation, 320–321 differential diagnosis, 321 thoracic and lumbar burst fracture vs., 315 thoracic and lumbar hyperextension injury vs., 329 - nerve, common peroneal, direct, common peroneal neuropathy vs., 1029 - neuroma, traumatic, peripheral nerve sheath tumor vs., 1007 - nonaccidental, osteogenesis imperfecta vs., 199 - penetrating spinal, SCIWORA vs., 353 - plexus and peripheral nerve lesions vs., 975 - scoliosis vs., 225, 230 - subdural hematoma, 386–387 differential diagnosis, 387 - thoracic outlet syndrome vs., 985 Traumatic meningocele See Trauma, dural tear Trisomy 21 See Down syndrome (trisomy 21) Tuberculosis - degenerative scoliosis vs., 236 - hypertrophic pachymeningitis vs., 861 - neurogenic (Charcot) arthropathy vs., 541 - Scheuermann disease vs., 471 - schistosomiasis vs., 635 - spinal cord metastases vs., 825 - superior sulcus tumor vs., 982 Tuberculous osteomyelitis, 578–583 - brucellar spondylitis vs., 591 - differential diagnosis, 579 - vertebral, pyogenic osteomyelitis vs., 573 Tuberous sclerosis, 202–205 - differential diagnosis, 203 - fibrous dysplasia vs., 855 - staging, grading, & classification, 204 Tumor mimics - epidural lipomatosis See epidural lipomatosis - hypertrophic pachymeningitis, 860–863 differential diagnosis, 861 - Kümmell disease, 856–857 Tumoral calcinosis, 968–971 - Baastrup disease vs., 461 - differential diagnosis, 969 - longus colli calcific tendinitis vs., 559 - lumbar facet arthropathy vs., 451 - osteochondroma vs., 725 Tumors See Neoplasms/tumors U Ulnar neuropathy, 1018–1021 - differential diagnosis, 1019 - imaging, 1019, 1021 - staging, grading, & classification, 1020 Unstable fracture, classification, 247 V VACTERL association, congenital scoliosis related to, 225 Variable central stenosis, 235 Varicella-zoster virus infection, HIV myelitis vs., 621 Vascular injury, cervical, 388–393 - differential diagnosis, 389–390 Vascular lesions - anatomy, 866–871 - arteriovenous fistula See Arteriovenous fistula (AVF) - arteriovenous malformations See Arteriovenous malformations (AVMs) - Bow Hunter syndrome, 936–937 - cavernous malformation See Cavernous malformation - embryology, 867 - imaging anatomy, 866 spinal arteries, 866–867 spinal veins, 867 vertebral artery, 866 - spinal artery aneurysm, 908–909 - spinal cord hemorrhage, nontraumatic, 932–935 clinical issues, 933 differential diagnosis, 933 imaging, 933, 934–935 - spinal cord infarction See Spinal cord infarction - spontaneous epidural hematoma, 918–923 - subarachnoid hemorrhage See Subarachnoid hemorrhage - subdural hematoma See Subdural hematoma - superficial siderosis, 928–931 - vascular malformations See Vascular malformations Vascular malformations - acute disseminated encephalomyelitis vs., 661 - spinal, syphilitic myelitis vs., 625 - type See Dural arteriovenous fistula (DAVF) - type See Arteriovenous malformations (AVMs), type (glomus-type) - type See Arteriovenous malformations (AVMs), type (juvenile type) - type See Arteriovenous fistula (AVF), type (perimedullary) - venolymphatic, superior sulcus tumor vs., 981 Vasculitic neuropathy, Guillain-Barré syndrome vs., 665 xxxi INDEX Vasculitis - nontraumatic spinal cord hemorrhage vs., 933 - systemic autoimmune, acute disseminated encephalomyelitis vs., 661 - vertebral artery dissection vs., 939 Vasospasm, catheter-related, cervical vascular injury vs., 390 Venous engorgement - above high-grade spinal stenosis, CSF leakage syndrome vs., 1095 - hypertrophic pachymeningitis vs., 861 Venous plexus - enlarged spinal, CSF leakage syndrome vs., 1095 - perivertebral, cement, vertebroplasty complications vs., 1057 Ventral cord herniation See Spinal cord herniation, idiopathic Ventriculus terminalis, 46–48, 46–49 - differential diagnosis, 47 - staging, grading, and classification, 47 - syringomyelia vs., 847 Vertebra(e) - anomalies, congenital syndromes without, scoliosis vs., 229–230 - butterfly, partial vertebral duplication vs., 153 - congenital displacement, segmental spinal dysgenesis vs., 105 - fractures acute, limbus vertebra vs., 39 history critical, failure of vertebral formation vs., 141 partial vertebral duplication vs., 153 - osteomyelitis, vertebroplasty complications vs., 1057 - rotation, in degenerative scoliosis, 235 - scalloping, posterior, degenerative scoliosis vs., 236 - subluxation, traumatic or degenerative, normal variant vs., 23 - surgical fusion Klippel-Feil spectrum vs., 137 vertebral segmentation failure vs., 145 - wedging, physiologic, anterior compression fracture vs., 332 Vertebral apophyseal fracture (Fx) See Apophyseal ring fracture Vertebral arch - anterior C1 defect, isolated, split atlas vs., 135 incomplete fusion, 128 - imaging anatomy, - ossification See Ossification, ligamentum flavum - posterior C1 defect, isolated, split atlas vs., 135 hypoplastic complete, 128 incomplete formation, 128 Vertebral artery - cervicomuscular collateral persistent first intersegmental artery vs., 873 persistent proatlantal artery vs., 877 - congenital hypoplasia of, vertebral artery dissection vs., 939 xxxii - dissection, 938–943 differential diagnosis, 939 - fenestrated persistent first intersegmental artery vs., 873 persistent proatlantal artery vs., 877 - imaging anatomy, 5, 866 - occlusion of, Bow hunter syndrome vs., 937 Vertebral artery injury (VAI) See Vascular injury, cervical Vertebral body - in ankylosing spondylitis, 547 - centroid measurement, 10 apical vertebral translation, 10 sagittal balance, 10 - displaced fracture, spondylolisthesis vs., 509 - recurrent disc herniation vs., 1065 - replacement cage See Cages Vertebral column blood supply, Vertebral discs See 'LVF entries Vertebral dysplasia See Vertebral formation and segmentation anomalies, failure of vertebral formation Vertebral formation and segmentation anomalies, 128–159 - craniovertebral junction embryology, 128–131 - failure of vertebral formation, 140–143 differential diagnosis, 141 dural dysplasia vs., 173 - Klippel-Feil spectrum See Klippel-Feil spectrum (KFS) - multiple, segmental spinal dysgenesis vs., 105 - normal variant vs., 23 - paracondylar process, 132–133 - partial vertebral duplication, 152–153 - split atlas, 134–135 - vertebral segmentation failure, 144–147 differential diagnosis, 145 staging, grading, & classification, 145–146 Vertebral hemangioma - normal variant vs., 23 - Paget disease vs., 949 - plasmacytoma vs., 757 - post-irradiation vertebral marrow vs., 1159 Vertebral marrow - normal fatty, post-irradiation vertebral marrow vs., 1159 - post-irradiation, 1158–1161 differential diagnosis, 1159 Vertebroplasty complications, 1056–1059 - differential diagnosis, 1057 - imaging, 1057, 1059 Vertebrovertebral arteriovenous fistula See Arteriovenous fistula (AVF), traumatic Viral myelitis See Myelitis, viral Viral neuritis, common peroneal neuropathy vs., 1029 Vitamin B12 deficiency - acute transverse myelopathy vs., 646 - HIV myelitis vs., 621 - paraneoplastic myelopathy vs., 687 von Recklinghausen disease See Neurofibromatosis type INDEX W Wallerian degeneration, 396–397 - differential diagnosis, 397 Wedge compression fractures, Scheuermann disease vs., 471 Whiplash fracture - cervical hyperextension injury vs., 297 - cervical hyperflexion injury vs., 291 Wilms tumor, neuroblastic tumor vs., 765 xxxiii ... algorithm Eur Spine J 22 ( 12) :27 87-99, 20 13 Malghem J et al: Necrotizing fasciitis: Contribution and limitations of diagnostic imaging Joint Bone Spine 80 (2) :146-54, 20 13 Go JL et al: Spine infections... 20 13 Go JL et al: Spine infections Neuroimaging Clin N Am 22 (4):755- 72, 20 12 DeSanto J et al: Spine infection/inflammation Radiol Clin North Am 49(1):105 -27 , 20 11 Celik AD et al: Spondylodiscitis... of the literature Rheumatol Int 29 (10): 123 7-41, 20 09 Hong SH et al: MR imaging assessment of the spine: infection or an imitation? Radiographics 29 (2) :599-6 12, 20 09 Karikari IO et al: Management