Lumbar Spine MRI

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Sagittal MRI Sequences

Sagittal MRI scans are typically taken across five standard planes. There may be further scans between these planes, or it may be slightly displaced to the left or right.

Sagittal MRI five standard planes and the intersecting structures

Plane	Extra-vertebral canal structures	Vertebral canal structures
Median	Vertebral bodies and intervertebral discs (AP and AF) anteriorly, and the spinous processes posteriorly	Conus medullaris at upper segmental levels, and the cauda equina at lower levels.
Paramedian	Vertebral bodies and intervertebral discs anteriorly (AP and AF), and the laminae posteriorly	May miss the spinal cord, and only show the cauda equina.
Transpedicular	Lateral sectors of the vertebral bodies, the lateral sectors of the intervertebral discs (AF +/- NP), the pedicles, and some portions of the facet joints. Slightly more medial intersects the inferiorly articular processes. Slightly more lateral intersects the superior articular processes	Spinal nerves and their dural sleeves as they pass under the pedicles
Tangential	Most lateral margins of the vertebral bodies and the AF at each segmental level, or the concavity of the vertebral body	No intersection
Peripheral	Transverse processes	No intersection

Check List for Interpretation

Before doing anything, first verify patient identification and the date of scan

Basic Pulse Sequences for MRI

Image Type	TR	TE	Fat Signal Intensity	Water Signal Intensity	Advantages	Disadvantages
T1	Short	Short	Bright	Dark	Best anatomic detail, rapid acquisition	Poor visualisation of pathology/oedema
T2	Long	Long	Intermediate	Bright	Moderate sensitivity for pathology/oedema	Poor spatial resolution, time consuming
Fat-suppressed T2	Long	Short	Very dark	Very bright	Most sensitive for pathology/oedema	Susceptible to artifacts related to magnetic resonance inhomogeneity
Gradient Echo	Short	Short	Intermediate	Intermediate/high	Excellent for articular cartilage, PVNS, and blood	Very susceptible to metallic artifacts
Proton Density	Long	Short	Intermediate/high	Intermediate	Excellent for meniscal pathology

Survey View

Count vertebra, and assess for transitional anatomy

Fat Suppressed Coronal

Assess facet joints for effusions, size, cartilage thickness, oedema. Look for extra spinal pathology. Scroll through the sacroiliac joints looking for osteoarthritis, oedema, effusions.

T1 Sagittals

In T1, spinal fluid is dark and fat is bright. Determine the left-right orientation. On the left, the gives off branches at ~L1. On the right, the renal artery runs posterior to IVC. The Aorta is wider than IVC.

Working from caudal to rostral observe:

• Neural foramina and nerve roots: nerve contact and compression.
• Intervertebral discs: width, protrusions/ herniations.
• Spinal column: alignment (spondylolisthesis), vertebral body shape (compression fractures, Schmorls’ nodes), posterior bony elements (spondylolysis), degenerative end plate changes (changes in fat content), hemangiomas.
• Retroperitoneal space: adenopathy, masses, great vessel aneurysm, etc

T2 Sagittals

In T2, spinal fluid is bright.

Working from caudal to rostral observe:

• Dural sac—cord and rootlets: width, compression, irregularities
• Intervertebral discs: width, protrusions/ herniations, hydration, high intensity zones
• Spinal column: alignment (spondylolisthesis), vertebral body shape (compression fractures, Schmorls’ nodes), posterior bony elements (spondylolysis), degenerative end plate changes (changes in fat content), hemangiomas.
• Posterior bony elements: breakage, listhesis, pseudo-articulations, etc.

T1 Axials

The CSF appears gray and fat appears bright. Proceed caudal to cranial.

Orientation – neural foramina lie at level of discs.

• Content of the spinal canal and neural foramina: Trace course of nerve roots through neural foramina
• Intervertebral discs— continuity, bulges, etc.
• Bone – Vertebral bodies; spondylolisthesis, posterior bony elements (spondylolysis, breakage)
• Ligamentam flavum: thickened appearance, impingement
• Retroperitoneal space: adenopathy, masses, muscle, fat infiltration of multifidus (see image)

T2 Axials

Spinal fluid appears bright. Proceed caudal to cranial.

• Content of the spinal canal and neural foramina: Trace course of nerve roots through neural foramina
• Intervertebral discs— continuity, bulges, etc.
• Bone – Vertebral bodies; spondylolisthesis, posterior bony elements (spondylolysis, breakage)
• Ligamentam flavum: thickened appearance, impingement
• Retroperitoneal space: adenopathy, masses, muscle, etc.

Assessment

Ensure you have covered all structures. Assess need for other studies

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,