Guideline to reporting of MRI Lumbar Spine

Poster No.: C-1808

Congress: ECR 2018
Type: Educational Exhibit
Authors: N. Ghoriwala, A. Nadamani, M. Varunya, A. Balachandran, S.
Ashwathappa, R. HV; Bangalore/IN
Keywords: Education and training, eLearning, MR, Mammography,
Musculoskeletal spine, Musculoskeletal soft tissue, Anatomy
DOI: 10.1594/ecr2018/C-1808

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Learning objectives

To learn an effective, accurate and concise method to analyze and report MRI of the
lumbar spine. For this, knowledge of the basic anatomy of the lumbar spine, sequences
used for MRI of lumbar spine and the methodology of reporting is required.

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Background

Anatomy of the lumbar spine:

Bones:

Anatomy of the lumbar vertebra:

• In a normal spine there are five lumbar vertebrae. It consists of a vertebral

body anteriorly and a neural arch posteriorly. The neural arch consists of
pedicles and laminae.
• There is a transverse process extending laterally on each side at the
junction of the pedicle and the lamina.
• There are also articular processes arising from the laminae superiorly and
inferiorly. The part of the lamina between the superior and inferior articular
facets on each is side is known as the pars interarticularis.
• A round eminence noted on the posterior part of the superior articular
[1]
process is known as the mamillary process.

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Fig. 1: Axial and sagittal views of a typical lumbar vertebra
References: Aditi Nadamani

Page 4 of 50
Fig. 2: Mid-sagittal T1W Section of the Lumbo-sacral Spine
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

Page 5 of 50
Fig. 3: Parasagittal T1W Section of the Lumbo-sacral Spine showing the Posterior
Neural Arch Elements
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

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Fig. 4: Axial T2W Section of the Lumbar Spine at the L2 vertebral level
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

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Fig. 5: Axial T2W Section of the Lumbar Spine at the L5 Vertebral Level
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

Anatomy of the sacrum:

Sacrum consists of five fused vertebrae. It has a central sacral body and paired lateral
sacral alae. The superior-most aspect of the central sacral body is known as the sacral
promontory. The spinous processes of the all the sacral vertebrae fuse together to form
the median sacral crest. The transverse processes of the sacral vertebrae on either side
fuse to form the lateral sacral crest.

[1]

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Fig. 6: Axial T2W Section of the Spine at the level of the Sacrum
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

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Fig. 7: Anatomy of the sacrum Ligaments of the vertebral column
References: Aditi Nadamani

Joints and ligaments of the lumbo-sacral vertebral column:

• Facet joints are synovial joints which are located between the articular
processes of the neural arches.
• Anterior longitudinal ligament extends from the base of the occiput along the
anterior surface of the vertebral bodies upto the upper sacrum.
• Posterior longitudinal ligament is along the posterior surface of the vertebral
bodies from the axis to the sacrum. Supraspinous ligament is attached to
the tips of the spinous processes from C7 to sacrum. Above C7, upto the
external occipital protruberance it is known as ligamentum nuchae.

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 • The adjacent vertebral laminae are connected by the ligamentum flava,
which extend from the anterior surface of one lamina to the posterior surface
of the lamina below bilaterally. Anterolaterally, they continue with the
[1]
capsule of the facet joint.

Spinal Cord:

• The spinal cord extends upto the level of L2 vertebra at birth and lower limit
of L1 at adulthood [conus medullaris]. Beyond this there is a prolongation of
pia mater known as filum terminale.
• The lumbar, sacral and coccygeal roots below the conus at L1-L2 level are
contained within the dura upto S2 known as cauda equina. The part of the
spinal cord from which a pair of spinal nerves arise is known as a spinal
segment - having a dorsal root and a ventral root.
• Lumbar spinal nerves exit below the pedicles of the corresponding
vertebrae, except for L5 nerve which passes under the pedicle of L5
vertebra. There are exiting and traversing nerve roots arising from the spinal
segment at each disc space. The traversing nerve root arising from a spinal
segment corresponds to the vertebral level below it, while the exiting nerve
root arising from the spinal segment corresponds to the vertebral level
[1]
above it in the lumbar vertebrae.

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Fig. 8: Axial T2W Section of the Lumbar Spine at L4-5 Disc Level showing the Exiting
and Traversing Nerve Roots
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

Intervertebral discs:

They are fibrocartilaginous discs which are amphiarthrodial. The main components are:
Nucleus pulposus, annulus fibrosus .

Fig. 9: Axial view of the disc

References: Aditi Nadamani

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Fig. 10: Axial T2W Section of the Lumbar Spine at L4-5 Disc Level
References: Department of Radiology, Vydehi Institute of Medical Sciences and
Research Centre 2018

MRI imaging of the lumbosacral spine:

• Our bodies contain innumerable hydrogen atoms which act as tiny magnets
themselves. When an external magnetic field comes in the vicinity of these
protons, they tend to align along the direction of the external magnetic field
producing a net magnetization which is in the longitudinal direction.
• Nuclei have an angular momemtum in the form of 'spin'. The force of the
external magnetic field will interact with this 'spin' causing the proton to have
a secondary spin or a wobble which is known as precession.
• When an external radiofrequency[RF] pulse is given, the protons in the body
will align away from the longitudinal field. The amount of rotation depends on
the magnitude and duration for which the RF pulse was given. If the amount
of rotation is 90 degree, the RF pulse is called a 90 degree pulse and the
[2]
magnetisation produced is called transverse magnetization.
• After the RF pulse has been given, the net magnetization tends to return to
the direction of the external magnetic field-this is called relaxation
• The time taken for this longitudinal magnetization to reach 63 percent of
[2]
its final value is called T1 relaxation . Different tissues relax at different
rates causing variation in the signals produced by them. For example, white
matter relaxes rapidly and therefore has a short T1 time, and thus has a

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 higher T1 signal intensity. Similarly, CSF relaxes slowly and has a longer T1
time, which produces a lower T1 signal intensity.
• When the RF pulse produces the transverse magnetization of the protons,
they tend to precess together in phase. However, when the pulse is stopped,
they tend to dephase. This rate at which the protons dephase is inversely
proportional to the signal intensity they produce on T2. For example, CSF
dephases slowly which causes a high T2 signal intensity.
• STIR[Short tau inversion recovery] sequences are done to suppress signals
from fat.

The appearances of tissues in these sequences are as follows:

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Fig. 11: Appearance of structures in T1W and T2W imaging
References: Aditi Nadamani

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Images for this section:

Fig. 1: Axial and sagittal views of a typical lumbar vertebra

© Aditi Nadamani

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Fig. 2: Mid-sagittal T1W Section of the Lumbo-sacral Spine

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 3: Parasagittal T1W Section of the Lumbo-sacral Spine showing the Posterior Neural
Arch Elements

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 4: Axial T2W Section of the Lumbar Spine at the L2 vertebral level

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 5: Axial T2W Section of the Lumbar Spine at the L5 Vertebral Level

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 7: Anatomy of the sacrum Ligaments of the vertebral column

© Aditi Nadamani

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Fig. 6: Axial T2W Section of the Spine at the level of the Sacrum

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 8: Axial T2W Section of the Lumbar Spine at L4-5 Disc Level showing the Exiting
and Traversing Nerve Roots

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 9: Axial view of the disc

© Aditi Nadamani

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Fig. 10: Axial T2W Section of the Lumbar Spine at L4-5 Disc Level

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

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Fig. 11: Appearance of structures in T1W and T2W imaging

© Aditi Nadamani

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Findings and procedure details

Technique of MRI of Lumbosacral Spine:

Two types of studies are done in the MRI imaging of the lumbar spine-screening and
full study.

In a full/detailed study, the patient is made to lie down in the supine position on the
MRI table. A spinal coil is placed under the patient. Multiple T1, T2 and STIR-weighted
axial,coronal and sagittal sections of the lumbosacral spine are routinely obtained.
Heavily weighted T2 images can be used to produce 'myelogram' sequences where the
spinal canal can be clearly assessed.

If any tumour/demyelination/infection is detected, then contrast studies can be done. Post

contrast images are also obtained using T1 sequences.

These studies are useful to focus on any pathology in the part suspected.

Screening studies are those where only sagittal T2W imaging is done. This is done
in cases of intracranial pathologies to detect any seedlings in the spine, particularly in
pediatric patients. It can also be used to assess any malformations in the spine in case of
congenital abnormalities detected in the brain such as Chiari malformation or to assess
metastasis from solid organs in some cases.

A systematic approach should be employed while reporting MRI images of the spine.
Reporting the MRI of spine should be done in the following order:

1. Alignment

2. Bones

3. Intervertebral disc

4. Spinal cord

5. Adjacent soft tissues

Alignment:

• Assessement of the curvature of the spine: The normal lumbar spine

has a lordotic curve. Assessment of the alignment must be done to look

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 for the normal lordotic curvature. Abnormalities like the loss/exaggeration
of lordosis & kyphosis can be made out on sagittal sections. A scoliotic
deformity can be readily made out on coronal sections.
• Listhesis :Listhesis is the displacement of a vertebra with respect to the
vertebra immediately below it. Anterolisthesis is the anterior displacement
of the vertebral body while retrolisthesis is the posterior displacement of
the vertebral body with respect to the inferior vertebra. Any anterior/retro
listhesis should be noted and if present, a break in the pars interarticularis
should be ruled out. The degree of listhesis is based on the distance
between the edges of the adjacent vertebrae. The forward sliding of the
fifth lumbar vertebra over the 1st sacral vertebra is referred to as tangential
slipping. It can be graded by dividing the top of the sacrum into four equal
sections as shown in the image below. Listheses of less than grade II
may occur due to ligament laxity or a break in the pars interarticularis,
whereas those of grade II or higher are definitive for a break in the pars
[3]
interarticularis.

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Fig. 12: Grading of Listhesis

References: Aditi Nadamani

• Counting of vertebrae: In a sagittal section of the whole spine, the

vertebrae must be counted downwards from the triangular dens, which
corresponds to the C2 vertebra. If, however, cervical images are not
available, counting can be done using the iliolumbar ligament which is
attached to the tip of the transverse process of L5 to the posterior part of the
iliac crest.
• The vertebrae at the lumbosacral junction are transitional. If there are 6
lumbar-type vertebrae, then it is known as lumbarisation of S1 vertebra

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 and if there are 4 lumbar type vertebrae, it is known as sacralisation of L5
vertebra.

Bones:

• The lumbar vertebrae are larger than the other vertebrae and have square
& horizontal spinous processes. The end plates of the vertebrae should be
smooth and irregular. The vertebral height must be uniform and any fusion/
compression/fractures must be looked for.
• Bone marrow imaging is best done with T1 sequences with marrow edema
being best appreciated on STIR sequences .
• In an adult spinal MRI the vertebral body appear bright on T1 when
compared to the adjacent intervertebral disc. Marrow reconversion /
infiltrative disorders result in alteration or lowering of the signal intensity.
• Marrow signal intensity changes in the endplates imply degeneration, also
known as Modic changes.

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Fig. 13: Modic changes at the vertebral end plates

References: Aditi Nadamani

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Fig. 14: Demonstration of the Types of Modic Changes on T1 and T2 Weighted Sagittal sections on MRI

References: Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre 2018

• Vertebral end plate abnormalities such as Schmorl's nodes and anterior/

posterior marginal end plate osteophytes may also be seen along with Modic
changes in a degenerative spine.

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Fig. 15: Schmorl's nodes Osteophytes

References: Aditi Nadamani

• Well defined T2 weighted hyperintensities in the bodies of the vertebrae

usually indicate hemangiomas.
• Facet joints are seen as bilateral T2W linear hyperintensities adjacent to the
hypointense ligamentum flavum. Loss of this hyperintensity is suggestive of
facetal arthopathy.
• Ligamentum flava are paired V-Shaped T2W hypointense structures noted
adjacent to the thecal sac and facet joints. The normal thickness of the
[4]
ligamentum flavum should be less then 4mm.

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 • The width of the bony spinal canal is measured from the mid region of the
posterior surface of vertebral body to the tip of the corresponding spinous
process.
• The normal bony canal width should be between 15-27mm
[5]

• Lateral recess is the area where the exiting nerve root runs towards the
foramen. Ligamentum flavum hypertrophy/facetal arthropathy/lateral disc
bulges can cause nerve compression/narrowing in this region.
• Lateral recess depth is the distance between the superior articular facet and
the superior part of the corresponding pedicle. Normal AP diameter should
[6]
be more than 2mm.
• Apart from the vertebrae, other visualized bones such as the pelvic bones,
visualized extent of femur and ribs should also be assessed.

Intervertebral disc spaces:

• Degenerative changes include all changes occuring in the disc and end
plate integrity and morphology.
• The central hyperintense nucleus pulposus and hypointense annulus
fibrosus should be visualized. The hydration of the disc should be assessed
to rule out desiccation. A pathological disc appears hypointense on T2
weighted images.
• Fissures/tears in the annulus fibrosus must be looked for.
• Mean disc height in the lumbar segments should be between 10.5-11.5mm
[7]
approximately.
• Herniation is defined as the localized or focal displacement of the disc
[8]
material beyond the limits of the intervertebral disc space.
• Focal disc bulge is defined as the extrusion of the disc material <25% of the
periphery of the disc as viewed in the axial plane. Asymmetric disc bulge is
[8]
the extrusion of the disc material >25% of the periphery.

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Fig. 16: Diffuse,Focal and Asymmetric disc bulges

References: Aditi Nadamani

• Disc bulges can be central,paracentral,foraminal or extraforaminal.

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Fig. 17: Patterns of disc bulge
References: Aditi Nadamani
• If the disc tissue extends beyond the edges of the disc, throughout the
circumference of the disc for a uniform distance of usually <3mm from the
annulus, it is known as diffuse disc bulging.
• Disc protrusion is a condition where the disc bulges in a way such that the
distance between the edges of the herniated portion is lesser than the width
of the base of the herniation.
• Disc extrusion is a condition where the width of the base of the disc
herniation is lesser than the distance between the edges of the herniated
portion.

Page 36 of 50
 • Disc migration indicates extrusion of the disc material away from the disc
space. Once, the disc material separates completely from the parent
disc, it is termed as disc sequestration. Contrast enhanced images often
supplement in the diagnosis of disc sequestration, since the sequestered
disc shows a peripheral enhancement due to long standing epidural
inflammation.

Fig. 18: Disc bulges and herniation

References: Aditi Nadamani

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 • When the disc herniates vertically through the adjacent vertebral end plates,
it forms a Schmorl's node.
• The anteroposterior diameter of the thecal sac should be more than 10mm.
• Narrowing/stenosis of the exiting and traversing nerve roots should be
[6]
identified [narrowing is <2mm of the diameter of the foramen].

Spinal cord:

• The spinal canal appears hyperintense on T2 and hypointense on T1 as it

contains CSF.
• The cord must be uniform in thickness.
• Narrowing/compression should be observed.
• If altered signal intensities are seen, demyelination/inflammation/infection/
injury should be ruled out
• Mass lesions must be carefully looked for if any lesion in the cord is detected
with contrast enhancement.
• Myelogram images which are heavily weighted T2 sequences are used
to assess the spinal canal alone. It can identify any discal/cord pathology
causing any change or narrowing in the spinal canal.

Adjacent soft tissues:

• Anterior longitudinal, posterior longitudinal, interspinous ligaments should be

assessed for any signal intensity changes.
• Adjacent musculature, i.e the psoas, quadratus and erector spinae should
be checked for any collection/abscess.
• Irregularities in the subcutaneous tissues should be looked for.
• Surrounding organs, such as the visualized extent of the liver, spleen,
kidneys, bowel, prostate and male genitoutinary system, uterus, ovaries
and the female genitourinary system should also be assessed for any
abnormalities.

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Images for this section:

Fig. 12: Grading of Listhesis

© Aditi Nadamani

Page 39 of 50
Fig. 13: Modic changes at the vertebral end plates

© Aditi Nadamani

Page 40 of 50
Fig. 14: Demonstration of the Types of Modic Changes on T1 and T2 Weighted Sagittal
sections on MRI

© Department of Radiology, Vydehi Institute of Medical Sciences and Research Centre

2018

Page 41 of 50
Fig. 15: Schmorl's nodes Osteophytes

© Aditi Nadamani

Page 42 of 50
Fig. 16: Diffuse,Focal and Asymmetric disc bulges

© Aditi Nadamani

Page 43 of 50
Fig. 17: Patterns of disc bulge

© Aditi Nadamani

Page 44 of 50
Fig. 18: Disc bulges and herniation

© Aditi Nadamani

Page 45 of 50
Conclusion

In conclusion, a brief summary of a basic approach to report an MRI of the lumbar spine
is given as following:

1) Alignment

• Curvature- Lordosis/kyphosis/scoliosis
• Any Listhesis
• Counting

2) Bones

• Shape and size of vertebral body

• Margins
• Bone marrow
• Facet joints
• Ligamentum flava
• Bony spinal canal width
• Lateral recess
• Other bones

3)Intervertebral disc spaces

• Hydration
• Disc height
• Morphology
• Diameter of the thecal sac
• Any narrowing/stenosis of exiting/traversing nerve roots

4) Spinal cord

• Contour
• Narrowing/compression
• Altered signal intensities-demyelination/edema/inflammation/infection if any
• Mass lesion

5) Adjacent soft tissues

• Ligaments- anterior & posterior longitudinal ligaments, interspinous

ligaments
• Adjacent musculature
• Subcutaneous tissues
• Surrounding organs

Page 46 of 50
Page 47 of 50
Personal information

Dr. Niharika Ghoriwala

Resident in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre

#82, Nallurahalli, Near BMTC 18th depot, Whitefield, Bangalore-560066

Karnataka, India

Contact: [email protected]

Dr. Aditi Nadamani

Resident in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre

#82, Nallurahalli, Near BMTC 18th depot, Whitefield, Bangalore-560066

Karnataka, India

Contact: [email protected]

Dr. Mary Varunya

Senior Resident in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre#82, Nallurahalli, Near BMTC
18th depot, Whitefield, Bangalore-560066

Karnataka, India

Dr. Abishek Balachandran

Assistant Professor in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre#82, Nallurahalli, Near BMTC
18th depot, Whitefield, Bangalore-560066

Karnataka, India

Page 48 of 50
Dr. Suresh Ashwathappa

Associate Professor in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre#82, Nallurahalli, Near BMTC
18th depot, Whitefield, Bangalore-560066

Karnataka, India

Dr. Ramprakash H. V.

Professor and HOD in the Department of Radiology

Vydehi Institute of Medical Sciences and Research Centre#82, Nallurahalli, Near BMTC
18th depot, Whitefield, Bangalore-560066

Karnataka, India

Page 49 of 50
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