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DOI: 10.1227/NEU.0000000000001323
NEUROSURGERY
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DEGENERATIVE SPINE
LBP is ubiquitous, affecting up to two-thirds of adults at some
period in their lives.3 Imaging, primarily with MRI and CT, is
used to evaluate the source of both LBP and neck pain. These
imaging modalities commonly identify disk degeneration, disk
herniations, and posterior element arthopathy; however, the
imaging findings of spine degeneration are present in a high
proportion of asymptomatic individuals and increase with age.5,6
Although many imaged-based degenerative changes are due to
the normal aging process, such imaging findings are often
interpreted as the cause of the patients back pain and initiate
a cascade of medical and surgical interventions, which may not be
helpful in relieving the symptoms.7
Nomenclature
Because imaging of the spine is used by all treating physicians,
a collaboration of multiple specialty societies yielded the nomenclature of lumbar disk pathology initially in 20018,9 and revised it
in 2014.10,11 Standard terms for normal and pathological
conditions of lumbar disks are described to accurately and
consistently communicate imaging findings for clinical and
FIGURE 1. Left, sagittal CT reconstruction demonstrates multilevel severe degenerative changes with loss of disk height, endplate
sclerosis, and vacuum phenomenon. Right, sagittal T2-weighted image shows corresponding intradiskal hypointensity and loss of
disk height. The levels of intradiskal vacuum phenomenon on the CT (yellow arrows) can become fluid-filled on MRI (red
arrows).
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FIGURE 2. Sagittal (A) STIR and (B) T2-weighted images show a hyperintense disk sequestration along the posterior
margin of the L1 vertebral body (white arrows). C, sagittal postcontrast T1-weighted, fat-saturated image demonstrates
peripheral enhancement of the disk (red arrow), which is separate from the parent disk. D, sagittal CT reconstruction
reveals vacuum phenomenon in the sequestered disk (yellow arrow).
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FIGURE 3. Sagittal (A) T1-weighted, (B) T2-weighted, and (C) STIR images of the lumbar spine exhibit type 1 fibrovascular endplates changes at L5-S1 with hypointense
T1, heterogeneously hyperintense T2, and hyperintense STIR signal intensities.
MRI (ie, Modic changes). The 3 types are type I (low T1 and high
T2 signal; Figure 3), type II (high T1 and T2 signal; Figure 4),
and type III (low T1 and T2 signal; Figure 5).14 The histology of
type I shows disruption and fissuring of the endplate and
vascularized fibrous tissues within the adjacent marrow. If
contrast is administered, there will be enhancement of the
endplate that may involve the disk and is presumably related to
the vascularized fibrous tissue within the adjacent marrow.14
Type II endplate changes demonstrate endplate disruption with
yellow (lipid) marrow replacement in the adjacent vertebral body,
resulting in the high T1 signal. Type I changes may reflect the
inflammatory, active stage of degenerative disk disease, whereas
FIGURE 4. Sagittal (A) T1-weighted, (B) T2-weighted, and (C) STIR images of the lumbar spine exhibit type 2 fatty marrow endplate changes at the L4-L5 level with
hyperintense T1, hyperintense T2, and hypointense STIR signal intensities.
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FIGURE 5. Sagittal (A) T1-weighted, (B) T2-weighted, (C) STIR, and (D) CT images of the lumbar spine exhibit type III
sclerotic marrow endplates changes at L5-S1 with hypointense T1, hypointense T2, and hypointense STIR signal intensities. On
CT, endplate sclerosis, subchondral cystic change, and endplate osteophytosis are seen. The intradiskal fluid on the MRI corresponds
to vacuum phenomenon on CT.
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FIGURE 6. Left, sagittal T2-weighted image demonstrates severe spinal canal narrowing at L2-L3 and L3-L4 in a postlaminectomy patient. Right, axial T2-weighted image at the L2-L3 level, just superior to the laminectomy, shows severe spinal
canal narrowing caused by a combination of symmetric disk bulge, facet hypertrophy, and ligamentum flavum thickening.
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FIGURE 8. Left, sagittal T2-weighted image demonstrates anterior disk osteophyte complexes and posterior ligamentum flavum
causing severe spinal canal narrowing at C4-C5 and C5-C6. There is abnormal cord T2 hyperintensity at the C4-C6 levels, which
reflects myelomalacia and gliosis. Right, axial T2-weighted image at the C4-C5 level shows severe spinal canal narrowing and
impingement of the cord caused by the anterior disk osteophyte complex and posterior ligamentum flavum.
NEUROSURGERY
FIGURE 9. A, axial T2-weighted image at the L3-L4 level shows facet hypertrophy and bilateral effusions. B, sagittal T2weighted image demonstrates grade 1 degenerative anterolisthesis of L3 on L4, where there is also a focal cranially extending disk
extrusion. C, lateral extension and (D) lateral flexion radiographs reveal abnormal motion at L3-L4.
myelography/CT myelography provides valuable diagnostic information beyond MRI. After intrathecal injection of myelographically
safe contrast, fluoroscopic images are obtained with the patient in
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FIGURE 10. Fused SPECT/CT images in the (A) coronal and parasagittal (B) right and (C) left planes display the significant increased radionuclide uptake in the right C1C2 facet joint (white arrows) and moderate uptake in the left C2-C3 facet joint (yellow arrow). This modality can help localize pain generators, which is helpful in the
setting of severe spondylosis.
different positions to obtain functional information about alignment and motion of the diskovertebral and facet joints and the effect
on the spinal canal. The CT myelogram gives superb spatial and
contrast resolution, even with metallic implants, and without the
susceptibility artifact from osseous structures seen on MRI. The
superior osseous delineation on CT myelography enables detection
of the osseous components to the spinal canal, subarticular recess,
and neural foraminal narrowing. Myelography/CT myelography is
an important study to confirm degenerative root impingement in
the subarticular recess as the cause of radiculopathy, which can be
underestimated by MRI (Figure 13).53 In potential surgical cases, it
should be noted that MRI has been shown to overestimate spinal
and neural foraminal stenosis compared with myelography/CT
myelography.54,55
Nuclear medicine bone scans have high sensitivity for increased
bone turnover but low diagnostic specificity.56,57 The addition of
SPECT to a bone scan improves the spatial resolution, and the
digital fusion of a CT scan of the area of interest with a bone scan
with SPECT imaging provides the anatomic resolution for
accurate localization of a pain generator,58 particularly of
posterior element origin.
The principal modality for spinal pathology evaluation is MRI,
which allows highly detailed visualization of spine anatomy in
a noninvasive process without ionizing radiation. The routine
sequences in a degenerative spine protocol are T1-weighted,
T2-weighted, STIR, and gradient echo sequences. Images may be
obtained in the sagittal, axial, and coronal planes and with
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FIGURE 11. Left, parasagittal T2-weighted image demonstrates a large synovial cyst extending anteromedially from the left
facet joint (curved yellow arrow). Right, axial T2-weighted image shows severe thecal sac narrowing caused by the synovial cyst,
which has a characteristic hypointense rim (white arrow).
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FIGURE 12. Parasagittal STIR images display edema in the L4 and L5 pedicles (left, white arrow) and the L4-L5 facet joint
(right, yellow arrow) caused by a stress reaction.
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FIGURE 13. A, sagittal postcontrast T1-weighted, fat-saturated image and (B) axial T2-weighted image show soft tissue
protruding from the L4-L5 disk space into the right subarticular zone (yellow arrows). C, CT myelogram sagittal reconstruction
better delineates the osteophytic component (red arrow) impinging on the transiting L5 nerve. The edematous right L5 nerve can
be precisely followed along its course on the (D) axial CT myelogram (white arrow).
SPINE INFECTION
Spinal infections may involve the intramedullary (eg, viral
myelitis, abscess), intradural extramedullary (eg, meningitis), and
extradural spaces. The latter includes epidural abscess, paraspinal
abscess, and diskitis-osteomyelitis (DOM). Spinal infection is the
most common form of hematogenous osteomyelitis in patients . 50
years of age and represents 3% to 5% of all cases of osteomyelitis.87
The increasing incidence has been attributed to an increase in
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FIGURE 14. A, fractional anisotropy (left), red-green-blue (RGB; middle) map, and T2-weighted image (right) from a normal volunteer. Fractional anisotropy map shows
uniform values throughout the cord. RGB demonstrates the principal direction of diffusivity along the longitudinal direction as depicted with blue. T2-weighted image shows
a normal cervical cord without atrophy or lesions. B, fractional anisotropy (left), RGB map (middle), and T2-weighted images (right) from a patient with cervical spondylotic
myelopathy show severe degenerative disk disease and stenosis at C3-C4, C4-C5, and C5-C6. There is decrease in fractional anisotropy values at sites of stenosis. RGB map shows
admixing of colors at similar levels. Courtesy of fEun-Kee Jeong, PhD, Utah Center For Advanced Imaging Research, University of Utah.
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FIGURE 15. Coronal half-Fourier acquisition single shot turbo spin echo
magnetic resonance myelograms of the (A) thoracic spine and (B) lumbar spine
illustrate the high-contrast resolution of this sequence. There is sharp contrast
between the dark signal of the spinal cord (white arrow) and nerves (red arrow)
and the bright signal of the cerebrospinal fluid. A nerve root sleeve diverticulum is
noted in the thoracic spine (yellow arrow).
FIGURE 16. This patient had an L4-L5 microdiskectomy a12 weeks previously
and complains of increasing LBP. Left, posterior-anterior and (right) lateral
radiographs demonstrate loss of disk height with irregular endplate erosions and
obscuration of the cortical margins (white arrows).
FIGURE 17. Sagittal (A) T1-weighted, (B) postcontrast T1-weighted, fatsaturated, (C) T2-weighted, and (D) STIR images of the lumbar spine exhibit
DOM at the L4-L5 level. There is T1 hypointensity, STIR hyperintensity, and
diffuse enhancement of the vertebral bodies. Peripherally enhancing (white
arrows), T2-hyperintense fluid (yellow arrow) is noted in the disk space. The
adjacent endplates exhibit irregular erosions (red arrow).
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FIGURE 18. Left, axial T2-weighted and (right) postcontrast axial T1-weighted, fat-saturated images shows T2-hyperintense, peripherally enhancing abscesses in the left psoas muscle (white arrows). Amorphous T2 hyperintensity and enhancing soft
tissue, representing phlegmon, are observed in the anterior paraspinal region and ventral epidural space (yellow arrow).
NEUROSURGERY
FIGURE 19. Sagittal (A) postcontrast T1-weighted, fat-saturated, (B) STIR, and axial (C) T2-weighted and (D) postcontrast T1-weighted images of the thoracic spine
exhibit 3-level tuberculous spondylodiskitis. There are T2/STIR hyperintensity and diffuse enhancement in the vertebral bodies. Peripherally enhancing, T2/STIR
hyperintense fluid is noted in the disk space with subligamentous spread. Affected vertebral bodies demonstrate anterior wedging and slight kyphotic deformity.
FIGURE 20. Left, sagittal STIR images and (right) DTIs demonstrate multilevel endplate hyperintensity. The DTI exhibits the claw sign, which is linear
hyperintensity at the border between normal marrow and the edematous marrow
and granulation tissue about the endplates.
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FIGURE 22. Left, sagittal STIR and (right) postcontrast T1-weighted, fatsaturated images demonstrate vertebral osteitis with high STIR signal intensity
with contrast enhancement at the anterosuperior and anteroinferior vertebral
body corners. These are examples of Romanus lesions in a patient with ankylosing
spondylitis.
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FIGURE 24. A, sagittal T2-weighted, (B) sagittal postcontrast T1-weighted, fat-saturated, (C) coronal CT, and (D) axial CT images in a patient with SNA at the L2-L3
level. The intradiskal space is fluid-filled with destruction and heterogeneous enhancement of irregular endplates. The CT images show debris, sclerosis, disorganization, vacuum
disk phenomenon (indicating excessive motion), and osteophytes.
CONCLUSION
Neuroradiological examinations play a valuable role in the
assessment of the spine disorders. The different imaging
modalities can provide specific diagnostic information. Currently, CT and MRI are the primary techniques to investigate
spine pathology, each having their advantages. Multidetector CT
displays exquisite osseous detail, with rapidity and multiplanar
reconstruction capability. MRI has a complementary role in
delineation of soft tissue abnormalities, which is helpful for
evaluating the extent of soft tissue involvement in spinal
infections. For degenerative spine evaluation, MRI is the
fundamental modality, providing soft tissue (eg, disk and
ligament) and osseous (eg, endplate diskogenic change) information. With continued advances in imaging techniques such as
dynamic MRI and DTI, more functional and microstructural
information may be obtained.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
REFERENCES
1. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation
tests as an aid to reduce unnecessary minimally invasive sacroiliac joint
procedures. Arch Phys Med Rehabil. 2006;87(1):10-14.
www.neurosurgery-online.com
2. Ren XS, Selim AJ, Fincke G, et al. Assessment of functional status, low back
disability, and use of diagnostic imaging in patients with low back pain and
radiating leg pain. J Clin Epidemiol. 1999;52(11):1063-1071.
3. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on
imaging. Ann Internal Med. 2002;137(7):586-597.
4. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging
vs radiographs for patients with low back pain: a randomized controlled trial.
JAMA. 2003;289(21):2810-2818.
5. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of
imaging features of spinal degeneration in asymptomatic populations. AJNR Am J
Neuroradiol. 2015;36(4):811-816.
6. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance scans of the lumbar spine in asymptomatic subjects: a prospective
investigation. J Bone Joint Surg Am. 1990;72(3):403-408.
7. Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are
first-time episodes of serious LBP associated with new MRI findings? Spine J.
2006;6(6):624-635.
8. Fardon DF. Nomenclature and classification of lumbar disc pathology. Spine
(Phila Pa 1976). 2001;26(5):461-462.
9. Fardon DF, Milette PC, Combined Task Forces of the North American Spine
Society, American Society of Spine Radiology, and American Society of
Neurology.Nomenclature and classification of lumbar disc pathology: recommendations of the combined task forces of the North American Spine Society,
American Society of Spine Radiology, and American Society of Neuroradiology.
Spine. 2001;26(5):E93-E113.
10. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL,
Sze GK. Lumbar disc nomenclature: version 2.0: recommendations of the
combined task forces of the North American Spine Society, the American Society
of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014;
14(11):2525-2545.
11. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL,
Sze GK. Lumbar disc nomenclature: version 2.0: recommendations of the
combined task forces of the North American Spine Society, the American Society
of Spine Radiology, and the American Society of Neuroradiology. Spine (Phila Pa
1976). 2014;39(24):E1448-E1465.
12. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance
classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976).
2001;26(17):1873-1878.
13. Ford LT, Gilula LA, Murphy WA, Gado M. Analysis of gas in vacuum lumbar
disc. AJR Am J Roentgenol. 1977;128(6):1056-1057.
14. Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk
disease: assessment of changes in vertebral body marrow with MR imaging.
Radiology. 1988;166(1 Pt 1):193-199.
15. Vital JM, Gille O, Pointillart V, et al. Course of Modic 1 six months after lumbar
posterior osteosynthesis. Spine (Phila Pa 1976). 2003;28(7):715-720; discussion 721.
16. Modic MT, Ross JS. Lumbar degenerative disk disease. Radiology. 2007;245(1):
43-61.
17. Rahme R, Moussa R. The Modic vertebral endplate and marrow changes:
pathologic significance and relation to low back pain and segmental instability of
the lumbar spine. AJNR Am J Neuroradiol. 2008;29(5):838-842.
18. Kuisma M, Karppinen J, Niinimaki J, et al. Modic changes in endplates of lumbar
vertebral bodies: prevalence and association with low back and sciatic pain among
middle-aged male workers. Spine (Phila Pa 1976). 2007;32(10):1116-1122.
19. Jensen TS, Bendix T, Sorensen JS, Manniche C, Korsholm L, Kjaer P.
Characteristics and natural course of vertebral endplate signal (Modic) changes in
the Danish general population. BMC Musculoskelet Disord. 2009;10:81.
20. Kjaer P, Leboeuf-Yde C, Korsholm L, Sorensen JS, Bendix T. Magnetic
resonance imaging and low back pain in adults: a diagnostic imaging study of 40year-old men and women. Spine (Phila Pa 1976). 2005;30(10):1173-1180.
21. Chung CB, Vande Berg BC, Tavernier T, et al. End plate marrow changes in the
asymptomatic lumbosacral spine: frequency, distribution and correlation with age
and degenerative changes. Skeletal Radiol. 2004;33(7):399-404.
22. Kanayama M, Togawa D, Takahashi C, Terai T, Hashimoto T. Cross-sectional
magnetic resonance imaging study of lumbar disc degeneration in 200 healthy
individuals. J Neurosurg Spine. 2009;11(4):501-507.
23. Weishaupt D, Zanetti M, Hodler J, et al. Painful lumbar disk derangement:
relevance of endplate abnormalities at MR imaging. Radiology. 2001;218(2):
420-427.
NEUROSURGERY
24. Albert HB, Briggs AM, Kent P, Byrhagen A, Hansen C, Kjaergaard K. The
prevalence of MRI-defined spinal pathoanatomies and their association with
Modic changes in individuals seeking care for low back pain. Eur Spine J. 2011;20
(8):1355-1362.
25. Arana E, Kovacs FM, Royuela A, et al. Modic changes and associated features in
Southern European chronic low back pain patients. Spine J. 2011;11(5):402-411.
26. Arpinar VE, Rand SD, Klein AP, Maiman DJ, Muftuler LT. Changes in
perfusion and diffusion in the endplate regions of degenerating intervertebral
discs: a DCE-MRI study. Eur Spine J. 2015;24(11):2458-2467.
27. Arnoldi CC, Brodsky AE, Cauchoix J, et al. Lumbar spinal stenosis and nerve
root entrapment syndromes: definition and classification. Clin Orthop Relat Res.
1976(115):4-5.
28. Tavee JO, Levin KH. Myelopathy due to degenerative and structural spine
diseases. Continuum (Minneap Minn). 2015;21(1 Spinal Cord Disorders):52-66.
29. Zhang C, Das SK, Yang DJ, Yang HF. Application of magnetic resonance imaging
in cervical spondylotic myelopathy. World J Radiol. 2014;6(10):826-832.
30. Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist. 2010;16
(3):176-187.
31. Baptiste DC, Fehlings MG. Pathophysiology of cervical myelopathy. Spine J.
2006;6(suppl 6):190S-197S.
32. Baron EM, Young WF. Cervical spondylotic myelopathy: a brief review of its
pathophysiology, clinical course, and diagnosis. Neurosurgery. 2007;60(1 suppl 1):
S35-S41.
33. Yong-Hing K, Kirkaldy-Willis WH. The pathophysiology of degenerative disease
of the lumbar spine. Orthop Clin North Am. 1983;14(3):491-504.
34. Lattig F, Fekete TF, Grob D, Kleinstuck FS, Jeszenszky D, Mannion AF.
Lumbar facet joint effusion in MRI: a sign of instability in degenerative
spondylolisthesis? Eur Spine J. 2012;21(2):276-281.
35. Lee JC, Cha JG, Yoo JH, Kim HK, Kim HJ, Shin BJ. Radiographic grading of
facet degeneration, is it reliable? A comparison of MR or CT grading with
histologic grading in lumbar fusion candidates. Spine J. 2012;12(6):507-514.
36. Keorochana G, Taghavi CE, Tzeng ST, et al. Magnetic resonance imaging
grading of interspinous ligament degeneration of the lumbar spine and its relation
to aging, spinal degeneration, and segmental motion. J Neurosurg Spine. 2010;13
(4):494-499.
37. Gorbach C, Schmid MR, Elfering A, Hodler J, Boos N. Therapeutic efficacy of
facet joint blocks. AJR Am J Roentgenol. 2006;186(5):1228-1233.
38. Weishaupt D, Zanetti M, Boos N, Hodler J. MR imaging and CT in
osteoarthritis of the lumbar facet joints. Skeletal Radiol. 1999;28(4):215-219.
39. Kim KY, Wang MY. Magnetic resonance image-based morphological predictors of
single photon emission computed tomography-positive facet arthropathy in patients
with axial back pain. Neurosurgery. 2006;59(1):147-156; discussion 147-156.
40. Matar HE, Navalkissoor S, Berovic M, et al. Is hybrid imaging (SPECT/CT)
a useful adjunct in the management of suspected facet joints arthropathy? Int
Orthop. 2013;37(5):865-870.
41. Hemminghytt S, Daniels DL, Williams AL, Haughton VM. Intraspinal synovial
cysts: natural history and diagnosis by CT. Radiology. 1982;145(2):375-376.
42. Apostolaki E, Davies AM, Evans N, Cassar-Pullicino VN. MR imaging of lumbar
facet joint synovial cysts. Eur Radiol. 2000;10(4):615-623.
43. Shah RV, Lutz GE. Lumbar intraspinal synovial cysts: conservative management
and review of the worlds literature. Spine J. 2003;3(6):479-488.
44. Pytel P, Wollmann RL, Fessler RG, Krausz TN, Montag AG. Degenerative spine
disease: pathologic findings in 985 surgical specimens. Am J Clin Pathol. 2006;
125(2):193-202.
45. Ulmer JL, Elster AD, Mathews VP, Allen AM. Lumbar spondylolysis: reactive
marrow changes seen in adjacent pedicles on MR images. AJR Am J Roentgenol.
1995;164(2):429-433.
46. Ulmer JL, Mathews VP, Elster AD, Mark LP, Daniels DL, Mueller W. MR
imaging of lumbar spondylolysis: the importance of ancillary observations. AJR
Am J Roentgenol. 1997;169(1):233-239.
47. Morrison JL, Kaplan PA, Dussault RG, Anderson MW. Pedicle marrow signal
intensity changes in the lumbar spine: a manifestation of facet degenerative joint
disease. Skeletal Radiol. 2000;29(12):703-707.
48. Sairyo K, Katoh S, Takata Y, et al. MRI signal changes of the pedicle as an
indicator for early diagnosis of spondylolysis in children and adolescents: a clinical
and biomechanical study. Spine (Phila Pa 1976). 2006;31(2):206-211.
49. Borg B, Modic MT, Obuchowski N, Cheah G. Pedicle marrow signal
hyperintensity on short tau inversion recovery- and T2-weighted images:
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
www.neurosurgery-online.com
97. Michel SC, Pfirrmann CW, Boos N, Hodler J. CT-guided core biopsy of
subchondral bone and intervertebral space in suspected spondylodiskitis. AJR Am
J Roentgenol. 2006;186(4):977-980.
98. Polley P, Dunn R. Noncontiguous spinal tuberculosis: incidence and management. Eur Spine J. 2009;18(8):1096-1101.
99. Tekkok IH, Berker M, Ozcan OE, Ozgen T, Akalin E. Brucellosis of the spine.
Neurosurgery. 1993;33(5):838-844.
100. Longo M, Granata F, Ricciardi K, Gaeta M, Blandino A. Contrast-enhanced MR
imaging with fat suppression in adult-onset septic spondylodiscitis. Eur Radiol.
2003;13(3):626-637.
101. Li FC, Zhang N, Chen WS, Chen QX. Endplate degeneration may be the
origination of the vacuum phenomenon in intervertebral discs. Med Hypotheses.
2010;75(2):169-171.
102. Bielecki DK, Sartoris D, Resnick D, Van Lom K, Fierer J, Haghighi P.
Intraosseous and intradiscal gas in association with spinal infection: report of
three cases. AJR Am J Roentgenol. 1986;147(1):83-86.
103. Eguchi Y, Ohtori S, Yamashita M, et al. Diffusion magnetic resonance imaging to
differentiate degenerative from infectious endplate abnormalities in the lumbar
spine. Spine (Phila Pa 1976). 2011;36(3):E198-E202.
104. Patel KB, Poplawski MM, Pawha PS, Naidich TP, Tanenbaum LN. Diffusionweighted MRI claw sign improves differentiation of infectious from degenerative
Modic type 1 signal changes of the spine. AJNR Am Journal Neuroradiol. 2014;35(8):
1647-1652.
NEUROSURGERY
105. Sheldon PJ, Forrester DM. Imaging of amyloid arthropathy. Semin Musculoskelet
Radiol. 2003;7(3):195-203.
106. Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P. Destructive
spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a fiveyear clinical radiological prospective study. Skeletal Radiol. 2001;30(8):431-441.
107. Jones EA, Manaster BJ, May DA, Disler DG. Neuropathic osteoarthropathy:
diagnostic dilemmas and differential diagnosis. Radiographics. 2000;20 Spec No:
S279-S293.
108. Frank AM, Trappe AE. The role of magnetic resonance imaging (MRI) in the
diagnosis of spondylodiscitis. Neurosurg Rev. 1990;13(4):279-283.
109. Rohde V, Meyer B, Schaller C, Hassler WE. Spondylodiscitis after lumbar
discectomy: incidence and a proposal for prophylaxis. Spine (Phila Pa 1976).
1998;23(5):615-620.
110. Boden SD, Davis DO, Dina TS, Sunner JL, Wiesel SW. Postoperative diskitis:
distinguishing early MR imaging findings from normal postoperative disk space
changes. Radiology. 1992;184(3):765-771.
111. Ross JS, Zepp R, Modic MT. The postoperative lumbar spine: enhanced MR
evaluation of the intervertebral disk. AJNR Am J Neuroradiol. 1996;17(2):323-331.
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