The FONAR Upright MRI

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1 Diagnostic Imaging Network Presents The FONAR Upright MRI The seat is attached to an MRI-compatible motorized bed that will translate in and out of the magnet, and move up and down

2 Your patient can flex, bend, extend

3 Variable Positioning: The bed also rotates from Upright to Recumbent, stopping at any angle in between

4 Patient with Low Back Pain After Surgery Lying Down L4 to S1 fusion Does a Lie-Down-Only Scanner see the patient s problem? Case courtesy of M. Rose, MD, Rose Radiology Centers

5 Patient with Low Back Pain After Surgery Lying Down Does a Lie-Down-Only Scanner see the patient s problem? NO! Case courtesy of M. Rose, MD, Rose Radiology Centers

6 Patient with Low Back Pain After Surgery Lying Down Upright, Weight-Bearing Does a Lie-Down-Only Scanner see the patient s problem? NO! Case courtesy of M. Rose, MD, Rose Radiology Centers

7 Patient with Low Back Pain After Surgery Lying Down Upright, Weight-Bearing The Recumbent-Only MRI MISSES the Pathology The anterolisthesis at L3/4, the associated spinal stenosis and the excessive mobility above the level of the fusion are visible only with the patient Upright Case courtesy of M. Rose, MD, Rose Radiology Centers

8 Patient with Low Back Pain After Surgery Lying Down Upright, Weight-Bearing The Recumbent-Only MRI MISSES the Pathology If this patient were scanned at 1.5 T, 3.0 T or any other field strength, his pathology would have been missed Case courtesy of M. Rose, MD, Rose Radiology Centers

9 Position Imaging TM (pmri TM ) Lying Down Upright, Weight-Bearing The Recumbent-Only MRI MISSES the Pathology Scan patients in their position of symptoms Same Patient Same Day Same Scanner Case courtesy of M. Rose, MD, Rose Radiology Centers

10 Recumbent

11 Recumbent Upright, Weight-Bearing The Recumbent-Only MRI MISSES the Pathology Position-Dependent Disc Herniation & Spinal Instability A focal posterior disc herniation at L5/S1 (arrow) and associated spinal instability (retrolisthesis) is visible only with the patient upright.

12 Recumbent Case courtesy of F. W. Smith, MD University of Aberdeen, Scotland

13 Recumbent Upright-Flexion The Recumbent-Only MRI MISSES the Pathology Ligamentous Rupture Associated With Spinal Instability The interspinous ligamentous rupture at the L4/5 level (arrow) is visible only with the patient in Upright-Flexion. Case courtesy of F. W. Smith, MD University of Aberdeen, Scotland

14 The best image is the one that doesn t miss the pathology

15 Recumbent

16 Recumbent Upright-Flexion Upright-Extension Further anterior shift Comparative posterior shift The recumbent-only MRI underestimates the pathology and misses its dynamic nature Same Patient Same Day Same Scanner

17 Fluctuating Spinal Stenosis The stenosis of the central spinal canal, compression of the underlying spinal cord and posterior focal ligamentous infolding are visible only with the patient in Upright-Extension.

18 Recumbent Upright-Extension Does the Recumbent-Only MRI see the patient s problem? NO!

19 Recumbent Upright-Extension The Recumbent-Only MRI MISSES the Pathology Position-Dependent Disc Herniation The position-dependent C4/5 focal posterior disc herniation (arrow) is visible only with the patient in Upright-Extension. This is not unexpected

20 Recumbent Extension Ligamentotactic Effects When you extend, the anterior longitudinal ligament becomes taut, and the posterior longitudinal ligament becomes lax.

21 Upright-Neutral Upright-Extension Based on this image, a surgeon would perform an anterior cervical decompression and fusion at C5/6, but the likelihood of success would be zero. WHY? Because the Upright-Extension scan shows an additional disc herniation at C4/5. Any sound surgical treatment would have to include both levels. Case courtesy of R. Marks, MD, Up & Open Imaging, Richardson, Texas

22 Scientific Data: Diagnosis

23 The Potential Value for MR Imaging in the Seated Position: A Study of 63 Patients Suffering from Low Back Pain and Sciatica [RSNA (2003)] F.W. Smith, M.D. et al. University of Aberdeen, Scotland 89% of the patients in a study of 63 patients with unexplained low back pain showed an obvious prolapse of an intervertebral disc, whose degree of prolapse changed between the neutral position and either flexion or extension. The Potential Value for MR Imaging in the Seated Position: A Study of 116 Patients Suffering from Low Back Pain and Sciatica [ESSR (2004)] F.W. Smith, M.D. et al. University of Aberdeen, Scotland For 18% of the patients in a study of 116 patients suffering from low back pain, the presence of a Grade I spondylolisthesis, not evident in the supine examination, was demonstrated in the seated position.

24 Scientific Data: Patient Outcome

25 Positional Upright Imaging of the Lumbar Spine Modifies the Management of Low Back Pain and Sciatica F.W. Smith, M.D. et al. University of Aberdeen, Scotland European Society of Skeletal Radiology, Oxford, England (2005) In a study of 25 patients with low back pain and sciatica referred for Lumbar Spine MRIs following at least one prior normal recumbent MRI within 6 months of referral: 13 patients (52%) demonstrated abnormalities in one or more of the seated postures that were not evident in the supine examination 3 cases with lateral disc herniation 6 cases with hypermobile disc at one or more levels 2 cases with previously unsuspected Grade I spondylolisthesis 2 cases with significant spinal canal stenosis

26 Positional Upright Imaging of the Lumbar Spine Modifies the Management of Low Back Pain and Sciatica F.W. Smith, M.D. et al. University of Aberdeen, Scotland European Society of Skeletal Radiology, Oxford, England (2005) In a study of 25 patients with low back pain and sciatica referred for Lumbar Spine MRIs following at least one prior normal recumbent MRI within 6 months of referral: 13 patients (52%) demonstrated abnormalities in one or more of the seated postures that were not evident in the supine examination Each of the 13 patients has undergone appropriate surgery and 6 months post-surgery they remain symptom free.

27 What else is special about the Upright MRI?

28 Large Patient Scanning Capability 350 lbs (160 kg) This Patient s Scan ETL= / mm 11 slices 5:05 FOV=32 cm 65-inch (165 cm) circumference RF receiver coil

29 The Solution for Patients that CANNOT Lie Down Severe Kyphosis Rendering Recumbent Imaging Impossible Sagittal images in the upright-seated position show compression of two thoracic vertebral bodies. Case courtesy of M. Rose, MD, Rose Radiology Centers

30 What about patient comfort?

31

32

33

34 It s Not Just For The Spine

35 How do we eliminate patient motion?

36 The bed s upright position is a tilt backwards at 7º which reduces patient motion

37

38 Fast Scanning Techniques One of 3 slices acquired in 38 seconds (Nex=2)

39 Fast Scanning Techniques Driven-Equilibrium Fast Spin Echo One of 3 slices acquired in 38 seconds (Nex=2)

40 The Impact of RF Receiver Coils

41 The patient sits upright between two vertical magnetic poles so there is a horizontal transaxial magnetic field in the magnet This is significant because of the rule in MRI that the axis of symmetry of the RF Receiver Coil should be perpendicular to the direction of the main magnetic field.

42 The Upright MRI can use solenoidal wrap-around RF Coils because when the patient is upright, the axis of the coil is perpendicular to the horizontal magnetic field.

43 The Upright has a unique inherent design advantage

44 Planar RF Coils can be used because the axis of the coil is perpendicular to the horizontal magnetic field. The Upright has a unique inherent design advantage

45 Planar RF Receiver Coil The unique transaxial horizontal magnetic field of the Upright MRI means it is the ONLY Open MRI system that can use planar (flat) receiver coils for spine imaging T= 4.5 F= 35 ETL = 3 TE = 17 Nex=2 2:37

46 Unique Medical Value: The Dynamic Nature of the Spine Weight-bearing Flexion Extension Rotation Lateral Bending Patient positioning plays a critical role in detecting clinically significant pathology

47 The best image is the one that doesn t miss the pathology Call us today at

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