Degenerative Disk Disease of the Cervical Spine: Spectrum of Imaging Findings

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1 Degenerative Disk Disease of the Cervical Spine: Spectrum of Imaging Findings Poster No.: P-0118 Congress: ESSR 2014 Type: Scientific Poster Authors: M. Tzalonikou, S. Yarmenitis, F. Laspas, G. Delimpasis, J Andreou ; Athens/GR, Marousi/GR Keywords: MR, CT, Conventional radiography, Musculoskeletal spine, Education, Arthritides DOI: /essr2014/P-0118 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 68

2 Purpose Cervical spondylosis is a chronic degenerative condition of the cervical spine affecting the vertebral bodies, intervertebral disks, facet joints and the contents of the spinal canal. It is commonly seen in people older than 40 years, is believed to be part of the normal aging process of the spine and will affect up to two-thirds of the population during their lifetime. The goal of our presentation is to illustrate the spectrum of imaging appearances of degenerative disease in the cervical spine on plain radiography, CT, MRI and to review the performance of each method. Methods and Materials Cervical spine radiographs, CT and MRI scans were retrieved from consecutive cases stored in our hospital's PACS database in a period of two months. Representative cases were selected and reviewed according to the presence of abormalities related to the: -alignement of cervical spine, -vertebral body height, -vertebral endplate, -neural foramen width, -joint space, -intervertebral disk and -uncovertebral and facet joints. In routine practice, the above entities are initially illustrated by plain radiographs. CT and MRI are used in order to obtain more detailed information. Standard radiographic views include anteroposterior and lateral projections. Oblique views are obtained for the evaluation of neural foramina and facet joints. Flexion and extension views are only needed in advanced spondylosis and may reveal instability. Since the introduction of multislice CT technology, CT scan imaging protocol includes volumetric data acquired from the region of interest. Axial reconstructions are the basic imaging data sets and ==== reconstructionin the coronal and sagital plane are created on a routine basis. Soft-tissue and bone window is essential. Three dimensional Page 2 of 68

3 reconstructions are not produced on a routine basis in cases of cervical spine spondylosis but only upon clinician's request. Overall, CT scanning time is short. MR Imaging protocol includes images in the coronal, axial and sagittal plane. In our institution, routine cervical spine MR protocol includes conventional sagital T1 and T2 turbo spin echo images and T2 fat-saturated images, axial T1 turbo spin echo and T2 gradient echo imges. At last, coronal T1 turbo spin echo images are acquired for evaluation of cervical spine scoliosis. Supplementary thin axial section (e.g. steady-state) may also be obtained to delineate with detail the margin of disk herniations and for the evaluation of neural foramina. MR scanning times are relatively long. Results Neck pain is the most frequent cause for imaging request of the cervical spine. Degenerative disease of the cervical spine is a common cause of intermittent neck pain and is also called spondylosis. Imaging findings in cervical spine degenerative disease include: -loss of the normal lordotic curvature of the cervical spine which may be presented eiter as straightening or reverse of the normal cervical spine lordosis, -joint space narrowing, -vertebral body degeneration and possible loss of height, -end-plate sclerosis, -uncovertebral joint hypertrophy and facet joint arthrosis, -syndesmophyte or osteophyte formation, -ligament calcification, -neural foramen stenosis and -disk disease which includes disk bulging, disk herniation and disk protrusion/extrusion, disk degeneration and vacuum phenomenon. Also, degenerative disease of the cervical spine may be associated with changes in the spinal cord. Page 3 of 68

4 Plain radiographs: They are of limited specificity but are still considered as the first imaging modality for the evaluation the cervical spine (Fig. 1-15). CT scans: Multislice CT provides more detailed information relative to radiographs for the investigation of cervical spine. This information is related to: -measurements of the spinal canal dimensions, -the neural foramina and the exiting nerve roots, -the intervertebral disk. Disk bulging and disk herniation can be directly visualised. Disk degeneration-dehydration and vacuum phenomenon can be readily identified and -the spinal canal contents. CT scan has definite advantages relative to the rest of the imaging modalities in the evaluation of the bony structures and of calcification in the soft tissues. With the use of multislice technology, it has become superior relative to other modalities since image reconstructions can be created in various planes. (Fig ). MRI: it is considered to be the imaging modality of choice for the investigation of degenerative disease of the spine in general and of course, of the cervical spine. This is mostly because of the method's excellent soft-tissue contrast capability. MRI is insensitive to the detection of soft tissue calcification and can lose details related to bone and bone cortex. It is, though, of undisputable superiority and provides additional information relative to plain radiographs and CT scans in the investigation of the: -intervertebral disk that comprises detection of disk degeneration, annular tears, disk bulge and disk herniation, -neural foramina and the neural elements within them, in particular neural foramen stenosis and impingement on nerve roots and -spinal cord. (Fig ). A diagnostic algorithm proposed for the investigation of cervical spine degenerative disease starts with plain radiographs in cases of persistent neck pain. In patients with severe pain, radicular pain and neurologic deficits, MRI is thought to be the investigation method of choice. CT should be considered if detailed information about the bony structures is needed. Page 4 of 68

5 Images for this section: Page 5 of 68

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7 Fig. 1: Anteroposterior view of the cervical spine. Normal exam. Page 7 of 68

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9 Fig. 2: Lateral view of the cervical spine. Normal exam. There is normal alignement of the cervical spine vertebrae and preservation of the normal lordotic curve. Normal height of the vertebral bodies. No joint space narrowing is identified. Page 9 of 68

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11 Fig. 5: Flexion view. Page 11 of 68

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13 Fig. 6: Extension view. Page 13 of 68

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15 Fig. 7: Lateral view. Straightening of the cervical spine. Otherwise, normal exam. Page 15 of 68

16 Fig. 8: Lateral view. Straightening and mild reverse of the normal lordotic curve of the cervical spine. Small anterior osteophyte formation is noted. Page 16 of 68

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18 Fig. 9: Lateral view. Normal alignement of the cervical spine. Small anterior osteophyte formation is noted at the C3-C4, C4-C5 and C5-C6 levels. There is joint space narrowing at the C4-C5 level and mild end-plate sclerosis. Uncovertebral joint hypertrophy at the C4-C5 and C5-C6 levels is also noted. Page 18 of 68

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20 Fig. 10: Lateral view. Loss of the normal lordotic curve and straightening of the cervical spine. Vertebral body height is normal. There is joint space narrowing, end-pate sclerosis and anterior osteophyte formation at the C4-C5 and C5-C6 levels. Mild uncovertebral joint hypertrophy is noted at the same levels. Page 20 of 68

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22 Fig. 11: Lateral view. Normal alignement of the cervical spine. Mild loss of height of the C4,C5 and C6 vertebral bodies. there is generous anterior osteophyte formation at the C4-C4 and C5-C6 levels. Very mild loss of height at the C6-C7 levels. Page 22 of 68

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24 Fig. 16: CT scan of the cevical spine. Coronal reformat. C5-C6 joint space narrowing, right C5-C6 uncovertebral joint hypertrophy and end-plate sclerosis of the C5 vertebra lower end-plate. Page 24 of 68

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26 Fig. 17: CT scan of the cevical spine. Sagital reformat. Mild posterior displacement of the C5 relative to the C4 vertebra. C5-C6 joint space narrowing, mild end-plate sclerosis and small anterior osteophyte at the same level. Fig. 18: Axial CT image through the upper cervical spine at the level of the intervertebral joint space. Page 26 of 68

27 Fig. 19: Axial CT image through the upper cervical spine. Page 27 of 68

28 Fig. 20: Axial CT image through the upper cervical spine at the level of the intervertebral joint space. Bone window. Page 28 of 68

29 Fig. 21: Axial CT image through the upper cervical spine. Page 29 of 68

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31 Fig. 33: Sag. T2 TSE image through the cervical spine. Midline level. Mild straightening of the cervical spine. Otherwise normal exam. Fig. 34: Ax. T2 GRE of the upper cervical spine at the C3-C4 intervertebral joint space level. Normal exam. Page 31 of 68

32 Fig. 35: Ax. T2 GRE of the upper cervical spine at the C4 upper end-plate level. Normal exam. Page 32 of 68

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34 Fig. 3: Right lateral oblique view. No stenosis of the neural foramina is identified. Page 34 of 68

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36 Fig. 4: Left lateral oblique view. No stenosis of the neural foramina is identified. Page 36 of 68

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38 Fig. 12: Anteroposterior view of the cervical spine. Very mild right-ward scoliosis of the cervical spine. Fig. 13: Lateral view. Straightening of the cervical spine. C4-C5, C5-C6 and C6-C7 joint space narrowing, end-plate sclerosis and mild anterior osteophytosis. Page 38 of 68

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40 Fig. 14: Right oblique view. Mild stenosis of the right C3-C4 and C5-C6 foramina and more severe of the right C4-C5 foramen. Page 40 of 68

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42 Fig. 15: Left oblique view. Stenosis of the left C4-C5 and C5-C8 foramina. Page 42 of 68

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44 Fig. 22: CT scan of the cervical spine. Sagital reformated images. Normal lordosis of the cervical spine. Normal height of the vertebral bodies. Mild C5-C6 and C6-C7 joint space narrowing, end-plate sclerosis and anterior osteophyte formation. Fig. 25: Axial section through the lower cervical spine. Extensive osteophyte formation and right uncovertebral joint hypertrophy. There is compression of the anterior aspect of the thecal sac and of the cervical cord. Spinal stenosis is identified. Page 44 of 68

45 Fig. 23: Axial section through the mid-cervical spine. Extensive left uncovertebral joint hypertrophy. There is stenosis of the left neural foramen and compression of the exiting nerve root. Page 45 of 68

46 Fig. 24: Axial section through the mid-cervical spine. Bone window. Same patient and same level as image 23. Extensive left uncovertebral joint hypertrophy. There is stenosis of the left neural foramen and compression of the exiting nerve root. Page 46 of 68

47 Fig. 26: Axial section through the lower cervical spine. Bone window. Same patient and same level as image 25. Extensive osteophyte formation and right uncovertebral joint hypertrophy. There is compression of the anterior aspect of the thecal sac and of the cervical cord. Spinal stenosis is identified. Page 47 of 68

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49 Fig. 37: Sag. T1 TSE image. Mid-line section. Straightening of the cervical spine. Multilevel disk disaese is identified. Page 49 of 68

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51 Fig. 38: Sag. T2 TSE image. Mid-line section. Same patient as in image.straightening of the cervical spine. Multilevel disk disease is identified (C3-C4, C4-C5, C5-C6). Fig. 39: Axial T2 gradient echo image. Midline posterior disk herniation with compression of the anterior aspect of the thecal sac. Mild left uncovertebral joint hypertrophy. Page 51 of 68

52 Fig. 40: Axial T2 gradient echo image. Left lateral posterior disk herniation with compression of the anterior aspect of the thecal sac. Page 52 of 68

53 Fig. 41: Axial T2 gradient echo image. Large posterior disk herniation with compression of the anterior aspect of the thecal sac and spinal cord. Spinal cord deformation is noted. There is stenosis of the spinal canal. No cervical myelopathy is noted. Page 53 of 68

54 Fig. 42: Axial T2 gradient echo image. Midline-left posterior disk herniation with compression of the anterior aspect of the thecal sac and the3 anterior aspect of the spinal cord. Page 54 of 68

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56 Fig. 27: CT scan of the cervical spine. Sagital reconstructions. Midline section. Straightening of the cervical spine. C5-C6 and C6-C7 joint space narrowing, end-pate sclerosis and small anterior and posterior osteophytes. Vacuum phenomenon at the C6C7 level. Page 56 of 68

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58 Fig. 28: CT scan of the cervical spine. Sagital reconstructions. Midline section. Multilevel degenerative disease. C3-C4, C4-C5 and C5-C6 mild joint space narrowing. Vacuum phenomenon in the same intervertebral disks. C4-C5 and C5-C6 pposterior osteophyte formation. Fig. 29: CT scan of the cervical spine. Degeneration and vacuum phenomenin of the intervertebral disk. Very small midline posterior disk herniation. Page 58 of 68

59 Fig. 30: CT scan of the cervical spine. Bone window.s ame patient and same level as image 29. Degeneration and vacuum phenomenin of the intervertebral disk. Very small midline posterior disk herniation. Page 59 of 68

60 Fig. 31: CT scan of the cervical spine. Axial section. Disk herniation. There is compression at the anterior aspest of the thecal sac and -most probably- of the cervical cord within the sac. Page 60 of 68

61 Fig. 32: CT scan of the cervical spine. Axial section. Bone window. Same patient and same level as image 31. Disk herniation. There is compression at the anterior aspest of the thecal sac and -most probably- of the cervical cord within the sac. Page 61 of 68

62 Fig. 36: Ax. ss image. Disk delineation is excellent. Neural foramina elements are clearly depisted. Page 62 of 68

63 Fig. 43: Axial T2 image through the cervical spine. Disk bulging is identified more prominent in left posterolateral position. Left foraminal stenosis is noted. Page 63 of 68

64 Fig. 44: Axial T2 section through the lower cervical spine. Prominent disk bulg and compression of the anterior aspect of the thecal sac and of the spinal cord. Mild spinal canal stenosis. Xeuraql foramina stenosis due to uncovertebral joint hypertrophy. Page 64 of 68

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66 Fig. 45: Sagital T2 section through the left lateral side of the spinal canal. Page 66 of 68

67 Conclusion Standard radiographs are still the first imaging modality used in order to evaluate degenerative disease of the cervical spine. CT scan is used if MRI cannot be performed and if bony abnormalities need to be evaluated. MRI is the imaging modality of choice because not only of its inherent capability for multiplanar imaging but mainly because of its very high tissue contrast resolution. References 1. Wilkinson M. The anatomy of cervical spondylosis. Proc R Soc Med Mar;57: Côté P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population. Spine (Phila Pa 1976) 2000;25: Hartvigsen J, Christensen K, Frederiksen H. Back and neck pain exhibit many common features in old age: A population-based study of 4,486 Danish twins years of age. Spine (Phila Pa 1976) 2004;29: Gallucci M, Puglielli E, Splendiani A, Pistoia F, Spacca G: Degenerative disorders of the spine. Eur Radiol 2005, 15, Hoff JT, Panadopoulos SM. Cervical disc disease and cervical spondylosis. In: Wilkins RH, Rengachary SS, eds.neurosurgery. New York, NY: McGraw-Hill; 1996: Personal Information M. Tzalonikou: Radiologist, CT-MRI Dpts, Hygeia-Mitera Private Hospital Group, Athens, Greece S. Yarmenitis: Radiologist, Head of Dpt of Diagnostic Radiology, Hygeia-Mitera Private Hospital Group, Athens, Greece F. Laspas: Radiologist, CT-MRI Dpts, Hygeia-Mitera Private Hospital Group, G. Delimpasis: Radiologist, MRI Dpt, 251 General Air Force Hospital, Athens, Greece J. Andreou: Radiologist, Chairman of Medical Imaging Dpts, Hygeia-Mitera Private Hospital Group, Athens, Greece. Page 67 of 68

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