Spine MRI Recognition Pattern

Systematic approach to interpreting spine MRI with key anatomical landmarks and pathological patterns

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1. Basic Principles

A. Standard Sequences

• T1-weighted:
  - Anatomical detail
  - Fat = bright, water = dark
  - Good for bone marrow evaluation
• T2-weighted:
  - Pathological changes
  - Water = bright, fat = variable
  - CSF bright, discs bright
• STIR:
  - Fat suppression
  - Sensitive for edema
  - Bone marrow pathology
• DWI/ADC:
  - Acute ischemia
  - Epidural abscess
  - Some tumors

B. Anatomical Planes

• Sagittal:
  - Overall spinal alignment
  - Vertebral bodies, discs
  - Spinal cord evaluation
• Axial:
  - Neural foramina
  - Central canal
  - Nerve root assessment

2. ABCDE Systematic Approach

Step

Assessment

Key Elements

A

Alignment

Scoliosis, spondylolisthesis, fractures

B

Bone

Marrow signal, fractures, lesions

C

Cord/Canal

Cord signal, stenosis, compression

D

Discs

Degeneration, herniation, hydration

E

Extras

Soft tissues, paravertebral, vessels

3. Degenerative Patterns

A. Disc Pathology

Finding

T1

T2

Features

Bulge

Isointense

Variable

Circumferential, <3mm beyond vertebra

Protrusion

Isointense

Dark (desiccation)

Focal, base wider than apex

Extrusion

Isointense

Variable

Apex wider than base, may migrate

Sequestration

Isointense

Variable

Free fragment, no continuity

B. Modic Changes

Type

T1

T2

Pathology

I

Hypointense

Hyperintense

Edema/inflammation

II

Hyperintense

Hyperintense

Fatty replacement

III

Hypointense

Hypointense

Sclerosis

4. Spinal Cord Pathology

A. Intramedullary Lesions

• MS plaques:
  - Ovoid, <2 vertebral segments
  - Peripheral, dorsal columns
  - T2 hyperintense, may enhance
• Ependymoma:
  - Central, well-circumscribed
  - May have hemorrhage
  - "Cap sign" (hemosiderin)
• Astrocytoma:
  - Eccentric, infiltrative
  - Longer segments
  - Cystic components common

B. Syringomyelia

• Features:
  - CSF-like signal in cord
  - May be focal or extensive
  - Look for Chiari or trauma

5. Infection & Inflammation

A. Discitis/Osteomyelitis

• Findings:
  - T1 hypointense disc/vertebra
  - T2 hyperintense
  - Endplate destruction
  - Enhancement post-contrast
  - Paravertebral abscess

B. Epidural Abscess

• Findings:
  - T2 hyperintense collection
  - Peripheral enhancement
  - DWI restriction
  - May compress cord

6. Trauma Patterns

A. Fracture Types

Type

Mechanism

MRI Findings

Compression

Axial load

Height loss, marrow edema

Burst

Severe axial load

Retropulsion, cord compression

Chance

Flexion-distraction

Horizontal through vertebra

B. Ligamentous Injury

• Findings:
  - T2 hyperintensity in ligaments
  - Discontinuity of fibers
  - Facet joint widening
  - STIR most sensitive

7. Tumor Patterns

A. Intradural Extramedullary

• Meningioma:
  - T1/T2 isointense to cord
  - Broad dural base
  - Homogeneous enhancement
• Schwannoma:
  - T2 hyperintense
  - "Dumbbell" shape
  - May enlarge neural foramen

B. Metastatic Disease

• Findings:
  - T1 hypointense (vs fatty marrow)
  - T2 variable
  - Enhancement common
  - May have pathologic fractures

8. Spine MRI Reporting Template

1. Technique: Sequences, planes, contrast
2. Alignment:
   - Curvature abnormalities
   - Spondylolisthesis
3. Bone marrow:
   - Signal abnormalities
   - Fractures/compression
4. Intervertebral discs:
   - Degeneration
   - Herniation (type/level)
5. Spinal canal/cord:
   - Stenosis degree
   - Cord signal abnormalities
6. Other findings:
   - Soft tissue abnormalities
   - Vascular malformations

Always correlate with clinical history and neurological findings. Compare with prior imaging when available. For degenerative changes, describe severity and relationship to neural structures. In trauma, assess ligamentous integrity and stability. For tumors, describe extent and compression effects. Consider contrast when infection or tumor is suspected but not contraindicated.

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