Herniated and Bulging Disc\Lumbar Spine

A side view of the lumbar spine shows normal discs, spinal canal, and nerve roots (see figure 1). Nerve roots normally float in the fluid-filled canal. Figure 2 shows a small herniated disc pushing into the canal toward nerve roots. Image courtesy of Intermountain Medical Imaging, Boise, Idaho. All rights reserved.



Axial MR image and Sagittal T-1 weighted MR image of the lumbar spine demonstrates disc herniation at L5-S1(asterisk).


A spinal disc herniation is a condition affecting the spine which a tear in the outer fibrous ring (annulus fibrosus) of an intervertebral disc allows the soft portion (nucleus pulposus)to bulge out. Tears in the annulus fibrousus usually arise from a previously existing disc protrusion, which is a condition where the outermost layers of the annulus fibrousus are still intact, but can bulge when the disc is under pressure.

Disc herniation can occur in any disc in the spine, but the two most common forms are lumbar and cervical disc herniation. The lumbar is the most common site for disc herniation and is the main cause for lower back pain. Lumbar disc herniations occur in the lower back, most often between L4 and L5 or between L5 and S1 vertebral bodies. Disc herniation can occur from general wear and tear, such as jobs that require constant sitting, or heavy lifting. Smoking is a major risk factor as the chemicals within smoke cause diminished nutrition and oxygenation of the discs leading to dehydration and degeneration which can progress to herniation. There is also a strong genetic component that has been known to contribute to lumbar disc herniation.

Symptoms of a herniated disc can vary depending on the location of the herniation and the type of soft tissue involved. They can range from little or no pain if the disc is the only tissue injured. However if the nerve roots are irritated or impinged by the herniated material the pain can be very severe. Unlike pulsating pain the pain that comes from a herniated disc is usually continuous and in a specific position of the body sometimes radiating down into other parts of the body. This kind of pain is known as electic shock pains. Other symptoms include tingling and numbness, muscle weakness, and could include bowel or bladder problems which require medical attention right away.

Most often your physician can a make the diagnosis of a herniated disc by a physical examination. The examination includes testing sensation, muscle strength, and reflexes and also utilizing different forms of imaging like X-ray, CT, and MRI. An MRI is the most commonly used exam in making the diagnosis of a herniated disc in conjunction with the physical examination findings.

Most often treatments of a herniated disc begin conservatively and become more aggressive if the symptoms persist. Treatment usually begins with rest and activity modification, along with ice and heat applications. Then physical therapy and anti-inflammatory medications, topical as well as oral. More aggressive treatments are also used such as epidural steroid injections and lastly surgery.

Metastatic epidural spinal cord compression / Thoracic spine

Figure 2. Epidural spinal cord compression on magnetic resonance imaging (MRI). Sagittal T1-weighted MRI through the thoracic spine demonstrates lymphoma (arrows) involving the T5 and T12 vertebral bodies extending posteriorly into the spinal canal and compressing the spinal cord (c) at both levels. T8 indicates the T8 vertebral body, and A indicates anterior.
Adapted with permission from Quint DJ. Indications for emergent MRI of the central nervous system. JAMA 2000;283:854.


Metastatic epidural spinal cord compression (MESCC) occurs when cancer metatasises to the vertebral bodies of the spine or epidural space and causes secondary compression of the spinal cord. MESCC is a common complication of malignancy that affects almost 5 percent of patients with cancer. Systemic cancers with a tendency for spinal cord metastasis include the following: breast, prostate, renal, or lung neoplasms: lymphoma, sarcoma, and multiple myeloma. Most frequently metastatic seeding appears in the thoracic spine, accounting for about 70 percent of the cases.

MESCC is a medical emergency that needs rapid diagnosis and treatment if permanent paralysis is to be prevented. Appoxiamately 90 percent of patients who are ambulatory at the time of diagnosis do not lose this ability posttreatment. New back pain in patients with cancer suggests epidural spinal cord compression. Pain that worsens when the patient is lying down or with percussion of vertebral bodies is characteristic of the condition. Later neurologic signs like incontinence and loss of sensory function are associated with permanent paraplegia.

The diagnosis of MESCC is best determined with the use of magnetic resonance imaging. MRI has surpassed myelography as the imaging study of choice. Most patients with epidural spinal cord compression need radiation treatment or surgery. Asymptomatic patients should be considered for immediate radiation therapy, and patients with progressive symptoms despite radiation therapy should be considered for sergical intervention.

Hangman's Fracture / Cervical Spine

Figure 25. Sagittal T1-weighted MR image of the cervical spine shows a hangman fracture with ligamentous injury and extensive prevertebral and epidural hematoma







Figure 13. Sagittal T2-weighted MR image of the cervical spine in a pediatric patient shows a C2 fracture with disruption of the tectorial membrane (arrow), findings that indicate a severe and unstable injury.




A Hangman's fracture is a fracture of both pedicles or pars interarticularis of the axis vertebra, the second cervical vertebra(C2). The fracture can be with or without subluxation of C2 or C3 and often causes death.

The name Hangman's fracture came from a broken neck involving a fracture of an upper cervical vertebra similar to the injury suffered in death by hanging. The head would be forced into hyperextension by the full weight of the body and therefore the force and distraction of the neck would cause the fracture. Now days this injury is seen due to sports injuries, motor vehicle accidents, diving into shallow water, along with deliberate or suicidal hanging.

Severe pain will usually be present at the point of injury. Pressure on a nerve may also cause pain from the neck down into the shoulders and arms. Bruising and swelling may be present at the back of the neck. When these symptoms arise, Doctors will usually order X-rays to detemine the severity and location of any fracture. Also they may order a neurological exam to be performed to assess for spinal cord injury. CT scans may also be ordered to look for abnormallties not visible by regular X-rays. Also MRI tests can be ordered to provide high resolution images of soft tissue to further determine damage to the spinal cord. Worse senario a patient may experience immediate consequences of numbness and paralysis in much of the body which makes this a very serious and unstable injury.

When numbness and paralysis are the symptoms, complete immoblizaton of the head and neck should be done as early as possible and before moving the patient. Immobilization is imperative to minimise or prevent further spinal cord injury. Collars, and traction should be used to immoblize and stablilize the neck before diagnosis and when cervical fracture has been diagnosed.

Surgery may be needed to stabilize the neck to relieve pressure on the spinal cord. Different surgeries are available depending on the injury. Vertabrae may have to be fused together to provide stability. Metal plates, screws, or wires may be needed to hold vertabrae or pieces of the vertabrae in place.

Neck Vessels / Dissection of the Carotid Artery

Top: Magnetic resonance angiography of right carotid artery dissection 2 cm from bifurcation (on left side). Bottom: Magnetic resonance angiography of right carotid artery dissection with clot in the wall (on left side). Dissection stops below skull base. Images contributed by Philip Kousoubris, MD.



Arterial dissection of the carotid arteries occurs when a small tear forms in the innermost lining of the arterial wall. Blood can enter into the space between the inner and outer layers of the vessel, causing stenosis or complete occlusion. Blood clots, or emboli originating from the dissection are thought to be the cause of infarction in the majority of cases of stroke in the presence of carotid artery dissection.

Carotid arterial dissections can be categorized as traumatic or spontaneous. Traumatic dissection is the result of either external mechanical injury, like blunt trauma, or trivial trauma that is related to a movement or abrupt change in head position, and sometimes strenuous physical exertion. Spontaneous dissections have no definitive precipitating factor, however they may be associated with systemic hypertension, connective tissue disorders, smoking, diabetes, oral contraceptives, a family history of cerebral infarction or cerebral and abdominal aortic aneurysms.

The signs and symptoms of carotid artery dissection may be divided into two categories:
Ischaemic
Decreased pupil size with drooping of the upper eyelid
Transient vision loss
Ischemic stroke

Non-ischaemic
Headaches
Neck pain

Recognizing a dissection early is essential because prompt anticoagulant therapy and endovascular repair greatly minimize the patients risk of infarction/stroke, neurologic disability, and death. Cervical arterial dissections are relatively rare. The combined incidence of both vertebral and carotid dissections is estimated to be 2.6 cases per 100,000 population. However, cervical arterial disections are the underlying reason in as many as 20 percent of the ischemic strokes that occur in patients 30 to 40 years old.

Nearly all imaging modalities have been used to demonstrate cervical arterial dissections. In the past conventional catheter angiography has been the standard for the diagnosis of arterial dissection, however increasing reliance has been placed on reconstructed cross-sectional imaging techniques, including CT scanning and MR angiography because of the noninvasive nature of these modalities. The many advantages of MRA's has made this the preferred method for the initial screening and evaluation of patients with suspected arterial dissection.

Soft Tissue Neck / Ranula

Figure (a) Axial T2 weighted MRI shows a high signal lesion in the left sublingual space extending to the submandibular space consistent with a plunging ranula (arrow). (b) Axial T1 weighted MRI with gadolinium enhancement of the same ranula showing minor rim enhancement of the cystic lesion (arrow)


MRI Coronal STIR and MRI T2 Sag images





A Ranula is a type of mucocele found on the floor of the mouth and usually involves the major salivary glands. Ranulas occur as a result of trauma or obstruction to the salivary gland excretory duct and spillage of mucus into the surrounding soft tissues. These lesions are divided into two types: oral ranulas and cervical or plunging ranulas. Oral ranulas are secondary to mucus extravasation that pools around the mylohyoid muscle, and the cervical or plunging ranulas are associated with mucus extravasation along the fascial planes of the neck.

A Ranulla looks like a bluish cyst located below the tongue. The cyst may fill the mouth and raise the tongue. Typically theses cysts are painless masses that do not change in size in response to chewing, eating, or swallowing. Ranulas tend to be relatively painless with little or no associated morbidity or mortality. Depending on the size and location, some ranulas may interfere with normal mastication.

Plunging ranulas can manifest as neck swelling in conjunction with, or independent of a ranula cyst on the floor of the mouth. Most reported plunging ranulas are 4 to 10 centemeters in size and are usually found in the submandibualr space. They have been reported to extend into the submental region, the contralateral neck, the nasopharynx up to the skull base, the retropharynx, and even into the upper mediastinum. Oral and plunging ranulas may affect swallowing, speech, or mastication and may result in airway obstruction. The very thoracic ranula may compromise respiratory funtion and may be life threatening.

Ranulas usually occur in children and younger adults. The cervical or plungling varient tends to occur a little later in life.

CT scanning is used to diagnose Ranulas, however MRI scanning is the most sensitive imaging study to evaluate the sublingual gland and its pathologic states. Many Ranulas resolve on their own and do not require surgical intervention. Medical therapy with medication is also a form of treatment. However if there is an airway obstruction or some sort of feeding problems, surgery is indicated.

Saccular Aneurysms

Left: A CT scan revealing a large intraparenchymal hemorrhage in the right frontal lobe. Right: A arteriogram of the same patient demonstrating a saccular aneurysm of the left callosomarginal artery.

Aneurysms develop because of a weakness in the wall of the vessel. Because of the weakness, a particular spot will balloon out and fill with blood. The pressure from the ballooning can affect surrounding nerves or brain tissue. The blood vessel can rupture, causing bleeding in the brain. The cause of most aneurysms is unknown. In a small number of patients, aneurysms are inherited with multiple family memebers affected. Studies have found that people with connective tissue disorders, polycystic kidney disease and certain circulatory disorders, such as arteriovenous malformations, are more likely to get aneurysms. Other potential causes include head trauma, cancer, high blood pressure, infection, tumors, cigarette smoking, and drug abuse. Oral contraceptives have also been a suspected cause.

A saccular aneurysm is a sac of blood attached by a neck to a blood vessel. Aneurysms fall into three size classifications: small (under 11mm in diameter), larger (11mm to 25mm) and giant (greater than 25mm). Aneurysms typically have no symptoms unless they rupture. If the aneurysm gets big enough to put pressure on surrounding organs there may be warning symptoms before it ruptures. These syptoms include loss of vision, double vision, headaches, pain behind the eyes, drooping eyelids, and nausea or vomiting with possible speech impairment, seizures, and neck pain.

Being diagnosed with a brain aneurysm is like having a ticking time bomb in your head. A person can go their entire life with an aneurysm and never notice anything. If an aneurysm ruptures, it can cause stroke, nerve damage, and even death. If a brain aneurysm is found before it ruptures, most likey the means of treatment will be a minimal invasive endovascular surgery to place coils, embolization or balloons to minimize the aneurysm, or even clipping to isolate the aneurysm.

Chronic Sinusitis

Coronal CT images of the sinuses before treatment and after.


Chronic sinusitis affects 32 million people each year and accounts for 11.6 million visits to the physicians offices. Chronic sinusitis affects people in all age groups and is a common disease worldwide. The cavities around the nasal passages known as the sinuses become inflamed and swollen and this interferes with the drainage and causes mucus to build up. Chronic sinusitis may be caused by an infection but can also be caused by growths in the sinuses known as nasal polyps, or a deviated nasal septum. While most people have a short-lived bout of sinusitis known as acute sinusitis, chronic sinusitis is sinusitis that lasts more than eight weeks or keeps coming back.

Patients with chronic sinusitis usually present the following symptoms:
Nasal stuffiness, nasal discharge, drainage of a thick, yellow or greenish discharge from the nose or down the back of throat, pain, tenderness and swelling around your eyes, cheeks, nose or forehead, headache, sore throat, fatigue or irritability,as well as a chronic unproductive cough.

To look for the cause of these symptoms a doctor may use several methods to help screen for chronic sinusitis such as Nasal Endoscopy, imaging sudies utilizing CT or MRI, nasal and sinus cultures along with allergy testing. Treatment for chronic sinusitis includes prescribing antibiotics, if allergies are a contributing factor immunotherapy (allergy shots) will be administered. In cases that continue to resist treatment or medication, endoscopic sinus surgery may be the only option.

Optic Nerve Glioma's

Coronal noncontrast T1-weighted MRI reveals a large intraorbital mass (arrow) centered on the optic nerve.

Coronal postgadolinium T1-weighted MRI with fat saturation (same patient as in Image above) reveals diffuse, intense enhancement of the intraorbital mass (arrow).


Axial postgadolinium T1-weighted MRI with fat saturation (same patient as in Images above) reveals diffuse, intense enhancement of the intraorbital mass. The lesion is confined to the orbit.

Optic nerve glioma's are the most common primary neoplasm of the optic nerve. They are found in or around the nerves that send messages from the eyes to the brain. A low-grade form of this neoplalm occurs most often in pediatric patients and presents itself as a benign tumor. Optic nerve and optic chiasmal gliomas are slow-growing and the tumor sometimes produces additional symptoms as it grows. In most young patients the presenting symptom is painless proptosis. Also other symptoms include optic atrophy, reduced visual acuity and large lesions may compress the optic chiasm causing nystagmus, or the glioma may also compress the third ventricle resulting in obstructive hydrocephalus accompanied by headache, nausea, and vomiting. Hypothalamic syptoms such as changes in appetitie or sleep may also occur. The benign glioma is usually very slow growing, if at all, over extended periods. However some lesions can progress causing visual impairment, so ongoing follow up is recommended.

Twenty percent of optic gliomas that extend to the optic chiasm or beyond into the optic radiations, demonstrate a more agressive course. Aggressive glioma is most common in adults and it is frequently fatal even with treatment. Despite aggressive radiation, chemotherapeutic, or surgical treatment, aggressive glioma is an almost uniformly fatal disease.

MRI is the prefered method of evaluation of the optic nerve glioma. Both the intraorbital lesion and its intracranial extent can be effectively characterized through MRI. Gadolinium enhanced T1-weighted images with the fat saturation can define the extent of the aggressive glioma.

Pituitary Apoplexy

Pituitary apoplexy occurs when a pituitary tumor spontaneously hemorrhages or when it outgrows its blood supply. Pituitary adenomas can suddenly bleed internally, leading to an abrupt increase in size which can cause compression of the pituitary gland and perisellar structures, the optic nerves, and the nerves that control eye movements. Pituitary tumor apoplexy is a rare endocrine emergency and is a potentially life-threatening disorder. All types of pituritary adenomas can be associated with apoplexy, especially larger tumors (macroadenomas). Signs and symptoms of pituitary apoplexy include headache, visual impairment, nausea and vomiting, altered mental status, meningismus, and fever. Headaches are the most prominent symptom in patients with pituitary apoplexy.

Pituitary apoplexy is best diagnosed with an MRI scan of the brain, with special attention to the pituitary. A CT scan of the pituitary gland also shows and abnormality but MRI is the preferred exam.

Effective treatment of pituitary apoplexy requires prompt administration of high-dose corticosteroid along with careful monitoring of fluid and electrolyte levels, and in most cases urgent transsphenoidal surgery is required. Careful monitoring of hormonal status by an endocrinologist during the acute phase of apoplexy and in the recovery phase is essential. Most patients have significant visual improvement after surgery, however allot of patients will have permanent hormone deficiencies due to pituitary injury and will require hormone replacement therapy for life. Thanks to the steroid medications we have today, patients rarely die from pituitary apoplexy if promptly diagnosed and treated.

Labyrinthitis

Labyrinthitis is an ear disorder that involves irritation and swelling of the inner ear. The parts of the inner ear become irritated and this interferes with their functions in hearing and balance. There are many causes of of labyrinthitis the most common cause occurs after an ear infection or upper respiratory infection. Symptoms include vertigo, dizziness, loss of balance and equilibrium, nausea and vomiting, ringing of the ear, and difficulty focusing the eyes because of involuntary eye movement. There are many different names for Labyrinthitis such as:
-Bacterial labyrinthitis
-Serous labyrinthitis
-Neuronitis
-Viral neurolabyrinthitis

Labyrinthitis usually goes away within a few weeks. Some symptoms may need treatment with antibiotics. Most patients are completely better and their hearing returns to normal. However, calcifications or ossificans can appear after Labyrinthitis.

Labyrinthitis ossificans. Axial CT shows new bone formation partially obliterating left cochlea.

Labryinthitis ossificans is the pathologic formation of new bone within the lumen of the otic capsule and usually occurs in response to a destructive or inflammatory process. It is a condition in which the inner ear is filled with fibrotic tissue, which then calcifies. It mostly affects the cochlea, but the vestibule and semicircular canals can also be involved. Labyrinthitis ossificans most commonly develop after having bacterial meningitis. Labyrinthitis ossificans can also result from temporal bone trauma, Leukemia, suppurative labyrinthitis, and autoimmune inner ear disease. Labyrinthitis ossificans can cause profound deafness and loss of vestibular function.


On the left images of a 56-year old male, who is a candidate for cochlear implantation. Small calcification in basal turn of cochlea as a result of labyrinthitis ossificans (arrows).

The treatment for this uses several different medications along with steroids as well as surgery and hearing aids. Since the occurrence of ossification virtually guarantees that hearing will not be restored the cochlear implant is a very important treatment option.

Wilson's Disease

Hyperintensities in the bilateral basal ganglia and thalami shown by T2-weighted MRI of the brain


Wilson's disease is a rare inherited disorder that causes the body to absorb and retain excessive amounts of copper. The accumulation of copper can damage many organs and tissues. The copper usually deposits in the liver, brain, kidneys, and the eyes. The liver and central nervous system are most often affected and are the most dangerous. If left untreated the copper can accumulate to life-threatening levels and can be fatal. Several different tests are used when diagnosing Wilson's disease. CT and MRI scans are used when diagnosing Wilson's of the brain. Other tests are also done to measure the amount of copper in the blood, urine, and liver. Although the copper accumulation begins at birth, symptoms of the disorder appear later in life. The most characteristic symptom of Wilson's is the Kayser-Fleisher ring which is a rusty brown ring around the cornea of the eye. Up to one-third of people with WD have neurological signs and symptoms, such as tremors, seizures, drooling, difficulty speaking, loss of fine motor skills, repetitive movements, slowness in movements. WD also causes behavioral and psychological problems such as abrupt personality changes, depression and neurotic behaviors.

If WD is detected early a person can enjoy a normal life and live a normal lifespan. Wilson's disease does require lifelong treatment by taking copper-reducing medication and avoiding copper containing vitamin and mineral supplements, along with foods high in copper. Wilson's disease itself is rare, but as many as one in 100 people has one defective ATP7B gene. WD is inherited and is an autosomal recessive trait, which means that to develop the disease you must inherit two copies of the defective gene, one from each parent. Exports recommend that all children and siblings of people with Wilson's be tested for disease.

This disease is very interesting to me because my ex-husbands family has a long history of Wilson's some cases even fatal and my daughter and grandchildren have been tested for this disease and are still being tested periodically for symptoms.