MRI SPINE /KNEE

DR, P S H HETTIARACHCHI
CONSULTANT RADIOLOGIST
ASIRI SURGICAL HOSPITAL
COLOMBO 5
 TISSUE COLOURS
• Water and pathology:
– White on T2,
– dark on T1.
– Pathology stays white on FLAIR, water doesn't
 TISSUE COLOURS

• Fat:
– white on T1 and T2
– dark on STIR and out of phase
 TISSUE COLOURS

• Hematoma: varying with time

 TISSUE COLOURS

• Bone Marrow: normally fatty

– white on T1
– White on T2
– replaced with edema or other pathology
• (dark on T1)
• Bone cortex, stones, and ligaments
– dark on everything
– Contusion is white
 TISSUE COLOURS

•
Tumor: hypervascular (neovascularity):
– white with gadolinium
 Approach to protocols

• T1 -MRI with dark fluid

• T2 -MRI with white water, inflammation
– cartilage is black
• STIR- T2 with dark fat
• Proton Density - cartilage is grey
– can suppress the fat
• Gadolinium enhanced - with fat suppressionT1
– bright blood
– dark fat
– Pathology bright
Magnetic resonance imaging (MRI) of
the spine
• A noninvasive procedure to evaluate different
types of tissue, including
– the spinal cord
– intervertebral disks
– spaces between the vertebrae through which the
nerves travel
– distinguish healthy tissue from diseased tissue.
Magnetic resonance imaging (MRI) of
the spine
• The cervical, thoracic and lumbar spine MRI
should be scanned in individual sections.
• The scan protocol parameter like e.g. the field
of view (FOV), slice thickness and matrix are
usually different for cervical, thoracic and
lumbar spine MRI, but the method is similar.
 Magnetic resonance imaging (MRI) of
the spine
• The standard views in the basic spinal MRI scan to
create detailed slices (cross sections) are
– sagittal T1 weighted and T2 weighted images over the
whole body part
– transversal (e.g. multi angle oblique) over the region
of interest with different pulse sequences according to
the result of the sagittal slices.
• Additional views or different types of pulse
sequences like fat suppression, fluid attenuation
inversion recovery (FLAIR) or diffusion weighted
imaging are created dependent on the indication.
 Indications:

• Neurological deficit, evidence of

radiculopathy, cauda equina compression
• Primary tumors or drop metastases
• Infection/inflammatory disease, multiple
sclerosis
• Postoperative evaluation of lumbar spine:
disk vs. scar
• Evaluation of syrinx
• Localized back pain with no radiculopathy (leg
pain)
 Contrast enhanced MRI
• Delineate infections, malignancies
• show a syrinx cavity
• support to differentiate the postoperative
conditions. After surgery for disk disease,
significant fibrosis can occur in the spine. This
scarring can mimic residual disk herniation.
• Magnetic resonance myelography evaluates
spinal stenosis and various intervertebral discs
can be imaged with multi angle oblique
techniques.
• Cine series can be used to show true range of
motion studies of parts of the spine.
• Advanced open MRI devices are developed to
perform positional scans in the position of
pain or symptom (e.g. Upright™ MRI formerly
Stand-Up MRI).
 Contraindications
• MRI systems use strong magnetic fields that attract any
ferromagnetic objects with enormous force.
• Caused by the potential risk of heating, produced from
the radio frequency pulses during the MRI procedure,
metallic objects like wires, foreign bodies and other
implants needs to be checked for compatibility.
• High field MRI requires particular safety precautions.
• In addition, any device or MRI equipment that enters
the magnet room has to be MR compatible.
• MRI examinations are safe and harmless, if these MRI
risks are observed and regulations are followed.
Safety concerns in magnetic resonance
imaging include:
• The magnetic field strength;
• possible 'missile effects' caused by magnetic forces;
• the potential for heating of body tissue due to the
application of the radio frequency energy;
• the effects on implanted active devices such as cardiac
pacemakers or insulin pumps;
• magnetic torque effects on indwelling metal (clips,
etc.);
• the audible acoustic noise;
• danger due to cryogenic liquids;
• the application of contrast medium;
 MRI Safety Guidance

• It is important to remember when working around a

superconducting magnet that the magnetic field is
always on.
• Under usual working conditions the field is never
turned off.
• Attention must be paid to keep all ferromagnetic items
at an adequate distance from the magnet.
• Ferromagnetic objects which came accidentally under
the influence of these strong magnets can injure or kill
individuals in or nearby the magnet, or can seriously
damage every hardware, the magnet itself, the cooling
system.
 MRI Safety Guidance

• The doors leading to a magnet room should be

closed at all times except when entering or
exiting the room.
• Every person working in or entering the magnet
room or adjacent rooms with a magnetic field has
to be instructed about the dangers.
• This should include the patient, intensive-care
staff, and maintenance-, service- and cleaning
personnel, etc..
 MRI Safety Guidance
• Leads or wires that are used in the magnet
bore during imaging procedures, should not
form large-radius wire loops.
• The patient’s skin should not be in contact
with the inner bore of the magnet.
 MRI Safety Guidance
• The outflow from cryogens like liquid helium is
improbable during normal operation and not
a real danger for patients
 MRI contrast
• The safety of MRI contrast agents is tested in
drug trials and they have a high compatibility
with very few side effects.
• The variations of the side effects and possible
contraindications are similar to X-ray contrast
medium, but very rare.
• In general, an adverse reaction increases with
the quantity of the MRI contrast medium and
also with the osmolarity of the compound.
 Cervical Spine 1 – Basic

• • Indications
– o Disc disease, pain, radiculopathy
• • Sequences
– o Sag T1 FSE/TSE
– o Sag T2 FSE/TSE
– o Ax T2 FSE/TSE
– o Ax TOF GRE
• • Optional
– o Cor T1 FSE/TSE
– o Cor T2 FSE/TSE
• For scoliosis, tethered cord and Neurofibromatosis, add
coronal
 Cervical Spine 2 – with contrast

• • Indications
– Tumor, Infection, MS, Syrinx, Transverse myelitis
• • Sequences
– Sag T1 FSE/TSE
– Sag T2 FSE/TSE
– Ax T1 FSE/TSE
– Ax T2 FSE/TSE
– Sag T1 +C FSE/TSE FS
– Ax T1 +C FSE/TSE FS
• • Optional
– Cor T1 FSE/TSE
– Cor T2 FSE/TSE
•
 Cervical Spine 3 – Trauma

• • Indications
– o Trauma
• • Sequences
– o Sag T1 FSE/TSE
– o Sag T2 FSE/TSE
– o Sag IR T2 FSE/TSE
– o Ax IR T2 FSE/TSE
– o Ax T2 FSE/TSE
• Can add sag T2 GRE to r/o hemorrhage
 Cervical Neurography (Brachial
Plexus)
• • Indications
– Post radiation therapy, eval for mass lesions, entrapment, denervation
• • Sequences
– Sag T2 FSE/TSE Scout
– Cor STIR
– Cor T1
– AX STIR
– Ax T1
– Cor T1 +C FS
– Ax T1 +C FS
• • Optional
– Cor T2 FSE/TSE FS
– Ax T2 FSE/TSE FS
– Sag T1 +C FS
 Cervical Neurography (Brachial
Plexus)
• Use the Cardiac or phased array Body coil rather
than the spine coil
• Cor images should be 3mm skip 0mm, Ax Images
4mm skip 1.5
• FOV should be from C4 through T1
• Use T2 FSE/TSE FS if STIR images fail
• Can add flow suppression or sat bands above,
below, and anterior
• Post process thick slab MIPs of STIR images if
possible
 Thoracic Spine 1 - Basic

• • Indications
– Disc disease, pain, radiculopathy
• • Sequences
– Sag T1 FSE/TSE
– Sag T2 FSE/TSE
– Ax T1 FSE/TSE
– Ax T2 FSE/TSE
• • Optional
– Cor T1 FSE/TSE
– Cor T2 FSE/TSE
 Thoracic Spine 2 – with contrast

• • Indications
– Tumor, Infection, MS, Syrinx, Transverse myelitis
• • Sequences
– Sag T1 FSE/TSE
– Sag T2 FSE/TSE
– Ax T1 FSE/TSE
– Ax T2 FSE/TSE
– Sag T1 +C FSE/TSE FS
– Ax T1 +C FSE/TSE FS
• • Optional
– Cor T1 FSE/TSE
– Cor T2 FSE/TSE
 Thoracic Spine 3 – Trauma

• • Indications
– Disc disease, pain, radiculopathy
• • Sequences
– Sag T1 FSE/TSE
– Sag T2 FSE/TSE
– Sag IR T2 FSE/TSE
– Ax T2 FSE/TSE
• • Optional
– Ax GRE
– Cor T1 FSE/TSE
– Cor T2 FSE/TSE
• Can add Sag GRE to rule out hemorrhage
 Routine L-Spine MRI
• Degenerative spine
– Sagittal T1 SE,
– Sagittal T2 FSE,
– angled axial PD/T2 FSE,
– Angled T1 stacked axials L3 to S2.
– No IV contrast.

•
 L-Spine MRI
• Trauma L-Spine MRI
– Sagittal T1 SE,
– Sagittal FSEIR,
– Axial T2 FSE with fat sat.
– Target axials to abnormality.
– No IV contrast.
• Post-Op L-Spine MRI
– Sagittal T1 SE,
– Sagittal FSEIR,
– Axial T2 FSE with fat sat.
– Target axials to abnormality at level of surgery
– IV contrast.
– Can add Sag GRE to rule out hemorrhage
 Osteomyelitis, Discitis
• pre-contrast:
– Sagittal T1 SE,
– Sagittal T2 FSE,
– Axial PD/T2 FSE,
• contrast: Gd (0.1 mmol / kg to max of 20 cc)
• post-contrast:
– Sagittal T1 SE,
– Axial T1 SE
 Tethered Cord

– Sagittal T1 SE,
– Sagittal T2 FSE,
– Axial T1 SE , T2 FSE,
• T10 to S2, using interslice gap as needed.
– No IV contrast.
 Spine Survey
• • Indications
– Metastases, Non-localized infection, acute myelopathy / cord compression
• • Sequences
– Sag T1 FSE/TSE
– Sag T2 FSE/TSE
– Ax T1 FSE/TSE
– Ax T2 FSE/TSE
– Sag T1 +C FSE/TSE FS
– Ax T1 +C FS (region of interest)
• • Optional
– Cor T1 FSE/TSE
– Cor T2 FSE/TSE
• • Comments
– sagittal images to determine where to obtain axial images
 MRI KNEE
• Common Indications
– Knee pain
– Knee instability
– Knee mass
• First Ask
– Is there a mass?______ When did you first discover the
mass?_______________________
– Does the problem relate to a recent injury? YES NO
DATE_____________________
– Where does the knee hurt ( FRONT - BACK - INSIDE - OUTSIDE )?
– Have you had surgery on your knee? YES NO
DATE__________________________
– Have you had an x-ray?
• If “mass” then schedule in early morning with Radiologist
monitoring. Patient may need gadolinium
• Otherwise schedule anytime.
• Instruct patient to bring x-rays if available.
 Patient Preparation:

• · Fill out safety screening and clinical

information form
• · Vitamin E capsule on the site of symptoms
and on any masses
• · Measure distance left or right from
centerline of magnet
• Coil: Extremity. Slightly externally rotate the foot
by about 10-15 degrees to stretch the anterior
cruciate ligament.
• Pack some cushions around the knee to help it
stay motion-free. A small cushion under the ankle
helps to keep the leg straight.
•
• Landmark: inferior region of patella.
•
• Patient Positioning: Supine, feet first.
• Series 1: Axial Proton Density
• Series 2: Sagittal Proton Density
• Oblique to the intercondylar notch
• Include all of medial and lateral menisci.
Subcutaneous fat medial and lateral to knee
joint may be excluded. If more slices are
required, increase TR.
•
• Series 3: Coronal Proton Density
• Oblique perpendicular to series 2.
• If more slices are required, increase TR.
• Keep TR > 3000 and ETL < 16
• If there is bone abnormality or soft tissue mass then it may be
necessary to increase FOV.
•
• Series 4: Coronal T2 Fat Sat (same as series 3 above)
•
• Series 5: Optional Cartilage:
• Usually cartilage is well seen on the proton density sequences
(series 1-3). However this in patients with cartilaginous injuries, this
extra sequence optimized for cartilage may be useful.
• Do not film this sequence. It is viewed on the computer work
station.
• If there is a Solid Mass suspicious for
CANCER:
• then make sure there is a vitamin E capsule
marking the site of the mass and perform
dynamic 2D or 3D Gd MRA during the
injection of single dose gadolinium followed
by axial and either sagittal or coronal T1 fat
sat spin echo sequences
• If there is hemophilia or if PVNS is suspected:
• Do a gradient echo sequence
• Series 8: Optional Gradient Echo:
• This sequence is useful for patient with
hemophilia or PVNS
• Make sure to cover all of the synovium