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MRI of the Head & Spine 2017 34 th Annual MRI Of the Head & Spine 2017: National Symposium Wednesday, April 5, 2017 The Venetian® | The Palazzo® • Las Vegas, Nevada Educational Symposia TABLE OF CONTENTS Wednesday, April 5, 2017 Imaging the Brachial and Lumbar-Sacral Plexus (Wende N. Gibbs, M.D.) ...................................................................... 355 MRI of the Cervical Spine - MSK Perspective (William B. Morrison, M.D.) ..................................................................... 369 Rheumatoid Arthritis and Seronegative Spondyloarthropathies (Jeffrey J. Peterson, M.D.) ............................................... 385 MRI of the Foot and Ankle (Mark H. Awh, M.D.) .......................................................................................................... 409 Experiences/Update in Sports MRI of the Shoulder (Charles P. Ho, M.D., Ph.D.) ........................................................... 445 MRI of the Shoulder: Beyond the Cuff (Mark H. Awh, M.D.) ......................................................................................... 461 SAVE THE DATES - 2018 Spring Symposia 355 356 Objectives Imaging the Brachial and • Describe imaging features and options for the brachial and lumbosacral Lumbosacral Plexus plexus and peripheral nerves • Review relevant plexus and regional anatomy Wende N Gibbs, MD • Discuss indications for imaging Assistant Professor of Radiology University of Southern California, Keck School of Medicine • Evaluate cases of the most commonly encountered pathologies Plexus and peripheral nerve imaging Peripheral nerve anatomy • Epineurium: • Nerve: – Dense vascular connective tissue – Morphology – Vasa nervorum – Alterations in caliber, signal, architecture, course • Perineurium: • Regional: – Fascicles have myelinated and unmyelinated axons – Compression from anatomic variant • Endoneurium: – Adjacent mass – Collagenous fibers and fluid • Diagnosis often requires integration of imaging data with patient history • Interfasicular epineurium and clinical exam and electrodiagnostic testing – Fatty material around fascicles • Blood nerve barrier: no enhancement Peripheral nerve imaging Peripheral nerve imaging • Symmetric • Abnormal • Normal – Size – Signal – Signal • T1 iso to muscle, T2 hyperintense (like – Morphology • T1 iso to muscle, mildly T2 hyperintense vessels) • enhancement – Signal intensity – Course – Shape / Caliber – Course Fascicular architecture on STIR • Fascicular pattern • Round/oval • Straight, no abrupt change, angles Intrafascicular pattern: • symmetric – Shape / Caliber • Nerve course endoneural fluid and axoplasmic flow – Architecture • Mass-like, nodular, distorted • Fat planes Interfascicular pattern: fibrofatty – Architecture connective tissue 357 Plexus and PNS imaging Pitfalls • FOV: as small as possible to maintain high resolution (focused based on clinical data) • Differentiating nerves from vessels • Anatomic sequence (T1): high resolution, thin section • Physiologic sequence (T2): • Perineural plexus – edema (fluctuations in endoneural fluid content) • Magic angle effect – SPAIR: uniform fat suppression, better SNR than STIR • 3D (isotropic voxels): nerves with oblique course, treatment planning • Inhomogeneous fat suppression • Contrast: infection or neoplasm Brachial plexus Anatomy Anatomy Clinical / Surgical • Roots: NF to scalene muscles • Supraclavicular: • Trunks: interscalene triangle – roots, trunks • Divisions: sup/post clavicle – Posterior triangle, between • Cords: inferior to clavicle, behind anterior and middle scalene m pectoralis minor m • Retroclavicular: divisions • Branches: distal to pec. minor m • Infraclavicular: cords 358 Roots (and cord) Roots (and cord) Ventral root Dorsal root • Most often trauma ganglion Dorsal root • Chronic: cervical spondylitic myelopathy • Nerve roots: – Dorsal (sensory) cell body in DRG DRG • Best evaluated on – Ventral (motor) cell bodies in cord cervical spine MRI or • Spinal Nerve: union of dorsal + ventral roots (distal to DRG) rootlets CT/MR myelogram • Ramus: 1st branch of spinal nerve • Peripheral nerve: neural conduit of one or more rami Supraclavicular plexus Supraclavicular plexus Ant. Scalene Anterior scalene Trunks Mid. Scalene Middle scalene Clavicle Linda et al., Radiographics, 2010 Subclavian A Subclavian V Roots and Trunks: medial to the scalene muscles Interscalene Triangle Retroclavicular plexus Infraclavicular plexus Clavicle Pec Major M Divisions Cords Clavicle Subclavian A 1st Rib Subclavian V Subclavian A Subclavius M Subclavian V Pec Minor M Pec Major M Costoclavicular Space Retropectoral Space 359 T2 FS / STIR: T2 FS / STIR: Mildly hyperintense – less than vessels Mildly hyperintense – less than vessels T1 Pre Indications • Trauma with plexopathy or nerve injury – Acute phase: MRI cervical spine (not BP) • Tumor T1 FS Post • Post treatment Recurrent breast cancer • Nerve entrapment or compression • Unexplained plexopathy Normally no enhancement Protocol Indirect signs of neuropathy • High Resolution T1 and HR STIR or T2 FS – Coronal: lays out nerves distal to roots • Infiltration of perineural fat – Sagittal or oblique (15 degrees) sagittal – Axial • Perineural edema • 3D T2 fat sat • Muscle edema – Isotropic voxels: MIPs • T1 Post contrast fat sat • Muscle atrophy – Tumor – Infectious/inflammatory 360 Muscle denervation Trauma • Acute: Normal • Early Subacute: Edema, paradoxical hypertrophy • Late Subacute: Mixed edema and atrophy • Chronic: atrophy Trauma Pre v Postganglionic • Adults: high energy force • Primary question in the acute trauma • Peds: traction during delivery setting – always get MRI cervical spine • Preganglionic • Complete avulsion: flail arm – Surgical repair difficult • Complete avulsion can have only partial paralysis due to – Goals: biceps (C6), shoulder mobility (C5) redundant muscle innervation • Postganglionic • Muscle denervation points to abnormal nerve – Intact fascicles: conservative management – Damaged: grafting • Look for associated vascular injury and fractures Preganglionic 361 Peripheral Avulsion Post ganglionic Most common Traction on arm Central Avulsion Cervical spine injury Moran, 2005 Courtesy of the Mayo Foundation Seddon and Sunderland Classification Degree of Prognosis MR Myelin Axon Nerve Injury I Neuropraxia Full recovery -Normal or + / - No -Incr T2 nerve and muscle II Axonotmesis Full recovery Increased T2 nerve Yes Yes Enlarged nerve Muscle denervation III Fair, incomplete Focal nerve enlargement Yes Yes Effaced fascicles Muscle denervation IV Poor Yes Yes V Neurotmesis Very poor Complete nerve discontinuity Yes Yes Muscle denervation Plexus Injury Malignancy Neuropraxia Axonotmesis Neurotmesis Endoneurium, Disruption of axon, Transection perineurium, connective tissue epineurium intact sheath intact Conduction intact in No conduction distal No conduction distal distal and proximal to injury (Wallerian to injury (Wallerian segment, not injured degeneration) degeneration) segment Temporary loss of Recovery possible, Recovery unlikely- function (hours to +/- surgery impossible without months) surgical intervention 362 Neuropathy in Cancer patient Breast • Compression from mass / lymphadenopathy Cancer • Direct extension – Pancoast • Perineural spread – HN, breast, GI, prostate, cervical – Nodular thickening, enhancement – PET: intense focal uptake • Radiation induced – Mild to moderate enlargement – Variable T2 – PET: Minimal to mild uptake Squamous Cell Ca Pancoast (Superior Sulcus Tumor) • Pancoast syndrome: – Severe shoulder/arm pain along C8, T1, T2 nerve trunks – Horner syndrome – Weakness and atrophy of intrinsic hand muscles Radiation Plexopathy • Increased T2/STIR SI • Ill-defined enhancement without a discrete mass • Enlarged, ill-defined plexus • Loss of fat planes and stranding • Post RT: 5 – 30 months 363 Benign Tumors Benign Tumor: Schwannoma Infectious/Inflammatory: Entrapment syndromes CIDP Entrapment syndromes Entrapment syndromes • Thoracic outlet syndrome • Thoracic outlet syndrome – Types – Cervical rib • Neurogenic (90-95%) • Vascular – enlarged C7 transverse – Locations process • Scalene triangle – fibrous bands • Costoclavicular – muscle hypertrophy • Retropectoralis minor space Linda et al., Radiographics, 2010 Magill et al. Neurosurg Focus, 2015 364 Lumbosacral plexus Anatomy Cejas et al., Radiologia, 2015 Anatomy PNS imaging • Symmetric – Size – Morphology – Signal intensity (fat sat variations) • Fascicular pattern • Nerve course • Fat planes Indications Protocol • Confirmation of involvement and extent in patients with • High Resolution T1 and HR STIR or T2 FS – Coronal oblique tumor – Sagittal or oblique (15 degrees) sagittal • Assess extent of injury – Axial oblique • 3D T2 (CUBE, SPACE) • Evaluate if MRI lumbar spine is indeterminate – Isotropic voxels: MIPs • Exclude mass lesion in patient with unilateral abnormality • T1 Post contrast fat sat on EMG – Axial oblique – Coronal oblique 365 Sciatica Entrapment: Piriformis syndrome • Herniated disc • Primary neurogenic tumor • Trauma • Piriformis syndrome • Bone tumor or metastasis • Pelvic tumor Entrapment of the sciatic nerve at the greater sciatic foramen: -muscle asymmetry -anatomic variant course of sciatic nerve DW-SSFP Cancer spread Endometriosis • From prostate, rectum, bladder, cervix to LS plexus along pelvic autonomic nerves (sup and inf hypogastric plexus • To bony pelvis and musculature Capek et al. Neurosurg Focus, 2015 Soldatos et al., Radiographics, 2013 Benign Tumor: NF1 Conclusion • Plexus/peripheral nerve evaluation: – Abnormal imaging
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