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32 S. Pollice et al.
8. Annertz M, Jonsson B, Stromqvist B et al (1995)
Serial MRI in the early postoperative period after
lumbar discectomy. Neuroradiology 37:177
9. Wilkinson LS, Elson E, Saifuddin A et al (1997)
Defining the use of Gd enhanced MRI in the
assessment of the post-operative lumbosacral spine.
Clin Radiol 52:530–534
10. Lee MJ, Kim S, Lee Sa et al (2007) Overcoming
artifacts from metallic orthopedic implants at highfield-strength MR imaging and multi-dectector CR.
Radiographics 27:791–803
11. Petersilge CA, Lewin JS, Duerk JL et al (1996)
Optimizing imaging parameters for MR evaluation of
the spine with titanium pedicle screws. AJR
166:1213–1218
12. Rudish A, Kremser C, Peer S et al (1998) Metallic
artifacts in MR imaging of patients with spinal
fusion. A comparison of implant materials and
imaging sequences. Spine 23:629–639
13. Viano AM, Gronemeyer SA, Haliloglu M et al
(2000) Improved MR imaging for patients with
metallic implants. Magn Reson Imag 18:287–295
14. Scarabino T, Giannatempo GM et al (1996) Fatsuppression imaging in neuroradiologia con sequenze
Fast-SE T2 pesate. Riv Neurorad 9:157–164
15. Tartaglino LS, Flanders AE, Vinitski S et al (1994)
Metallic artifacts on MR images of the postoperative
spine: reduction with fast spin echo techniques.
Radiology 190:565–569
16. Mirowitz SA, Shady KL (1992) Gadopentetate
dimeglumine-enhanced MR imaging of the
postoperative lumbar spine: comparison of fatsuppressed and conventional T1-weghted images.
AJR 159:385–389
17. Gallucci M, Caulo M, Masciocchi C (2001) il
Rachide operato. In Compendio di Risonanza
magnetica a cura di Dal Pozzo G, Utet Ed,
pp. 1047:1071
18. Dansie D, Leutmer MA (2004) MRI findings after
successful vertebroplasty. AJNR 26:1595–1600
19. Lin WC, Chen HL, Lu CH et al (2011) Dynamic
contrast-enhanced magnetic resonance imaging for
evaluating intraosseous cleft formation in patients
with osteoporotic vertebral compression fractures
before vertebroplasty. Spine 36:1244–1250
20. Biffar A, Dietrich O, Sourbron S, et al. (2010)
Diffusion and perfusion imaging of bone marrow.
Eur J Radiol 76:323–328
21. Biffar A, Schmidt GP, Sourbron S et al (2011)
Quantitative analysis of vertebral bone marrow
perfusion using dynamic contrast-enhanced MRI:
initial results in osteoporotic patients with acute
vertebral fracture. J Magn Reson Imag 33:676–683
22. Biffar A, Sourbron S, Dietrich O et al (2010)
Combined diffusion-weighted and dynamic contrastenhanced imaging of patients with acute osteoporotic
vertebral fractures. Eur J Radiol 76:298–303
23. Nowicki B, Runyan RS, Smith N et al (1990) Effect
of axial loading on neural foramina and nerve roots
in the lumbar spine. Radiology 11:389–392
24. Saifuddin A, Blease S, MacSweeney E (2003) Axial
loaded MRI of the lumbar spine. Clin Radiol
58:661–671
25. Willen J, Danielson B, Gaulitz A et al (1997)
Dynamic effects on the lumbar spine: axially loaded
CT-myelography and MRI in patients with sciatica
and/or neurogenic claudication. Spine 22:2968–2976
26. Wildermuth S, Zanetti M, Duewell S, et al. (1998)
Lumbar spine: quantitative and qualitative
assessment of positional (upright flexion and
extension) MR imaging and myelography.
Radiology 208:834
27. Splendiani A, Di Fabio MV, Barile A, et al. (2008)
Tecnica di studio RM del rachide lombare sotto
carico. In Imaging del rachide. Il vecchio e il nuovo a
cura di A. Leone e F. Martino, Springer, pp 123–134
Post-treatment Imaging
Saverio Pollice, Michela Capuano, Roberto Stanzione,
Marianna Schiavariello and Tommaso Scarabino
5
Postoperative controls are required by the neurosurgeon, orthopedic, and interventional radiologist to check the result of surgery, position of
implants, adequacy of decompression, fusion
status, and potential complications. Moreover,
because of medico-legal effects, it is important to
assess if disease is not radically cured and to
identify further possible clinical pathologies
when the result does not correspond to expectations 1–5. For optimal evaluation of the normal
and abnormal postoperative imaging appearances, radiologists need an understanding of the
various approaches, techniques, hardware, and
devices used and a knowledge of their advantage
and limitations. It is also necessary to integrate
data imaging with clinical history, type of the
underlying disease, surgical technique, type of
biomedical device used, level, extension and date
of the therapeutic procedure, examinations carried outbefore treatment (i.e. electromyography).
5.1 Diskectomy
Controls post-diskectomy are performed only
with MRI [8]. Most MRI studies of the spine
concern the effects of lumbar hernia surgery.
S. Pollice M. Capuano R. Stanzione
M. Schiavariello T. Scarabino (&)
Department of Radiology—Neuroradiology,
‘‘Lorenzo Bonomo’’ Hospital, Andria, Italy
e-mail: tscarabino@hotmail.com
5.1.1 Surgery in Lumbar Hernia
For correct interpretation of imaging after surgery it is important to know the normal and
pathological MR semiotics of structures
involved such as bone, paraspinal tissue, disk,
and spinal canal [6–13]. Bone and paraspinal
tissue changes are related to the type of surgical
procedure that ranges from disappeared hemilaminectomy characterized by total or partial
resection of the lamina and ligamentum flavum
to less invasive microsurgical approaches where
it is often difficult to recognize, especially after a
long time, the signs of surgery. Intervertebral
disk, however, can sometimes appear hypointense on T1, hyperintense on T2 with associated
disruption of the annulus fibrosus, and in 80 %
of cases can also show contrast enhancement.
This finding (‘‘mechanical or chemical discitis’’) disappears after 4–5 weeks and is not
associated with positive inflammation indices
[14]. Rarely after diskectomy moderate irregularities of vertebrae profiles may occur with
hypointensity in T1, hyperintensity in T2, and
contrast enhancement of subchondral spongiosa,
in relation to bone marrow edema. This is an
occurrence without pathological significance
(‘‘aseptic spondylodiscitis’’), which disappears
in a few weeks, not to be confused with disk
degeneration already present in preintervention.
‘‘Pseudo-hernia,’’ common in early post-surgery, may simulate a recurrence-persistence
without any symptom. It is localized in the
anterior epidural space and consists of
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_5, Springer-Verlag Italia 2014
33
34 S. Pollice et al.
compression on the dural sack caused by edema
of soft tissues, bleeding, and granulation. Usually, within 1–2 months, it tends to disappear or
at least to become increasingly limited without
dural compressive effects. Then an attraction
scar on the dural sack can occur.
Recurrent Hernia Versus Postoperative Scar
In the 2 months after diskectomy, persistence of
symptoms arising from compression on roots and
dural sack can be related to residual or recurrent
hernia or/and exuberant scar. Differential diagnosis between them is difficult as a result of the
frequent coexistence of both. It is necessary to
exactly know the anatomy and the different
semiological aspects such as mass effect, dural
traction, impression on the dural sack, relations
with the disk, and pattern of impregnation, especially immediately after surgery [2] (Table 5.1).
Usually, diskal hernia causes mass effect with
impression on the anterolateral dural sack
without dural traction and with a clear continuity
with the disk. There is no early CE for pathological lack of vascularization; sometimes early
peripheral contrast enhancement with delayed
(10 min) central diffusion due to the presence of
granulation tissue can be found; in later phase
(1 month) CE can occur for a diffusion mechanism. Conversely, in surgical scar, in early stage,
there is no mass effect, but there is dural traction
and contiguity with the disk. Exuberant scar
tissue surrounds generally the dural sac (especially along the surgical edges) with possible
compression mechanism. Contrast enhancement
is early, intense, and diffused thanks to neoangiogenesis; then trends to significantly
disappear at least after 1 year [2, 15, 16].
Therefore, CE-MR images acquired within
7–10 min are important for differential
diagnosis.
Complications
Complications are radiculitis, discitis, spondylitis, spondylodiscitis, arachnoidal inflammation,
CSF fistula, hematoma, seroma, meningoceles,
and pseudo-meningoceles.
Radiculitis
Radiculitis is present in about 20 % of treated
patients for lumbar hernia with recurrent or
persistent low back pain. It is characterized by
pathological CE of the roots, secondary to temporary damage of their barrier caused by surgery
or chronic trauma of slipped disk before surgery
[17, 18]. This finding should be considered
pathological if documented after 6 months, as
before, although present and asymptomatic, is
not pathological because, it is a part of the regular post-surgery evolution.
Diskitis-Spondylitis-Spondylodiscitis
Infectious complications are appreciable at short
time after surgery, characterized by the appearance after a short healthy period of persistent
and progressive low back pain associated with
inflammatory markers increase. In contrast to
diskitis and spondylitis, rare and characterized by signal alteration (T1 hypointensity, T2
Table 5.1 Semiological aspects for the differential diagnosis between postoperative scar and recurrent hernia
(modified by Gallucci M, et al.: ‘‘Il Rachide operato. In Compendio di Risonanza magnetica a cura di Dal Pozzo G,
Utet Ed, 2001’’) [2]
Post-surgical scar Recurrent hernia
Mass effect No Yes
Dural traction Yes No
Impression on dural sack Posterolateral Anterolateral
Relationship with the disk Contiguity Continuity
CE Yes No
5 Post-treatment Imaging 35
hyperintensity) and CE, respectively, of the
intervertebral disk and vertebral body, spondylodiscitis is the most common infectious complication (5 %), especially after removal of
hernia and disk ‘‘curettage’’ [19].
For accurate and early diagnosis it is important to evaluate symptoms, phlogosis index
(fever, elevated ESR, elevated CRP), and MRI.
Magnetic resonance shows signal alteration of
the disk and subchondral bone (T1 hypointensity,
T2 hyperintensity). There is CE with possible
and pathological involvement of paravertebral
surrounding soft tissues and spine canal with
impression on root and dural sack. Risk factors
can be related to the nature of the spinal
pathology and the surgical procedure such as
extensive soft tissue dissection, longer operating
time, soft tissue devitalization, kind of surgical
instrumentation, and systemic health conditions.
To prevent postoperative infections it is necessary prophylactic antibiotics, meticulous
adherence to aseptic technique, and frequent
release of retractors to avoid myonecrosis. Use of
antibiotics against Gram-positive is frequent
(staphylococcus aureus, staphylococcus epidermitis, and beta-hemolytic streptococcus). Sometimes, more aggressive surgical treatment may be
required to help the eradication of the infection,
providing an adequate wound closure and
maintaining spine column mechanical stability.
arachnoiditis are scattered groups of matted or
clampe nerve roots, an empty teca sack caused
by adhesion of the nerve roots to its walls and an
intrathecal soft tissue mass with a broad dural
base, representing a large group of matted roots
that may obstruct the cerebrospinal fluid pathways [20]. Moreover, there is low CE of cauda
roots. CSF fistulae can appear in case of bacterial or fungal meningitis at a distance of months
or even years after surgery.
Epidural Hematoma
Epidural hematoma may be associated with an
excessive or uncontrolled intraoperativebleeding. A
neurological deterioration may occur for compression mechanism, thus requiring decompression
[21]. Inthis case, it is essential for MR evaluation in
urgency. It is a liquid collection, with smooth margins, with MRI signal variable in relation to the
various stages of hemoglobin degradation.
Seroma
Seromas are sterile cyst paraspinal collections,
usually a result of untreated hematoma and then
with CSF-like MR signal.
Meningoceles and Pseudomeningoceles
Abscess
Abscess, alone or in association with diskitis or
osteitis, is characterized by a collection that
extends from the disk to the epidural space. It is
characterized by T2 hyperintensity with irregular
peripheral rim CE. This complication, although
rare, may occur 2–4 weeks after surgery and may
become a possible cause of new neurological
deficits requiring urgent decompression.
Arachnoidal Inflammation and CSF Fistula
Arachnoid phlogosis is not common (6–16 % of
surgery), especially in opening or fissuring of the
dural sack. The three MR patterns in adhesive
Meningoceles are CSF collections communicating with the subarachnoid space caused by
arachnoid herniation through the surgical dural
breach. Conversely, pseudomeningoceles is an
extra-meningeal collection, with non-homogeneous signal in relation to the presence of proteins or blood with fistula communicating with
the subarachnoid space. Both types of CSF
collections may extend outside or inside the
vertebral canal.
5.1.2 Surgery in Cervical Hernia
Post-surgery imaging of cervical hernia is related
to the type of therapeutic procedure. In arthrodesis, bone graft used presents a variable MR
36 S. Pollice et al.
signal in relation to intrinsic characteristics of
itself and to the variability of the vascularization
following surgery. In established arthrodesis
interbody space is no longer evident andvertebral
bodies have a continuous and homogeneous
structure, hardly distinguishable from the adjacent, with low MR signal in all sequences. In
anterior microdiskectomy, bone graft has a rectangular shape and varying MR signal. Recently,
in microdiskectomy vertebral prostheses of various materials are used (carbon, methacrylate)
whose signal appears low in all sequences.
5.2 Vertebroplasty
In postvertebroplasty, imaging shows distribution of synthetic cement (PMMA) in the treated
body in which can occur changes in density (Xrays or CT) or signal intensity (MRI) [22–24]. In
preoperative is present edema pattern of subchondral spongiosa (hyperintensity in fat suppression STIR); 1 week later there is usually
STIR hypointensity in the cement with hyperintense edematous surrounding area also in
relation to macrophage reaction; 1 month later
hypointensity of cement persists with surrounding thin remaining hyperintensity caused by
fibroelastic reaction.
Pattern of cement distribution is variable:
rounded, like map, point or oval, homogeneous,
or inhomogeneous. Body morphology may
appear like vertebra plana, vertebra with
depression of the inferior or superior border,
biconcave lens. Usually after percutaneous procedure, there is no significant morphological
change of vertebral body caused by diffusive and
no expansive cement behavior.
Complication detectable with imaging is
represented by passage of cement in undesirable
sites (epidural venous plexus, lumbar or foraminal veins, intradiskal space, spinal cana)
resulting in root or spinal cord compression and
not commonly in pulmonary embolism. This
happens rarely thanks to double scopic and CT
guidance (1–2 % osteoporosis, 10.5 % metastasis). Infections and bleeding are rare.
5.3 Conventional and Dynamic
Stabilization
Imaging of a traditional/dynamic stabilization
can provide a series of information regarding the
correct/invalid positioning of the device, device
integrity, fracture reduction, vertebral body
morphology, somatic posterior walls alignment,
conditions of the bone (in case of myelic
trauma), presence in the canal of bone fragments, post-surgical treatment complications
(bleeding, abscesses, meningoceles), emergence
of new diseases, or the progression of disease.
For accurate postoperative assessment, radiologists and neuroradiologists should exactly
know normal imaging appearances of the lumbar
spine after stabilization, after fusion and disk
replacement with various approaches, techniques, and devices [25–30].
In early post-surgery, in the absence of significant neurological symptoms, traditional Xray can supply most of the information requested
by the neurosurgeon. X-ray, in anteroposterior
and lateral can document the precise positioning
of the interspinous supports, any dislocations,
rare complications such as fracture of the spinous process.
In some cases, however, X-ray can cause
doubts especially when synthetic means are
placed in critical locations such as cervical or
dorsal, hence it may be useful to perform CT
with multiplanar and 3D reconstructions. In the
assessment of stabilization with plates and
screws, some authors have developed a score
system in relation to the position of the screw
(inside, laterally or medially) with respect to the
pedicle and the vertebral body [31]. Sometimes,
CT is useful to evaluate the formation of bone
when using porous osteoinductive metals. MRI
is essential in presence of a significant neurological symptoms to clearly assess neural
structures.
MRI should be performed even in the presence of infection or dural injury, characterized
by pathognomic symptoms. With the various
diagnostic tools (RX, CT, MRI) available, mechanical complications related to
5 Post-treatment Imaging 37
instrumentation and fusion (improper device
placement, pseudarthrosis, progression of disease at the adjacent non-fused segments) are
distinguished from non-mechanical complications (infection, postoperative hematoma, pseudomeningocele) that usually occur sooner [29,
30]. Implant fractures are secondary to the
repetitive stress of spinal movements. A fractured or dislodged device is frequently, but not
always, associated with regional motion and
instability, which may lead to pseudoarthrosis.
Instrumentation can cause chronic tissue
irritation leading to pain and sometimes tissue
necrosis, which can be indications for hardware
removal.
It is possible the onset of degenerative
changes at the disk above or below the fused
segments because of the reduced number of
mobile segments. This complication is reported
in 10.2 % of patients with posterior fusion and it
is more frequently seen at long-term follow-up
and in the lumbosacral spine.
Early recognition of infections, hematomas,
and abscesses to take an appropriate treatment
and thus minimize the effects is essential.
References
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magnetica a cura di Dal Pozzo G, Utet Ed,
pp 1047–1071
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Neuroradiology 44:723–739
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(1996) L’imaging con RM del rachide cervicale
operato. Radiol Med 92:671–676
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Serial MRI in the early postoperative period after
lumbar discectomy. Neuroradiology 37:177
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9. Mirowitz SA, Shady KL (1992) Gadopentetate
dimeglumine-enhanced MR imaging of the
postoperative lumbar spine: comparison of fatsuppressed and conventional T1-weghted images.
AJR 159:385–389
10. Gallucci M, Bozzao A, Orlandi B et al (1995) Does
post contrast MR enhancement in lumbar disk
herniation have prognostic value? J Comput Assist
Tomogr 19:34–38
11. Scarabino T, Giannatempo GM et al (1996) Fatsuppression imaging in neuroradiologia con sequenze
Fast-SE T2 pesate. Riv Neurorad 9:157–164
12. Wilkinson LS, Elson E, Saifuddin A et al (1997)
Defining the use of Gd enhanced MRI in the
assessment of the post-operative lumbosacral spine.
Clin Radiol 52:530–534
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the intervertebral disk. AJNR 17:323–331
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imaging from normal post-operative disk space
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scar over a 1 year period. AINR 19:183–186
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relationship between epidural fibrosis and sciatica in
the lumbar post discectomy syndrome. A study with
contrast-enhanced magnetic resonance imaging in
symptomatic and asymptomatic patients. Spine
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Lumbosacral nerve root enhancement with disk
herniation on CE MR. AJNR 17:1619–1625
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nerve enhancement with Gd-DTPA: MR correlation
with the post-operative lumbosacral spine. AJNR
14:383
19. Nasto LA, Colangelo D, Rossi B et al (2012) Postoperative spondylodiscitis. Eur Rev Med Pharmacol
Sci 16(2):S50–S57
20. Ross JS, Masaryk TJ, Modic MT et al (1987) MR
imaging of lumbar arachnoiditis. AJR
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comparison to patients requiring surgical revision.
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Imaging RM post-vertebroplasty. Radiol Med
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38 S. Pollice et al.
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following intervertebral disk surgery, surgical
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Part II
Clinical Cases
Following case studies have the same order of the pathologies discussed
in the text. Each case is marked by three lines, respectively: spinal
pathology, type of treatment and imaging.
Herniated Lumbar Disk Diskectomy
Aseptic Spondylodiscitis
Paola D’Aprile and Alfredo Tarantino
• Asymptomatic patient, absence of inflammatory markers, after treatment
for herniated disks treated by diskectomy with laminectomy at L5-S1
• MR early postoperative follow-up
Early Postoperative Follow-Up
Fig. 1 a–b. CE fat sat
T1—sagittal (a) and axial
(b) projection. At L5-S1
regular disk CE with
presence of granulation
tissue in the subchondral
spongiosa adjacent the
opposite vertebral bodies
and epidural space along
the surgical wound (not
due to infection)
Case
1
P. D’Aprile (&) A. Tarantino
Department of Neuroradiology, ‘‘San Paolo’’ Hospital, Bari, Italy
e-mail: paoladaprile@yahoo.it
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_6, Springer-Verlag Italia 2014
41
Herniated Lumbar Disk Diskectomy
Aseptic Spondilodyscitis
Paola D’Aprile and Alfredo Tarantino
• Asymptomatic patient, absence of flogosis markers, herniated
disk treated by diskectomy and large laminectomy at L3–L4
• Early postoperative MR follow-up
Early Postoperative Follow-Up
Case
2
Fig. 1 a–c. Sagittal CE SE T1 (a), sagittal CE fat sat SE T1 (b–c). Slight physiological CE (non-infectious) of
subchondral spongiosa at L3–L4 for the presence of reactive granulation tissue, rear disk profile close to the annulus is
also involved (a). These findings are emphasized in fat sat imaging (b–c). Regular CE of para-spinal soft tissue at the
surgical breach (laminectomy). Regular CE is also appreciable at the disk L1–L2 where coexists ernia intraspongiosa
with the same CE (aseptic discitis)
P. D’Aprile (&) A. Tarantino
Department of Neuroradiology, ‘‘San Paolo’’ Hospital, Bari, Italy
e-mail: paoladaprile@yahoo.it
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_7, Springer-Verlag Italia 2014
43