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Low Back Pain¹

¹ From the Departments of Radiology (M.N.B.Z.), Orthopedic Surgery (S.C.D., M.P.W.), and Neurosurgery (G.F.G.), Hoag Memorial Hospital Presbyterian, One Hoag Dr, Newport Beach, CA 92658. Received July 8, 1999; revision requested September 9; revision received November 5; accepted November 19. Address correspondence to M.N.B.Z. (e-mail: ezbz@primenet.com).

View larger version (115K): [in a new window]   Figure 1a. Diskitis and paraspinous abscess in a 17-year-old boy with unrelenting low back pain that awakened him at night and low-grade fever at physical examination. (a) Sagittal, nonenhanced, T2-weighted MR image (repetition time msec/echo time msec, 3,500/98) shows increased signal intensity of the vertebral bodies immediately adjacent to the L1-2 intervertebral space. A more diffuse signal intensity increase throughout the L2 vertebral body also is seen. Note that the disk itself has relatively low signal intensity except immediately at the site of the end plate signal intensity alteration. (b) Corresponding sagittal, contrast material-enhanced, T1-weighted MR image (450/10) shows enhancement of the abnormal end plates. Slight enhancement of the parent disk also is seen. (c) Transverse, postcontrast, T1-weighted MR image (800/13) obtained at the level of the intervertebral space shows enhancing tissue extending from the intervertebral space into the right neural foramen (arrow). (d) Transverse, postcontrast, T2-weighted MR image (2,800/100) obtained at a lower level shows myositis and a small focal abscess (arrow) within the right psoas muscle.

View larger version (113K): [in a new window]   Figure 1b. Diskitis and paraspinous abscess in a 17-year-old boy with unrelenting low back pain that awakened him at night and low-grade fever at physical examination. (a) Sagittal, nonenhanced, T2-weighted MR image (repetition time msec/echo time msec, 3,500/98) shows increased signal intensity of the vertebral bodies immediately adjacent to the L1-2 intervertebral space. A more diffuse signal intensity increase throughout the L2 vertebral body also is seen. Note that the disk itself has relatively low signal intensity except immediately at the site of the end plate signal intensity alteration. (b) Corresponding sagittal, contrast material-enhanced, T1-weighted MR image (450/10) shows enhancement of the abnormal end plates. Slight enhancement of the parent disk also is seen. (c) Transverse, postcontrast, T1-weighted MR image (800/13) obtained at the level of the intervertebral space shows enhancing tissue extending from the intervertebral space into the right neural foramen (arrow). (d) Transverse, postcontrast, T2-weighted MR image (2,800/100) obtained at a lower level shows myositis and a small focal abscess (arrow) within the right psoas muscle.

View larger version (167K): [in a new window]   Figure 1c. Diskitis and paraspinous abscess in a 17-year-old boy with unrelenting low back pain that awakened him at night and low-grade fever at physical examination. (a) Sagittal, nonenhanced, T2-weighted MR image (repetition time msec/echo time msec, 3,500/98) shows increased signal intensity of the vertebral bodies immediately adjacent to the L1-2 intervertebral space. A more diffuse signal intensity increase throughout the L2 vertebral body also is seen. Note that the disk itself has relatively low signal intensity except immediately at the site of the end plate signal intensity alteration. (b) Corresponding sagittal, contrast material-enhanced, T1-weighted MR image (450/10) shows enhancement of the abnormal end plates. Slight enhancement of the parent disk also is seen. (c) Transverse, postcontrast, T1-weighted MR image (800/13) obtained at the level of the intervertebral space shows enhancing tissue extending from the intervertebral space into the right neural foramen (arrow). (d) Transverse, postcontrast, T2-weighted MR image (2,800/100) obtained at a lower level shows myositis and a small focal abscess (arrow) within the right psoas muscle.

View larger version (171K): [in a new window]   Figure 1d. Diskitis and paraspinous abscess in a 17-year-old boy with unrelenting low back pain that awakened him at night and low-grade fever at physical examination. (a) Sagittal, nonenhanced, T2-weighted MR image (repetition time msec/echo time msec, 3,500/98) shows increased signal intensity of the vertebral bodies immediately adjacent to the L1-2 intervertebral space. A more diffuse signal intensity increase throughout the L2 vertebral body also is seen. Note that the disk itself has relatively low signal intensity except immediately at the site of the end plate signal intensity alteration. (b) Corresponding sagittal, contrast material-enhanced, T1-weighted MR image (450/10) shows enhancement of the abnormal end plates. Slight enhancement of the parent disk also is seen. (c) Transverse, postcontrast, T1-weighted MR image (800/13) obtained at the level of the intervertebral space shows enhancing tissue extending from the intervertebral space into the right neural foramen (arrow). (d) Transverse, postcontrast, T2-weighted MR image (2,800/100) obtained at a lower level shows myositis and a small focal abscess (arrow) within the right psoas muscle.

View larger version (88K): [in a new window]   Figure 2a. Degenerative disk protrusion in a 48-year-old woman with low back pain, a positive diskogram, and a concordant pain response at the L5-S1 disk level. (a) Diskogram shows a normal appearance at the L3-4 intervertebral space. The abnormal L4-5 intervertebral space shows focal extension of the diskographic dye (arrow) into the ventral epidural space and the abnormal-appearing L5-S1 disk, the site of concordant pain, although no posterior extension of dye is seen there. (b) Postdiskographic CT scan at the L4-5 interspace clearly depicts the posterior extension of the diskographic dye (arrow) into the ventral epidural space through the annular defect. Despite this appearance, no pain was elicited at the L4-5 intervertebral space level.

View larger version (106K): [in a new window]   Figure 2b. Degenerative disk protrusion in a 48-year-old woman with low back pain, a positive diskogram, and a concordant pain response at the L5-S1 disk level. (a) Diskogram shows a normal appearance at the L3-4 intervertebral space. The abnormal L4-5 intervertebral space shows focal extension of the diskographic dye (arrow) into the ventral epidural space and the abnormal-appearing L5-S1 disk, the site of concordant pain, although no posterior extension of dye is seen there. (b) Postdiskographic CT scan at the L4-5 interspace clearly depicts the posterior extension of the diskographic dye (arrow) into the ventral epidural space through the annular defect. Despite this appearance, no pain was elicited at the L4-5 intervertebral space level.

View larger version (123K): [in a new window]   Figure 3a. L5-S1 disk extrusion in a 42-year-old man with left-sided sciatica. (a) Sagittal, nonenhanced, dual-echo MR image (3,500/18,98) shows a large extruded fragment (arrow) migrating inferiorly from the L5-S1 intervertebral space. Note the defect of the annulus, the low-signal-intensity margin of the disk at the normal levels. Note also the similarity between the signal intensity within the extruded fragment and that of the parent disk, which is indicative of acuity. (b) Transverse nonenhanced T1-weighted MR image (400/15) shows the large extruded fragment (arrows) displacing the transiting S1 nerve against the posterior lamina of the S1 vertebral body. The fragment is apparently effacing the nerve sleeve. Relatively little thecal sac compromise is seen owing to the capacious canal at this level.

View larger version (111K): [in a new window]   Figure 3b. L5-S1 disk extrusion in a 42-year-old man with left-sided sciatica. (a) Sagittal, nonenhanced, dual-echo MR image (3,500/18,98) shows a large extruded fragment (arrow) migrating inferiorly from the L5-S1 intervertebral space. Note the defect of the annulus, the low-signal-intensity margin of the disk at the normal levels. Note also the similarity between the signal intensity within the extruded fragment and that of the parent disk, which is indicative of acuity. (b) Transverse nonenhanced T1-weighted MR image (400/15) shows the large extruded fragment (arrows) displacing the transiting S1 nerve against the posterior lamina of the S1 vertebral body. The fragment is apparently effacing the nerve sleeve. Relatively little thecal sac compromise is seen owing to the capacious canal at this level.

View larger version (132K): [in a new window]   Figure 4a. L1-2 disk extrusion and migration in a 52-year-old man with right groin pain. (a) Transverse nonenhanced CT scan shows a vague abnormality (arrows) of the right half of the canal, with a suggestion of high attenuation. This finding is relatively nonspecific. (b) Sagittal contiguous nonenhanced T2-weighted MR images (3,500/48) show a soft-tissue mass (arrows) consistent with extrusion of disk material (particularly on the off midline image, where the contiguity of the material with the parent disk is shown). The fact that the mass is centered at the parent disk intervertebral space and the contiguity of the mass with the parent disk, as opposed to the nonspecific masslike appearance at CT (a), strongly support disk extrusion. Varying degrees of disk degeneration and protrusion are seen at the lower four levels.

View larger version (204K): [in a new window]   Figure 4b. L1-2 disk extrusion and migration in a 52-year-old man with right groin pain. (a) Transverse nonenhanced CT scan shows a vague abnormality (arrows) of the right half of the canal, with a suggestion of high attenuation. This finding is relatively nonspecific. (b) Sagittal contiguous nonenhanced T2-weighted MR images (3,500/48) show a soft-tissue mass (arrows) consistent with extrusion of disk material (particularly on the off midline image, where the contiguity of the material with the parent disk is shown). The fact that the mass is centered at the parent disk intervertebral space and the contiguity of the mass with the parent disk, as opposed to the nonspecific masslike appearance at CT (a), strongly support disk extrusion. Varying degrees of disk degeneration and protrusion are seen at the lower four levels.

View larger version (140K): [in a new window]   Figure 5a. Grade IV spondylolisthesis in a 17-year-old boy with chronic low back pain and no neurologic dysfunction. (a) Sagittal midline nonenhanced dual-echo MR image (3,500/16, 98) shows grade IV spondylolisthesis of the L5 vertebra with respect to the S1 vertebra, with almost complete canal stenosis in the center. Note the overriding of the L5 vertebra anterior to the S1 vertebra. Note also the degenerated disk, two components (arrows) of which are adhering to the parent L5 and S1 vertebral bodies, without extrusion into the canal. (b) Sagittal nonenhanced MR image (3,500/16, 98) far left of the midline shows the complete obliteration (arrows) of the L5-S1 foramen due to the anatomic deformity produced by the spondylolisthesis; despite this, no discrete neural compromise of the L5 nerve root was encountered clinically.

View larger version (137K): [in a new window]   Figure 5b. Grade IV spondylolisthesis in a 17-year-old boy with chronic low back pain and no neurologic dysfunction. (a) Sagittal midline nonenhanced dual-echo MR image (3,500/16, 98) shows grade IV spondylolisthesis of the L5 vertebra with respect to the S1 vertebra, with almost complete canal stenosis in the center. Note the overriding of the L5 vertebra anterior to the S1 vertebra. Note also the degenerated disk, two components (arrows) of which are adhering to the parent L5 and S1 vertebral bodies, without extrusion into the canal. (b) Sagittal nonenhanced MR image (3,500/16, 98) far left of the midline shows the complete obliteration (arrows) of the L5-S1 foramen due to the anatomic deformity produced by the spondylolisthesis; despite this, no discrete neural compromise of the L5 nerve root was encountered clinically.

View larger version (143K): [in a new window]   Figure 6. Transverse, nonenhanced, T2-weighted MR image (3,500/98) obtained in a 58-year-old woman with postoperative pain shows postoperative spinal fluid leakage. The fluid collection (arrows) is emanating from the spinal canal posteriorly. The high signal intensity of the fluid, its indentation of the thecal sac, as well as its location, are all consistent with cerebrospinal fluid leakage. The higher signal intensity of the fluid collection compared with the signal intensity of the parent cerebrospinal fluid is partly due to the lack of internal nerve roots, as well as to the lack of pulsation within the collection.

View larger version (119K): [in a new window]   Figure 7a. Arachnoiditis in a 52-year-old woman with postoperative back pain. (a) Sagittal, postcontrast, T1-weighted image (450/10) shows enhancement of the cauda equina nerve roots (arrows) and their adherence to the posterior surgical site. (b) Transverse, postcontrast, T1-weighted MR image (800/13) shows clumping (arrow) of the nerve roots at the L3-4 level. The findings of adhesion and enhancement represent changes of arachnoiditis.

View larger version (134K): [in a new window]   Figure 7b. Arachnoiditis in a 52-year-old woman with postoperative back pain. (a) Sagittal, postcontrast, T1-weighted image (450/10) shows enhancement of the cauda equina nerve roots (arrows) and their adherence to the posterior surgical site. (b) Transverse, postcontrast, T1-weighted MR image (800/13) shows clumping (arrow) of the nerve roots at the L3-4 level. The findings of adhesion and enhancement represent changes of arachnoiditis.

View larger version (141K): [in a new window]   Figure 8. Transverse nonenhanced MR image (800/13) of the spine at the L4 level obtained in a 32-year-old woman following fusion shows pedicle screw (titanium) artifact (two-sided arrow). Despite the artifact, the central canal is well delineated.