Table Of ContentD. Krause J. L. Drape
D. Maitrot B. Woerly J. Tongio
CTandMRI
of Disk Herniations
With a Foreword by Luc Picard
With 242 Figures in 606 Parts
and 3 Tables
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Hong Kong Barcelona
Dr. DENIS KRAUSE
Dr. JEAN Luc DRAPE
Professor Dr. DANIEL MAITROT
Dr. BERNARD WOERLY
Professor Dr. JEAN TONGIO
C. H. U. Strasbourg-Hautepierre
Avenue Moliere, 67098 Strasbourg
France
ISBN-13: 978-3-642-73593-6 e-ISBN-13: 978-3-642-73591-2
001: 10.\007/978-3-642-73591-2
Library of Congress Cataloging-in-Publication Data.
CT and MRI of disk herniations 1 D. Krause ... ret a1.]. p. cm.
Includes bibliographical references. Includes index.
1. intervertebral disk-Hernia. 2. Intervertebral disk-Hernia-Tomography. 3. Intervertebral disk-Hernia-Mag
netic resonance imaging. 4. Vertebrae, Lumbar-imaging. 5. Vertebrae, Cervical-Imaging. I. Krause, D. (Denis)
[DNLM: 1. Cervical Vertebrae-anatomy & histology. 2. Intervertebral Disk Displacement-diagnosis. 3. Lum
bar Vertebrae-anatomy & histology. 4. Magnetic Resource Imaging. 5. Thoracic Vertebrae-anatomy & histolo
gy. 6. Tomography, X-Ray Computed.
WE 740 C959] RD771.I6C8 1991 617.3'75-dc20 DNLM/DLC for Library of Congress 90-9932 CIP
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Acknowledgements
We would like to express our gratitude to the following:
Mr. Dany Vetter, for the beautiful photographic work;
Mrs. Monique Holterbach, Sonia Lienhardt, and Monique Funck,
for their excellent secretarial assistance;
Dr. Antonio Perez-Infante, for the translation;
and the firms Schering and Boots-Dacour,
for their encouragement and support.
Foreword
The ever-increasing interest in the spine and its pathology is not surprising.
Acting as the main support of an erect posture unique in the animal kingdom,
the human spine is, owing to its numerous articulations, at the same time a
supple structure that can respond to the many stresses which are put on it.
Constant movement is necessary to preserve its function, but regular and well
positioned rest is also essential. The high frequency of spinal disorders result
ing from misuse is easily explained by day-to-day reality.
Among the disorders that result from misuse of the spine, herniated disk,
leading to radicular compression, is one of the most frequent. New tech
niques, less invasive and yielding more precise information, have been pro
gressively developed for the diagnosis of this disease and at the same time
new methods of treatment have appeared, giving us a much broader range of
choices and decisions to make.
In the face of this evolving, complex situation, a multidisciplinary team
from Strasbourg decided to clarify the topic. A single man's experience, what
ever his qualities, would certainly have been insufficient and the necessarily
limited views of a single speciality would also have been a handicap. This re
markable work is thus the result of collaboration between clinical and inter
ventional radiologists and a neurosurgeon.
Denis Krause, Jean-Luc Drape, and Bernard Woerly, all in the radiology
department headed by Professor Jean Tongio, have been working for a long
time to assess precisely the symptoms of disk herniation, especially on CT
scans and MR images. This innovative team was the first to use an oblique
view centered on the nerve roots in MRI, first at the lumbar level and later at
the cervical level, which led to instructive correlations with the already known
findings on myelograms.
Obviously, this special interest has also led to developments in percutane
ous methods of treatment, mainly chemonucleolysis. In fact, Denis Krause
and his colleagues were among the first to use chemonucleolysis at the cervi
cal level. The technique that was developed led to a very high success rates,
higher than are generally obtained at the lumbosacral level. The contribution
of Daniel Maitrot on surgery is a reflection of his wide knowledge and exper
tise.
The enthusiasm and competence of this multidisciplinary team has led to a
real tour de force. The reader has before him the whole of current knowledge
necessary to a full understanding of the problems, especially concerning the
therapeutic approach. As everyone knows, we do not treat a lesion but a hu
man being, and for this the understanding of the links between the visible radio-
VIII Foreword
anatomical lesions and the clinical findings provided by this book is mandato
ry. The book will thus permit both nonspecialist and specialist alike to find all
the clinical, anatomical, radiological, and therapeutic data necessary for the
best possible decision making.
CT and MRI of Disk Herniations is a timely book. The text is clear and the
abundant illustrations facilitate reading and understanding. I would like to
thank and congratulate my friends from Strasbourg, and wish this book all the
success it deserves: it should become the modem state-of-the-art reference
work on a difficult topic where the success of intervention has such important
individual as well as social consequences.
Nancy, September 1990 Luc PICARD
Professor of Neuroradiology,
Faculty of Medicine of Nancy,
Head of Department of Diagnostic
and Interventional Neuroradiology,
University Hospital of Nancy
Contents
Computed Tomography
Cervical Disk Herniations. 3
Introduction . 3
Clinical Study 3
Clinical Signs of Cervicobrachial Neuralgia 3
Clinical Examination . 4
Clinical Types . . . . . . . . . . . . . . 5
Differential Diagnosis ........ . 5
Etiology of Cervicobrachial Neuralgia 5
Soft Disk Herniation 6
Definition . . . . 6
Mechanisms . . . 6
Spontaneous Evolution . 7
Anatomy of the Lower Cervical Spine 7
Spinal Canal ........ . 7
Spinal Cord and Meninges . 7
Intervertebral Disk . . 7
Epidural Space . . . . . . . 8
Cervical Spinal Nerves ... 9
Topography of Cervical Roots 10
CT Scanning Techniques . 10
Parameters . . . . . . . 10
Sections ....... . 10
Intravenous Injection of Contrast Medium . 11
Examination . 11
Radioanatomy. . 12
Foraminal Plane 12
Diskal Plane . . 12
Pedicular Plane . 13
x
Contents
Radiographic Investigation of Soft Cervical Disk Herniations 13
Conventional Investigations . . . . . . . . . . . . . . . . . 13
Plain Films ....................... . 13
Myelography with Nonionic Water-solub!e Contrast Media 14
Cervical Diskography .... 14
CT Signs of Cervical Herniations 14
Stasis of the Foraminal Veins: The Basic and Pathognomic Sign 14
Cervical Herniation . . . . 15
Other Types of Herniation 21
Interpretation of CT Scans . 22
Herniation and Arthrosis . 23
Younger People ... . 23
Older People .... . 25
Cervical Arthrotic Myelopathy 25
Evolution of Unoperated Soft Disk Herniations 27
Differential Diagnosis .... 29
Magnetic Resonance Imaging 30
Cervical Chemonucieolysis . 31
Introduction ..... . 31
Patient Selection .. . 32
Techniques: Diskography 32
Positioning of Patient. 32
Disk Puncture . . . 32
Diskography. . . . 32
Chemonucleolysis . 33
Postdiskography CT . 33
Results after Chemonucleolysis 36
Clinical Findings 36
CT Appearance 36
In Conclusion . 36
Conclusion .... 38
Thoracic Disk Herniations 39
Introduction . . . 39
Clinical Findings 39
Surgery ..... . 40
CT Scans and MRI 40
Contents XI
Lumbar Disk Herniations . 45
Clinical Findings . . . . . 45
Medical History . . . . 45
Physical Examination. 46
Atypical Sciatica ... 47
Hyperalgesic Sciatica . 47
Recurrent Alternating Sciatica . 47
Cauda Equina Syndrome ... 47
Sciatica with a Motor Deficit . 48
Sciatica with Lumbar Spinal Stenosis 49
Sciatica with a Narrow Lateral Recess 50
Femoral Sciatica .. 50
Incomplete Sciatica . . . . . 50
Mild Sciatic Pain . . . . . . 50
Radiculalgias at Other Sites 50
Refractory Sciatica . . . 51
"Symptomatic" Sciatica 51
Pathogenesis. . . . . . . . . . . 53
Development of Lumbar Disks 53
Embryo and Fetus . 53
Child ........ . 54
Anatomy of Adult Disk. 54
Nucleus Pulposus .. 54
Anulus Fibrosus. . . 54
Vertebral Cartilaginous Plates 55
Vascularization and Innervation . 55
Histology .. 55
Biochemistry .. 55
Collagen ... 55
Proteoglycans 56
Water and Solutes. 56
Enzymes ..... . 56
Disk Aging ...... . 56
Biomechanics of the Lumbar Disk 57
Individual Physiological Roles of Disk Components 57
Physiological Role of Disk as Functional Unit . 58
Structural Deterioration of Lumbar Disk . . . . . . . . 59
Mechanisms of Onset. . . . . . . . . . . . . . . . . 59
Anatomic Alterations: Genesis of Disk Herniation 60
Biomechanical Consequences of Disk Degeneration 64
Radiologic Examinations . 65
Routine Radiographs . 65
XII Contents
Myelography ..... 65
Lumbar Phlebography 66
Epidurography . . . . 67
Diskography. . . . . . 67
Normal Diskogram 67
Disk Herniation . 67
Degenerate Disks . 67
CT .......... . 67
Magnetic Resonance Imaging (MRI) 68
Postdiskography CT 68
CT: Anatomic Aspects . . 71
Section Through the Disk ... . . . . . . . 71
Section Through the Upper Portion of the Vertebral Body 74
Section Through the Midportion of the Vertebral Body 77
Section Through the Intervertebral Foramen . 77
The Paraspinal Region . . . . . . . . . . . . . . . . . . 79
Paravertebral Muscles ..:.. . . . . . . . . . . . 79
The Extraspinal Course of the Lumbosacral Roots 79
The Ascending Lumbar Veins 80
Bowel ................. . 80
Kidneys and Ureters ......... . 80
Consequences for the Nervous Structures 80
Computed Tomography Technique . 82
CT Examination Technique 82
The Patient ...... . 82
Sections ........ . 82
Qualitative Criteria of CT Images 83
Irradiation and Cost . . . . . . . 84
Methodology and Approach to Herniation Imaging 85
Reliability of CT (in 160 CT-Surgical Correlations) 87
Common Herniations . . . . . . . . . . . . . . . . . . . . . 88
Clinical Considerations. . . . . . 88
CT Features . . . . . . . . . . . . 88
Direct Signs of Disk Lesions . 88
Epidural Fat Involvement . 94
Signs of Root Involvement . 94
Thecal Sac Deviation . . . . 95
Surgical Findings . . . . . . . . 95
Large and Small Common Herniations 96
Large Herniations. 96
Small Herniations . 99
Postdiskography CT . 101
