Table Of ContentSeries Editor
David M. Yousem, MD, MBA
Professor of Radiology
Director of Neuroradiology
Russell H. Morgan Department of Radiology and Radiological Science
The Johns Hopkins Medical Institutions
Baltimore, Maryland
Other Volumes in the CASE REVIEW Series
Brain Imaging, Second Edition
Breast Imaging, Second Edition
Cardiac Imaging, Second Edition
Duke Review of MRI Principles
Emergency Radiology
Gastrointestinal Imaging, Third Edition
General and Vascular Ultrasound, Second Edition
Genitourinary Imaging, Second Edition
Musculoskeletal Imaging, Second Edition
Nuclear Medicine, Second Edition
Obstetric and Gynecologic Imaging, Third Edition
Pediatric Imaging, Second Edition
Thoracic Imaging, Second Edition
Vascular and Interventional Imaging
Efrat Saraf-Lavi, MD
Associate Professor of Clinical Radiology
Neuroradiology Section,
Medical Director of Applebaum MRI Center
University of Miami, Miller School of Medicine
Miami, Florida
C A S E R E V I E W
Spine Imaging
THIRD EDITION
C A S E R E V I E W S E R I E S
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
SPINE IMAGING: CASE REVIEW, Third Edition ISBN: 978-1-4557-5116-7
Copyright © 2014, 2008, 2001 by Saunders, an imprint of Elsevier Inc.
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Notices
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Library of Congress Cataloging-in-Publication Data
Saraf-Lavi, Efrat, author.
Spine imaging : case review / Efrat Saraf-Lavi. -- Third edition.
p. ; cm. -- (Case review series)
Preceded by: Spine imaging : case review / Brian C. Bowen, Alfonso Rivera, Efrat Saraf-Lavi. 2nd ed. c2008.
Includes bibliographical references and indexes.
ISBN 978-1-4557-5116-7 (paperback : alk. paper)
I. Bowen, Brian C. Spine imaging. Preceded by (work): II. Title. III. Series: Case review series.
[DNLM: 1. Spinal Diseases--radiography--Case Reports. 2. Diagnostic Imaging--methods--Case Reports. WE 725]
RD768
616.7'30754--dc23 2013035842
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my dear parents,
my companion Randy,
and my amazing boys
Koren and Ariel
SERIES FOREWORD
I have been very gratified by the popularity and positive feedback that the authors of the Case Review series
have received for their volumes. Reviews in journals and on-line sites, as well as word-of-mouth comments,
have been uniformly favorable. The authors have done an outstanding job in filling the niche of an afford-
able, easy-to-access, case-based learning tool that supplements the material in The REQUISITES series.
I have been told by residents, fellows, and practicing radiologists that the Case Review series books are ideal
for studying for oral Board examinations and subspecialty certification tests.
Although some students learn best in a noninteractive study book mode, others need the stimulation
of being quizzed. The format of the Case Review series (which consists of showing a few images needed
to construct a differential diagnosis and then asking a few clinical and imaging questions) was designed to
simulate the Board examination experience. The only difference is that the Case Review books provide the
correct answer and immediate feedback. The limit and range of the reader's knowledge are tested through
scaled cases ranging from relatively easy to very difficult. The Case Review series also offers a brief discus-
sion of each case, a link back to the pertinent volume of The REQUISITES, and up-to-date references
from the literature.
Because of the popularity of on-line learning, we have published new editions on the Web. We also
have adjusted to the new Boards examination format, which will be electronic and largely case-based. We
are ready for the new Boards! The Case Review questions have been reframed into multiple-choice format,
the links are dynamic to on-line references, and feedback is interactive with correct and incorrect answers.
Personally, I am very excited about the future. Join us.
David M. Yousem, MD, MBA
vi
BOOK FOREWORD
I am happy to present for your reading pleasure the third edition of Spine Imaging: Case Review, by Dr. Efrat
Saraf-Lavi. Dr. Saraf-Lavi has updated the cases, reformatted the material for on-line education, intro-
duced new techniques and new entities, and made this an outstanding resource for residents and fellows
in neuroradiology preparing for the new end-of-residency Board examinations, as well as neuroradiology
subspecialty Boards. The University of Miami's neuroradiology team is world renowned in spine imaging,
and Dr. Saraf-Lavi provides a level of expertise unmatched by many programs elsewhere in the world.
I congratulate her for leading the efforts to make Spine Imaging an anchor of the Case Review series. I am
especially pleased that her material will be in support of Neuroradiology: The REQUISITES, which I have
co-authored. It's an honor to have that affiliation. Enjoy!
David M. Yousem, MD, MBA
vii
PREFACE
The third edition of Spine Imaging has been updated from the previous editions and is tailored to fit the
latest computer-based certifying examination format. The cases included in the third edition were selected
to comply with the American Board of Radiology study guide for the spine. Each case contains a set of
spine images and four related multiple-choice questions. The first question is the differential diagnosis for
the case, and more than one answer may be correct. For the remaining three questions, only one answer is
correct. On the following page are the answers to the questions as well as teaching points and comments
on the case, including background, histopathology, imaging findings, and management. Literature refer-
ences and a cross-reference to the parent textbook (Neuroradiology: The REQUISITES, Third Edition) are
provided. Nearly all the cases in the third edition are either a new diagnostic entity with new images and
text or a similar diagnostic entity as in the second edition with new images and text. A few cases use the
same images as in the second edition but with revised text. Many of the entities discussed in the third edi-
tion are covered in more depth than in the previous edition. The literature references have been updated,
and the text addresses patient management, which is often asked during the Board examination.
My goal has been to increase the diversity of cases and the information content of each case, provid-
ing additional insights for all readers but especially those who are preparing for examinations such as
the Diagnostic Radiology Core and Certifying Examinations, Neuroradiology Subspecialty Examination
(CAQ), and Maintenance of Certification (MOC). This edition also provides images of higher quality and
resolution, and the cases were selected on the basis of criticisms, comments, and recommendations that
the author has received from residents and fellows over the past 3 years.
Efrat Saraf-Lavi, MD
ix
ACKNOWLEDGMENTS
I am both honored and especially grateful to David Yousem, who offered me the opportunity to write the
third edition of Spine Imaging and to continue the work of individuals who labored so diligently on the first
two editions. I would to thank managing editor, Gina Donato, who guided me through the final stages of
the manuscript, seamlessly bringing together the case material. I extend a special and deep appreciation
to Brian Bowen, my teacher, my mentor, my colleague, and my friend who authored the first edition and
co-authored the second edition of the Case Review Series. His wisdom and achievements inspired me to
continue his work with the Case Review Series and to make it as professional and useful as possible to resi-
dents, fellows, and colleagues. I would like to single out Armando Ruiz for contributing and writing five of
the cases in the book. I also want to thank my colleague, Charif Sidani, and our program residents, Maria
Juliana Borja and Harry G. Greditzer, for contributing two cases each to the book.
I want to thank my colleagues in the Neuroradiology section at the University of Miami, Miller School
of Medicine who pointed out interesting cases to include and continue to provide an environment that
encourages dialogue and critical assessment of spine imaging methods and results during our biweekly
division conferences. As a professional group of colleagues at the medical school, we continue to benefit
from our close working relationship with faculty members in the Departments of Neurological Surgery,
Neuroradiology, and Orthopedic Surgery, as well as researchers at the interdisciplinary Miami Project to
Cure Paralysis. These and other individuals have contributed directly or indirectly to the materials in the
third edition.
Finally, I want to thank Robert Quencer, chairman of the Department of Radiology at the University
of Miami, Miller School of Medicine, former editor-in-chief of the American Journal of Neuroradiology, and
a former president of the American Society of Neuroradiology, who gave his valuable time to review the
cases. His comments and suggestions were incisive and added an additional level of editorial scrutiny, and
his contributions have resulted in a more readable and informative third edition, which is more contempo-
rary in educational scope.
Efrat Saraf-Lavi, MD
x
CASE 1
A B C
D
History: A patient presents with left lower extremity pain and 3. Which of the following sequences would be used to dif-
numbness. ferentiate a Tarlov cyst from a cystic schwannoma?
a. T1-weighted
1. What should be included in the differential diagnosis? b. T1-weighted with contrast agent administration
(Choose all that apply.) c. T2-weighted
a. Tarlov cyst d. Short tau inversion recovery (STIR)
b. Epidural abscess
c. Chordoma 4. Tarlovcystisclassifiedaswhichtypeofmeningealcyst?
d. Ependymoma a. Type IA
e. Cystic schwannoma b. Type IB
c. Type II
2. What are the typical signal characteristics of a Tarlov cyst d. Type III
on MRI?
a. Hyperintense on T1-weighted images and hyperintense
on T2-weighted images
b. Hypointense on T1-weighted images and hypointense
on T2-weighted images
c. Hyperintense on T1-weighted images and hypointense
on T2-weighted images
d. Hypointense on T1-weighted images and hyperintense
on T2-weighted images
3
