"The relationship of the mass to the cord is of prime importance and typically two compartments are considered: intramedullary (i.e. within the cord), intradural extramedullary (i.e. within the theca but outside of the cord). Additionally, the cauda equina region is often considered separately as a number of lesions are particular to it. The vast majority of cases will then fall into a relatively small number of more common entities for each region (for a more complete list please refer to neoplasms of the spinal canal):"
"spinal cord segment(s) affected (see below)"
"Ultrasound, except in the infant, does not have a role in diagnosis, as it is unable to image the intradural compartment due to the overlying posterior spinal elements."
"The spinal cord is rostrally continuous with the medulla oblongata and extends caudally to the conus medullaris. In adults, the tip of the conus typically terminates at the level of L1-L2, however it may terminate as high as mid-T12 or as low as L2-L3. The cord has two enlargements, cervical (C4-T1) and lumbosacral (T11-L1). The cervical enlargement provides innervation to the upper limbs via the brachial plexus, while the lumbosacral enlargement innervates the lower limbs via the lumbosacral plexus."
"The spinal cord is rostrally continuous with the medulla oblongata and extends caudally to the conus medullaris. In adults, the tip of the conus typically terminates at the level of L1-L2, however it may terminate as high as mid-T12 or as low as L2-L3. The cord has two enlargements, cervical (C4-T1) and lumbosacral (T11-L1). The cervical enlargement provides innervation to the upper limbs via the brachial plexus, while the lumbosacral enlargement innervates the lower limbs via the lumbosacral plexus."
Expected headings
"Imaging options"
"MRI protocol"
"Normal appearance on MRI"
"Systematic approach to interpretation"
"Location"
"Intramedullary lesions"
"Intradural extramedullary lesions"
"Cauda equina / filum terminale lesions"
"Signal characteristics"
"T1"
"T2"
"Contrast enhancement"
"Blood products"
"Multiplicity"
"Spinal level nomenclature"
"Myelography historically was of prime importance but is now done only in patients for whom an MRI is contraindicated (e.g. those fitted with a non-MRI-compatible/conditional pacemaker) or who could potentially have too much artifact from spinal instrumentation, or occasionally as a problem-solving technique (e.g. spinal arachnoid cyst vs ventral cord herniation). This is usually combined with CT (i.e. CT myelography)."
"Intradural extramedullary lesions may be related to nerve roots and may extend into the foramen (e.g. schwannomas and neurofibromas) or they may have a broad dural attachment (e.g. meningiomas) or be attached to the cord (leptomeningeal metastases)."
"Care should be taken to assess for the presence of prominent vascular flow voids, which may either indicate a vascular tumour (e.g. haemangioblastoma) or a vascular malformation (e.g. spinal dural arteriovenous fistula)."
"Depending on the likely diagnosis, examination of the rest of the neuraxis may be required and is recommended especially when appearances suggest leptomeningeal metastases or ependymoma. Similarly, the presence of multiple lesions (e.g. spinal nerve sheath tumours) may raise concern for a phakomatosis (e.g. NF1 or NF2)."
"As with all studies, having a systematic approach to intradural lesions is essential if subtle lesions are to be detected and the differential adequately narrowed. There is no single correct way to do this, and what is presented is merely a personal approach."