Stand-Up MRI CASE STUDIES back to Stand-Up MRI ›››
Spondylolisthesis shown to require additional fusion segment once its degree of instability, not visible by recumbent-only MRI, was demonstrated by Fonar Upright MRI.
Clinical Case Overview
The patient was a 49-year-old male who had had a 20-year history of chronic back pain and a three-year history of right lower extremity radiculopathy.
Prior to the Upright™ scan, the patient was scanned in a recumbent-only MRI (1.5T). It showed a right paracentral disk herniation at L5-S1. Based on the recumbent images, neurosurgeon Bennie W. Chiles III, M.D., said:
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“I would have likely performed a diskectomy at L5-S1 to relieve pressure on the nerve root, along with an L5-S1 fusion for the back pain. Fusing L4-5 was not an initial consideration because no spinal instability was seen on the recumbent MRI.
When the dynamic flexion and extension images performed in the Upright™ MRI demonstrated an instability at L4-5 and showed the full extent of that instability once the patient’s body weight was applied, I chose to also fuse L4-5 during the procedure rather than treat L5-S1 alone.
The result was a better outcome for the patient whose severe right leg pain is now gone and whose back pain is much reduced.”
Bennie W. Chiles III, M.D., F.A.C.S.
Westchester Spine and Brain Surgery, PLLC
Hartsdale, New York,
Upright Imaging of Westchester, P.C.
Yonkers, New York
Ice Hockey Player with Posttraumatic Transient Spinal Cord Injury (TSCI)
Clinical Case Overview
Following a violent body check, a professional ice hockey player experienced a sudden total quadraparesis that paralyzed him during play for a full minute. The upright flexion and extension images showed two centromedullary cord contusions where only one was visible on the neutral upright scan. 
The two contusions accounted for the quadraparesis that caused his sudden transient paralysis on the ice while playing.
The critically compromising stenosis at C 3-4, visualized only by means of the FONAR Upright™ MRI extension images in this athlete with a congenitally tight spinal canal, was responsible for the acute cord compression and centromedullary contusions that resulted in the acute transient paralysis (1 minute duration) of this athlete. His lesions were visible only on upright extension.
Following anterior decompression and interbody fusion with a composite cage, this hockey player, who might otherwise have had his professional athletic career terminated, was back on the ice competing, 3 months after surgery.
J.P. Elsig, M.D.
Orthopedic Surgeon
Fellow of the Swiss Orthopedic Society
Member of the Board of the Swiss Spine Society
FMRI Zentrum
Zurich, Switzerland
Transient Quadriparesis with Drop Attack and Chronic Neck and Arm Pain
Clinical Case Overview
A 40-year old lady had been suffering for years from neck pain. A prior recumbent MRI had shown a C 5-6 disc degeneration with a posterior bulge and a moderate segmental kyphosis.
Despite repeated attempts with conservative treatment, the patient's symptoms worsened and were marked by the onset of transient paresthesias, transit loss of muscle tone in the legs and drop attacks.
When the Upright™ MRI was performed, it showed both an increased disc protrusion and segmental kyphosis at C5-6 relative to the recumbent MRI (thick arrow), as well as, a descent of the cerebellar tonsils behind the arch of C1 (thin arrow) accompanied by brainstem compression (double arrow) against the odontoid process. This Chiara I Malformation, with position-related downward herniation through the foramen magnum visible only by means of the FONAR Upright™ MRI, explained the drop attacks and the transient loss of tone in the legs, which could not be accounted for by only the C 5-6 bulge seen on the recumbent MRI.
With the achievement of the correct diagnosis of the patient's symptoms, made possible by the FONAR Upright™ MRI, the correct surgical treatment was accomplished and consisted of a posterior fossa decompression plus a C1 laminectomy and dural plasty. The C 5-6 herniation and kyphosis that was aggravated by the upright position was treated with an anterior C 5-6 discectomy and a cage placement.
J.P. Elsig, M.D.
Orthopedic Surgeon
Fellow of the Swiss Orthopedic Society
Member of the Board of the Swiss Spine Society
FMRI Zentrum
Zurich, Switzerland
Severe Kyphosis Rendering Recumbent Imaging Impossible
Sagittal images of the lumbosacral (6A) and thoracic (6B) spines in the upright-seated position shows compression of two thoracic vertebral bodies. This was ultimately found to be due to osteoporosis. The patient suffered from sufficiently marked kyphosis to render recumbent imaging impossible by either computed tomography or MRI.
Images courtesy of Imaging Center At Boot Ranch
Ligamentous Rupture Associated With Mobile Anterolisthesis
Anterolisthesis at L4/5 is noted in the recumbent view (4A). The standing flexion scan (4C) shows an interspinous ligamentous rupture at the L4/5 level (arrow).
Images courtesy of University of Aberdeen
Positional Generation of Clinical Symptoms
The recumbent image (15A) shows posterior disc protrusions at C5/6 and C6/7. Also note the adequate CSF space anterior to the spinal cord The upright-flexion image (15C) shows draping of the spinal cord over the posteriorly protruding discs. Clinically this patient exhibited L’Hermitte’s sign in the upright-flexion position.
The recumbent scan (9A) demonstrates no evidence of bladder or uterine prolapse and shows the levator sling is parallel to [and partially obscured by] the pubococygeal line. Note the decent of the bladder and uterus relative to the pubococygeal line which occurs with standing (9B) and is accentuated in the standing-straining view (9C). Note the levator sling (arrow) is oblique and non-parallel to the line when standing (9B), and straightens further when straining (9C).
Position-Related Recurrent Disc Herniation
The recumbent scan for this patient with right-sided radiculopathy following partial discectomy is shown on the left. The upright scan (right) shows a disc herniation at L5/S1.
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Images courtesy of Manuel S. Rose, M.D.- Rose Radiology Centers
Evaluation of Spinal Stability
The recumbent scan (left) demonstrates minor degenerative anterolisthesis at L4/5. The upright-flexion study (right) reveals further anterior slip of L4 on L5. These scans show hypermobile translational spinal instability, which can be a surgical indication in a case of related low back pain.
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Images courtesy of Melville MRI, P.C.
Upright Dynamic MRI Reveals Hidden Disc Herniation
The axial standing-extension gradient echo image (right) demonstrates a focal posterior disc herniation at the C4/5 level not visible on the recumbent scan. Note the associated spinal cord compression on the standing-extension scan.
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Images courtesy of Melville MRI, P.C
Severe Spondylolisthesis Undetected by Recumbent MRI
Clinical Case Overview
A 57-year old woman presented with pain of one year's duration following failed back surgery performed in 2001*.
The patient continued to experience persistent low back-pain, accompanied by sensations of coldness and numbness in both thighs and legs. The patient often required mechanical support to stabilize her walking.
During the year following surgery, the patient sought help from multiple medical specialists. She provided her recumbent MRI images to them. She was told the images showed nothing that could account for her symptoms and that nothing more could be done. Her surgeon rejected the prospect of additional surgery. A Florida neurologist suggested to her that her problem was “in her head.”
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The imaging center that evaluated her recommended she be scanned in an Upright™ MRI due to the possibility that an Upright™ scan, unlike the conventional recumbent scan, is weight-bearing and "might uncover something." Her family physician wrote the prescription, and the patient drove from her home in the Florida panhandle to the closest FONAR Upright™ MRI center, which at the time was in Tampa over 425 miles away.
The patient was scanned in the patented FONAR Upright™ MRI in early 2002, one year after her spinal fusion. Both Upright™ and recumbent scans were performed on her in the multi-position FONAR Upright™ MRI.
The recumbent MRI (left image) exhibited only a normal lumbar lordotic curve and a modest bulge of the L3-4 intervertebral disc, consistent with her prior recumbent MRI scans. The FONAR Upright™ scan (right image) revealed, however, a marked position-dependent subluxation (anterolisthesis) at L3-4 and an accompanying spinal stenosis that were not visible on the recumbent MRI.
The patient's Upright™ images established that there was a genuine physical basis for her symptoms, whereas her recumbent MRI images had failed to do so. The new Upright™ images supplied her surgeon with the necessary evidence that additional surgery was warranted to correct her problem.
A spinal fusion was performed at L3-4 one month after the patient's Upright™ MRI scan. The surgical outcome was positive. To date, almost four years post-op, the patient remains symptom free and reported to FONAR, "Thank you for giving me my life back."
* laminectomy and L45S1 fusion
Manuel S. Rose, M.D.
Radiologist
Rose Radiology Centers
Florida, USA
UPRIGHT DYNAMIC MRI REVEALS OCCULT DISC HERNIATION
Professor J. Randy Jinkins, MD, FACR, FEC
Department of Radiology
Downstate Medical Center
State University of New York
450 Clarkson Avenue
Brooklyn, NY 11203
USA
"This MRI unit is important in that it enables the medical imaging specialist to uncover significant occult disease that is not apparent on the recumbent MRI studies"
J. Randy Jinkins, MD, FACR, FEC
Clinical Case Overview
37 year-old male with bilateral pain and tingling in hands exacerbated upon flexion of the cervical spine.
Case Study
The images shown below were acquired on the Fonar Stand-Up™ MRI. The sagittal image in Figure 1 was acquired with the patient in a conventional recumbent position; Figure 2 is of the same patient, but in a standing position during extension. The standing-extension image demonstrates marked stenosis of the central spinal canal resulting from posterior disc protrusions extending into the anterior aspect of the spinal canal and focal ligamentous infolding posteriorly. Note that the resulting compression of the underlying spinal cord is not evident on the recumbent scan. (Scanning parameters for sagittal scans: TR= 3000 msec; TE = 160 msec; ETL = 15; 4.0 mm slice; scan time: 2:55 min - recumbent, 3:19 min - standing extension.)
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Figure 1: Sagittal T2-weighted fast spin echo (FSE) image in recumbent position |
Figure 2: Sagittal T2-weighted FSE image in standing position during extension |
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The gradient recalled echo T2*-weighted axial images are from the same patient. The standing extension image (Figure 4) demonstrates a focal posterior disc herniation at C4/5 level that is not visible on the recumbent scan (Figure 3). Patient positioning and dynamic maneuvers clearly play a critical role in detecting clinically significant spinal pathology. Note that a final diagnosis based only on the recumbent scan would result in a missed pathologic diagnosis. (Scanning parameters for axial scans: TR = 506 msec; TE = 22 msec; FA = 20º; 4.0 mm slice; scan time: 5:04 min.)
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Figure 3: Axial T2*-weighted gradient recalled echo (GRE) image of patient in recumbent position |
Figure 4: Axial T2*-weighted GRE image of patient in standing-extension |
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Diagnosis: Fluctuating intervertebral disc herniation dependent upon patient position and dynamic physical maneuver
Clinical Studies performed at:
Melville MRI - Long Island
FONAR Corporation, Melville, NY
