Blind Spots in Spine Imaging

Mougnyan Cox, MD; Linda Bagley, MD; Joseph Philip, MD; Joshua Thatcher, MD; Ike Thacker, MD; Conan Gomez; Kennith Layton, MD


Appl Radiol. 2022;51(2):15-23. 

In This Article

Soft-tissue Lesions

Aside from the spinal cord and canal, other critical structures such as the nasopharynx, oropharynx, and cervical lymph nodes are frequently visualized in cervical spine imaging, even in the presence of saturation bands (Figure 8). Most mildly enlarged lymph nodes in younger patients are reactive, but they assume greater importance in patients over age 40. Sagittal MRI may also reveal portions of the posterior fossa and even the sella turcica and cavernous sinuses. Thyroid nodules and masses are also commonly demonstrated. When reviewing thoracolumbar images, radiologists should look out for lung tumors and nodules. Small layering pleural effusions are common, as are esophageal abnormalities that may be a source of pain (Figure 9).

Figure 8.

Middle-aged patient with neck pain. Axial T2 gradient echo image demonstrates a right oropharyngeal mass (arrow) suspicious for carcinoma.

Figure 9.

Older patient with back pain and bacteremia. Contrast-enhanced CT of the thoracic spine does not show any concerning osseous findings but does show abnormal thickening and edema of the esophagus (arrow). Subsequent endoscopy confirmed esophagitis and mucosal ulcerations.

Lumbar spine imaging is often performed to evaluate for low back pain; a careful, level-by-level review of the images for spinal canal and bilateral foraminal and subarticular and lateral recess stenoses can be tedious. However, after a detailed review and report of degenerative changes, an equally careful review for extraspinal findings can be fruitful, especially in older patients. Renal tumors may present with back pain (Figure 10), as may pancreatic, peri-pancreatic (Figure 11), and gall bladder abnormalities. Simple hepatic and renal cysts are common, and they must be reported when they demonstrate concerning features.

Figure 10.

Axial T2 (A) lumbar MRI performed for back pain shows a heterogeneous mass in the left kidney (arrow).

Figure 11.

Middle-aged patient with mid-back pain. Axial T2 image (A) of the thoracic spine shows a round flow void contiguous with the distal splenic artery, suspicious for a splenic artery aneurysm (arrow), which is confirmed by contrast-enhanced CT (B) of the abdomen.