Tommaso Scarabino · Saverio Pollice ·

Giuseppe Carmine Iaffaldano ·

Domenico Catapano Editors

Imaging Spine
After Treatment
A Case-based Atlas
Second Edition

123
Imaging Spine After Treatment
Tommaso Scarabino • Saverio Pollice
Giuseppe Carmine Iaffaldano
Domenico Catapano
Editors

Imaging Spine After

Treatment
A Case-based Atlas

Second Edition
Editors
Tommaso Scarabino Saverio Pollice
Department of Radiology/Neuroradiology Department of Radiology
L. Bonomo Hospital San Nicola Pellegrino Hospital
Andria, Italy Trani, Italy

Giuseppe Carmine Iaffaldano Domenico Catapano

Department of Neurosurgery Department of Neurosurgery
Ospedale L. Bonomo Ospedale L. Bonomo
Andria, Italy Andria, Italy

ISBN 978-3-031-42550-9    ISBN 978-3-031-42551-6 (eBook)

https://doi.org/10.1007/978-3-031-42551-6

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2023
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Foreword

Imaging of the spine represents since many years a fundamental step in the identification of the
disease and then in the following treatment planning.
Treatment is influenced by proposed and executed diagnostic work up, both in terms of used
diagnostic techniques that uses qualitative and iconographic interpretation.
The first point is the virtuous plot between quality of examinations and diagnostic result, is
definitely under the responsibility of the radiologist dedicated to the pathology of the spine and
moreover must be linked appropriately and professionally impeccable.
The second point is related to the professional preparation that, although integrated by
experience, can not be separated from a thorough clinical and technological knowledge, con-
stantly updated through professional training.
This definition becomes essential when you have to study the “difficult” field of post-­
surgical imaging, where, in addition to the knowledge of surgical techniques and their results,
there is the uneasy task of expressing an opinion with high diagnostic value in the medical-­
legal branch.
A text that takes into account these important factors must become an integral part of cul-
tural background in diagnostic imaging especially for radiologists dedicated to the study of the
pathology of the spine.
This volume examines, in a comprehensive way, the normal and pathological features that
may arise in diagnostic imaging in the operated spine, by specifying the role of the various
imaging techniques, their use, the “prickly” boundary between normal and pathological and
then the different pathological findings.
A praise to the authors and especially to Tommaso Scarabino for being able to pick up an
important case study collection, clearly and comprehensive structured, easy to read and
reference.
This text, therefore, must be present on the desk for frequent use.
My invitation can only be so to acquire and use this text, to increase diagnostic performance
towards colleagues but particularly for the benefits of patients.

Radiodiagnostica CTO Carlo Faletti

AO Città della Salute e della Scienza
Turin, Italy
2013

* (adapted from “Imaging Spine After Treatment” edit by Tommaso Scarabino and Saverio
Pollice, First Edition, Springer 2014)

v
Preface

This paper provides a review about imaging assessment of the spine after treatment. This dis-
cussion is preceded by a detailed examination of spinal disorders (major cause of surgery and/
or interventional radiology) and its various types of treatments used in daily clinical practice.
In general, any surgical approach alters the normal anatomical and functional arrangement
of the district which is aimed, therefore image interpretation cannot ignore a correct set of
knowledge in the field of anatomy, pathophysiology, drug compliance, interventional radiol-
ogy, and surgery.
Neuroradiological imaging plays an important role in the post-operative evaluation of
patients undergoing spinal surgery. In particular, it is essential in documenting normal and
pathological post-treatment changes, specific to approach type; in detecting any complications
and in the follow-up.
Imaging assessment of spine after surgery is complex and depends upon several factors
including: surgical procedures and disease for which it was performed; biomechanical of the
underlying cortical and cancellous bone; conditions of muscles, intervertebral disc and liga-
ments; time since surgery procedures; duration and nature of the post-surgical syndrome.
Depending upon these factors, one or a combination of complementary imaging modalities
(XR, CT, MR) may be required to evaluate effectiveness of the treatment; to demonstrate any
clinically relevant abnormality at the treated region and adjacent structures; to assist the inter-
ventional radiologist or surgeon in deciding if it is necessary to intervene again, in which
nature and in which vertebral level(s).

Andria, Italy Tommaso Scarabino

Trani, Italy  Saverio Pollice
Andria, Italy  Giuseppe Carmine Iaffaldano
Andria, Italy  Domenico Catapano

vii
Acknowledgments

The topic of this volume is the neuroradiological imaging of spinal pathology after surgery or
interventional radiology treatment. Normal and pathological findings (including complica-
tions) in X-ray, CT, and MRI will be evaluated.
This book is presented as a text-atlas. The first part (text) is essential and synthetic and talks
about spinal diseases subjected to interventional procedure and/or surgery with its specific and
various types of approach. Afterwards radiological and neuroradiological diagnostic tech-
niques in post-treatment are assessed. The second part (atlas) instead includes a large iconog-
raphy as the result of multi-centre collaboration with top experts in this matter to which I
express my gratitude. Without their essential collaboration would not have been possible to
carry out the work!
Finally, a sincere thanks to the publishing house Springer Verlag Italy and in particular to
Ms. Cerri, for the enthusiasm with which she received this scientific initiative, and to the whole
team for the great care and professionalism shown in the drafting of the publication.

Tommaso Scarabino

ix
Contents

Part I

1 Pathology���������������������������������������������������������������������������������������������������������������������   3
Carla Leuci, Corradino Samarelli, Saverio Pollice, and Tommaso Scarabino
1.1 Disk Herniation���������������������������������������������������������������������������������������������������   3
1.2 Canal Stenosis�����������������������������������������������������������������������������������������������������   4
1.3 Vertebral Instability���������������������������������������������������������������������������������������������   5
1.4 Vertebral Fractures�����������������������������������������������������������������������������������������������   6
References���������������������������������������������������������������������������������������������������������������������   6
2 Interventional Radiology�������������������������������������������������������������������������������������������   9
Alberto Palombella, Fabio Quinto, Paolo Cerini, Emanuele Malatesta,
and Tommaso Scarabino
2.1 Percutaneous Techniques for Diskal Hernia �������������������������������������������������������   9
2.2 Percutaneous Techniques in Vertebral Collapses������������������������������������������������� 11
References��������������������������������������������������������������������������������������������������������������������� 13
3 Surgery������������������������������������������������������������������������������������������������������������������������� 15
Domenico Catapano, Antonello Curcio, Filippo Flavio Angileri, Simona Ferri,
Rossella Zaccaria, Michele Santoro, Giuseppe Carmine Iaffaldano,
Fabio Cacciola, and Antonino Germanò
3.1 Surgery Techniques in Lumbar Diskal Hernia����������������������������������������������������� 15
3.2 Surgery in Lumbar Degenerative Disorders�������������������������������������������������������� 16
3.3 Anterior Cervical Diskectomy and Fusion ��������������������������������������������������������� 23
References��������������������������������������������������������������������������������������������������������������������� 24
4 Imaging Modalities����������������������������������������������������������������������������������������������������� 27
Carmela Garzillo, Saverio Pollice, and Tommaso Scarabino
4.1 X-Ray������������������������������������������������������������������������������������������������������������������� 27
4.2 Ultrasound����������������������������������������������������������������������������������������������������������� 27
4.3 Computed Tomography��������������������������������������������������������������������������������������� 27
4.4 Magnetic Resonance ������������������������������������������������������������������������������������������� 28
References��������������������������������������������������������������������������������������������������������������������� 29
5 Post-Treatment Imaging��������������������������������������������������������������������������������������������� 31
Umberto Tupputi, Michela Capuano, Saverio Pollice, and Tommaso Scarabino
5.1 Diskectomy ��������������������������������������������������������������������������������������������������������� 31
5.2 Vertebroplasty ����������������������������������������������������������������������������������������������������� 33
5.3 Conventional and Dynamic Stabilization������������������������������������������������������������� 33
References��������������������������������������������������������������������������������������������������������������������� 34

xi
xii Contents

Part II Clinical Cases

6 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 39
Paola D’Aprile and Alfredo Tarantino
6.1 Early Postoperative Follow-Up��������������������������������������������������������������������������� 39
7 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 41
Paola D’Aprile and Alfredo Tarantino
7.1 Early Postoperative Follow-Up��������������������������������������������������������������������������� 41
8 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 43
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
8.1 Early Postoperative Follow-Up��������������������������������������������������������������������������� 43
9 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 45
Simone Salice, Domenico Tortora, Valentina Panara, Massimo Caulo,
and Armando Tartaro
9.1 Postoperative Follow-Up������������������������������������������������������������������������������������� 45
10 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 47
Paola D’Aprile and Alfredo Tarantino
10.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 47
11 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 49
Paola D’Aprile and Alfredo Tarantino
11.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 49
12 Herniated
 Lumbar Disk. Diskectomy����������������������������������������������������������������������� 51
Ferdinando Caranci, Anna Caliendo, Carmen Castagnolo, Raffaele Nappi,
and Achille Marotta
12.1 Preoperative Imaging����������������������������������������������������������������������������������������� 51
12.2 Postoperative Follow-Up After 1 Month����������������������������������������������������������� 54
12.3 Postoperative Follow-Up After 3 Months ��������������������������������������������������������� 56
12.4 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 57
13 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 61
Paola D’Aprile and Alfredo Tarantino
13.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 61
14 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 63
Paola D’Aprile and Alfredo Tarantino
14.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 63
15 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 65
Simone Salice, Domenico Tortora, Valentina Panara, Massimo Caulo, and
Armando Tartaro
15.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 65
16 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 67
Paola D’Aprile and Alfredo Tarantino
16.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 67
17 Herniated
 Lumbar Disk Micro-Diskectomy������������������������������������������������������������� 69
Paola D’Aprile and Alfredo Tarantino
17.1 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 69
18 Herniated
 Lumbar Disk Diskectomy ����������������������������������������������������������������������� 71
Paola D’Aprile and Alfredo Tarantino
18.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 71
18.2 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 73
Contents xiii

19 
Herniated Lumbar Disk Diskectomy ����������������������������������������������������������������������� 75
Paola D’Aprile and Alfredo Tarantino
19.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 75
20 
Herniated Lumbar Disk Diskectomy ����������������������������������������������������������������������� 77
Paola D’Aprile and Alfredo Tarantino
20.1 Postoperative Follow-up ����������������������������������������������������������������������������������� 77
21 
Herniated Lumbar Disk Diskectomy ����������������������������������������������������������������������� 81
Paola D’Aprile and Alfredo Tarantino
21.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 81
21.2 Postoperative Follow-Up After 5 Days ������������������������������������������������������������� 83
21.3 Late-Operative Follow-Up After 1 Year������������������������������������������������������������� 84
22 
Herniated Lumbar Disk Diskectomy and Stabilization ����������������������������������������� 85
Achille Marotta, Raffaele Nappi, Anna Caliendo, Carmen Castagnolo,
and Ferdinando Caranci
22.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 85
22.2 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 87
22.3 Postoperative Follow-Up After 9 Months ��������������������������������������������������������� 88
22.4 Postoperative Follow-Up After 12 Months ������������������������������������������������������� 89
23 
Herniated Lumbar Disk Diskectomy and Stabilization ����������������������������������������� 93
Chiara Potente, Roberto Trignani, Tommaso Scarabino, and Gabriele Polonara
23.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 93
23.2 Late Postoperative Follow-Up��������������������������������������������������������������������������� 94
24 
Herniated Lumbar Disk Diskectomy and Stabilization ����������������������������������������� 97
Chiara Potente, Roberto Trignani, Tommaso Scarabino, and Gabriele Polonara
24.1 Late Postoperative Follow-Up��������������������������������������������������������������������������� 97
25 
Herniated Lumbar Disk Intradiskal Percutaneous Procedure������������������������������� 101
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
25.1 Preoperative Imaging����������������������������������������������������������������������������������������� 101
25.2 Intraoperative Imaging��������������������������������������������������������������������������������������� 101
25.3 Postoperative Follow-Up After 10 Days ����������������������������������������������������������� 102
25.4 Postoperative Follow-Up After 3 Weeks����������������������������������������������������������� 103
26 
Herniated Lumbar Disk Percutaneous Intradiskal Procedure������������������������������� 105
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
26.1 Intraoperative Imaging��������������������������������������������������������������������������������������� 105
26.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 105
26.3 Postoperative Follow-Up after 36 h������������������������������������������������������������������� 106
26.4 Subsequent Postoperative Follow-Up ��������������������������������������������������������������� 107
27 
Extraforaminal L5-S1 Herniated Disk: Transmuscular Approach����������������������� 109
Domenico Catapano and Vincenzo Monte
28 
Intra-Extraforaminal L3-L4 Herniated Disk: Transmuscular Approach������������� 111
Domenico Catapano and Vincenzo Monte
29 
Herniated Lumbar Disk Anterior Diskectomy��������������������������������������������������������� 113
Tommaso Scarabino, Michele Maiorano, Fabio Quinto, Michele Santoro,
and Raniero Mignini
29.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 113
30 Herniated Lumbar Disk. Lateral Diskectomy and Interbody Arthrodesis.
Posterior Stabilization ����������������������������������������������������������������������������������������������� 115
Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo, and Francesco Zenga
xiv Contents

31 Recurrent
 Herniated Lumbar Disk Patient Reoperated����������������������������������������� 117
Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi, Christian Cossandi,
Piergiorgio Car, Gabriele Panzarasa, and Alessandro Carriero
31.1 Preoperative Imaging����������������������������������������������������������������������������������������� 117
31.2 Preoperative Imaging After 10 Months������������������������������������������������������������� 118
31.3 Postoperative Follow-Up����������������������������������������������������������������������������������� 119
32 Recurrent
 Herniated Lumbar Disk Stabilization ��������������������������������������������������� 121
Tommaso Scarabino, Fabio Quinto, Roberto Stanzione, Francesco Paradiso,
and Raniero Mignini
32.1 Preoperative Imaging����������������������������������������������������������������������������������������� 121
32.2 Preoperative Follow-Up������������������������������������������������������������������������������������� 122
32.3 Early Postoperative Follow-Up������������������������������������������������������������������������� 124
32.4 Late Postoperative Follow-Up��������������������������������������������������������������������������� 125
33 Dorsal
 Herniated Disk Diskectomy and Stabilization��������������������������������������������� 127
Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi, Christian Cossandi,
Piergiorgio Car, Gabriele Panzarasa, and Alessandro Carriero
33.1 Preoperative Imaging����������������������������������������������������������������������������������������� 127
33.2 Postoperative Follow-Up after 4 Months����������������������������������������������������������� 129
34 Herniated
 Cervical Disk Anterior Diskectomy ������������������������������������������������������� 131
Tommaso Scarabino, Fabio Quinto, Saverio Lorusso, Anna Totagiancaspro,
and Raniero Mignini
34.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 131
35 Herniated
 Cervical Disk Anterior Diskectomy ������������������������������������������������������� 133
Teresa Popolizio, Francesca Di Chio, Giovanni Miscio,
and Giuseppe Guglielmi
35.1 Preoperative Imaging����������������������������������������������������������������������������������������� 133
35.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 134
36 Herniated
 Cervical Disk Anterior Diskectomy ������������������������������������������������������� 135
Tommaso Scarabino, Saverio Pollice, Angela Lorusso, Vincenzo Brandini,
and Michele Santoro
36.1 Preoperative Imaging����������������������������������������������������������������������������������������� 135
36.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 137
37 Herniated
 Cervical Disk. Anterior Diskectomy and Arthrodesis��������������������������� 139
Giuseppe Carmine Iaffaldano, Claudia Pennisi, Stefania D’Avanzo,
Francesco Paradiso, Michele Santoro, and Domenico Catapano
38 Herniated
 Cervical Disk and Osteophytosis. Anterior
Decompression and Arthrodesis ������������������������������������������������������������������������������� 141
Domenico Catapano, Costanzo De Bonis, and Leonardo Gorgoglione
39 Herniated
 Cervical Disk. Anterior Diskectomy and Arthroplasty������������������������� 143
Rossella Zaccaria, Simona Ferri, Antonello Curcio, Fabio Cacciola,
and Antonino Germanò
39.1 Preoperative MRI����������������������������������������������������������������������������������������������� 143
39.2 Postoperative X-Ray ����������������������������������������������������������������������������������������� 144
40 Herniated
 Cervical Disk Anterior Diskectomy ������������������������������������������������������� 145
Teresa Popolizio, Francesca Di Chio, Michelangelo Nasuto,
Leonardo Gorgoglione, and Giuseppe Guglielmi
40.1 Preoperative Imaging����������������������������������������������������������������������������������������� 145
40.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 147
Contents xv

41 Cervical Ossified Posterior Longitudinal Ligament. Anterior

Decompression and Stabilization������������������������������������������������������������������������������� 149
Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco, and Fabio Cofano
42 
Cervical Spondylotic Myelopathy. Anterior and Posterior Approach������������������� 151
Antonello Curcio, Simona Ferri, Rossella Zaccaria, Fabio Cacciola,
Antonino Germanò, and Filippo Flavio Angileri
43 Cervical Spondylodiskitis Corpectomy��������������������������������������������������������������������� 153
Teresa Popolizio, Giuseppe Guglielmi, and Rosy Setiawati
43.1 Preoperative Imaging����������������������������������������������������������������������������������������� 153
43.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 155
44 
Cervical Spondylitis. Anterior and Posterior Approach����������������������������������������� 157
Simona Ferri, Rossella Zaccaria, Antonello Curcio, Fabio Cacciola,
Filippo Flavio Angileri, and Antonino Germanò
44.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 158
45 Septic Spondylodiskitis in Removal of Herniated Cervical Disk.
Anterior Approach Surgery��������������������������������������������������������������������������������������� 159
Chiara Potente, Tommaso Scarabino, and Gabriele Polonara
45.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 159
46 
Herniated Cervical Disk. Anterior Diskectomy������������������������������������������������������� 161
Chiara Potente, Tommaso Scarabino, and Gabriele Polonara
46.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 161
47 
Synovial Cyst. Minimally Invasive Surgical Approach������������������������������������������� 163
Domenico Catapano, Costanzo De Bonis, and Leonardo Gorgoglione
48 
Synovial Cysts. Surgical Removal����������������������������������������������������������������������������� 165
Ferdinando Caranci, Luca Brunese, Domenico Cicala, and Francesco Briganti
48.1 Preoperative Imaging����������������������������������������������������������������������������������������� 165
48.2 Preoperative Imaging����������������������������������������������������������������������������������������� 167
48.3 Postoperative Follow-Up After 2 Months ��������������������������������������������������������� 169
48.4 Postoperative Follow-Up After 3 Months ��������������������������������������������������������� 170
49 
Instability and Lumbar Stenosis. Positioning of Interspinous Device������������������� 171
Tommaso Scarabino, Saverio Pollice, Michela Capuano, Michele Santoro,
and Raniero Mignini
50 
Degenerative Lumbar Instability. Double Interspinous Device Positioning��������� 175
Tommaso Scarabino, Michele Maiorano, Tullia Garribba, Giuseppe Diaferia,
and Michele Santoro
50.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 175
51 
Lumbar Degenerative Instability. Interspinous Device Positioning����������������������� 179
Paola D’Aprile and Alfredo Tarantino
51.1 Preoperative Imaging����������������������������������������������������������������������������������������� 179
51.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 180
52 
Degenerative Lumbar Instability. Double Interspinous Device Positioning��������� 181
Paola D’Aprile and Alfredo Tarantino
52.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 181
53 
Lumbar Degenerative Instability. Interspinous Device Positioning����������������������� 183
Paola D’Aprile and Alfredo Tarantino
53.1 Preoperative Imaging����������������������������������������������������������������������������������������� 183
53.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 185
xvi Contents

54 Stenosis
 and Degenerative Lumbar Instability. Positioning of Double
Interspinous Device����������������������������������������������������������������������������������������������������� 187
Tommaso Scarabino, Michela Capuano, Roberto Stanzione,
Anna Totagiancaspro, and Michele Santoro
54.1 Preoperative Imaging����������������������������������������������������������������������������������������� 187
54.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 189
55 Stenosis
 and Degenerative Lumbar Instability. Interspinous Device
Positioning������������������������������������������������������������������������������������������������������������������� 191
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
55.1 Preoperative Imaging����������������������������������������������������������������������������������������� 191
55.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 193
56 Stenosis
 and Degenerative Lumbar Instability Interspinous Device
Positioning������������������������������������������������������������������������������������������������������������������� 195
Tommaso Scarabino, Fabio Quinto, Francesco Nemore, Carlo Delvecchio,
and Michele Santoro
56.1 Preoperative Imaging����������������������������������������������������������������������������������������� 195
56.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 196
57 Degenerative
 Lumbar Instability. Interspinous Device Positioning����������������������� 199
Paola D’Aprile and Alfredo Tarantino
57.1 Late Postoperative Follow-Up��������������������������������������������������������������������������� 199
58 Degenerative
 Lumbar Instability Interspinous Device Positioning����������������������� 201
Ferdinando Caranci, Domenico Cicala, Vincenzo Giugliano,
Francesco Briganti, and Luca Brunese
58.1 Preoperative Imaging����������������������������������������������������������������������������������������� 201
58.2 Postoperative Follow-Up After 3 Months ��������������������������������������������������������� 203
59 Degenerative
 Lumbar Instability. Interspinous Device Positioning����������������������� 207
Paola D’Aprile and Alfredo Tarantino
59.1 Postoperative Follow-Up After 2 Months ��������������������������������������������������������� 207
60 Degenerative
 Lumbar Instability. Stabilization and Interspinous
Device Positioning������������������������������������������������������������������������������������������������������� 211
Tommaso Scarabino, Angela Lorusso, Pietro Maggi, Carmen Bruno, and
Michele Santoro
60.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 211
61 Degenerative
 Lumbar Instability Rigid Posterior Stabilization����������������������������� 213
Teresa Popolizio, Francesco Gorgoglione, and Giuseppe Guglielmi
61.1 Preoperative Imaging����������������������������������������������������������������������������������������� 213
61.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 214
62 Degenerative
 Lumbar Instability Rigid Posterior Stabilization����������������������������� 215
Tommaso Scarabino, Saverio Pollice, Marianna Schiavariello,
Giuseppe Carmine Iaffaldano, and Raniero Mignini
62.1 Preoperative Imaging����������������������������������������������������������������������������������������� 215
62.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 216
63 Lumbar
 Canal Stenosis. Minimally Invasive Decompression��������������������������������� 217
Domenico Catapano, Costanzo De Bonis, and Leonardo Gorgolione
64 Lumbar
 Stenosis and Degenerative Instability Posterior Rigid Stabilization������� 219
Tommaso Scarabino, Maurizio Lelario, Pietro Maggi, Carmen Bruno, and
Raniero Mignini
64.1 Preoperative Imaging����������������������������������������������������������������������������������������� 219
64.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 221
Contents xvii

65 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 223
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
66 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 225
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
67 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 227
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
68 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 229
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
69 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 231
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
70 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 233
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
71 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 235
Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco, and Francesco Zenga
72 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 237
Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo, and Diego Garbossa
73 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 239
Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo, and Fabio Cofano
74 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 241
Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco, and Diego Garbossa
75 
Lumbar Stenosis and Degenerative Instability. Interbody Arthrodesis and
Posterior Stabilization ����������������������������������������������������������������������������������������������� 243
Giuseppe Di Perna, Nicola Zullo, and Emanuele Bavaresco
76 
Degenerative Lumbar Instability Rigid Posterior Stabilization����������������������������� 245
Luigi Manfrè
76.1 Preoperative Imaging����������������������������������������������������������������������������������������� 245
76.2 Intraoperative Imaging��������������������������������������������������������������������������������������� 246
76.3 Postoperative Follow-Up����������������������������������������������������������������������������������� 247
77 
Degenerative Lumbar Instability Stabilization������������������������������������������������������� 249
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
77.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 249
77.2 Postoperative Follow-Up After 3 Years������������������������������������������������������������� 250
77.3 Stop of Contrast Media in L2–L3 ��������������������������������������������������������������������� 251
78 Junctional Syndrome. Lateral Interbody Fusion and Posterior
Decompression-Stabilization������������������������������������������������������������������������������������� 253
Emanuele Bavaresco, Nicola Zullo, and Giuseppe Di Perna
xviii Contents

79 Junction
 Syndrome. Lateral Interbody Arthrodesis����������������������������������������������� 255
Simona Ferri, Rossella Zaccaria, Antonello Curcio, Fabio Cacciola,
and Antonino Germanò
79.1 Postoperative X-Ray ����������������������������������������������������������������������������������������� 255
80 Degenerative
 Lumbar Instability Rigid Posterior Stabilization����������������������������� 257
Ferdinando Caranci, Achille Marotta, Domenico Cicala,
and Francesco Briganti
80.1 Postoperative Follow-Up After 1 Month����������������������������������������������������������� 257
80.2 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 258
80.3 Postoperative Follow-Up After 9 Months ��������������������������������������������������������� 260
81 Degenerative
 Lumbar Instability Dynamic Stabilization��������������������������������������� 263
Tommaso Scarabino, Michele Maiorano, Tullia Garribba, Giuseppe Diaferia,
and Raniero Mignini
81.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 263
81.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 265
82 Degenerative
 Lumbar Instability. Screws Loosening and Irregular
Positioning������������������������������������������������������������������������������������������������������������������� 267
Costanzo De Bonis, Domenico Catapano, and Leonardo Gorgoglione
83 Degenerative
 Cervical Instability Stabilization–Posterior Decompression����������� 269
Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi, Christian Cossandi,
Marco Pelle, Gabriele Panzarasa, and Alessandro Carriero
83.1 Preoperative Imaging����������������������������������������������������������������������������������������� 269
83.2 Postoperative Follow-Up After 1 Year��������������������������������������������������������������� 271
84 Traumatic
 Lumbar Dislocation Percutaneous Stabilization����������������������������������� 273
Gabriele Polonara, Chiara Potente, Roberto Trignani, and Tommaso Scarabino
84.1 Preoperative Imaging����������������������������������������������������������������������������������������� 273
84.2 Postoperative Follow-Up After 1 Month����������������������������������������������������������� 275
85 Dorsal
 Traumatic D10–D11 Dislocation. Decompression, Realignment, and
Stabilization. ��������������������������������������������������������������������������������������������������������������� 277
Domenico Catapano, Costanzo De Bonis, and Leonardo Gorgolione
86 Traumatic Dorso-Lumbar Fracture������������������������������������������������������������������������� 279
Simona Ferri, Rossella Zaccaria, Antonello Curcio, Fabio Cacciola, and
Antonino Germanò
87 Cervical
 Traumatic Dislocation Stabilization, Canal Decompression, and
Diskectomy������������������������������������������������������������������������������������������������������������������� 281
Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano, Christian Cossandi,
Giuliana Fini, Gabriele Panzarasa, and Alessandro Carriero
87.1 Preoperative Imaging����������������������������������������������������������������������������������������� 281
87.2 Postoperative Follow-Up (First Surgery)����������������������������������������������������������� 282
87.3 Postoperative Follow-Up (Re-surgery) ������������������������������������������������������������� 283
88 Traumatic
 Cervical Fracture-Dislocation. Conservative Treatment��������������������� 285
Achille Marotta, Domenico Cicala, Carmen Castagnolo, Luca Brunese,
and Ferdinando Caranci
88.1 Pre-treatment Imaging��������������������������������������������������������������������������������������� 285
88.2 Follow-Up After 2 Months of Conservative Treatment������������������������������������� 286
88.3 Follow-Up After 4 Months��������������������������������������������������������������������������������� 287
Contents xix

89 
Traumatic Cervical Dislocation and Fracture Anterior Stabilization������������������� 289
Tommaso Scarabino, Michela Capuano, Roberto Stanzione,
Giuseppe Carmine Iaffaldano, and Michele Santoro
89.1 Preoperative Imaging����������������������������������������������������������������������������������������� 289
89.2 Post-Treatment Conservative Follow-Up����������������������������������������������������������� 291
89.3 Early Postoperative Follow-Up������������������������������������������������������������������������� 293
90 Traumatic Cervical Fracture-Dislocation. Anterior and Posterior
Approach��������������������������������������������������������������������������������������������������������������������� 295
Giuseppe Diaferia, Giuseppe Carmine Iaffaldano, Mario Bianco,
Francesco Paradiso, Michele Santoro, and Domenico Catapano
91 Scoliosis Stabilization������������������������������������������������������������������������������������������������� 299
Ferdinando Caranci, Andrea Elefante, Domenico Cicala,
and Francesco Briganti
91.1 Preoperative Imaging����������������������������������������������������������������������������������������� 299
91.2 Postoperative Follow-Up After 24 h ����������������������������������������������������������������� 300
91.3 Postoperative Follow-Up After 20 Days ����������������������������������������������������������� 301
92 
Kyphoscoliosis Stabilization CSF Fistula����������������������������������������������������������������� 303
Simone Salice, Domenico Tortora, Valentina Panara, Massimo Caulo,
and Armando Tartaro
92.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 303
93 Osteoporotic Lumbar Collapse Vertebroplasty������������������������������������������������������� 305
Francesco Fabbiano, Alessandro Stecco, Silvio Ciolfi, Emanuele Malatesta,
Alessio Usurini, Rita Fossaceca, and Alessandro Carriero
93.1 Preoperative Imaging����������������������������������������������������������������������������������������� 305
93.2 Post-vertebroplasty Follow-Up (8 Months)������������������������������������������������������� 307
94 Traumatic Lumbar Fracture, Vertebroplasty ��������������������������������������������������������� 309
Giuseppe Carmine Iaffaldano, Pasquale Crudele, Giuseppe Diaferia,
Francesco Paradiso, Michele Santoro, and Domenico Catapano
95 Traumatic Lumbar Collapse: Percutaneous Mechanical Vertebral
Augmentation ������������������������������������������������������������������������������������������������������������� 313
Giuseppe Diaferia, Pasquale Crudele, Stefania D’Avanzo, Mario Bianco,
Claudia Pennisi, and Domenico Catapano
96 Dorsal Osteoporotic Collapse Vertebroplasty ��������������������������������������������������������� 315
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
96.1 Early Post Vertebroplasty Follow-Up ��������������������������������������������������������������� 315
96.2 Late Post Vertebroplasty Follow-Up ����������������������������������������������������������������� 316
97 Osteoporotic Dorsal Collapse Vertebroplasty ��������������������������������������������������������� 317
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
97.1 Post-vertebroplasty Follow-Up ������������������������������������������������������������������������� 317
98 
Osteoporotic Lumbar Collapse Kyphoplasty����������������������������������������������������������� 319
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
98.1 Early Post-kyphoplasty Follow-Up������������������������������������������������������������������� 319
98.2 Post-kyphoplasty Follow-Up (2 Years) ������������������������������������������������������������� 320
99 Traumatic Lumbar Collapse Vertebroplasty����������������������������������������������������������� 321
Tommaso Scarabino, Michele Maiorano, Claudia Rutigliano,
Vincenzo Brandini, and Michele Santoro
99.1 Post-vertebroplasty Follow-Up ������������������������������������������������������������������������� 321
xx Contents

100 Multiple Lumbar Traumatic Collapses Vertebroplasty������������������������������������������ 323

Tommaso Scarabino, Angela Lorusso, Saverio Pollice,
Giuseppe Carmine Iaffaldano, and Raniero Mignini
100.1 Preoperative Imaging����������������������������������������������������������������������������������������� 323
100.2 Post-vertebroplasty Follow-Up ������������������������������������������������������������������������� 324
101 Multiple Dorsal-Lumbar Traumatic Collapses Vertebroplasty����������������������������� 325
Tommaso Scarabino, Michele Maiorano, Tullia Garribba, Vincenzo Brandini,
and Raniero Mignini
101.1 Preoperative Imaging����������������������������������������������������������������������������������������� 325
101.2 Early Post-vertebroplasty Follow-Up ��������������������������������������������������������������� 328
102 Traumatic Dorsal Collapse Vertebroplasty ������������������������������������������������������������� 331
Tommaso Scarabino, Fabio Quinto, Saverio Lorusso, Francesco Paradiso,
and Raniero Mignini
102.1 Preoperative Imaging����������������������������������������������������������������������������������������� 331
102.2 Early Post-vertebroplasty Follow-Up ��������������������������������������������������������������� 332
103 Traumatic
 Lumbar Collapse Rigid Stabilization and Vertebral Body
Stenting ����������������������������������������������������������������������������������������������������������������������� 335
Chiara Potente, Roberto Trignani, Tommaso Scarabino, and Gabriele Polonara
103.1 Preoperative Imaging����������������������������������������������������������������������������������������� 335
103.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 336
104 Lumbar
 Collapse in Lymphoma Vertebroplasty����������������������������������������������������� 339
Sivio Ciolfi, Alessandro Stecco, Francesco Fabbiano, Emanuele Malatesta,
Alberto Zuccalà, Rita Fossaceca, and Alessandro Carriero
104.1 Preoperative Imaging����������������������������������������������������������������������������������������� 339
104.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 340
104.3 Late Postoperative Follow-Up��������������������������������������������������������������������������� 341
105 Malignant Dorsal Collapse Vertebroplasty��������������������������������������������������������������� 343
Ferdinando Caranci, Andrea Elefante, Antonio Volpe, and Francesco Briganti
105.1 Preoperative Imaging����������������������������������������������������������������������������������������� 343
105.2 Post-vertebroplasty Follow-Up ������������������������������������������������������������������������� 346
106 Lumbar
 Collapse in Chordoma Vertebral Drawing����������������������������������������������� 349
Tommaso Scarabino, Fabio Quinto, Michele Maiorano, Michela Capuano,
and Saverio Pollice
106.1 Preoperative Imaging����������������������������������������������������������������������������������������� 349
106.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 351
106.3 Postoperative Follow-Up 6 Months������������������������������������������������������������������� 352
107 Dorsal
 Collapse in Multiple Myeloma Vertebroplasty ������������������������������������������� 353
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo
107.1 Early Postvertebroplasty Follow-Up����������������������������������������������������������������� 353
107.2 Postvertebroplasty Follow-Up After 6 Months ������������������������������������������������� 356
107.3 Postvertebroplasty Follow-Up After 1 Year������������������������������������������������������� 357
108 Malignant
 Lumbar Collapse Thermal Ablation Through Radiofrequency
and Vertebroplasty ����������������������������������������������������������������������������������������������������� 359
Simone Salice, Domenico Tortora, Valentina Panara, Massimo Caulo, and
Armando Tartaro
108.1 Preoperative Imaging����������������������������������������������������������������������������������������� 359
108.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 360
108.3 Postoperative Follow-Up After 6 Months ��������������������������������������������������������� 361
Contents xxi

109 Dorsal
 Collapse in Myeloma: Percutaneous Mechanical Vertebral
Augmentation ������������������������������������������������������������������������������������������������������������� 363
Pasquale Crudele, Giuseppe Carmine Iaffaldano, Giuseppe Diaferia,
Francesco Paradiso, Michele Santoro, and Domenico Catapano
110 Dorsal
 Collapse in Myeloma Stabilization��������������������������������������������������������������� 365
Teresa Popolizio, Giuseppe Guglielmi, and Rosy Setiawati
110.1 Preoperative Imaging����������������������������������������������������������������������������������������� 365
110.2 Postoperative Imaging��������������������������������������������������������������������������������������� 367
111 Neoplastic Cervical Dislocation-­Collapse Vertebral Removal ������������������������������� 369
Tommaso Scarabino, Fabio Quinto, Claudia Suriano, Francesco Paradiso,
and Michele Santoro
111.1 Preoperative Imaging����������������������������������������������������������������������������������������� 369
111.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 371
111.3 Postoperative Follow-Up After 3 Months ��������������������������������������������������������� 372
112 Traumatic
 Lumbar Fracture: Somatic Reconstruction ����������������������������������������� 373
Simona Ferri, Rossella Zaccaria, Antonello Curcio, Fabio Cacciola, and
Antonino Germanò
113 Traumatic
 Lumbar Collapse Stabilization and Canal Decompression����������������� 375
Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano, Christian Cossandi,
Rita Merla, Gabriele Panzarasa, and Alessandro Carriero
113.1 Preoperative Imaging����������������������������������������������������������������������������������������� 375
113.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 376
114 Traumatic
 Lumbar Collapse Double Stabilization and Decompression��������������� 377
Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano, Rita Merla,
Giuliano Allegra, Gabriele Panzarasa, and Alessandro Carriero
114.1 Preoperative Imaging����������������������������������������������������������������������������������������� 377
114.2 Postoperative Follow-Up After 1st Surgery������������������������������������������������������� 379
114.3 Postoperative Follow-Up After 2nd Surgery����������������������������������������������������� 380
115 Multiple
 Traumatic Dorsal Collapses Double Stabilization����������������������������������� 381
Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano, Rita Merla,
Christian Cossandi, Giuliano Allegra, Gabriele Panzarasa,
and Alessandro Carriero
115.1 Preoperative Imaging����������������������������������������������������������������������������������������� 381
115.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 383
116 Traumatic
 Dorsal Collapse: Rigid Stabilization ����������������������������������������������������� 385
Giuseppe Diaferia, Giuseppe Carmine Iaffaldano, Pasquale Crudele,
Francesco Paradiso, Michele Santoro, and Domenico Catapano
117 Traumatic
 Lumbar Collapse Rigid Stabilization����������������������������������������������������� 387
Chiara Potente, Roberto Trignani, Tommaso Scarabino, and Gabriele Polonara
117.1 Postoperative Follow-Up After 1 Year��������������������������������������������������������������� 387
118 Multiple
 Collapses Rigid Stabilization��������������������������������������������������������������������� 389
Tommaso Scarabino, Michela Capuano, Francesco Nemore, Carlo Delvecchio,
and Raniero Mignini
118.1 Preoperative Imaging����������������������������������������������������������������������������������������� 389
118.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 390
118.3 Postoperative Follow-Up����������������������������������������������������������������������������������� 391
xxii Contents

119 Traumatic
 Cervical Fracture Anterior Stabilization����������������������������������������������� 393
Tommaso Scarabino, Saverio Pollice, Marianna Schiavariello,
Vincenzo Brandini, and Raniero Mignini
119.1 Preoperative Imaging����������������������������������������������������������������������������������������� 393
119.2 Posttreatment Follow-Up After 4 Days (Conservative Treatment) ������������������� 396
119.3 Postoperative Follow-Up����������������������������������������������������������������������������������� 396
120 Cervical
 Traumatic Fracture Posterior Stabilization ��������������������������������������������� 397
Tommaso Scarabino, Claudia Rutigliano, Pietro Maggi, Francesco Paradiso,
and Raniero Mignini
120.1 Preoperative Imaging����������������������������������������������������������������������������������������� 397
120.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 399
121 Cervical
 Traumatic Fracture: Posterior Stabilization��������������������������������������������� 401
Tommaso Scarabino, Michela Capuano, Claudia Suriano,
Giuseppe Carmine Iaffaldano, and Raniero Mignini
121.1 Preoperative Imaging����������������������������������������������������������������������������������������� 401
121.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 404
122 Cervical Traumatic Fracture Vertebral Removal ��������������������������������������������������� 405
Tommaso Scarabino, Maurizio Lelario, Pietro Maggi, Francesco Paradiso,
and Michele Santoro
122.1 Preoperative Imaging����������������������������������������������������������������������������������������� 405
122.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 408
122.3 Postoperative Follow-Up After 1 Month����������������������������������������������������������� 409
123 Traumatic
 Cervical Vertebral Body Fracture: Anterior Corpectomy, Bone
Grafting, and Stabilization����������������������������������������������������������������������������������������� 411
Domenico Catapano, Costanzo De Bonis, and Leonardo Gorgoglione
124 Traumatic
 Cervical Fracture: Anterior Decompression and Arthrodesis������������� 413
Domenico Catapano, Pasquale Crudele, Stefania D’Avanzo, Mario Bianco,
Claudia Pennisi, and Giuseppe Diaferia
125 Traumatic
 Cervical Fracture Vertebral Removal ��������������������������������������������������� 417
Tommaso Scarabino, Saverio Pollice, Marianna Schiavariello,
Vincenzo Brandini, and Michele Santoro
125.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 417
125.2 Postoperative Follow-Up����������������������������������������������������������������������������������� 420
125.3 Late Postoperative Follow-Up��������������������������������������������������������������������������� 421
126 Odontoid
 Traumatic Fracture: Suboccipito-cervical Stabilization ����������������������� 423
Antonello Curcio, Simona Ferri, Rossella Zaccaria, Fabio Cacciola,
and Antonino Germanò
127 Odontoid Traumatic Fracture Stabilization������������������������������������������������������������� 425
Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi, Martina Quagliozzi,
Christian Cossandi, Gabriele Panzarasa, and Alessandro Carriero
127.1 Preoperative Imaging����������������������������������������������������������������������������������������� 425
127.2 Postoperative Follow-Up After 1 Year��������������������������������������������������������������� 426
128 Odontoid Traumatic Fracture Stabilization������������������������������������������������������������� 427
Chiara Potente, Tommaso Scarabino, and Gabriele Polonara
128.1 Early Postoperative Follow-Up������������������������������������������������������������������������� 427
Contents xxiii

129 Atlanto-occipital
 Malformation Anterior Odontoid Drawing ������������������������������� 429
Teresa Popolizio, Francesca Di Chio, Leonardo Gorgoglione,
and Giuseppe Guglielmi
129.1 Preoperative Imaging����������������������������������������������������������������������������������������� 429
129.2 Early Postoperative Follow-Up������������������������������������������������������������������������� 430
130 Amyotrophic
 Lateral Sclerosis Stem Cell Transplant��������������������������������������������� 431
Alessandro Stecco, Letizia Mazzini, Mariangela Lombardi,
Francesco Fabbiano, Anna Viola, Roberto Cantello, and Alessandro Carriero
130.1 Postoperative Follow-Up����������������������������������������������������������������������������������� 431
131 Functional MR ����������������������������������������������������������������������������������������������������������� 435
Marco Di Terlizzi, Michele Ricciardi, Tommaso Scarabino,
and Francesco Ricciardi
Contributors

Giuliano Allegra Department of Neurosurgery, “Maggiore della Carità” University Hospital,

Novara, Italy
Filippo Flavio Angileri Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Emanuele Bavaresco Casa di Cura “Città di Bra”, Bra, Italy
Mario Bianco Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Vincenzo Brandini Department of Neurosurgery, “L. Bonomo” Hospital, Andria, BT, Italy
Francesco Briganti Unit of Neuroradiology, Advanced Biomedical Sciences Department,
“Federico II” University, Naples, Italy
Luca Brunese Department of Health Science, Chair of Radiology, University of Molise,
Campobasso, Italy
Carmen Bruno Department of Neurosurgery, “L. Bonomo” Hospital, Andria, BT, Italy
Fabio Cacciola Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Anna Caliendo Advanced Biomedical Sciences Department, Unit of Neuroradiology,
“Federico II” University, Naples, Italy
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
Roberto Cantello Department of Radiology, “Maggiore della Carità” University Hospital,
Novara, Italy
Department of Neurology, “Maggiore della Carità” University Hospital, Novara, Italy
Michela Capuano Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
Ferdinando Caranci Unit of Neuroradiology, Advanced Biomedical Sciences Department,
“Federico II’ University, Naples, Italy
Piergiorgio Car Department of Neurosurgery, “Maggiore della Carità” University Hospital,
Novara, Italy
Alessandro Carriero Department of Radiology, “Maggiore della Carità” University Hospital,
Novara, Italy
Carmen Castagnolo Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
Domenico Catapano Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy

xxv
xxvi Contributors

Massimo Caulo Department of Neurosciences and Imaging, Institute of Advanced Biomedical

Technologies, ‘G. D’Annunzio” University, Chieti-Pescara, Italy
Paolo Cerini Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, Andria, BT,
Italy
Domenico Cicala Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
Silvio Ciolfi Department of Radiology, “Maggiore della Carità” University Hospital, Novara,
Italy
Fabio Cofano Neurosciences Department “Rita Levi Montalcini”, University of Turin, Turin,
Italy
“Humanitas Gradenigo” Hospital, Turin, Italy
Christian Cossandi Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy
Pasquale Crudele Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Antonello Curcio Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Paola D’Aprile Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy
Stefania D’Avanzo Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Costanzo De Bonis Department of Neurosurgery, “Casa Sollievo della Sofferenza” I.R.C.C.S,
S. Giovanni Rotondo, Italy
Carlo Delvecchio Department of Neurosurgery, “Miulli” Hospital, Acquaviva, Italy
Department of Neurosurgery, “Lorenzo Bonomo” Hospital, Andria, Italy
Giuseppe Diaferia Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Francesca Di Chio Department of Radiology, Scientific Institute Hospital, “Casa Sollievo
della Sofferenza”, San Giovanni Rotondo (Fg), Italy
Department of Radiology, University of Foggia, Foggia, Italy
Giuseppe Di Perna Neurosciences Dept. “Rita Levi Montalcini”, University of Turin, Turin,
Italy
Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Turin, Italy
Neurosciences Department “Rita Levi Montalcini”, University of Turin, Turin, Italy
Marco Di Terlizzi Radiology Center, Andria, Italy
Andrea Elefante Unit of Neuroradiology, Advanced Biomedical Sciences Department,
“Federico II” University, Naples, Italy
Francesco Fabbiano Department of Radiology, “Maggiore della Carita`” University Hospital,
Novara, Italy
Simona Ferri Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Giuliana Fini Department of Radiology, “Maggiore della Carita`” University Hospital,
Novara, Italy
Rita Rita Fossaceca Department of Radiology, “Maggiore della Carita`” University Hospital,
Novara, Italy
Contributors xxvii

Diego Garbossa Neurosciences Department “Rita Levi Montalcini”, University of Turin,

Turin, Italy
Tullia Garribba Department of Radiology—Neuroradiology, ‘L. Bo-nomo’ Hospital, Andria,
BT, Italy
Carmela Garzillo Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, Andria,
BT, Italy
Antonino Germanò Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Vincenzo Giugliano Unit of Diagnostic Imaging, GE.P.O.S. Clinic, Telese Terme, BN, Italy
Francesco Gorgoglione Department of Orthopedics, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
Leonardo Gorgoglione Department of Neurosurgery, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
Department of Neurosurgery, “Casa Sollievo della Sofferenza” I.R.C.C.S, S. Giovanni
Rotondo, Italy
Leonardo Gorgolione Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
Gianluigi Guarnieri Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
Giuseppe Guglielmi Department of Radiology, University of Foggia, Foggia, Italy
Giuseppe Carmine Iaffaldano Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy
Roberto Izzo Department of Neuroradiology, “Cardarelli” Hospital, Naples, Italy
Maurizio Lelario Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, Andria,
BT, Italy
Carla Leuci Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, Andria, BT,
Italy
Mariangela Lombardi Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
Department of Radiology - Neuroradiology, L. Bonomo Hospital, Novara, Italy
Angela Lorusso Department of Radiology—Neuroradiology, “Lorenzo Bonomo” Hospital,
Andria, Italy
Pietro Maggi Department of Radiology—Neuroradiology, “L. Bonomo” Hospital, Andria,
BT, Italy
Michele Maiorano Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
Emanuele Malatesta Department of Radiology, “Maggiore della Carità” University Hospital,
Novara, Italy
Department of Radiology - Neuroradiology, L. Bonomo Hospital, Novara, Italy
Luigi Manfrè Department of Neuroradiology, Cannizzaro’ Hospital, Catania, Italy
Achille Marotta Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
Letizia Mazzini Department of Neurology, “Maggiore della Carità” University Hospital,
Novara, Italy
xxviii Contributors

Rita Merla Department of Radiology, “University Hospital”, Campobasso, Italy

Department of Radiology, “Maggiore della Carità University Hospital”, Novara, Italy
Raniero Mignini Department of Neurosurgery, “Lorenzo Bonomo” Hospital, Andria, Italy
Giovanni Miscio Department of Radiology, Scientific Institute Hospital “Casa Sollievo della
Sofferenza”, San Giovanni Rotondo, FG, Italy
Vincenzo Monte Department of Neurosurgery, “Casa Sollievo della Sofferenza” I.R.C.C.S,
S. Giovanni Rotondo, Italy
Mario Muto Department of Neuroradiology, ‘Cardarelli’ Hospital, Naples, Italy
Raffaele Nappi Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
Michelangelo Nasuto Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
Department of Radiology, University of Foggia, Foggia, Italy
Saverio Lorusso Department of Radiology-Neuroradiology, L. Bonomo Hospital, Andria,
Italy
Alberto Palombella Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
Valentina Panara Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, “G. D’Annunzio’ University, Chieti-Pescara, Italy
Gabriele Panzarasa Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy
Francesco Paradiso Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Neurosurgical Operative Unit, “L. Bonomo” Hospital, Andria, Italy
Marco Pelle Department of Radiology, “Maggiore della Carità” University Hospital, Novara,
Italy
Claudia Pennisi Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Saverio Pollice Department of Radiology, San Nicola Pellegrino Hospital, Trani, Italy
Gabriele Polonara Department of Neuroradiology, University Hospital, Ancona, Italy
Teresa Popolizio Department of Neuroradiology, Scientific Institute Hospital “Casa Sollievo
della Sofferenza”, San Giovanni Rotondo, FG, Italy
Chiara Potente Department of Neuroradiology, University Hospital, Ancona, Italy
Martina Quagliozzi Department of Radiology, “Maggiore della Carita`” University Hospital,
Novara, Italy
Fabio Quinto Department of Radiology—Neuroradiology, “L. Bonomo” Hospital, Andria,
BT, Italy
Francesco Ricciardi Radiology Center, Andria, Italy
Michele Ricciardi Radiology Center, Andria, Italy
Claudia Rutigliano Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
Simone Salice Department of Neurosciences and Imaging, Institute of Advanced Biomedical
Technologies, “G. D’Annunzio” University, Chieti-Pescara, Italy
Contributors xxix

Corradino Samarelli Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,

Andria, BT, Italy
Michele Santoro Department of Neurosurgery, “L. Bonomo” Hospital, Andria, Italy
Neurosurgical Operative Unit, “L. Bonomo” Hospital, Andria, Italy
Tommaso Scarabino Department of Radiolgy/Neuroradiology, L. Bonomo Hospital, Andria,
Italy
Marianna Schiavariello Department of Radiology—Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
Rosy Setiawati Department of Radiology, Rumah Satik Surabaya International Hospital,
Surabaya, Indonesia
Roberto Stanzione Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
Alessandro Stecco Department of Radiology, “Maggiore della Carita`” University Hospital,
Novara, Italy
Claudia Suriano Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, Andria,
BT, Italy
Alfredo Tarantino Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy
Armando Tartaro Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, ‘G. D’Annunzio” University, Chieti-Pescara, Italy
Domenico Tortora Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, ‘G. D’Annunzio” University, Chieti-Pescara, Italy
Anna Totagiancaspro Department of Neurology, “Lorenzo Bonomo” Hospital, Andria, Italy
Roberto Trignani Department of Neurosurgery, University Hospital, Ancona, Italy
Umberto Tupputi Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
Alessio Usurini Department of Radiology, “Maggiore della Carità” University Hospital,
Novara, Italy
Anna Viola Department of Radiology, “Maggiore della Carità” University Hospital, Novara,
Italy
Antonio Volpe Unit of Neuroradiology, Advanced Biomedical Sciences Department,
“Federico II" University, Naples, Italy
Rossella Zaccaria Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy
Francesco Zenga Neurosciences Department “Rita Levi Montalcini”, University of Turin,
Turin, Italy
Alberto Zuccalà Department of Radiology, “Maggiore della Carità” University Hospital,
Novara, Italy
Nicola Zullo Casa di Cura “Città di Bra”, Bra, Italy
Part I
 Pathology
1
Carla Leuci, Corradino Samarelli, Saverio Pollice,
and Tommaso Scarabino

Causes of surgery and interventional radiology on spine are starts at a young age, and the prevalence is the highest in
represented largely by disk herniation (most commonly lum- middle-aged population [5]. Who is affected many times,
bar), which we will discuss further in this treatment. Stenosis unfortunately, begin a diagnostic and therapeutic route
of the vertebral canal, vertebral instability, and vertebral involving orthopedic, neurosurgeon, physiatrist, and neurol-
fractures will also be analyzed [1, 2]. The therapeutic treat- ogist. Its natural history provides for a first time period (of
ment of spinal pathology initially includes conservative ther- variable length between 3 and 6 weeks) characterized by
apy and in case of failure a number of surgical procedures pain (more or less intense) which is followed by a second
and/or interventional radiology approaches, with varying phase in which the painful symptomatology is attenuated
degrees of invasiveness, such as diskectomy, vertebroplasty, and then disappears leaving the place to symptoms of neuro-
and surgical stabilization. With recent advances of interven- logical deficit (decrease in strength of muscle innervated by
tion techniques and devices used, minimally invasive the compressed root) [6–9]. Herniated disk, commonly lum-
approaches are becoming increasingly popular for the treat- bar, is the main cause for surgery on the spine, not always
ment of spine disorders. In particular, minimally invasive resolutive. Younger patients with higher baseline disability
spine surgery attempts to: decrease iatrogenic muscle injury, without neurological deficit are at increased risk of undergo-
decrease pain, and speed postoperative course by the use of ing revision surgery for reherniation. Those considering revi-
smaller incisions and specialized instruments. sion surgery for reherniation will likely improve significantly
following surgery, but possibly not as much as with primary
diskectomy [10]. In postoperative course may arise in fact a
1.1 Disk Herniation recurrence or a fibrous scar that if hypertrophic can compress
and irritate the affected nerve and require a second operation
Disk herniation (DH) is the displacement of disk material (the rate of re-operation is around 3–15%).
(nucleus pulposus or annulus fibrosis) beyond the interverte-
bral disk space [3]. DH is one of the most common diseases
with very high social costs; it is the first cause for absentee- 1.1.1 Lumbar Disk Hernia
ism from work and the second for permanent disability.
Around 55% of the population in European countries reports Lumbar disk herniation is a degenerative disease of the inter-
at least once in life a variable episode of low back pain and vertebral disk that arises from the rupture of the annulus
80% a simple low back pain [4]. Approximately, 10% of fibrosus and subsequent leakage of nucleus pulposus in spi-
people who experience low-back pain develop chronic low-­ nal canal with compression on dural sack and nerve root.
back pain. Approximately, 1% of the population is com- Lumbar disk herniation is a common sequela of degenerative
pletely disabled due to low-back pain. Low-back pain often spine disease and it’s estimated that 30% of the population
will experience it at some point in their lifetime [11].
Especially in people of 30–50 years with low back pain,
C. Leuci · C. Samarelli ∙ T. Scarabino (*) symptoms originate from radiculopathy due to compression
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
of lumbosacral nerve roots (pain radiating along the course
Andria, BT, Italy
e-mail: [email protected]; [email protected] of the sciatic nerve, from gluteal region to the back of the
thigh and posterolateral leg up the ankle) or crural suffering
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, (pain along the anterior or anterior-medial thigh, along the
Trani, Italy course of the crural nerve), causing functional impairment.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 3

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_1
4 C. Leuci et al.

Radicular pain is caused by mechanical compression, inflam- failure of conservative therapy; the presence of symptoms
matory effects, vascular and biochemical modifications and signs of sensory or motor involvement in the correspond-
caused by the contact between the disk and nerve roots. ing dermatomer; electromyography positive for severe root
Diagnosis involves the collection of anamnestic data; damage and recent documentation of disk herniation on MRI
physical examination and clinical trials to assess root or CT. The cauda equina syndrome from herniated disk is an
involvement (irritative, deficit, paretic), diagnostic imaging absolute indication for surgery to be performed urgently.
(X-ray, computed tomography CT, magnetic resonance
MRI), and instrumental examination (electromyography). In
the diagnosis of lumbar disk herniation, myelography is not 1.1.2 Cervical Disk Hernia
as sensitive as MRI, and MRI has a higher positive rate.
Compared with CT, it has more imaging parameters, multi- Cervical hernia is less common than lumbar. It can show
ple tissue variable functions, more flexible and extensive, no nonspecific symptoms such as neck pain and shoulder pain.
radiation, and no damage to the human body, and its diag- Specific symptoms are radiculopathy with arms pain or
nostic accuracy is better than that of CT scan [12]. myelopathy with spasticity, abnormal reflexes, abnormal
Treatment may be conservative or can contemplate surgi- walking, and bladder dysfunction. Radiological diagnosis
cal procedures and/or interventional radiology approach. requires as a first step X-ray of the cervical spine in double
The choice of treatment depends in general on two elements: projection (lateral and anteroposterior), followed by MRI,
the entity or the persistence of acute symptoms and the pres- which still represents the gold standard. The treatment ini-
ence of a functional damage. This latter aspect is sometimes tially may be pharmacological (analgesics, muscle relaxants,
highlighted (in case of serious damage root) by the decreased NSAIDs). Even physiokinesitherapy and the use of cervical
(or absent) functionality of the muscles innervated by that collar may be useful. In absence of any clinical improve-
root. In this case, a great help is the electromyographic ment, surgical treatment is recommended which may include
examination that tells us precisely the functional status of the anterior arthrodesis; anterior microdiskectomy with inter-
root compressed by herniated disk. This test, performed by body fusion anterior cervical diskectomy and fusion (ACDF)
implanting small needles along the lower limb, records the or arthroplasty, evolution of classic ACDF, with implantation
electrical potentials sent along nerve roots to the muscles for of a prosthetic disk that replaces the degenerated [13].
their contraction. Compression (and inflammatory state that Indications for surgical intervention include severe or pro-
follows) alters the ability of conducting electrical stimula- gressive neurological compromise and significant pain that is
tion along the nerve fibers and thus alters the electrical char- refractory to non-operative measures. There are several tech-
acteristics of these pulses. Recording these changes allows to niques described based on pathology. The gold standard
obtain a quantitative assessment of root damage and also to remains the anterior cervical diskectomy with fusion, as it
determine whether the damage is recent or old. allows the removal of the pathology and prevention of recur-
Conservative therapy for at least 7–10 days, or until the rent neural compression by performing a fusion. A posterior
disappearance of intense pain, consists of absolute absten- laminoforaminotomy can be a consideration in patients with
tion from even moderate physical actions, from assumption anterolateral herniations. Total disk replacement is an emerg-
of incorrect positions, or from trunk flexion. Pharmacotherapy, ing treatment modality, where indications remain controver-
recommended for a short time, involves administration of sial [14].
corticosteroids (betamethasone or methyl-prednisolone),
nonsteroidal anti-inflammatory (NSAIDs), pain relievers
(tramadol, paracetamol, paracetamol? codeine, morphine), 1.2 Canal Stenosis
muscle relaxants, and periradicular infiltration therapy. After
the hyperacute phase, physiatric evaluation may be required Spinal stenosis is a condition in which the nerve roots are
to start postural exercises and neuromuscular electrical stim- compressed by a number of pathologic factors, congenital or
ulation. In addition to standard medical treatments, several acquired, leading to symptoms such as pain, numbness, and
alternative treatments have also been shown to provide effec- weakness. The upper neck (cervical) and lower back (lum-
tive pain relief for many patients. Most common alternative bar) areas most frequently are affected, although the thoracic
care actually are chiropractic manipulation, acupuncture, spine also can be compressed most frequently by a disk her-
and massage therapy. niation. Three different anatomic sites within the vertebral
Surgical options are: open surgery, micro-surgery, and canal can be affected by spinal stenosis. First, the central
minimally invasive percutaneous surgery. These are used for canal, which houses the spinal cord, can be narrowed in an
different types of herniated disks: contained or extruded, anterior-posterior dimension, leading to compression of neu-
with and without dislocated fragment, and with or without ral elements and reduction of blood supply to the spinal cord
narrow canal. Criteria for elective surgical indication is the in the cervical area and the cauda equina in the lumbar area.
1 Pathology 5

Secondly, the neural foramen, which are openings through With age, joints (intervertebral disk, interapophyseal
which the nerve roots exit the spinal cord, can be compressed joints) that allow movements of the spine (flexion, extension,
as a result of disk herniation, hypertrophy of the facet joints and rotation) undergo degenerative changes that alter struc-
and ligaments, or unstable slippage of one vertebral body ture and functioning. In particular, intervertebral disk goes
relative to the level below. Lastly, the lateral recess, which is through dehydration with reduction of its thickness and
seen in the lumbar spine only and is defined as the area long hence distance between the two bodies which is interposed.
the pedicle that a nerve root enters just before its exit through The annulus, which adheres firmly to the edges of the verte-
the neural foramen, can be compressed from a facet joint bral bodies, protrudes beyond the limiting bodies, profiles.
hypertrophy. Depending on the level of the spine affected, The reduction in height of the disk, placed in the anterior part
each type of compression can lead to different symptoms of the vertebra, involves on the interapophyseal joints a
that warrant a particular treatment modality [15]. Acquired greater burden to which they are not predisposed with wear
causes are usually multiple: disk herniation, spondylolisthe- of the cartilage and increase of ligamentous laxity (microin-
sis, disk arthrosis, marginal osteophytes, facet joint arthrosis stability) that thus determines inflammatory processes
with a consequent reduction of canal amplitude, calcification responsible for low back pain.
of the joint capsule, hypertrophy, and calcification of the Over time, even ligaments that keep vertebrae, together
posterior longitudinal ligament and yellow ligaments, hyper- with the joints, stretch out causing abnormal increase in
ostosis of the plates [16, 17]. Stenosis is also documented amplitude of movement allowed. Moreover, the progressive
after surgical procedures as a result of exuberant failure of the ligaments leads to slipping of vertebra over the
degeneration. lower (degenerative spondylolisthesis). The body responds
Symptoms of lumbar stenosis, more frequent than the trying to block the abnormal movements by affixing new
remaining districts, are neurogenic claudication, represented bone to strengthen the joints. Joints hypertrophy and distor-
by inability of the patient to walk long distances for the onset tion cause progressive narrowing of canal and related neuro-
of pain in the upright position. This pain is emphasized in logical syndrome (root canal stenosis, sciatic nerve suffering).
walking, with sensation of heavy legs and progressive lack of Osteophytes that are formed along the edges can form bone
strength. CT and MRI with axial acquisitions allow to accu- bridges which block the articulation. Osteoporosis may
rately measure the amplitude of the canal, both central and worsen this context by associating possibly a “crushing”
lateral [18]. spine.
Treatment may be conservative: epidural steroid injec- Symptoms are postural pain (conditioned by the position
tions, NSAIDs, calcitonin, prolonged bed rest, magnetother- of the body), more pronounced at certain times of the day
apy, ionophoresis, neuro-electrical stimulation, physical (getting out of bed) and accentuated by fatigue, sometimes
therapy (postural exercises, swimming), corsets, and exter- (especially when stenosis of the spinal canal coexists) asso-
nal orthoses. Traditional surgery consists of enlargement of ciated with numbness and weakness in the lower limbs. In
the neural canal through posterior laminectomy without or the forms secondary to traumatic accidents, local acute pain
with foraminotomy, partial or total arthrodesis with inter- prevails, usually at the fractured vertebrae, with associated
body screws and bars. Minimally invasive surgery instead neural damage (paresis or paralysis). Clinical history of
uses interspinous devices. these individuals allows a diagnosis of instability. The objec-
tive evaluation is then indispensable; radiological examina-
tions help to determine the stage of instability, although
1.3 Vertebral Instability sometimes there is not always a correlation between clinical
and imaging.
Vertebral instability can be from muscle–tendon–ligament– Spinal instability as a result of a neoplastic process dif-
disk insufficiency secondary to degenerative spinal disease, fers significantly from high-energy traumatic injuries in
which can be traumatic or rarely congenital and can lead to a the pattern of bony and ligamentous involvement, potential
progressive failure with consequent alteration of joint mobil- for healing, neurologic manifestations, and bone quality. It
ity and pain. There are different patterns of instability based requires a specific and different set of criteria for stability
on the pathophysiologic mechanisms that sustain the pro- assessment. Neoplastic spine instability has been defined
cess: degenerative, traumatic, and neoplastic [19]. by the Spine Oncology Study Group as loss of spinal
Instability of degenerative origin is most common, affect- integrity as a result of a neoplastic process associated with
ing usually the last lumbar vertebrae [20–22]. This condi- movement-­related pain, symptomatic or progressive defor-
tion, despite enormous variability, from simple postural mity, and/or neural compromise under physiologic loads
imbalance can evolve gradually in protrusion, disk hernia, [19].
muscle failure, arthritic degeneration, amplitude reduction of X-rays are performed in anteroposterior, lateral and
the central, and lateral spinal canal. oblique with associated dynamic study in the upright (in
6 C. Leuci et al.

maximum flexion and extension) in order to verify the pres- tures; (2) transition zone: the thoracolumbar region is rela-
ence of a slide of a vertebra to the other (in the absence of tively straight (kyphosis from 0 to 10) and situated between
congenital anomaly such as spondylolysis with spondylolis- the kyphotic thoracic and lordotic lumber spine; unlike the
thesis). With X-ray, it is also possible to document the pres- thoracic spine, the absence of costovertebral structures no
ence of diskopathy, osteophytes, spinal deviations, and areas longer protects the thoracolumbar zone; and (3) facet joints:
of greatest sclerosis (index of functional overload). CT scan facet joints of the thoracic spine are coronally oriented to
evaluates the root canal diameters (central and lateral), shows resist flexion-extension and that of lumbar spine are sagit-
the interapophyseal joints, the epidural fat, and muscle atro- tally oriented to allow flexion-extension. In the thoracolum-
phy. CT also detect even the tiniest fractures in the middle bar area, facet joints show a transition from predominantly
and posterior columns, revealing potentially unstable lesions. coronal to predominantly sagittal orientation [19].
CT also allows an excellent evaluation of vertebral align- Symptoms usually include back pain with breathing dif-
ment and the spatial position of dislocated bone fragments, ficulty due to decreased lung capacity. X-ray detects the dis-
both in the cervical and thoracolumbar districts when con- tortion of somatic profiles. CT has a better spatial resolution.
ventional radiography failed [19]. In the early phase MRI identifies the intracancellous edema,
MRI analyzes the disk degeneration, the diskopathies, the signal of bone bruise, and possible fracture, even in absence
stages of disk-somatic degeneration (Modic), and the fatty of deformation of somatic profiles. In case of non-­
atrophy of the deep spinal musculature. Apart from instabil- myelophatic traumatic fractures, treatment may be conserva-
ity assessment, in many cases, dynamic MRI has proved to tive with positioning of bust for 3 months associated with
reveal disk-radicular conflicts not depicted on conventional MR follow-up. Surgery is quickly necessary in case of unsta-
MRI studies [19]. ble myelopathic fractures. The aim of surgery is to perform a
Treatment is multimodal and can include medical conser- spinal stabilization with minimally invasive technique using
vative therapy associated with spinal manipulation, neuro-­ pedicle screws and rods percutaneously inserted. The pur-
reflex, and physiokinesitherapy. The neurosurgeon and pose is to determine bony fusion to prevent segmental move-
orthopedic have two options: the traditional stabilization ments. Another therapeutic option is the percutaneous
(“fusion surgery”) in the macro-instability and the dynamic vertebroplasty [25–27]. Sometimes single or multiple cor-
stabilization (“non-fusion surgery”) used instead in the pres- pectomy may be necessary to replace the vertebral body,
ence of micro-instability and in cases where it is necessary to especially in the case of cancer or infection.
preserve the movement [23, 24].

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16. Nowicki BH, Haughton VM, Schmidt TA et al (1996) Occult lum- 14:B-354
bar lateral spinal stenosis in neural foramina subjected to physi- 27. Dublin AB, Hartman R, Latchaw P et al (2005) The vertebral body
ologic loading. AJNR 17:1605–1614 fracture in osteoporosis: restoration of height using percutaneous
17. Schönström N, Lindahl S, Willen J et al (1989) Dynamic changes vertebroplasty. AJNR 26:489–492
in the dimensions of the lumbar spinal canal: an experimental study
in vitro. J Orthop Res 7:115–121
 Interventional Radiology
2
Alberto Palombella, Fabio Quinto, Paolo Cerini,
Emanuele Malatesta, and Tommaso Scarabino

Interventional radiology of the spine includes a set of mini- ally quite limited in time and influenced by the progression
mally invasive surgical procedures with percutaneous of disk degeneration. These procedures include intradiskal
approach, used primarily for the treatment of diskal hernia electrothermal therapy (IDET), chemonucleolysis, cobla-
(especially lumbar) and vertebral collapse of different tion, laser diskectomy, and oxygen ozone therapy.
nature [1].
These techniques involve short time hospitalization, are
usually practicable in day surgery, and do not require general 2.1.1 Percutaneous Mechanical
anesthesia. Decompression Technique

The rationale of mechanical decompression is based on the

2.1 Percutaneous Techniques for Diskal theory provided by Hijikata who assumed that a small reduc-
Hernia tion in disk volume, obtained by mechanical removal, reflects
in a drop of intradiskal hydrostatic pressure. According to
Interventional techniques with percutaneous approach for several studies, the success rate of these techniques varies
diskal hernia are based on the principle of “empty of nucleus between 75 and 80% [3].
pulposus”(both by physical and chemical ways) in order to There are available several semi-automatic devices con-
reduce its volume and thus indirectly the compression of sisting in a rotating screw inserted in a needle lumen. Once
nerve root. Compared to surgery, they are less invasive, with the needle tip reaches the disk center under CT o fluoro-
similar efficacy and lower risk of recurrences, thanks to an scopic guidance, the automatic rotation of the screw, in com-
external approach. They also have the advantage of being bination with a continuous manual antero-posterior
repeatable without precluding, in case of failure, the use of oscillation, leads to a remotion of a volume between 1–3 mL
traditional surgery [2]. for a treatment of 3 min. Other techniques include pneumatic
They find indication especially in young patients with or water-driven suction-cutting probes.
disk protrusion, where disk degeneration is the only source
of pain, and therefore, all the degenerative phenomena typi-
cal of the advanced age are absent. Positive result is gener- 2.1.2 Intradiskal Electrothermal Therapy

A. Palombella IDET or intradiskal electrothermal annuloplasty (IDEA) is a

Department of Radiology/Neuroradiology, “L. Bonomo” Hospital, new and minimally invasive technique for the treatment of
Andria, BT, Italy diskogenic low back pain. It involves percutaneous threading
e-mail: [email protected]
of a flexible catheter into the disk under fluoroscopic guid-
F. Quinto · P. Cerini · T. Scarabino (*) ance. The catheter, composed of thermal resistive coil, heats
Department of Radiology/Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
the posterior annulus of the disk, causing contraction of col-
e-mail: [email protected] lagen fibers and destruction of afferent disk nociceptors.
E. Malatesta
Breakage of heat sensitive hydrogen bonds of the collagen
Department of Radiology, “Maggiore della Carità” University fibers causes collagen contraction. With disk temperatures
Hospital, Novara, Italy reaching 650 °C collagen may contract as much as 35% from
Department of Radiology - Neuroradiology, L. Bonomo Hospital, its original size. The tightening of annular tissue may
Novara, Italy enhance the structural integrity of degenerated disk and

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 9

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_2
10 A. Palombella et al.

repair the annular fissures. The process of disk restructuring this decompression, the nerve root regains the lost space and
(as shown by time courses of patient’s pain relief) may take is no longer marked by protruding disk, and thus not sub-
several months to reach its full extent. IDET might also jected to mechanical irritation responsible for the pain [10,
cause destruction of sensitized nociceptors in the annular 11]. Treatment takes about 30 min and is performed under
wall. Denervation by thermal energy is used widely for local anesthesia or with patient mildly sedated in order to
peripheral and central nervous system lesioning and might verify immediately the disappearance of pain. No surgical
contribute to partial and initial pain relief following the pro- wound is practiced, and the patient can be dismissed the
cedure [4, 5]. same day or, in special cases, the immediately following.
IDET is minimally invasive and has a low complication There are no risks, thanks to the use of not high temperatures
rate. In a systematic review of intradiskal percutaneous mini- (max 70°), which are not able to cause irritation or damage
mally invasive procedures for chronic low back pain, Gelalis to the adjacent spinal cord. Pandolfi et al. proved a 50% com-
et al. concluded that IDET, when performed in properly plete pain relief in 18 patients treated with coblation in the
selected patients, may eliminate or delay the need for surgi- shortly post-treatment follow-up which were maintained in
cal intervention for an extended period, with few reported the 2-year follow-up for 30% of the patients without signifi-
adverse effects [6]. cant peri- and post-procedural complication [12].

2.1.3 Chemonucleolysis 2.1.5 Laser Diskectomy

Chemonucleolysis is a minimally invasive interventional In the last 5 years, this minimally invasive technology has
procedure characterized by destruction of the nucleus by the improved particularly through the use of highly precise and
injection in the intervertebral disk of papain, enzyme which safe surgical laser, making the procedure without risk, as
destroys nucleus without damaging the neighboring struc- long as performed in hospitalized structures and experienced
tures. Papain is injected percutaneously with posterolateral hands.
approach in the intervertebral space, until the level of the Under fluoroscopic or CT guidance, a fine needle (less
hernia. This technique should be preceded by allergy test to than 1 mm) is introduced in herniated intervertebral disk
papain and for radiological examinations (CT, MRI) to con- with interlaminar or transforaminal or extraforaminal
firm diagnosis of hernia. Procedure is performed under light approach. Once checked the correct position, a thin optical
anesthesia (analgesics and neuroleptics), takes about 20 min, fiber of 360 uM is introduced inside the needle, connected to
and requires 3–4 days of hospitalization. In 40% of cases, the the laser, whose action towards the herniated disk is partial
healing occurs 3 days after the treatment, but sometimes vaporization with consequent retraction of the hernia, reduc-
later. Therapy is considered failed if a month after there was tion of intradiskal pressure, and improvement of disk radicu-
no sign of remission. Percentage of success is about 70% [7, lar conflict [13]. Laser also alters the chemical and physical
8]. This percutaneous treatment, very popular in the 1980s, structure of the nucleus pulposus and thus can change the
was phased out for possible adverse reactions to chemical chemical origin of pain by interfering with the mediators of
parts. Recently was introduced a new agent for chemonucle- the inflammatory process. After laser treatment, both macro-
olysis, the Condoliase, a mucopolysaccharidase highly spe- scopic and histological characteristics are different for effect
cific for chondroitin sulfate and hyaluronic acid, two of the of depolymerization of condromucoprotein of the nucleus
most abundant glycosaminoglycans in the nucleus pulposus pulposus. This process can have a positive influence on the
of the intervertebral disk. In a recent study, Okada et al. progression of the degenerative process and in the stabiliza-
obtained an improvement of symptoms in 85.4% of the tion of the segment.
patients without severe adverse events [9]. The procedure, normally performed under local anesthe-
sia and sometimes a slight analgesic, takes 15–20 min for a
single level treatment. It is normally devoid of significant
2.1.4 Coblation pain symptoms unlike other techniques that utilize heat
(coblation, nucleus plastic, radio frequency), since the laser
This minimally invasive interventional procedure is per- allows to concentrate very high powers without dissipation
formed for “contained” hernia that irritates nerve root caus- of heat into the surrounding tissues. The physical character-
ing pain in absence of massive muscular deficits. This istics of the optical fibers (pure silicon) and their emission
percutaneous technique involves the insertion of a needle mode allows in fact to concentrate the energy in just a few
into the disk space under radiological control. At this level, a mm with energy absorption rate greater than 90%.
series of cold ablations are produced to lose the disk tension, Patient can be dismissed within the day (day surgery).
vaporize part of the nucleus pulposus, and reduce pressure There is no surgical wound or any instability after the
on the irritated root. It is a cold disk lysis without irritating procedure. Antibiotic prophylaxis with analgesics to
effects of the other traditional techniques of aspiration. By need is carried out for 3 days. A day of rest is recom-
2 Interventional Radiology 11

mended and returning to the normal working life occurs space. Headache is caused instead due to epidural anesthetic
within 1 week. diffusion. It is recommended a 48-h postoperative period of
Results are satisfying in about 80% of cases with a signifi- no absolute rest with the beginning of specific physiokinesi-
cant reduction of complications conversely present in tradi- therapy after a week.
tional surgery [14, 15]. In case of failure, it can be repeated
without any compromise for the use of traditional surgery.
Laser energy is safer with the endoscopic technique that 2.1.7 Biomaterial Implantational Disk Cell
allows to clearly see the surgical field, to dose more appro- Therapies
priate energy, to irrigate and aspire. Focus of the energy on
the herniated disk allows material removal in a more effec- While a field still in early development, bioengineering-­
tive and safe way [16]. based strategies employing novel biomaterials are emerging
Laser energy can be applied at a reduced dose (Low Level as promising alternatives for clinical treatment of interverte-
Laser) in thermodiskoplasty, which does not aim to remove bral disk disorders.
disk material, but only to change the intradiskal, physical, The intervertebral disk undergoes a degenerative process
and chemical environment [17]. The thermodiskoplasty acts resulting in loss of proteoglycans, loss of disk height, and
both on diskal pain, both on disk radicular conflict in small tears with generation of herniation fragments. While the
dimension hernia. With non-ablative doses, laser energy mainstream treatment is aimed at relieving the symptoms, a
causes a contraction of the disk tissue by about 15% (photo- relative new approach is based in implantation of biomateri-
coagulation effect). als to restore the disk function. The approaches initially pur-
sued to restore NP height, function, and motion focused on
the use of in situ hydrating, synthetic polymers to restore NP
2.1.6 Oxygen Ozone Therapy hydration, and, consequently, IVD disk pressure and disk
height [21].
It is a minimally invasive interventional procedure extremely Disk reparative therapy using soft biomaterial may be
reliable and competitive. It has recently developed much useful, as well, to compensate for defects occurring after dis-
more respect than other percutaneous techniques because it kectomy. A diskectomy for a herniated disk relieves pain by
is considered as a valid alternative to surgery. It consists of removing the nucleus polposus through fissures in the annu-
periganglionic intradiskal injection of a mixture of O2–O3 lus fibrosus, which relieves nerve compression. However,
(3–10 cc, concentration of 30 mg/ml) in order to have lytic this procedure does not aim to repair defects in the NP or AF,
action, anti-inflammatory, and analgesic effects [18–20]. and the defect within the IVD produced by diskectomy can
This result is obtained thanks to three mechanisms: (1) Direct lead to undesirable postoperative outcomes, including fur-
action on mucopolysaccharides of the nucleus with release ther disk degeneration, chronic low back pain, and recurrent
of H2O and reduction of size of the disk that compresses the herniation [22]. To date, tis interesting field is still under
root, (2) improved oxygenation and reduction of inflamma- investigation and no suitable biomaterial has been approved
tion at the site of the disease for oxidizing action on algo- [23].
genic mediators of pain (in herniated disk there is increase in
chondrocytes, cytokines, prostaglandin E2, and sensitivity to
bradykinin), and (3) improved micro circulation for rising 2.2 Percutaneous Techniques in Vertebral
venous stasis and loss of oxygenated blood caused by Collapses
mechanical compression.
The chronic reduction of oxygen is partly responsible for Percutaneous interventional techniques currently used in
the pain, because nerve roots are susceptible to hypoxia. treating various nature collapses (osteoporotic, traumatic,
Patient, pretreated with antibiotic therapy, is placed in prone and neoplastic) are represented by vertebroplasty and kypho-
position with use of the pillow, in order to reduce the physi- plasty. Both reach a similar result, with specific advantages
ological lumbosacral lordosis. The procedure is performed in and disadvantages (mainly the lower cost in vertebroplasty).
a comfortable and sterile setting, with mild sedation and
local anesthesia. The interbody space is identified under
scopic or CT control, then a needle is placed in the nucleus 2.2.1 Vertebroplasty
pulposus through which is introduced a mixture of O2O3.
Mostly, it includes the injection of steroids and anesthetics, Percutaneous vertebroplasty (PVP) is a therapeutic, mini-
as long as patients are not already treated for recurrent disk mally invasive, image-guided procedure that involves injec-
herniation and scarring following surgery. By this way, the tion of radio-opaque bone cement into a partially collapsed
appearance of any transient paraplegia (lasting 2 h) is avoided vertebral body, in an effort to provide pain relief and stabil-
due to postsurgical inflammatory processes in the epidural ity. The main indication for vertebroplasty are: painful
12 A. Palombella et al.

o­steoporotic vertebral collapses, painful vertebrae due to 4 h can be dismissed with muscle relaxants therapy. The pre-
benign bone tumors (e.g. hemangioma, giant cell tumor, treatment evaluation should first include clinical examina-
aneurysmal bone cyst) or malignant bone infiltration (multi- tion in order to focus the level of pain (pain must be treated,
ple myeloma, metastasis), painful fractures associated with not the image!!). Preliminary PT, PTT, platelets and INR
osteonecrosis (Kummel’s disease). In the setting of osteopo- examinations are necessary to have the certainty that the
rotic vertebral fractures, patients should initially receive patient can be submitted to surgery, for which is significant
medical management and vertebroplasty should be limited to evaluate breathing capacity and if patient can stay prone.
patients with severe pain, refractory to conservative therapy. Diagnostic algorithm pretreatment involves X-ray that
Thus, vertebral augmentation is not indicated in mild or documents the collapse, sometimes associated with a tar-
moderate pain for osteoporotic compression fractures, since geted CT scan. MR is still the gold standard because it is able
evidence has not shown vertebroplasty to be more beneficial to clearly identify the vertebra to be treated. MR particular
than a placebo in this population [24]. Vertebroplasty is also sequences (fast field eco T2 weighted with fat suppression or
useful in patients with multiple fractures where possible, and STIR) document edema pattern in the cancellous bone of the
further collapses would lead to respiratory compromission, fractured vertebrae, even in the absence of clear vertebral
in unconsolidated fractures in healthy bone and in treatment collapse. Conversely, ld collapses, without edema pattern,
of cystic degeneration [25–27]. Absolute contraindications should not be treated [29–31]. The choice of vertebra to be
are stable asymptomatic fractures, effective medical therapy, treated is in fact based not only on the shape at X-ray but
osteomyelitis in fractured vertebra, uncorrectable coagulop- even in the presence of edema on MRI proving that fracture
athy, allergy to components, and local or systemic infections is recent. This finding should be related to the precise site of
such as spondylodiskitis. Relative contraindications are pain reported by the patient with a targeted digital pressure.
radicular pain or radiculopathy caused by compressive syn- Vertebroplasty obtains excellent results in treatment of
drome not related to vertebral fracture, fragment displaced pain caused mainly by osteoporosis (with positive results up
posteriorly with compromission [20% of the spinal canal, to 90%), and in less measure in treatment of vertebral metas-
tumor extended into the epidural space, acute traumatic frac- tases (approximately 70% efficacy) [32]. One-third of all
ture of not osteoporotic vertebra, severe compression of the vertebral fractures is attributable to osteoporosis and in Italy
vertebral body, and stabilized fracture without pain lasting there are approximately 100,000 vertebral fractures each
more than a year. This technique originally described by year (1/3 of them with significant pain). Conventional treat-
Deramond et al. in 1987 for the treatment of an aggressive ment involves a long immobilization (30–60 days) and anal-
vertebral hemangioma [28] has been widely circulated in gesic with the risk of complications (thrombophlebitis or
other European countries (including Italy) and United States, pneumonia). Multiple osteoporosis fractures can also be
favored above all by lower costs of DRG (diagnosis related treated in the same session (up to three) when symptomatic
group) compared to other similar techniques (kyphoplasty). and white edema pattern (if there is no pain, no treatment
Vertebroplasty consists of the injection in the center of the should be carried out) [33]. Sometimes it is advisable to treat
vertebral body of few cc (may also be enough 2–5 cc) of low the clinically most affected vertebra and then treat the other
viscosity bone cement, called polymethyl-methacrylate collapses at a later time. The majority of patients (80–85%),
(PMMA), which diffuses within the fractured vertebral body, which benefited from this therapy reported a reduction or
distributing itself along the lines of failure (regardless of the resolution of pain during the first 14 days, with an average of
outcome of imaging). This material solidifies quickly, result- 72 h, which made it possible to stop wearing the bust, to
ing in the immediate consolidation of the bone and prevent- reduce analgesics, and thus to improve the quality of life.
ing further collapses. It results in reduction of pain that The recently published VAPOUR multicenter, randomized,
definitively disappears within maximum 24 h so that patients double-blind trial found vertebroplasty to be superior to pla-
can repurchase regular mobility. A specifically conformed cebo intervention for pain reduction in patients with acute
metal needle (10–15 cm in length with a gauge of 10–15 G) osteoporotic fractures <6 weeks; the most benefit from the
is introduced under the double combined guide of CT and procedure was shown in the thoracolumbar spinal segment
digital fluoroscopy, in order to minimize the execution time [34].
(20–30 min) and then the related risks. Approach is usually In vertebra affected by metastases or primary tumor
trans somatic (with small and unique surgical breech to reach (angioma, myeloma, plasmacytoma) vertebroplasty allows
the center of the body), sometimes trans pedicle (for levels to quickly obtain the stabilization of the itself and the reduc-
L4 and L5). This procedure is performed with patient awake, tion/resolution of pain within 12–24 h after treatment in
in presence of the anesthetist that monitors vital functions, 96–98% of cases (the radio and chemotherapy reach analge-
usually under local anesthesia, preferably in day surgery. sia in 2–4 weeks), with significant improvement of quality of
After the procedure, patient can stand up after 2 h, then after life. In such cases, vertebroplasty is still a palliative treat-
2 Interventional Radiology 13

ment and is not in any way considered as a cancer treatment; 2.2.3 Percutaneous Implant Technique
patients should therefore continue to perform traditional
therapies [35, 36]. Within this procedure it is also possible This technique was introduced in order to impede the sec-
perform a spine biopsy. Complications are iatrogenic dam- ondary loss of vertebral body height encountered with
age due to puncture with temporary increase in pain and pos- kyphoplasty after balloon deflation and till cementation.
sible passage of cement in unwanted locations, usually Implant technique should be reserved for young patients
modest and precocious thanks to the double scopic and CT with acute (<7 days) traumatic fractures and a significant
guidance (1–2% osteoporosis, 10.5% in the case of (°15) local kyphotic angle, as in such cases correction of the
metastases). deformity is desired. In the rest of the cases, a simple PVP
Carried out vertebroplasty moreover, there is the risk that may still be a better choice, as it may be equally effective in
the adjacent vertebra, over or below, might collapse. In the providing pain relief and is less invasive [39].
event of intradiscal dripping of cement the risk of a new frac- The technique varies depending on the device used [40].
ture increases. Three of the most common percutaneous vertebral aug-
mentation systems for the treatment of osteoporotic vertebral
fractures are: Vertebral Body Stenting® (VBS), OsseoFix®
2.2.2 Kyphoplasty and Spine Jack®. VBS is a titanium device accompanied by
a hydraulic (as opposed to mechanical) working system
Kyphoplasty is a minimally invasive interventional proce- which allows a partial and not immediate possibility to con-
dure in the treatment of vertebral thoracolumbar painful frac- trol the opening of the device. On the other hand, OsseoFix®
tures caused by primary or secondary osteoporosis, by and Spine Jack® are accompanied by a mechanical working
neoplastic osteolytic metastases, vertebral hemangiomas, system which allows a progressive and controlled reduction
and trauma [37]. Contraindications include pregnancy, coag- of the vertebral fracture.
ulation abnormalities, and pain not associated with vertebral Korovessis et al. report cement leakage rate per vertebra
collapses. This technique is performed in the majority of to be lower in the supplement implant than the PKP group.
cases with patient awake, under local anesthesia. Through an They also report no significant difference on post-procedure
incision of 1 cm, an inflatable pad is inserted into the frac- new fracture rate, when compared to the PKP group [41].
tured vertebral body. Balloon is then inflated to reduce the
fracture and restore the height of the body, subsequently it is
deflated and removed, leaving a cavity in the vertebral body. References
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Golmohammadi K, Kallmes DF (2018) Percutaneous vertebro- et al (2016) Third-generation percutaneous vertebral augmentation
plasty for osteoporotic vertebral compression fracture. Cochrane systems. J Spine Surg (Hong Kong) 2:13–20
Database Syst Rev 11(11):CD006349 41. Korovessis P, Vardakastanis K, Repantis T, Vitsas V (2013) Balloon
25. Bonetti M, Fontana A, Martinelli F et al (2011) Oxygen-ozone kyphoplasty versus KIVA vertebral augmentation–comparison of 2
therapy for degenerative spine disease in the elderly: a prospective techniques for osteoporotic vertebral body fractures: a prospective
study. Acta Neurochir 108:137–142 randomized study. Spine (Phila. Pa. 1976) 38:292–299
 Surgery
3
Domenico Catapano, Antonello Curcio,
Filippo Flavio Angileri, Simona Ferri, Rossella Zaccaria,
Michele Santoro, Giuseppe Carmine Iaffaldano,
Fabio Cacciola, and Antonino Germanò

Surgery of spinal pathology should include: high cure rates; of the patient, technique specific risks. Possible early com-
possibility of simply intervening on patients already treated; plication of spinal surgery is thromboembolism whose risks
low recurrence rate; absence of contraindications; minimal can be reduced but not absolutely removed with anticoagu-
side effects; no complications in the short, medium, and long lant prophylaxis. Risk of mortality from pulmonary embo-
term; no acute or chronic toxicity; absence of requiring long lism at 30 days after surgery varies between 0.5 and 1.5 per
hospitalization; short convalescence; maximum conservativ- 1000 patients [4–9]. In early postoperative, and up to 2 weeks
ity of spinal biomechanics in treated district; reduction of the after, neurological lesions are most commonly secondary to
need of postoperative use of orthopedic devices (busts, cor- direct compression of neural elements. This is often caused
sets, etc.); and low cost. by compression of a possible hematoma, epidural abscess, or
Spinal surgery, as happens for the other districts, may pseudomeningocele.
present complications. Considering all spinal tracts, among Surgery should be done only in case of real need and with
all complications, the most common are pulmonary (13%), minimum trauma and invasiveness. The two most common
then hematological (10.75%), urological (9.18%), cardiac surgical approach in lumbar spine surgery are: decompres-
(8.4%), neurological, (7.35%), and gastrointestinal (3.9%), sion for the treatment of hernia and fusion for the degenera-
which can be classified according to the mechanism and the tive pathology.
time in which they occur [1–3]. Causes of injury are gener- Decompression surgery involves removing a small por-
ally direct or indirect. tion of the bone over the nerve root and then of disk material
Direct injuries (tear, compression, traction and avulsion to relieve pinching of the nerve (microdiskectomy or lami-
of the neural elements) are most commonly the result of a nectomy). Lumbar spinal fusion involves using bone graft to
technical failure of the surgeon. Indirect injuries are due to stop the motion at a painful vertebral segment in order to
the alteration of the blood supply to the spinal cord and nerve decrease suffering. Several medical devices with different
roots, or to the gradual compression of the neural elements, techniques are available in spinal fusion surgery [10, 11].
for example in the correction of a deformity or for a postop-
erative hematoma. This kind of lesion is usually the result of
ischemia or disruption of the vascular flow. 3.1 Surgery Techniques in Lumbar Diskal
According to the time they occur, complications are clas- Hernia
sified into intra-operative, early postoperative (1–14 days),
postoperative or later (after 14 days), whose gravity is related Intervertebral disk synergically works with interapophyseal
with complexity of surgery. Intraoperative events are usually joints forming thus a functional unit (FSU). It has moreover,
related to complications deriving from anesthesia, position a close relationship with neural adjacent structures, and it is
strongly stimulated by pressure and torsion forces of head
and trunk. Its functionality therefore is important in deter-
D. Catapano (*) · M. Santoro · G. C. Iaffaldano
mining quality of life.
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy Spinal surgery should be effective respecting the sur-
e-mail: [email protected]; [email protected] rounding structures as much as possible. It must be a correla-
A. Curcio · F. F. Angileri · S. Ferri · R. Zaccaria · F. Cacciola tion between reported symptoms (areas of pain irradiation,
A. Germanò paresthesia, functional limitation), clinical examination
Neurosurgery, Department of Biomedical and Dental Sciences and (clinical trials and reflections), and imaging (CT, MRI) [12,
Morphofunctional Imaging, University of Messina, Messina, Italy
13]. Surgery is feasible when symptoms persist more than
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 15

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_3
16 D. Catapano et al.

6 weeks and pain is unresponsive to analgesic, or when con- insufficient) with consequent pain syndrome (called “kiss-
servative treatments fails. Anyway, surgery represents the ing spine”), early facets arthrosis, narrowing of the canal,
first choice when new neurological deficits appear. formation of osteophytes, possible nerve entrapment and
Nowadays, the available techniques are standard diskectomy then further return of pain. Moreover, there may be a recur-
(open decompression), microdiskectomy (or small open sur- rence or a fibrous scar that if hypertrophic can compress
gery), and endoscopic diskectomy (transforaminal or inter- and irritate the affected nerve and require a second opera-
laminar), carried out in order to solve the compression and tion (the risk of reoperation is around 3–15%). When sci-
delete the material that triggers the inflammatory process atic pain is due to lumbar spinal stenosis, surgery involves
responsible for the pain. Each of these techniques offers removal of disk and part of the bone which is pinching
advantages and disadvantages and the choice depends from nerve root.
several reasons (for example, in the presence of root canal Decompressive surgery is performed by laminotomy
stenosis standard diskectomy or microdiskectomy are pre- (bone resection limited to small segments of inferior margin
ferred) [14–18]. In cauda equine syndrome, surgery should of the cephalic lamina and the superior margin of the caudal
be carried out urgently. lamina), laminectomy (bone resection of the entire width of
lamina), laminectomy and facetectomy (bone resection of
part or full facet joint in addition to cephalic and caudal
3.1.1 Standard Diskectomy, laminae).
Microdiskectomy, and Endoscopic Access to the spine occurs through maximum 3 cm inci-
Diskectomy sion focused on the vertebral body, with dissection of the
muscle and small opening in the ligamentum flavum, some-
Surgical management of severe radiculopathy with or with- times with minimal removal of part of the upper sheet
out neurological deficit is useful when conservative mea- (hemilaminectomy).
sures have failed [19]. Standard diskectomy involves After lumbar laminectomy approximately 70–80% of
open-air full or partial removal of the herniated nucleus patients typically experience relief from sciatic nerve pain.
pulposus which is causing compression on the neural ele- Surgical complications, such as wound infections and
ments. Microdiskectomy consists instead in full or partial nerve roots damage, are more frequent than in microdiskec-
removal of the herniated nucleus pulposus, with the aid of tomy or endoscopic diskectomy.
the surgical microscope that zoom neural structures (dural
sack and nerve root). In the last decade, the introduction of
endoscopy in spine surgery offered a less invasive approach 3.2 Surgery in Lumbar Degenerative
with smaller incision and reduced muscle splitting while Disorders
allowing better visualization and facilitating earlier recov-
ery [20, 21]. Two core endoscopic techniques have evolved It is used when conservative management has failed, in
in the lumbar spine; interlaminar and transforaminal spondylolisthesis, scoliosis, or deformity, post-diskectomy
approaches respectively [21, 22]. Even though microscopic syndromes, segmental instability adjacent to a previous
diskectomy is currently the gold standard technique, after a fusion site, unstable spine caused by infections, tumors, or
review of the literature comparing endoscopic to open or fractures. It can be performed with traditional stabilization
microscopic surgery, endoscopic surgery had comparable (known as fusion surgery) or with “dynamic
results and multiple advantages in most cases including stabilization”(non-fusion surgery) [10, 11].
earlier recovery, decrease blood loss, less back pain, higher Once stabilization consisted in weld the two adjacent ver-
patient [23]. It should be emphasized, however, that trans- tebrae with each other to abolish any abnormal motion (tra-
foraminal endoscopic surgery needs a complete revamp of ditional stabilization by fusion) thanks to access to posterior
the under-­standing of the anatomy and surgical technique surface of the vertebrae with gouges, scalpels and rongeurs,
as it is very different to what has been the practice for spine to activate a mechanism aiming to callus formation. Over the
surgeons. All these techniques allow mobilizing and dis- years, with the development of materials and surgical tech-
missing the patient in the first day if no complications arise. niques, posterior arthrodesis was replaced by the posterolat-
However, may occur instability and spinal pain in a short eral (including the articular apophyses and transverse
time. With the lack of disk and then its damping function, processes), then by the distraction and internal stabilization
the disk above and below will work harder with resulting associated with arthrodesis; in the 70s finally, there was the
risk of other hernias, especially in patients performing emergence of stabilization with transpedicular screws. Since
heavy physical activity or overweight. Another conse- the 90s developed a new surgical concept which aims to
quence is the appearance of scoliosis (lateral inclination of abolish abnormal motions between the bodies maintaining
the spine from the operated side where disk thickness is normal mobility of the joints (called “dynamic” or “elastic”
3 Surgery 17

stabilization) using less rigid instrumentations and materials may be considered necessary in cases of scoliosis, kyphosis,
with bone-like elasticity in order to preserve, at least partly, spondylolisthesis and lumbar deformity, fractures, tumors,
spinal micro movements. infections, rarely in treatment of only pain.
Recently emerged the need to use a hybrid technique,
with new instrumentations able to respond in a modular way, 3.2.1.2 Advances Lumbar Spinal Fusion
according to the pathology and the choice of the surgeon, in Lumbar interbody fusion (LIF) is an established treatment
order to abolish or preserve the motions of each functional for a number of spinal disorders including; degenerative
spinal unit. pathologies, traumas, infections, and neoplasms. LIF
involves the placement of an implant (cage, spacer, or struc-
tural graft) within the intervertebral space following diskec-
3.2.1 Fusion Surgery tomy and endplate preparation. LIF is done using five main
approaches: Posterior lumbar interbody fusion (PLIF), trans-
Fusion surgery consists of fusion of two or more adjacent foraminal lumbar interbody fusion (TLIF or MI-TLIF),
bodies and removal of the intervertebral disk in order to stop oblique/anterior psoas lumbar interbody fusion (OLIF/ATP),
the motion at painful vertebral segment (whit decreasing of laparoscopic or open anterior lumbar interbody fusion
pain generated from the joint), to stabilize the spine, to (ALIF), extreme lateral lumbar interbody fusion (XLIF) disk
replace resected components, to maintain anatomic align- and trans-sacral fusion (axial lumbar interbody fusion,
ment and to prevent pseudarthrosis. AxialLIF) [10, 11]. Purpose of all interbody fusion devices is
Spinal fusion involves the insertion of a bone graft (to to remove degenerate disk material, restore and maintain
stimulate bone growth) or bone graft substitute (natural or disk space height and normal sagittal contours (lordosis),
synthetic material to replace bone tissue and stimulate and increase stability of treated segment. Each technique can
growth) between two vertebral elements with or without any stand alone or can be associated with supplemental segmen-
material in the space left by disk removal. Bone fusion occurs tal instrumentation.
within 4–5 months after surgery. Bone graft does not deter-
mine fusion at the time of the surgery but allow growing of Anterior Lumbar Interbody Fusion
new bone to interfuse a section of the spine together (into ALIF is performed by using an anterior approach when
one long bone). For few months after surgery, some devices pain is predominantly diskogenic and posterior decompres-
are typically used to provide stability for that section; over sion is not required. For this technique, the patient is posi-
the long term the solid fusion occurred, provides itself to sta-tioned supine. Incision and approach includes midline,
bility [24]. Devices commonly used are rods and plates, paramedian, or Mini-Pfannenstiel (L5/S1) incision with a
translaminar or facet screws, transpedicular screws, inter- retroperitoneal corridor and vascular mobilization and dis-
body spacers [25]. The choice of these devices depends on section. The ALIF approach is suitable for L4/L5 and L5/
clinical problem, anatomic location, and surgeon preference S1 levels, primarily the latter due to vascular anatomy. An
[10, 11, 26]. anterior approach provides for a much more comprehensive
evacuation of the disk space, and this leads to increase sur-
3.2.1.1 Lumbar Spine Fusion face area available for a fusion. A larger spinal implant can
Traditionally there are different ways to fuse lumbar spine. be inserted with following superior stabilization. This
Anterior and posterior fusion procedures are frequently com- approach could be either done in stand-alone technique or,
plicated by persistent or recurrent low back pain that is prob- for a more rigid fixation whenever is required, could be
ably multifactorial and caused by surgical approach, supplemented by screws and rods or plates, which may be
pseudoarthrosis and development of adjacent-level disease. placed either anteriorly or posteriorly (both anterior and
Traditional surgery can also result in complications like vas- posterior technique). In cases where there is not instability,
cular and bowel injury, sympathetic dysfunction and can an ALIF alone can be sufficient especially in cases of one
improve long-term clinical outcomes. Advanced alternative level degenerative disk disease and where disk space col-
minimally invasive approaches have been developed to avoid lapse is not excessive.
these complications [10, 11]. The recent innovative biologic Contraindications of ALIF include prior significant
osteoinductive materials like BMP (bone morphogenic pro- abdominal surgery with adhesions or adverse vascular anat-
tein) are able to reduce adjacent-level disease. Motion-­ omy, severe peripheral vascular disease, solitary kidney on
preserving devices, moreover, can be causes of complications the exposure side, spinal infection, and high-grade (Grade
[10, 11]. 2+) degenerative spondylolisthesis in the absence of poste-
Lumbar spinal fusion surgery is more effective when rior fusion. Isthmic spondylolisthesis at L5/S1 is a relative
involving only one vertebral segment, not determining contraindication and should include posterior fixation in
mostly any limitation in motion. Multi-level fusion surgery combination with the ALIF technique. ALIF also spares the
18 D. Catapano et al.

posterior spinal muscles and anterolateral psoas muscles, retract nerve roots, whit reduction of injury and scarring
which can reduce postoperative pain and disability. around roots respect to PLIF.
Disadvantages of the ALIF technique include complications Indications for a TLIF approach include all degenera-
related to the approach such as retrograde ejaculation, vis- tive pathologies, including large-scale disk prolapse,
ceral and vascular lesions. degenerative disk disease, recurrent disk herniation, pseud-
arthrosis, and symptomatic spondylosis. Contraindications
Posterior Lumbar Interbody Fusion are similar to PLIF and include extensive epidural scar-
PLIF is performed by using a posterior surgical approach ring, arachnoiditis, active infection and conjoined nerve
(bilateral partial laminectomies, caudal and cephalic) fol- roots (which may preclude access to the disk space), and
lowed by diskectomy. Bone graft material or heterologous osteoporotic patients.
bone cement could pack, inside the cage or around the Compared to a traditional PLIF technique, the TLIF
cage, depending only on type of cage used. Further bone approach preserves ligamentous structures that are instru-
graft material could be packed anteriorly or/and into the mental in restoring biomechanical stability of the segment
remainder of the disk space. Posterior instrumentation is and adjacent structures.
performed to provide a rigid support until bone fusion
occurs. Endoscopic Transforaminal Lumbar Interbody Fusion
Posterior surgery has a higher potential for a solid fusion Endo-TLIF was first described by Jacquot and Gastambide
rate than posterolateral because the bone is inserted into the in France in 2013 [27]. Compared to the classic MIS-TLIF,
anterior portion of the spine. Bone in the anterior portion early efficacy is better for Endo-TLIF, whereas medium-
fuses better because there is more surface area than in the and long-term efficacies is similar for both procedures. VAS
posterolateral gutter, and also because the bone is under score is significantly lower in the Endo-TLIF than in the
compression. Conversely, not as much of the disk space can MIM-TLIF group at discharge; however, there was no sig-
be removed with a posterior approach. Moreover, there is a nificant difference in the VAS scores or ODI between the
small risk that inserting a cage posteriorly will allow it to groups at 1 and 2 years postoperatively. This indicates that
retro pulse back into the canal and create neural compres- neither procedure has an absolute advantage over the other
sion. There are drawbacks that a surgeon should be wary of in this respect As a disadvantage, Endo-TLIF requires more
when performing PLIF. First, there may be significant para- intraoperative radiation than MIS-TLIF and operators
spinal iatrogenic injury associated with sustained muscle should have sufficient experience in open lumbar fusion sur-
contracture. This can delay recovery and mobilization due gery and endoscopic nonfusion surgery before performing
to approach-related muscle trauma. Using this technique, it Endo-TLIF.
can be difficult to correct coronal imbalance and restore lor- Sometimes leg numbness after Endo-TLIF may be due to
dosis. Endplate preparation can be challenging compared to the stretching of the nerve root during endoscopic decom-
anterior fusion approaches. Other potential risks include pression or cage implantation (oversized cage) because of
nerve root retraction injury causing fibrosis and chronic the limited field of view and surgical space. Hence, Endo-­
radiculopathy. TLIF needs to be meticulously performed, to avoid nerve
damage [28].
Transforaminal Lumbar Interbody Fusion
TLIF is similar to the posterior one but is performed by using Posterolateral Fusion
a more lateral approach that leaves the midline bone struc- It is performed as an alternative to PLIF when there is a
tures intact, minimizes central spinal canal disruption, and severe loss of disk space height and when the insertion of a
reduces dural tube traction and exposure. posterior interbody spacer might cause neurologic compro-
A total facetectomy is generally performed to gain access mise. Bone graft material is placed laterally (between trans-
to the lateral disk space. Transforaminal interbody spacers verse processes) rather than anteriorly (between vertebral
are crescent shaped and are placed anteriorly in the disk bodies). Posterolateral fusion is usually supplemented by
space. TLIF procedure has several theoretical advantages posterior instrumentation.
over some other forms of lumbar fusion. First of all, bone
fusion is enhanced because bone graft is placed both along Lateral Interbody Fusion
the gutters of the spine posteriorly but also in the disk space. The LLIF or extreme lateral interbody fusion (XLIF) tech-
Furthermore a spacer is inserted into the disk space helping nique was described by Ozgur et al. [29] in 2006 involves
to restore normal height and opening up nerve foramina to access to the disk space via a lateral retroperitoneal corridor,
take pressure off the nerve roots. Finally, a TLIF procedure transpsoas. LLIF is suitable for conditions requiring access
allows the surgeon to insert bone graft and spacer into the to the interbody disk space from T12/L1 to L4/5. This tech-
disk space from a unilateral approach without having to nique is not suitable for the L5/S1 level, due to the position
3 Surgery 19

of the iliac crest hindering lateral access. Also, more caudal Similar to LLIF, OLIF is excellent for the correction of
to the lumbar spine, the lumbar plexus runs more anteriorly sagittal and coronal deformity, especially lumbar degenera-
and the iliac vessels run more laterally, which increases the tive scoliosis with laterolisthesis. The OLIF approach is con-
risk of injury through a lateral approach. The patient is posi- traindicated in patients with severe central canal stenosis and
tioned laterally, with the left or right side up depending on high-grade spondylolisthesis. Advantages of the OLIF
surgeon preference and ease of access. A small lateral inci- approach include that it facilitates MIS surgery with rapid
sion is made based on the position and angulation of the disk postoperative mobilization. OLIF also allows for aggressive
on image intensification when the patient is positioned. deformity correction, high fusion rates with complete disk
Neuromonitoring is essential for transpsoas access to the space clearance. Lumbar plexus and psoas injury is unlikely
disk space. since the dissection is performed anterior to the psoas.
Diskectomy is performed after obtaining access to the However, potential risks associated with OLIF surgery
disk space, leaving intact posterior annulus. An implant and include sympathetic dysfunction and vascular damage.
bone graft are then placed in the disk space and then inci-
sions are closed. These implants have a characteristic long-­ Trans-Sacral Fusion
rectangular shape, designed to maximize surface area on This is a minimally invasive access via a retroperitoneal pre-
which the epiphyseal ring can rest. The LLIF approach is sacral approach which consists in the anterior fixation of the
suitable for all degenerative indications. XLIF is minimally L5-S1 spine segment.
invasive spine surgery designed to accomplish spinal fusion AxiaLIF aims to perform anterior fusion at L5-S1 in pres-
with several advantages including minimal tissue damage, ence of degenerative disk disease, degenerative lumbar sco-
minimal blood loss, small incisions and scars, minimal post-­ liosis and symptomatic instability and stenosis.
operative discomfort, relatively quick recovery time, and Contraindications for this procedure include severe degen-
return to normal function. It is an excellent option for the erative disk disease with complete collapse of the disk space
correction of sagittal and coronal deformity, especially lum- and previous retroperitoneal surgery.
bar degenerative scoliosis with laterolisthesis. However, the AxiaLIF is performed by using a series of guide pins and
LLIF approach may not be suitable for severe central canal dilator tubes that are inserted under fluoroscopic guidance to
stenosis, bony lateral recess stenosis, and high-grade spon- obtain access to the L5-S1 disk space. Diskectomy is then per-
dylolisthesis. Disadvantages include potential risks of lum- formed percutaneously. Bone graft material is introduced into
bar plexus, psoas muscle, and intestinal injury, particularly at the disk space, and threaded titanium pin is placed across the
the L4/5 level. Vascular injury, if it occurs, can be difficult to disk space. This procedure avoids damage to the paraspinal
control and is another risk of the lateral transpsoas approach. muscles and nerves (posterior or lateral), avoids abdominal
Some patients complain of paresthesia or dysesthesia of the exposure and the risks associated with it, maintains spinal sta-
thigh, most commonly in the distribution of the anterior cuta- bility while leaving the native structures intact. Reported com-
neous branch of the femoral nerve. Sensory abnormalities plications included pelvic visceral injury and pseudoarthrosis.
are probably related to neural stretching as a result of patient AxiaLIF 1 L must be used in combination with legally
positioning. available posterior fixation systems such as transfacet and
pedicle screws.
Oblique Interbody Fusion
The OLIF approach was first described by Michael Mayer in
1977 [30] and involves MIS access to the disk space through 3.2.2 Osteoinductive Bone Graft Substitutes
a corridor between the peritoneum and the psoas muscle.
Similar to a LLIF approach, OLIF does not require posterior Large number of spinal fusion procedures involve the use of
surgery, laminectomy, facetectomy, or spinal or paraspinal bone graft material. There are a lot of considerations to eval-
muscle stripping. However, unlike the lateral transpsoas uate when deciding which type of bone graft options to use.
approach, the OLIF technique does not dissect or traverse the Reconstructive bone surgery aims to regenerate the loss
psoas muscle. For this technique, the patient is positioned or reabsorption of bone substance through the use of materi-
laterally, left or right side up depending on surgeon prefer- als and techniques that allow to mimic and activate specific
ence and ease of access. A lateral and paramedian incision is and fundamental reparative mechanisms such as osteogene-
made based on the position and angulation of the disk on sis, osteoinduction, and osteoconduction.
image intensification when the patient is positioned.
Neuromonitoring is unnecessary because the anatomical cor- • Osteogenesis: Formation of new bone directly by pro-
ridor anterior to the psoas muscle is used for access. The genitor cells and osteoblasts.
OLIF technique is suitable for L1-S1 levels. Indications for • Osteoinduction: Regulatory activity of growth factors
OLIF include all degenerative indications. capable of triggering the differentiation of mesenchymal
20 D. Catapano et al.

cells in an osteoblastic sense and the bone regeneration 3.2.3 Dynamic Stabilization
process.
• Osteoconduction: Support provided by a matrix (or scaf- Fusion surgery has been shown to alter the normal biome-
fold) which allows the deposition of new osteoid chanics of the spine, and this is believed to contribute to the
substance. development of adjacent-level disease. To overcome such
disadvantages, an alternative to vertebral fusion procedures
The main factors to be taken into account include type of is the dynamic stabilization [10, 11, 31–33]. It has become
spinal fusion, number of levels of spine involved, location of increasingly popular in attempt to provide stability while
fusion, patient risk factors for non-fusion (e.g., if patient is maintaining near-normal biomechanics and motions, to miti-
obese, smoker, poor bone quality), surgeon experience, and gate negative effects on adjacent segments and thus to pre-
preference. Using patient’s own bone is considered the gold vent progressive degeneration. Dynamic stabilization is a
standard (autograft). However, this is not the best option for not-fusion system performed in patients with low back pain
all patients. In autograft placement, a bone graft is harvested originating from chronic degeneration of the lumbar spine.
from the patient, typically from the iliac crest. While this There is a wide variety of dynamic stabilization devices
poses little risk of infection or rejection, it has been shown (total or partial disk replacement, interspinous process
conversely increased surgical time, relatively limited quanti- decompression devices, pedicle screws and artificial liga-
ties of bone graft material, and frequent donor-site pain. In ments, and posterior element replacement systems) that may
allografting, instead, bone is harvested from a donor and be used alone for stabilization or in combination with fusion
while this process decreases surgical time and morbidity at devices. It is important to note that with any type of spine
the harvesting site, there is opportunity for infection. fusion there is a risk of clinical failure (meaning that patient
Allografts, moreover, decreases ability to stimulate new pain does not go away) despite achieving a successful fusion.
bone formation. In an effort to reduce surgical risks and pos- Obtaining a successful result from a spine fusion requires a
sible complications with using patient own bone and to number of factors, including an accurate preoperative diag-
enhance rates of fusion, the spine medicine community is nosis, a technologically adept surgeon, and a patient with a
focusing resources on developing better options like osteoin- reasonably healthy lifestyle (nonsmoker, non-obese), who is
ductive bone graft substitutes. motivated to pursue rehabilitation and restoration of his
Alloplastic bone substitutes must mimic the porosity of functions.
cancellous bone, which ranges from approximately 50% to The use of dynamic stabilization arises from the need to
80% porosity, depending on many factors. Furthermore, the intervene early on the degenerative cascade by restoring the
pores of the bone substitute must be large enough for cells to physiological rigidity and stability to the spinal functional
migrate and blood vessels to pass through them (i.e., the unit, while preserving the natural mobility of the spinal seg-
diameter of the pores should be at least one hundred microm- ment before the effects of degeneration become irreversible.
eters). Finally, the porosities must be interconnected (the This type of approach is indicated in the following cases:
pores must be “connected” to each other, not “isolated”). Of
course, bone substitutes must also offer sufficient mechani- • Degenerative instabilities up to I degree of both antero-
cal properties and respond to several biological and retrolisthesis, with or without relative level stenosis.
requirements. • Spondylosis, when the degenerative phenomena of the
Bone morphogenic protein (BMP) is a synthetic osteoin- functional unit are still in progress with MRI images up to
ductive material that promotes bone creation and remodel- grade 2 of the Modic 1998 classification.
ing. It has been reported to induce bone growth that is • Disks degenerated up to grade IV of the Pfirrmann 2001
equivalent to or even greater than that induced by an auto- classification.
graft. BMP is delivered to the fusion site on an absorbable
collagen sponge with interbody cages or bone dowels. BMP The three-joint nature of the functional spinal unit, con-
use has been shown to yield radiographic fusion rates supe- sisting of disk space and two facet joints, allows for multiple
rior to those achieved with iliac crest bone grafts [11]. The device categories and approaches. These can be divided into
normal phases of bone healing include an initial inflamma- two main categories: anterior and posterior motion preserva-
tory response, a resorptive phase, sub-periosteal and endos- tion devices. Anterior motion preservation devices include
teal proliferation, bone formation, consolidation, and finally, total disk replacements and partial disk-nucleus replace-
remodeling by osteoclast and osteoblast activity. ments. Posterior motion preservation devices include inter-
3 Surgery 21

spinous devices, pedicle screw-based dynamic posterior 3.2.3.3 Interspinous Devices

stabilization devices, and facet replacement devices. Interspinous devices (also known as “interspinous spacers”
The innovative trend therefore goes toward the conserva- or “damping devices”) are used for the treatment of low
tion rather than the surgical destruction of the joint, trying to
back pain and sciatic pain in degenerative disease of the
avoid or limit the surgical blockage of the joint of a section lumbar spine (originating from disk, hernia, and facet
of the column, to the detriment of the neighboring segments joints), but also to treat segmental instability and canal ste-
which, subjected to the same pre-existing postural errors to nosis. In relation to clinical, leading candidates are patients
which is added the dynamic compensation of the blocked with neurogenic intermittent claudication that includes
vertebral segments, too undergo degeneration. symptoms of radicular pain on standing and walking, sen-
The goal is to support a synthetic dynamic implant, which sation disturbance, and loss of strength in the legs
does not replace but supports the osteo-articular anatomical [38–40].
complex in its natural function and therefore avoids imbal- Rational use of interspinous devices, positioned between
ances between one segment of the spine and another. the spinous processes is based on the observation that in
many patients with canal stenosis pain improves with the
3.2.3.1 Total Disk Replacement motions of flexion thanks to discharge of load on posterior
Also known as disk arthroplasty, performed in cervical and annulus (considered in many cases the “pain generator”).
lumbar spine, it was developed as an alternative to anterior These implants reduce the load on disk and facet joints, with
fusion in patients whose pain probably originates primarily significant increase in foraminal height, width and cross-­
from disk degeneration without nerve root involvement. The sectional area; in intervertebral angle, in disk space height,
aim is to closely replicate the normal spine biomechanics in and with decrease in epidural pressure and nerve root
attempt to prevent development of adjacent-level degenera- compression.
tion and arthrodesis-related complications like pseudo-­ As a result, the ideal patients, candidates for dynamic sta-
arthrosis, iliac crest donor site pain. bilization with interspinous spacers present position-­
This procedure include removal of the diseased disk and dependent pain relieved with flexion.
insertion of a prothesis to alleviate diskcogenic pain and to Placement procedure on the rear wall of the bodies
restore normal disk height. Diskectomy should be performed, between spinous processes at the symptomatic or adjacent
with removal of the native annular fibers and of the anterior level to fusion is performed under general anesthesia, some-
and posterior longitudinal ligaments There must be at least times local in elderly patients for whom extensive open sur-
4 mm of residual disk height and lack of significant endplate gery may present great surgical risk.
degeneration to provide satisfactory anchorage for the The surgery of short duration (about 30 min) provides a
replacement device. The presence of facet joint degeneration small skin incision of 3–4 cm. The placement is simple,
is a contraindication to total disk replacement [34]. Devices because it involves only the posterior surface of the spine
are of different types [35] and all contain radiopaque end- without “opening” the spinal canal.
plates characteristically located in the disk space. Modern This surgery substantially has not any risk; specific com-
artificial disks consist of two parallel plates (usually metal- plications are fracture of spinous process, implant migration,
lic) with exterior toothlike projections designed to securely infection and dural injury.
anchor itself to the adjacent vertebrae and so limit migration. In addition, these devices are relatively easy to remove
Polyethylene core between the plates allows motion and pro- and often do not preclude the use of other devices and thera-
vides cushioning. The core is radiolucent, but it contains a pies. In many cases it can also be used in combination with
metal wire for identification on imaging. foraminal selective decompression.
Implantation is less invasive than disk arthroplasty or con-
3.2.3.2 Partial Disk Replacement ventional fusion, and the procedure leaves both the anterior
It replaces the nucleus while restoring the normal biome- and posterior longitudinal ligaments intact. In some devices,
chanical function of the disk and of the segment. Currently, the supraspinous ligament and even portions of the interspi-
there are two general types of nucleus replacement devices: nous ligament are left intact.
injectable and preformed [36, 37]. Injectable nucleus replace- IPD may be considered a less invasive alternative to open
ment devices are further subdivided into uncontained and decompression in patients with degenerative pathologies,
contained. Preformed implants are further subdivided into avoiding the typical surgical complications such as epidural
non-articulating and articulating. losses and hematomas; however, a high complication rate
22 D. Catapano et al.

has been described in almost all studies comparing surgical spinous processes at the level above and below. To insert the
approaches with IPD. device it’s necessary to disconnect the interspinous and
It is important to clarify that IPD treatment failure may be supraspinatus ligaments and then sutured.
related to “real” complications such as displacement of the
device and erosion/rupture of the spinal process, or to “fail- Diam
ure” with revision surgery mandatory. DIAM consists of a silicon core covered by a polyester
Device displacement may be related to posterior ligament sleeve. The core and sleeve are held in the interspinous space
impairment due to weather surgical necessary to place the by three mesh bands. Two of the bands encircle the adjacent
IPD; also incorrect patient selection, especially due to ana- spinous processes, while a third encases the supraspinous
tomical difficulties, may be responsible for moving the ligament.
IPD. In a case of “lack of success,” Meyer et al. suggested Packed with compressible material, it is not a true stabi-
that it is almost related to patient selection and for lizer because it lacks its own stabilizing force. It maintains
­biomechanical reasons [41]; in fact, Moojen et al. [42] sug- the rigidity of the rear compartment of the functional unit
gested that the cross-sectional area of the channel spinal cord formed by the intervertebral disk and interapophyseal joints
may be less after IPD placement than after surgical laminec- finding indication when the size of the root canal should be
tomy, leading to an early symptom recurrence in those preserved.
patients with severe DLSS treated with IPD. The silicon device are radiolucent, but radiopaque mark-
Materials mainly used are X-stop, Wallis, Viking, DIAM, ers along the superior edge of the core allow for radiographic
Coflex, Ellipse, In Space. identification. A group from Italy recently reported that in a
series of 912 patients, there was a significant reduction in
X-Stop pain and a high rate of patient satisfaction. In their series,
X-Stop is the most used interspinous decompression device. there was a 3.8% complication rate including infections,
It consists of two parallel lateral wings that prevent itself fractures in the spinous processes, and removal of the device
lateral migration connected by a titanium rod or spacer. combined with fusion [45].
During implantation, the rod is inserted in transverse way,
penetrating the interspinous ligament. It is constrained Coflex
anteriorly by the lamina, cranio-caudally by the spinous The Coflex is a U-shaped titanium implant that is placed into
processes, and posteriorly by the supraspinous ligament. the interspinous space with clips on the upper and lower mar-
The rod places the patient in slight flexion, while limiting gins that allow the locking. While the height of the device
extension. The flexion obtained by the insertion of the distracts the foraminal opening, the “U” shape is designed to
device leads to stretching of yellow ligaments and distract- allow controlled movement in forward and backward bend-
ing of nerve foramina. ing. Implantation of this device is more invasive than others,
Results of multi-center trials conducted in USA indicated involving resection of both interspinous and supraspinous
that in patients with pain arising from neurogenic claudica- ligaments. The results, based on pain and patient satisfac-
tion (a symptom of spinal stenosis), X-STOP provided sig- tion, are favorable [46].
nificantly greater pain relief than epidural steroid injections
(the treatment used as a comparative control) [43]. Ellipse
Ellipse is mixed material, PEEK and titanium, consisting of
Wallis a main body and a closure module. The main body cranially
Wallis is polyetheretherketone (PEEK) with elastic like-bone and caudally has two saddles that facilitate the housing of the
characteristics, stabilized with two strips of Dacron. Although spinous processes. It also has a specially formed groove to
it is not truly compressible, properties of material are very allow the closure module to rotate inside it. Once placed
close to the elastic modulus of the posterior spine. The two between the spinous processes, the device is closed by rotat-
strips of Dacron embrace the upper and lower spinous pro- ing the closure module into the special groove. The locking
cesses, pulled with a special tool. Compared to other inter- of the closure on the main body is through “tab” directly
spinous systems also allows to enlarge anterior disk space. formed on this, that prevent slippage.
In clinical trial, involving 300 patients treated for recur- Its geometry allows a lateral insertion with minimally
rent disk herniation, patients who incorporated Wallis in sec- invasive surgical technique, avoiding the excision and
ond diskectomy had significantly better results [44]. removal of the supraspinatus and interspinous ligaments.

Viking In-Space
Viking is of cylindrical shape and also made of PEEK, with In-Space consists of PEEK radiolucent body and titanium
two upper and lower wings which allow the fixing of the alloy (TAV) screw and wings to allow radiographic assess-
3 Surgery 23

ment of the correct installation. Turning the screw, the carbon-fiber-reinforced polymer cages are radiolucent, and
implant closes and the wings are deployed along the spinous the metallic rods that hold them together mark their position
processes. The wings prevent ventral and lateral migration of as do radiopaque metallic dots. Vertebral body replacement
the implant, while the intact supra-spinous ligament prevents may involve one or more segments. Lateral, anterior, or pos-
dorsal displacement. terior screws with plates or rods are inserted for additional
The percutaneous lateral approach does not allow strip- stability.
ping of the paraspinal muscles. Moreover, supraspinous liga- For vertebral reconstruction, “custom-made” titanium
ment is left intact, interspinous ligament is only pierced to vertebral prostheses have recently been designed, created by
the size of the implant, no bone needs to be removed to facil- 3D printing starting from the patient’s pre-operative CT
itate the insertion of the implant. images, with the advantage of perfect adaptation to the ana-
tomical structure of the patient himself and a reduction of
surgical times. The stability of these prostheses compared to
3.2.4 Posterior Pedicle Fixation-Based commercial ones is being evaluated through a clinical study
Dynamic Stabilization Devices approved by the IOR Ethics Committee.

Posterior dynamic stabilization, or “soft stabilization,”

attempts to restore functional stability while maintaining 3.3 Anterior Cervical Diskectomy
some or all intersegmental motions. These devices incorpo- and Fusion
rate radiopaque posterior pedicle screws, with limited motion
allowed. Primary indications are symptomatic lumbar spinal The anterior cervical diskectomy and fusion (ACDF) con-
stenosis and degenerative spondylolisthesis. The Dynesys sists of removal of cervical disk herniation through an ante-
device is the most widely used in the dynamic posterior sta- rior approach to relieve spinal cord or nerve root pressure
bilization [11]. It can be used in up to five contiguous levels and alleviate corresponding pain, weakness, numbness, and
from L1 to S1. It employs two titanium pedicle screws at tingling. Fusion is almost always done at the same time as
each treated level. The screws at adjacent levels are con- the diskectomy in order to stabilize the cervical segment.
nected by a radiolucent polyethylene terephthalate cord sur- Anterior cervical diskectomy and fusion is generally indi-
rounded by a polycarbonate urethane spacer. The cord cated in patients with spondylosis or disk herniation of the
stretches to allow some motion but limits flexion at the cervical spine with myelopathy/radiculopathy that is unre-
treated level. The spacer consents for some compressibility sponsive to conservative therapy. Furthermore, it can also be
thereby allowing limited flexion. indicated in some malignant, traumatic, or infectious pro-
cesses of the cervical vertebrae that cause instability.
The procedure is performed by an anterolateral neck inci-
3.2.5 Facet Replacement Devices sion with a surgical approach passing between the aerodiges-
tive tract (trachea, esophagus, pharyngeal muscles) medially
Disease of facet joints leads to narrowing of spine canal, nar- and the carotid neurovascular bundle (carotid artery, internal
rowing of the foramina, and spondylolisthesis. In some jugular vein, vagus nerve) laterally.
patients, there is degeneration of facets with relative preser- The intervertebral disk is then resected along with the
vation of the disk. In this setting, it is biomechanically unde- fibrocartilage overlying the adjacent vertebral endplates (to
sirable to remove the disk. These patients should be treated allow for eventual bony fusion). The posterior longitudinal
with decompression that, however, can lead to instability ligament can be traced, including removal of osteophytes
often making necessary concurrent fusion. Facet replace- and disk protrusion and extending laterally to decompress
ment devices have been created in an attempt to replace only the neural exit foramen [48].
the diseased elements in facet arthropathy and spinal steno- Once decompression has taken place, an interbody spacer
sis, while maintaining normal or near-normal biomechanics (or “cage”) of some sort is introduced to assist fusion/
of the spine [11]. improve stability.
The general procedure for ACDF includes the following
steps: (1) anterior surgical approach, (2) disk removal, (3)
3.2.6 Vertebral Body Replacement canal decompression, (4) anterior cervical fusion with inser-
tion of bone graft into the evacuated disk space [49, 50]. This
Vertebral body replacement may be necessary after a resec- latter step prevents disk space collapse and promote growing
tion (corpectomy) because of tumor, infection, or major together of the two vertebrae into a single unit; thereby it
trauma [10, 47]. The device may be an expandable hollow avoids local deformity (kyphosis) with preservation of right
cylinder packed with bone graft material or cement. Stackable space for nerve roots and spinal cord.
24 D. Catapano et al.

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replacement: devices and complications. Radiographics 29(1):105– clinical review. J Nippon Med Sch 79(1):37–45. https://doi.
118. https://doi.org/10.1148/rg.291075740 org/10.1272/jnms.79.37
36. Cs S et al (2003) Partial disc replacement with the PDN prosthetic 51. Buttermann GR (2018) Anterior cervical discectomy and fusion
disc nucleus device: early clinical results. J Spinal Disord Tech outcomes over 10 years: a prospective study. Spine 43(3):207–214.
16(4):324. https://doi.org/10.1097/00024720-­200308000-­00003 https://doi.org/10.1097/BRS.0000000000002273
 Imaging Modalities
4
Carmela Garzillo, Saverio Pollice, and Tommaso Scarabino

Imaging is important in the presurgery as a “guide” for the equina compression, both of which are common indications
surgeon or interventional radiologist, both in postsurgery, for postoperative MR.
when the neuroradiologist becomes the “supervisor” of the During follow-up, the comparison with previous studies
therapeutic route. The “finished product” of a treatment can in order to detect any changes in component position, bony
be precisely documented with imaging. In particular, the alignment, implant fractures, changes in the bone-implant
postoperative imaging examination evaluates position of interface, which may signify the imminent failure of a device
implants, adequacy of decompression, fusion status, and or other complications, is essential.
potentially complications. The available methods of imaging Usually this study is performed in the upright position in
are the X-rays (XR), Ultrasound (US), computed tomogra- antero-posterior, lateral, and oblique-lateral projection and
phy (CT), and magnetic resonance (MR). Modality and pro- sometimes is associated with a dynamic study in flexion–
tocol used to image the postoperative spine depend on the extension. In the latter case, radiographic evidence of insta-
district, clinical question, type of disease treated, and instru- bility includes translation of 3 mm or more in L1–L4
mentation used [1, 2]. vertebrae, 5 mm at the L5–S1 interspace, or more 10O of
angulation between adjacent vertebrae.

4.1 X-Ray
4.2 Ultrasound
X-Ray (XR) is the starting point in diagnostic imaging
thanks to its peculiarities: non-invasive, low cost, wide avail- US examination has the advantage to be a safe, cost-­effective,
ability, easy to perform and interpret, optimum view of the widely accessible technique that plays a limited rule in the
containing, ideal for checking accurate spinal alignment study of postoperative superficial fluid collections and as a
without synthetic means artifacts. It should be performed to guide for therapeutic intervention [5].
assess bone component, exact position of the devices (for
example, in the stabilization), or distribution of used materi-
als (such as cement post-vertebroplasty) [3]. XR have a few 4.3 Computed Tomography
limitations: it cannot evaluate soft tissue structures (such as
neural elements, recurrent disk herniations, or scar tissue), it CT is considered the modality of choice for imaging bone
cannot show bone loss until there is a decrease of more than detail and assessing osseous formation and implant position.
30–40% [4] and it has low value in the non-instrumented For this reason, CT has an important role in postoperative
postoperative spine assessment. XR also cannot be used to assessment of fusion surgery [6]. CT is useful for detecting
reliably exclude the presence of bone metastases or of cauda and grading spinal and/or foraminal stenosis and in follow-
­up after surgery. Moreover, CT after iv contrast media pro-
vides reliable differentiation between postoperative scarring
C. Garzillo · T. Scarabino (*) and recurrent disk herniation [7].
Department of Radiology/Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
CT is often used in case of inadequate XR evaluation and
e-mail: [email protected] in the study of critical areas. It provides better evaluation of
S. Pollice
fusion progression than XR.
Department of Radiology, San Nicola Pellegrino Hospital, Multiplanar and three-dimensional reconstructions
Trani, Italy increase CT diagnostic power. Some authors have also tested

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 27

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_4
28 C. Garzillo et al.

the intraoperative 3D scans after pedicle screw positioning in of MRI of the treated spine that does not differ significantly
order to avoid false placement and primary neurovascular from a basic study including conventional sagittal and axial
damages. images T1 and T2 weighted (FSE), shortly affected by arti-
Immediate correction of misplaced screws decreases the facts caused by metal or any other surgical material used [18,
secondary revision rate of patients and prevents secondary 19]. In the presence of synthesis means (clips, prostheses,
neurovascular problems, instability, or dislocation of the stabilizers), SE and GE sequences should be avoided because
fixature [8]. of its particular sensitivity to magnetic susceptibility. Another
Unfortunately, quality of imaging can sometimes be important recommendation to be followed is the use, after
affected by the presence of artifacts due to metallic devices the execution of a basic study of TSE T2 with Fat Saturation
that are currently less noticeable thanks to new materials (or STIR) to best emphasize pathology within spinal or epi-
(titanium, polyetheretherketone) or by using special projec- dural adipose tissue [20]. For the same reason it is essential,
tions (perpendicular to the orthopedic implant so that the especially in the case of inflammation, for the use of the con-
beam transverses the metallic cross-section with the smallest trast agent in TSE T1 Fat Sat [7, 21]. The use of fat suppres-
diameter) or appropriate imaging algorithms (use of high sion in TSE T2 and TSE T1 after contrast medium increases
peak voltage, high tube current, narrow collimation) and the sensitivity, emphasizing the characteristic “edema pat-
reconstruction (use of thick sections, lower kernel values) tern” index of bone bruising, inflammation, or cellular infil-
[9]. Furthermore, advances in monoenergetic images from tration [22, 23]. Fat saturated post Gadolinium T1 sequences
dual-energy CT techniques allow the selection of the optimal are added to protocols to show disk, soft tissues and collec-
range of energy (usually from 95 to 150 keV) to reduce tions enhancement in infectious processes [24, 25]. New and
metallic artifacts and improve the accuracy of image inter- advanced methods of MR imaging, such as diffusion and
pretation [10]. perfusion, already tested in the study of the brain, have a
potential application for differential diagnosis in evaluation
of ischemic, neoplastic and inflammatory conditions [26–
4.4 Magnetic Resonance 29]. In suspected impaired post-treatment, spinal mobility
and staticity is useful specific instrumental study through
MRI is test of choice in the evaluation of postsurgical proce- new open MRI systems, low and medium intensity magnetic
dures in patients with persisting or recurrence of pain with field, which allows a study even in the upright position.
characteristics similar or different than previous surgery Conventional MR imaging has the significant limitation to
[11]. MR allows, by virtue of its known peculiarities (high study the spine in a position of relative rest because images
sensitivity, multi-planarity, multi-parametric, high and con- are acquired with the patient in supine position and often the
trast spatial resolution, accurate simultaneous display of con- pain occurs or gets worse in the upright position. Some CT/
taining and contained), correct diagnosis and therefore MR studies showed 30% false negatives for which in 1/3 of
precise therapeutic indications. MRI is essential in assessing cases MR performed only in the supine position is not able to
the involvement of the nervous tissue in the pathology to be answer the clinical question. In these subjects the study of
treated. Compared with XR and CT, MR imaging is much the spine in the upright position therefore arises as comple-
more accurate in the evaluation of tissue enhancement mentary. Until recently, the only practicable examination in
(allowing easier discrimination between herniation versus the upright position of the spine was X-ray. In recent years
epidural fibrosis) [12], bone marrow edema, and in docu- portable devices for axial loading of the lumbar spine in CT
menting and monitoring complications such as soft tissue and MR were developed in order to assess the amplitude of
and joint inflammation, nerve root enhancement, hemor- the spinal canal in a more physiological state like in the erect
rhage, and spinal stenosis. Artifacts by ferromagnetic mate- position or by using axial loading either by flexion–exten-
rial, in the past often present and able to affect imaging sion [30–33]. It was shown that the space within the canal is
quality, are currently less evident thanks to new synthesis posture dependent because there is a significant reduction of
materials (titanium) to the use of particular sequences less spine cross-sectional area during axial loading resulting in
sensitive to magnetic susceptibility (Fast SE) and modifying increased diagnostic specificity of the spinal stenosis.
frequency- and phase-encoding directions. Therefore, they Actually dedicated MRI allow to perform examination in the
no longer represent an obstacle or a contra-indication to MRI upright position but they are not much diffused [34]. Thereby
examination [13–16]. The introduction of newer coils allows it is possible to assess in a dynamic manner the various com-
the use of 3 T MRI machines, overcoming the main limit of ponents of the column and its relationship in different stages
artifacts increase proportional to higher magnet strength of the movement by virtue of the variation of a number of
[17]. physiological variables such as reduction of the lumbosacral
For a clear interpretation of postsurgery imaging, it is angle (normal value 120–180°), increase of the lordosis
necessary to know the technical and methodological aspects angle (normal value 50°), reduction of the thickness of the
4 Imaging Modalities 29

intersomatic disk, and the size of the dural sac. These find- 9. Watzke O, Kalender WA (2004) A pragmatic approach to metal
ings can be detected precisely in the passage from the supine artifact reduction in CT: merging of metal artifact reduced images.
Eur Radiol 14:849–856
to upright position. It is possible to identify also spondylolis- 10. Katsura M, Sato J, Akahane M, Kunimatsu A, Abe O (2018)
thesis and radicular conflicts, not detectable with a static Current and novel techniques for metal artifact reduction at CT:
study or to evidence pathological static and mobility subse- practical guide for radiologists. Radiographics 38(2):450–461
quent to highly invasive surgery, even if also minimally inva- 11. Annertz M, Jonsson B, Stromqvist B et al (1995) Serial MRI in the
early postoperative period after lumbar discectomy. Neuroradiology
sive and conservative treatment may arise from 37:177
microinstability for the excision of muscle-ligamentous 12. Wilkinson LS, Elson E, Saifuddin A et al (1997) Defining the use of
structures. These structures, richly innervated, actively par- Gd enhanced MRI in the assessment of the post-operative lumbosa-
ticipate in the continuous postural adjustments of the spine, cral spine. Clin Radiol 52:530–534
13. Lee MJ, Kim S, Sa L et al (2007) Overcoming artifacts from metal-
keeping the statics and dynamics. Moreover the onset of lic orthopedic implants at high-field-strength MR imaging and
degenerative processes in the spinal functional unit as a multi-dectector CR. Radiographics 27:791–803
result of altered load can result in central and lateral canal 14. Petersilge CA, Lewin JS, Duerk JL et al (1996) Optimizing imag-
stenosis. MR imaging in the upright position has some limi- ing parameters for MR evaluation of the spine with titanium pedicle
screws. AJR 166:1213–1218
tations such as the use of low magnetic field intensity with 15. Rudish A, Kremser C, Peer S et al (1998) Metallic artifacts in MR
following not high images quality and the need of consider- imaging of patients with spinal fusion. A comparison of implant
able patient cooperation. In patient with incompatible car- materials and imaging sequences. Spine 23:629–639
diac implantable electronic device, some cerebral aneurysm 16. Viano AM, Gronemeyer SA, Haliloglu M et al (2000) Improved
MR imaging for patients with metallic implants. Magn Reson Imag
clips, claustrophobic or not cooperating or in case of not 18:287–295
diagnostic examination because of artifact, conventional 17. Malhotra A, Kalra VB, Wu X et al (2015) Imaging of lumbar spinal
myelography or CT myelography may be performed to eval- surgery complications. Insights Imaging 6:579–590
uate spinal canal, foramina, and lateral recess nerve root 18. Scarabino T, Giannatempo GM et al (1996) Fat-suppression
imaging in neuroradiologia con sequenze Fast-SE T2 pesate. Riv
compression [4]. However, after instrumentation of the lum- Neuroradiol 9:157–164
bar spine, puncture of the lumbar thecal sac may be compli- 19. Tartaglino LS, Flanders AE, Vinitski S et al (1994) Metallic arti-
cated by distortion of the anatomy (scarring, removal of facts on MR images of the postoperative spine: reduction with fast
posterior elements, addition of bone graft material) or the spin echo techniques. Radiology 190:565–569
20. Mirowitz SA, Shady KL (1992) Gadopentetate dimeglumine-­
presence of metallic implants. Occasionally in this situation, enhanced MR imaging of the postoperative lumbar spine: compari-
a cervical puncture is necessary. Following the injection of son of fat-suppressed and conventional T1-weghted images. AJR
contrast material into the thecal sack, the imaging may be 159:385–389
acquired with an angle to avoid obscuration of the relevant 21. Gallucci M, Caulo M, Masciocchi C (2001) il Rachide operato. In:
Compendio di Risonanza magnetica a cura di Dal Pozzo G, Utet
nerve roots by the implanted devices. Ed, p 1047–1071
22. Dansie D, Leutmer MA (2004) MRI findings after successful verte-
broplasty. AJNR 26:1595–1600
23. Lin WC, Chen HL, Lu CH et al (2011) Dynamic contrast-enhanced
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bar interbody fusion: current concepts. AJNR 26:2057–2066 weighted and dynamic contrast-enhanced imaging of patients with
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31. Saifuddin A, Blease S, MacSweeney E (2003) Axial loaded MRI of flexion and extension) MR imaging and myelography. Radiology
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32. Willen J, Danielson B, Gaulitz A et al (1997) Dynamic effects on the 34. Splendiani A, Di Fabio MV, Barile A et al (2008) Tecnica di studio
lumbar spine: axially loaded CT-myelography and MRI in patients RM del rachide lombare sotto carico. In: Leone A, Martino F (eds)
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 Post-Treatment Imaging
5
Umberto Tupputi, Michela Capuano, Saverio Pollice,
and Tommaso Scarabino

Postoperative controls are required by the neurosurgeon, disk, and spinal canal [6–13]. Bone and paraspinal tissue
orthopedic, and interventional radiologist to check the result changes are related to the type of surgical procedure that
of surgery, position of implants, adequacy of decompression, ranges from disappeared hemi-laminectomy characterized
fusion status, and potential complications. Moreover, by total or partial resection of the lamina and ligamentum
because of medico-legal effects, it is important to assess if flavum to less invasive microsurgical approaches where it is
disease is not radically cured and to identify further possible often difficult to recognize, especially after a long time, the
clinical pathologies when the result does not correspond to signs of surgery. Intervertebral disk, however, can sometimes
expectations [1–5]. For optimal evaluation of the normal and appear hypointense on T1, hyperintense on T2 with associ-
abnormal postoperative imaging appearances, radiologists ated disruption of the annulus fibrosus, and in 80% of cases
need an understanding of the various approaches, techniques, can also show contrast enhancement.
hardware, and devices used and a knowledge of their advan- This finding (“mechanical or chemical diskitis”) disap-
tage and limitations. It is also necessary to integrate data pears after 4–5 weeks and is not associated with positive
imaging with clinical history, type of the underlying disease, inflammation indices [14]. Rarely after diskectomy moder-
surgical technique, type of biomedical device used, level, ate irregularities of vertebrae profiles may occur with hypoin-
extension and date of the therapeutic procedure, examina- tensity in T1, hyperintensity in T2, and contrast enhancement
tions carried out before treatment (i.e., electromyography). of subchondral spongiosa, in relation to bone marrow edema.
This is an occurrence without pathological significance
(“aseptic spondylodiscitis”), which disappears in a few
5.1 Diskectomy weeks, not to be confused with disk degeneration already
present in preintervention.
Controls post-diskectomy are performed only with MRI [6]. “Pseudo-hernia,” common in early post-surgery, may
Most MRI studies of the spine concern the effects of lumbar simulate a recurrence-persistence without any symptom. It is
hernia surgery. localized in the anterior epidural space and consists of com-
pression on the dural sack caused by edema of soft tissues,
bleeding, and granulation. Usually, within 1–2 months, it
5.1.1 Surgery in Lumbar Hernia tends to disappear or at least to become increasingly limited
without dural compressive effects. Then an attraction scar on
For correct interpretation of imaging after surgery, it is the dural sack can occur.
important to know the normal and pathological MR semiot-
ics of structures involved such as bone, paraspinal tissue, 5.1.1.1 Recurrent Hernia Versus
Postoperative Scar
In the 2 months after diskectomy, persistence of symptoms
arising from compression on roots and dural sack can be
U. Tupputi · M. Capuano · T. Scarabino (*) related to residual or recurrent hernia or/and exuberant scar.
Department of Radiology/Neuroradiology, [15] Differential diagnosis between them is difficult as a
L. Bonomo Hospital, Andria, Italy result of the frequent coexistence of both. It is necessary to
e-mail: [email protected]
exactly know the anatomy and the different semiological
S. Pollice aspects such as mass effect, dural traction, impression on the
Department of Radiology, San Nicola Pellegrino Hospital,
Trani, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 31

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_5
32 U. Tupputi et al.

Table 5.1 Semiological aspects for the differential diagnosis between 5.1.1.4 Diskitis-Spondylitis-Spondylodiskitis
postoperative scar and recurrent hernia (modified by Gallucci M, et al.: Infections occurring at the surgical site are the most common
“Il Rachide operato. In Compendio di Risonanza magnetica a cura di
Dal Pozzo G, Utet Ed, 2001”) [2] cause of morbidity following spinal procedures, ranging
from 0.09% to 16% [22], resulting in prolonged hospitaliza-
Post-surgical scar Recurrent hernia
Mass effect No Yes
tion, wound debridement, hardware failure, revision surgical
Dural traction Yes No procedures, implant removal, and long-term use of intrave-
Impression on dural sack Posterolateral Anterolateral nous antibiotics [23].
Relationship with the disk Contiguity Continuity Infectious complications are appreciable at short time
CE Yes No after surgery, characterized by the appearance after a short
healthy period of persistent and progressive low back pain
dural sack, relations with the disk, and pattern of impregna- associated with inflammatory markers increase. In contrast
tion, especially immediately after surgery [2] (Table 5.1). to diskitis and spondylitis, rare and characterized by signal
Usually, diskal hernia causes mass effect with impression alteration (T1 hypointensity, T2 hyperintensity) and CE,
on the anterolateral dural sack without dural traction and respectively, of the intervertebral disk and vertebral body,
with a clear continuity with the disk. There is no early CE for spondylodiskitis is the most common infectious complica-
pathological lack of vascularization; sometimes early periph- tion (5%), especially after removal of hernia and disk “curet-
eral contrast enhancement with delayed (10 min) central dif- tage” [24].
fusion due to the presence of granulation tissue can be found; For accurate and early diagnosis, it is important to evalu-
in later phase (1 month), CE can occur for a diffusion mecha- ate symptoms, phlogosis index (fever, elevated ESR, elevated
nism. Conversely, in surgical scar, in early stage, there is no CRP), and MRI. Magnetic resonance shows signal alteration
mass effect, but there is dural traction and contiguity with the of the disk and subchondral bone (T1 hypointensity, T2
disk. Exuberant scar tissue surrounds generally the dural sac hyperintensity). There is CE with possible and pathological
(especially along the surgical edges) with possible compres- involvement of paravertebral surrounding soft tissues and
sion mechanism. Contrast enhancement is early, intense, and spine canal with impression on root and dural sack. Risk fac-
diffused thanks to neo-angiogenesis; then it tends to signifi- tors can be related to the nature of the spinal pathology and
cantly disappear at least after 1 year [2, 15, 16]. Therefore, the surgical procedure such as extensive soft tissue dissec-
CE-MR images acquired within 7–10 min are important for tion, longer operating time, soft tissue devitalization, kind of
differential diagnosis. surgical instrumentation, and systemic health conditions.
To summarize, in residual disc herniation there is no cen- To prevent postoperative infections, it is necessary to pro-
tral enhancement; on the other hand, in epidural fibrosis, phylactic antibiotics, meticulous adherence to aseptic tech-
there is a uniform enhancement of scar tissue in the anterior, nique, and frequent release of retractors to avoid myonecrosis.
lateral, or posterior epidural space [17]. Use of antibiotics against Gram-positive is frequent (staphy-
lococcus aureus, staphylococcus epidermitis, and beta-­
5.1.1.2 Complications hemolytic streptococcus). Sometimes, more aggressive
Complications are radiculitis, diskitis, spondylitis, spondylo- surgical treatment may be required to help the eradication of
discitis, arachnoidal inflammation, CSF fistula, hematoma, the infection, providing an adequate wound closure and
seroma, meningoceles, and pseudo-meningoceles. maintaining spine column mechanical stability.

5.1.1.3 Radiculitis 5.1.1.5 Abscess

Radiculitis is present in about 20% of treated patients for Abscess, alone or in association with diskitis or osteitis, is
lumbar hernia with recurrent or persistent low back pain. It is characterized by a collection that extends from the disk to the
characterized by pathological CE of the roots, secondary to epidural space. It is characterized by T2 hyperintensity with
temporary damage of their barrier caused by surgery or irregular peripheral rim CE. This complication, although
chronic trauma of slipped disk before surgery [18, 19]. This rare, may occur 2–4 weeks after surgery and may become a
finding should be considered pathological if documented possible cause of new neurological deficits requiring urgent
after 6 months, as before, although present and asymptom- decompression.
atic, it is not pathological because it is a part of the regular
post-surgery evolution. 5.1.1.6 Arachnoidal Inflammation and CSF
If a radicular infection is suspected, MRI postcontrast fat-­ Fistula
saturated T1 sequences depict augmented root contrast Arachnoid phlogosis is not common (6–16% of surgery),
enhancement [20, 21]. especially in opening or fissuring of the dural sack. The three
5 Post-Treatment Imaging 33

MR patterns in adhesive arachnoiditis are scattered groups of 5.2 Vertebroplasty

matted or clamped nerve roots, an empty teca sack caused by
adhesion of the nerve roots to its walls, and an intrathecal In postvertebroplasty, imaging shows distribution of syn-
soft tissue mass with a broad dural base, representing a large thetic cement (PMMA) in the treated body in which changes
group of matted roots that may obstruct the cerebrospinal in density (X-rays or CT) or signal intensity (MRI) can occur
fluid pathways [25]. Moreover, there is low CE of cauda [29–31]. Preoperatively, edema pattern of sub-chondral
roots. CSF fistulae can appear in case of bacterial or fungal spongiosa is present (hyperintensity in fat suppression
meningitis at a distance of months or even years after STIR); 1 week later there is usually STIR hypointensity in
surgery. the cement with hyperintense edematous surrounding area
also in relation to macrophage reaction; 1 month later,
5.1.1.7 Epidural Hematoma hypointensity of cement persists with surrounding thin
Epidural hematoma may be associated with an excessive or remaining hyperintensity caused by fibroelastic reaction.
uncontrolled intraoperative bleeding. A neurological deterio- Pattern of cement distribution is variable: rounded, like
ration may occur for compression mechanism, thus requiring map, point or oval, homogeneous, or inhomogeneous. Body
decompression [26]. In this case, it is essential for MR evalu- morphology may appear like vertebra plana, vertebra with
ation in urgency. It is a liquid collection, with smooth mar- depression of the inferior or superior border, biconcave lens.
gins, with MRI signal variable in relation to the various Usually after percutaneous procedure, there is no significant
stages of hemoglobin degradation. morphological change of vertebral body caused by diffusive
A large epidural hematoma usually presents variable and no expansive cement behavior.
degrees of neurologic impairment, requiring prompt surgical Complication detectable with imaging is represented by
evaluation, while hematomas with less than one vertebral passage of cement in undesirable sites (epidural venous
segment of extension slowly reabsorb [27, 28]. plexus, lumbar or foraminal veins, intradiskal space, spinal
canal).
5.1.1.8 Seroma Extravasation into the epidural space is associated with
Seromas are sterile cyst paraspinal collections, usually a increased morbidity from nerve root or spinal cord compres-
result of untreated hematoma and then with CSF-like MR sion; and extravasation into the anterior venous plexus can
signal. be associated with increased risk of mortality in those rare
cases where venous extravasation leads to significant embo-
5.1.1.9 Meningoceles and Pseudomeningoceles lization of cement into the pulmonary arteries [32].
Meningoceles are CSF collections communicating with the This happens rarely thanks to double scopic and CT guid-
subarachnoid space caused by arachnoid herniation through ance (1–2% osteoporosis, 10.5% metastasis). Infections and
the surgical dural breach. Conversely, pseudomeningoceles bleeding are rare.
is an extra-meningeal collection, with non-homogeneous
signal in relation to the presence of proteins or blood with
fistula communicating with the subarachnoid space. Both 5.3 Conventional and Dynamic
types of CSF collections may extend outside or inside the Stabilization
vertebral canal.
Imaging of a traditional/dynamic stabilization can provide a
series of information regarding the correct/invalid position-
5.1.2 Surgery in Cervical Hernia ing of the device, device integrity, fracture reduction, verte-
bral body morphology, somatic posterior walls alignment,
Postsurgery imaging of cervical hernia is related to the type conditions of the bone (in case of myelic trauma), presence
of therapeutic procedure. In arthrodesis, bone graft usually in the canal of bone fragments, post-surgical treatment com-
presents a variable MR signal in relation to intrinsic charac- plications (bleeding, abscesses, meningoceles), emergence
teristics of itself and to the variability of the vascularization of new diseases, or the progression of disease.
following surgery. In established arthrodesis, interbody For accurate postoperative assessment, radiologists and
space is no longer evident and vertebral bodies have a con- neuroradiologists should exactly know normal imaging
tinuous and homogeneous structure, hardly distinguishable appearances of the lumbar spine after stabilization, after
from the adjacent, with low MR signal in all sequences. In fusion and disk replacement with various approaches, tech-
anterior microdiskectomy, bone graft has a rectangular shape niques, and devices [33–38].
and varying MR signal. Recently, in microdiskectomy verte- In early postsurgery, in the absence of significant neuro-
bral prostheses of various materials are used (carbon, meth- logical symptoms, traditional X-ray can supply most of the
acrylate) whose signal appears low in all sequences. information requested by the neurosurgeon. X-ray, in antero-
34 U. Tupputi et al.

posterior and lateral can document the precise positioning of 6. Grane P (1998) The post-operative lumbar spine. A radiological
the interspinous supports, any dislocations, rare complica- investigation of the lumbar spine after discectomy using MR imag-
ing and CT. Acta Radiol 39:2–11
tions such as fracture of the spinous process. 7. Annertz M, Jonsson B, Stromqvist B et al (1995) Serial MRI in the
In some cases, however, X-ray can cause doubts espe- early postoperative period after lumbar discectomy. Neuroradiology
cially when synthetic means are placed in critical locations 37:177
such as cervical or dorsal, hence it may be useful to perform 8. Babar S, Saifuddin A (2002) MRI of the post- discectomy lumbar
spine. Clin Radiol 57:969–981
CT with multiplanar and 3D reconstructions. In the assess- 9. Mirowitz SA, Shady KL (1992) Gadopentetate dimeglumine-­
ment of stabilization with plates and screws, some authors enhanced MR imaging of the postoperative lumbar spine: compari-
have developed a score system in relation to the position of son of fat- suppressed and conventional T1-weghted images. AJR
the screw (inside, laterally, or medially) with respect to the 159:385–389
10. Gallucci M, Bozzao A, Orlandi B et al (1995) Does post contrast
pedicle and the vertebral body [39]. Sometimes, CT is use- MR enhancement in lumbar disk herniation have prognostic value?
ful to evaluate the formation of bone when using porous J Comput Assist Tomogr 19:34–38
osteoinductive metals. MRI is essential in presence of a sig- 11. Scarabino T, Giannatempo GM et al (1996) Fat- suppression
nificant neurological symptoms to clearly assess neural imaging in neuroradiologia con sequenze Fast-SE T2 pesate. Riv
Neuroradiol 9:157–164
structures. 12. Wilkinson LS, Elson E, Saifuddin A et al (1997) Defining the use of
MRI should be performed even in the presence of infec- Gd enhanced MRI in the assessment of the post-operative lumbosa-
tion or dural injury, characterized by pathognomic symp- cral spine. Clin Radiol 52:530–534
toms. With the various diagnostic tools (RX, CT, MRI) 13. Ross JS, Zeep R, Modiv MT (1996) The post- operative lumbar
spine. Enhanced MR evaluation of the intervertebral disk. AJNR
available, mechanical complications related to instrumenta- 17:323–331
tion and fusion (improper device placement, pseudarthrosis, 14. Boden SD, Davis DO, Dina TS et al (1992) Postoperative disk it
progression of disease at the adjacent non-fused segments) is: distinguish early MR imaging from normal post-operative disk
are distinguished from non-mechanical complications (infec- space changes. Radiology 184:765–771
15. Ross JS, Obuchowski N, Zepp R (1998) The postoperative lum-
tion, postoperative hematoma, pseudomeningocele) that usu- bar spine: evaluation of epidural scar over a 1 year period. AINR
ally occur sooner [37, 38]. Implant fractures are secondary to 19:183–186
the repetitive stress of spinal movements. A fractured or dis- 16. Annertz M, Jonsson B, Stromqvist B et al (1995) No relationship
lodged device is frequently, but not always, associated with between epidural fibrosis and sciatica in the lumbar post discec-
tomy syndrome. A study with contrast-enhanced magnetic reso-
regional motion and instability, which may lead to nance imaging in symptomatic and asymptomatic patients. Spine
pseudoarthrosis. 20:449–453
Instrumentation can cause chronic tissue irritation leading 17. Komori H, Okawa A, Haro H, Muneta T, Yamamoto H, Shinomiya
to pain and sometimes tissue necrosis, which can be indica- K (1998) Contrast-enhanced magnetic resonance imaging in con-
servative management of lumbar disc herniation. Spine 23(1):67–73
tions for hardware removal. 18. Itoh R, Murata K, Komata M et al (1996) Lumbosacral nerve root
The onset of degenerative changes at the disk above or enhancement with disk herniation on CE MR. AJNR 17:1619–1625
below the fused segments is possible because of the reduced 19. Jinkins JR, Garret D, Osborne AG et al (1993) Spinal nerve enhance-
number of mobile segments. This complication is reported in ment with Gd-DTPA: MR correlation with the post-­operative lum-
bosacral spine. AJNR 14:383
10.2% of patients with posterior fusion and it is more fre- 20. Splendiani A, D'Orazio F, Patriarcaetal L (2017) Imagingofpost-
quently seen at long-term follow-up and in the lumbosacral operative spine in intervertebral disc pathology. Musculoskel- etal
spine. Early recognition of infections, hematomas, and Surgery 101(Supplement 1):75–84
abscesses is essential to take an appropriate treatment and 21. Leonardi MA, Zanetti M, Saupe N, Min K (2010) Early post-
operative MRI in detecting hematoma and dural compression after
thus minimize the effects. lumbar spinal decompression: prospective study of asymptomatic
patients in comparison to patients requiring surgical revision. Eur
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con RM del rachide cervicale operato. Radiol Med 92:671–676 19:2216–2222
5 Post-Treatment Imaging 35

27. Jain NK, Dao K, Ortiz AO (2014) Radiologicevaluationand man- gical decompression, intervertebral bone fusion, and spinal instru-
agement of postoperative spine paraspinal fluid collec- tions. mentation. Radiol Clin N Am 39:1–29
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Kavanagh EC (2019) MR imaging of spinal hae- matoma: a picto- 35. Murtagh RD, Quencer RM, Cohen DS et al (2009) Normal and
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 Part II
Clinical Cases

Following case studies have the same order of the pathologies discussed in the text. Each case
is marked by three lines, respectively: spinal pathology, type of treatment and imaging.
 Herniated Lumbar Disk Diskectomy
Aseptic Spondylodiscitis
6
Paola D’Aprile and Alfredo Tarantino

• Asymptomatic patient, absence of inflammatory markers,

6.1 Early Postoperative Follow-Up
after treatment for herniated disks treated by diskectomy
with laminectomy at L5-S1.
See Fig. 6.1.
• MR early postoperative follow-up.

Fig. 6.1 (a and b) CE fat sat

a
T1—sagittal (a) and axial (b)
projection. At L5-S1 regular
disk CE with presence of
granulation tissue in the
subchondral spongiosa
adjacent the opposite
vertebral bodies and epidural
space along the surgical
wound (not due to infection)

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 39

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_6
 Herniated Lumbar Disk Diskectomy
Aseptic Spondylodiscitis
7
Paola D’Aprile and Alfredo Tarantino

• Asymptomatic patient, absence of flogosis markers, her-

7.1 Early Postoperative Follow-Up
niated disk treated by diskectomy and large laminectomy
at L3–L4.
See Fig. 7.1.
• Early postoperative MR follow-up.

a b c

Fig. 7.1 (a–c) Sagittal CE SE T1 (a), sagittal CE fat sat SE T1 (b–c). in fat sat imaging (b–c). Regular CE of para-spinal soft tissue at the
Slight physiological CE (non-infectious) of subchondral spongiosa at surgical breach (laminectomy). Regular CE is also appreciable at the
L3–L4 for the presence of reactive granulation tissue, rear disk profile disk L1–L2 where coexists hernia intraspongiosa with the same CE
close to the annulus is also involved (a). These findings are emphasized (aseptic diskitis)

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 41

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_7
 Herniated Lumbar Disk Diskectomy
Scars Sequelae
8
Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with previous low back pain due to herniated disk

treated by diskectomy and left laminectomy at L5–S1.
8.1 Early Postoperative Follow-Up
• Early postoperative MR follow-up.
See Fig. 8.1.

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 43

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_8
44 M. Muto et al.

b c

Fig. 8.1 (a–c) CE fat sat SE T1 sagittal (a) and axial (b–c). Epidural lateral left fibrosis with CE of L5–S1 subchondral spongiosa (a). Rear-left
granulation tissue along surgical breach (b–c)
 Herniated Lumbar Disk Diskectomy
Scars Sequelae
9
Simone Salice, Domenico Tortora, Valentina Panara,
Massimo Caulo, and Armando Tartaro

• Patient with previous right low back pain due to herniated

disk treated by microdiskectomy and laminoflavectomy at
9.1 Postoperative Follow-Up
L5-S1.
See Fig. 9.1.
• Postoperative follow-up RM.

a b c

Fig. 9.1 (a–e) FSE T1 sagittal (a), FSE T2 sagittal (b) and axial (d), CE fat sat T1 sagital (c) and axial (e)

S. Salice · D. Tortora · V. Panara · M. Caulo · A. Tartaro (*)

Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, “G. D’Annunzio” University,
Chieti-Pescara, Italy
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 45

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_9
46 S. Salice et al.

d e

Fig. 9.1 (continued)

 Herniated Lumbar Disk Diskectomy
Pathological Postoperative Scar
10
Paola D’Aprile and Alfredo Tarantino

• Patient with persisting right low back pain in L5-S1 herni-

10.1 Early Postoperative Follow-Up
ated disk treated by diskectomy and laminectomy.
• Early MR postoperative follow-up.
See Fig. 10.1

a b c

Fig. 10.1 (a–c) SE T1 (a) and axial CE fat sat (b–c). Without fat sat but surrounds the dural sack (a). (b) CE of scar surrounding edematous
and Gd administration, it is possible only to hypothesize the presence of nerve root. With respect to recurrent hernia, the nerve root is apprecia-
S1 right periradicular scar because epidural material does not compress ble along its course in axial sections (b–c)

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 47

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_10
 Herniated Lumbar Disk Diskectomy
Pathological Postoperative Scar
11
Paola D’Aprile and Alfredo Tarantino

• Patient with persisting right low back pain in L5–S1 her- 11.1 Postoperative Follow-Up
niated disk treated by diskectomy.
• MR postoperative follow-up. See Fig. 11.1.

a b c

Fig. 11.1 (a–c) Axial CE fat sat SE T1 (a–c). Exuberant scar surrounding nerve root and slightly compressing the dural sac

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 49

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_11
 Herniated Lumbar Disk. Diskectomy
Pathological Postoperative Scar
12
Ferdinando Caranci, Anna Caliendo, Carmen Castagnolo,
Raffaele Nappi, and Achille Marotta

• Patient with persisting right low back pain in herniated 12.1 Preoperative Imaging
disk treated by laminectomy-flavectomy.
• Preoperative imaging and MR postoperative follow-up See Fig. 12.1.
MR after 1, 3, and 6 months.

F. Caranci (*) · A. Caliendo

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy
C. Castagnolo · R. Nappi · A. Marotta
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 51

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_12
52 F. Caranci et al.

a b c

Fig. 12.1 (a–g) FSE T2 sagittal (a–c) and axial (d–g) sections. Small right intraforaminal hernia, (arrow) in L3–L4 compressing the adjacent
nerve root
12 Herniated Lumbar Disk. Diskectomy 53

d e

f g

Fig. 12.1 (continued)

54 F. Caranci et al.

12.2 Postoperative Follow-Up After

1 Month

See Fig. 12.2.

a b c

Fig. 12.2 (a–g) CE fat sat SE T1 sagittal and axial sections. Exuberant granulation tissue characterized by intense CE, in the right retrovertebral
space at L3–L4. (a–g) This tissue extends over lamino-flavectomy in the right foramen, close to L3 nerve root, thickened by flogosis (arrow)
12 Herniated Lumbar Disk. Diskectomy 55

d e

f g

Fig. 12.2 (continued)

56 F. Caranci et al.

12.3 Postoperative Follow-Up After

3 Months

See Fig. 12.3

a b c

Fig. 12.3 (a–g) CE fat sat SE T1 sagittal and axial sections. Granulation tissue, even if characterized by high CE, is mildly reduced. Right L3
nerve root is thickened and surrounded by pathological tissue (arrow)
12 Herniated Lumbar Disk. Diskectomy 57

12.4 Postoperative Follow-Up After

6 Months

See Fig. 12.4.

d e

f g

Fig. 12.3 (continued)

58 F. Caranci et al.

a b c

Fig. 12.4 (a–g) CE fat sat SE T1 sagittal and axial sections. Persisting granulation tissue, evolving in fibrosis with involvement of L3 nerve root
(arrow)
12 Herniated Lumbar Disk. Diskectomy 59

d e

f g

Fig. 12.4 (continued)

 Herniated Lumbar Disk Diskectomy
Recurrence
13
Paola D’Aprile and Alfredo Tarantino

• Patient with right persisting low back pain in L5–S1 her- 13.1 Early Postoperative Follow-Up
niated disk treated by Diskectomy and laminectomy with
removal of joints. See Fig. 13.1.
• MR early postoperative follow-up.

a b c

Fig. 13.1 (a–e) SE T1 (a) and fat sat FSE T2 (b) sagittal, CE fat sat SE recurrent hernia surrounded by CE granulation tissue with involvement
T1 sagittal (c), and axial (d–e). Right L5-S1 dural sac compression due of the rear surgical breach. Both nerve roots at lower level are cleary
to material adjacent to the disk and with its same MR signal. (c–d): visualized (e)

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 61

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_13
62 P. D’Aprile and A. Tarantino

d e

Fig. 13.1 (continued)

 Herniated Lumbar Disk Diskectomy
Recurrence
14
Paola D’Aprile and Alfredo Tarantino

• Patient with persisting left low back pain in L4–L5 herni- 14.1 Postoperative Follow-Up
ated disk treated by diskectomy and large laminectomy.
• MR postoperative follow-up. See Fig. 14.1.

a b c

Fig. 14.1 (a–f) SE T1 (a), FSE T2 (b), CE fat sat SE T1 sagittal (c), SE sat imaging limits diagnosis, conversely (c, f–g) gd administration and
T1 axial (d–e), and CE fat sat SE T1 axial (f–g). Recurrent hernia adja- fat sat allows to document left recurrence
cent to L4–L5 disk (a–b). (d–e): absence of gd administration and fat

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 63

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_14
64 P. D’Aprile and A. Tarantino

d e

f g

Fig. 14.1 (continued)

 Herniated Lumbar Disk Diskectomy
Recurrent Hernia and Coexisting Fibrous Scar
15
Simone Salice, Domenico Tortora, Valentina Panara,
Massimo Caulo, and Armando Tartaro

• Patient with persisting left low back pain in L5-S1 herni- 15.1 Postoperative Follow-Up
ated disk treated by diskectomy.
• MR postoperative follow-up. See Fig. 15.1.

S. Salice · D. Tortora · V. Panara · M. Caulo · A. Tartaro (*)

Institute of Advanced Biomedical Technologies,
Chieti-Pescara, Italy
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 65

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_15
66 S. Salice et al.

a b

c d

Fig. 15.1 (a–d) FSE T1 sagittal (a) and axial (c), FSE fat sat T1 sagittal (b) and CE FSE fat sat T1 sagittal (d). Recurrent hernia (a, b) surrounded
by fibrous scar (d) with compression on left S1 nerve root (c)
 Herniated Lumbar Disk Diskectomy
Recurrence and Fibrous Scar
16
Paola D’Aprile and Alfredo Tarantino

• Patient with persisting right low back pain in L5-S1 herni- 16.1 Postoperative Follow-Up
ated disk treated by diskectomy.
• MR postoperative follow-up. See Fig. 16.1.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 67

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_16
68 P. D’Aprile and A. Tarantino

a b

c d

Fig. 16.1 (a–d) SE T1 (a and b) CE fat sat T1 axial (c and d). administration and fat sat imaging (a–b) do not allow correct differen-
Differential diagnosis between recurrent hernia and post-surgical tial diagnosis. Recurrent hernia (c) coexisting with the fibrous scar sur-
fibrous scar is difficult because it is often coexisting. Absence of gd rounding the nerve root (d)
 Herniated Lumbar Disk
Micro-Diskectomy 17
Aseptic Radiculitis

Paola D’Aprile and Alfredo Tarantino

• Patient with right persisting low back pain in L5–S1 her- 17.1 Postoperative Follow-Up After
niated disk treated by micro-diskectomy. 6 Months
• Late MR postoperative follow-up (6 months).
See Fig. 17.1.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 69

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_17
70 P. D’Aprile and A. Tarantino

a b

Fig. 17.1 (a–c) SE T1 axial (a, b) CE fat sat SE T1 axial (c). Slight L5–S1 right intraforaminal engagement that compresses the adjacent root
sheath (a). Right sheath CE (c)
 Herniated Lumbar Disk Diskectomy
Septic Spondylodiskitis
18
Paola D’Aprile and Alfredo Tarantino

• Patient with right low back pain and high level flogosis 18.1 Early Postoperative Follow-Up
markers in L4–L5 septic spondylitis after diskectomy.
• Early and late MR postoperative follow-up (6 months See Fig. 18.1.
after appearance of sphincter disorders).

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 71

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_18
72 P. D’Aprile and A. Tarantino

a b

c d

Fig. 18.1 (a–d) SE T1 (a), FSE T2 fat sat sagittal (b); CE fat sat SE T1 sagittal (c) and axial (d). L4–L5 infective spondylodiskitis with involve-
ment of intervertebral disk and bodies which are characterized by typical signal alteration (hyper intensity in T2–b) and CE (c–d)
18 Herniated Lumbar Disk Diskectomy 73

18.2 Postoperative Follow-Up After

6 Months

See Fig. 18.2.

a c

Fig. 18.2 (a–c) CE fat sat SE T1 sagittal (a, c) and axial (b). Conus CE in myelitis associated with leptomeningeal CE in dural fistula
 Herniated Lumbar Disk Diskectomy
Septic Spondylodiskitis
19
Paola D’Aprile and Alfredo Tarantino

• Patient with low back pain and flogosis high-level mark- 19.1 Early Postoperative Follow-Up
ers in septic spondylodiskitis following L4–L5
diskectomy. See Fig. 19.1.
• Early MR postoperative follow-up.

a b c

Fig. 19.1 (a–c) FSE T2 fat sat (a–b) SE fat sat CE T1 (c) sagittal. Septic spondylodiskitis: L4–L5 disk and vertebral hyper intensity (a–b), site of
previous diskectomy, no pathological CE of the disk (c)

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 75

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_19
 Herniated Lumbar Disk Diskectomy
Septic Spondylodiskitis
20
Paola D’Aprile and Alfredo Tarantino

• Patient with right low back pain and high-level flogosis 20.1 Postoperative Follow-up
markers in septic spondylodiskitis following L4–L5
diskectomy. See Fig. 20.1.
• MR postoperative follow-up with PWI.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 77

T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_20
78 P. D’Aprile and A. Tarantino

a b c

Fig. 20.1 (a–f) SE T1 (a) and FSE T2 fat sat (b) sagittal, CE fat sat SE hypointensity (a), T2 hyperintensity (b), and CE (c–e). PWI with dia-
T1 sagittal (c) and axial (d–e), PWI (f–g). Septic spondylodiskitis in gram intensity/time in ROI inside normal and pathological regions. In
L4–L5 with involvement of disk and adjacent vertebral bodies: T1 pathological areas there is increase of perfusion index (f–g)
20 Herniated Lumbar Disk Diskectomy 79

d e

f g

Fig. 20.1 (continued)

 Herniated Lumbar Disk Diskectomy
Spondylitis—Arachnoiditis—Abscess
21
Paola D’Aprile and Alfredo Tarantino

• Patient with low back pain and high-level flogosis mark- 21.1 Early Postoperative Follow-Up
ers in septic spondylitis with arachnoiditis and abscess
following diskectomy. Complete regression of symptoms See Fig. 21.1.
after antibiotic therapy.
• Early MR postoperative follow-up (1 and 5 days) and late
(1 year).

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

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82 P. D’Aprile and A. Tarantino

Fig. 21.1 (a–c) CE fat sat SE

a b
T1 sagittal (a–b) and axial
(c). Postsurgical septic
spondylitis with pathological
CE of L4 inferior subchondral
spongiosa (a–b) with
associated arachnoiditis,
bundling cauda, and CE of the
roots (c)

c
21 Herniated Lumbar Disk Diskectomy 83

21.2 Postoperative Follow-Up After 5 Days

See Fig. 21.2.

b c

Fig. 21.2 (a–c) CE fat sat SE T1 sagittal (a) and axial (b–c). Infection is worsened with formation of intradural abscess (a) and along surgical
breach in the extra-dural space (b–c)
84 P. D’Aprile and A. Tarantino

21.3 Late-Operative Follow-Up After 1 Year

See Fig. 21.3.

Fig. 21.3 CE fat sat SE T1. Complete regression of the infectious find-
ings. Low signal in sclerosis of L4 inferior subchondral spongiosa
 Herniated Lumbar Disk Diskectomy
and Stabilization 22
Pathological Fibrous Scar

Achille Marotta, Raffaele Nappi, Anna Caliendo,

Carmen Castagnolo, and Ferdinando Caranci

• Patient with persisting left low back pain and absence of 22.1 Early Postoperative Follow-Up
achilles tendon reflex following L5–S1 diskectomy with
positioning of cage and L4–S1 posterior stabilization See Fig. 22.1.
through metallic trans-peduncular screws.
• Early and late XR/CT/MR postoperative follow-up (6, 9,
and 12 months).

A. Marotta · R. Nappi · A. Caliendo · C. Castagnolo

Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
F. Caranci (*)
Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy

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86 A. Marotta et al.

Fig. 22.1 (a–b) Lumbosacral

a b
XR: posteroanterior (a) and
lateral (b) views. L5–S1
diskectomy, intervertebral
cage, and L4-S1 posterior
stabilization
22 Herniated Lumbar Disk Diskectomy and Stabilization 87

22.2 Postoperative Follow-Up After

6 Months

See Fig. 22.2.

a b

Fig. 22.2 (a–b) Lumbosacral dynamic XR: lateral views in hyperflexion (a) and in hyperextension (b). No evidence of instability, preserved
alignment of posterior vertebral profile
88 A. Marotta et al.

22.3 Postoperative Follow-Up After

9 Months

See Fig. 22.3.

a b c d e

f g h i

j k l m

Fig. 22.3 (a–m) MPR sagittal (a–e) and axial sections at L4–L5 (f–i) document angulation of right pin with respect to its screw (arrow); axial
and L5-S1 (j–m). Post-surgery inhomogeneity of retrovertebral space images at L5-S1 (j–m) document the cause of low back pain due to left
due to the presence of fibrotic tissue (a–e). Axial images at L4–L5 (f–i) S1 root surrounded by fibrous scar (arrowheads)
22 Herniated Lumbar Disk Diskectomy and Stabilization 89

22.4 Postoperative Follow-Up After

12 Months

See Figs. 22.4, 22.5.

a b c

Fig. 22.4 (a–g) FSE T2 sagittal (a–c) and axial sections (d–g). Presence of intermediate signal fibrous-like tissue occupying left epidural space
at L5-S1, with indissociability of S1 root
90 A. Marotta et al.

d e

f g

Fig. 22.4 (continued)

22 Herniated Lumbar Disk Diskectomy and Stabilization 91

a b c d

e f g h

i j k l

m n o p q

Fig. 22.5 (a–q) CT and CE CT (a–h), coronal (i–l), and sagittal MPR (arrow), with indissociability of S1 root. Sagittal MPR sections (m–q)
sections (m–q). Fibrous scar at L5-S1 (a–d) with mild CE (e–h); coro- show slight reduction in height and calcification of L5-S1 intervertebral
nal MPR sections (i–l) confirm obliteration of left epidural space space
 Herniated Lumbar Disk Diskectomy
and Stabilization 23
Septic Spondylodiskitis

Chiara Potente, Roberto Trignani, Tommaso Scarabino,

and Gabriele Polonara

• Patient with recurrent low back pain after left hemi-­ 23.1 Early Postoperative Follow-Up
lamino-­flavectomy, L5–S1 diskectomy and dynamic ver-
tebral stabilization with posterior metallic flexible bars See Fig. 23.1.
and transpedicular screws at L4, L5, and S1.
• Early and late CT-MR postoperative follow-up (after
removal of bars and screws).

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
R. Trignani
Department of Neurosurgery, University Hospital, Ancona, Italy
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

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94 C. Potente et al.

a b c

Fig. 23.1 (a–c) Bone CT axial (a) MPR sagittal (b), and coronal (c). Postsurgery bone resorption surrounding screws: especially right S1 (arrow)

23.2 Late Postoperative Follow-Up

See Figs. 23.2, 23.3.

23 Herniated Lumbar Disk Diskectomy and Stabilization 95

Fig. 23.2 (a–c) SE T1 b

a
sagittal (a) FSE fat sat T2
sagittal (b), and axial (c).
L5–S1 signal alteration in
flogosis that extend to
epidural space. Narrowing of
dural sac. Flogosis develops
in lateral-rear-left space, site
of previous
hemi-laminectomy

c
96 C. Potente et al.

a b c

d e

Fig. 23.3 (a–e) CE fat sat T1 sagittal (a, b), coronal (c), and axial (d, e). Intensive CE of flogosis tissue with lateral-left liquid collection that
extend posteriorly in soft tissue surrounding spine. Inhomogeneous CE of vertebral bodies and surrounding soft tissue
 Herniated Lumbar Disk Diskectomy
and Stabilization 24
Spondylodiskitis-Radiculitis

Chiara Potente, Roberto Trignani, Tommaso Scarabino,

and Gabriele Polonara

• Patient with recurrent low back pain after percutaneous 24.1 Late Postoperative Follow-Up
hybrid rear stabilization by transpeduncular screws and
bars (strict component on L5–S1 and flexible on L3–L4 See Figs. 24.1, 24.2.
and L4–L5).
• Late MR postoperative follow-up.

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
R. Trignani
Department of Neurosurgery, University Hospital, Ancona, Italy
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

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98 C. Potente et al.

a b c

Fig. 24.1 (a–d) SE T1 (a), FSE T2 (b), STIR sagittal (c), and FSE tral inferior region of L2 and superior of L3. L2–L3 disk herniates
axial (d). Signal alteration of L2–L3 disk and vertebral bodies in spon- posteriorly (a − d) compressing dural sac in right paramedian with root
dylodiskitis with subchondral involvement (a − c) especially in the cen- conflict
24 Herniated Lumbar Disk Diskectomy and Stabilization 99

Fig. 24.2 (a–c) SE T1

a
sagittal (a), and SE fat-sat T1
axial (b, c). Homogeneous CE
of the herniated fragment (a).
In L2–L3 epidural collection
with slight bilateral
intraforaminal expansion (a,
b); CE of surrounding soft
tissue probably involved by
flogosis (b, c). CE of nerve
root in radiculitis (a − c,
arrows)

b c
 Herniated Lumbar Disk Intradiskal
Percutaneous Procedure 25
Septic Spondylodiskitis

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with incremented low back pain, fever, ESR, and PCR 25.2 Intraoperative Imaging
high levels after percutaneous L4–L5 intra-diskal treatment
through left posterolateral approach under CT guide. See Fig. 25.2.
• Preoperative imaging and early and late MR postopera-
tive follow-up (10 days and 3 weeks).

25.1 Preoperative Imaging

See Fig. 25.1.

Fig. 25.2 CT axial

Fig. 25.1 FSE T2 sagittal. L4–L5 and L5-S1 left posterolateral hernia

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, Cardarelli Hospital, Naples, Italy

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102 M. Muto et al.

25.3 Postoperative Follow-Up After

10 Days

See Fig. 25.3.

Fig. 25.3 (a–b) SE T1 and

FSE T2 sagittal. L3–L5 a b
spondylodiscitis with L4–L5
signal alteration, not evident
in presurgery (a, b)
25 Herniated Lumbar Disk Intradiskal Percutaneous Procedure 103

25.4 Postoperative Follow-Up After

3 Weeks

See Fig. 25.4.

a b

Fig. 25.4 (a–c) SE T1 sagittal (a), STIR sagittal (b), and axial (c). Infection is worsened at L3–L5 (a, b). Infectious tissue in L4–L5 right pos-
terolateral and paravertebral region (c)
 Herniated Lumbar Disk Percutaneous
Intradiskal Procedure 26
Retroperitoneal Paravertebral Hematoma

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with abdominal pain following percutaneous 26.2 Early Postoperative Follow-Up
treatment in diskal hernia with right posterolateral CT-­
guided approach. See Fig. 26.2.
• Intraoperative and postoperative imaging. Early and late
CT follow-up (worsening of clinical conditions).

26.1 Intraoperative Imaging

See Fig. 26.1.

Fig. 26.2 CT axial

Fig. 26.1 CT axial during percutaneous L4–L5 treatment with right

posterolateral approach in prone position. Patient suspended antiplate-
let therapy 7 days before (with regular INR)

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology|, Cardarelli Hospital, Naples, Italy

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106 M. Muto et al.

26.3 Postoperative Follow-Up after 36 h

See Fig. 26.3.

a b

c d

Fig. 26.3 (a–d) CE TC arterious phase, axial (a, b), coronal MPR (c), and sagittal (d) in abdominal pain. Large retroperitoneal-paravertebral
blood collection at L1–S1 with fluid–fluid level (a–d)
26 Herniated Lumbar Disk Percutaneous Intradiskal Procedure 107

26.4 Subsequent Postoperative Follow-Up

See Fig. 26.4.

a b

c d

Fig. 26.4 (a–d) CE TC arterious phase, axial (a, b), MPR sagittal (c), and coronal (d). Blood collection incremented in size with signs of active
bleeding (a–d)
 Extraforaminal L5-S1 Herniated Disk:
Transmuscular Approach 27
Regular Finding

Domenico Catapano and Vincenzo Monte

• Long term history of left sciatalgia. Previous interspinous See Figs. 27.1, 27.2, 27.3, and 27.4.
stabilization.
• Herniated disk removal via transmuscular paramedian
extracanalar approach.
• Preoperative and postoperative MRI.

a b c

Fig. 27.1 Preoperative sagittal T2 (a), T1 (b), and L5-S1 axial T2 (c) MRI showing left extraforaminal herniated disk (arrow)

D. Catapano (*)
Department of Neurosurgery, “Bonomo” Hospital, Andria, Italy
V. Monte
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S, S. Giovanni Rotondo, Italy

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110 D. Catapano and V. Monte

a b c

Fig. 27.2 Preoperative sagittal T2 (a), T1 (b) and L5-S1 axial T2 (c) MRI showing left L5 nerve root cranial dislocation (arrow) by extraforaminal
herniated disk

a b c

Fig. 27.3 Postoperative sagittal T2 (a), T1 (b), and L5-S1 axial T2 (c) MRI (at the same Fig. 27.1 level) showing removed herniated disk and the
paramedian paravertebral transmuscular approach (arrows)

a b c

Fig. 27.4 Postoperative sagittal T2 (a), T1 (b), and L5-S1 axial T2 (c) MRI (at the same Fig. 27.2 level) showing left L5 nerve root normal course
after removal of herniated disk
 Intra-Extraforaminal L3-L4 Herniated
Disk: Transmuscular Approach 28
Regular Findings

Domenico Catapano and Vincenzo Monte

• Long-term history of right cruralgia. See Figs. 28.1., 28.2., and 28.3..
• Herniated disk removal by transmuscular paramedian
extracanalar approach.
• Preoperative and postoperative MRI.

a b c

Fig. 28.1. Preoperative sagittal T1 (a), axial T1 L3-L4 (b), and axial T2 L3-L4 (c) MRI showing right intra-extraforaminal herniated disk (arrows)

D. Catapano (*)
Department of Neurosurgery, “Bonomo” Hospital, Andria, Italy
V. Monte
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S, S. Giovanni Rotondo, Italy

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112 D. Catapano and V. Monte

a b c

Fig. 28.2. Preoperative sagittal T1 (a), axial T1 L3-L4 (b), and axial T1 with contrast L3-L4 (c) MRI showing right intra-extraforaminal herniated
disk

a b c

Fig. 28.3. Postoperative sagittal T1 (a), axial T1 (b), and axial T2 (c) MRI showing removed herniated disk and the paramedian paravertebral
transmuscular approach (arrows)
 Herniated Lumbar Disk Anterior
Diskectomy 29
Normal Findings

Tommaso Scarabino, Michele Maiorano, Fabio Quinto,

Michele Santoro, and Raniero Mignini

• Patient with low back pain in L5–S1 herniated disk treated 29.1 Early Postoperative Follow-Up
by diskectomy and prosthesis positioning through ante-
rior approach (Anterior Lumbar Interbody Fusion, ALIF). See Fig. 29.1.
• Early XR postoperative follow-up.

a b

Fig. 29.1 (a–b) XR antero-posterior (a), and lateral (b). Effects of ALIF at L5–S1 with regular positioning of the device

T. Scarabino · M. Maiorano · F. Quinto

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Santoro · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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 Herniated Lumbar Disk. Lateral
Diskectomy and Interbody Arthrodesis. 30
Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo,

and Francesco Zenga

• Ten years history of low back pain. More recent left L5 See Fig. 30.1, 30.2.
intense radiculopathy, numbness, and dysesthesia and
unsatisfactory conservative efforts in pain control. MRI
showed L4-L5 diskopathy (Pfirmann 4) with left parame-
dian disk herniation.
• Lateral diskectomy and interbody arthrodesis via XLIF
(eXtreme Lateral Interbody Fusion) approach.
• Pre- and postoperative images.

Fig. 30.1 Preoperative

a b
sagittal (a) and axial (b) MRI
showing L4-L5 diskopathy
(Pfirmann 4) with left
paramedian disk herniation
compressing the left L5
transiting root

G. Di Perna (*) · F. Zenga

Neurosciences Dept. “Rita Levi Montalcini”, University of Turin,
Turin, Italy
E. Bavaresco · N. Zullo
Casa di Cura “Città di Bra”, Bra, Italy

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116 G. Di Perna et al.

a b c

Fig. 30.2 Postoperative LL (a) and AP (b) X-ray showing L4-L5 inter- screws. Note (c) the restored segmental lordosis with good sagittal
body cage giving support on the lateral cortical surface of vertebral alignment and normal pelvic tilt
bodies and posterior fixation through divergent cortical bone trajectory
 Recurrent Herniated Lumbar Disk
Patient Reoperated 31
Regular Findings

Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi,

Christian Cossandi, Piergiorgio Car, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with recurrent herniated disk already treated by 31.1 Preoperative Imaging
left L4–L5 interlaminotomy and hernia removal.
• MR preoperative imaging and postoperative follow up. See Fig. 31.1.

Fig. 31.1 FSE T2 sagittal

a b
(a), and axial (b). L4–L5
recurrent left paramedian-­
intraforaminal hernia that
migrates caudally,
characterized by herniated
nucleus pulposus (hydrated
and T2 hyperintense); absence
of radicular conflict

A. Stecco · F. Fabbiano · S. Ciolfi · A. Carriero (*)

Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
C. Cossandi · P. Car · G. Panzarasa
Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy

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118 A. Stecco et al.

31.2 Preoperative Imaging After

10 Months

See Fig. 31.2.

Fig. 31.2 FSE T2 sagittal

(a), and axial (b).
a b
Incremented left lateral
compression on dural sac and
intraforaminal expansion
31 Recurrent Herniated Lumbar Disk Patient Reoperated 119

31.3 Postoperative Follow-Up

See Fig. 31.3.

Fig. 31.3 FSE T2 sagittal

a b
(a), and axial (b). Herniated
disk previously documented is
not yet appreciable. The disk
is thinner and protrudes
posteriorly in absence of L4
root conflicts. Fibrous scar
adjacent to left posterolateral
dural sac without signs of
disk root conflict
 Recurrent Herniated Lumbar Disk
Stabilization 32
Regular Findings

Tommaso Scarabino, Fabio Quinto, Roberto Stanzione,

Francesco Paradiso, and Raniero Mignini

• Patient with recurrent herniated disk already treated by 32.1 Preoperative Imaging
diskectomy and positioning of L4–L5 interbody prosthe-
sis through anterior approach (Anterior Lumbar Interbody See Fig. 32.1.
Fusion, ALIF).
• Preoperative imaging and early/late XR postoperative
follow-up.

a b c

Fig. 32.1 SE T1 and CE T1 (a, b), FSE T2 sagittal (c), and CE SE T1 axial (d–e). Left L4–L5 persisting hernia and surrounding fibrous scar

T. Scarabino (*) · F. Quinto · R. Stanzione

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
F. Paradiso · R. Mignini
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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122 T. Scarabino et al.

d e

Fig. 32.1 (continued)

32.2 Preoperative Follow-Up

See Fig. 32.2.

32 Recurrent Herniated Lumbar Disk Stabilization 123

Fig. 32.2 XR presurgery

anteroposterior (a), lateral
a b
(b). Slight reduction of D11,
D12, and L1 height
124 T. Scarabino et al.

32.3 Early Postoperative Follow-Up

See Fig. 32.3.

Fig. 32.3 XR anteroposterior

a b
(a), lateral (b). L4–L5 ALIF:
Regular positioning of the
device
32 Recurrent Herniated Lumbar Disk Stabilization 125

32.4 Late Postoperative Follow-Up

See Fig. 32.4.

Fig. 32.4 XR anteroposterior

a b
(a), and lateral (b). ALIF
 Dorsal Herniated Disk Diskectomy
and Stabilization 33
Regular Findings

Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi,

Christian Cossandi, Piergiorgio Car, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with herniated disk and canal stenosis treated by 33.1 Preoperative Imaging
diskectomy with posterolateral transpedicular approach
and further surgery of laminectomy and pedicular See Fig. 33.1.
stabilization.
• MR preoperative imaging and late postoperative follow-
­up (4 months).

A. Stecco · F. Fabbiano · S. Ciolfi · A. Carriero (*)

Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
C. Cossandi · P. Car · G. Panzarasa
Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 127
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128 A. Stecco et al.

Fig. 33.1 FSE T2 sagittal

a b
(a), STIR (b), and FSE T2
axial (c). D11–D12 canal
stenosis with compression on
spinal cord anteriorly due to
median-right paramedian disk
hernia and rear to
interapophyseal arthrosis with
yellow ligaments hypertrophy.
Spinal cord is thinner with
compressive myelopathic
signal alteration (arrow b)

c
33 Dorsal Herniated Disk Diskectomy and Stabilization 129

33.2 Postoperative Follow-Up after

4 Months

See Fig. 33.2.

Fig. 33.2 FSE T2 sagittal

a
(a), and FSE T2 axial (b, c).
After resurgery, reduction of
D11–D12 disk hernia and of
spinal cord compression.
There is still evident
myelopathic signal alteration.
(c) Transpedicular screws
positioning without
compression on the
surrounding spinal cord space

b c
 Herniated Cervical Disk Anterior
Diskectomy 34
Regular Findings

Tommaso Scarabino, Fabio Quinto, Saverio Lorusso,

Anna Totagiancaspro, and Raniero Mignini

• Patient with bilateral cervical pain in C5–C6 herniated 34.1 Early Postoperative Follow-Up
disk treated by anterior diskectomy and intervertebral
cage. See Fig. 34.1.
• Early XR postoperative follow-up.

a b c

Fig. 34.1 XR anteroposterior (a), lateral (b, zoom in c). Radiopacity in C5–C6 of the device

T. Scarabino (*) · F. Quinto

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Lorusso
Department of Radiology-Neuroradiology, L. Bonomo Hospital,
Andria, Italy
A. Totagiancaspro · R. Mignini
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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 Herniated Cervical Disk Anterior
Diskectomy 35
Regular Findings

Teresa Popolizio, Francesca Di Chio, Giovanni Miscio,

and Giuseppe Guglielmi

• Patient with bilateral cervical pain in C5–C6 herniated

disk treated by anterior diskectomy and intervertebral
prosthesis positioning.
• XR/MR preoperative imaging and postoperative
follow-up.

35.1 Preoperative Imaging

See Fig. 35.1.

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital, “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy
F. Di Chio · G. Miscio
Department of Radiology, Scientific Institute Hospital, “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy
G. Guglielmi
Department of Radiology, Scientific Institute Hospital, “Casa
Fig. 35.1 FSE T2 sagittal. Partial inversion of cervical lordosis. C4–
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy
C5 posterior disk protrusion. Posterior herniated disk compressing
Department of Radiology, University of Foggia, Foggia, Italy dural canal at C5–C6

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134 T. Popolizio et al.

35.2 Postoperative Follow-Up

See Fig. 35.2.

Fig. 35.2 XR (a), and FSE

a b
T2 sagittal (b). C5–C6
prosthesis
 Herniated Cervical Disk Anterior
Diskectomy 36
Regular Findings

Tommaso Scarabino, Saverio Pollice, Angela Lorusso,

Vincenzo Brandini, and Michele Santoro

• Patient with cervical pain in C5–C6 herniated disk treated 36.1 Preoperative Imaging
by diskectomy and intervertebral prosthesis.
• MR/XR preoperative imaging and postoperative See Fig. 36.1.
follow-up.

T. Scarabino (*) · A. Lorusso

Department of Radiology—Neuroradiology, Lorenzo Bonomo
Hospital, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital,
Trani, Italy
V. Brandini · M. Santoro
Department of Neurosurgery, Lorenzo Bonomo Hospital,
Andria, Italy

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136 T. Scarabino et al.

Fig. 36.1 XR lateral (a),

a
dynamic acquisitions: max
extension (b), and max
flexion (c). C5–C6 and
C6–C7 intervertebral space
reduction. Slight C5–C6
degenerative listhesis not
changing in dynamic
acquisitions

b c
36 Herniated Cervical Disk Anterior Diskectomy 137

36.2 Postoperative Follow-Up

See Figs. 36.2 and 36.3.

Fig. 36.2 XR anteroposterior

a b
(a), lateral (b), dynamic
acquisitions: max extension
(c), and max flexion (d).
Slight anterolisthesis
persisting at C5–C6 not
changing in dynamic
acquisitions

c d
138 T. Scarabino et al.

Fig. 36.3 SE T1 (a), FSE T2

a b
(b), sagittal, FSE T2 (c), and
GE* T2 (d) axial. C5–C6
prosthesis. Magnetic
susceptibility artifacts (mostly
in GE T2*) limit correct
evaluation of the district

c d
 Herniated Cervical Disk. Anterior
Diskectomy and Arthrodesis 37
Early Effects

Giuseppe Carmine Iaffaldano, Claudia Pennisi,

Stefania D’Avanzo, Francesco Paradiso, Michele Santoro,
and Domenico Catapano

• Lower limbs myelopathy symptoms. Radiological images See Figs. 37.1 and 37.2.
showed C6–C7 herniated disk with spinal cord compres-
sion and myelopathic signal.
• Anterior approach with diskectomy and arthrodesis with
titanium cage.
• Preoperative and early postoperative imaging.

Fig. 37.1 Preoperative

a b
sagittal (a) and axial (b) T2
MRI showing spinal cord
compression and myelopathy
signal

G. C. Iaffaldano · C. Pennisi · S. D’Avanzo · F. Paradiso

M. Santoro · D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 139
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140 G. C. Iaffaldano et al.

Fig. 37.2 First postoperative

a b
day sagittal (a) and axial (b)
CT scan showing diskectomy
and arthrodesis with titanium
cage
 Herniated Cervical Disk
and Osteophytosis. Anterior 38
Decompression and Arthrodesis
Early and Late Findings

Domenico Catapano, Costanzo De Bonis,

and Leonardo Gorgoglione

• Six years before C4–C5 and C5–C6 diskectomy and See Figs. 38.1, 38.2, and 38.3.
arthrodesis in spondylo-diskarthrosis myelopathy.
• Actual sudden tetraparesis worsening after fall on the
back with neck hyperflexion.
• Preoperative and postoperative images.

Fig. 38.1 Preoperative

sagittal (a) and axial CT scan
a b
at C3–C4 level (b) with
evidence of osteophytosis and
canal stenosis. Note previous
arthrodesis with interbody
cages and fusion at C4–C5
and C5–C6 level

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy
C. De Bonis · L. Gorgoglione
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S, S. Giovanni Rotondo, Italy

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142 D. Catapano et al.

a b c

Fig. 38.2 Preoperative sagittal T1 (a), post sagittal T2 (b), and axial T2 MRI scan at C3–C4 level (c) with evidence of new myelopathy signal and
disk-­osteophytosis spinal cord compression. Note previous arthrodesis with interbody cages and fusion at C4–C5 and C5–C6 level

a b c

Fig. 38.3 Postoperative after 1 month sagittal T2 (a), post sagittal T1 (b), and axial T2 MRI scan at C3–C4 level (c). Note the recent and previous
arthrodesis and the satisfying spinal cord decompression
 Herniated Cervical Disk. Anterior
Diskectomy and Arthroplasty 39
Regular Findings

Rossella Zaccaria, Simona Ferri, Antonello Curcio,

Fabio Cacciola, and Antonino Germanò

• Left cervicobrachialgia refractory to pharmacological 39.1 Preoperative MRI

therapy.
• Cervical intervertebral disk replacement with disk See Fig. 39.1.
prosthesis.
• Preoperative and postoperative images.

Fig. 39.1 Left C5–C6 disk

herniation

R. Zaccaria · S. Ferri · A. Curcio (*) · F. Cacciola · A. Germanò

Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 143
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144 R. Zaccaria et al.

39.2 Postoperative X-Ray

See Fig. 39.2.

Fig. 39.2 Postoperative A-P

(a) and L-L (b) X-ray in
a b
neutral position. L-L in
maximum extension (c) and
maximum flexion (d) X-ray
position. Note the artificial
disk mobility in flexion-­
extension position

c d
 Herniated Cervical Disk Anterior
Diskectomy 40
Early Effects

Teresa Popolizio, Francesca Di Chio,

Michelangelo Nasuto, Leonardo Gorgoglione,
and Giuseppe Guglielmi

• Patient with previous cervical pain in C5–C6 herniated 40.1 Preoperative Imaging
disk treated by anterior diskectomy and intervertebral
prosthesis. See Fig. 40.1.
• MR preoperative imaging and postoperative follow-up.

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital, “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy
F. Di Chio · M. Nasuto
Department of Radiology, University of Foggia, Foggia, Italy
L. Gorgoglione
Department of Neurosurgery, Scientific Institute Hospital, “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy
G. Guglielmi
Department of Radiology, University of Foggia, Foggia, Italy
Department of Radiology, Scientific Institute Hospital, “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (Fg), Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 145
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146 T. Popolizio et al.

Fig. 40.1 SE T1 (a), and

a b
FSE T2 (b) sagittal. Partial
inversion of cervical lordosis.
C5–C6 posterior herniated
disk compressing dural canal.
C6–C7 posterior disk
protrusion
40 Herniated Cervical Disk Anterior Diskectomy 147

40.2 Postoperative Follow-Up

See Fig. 40.2.

a b c

Fig. 40.2 FSE T2 (a), SE T1 (b), and CE T1 (c) sagittal. C5–C6 surgery. CE of involved vertebrae and thickening of rear longitudinal ligament
 Cervical Ossified Posterior Longitudinal
Ligament. Anterior Decompression 41
and Stabilization
Regular Findings

Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco,

and Fabio Cofano

• Bilateral C5 and C6 radiculopathy; lower limbs See Figs. 41.1 and 41.2.
myelopathy.
• Cervical ossified posterior longitudinal ligament. Anterior
C4–C5 corpectomy, vertebral body replacement with
expandable titanium cage and C3–C6 plate fixation.
• Preoperative CT and MRI; postoperative XR.

G. Di Perna (*)
Department of Neurosciences “Rita Levi Montalcini”, University
of Turin, Turin, Italy
N. Zullo · E. Bavaresco
Casa di Cura “Città di Bra”, Bra, Italy
F. Cofano
Department of Neurosciences “Rita Levi Montalcini”, University
of Turin, Turin, Italy
“Humanitas Gradenigo” Hospital, Turin, Italy

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150 G. Di Perna et al.

a b c

Fig. 41.1 (a) Preoperative sagittal MRI showing C4–C5 and C5–C6 longitudinal ligament (OPLL) from C4 to C6; (c) axial view showing
disk herniation with spinal cord compression; (b) CT scan revealed the C4–C5 left disk herniation; (d) axia CT scan showing calcified disk
calcific nature of disk herniation and the presence of ossified posterior herniation at the same level

a b c

Fig. 41.2 (a, b) Postoperative L-L X-ray (a), A-P X-ray (b), and sagittal CT scan (c) showing anterior C4–C5 corpectomy, vertebral body replace-
ment with expandable titanium cage, and C3–C6 plate fixation. Note calcified ligament removal and anterior decompression
 Cervical Spondylotic Myelopathy.
Anterior and Posterior Approach 42
Regular Findings

Antonello Curcio, Simona Ferri, Rossella Zaccaria,

Fabio Cacciola, Antonino Germanò,
and Filippo Flavio Angileri

• Patient with tetraparesis due to a severe C4–C7 spondylo- See Figs. 42.1 and 42.2.
genic myelopathy.
• 360° approach with anterior corpectomy, custom made
expandable cervical cage, and posterior stabilization.
• Preoperative and postoperative images.

a b c

Fig. 42.1 Preoperative T2 MRI Sagittal scan (a), axial C4–C5 scan (b), axial C6–C7 scan (c). Note spondylo-diskarthrosis with spinal cord com-
pression and myelopathy signal

A. Curcio (*) · S. Ferri · R. Zaccaria · F. Cacciola · A. Germanò

F. F. Angileri
Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

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152 A. Curcio et al.

a b c

d e f

Fig. 42.2 Postoperative CT scan (a, b, c) showing: anterior approach with C5, C6, and C7 corpectomy; somatoplasty with expandable porous
titanium cage and plating; posterior approach with rear stabilization. 3D CT reconstruction (d, e, f)
 Cervical Spondylodiskitis Corpectomy
Sequelae
43
Teresa Popolizio, Giuseppe Guglielmi, and Rosy Setiawati

• Patient with cervical spondylodiskitis and epidural 43.1 Preoperative Imaging

abscess treated by corpectomy and anterior fixation at
C5–C7. See Fig. 43.1.
• Preoperative imaging and postoperative follow-up RM.

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (FG), Italy
G. Guglielmi
Department of Radiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo (FG), Italy
Department of Radiology, University of Foggia, Foggia, Italy
R. Setiawati
Department of Radiology, Rumah Satik Surabaya International
Hospital, Surabaya, Indonesia

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154 T. Popolizio et al.

Fig. 43.1 FSE T2 (a) and

a b
STIR (b) sagittal, SE T1 axial
(c, d). C6–C7 bone marrow
edema with anterior epidural
fluid collection and C6–C7
diskitis compressing
anteriorly spinal cord
(spondylitis with epidural
abscess). C4–C8
myeloedema. Fluid collection
filled between anterior
longitudinal ligament and
spine

c d
43 Cervical Spondylodiskitis Corpectomy 155

43.2 Postoperative Follow-Up

See Fig. 43.2.

Fig. 43.2 FSE T2 (a) and

CESE T1 (b) sagittal. Slight
a b
bone marrow edema. Metallic
artifact. No pathological
CE. Spinal cord atrophy with
C6–C7 myelomalacia
 Cervical Spondylitis. Anterior
and Posterior Approach 44
Regular Findings

Simona Ferri, Rossella Zaccaria, Antonello Curcio,

Fabio Cacciola, Filippo Flavio Angileri,
and Antonino Germanò

• Patient with tetraparesis due to a somatic C5–C6–C7 See Fig. 44.1.

body collapse by tuberculous spondylitis (Pott disease).
• Anterior corpectomy; vertebral body replacement with
titanium mesh cage; anterior and posterior stabilization.
• Preoperative and postoperative images.

Fig. 44.1 Preoperative

sagittal (a) and axial (b)
a b
T2-MRI showing Severe C4–
C7 sponylogenic myelopathy
(Pott syndrome)

S. Ferri · R. Zaccaria · A. Curcio (*) · F. Cacciola · F. F. Angileri ·

A. Germanò
Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 157
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158 S. Ferri et al.

44.1 Early Postoperative Follow-Up

See Fig. 44.2.

Fig. 44.2 Postoperative X-ray (a) and sagittal CT (b) showing: poste-
rior rods-screws stabilization; C5 and C6 total corpectomy and C7 par-
tial corpectomy; somatoplasty with titanium mash and plating with
titanium plate and screws
 Septic Spondylodiskitis in Removal
of Herniated Cervical Disk. Anterior 45
Approach Surgery
Chylothorax Subsequent Rupture of Thoracic
Duct

Chiara Potente, Tommaso Scarabino,

and Gabriele Polonara

• Patient with septic spondylodiskitis following anterior 45.1 Early Postoperative Follow-Up
approach surgery in treatment of herniated disk.
• MR early postoperative follow-up. See Fig. 45.1.

a b

Fig. 45.1 FSE T2 sagittal (a), coronal (b), and axial (c, d). T2 hyperintense large liquid collection completely occupying right hemithorax due to
chylothorax

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

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160 C. Potente et al.

Fig. 45.1 (continued)

 Herniated Cervical Disk. Anterior
Diskectomy 46
Prevertebral Hematoma

Chiara Potente, Tommaso Scarabino,

and Gabriele Polonara

• Patient with severe dyspnea few hours after anterior dis- 46.1 Early Postoperative Follow-Up
kectomy and intervertebral cage positioning.
• Early CT postoperative follow-up. See Fig. 46.1.

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

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162 C. Potente et al.

Fig. 46.1 CT (a) and CE CT

a b
(b), bone window MPR
sagittal (c), CE soft tissue
window sagittal (d), CE soft
tissue window coronal (e, f).
Large blood collection in the
prevertebral space that
displaces trachea and larynx
right-lateral-anteriorly,
laterocervical vessels
left-lateral posteriorly (a−c).
Contrast medium leakage
inside the hematoma (d−f)

c d

e f
 Synovial Cyst. Minimally Invasive
Surgical Approach 47
Regular Findings

Domenico Catapano, Costanzo De Bonis,

and Leonardo Gorgoglione

• Short-term history of sudden neurogenic claudicatio and See Figs. 47.1 and 47.2.
right cruralgia. No instability evidence at dynamic lumbar
XR.
• Minimally invasive partial hemilaminectomy and syno-
vial cyst removal.
• Preoperative and late postoperative MRI.

a b c

Fig. 47.1 Preoperative sagittal T1 (a), T2 (b), and L3–L4 axial T2 (c) MRI showing cauda equina compression by right hemorrhagic synovial cyst
(arrows)

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy
C. De Bonis · L. Gorgoglione
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S, S. Giovanni Rotondo, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 163
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164 D. Catapano et al.

a b c

Fig. 47.2 Postoperative sagittal T1 (a), T2 (b), and L3–L4 axial T2 (c) MRI showing resolution of cauda equina compression and the minimally
invasive surgical approach with partial hemilaminectomy (arrows)
 Synovial Cysts. Surgical Removal
Recurrence
48
Ferdinando Caranci, Luca Brunese, Domenico Cicala,
and Francesco Briganti

• Patient with recurrent radiculitis after synovial cyst 48.1 Preoperative Imaging
removal at L4–L5 and a short healthy period.
• MR preoperative imaging and postoperative follow-up See Fig. 48.1.
after 2 and 3 months (with only symptomatic therapy).

F. Caranci (*) · F. Briganti

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy
L. Brunese
Department of Health Sciences, Chair of Radiology, University of
Molise, Campobasso, Italy
D. Cicala
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 165
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166 F. Caranci et al.

a b c

Fig. 48.1 FSE T2 sagittal (a–c) and axial (d–g) sections. L4–L5 small cystic lesion in right foraminal recess (arrow), supplied by inter-­apophyseal
fluid. Bilateral interapophyseal degenerative phenomenon, with articular hypertrophy and subsequent narrowing of vertebral canal (e–g)
48 Synovial Cysts. Surgical Removal 167

d e

f g

Fig. 48.1 (continued)

48.2 Preoperative Imaging

See Fig. 48.2.

168 F. Caranci et al.

a b c

d e f

Fig. 48.2 FSE T2 sagittal sections in supine (a–c) and orthostatic position (d–f). Moving from supine (a–c) to orthostatic position (d–f), there is
narrowing of vertebral canal at L4–L5 with incremented “impingement” of synovial cyst (arrow)
48 Synovial Cysts. Surgical Removal 169

48.3 Postoperative Follow-Up After

2 Months

See Fig. 48.3.

Fig. 48.3 FSE T2 sagittal a b c

(a–c) and axial sections (d–g).
At L4–L5 inhomogeneity of
retro-vertebral muscles due to
surgery (a–c) with removal of
right yellow ligament (d–g).
Right synovial cyst (b–e,
arrow) is still present
(probably recurrence) and
communicating with
interapophyseal fluid. Further
synovial cyst at L3–L4 (b,
arrowhead)

d e

f g
170 F. Caranci et al.

48.4 Postoperative Follow-Up After

3 Months

See Fig. 48.4.

Fig. 48.4 FSE T2 sagittal a b c

(a–c) and axial sections (d–g).
Reduction of the right L4–L5
synovial cyst (b–e, arrow),
related with clinical
improvement. The further
synovial cyst is more evident
at L3–L4 (a, arrowhead)

d e

f g
 Instability and Lumbar Stenosis.
Positioning of Interspinous Device 49
Regular Findings

Tommaso Scarabino, Saverio Pollice, Michela Capuano,

Michele Santoro, and Raniero Mignini

• Instability and lumbar stenosis treated by interspinous See Figs. 49.1, 49.2, 49.3, 49.4 and 49.5.
devices (X-Stop, Wallis, DIAM, Coflex, In-Space).
• Medical device and related XR imaging.

a b c

Fig. 49.1 Interspinous device X-Stop. (a) Device. (b, c) XR lateral and craniocaudally by the spinous processes, and posteriorly by the supra-
anteroposterior. X-Stop consists of two parallel lateral wings that pre- spinous ligament. The rod places the patient in slight flexion, while
vent itself lateral migration connected by a titanium rod or spacer. limiting extension. The flexion obtained by the insertion of the device
During implantation, the rod is inserted in transverse way, penetrating leads to stretching of yellow ligaments and distracting of nerve
the interspinous ligament. It is constrained anteriorly by the lamina, foramina

T. Scarabino (*)
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, Trani,
Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
M. Santoro · R. Mignini
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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172 T. Scarabino et al.

Fig. 49.2 Interspinous

Wallis. (a) Device. (b) XR a b
lateral. Wallis is
polyetheretherketone (PEEK)
with elastic-like bone
characteristics, stabilized with
two strips of Dacron.
Although it is not truly
compressible, properties of
material are very close to the
elastic modulus of the
posterior spine. The two strips
of dacron embrace the upper
and lower spinous processes,
pulled with a special tool.
Compared to other
interspinous systems also
allow to enlarge anterior disk
space

a b c

Fig. 49.3 Interspinous DIAM. (a) Device. (b, c) XR lateral and antero- for radiographic identification. Packed with compressible material is
posterior. DIAM consists of a silicon core covered by polyester sleeve. not a true stabilizer because it lacks its own stabilizing force. It main-
The core and sleeve are held in the interspinous space by three mesh tains the rigidity of the rear compartment of the functional unit formed
bands. Two of the bands encircle the adjacent spinous processes, while by the intervertebral disk, and interapophyseal joints finding indication
a third encases the supraspinous ligament. The silicon device is radiolu- when the size of the root canal should be preserved
cent, but radiopaque markers along the superior edge of the core allow
49 Instability and Lumbar Stenosis. Positioning of Interspinous Device 173

Fig. 49.4 Interspinous

a b
Coflex. (a) Device. (b) XR
lateral. The Coflex is a
U-shaped titanium implant
that is placed into the
interspinous space with clips
on the upper and lower
margins that allow the
locking. While the height of
the device distracts the
foraminal opening, the “U”
shape is designed to allow
controlled movement in
forward and backward
bending. Implantation of this
device is more invasive than
others, involving resection of
both interspinous and
supraspinous ligaments

a b

Fig. 49.5 Interspinous In-Space. (a) Device. (b) XR lateral. In-Space of the implant while the intact supraspinous ligament prevents dorsal
consists of PEEK radiolucent body and titanium alloy (TAV) screw and displacement. The percutaneous lateral approach not allow stripping of
wings to allow radiographic assessment of the correct installation. the paraspinal muscles. Moreover supraspinous ligament is left intact,
Turning the screw, the implant closes and the wings are deployed along interspinous ligament is only pierced to the size of the implant, no bone
the spinous processes. The wings prevent ventral and lateral migration needs to be removed to facilitate the insertion of the implant
 Degenerative Lumbar Instability.
Double Interspinous Device Positioning 50
Regular Findings

Tommaso Scarabino, Michele Maiorano, Tullia Garribba,

Giuseppe Diaferia, and Michele Santoro

• Patient with low back pain due to vertebral instability 50.1 Postoperative Follow-Up
treated by double interspinous device (DIAM) at L4–L5
and L5–S1. See Figs. 50.1 and 50.2.
• XR/MR postoperative follow-up.

T. Scarabino (*) · M. Maiorano · T. Garribba

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
G. Diaferia · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 175
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176 T. Scarabino et al.

Fig. 50.1 XR anteroposterior

a b
(a) and lateral (b) Dynamic
acquisition in max extension
(c), and max flexion (d).
Positioning of double
interspinous device at L4–L5
e L5–S1 (little radio-opacity
of the device is appreciable).
Slight left lumbar scoliosis.
Slight anterior listhesis L5–S1
not changing in dynamic
acquisition

c d
50 Degenerative Lumbar Instability. Double Interspinous Device Positioning 177

Fig. 50.2 SE T1 (a), FSE T2

a b
sagittal (b), SE T1 axial (c).
Normal positioning of device
(low signal)

c
 Lumbar Degenerative Instability.
Interspinous Device Positioning 51
Regular Findings

Paola D’Aprile and Alfredo Tarantino

• Patient with low back pain in vertebral instability due to 51.1 Preoperative Imaging
L4–L5 diskal degeneration treated by interspinous device.
• MR preoperative imaging and post-operative follow-up. See Fig. 51.1.

Fig. 51.1 SE T1 (a) and fat

sat FSE T2 (b). L4–L5 disk
a b
height reduction and
dehydration with reduction of
amplitude of the interspinous
space

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, San Paolo Hospital, Bari, Italy

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180 P. D’Aprile and A. Tarantino

51.2 Postoperative Follow-Up

See Fig. 51.2.

Fig. 51.2 SE T1 (a) FSE fat

a b
sat T2 (b). No imaging and
clinical improvement
 Degenerative Lumbar Instability.
Double Interspinous Device Positioning 52
Regular Findings

Paola D’Aprile and Alfredo Tarantino

• Patient with low back pain due to vertebral instability in 52.1 Postoperative Follow-Up
L4–L5 and L5–S1 diskopathy treated by double interspi-
nous device positioning (X-Stop). See Fig. 52.1.
• MR postoperative follow-up.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

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182 P. D’Aprile and A. Tarantino

a b c

d e

Fig. 52.1 SE T1 (a) FSE fat sat T2 (b) sagittal, CE fat sat SE T1 sagittal (c), and axial (d, e). No signal of interspinous device at L4–L5 and L5–S1
with slight inflammatory CE of adjacent soft tissue
 Lumbar Degenerative Instability.
Interspinous Device Positioning 53
Regular Findings

Paola D’Aprile and Alfredo Tarantino

• Patient with algic Baastrup due to interspinous L4–L5 53.1 Preoperative Imaging
arthrosis treated by interspinous device positioning
(DIAM). See Fig. 53.1.
• MR preoperative imaging and postoperative follow-up.

P. D’Aprile (*)
Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy
A. Tarantino
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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184 P. D’Aprile and A. Tarantino

Fig. 53.1 XR lateral (a), CE

a b
fat sat SE T1 sagittal (b), and
axial (c). Interspinous kissing
is visualized in XR (a) and
MR (b). (b, c) MR: CE of the
spinous processes and of
surrounding soft tissue due to
edema following reduction of
amplitude of interspinous
space

c
53 Lumbar Degenerative Instability. Interspinous Device Positioning 185

53.2 Postoperative Follow-Up

See Fig. 53.2.

Fig. 53.2 XR. Regular positioning of device DIAM (arrow)

 Stenosis and Degenerative Lumbar
Instability. Positioning of Double 54
Interspinous Device
Regular Findings

Tommaso Scarabino, Michela Capuano,

Roberto Stanzione, Anna Totagiancaspro,
and Michele Santoro

• Patient with low back pain in stenosis and degenerative 54.1 Preoperative Imaging
vertebral instability treated by positioning of double inter-
spinous device (X-Stop) at L3–L4 and L4–L5. See Fig. 54.1.
• XR/CT preoperative imaging and postoperative
follow-up.

T. Scarabino (*) · R. Stanzione

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
A. Totagiancaspro · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 187
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188 T. Scarabino et al.

Fig. 54.1 XR lateral (a) and

anteroposterior (b). Right a b
lumbar scoliosis. Slight
degenerative L4–L5
anterolisthesis
54 Stenosis and Degenerative Lumbar Instability. Positioning of Double Interspinous Device 189

54.2 Postoperative Follow-Up

See Fig. 54.2 and 54.3.

a b c d

Fig. 54.2 XR lateral (a) and anteroposterior (b) dynamic acquisition in max flexion (c) and extension (d). L4–L5 anterolisthesis persisting and
incrementing in max extension

Fig. 54.3 CT Axial (a), MPR

a b
coronal (b). Regular
positioning of device

c
 Stenosis and Degenerative Lumbar
Instability. Interspinous Device 55
Positioning
Regular Findings

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with low back pain in degenerative L4–L5 antero- 55.1 Preoperative Imaging
listhesis and following canal stenosis treated by interspi-
nous device and percutaneous procedure. See Fig. 55.1.
• XR/CT preoperative imaging and postoperative
follow-up.

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

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192 M. Muto et al.

Fig. 55.1 FSE T2 sagittal (a)

axial (b, c). I grade L4–L5
a
anterolisthesis with interposed
protruding disk and clover
stenosis. L3–L4 and L5–S1
herniated disk

c
b
55 Stenosis and Degenerative Lumbar Instability. Interspinous Device Positioning 193

55.2 Postoperative Follow-Up

See Figs. 55.2 and 55.3.

Fig. 55.2 CT axial (a, b). a b

L4–L5 clover stenosis and
disk protrusion

Fig. 55.3 Fluoroscopic control after percutaneous treatment through

right-oblique approach
 Stenosis and Degenerative Lumbar
Instability Interspinous Device 56
Positioning
Regular Findings

Tommaso Scarabino, Fabio Quinto, Francesco Nemore,

Carlo Delvecchio, and Michele Santoro

• Patient with low back pain in stenosis and instability 56.1 Preoperative Imaging
treated by interspinous device positioning (Superior) at
L4–L5 See Fig. 56.1.
• MR preoperative imaging and XR/MR postoperative
follow-up

a b c

Fig. 56.1 SE T1 (a), FSE T2 (b) sagittal, FSE T2 axial (c). L4–S1 central-lateral stenosis

T. Scarabino (*) · F. Quinto · F. Nemore

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
C. Delvecchio · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 195
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196 T. Scarabino et al.

56.2 Postoperative Follow-Up

See Figs. 56.2 and 56.3.

a b c d

Fig. 56.2 XR anteroposterior (a), lateral (b), dynamic acquisitions in max extension (c) and flexion (d). Regular positioning of device. Right
scoliosis. L5 slight anterolisthesis increasing during max extension
56 Stenosis and Degenerative Lumbar Instability Interspinous Device Positioning 197

Fig. 56.3 FSE T2 sagittal. Regular positioning of device. Stenosis per-

sisting at L4–S1
 Degenerative Lumbar Instability.
Interspinous Device Positioning 57
Fibrous Scar and Infection

Paola D’Aprile and Alfredo Tarantino

• Patient with persisting and increasing degenerative low 57.1 Late Postoperative Follow-Up
back pain treated by L4–L5 interspinous device
positioning. See Fig. 57.1.
• MR late postoperative follow-up.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

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200 P. D’Aprile and A. Tarantino

a b c

d e f

Fig. 57.1 CE fat sat SE T1 sagittal (a, b), coronal (c), and axial (d–f). CE of soft tissue surrounding device at L4–L5 due to scar and infection
(cause of pain)
 Degenerative Lumbar Instability
Interspinous Device Positioning 58
Fibrous Stenosis

Ferdinando Caranci, Domenico Cicala,

Vincenzo Giugliano, Francesco Briganti,
and Luca Brunese

• Patient treated by removal of L4–L5 herniated disk with 58.1 Preoperative Imaging
previous left lamino-flavectomy. Persisting left low back
pain and claudication requires interspinous device posi- See Fig. 58.1.
tioning with subsequent worsening of clinical conditions
and imaging.
• MR preoperative imaging and late postoperative follow-
­up (3 months).

F. Caranci (*) · F. Briganti

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy
D. Cicala
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
V. Giugliano
Unit of Diagnostic Imaging, GE.P.O.S. Clinic,
Telese Terme, BN, Italy
L. Brunese
Department of Health Science, Chair of Radiology, University of
Molise, Campobasso, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 201
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202 F. Caranci et al.

a b c

d e f

Fig. 58.1 SE T1 sagittal (a–c), FSE T2 sagittal (d–f), and SE T1 axial sections (g–j). L4–L5 disk protrusion occupying both inferior foraminal
recesses; narrowing of canal (a–f). Left lamino-flavectomy (arrow) with fibrous scar in left epidural space (g–j, arrowhead)
58 Degenerative Lumbar Instability Interspinous Device Positioning 203

g h

i j

Fig. 58.1 (continued)

58.2 Postoperative Follow-Up After

3 Months

See Fig. 58.2.

204 F. Caranci et al.

a b c

d e f

Fig. 58.2 SE T1 sagittal (a–c), FSE T2 sagittal (d–f), and SE T1 axial pression of posterior profile of the dural sac (e, arrow). Clinical worsen-
sections (g–j). L4–L5 DIAM. Interspinous diastase and fibrous scar ing of radicular pain. Hypertrophy of epidural fatty tissue (g, arrowhead)
cause a reduction of sagittal diameter of the vertebral canal with com- contributes to stenosis
58 Degenerative Lumbar Instability Interspinous Device Positioning 205

g h

i j

Fig. 58.2 (continued)

 Degenerative Lumbar Instability.
Interspinous Device Positioning 59
Septic Spondylodiskitis

Paola D’Aprile and Alfredo Tarantino

• Patient with persisting low back pain and high level flogo- 59.1 Postoperative Follow-Up After
sis markers after interspinous device positioning. 2 Months
• Late MR postoperative follow-up (2 months).
See Fig. 59.1.

P. D’Aprile (*) · A. Tarantino

Department of Neuroradiology, “San Paolo” Hospital, Bari, Italy

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208 P. D’Aprile and A. Tarantino

a b c

Fig. 59.1 SE T1 (a, b), FSE fat sat T2 (c, d) sagittal, CE fat sat SE soft tissue, and right psoas muscle (e, h). Intracanal expansion and soft
T1sagittal (e, f), and axial (g, h). Severe spondylodiskitis (T1 hypoin- tissue micro-abscesses along surgical breach
tensity a, b, T2 hyperintensity c, d) CE of disk, spongiosa, paravertebral
59 Degenerative Lumbar Instability. Interspinous Device Positioning 209

d e f

g h

Fig. 59.1 (continued)

 Degenerative Lumbar Instability.
Stabilization and Interspinous Device 60
Positioning
Regular Findings

Tommaso Scarabino, Angela Lorusso, Pietro Maggi,

Carmen Bruno, and Michele Santoro

• Patient with low back pain in vertebral instability treated 60.1 Postoperative Follow-Up
by stabilization through L4–L5 screws, bars, and previ-
ously by interspinous device (X-Stop). See Fig. 60.1.
• Early XR/MR postoperative follow-up.

T. Scarabino (*) · A. Lorusso · P. Maggi

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
C. Bruno · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 211
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212 T. Scarabino et al.

Fig. 60.1 XR lateral (a) and

a b
anteroposterior (b)
 Degenerative Lumbar Instability Rigid
Posterior Stabilization 61
Regular Findings

Teresa Popolizio, Francesco Gorgoglione,

and Giuseppe Guglielmi

• Patient with low back pain which extends to arms in L5–

S1 degenerative listhesis treated by posterior rigid stabili-
zation and transpeduncular screws positioning.
• XR preoperative imaging and postoperative follow-up.

61.1 Preoperative Imaging

See Fig. 61.1.

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
F. Gorgoglione
Department of Orthopedics, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
G. Guglielmi Fig. 61.1 XR lateral. L5–S1 anterolisthesis
Department of Radiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
Department of Radiology, University of Foggia, Foggia, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 213
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214 T. Popolizio et al.

61.2 Postoperative Follow-Up

See Fig. 61.2.

Fig. 61.2 XR sagittal. Regular positioning of metallic device

 Degenerative Lumbar Instability Rigid
Posterior Stabilization 62
Regular Findings

Tommaso Scarabino, Saverio Pollice,

Marianna Schiavariello, Giuseppe Carmine Iaffaldano,
and Raniero Mignini

• Patient with back pain which extends in lower limbs and 62.1 Preoperative Imaging
neurogenic claudicatio in L4–L5 degenerative antero lis-
thesis treated by posterior rigid stabilization and interver- See Fig. 62.1.
tebral prosthesis posteriorly placed (Posterior Lumbar
Fusion Surgery, PLIF).
• Early XR preoperative imaging and postoperative
follow-up.

Fig. 62.1 Dynamic XR

lateral max flexion (a) and
a b
max extension (b).
Anterolisthesis L4–L5 mostly
appreciable in max flexion (a)

T. Scarabino · M. Schiavariello
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, Trani,
Italy
G. C. Iaffaldano · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 215
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216 T. Scarabino et al.

62.2 Early Postoperative Follow-Up

See Fig. 62.2.

Fig. 62.2 XR anteroposterior

a
(a) and lateral (b, c). Regular
positioning of device. (c)
Radio-opaque markers at
L4–L5

b c
 Lumbar Canal Stenosis. Minimally
Invasive Decompression 63
Regular Findings

Domenico Catapano, Costanzo De Bonis,

and Leonardo Gorgolione

• Long-term history of neurogenic claudication without

low back pain. At MRI lumbar canal stenosis above all at
L3–L4 and L4–L5 levels. No instability evidence at
dynamic lumbar XR.
• Minimally invasive surgical bilateral flavectomy via
monolateral partial hemilaminectomy.
• Preoperative and late postoperative MRI. (see Figs. 63.1,
63.2, 63.3, and 63.4)

a b c

Fig. 63.1 Preoperative sagittal T2 (a), T1 (b), and L3–L4 axial T2 (c) MRI showing lumbar canal stenosis (Schizas grade C) and ligamentum
flavum hypertrophy

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy
C. De Bonis · L. Gorgolione
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 217
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218 D. Catapano et al.

a b c

Fig. 63.2 Preoperative sagittal T2 (a), T1 (b), and L4–L5 axial T2 (c) MRI showing lumbar canal stenosis (Schizas grade B) and ligamentum
flavum hypertrophy

a b c

Fig. 63.3 Postoperative sagittal T2 (a), T1 (b), and L3–L4 axial T2 (c) MRI showing lumbar canal decompression after bilateral flavectomy via
monolateral partial hemilaminectomy

a b c

Fig. 63.4 Postoperative sagittal T2 (a), T1 (b), and L4–L5 axial T2 (c) MRI showing lumbar canal decompression after bilateral flavectomy via
monolateral partial hemilaminectomy
 Lumbar Stenosis and Degenerative
Instability Posterior Rigid Stabilization 64
Regular Findings

Tommaso Scarabino, Maurizio Lelario, Pietro Maggi,

Carmen Bruno, and Raniero Mignini

• Patient with low-back pain in stenosis and vertebral insta- 64.1 Preoperative Imaging
bility treated by rigid posterior stabilization and interver-
tebral prosthesis posteriorly placed with trans-foraminal See Fig. 64.1.
approach (Transforaminal Lumbar Interbody Fusion
Surgery, TLIF).
• MR preoperative imaging and early XR postoperative
follow-up.

T. Scarabino · P. Maggi
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Lelario
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
C. Bruno · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 219
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220 T. Scarabino et al.

a b c

Fig. 64.1 SE T1 (a), FSE T2 (b), STIR (c) sagittal. Severe congenital stenosis with L4–L5 disk height reduction
64 Lumbar Stenosis and Degenerative Instability Posterior Rigid Stabilization 221

64.2 Early Postoperative Follow-Up

See Fig. 64.2.

Fig. 64.2 XR anteroposterior

(a) sagittal (b). Regular a b
positioning of device
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 65
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain in orthostasis. Radiological

images showed L4–L5 degenerative diskopathy and grade
I spondylolisthesis.
• Intersomatic arthrodesis via TLIF (Transforaminal
Lumbar Interbody Fusion) and posterior rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 65.1 and 65.2).

Fig. 65.1 Preoperative MRI a b

(a) and X-ray (b) showing
grade I spondylolisthesis

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

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224 C. De Bonis et al.

a b c

Fig. 65.2 Postoperative images: L-L (a) and A-P (b) X-ray; sagittal CT scan (c). Note spondylolisthesis reduction
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 66
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain in orthostasis. Radiological

images showed L4–L5 degenerative diskopathy, instabil-
ity, and grade I spondylolisthesis.
• Intersomatic arthrodesis (Transforaminal Lumbar
Interbody Fusion, TLIF) and posterior rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 66.1 and 66.2).

a b c

Fig. 66.1 Preoperative flexion (a) and extention (b) X-ray showing instability. Preoperative sagittal CT scan (c) showing degenerative
diskopathy

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 225
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226 C. De Bonis et al.

a b c

Fig. 66.2 Postoperative L-L (a) and A-P (b) X-ray. Postoperative sagittal CT scan (c). Note arthrodesis and spondylolisthesis reduction
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 67
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain neurogenic claudication.

Radiological images showed L4–L5 degenerative discop-
athy and canal stenosis.
• Intersomatic arthrodesis (Transforaminal Lumbar
Interbody Fusion, TLIF) and posterior rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 67.1 and 67.2).

Fig. 67.1 Preoperative

a b
sagittal (a) and axial (b) MRI
showing L4–L5 degenerative
discopathy and canal stenosis

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 227
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228 C. De Bonis et al.

Fig. 67.2 Postoperative L-L

a b
(a) and A-P (b) X-ray
showing arthrodesis
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 68
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain and left sciatalgia. Radiological

images showed L4–L5 degenerative diskopathy and L5–
S1 left lateral canal stenosis.
• Intersomatic L5–S1 arthrodesis (Transforaminal Lumbar
Interbody Fusion, TLIF) and posterior L4–S1 rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 68.1 and 68.2).

Fig. 68.1 Preoperative

a b
sagittal (a) and axial (b) T2
MRI showing degenerative
diskopathy at L4–L5 and
L5–S1 level and lateral canal
stenosis at left L5–S1 level

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

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230 C. De Bonis et al.

a b c

Fig. 68.2 Postoperative L-L X-ray (a), sagittal (b), and axial (c) CT scan showing decompression and arthrodesis
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 69
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain and lower limbs neurogenic

claudication. Radiological images showed L4–L5 degen-
erative diskopathy and L3–L5 canal stenosis.
• Intersomatic L4–L5 arthrodesis (Transforaminal Lumbar
Interbody Fusion, TLIF), L3–L4 laminectomy and poste-
rior L3–L5 stabilization.
• Pre- and postoperative images (see Figs. 69.1 and 69.2).

Fig. 69.1 Preoperative

a b
sagittal T2 (a) and STIR (b)
MRI showing L4–L5
degenerative diskopathy and
L3–L4 canal stenosis

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “Bonomo” Hospital, Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 231
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232 C. De Bonis et al.

a b c

Fig. 69.2 Postoperative L-L X-ray (a), A-P X-ray (b), and sagittal CT scan (c) showing arthrodesis. Note restore of intersomatic space height and
canal decompression (c)
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 70
and Posterior Stabilization
Regular Findings

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• History of low back pain and lower limbs neurogenic

claudication. Radiological images showed lumbar scolio-
sis, multiple levels degenerative diskopathy, and canal
stenosis.
• Intersomatic L3–L4 and L4–L5 arthrodesis
(Transforaminal Lumbar Interbody Fusion, TLIF) and
posterior L3–S1 stabilization.
• Pre- and postoperative images (see Figs. 70.1 and 70.2).

Fig. 70.1 Preoperative

sagittal T2 MRI (a) showing
a b
multiple levels degenerative
diskopathy and stenosis.
Preoperative A–P Xray (b)
showing scoliosis

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 233
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234 C. De Bonis et al.

Fig. 70.2 Postoperative L-L

X-ray (a) showing
a b
arthrodesis. Postoperative
coronal CT scan (b) showing
arthrodesis and partial
scoliosis correction
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 71
and Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco,

and Francesco Zenga

• History of low back pain and intensive L5 radiculopathy.

Radiological images showed spondylolisthesis
(Mayerding grade 1) with severe bilateral foraminal ste-
nosis and L4–L5 diskopathy with compensatory retrolis-
thesis and left disk herniation with pre-foraminal
compression of L5 transiting root.
• Intersomatic arthrodesis (Posterior Lombar Interbody
Fusion, PLIF) approach and posterior rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 71.1 and 71.2).

G. Di Perna (*) · F. Zenga

Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
N. Zullo · E. Bavaresco
Casa di Cura “Città di Bra”, Bra, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 235
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236 G. Di Perna et al.

a b c

Fig. 71.1 (a) Lateral MRI showing L5–S1 spondylolisthesis and L4–L5 retrolisthesis; (b) MRI showing severe bilateral L5–S1 foraminal steno-
sis; (c) axial MRI showing L4–L5 left disk herniation with pre-foraminal compression of L5 transiting root

a b c

Fig. 71.2 Postoperative LL (a) and AP (c) X-ray showing L4–L5 and L5–S1 interbody cage and posterior instrumentation. Focus on LL X-ray
(b) showing L5–S1 spondylolisthesis reduction
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 72
and Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo,

and Diego Garbossa

• Long history of worsening low back pain and both legs bined lateral and posterior approach was choose (see
neurogenic claudication and numbness. Radiological Fig. 72.1).
images revealed severe L1–L5 vertebral stenosis (Schizas XLIF was performed at L2–L3, L3–L4, L4–L5 levels in
grade D at L3–L4 and L4–L5) and L5–S1 right severe order to correct coronal imbalance, provide large support for
foraminal stenosis. Lumbar lordosis was completely com- vertebral body fixed in a long construct and to maximize
promised and a mild degenerative scoliosis was found. lumbar lordosis correction. Posterior L5–S1 PLIF was per-
CT scan revealed complete gaseous degeneration of all formed to directly decompress L5–S1 foramina and to pro-
lumbar disks. vide adequate support and lordosis at that level. Finally,
• Interbody arthrodesis and posterior stabilization. T11–S2 posterior screw fixation was performed in order to
• Pre- and postoperative images. provide a long and solid construct. S2 screw with sacroiliac
joint fixation was chosen in order to increase the base of the
Considering the severe lumbar stenosis, the loosening of construct and in order to reduce junctional sacroiliac joint
lumbar lordosis and the fulcrum of degenerative scoliosis at mechanical disfunction (see Fig. 72.2).
L2–L3 level, thoracic-lumbar instrumentation with com-

G. Di Perna (*) · D. Garbossa

Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
E. Bavaresco · N. Zullo
Casa di Cura “Città di Bra”, Bra, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 237
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238 G. Di Perna et al.

a b c e f

Fig. 72.1 Preoperative MRI showing severe L1–S1 diskopathy and degenerative lumbar scoliosis with L3–L4 lateral spondylolisthesis;
vertebral stenosis: sagittal view showing central (a) and right (b) L3–L4 coronal CT scan (f) showing important disk degeneration (Pfirmann 5)
and L4–L5 foraminal stenosis; axial view (c) showing L3–L4 stenosis; at all lumbar disks
axial view (d) showing L4–L5 stenosis; coronal view (e) showing

a b c

Fig. 72.2 Postoperative AP (a) and LL (b) X-ray showing: T11–S2 Interbody Fusion, PLIF) approach. Intraoperative image showing pos-
posterior rod-screws stabilization; L2 to L5 interbody cages positioned terior rod-screws T11–S2 construct and L1–S1 posterior laminectomy
through lateral (eXtreme Lateral Interbody Fusion, XLIF) approach; and artrectomy with decompressed dural sac (c)
L5–S1 interbody cages positioned through posterior (Posterior Lumbar
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 73
and Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Emanuele Bavaresco, Nicola Zullo,

and Fabio Cofano

• Low back pain from 2 years, leg pain worsening and neu-
rogenic claudication. Previous right sacroiliac joint fusion
without improvement. Radiological exams revealed L4–
L5 degenerative spondylolisthesis with bilateral recess
stenosis and L5–S1 diskopathy.
• L4–L5 interbody arthrodesis via lateral (eXtreme Lateral
Interbody Fusion, XLIF) approach, L5–S1 interbody
arthrodesis via posterior (Posterior Lumbar Interbody
Fusion, PLIF) approach and posterior rods-screws
stabilization.
• Pre- and postoperative images (see Figs. 73.1 and 73.2).

G. Di Perna (*)
Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
E. Bavaresco · N. Zullo
Casa di Cura “Città di Bra”, Bra, Italy
F. Cofano
Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
“Humanitas Gradenigo” Hospital, Turin, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 239
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240 G. Di Perna et al.

a b c d

Fig. 73.1 Preoperative sagittal (a, b) MRI showing L4–L5 degenera- MRI showing lumbar stenosis due to spondylolisthesis and articular
tive spondylolisthesis with bilateral recess stenosis and L5–S1 diskopa- process degeneration (Schizas B)
thy; (c) CT scan revealed gaseous degeneration of L5–S1 disk; (d) axial

Fig. 73.2 Postoperative LL

a b
(a) and AP (b) X-ray showing
L4–L5 interbody cage
positioned through lateral
approach and L5–S1
interbody cages positioned
through posterior approach
and posterior fixation through
divergent cortical bone
trajectory screws. Increase in
lumbar lordosis was also
observed. Previous right
sacroiliac joint fusion (arrow)
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 74
and Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Nicola Zullo, Emanuele Bavaresco,

and Diego Garbossa

• Long history of low back pain and severe L4 and L5 bilat-

eral radiculopathy and neurogenic claudication. MRI
revealed: severe L3–L4 (Schizas C) and L4–L5 (Schizas
D) vertebral stenosis and bilateral foraminal stenosis; L3–
L4 and L4–L5 degenerative spondylolisthesis; sagittal
imbalance with L3–S1 kyphosis.
• Anterior Lombar Interbody Fusion (ALIF) L5–S1;
Oblique Lateral Interbody Fusion (OLIF) L3–L4 and L4–
L5; posterior L3–S1 decompression and fusion with
extreme screws augmentation.
• Pre- and postoperative MRI (see Figs. 74.1 and 74.2).

G. Di Perna (*) · D. Garbossa

Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
N. Zullo · E. Bavaresco
Casa di Cura “Città di Bra”, Bra, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 241
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242 G. Di Perna et al.

a b c e

d f

Fig. 74.1 Preoperative MRI showing severe L3–L4, L4–L5 vertebral e) and articular facets edema (arrow in fig. f) and optimal vascular ana-
stenosis and degenerative spondylolisthesis. (a, b) Sagittal view show- tomic condition for anterior approach (star). Arrow-head in fig. f
ing central and right foraminal stenosis. (c) Axial view showing L3–L4 showed anterior displacement of lumbar plexus, inadequate condition
stenosis. (d) Axial view showing L4–L5 stenosis. (e, f) Axial view for extreme lateral trans-psoas approach
showing right intra-extra foraminal L5–S1 disk herniation (arrow in fig.

a b c

Fig. 74.2 (a–c) Postoperative LL–AP X-ray showing L5–S1 ALIF, L3–L4 and L4–L5 OLIF and posterior fixation with lumbar lordosis recon-
struction and spondylolisthesis reduction. Screw augmentation at L3 and S1
 Lumbar Stenosis and Degenerative
Instability. Interbody Arthrodesis 75
and Posterior Stabilization
Regular Findings

Giuseppe Di Perna, Nicola Zullo, and Emanuele Bavaresco

• One year history of low back pain, left S1 radiculopathy

and worsening of ambulation autonomy. MRI revealed
L5–S1 diskopathy with bilateral foramina stenosis and
left paramedian disk herniation. Relevant segmental loss
of lordosis was observed in a context of degenerative lum-
bar lordosis with L3–S1 diskopathy.
• Anterior Lombar Interbody Fusion (ALIF) and posterior
bilateral artrectomy and fixation.
• Pre- and postoperative images (Figs. 75.1 and 75.2).

Fig. 75.1 Preoperative MRI

showing severe L5–S1
a b
diskopathy and foramina
stenosis. Sagittal view (a)
shows lumbar loss of lordosis
and compressed S1 root; axial
view (b) showing left
paramedian disk herniation

G. Di Perna (*)
Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy
N. Zullo · E. Bavaresco
Casa di Cura “Città di Bra”, Bra, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 243
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244 G. Di Perna et al.

Fig. 75.2 Postoperative LL

a b
(a) and AP (b) X-ray showing
L5–S1 interbody cages
positioned through anterior
approach and posterior L5–S1
fixation
 Degenerative Lumbar Instability Rigid
Posterior Stabilization 76
Regular Findings

Luigi Manfrè

• Patient with bilateral neurogenic claudication and sciatic 76.1 Preoperative Imaging
pain in L5 dermatometer in L5–S1 listhesis treated by
percutaneous posterior CT-guided stabilization through See Fig. 76.1.
trans-peduncular screw at L4, L5, and S1 (45 mm) and
bars (60 mm).
• CT preoperative imaging and postoperative follow-up.

a b c

Fig. 76.1 CT. MPR sagittal bone window (a), soft tissue window (b), 3D (c). L5 anterolisthesis with L5–S1 foraminal stenosis

L. Manfrè (*)
Department of Neuroradiology, “Cannizzaro” Hospital,
Catania, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 245
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246 L. Manfrè

76.2 Intraoperative Imaging

See Fig. 76.2.

Fig. 76.2 Percutaneous CT-guided stabilization with screws and bars

determines posterior traction on L4 and slight distraction to reopening
L5–S1 foramen
76 Degenerative Lumbar Instability Rigid Posterior Stabilization 247

76.3 Postoperative Follow-Up

See Fig. 76.3.

a b c

Fig. 76.3 CT. MPR bone window sagittal (a, b), 3D (c). Reduction of L5 listhesis, foramen expansion, and disappearance of symptoms in 2 weeks
 Degenerative Lumbar Instability
Stabilization 77
Junctional Syndrome

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with low back pain in vertebral instability treated 77.1 Early Postoperative Follow-Up
by L3–L5 stabilization.
• Early and late XR/CT postoperative follow-up (3 years). See Fig. 77.1.

Fig. 77.1 (a, b) XR lateral

a b
and anteroposterior. Dynamic
acquisitions under
fluoroscopy show regular
lumbar stability

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, Cardarelli Hospital, Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 249
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250 M. Muto et al.

77.2 Postoperative Follow-Up After 3 Years

See Fig. 77.2.

Fig. 77.2 (a, b) Sagittal

a b
MPR L2–L3 junctional
syndrome
77 Degenerative Lumbar Instability Stabilization 251

77.3 Stop of Contrast Media in L2–L3

See Fig. 77.3.

Fig. 77.3 (a, b)

Myelography: lateral and
a b
anteroposterior
 Junctional Syndrome. Lateral Interbody
Fusion and Posterior 78
Decompression-Stabilization
Regular Findings

Emanuele Bavaresco, Nicola Zullo, and Giuseppe Di Perna

• Previous L4–L5 posterior decompression and L4–S1 sta-

bilization. Actual history of low back pain, left radicu-
lopathy and severe neurogenic claudication. At MRI
evidence of high-grade diskopathy at the adjacent seg-
ment (L3–L4) of the previous construct with left disk her-
niation and stenosis, sagittal imbalance was also observed.
• Interbody arthrodesis via XLIF (eXtreme Lateral
Interbody Fusion) approach.
• Pre- and postoperative images (see Figs. 78.1 and 78.2).

a b c

Fig. 78.1 Preoperative MRI showing sagittal (a) and axial (b) views high grade diskopathy at the adjacent segment (L3–L4) of the previous
construct with left disk herniation and stenosis. CT scan showing previous instrumentation (c)

E. Bavaresco · N. Zullo
Casa di Cura “Città di Bra”, Bra, Italy
G. Di Perna (*)
Neurosciences Department “Rita Levi Montalcini”, University of
Turin, Turin, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 253
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254 E. Bavaresco et al.

Fig. 78.2 Postoperative

antero-posterior (a) and
a b
lateral (b) X-ray showing
L3–L4 hyperlordotic
interbody cages fixed with
transomatic screws.
Segmental lordosis gain was
about 20°
 Junction Syndrome. Lateral Interbody
Arthrodesis 79
Regular Findings

Simona Ferri, Rossella Zaccaria, Antonello Curcio,

Fabio Cacciola, and Antonino Germanò

• Previous L4–L5 posterior stabilization. Actual history of 79.1 Postoperative X-Ray

lumbalgia, right L4 radiculopathy, and neurogenic claudi-
cation by L3–L4 canal stenosis and Junctional See Figs. 79.1 and 79.2.
syndrome.
• Interbody arthrodesis via XLIF (eXtreme Lateral
Interbody Fusion) approach.
• Pre- and postoperative images.

Fig. 79.1 Stenosis of the

lateral recesses of L3–L4
associated with
osteochondrosis of the
somatic plates and stenosis of
the right foramen

S. Ferri · R. Zaccaria · A. Curcio (*) · F. Cacciola · A. Germanò

Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 255
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256 S. Ferri et al.

Fig. 79.2 XLIF antero-­

lateral approach: L3–L4
a b
microsurgical diskectomy,
neurocalibration of the
neuroforamina and
arthrodesis with custom-made
cage
 Degenerative Lumbar Instability Rigid
Posterior Stabilization 80
Device Infection

Ferdinando Caranci, Achille Marotta, Domenico Cicala,

and Francesco Briganti

• Patient with pain in vertebral instability and I grade L5– 80.1 Postoperative Follow-Up After
S1 listhesis treated by posterior stabilization through L4– 1 Month
S1 trans-peduncular screws.
• CT/MR postoperative follow-up after 1 and 6 months; See Fig. 80.1.
MR evaluation 3 months after device removal.

a b c d e

Fig. 80.1 STIR sagittal (a–c), fat sat SE T1 coronal (d) and CE coronal (e) sections. T2 hyperintensity of retrovertebral muscles due to edema and
flogosis caudally extending until sacrum bone. CE in the superior part of stabilization device (e)

F. Caranci (*) · F. Briganti

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, Federico II University, Naples, Italy
A. Marotta · D. Cicala
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 257
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258 F. Caranci et al.

80.2 Postoperative Follow-Up After

6 Months

See Figs. 80.2 and 80.3.

Fig. 80.2 STIR sagittal a b c

(a–c), TSE T2 axial sections
(d–g). Slight reduction of
flogosis with inhomogeneous
signal especially in the right
retrovertebral space

d e

f g
80 Degenerative Lumbar Instability Rigid Posterior Stabilization 259

a b c d

e f g h

i j k l

m n o p

Fig. 80.3 CT soft (a–d) and bone window (e–h) sections, MPR sagittal (i–l), coronal sections (m–p). Clod-like calcification in right retrovertebral
muscles surrounding superior part of device (arrow) and extending along the lamina
260 F. Caranci et al.

80.3 Postoperative Follow-Up After

9 Months

See Figs. 80.4 and 80.5.

Fig. 80.4 TSE T2 sagittal a c

b
(a–c), axial (d–g), CE fat sat
T1 axial (h–k) sections.
Reduction of flogosis in
retrovertebral muscles (a–c),
with massive calcification of
right retrovertebral tissues
(arrow, f, k). Bilateral
retrovertebral and right
foraminal CE (arrowhead)

d e

f g
80 Degenerative Lumbar Instability Rigid Posterior Stabilization 261

h i

j k

Fig. 80.4 (continued)

262 F. Caranci et al.

a b

c d

e f g h

i j k l

Fig. 80.5 CT axial (a–d), MPR sagittal (e–h), coronal (i–l) sections. Large calcification of retrovertebral right muscles. Removal of device
(arrow)
 Degenerative Lumbar Instability
Dynamic Stabilization 81
Irregular Positioning of Screws and
Repositioning

Tommaso Scarabino, Michele Maiorano, Tullia Garribba,

Giuseppe Diaferia, and Raniero Mignini

• Patient with low back pain invertebral instability treated 81.1 Early Postoperative Follow-Up
by L4–L5 dynamic stabilization through transpeduncular
screws (Dynesys) and L4 left screw repositioning. See Fig. 81.1.
• XR/CT early postoperative follow-up.

T. Scarabino · M. Maiorano · T. Garribba

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
G. Diaferia · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 263
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264 T. Scarabino et al.

Fig. 81.1 XR anteroposterior

a b
(a), lateral (b), CT axial (c,
d), L4–L5 device. (a, b)
Radio-opaque screws and
radiolucent lateral bars. (b)
Screws (especially left) inside
positioned with respect to
peduncles

c d
81 Degenerative Lumbar Instability Dynamic Stabilization 265

81.2 Postoperative Follow-Up

See Fig. 81.2.

Fig. 81.2 (a–d) CT axial:

a b
screws repositioning

c d
 Degenerative Lumbar Instability.
Screws Loosening and Irregular 82
Positioning
Revision Surgery

Costanzo De Bonis, Domenico Catapano,

and Leonardo Gorgoglione

• Previous rods-screws posterior stabilization. Radiological a b

images showed screws loosening and malposition.
• Revision surgery.
• Pre- and postoperative images (see Figs. 82.1, 82.2, and
82.3).

Fig. 82.1 Pre-revision surgery A-P (a) and L-L (b) X-ray

Fig. 82.2 Pre-revision

a b
surgery axial CT scan: L2
vertebral body (a), note right
screw loosening and
endocanalar position; L3
vertebral body (b), note right
screw endocanalar position

C. De Bonis (*) · L. Gorgoglione

Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy
D. Catapano
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 267
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268 C. De Bonis et al.

Fig. 82.3 Post-revision

surgery axial CT scan: L2
a b
vertebral body (a), note right
screw repositioning; L3
vertebral body (b), note right
screw repositioning
 Degenerative Cervical Instability
Stabilization–Posterior Decompression 83
Screw Rupture

Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi,

Christian Cossandi, Marco Pelle, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with vertebral instability in grade II C1–C2 degen- 83.1 Preoperative Imaging
erative listhesis treated by stabilization through screws
positioned in C1 lateral Process and in C2 isthmus. C0– See Fig. 83.1 and 83.2.
C1 posterior decompression (laminectomy and foramen
opening).
• CT/MR early preoperative imaging and late postoperative
follow-up.

a b c

Fig. 83.1 CT MPR parasagittal (a), sagittal (b), MR FSE T2 sagittal protrusions in C3–C7, interapophyseal arthrosis with yellow ligaments
(c). Anterior C1–C2 grade II listhesis (a, b) and atlas-odontoid arthro- hypertrophy: these alterations cause obliteration of epidural space ante-
sis; restriction of foramen magnum and of bulb-medullary district that rior and posterior
shows T2 hyperintensity for compressive alteration (c). Multiple disk

A. Stecco (*) · F. Fabbiano · S. Ciolfi · M. Pelle · A. Carriero

Department of Radiology, Maggiore della Carità University
Hospital, Novara, Italy
e-mail: [email protected]
C. Cossandi · G. Panzarasa
Department of Neurosurgery, Maggiore della Carità University
Hospital, Novara, Italy

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270 A. Stecco et al.

a b

Fig. 83.2 FSE T2 (a), CT axial (b). Regular C1–C2 alignment. No signs of cord compression and/or myelopathy
83 Degenerative Cervical Instability Stabilization–Posterior Decompression 271

83.2 Postoperative Follow-Up After 1 Year

See Fig. 83.3.

Fig. 83.3 (a, b) CT MPR

a b
sagittal. Left C1 screw
rupture. Further surgery is not
necessary thanks to clinical
stability
 Traumatic Lumbar Dislocation
Percutaneous Stabilization 84
Regular Findings

Gabriele Polonara, Chiara Potente, Roberto Trignani,

and Tommaso Scarabino

• Patient with traumatic L2–L3 dislocation treated by per- 84.1 Preoperative Imaging
cutaneous stabilization through transpeduncular screws
and rigid bars in L2–L3. See Figs. 84.1 and 84.2.
• CT/MR early preoperative imaging and postoperative
follow-up (1 month later).

Fig. 84.1 CT thorax-­

abdomen (a), MPR sagittal
a b
(b). L2–L3 irregular
alignment

G. Polonara (*) · C. Potente

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
R. Trignani
Department of Neurosurgery, University Hospital, Ancona, Italy
T. Scarabino
Department of Radiology—Neuroradiology, Lorenzo Bonomo
Hospital, Andria, Italy

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274 G. Polonara et al.

Fig. 84.2 STIR sagittal (a),

FSE fat sat T2 sagittal (b),
a b
and axial (c). Interspinous
L2–L3 gap and opening of
interapophyseal articulations
in traumatic hyper-flexion.
Complete rupture of L2–L3
yellow and interspinous
ligaments. Posterior L2–L3
disk detachment from L3 with
probably rupture of posterior
longitudinal ligament

c
84 Traumatic Lumbar Dislocation Percutaneous Stabilization 275

84.2 Postoperative Follow-Up After

1 Month

See Fig. 84.3.

Fig. 84.3 FSE T2 sagittal (a)

a b
and axial (b). L2–L3 vertebral
stabilization through
transpeduncular screws and
posterior metallic bars.
Regular alignment and
reduction of interspinous gap
 Dorsal Traumatic D10–D11 Dislocation.
Decompression, Realignment, 85
and Stabilization.
Regular Findings

Domenico Catapano, Costanzo De Bonis,

and Leonardo Gorgolione

• Paraplegia after car accident and D10–D11 dislocation.

• Decompressive laminectomy, realignment, and
stabilization.
• Preoperative CT and MRI scan; postoperative CT scan
(see Figs. 85.1, 85.2, and 85.3).

Fig. 85.1 Preoperative CT

a b
sagittal (a) and axial (b) scan
showing D10–D11 dislocation
with spine canal fractured
bone invasion

D. Catapano (*)
Department of Neurosurgery, “Bonomo” Hospital, Andria, Italy
C. De Bonis · L. Gorgolione
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy

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278 D. Catapano et al.

a b c d

Fig. 85.2 Preoperative MRI T1 sagittal (a), T1 axial (b), T2 sagittal (c), and T2 axial (d) showing D11 translation, spinal injury, subligamentous
hematoma (dashed arrow), and posterior soft tissue injury (solid arrow)

Fig. 85.3 Postoperative CT

scan showing vertebral
a b
realignment, transpedicle
screws stabilization (a), and
spine cord decompression (b)
 Traumatic Dorso-Lumbar Fracture
Combined Dorso-Lumbar Vertebral Stabilization
86
and Somatic Reconstruction

Simona Ferri, Rossella Zaccaria, Antonello Curcio,

Fabio Cacciola, and Antonino Germanò

• 26 year old female. Attempted suicide. No neurological

deficit. Lumbar pain. Traumatic fracture of D12–L1.
• Percutaneus mechanical L1 vertebral height augmenta-
tion and cement injection and D12–L2 rods-screws
stabilization.
• Preoperative and early postoperative MRI (see Figs. 86.1
and 86.2).

Fig. 86.1 Fracture of L1 soma with reduction in height of the anterior

2/3 and retropulsion of the posterosuperior edge toward spinal canal.
The vertebral spongiosa is extensive edematous

S. Ferri · R. Zaccaria · A. Curcio (*) · F. Cacciola · A. Germanò

Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

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280 S. Ferri et al.

Fig. 86.2 Combined approach: D12–L2 ligamentotaxis and stabiliza-

tion with titanium system; L1 percutaneous mechanical vertebral aug-
mentation and cement injection
 Cervical Traumatic Dislocation
Stabilization, Canal Decompression, 87
and Diskectomy
Regular Findings

Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano,

Christian Cossandi, Giuliana Fini, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with grade II C5–C6 anterior traumatic listhesis 87.1 Preoperative Imaging
treated by stabilization through metallic screws, anterior
decompression, diskectomy and intervertebral C5–C6 See Fig. 87.1.
mesh positioning.
• CT/MR preoperative imaging and postoperative
follow-up.

a b c

Fig. 87.1 CT axial (a, b) and MPR sagittal (c). Anterior C5–C6 II grade listhesis with intracanal bone fragment. Further bone fragment is anteri-
orly displaced. Arthrosis

A. Stecco (*) · S. Ciolfi · F. Fabbiano · G. Fini · A. Carriero

Department of Radiology, Maggiore della Carità University
Hospital, Novara, Italy
C. Cossandi · G. Panzarasa
Department of Neurosurgery, Maggiore della Carità University
Hospital, Novara, Italy

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282 A. Stecco et al.

87.2 Postoperative Follow-Up (First

Surgery)

See Fig. 87.2.

Fig. 87.2 FSE T2 (a) STIR

a b
sagittal (b). Stabilization and
regular spine alignment. T2
spinal cord hyperintensity in
C5–C6 due to compression by
median disk hernia and by
yellow ligaments and
interapophyseal articulations
hypertrophy
87 Cervical Traumatic Dislocation Stabilization, Canal Decompression, and Diskectomy 283

87.3 Postoperative Follow-Up (Re-surgery)

See Fig. 87.3.

Fig. 87.3 CT axial (a) and

MPR sagittal (b). Diskectomy a b
and C5–C6 intervertebral
mesh positioning. Regular
alignment and positioning of
mesh and metallic screws
 Traumatic Cervical Fracture-Dislocation.
Conservative Treatment 88
Delayed Impaired Consolidation

Achille Marotta, Domenico Cicala, Carmen Castagnolo,

Luca Brunese, and Ferdinando Caranci

• Patient with C7–D1 fracture/dislocation (fell out of bed) 88.1 Pre-treatment Imaging
conservatively treated by cervical collar (stabilization not
possible for clinical conditions). C7–D1 fracture-dislocation (peduncle/lamina). C6–D1
• CT/MR pre-treatment imaging and follow-up after 2 and edema with related disk T2 hyperintensity; small epidural
4 months. hematoma (arrow), pre- and retrovertebral edema due to lig-
ament distraction (STIR). No signal alteration of spinal cord.
See Fig. 88.1.

a b c d e f

Fig. 88.1 SE T1 (a, b), FSE T2 (c, d), STIR (e, f) sagittal sections

A. Marotta · D. Cicala · C. Castagnolo

Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy
L. Brunese
Radiology, Department of Health Science, University of Molise,
Campobasso, Italy
F. Caranci (*)
Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy

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286 A. Marotta et al.

88.2 Follow-Up After 2 Months

of Conservative Treatment

C6–C7 structural collapse with irregular endplates. See Figs.

88.2, 88.3.

a b c d e f

Fig. 88.2 SE T1 (a, b), FSE T2 (c, d), STIR (e, f) sagittal sections. Reabsorption of epidural hematoma at C7–D1; C6–C7 eight reduction and
anterior wedging. C5–C7 edema

Fig. 88.3 (a, b) MPR CT

reconstructions. Bone
a b
morphologic abnormalities
are more clearly depicted,
with C5–C7 collapse and
C6–C7 anterior wedging
88 Traumatic Cervical Fracture-Dislocation. Conservative Treatment 287

88.3 Follow-Up After 4 Months

C5–C7 collapse, unchanged remaining findings. See Figs.

88.4, 88.5.

a b c d e f

Fig. 88.4 SE T1 (a, b), FSE T2 (c, d), STIR (e, f) sagittal sections. Signal alteration improvement, no further collapses. Persisting instability with
C7–D1 dislocation, C6 retrolisthesis with cord compression

Fig. 88.5 (a–d) MPR CT

a b
sagittal reconstructions

c d
 Traumatic Cervical Dislocation
and Fracture Anterior Stabilization 89
Regular Findings

Tommaso Scarabino, Michela Capuano,

Roberto Stanzione, Giuseppe Carmine Iaffaldano,
and Michele Santoro

• Patient with C6–C7 traumatic dislocation and fracture at 89.1 Preoperative Imaging
first conservatively and then treated by anterior stabiliza-
tion (anterior plate fixed by screws at C6–C7). See Fig. 89.1.
• Preoperative imaging and early XR postoperative
follow-up.

T. Scarabino (*) · R. Stanzione

Department of Radiology—Neuroradiology, Lorenzo Bonomo
Hospital, Andria, Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
G. C. Iaffaldano · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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290 T. Scarabino et al.

a b c

d e f

g h

i j k

Fig. 89.1 CT axial (a–f), MPR sagittal (g, h), SE T1 (i), FSE T2 (j), (i–k) C7–D1 soft tissue thickening due to anterior longitudinal align-
STIR (k). C6–C7 fracture and dislocation with involvement of pedun- ment lesion (j, k). Disk involvement with STIR hyperintensity (k)
cles, transverse processes and C6. Epidural hematoma starting from C7
89 Traumatic Cervical Dislocation and Fracture Anterior Stabilization 291

89.2 Post-Treatment Conservative

Follow-Up

See Fig. 89.2.

a b

Fig. 89.2 XR presurgery (a), MPR sagittal CT (b), SE T1 (c), and FSE T2 (d). Regular alignment after C6–C7 conservative treatment
292 T. Scarabino et al.

c d

Fig. 89.2 (continued)

89 Traumatic Cervical Dislocation and Fracture Anterior Stabilization 293

89.3 Early Postoperative Follow-Up

See Fig. 89.3.

Fig. 89.3 XR antero-­

a b
posterior (a), and lateral (b).
C6-C7 anterior stabilization
 Traumatic Cervical Fracture-Dislocation.
Anterior and Posterior Approach 90
Regular Findings

Giuseppe Diaferia, Giuseppe Carmine Iaffaldano,

Mario Bianco, Francesco Paradiso, Michele Santoro,
and Domenico Catapano

• Severe tetraparesis after car accident. Radiological exams

showed C5–C6 fracture-dislocation.
• Anterior and posterior stabilization.
• Pre- and postoperative images (see Figs. 90.1, 90.2, and
90.3).

Fig. 90.1 Preoperative

a b
sagittal T2 (a) and STIR (b)
MRI showing C4–C5
dislocation. Note spinal cord
compression and myelopathy
signal

G. Diaferia · G. C. Iaffaldano · M. Bianco · F. Paradiso ·

M. Santoro · D. Catapano (*)
Neurosurgical Operative Unit, “L. Bonomo” Hospital,
Andria, Italy

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296 G. Diaferia et al.

a b c

Fig. 90.2 Preoperative sagittal median (a), left paramedian (b), axial (c), and post-rendering (d) CT showing C4–C5 dislocation and left joint
fracture (arrow)
90 Traumatic Cervical Fracture-Dislocation. Anterior and Posterior Approach 297

a b

Fig. 90.3 Postoperative sagittal (a) and axial (b) CT showing: anterior stabilization with plate-screws and arthrodesis with titanium cage; poste-
rior stabilization by wiring of spinous process
 Scoliosis Stabilization
Spinal Cord Ischemia
91
Ferdinando Caranci, Andrea Elefante, Domenico Cicala,
and Francesco Briganti

• 14 year old patient with severe scoliosis treated by stabi- 91.1 Preoperative Imaging
lization device
• Preoperative imaging: early (24 h) and late (20 days) See Fig. 91.1.
postoperative follow-up.

Fig. 91.1 XR antero-­ a b

posterior (a) and lateral (b)
views. Right-convex
thoraco-lumbar scoliosis,
reduction of sagittal curves

F. Caranci (*) · A. Elefante · F. Briganti

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, Federico II University, Naples, Italy
D. Cicala
Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua, CE, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 299
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300 F. Caranci et al.

91.2 Postoperative Follow-Up After 24 h

See Fig. 91.2.

Fig. 91.2 RM TSE T2 a b

sagittal (a–b), GE T2* axial
(c–f). Susceptibility artifacts
(due to metallic distractor)
until D3. C5–D1 spinal cord
enlargement (a–b), with grey
substance hyperintensity (c–f)
due to ischemia

c d

e f
91 Scoliosis Stabilization 301

91.3 Postoperative Follow-Up After

20 Days

See Fig. 91.3.

Fig. 91.3 TSE T2 sagittal

(a–b) sections. Ischemic area
a b
reduction, corresponding to
clinical improvement
 Kyphoscoliosis Stabilization CSF Fistula
CSF Fistula
92
Simone Salice, Domenico Tortora, Valentina Panara,
Massimo Caulo, and Armando Tartaro

• Patient with severe kyphoscoliosis treated by transpedicu- a b

lar bars, screws, and multiple laminectomy
• Postoperative follow-up

92.1 Postoperative Follow-Up

See Fig. 92.1.

Fig. 92.1 (a–c) FSE T1 and STIR sagittal (a, b) FSE T2 axial (c). CSF
in paravertebral soft tissue fistula-supplied
S. Salice · D. Tortora · V. Panara · M. Caulo · A. Tartaro (*)
Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, “G. D’Annunzio” University,
Chieti-Pescara, Italy
e-mail: [email protected]

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304 S. Salice et al.

Fig. 92.1 (continued)

 Osteoporotic Lumbar Collapse
Vertebroplasty 93
Regular Findings

Francesco Fabbiano, Alessandro Stecco, Silvio Ciolfi,

Emanuele Malatesta, Alessio Usurini, Rita Fossaceca,
and Alessandro Carriero

• Patient with osteoporotic L1 collapse treated by 93.1 Preoperative Imaging

vertebroplasty
• Preoperative imaging and postoperative late MR follow- See Fig. 93.1.
­up (8 months) that shows further D12 collapse

a b

Fig. 93.1 (a–g) XR (a), CT MPR sagittal (b), SE T1 sagittal (c), FSE T2 sagittal (d) and coronal (e) STIR sagittal (f), GE axial (g). L1 collapse,
edema pattern (hyperintensity in f), intracanalar expansion of rear profiles with anterior epidural space obliteration, no compressive myelopathy

F. Fabbiano · A. Stecco (*) · S. Ciolfi · A. Usurini · R. Fossaceca

A. Carriero
Department of Radiology, Maggiore della Carità University
Hospital, Novara, Italy
E. Malatesta
Department of Radiology, Maggiore della Carità University
Hospital, Novara, Italy
Department of Radiology - Neuroradiology, L. Bonomo Hospital,
Andria, Italy

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306 F. Fabbiano et al.

c d e

f g

Fig. 93.1 (continued)

93 Osteoporotic Lumbar Collapse Vertebroplasty 307

93.2 Post-vertebroplasty Follow-Up

(8 Months)

See Fig. 93.2.

Fig. 93.2 (a–d) SE T1 (a),

a b
FSE T2 (b), STIR (c), sagittal,
FSE T2 axial (d). L1 cement
hypointensity, edema
improvement. Unchanged L1,
no myelopathy. In D12
superior profile depression,
STIR hyperintensity for
edema and slight posterior
dislocation of posterosuperior
edge. The disk in D11–D12
shows high signal
hyperintensity T2/STIR for
inflammatory involvement
(“hot disk”); it is associated
with median-left paramedian
disk protrusion, no
myelopathy. Further
vertebroplasty in D12 is
required

c d
 Traumatic Lumbar Fracture,
Vertebroplasty 94
Regular Findings

Giuseppe Carmine Iaffaldano, Pasquale Crudele,

Giuseppe Diaferia, Francesco Paradiso, Michele Santoro,
and Domenico Catapano

• Lumbalgia after accidental fall. MRI showed L1 left half

body wedge-compression fracture.
• Vertebroplasty.
• Pre-, intra-, and postoperative images (see Figs. 94.1 and
94.2).

G. C. Iaffaldano · P. Crudele · G. Diaferia · F. Paradiso · M. Santoro

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

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310 G. C. Iaffaldano et al.

Fig. 94.1 Preoperative MRI:

left paramedian sagittal STIR
a b
(a) and axial T2 (b) images
showing the fracture; axial T2
(c) and sagittal STIR (d)
through the left pedicle

c d
94 Traumatic Lumbar Fracture, Vertebroplasty 311

Fig. 94.2 Intraoperative A-P

a b
(a) and L-L (b) fluoroscopy
during percutaneous trans left
pedicle cement injection.
Fluoroscopy at the end of
procedure in A-P (c) and L-L
(d) projection

c d
 Traumatic Lumbar Collapse:
Percutaneous Mechanical Vertebral 95
Augmentation
Regular Findings

Giuseppe Diaferia, Pasquale Crudele, Stefania D’Avanzo,

Mario Bianco, Claudia Pennisi, and Domenico Catapano

• Traumatic L1 vertebral body collapse. Lumbar CT and

MRI showed L1 wedge-compression (A1, AO Spine
Classification) fracture.
• Percutaneous mechanical vertebral augmentation and
cement injection.
• Pre- and postoperative images (see Figs. 95.1, 95.2, and
95.3).

Fig. 95.1 Preoperative

sagittal (a) and axial (b) CT
a b
scan showing L1 wedge-­
compression fracture

G. Diaferia · P. Crudele · S. D’Avanzo · M. Bianco · C. Pennisi

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

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314 G. Diaferia et al.

a b c d

Fig. 95.2 Preoperative sagittal T1 (a), T2 (b), STIR (c), and axial T2 (d) MRI showing L1 wedge-compression fracture

Fig. 95.3 Vertebral body

height and kyphosis angle
a b
before (a and b) and after (c
and d) treatment. Note
vertebral body height
augmentation and kyphosis
angle reduction after
percutaneous mechanical
vertebral augmentation and
cement injection

c d
 Dorsal Osteoporotic Collapse
Vertebroplasty 96
Intracanalar Cement Leakage

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with D6 osteoporotic collapse treated by 96.1 Early Post Vertebroplasty Follow-Up
vertebroplasty
• XR/CT/MR early and late follow-up See Figs. 96.1 and 96.2.

Fig. 96.1 (a, b) Dorsal

a b
fluoroscopy lateral (a)
posteroanterior (b).
Intracanalar cement leakage
at D6

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 315
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316 M. Muto et al.

Fig. 96.2 (a, b) CT axial (a) a b

MPR sagittal (b). Intracanalar
left posterolateral cement
leakage

96.2 Late Post Vertebroplasty Follow-Up

See Fig. 96.3.

Fig. 96.3 FSE T2 sagittal. Intracanalar cement compresses spinal

cord, no myelopathy
 Osteoporotic Dorsal Collapse
Vertebroplasty 97
Spondylitis

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with D9 osteoporotic collapse (ESR and PCR 97.1 Post-vertebroplasty Follow-Up
increase, fever) treated by vertebroplasty at D8–D9
• MR follow-up See Fig. 97.1.

a b

Fig. 97.1 (a, b) SE T1 and FSE T2 sagittal (a) CE fat sat T1 (c). D8 infectious spondylitis (T1 and T2 hypointensity a), pathological subchondral
CE extending in paravertebral soft tissue (b)

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 317
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318 M. Muto et al.

Fig. 97.1 (continued)

 Osteoporotic Lumbar Collapse
Kyphoplasty 98
No Vertebral Growth

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with L3 osteoporotic collapse treated by 98.1 Early Post-kyphoplasty Follow-Up

kyphoplasty
• Early and late post-kyphoplasty XR follow-up See Fig. 98.1.

Fig. 98.1 (a, b) XR a b

posteroanterior (a) and lateral
(b). L3 height restoration, no
cement leakage

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 319
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320 M. Muto et al.

98.2 Post-kyphoplasty Follow-Up (2 Years)

See Fig. 98.2.

Fig. 98.2 (a, b) XR PA (a)

and LL (b). L3 superior a b
profile depression and height
reduction
 Traumatic Lumbar Collapse
Vertebroplasty 99
Extracanalar Cement Leakage

Tommaso Scarabino, Michele Maiorano, Claudia Rutigliano,

Vincenzo Brandini, and Michele Santoro

• Patient with L3 post-traumatic vertebral collapse treated 99.1 Post-vertebroplasty Follow-Up

by vertebroplasty
• Early XR follow-up See Fig. 99.1.

Fig. 99.1 (a, b) XR a b

antero–posterior (a) and
lateral (b). Cement in left
paravertebral space, no
symptoms

T. Scarabino (*) · M. Maiorano

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
C. Rutigliano
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
V. Brandini · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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 Multiple Lumbar Traumatic Collapses
Vertebroplasty 100
Intra-extracanalar Cement Leakage

Tommaso Scarabino, Angela Lorusso, Saverio Pollice,

Giuseppe Carmine Iaffaldano, and Raniero Mignini

• Patient with L1–L3 posttraumatic collapses treated by 100.1 Preoperative Imaging

vertebroplasty.
• MR preoperative imaging and CT follow-up. See Fig. 100.1.

a b c

Fig. 100.1 (a–c) SE T1 (a), FSE T2 (b), STIR (c) sagittal. Partial L1 and L3 collapses with superior profile depression, edema pattern, and normal
rear profile

T. Scarabino (*) · A. Lorusso

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, Trani,
Italy
G. C. Iaffaldano · R. Mignini
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

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324 T. Scarabino et al.

100.2 Post-vertebroplasty Follow-Up

See Fig. 100.2.

a b

c d

e f g

h i

Fig. 100.2 (a–i) CT axial (a–d), MPR sagittal (e–g), coronal (h–i). Bilateral anterior cement endocanalar leakage (c–d–f–g); right extracanalar
leakage (a–b–e–h–i)
 Multiple Dorsal-Lumbar Traumatic
Collapses Vertebroplasty 101
Intra-canalar Cement Leakage

Tommaso Scarabino, Michele Maiorano, Tullia Garribba,

Vincenzo Brandini, and Raniero Mignini

• Patient with D12–L1 post-traumatic collapses treated by 101.1 Preoperative Imaging

vertebroplasty
• XR/CT/MR preoperative imaging and early XR/MR See Fig. 101.1.
follow-up

T. Scarabino · M. Maiorano · T. Garribba

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
V. Brandini · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 325
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326 T. Scarabino et al.

a b

Fig. 101.1 (a–f) XR anteroposterior (a–b) lateral (c), MPR sagittal CT (c), SE T1 (d), FSE T2 (e), STIR (f). D12–L1 superior profile depression.
Edema pattern: T1 hypointensity (d), T2 iso-/hyperintensity (f)
101 Multiple Dorsal-Lumbar Traumatic Collapses Vertebroplasty 327

b c d

Fig. 101.1 (continued)

328 T. Scarabino et al.

101.2 Early Post-vertebroplasty Follow-Up

See Figs. 101.2 and 101.3.

a b c

Fig. 101.2 (a–c) XR anteroposterior (a–b), lateral (c). D12 and L1 vertebroplasty (partially collapsed). Posterior cement leakage at L1 (c)
101 Multiple Dorsal-Lumbar Traumatic Collapses Vertebroplasty 329

a b c

Fig. 101.3 (a–c) FSE T2 sagittal (a), right para-sagittal (b), axial (c). D12–L1 superior profile depression post-vertebroplasty. Epidural right
cement leakage. No symptoms
 Traumatic Dorsal Collapse
Vertebroplasty 102
Intra-canalar Cement Leakage

Tommaso Scarabino, Fabio Quinto, Saverio Lorusso,

Francesco Paradiso, and Raniero Mignini

• Patient with post-traumatic D12 collapse treated by 102.1 Preoperative Imaging

vertebroplasty
• MR preoperative imaging and XR/CT early follow-up See Fig. 102.1.

T. Scarabino · F. Quinto
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Lorusso
Department of Radiology-Neuroradiology, L. Bonomo Hospital,
Andria, Italy
F. Paradiso · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 331
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332 T. Scarabino et al.

a b c

Fig. 102.1 (a–c) SE T1 (a), FSE (T2) (b), STIR (c) sagittal. Post-traumatic partial D12 collapse with superior profile depression, edema pattern
(T1 hypointensity, T2 iso-hyperintensity, STIR hyperintensity), and regular rear profile

102.2 Early Post-vertebroplasty Follow-Up See Fig. 102.2.

102 Traumatic Dorsal Collapse Vertebroplasty 333

Fig. 102.2 (a–h) XR

a b
anteroposterior (a), lateral
(b), CT axial (c–f), MPR
sagittal (g), right parasagittal
(h), cement rear overflowing
in D12 vertebroplasty (a).
c–h, epidural cement leakage

c d
334 T. Scarabino et al.

e f

g h

Fig. 102.2 (continued)

 Traumatic Lumbar Collapse Rigid
Stabilization and Vertebral Body 103
Stenting
Regular Findings

Chiara Potente, Roberto Trignani, Tommaso Scarabino,

and Gabriele Polonara

• Patient with L1 and L4 collapse treated by stabilization 103.1 Preoperative Imaging

through transpedicular screws and rigid bars in D12–L2
and by L4 vertebral body stenting See Fig. 103.1.
• Preoperative imaging and early CT postoperative
follow-up

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
R. Trignani
Department of Neurosurgery, University Hospital, Ancona, Italy
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 335
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336 C. Potente et al.

a b c

d e

Fig. 103.1 (a–e) Thorax-abdomen CT. MPR sagittal (a, c), coronal (b), axial images at L1 (d) and L4 (e). L1 fracture and anterior wedging with
backing of posterosuperior edge (a, c, d); superior fracture of L4 with backing of the posterosuperior edge (a, b, c, e)

103.2 Postoperative Follow-Up

See Fig. 103.2

103 Traumatic Lumbar Collapse Rigid Stabilization and Vertebral Body Stenting 337

a b c

d e f g

h i

Fig. 103.2 (a–i) CT axial at L1 (a, b) and L4 (c). MPR sagittal (d−g) e). L1 stabilization by bar and metallic screws at D12–L2 (f–i) and ver-
and coronal (h, i). Cord decompression by L1 bilateral laminectomy tebral body stenting at L4 (c–i). Narrowing of canal at L4 due to the
and L1–L2 aphophyses removal (a, b, d, e). Relocation of L1 edge (d, presence of bone fragment (c–e)
 Lumbar Collapse in Lymphoma
Vertebroplasty 104
Intervertebral Cement Leakage

Sivio Ciolfi, Alessandro Stecco, Francesco Fabbiano,

Emanuele Malatesta, Alberto Zuccalà, Rita Fossaceca,
and Alessandro Carriero

• Patient 80 years old with L5 pathological collapse treated 104.1 Preoperative Imaging
by vertebroplasty through right transpedicular approach
• Preoperative imaging and early/late MR follow-up See Fig. 104.1.

a b c

Fig. 104.1 (a–c) CT MPR sagittal (a), FSE T2 (b) STIR (c) sagittal. Biconcave lens L5 pathological fracture (T2 hyperintensity), grade I listhesis
(L4–L5 and L5–S1) with restriction of spine canal; L4–L5 and L5–S1 protrusions

S. Ciolfi · A. Stecco (*) · F. Fabbiano · A. Zuccalà · R. Fossaceca

A. Carriero
Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
E. Malatesta
Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
Department of Radiology - Neuroradiology, L. Bonomo Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 339
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340 S. Ciolfi et al.

104.2 Postoperative Follow-Up

See Fig. 104.2.

a b c

Fig. 104.2 (a–c) CT MPR coronal (a) and sagittal (b–c). Cement in L5–S1 intervertebral space. Unchanged L5
104 Lumbar Collapse in Lymphoma Vertebroplasty 341

104.3 Late Postoperative Follow-Up

See Fig. 104.3.

a b c

Fig. 104.3 (a–c) SE T1 (a–b) and FSE T2 (c). Small cement hypointensity in L5–S1. Further L5 height reduction, unchanged L4–L5 and L5–S1
listhesis. No more appreciable L5 malignant tissue
 Malignant Dorsal Collapse
Vertebroplasty 105
Extra-axial Hematoma

Ferdinando Caranci, Andrea Elefante, Antonio Volpe,

and Francesco Briganti

• D11 malignant collapse treated by vertebroplasty 105.1 Preoperative Imaging

• Preoperative imaging and CT/MR follow-up
See Figs. 105.1, 105.2, and 105.3.

F. Caranci (*) · A. Elefante · A. Volpe · F. Briganti

Advanced Biomedical Sciences Department, Unit of
Neuroradiology, “Federico II” University, Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 343
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344 F. Caranci et al.

a b c

Fig. 105.1 (a–c) SE T1 (a), TSE T2 (b) STIR (c) sagittal sections. D11 malignant collapse with posterior profile overflowing and compressing
conus
105 Malignant Dorsal Collapse Vertebroplasty 345

Fig. 105.2 (a–d) CT axial

sections. D11 lytic alteration
a b
involving both peduncles
(mostly left)

c d
346 F. Caranci et al.

Fig. 105.3 (a–d) CT axial

sections. Epidural cement
a b
leakage

c d

105.2 Post-vertebroplasty Follow-Up

See Fig. 105.4.

105 Malignant Dorsal Collapse Vertebroplasty 347

Fig. 105.4 (a–f) SE T1 (a),

a b
TSE T2 (b) sagittal, TSE T2
axial (c–f) sections. Extra-­
axial blood collection
extending in D8–L2 epidural
space. Secondary
compression of spinal cord
with signs of myelopathy

c d

e f
 Lumbar Collapse in Chordoma Vertebral
Drawing 106
Regular Findings

Tommaso Scarabino, Fabio Quinto, Michele Maiorano,

Michela Capuano, and Saverio Pollice

• Patient with L1 collapse treated by drawing and D11–L3 106.1 Preoperative Imaging
stabilization through transpedicular screws, bars and cage
• Preoperative imaging and early/late MR follow-up See Fig. 106.1.

a b c d

Fig. 106.1 (a–f) RM SE T1 (a), FSE T2 (b), STIR sagittal (c), CE T1 sagittal (d), and axial (e–f). L1 partial collapsed (T1 hypointensity, T2/STIR
hyperintensity) and pathological CE. Intracanalar expansion

T. Scarabino (*) · F. Quinto · M. Maiorano

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, Trani,
Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 349
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350 T. Scarabino et al.

e f

Fig. 106.1 (continued)

106 Lumbar Collapse in Chordoma Vertebral Drawing 351

106.2 Early Postoperative Follow-Up

See Fig. 106.2.

a b c d

e f

Fig. 106.2 (a–f) SE T1 (a), FSE T2 (b), STIR (c) sagittal, CE T1sagittal (d) and axial (e–f). Postsurgery susceptibility artifacts. D12–L2 retro-
vertebral fluid collection. CE of surrounding soft tissue in reactive flogosis
352 T. Scarabino et al.

106.3 Postoperative Follow-Up 6 Months

See Fig. 106.3.

a b c

Fig. 106.3 (a–d) SE T1 (a), STIR (b) sagittal, CE T1 sagittal (c) and axial (d). Regular findings
 Dorsal Collapse in Multiple Myeloma
Vertebroplasty 107
Spondylitis

Mario Muto, Gianluigi Guarnieri, and Roberto Izzo

• Patient with D8 collapse by vertebroplasty. Recurrence of 107.1 Early Postvertebroplasty Follow-Up

pain (ESR and PCR increase, fever)
• Early and late MR follow-up (6 months/1 year) See Figs. 107.1 and 107.2.

M. Muto (*) · G. Guarnieri · R. Izzo

Department of Neuroradiology, “Cardarelli” Hospital,
Naples, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 353
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354 M. Muto et al.

Fig. 107.1 (a–c) STIR

a b
sagittal (a), CE fat sat T1
sagittal (b) axial (c). D8–D9
infectious spondylitis (T2
hyperintensity) (a) and D8
pathological CE (b) with
expansion in surrounding soft
tissue (c)

c
107 Dorsal Collapse in Multiple Myeloma Vertebroplasty 355

Fig. 107.2 (a, b) MPR

a b
sagittal (D8 erosion and
collapse)
356 M. Muto et al.

107.2 Postvertebroplasty Follow-Up After 6

Months

See Fig. 107.3.

Fig. 107.3 (a–c) FSE T2

a b
sagittal (a) CE fat sat T1
sagittal (b) axial (c). CE and
T2 hyp reduction at D8–D9
(a–b). Persisting flogosis (c)

c
107 Dorsal Collapse in Multiple Myeloma Vertebroplasty 357

107.3 Postvertebroplasty Follow-Up After

1 Year

See Fig. 107.4.

a b c

Fig. 107.4 (a–c) SE T1 (a) FSE T2 (b) sagittal, MPR sagittal (c). Complete regression after antibiotics. D8 sclerosis (low signal) and D7 intra-
canalar backing, no symptoms
 Malignant Lumbar Collapse Thermal
Ablation Through Radiofrequency 108
and Vertebroplasty
Paravertebral Necrotic Collection

Simone Salice, Domenico Tortora, Valentina Panara,

Massimo Caulo, and Armando Tartaro

• Patient with L3 malignant collapse in breast cancer treated 108.1 Preoperative Imaging
by thermal ablation with radiofrequency and L3 transpe-
dicular percutaneous vertebroplasty See Fig. 108.1.
• Preoperative imaging and early/late MR follow-up

Fig. 108.1 (a, b) SE T1 (a)

a b
STIR (b) sagittal. L3 collapse

S. Salice · D. Tortora · V. Panara · M. Caulo · A. Tartaro (*)

Department of Neurosciences and Imaging, Institute of Advanced
Biomedical Technologies, G. D’Annunzio University,
Chieti-Pescara, Italy
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 359
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360 S. Salice et al.

108.2 Postoperative Follow-Up

See Fig. 108.2.

Fig. 108.2 (a–d) SE T1 and

STIR sagittal (a–b), T2 and
a b
CE fat sat T1 axial (c–d). L3
thermal ablation and
vertebroplasty (a–b) with
necrotic collection along
surgical breach (c–d), left
psoas involvement (d)

c d
108 Malignant Lumbar Collapse Thermal Ablation Through Radiofrequency and Vertebroplasty 361

108.3 Postoperative Follow-Up After 6

Months

See Fig. 108.3.

Fig. 108.3 (a–d) SE T1 and

a b
STIR sagittal (a–b), FSE T2
and CE fat sat T1 axial (c–d).
Collection resorption (c) and
CE reduction (d)

c d
 Dorsal Collapse in Myeloma:
Percutaneous Mechanical Vertebral 109
Augmentation
Regular Finding

Pasquale Crudele, Giuseppe Carmine Iaffaldano,

Giuseppe Diaferia, Francesco Paradiso, Michele Santoro,
and Domenico Catapano

• Patient with D8 vertebral body collapse in myeloma

• Percutaneous mechanical vertebral augmentation and
cement injection
• Preoperative and intraoperative images (see Figs. 109.1,
109.2, and 109.3)

a b c

Fig. 109.1 Preoperative T1 (a), T2 (b), and STIR (c) MRI showing D8 vertebral body collapse

P. Crudele · G. C. Iaffaldano · G. Diaferia · F. Paradiso · M. Santoro

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 363
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364 P. Crudele et al.

a b c

Fig. 109.2 L-L Intraoperative fluoroscopy: percutaneous transpedicular vertebral body access (a); mechanical vertebral augmentation (b); cement
injection (c)

Fig. 109.3 Intraoperative

fluoroscopy: L-L (a) and A-P
a b
(b) final findings
 Dorsal Collapse in Myeloma
Stabilization 110
Sequelae

Teresa Popolizio, Giuseppe Guglielmi, and Rosy Setiawati

• Patient with D6 collapse in myeloma treated by D3–D5 110.1 Preoperative Imaging

and D7–D9 posterior stabilization
• Preoperative imaging and MR follow-up See Fig. 110.1.

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
G. Guglielmi
Department of Radiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
Department of Radiology, University of Foggia, Foggia, Italy
R. Setiawati
Department of Radiology, Rumah Satik Surabaya International
Hospital, Surabaya, Indonesia

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 365
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366 T. Popolizio et al.

Fig. 110.1 (a–b) SE T1 (a),

a b
FSE T2 (b) sagittal. D6
collapse with bone marrow
replacement by soft tissue
mass extending in the anterior
epidural space and
compressing spinal cord
110 Dorsal Collapse in Myeloma Stabilization 367

110.2 Postoperative Imaging

See Fig. 110.2.

Fig. 110.2 FSE T2 sagittal. D6 post surgery collapse: no further epi-

dural mass or cord compression. Metallic artifacts
 Neoplastic Cervical Dislocation-­Collapse
Vertebral Removal 111
Regular Findings

Tommaso Scarabino, Fabio Quinto, Claudia Suriano,

Francesco Paradiso, and Michele Santoro

• Patient with C2–C3 neoplastic dislocation collapse. 111.1 Preoperative Imaging

Prosthesis positioning at C2 and C4
• XR preoperative imaging and early XR/MR follow-up See Fig. 111.1.

T. Scarabino (*) · F. Quinto

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
C. Suriano
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
F. Paradiso · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 369
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370 T. Scarabino et al.

Fig. 111.1 (a–c) XR max

a
extension lateral (a), SE T1
(b) and STIR (c). C2–C3
fracture dislocation. C3
collapse, edema pattern (b–c),
and spinal cord compression.
Both findings are malignant

b c
111 Neoplastic Cervical Dislocation-Collapse Vertebral Removal 371

111.2 Early Postoperative Follow-Up

See Fig. 111.2.

Fig. 111.2 (a–c) XR lateral.

Vertebral removal and
a b
prosthesis positioning in C3

c
372 T. Scarabino et al.

111.3 Postoperative Follow-Up After 3

Months

See Fig. 111.3.

Fig. 111.3 (a, b) SE T1 (a)

a b
and FSE T2 (b) sagittal.
Susceptibility
artifacts at C2–C4
 Traumatic Lumbar Fracture: Somatic
Reconstruction 112
Regular Findings

Simona Ferri, Rossella Zaccaria, Antonello Curcio,

Fabio Cacciola, and Antonino Germanò

• A 21-year-old female. No neurological deficit. L1 verte- See Figs. 112.1 and 112.2.
bral body fracture (type A.3, AO Spine Classification)
• Percutaneous mechanical vertebral augmentation and
cement injection
• Preoperative and early postoperative MRI

Fig. 112.1 Preoperative MRI showing reduction in height of the verte-

bra body, measured as the distance between upper and lower plate

S. Ferri · R. Zaccaria · A. Curcio (*) · F. Cacciola · A. Germanò

Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 373
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374 S. Ferri et al.

Fig. 112.2 Percutaneous

mechanical vertebral
augmentation and cement
injection. Notice the
augmentation of vertebra
body height
 Traumatic Lumbar Collapse
Stabilization and Canal Decompression 113
Regular Findings

Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano,

Christian Cossandi, Rita Merla, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with L2 traumatic collapse treated by L1–L2–L3 113.1 Preoperative Imaging

stabilization through transpedicular screws and L2–L3
bilateral laminotomy See Fig. 113.1.
• Preoperative imaging and CT follow-up

a b c

Fig. 113.1 (a–c) XR lateral (a), CT axial (b), and MPR sagittal (c). (a) L2 superior profile depression with intracanalar fractured fragment that
compresses dural sac. (b) L2 multifragmentary fracture with intracanalar fragment dislocation. Further fragment is anteriorly displaced

A. Stecco · S. Ciolfi · F. Fabbiano · R. Merla · A. Carriero (*)

Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
C. Cossandi · G. Panzarasa
Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 375
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376 A. Stecco et al.

113.2 Postoperative Follow-Up

See Fig. 113.2.

Fig. 113.2 (a, b) CT axial

a b
(a) and MPR sagittal (b).
Devices correctly positioned
with regular alignment
 Traumatic Lumbar Collapse Double
Stabilization and Decompression 114
Regular Findings

Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano,

Rita Merla, Giuliano Allegra, Gabriele Panzarasa,
and Alessandro Carriero

• Patient with L4 traumatic collapse treated by L3–L5 pos- 114.1 Preoperative Imaging
terior stabilization through transpedicular screws, L3
decompression, L3 prosthesis positioning after 4 months See Fig. 114.1.
(Obelisc) through anterolateral approach
• Preoperative imaging and XR/CT follow-up

A. Stecco · S. Ciolfi · F. Fabbiano · R. Merla · A. Carriero (*)

Department of Radiology, “Maggiore Della Carità” University
Hospital, Novara, Italy
G. Allegra · G. Panzarasa
Department of Neurosurgery, “Maggiore Della Carità” University
Hospital, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 377
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378 A. Stecco et al.

Fig. 114.1 (a–c) SE T2 (a), b

a
STIR (b) sagittal, SE T2
sagittal (c). L4
plurifragmentary fracture with
rear profile overflowing,
restriction of spine canal and
dural sac compression (a, b).
STIR (b) L4 edema. Dural sac
compression

c
114 Traumatic Lumbar Collapse Double Stabilization and Decompression 379

114.2 Postoperative Follow-Up After 1st

Surgery

See Fig. 114.2.

Fig. 114.2 (a, b) XR lateral

a b
(a), CT axial (b).
Stabilization. Posterior profile
L4 dislocation. (b)
Transpedicular screw
correctly positioned
380 A. Stecco et al.

114.3 Postoperative Follow-Up After 2nd

Surgery

See Fig. 114.3.

Fig. 114.3 MPR sagittal. “Obelisc cage” at L4 with reduction of L4

posterior profile retropulsion, no symptoms
 Multiple Traumatic Dorsal Collapses
Double Stabilization 115
Regular Findings

Alessandro Stecco, Silvio Ciolfi, Francesco Fabbiano,

Rita Merla, Christian Cossandi, Giuliano Allegra,
Gabriele Panzarasa, and Alessandro Carriero

• Patient with D6–D11 traumatic collapses treated by pos- 115.1 Preoperative Imaging
terior double stabilization through transpedicular screws
at D10, D11, and D12. D10–D11 laminectomy See Fig. 115.1.
• Preoperative imaging and XR/CT follow-up

A. Stecco (*) · S. Ciolfi · F. Fabbiano · R. Merla · A. Carriero

Department of Radiology, “Maggiore della Carità University
Hospital”, Novara, Italy
C. Cossandi · G. Allegra · G. Panzarasa
Department of Neurosurgery, “Maggiore della Carità University
Hospital”, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 381
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382 A. Stecco et al.

a b c

d e

Fig. 115.1 (a–e) CT MPR sagittal (a), FSE T2 (b), STIR (c), sagittal, ened and hyperintense (b–c) due to myelopathy. Recent D6 fracture
FSE T2 axial (d–e). D11 plurifragmentary fracture with intracanal with anterior wedging and intracanal overflowing (3 mm) of rear pro-
expansion of posterosuperior profile; at this level spinal cord is thick- file; at this level hyperkyphosis without cord signal alteration
115 Multiple Traumatic Dorsal Collapses Double Stabilization 383

115.2 Postoperative Follow-Up

See Fig. 115.2.

a b c

Fig. 115.2 (a–e) XR (a), CT axial (d–e), and MPR sagittal (b, c, d). Transpedicular screws correctly positioned in D10, D11, D12, D5, D6, and
D7. Unchanged D6 and D11 rear profile
 Traumatic Dorsal Collapse: Rigid
Stabilization 116
Device Rupture and Screw Malpositioning

Giuseppe Diaferia, Giuseppe Carmine Iaffaldano,

Pasquale Crudele, Francesco Paradiso, Michele Santoro,
and Domenico Catapano

• Precipitation trauma with D7 burst fracture

• Posterior rod-screw stabilization
• Pre- and postoperative findings (see Figs. 116.1, 116.2,
and 116.3)

Fig. 116.1 Preoperative sagittal T2 MRI showing D7 fracture

G. Diaferia · G. C. Iaffaldano · P. Crudele · F. Paradiso · M. Santoro

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 385
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386 G. Diaferia et al.

Fig. 116.2 Postoperative

a b
sagittal right paramedian (a)
and axial (b) CT showing
incorrect right D5 screw
position with intracanal
course

Fig. 116.3 Postoperative

sagittal left paramedian (a)
a b
and axial (b) CT showing left
D9 screw tulip-head rupture
(arrow)
 Traumatic Lumbar Collapse Rigid
Stabilization 117
Screw Loosening

Chiara Potente, Roberto Trignani, Tommaso Scarabino,

and Gabriele Polonara

• Patient with L2 traumatic collapse treated by percutane- 117.1 Postoperative Follow-Up After 1 Year
ous rigid stabilization, bars, and transpedicular screws at
L1 and L3 See Fig. 117.1.
• Late CT postoperative follow-up (1 year)

C. Potente · G. Polonara (*)

Department of Neuroradiology, University Hospital, Ancona, Italy
e-mail: [email protected]
R. Trignani
Department of Neurosurgery, University Hospital, Ancona, Italy
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 387
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388 C. Potente et al.

Fig. 117.1 (a–f) CT D12-L4

a b
(a, b), MPR sagittal (c, d),
and coronal (e, f). Bone
alteration surrounding left L1
transpedicular screw with
rarefaction and peripheral
sclerosis (a, b, e, f, short
arrow); front-end screw
reaches L1 superior surface
(c, long arrow). L2 fracture
with superior surface
depression (e)

c d

e f
 Multiple Collapses Rigid Stabilization
Device Rupture
118
Tommaso Scarabino, Michela Capuano,
Francesco Nemore, Carlo Delvecchio,
and Raniero Mignini

• Patient with multiple vertebral collapses due to

Echinococcus cysts previously treated by stabilization
through plaques and transpedicular screws
• CT preoperative imaging and XR/MR early and late
follow-up

118.1 Preoperative Imaging

See Fig. 118.1.

T. Scarabino · F. Nemore
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy Fig. 118.1 MPR sagittal. Device rupture

C. Delvecchio · R. Mignini (*)

Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 389
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390 T. Scarabino et al.

118.2 Early Postoperative Follow-Up

See Fig. 118.2.

Fig. 118.2 (a, b) XR

anteroposterior (a) and
a b
sagittal (b). Stabilization with
lateral bars
118 Multiple Collapses Rigid Stabilization 391

118.3 Postoperative Follow-Up

See Fig. 118.3.

a b c

Fig. 118.3 (a–c) FSE T2 sagittal. Susceptibility artifacts

 Traumatic Cervical Fracture Anterior
Stabilization 119
Regular Findings

Tommaso Scarabino, Saverio Pollice,

Marianna Schiavariello, Vincenzo Brandini,
and Raniero Mignini

• Patient with C2 traumatic fracture treated at first with col- 119.1 Preoperative Imaging
lar and then by anterior stabilization through trans-­
odontoid screw See Fig. 119.1.
• Preoperative imaging and early XR/CT follow-up

T. Scarabino · M. Schiavariello
Department of Radiology—Neuroradiology, “Lorenzo Bonomo
Hospital”, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital,
Trani, Italy
V. Brandini · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo Hospital”,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 393
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394 T. Scarabino et al.

b c

d e

Fig. 119.1 (a–i) XR lateral (a), CT axial (b–e), MPR sagittal (f), 3D sagittal, and coronal (g–h), FSE T2 sagittal (i). Odontoid posteriorly dis-
placed (a). CT confirms XR findings with peduncles and lateral masses involvement. (i) C2 edema
119 Traumatic Cervical Fracture Anterior Stabilization 395

f g

h i

Fig. 119.1 (continued)

396 T. Scarabino et al.

119.2 Posttreatment Follow-Up After 4 Days 119.3 Postoperative Follow-Up

(Conservative Treatment)
See Fig. 119.3.
See Fig. 119.2.

Fig. 119.3 XR lateral. Regular screw positioning

Fig. 119.2 MPR sagittal. Fractured fragments alignment

 Cervical Traumatic Fracture Posterior
Stabilization 120
Regular Findings

Tommaso Scarabino, Claudia Rutigliano, Pietro Maggi,

Francesco Paradiso, and Raniero Mignini

• Patient with C2 traumatic fracture treated by C1–C3 pos- 120.1 Preoperative Imaging
terior rigid stabilization through lateral bars, translateral
mass screws, and C2 transition screw See Fig. 120.1.
• CT preoperative imaging and early XR/CT postoperative
follow-up

a b

c d

Fig. 120.1 (a–g) CT axial (a–d), MPR sagittal (e, zoom in f) and coronal (g). Odontoid fracture with right lamina involvement

T. Scarabino · P. Maggi
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
C. Rutigliano
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
F. Paradiso · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 397
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398 T. Scarabino et al.

e f

Fig. 120.1 (continued)

120 Cervical Traumatic Fracture Posterior Stabilization 399

120.2 Early Postoperative Follow-Up See Fig. 120.2.

a b

c d

e f

Fig. 120.2 (a–l) XR anteroposterior (a), lateral (b), CT axial (c–f), MPR sagittal (g–i), and coronal (j–l). Alignment of fractured fragments with
regular positioning of plaques and screws
400 T. Scarabino et al.

g h i

j k l

Fig. 120.2 (continued)

 Cervical Traumatic Fracture: Posterior
Stabilization 121
Regular Findings

Tommaso Scarabino, Michela Capuano,

Claudia Suriano, Giuseppe Carmine Iaffaldano,
and Raniero Mignini

• Patient with C2 traumatic fracture treated by C1–C3 pos- 121.1 Preoperative Imaging
terior rigid stabilization through translateral mass screws
and lateral bars See Fig. 121.1.
• CT preoperative imaging and early XR/CT postoperative
follow-up

T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
M. Capuano
Department of Radiology/Neuroradiology, L. Bonomo Hospital,
Andria, Italy
C. Suriano
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
G. C. Iaffaldano · R. Mignini (*)
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 401
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402 T. Scarabino et al.

a b

c d

Fig. 121.1 (a–i) CT axial (a–d), MPR sagittal (e), parasagittal (f), CT Hyperintensity of prevertebral soft tissue due to distraction of anterior
angiography coronal (g–h) and FSE T2 sagittal (i). Odontoid and longitudinal ligament (i)
peduncles composed fracture. Regular findings in CT angiography.
121 Cervical Traumatic Fracture: Posterior Stabilization 403

e f g

h i

Fig. 121.1 (continued)

404 T. Scarabino et al.

121.2 Early Postoperative Follow-Up

See Fig. 121.2.

a b

c d e

f g h i

Fig. 121.2 (a–i) XR anteroposterior (a), lateral (b), CT axial (c–d), MPR parasagittal (e), and coronal (f–i). Regular alignment of fractured frag-
ments, regular positioning of plaques, and screws
 Cervical Traumatic Fracture Vertebral
Removal 122
Regular Findings

Tommaso Scarabino, Maurizio Lelario, Pietro Maggi,

Francesco Paradiso, and Michele Santoro

• Patient with C5 traumatic fracture treated by drawing and a

cage positioning (fixed to C4–C6)
• XR/CT/MR preoperative imaging and early/late XR post-
operative follow-up

122.1 Preoperative Imaging

See Fig. 122.1.

T. Scarabino (*) · P. Maggi Fig. 122.1 (a–j) XR lateral (a), CT axial (b–e), MPR sagittal bone
Department of Radiology—Neuroradiology, “Lorenzo Bonomo” window (f), and soft tissue window (g), SE T1 (h), FSE T2 (i), STIR (j).
Hospital, Andria, Italy C5 traumatic fracture and wedging with lordosis inversion. Edema pat-
M. Lelario tern (j)
Department of Radiology/Neuroradiology, “L. Bonomo” Hospital,
Andria, BT, Italy
F. Paradiso · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 405
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406 T. Scarabino et al.

b c

d e

Fig. 122.1 (continued)

122 Cervical Traumatic Fracture Vertebral Removal 407

f g

h i j

Fig. 122.1 (continued)

408 T. Scarabino et al.

122.2 Early Postoperative Follow-Up

See Fig. 122.2.

Fig. 122.2 (a, b) XR

a b
anteroposterior (a) and lateral
(b). Stabilization with
vertebral drawing and cage
positioning
122 Cervical Traumatic Fracture Vertebral Removal 409

122.3 Postoperative Follow-Up After 1

Month

See Fig. 122.3.

Fig. 122.3 (a, b) XR

a b
anteroposterior (a) and lateral
(b). Regular findings
 Traumatic Cervical Vertebral Body
Fracture: Anterior Corpectomy, Bone 123
Grafting, and Stabilization
Regular Finding

Domenico Catapano, Costanzo De Bonis,

and Leonardo Gorgoglione

• Severe tetraparesis after traumatic complete C5 vertebral

body burst fracture (type A4 according to AO Spine
Subaxial Injury Classification System)
• Anterior approach with corpectomy, bone graft from iliac
crest, and plate-screw stabilization
• Preoperative and postoperative imaging (see Figs. 123.1,
123.2, and 123.3)

a b c

Fig. 123.1 Preoperative sagittal (a), coronal (b), and axial (c) CT scan showing C5 vertebral body complete burst fracture

D. Catapano (*)
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy
C. De Bonis · L. Gorgoglione
Department of Neurosurgery, “Casa Sollievo della Sofferenza”
I.R.C.C.S., S. Giovanni Rotondo, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 411
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412 D. Catapano et al.

a b c

Fig. 123.2 Preoperative sagittal STIR (a), T2 (b), and axial (c) MRI showing C5 vertebral body fracture, vertebral body retropulsion with spinal
cord compression and myelopathic signal

a b c

Fig. 123.3 Postoperative sagittal (a), coronal (b), and axial (c) CT scan showing the bone graft from iliac crest and plate-screw anterior
stabilization
 Traumatic Cervical Fracture: Anterior
Decompression and Arthrodesis 124
Regular Finding

Domenico Catapano, Pasquale Crudele,

Stefania D’Avanzo, Mario Bianco, Claudia Pennisi,
and Giuseppe Diaferia

• Severe tetraparesis after accidental fall with cervical

hyperextension. Radiological images showed C5–C6
anterior longitudinal ligament and disc distraction inju-
ries (type B3 according to AO Spine Subaxial Injury
Classification System), spinal cord compression, and
myelopathic signal.
• Anterior approach with osteophytectomy, arthrodesis
with titanium cage, and stabilization with plate-screws.
• Preoperative and postoperative imaging (see Figs. 124.1,
124.2, 124.3, 124.4, and 124.5).

Fig. 124.1 Preoperative

a b
sagittal (a) and axial (b) CT
scan showing distraction of
C5–C6 interbody space and
osteophyte (arrow)

D. Catapano (*) · P. Crudele · S. D’Avanzo · M. Bianco

C. Pennisi · G. Diaferia
Department of Neurosurgery, “L. Bonomo” Hospital,
Andria, Italy

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414 D. Catapano et al.

a b c

Fig. 124.2 Preoperative sagittal T1 (a), T2 (b), and STIR (c) MRI showing C5–C6 anterior longitudinal ligament and disc distraction injuries,
spinal cord compression, and myelopathic signal

Fig. 124.3 Postoperative

a b
sagittal (a) and axial (b) CT
scan showing the interbody
arthrodesis with cage and
plate-screw anterior
stabilization

Fig. 124.4 Postoperative

sagittal (a) and axial (b) CT
a b
scan. Note the
osteophytectomy
124 Traumatic Cervical Fracture: Anterior Decompression and Arthrodesis 415

a b c

Fig. 124.5 Postoperative 1 week sagittal T1 (a), T2 (b), and STIR (c) MRI showing arthrodesis, spinal cord decompression, and myelopathic
signal reduction
 Traumatic Cervical Fracture Vertebral
Removal 125
Surrounding Soft Tissue Infection

Tommaso Scarabino, Saverio Pollice,

Marianna Schiavariello, Vincenzo Brandini,
and Michele Santoro

• Patient with C5 traumatic fracture treated by vertebral 125.1 Early Postoperative Follow-Up
drawing and prosthesis positioning fixed by transvertebral
screws at C4–C6 See Fig. 125.1.
• Early/late XR/CT/MR postoperative follow-up

T. Scarabino (*) · M. Schiavariello

Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy
S. Pollice
Department of Radiology, San Nicola Pellegrino Hospital, Trani,
Italy
V. Brandini · M. Santoro
Department of Neurosurgery, “Lorenzo Bonomo” Hospital,
Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 417
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418 T. Scarabino et al.

a b

Fig. 125.1 (a–g) XR anteroposterior (a), lateral (b), CT axial (c–e), and MPR sagittal (f–g). C5 prosthesis C4–C6-fixed. Lordosis inversion
125 Traumatic Cervical Fracture Vertebral Removal 419

c d e

f g

Fig. 125.1 (continued)

420 T. Scarabino et al.

125.2 Postoperative Follow-Up

See Fig. 125.2.

Fig. 125.2 (a–e) CT axial.

Soft tissue thickening and air
a b
collection in the right
anterolateral region of the
neck, between carotid space
and thyroid

c d

e
125 Traumatic Cervical Fracture Vertebral Removal 421

125.3 Late Postoperative Follow-Up a

See Fig. 125.3.

Fig. 125.3 (a–c) FSE fat sat axial. Loss of superficial tissue in the
right anterolateral region of the neck. No abscesses
 Odontoid Traumatic Fracture:
Suboccipito-cervical Stabilization 126
Regular Findings

Antonello Curcio, Simona Ferri, Rossella Zaccaria,

Fabio Cacciola, and Antonino Germanò

• Neck pain, tetra-pyramidalism, dysphagia, and

pharyngodynia
• Fracture of C2 (D'Alonzo type 2). Dislocation reduction
by external cervical traction and suboccipito-­ cervical
stabilization
• Preoperative and postoperative images (see Figs. 126.1,
126.2, 126.3, and 126.4)

Fig. 126.1 Preoperative CT

a b
sagittal scan showing the
odontoid dislocation and
osteopenia (a) and CT axial
scan showing severe reduction
in width of cervical spine
canal

A. Curcio (*) · S. Ferri · R. Zaccaria · F. Cacciola · A. Germanò

Neurosurgery, Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Messina, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 423
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424 A. Curcio et al.

a b c

Fig. 126.2 Preoperative 3D reconstruction of bone window CT scan in lateral (a), superior (b), and posterior (c) projection showing odontoid
dislocation

Fig. 126.3 CT scan showing

a b
dislocation reduction after
external cervical traction.
Sagittal (a) and coronal (b)
plane

Fig. 126.4 Postoperative X-ray showing suboccipito-cervical

stabilization
 Odontoid Traumatic Fracture
Stabilization 127
Intraoperative Bleeding

Alessandro Stecco, Francesco Fabbiano, Silvio Ciolfi,

Martina Quagliozzi, Christian Cossandi,
Gabriele Panzarasa, and Alessandro Carriero

• Patient with odontoid traumatic fracture treated by poste- 127.1 Preoperative Imaging
rior stabilization through screws in C1 lateral process and
in C2 isthmus and peduncles See Fig. 127.1.
• Preoperative imaging and late CT postoperative
follow-up

Fig. 127.1 (a–b) CT axial

a b
(a), MPR sagittal (b).
Odontoid displaced fracture
with posterior intracanal
fragment displacement.
C1–C2 dislocation and other
composed fracture of
odontoid base and top (type I
and II)

A. Stecco (*) · F. Fabbiano · S. Ciolfi · M. Quagliozzi

A. Carriero
Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
C. Cossandi · G. Panzarasa
Department of Neurosurgery, “Maggiore della Carità” University
Hospital, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 425
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426 A. Stecco et al.

127.2 Postoperative Follow-Up After 1 Year

See Fig. 127.2 and 127.3.

Fig. 127.2 (a, b) CT

angiography (a) and MPR
a b
sagittal (b). Buffered vertebral
intraoperative bleeding. For
this reason no C1 screw
positioning. No surgical
complications. Regular
findings at CT angiography.
Regular positioning of
transpedicular screws. No
recent bleeding

Fig. 127.3 (a, b) CT axial

a b
(a) and MPR sagittal (b).
Regular alignment of
fractured fragments. Regular
positioning of right C1 screw
 Odontoid Traumatic Fracture
Stabilization 128
Epiglottis Falling in Exudative Collection

Chiara Potente, Tommaso Scarabino,

and Gabriele Polonara

• Patient with choke sensation in the first night after odon- 128.1 Early Postoperative Follow-Up
toid stabilization
• CT postoperative follow-up See Fig. 128.1.

a b c

Fig. 128.1 (a–c) CT (a), MPR sagittal (b) and coronal (c). Motion artifacts in difficulty breathing. C2 fracture treated by screw. Soft tissue
obstructs airways through epiglottis falling

C. Potente · G. Polonara (*)

Department of Neurosurgery, University Hospital, Ancona, Italy
e-mail: [email protected]
T. Scarabino
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 427
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 Atlanto-occipital Malformation Anterior
Odontoid Drawing 129
Sequelae

Teresa Popolizio, Francesca Di Chio,

Leonardo Gorgoglione, and Giuseppe Guglielmi

• Patient with atlanto-occipital malformation treated by 129.1 Preoperative Imaging

odontoid drawing through anterior transpalatal approach
• Preoperative imaging and CT postoperative follow-up See Fig. 129.1.

a b c

Fig. 129.1 (a–c) MPR sagittal (a), max flexion (b) and max extension (c). Atlanto-occipital malformation with occipital merging and basilar
artery compression, slight odontoid instability, superoposteriorly displaced

T. Popolizio (*)
Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
F. Di Chio
Department of Radiology, University of Foggia, Foggia, Italy
L. Gorgoglione
Department of Neurosurgery, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
G. Guglielmi
Department of Neuroradiology, Scientific Institute Hospital “Casa
Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
Department of Radiology, University of Foggia, Foggia, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 429
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430 T. Popolizio et al.

129.2 Early Postoperative Follow-Up

See Fig. 129.2.

Fig. 129.2 MPR sagittal. Odontoid removal

 Amyotrophic Lateral Sclerosis Stem Cell
Transplant 130
Pseudo-myelopathy

Alessandro Stecco, Letizia Mazzini, Mariangela Lombardi,

Francesco Fabbiano, Anna Viola, Roberto Cantello,
and Alessandro Carriero

• 1 month after transplant: D6–D8 laminotomy and stem 130.1 Postoperative Follow-Up
cell injection in fluid solution through microinjectors
• Postoperative follow-up: MR and DTI See Figs. 130.1, 130.2, and 130.3.

A. Stecco · F. Fabbiano · A. Viola · A. Carriero (*)

Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
L. Mazzini
Department of Neurology, “Maggiore della Carità” University
Hospital, Novara, Italy
M. Lombardi
Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
Department of Radiology-Neuroradiology, L. Bonomo Hospital,
Andria, Italy
R. Cantello
Department of Radiology, “Maggiore della Carità” University
Hospital, Novara, Italy
Department of Neurology, “Maggiore della Carità” University
Hospital, Novara, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 431
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432 A. Stecco et al.

a b c

Fig. 130.1 (a–c) SE T1 (a), FSE T2 (b), and STIR (c) sagittal. T2 hyperintensity of spinal cord probably due to myelopathy or hydromyelic dila-
tation in the region of previous transplant
130 Amyotrophic Lateral Sclerosis Stem Cell Transplant 433

Fig. 130.2 (a–d) FSE T2

(a), zoom (b), sagittal and
a b
axial (c) and CE SE T1 (Gd
0.5 m) (d). Anteroposterior
spinal cord distraction causing
swelling (a–b), T2
hyperintensity (c), no CE (d)

c d
434 A. Stecco et al.

a b c

Fig. 130.3 (a–d) DTI with multiple ROI positioned in the cord hyper- neuronal loss (d). This conclusion is supported by incremented ADC
intensity (HYPER) and in appearing normal regions (UPPER normal-­ (d) (typical of fluid collection). Fiber-tracking (b) no signs of atrophy
appearing spinal cord, NASC; LOWER NASC); fiber-tracking, coronal, of spinal cord even when it has altered signal intensity. FA values,
and sagittal (c) table: FA and ADC values in related ROI (d). Fiber-­ related to trophism and neuronal density, are similar in the three levels
tracking (b) no signs of spinal cord atrophy with regular fiber recon- (two of control and one of lesion) showing that in this region there is a
struction even when signal is altered. FA values, related to tropism and fluid collection instead a neuronal loss (d). This conclusion is supported
neuronal density, are similar in the three levels (two of control and one by incremented ADC (d) (typical of fluid collection)
of lesion) showing that in this region there is a fluid collection instead a
 Functional MR
Normal and Pathological Semeiotics
131
Marco Di Terlizzi, Michele Ricciardi, Tommaso Scarabino,
and Francesco Ricciardi

• Comparison between supine and upright position with

evaluation of lumbosacral angles (normal value 120°–
180°), lordosis angle (normal value 50°), and interverte-
bral disk thickness in healthy, in herniated disk, and in
spondylolisthesis untreated and treated by stabilization
(see Figs. 131.1, 131.2, 131.3, and 131.4)

M. Di Terlizzi · M. Ricciardi · F. Ricciardi

Radiology Center, Andria, Italy
T. Scarabino (*)
Department of Radiology—Neuroradiology, “Lorenzo Bonomo”
Hospital, Andria, Italy

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 435
T. Scarabino et al. (eds.), Imaging Spine After Treatment, https://doi.org/10.1007/978-3-031-42551-6_131
436 M. Di Terlizzi et al.

a b c

Fig. 131.1 (a–f) Supine (a–c–e), upright (b–d–f) in healthy with evaluation of lumbosacral angle (a–b), lordosis angle (c–d), disk thickness
(e–f)
131 Functional MR 437

d e f

Fig. 131.1 (continued)

438 M. Di Terlizzi et al.

Fig. 131.2 (a–f) Supine (a,

a b
c, e), upright (b, d, f) sagittal
and axial in right intra-/
extraforaminal herniated disk,
better displayed in upright.
Narrowing of spinal canal (f)

c d

e f
131 Functional MR 439

a b

c d

Fig. 131.3 (a–d) Supine (a), upright (b), sagittal, supine (c), and upright (d) axial in anterior listhesis L4–L5 better displayed in upright with
further reduction of amplitude of spinal canal
440 M. Di Terlizzi et al.

Fig. 131.4 (a–b) Supine (a),

upright (b) sagittal in
a b
spondylolisthesis treated by
stabilization through plaques
and screws. No modification
in upright demonstrates
efficacy of surgery