Diagnostic Procedure

By: Sara Anis

3rd lecture: Degenerative diseases

Dr. Mamdouh Mahfouz

- Degenerative disease of the spine means spondylosis or spondylo

degenerative changes
- It is important when you look at x-ray or CT or MRI you should know
exactly what you want.

Examination technique:

 Supine position.
 Scanogram (lateral).
 Scan intervals.

Contrast administration: at the CT we not inject contrast except in 3

purposes:

- Yes: post-operative lumbar spine --- Inflammatory and neoplastic lesions

(tumors)
- No: Any other pathology (disc lesions, spinal trauma, congenital
anomalies)

MR machines: we have 4 types of devices (closed, open, extremity,

dynamic).

Degenerative diseases: each one of them has 3 subdivisions:

 Spinal canal stenosis

 Disc lesions
 Bone marrow changes
 Ligamentous pathology
 Osseous changes
 Spondylolisthesis
  Cord pathology

Spinal canal stenosis

1. Congenital: is idiopathic the canal is stenotic its antroposterior diameter
is less than 13 mm.
- Occur at the lumbar only (because we measure the diameter at the
lumbar only)

16 = Normal 12 = Abnormal

Thecal sac

2. Developmental type: the canal at this type has

normal diameter but it is stenotic because of 3
causes:
- Hypertrophied laminae: thickness of the lamina
- Hypertrophied articular facets
- Hypertrophied ligament flava: which present
inside the spinal canal (normally it is thick, but if
its thickness increased more it will make canal
stenosis).
Lig. flava Lamina Articular
facet
 C
A B
Lamina

Facet

Canal

- Pic (A) is the normal shape of the spinal canal, normal lamina and normal
facet
- pic (B) is the developmental type of the canal stenosis, if compared with
pic (A): the canal is stenotic, the lamina is shorter than of the pic (A) and
the facet is more thickened

Developmental Normal canal

canal

Thecal sac

Ligamenta flava

Lamina Articular facet

- At the picture: if you compared the normal one with developmental one
you will find: the articular facet at the normal picture is with normal
shape while at the developmental is very big
- Also the lamina at the developmental picture is very short and thick and
the angle between it and the other lamina is acute angle, while at the
 normal picture the lamina is with normal shape and the angle between it
and the other lamina is obtuse angle ‫ منفرجة‬.
- Also the ligamentum flava is at the normal picture ‫ فتلة سميكه شويه‬differ
from the developmental ‫حبل رفيع حبتين‬
- The thecal sac is filling in contrast at both: but at the normal picture is
normal circular while at the developmental is compressed from the sides
and not circular.
- So at the developmental type: If you measure the diameter of the canal
you will find it is normal but the space inside the canal is very narrow
- The ligament at the MRI appears black at all the pictures at the T1 and
T2. So, The ligamentum flava behind the spinal canal appear black

Normal ligamentum
flava

Thecal sac Abnormal ligamentum

flava (very thick)
Ligamentum
flava

Axial Sagittal

- When the ligamentum flava become thick the thecal sac become thick
and compressed the spinal canal and the nerve root.

Abnormal
Normal
Ligamentum
Ligamentum
flava
flava
- Example from internet show very severe case with hypertrophied
ligamentum flava lead to high compression of the thecal sac.

Compressed
thecal sac

Very hypertrophied
Ligamentum flava

- So we see the ligamentum flava at the axial and the sagittal view

Sagittal view: normal Sagittal view: hypertrophied

ligamentum flava ligamentum flava

3. Acquired Type: as the disc and osteophytes ….

- The patient may have the 3 types congenital, developmental and the
acquired, and that is the most of what we see at the clinical practice, as
the picture below:
‫ انواع مع بعض مش بس نوع واحد‬3 ‫الطبيعي ان المريض بييجي عنده ال‬

A B

 Pic A: Spinal canal stenosis

 Pic B: Laminae are thick and the angle between them is acute angle,
thickness of the ligamentum fava and also there is disc.
So;

 Idiopathic or congenital: when measured the diameter = less than 13mm

 Developmental: the diameter normal but there is thickness and shortness
of the lamina and the angle between them is acute or there is thickness of
the ligamentum flava and the articular facet is short and thick

- When look at sagittal view: the normal is to see the cauda equine nerve
roots around them the CSF from all sides. At the picture below there are
3 images, which is the normal one of them?

A B C
- The normal spinal canal is pic (B), the pic (A) is very stenotic and the pic
(C) is very wide (capacious spinal canal).

This is the capacious spinal canal, when measure the diameter = 2 cm and
more which cause pain (no surgical treatment, only by PT)

- At the cervical: we know that the canal not stenotic when look at sagittal
T2 and see that the CSF is in front and behind the cord, if the CSF not
completely around the cord it means it stenotic.

- There is grades if the stenosis:

  1st grade (mild stenosis): is when the CSF be in one side only as
pic (A), it is present in front of the cord only not from behind.
 2nd grade (moderate stenosis): the CSF not present in the 2
sides.
 3rd grade (severe stenosis) the CSF not presents in the 2 sides
and the cord is compressed.
To know the compression: at the stenotic area there is
compression at the cord at this area and its diameter less than
above it and below.

Area of stenosis

- So, at the picture below, the pic (A) is mild stenosis (because CSF is
behind only), and the pic (B) is moderate stenosis because the cord is the
same diameter at its all length and the CSF absent in front and behind.

A B
- The picture below is the CT myelography: pic A is normal cord, while
pic (B) and pic (C) are severe stenosis

C
A B

Disc Lesions

- The disc lesions are:

 Degeneration.
 Bulge.
 Herniation.

Normal lumbar disc:

A B
- The normal disc at the CT is concave backward and the depth of the
concavity has no grades ‫مالهاش عمق‬, so the concavity at the above pic (A)
and (B) is the same thing.

Normal cervical disc:

- The normal cervical disc: there must be no disc material behind the bone

There is a lot of
disc material behind
the bone

- The disc at the MRI is black at the T1 and white at the T2, and in the
same line with its above and below vertebra, so all the discs in the picture
below are normal.
Disc degeneration: 3 steps

 Loss of water >> decrease the T2 signal [the water become black
at the MRI].
 Loss of height >> narrowing of disc spaces [x-ray, MR, CT?]
 Intradiscal air (vacuum phenomena) [CT].
‫ ويطلع جواه هواء‬nucleus ‫تتحلل ال‬

- The water seen at the MRI at T2 (when the CSF white at the T2 >> the
disc also must be white at the T2 and in the same line with the above and
below vertebra), but if the disc is black this means it is degenerated (and
write at the MRI report: degenerated, loss of T2 signal).
- Then the space became narrow due to water loss which appears at the x-
ray and also MRI
N.B the lumbar discs normally widen from up to down ‫بيوسع وانت نازل‬
‫لتحت‬

Normal disc
space

Narrowing of
disc space

X-ray MRI: 2 problems here

at L5-S1: the 1st is loss
of water and the 2nd it
enter inside the spinal
canal.

- Then the disc will have water inside due to nucleus degeneration (the air
seen be x-ray, MRI, CT). The CT is the best of them to see the air
because it colored black. Air inside the disc called vacuum phenomena.
 - The vacuum phenomena: ‫ معناها ان الديسك جاب آخره‬the disc is totally
degenerated.

CT X-ray

Air at the disc

Air at the disc

- At the picture below: the CT is better than x-ray in showing the air, the x-
ray shows the air but when it became bigger ‫ اما بيكبر شويه ويبقي واضح‬.

Air (the black Air (the black

spots at the disc) spots at the disc)

x-ray CT sagittal reconstruction

Look at this picture, where is the

affected disc?
 - The disc at the CT is concave backward as pic (B) and if it is straight or
convex it is bulged.
- Difference between bulge and herniation; the nucleus is surrounded by
annulus from all sides.
annulus ‫ والعيش هو ال‬nucleus ‫ الطعمية هي ال‬, ‫زي ساندوتش الطعميه‬
- The annulus cover the nucleus from al the sides. When the annulus
become weak due to aging or increase load and friction >> it will become
loose ‫ >> تبتدي تريح وتفرد في جميع الجهات‬this is called bulge (annulus
relaxation ‫)مصطلح قديم ال زال بيتكتب في التقرير بس في مصر فقط‬.
- The herniation means that the annulus torn and the nucleus go outside it
called focal (focal ‫)حته صغيرة بارزه‬, this focal go inside the spinal canal
(from right or left or backward at middle).
- At pic (A) the disc is circular ‫ >> فارد في كل مكان‬bulge
- At pic (C) the disc is go outside (focal) >> herniation

So:
- Disc bulge = Intact annulus = Diffuse pathology
- Disc =Disc herniation = Torn annulus = Focal pathology

Disc bulge Disc herniation

A B C

- The focal may diffuse to the right backward as (A) >> right sciatica, or
may be to the left as (B) >> left sciatica, if it at the middle as (C) >> the
patient will have LBP not sciatic pain.

A B

C
 - The disc at those picture is bulge because the backward edge is diffused

- If you look at this MRI of lumbar spine, you will see that the disc at
picture is degenerated and go inside the spinal canal, and if you want to
know if this disc is herniated or bulged >> look at the axial section
- At the axial section: if the disc attach from left to right >> the disc is
bulged. And if it is focal >> the disc is herniated

The disc at sagittal view is degenerated, when look at the axial:

The L4-5 attach from left to right >> so it is bulged, and the L5-S1, also attached from left to
right >> so it is bulged.

- What is the difference between bulge and herniation in the management?

  The bulge has no surgery treatment, treated by physical therapy.
 The herniation need surgical intervention to remove the focal,
because the annulus torn and the nucleus become inside the spinal
canal.
- Therefore, it is very important to differ between the disc and the
herniation.
- At the MRI below, L3-4 and L4-5 are inside the spinal canal, and to
know they are bulged or herniated you should look at the axial section;
then at the axial there is attachment of the disc from left to the >> so this
means it is bulged

- The picture below is MRI of cervical spine, at the sagittal view T2 (CSF
white), there is small degenerated discs at C4-5 and C5-6.

The C5-6 at axial

is attached from
The C4-5 at left to right but is
axial is more at left so this
attached from means that the
left to right so annulus is more
it is bulged weak at the left
side, if the patient
make any wrong
movement it may
torn and cause
Sagittal T2 herniation
- If the annulus torn, it will be torn in 1 of 5: the 5 is the colors at the
picture below:
 Red: torn at the middle called central disc
herniation.
 Blue: paracentral herniation
 Green: foraminal herniation (because this
is the site of the foramina in which the
nerve root pass)
 Orange: extra-foraminal herniation
 Yellow: Anterior disc bulge or herniation
(has no value ‫ مالوش اي قيمه‬because the
abdomen is very wide and nothing will
compressed).
- The central and the paracentral is the most common seen in the clinical
practice.
- At the picture below: the disc at the MRI is bulged or herniated anteriorly
towards the aorta, but nothing will happen ‫مش هيعمل اي حاجه وليس له اي قيمه‬

- At the picture below: the Pic (A) the annulus torn to the left (annulus
only torn from one side (right or left or at the middle) >> the disc
herniate and compress the left nerve root causing left sciatica.
- Pic (B) the MRI T1 (thecal sac is black) the disc herniated at the left and
compressed the left nerve root: then it will written at the report as left
posterolateral disc herniation.

B A

- At the picture (A) below there is a disc, is it bulged or herniated? And

at which side? The answer it is herniated to the right side (most of the
disc is to the right side and part of it is at the center so it is central and
paracentral)
- Then at the same picture if someone ask what the area (1) is? This area is
when the disc was bulge and right annulus was more weak than the left
and it torn, the disc herniated to the right.

RT LT

A
- At the pic below: the Pic (A) is bulged and the pic (B) is herniated to the
left.

A B

- At the pic below the L4-5 disc is degenerated and go inside the spinal
canal
- Then to know it is bulge or herniation look at the axial >> it is herniated
to the right.

- Disc protrusion: before the annulus totally

torn it is partly torn, this is the protrusion
(the internal fibers of the annulus torn and
the external fibers is still not torn).
- But the annulus not shown in the MRI, so you don’t know if it is
protrusion or herniation.
- There is an easy way to know: the protrusion is a step before the
herniation, at the picture below there is focal and to know it is protruded
or herniated >> draw 2 lines; 1st line at the base of the disc and the
second line at the apex of the disc >> then measure the space between the
2 lines;
 If it is = 2 mm >> protrusion (the annulus not totally torn).
 If it is = 3mm and more >> herniation (the annulus totally torn).

- Look at the MRI below: the C2/3 and C3/4 is slightly protruded >> when
see the axial by the experience without measurement; if it is very small
>> means protrusion, but if bigger >> means herniation
- The pic below is herniated disc: because after measurements it is > 2mm

- At the picture below: someone will see it is protrusion and other one will
see it is herniation (this is common in clinical practice) ‫واقف في النص‬, at
this case you write the report as you see.
- Now (not in Egypt) they not write protrusion because it will be at the
future herniation and they must deal with it as herniation.

- Are you able to know from the sagittal view if it is herniated or bulge?
Yes, but if only all the sagittal pictures present not only one picture (the
sagittal is transected from right to left or from left to right, all the MRI
picture is transected from Left to the Right, the 1st picture at the film is
the left side of the patient and the last picture of the film is the right side
of the patient), look at the picture below:
 3 Sagittal of the patient
from Left to Right

1st sagittal 2nd 3rd

- At the above picture; look at the middle picture L5-S1 and see its size
carefully, then look at the left picture (1st)>> it become smaller, then look
at the right picture >> it become bigger. So this disc is herniated to the
right.

This is the axial of the above picture and

the L5-S1 disc is herniated to the right

At the sagittal if the L4-5 disc size at the

middle pic is the same at the left picture
and at the right pic >> means disc bulge

- At the picture below: the L5-S1 is herniated to the right.

L5-S1
axial
- Stages of disc herniation:
 Protrusion: partial tear and the outer fiber intact
 Herniation: tear of all fibers and the disc go outside the annulus.
 Migration: after it herniates, it migrate may go downward or
upward and at this case called herniation with migration)
N.B it is impossible for the disc bulge to migrate (because the
annulus must torn first to allow the disc to migrate)
bulge with migration ‫مفيش حاجه اسمها في التقرير‬

‫ برضه ده كالم‬.. ‫علشان الجاذبية االرضيه‬ Disc migrate downward ‫زمان كانوا بيقولوا ان‬
‫غير صحيح‬

The disc migrate according to the site of the annulus tear.

 Sequestration: part of the disc is separated from the original disc

- Look at the pic below: this is herniation and caudal migration of the
disc at the MRI
- And to know if it is right
or left the axial or all the
sagittal pic must be
available.
- At the past before MRI, they know the migration by looking at film: see
the pic below: it show L5- S1disc herniation to the left >> then take the
next 3 axial sections, all of them show the disc herniation with the
caudal herniation

- At the MRI only one picture show the migration >> then look to the axial
to know the direction (right or left).

Axial show the herniation is

to the left

Herniation with
Cranial migration
- If the apex of the disc separated from the disc itself >> it is called
sequestration
- So the disc at the pic below is: Right posterolateral disc herniation
with cephalic migration and sequestration

- The same is here the sequestrated disc fragment to the left so it is left
posterolateral disc herniation with cephalic migration and
sequestration
- So. Spinal canal stenosis 3 types (congenital, developmental and
acquired)
- The disc lesion are 3 (degeneration, bulge and herniation) before the
herniation there is protrusion and after the herniation there is migration
and sequestration.

Bone marrow changes

[Only seen on MRI]

 Edema.
 Fatty.
 Sclerosis.
- When the disc degenerate >> loss its water >> become smaller ‫يكش في نفسه‬
>> the disc above and below end plate will change, these changes are 3
types:
- 1st change is water, 2nd change is fat, 3rd change bony sclerosis
- Water is black at T1 and white at the T2. At the pic below the end plates
of the L5-S1 disc is black at the T1 and white at the T2 >> so it is water
changes at the end plate (type 1 degeneration: bone marrow edema).

T1 T2

- At the pic below the L5-S1 end plate is black at the T1 (pic A) and white
at the T2 (pic B) is also type 1 degeneration.
 A B

- At the pic below the L4-5 end plates is black at the T1 and white at the
T2 >> so it is type 1 degeneration

- The fat is opposite to the water so it is white at the T1 and black at the
T2.
- At the pic below the L3-4 endplates is white at T1 and white at the T2 >>
so it is (type 2 degeneration or fatty changes)

T1 T2
- At the pic below (A); the L2-3 disc end plate is black at the T1 and white
at the T2 >> Type 1 degeneration, and at the (B); L5-S1 disc end plate is
white at the T1 and white at the T2 >> so it is type 2 degeneration. So the
spine may have different types or one type.

- Type 3 is bone sclerosis: sclerosis mean cortex and the cortex is black at
both T1 and T2. So, if you see the end plate at the T1black and became
white at the T2 >> means type 1 degeneration, and if you see the end
plate at the T1 and became black at the T2 >> means type 3 degeneration
- If the end plate is white at the T1 >> no need to look at T2 (because it is
fat).
- Bone sclerosis seen also at the x-ray and CT
- Narrow disc space at x-ray is associated with end plate sclerosis (pic A),
and if you make CT you will see the vertebral end plate sclerotic (pic B).
- The water and the fat seen only at the MRI.

A B

- At the pic (A) below: T1 with black CSF and the end plates black then at
the T2 the CSF is white and the end plates is also black >> type 3
degeneration bone sclerosis, which is also seen at the x-ray (pic B)
sclerotic end plates

A B
 Osseous pathology

- There is a difference between the

bone marrow and the bone itself
- The bone itself develop 3 problems:
 Osteophytes: it develop anteriorly
and posteriorly, the important
osteophytes is that develop
posteriorly because of the spinal
canal. The only important anterior A
osteophytes is at the cervical
because it affect the swallowing
(A).
 Schmorl nodes
 Osteoarthritis

Osteophytes:

- If there is anterior osteophytes at the lumbar it is not important because

the abdomen is very wide as the axial at the pic below, but the posterior
osteophytes as the sagittal at the pic below, is important because it affects
the spinal canal
- The pic below show the posterior osteophytes at the cervical which affect
the spinal canal.

- The pic below: the axial view (A) show disc herniation to the right, when
look at (B) there is something look like the disc but it is bone because it
colored black as the nearby bones >> so this disc associated with
osteophytes and this is normal because with disc herniation the raise the
periosteum and this lead to osteophytes (at the past it called hard disc
means disc with osteophytes and the disc without osteophytes called soft
disc).

A B
 Schmorl nodes:

- At the schmorl nodes the disc penetrate the annulus from above or from
below so make gab at the its superior or inferior vertebra ‫( حفره‬if it
penetrate anteriorly it will go to abdomen and if penetrate posteriorly it
will affect the spinal canal and if it penetrate superiorly it will affect the
above vertebra and if penetrate inferiorly it will affect the below vertebra)
- This gab called schmorl node or central disc herniation
- It seen at the CT or MRI the vertebra has a gab inferiorly or superiorly or
both, see the pic below:

Schmorl node at
sagittal

Schmorl node at
axial

- The schmorl node not affect the nerve roots, but the schmorl node when
it acute it surround by bone marrow edema which cause pain
- So if you make MRI and see the
schmorl node as at the pic below
and they are not surrounded by
bone marrow edema >> no
symptoms (but written in the
report).
- But if make MRI and see the schmorl node and around it bone marrow
edema (black at the T1 and white at the T2) >> called acute schmorl node
and this cause pain to the patient.

Osteoarthritis:

- It is a group of things that occur at the joint of the spine (the lumbar spine
facet joint, cervical spine facet joint and the neurocentral joint)
 Narrowing of the joint space: as the pic below (A) there is good
joint and OA joint and this is occur at the scoliotic patient or the
polio because of the load on one side only.
 Sunchondral bone sclerosis: associated with the narrowing of the
space, see pic below (C)
 Marginal osteophyte lipping: see pic below (B) ‫بروزات عظمية‬
 Subchondral pseudocysts: small cysts seen as black spots due to
ths sunovium penetrate the bone ‫ بيحفر في العظمة نفسها‬see the pic
below (D)
 Intra – articular gas: is inside the joint
 Loose bodies: break of the osteophytes then became loose bodies,
it found at the big joints as the knee, hip but the facets has no loose
bodies.
 A

D B

- OA at the Neurocentral joint:

narrowing

This area is for passing

the nerve roots so any
osteophytes at this
area will affect the
nerve roots

- The osteophytes may treated by surgery or only by physical therapy

 Ligamentous Pathology

- There is many ligaments at the spine in all directions; the most important
ligament is those inside the spinal canal. The ligamentum flava and the
posterior longitudinal ligament is the most important ligaments.
- The ligamentum flava is posterior to the spinal canal, and the posterior
longitudinal is at the edge of the vertebrae from the posterior along its
length.
- 3 problems at the ligaments may
occur:
 Hypertrophy
 Calcification
 Ossification

- The hypertrophy discussed before became thick and appear at axial and
sagittal as the above picture.
- The calcification: the calcium at the MRI is black at all pictures, and the
ligaments at the MRI is black at all pictures >> so if there is ligaments
and calcifi you will not know it at the MRI, so it is shown at the CT and
the calcium appear white.
- At the pic below: the white area is the ligamentum flava so it is calcified.
- And this ligamentum flava at the cervical, the left one is normal but the
right one is calcified as the pic below.

- Buckling: when the space between the vertebrae narrow the ligament
become loose ‫ بيتكوم علي نفسه‬.
- Calcification and hypertrophy occur at the ligamentum flava while the
ossification not. Ossification occur at the posterior longitudinal ligament
PLL.
- The ossification: means bone inside the ligament itself and become thick
with no cause
- It shown by the CT and appear ossified as he picture below along the
length of the vertebra from posterior.

- When make CT the osteophyte appear as the ossified ligaments because

the both are bone. So how to differentiate between them? If you look at
the above picture at sagittal you will see that the ligament not attach to
the vertebra ‫ مش الزق في الفقرات في بينهم مسافه صغيره‬, at the axial section as
the pic below the ligament will appear ‫ زي حاجه متعلقه ليها عنق‬while the
osteophytes the base of it is wide and attach to the vertebra ‫الزقه فيها علي‬
‫طول‬

Ossification Osteophyte
- At the MRI the ossified ligament will appear black at both T1 and T2, at
the pic below the PLL is colored black line along the vertebrae, and at the
CT sagittal it is too obvious colored white and not attached to vertebra,
and at the CT axial it will appear away from the back of the vertebra and
colored as the bone.

T1 T2 CT sagittal
CT axial

- At the MRI as the pic below it will be like long black tape posterior to the
vertebrae (no one can say that it is disc herniation or migration because
no disc will pass 3 vertebrae)


- Ossification anteriorly at the anterior longitudinal ligament is not
important
 Spinal Instability

- 3 forms:
 Lytic Spondylolisthesis.
 Degenerative Spondylolisthesis
 Retrolisthesis
- The vertebra move forward or backward, if move forward called listhesis
or antrolisthesis, and if move backward retrolisthesis.
- The name is called on the up vertebrae: if there is movement at L5-S1 the
L5 is the vertebra that moved not S1.
- It is 4 grades:
 1st degree: from the cyst to the 1st quartet of the lower vertebra
 2nd degree: from the point of the 1st degree to another quarter of
the lower vertebra (half of the vertebra)
 3rd degree: from the 2nd degree to another quarter (3/4 of the
vertebra)
 4th degree: when the vertebra become in front the lower one.
- The retrolisthesis has no degrees.
- Causes of the spondylolisthesis: break of the pars interarticularis or facet
OA.
- At the 1st degree the 2 causes are possible but from the second degree
there must be breaking of the pars
- When the pars break called >> Lytic Spondylolisthesis
- When the facet has OA called >> degenerative Spondylolisthesis
- At the pic below x-ray oblique view, the neck of the dog is the pars, it is
break at the left picture

- If the pars break and the vertebra not moved called spondylolysis, if
moved called spondylolisthesis.
- Examples:

The pars is obvious that

Place of
is broken because it is the pars at
2nd degree. the lateral
view
This is the 3rd degree and the
pars must be broken

- To know the cause: At the level of the spondylolisthesis see the facet
joint at the axial and if there is OA >> means it is the degenerative but if
the facet normal >> means the pars is broken.
- At the pic below: the L4 move on L5 2st degree and at the axial there is
OA at facet joint so it is degenerative spondylolisthesis.

- At this CT the L4 move on L5

- At the MRI the L3 move om L4 and
L5 move on L5 (multilevel)
- The multilevel may one forward
and other vertebra move backward

CT
MRI
 - The retrolisthesis the vertebra move backward and there is no relation
between it to the pars or the facet and it does not has degrees.
- At the pic L4 move backward on L5 and L5 move backward on S1

- Multidirectional spinal instability:

retrolisthesis

spondylolithesis

Cord pathology

Degenerative myelopathy: they are 3 and all appear as a white spot.

- Edema: when there is disc compressed the cord cause edema and
ischemia and atrophy, when the cord compressed a white spot appear at
the cord (water) at the T2, see the pic below
- Early myelomalacia: reversible
- Late myelomalacia: irreversible

The difference between the 3 types is at the clinical, the edema and the
reversible myelomalacia is when release the compression the patient will
become good while the irreversible he will not be good again (permanent
damage of the cord).

At the radiology they can’t be differentiated, but at the report write that the
cord is very compressed (significant cord compression)

White spot at
White spot but the
the cord
cord not compressed
(edema)
(not edema) may be
any disease or tumor
‫مالناش دعوه بيه‬

- Here also the cord compressed and there is white substance inside it.
- This cord compressed from in front by the disc and from behind by
ligamentum flava
-
- The last line at the report they write the spinal shadows and always they
are normal except at fractures, infection and tumor
- The fracture cause hernia and the infection cause abscess and the tumor
may extend outside the vertebra and invade the paraspinal muscles.

fracture infection tumor