INTRODUCTION

• Clinical problems of the human spine continue to be

prevalent in society  Frequently particularly at the
lumbar level
• Conventional radiology with dynamic projections 
technical reference to assess the degree of instability
but inadequate to assess stability in case of spinal
fractures limited by its diagnostic use in the assessment
of disc and radicular pathologies
• CT  yields high-resolution reconstructions in every
spatial plane to detect even the tiniest fractures,
revealing potentially unstable lesions.
• MRI  directly assesses ligaments integrity, which is
crucial for spine stability
PATHOLOGIC PRINCIPLES
OF INSTABILITY
• instability: “the loss of the ability of the spine under
physiologic loads to maintain its patterns of
displacement so there is no initial or additional
neurologic deficit, no major deformity, and no
incapacitating pain.” (White and Panjabi)
Degenerative Instability
• lesion of a component of the column  an
inappropriate response of the muscles  an erroneous
positional feedback of the column  3 steps of
degenerative cascade  chronic dysfunction and pain
• 3 steps of degenerative cascade:
• Dysfunction: occasional undefined low back pain, with no or
minimal changes in the spinal joints; frequently, no imaging
findings are appreciable.
• Instability: back pain becomes more and more frequent to
chronic. Multiple signs are appreciable on radiologic
examinations (x-ray, MRI, and CT scans), such as facets
degeneration and disk space narrowing  abnormal
vertebral movement and alignment up to anterolisthesis or
retrolisthesis.
• Restabilization: structural compensatory remodeling
phenomena  ↓ mobility, stiffness.
 Traumatic Instability
• Spine: 3 vertical columns (Denis, et al):
• Anterior: anterior halves of the bodies and disks + ALL
• Middle: posterior half of the bodies and disks + PLL
• Posterior: neural arches and the posterior ligamentous
complex (supraspinous, interspinous, and flava
ligaments) and facet joint capsules
• simultaneous failure of at least 2 columns 
instability
• Most common site: thoracolumbar (L1, T12).
reasons: (1) mobility (2) transition zone (3) facet
joints

Denis F. The three columns spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–31.
 Traumatic Instability
• Thoracolumbar fractures
classified by Magerl :
• A: stable / partially
compromised, PLL intact
• B: (1) and (2): unstable in
flexion because PLL is
injured but stable
extension (intact ALL); (3)
unstable in extension,
maybe stable in flexion if
PLL intact
• C: all type is unstable
• Imaging: MRI

Denis F. The three columns spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–31.
 Neoplastic Instability
• Neoplastic spine instability:
loss of spinal integrity as a
result of a neoplastic process
associated with movement-
related pain, symptomatic or
progressive deformity, and/or
neural compromise under
physiologic loads (Spine
Oncology Study Group)

Denis F. The three columns spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–31.
IMAGING IN SPINAL
INSTABILITES
 Dynamic Radiography
• dynamic modality  upright AP and true lateral neutral-flexion-
extension projections
• Degree of listhesis: (White and Panjabi)

A.A. White, M.M. Panjabi (Eds.), Clinical biomechanics of the spine, 2nd ed, JB Lippincott, Philadelphia, PA, 1990.
Computerized Tomography
• Conventional radiology is inadequate for the
assessment of stability in case of trauma
• CT can detect even the tiniest fractures in the
middle and posterior columns, revealing potentially
unstable lesions, and also allows an excellent
evaluation of vertebral alignment and the spatial
position of dislocated bone fragments -> preferred
imaging modality in acute multitrauma patients
• In degenerative instability, CT scans  provide
indirect signs of instability and relevant information
about predisposing anatomic factors,
Axial Load MRI
• Because the conventional MRI examinations of the
spine usually are performed in supine position, in
functional rest, the loading conditions differ from those
known to elicit the symptoms in patients affected by
lumbar spine instability; this is frequently exacerbated
by upright standing and hidden in the supine position
• In supine position, various pathologic features, can
remain undetected compared with that observed in the
standing position.
• relevant flaw of the axial-loaded MRI: this approach
does not consider the influence that head/body weight
and muscle activation have on the lumbar spine
stability
Dynamic MR Imaging
• Apart from instability assessment, in many cases
dynamic MRI has proved to reveal disk-radicular
conflicts not depicted on conventional MRI studies
• In the degenerative instability process, the
restabilization phase is challenging to interpret without
the aid of a dynamic study of the spine: it concerns
both the nerve root compression at the level of
foramina, due to osteophytes, and the activation of
postural effects of body weight mediated by abdominal
and paraspinal muscles, moving from orthostatic to
standing position.
• Because of the relative novelty of this approach, clinical
and diagnostic criteria have not yet been clearly
defined, so further clinical trials are required
Dynamic MRI of a 53-year-old man affected by lumbar pain acquired
on a 0.5-T magnet. T2-weighted turbo spin-echo sequence in sagittal
midline in (A) supine and (B) upright standing. L4-L5 anterolisthesis
becomes evident in upright (squared enlargements). White lines
indicate the posterior walls alignment.
Dynamic MRI of a 56-year-old man affected by lumbar pain
acquired on a 0.25-T magnet. T2-weighted turbo spin-echo
sequence in sagittal midline in (A) supine and (B) upright standing.
L4-L5 discal protrusion becomes evident in upright; the disk
appears clearly dehydrated (dark disk sign).
 Dynamic MRI of a 61-year-old
woman affected by lumbar pain
acquired on a 0.5-T magnet.
Axial T2-weighted turbo spin-
echo sequence in (A) supine and
(B) upright standing. Right discal
protrusion with intraforaminal
radicular conflict (white circle)
becomes evident in upright.
SUMMARY
• The spine is a complex structure, the integrity of which
depends on multiple anatomic elements that are
functionally strictly related to each other. Different
pathologic processes can modify this biomechanical
balance, creating spinal instability and consequent back pain
and functional impairment.
• Multiple imaging modalities are used in daily practice to
assess this clinical condition; however, because of the lack
of a univocal definition of instability, the diagnosis is not
always correctly obtained.
• Nowadays novel MRI systems allow studying the spine in
more realistic loading conditions able to elicit symptoms in
patients affected by spine instability. Further trials are
required to clearly understand the correct diagnostic
pathway in the light of these new technologies to choose
the best therapeutic approach.