1. 1. 54NEURORADIOLOGY OF SPINE DAVID SUTTON
2. 2. DAVID SUTTON PICTURES DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL
3. 3. Fig. 54.1 Normal and degenerative lumbar intervertebral discs. Sagittal (A) and axial (B) MRI, T weighted contrast Normal discs are surrounded by low signal from the annulus fibrosis and partly divided horizontally by a low-signal band, not present in children's discs.
4. 4. Fig. 54.2 Normal and degenerative cervical intervertebral discs and general anatomy. Sagittal MRI. (The cerebellar tonsus seem to be low lying).
5. 5. Fig. 54.3 Normal dorsal vertebral, CT axial section. Normal defects in the cortex of the vertebral body for the passage of the veins are shown; the posterior defect is for the basivertebral veins. Note the circular spinal canal with equal sagittal and coronal diameters.
6. 6. Fig. 54.4 Myelogram and CT myelography in a patient with rheumatoid arthritis and seemingly mild anterior atlanto-axial subluxation and severe spinal cord damage. (A) Sagittal image reformatted from multiple axial slices (no contrast). (B and C) Lateral views of the myelogram in flexion and extension. (D) Axial CT images of the myelogram showing the flattened damaged spinal cord.
7. 7. Fig. 54.4 Myelogram and CT myelography in a patient with rheumatoid arthritis and seemingly mild anterior atlanto-axial subluxation and severe spinal cord damage. (A) Sagittal image reformatted from multiple axial slices (no contrast). (B and C) Lateral views of the myelogram in flexion and extension. (D) Axial CT images of the myelogram showing the flattened damaged spinal cord.
8. 8. Fig. 54.6 Extradural injection of contrast medium. Myodil globules have extended throughout the lumbar and sacral epidural space, through the intervertebral foramina and along the course of the sacral plexuses.
9. 9. Fig. 54.7 Subdural contrast medium. (A) AP projection. (B) Lateral projection. (C) Oblique projection. The appearances superficially simulating an enlarged spinal cord are due to the contrast medium outlining the outer border of the arachnoid membrane. Note that the inner border of the contrast column appears lobulated and that its upper border does not form a fluid level with unopacified CSF
10. 10. Fig. 54.8 Spinal angiogram, selective injection. Normal study. The arteria radicularis magna arises from the left tenth intercostals artery. It fills the anterior spinal artery and there is retrograde filling of other anterior radiculomedullary vessels. The posterolateral arteries of the spinal cord are also filled through the cruciate anastomosis at the conus.
11. 11. Fig. 54.9 Dural arteriovenous fistula, left second lumbar angiogram. AP and lateral projections. (A and B) Large arrow, the fistula; small arrows, the draining vein.
12. 12. Fig. 54.10 Cystic astrocytoma, cervical spine lateral projection. The spinal canal is expanded. The posterior borders are concave. The line of the conjoined laminae bordering the posterior margin of the spinal canal is flattened and its length increased.
13. 13. Fig. 54.11 Neurofibromatosis. (A,B) Lumbar spine X-ray. The L3/L4 intervertebral foramen is enlarged, with erosion of the inferior border of the third lumbar pedicle and the adjacent part of the posterior surface of the vertebral body. (C) Myelogram. A neurofibroma on the fourth lumbar nerve root is partly intradural, causing a well-defined filling defect within the theca at the L3 level, and partly extradural, displacing the theca medially away from the pedicle and intervertebral foramen. There is another intradural tumour at T11 /T12 level which deviates the termination of the spinal cord and nerve roots toward the left and causes complete obstruction. Histology showed this tumour to be a neurofibrosarcoma.
14. 14. Fig. 54.12 Lipomyelomeningodysplasia. Sagittal T,-weighted image. There is high signal from the epidural fat and from the lipomatous mass. The latter is subcutaneous, within the lumbosacral spina bifida, and extends through the dura and then superiorly to blend with the posterior border of the spinal cord which extends down to the lumbosacral region. The dark band extending centrally within the intradural part of the lipoma as far as the cord is presumed to be a fibrous septum.
15. 15. Fig. 54.13 Diastematomyelia. (A,B) Myelogram. The width of the spinal canal is increased in the lower thoracic region and it is divided by a bony spicule at T10 level. There is a long cleft of the spinal cord extending from the fourth thoracic to the second lumbar levels; the conus medullaris is at L3/4 disc level. (C) Computed myelogram. Contiguous axial sections of lower thoracic region pass through the bony spur which is dividing the spinal cord and the subarachnoid space.
16. 16. Fig. 54.13 Diastematomyelia. (A,B) Myelogram. The width of the spinal canal is increased in the lower thoracic region and it is divided by a bony spicule at T10 level. There is a long cleft of the spinal cord extending from the fourth thoracic to the second lumbar levels; the conus medullaris is at L3/4 disc level. (C) Computed myelogram. Contiguous axial sections of lower thoracic region pass through the bony spur which is dividing the spinal cord and the subarachnoid space.
17. 17. Fig. 54.14 Diastematomyelia, lipoma. (A) Sagittal T,- weighted sequence. (B) Axial T1 sequence. A posteriorly situated lipoma at L5 and S1 levels extends through the dura into the subcutaneous tissues. A band extends from the inferior margin of the posterior surface of the fifth lumbar vertebral body into the lipoma. The spinal cord is divided into two unequal parts, which extend one behind the other through the lumbar region and which both blend into the anterior border of the lipoma at L5 level, with the band passing between them.
18. 18. Fig. 54.15 Chiari malformation, syringomyelia. Midsagittal T1 weighted section through brainstem and upper cervical region. The cerebellar tonsils are elongated and extend well below the level of the arch of the atlas. The medulla is elongated and the depressed dorsal column nuclei are below the tonsils. The medulla is compressed between the odontoid and the depressed cerebellar tonsils. There is a syrinx distending the spinal cord below the inferior border of C2 and there is four-ventricular hydrocephalus.
19. 19. Fig. 54.16 Congenital fusion of cervical vertebrae with spondylosis: myelogram. Congenital fusion of the fourth, fifth and sixth cervical vertebrae with degenerative changes at discs above and below. Osteophytes at C3/4 level compress the spinal cord and nerve root sheaths. Osteophytes at C6/7 level compress the root sheaths only.
20. 20. Fig 54.17 Atlanto-occipital assimilation: reformatted CT sections in coronal (A), sagittal (B,C) through condyles and axial (D) planes. The left occipital condyle and lateral mass of atlas are small, relatively dense and completely fused. The joint space between the right occipital condyle and lateral mass is incomplete. The posterior arch of the atlas is closely applied but not fused to the skull bone.
21. 21. Fig. 54.18 Absent thoracic pedicle: CT. The left pedicle of the seventh thoracic vertebra is almost completely absent. The bone bordering the defect is corticated and the articulation with the corresponding rib is anomalous. The bone defect is filled by fat continuous with the epidural fat outlining the outer margin of the dura, which is in a normal position.
22. 22. Fig. 54.19 (A,B) Dural ectasia in neurofibromatosis: myelogram. The subarachnoid space is markedly expanded in the lower half of the thoracic and upper lumbar regions. The corresponding part of the spinal canal is markedly expanded in this region and there is erosion of the posterior borders of the vertebral bodies and of the pedicles.
23. 23. Fig. 54.20 Comminuted fracture of thoracic spine: fractures of the ninth and eighth thoracic vertebrae with anterior subluxation of the eighth. Axial sections through the ninth (A) and the eighth (B) thoracic vertebra, and reformatted sagittal (C) and coronal (D) sections. There is a comminuted fracture with disruption of the body and neural arch of the ninth thoracic vertebra. A fragment has been separated from the posterior inferior margin of the body of the eighth thoracic vertebra and there is anterior subluxation of the rest of the vertebra. The spinal canal is markedly narrowed and the spinal cord is compressed by displaced bone fragments. The subarachnoid space is opacified by a blood clot at T9 and T10 levels. (E,F) MRI of cervical spine. Whiplash injury in road traffic accident 6 months previously. Sagittal sections: T,-weighted (E); T2 weighted (F). The spinal canal is narrowed due to spondylosis. A small focus of aging haematoma is shown in the spinal cord at CT, possibly an unrelated cavernoma rather than an evolving haemorrhagic contusion.
24. 24. Fig. 54.20 Comminuted fracture of thoracic spine: fractures of the ninth and eighth thoracic vertebrae with anterior subluxation of the eighth. Axial sections through the ninth (A) and the eighth (B) thoracic vertebra, and reformatted sagittal (C) and coronal (D) sections. There is a comminuted fracture with disruption of the body and neural arch of the ninth thoracic vertebra. A fragment has been separated from the posterior inferior margin of the body of the eighth thoracic vertebra and there is anterior subluxation of the rest of the vertebra. The spinal canal is markedly narrowed and the spinal cord is compressed by displaced bone fragments. The subarachnoid space is opacified by a blood clot at T9 and T10 levels. (E,F) MRI of cervical spine. Whiplash injury in road traffic accident 6 months previously. Sagittal sections: T,- weighted (E); T2 weighted (F). The spinal canal is narrowed due to spondylosis. A small focus of aging haematoma is shown in the spinal cord at CT, possibly an unrelated cavernoma rather than an evolving haemorrhagic contusion.
25. 25. Fig. 54.21 Old fracture of odontoid peg with non-union and anterior subluxation. (A) Reformatted sagittal section. (B-E) Axial sections. B is at the level of the upper border of the anterior arch of the atlas, C at the level of the lower border of displaced odontoid, D through the upper border of the posterior arch of the second cervical vertebra, and E 3mm below D. The theca is impressed by the posterior margin of the lower fragment of the second cervical vertebra, and the spinal cord is deformed and compressed between it and the posterior arch of the first cervical vertebra. Arrows mark anterior arch of atlas, odontoid fragment, lower fragment of second cervical vertebra; arrowhead = posterior arch of second cervical vertebra.
26. 26. Fig. 54.22 Rheumatoid arthritis. Sagittal MRI, T2 - weighted contrast. Severe erosion of the odontoid, vertical atlanto-axial subluxation and degenerate subaxial disease with spinal cord damage are shown.
27. 27. Fig. 54.23. Rheumatoid arthritis with atlanto-axial subluxation. (A,B) CT axial sections at level of the atlas. (C) Midsagittal reformatted section. There is erosion of the odontoid peg and anterior subluxation of the atlas; the spinal cord is compressed by the odontoid peg and posterior arch of the atlas.
28. 28. Fig. 54.24 Spondylolisthesis of the fourth lumbar vertebra at CT. (A,a) At the level of the pedicles and superior articular facets. (B,b) Through fractured pars intra-articularis. Images are made at window setting appropriate to show both soft tissue and bone. Note that the forward slip of the body of L4 has elongated the sagittal diameter of the spinal canal; there is no nerve root compression.
29. 29. Fig. 54.25 Degenerative lumbar canal stenosis: T 2 -weighted sagittal section of lumbar spine. There is low signal from all the discs, indicating ageing, but the decline in intensity is greater in the lower lumbar region due to additional disc degeneration with dehydration. The lower lumbar discs are narrowed and there is anterior subluxation of two vertebral bodies, with minor posterior protrusion of the annuli impressing the anterior surface of the theca. There is more prominent impression of the posterior surface of the theca due to infolding of the posterior ligaments associated with apophyseal osteoarthritis. The combination is causing degenerative canal stenosis.
30. 30. Fig. 54.26 Acute intraspinal haemorrhage. Sagittal (A) and axial (B) MRI with T,-weighted contrast. The extensive posteriorly located haematoma is well shown. This one probabally is subdural in location, and was spontaneous.
31. 31. Fig. 54.27 Pyogenic infection, L5/S1 disc. (A) Axial section at level of L5; (B) at level of S1. (C) Axial reformatted section. The bone is destroyed adjacent to the disc space, leaving a large cavity with adjacent sclerosis around the disc. There is no intraspinal extension.
32. 32. Fig. 54.28 Neurofibroma: axial section, cervical region, T 1- weighte sequence. There is a slightly lobulated mass grossly enlarging the left inter-vertebral foramen and eroding the adjacent bone. An intraspinal component of the mass displaces the theca and spinal cord toward the right and compresses them. A paravertebral component forms a mass displacing the deep cervical muscles. The extent of this dumb- bell neurofibroma is evident from this single study.
33. 33. Fig. 54.29 Metastasis CT. Sclerotic metastases involving the right side of the sacrum were shown by plain films but are seen more clearly by axial CT. This also shows bone destruction around the right sacral foramen and a vertical pathological fracture through the body of the sacrum.
34. 34. Fig. 54.30 (A) Osteoblastoma of cervical spine. The right pedicle and lateral mass of the sixth cervical vertebra are enlarged and sclerotic, with an irregular central low-density nidus. (B) Osteoid osteoma. CT scan of mid-thoracic spine. There is sclerosis with focal expansion involving the left lamina. The tumour encroaches on the epidural space and contains a small nidus which is of low density.
35. 35. Fig. 54.31 Sacral chordoma. (A) A fairly well defined region of destruction involving the bodies and left lateral masses of the lowest two segments of the sacrum. (B,C) CT sections through the fourth and fifth segments of the sacrum. A mass of density slightly lower than that of muscle is expanding and destroying the bone of the bodies and left lateral masses of the fourth and fifth segments of the sacrum. (Contrast in loops of small bowel)
36. 36. Fig. 54.32 Haemangioma of bone, lateral lumbar spine. The secondary trabeculae of the body of the second lumbar vertebra are thickened; the vertical striate appearance is typical of a haemangioma.
37. 37. Fig. 54.33 Paget's disease. (A) Lateral thoracic spine. The body and neural arch of the twelfth thoracic vertebra are enlarged and the bone texture is abnormal. (B,C) CT axial sections, lower dorsal vertebra. Note abnormal irregular bone texture throughout the vertebral body, neural arch and appendages; the whole vertebra is slightly enlarged.
38. 38. Fig. 54.34 Far lateral lumbar disc prolapse. (A,B) CT axial sections. (A) Through L3/4 disc space, showing a soft-tissue mass contiguous with the right posterolateral aspect of the disc, encroaching into the intervertebral foramen and extending lateral to it. (B) Section 6mm higher than A, and at level of the lower part of the body of the third lumbar vertebra. The disc prolapse forms a soft-tissue mass in the path of the emerging right L3 nerve root, which is not visible due to the absence of epidural fat. The left L3 root (arrow) is clearly shown. (C,D) MRI L4/5 lateral disc prolapse. Sagittal T1 -weighted sections. Encroachment of prolapsed disc substance into the L4/5 intervertebral foramen obliterates the epidural fat around the emerging nerve root.
39. 39. Fig. 54.34 Far lateral lumbar disc prolapse. (A,B) CT axial sections. (A) Through L3/4 disc space, showing a soft-tissue mass contiguous with the right posterolateral aspect of the disc, encroaching into the intervertebral foramen and extending lateral to it. (B) Section 6mm higher than A, and at level of the lower part of the body of the third lumbar vertebra. The disc prolapse forms a soft-tissue mass in the path of the emerging right L3 nerve root, which is not visible due to the absence of epidural fat. The left L3 root (arrow) is clearly shown. (C,D) MRI L4/5 lateral disc prolapse. Sagittal T1 - weighted sections. Encroachment of prolapsed disc substance into the L4/5 intervertebral foramen obliterates the epidural fat around the emerging nerve root.
40. 40. Fig. 54.35 Extruded (sequestrated) disc protrusion. (A) Sagittal T 2- weighted section of lumbar spine. The L4/5 disc space is narrowed and the signal returned from the nucleus is decreased. There is a slightly lobulated extradural mass behind the L4/5 disc and upper half of the body of the fifth lumbar vertebra which is compressing the spinal theca. The signal returned from it is similar to that of the normal L3/4 nucleus. It was an extruded fragment removed at surgery. Such fragments commonly give higher signal than the damaged disc from which they originate. (B-E) Sequestrated lumbosacral disc prolapse. T,-weighted sections lumbar spine: B,C sagittal; D,E axial. The disc fragment extends behind the upper part of the right side of the body of the sacrum. It displaces the first sacral nerve root posteriorly and erodes the sacral body.
41. 41. Fig. 54.35 Extruded (sequestrated) disc protrusion. (A) Sagittal T 2- weighted section of lumbar spine. The L4/5 disc space is narrowed and the signal returned from the nucleus is decreased. There is a slightly lobulated extradural mass behind the L4/5 disc and upper half of the body of the fifth lumbar vertebra which is compressing the spinal theca. The signal returned from it is similar to that of the normal L3/4 nucleus. It was an extruded fragment removed at surgery. Such fragments commonly give higher signal than the damaged disc from which they originate. (B-E) Sequestrated lumbosacral disc prolapse. T,-weighted sections lumbar spine: B,C sagittal; D,E axial. The disc fragment extends behind the upper part of the right side of the body of the sacrum. It displaces the first sacral nerve root posteriorly and erodes the sacral body.
42. 42. Fig. 54.36 Extruded fragment from a degenerate L3/L4 intervertebral disc. (A,B) Sagittal and axial MRI with T2-weighted contrast. A large migratory extruded disc fragment ascends on the right behind the L3 vertebral body. (C,D) Sagittal and axial MRI 8 weeks later shows spontaneous resolution of the extrusion.
43. 43. Fig. 54.37 Ossification of the posterior longitudinal ligament. Sagittal (A) and axial (B) MRI with T 2 - weighted contrast. The axial image is between the intervertebral discs and shows the large low-signal thickened ligament looking somewhat like a mushroom.
44. 44. Fig. 54.38 Lumbar spinal canal stenosis with entrapment of the cauda equina. Sagittal MRI with T 2 - weighted contrast showing stenosis of the spinal canal at L4-L5; CSF signal is excluded at the level of the stenosis, and there is redundant coiling of many of the intradural spinal roots above
45. 45. Fig. 54.39 Canal stenosis. CT sections through lumbar spinal canal. Note the short pedicles (bottom right image) and medially placed apophyseal joints. The combination causes marked reduction of the sagittal diameter of the lateral parts of the spinal canal, which is further compromised by osteoarthritic changes in the apophyseal joints.
46. 46. Fig. 54.40 Syringomyelia. Parasagittal T,-weighted sequence. The low signal subarachnoid CSF outlines the expanded spinal cord and also the intramedullary cyst, which shows a typical lobulated appearance. One of the cerebellar tonsils is outlined with its lower pole extending to the level of the arch of the atlas.
47. 47. Fig. 54.41 Ependymoma. Sagittal and axial with T2-weighted contrast shows an extensive tumour filling much of the lumbosacral spinal canal and cavitated spinal cord above.
48. 48. Fig. 54.42 Intradural lipoma. T1 - weighted MRI. Sagittal section through posterior fossa and upper cervical region. The posterior fossa and foramen magnum are normal. There is a large mass returning high signal and typical of fat. It lies within the subarachnoid space posteriorly, enlarging the spinal canal and displacing the spinal cord anteriorly. The spinal cord is markedly thinned and the cord substance appears to be almost completely replaced by fat over most of the extent of the tumour. The appearances are typical of a large intradural and partially intramedullary lipoma. These tumours typically extrude from the posterior surface of the cord between the dorsal columns.
49. 49. Fig. 54.43 Multiple sclerosis. An axial T 2 - weighted MRI at C6 shows a typical plaque in the right lateral column, reaching to the pial surface of the spinal cord.
50. 50. Fig. 54.44 Myelogram neurofibroma. (A) AP projection. (B) Oblique projection. The tumour is intradural on the right side at C4/5 level and its margins are clearly outlined by the contrast medium in the subarachnoid space which is widened around the tumour. The spinal cord is compressed and displaced by the mass.
51. 51. Fig. 54.45 Neurofibromatosis with multiple tumours. Sagittal T,-weighted MRI sections. (A) Posterior fossa and cervical region. (B) Thoracic region. (C) Cervical region after gadolinium enhancement. (D) Thoracic region after gadolinium enhancement. The patient has neurofibromatosis and there are multiple tumours. Some are intradural extramedullary schwannomas. A good example is shown anteriorly at C2 level. The upper border of this tumour is outlined against the cerebrospinal fluid, but its posterior border blends with the spinal cord which gives signal of similar intensity. The extent of this tumour i s evident on the enhanced scan. Some of the tumours are extradural. An example is shown posteriorly in the mid-thoracic region B; the upper and lower borders are outlined against the extradural fat behind the spinal cord. The anterior margin is only slightly denser than the cord substance. After injecting gadolinium (D), the tumour is enhanced. Its anterior border, which is compressing the dura and the cord, is more evident but the intensity of signal from the enhanced tumour is similar to that of the epidural fat, making the upper and lower limits more difficult to define. An intramedullary tumour is also present, expanding the cord in the lower dorsal region. The margins are not distinguished from cord substance on the plain scan B but are evident with ring enhancement after gadolinium (arrow in D).
52. 52. Fig. 54.45 Neurofibromatosis with multiple tumours. Sagittal T,- weighted MRI sections. (A) Posterior fossa and cervical region. (B) Thoracic region. (C) Cervical region after gadolinium enhancement. (D) Thoracic region after gadolinium enhancement. The patient has neurofibromatosis and there are multiple tumours. Some are intradural extramedullary schwannomas. A good example is shown anteriorly at C2 level. The upper border of this tumour is outlined against the cerebrospinal fluid, but its posterior border blends with the spinal cord which gives signal of similar intensity. The extent of this tumour i s evident on the enhanced scan. Some of the tumours are extradural. An example is shown posteriorly in the mid-thoracic region B; the upper and lower borders are outlined against the extradural fat behind the spinal cord. The anterior margin is only slightly denser than the cord substance. After injecting gadolinium (D), the tumour is enhanced. Its anterior border, which is compressing the dura and the cord, is more evident but the intensity of signal from the enhanced tumour is similar to that of the epidural fat, making the upper and lower limits more difficult to define. An intramedullary tumour is also present, expanding the cord in the lower dorsal region. The margins are not distinguished from cord substance on the plain scan B but are evident with ring enhancement after gadolinium (arrow in D).
53. 53. Fig. 54.46 Meningioma. (A,B) Myelogram. A partially calcified mass forms a slightly irregular defect within the theca on the left side posteriorly in the upper thoracic region and compresses the spinal cord. (C,D) Computed myelogram. The calcification within the tumour is mainly peripheral and is well shown on D, where the subarachnoid space is almost totally occluded. On C, the irregular medial margin of the tumour is shown, together with the flattened spinal cord, which is displaced anteriorly and towards the right. (E-G) Cervical meningioma-MRI: T2 weighted E; T,- weighted F; T,-weighted after gadolinium G. The tumour has a broad base on the dura anterior to the spinal cord which is displaced posteriorly and compressed. The tumour returns high signal on T 2 -low on T,-weighted, and enhances markedly.
54. 54. Fig. 54.46 Meningioma. (A,B) Myelogram. A partially calcified mass forms a slightly irregular defect within the theca on the left side posteriorly in the upper thoracic region and compresses the spinal cord. (C,D) Computed myelogram. The calcification within the tumour is mainly peripheral and is well shown on D, where the subarachnoid space is almost totally occluded. On C, the irregular medial margin of the tumour is shown, together with the flattened spinal cord, which is displaced anteriorly and towards the right. (E- G) Cervical meningioma-MRI: T2 weighted E; T,-weighted F; T,- weighted after gadolinium G. The tumour has a broad base on the dura anterior to the spinal cord which is displaced posteriorly and compressed. The tumour returns high signal on T 2 -low on T,- weighted, and enhances markedly.
55. 55. Fig. 54.46 Meningioma. (A,B) Myelogram. A partially calcified mass forms a slightly irregular defect within the theca on the left side posteriorly in the upper thoracic region and compresses the spinal cord. (C,D) Computed myelogram. The calcification within the tumour is mainly peripheral and is well shown on D, where the subarachnoid space is almost totally occluded. On C, the irregular medial margin of the tumour is shown, together with the flattened spinal cord, which is displaced anteriorly and towards the right. (E-G) Cervical meningioma-MRI: T2 weighted E; T,-weighted F; T,-weighted after gadolinium G. The tumour has a broad base on the dura anterior to the spinal cord which is displaced posteriorly and compressed. The tumour returns high signal on T 2 -low on T,-weighted, and enhances markedly.
56. 56. Fig. 54.47 Spinal dural arteriovenous fistula with intradural drainage. Sagittal (A) and coronal (B) MRI with T2 - weighted contrast in the cervical region showing markedly enlarged intradural veins.
57. 57. Fig. 54.48 Dural arteriovenous fistula, left second lumbar angiogram. (A) AP projection. (B) Lateral projection. The fistula is on the left side of the dura at L2 level and it drains superiorly through a vein ascending along the posterolateral aspect of the subarachnoid space to enter the posterior coronal venous system at T12 level. Veins then pass around the left side of the cord to fill the anterior coronal plexus also. Large arrow = fistula; small arrows = draining vein.
58. 58. Fig. 54.49 AVM of the spinal cord. (A) Left vertebral angiogram. (B) Left sixth intercostal angiogram. The AVM is at the cervico-thoracic junction. It is supplied (A) from above by the enlarged anterior spinal artery descending from the cervical region and (B) by an enlarged tortuous vessel, presumably a posterior spinal artery, ascending along the posterolateral aspect of the cord.