Medserena Upright MRI Case Studies

Upright MRI Dynamic positional magnetic resonance imaging

• MRI examination with natural weight-bearing in standing and seated positions.

• Examinations in various postures for a precise and conclusive diagnosis.

• Upright MRI examinations – truly open and unrestricted for patients suffering from claustrophobia.

• Magnetic resonance imaging for severely overweight patients.

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Medserena Upright MRI Centres London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington London, SW7 4ES

26-28 The Boulevard, West Didsbury Manchester, M20 2EU

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The specific features of upright magnetic resonance imaging Our centres operate upright MRI systems, which differ from conventional tunnel systems and semi-open systems.

The key feature of upright MRI is that now, for the first time, an MRI scan can be carried out in the upright, natural weightbearing position. Complete functional assessments are feasible with upright MRI - whether in the standing or seated, supine or functional position. In many cases, this provides a thorough, more conclusive diagnosis that cannot be achieved with conventional MRI scans performed only in the supine position.

Magnetic resonance imaging in a natural weightbearing position The basic advantage of upright MRI compared to a purely conventional MRI scan is that the weight-bearing structures of the body can be imaged under physiological loading.

Using this system, spinal or neural foraminal narrowing in the region of the spinal column and instability on loading, for example, can be detected and quantified. To date, this has only been possible with conventional functional X-rays or by using invasive methods (myelography).

MRI images in various postures

The upright MRI system can also be used to carry out examinations in various functional postures.

Furthermore, joints can be examined in various functional postures.

For instance, in addition to the upright position, the spinal column can be imaged with flexion (bending forwards), extension (stretching backwards), rotation and even with lateral (side) tilt.

Upright MRI is also indicated for small pelvis examinations since this approach provides a better estimate, in a weight-bearing position, of the actual extent of frequently encountered pelvic floor insufficiency.

This highlights position-dependent disorders which could not be detected until now.

Instability in particular can be highlighted from a functional perspective and quantified. Similarly, the actual extent of function-dependent spinal or neural foraminal narrowing and their pathological mechanisms can be imaged.

Upright MRI allows virtually unlimited freedom of movement therefore the patient can take up almost any position.

Thus patients can be examined accurately in the position thatproduces pain. This provides a more precise and conclusive diagnosis.

Claustrophobic patients They can actually watch a TV program or DVD on a large 50� screen.

The coils (even the head coils) are designed to allow a clear view of the surrounding area outside of the system, at any time.

An accompanying person can stay in the MRI room with the patient during the examination. Certain restrictions must however, be complied with (pacemakers, insulin pumps, etc.).

Examinations using the truly open upright MRI are also well tolerated by patients with severe claustrophobia.

Patients can clearly see outside the system during the examination.

London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Upright MRI Dynamic positional magnetic resonance imaging

Clinical Indications

The diagnostic focus of our centres is dynamic positional magnetic resonance imaging of the spine and large joints, although upright weight-bearing MRI has advantages across a broad range of indications. Thanks to the truly open design of the upright MRI system, patients suffering from claustrophobia who may otherwise go unexamined are able to undergo the scan without difficulty.

Lumbar spine

Cervical spine

In the case of recurrent or persistent lumbar pain, either as a primary diagnostic procedure or where previous conventional MRI has failed to identify the cause of symptoms.

In the case of chronic or recurrent pain as the initial examination or if previous attempts at diagnosis have proved unsuccessful.

Confirmation/exclusion of degenerative changes.

The following conditions in particular can be diagnosed via upright MRI with no need for any additional examinations: Proof or exclusion of segmental instability in patients with degenerative changes or after recent trauma.

Exclusion of spondylolisthesis in patients with known retro- or anterolisthesis within the framework of a degenerative pseudospondylolisthesis or isthmic spondylolisthesis.

To diagnose the disease mechanism and extent of spinal narrowing, especially in the case of multi-segmental spinal stenoses, including localization of the region with maximum narrowing in various positions.

Position-dependent, neural foraminal narrowing due to occult neural foraminal narrowing in the supine position. In the case of “Failed Back Surgery Syndrome� (FBSS) to establish the causative disease mechanism with loading.

Spinal examinations in the case of marked scoliosis and kyphosis are also feasible, with accurate angle measurements.

Examinations of the bony pelvis including the sacrum and sacroiliac joints.

Confirmation and/or exclusion of increased segmental mobility (also known as segmental collapse or angular instability).

Existing retro- or anterolisthesis to rule out an anterior drawer component or confirm listhesis with loading.In the presence of disc protrusion and pain inconsistent with the extent of disc herniation.

In the case of position-dependent radicular symptoms. With multi-segmental spinal narrowing to establish the site of greatest narrowing in various positions.

In the case of unclear myelopathy to rule out or confirm compression of the cervical myelon in various positions including flexion and extension In the case of unclear syringohydromyelia to rule out Chiari malformation type I.

Craniocervical junction

Comparative images in the supine position can also be recorded.

Examination of the craniocervical junction with weight bearing and in various functional postures.

Functional images of the large joints can be taken in various positions.

Confirmation or exclusion of instability or dysfunction in the atlanto-occipital region in patients with diffuse posturedependent sympathetic symptoms, especially following whiplash injury or capsular or ligament changes or in patientswith the hypermobile Ehlers-Danlos Syndrome (hEDS).

Head

Thoracic spine

Comparative images of the cranium in the upright and supine positions.

In the case of persistent pain in the thoracic spine when previous diagnostic attempts proved unsuccessful.

Confirmation / exclusion of segmental instability in the case of degenerative changes or status post-trauma.

Erect spinal examinations in the case of marked scoliosis and kyphosis with accurate angle measurements.

Joints MRI scans of the joints including the shoulder, knee, hip, ankle, elbow, wrist and feet.

Examination of weight-bearing joints such as the knee and hip joint in the natural, weight-bearing, standing position.

London

Examination of the cranium and the cervico-occipital region for almost all neuro-radiological and ENT investigations including arterial and venous vascular imaging.

Examination of the craniocervical junction in a weight-bearing position and in various functional postures.

Pelvis PelvisExamination of small pelvic organs to generate comparative images and functional analysis in the case of pelvic floor dysfunction in the supine, standing and seated positions.

An excellent demonstration of the prostate gland and urinary bladder can be performed with the patient sitting.

Additional examinations Please contact us to find out whether the examination you require is feasible.

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Lumbar Spine Case studies of dynamic positional upright magnetic resonance imaging

Severe, functional spinal canal stenosis in the lumbar spine region with natural weight-bearing in the standing and seated positions.

The 60 year-old patient presented here is suffering from chronic, recurrent lumbar syndrome, which has become progressively worse over the last 2 years. This is accompanied by pseudoradical lumbar ischialgia radiating to both legs, depending on load and posture, and limited walking ability.

explanation for the patient’s symptoms. Only the upright MRI scan clarified the position and weight dependent symptoms: Absolute, function dependent spinal canal stenosis with pincer shaped narrowing of the Cauda equina visible in segment L-4/5 in the standing extension posture.

An earlier examination in the supine position did not confirm diagnosis. Upright MRI confirmed dynamic spinal canal stenosis.

Upright MRI was carried out with natural weight-bearing in an upright neutral seated position with seated flexion and standing extension. The findings were compared with external conventional MRI scans taken in the supine position five months earlier.

Evidence in segment L3/4 of function-dependent, relative spinal canal stenosis with narrowing of the Caudia equina in the standing extension posture and function-dependent pseudospondylolisthesis with functional anterolisthesis of L3 (ventral displacement of 3-4 mm / grade 1 according to Meyerding) with unremarkable dorsal alignment in the supine and seated positions. The neural foramina in segments L3 to S1 are significantly narrowed on both sides in a natural weightbearing position but especially in the standing extension position.

The examination carried out five months earlier in the supine position, and used as a comparison, did not provide any obvious

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A: Sagittal T2-weighted supine B: Sagittal T2-weighted seated C: Axial T2-weighted seated with L3/4 D: Axial T2-weighted seated with L4/5 E: Sagittal T2-weighted standing F: Axial T2-weighted standing with L3/4 G: Axial T2-weighted standing with L4/5

Functional severe spinal canal stenosis due to unstable anterolisthesis and position-dependent intraspinal synovial cysts.

In segment L5/S1, there is evidence of a mediodorsal disc prolapse, predominantly to the left side, with moderate to severe narrowing of the spinal canal and bilateral hypertrophic facet joint osteoarthritis.

This case refers to a 62 year-old male patient presenting recurrent lumbar syndrome for 2 years and treated with conservative pain therapy. Symptoms include persistent low back pain and pseudoradical lumbar ischialgia, clearly radiating as far as the feet on the right side. In addition, his walking ability is limited to 100 m.

In the seated anteflexion position (Fig. A) there is evidence in segment L4/L5 of anterolisthesis extending over 5 mm from L4 to L5, regressing to 3 mm on standing retroflexion (Fig. C).

In this segment, there is also evidence of extensively hypertrophic Ligamenta flava and severe facet joint osteoarthritis with functional, intraspinal facet joint cysts to the right, increasing to 7 mm in diameter in the standing position (Figs. C + D).

Marked additional weight-bearing and posture-dependent symptoms especially on standing and walking as well as functional improvement in symptoms when load is lifted in seated and anteflexion positions.

No clear indication from external MRI previously taken in the supine position. The consultation comprised upright MRI to examine the lumbar spine under natural weight-bearing conditions and in functional positions in a patient presenting treatment-refractory lumbar syndrome.

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In segment L3/L4, unstable retrolisthesis of 2 mm is apparent in the standing position (Fig. C) accompanied by hypermobility of the disc, regressing in anteflexion (FIg. A), and associated with active facet joint osteoarthritis, predominantly to the right, with marked hypertrophy of the Ligamenta flava and broad-based disc protrusion with slight narrowing of the neural foramina and spinal canal.

Severe functional spinal canal stenosis to the right is of crucial significance in terms of the patient’s weight-bearing-dependent symptoms.

This is triggered by unstable antelisthesis from L4 to L5 with severe, bilateral facet joint osteoarthritis and functionally increasing intraspinal facet joint cysts to the right.

In this case, upright MRI again highlighted the cause of the patient’s weight-bearing-dependent symptoms as a result of the individually adapted examination performed in various weightbearing positions.

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The upright MRI scan was performed with the patient upright and in a natural weight-bearing position. Sagittal T2-weighted images in seated anteflexion (Fig. A), upright seated (Fig. B) and standing (Fig. C) positions. Figure D) shows axial T2-weighted images in the standing position at L4 / L5.

Upright MRI scans can be performed in an upright position and therefore natural weight-bearing position.

The spine can therefore be examined under real conditions.

Pressure on the discs in particular is 11 times greater in the forward leaning seated position compared to the supine position.

Weight-bearing disorders can be clearly identified with upright MRI.

Intradiscal pressure for different body positions, normalized to an upright position (100%). Test person 70 kg, 168 cm, 45 years old.

A.L. Nechemson, Spine 1, #1, pp. 59-71, 1976; H-J. Wilke, P. Neef, M. Caimi, T. Hoogland and L.E. Claes, Spine 24, #8, pp. 755-762, 1999

Furthermore, functional examinations can also be performed with flexion, reclining or lateral movements using the upright approach. Movement-dependent conditions can therefore be identified with the MRI scan and diagnosed more accurately.

Functional instability in the lumbar spine with natural weight-bearing in standing and seated positions.

This particular case involves a patient whose condition can be diagnosed on the basis of an MRI scan performed in a natural weight-bearing position. This would not be feasible with conventional supine MRI. The 34 year-old patient presented here complained postoperatively of weight-bearing and posture-dependent pain, increasing throughout the day and radiating to both legs, as well as numbness in the soles of the feet and paraesthesia mainly to the right, mostly on bending forwards. No symptoms were experienced in the supine position. Several operations were performed in the L5/S1 region, the most recent procedure being hemilaminectomy 5 months ago. No symptom-free interval guaranteed following surgery.

A supine MRI scan performed 4 months earlier did not confirm the diagnosis. Upright MRI confirmed functional stenosis.

Upright MRI was carried out in a natural weight-bearing position, in the upright neutral seated position, with seated flexion and standing extension, and in the neutral supine position with no weight bearing. The findings were compared with external supine scans taken four months earlier.

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Diagnosis: The examination performed four months earlier and presented for comparison as well as the supine scan performed on the same day using the upright MRI system did not provide any obvious explanation for the persistent symptoms experienced by the patient since surgery.

Only the kinetic-positional upright MRI scan provided a full explanation of the cause of the symptoms: In segment L5 / S1 in anteflexion, evidence of anterolisthesis from L5 to S1 of 7 mm, regressing to 5 mm in the standing extension position , evaluated as clearly unstable anterolisthesis accompanied by angular instability.

Overall, broad-based disc protrusion in contact with nerve roots L5 and padding of the dural sac at the S1 outflow on both sides. Mild to moderate spinal canal stenosis. Moderate neural foraminal stenosis to the right and severe neural foraminal stenosis to the left with recurring functional increase on anteflexion.

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Whereas both spinal and neural foraminal narrowing is apparent in the supine images, there is no evidence in the supine and standing images of unstable ventrolisthesis from L5 to S1. The latter was fully apparent only in the anteflexion position with a shift of 7mm.

The functional images of upright MRI confirm diagnoses, which would remain unclear with a conventional supine MRI scan.

E A: Sagittal T2-weighted supine B: Sagittal T2-weighted standing C: Sagittal T2-weighted seated D: Sagittal T2-weighted flexion E: Coronal STIR seated with right convex scoliosis in the lower lumbar region with pelvic misalignment

Spinal narrowing caused by unstable anterolisthesis and intraspinal synovial cysts.

The 77 year-old patient presented here complained of weightbearing-dependent lumboischialgia persisting for more than one year.

Nine months before the upright MRI, a synovial cyst, believed to be causing the symptoms, was removed from the small left vertebral joint L4/5. The back pain and pain in the right leg have improved. The pains in the left leg, in L5 - dermatoma - improved for only three months.

Given the persistent symptoms, a Coflex implant was introduced between L4 and L5, one month before the upright MRI, in order to stabilise the affected segment. Post-surgical pain was identical to that experienced prior to surgery.

Standard supine MRI scan The conventional supine MRI scan confirmed that severe neural foraminal or spinal narrowing could be ruled out with status post Coflex implantation in L4/5.

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A-B: Sagittal T2-weighted standard supine image

An examination conducted in the supine position highlighted degenerative changes overall, as it did prior to surgery, but without severe spinal or neural foraminal narrowing. A kinetic positional upright MRI scan was then performed to rule out functional instability.

Upright MRI functional examination in a natural weight-bearing standing position

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Natural weight-bearing revealed severe spinal narrowing in L4/5. This is due to degenerative anterolisthesis measuring 7 mm, from L4 to L5, with severe, bilateral, hypertrophic spondylarthrosis.

The ventral shift does not change position with loading. Spinal narrowing is accentuated by bilateral synovial cysts, curving in an intraspinal direction, on the small vertebral joints L4/5, on both sides. The cysts have a diameter of 11 mm to the left and 6 mm to the right. Accentuation of spinal narrowing is apparent in both the reclining and standing positions.

C-D: Sagittal T2-weighted functional image in standing position

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The examination shows severe, spinal narrowing exacerbated in the reclining and standing positions with unstable, degenerative anterolisthesis from L4 to L5 and severe, hypertrophic spondylarthrosis following intraspinal synovial cysts, predominantly to the left.

This particular case clearly accentuates the dynamic components and various factors that can lead to spinal narrowing. These components cannot be highlighted with a conventional supine MRI scan alone.

London

E-F: Sagittal T2-weighted functional image in standing position

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Cervical spine Functional MRI scan of the cervical spine upright in a natural weight-bearing position

The upright MRI system allows MRI diagnosis of the cervical spine in the upright, natural weight-bearing position.

Full functional assessments are also feasible with upright MRI scans. In addition to the neutral, upright position, the cervical spine can also be imaged in the flexion, extension, lateral tilt and rotation positions.

This system can be used to image disorders that cannot be detected with conventional MRI scans performed in the supine position.

The patient presented in this case has no history of cervical spine problems. Over the last six months, this patient has been experiencing regular bouts of vestibular vertigo of approximately 10 minutes’ duration.

There have also been occasional complaints about headaches during this period.

A functional examination of the cervical spine was therefore carried out with specific focus on the craniocervical junction in the upright MRI scan.

Os odentoideum Posterior arch of the atlas

A: Sagittal T2-weighted supine

Myelopathy

B: Sagittal T2-weighted supine

Instability in the region of the craniocervical junction was highlighted during the functional examination with evidence of circumscribed, pincer-shaped narrowing of the cervical myelon on flexion (Fig. a).

Particular attention should be paid to congenital aplasia of the dens axis which, in the usual region of the apex of the dens axis, comprises only a small core bone (Os odontoideum). In the flexion position (Fig. a), there is obviously a circumscribed forward shift of the atlas towards the Foramen magnum causing considerable narrowing of the spinal canal on the upper dens level.

C: Sagittal T2-weighted supine

In the extension position (Fig. c), the shift of the atlas towards the Epistropheus is visible with marked myelon decompression.

Circumscribed myelopathy is apparent in the region of the upper dens, at the Ligamentum transversum level.

Secondary findings include intervertebral disc degeneration at levels C3 to C6 with flat disc protrusions of no clinical relevance.

Diagnosis was confirmed through a functional upright MRI scan.

Functional multi-segmental spinal canal stenosis in the region of the cervical spine.

The 44 year-old female patient presented here is intolerant to numerous chemicals. She is complaining of discomfort in both shoulders and a diffuse, bilateral tingling sensation in the upper extremities. No dizziness and headaches were reported.

An MRI scan of the cervical spine was taken to clarify the symptoms.

Standard MRI scan in the supine position A

A standard MRI scan in the supine position revealed flat, dorsal protrusions of the intervertebral discs in segments C 4/5 and C 5/6 with no evidence of spinal canal stenosis or nerve root compression at these levels. Signs of slight compression of the myelon at C 5/6.

Upright MRI scan with natural weight-bearing position B

No significant changes in intervertebral disc status in segments C 4/5 and C 5/6 in the upright neutral seated position compared to a standard MRI scan in the supine position.

B: Sagittale T2-weighted image in the neutral seated position

A: Sagittale T2-weighed standard supine image

Upright MRI functional examination in a natural weight-bearing seated position The flexion position (FIg. C) revealed only very flat intervertebral disc protrusion in the dorsal region, in segments C 4/5 and C 5/6.

The ventrodorsal diameter of the central sections of the spinal canal at these levels was clearly wider compared to images taken in the upright neutral position (Fig. B).

However, the extension position (Fig. d) highlighted a marked reduction in spinal canal diameter due to extended protrusion of the intervertebral discs essentially in the left mediolateral region with compression of the myelon and additional osseous components.

Slight retrolisthesis of C5 and C6 were highlighted in a natural weight-bearing position on the upright MRI scan. An anterior instability could be ruled out on functional assessment.

The upright MRI functional examinations with flexion and extension revealed posture- and movement-dependent multisegment spinal canal stenosis from C4 to C7, predominantly in the left median and paramedian regions, which explains the patient’s symptoms.

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C: Sagittal T2-weighted, flexed and seated D: Sagittal T2-weighted, extended and seated

Severe functional spinal canal stenosis of the cervical spine The patient presented here sustained considerable bruising to the head and cervical spine on falling down the stairs in 1999.

This resulted in contusion of the myelon and instability between C2 and C3.

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A: Sagittal T2-weighted image in the neutral position

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C: Sagittal T2-weighted with flexion

Paraplegia with total flaccid paresis of the arms and legs occurred immediately after the fall.

Rehabilitation resulted in incomplete restoration, predominantly to the left as opposed to the right.

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B: Axial T2-weighted image in the neutral position

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D: Axial T2-weighted with flexion

The instability in segments C2-C3 was clearly apparent from the functional images in a natural weight-bearing position.

considerably narrows the area near the protruding intervertebral disc on the dorsal side and, on the ventral side, the spinal canal, and compresses the myelon.

In the sagittal neutral position (Fig. A), there is evidence of a tapering structure in the dorsal region, causing pincer-shaped narrowing of the spinal canal in intervertebral discs C2-C3.

This is probably the raised Ligamentum flavum, which appears partially calcified.

Disc protrusion in C2-C3 levels off considerably in the sagittal flexion position (Fig. C). Even the circumscribed protrusion is no longer evident from the dorsal view. Hence the spinal canal now appears to be considerably wider with less compression of the myelon.

The axial image with flexion (Fig. D) clearly highlights the expansion of the spinal canal which is probably mostly due to the levelling off of the protruding discs in segments C2-C3 and the fact that the Ligamentum flavum is now tightened and positioned dorsally.

The axial-weighted image in the neutral position (Fig. B) reveals a crescent-shaped structure with signal reduction, which

There is evidence of severe narrowing of the neural foramina in both the neutral and flexion positions on both sides.

Position-dependent intervertebral disk prolapse in the region of the cervical spine The 44 year-old female patient presented here has been complaining, for approximately one year, of cervical spine discomfort radiating to the head and face.

The discomfort was mainly experienced in the upright position and was particularly severe on leaning backwards. Nerve root compression in segment C7 was suspected following clinical examination.

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A: Sagittal T2-weighted on flexion

B: Sagittal T2-weighted in a neutral position

A conventional MRI scan in the supine position revealed protrusion (approximately 3 mm) in cervical vertebrae 5/6 with no essential narrowing of the spinal canal and no adverse effects on nerve roots.

Given the persistent discomfort, an upright MRI scan was performed with the cervical spine in a natural weight-bearing position together with additional functional images on flexion and extension.

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C: Sagittal T2-weighted on extension

D: Axial T2-weighted in the neutral position

The finding: The upright MRI scan was performed seated, upright and in a natural weight-bearing position.

Images in the neutral position reveal intervertebral disc prolapse extending from the median / mediolateral to the intraforaminal region on the left, with compression of the myelon and compression and displacement of nerve root C7 in the left, interspinal region.

The intervertebral disc protrudes the dorsal vertebra by 5 mm.

The ventrodorsal diameter of the central sections of the spinal canal are narrowed to 6 mm as a result. The functional images confirmed a reduction in the extent of the intervertebral disc prolapse on flexion and an increase in the width of the central sections of the spinal canal to 8 mm.

London

The functional images on extension revealed a marked increase in intervertebral disc findings with primarily craniocaudal expansion and marked protrusion of the posterior longitudinal ligament. The Ligamenta flava was also prominent, resulting overall in the central narrowing of the spinal canal to 4.5 mm.

The cause of the symptoms could be accurately diagnosed through functional examination via upright MRI in the upright, natural weight-bearing position. Nerve root compression suspected on the basis of clinical findings could be confirmed.

Position-dependent compression of the myelon was also detected.

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

MRI imaging with substantially reduced artefacts following spinal fusion

Upright MRI allows imaging to be carried out with a marked reduction in artefacts in patients with implantable devices.

The horizontal right / left orientation of the main magnetic field, combined with a steel shield weighing 130 tonnes, special coil technologies and metal artefact-reducing sequences, allows upright MRI imaging to be performed despite the presence of metal objects in the examination area, such as implantable material.

Patients who have undergone surgery can be scanned in the upright MRI and a findings Report produced.

Precise diagnoses are extremely important for patients due to the frequent onset of instabilities at a later stage, therefore, doctors treating patients at a later stage can choose the most useful form of therapy.

This is particularly noticeable in extensive surgical procedures, e.g. the implantation of a Harrington rod in scoliosis patients.

These cases cannot be examined in a conventional tunnel system due to the thermal effect of metal.

However, in upright MRI, objects implanted long-term in the body such as intramedullary nails, prostheses or spinal fusion show a marked reduction in image artefact unlike conventional MRI systems.

The risk of heating or resonance-induced oscillation of the implanted material is eliminated.

Female patient with lumbar syndrome following extensive spinal fusion.

1.5 Tesla Tunnel System

The case presented here refers to a 61 year-old female patient with persistent, post-operative lumbar syndrome following extensive spinal fusion from lumbar vertebra 2 to lumbar vertebra 5 with additional cage implantations and recurrent, clearly load- and position-dependent lumbar ischialgia with right-sided radiation particularly when seated and standing, and relatively no symptoms in the supine position.

A post-operative MRI scan in the supine position in a 1.5 Tesla tunnel system could not be assessed diagnostically because of extensive metal artefacts.

Fully Open Upright MRI

1.5 T tunnel system

Upright MRI

Axial T2

Axial T2

1.5 T tunnel system

Upright MRI

Therefore, a targeted upright MRI scan was performed, focusing on load- and position-dependent symptoms and as a result of substantially reduced metal artefact formation.

The diagnosis: The dynamic positional upright MRI scan carried out highlighted the cause of the symptoms and revealed atypical medial positioning / DD (differential diagnosis) incorrect positioning of the right pedicle screw at lumbar vertebra segment 3 with potential irritation of the right nerve root L3. Otherwise, correct positioning of the implanted material in a patient with marked lumbar scoliosis.

Evidence in lumbar vertebra 4/5 of paramedian intervertebral disc prolapse with accentuated adjacent involvement as far as the right nerve root L4 and subsequent risk of irritation with natural weight-bearing in seated and standing positions.

Axial T2

Axial T2

1.5 T tunnel system

Upright MRI

Sagittal T2

Sagittal T2

1.5 T tunnel system

Upright MRI

Subsequent degeneration in lumbar vertebra segment 1/2 with onset of posterior instability with apparent structural breakdown on the posterior border of the spinal canal on extension in the standing position and consecutively relative function-dependent spinal canal stenosis.

A clear diagnosis could be made to clarify the patient’s symptoms through extremely low metal artefact sensitivity and function images in a natural weight-bearing position.

London

Sagittal T1

Sagittal T1

1.5 T tunnel system

Upright MRI

Coronary STIR

Coronary STIR

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

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Shoulder joint Patient with severe claustrophobia and pain in the left shoulder with restricted mobility.

The case presented is that of a 51 year-old patient with acute left shoulder pain of 2 weeks’ duration with restricted mobility.

No evidence of activated osteoarthritis in the AC (acromioclavicular) joint.

The referral for a MRI scan was made on the basis of suspected rotator cuff tear. No previous surgery on the left shoulder joint.

The patient suffers from severe claustrophobia. The patient would not tolerate a conventional MRI scan in a tunnel system.

The subacromial space is moderately narrowed with a width of 6 mm. Alteration in signal intensity in the supraspinatous tendon at the muscle-tendon junction, but no disruption in continuity.

Evidence of fluid cuff around the long biceps tendon, probably indicative of mild tendinitis.

The upright MRI shoulder scan, which was fully tolerated by the patient, ruled out rotator cuff tear, which was originally suspected.

Overall, the scan revealed a shoulder joint consistent with the patient’s age, with the onset of omarthrosis and osteophyte formation accompanied by narrowing of the joint space and minor joint effusion.

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A: Coronal 3D sequence

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B: Coronal T1-weighted

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C: Coronal STIR sequence

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D: Sagittal T2-weighted

E: Sagittal T2-weighted

F: Transversal T2-weighted

Knee

Hip In addition to conventional magnetic resonance imaging of the hip joints, examinations can also be carried out in natural weight-bearing positions with upright MRI. The hips can also be examined in various positions such as rotation or flexion.

Weight-bearing knee joint function test with various degrees of flexion In upright MRI, in addition to conventional knee-joint examinations, function tests can also be carried out in natural weight-bearing positions and with various degrees of flexion.

The images shown below were recorded in a patient who complained of stabbing pains on climbing the stairs. The symptoms disappeared when the knee was fully extended.

Upright MRI highlighted patellar contusion with 60째 flexion of the femoral condyle.

The patient can clearly see outside the system during the examination. Therefore, the procedure is also particularly well tolerated by patients with claustrophobia.

The series of images shows a 17 year-old male patient following treatment for epiphyseal dislocation of the left femoral head with pain in the left hip on flexion.

The function test conducted with upright MRI detected an impingement.

30째 flexion

Standing neutral axial

Standing neutral coronal

Left axial flexion

Left coronal flexion

60째 flexion

90째 flexion

London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Dynamic upright MRI Pelvic floor diagnosis in a natural weight-bearing position

Pelvic floor diagnosis with an upright MRI scan – functional diagnosis and comfortable examination The upright MRI system is particularly suitable for diagnosing functional pelvic floor disorders.

The method combines the advantages of an MRI scan with the essentially improved functional imaging in the physiological seated position.

The method provides a valid diagnosis for the definitive classification of load-dependent or function-dependent displacement of the small pelvic organs. The quality of the reproducible images can prove useful in devising subsequent treatment plans and considering surgical indications.

Furthermore, the system improves compliance as patients are examined in a familiar position, which is essential in order to achieve diagnostically viable scan results.

The truly open design of the upright MRI system also creates a far more pleasant examination environment for patients with claustrophobia.

A new approach to diagnosis with seated MRI defecography The 69 year-old female patient presented here has complained for years about pain on micturition, a combination of urge and stress incontinence, urination frequency and nocturia. The patient also reported chronic deterioration in bowel movements and the sensation of incomplete defecation with force.

A dynamic MRI scan with defecation following rectal gel application was performed in the seated position using the truly open upright MRI system to clarify painful symptoms and carry out function imaging of the pelvic floor.

Her medical history includes total hysterectomy as well as sigma resection with subsequent stenosis of low rectal anastomosis and bougienage (dilatation). The last colonoscopy revealed moderate residual stenosis with no evidence of further pathological findings.

A

B

A: Sagittal T2 in neutral seated position B: Sagittal T2 in seated, max. strained position C: Sagittal T2 in seated, relaxed position

C

Dynamic imaging of defecation.

The finding: Examination performed in the upright seated position with contraction and maximum straining of pelvic floor prior to defecography.

Evidence of correct positioning of full bladder and extensive coverage of urethra in the neutral position. Correct width of pubococcygeal angle with slight widening of anorectal junction following gel application.

Primary evacuation of rectal ampulla in defecography with no evacuation of the anterior rectocele. Entrapment of the gel located in the proximal rectal ampulla as a result of the descending bladder with marked cystocele and concomitant displacement of the urethra as evidence of hypermotility of the urethra with position-dependent dilatation of the internal urethral ostium. Mechanically-induced urethral occlusion with increasing cystocele descent.

Adequate elevation of the pelvic floor under contraction, with no evidence of impaired motility. Under maximum relaxation, anterior rectocele starts to form with obvious descent of bladder floor clearly below the pubococcygeal line.

Also evidence of slight displacement of mesenterial fatty tissue in pouch of Douglas / peritoneocele on applying forced pressure to the abdomen.

London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

No room for “fear of confined spaces�

The upright MRI system can be used to examine patients with severe claustrophobia Claustrophobia prevents many patients from undergoing an MRI scan despite severe pain. This has high cost implications for doctors, therapists and medical insurance companies.

But the patient comes off the worst: Instead of getting a diagnosis, he/she often has to put up with severe pain for months on end.

The upright magnetic resonance imaging system is the answer!

An examination using the upright MRI system is well tolerated by patients with severe claustrophobia. atients can clearly see outside the system during the P examination. hey can actually watch a TV programme or DVD, on a large T screen, during the examination.

The coils (even the head coils for brain scans) are designed to allow patients to clearly see outside the system. he person accompanying the patient can stay in the MRI room T during the examination.

Patient with extreme claustrophobia and unknown swallowing disorder The case presented concerns a 68 year-old male patient with swallowing difficulties, who feels as though he has “a lump in his throat” and whose medical history includes bilateral cervical swelling of a few days’ duration. Generally feels ill. No relevant previous conditions Moderate obesity, moderate asymmetry of the cervical soft tissue mostly to the right side with enlarged lymph nodes on both sides, on palpation.

A

B

E

The patient suffers from severe claustrophobia. The patient did not tolerate an examination in a conventional tunnel MRI system.

Consequently, an examination was performed using a truly open MRI system in this generally anxious patient with strong cervical soft tissue, in order to differentiate between peritonsillar abscess and neoplasm.

C

D

The MRI scan was performed in the seated position using the truly open upright MRI system in this patient presenting with severe claustrophobia and agitation.

Unenhanced T1, T2, STIR and Dixon sequences, and contrast-supported T1 sequences were used.

A: T1-axial B: T1-axial with contrast agent C: T1-sagittal D: T1-sagittal with contrast agent E: Coronary STIR sequence

The finding: Fig. A: The axial T1-weighted sequence shows sub-total displacement of the oropharyngeal lumen with an approximately homogeneous space-occupying lesion to the right of the tonsils, in the region of the tongue base, overlapping the mid line.

Fig. B: Following administration of the contrast agent, virtually homogeneous enhancement of the afore-mentioned spaceoccupying lesion, primarily in the margins. Maximum diameter of the space-occupying lesion: 2.8 x 3.7 x 5.1 cm. Slight fluid deposits in the adjacent parapharyngeal soft tissues. No proof of infiltration of the space-occupying lesion in the parapharyngeal space.

Fig. C: Sagittal T1-weighted sequence: The afore-mentioned space-occupying lesion extends caudally to the glottis with signs of infiltration.

London

Fig. E: Coronary STIR sequence and Fig. D: The sagittal T1-weighted sequence highlights marked, cervical lymphadenopathy to the right with partly confluent, partly nonhomogeneous, necrotic bundles of lymph nodes at levels II A/B, III, IV and V A/B.

The diagnosis: Despite partly substantial movement artefacts, the MRI images display a series of findings indicative of oropharyngeal cancer to the right of the tonsils with ipsilateral and contralateral lymph node metastases, thus T3 N2c.

The patient would not have tolerated a closed system MRI scan and the diagnosis would therefore have been substantially delayed.

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Upright MRI Web portal Medserena Upright MRI Centre www.trulyopenmri.com Here you can find state-of-the-art information on upright magnetic resonance imaging such as clinical indications, actual case studies and the latest centre news.

We have also put together a clinical study review of dynamic positional magnetic resonance imaging for you with respective links to the original academic papers.

Referrer portal: www.myupright.com We have included the web portal, myupright-mri.com for our referring doctors. Doctors referred to us can look at their patients’ MRI scans directly in a web viewer.

This is obviously subject to compliance with data protection issues. Pre-requisites include a dedicated referring doctor log-in with corresponding management of rights (access only to “his/ her” patients) and previous patient consent.In order for you to get started, we have authorised access for you with the user name: demouk and password: demouk Please contact us should you require any further information.

Patient portal www.fear-of-mri.com www.back-pain-mri.com This is where we explain the option of upright magnetic resonance imaging to patients in everyday language.

There is a particular focus on “anxious patients” who suffer from claustrophobia or are afraid of the conventional tunnel examination.

Here patients can familiarise themselves in advance with the upright MRI system and find out about examination options.

London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Scientific Articles / Studies Lumbar spine Intervertebral disc degeneration / hyperlordosis The Response of the Nucleus Pulposus of the Lumbar Intervertebral Discs to Functionally Loaded Positions Lindsay A. Alexander BSc et al. | Robert Gordon University, Aberdeen Spine Volume 32, Number 14, pp1508-1512 Intervertebral disc degeneration Missed Lumbar Disc Herniations Diagnosed With Kinetic Magnetic Resonance Imaging Jun Zou MD et al. | Department of Orthopedic Surgery | University of California, Los Angeles Spine Volume 33, Number 5, pp E140-E144 Intervertebral disc degeneration Dynamic Bulging of Intervertebral Discs in the Degenerative Lumbar Spine Jun Zou MD et al. | Department of Orthopedic Surgery | University of California, Los Angeles Spine Volume 34, Number 23, pp 2545-2550 Spinal stenosis The Effect of Lumbar Flexion and Extension of the Central Canal with Dynamic MRI Feng Wie MD et al. | University of California, Los Angeles The Spine Journal, 09/10 2007, Volume 7, Number 5S Spinal stenosis Pathomechanism of Spinal Canal Stenosis - Upright MRI Image Gallery P. Niggemann et al. | Private Practice for Upright Magnetic Resonance Imaging, Cologne Spinal stenosis Lumbar Stenosis Rates in Symptomatic Patients Using Weight-Bearing and Recumbent Magnetic Resonance Imaging John W. Gilbert MD et al. | Spine and Brain Neurosurgical Center Lexington

Lumbar spine Instabilities Missed Spondylolisthesis in Static MRIs but Found in Dynamic MRIs in the Patients with Low Back Pain Soon-Woo Hong, MD et al. | University of California, Los Angeles The Spine Journal, 09/10 2007, Volume 7, Number 5S Instabilities Spondylolysis and Spondylolisthesis P. Niggemann et al. | Private Practice for Upright Magnetic Resonance Imaging, Cologne Spine Volume 36, Number 22, ppE1463-E1468 Instabilities Repeat Upright Positional Magnetic Resonance Imaging for Diagnosis of Disorders Underlying Chronic Noncancer Lumbar Pain John W. Gilbert MD et al. | Spine and Brain Neurosurgical Center Lexington Reviews Upright positional MRI of the lumbar spine F. Alyas et al.

Intervertebral disc height / angular instability Lumbar Spine Disc Height an Curvature Responses to an Axial Load Generated by a Compression Device Compatible with Magnetic Resonance Imaging Shinji Kimura MD et al. | Department of Orthopedic Surgery | University of California, San Diego Spine Volume 26, Number 23, pp2596-2600 Intervertebral disc height / lordosis / DSCA (dural-sac cross-sectional area) The Effect of Body Position and Axial Load on Spinal Canal Morphology - an MRI Study of Central Spinal Stenosis Rasmus Madsen BSc et al. | University of Aberdeen Spine Volume 33, Number 1, pp 61-67 Neural foraminal stenosis Positional MRI of the Lumbar Spine: Does it demonstrate Nerve Root Compromise Not Visible at Conventional MR Imaging Dominik Weishaupt MD et al. | Institute of Diagnostic Radiology, University Hospital, Zurich Radiology 2000, 215:247-253 Myelography Lumbar Spine: Quantitative and Qualitative Assessment of Positional (Upright Flexion and Extension) MR Image and Myelography Simon Wildermuth MD et al. | Institute of Diagnostic Radiology, University Hospital, Zurich Radiology 1998, 207:391-398 Spinal stenosis Dynamic Lumbar Spinal Stenosis: The Usefulness of Axial Loaded MRI in Preoperative Evaluation Kyung-Chul Choi et al. | Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea J Korean Neurosurg Soc 46:265-268; 2009

We have listed studies on kinetic positional magnetic resonance imaging and web links to the original articles on the www.upright-mrt.de website.

Cervical spine Review Diagnostic accuracy of MRI following whiplash injury is improved by routine imaging of the cranio-cervical junction Francis W. Smith | Radiological Society of North America | 100th Annual meeting, Chicago, December 2014 Intervertebral disc degeneration Positional MRI: A valuable Tool in the Assessment of Disc Bulge Payam Moazzaz, MD et al. | University of California, Los Angeles, CA, USA The Spine Journal, 09/10 2007, Volume 7, Number 5S Intervertebral disc degeneration Imaging in the position that causes pain John W. Gilbert, et al. | Online article 08/2007 Neural foraminal stenosis Open Stand-Up-MRI: A new instrument for Positional Neuroimaging John W. Gilbert et al. | Spine and Brain Neurosurgical Center Lexington Journal of Spinal Disorders & Techniques 04/2006 Hypermobility in the region of the cervical spine Kinematic Analysis of Relationship Between the Grade of Disc Degeneration and the Motion Unit in Cervical Spine Masashi Miyazaki MD et al. | University of California, Los Angeles, CA, USA The Spine Journal, 09/10 2007, Volume 7, Number 5S Instability Axial load-dependent cervical spine alternations during simulated upright posture: a comparison of healthy controls and patients with cervical degenerative disease Shinji Kimura MD et al. | Department of Orthopedic Surgery | University of California, San Diego J. Neurosurg Spine, Volume 2, 02/2005

Cervical & Lumbar spine Herniated discs and instabilities Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spine Antonio Ferriero Perez Millan Garcia Isidro et al.

Review Dymanic imaging of the spine with an open upright MRI: present results and future perspectives of fmri Jean Pierre Elsig MD et al. | fmri Center Zurich Eur J Orthop Surg DOI 10.1007/s00590-006-0153-5 Review Upright, Weight-Bearing, Dynamic-kinetic Magnetic Resonance Imaging of the Spine Review of the First Clinical Results JR Jinkins et al. | Departement of Radiological Sciences, Medical College of Pensilvania-Hahnemann J HK Coll Radiol 2003;6:55-74

Cervical & Lumbar spine Review Imaging based planning for spine surgery Jean Pierre Elsig MD et al. | fmri Center Zurich Minimale Invasive Therapie 2006, 1-7 Review Magnetic Resonance Imaging of the Weight-Bearing Spine Dominik Weishaupt MD et al. | Institute of Diagnostic Radiology, University Hospital, Zurich Seminars in Musculoskeletal Radiology, Volume 7, Number 4, 2003

Jugular & Cerebral veins Positional Venous MR Angiography: An Operator-Independent Tool to Evaluate Cerebral Venous Outflow Hemodynamics P. Niggemann et al. | Departement of Radiology, University of Bonn, Germany AJNR, Am J Neuroradiol 2012 Position Dependent Changes of the Cerebral Venous Drainage - Implications for the Imaging of the Cervical Spine P. Niggemann et al. | Private Practice for Upright Magnetic Resonance Imaging, Cologne Cen Eur Neurosurg 2011; 72:32-37

Shoulder Labrum glenoidale (glenoid labrum) Upright MRI of Shoulder Demonstrates Labrum Dynamics J.W.-P. Michael et al. | Departement of Orthopedic Surgery, University of Cologne Int J Sports Med 2008; 29:999-1002

Pelvic floor Review Dynamic MRI Imaging of the Pelvic Floor: a Pictoral Review Maria Chiara Colaiacomo, Gabriele Masselli, Elisabetta Polettini, Silvia Lanciotti, Emanuele Casciani, Luca Bertini, Gianfranco Gualdi RadioGraphics 2009, Vol 29, Issue 3

We have listed studies on dynamic positional magnetic resonance imaging and web links to the original articles on the www.trulyopenmri.com website: https://www.trulyopenmri.com/clinical-studies-for-upright-mri

London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington, London, SW7 4ES

26-28 The Boulevard, West Didsbury, Manchester, M20 2EU

www.trulyopenmri.com

www.trulyopenmri.com

Medserena Upright MRI Centres London

Manchester

020 7370 6003

0161 434 8039

london@trulyopenmri.com

manchester@trulyopenmri.com

114a Cromwell Road, Kensington London, SW7 4ES

26-28 The Boulevard, West Didsbury Manchester, M20 2EU

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