Confusing spinal disorders are not uncommonly encountered in daily routine practice; reliably differentiating between real lesions and mimics, tumors and non-tumoral masses, as well as benign and malignant lesions is often challenging. For example, a herniated disk can mimic an epidural tumor such as a schwannoma, especially if the herniated disk is sequestered away from the parent disk and shows high T2-weighted signal with enhancement. Nonetheless, there are often useful imaging clues that allow for differentiation of these conditions.

In this chapter, we will describe practical tips helpful in the accurate diagnosis of the following potentially confusing spinal disorders: herniated disk versus schwannoma, spondylolytic versus degenerative spondylolisthesis, focal red marrow versus metastasis, postoperative scar versus recurrent disc herniation, benign osteoporotic vertebral fracture versus malignant vertebral fracture, os odontoideum versus odontoid process fracture, neurofibromatosis type 1 versus type 2, infectious spondylitis versus Modic type 1 endplate degenerative change, spinal cord herniation versus intradural arachnoid cyst, spinal arteriovenous fistula versus hypervascular tumor with intratumoral shunt, ankylosing spondylitis versus diffuse idiopathic skeletal hyperostosis, pyogenic spondylitis versus tuberculous spondylitis, spinal cord tumor versus nonneoplastic myelopathy, acute transverse myelitis versus multiple sclerosis, ependymoma versus astrocytoma, schwannoma versus meningioma, chordoma versus giant cell tumor, vertebral hemangioma versus Paget’s disease, sacroiliitis of spondyloarthropathy versus osteitis condensans ilii, as well as sacral insufficiency fracture versus sacral osteomyelitis.