Degenerative spinal pathology is one of the most common causes of pain in society. Degenerative disease of the spinal column is highly prevalent in the general population, and its incidence increases with age.

Pain is the main symptom among those individuals most commonly associated with this pathologic condition; others are neurologic disorders (i.e. sensory, motor, neurovegetative dysfunctions).

Different factors, both individually and concomitantly, can result in degenerative processes of the spine, such as mechanical (e.g. postural anomalies, heavy weight-bearing, sports), anatomic (e.g. malformations, dysplasias) and metabolic factors (e.g. diabetes).

The lumbar spine is most frequently involved; up to 70–80 % of people have low back pain during their lifetime [1].

It is understood that only a certain number of patients with back pain will be found to have a disc herniation, spinal stenosis or well-known causes of pain; in the other cases it may be difficult to discover the source of pain. It is equally well understood that the syndrome may arise from the posterior elements/perispinal tissues of the lumbar spine, which are richly innervated [2–4].

The diagnostic techniques of computed tomography (CT) and magnetic resonance imaging (MRI) have made an important contribution to the study of degenerative diseases of the spinal column. In particular, MRI provides a very sensitive method for examining degenerative phenomena of the spine, even in the initial stages of the disease lifetime [1–3, 5–9].

However, traditional MRI of patients with low back pain does not always enable clear identification of pain aetiology. In our experience, T2-weighted sequences with fat saturation and, when indicated, T1-weighted sequences with fat saturation after intravenous administration of contrast medium provide a more sensitive picture of the degenerative changes of the spinal column and occasionally disclose pathologic conditions unsuspected during a “standard” MRI examination [1–3, 5].

All the patients in this series were examined with a 1.5 T MR system (Siemens Symphony TIM) by using the following basic study protocol:

An efficient spinal imaging protocol must comprise T2-weighted sequences with fat suppression, in particular with fat saturation technique or STIR sequences, in order to clearly visualize hyperintensity corresponding to oedematous lesions, otherwise not easily identifiable with “standard” imaging sequences without fat suppression (Fig. 2.1).

In the same way, administration of contrast medium must be followed by T1 sequences with fat saturation, in order to clearly identify the active inflammation.

The indication for contrast medium administration was based on evidence of osteo-articular or muscular-ligamentous oedema in T2-weighted images with fat saturation. In some selected cases, we administered contrast medium although the basic scan failed to disclose oedematous lesions on T2-weighted images (e.g. in cases of clinical-radiological discrepancy).

In this series we administered intravenous paramagnetic contrast medium (Dotarem – Guerbet – 0.5 mmol/ml, 0.2 ml/kg dose).

The fat saturation technique consists in a spectral saturation of the fat, by adding a selective radiofrequency (RF) impulse on the fat frequency. To determine the fat frequency, the machine checks for the presence of approximately a 130-Hz peak, as compared with the resonance frequency of water, at which point it emits the RF impulse. The effect of the impulse is to excite the fat over 180°, whereby it will be unable to return the signal. Such a technique enables the saturation of the fat signal on almost all of the available sequences, from spin-echo to gradient-echo, using any type of MRI sequence (T1, T2, T2*).

We have to remember that fat signal can be suppressed also by using STIR sequences, but, in our experience, this technique has a long acquisition time, whereas FS technique substantially does not change the relative acquisition time.

Today, the correct diagnosis is important in effecting improved aeration outcomes: it will be reflected in an elevated benefit/cost ratio with regard to MRI and will enable more accurate therapy of the specific source of painful symptoms (e.g. microinvasive percutaneous treatment).

In this text-atlas we deal with the following degenerative spinal changes, with particular attention on corresponding inflammatory aspects: disc degeneration, disc herniation, facet joint pathology (e.g. osteoarthritis, joint effusion, synovitis, and synovial cysts), spondylolysis, canal stenosis, spinal/perispinal ligamentous degenerative-inflammatory changes and perispinal muscular changes. Moreover, we show some unusual clinical cases.