Radiology Spine revised Example For Students

Radiology: Spine revised Cervical Spine AP Open Mouth com/wp-content/uploads/2017/09/cervical-ap.png title=Cervical AP alt=Cervical AP> Cervical AP com/wp-content/uploads/2017/09/cervical-lateral.png title=Cervical Lateral alt=Cervical Lateral> Cervical Lateral Cervical Spine Oblique X-ray com/wp-content/uploads/2017/09/flexion-extension.png title=FLEXION EXTENSION alt=FLEXION EXTENSION> FLEXION EXTENSION Dens Fracture com/wp-content/uploads/2017/09/dens-type-ii-fracture.png title=DENS TYPE II FRACTURE alt=DENS TYPE II FRACTURE> hard to see, thin gray line- L image: should be smooth line from C2 body and dens, instead theres a break at L right arrow- R image: lat. view, can see better DENS TYPE II FRACTURE png title=FLEXION INJURIES alt=FLEXION INJURIES> 1) Anterior subluxation 2) Simple wedge3) Unstable wedge4) Unilateral interfacet dislocation5) Bilateral interfacet dislocation6) Flexion teardrop fracture7) ant atlantoaxial dislocation FLEXION INJURIES Jumped Facets (Facet Dislocation) png title=Jumped Facets (Facet Dislocation) examples alt=Jumped Facets (Facet Dislocation) examples> U/L jumped facet = AKA perched facet dislocation Jumped Facets (Facet Dislocation) examples EXTENSION INJURIES png title=Hangman Fracture alt=Hangman Fracture> *Fx involving both pars interarticularis of C2*Image shows fx at bilat lamina pedicles, and usually anterolisthesis at C2-C3 Hangman Fracture *looking for indirect sign, change in lat. masses of C1 arch and the dens (L lat mass is further from dens)(hard to see on XR > CT) Jefferson Fracture com/wp-content/uploads/2017/09/lumbar-spine-lateral.png title=Lumbar Spine Lateral alt=Lumbar Spine Lateral> IV disc spacesSPPediclesAlignmentVB height Lumbar Spine Lateral -in Lumbar Oblique-Nose = TP Process-Ear = Superior articular facet-Eye = Pedicle-Neck = Pars Interarticularis (look for lucency here)-Front Leg = Inferior articular facet SCOTTY DOG SIGN com/wp-content/uploads/2017/09/scotty-dog-sign-pic.png title=(SCOTTY DOG SIGN pic) alt=(SCOTTY DOG SIGN pic)> Pars Interarticularis #, often assoc. with anterolisthesis> young pts (SCOTTY DOG SIGN pic) png title=Spondylolisthesis grades alt=Spondylolisthesis grades> 1: 0 25% 2: 25 50% 3: 51 75% 4: 76 100% 5 (Spondyloptosis): >100% Spondylolisthesis grades *lumbar pars defect *stress fx from repetitive injury Spondylolysis png title=SPONDYLOSIS (PARS DEFECT) with SPONDYLOLISTHESIS alt=SPONDYLOSIS (PARS DEFECT) with SPONDYLOLISTHESIS> -usually B/L-excess bone-facet jts trying to stabilize themselves SPONDYLOSIS (PARS DEFECT) with SPONDYLOLISTHESIS *FLEXION FRACTURES:*1) *Compression Fracture*: Anterior part of vertebral body breaks/loses height while posterior part of vertebral body is intact. Usually stable.2) *Axial Burst Fracture*: Vertebra loses height along both anteriorly posteriorly*EXTENSION FRACTURES:*1) *Extension/distraction (Chance) fracture*: Vertebra is pulled apart (distracted). (AKA seatbelt #)(ROTATION FRACTURES:)1)Transverse process fracture: Uncommon; from rotation or extreme lateral bending2)Fracture-dislocation Involves bone and/or soft tissue in which vertebra may move off an adjacent vertebra (displaced). Unstable injury. TYPES OF THORACIC AND LUMBAR SPINE FRACTURES AKA Compression -ant VB Wedge Fracture com/wp-content/uploads/2017/09/compression-fracture.png title=COMPRESSION FRACTURE alt=COMPRESSION FRACTURE> magnified view on R- loss of height ant COMPRESSION FRACTURE *Compression injury to ant. vertebral body and transverse # through post. vertebral body Chance Fracture *Vertical disc herniations through the cartilaginous vertebral body endplates > concave endplates (vs. parallel like normal)-can be just inf., just sup., or both-smooth remodeling Schmorls Node png title=AP Sacrum alt=AP Sacrum> -SI Joints-Sacral ALA-Coccyx AP Sacrum -Sacral Coccygeal angle-Cortical Integrity-Pre-Sacral soft tissue Lateral Sacrum png title=SI Joints alt=SI Joints> (normal SI jt.) SI Joints -not at SI jt-most are vertical LEFT SACRAL FRACTURE Evaluation of Bony architecture (limited evaluation of spinal cord and nerve roots) Indications for CT Scan com/wp-content/uploads/2017/09/normal-cervical-spine.png title=Normal Cervical Spine alt=Normal Cervical Spine> saggital view-CT scan: you see more of the bony and soft tissue structures-white: bone-gray: fat, muscles, vessels-black: air Normal Cervical Spine , C1-6 alt=Normal C-Spine Vert., C1-6> axial view- C1: complete ring Normal C-Spine Vert., C1-6 png title=Normal Thoracic Spine alt=Normal Thoracic Spine> saggital view- the worse the scoliosis, the worse the image (you wont see all vert. clearly)- bone soft tissue windows Normal Thoracic Spine alt=Normal Thoracic Spine Vert.> Normal Thoracic Spine Vert. png title=Normal Thoracic Spine Vert. cont. alt=Normal Thoracic Spine Vert. cont. > Normal Thoracic Spine Vert. cont. png title=NORMAL CT LUMBAR SPINE alt=NORMAL CT LUMBAR SPINE> bone window L, ST window R NORMAL CT LUMBAR SPINE > NORMAL CT LUMBAR SPINE Vert. cont. alt=NORMAL CT LUMBAR SPINE Vert. cont.> NORMAL CT LUMBAR SPINE Vert. cont. L5 CONGENITAL PARS DEFECT (xray) com/wp-content/uploads/2017/09/l5-congenital-pars-defect-ct.png title=L5 CONGENITAL PARS DEFECT (CT) alt=L5 CONGENITAL PARS DEFECT (CT)> L: midline (cant see #)Middle: more lateral, start to see defectR: lateral # L5 CONGENITAL PARS DEFECT (CT) alt=L5 CONGENITAL PARS DEFECT CT cont.> axial- much better on CT than xray- facet jts: obliquely oriented defect/lucency- pars articularis: horizontally oriented defect/lucency- spinal canal more flute-like/champagne shape (instead of round) > widening due to ant. slippage that usually goes along w/pars defect L5 CONGENITAL PARS DEFECT CT cont. com/wp-content/uploads/2017/09/l5-burst-fracture.png title=L5 BURST FRACTURE alt=L5 BURST FRACTURE> CT- vert. lost height, lots of # lineslooking for:1) retropulsion of bone (bone fragment extending back into spinal canal)?2) canal stenosis, esp. in thoracic?> MRI imaging L5 BURST FRACTURE com/wp-content/uploads/2017/09/l5-burst-fracture-axial.png title=L5 BURST FRACTURE axial alt=L5 BURST FRACTURE axial> CT, soft-tissue window, bad canal stenoisis L5 BURST FRACTURE axial usually through-and-through #, or just ant. vert. body (rarely just post. vert. body)- this example: some post. retropulsion (were a bit below the conus hopefully, but some folks have conus at L2 > MRI) L1 OSTEOPENIC COMPRESSION FRACTURE flattening of thecal sac > canal stenosis L1 OSTEOPENIC COMPRESSION FRACTURE axial png title=KYPHOSIS (1 mo later) alt=KYPHOSIS (1 mo later)> more loss of vert. height- retropulsion: causing more SC stenosis? Pt may have more Sxs KYPHOSIS (1 mo later) VERTEBRAL AUGMENTATIONFOR TREATMENT OF PAIN RELATED TO COMPRESSION FRACTURES 1) Osteoporosis (most common)2) Direct acute trauma in healthy vertebra3) Neoplasms- Infiltrative neoplasms(eg multiple myeloma, lymphoma)- Metastatic neoplams (eg prostate, breast, lung)- Primary bone neoplasm(hemangiomas, giant cell tumors) Most Common Causes of Vertebral Compression Fractures Conservative Management (if theyre simple #s) for 4-6 wks-initial and gold standard of treatment-medical management with or without methods of immobility-medications (NSAIDS and narcotics) Complications of medications -NSAIDS Gastrointestinal hemorrhage, ulcers-Narcotics constipation, nausea, somnolence, addiction-Most patients with osteoporotic fractures have spontaneous resolution of pain within 4-6 weeks from initial onset, *even without medication!*- vert. augmentation > considered if sig. CIs to pain meds, or are still in sig. pain/compromise to ADL after 6 wks Management of Compression Fracture -Procedures used for palliation of pain related to vertebral compression fractures-Types of Vertebral Augmentation1) Percutaneous Vertebroplasty (PV)2) Balloon-assisted Kyphoplasty-Both involve injection of an acrylic cement under local anesthesia and either fluoroscopic guidance (or, less commonly, CT guidance) to control the pain of vertebral fractures -85-90% patients have rapid pain relief Vertebral Augmentation 1) Pain localized to a fracture or tumor2) Pain refractory to medical management medical management for at least 6-12 weeks3) Fracture less than 12 months old 4) Contraindications to medications or requirement for IV narcotics and hospital admission Vertebral Augmentation pt selection criteria 1) Fracture extending to posterior vertebral cortex retropulsed fragment 2) Cord compression 3) Radiculopathy 4) Fever and/or sepsis 5) Coagulopathy (bleeding disorder) > take-home: conservative tx HAS TO BE DONE 1st!!! Vertebral Augmentation Exclusionary Criteria -Injection of low-viscosity acrylic cement (methylmethacrylate) directly into vertebral body using a unipedicle or bipedicle needles -Typically perfomed in an O/P setting-Objective: treatment of pain (preventing painful motion of vertebral body fragments moving against one another); presence of cement also stabilizes vertebra from suffering another fracture. -DOES NOT RESTORE VERTEBRAL BODY HEIGHT -may be done prophylactically for at-risk vertebra between two other abnormal vertebraetake-home > cement injected, for pain and not height Percutaneous Vertebroplasty Low Complication Rate (1-3.9%) Acute Complications:-Cement leak (symptomatic or asymptomatic) [biggest issue, esp. post. The Disadvantages of Homeschooling vs Traditional Educations Essay 2> similar to last slide Lumbar cont. 2 com/wp-content/uploads/2017/09/modic-changes.png title=MODIC CHANGES alt=MODIC CHANGES> *Type I:* -T1 hypointense (dark) and T2 hyperintense (bright)-Bone marrow edema inflammation*Type II:*-T1 hyperintense and T2 iso/mildly hyperintense (bright spots) -Conversion of normal hemopoietic (red) bone marrow into fatty (yellow) marrow*Type III:* -T1 and T2 hypointense (dark)-Subcondral bone sclerosis MODIC CHANGES *Type I:* -T1 hypointense (dark) and T2 hyperintense (bright)-bright: bone marrow edema inflammation MODIC CHANGES Type I com/wp-content/uploads/2017/09/modic-changes-type-ii.png title=MODIC CHANGES Type II alt=MODIC CHANGES Type II> *Type II:*-T1 hyperintense and T2 iso/mildly hyperintense (bright spots) -Conversion of normal hemopoietic (red) bone marrow into fatty (yellow) marrow MODIC CHANGES Type II *Type III:* -T1 and T2 hypointense (dark)-Subcondral bone sclerosis MODIC CHANGES Type III -Naked bone of outer periphery of vertebral body-Outer fibers of disc (Sharpeys Fibers) anchor themselves into this region -*Bone spurs (osteophytes) arise form this region* as a result of prolonged pulling/tugging of Sharpeys fibers RING APOPHYSIS com/wp-content/uploads/2017/09/disc-anatomy.png title=DISC ANATOMY alt=DISC ANATOMY> Nucleus Pulposus:-*water-rich* gelatinous center of disc-bear axial load of body; pivot point for movt Annulus Fibrosus: -more *fibrous* than nucleus, higher collagen / lower water content-hold in place the highly pressurized nucleus-composed of 15-25 concentric sheets of collagen named LAMELLAE.-outer lamellae = SHARPEYS FIBERS DISC ANATOMY png title=DISC Problems anatomy alt=DISC Problems anatomy> DISC Problems anatomy OSTEOPHYTES MRI png title=MRI CERVICAL DDD Osteophytes alt=MRI CERVICAL DDD Osteophytes> MRI CERVICAL DDD Osteophytes Facets = Synovial Joints-Prone to osteoarthritis-*Osseous overgrowth can results in lateral canal stenosis (neural foraminal stenosis)*-Associated with facet synovial cysts and degenerative disc disease FACET ARTHROPATHY, CT SCAN png title=Facet Arthropathy CT SCAN (cont) alt=Facet Arthropathy CT SCAN (cont)> Axial view (lose the nice hamburger shape, excess bone formation) Facet Arthropathy CT SCAN (cont) *Uncovertebral joints (Luschkas joints)*-formed between uncinate processes above and uncus below-exist from C3 to C7-allow for flexion and extension; limit lateral flexion*Uncovertebral joint hypertrophy*-osteophytes (bone spurs) form in response to degeneration of the spine to try to maintain stability of the spine-can lead to lateral canal (foraminal stenosis) in the cervical spine Uncovertebral Hypertrophy, CT SCAN png title=UNCOVERTEBRAL HYPERTROPHY MRI alt=UNCOVERTEBRAL HYPERTROPHY MRI> UNCOVERTEBRAL HYPERTROPHY MRI Ligamentum Flavum -provides stability and protection to spine-connects the vertebral bodies together-flexible >> normally thicker when standing or leaning back and thinner when sitting or bending forwardHypertrophy/Thickening of the Ligamentum Flavum-natural part of aging process-spine is trying to provide itself with additional support when injury or aging occurs-thickened ligament becomes less flexible and weaker and can encroach on the spinal canal Ligamentum Flavum Thickening, MRI png title=Calcified Ligamentum Flavum CT SCAN alt=Calcified Ligamentum Flavum CT SCAN> Calcified Ligamentum Flavum CT SCAN Normal Abnormal Disc *Radicular pain:*-Pain arising from the spinal root level (vs referred pain from facet joint, SI joint, etc.. )-Sciatica (most common type of radiculopathy)-Burning, stinging /or numbness in buttock, thigh, leg, /or foot; +/- Back pain*Non-radicular pain:* -Pain radiating in a non-dermatomal pattern RADICULOPATHY Specific type of Radiculopathy where pain is caused by impingement/irritation of one of the three lowest lumbar nerve roots (L4, L5 S1) which make up the Sciatic Nerve Treatment is often nonsurgically unless concurrent cauda equina symptoms present or not responding to conservative therapy SCIATICA Normal annulus fibrosus:-Strong and keeps pressurized nucleus pulposus from escaping outwardAnnular Tears/Fissures:-Separations between one of more of the annular lamellae-Avulsion of fibers from the vertebral insertion ANNULAR TEARS (FISSURES) Modified Dallas Discogram Classification Gold Standard = Discography (no longer performed)MRI: can pick up some annular tears, but not all-Will affect nearly 40% of chronic back pain sufferers, but often difficult to diagnose -Contrast MRI better than noncontrast MRI -NonContrast MRI: *T2 hyperintensity along annulus*-Contrast MRI: *lights up granulation tissue in healing/healed annular disc tear* Diagnosis of Annular Tears, MRI png title=ANNULAR TEAR MRI (cont.) alt=ANNULAR TEAR MRI (cont.)> ANNULAR TEAR MRI (cont.) com/wp-content/uploads/2017/09/annular-tear-imaging.png title=ANNULAR TEAR imaging alt=ANNULAR TEAR imaging> ANNULAR TEAR imaging disk disease terminology alt=Degen. disk disease terminology> free fragment, AKA sequestration Degen. disk disease terminology -Displacement of disc material circumferentially (50-100%) beyond edges of ring apophyses-*Not a type of disc herniation* -Types:(1) Symmetrical (2) Asymmetrical DISC BULGE png title=CT L4-L5 DISC BULGE alt=CT L4-L5 DISC BULGE> CT L4-L5 DISC BULGE DISC BULGE image png title=MRI L4-L5 DISC BULGE alt=MRI L4-L5 DISC BULGE> circumferential MRI L4-L5 DISC BULGE -*Localized ( DISC HERNIATION 1) Intravertebral disc herniation (Schmorls node) 2) Protrusion3) Extrusion4) Sequestration TYPES OF DISC HERNIATIONS -Intravertebral disc herniation-Disc extends vertically (up or down) into the vertebral body through a defect in the endplate-Rarely symptomatic SCHMORLS NODES -Greatest distance (in any plane) between edges of disc material beyond disc space is less than distance between edges of disc material at the base in the same plane.-PLL is ALWAYS intact (contained disc herniation)(1) *Focal*: size of protrusion is DISC PROTRUSION DISC PROTRUSION cont DISC PROTRUSIONS imaging -In at least one plane, distance between the edges of the disc material beyond disc space is greater than distance between edges of disc material at the base (Dome of herniation is greater in width than base of herniation) OR-No continuity exists between the herniated disc material and the disc space-*PLL is disrupted (uncontained disc herniation)* DISC EXTRUSION axial DISC EXTRUSION imaging saggital: T1 T2 ONLY- ID neural foramina region (key-hole structures) DISC EXTRUSION imaging (cont) Sequestration-Extruded disc material completely loses continuity with disc spaceMigration-Extruded disc material migrates away from site of extrusion-Can be contiguous or noncontinguous (sequestration) with disc space DISC EXTRUSION (cont) DISC SEQUESTRATION DISC SEQUESTRATION images DISC EXTRUSION W/MIGRATION DISC EXTRUSION W/MIGRATION (cont) Based upon sagittal planes through the axial planeCentral Zone:-Zone between sagittal planes passing through medial edges of each facet (based on Sag Plane)-Zones on either side of center plane:(1) Right central (2) Left centralSubarticular Zone:-Zone between sagittal planes passing though medial edge of facet and medial edge of pedicle Foraminal Zone:-Zone between sagittal planes passing through medial and lateral edges of pedicleExtraforaminal Zone:-Zone beyond sagittal plane passing through lateral edge of pedicle LOCATION OF DISC HERNIATIONS Characteristic pattern of neuromuscular and urogenital symptoms resulting from simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris.Symptoms: Low back pain Sciatica (unilateral or bilateral) Saddle sensory disturbances Bladder and bowel dysfunction Variable lower extremity motor and sensory loss-Immediate referral for MRI or CT-*Surgical Emergency immediate surgical consult needed* Cauda Equina Syndrome shell have an arrow to the issue!