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Radiology: Spine – revised

Cervical Spine - AP Open Mouth
Cervical Spine – AP Open Mouth
Cervical AP
Cervical AP
Cervical Lateral
Cervical Lateral
Cervical Spine - Oblique X-ray
Cervical Spine – Oblique X-ray
FLEXION & EXTENSION
FLEXION & EXTENSION
Dens Fracture
Dens Fracture
DENS TYPE II FRACTURE
– hard to see, thin gray line
– L image: should be smooth line from C2 body and dens, instead there’s a break at L right arrow
– R image: lat. view, can see better
DENS TYPE II FRACTURE
FLEXION INJURIES
1) Anterior subluxation
2) Simple wedge
3) Unstable wedge
4) Unilateral interfacet dislocation
5) Bilateral interfacet dislocation
6) Flexion teardrop fracture
7) ant atlantoaxial dislocation
FLEXION INJURIES
Jumped Facets (Facet Dislocation)
Jumped Facets (Facet Dislocation)
Jumped Facets (Facet Dislocation) examples
U/L jumped facet = AKA “perched facet dislocation”
Jumped Facets (Facet Dislocation) examples
EXTENSION INJURIES
EXTENSION INJURIES
Hangman Fracture
*Fx involving both pars interarticularis of C2
*Image shows fx at bilat lamina & pedicles, and usually anterolisthesis at C2-C3
Hangman Fracture
Jefferson 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
Lumbar Spine Lateral
IV disc spaces
SP
Pedicles
Alignment
VB height
Lumbar Spine Lateral
SCOTTY DOG SIGN
-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
(SCOTTY DOG SIGN pic)
Pars Interarticularis #, often assoc. with anterolisthesis
–> young pts <30 y/o, sports/stress-related activity
(SCOTTY DOG SIGN pic)
Spondylolisthesis grades
1: 0 – 25%
2: 25 – 50%
3: 51 – 75%
4: 76 – 100%
5 (Spondyloptosis): >100%
Spondylolisthesis grades
Spondylolysis
*lumbar pars defect
*stress fx from repetitive injury
Spondylolysis
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 bending

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2)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
Wedge Fracture
AKA Compression
-ant VB
Wedge Fracture
COMPRESSION FRACTURE
magnified view on R
– loss of height ant
COMPRESSION FRACTURE
Chance Fracture
*Compression injury to ant. vertebral body and transverse # through post. vertebral body
Chance Fracture
Schmorl's Node
*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

Schmorl’s Node
AP Sacrum
-SI Joints
-Sacral ALA
-Coccyx
AP Sacrum
Lateral Sacrum
-Sacral Coccygeal angle
-Cortical Integrity
-Pre-Sacral soft tissue
Lateral Sacrum
SI Joints
(normal SI jt.)
SI Joints
LEFT SACRAL FRACTURE
-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
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
Normal C-Spine Vert., C1-6
axial view
– C1: complete ring
Normal C-Spine Vert., C1-6
Normal Thoracic Spine
saggital view
– the worse the scoliosis, the worse the image (you won’t see all vert. clearly)
– bone & soft tissue windows
Normal Thoracic Spine
Normal Thoracic Spine Vert.
Normal Thoracic Spine Vert.
Normal Thoracic Spine Vert. cont.
Normal Thoracic Spine Vert. cont.
NORMAL CT LUMBAR SPINE
bone window L, ST window R
NORMAL CT LUMBAR SPINE
NORMAL CT LUMBAR SPINE Vert.
NORMAL CT LUMBAR SPINE Vert.
NORMAL CT LUMBAR SPINE Vert. cont.
NORMAL CT LUMBAR SPINE Vert. cont.
L5 CONGENITAL PARS DEFECT (xray)
L5 CONGENITAL PARS DEFECT (xray)
L5 CONGENITAL PARS DEFECT (CT)
L: midline (can’t see #)
Middle: more lateral, start to see defect
R: lateral #
L5 CONGENITAL PARS DEFECT (CT)
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.
L5 BURST FRACTURE
– CT
– vert. lost height, lots of # lines
looking for:
1) retropulsion of bone (bone fragment extending back into spinal canal)?
2) canal stenosis, esp. in thoracic?
–> MRI imaging
L5 BURST FRACTURE
L5 BURST FRACTURE - axial
– CT, soft-tissue window, bad canal stenoisis
L5 BURST FRACTURE – axial
L1 OSTEOPENIC COMPRESSION FRACTURE
– usually through-and-through #, or just ant. vert. body (rarely just post. vert. body)
– this example: some post. retropulsion (we’re a bit below the conus hopefully, but some folks have conus at L2 –> MRI)
L1 OSTEOPENIC COMPRESSION FRACTURE
L1 OSTEOPENIC COMPRESSION FRACTURE - axial
– flattening of thecal sac –> canal stenosis
L1 OSTEOPENIC COMPRESSION FRACTURE – axial
KYPHOSIS (1 mo later)
– more loss of vert. height
– retropulsion: causing more SC stenosis? Pt may have more Sx’s
KYPHOSIS (1 mo later)
VERTEBRAL AUGMENTATION
FOR TREATMENT OF PAIN RELATED TO COMPRESSION FRACTURES
1) Osteoporosis (most common)
2) Direct acute trauma in healthy vertebra
3) 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 they’re 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. CI’s 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 Augmentation
1) 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 tumor
2) Pain refractory to medical management
– medical management for at least 6-12 weeks
3) 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 vertebrae

take-home –> cement injected, for pain and not height

Percutaneous Vertebroplasty
Low Complication Rate (1-3.9%)

Acute Complications:
-Cement leak (symptomatic or asymptomatic)
-Cement pulmonary embolism (asymptomatic or symptomatic)
-Bleeding/hematoma
-Infection
-Neurological deficiet (transient or permanent)

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Delayed Complications:
-New fracture at other levels?
–> diminished compliance of vertebra b/c of cement places remaining vertebral bodies at higher risk for fx?
OR
–> “Clustering of fractures” as natural history of osteoporosis

Percutaneous Vertebroplasty – Complication Rate
image of cement in vert. body
image of cement in vert. body
Balloon Kyphoplasty
– Inflation of one or two intravertebral body high pressure balloon tamps to create a cavity in which high-viscosity arcylic cement is then injected

– Performed via unipedicle (1 balloon) or bipedicle (2 balloons)

– Margins of the cavity are lined by the displaced, fragmented trabeculae.

– Usually requires hospitalization (as opposed to Perc Vertebroplasty)
–> pain relief AND restores height loss

Balloon Kyphoplasty
-Because the injection of acrylic under pressure is likely to pass through the fracture into the spinal canal, a posterior cortical defect is considered a relative contraindication for vertebroplasty

-Vertebroplasty also is contraindicated in cases involving a bone infection such as diskitis with osteomyelitis.

Contraindications for PV or Kyphoplasty
CT MYELOGRAM - INDICATION
Need CT delineation of soft tissue structures within spinal canal for:
1) Patient who cannot get MRI
2) Patient with surgical hardware in spine which obscures visualization of spinal canal on MRI and CT scan.

EG: Evaluation for degree of canal stenosis and/or cord compression, disc herniation, arachnoiditis

CT MYELOGRAM – INDICATION
Injection of contrast material into thecal sac under flouroscopic guidance with subsequent CT imaging of the spine
CT MYELOGRAM – Technique:
-Bleeding disorder (elevated PTT/INR)
-Less frequently performed due to the invasive nature of the test and associated risks.
CT MYELOGRAM – Contraindication/Relative contraindications:
1) DEGENERATIVE DISEASE
-Disc herniation
-Spinal stenosis and Cord compression
-Nerve Root Impingement (Radiculopathy/Sciatica)

2) OSSEOUS AND EXTRAOSSEOUS INFECTION
-Discitis/Osteomyelitis
-Epidural and Paraspinal Abscess

3) NEOPLASM
-Osseous Metastasis
-Spinal cord, epidural or nerve root mass

4) DEMYELINATING/INFLAMMATORY DISEASES:
-Eg. Multiple sclerosis lesions (cervical & thoracic)

5) TRAUMA
-Acute versus Chronic Fractures
-Epidural/Subdural Hematomas
-Ligamentous rupture

6) POSTOPERATIVE SPINE:
-Recurrent disc herniation versus Postoperative
-Granulation tissue

MRI INDICATIONS
-No ionizing radiation

Contraindications:
>> Absolute
– Ferromagnetic Aneurysm clip
– Cardiac pacemaker
– Orbital metallic foreign body, cochlear implant, IVC filter

>> Relative
– Metal fragments (depending on location -> soft tissue burn)
– First trimester pregnancy (risks vs. benefits)
– Transcutaneous nerve stimulators
– Severe claustraphobia

MRI CONTRAINDICATIONS
-Degenerative Disease
-Lumbar back pain
-Radiculopathy
-Preoperative Planning

-Patient with EGFR <30 (measure of kidney function), contrast is considered contraindicated due to increased risk of Nephrogenic Sytemic Fibrosis (NSF)

NONCONTRAST MRI:
– Postoperative spine recurrent back pain evaluation:
>> to see granulation tissue vs. recurrent/new disc herniation
– Metastatic Bone disease (bone and spinal cord)
– Primary Spinal Cord lesions (tumor, demyelinating disease, )
– Spinal Infection (discitis/osteomyelitis, epidural abscess)
CONTRAST ENHANCED MRI:
typical protocols:

*MRI Cervical Spine*
-T1 weighted images (Sag & Ax)
-T2 weighted images (Sag & Ax)
-STIR (Sag)
-Gradient Echo (Axial) –> bone black, fluid bright, *accentuates bony structures* b/c there’s so much bony path. in C-spine

*MRI Thoracic & Lumbar Spine*
T1 weighted images (Sag & Ax)
T2 weighted images (Sag & Ax)
STIR (Sag)

NonContrast MRI Sequences for Spine
*Water: T1 hypointense (dark), T2 & STIR hyperintense (white)*
-CSF
-normal disc space
-bone or soft tissue edema
-fluid collections (postoperative seroma, synovial cysts, abscesses)

*Fat: T1 & T2 hyperintense (bright), STIR hypointense (dark)*
-Subcutaneous fat, yellow (fatty) bone marrow,
-“Yellow” (fatty) bone marrow: age-related; degenerative
-Fat-containing lesions (eg Lipoma)

*Normal Bone: T1, T2 & STIR hypointense (dark)*
-Vertebral bodies and posterior elements of spine

*Sclerotic Bone: T1, T2, and STIR markedly hypointense (very dark)*
-Degenerative sclerosis, Sclerotic Metastasis, Calcified ligament or disc

Basics MRI Principles
Normal MRI Lumbar Spine
T2 & STIR: fluid bright
– CSF, thecal sacs

STIR: fat dark (“suppressed”)
T2: fat bright

“signal intensity” of the structures in MR
– general rule: disk space should always be darker than vertebral bodies, normal “marrow intensity”, in T1
– as we age, the signal changes (more fat) –> but this rule still applies
– if it’s darker –> abnormal. Tumor? Sclerosis (bone getting denser d/t degen. or malignancy)?

– general rule: disk space will always be bright on T2 & stir (b/c most of the disc is fluid)

Normal MRI Lumbar Spine
Normal MRI Lumbar Spine - Intevertebral Neural Foramina
– keyhole structures at level of disc space
– contain fat & nerve roots
– want to ensure they’re ~symmetrical w/in their region (C, T, L)
– T1&2: bright signal (fat) surrounding dark signal (nerve root)
– STIR: vessels around nerve root (a little bright), but fat supressed –> STIR not a great view of foramina
–> looking for any encroachment/narrowing (facet arthropathy, disc herniation, etc)
Normal MRI Lumbar Spine – Intevertebral Neural Foramina
NORMAL MRI LUMBAR SPINE - cont
axial view
– can see thecal sac and CE nerve roots (vs. CT imaging)
–> can tell is there’s any compression
NORMAL MRI LUMBAR SPINE – cont
NORMAL MRI LUMBAR SPINE - cont 2
through the disc space
– neural foramena: fat (bright) + n. roots (dark)
NORMAL MRI LUMBAR SPINE – cont 2
Normal MRI Lumbar Spine - cont
– moving down through bodies, coming into disc space in middle images
– T2: body is gray, disc space is brighter (fluid)
Normal MRI Lumbar Spine – cont
Cervical spine:
– exiting nerve root at the disc space is from the level below (eg at C5-C6, C6 exiting nerve roots noted; at C7-T1, C8 exiting nerve roots noted)

Thoracic & Lumbar spine:
– exiting nerve root at the disc space is from the level above (eg at T1-T2, exiting nerve roots are T1)
*Cervical Spine: You have Uncovertebral Joints*
*Thoracic/Lumbar Spine: No uncovertebral joints*

Cervical vs. Thoracic & Lumbar Spine
-Articulation point of the vertebra
-Composed of inferior and superior articular processes and the facet joint

-Function: carry axial load of body limit range of motion of the spine
-Form back border of the intervertebral foramen
–> *can cause LATERAL CANAL STENOSIS when hypertrophied from osteoarthritis*

*ZYGAPOPHYSEAL (FACET) JOINTS*
Spinal Nerves - Intevertebral Neural Foramina
-Foramen through which the spinal nerves exit the spinal canal.
-Within foramen, the motor & sensory nerve roots merge into single Spinal Nerve (sensory and motor fibers). Termed “Exiting Nerve”
-
Spinal Nerves – Intevertebral Neural Foramina
Lumbar Spine Anatomy
-Spinal cord typically terminates at L1-L2 (Conus Medullaris);

-Inferior to conus medullaris, thecal sac contains pia-wrapped 3-5 lumbar, 5 sacral and 1 coccygeal nerves collectively called *CAUDA EQUINA*

-Cauda Equina = nerves hang like a “horse tail” inferior to L2 within the thecal sac

Lumbar Spine Anatomy
Lumbar cont.
– CT Myelogram: thecal sac is bright, b/c w/contrast!
– MR: soft tissue easier to see
– facet jts: should look smooth, like a hamburger bun (inf. is top of bun, sup. is bottom of bun) –> some facet arthropathy seen in these images
Lumbar cont.
Lumbar cont. 2
– similar to last slide
Lumbar cont. 2
[Supplies whole skin of the leg, the muscles of the back of the thigh and those of the leg & foot

Comprised of spinal nerves L4 through S3

Contains fibers from both the anterior and posterior division of the lumbosacral plexus]

MODIC CHANGES
*Type I:*
-T1 hypointense (dark) and T2 hyperintense (bright)
-Bone marrow edema & inflammation
[-Strongly associated w/active low back sxs and segmental instability
-Predicts excellent outcome post lumbar fusion surgery]

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*Type II:*
-T1 hyperintense and T2 iso/mildly hyperintense (bright spots)
-Conversion of normal hemopoietic (red) bone marrow into fatty (yellow) marrow
[-Less clearly associated w/LBP
-Indicates more biomechanically stable state
-Superimposed stress may induce conversion to Type I]

*Type III:*
-T1 and T2 hypointense (dark)
-Subcondral bone sclerosis


MODIC CHANGES
MODIC CHANGES Type I
*Type I:*
-T1 hypointense (dark) and T2 hyperintense (bright)
-bright: bone marrow edema & inflammation

[-Strongly associated w/active low back sxs and segmental instability
-Predicts excellent outcome post lumbar fusion surgery]

MODIC CHANGES Type I
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
[-Less clearly associated w/LBP
-Indicates more biomechanically stable state
-Superimposed stress may induce conversion to Type I]
MODIC CHANGES Type II
MODIC CHANGES Type III
*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 (Sharpey’s Fibers) anchor themselves into this region
-*Bone spurs (osteophytes) arise form this region* as a result of prolonged pulling/tugging of Sharpey’s fibers
RING APOPHYSIS
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 = SHARPEY’S FIBERS

DISC ANATOMY
DISC Problems anatomy
DISC Problems anatomy
OSTEOPHYTES - MRI
OSTEOPHYTES – MRI
MRI CERVICAL DDD - Osteophytes
MRI CERVICAL DDD – Osteophytes
FACET ARTHROPATHY, & CT SCAN
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
Facet Arthropathy - CT SCAN (cont)
Axial view (lose the nice hamburger shape, excess bone formation)
Facet Arthropathy – CT SCAN (cont)
Uncovertebral Hypertrophy, & CT SCAN
*Uncovertebral joints (Luschka’s 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
UNCOVERTEBRAL HYPERTROPHY - MRI
UNCOVERTEBRAL HYPERTROPHY – MRI
Ligamentum Flavum Thickening, & 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 forward

Hypertrophy/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
Calcified Ligamentum Flavum - CT SCAN
Calcified Ligamentum Flavum – CT SCAN
Normal & Abnormal Disc
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

[Causes of Radiculopathy/Sciatica:
1) Disc herniation induced radiculopathy/sciatica
2) Grade V annular tear induced radiculopathy/sciatica (chemical radiculopathy)
3) Discogenic radiculopathy/sciatica (“referred pain) – irritation of the sinuvertebral nerves along annulus which is perceived as pain]

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 outward

Annular 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

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
ANNULAR TEAR MRI (cont.)
ANNULAR TEAR MRI (cont.)
ANNULAR TEAR imaging
ANNULAR TEAR imaging
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
CT L4-L5 DISC BULGE
CT L4-L5 DISC BULGE
DISC BULGE image
DISC BULGE image
MRI L4-L5 DISC BULGE
circumferential
MRI L4-L5 DISC BULGE
-*Localized (<50%) displacement of disc material beyond limit of disc space* -Disc material may be nucleus, cartilage, fragmented apophyseal bone, anular tissue or combination of aforementioned structures -What defines borders of Disc Space? (1) Cranio-caudad: vertebral body endplates (2) Anterior-Posterior: outer edges of ring apophyses, exclusive of osteophytes
DISC HERNIATION
1) Intravertebral disc herniation (Schmorl’s node)
2) Protrusion
3) Extrusion
4) 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
SCHMORL’S NODES
DISC PROTRUSION
-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 <25% of disc circumference (2) *Broad-based*: size of protrusion is 25-50% of disc circumference
DISC PROTRUSION
DISC PROTRUSION cont
DISC PROTRUSION cont
DISC PROTRUSIONS imaging
DISC PROTRUSIONS imaging
DISC EXTRUSION
-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
DISC EXTRUSION imaging
axial
DISC EXTRUSION imaging
DISC EXTRUSION imaging (cont)
saggital: T1 & T2 ONLY
– ID neural foramina region (key-hole structures)
DISC EXTRUSION imaging (cont)
Sequestration
-Extruded disc material completely loses continuity with disc space

Migration
-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
DISC SEQUESTRATION images
DISC SEQUESTRATION images
DISC EXTRUSION W/MIGRATION
DISC EXTRUSION W/MIGRATION
DISC EXTRUSION W/MIGRATION (cont)
DISC EXTRUSION W/MIGRATION (cont)
LOCATION OF DISC HERNIATIONS
Based upon sagittal planes through the axial plane

Central 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 central

Subarticular 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 pedicle

Extraforaminal Zone:
-Zone beyond sagittal plane passing through lateral edge of pedicle

[Sample exam Q:
protrusion in left subarticular zone of L5: descending n root compression symptoms at L5]

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
– she’ll have an arrow to the issue!

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Radiology: Spine - revised
Artscolumbia

Artscolumbia

Cervical Spine - AP Open Mouth
Cervical Spine - AP Open Mouth
2018-10-20 06:38:34
2018-10-20 06:38:34
Radiology: Spine - revised
$ 13.900 2018-12-31
artscolumbia.org
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