Cervical Spine – AP Open Mouth
Cervical AP
Cervical Lateral
Cervical Spine – Oblique X-ray
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 there’s a break at L right arrow- R image: lat. view, can see better
DENS TYPE II FRACTURE
1) Anterior subluxation 2) Simple wedge3) Unstable wedge4) Unilateral interfacet dislocation5) Bilateral interfacet dislocation6) Flexion teardrop fracture7) ant atlantoaxial dislocationFLEXION INJURIES
Jumped Facets (Facet Dislocation)
 examples” alt=”Jumped Facets (Facet Dislocation) examples”></p></div>
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U/L jumped facet = AKA “perched facet dislocation”Jumped Facets (Facet Dislocation) examples
EXTENSION INJURIES
*Fx involving both pars interarticularis of C2*Image shows fx at bilat lamina & pedicles, and usually anterolisthesis at C2-C3Hangman 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
IV disc spacesSPPediclesAlignmentVB heightLumbar 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
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Pars Interarticularis #, often assoc. with anterolisthesis–> young pts <30 y/o, sports/stress-related activity(SCOTTY DOG SIGN pic)
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
 with SPONDYLOLISTHESIS” alt=”SPONDYLOSIS (PARS DEFECT) with SPONDYLOLISTHESIS”></p></div>
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-usually B/L-excess bone-facet jts trying to stabilize themselvesSPONDYLOSIS (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
magnified view on R- loss of height antCOMPRESSION 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
Schmorl’s Node
-SI Joints-Sacral ALA-CoccyxAP Sacrum
-Sacral Coccygeal angle-Cortical Integrity-Pre-Sacral soft tissue
Lateral Sacrum
(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
saggital view-CT scan: you see more of the bony and soft tissue structures-white: bone-gray: fat, muscles, vessels-black: airNormal Cervical Spine
axial view- C1: complete ringNormal C-Spine Vert., C1-6
saggital view- the worse the scoliosis, the worse the image (you won’t see all vert. clearly)- bone & soft tissue windowsNormal Thoracic Spine
Normal Thoracic Spine Vert.
Normal Thoracic Spine Vert. cont.
bone window L, ST window RNORMAL CT LUMBAR SPINE
NORMAL CT LUMBAR SPINE Vert.
NORMAL CT LUMBAR SPINE Vert.
cont.
L5 CONGENITAL PARS DEFECT (xray)
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L: midline (can’t see #)Middle: more lateral, start to see defectR: lateral #L5 CONGENITAL PARS DEFECT (CT)
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 defectL5 CONGENITAL PARS DEFECT – CT cont.
– 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 imagingL5 BURST FRACTURE
– CT, soft-tissue window, bad canal stenoisisL5 BURST FRACTURE – axial
– 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
– flattening of thecal sac –> canal stenosis
L1 OSTEOPENIC COMPRESSION FRACTURE – axial
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– more loss of vert. height- retropulsion: causing more SC stenosis? Pt may have more Sx’sKYPHOSIS (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 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 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.
leak]-Cement pulmonary embolism (asymptomatic or symptomatic)-Bleeding/hematoma-Infection-Neurological deficiet (transient or permanent) 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
– 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
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, arachnoiditisCT 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 Abscess3) NEOPLASM-Osseous Metastasis-Spinal cord, epidural or nerve root mass4) DEMYELINATING/INFLAMMATORY DISEASES:-Eg.
Multiple sclerosis lesions (cervical & thoracic)5) TRAUMA -Acute versus Chronic Fractures-Epidural/Subdural Hematomas-Ligamentous rupture6) POSTOPERATIVE SPINE:-Recurrent disc herniation versus Postoperative -Granulation tissue
MRI INDICATIONS
-No ionizing radiationContraindications:>> 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
T2 & STIR: fluid bright- CSF, thecal sacsSTIR: 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
– 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
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
through the disc space- neural foramena: fat (bright) + n. roots (dark)
NORMAL MRI LUMBAR SPINE – cont 2
– 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*
-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
-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 sacLumbar Spine Anatomy
– 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 imagesLumbar cont.
– similar to last slideLumbar cont. 2
*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 sclerosisMODIC CHANGES
*Type I:* -T1 hypointense (dark) and T2 hyperintense (bright)-bright: bone marrow edema & inflammation
MODIC CHANGES Type I
*Type II:*-T1 hyperintense and T2 iso/mildly hyperintense (bright spots) -Conversion of normal hemopoietic (red) bone marrow into fatty (yellow) marrowMODIC 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 (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
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 FIBERSDISC ANATOMY
DISC Problems anatomy
OSTEOPHYTES – MRI
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
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Axial view (lose the nice hamburger shape, excess bone formation)Facet Arthropathy – CT SCAN (cont)
*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
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
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
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ANNULAR TEAR MRI (cont.)
ANNULAR TEAR imaging
free fragment, AKA sequestrationDegen. 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
DISC BULGE image
circumferentialMRI 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) 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
SCHMORL’S 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 <25% of disc circumference (2) *Broad-based*: size of protrusion is 25-50% of disc circumference
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
– she’ll have an arrow to the issue!
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2018-10-20 06:38:34