Presentation Materials

Master the Basics of Spinal
Radiology
Roman Klufas, MD
May 18, 2016
Objective

To introduce the legal community to the
appropriate use and interpretation of spinal
imaging, particularly in the setting of
trauma.
Outline
Anatomy
 Imaging Modalities
 Lexicon of Spinal Imaging
 Report
 Causation, are the findings acute?

Spine Radiology
Cervical Spine
 Thoracic Spine
 Lumbar Spine

Cervical Spine – AP/LAT
Cervical Spine - Anatomy
Netter Diagram

Vertebral Artery
Cervical Spine – Obliques
Cervical Spine – Flex - Ext
Cervical Spine – Open Mouth
Cervical Spine - Anatomy
Dermatomes
Dermatomes


Nerve root affected
Cervical disease
causes
–
–
–
–
Headache
Intrascapular pain
Myelopthy
Lower extremity
findings
Physical Exam




From: Manelfe, et al
C5 – loss of biceps
reflex
C6 – loss of brachial
radial reflex
C7 – loss of triceps
reflex
C8 loss of ulnar or
pronator reflex
Thoracic Spine – AP/LAT
LUMBAR SPINE – PLAIN
FILMS
LUMBAR SPINE - AP/LAT
LUMBAR SPINE – OBLIQUES
LUMBAR SPINE HARDWARE
MODALITIES
X-Ray
 MRI
 CT
 Ultrasound
 Nuclear Medicine

X-Ray – How does it work?
X-Ray
DR
 CR
 Film
 Printed films, CD, USB

LUMBAR SPINE - AP/LAT
Plain Films – X-ray
Quick
 Inexpensive
 Great for spinal alignment
 Radiation
 Patients perception

Cervical Spine – Flex - Ext
MRI

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No radiation
Contrast resolution
Soft tissue resolution
Infarct detection
Vascular studies

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

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Motion sensitive
Spatial resolution
Bone detail
Time
Acute blood
MRI – How does it work?
MRI
High field
 Open – low field
 In between

Basic Terms -MRI
Signal
 T1
 T2
 Inversion recovery

Foraminal Stenosis
MRI - Contrast

Gadolinium based agents
CT

Fast
Spatial resolution
Motion
Vascular studies
Bone
Acute blood

Ionizing radiation

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CT
Single slice
 Spiral
 Multislice – 4 to 64 slice systems

CT – How does it work?
Basic Terms - CT
Attenuation
 Hounsfield Units

Cervical Trauma
Ultrasound



No radiation
Fast
Vascular studies



Operator dependent
Equipment dependent
Patient limited
Nuclear Medicine Studies
Bone Scan
 SPECT

Spinal Imaging Vocabulary
Hard vs Soft Disc
Hard vs Soft Disc
Central Stenosis
Central Stenosis
Central Stenosis
Cervical Stenosis- Central
Flexion and Extension
Foraminal Stenosis
Foraminal Stenosis
Cervical Trauma
STIR sequences are most important
 Don’t rely on MR to exclude a fracture
 MR may or may not demonstrate
ligamentous instability
 Flexion – Extension plain films or CT are
still important

Cervical Trauma
Cervical Trauma
Cervical Trauma
Cord Contusion
Odontoid Fracture

Jefferson Fracture

Hangmans Fracture

TEARDROP FRACTURES

Clay Shoeveler’s Fracvture

Cervical Trauma – Facet Jump
ACDF

Myelopathy

Common symptoms
–
–
–
–
–

Clumsy or weak hands
Leg weakness or stiffness
Neck stiffness
Pain in shoulders or arms
Unsteady gait
Common signs
–
–
–
–
Atrophy of the hand musculature
Hyperreflexia
Lhermitte's sign
Sensory loss
Myelopathy
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Amyotrophic lateral sclerosis
Tumors
Hereditary spastic paraplegia
Multiple sclerosis
Normal pressure hydrocephalus
Spinal cord infarction
Syringomyelia
Vitamin B12 deficiency
SCIWORA Syndrome:
Spinal Cord Injury w/o Radiologic
Abnormality
 Occurs most often in pediatric
population
 up to 2/3 of severe cervical injuries in
children < 8 years of age
 inherent elasticity in pediatric cervical
spine

SCIWORA Syndrome:

Causes
–
–
–
–
Transverse atlantal ligament injury
Cartilagenous endplate fracture
Ligamentous injury
Diagnosis of exclusion
Epidural Hematoma
Cervical and upper thoracic spine
 Severe localized pain
 Radicular features in hours
 If progression: paraparesis, quadriparesis
 Can be seen post trauma, even minor
trauma
 More common than subdural

Epidural Hematoma



Seen in athletes, straining to defecate
Can be triggered with sudden changes in thoracic
and abdominal pressure
Seen with
– Liver failure
– Anticoagulation
– Arthritis drugs

Consider diagnosis if recent intervention like ESI
or other pain procedures
Epidural Hematoma
Epidural Hematoma
Epidural Hematoma
Usually surgically treated
 If patient is stable they can be closely
watched
 Is spinal angiogram indicated?
 Is myelography/CTM indicated?

Traumatic Nerve Root Avulsion
Traumatic Nerve Root Avulsion
Traumatic Nerve Root Avulsion




Most common in lower cervical spine from
traction on arm
Wringer’s injury
Also seen in lumbar spine and thoracic spine less
commonly
Traumatic dural tears arise either from
– Laceration of the dura, with fracture
– Avulsion of the nerve root
Chiari I
Vertebral Artery Dissection
Vertebral Artery Dissection
Vertebral Artery Dissection
Most Common in V3 segment
 Occipital pain
 Point finger to occipital region
 Lateral medullary stroke
 Follow with MRI/MRA to resolution
 Look at V1 segment in trauma

Vertebral Artery Dissection
SPONDYLOSIS
 SPONDYLOLITHESIS
 SPONDYLOLYSIS
 What does these mean?

SPINAL STENOSIS
SPONDYLOLISTHESIS
vs
SPONDYLOLYSIS
SPONDYLOLYSIS
bilateral
SPONDYLOLYSIS
unilateral
SPONDYLOLISTHESIS
with lysis
Widened canal with associated spondylolysis
SPONDYLOLISTHESIS
without lysis
Spinal stenosis without associated spondylolysis
Compression Fracture

www.ski injury.com
Compression Fracture
Is it recent?
Marrow edema
 STIR
 History
 Follow up

Compression Fracture
Benign or Malignant?
Anterior versus posterior vertebral body
 Extension to posterior cortical margin
 Posterior element involvement
 Epidural disease
 Other lesions
 If not sure, call indeterminate and follow up

The Spine Report
What is a normal spine MRI?
Age related
 20% abnormal at age 20
 80% by age 60

BACK PAIN
Two percent of US workers experience
compensable back injuries each year
 500,000 cases
 LBP accounts for 19% of all workers
compensation claims in the United States

What is a normal spine MRI?
Age realted
 20% abnormal at age 20
 80% by age 60

Normal

normal disc: 1. A fully and normally developed disc with no changes
attributable to trauma, disease, degeneration, or aging. The bilocular
appearance of the adult nucleus is considered a sign of normal
maturation. 2. (Non-Standard) [A disc that may contain one or more
morphologic variants which would be considered normal given the
clinical circumstances of the patient.]. Note: Many congenital and
developmental variations may be normal in that they are not associated
with symptoms; certain adaptive changes in the disc may be normal
considering adjacent pathology, and certain degenerative phenomena
may be normal given the patient's age; however, classification and
reporting for medical purposes is best served if such discs are not
considered normal. What is clinically normal for a given patient is a
clinical judgment independent of the need to describe any variation in
the disc itself.
HERNIATION

herniated disc, herniation (n), herniate (v): 1. Localized displacement of disc material
beyond the normal margins of the intervertebral disc space. 2. (Non-Standard) [Any
displacement of disc tissue beyond the disc space]. Note: Localized means, by way of
convention, less than 50% (180 degrees) of the circumference of the disc. Disc material
may include nucleus, cartilage, fragmented apophyseal bone, or fragmented anular
tissue. The normal margins of the intervertebral disc space are defined, craniad and
caudad, by the vertebral body end-plates and peripherally by the edges of the vertebral
body ring apophyses, exclusive of osteophytic formations. Herniated disc generally
refers to displacement of disc tissues through a disruption in the anulus, the exception
being intravertebral herniations (Schmorl's nodes) in which the displacement is through
vertebral end-plate. Herniated discs in the horizontal (axial) plane may be further
subcategorized as protruded or extruded. Herniated disc is sometimes referred to as
"herniated nucleus pulposus," but the term herniated disc is preferred because displaced
disc tissues often include cartilage, bone fragments, or anular tissues. The term
"ruptured disc" is used synonymously with herniated disc, but is more colloquial and
can be easily confused with violent, traumatic rupture of the anulus or end-plate. The
term "prolapse" has also been used as a general term for disc displacement, but its use
has been inconsistent. The term herniated disc does not infer knowledge of cause,
relation to injury or activity, concordance with symptoms, or need for treatment.
Disc
Terminology
North American Spine Society




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Herniation- Use this term if you can’t be more
specific after workup
Annular Bulge – Concentric extension of disc
beyond vertebral margin
Protrusion – Focal extension beyond disc margin,
but contained by annulus or PLL
Extrusion - Focal extension beyond disc margin,
not contained by annulus or PLL
Sequestration – Free fragment, not contiguous
with disc
Disc Terminology
Bulge has no focality, annulus is intact
 Protrusion is focal but the annulus is intact
 Herniation implies that the annulus is
disrupted

Lumbar Protrusion- HNP
Lumbar HNP



Radiculopathy
Affects nerve roots in
the lateral recess
For example, L5-S1
disc gives S1
radiculopathy for this
reason
Lumbar HNP
Lumbar HNP
The Spine Report
North American Spine Society
 Herniation- Use this term if you can’t be more
specific after workup
 Annular Bulge – Concentric extension of disc
beyond vertebral margin
 Protrusion – Focal extension beyond disc margin,
but contained by annulus or PLL
 Extrusion - Focal extension beyond disc margin,
not contained by annulus or PLL
 Sequestration – Free fragment, not contiguous
with disc
The Spine Report
Terminology does not imply prognosis

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90% of sciatica resolves with conservative
treatment
Likely due to decreased nerve root edema
Improves symptoms with flexion
Mechanisms:
–
–
–
–
Resorbtion of disc by proliferation of blood vessels
Disc can reenter annulus through the tear
Soft discs can migrate in epidural space
Nerve root can resorb itself in the foramen
Facet Changes

Capsular hypertrophy
– Secondary to synovitis
– Cartilagenous thinning
– Instability stage

Facet hypertrophy
– Sclerosis
– Fatty osteophytes
– Arthrosis stage
Early instability
Arthrosis stage
Degenerative Endplate Change
TYPE I
TYPE III
TYPE II
Spontaneous Regression of Disc
Herniation



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90% of sciatica resolves with conservative treatment
Likely due to decreased nerve root edema
Improves symptoms with flexion
Mechanisms:
–
–
–
–
Resorbtion of disc by proliferation of blood vessels
Disc can reenter annulus through the tear
Soft discs can migrate in epidural space
Nerve root can resorb itself in the foramen
Flexion and Extension
Open magnet sitting
Spinal Stenosis
Spinal Stenosis -foraminal
disease



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Foraminal narrowing
Use sagittals
Radicular features
CT can be also useful
SPONDYLOLYSIS
unilateral
SPONDYLOLYSIS
bilateral
SPONDYLOLISTHESIS
with lysis
Widened canal with associated spondylolysis
HIZ- Hypertintense zones



Painful annular fissure
Precursor to HNP
Bright on T2
– Granulation
– Edema

Marker for IDD
– Pain w/o radiculopathy

Concordance with
discogram
Annular Tears



Circumferential
Radial
Transverse
IDD – Internal Disc
Derangement
Normal height disc
 Low signal on T2
 Pain
 Positive Discogram

IDD
Synovial Cyst
Sacroiliac Joint DJD




Can be a cause of back
pain
Look for DJD and
sacroileitis
Post fusion
Important to see upper
sacrum
Insufficiency Fracture
SPINE – CT or MRI?
When is MRI not enough?
Thank you!