RADD 4820 WEEK 8 - Shade Of My Heart



RADD 4820 WEEK 8 - Shade Of My Heart
RADD 4820 WEEK 8
Wade Gustafson
♦ History: A 19 year old male admitted to the ER following
a motor vehicle accident.
♦ Clinical: Acute pain and tenderness. Radiographs were
Plain Film Lateral and APLC
Flexion Teardrop
Fracture of C6
Swim Lateral Plain Film with MRI
CT Image
Clinical Insight
♦ This hyperflexion type injury is considered highly
unstable and neurologic involvement such as
quadraplegia is present in a very high percentage of
patients ( 87%).
♦ Intervertebral disc damage is common.
Skogsbergh, NCC Postgraduate Radiology, 1995
Shep Proudfoot
History: A 27 year old male unbelted driver of a truck had a head on collision of
his “airborne” vehicle with a house. His head was wedged between the seat and
door with his feet draped over the steering wheel.
Clinical: Trace muscle strength deltoid bilaterally. No distal strength or sensation
below C5. Plain films showed C5 compression fracture. Plain film,CT and MR
were performed.
Lateral Cervical Plain Film
MR Axial Images
Gradient Echo Sagittal MRI
CT Study
C5 Burst Fracture
Clinical Insight
♦ Burst fractures are most common in the C5-C7 region, about 75%.
♦ Advanced imaging such as CT or MRI is critical in assessing
possible adverse effects on the cord.
Skogsbergh, NCC Postgraduate Radiology, 1995
Osgood Fielding III
♦ History: This 53 year old male complained of numbness and
weakness in his arms for two months following a hyperextension
neck injury incurred in a MVA.
♦ Clinical: None available. MRI examination was performed.
MRI Axial and Sagittal T2 Images
Post Traumatic
Cord Myelomalacia
Clinical Insight
♦ The pathologic correlation of abnormal signal within the cord with a
combination of neuronal loss, demyelination and infarction has been termed
myelomalacia. These changes are not uncommon with trauma or spinal
stenosis. Once present however they are not usually reversed by
subsequent decompressive procedures.
Skogsbergh, NCC Postgraduate Radiology, 1995
John Jacob Jingleheimer Schmidt
♦ 16 year old male
♦ Automobile accident
♦ Dull aching neck pain
♦ Shooting pain right shoulder
♦ Mid- and lower-back pain
John Jacob Jingleheimer Schmidt
♦ Cervical Spine
♦ C2 - 3 congenital block
John Jacob Jingleheimer Schmidt
♦ Thoracic Spine
♦ Negative study
Paul Vitti
♦ 33 year old male
♦ 3 week duration
♦ Severe, sharp low back pain
♦ Dull radiating pain down both thighs to calves
Paul Vitti
♦ L5 - S1 central 4 - 5 mm contained disc herniation
with slight dissection inferiorly indenting thecal sac
♦ L4 - L5 small central protrusion with circumferential
annular tear
Ben Sobel
♦ 19 year old male
♦ Lifting bags of cement
♦ Acute LBP
♦ Sharp left buttock, thigh and leg pain
Ben Sobel
♦ L5 - S1: 12 - 14 mm uncontained disc
herniation with thecal sac and nerve root
♦ L4 - L5: 8 - 9 mm (same as L5 - S1)
♦ 2 level stenosis
Marge Gunderson
♦ Chronic low back and left buttock pain
♦ Recent exacerbation of tingling and pain
♦ Thoracic and lumbar images
Marge Gunderson
♦ L5 - S1
♦ Left-central 15 - 20 mm uncontained disc
♦ Sequestered fragment
♦ Compresses & obliterates L5 and S1 nerve roots
♦ Facet arthrosis
Marge Gunderson
♦ Thoracic Spine
♦ Extradural mass extending anteriorly
from T10 - 11 facet joint
♦ Indents thecal sac
♦ Diagnosis: Synovial cyst
Brian Hope
♦ History: This patient recalls sustaining a back injury 3 years ago as
a result of a fall. Specifics regarding the injury were not able
♦ Clinical: Progressive hypoaesthesia in the lower extremities with
loss of motor strength is noted. An MRI examination was performed.
Sagittal Proton Density MRI
Sagittal T2 MRI
Axial T2 MRI
Sugar Kane Kowalczyk
♦ 44 year old female
♦ Grabbing, aching low back pain
♦ Shooting, radiating bilateral leg pain
♦ 2 month duration
Sugar Kane Kowalczyk
♦ Degenerative spondylolisthesis L4 with desiccation
and degenerative bulge L4 - L5
♦ 5 - 6 mm synovial cyst at L4 - L5 on the left
♦ Thecal sac and left L5 nerve root compressed by
synovial cyst
Charlie McManus
♦ Low back pain
♦ Starting to develop Cauda Equina syndrome
Plain Film Study
MRI and CT Studies
Posterior Apophyseal Ring Fractures
♦ Represents a separation of the posterior vertebral
body ring apophysis.
♦ The term Posterior Limbus Bone has also been
applied to this phenomenon.
Post. apoph. ring fx. cont’d
♦ Inherent weakness of the osteocartilaginous junction between the
apophysis and the vertebral body.
♦ Most often found in adolescents and young adults (average age 3233 yr)
♦ Traumatic etiology; MVA, weight lifting, sports injuries and
gymnastics are common known precipitants.
Knudsen etal., JMPT 1998; 21: 281-287
Post. apoph. ring fx. cont’d
♦ Clinical Features:
Stiffness and spasm
Neurogenic claudication
Cauda equina syndrome
Yochum TR, Rowe JR; Essentials of Skeletal Rad; 1996
Truman Burbank
♦ Low back pain
♦ Not responding to conservative treatment
High Intensity Zone on MRI
High Signal Intensity Zones in the Posterior
Anulus Fibrosis
♦ Correlation between high signal intensity in the
posterior anulus on MRI and anular tears seen on
anatomic sectioning and discography.
High Signal Intensity Zone and Painful Anular
♦ OBJECTIVE: To determine the sensitivity of magnetic resonance
imaging in the detection of painful anular tears manifested by high
signal intensity zones (HIZ).
♦ METHODS: Anular tears as identified on MRI were compared with
the demonstration of painful anular tears on discogram, which has
been considered the gold standard.
HIZ cont’d
♦ RESULTS: 58 patients had a total of 86 anular tears evidenced on
discography. 70 of these tears were associated with concordant pain
provocation. 27 HIZs were identified with MRI. Of the 27, 24 were
associated with pain reproduction by discography.
HIZ cont’d
♦ CONCLUSION: The HIZ is a marker of a painful posterior anular tear. It has
a high specificity and positive predictive value for concordant pain in an
anular tear however, suffers from a low sensitivity. Thus the usefulness of
this sign may be limited.
Saifuddin et al, Spine 1998; 23: 453-457
Jesminder Kaur Bhamra
♦ 39 year old female
♦ 9 month duration dull constant neck pain
♦ Tingling radiation into arms and shoulders, esp. right side
Jesminder Kaur Bhamra
! Hypolordosis
! Mild bulge C5-6, C6-7 (not
visible here)
! Disc desiccation
! No effect on cord
! No effect on n. roots
Fanny Ekdahl
♦ 35 year old female
♦ Automobile accident
♦ Immediate onset of LBP
♦ Radiating numbness and sharp pain to both buttocks and thighs
Fanny Ekdahl
♦ L5 - S1 non-contained 8-9 mm right paracentral disc
♦ Displaces right S1 nerve root
♦ L3 - L4 degenerative disc protrusion
♦ Reduced signal both levels
Nick Martinelli
♦ 21 year old male
♦ Low back pain
♦ Pain in buttocks and thighs
Nick Martinelli
♦ L4-L5: Mild degenerative disc bulge
♦ No effect on cauda equina or nerve
♦ Inferior L4 Schmorl’s node
Torekov Port, Sweden
Mona Dearly
– 46 year old female
– Complains of severe lower back pain and associated numbness/tingling
into the right leg
– Denies trauma
– No history of surgery/malignancy
– Orthopedic/neurologic tests were positive for a space occupying lesion
(HNP) at the L4-L5 level
– A course of VAX-D, McKenzie protocol and Flexion/Distraction all failed
to centralize the symptoms
Normal or abnormal?
Normal or abnormal?
Normal or abnormal?
Incontinentia Buttocks
48 F, severe constant LBP, wakes her up at night, recurrent bladder infections,
Numbness in left groin, loss of thigh musculature. X-rays negative.
Incontinentia Buttocks.
DX: Spinal Meningioma
MRI Myelogram
Alexander Ekdahl
♦ 11 yo boy with occasional long tract symptoms (clonus, spasticity,
bladder involvement, sensory deficits)
Alexander Ekdahl, Os odontoideum
♦ 3D CT
Alexander Ekdahl, Os Odontoideum
♦ 3D CT
Noxema Jackson, extrapleural sign
♦ 67 male with right chest pain.
Noxema Jackson, Plasmacytoma
Mr. Creosote, 35 M, fell 5 weeks ago.
♦ Normal?
Mr. Creosote, acute/sub-acute rupture of patellar tendon
Vida Boheme, MVA
Vida Boheme, Lytic lesion C7
Miss Chi-Chi Rodriguez, Low back pain
Miss Chi-Chi Rodriguez, DX: discitis.
J.A. Pinkerton, low back pain
J.A.Pinkerton, Low back pain, Baastrup’s disease
Mickey Bricks, chronic sinusitis.
Mickey Bricks, chronic sinusitis, continued
Ethmoid sinusitis with deviated septum
Sphenoid sinusitis
Different maxillary sinusitis case
♦ Take home message?
Do not order a sinus xray when evaluating for
sinus disease/sinusitis!!!
Why bother ordering a
test that is going to be
wrong almost half the
♦ Gold standard for sinus
imaging is CT.
MRI of the sinuses
Chronic sphenoid sinusitis with intracranial
and intraorbital extension.
Chronic ethmoid sinusitis with
intraorbital extension.
Rostro-caudal subluxation
Spondylolisthesis, X-ray and MRI correlation
An 11 year old girl
♦ Which choice is
most likely the chief
Bilateral hip pain
Left hip pain
Right hip pain
Sacral pain
Suprapubic pain.
Finding: widening of the physis.
♦ Can you select the
actual diagnosis?
Juvenile idiopathic
MRI shows edema and enhancement
adjacent to the physis.
Slipped Capital Femoral Epiphysis
♦ SCFE is a Salter-Harris 1 fracture of the capital femoral physis,
which occurs secondary to repetitive stress from weight bearing.
Most common in boys age 10-17
Obesity is a significant risk factor.
Contralateral SCFE is common (18-100%) and usually occurs within
24 months of the first occurrence.
Evaluation begins with plain radiographs including pelvis AP and
bilateral hips frog-lateral views.
Klein's line, drawn along the superior aspect of the femoral neck,
should intersect the epiphysis. If it does not, then SCFE is likely.
Widening of the physis may occur before the slip is recognizable (as
in our case).
Treatment is immediate internal fixation in-situ (without attempted
reduction) using a single cannulated screw.
Delay in treatment increases the risk of avascular necrosis of the
femoral head.
Boy with abnormal physical exam
♦ Which of the
following choices
T/F Multifocal
T/F Cortical
T/F Aggressive
periosteal reaction
Same images. Can you select the diagnosis?
Ewing’s sarcoma
Elderly female with new palpable breast lump
♦ T/F High density mass?
♦ T/F Indistinct margins?
♦ T/F Irregular shape ?
Elderly female with new palpable breast lump
♦ DUS shows hypo
echoic mass with
echogenic halo.
♦ Biopsy revealed
invasive ductal
♦ IDCA(infiltrating
ductal carcinoma)
is the MC breast
Man with pain
♦ Please respond to
the following with
Bilateral process?
Involves acetabulum?
Involves femoral head?
Compatible with acute
Man with pain
♦ Which ONE of the
following (if any) does not
belong in the differential
A. Septic joint (such as TB)
B. Metastatic renal cell
C. Metastatic lung
D. Multiple myeloma.
E. All of the above belong in
the differential diagnosis
Man with pain
♦ Differential diagnosis:
♦ Metastatic disease
♦ Multiple myeloma
♦ Infection- more specifically TB
♦ Erosive arthritis
♦ Diagnosis: Metastatic carcinoma of unknown origin.
♦ The differential for lucent bony lesions is long. The difference with this
case is that the lesion appears to involve both the femoral head and
acetabulum, and so crosses the joint space.
♦ Lesions that cross the joint: Inflammation, infection, trauma, malignancy.
♦ Malignancy that crosses a joint: lymphoma, chondrosarcoma, chordoma,
multiple myeloma, metastasis.
♦ The most common joints to be involved are the SI joint, followed by the
vertebral disc spaces, and the facet joints.
♦ 62 year old male with sudden onset of slurred speech, left sided
weakness and nausea.
♦ How do we find out if it is ‘wet’ or ‘dry” stroke?
CT scan: fast and easily available
Hemorrhagic stroke, with edema
Right hemispheric Ischemic stroke
People at risk
Image before 6 hrs
For those of you who noticed…
♦ Paul Vitti, in Analyze This
♦ Freddy Benson, in Dirty Rotten
Janet Colgate, in Dirty Rotten
Lawrence Jamieson, in Dirty
Rotten Scoundrels.
Jerry Lundegaard, in Fargo
Carl Showalter, in Fargo
Fanny Eubanks, in Dirty Rotten
Gaear Grimsrud, in Fargo
Wade Gustafson, in Fargo
Shep Proudfoot, in Fargo
Osgood Fielding III, in Some Like it
John Jacob Jingleheimer Schmidt,
in To Wong Foo Thanks for
Everything, Julie Newmar.
Mr. Creosote, in The Meaning of
Life, by Monty Python
Ben Sobel, in Analyze This
Marge Gunderson, in Fargo
Brian Hope, in Nuns on the Run
Sugar Kane Kowalczyk, in Some Like It Hot.
Charlie McManus, in Nuns on the Run
Truman Burbank, in The Truman Show
Jesminder Kaur Bhamra, in Bend it Like
Fanny Ekdahl, in Fanny and Alexander
Nick Martinelli, in Rhinestone
Mona Dearly, in Drowning Mona
Alexander Ekdahl, in Fanny and Alexander
Noxema Jackson, in To Wong Foo Thanks for
Everything, Julie Newmar.
Mr. Creosote, in The Meaning of Life, by Monty
Vida Boheme, in To Wong Foo Thanks for
Everything, Julie Newmar.
Chi-Chi Rodriguez, in To Wong Foo Thanks for
Everything, Julie Newmar.
J.A.Pinkerton, in Pink Floyd, The Wall.
Incontinentia Buttocks, in Life of Brian, by Monty
Mickey Bricks, in Hustle, the BBC TV series
Hanstholm harbor, Denmark

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