Radiological assessment – Part 2
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Transcript of Radiological assessment – Part 2
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60F
T2 T1 T1FS con
T1 T1FS con
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70M
T2 T1 T1FS con
T1 T1FS con
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35M PBA T2 T2 T1
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• 72 year old male• Non mechanical back pain• Known prostate Ca:
– Raised PSA (20)– Nodule on DRE– +ve on biopsy
• Staging investigations
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What is the most appropriate imaging modality for the spine?
1. Plain film2. CT3. Scintigraphy (bone scan) 4. MRI
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64F Breast Ca
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T2 T1 T1FS con
76M CRC
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T2
54M RCC
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• 62 year old male• Severe low back pain of rapid onset• Febrile and unwell• 4 weeks ago underwent abdominal surgery for
perforated diverticulitis
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What is the most likely diagnosis?
1. Acute disc herniation2. Discitis/ osteomyelitis3. Crush fracture secondary to osteoporosis4. Metastatic cancer
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What is the most appropriate imaging modality?
1. Plain film2. CT3. Scintigraphy (bone scan) 4. MRI
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T2 T1 T1FS con
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T2 T1FS con
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• 37 year old male• Low back and buttock pain, increasing over
several months• Worse in morning; reduced by activity
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What is the most likely diagnosis?
1. Acute disc herniation2. Facet joint degeneration3. Inflammatory spondyloarthropathy4. Metastatic cancer
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Seronegative spondyloarthropathies (SpA)
• European Spondyloarthropathy Study Group (ESSG) Arthritis Rheum 1991;34:1218-1227– Ankylosing spondylitis– Reactive arthritis– Arthritis spondylitis with inflammatory bowel disease– Arthritis spondylitis with psoriasis– Undifferentiated spondyloarthropathy (uSpA)
• Clinical features + HLA-B27• Rheumatoid factor –ve = seronegative
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ANKYLOSING SPONDYLITIS
• Chronic inflammatory disease, primarily affecting spine and sacroiliac joints
• Osteitis:– Bone erosions; sclerosis; ankylosis
• Peripheral arthritis: – Asymmetrical; lower limb
• Enthesopathy: – Plantar fasciitis– Distal Achilles tendonosis and paratendonitis
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DIAGNOSIS OF AS
• Radiographic grading of sacroiliitis 0-4Kellegren Atlas of Standard Radiographs in Arthritis,
Oxford 1963• Grade 0 = normal• Grade 1 = suspicious (mild blurring)• Grade 2 = minimal sclerosis, some erosions• Grade 3 = severe erosions, joint widening, partial
ankylosis• Grade 4 = complete ankylosis
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Radiographic grading of AS• Grade 0• Grade 1 • Grade 2• Grade 3 • Grade 4
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Dx of AS: Modified New York criteria
• Arthritis Rheum 1984;27:361-368• Clinical:
1. LBP & stiffness > 3/12 improved by exercise2. ↓ motion lumbar spine sagittal and frontal3. ↓ chest expansion for age & sex
• Radiological: – Grade ≥ 2 bilateral– Grade 3-4 unilateral
• AS = 2/3 clinical + radiological
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Problems with radiographic grading
• May take years for radiographic changes to develop– Early cases excluded from research and treatment
• Most radiographic signs in AS reflect healing processes, not disease activity– cf erosions in RA
• Most radiographic signs in AS irreversible• Radiographs do not detect inflammation
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T2FS
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T1
STIR
STIR
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Response to DMARD eg infliximab
– Braun Ann Rheum Dis 2002;61:iii51-iii60
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• 45 year old male• 2 weeks post discectomy L4/5• Recurrent bilateral leg pain
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What is the most appropriate imaging modality?
1. Plain film2. CT3. Scintigraphy (bone scan) 4. MRI
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T2T1
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T2
T1FScon
T2
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T1FScon
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• Dx: recurrent disc:– Central herniation + huge sequestration virtually filling
the spinal canal• Note peripheral enhancement pattern• DD: fibrosis
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• 51 year old female• Left sciatica
– Intermittent pain and paraesthesia
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T2 T1 T1FS con
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What is the most likely diagnosis?
1. Massive disc sequestration2. Discitis complicated by abscess3. Synovial cyst4. Benign peripheral nerve sheath tumour
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T2 T1 T1FS con
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• Dx: benign peripheral nerve sheath tumour (BPNST) of left L3 nerve root– Many clinicians use the term ‘neuroma’
• Pathologically imprecise term– Most are benign
• Schwannoma or neurofibroma• Difficult (impossible) to differentiate on imaging
– BPNST is probably the best terminology– Associated with NF1 and ‘NF2’ (MISME)
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• 66 year old female• Severe lower back pain on and off for years• More recent (2 months) development of right
sciatica
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What is the most likely diagnosis?
1. Massive disc sequestration2. Discitis complicated by abscess3. Synovial cyst4. Benign peripheral nerve sheath tumour
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L4/5
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• Severe OA of facet (zygoapophyseal) joints• Round heterogeneous lesion projecting into right
spinal canal• Note: close relationship to facet joint• Dx: synovial cyst
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Synovial cyst lumbar facet joint
• Fairly common• Key is relationship to degenerate facet joint• Density may vary from pure cyst to varying levels of
calcification and heterogeneity• Usually present clinically with intractable sciatica• May respond to aspiration and steroid injection, but
usually treated surgically
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T2 T1
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T2 T1
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Image interpretation: spine
• Anatomy• Cross sectional techniques:
– CT– MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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