SpineSpine

Imaging Techniques:Imaging Techniques:Plain film………traumaPlain film………traumaMRI………can see spinal cord & nerves.MRI………can see spinal cord & nerves.CT……….spinal trauma; burst fracturesCT……….spinal trauma; burst fracturesRadionuclide bone scan…..metastasesRadionuclide bone scan…..metastasesMyelography.Myelography.

Plain filmPlain film

Normal appearance:Normal appearance:

Vert. body is rectangular in shape in the lateral Vert. body is rectangular in shape in the lateral view.view.

Disc spaces; normally have the same height at all Disc spaces; normally have the same height at all levels in the C. & D. spine. In the L.Spine levels in the C. & D. spine. In the L.Spine increases in height going down.increases in height going down.

Signs of abnormality on plain Signs of abnormality on plain radiographsradiographs

Disc space narrowingDisc space narrowing

Collapsed verteb. body …..lost height. Seen in the lateral Collapsed verteb. body …..lost height. Seen in the lateral view, or sagittal MRI. Look at the adjacent disc and view, or sagittal MRI. Look at the adjacent disc and pedicles.pedicles.

Pedicles Pedicles

Dense vertebraeDense vertebrae

Lytic lesion in the vertebraeLytic lesion in the vertebrae

Paravertebral shadowParavertebral shadow

Disc space narrowingDisc space narrowing

Causes;Causes;

DDDDDD

Infection.Infection.

Causes of Collapsed vertebraCauses of Collapsed vertebra Metastases & M.M. Metastases & M.M. Discs…..Normal Discs…..Normal Pedicles….destrcted in Metastases.Pedicles….destrcted in Metastases.

Infection……..Infection…….. adjacent disc narrow or obliterated. adjacent disc narrow or obliterated. Pedicles intact.Pedicles intact.

Osteoporosis & osteomalacia…Osteoporosis & osteomalacia… Disc normal or slight increase in heightDisc normal or slight increase in height Pedicles intactPedicles intact

Trauma.. Wedge shape with concave sup. surface. Trauma.. Wedge shape with concave sup. surface. Normal disc. Normal disc. Associated fracture of pedicles, neural archAssociated fracture of pedicles, neural arch

Eosinophil granuloma in children & young adults ………“vertebra Eosinophil granuloma in children & young adults ………“vertebra plana” plana”

the adjacent discs & pedicles are intact.the adjacent discs & pedicles are intact.

PediclesPedicles

On plain films …..On plain films ….. best assessed in the frontal view, except best assessed in the frontal view, except

in the C. spine….oblique view. in the C. spine….oblique view. very well seen in CTvery well seen in CT

Destruction or sclerosis of one or more is Destruction or sclerosis of one or more is reliable sign of metastases.reliable sign of metastases.

Dense vertebraeDense vertebrae

Sclerosis may affect one or more vert.Sclerosis may affect one or more vert.Causes:Causes:

Metastases:…. …Ca prostate, & breast.Metastases:…. …Ca prostate, & breast.

LymphomaLymphoma

Paget’s dis. Enlarged verteb with coarse Paget’s dis. Enlarged verteb with coarse trabecular pattern.trabecular pattern.

Hemangioma; vertical striation in a normal size Hemangioma; vertical striation in a normal size vertebravertebra

Lytic lesion within a vertebra Lytic lesion within a vertebra

May affect one or more vertebraeMay affect one or more vertebraeCauses:Causes: Metastases….Lung, breast, kidneys.Metastases….Lung, breast, kidneys.

M.M or Plasmacytoma.M.M or Plasmacytoma.

Lymphoma.Lymphoma.

Infection….Lysis of two adjacent vert with Infection….Lysis of two adjacent vert with narrowed the intervening disc.narrowed the intervening disc.

Paravertebral shadowParavertebral shadow Dorsal region is the easiest place to recognize itDorsal region is the easiest place to recognize it

Lumber spine ….large enough to displace psoas shadow.Lumber spine ….large enough to displace psoas shadow.

C. Spine; Lateral view shows ant. displacement of the pharyngeal C. Spine; Lateral view shows ant. displacement of the pharyngeal air.air.

Causes;Causes; InfectionInfection

Malignant neoplasm.Malignant neoplasm.

Hematomas following trauma.Hematomas following trauma.

Myeloma/Myeloma/Metastases/Metastases/Lymphoma Lymphoma M.M. cause lytic lesions only.M.M. cause lytic lesions only.

Multiple lytic lesions are either M.M. or Metastases.Multiple lytic lesions are either M.M. or Metastases.

Metast. & M.M. both cause collapse verteb.Metast. & M.M. both cause collapse verteb.

Metastases often involve both verteb bodies & pedicles.Metastases often involve both verteb bodies & pedicles.

Lymphoma & metastases may cause lytic. Sclerotic or Lymphoma & metastases may cause lytic. Sclerotic or mixture of both.mixture of both.

MRI is the most accurate test for all.MRI is the most accurate test for all.

MRI will show compression of the spinal cod or nerve roots MRI will show compression of the spinal cod or nerve roots by soft tissue mass.by soft tissue mass.

InfectionInfection Common infecting organisms. TB & Staph.Common infecting organisms. TB & Staph.

The hallmark is destruction of two vertebral bodies with the The hallmark is destruction of two vertebral bodies with the intervening disc.intervening disc.

Collapse of verteb. bodies leading to gibbus formation.Collapse of verteb. bodies leading to gibbus formation.

Paravertebral soft tissue shadow which may calcify in TB.Paravertebral soft tissue shadow which may calcify in TB.

Plain film, CT & MRI all can show the changes. MRI is the Plain film, CT & MRI all can show the changes. MRI is the best.best.

Needle biopsy under CT or fluoroscopy Needle biopsy under CT or fluoroscopy

Spinal TraumaSpinal Trauma Plain films: Look for Plain films: Look for Fractures & alignment.Fractures & alignment.

CT in Major trauma:CT in Major trauma: no manipulation no manipulation difficulties in monitoring patients in MRI.difficulties in monitoring patients in MRI.

In unconscious patients:In unconscious patients: CT of C. spine with CT of head…. CT of C. spine with CT of head…. Reconstruction of the images in sagittal and coronal planes. Reconstruction of the images in sagittal and coronal planes.

Look for fracture C1,C2 (atlanto-axial interval) & C7-T1Look for fracture C1,C2 (atlanto-axial interval) & C7-T1

CT can show # laminae & pedicles CT can show # laminae & pedicles bony fragments inside the spinal canal (burst #)bony fragments inside the spinal canal (burst #)

MRIMRI

The spine is divided into 3 columns:The spine is divided into 3 columns: Ant…………ALL & ant 2/3 verteb bodyAnt…………ALL & ant 2/3 verteb body

Middle……post 1/3 of verte. body & PLLMiddle……post 1/3 of verte. body & PLL

Post………Pedicles, laminae & spinus pro. Post………Pedicles, laminae & spinus pro.

The spinal stability depends on the integrity of the The spinal stability depends on the integrity of the middle and post. columns.middle and post. columns.

Fractures of ant. 1/3 stable # like the commonly Fractures of ant. 1/3 stable # like the commonly seen wedge fractures of osteoporosisseen wedge fractures of osteoporosis

Spinal StabilitySpinal Stability

Jefferson #.... Lat. Masses of atlas Jefferson #.... Lat. Masses of atlas

Hangman’s #.....arch of C2 …Severe Hangman’s #.....arch of C2 …Severe hyperextension.hyperextension.

Tear drop #.... Tear drop #.... On the ant. surface of verte. body …On the ant. surface of verte. body … as a result of severe flexion injury…..may indicate as a result of severe flexion injury…..may indicate

a serious injury a serious injury

Whiplash injuryWhiplash injury

MRI in Spinal traumaMRI in Spinal trauma

Valuable in pat. with neurological deficits as Valuable in pat. with neurological deficits as it may demonstrate a potentially treatable it may demonstrate a potentially treatable abnormality like disc protrusion or abnormality like disc protrusion or hematoma.hematoma.

MRI can show hemorrhage & contusion of the MRI can show hemorrhage & contusion of the spinal cord.spinal cord.

SCIWORA syndrome…….Spinal Cord Injury SCIWORA syndrome…….Spinal Cord Injury Without Radiological Abnormality ..in childrenWithout Radiological Abnormality ..in children

The signs of spondylosis on The signs of spondylosis on plain filmsplain films

Disc space narrowingDisc space narrowing

Osteophyte formation and sclerosis, which Osteophyte formation and sclerosis, which frequently occur on the adjoining surfaces frequently occur on the adjoining surfaces of the vertebral bodies.of the vertebral bodies.

Osteophytes on the posterior surface of the Osteophytes on the posterior surface of the vertebral bodies narrow the spinal canal vertebral bodies narrow the spinal canal and may encroach on the exit foramina of and may encroach on the exit foramina of the spinal nervesthe spinal nerves

MRI in the spondylosis MRI in the spondylosis

Dehydration (Reduced signal in T2)Dehydration (Reduced signal in T2)

Reduction in the height of the disc & Reduction in the height of the disc & may bulge.may bulge.

MRI Lumber disc herniationMRI Lumber disc herniation

Majority occur posterolaterally at L4-Majority occur posterolaterally at L4-L5 & L5-S1 levels.L5 & L5-S1 levels.

> 1/3 of demonstrably herniated > 1/3 of demonstrably herniated discs are asymptomatic. So the discs are asymptomatic. So the criteria for surgery must be clear-cut criteria for surgery must be clear-cut evidence of compression of the evidence of compression of the clinically affected nerve roots. clinically affected nerve roots.

Failed back syndrome Scarring Vs Failed back syndrome Scarring Vs recurrent disc. Scarring enhances, recurrent disc. Scarring enhances, while disc herniation does not.while disc herniation does not.

Cervical disc herniationCervical disc herniation

Majority occur at the lower three disc Majority occur at the lower three disc levels.levels.

MRI can identify disc herniation MRI can identify disc herniation encroaching on the spinal cord & or encroaching on the spinal cord & or nerve roots.nerve roots.

Spinal stenosisSpinal stenosis

A narrow spinal canal may lead to cord or A narrow spinal canal may lead to cord or nerve root compression esp. when nerve root compression esp. when spondylotic changes supervenespondylotic changes supervene

Symptomatic spinal stenosis is Symptomatic spinal stenosis is encountered in the C.& L. regions.encountered in the C.& L. regions.

MRI is the ideal method of demonstrating MRI is the ideal method of demonstrating the size and the shape of the spinal canal the size and the shape of the spinal canal and thus diagnosing SCSand thus diagnosing SCS

Ankylosing SpondylitisAnkylosing Spondylitis

Affects principally SI joints and the spine.Affects principally SI joints and the spine. Both SI joints are invariably affected by Both SI joints are invariably affected by

the time spinal involvement has occurred.the time spinal involvement has occurred. The earliest changes are haziness of the SI The earliest changes are haziness of the SI

joints followed by erosions. Finally there joints followed by erosions. Finally there will be obliteration of the joint space with will be obliteration of the joint space with bony ankylosis.bony ankylosis.

In the spine; squaring of the vertebral In the spine; squaring of the vertebral bodies with ossification of the lig. & bodies with ossification of the lig. & vertical bony bridges bamboo spine vertical bony bridges bamboo spine

Spina bifidaSpina bifida

Incomplete closure of the spinal canal.Incomplete closure of the spinal canal.Usu. seen in the L.S. spine.Usu. seen in the L.S. spine.May be associated with Spinal cord May be associated with Spinal cord

abnormality.abnormality.Malformatin of the vertebral bodiesMalformatin of the vertebral bodies

(Spinal dysraphism)……Dx (Spinal dysraphism)……Dx antenatally by US.antenatally by US.

Spina bifida occulta of no significanceSpina bifida occulta of no significance

Spondylolysis & Spondylolysis & spondlyolisthesisspondlyolisthesis

Defect in the pars interarticularisDefect in the pars interarticularisForeward slip of one vertebral body Foreward slip of one vertebral body

on the one below. Occurs most on the one below. Occurs most frequently at L.S. junction & bet. L4 frequently at L.S. junction & bet. L4 & L5.& L5.

Seen in the lateral view.Seen in the lateral view.

Spinal cord CompressionSpinal cord Compression

MRI can show the site, size & extent of the MRI can show the site, size & extent of the compression.compression.

Extra-dural lesions; metast, TB, Cervical Extra-dural lesions; metast, TB, Cervical disc herniation. Lumber disc prolapse disc herniation. Lumber disc prolapse causes no cord compression as the cord causes no cord compression as the cord doesnot extend below L1doesnot extend below L1

Intradural but extramedullary( within the Intradural but extramedullary( within the dura but not the cord) like neurofibroma dura but not the cord) like neurofibroma and meningioma.and meningioma.

Intramedullary lesions tumors like Intramedullary lesions tumors like ependymoma or hemorrhage.ependymoma or hemorrhage.

Other lesions of the spinal Other lesions of the spinal cordcord

SyringomyeliaSyringomyeliaDemyelinating plaques of MSDemyelinating plaques of MS