Nomenclature in spine mri

Imaging Degeneration of the Lumbar Spine:

THE 1ST LESSONS

Hieder A`ala601

MUST

Course Outline

• Introduction, Nomenclature, Evidence for Imaging

• Natural History and Prognosis

• New Techniques

Spine Nomenclature and Evidence for Imaging

Talk Objectives

• “Background”

• Nomenclature for disc findings

• Who should be imaged- evidence basis?

15th Century Turkish Treatment- Cauterization

21st Century American Treatment

What sounds straightforward isn’t always

Frequency of Back Pain Types

1% tumor, infection,

inflammatory arthritis

2% visceral

97%

“mechanical”

“Mechanical” Causes of Low Back Pain

• Lumbar strain, sprain (70%)

• Degen (disc and facets) (10%)

• Herniated disc (4%)

• Spinal stenosis (3%)

• Osteoporotic comp fracture (4%)

The Least We Can Do: Speak the Same Language

Nomenclature for disc findings

Consensus Nomenclature

Question???

• What is the ASNR/NASS nomenclature for describing lumbar discs?


• normal• degeneration• anular tears• herniation


• normal–well hydrated disc–central dark band= central

fibrosus

age-related changes=NOT normal

Intranuclear Cleft

Normal


• normal• degeneration

–desiccation–narrowing–bulging–endplate changes–osteophytes

Glossary of disc pathology terms

• Herniation: nonspecific term subject to misinterpretation. – Not recommended.

• Bulge: diffuse enlargement of disc area– Very common– Usually not clinically important– May contribute to spinal stenosis

• Protrusion: nucleus pulposis pushes focally through fibers of annulus fibrosis– Base wider than apex– May focally impinge on nerve or thecal sac


• Extrusion: nucleus material pushes out beyond posterior longitudinal ligament but remains in contact with disc space– Apex wider than base– Likely to impinge on nerve roots

• Sequestration: Disc fragment isolated from parent disc


• Localizing terms:–Central

–Paracentral

–Foraminal

–Lateral

Desiccation Narrowing

Disc Degeneration

Disc Degeneration: Findings?

Narrowing

Endplate sclerosis

Osteophytosis

Vacuum Disc

Bulging


• normal• degeneration• anular tear=anular fissure (high

intensity zones=HIZ)• herniation

Degeneration and Tears


• Herniation– localized displacement of disc

>50% (180o) = bulge

<50% = herniation


• normal• degeneration• anular tears• herniation

–protrusion–extrusion

Disc Classification

Protrusion Extrusion

Canal

Disc

Bony Endplate

Normal Bulge

Disc Classification

Protrusion

Extrusion

Classification of Nerve Root Condition

• Normal

• Contacted

• Displaced

• Compressed

Normal Nerve Roots

Contacted Nerve Root

Displaced Nerve Root

Compressed Nerve Root

Displaced and Compressed Nerve Root

Talk Objectives

• “Background”

• Nomenclature for disc findings

• Who should be imaged- evidence basis?

6%

32%

64%

0%

20%

40%

60%

80%

100%

bulge protrusion extrusion

Prevalence of Disc Findings in Subjects without LBP

Bulge Protrusion Extrusion

Disc Degeneration

• Signal loss on T2-weighted images

• Height loss

Disc Degeneration

Anular Tear

Take Home Points Regarding Prevalence

• many imaging findings are common in asx’s

• certain findings are related to prior low back pain and more likely to be clinically important–extrusions, root comp, stenosis

Rationale for Imaging

• r/o low prob red flag condition

• rule-in treatable conditions–stenosis–herniated disc–spondyloarthropathy–instability ?

Early Imaging Red Flags

• ? Fx–h/o major trauma

–minor trauma in older or osteoporotic pt

Red Flags

• age>50 or <20

• h/o malignancy

• constitutional sx

• ↑ infection risk (IVDA, HIV, etc)

Red Flags

• possible cauda equina syndrome–saddle anesthesia

–urinary retention

–severe/progressive neurologic deficit in lower extremity

Nomenclature in spine mri

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