Spine Radiology x ray ct mri normal anatomy
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Spine Radiology
Cervical spine
Thoracolumbar spineX-RAY
CT
MRI
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CERVICAL SPINE Standard views
- Lateral view
- Anterior-Posterior (AP) view
- Odontoid Peg view (or Open Mouth view)
In trauma case these images are all difficult to acquire because thepatient may be in pain, confused, unconscious, or unable tocooperate due to the immobilisation devices.
Additional views
- 'Swimmer's view'
If the lateral view does not show the vertebrae down to T1 then arepeat view with the arms lowered or a 'Swimmer's view' may berequired.
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Systematic approach to interpret
cervical spine xray
Coverage- Adequate?
Alignment-Anterior/Posterior/Spinolaminar
Bones- Cortical outline/Vertebral bodyheight
Spacing- Discs/Spinous processes Soft tissues - Prevertebral
Edge of image
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AP View
Coverage- The AP view shouldcover the whole C-spine andthe upper thoracic spine
Alignment - The lateral edgesof the C-spine are aligned (redlines )
Bone- Fractures are moreclearly visible on lateral view
Spacing- The spinousprocesses (orange) are in astraight line and spacedapproximately evenly
Soft tissues- Check for surgicalemphysema
Edges of image- Check forinjury to the upper ribs andthe lung apices forpneumothorax
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Lateral viewthe most informative image
Coverage- All vertebrae are visible from the
skull base to the top of T1/T2 (If T1 is not
visiblerepeat image with the patient's
shoulders lowered or a 'swimmer's' view may
be necessary
Alignment- Check the Anterior lineGREEN
(the line of the anterior longitudinal ligament),
the Posterior lineORANGE(the line of the
posterior longitudinal ligament), and the
Spinolaminar lineRED(the line formed by the
anterior edge of the spinous processes -
extends from inner edge
of skull).
Bone- Trace the cortical
outline of all the bones
to check for fractures
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Lateral
Bone- The cortical outlineis not always well definedbut forcing your eye aroundthe edge of all the boneswill help identify fractures
C2 Bone Ring- At C2 (Axis) thelateral masses viewed sideon form a ring of corticatedbone (red ring )
This ring is not complete in all
subjects and may appear asa double ring
A fracture is sometimes seenas a step in the ring outline
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Lateral view Disc spaces- The vertebral bodies are
spaced apart by the intervertebral discsThese spaces should be approximatelyequal in height
Prevertebral soft tissue- Somefractures cause widening of theprevertebral soft tissue due toprevertebral haematoma
- Normal prevertebral soft tissue(asterisks) - narrow down to C4 and
wider below- Above C4 1/3rd vertebral body width
- Below C4 100% vertebral body width
Note:Not all C-spine fractures areaccompanied by prevertebralhaematoma - lack of prevertebral soft
tissue thickening should NOTbe takenas reassuring
Edge of image- Check other visiblestructures
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Odontoid peg /Open mouth view Its primary purpose is to view
lateral mass alignment.
If a fracture of the odontoid
peg (dens) is presentoftennot visible with this view. If apeg fracture is not visible, butis suspected clinically by a
senior clinician, then furtherimaging with CT should beconsidered.
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Open Mouth view-
cont.
This view is consideredadequate if it shows thealignment of the lateralprocesses of C1 and C2(redcircles)
The distance between the pegand the lateral masses of C1(asterisks) should be equal oneach side
Note:In this image theodontoid peg is fully visible
which is not often achievablein the context of trauma dueto difficulty in patientpositioning
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Swimmers viewIf the lateral view does not show the vertebrae down to T1 then a repeat view with the arms
lowered or a 'Swimmer's view'may be required.
This is an oblique view whichprojects the humeral heads awayfrom the C-spine.
A swimmer's view may be usefulin assessing alignment at the
cervico-thoracic junction if C7/T1has not been adequately viewedon the lateral image, or on arepeated lateral image with theshoulders lowered.
The view is difficult to achieve,and often difficult to interpret. Ifplain X-ray imaging of the cervico-thoracic junction is limited thenCT may be required.
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Swimmers view- cont.
Oblique image with the
humeral heads projected
away from the C-spine
The cervico-thoracicjunction can be seen
Check alignment by
carefully matching the
corners of each adjacentvertebral body -
anteriorly and posteriorly
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Thoracolumbar spine
Standard views
- AP
- Lateral
Systematic approach- Coverage - Adequate?
- Alignment - Anterior/Posterior/Lateral
- Bones - Cortical outline/Vertebral body height
- Spacing - Discs/Spinous processes/Pedicles- Soft tissues - Paravertebral
- Edge of image
Coverage The whole spine is
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Thoracic s Lateral and AP Coverage- The whole spine is
visible on both views (T1 till T12)
Alignment - Follow the cornersof the vertebral bodies from one
level to the next
Bones- The vertebral bodiesshould gradually increase in sizefrom top to bottom
Spacing- Disc spaces graduallyincrease from superior toinferior
Soft tissues - Check theparavertebral line (in AP image)
Edge of image - Check the otherstructures visible
L l (i d il)
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Lateral (in detail)
Alignment - Vertebral body alignmentis assessed by carefully matching theanterior and posterior corners of thevertebral bodies with the adjacentvertebra
Bones - Gradual increase in vertebral
body height from superior to inferior
Spacing - Disc spaces graduallyincrease in height from superior toinferior
VB = Vertebral body
P = Pedicle
SP = Spinous process (ribs overlying)
F = Spinal nerve exit foramen
AP (i d il)
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AP (in detail) Alignment- The vertebral bodies and
spinous processes (SP) are aligned
Bones- The vertebral bodies and pediclesare intact
Other visible bony structures include the
- transverse processes (TP)
- -ribs- costovertebral and costotransverse joints
Spacing- Each disc space is of equal heightwhen comparing left with right. The pediclesgradually become wider apart from superior
to inferior
Soft tissue - Note the normal paravertebralsoft tissue which forms a straight line on theleft - distinct from the aorta
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Lumbar s Lateral Coverage - The whole L-
spine should be visible
Alignment - Follow thecorners of the vertebralbodies from one level tothe next (dotted lines)
Bones- Follow the corticaloutline of each bone
Spacing- Disc spacesgradually increase in heightfrom superior to inferior -Note: The L5/S1 space isnormally slightly narrower
than L4/L5
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Lateral (in detail)
Check the cortical outline of
each vertebra
The facet joints comprisethe inferior and superiorarticular processes of eachadjacent level
The pars interarticularisliterally means 'part
between the joints'- P = Pedicle
- SP = Spinous process
L spine Normal
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L-spine - NormalAP
Alignment- The vertebralbodies and spinous processesare aligned
Bones- The vertebral bodiesand pedicles are intact
Spacing - Gradually increasingdisc height from superior to
inferior. The pedicles graduallybecome wider apart fromsuperior to inferior - Note: Thelower discs are angled awayfrom the viewer and so are less
easily assessed on this view
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L-spine - Normal
AP
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L-spine AP (detail)
Check carefully for pedicle integrity andtransverse process fractures
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Three column model -
Fracture Anterior column = Anterior
half of the vertebral bodiesand soft tissues
Middle column = Posteriorhalf of the vertebral bodiesand soft tissues
Posterior column = Posteriorelements and soft softtissues
Three column
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Three column
model
Injuries 1 and 2 affectone column only andare considered 'stable'
1 - Spinous processinjury
2 - Anteriorcompression injury
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Injuries 3 and 4 affecttwo or more columnsand are considered'unstable'
3 - 'Burst' fracture
4 - Flexion-distractionfracture - 'Chance'type injury
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CT scan of spine Up to 20 % of fractures are missed on conventional radiographs.
The advantages of CT are:
1. CT is excellent for characterizing fractures and identifying osseouscompromise of the vertebral canal because of the absence ofsuperimposition from the transverse view.
2. CT provides patient comfort by being able to reconstruct images in
the axial, sagittal, coronal, and oblique planes from one patientpositioning.
The limitations of CT are:
1. difficult to identify those fractures oriented in axial plane (e.g. dens
fractures).2. unable to show ligamentous injuries.
3. relatively high costs.
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CT Cervical Spine Axial
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CT Cervical Spine Coronal
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CT Cervical Spine Sagittal
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CT Thoracic Spine Axial
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CT Thoracic-Lumbar Spine
Sagittal
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CT Lumbar Spine Axial
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Zyapophyseal joint= facet joint
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MRI Most sensitive imaging modality in the study of spine disease.
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Difference between T1 and T2 image
T1-weighted image T2-weighted image
Bone marrow Hyperintense/high
signal
(white)
Hypointense/low signal
(black )
CSF Hypointense/low signal(black )
Hyperintense/high signal(white)
Neural tissue
(eg.spinal cord/nerve roots)
Intermediate signal Intermediate signal
Cortical bone Hypointense Hypointense
Intervertebral disc Intermediate signal Hyperintense
(because of the water content)
T1-weighted sagittal,
cervicothoracic spine
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The spinal cord is veryeasily seen.
The CSF anterior andposterior to the cord is
hypointense.
The high signal arising fromthe vertebral body bonemarrow (arrows) is due tothe fat content.
The disk spaces are readilyvisualized and are of lowersignal intensity
T2-weighted sagittallumbar spine
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CSF is now very hyperintense,and the spinal cord appears tohave relatively low signalintensity.
The disks (arrowheads),because of their water content(when normal), appear higherin signal intensity whencompared with the T1-
weighted image. The bone marrow, on the other
hand, is lower in signalintensity .
Lumbar spineT1 & T2
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Axial T2 wtd MRI of cervical spine at C5-C6 level
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Axial T1 wtd MRI of thoracic spine
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