SS - MSIH 16 - Imaging of the Back

8/9/2019 SS - MSIH 16 - Imaging of the Back

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Pioneer Batch Class of 2012

MODULE Musculoskeletal Module DATE August 31, 2007

LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

Page 1 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.Macapinlac-Tumibay-Vega

Topic Outline:

I. Objectives

II. Modalities (Review)III.X-Rays of the SpineIV. Back and Spine

Imaging CheklistV. Computed

Tomography (CTScan)

VI. Magnetic ResonanceImaging (MRI)

VII.X-ray MyelographyVIII. Summary

I. Objectives*Interpret NORMAL radiological images of the spinebased on knowledge of gross anatomyA. Know appropriate modalities for imaging of the

spineB. Identify structures of the spine from multiplanar

radiological images imaging is approached by sections e.g., thoracic, cervical,etc.

II. Modalities (for the back):

A. most used: Xrays, CT scan, MRIB. X-rays (radiographs)C. Computed Tomography (CT Scan)D. Magnetic Resonance ImagingE. UltrasoundF. Myelography, Arteriography, Venography

III.X-rays of the Spine A. Standard:

-Antero-posterior (aka frontal view) view- Lateral view (aka profile view)- Oblique, right and lefto When necessary to view other structures

intervening structures such as the IV discs andspinal cord are not visible or resolved well in X-ray

radiographs there is a need to view the 2D images of X-rays

with a mindset of the true 3D image from the living

body

B. Other views:For evaluation of abnormalities (Back or neck painScoliosis, Trauma, other conditions)- Spot film- Flexion/Extension Views

*Same STANDARD views (AP and lateral) for Cervical,Thoracic, and Lumbo-sacral region

According to Moore and Dalley

IV. Back and Spine Imaging Checklist

- Number of vertebrae(normal number and appearance)- Shape-Alignment- Curvature- Density/Signal intensity of Bone and other tissues

Radiography

Examinations of the vertebral column usuallyrequires bothAP and lateral viewsConventionalmethods are excellent for highcontrast structures like bone; advent ofdigitalradiographyallows improved contrast resolution

A B

Figure IV. (A) Radiograph of the lower back with abnormality.(B) Radiograph of the lower back without abnormality.


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images are 2d pictures, but have to imagine the structuresas 3d life-like structures

when you are familiar with the normal then you can

understand the abnormal

Diff. b/n cervical and thoracic regionAside from number, on AP view can see ribs

Lateral view ribs

Lumbar spine

1. more lardotic2.

Vertebral bodies do not have ribs attached to them

V. Computed Tomography (CT Scan)

Standard:Axial images (across the body, horizontal)Computer reconstruction:

- Multi-planar (different planes)- 3D


CT Scan scannogram- diagram of where image was acquired- Bony structure is emphasized in the CT scan

CT

differentiates between white and greymatter of the brain and spinal cordimproved radiologic assessment offractures of the vertebral column,particularly in determining degree ofcompression of the Spinal cord(McCormick, 2000)images of vertebral column used to detect:

fractures lesions congenital abnormalities

herniations and displaced fragments of IVdiscs are recognizable

Figure IV. (CR)adiograph of the ExtendedCervical Spine (Lateral view)

Figure IV. (D)Radiograph of the FlexedCervical Spine (Lateral view)

CD

Figure IV. (E)Radiograph of the CervicalSpine (Lateral view)

Figure IV. (F) Radiographof the Cervical Spine (AP

view)

EF

Figure IV.(G) Radiograph of the

Thoracic Spine

G

Figure IV. (H) Radiograph of thelumber spine during lateral bending(Anteroposterior view)

H


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CT scan 3D reconstruction figure- useful for the surgeon to plan out before surgery

Advantages of CT- emphasis on BONE DETAILand CALCIFICATION- No contraindication for metallic implants, pacema

ambubag- Faster than MRI

- Axial image- Use of scannogram to orient oneself as to where the im

was taken

VI. MRI (Magnetic Resonance Imaging)

Standard Images are produced in 3 planes:- Axial- Sagittal- Coronal images- Computer reconstruction

Advantages of MRI- Better SOFT TISSUE detail- Intervertebral discs, spinal cord- Early subtle changes/edema of bone and other tis- Bone contusions- No harmful ionizing radiation

Figure V. (A., B and C) CT scan = axial image of cervical vertebrae

C

Figure V. (D) CT scan = axial image= thoracic level

D

Figure V. (E) Normal anatomy on CT

E


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Figure VI. (A) Normal anatomy on MRI

MRI

Cervical spine: vertebrae

spinal canal CSF Intervertebral disk

A

Figure VI. (B and C) Axial MRI image vs. Axial CTimage

BC

D

Figure VI. (D) Axial image figure. With Vertebra, Spinal canal, Paraspinal

muscle (1-disc & vertebral body of L$; 2- exiting L4 root nerve; 3- L5 rootnerve; 4- thesal sac of cauda equine; 5- facet joint; 6- errector spinalismuscle

Figure VI. (E)Sagittal MRI,lateral view

E

Figure VI. (F)

MRI sagittal

F


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Lumbar and sacral spineAxial figureSagittal figure


VII. X-ray Myelography

Iodinated contrast injection into the CSF space- injection of contrast to enhance details in the radiograph


VIII. Summary

X-ray, CT, and MRI are modalities most used forimaging of the back and spine

Images are 2-dimensional or flat, but must beinterpreted as 3-dimensional

Have to be familiar with normal anatomy to be abunderstand and assess images adequately

Check for NORMAL: vertebral number, shape,alignment, curvature, density/signal intensity of band other tissues

MyelographyIs a radiopaque contrast study that allows

visualization of the spinal cord and spinal nerverootsProcedure: withdrawal of CSF by lumbarpuncture contrast material injected into spinalsubarachnoid spaceShows extent of subarachnoid space and itsextensions around the spinal nerve roots withinthe dural sheathsHas largely been supplanted by high-resolutionMRI (McCormick et al., 2000)

Magnetic Resonance ImagingLike CT: computer-assisted; unlike CT: X-rays

are not usedDisadvantage: have to remain motionless insidescanner for long periods of time time spent ismarkedly decreased nowProduces extremely good images of the vertebralcolumn, spinal cord, and CSFClearly demonstrates components of IV discsand shows their relationship to the vertebralbodies and longitudinal ligaments

Imaging procedure of choice forevaluating IV disc disorders

Herniations of the nucleus pulposus and itsrelationship to the spinal nerve roots are also

well definedCan demonstrate spinal cord or nerve rootcompression and indicate the degree ofdegenerative change within the IV discIdeal screening procedure for the differentialdiagnosis of structural disorders affecting thespinal cord and spinal nerve roots

Figure VI. (H) MRI Lumbar and Sacral Spine Sagital

Figure VI. (G) MRI Cervical Spine axial

G

H


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Clinical history and Physical Examination areimportant to be able to choose the appropriateimaging modality best suited to help diagnose thepatients problem

-END-

Sources:1. www.back2backchiropractic.com/xrays.htm2. www.medscape.com3. www.surgeryencyclopedia.com/La-Pa/Myelography.html 4. Dalley, AF and Gold, DJ. 2005. Grants Dynamic Human

Anatomy, Student Version 2.0 CD, 11th ed. Philadelphia:Lippincott Williams&Wilkins.

5. Moore KL and Dalley AF. 2006. Clinically OrientedAnatomy, 5th ed. Philadelphia: LippincottWilliams&Wilkins.

GREETINGS from the -Men:

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SS - MSIH 16 - Imaging of the Back

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