Vertebral Fracture Classification Vertebral Fracture Classification By By

Advanced ImagingAdvanced Imaging

Jalal Jalal Shokouhi-M.D.Jalal Jalal Shokouhi-M.D.General secretary of ISR General secretary of ISR

(Iranian society of radiology)(Iranian society of radiology)Jalaljalalshokouhi@hotmail.comJalaljalalshokouhi@hotmail.com

MRI might change vertebral body MRI might change vertebral body fracture classificationfracture classification

Special thanks to:Special thanks to:

Rahimi Zadeh –MDRahimi Zadeh –MD

Khadivi –MDKhadivi –MD

Ali Akbar Ameri –MDAli Akbar Ameri –MD

Gholamreza Bakhshande pour –MDGholamreza Bakhshande pour –MD

Hamid Mohammad pour –MDHamid Mohammad pour –MD

A:A: Compression fractures: Compression fractures:

A1A1: : Impaction:Impaction: A1.1=Endplate infractionA1.1=Endplate infraction

A1.2=Wedge fracture A1.2=Wedge fracture

A1.3=Body compressionA1.3=Body compression

A2: SplitA2: Split

A3: BurstA3: Burst

B:B: Flexion/ Extension injuryFlexion/ Extension injury

C:C: Rotation injury Rotation injury

T-Score/Z-Score/BMD/WHOT-Score/Z-Score/BMD/WHO

* Intact posterior column* Intact posterior column

Flow diagram for determining the type level of Flow diagram for determining the type level of the AO classificationthe AO classification

RN ScanRN Scan

FRACTURE EVALUATIONFRACTURE EVALUATION

X-RaysX-Rays

CT ScanCT Scan

MRIMRI

MiscellaneousMiscellaneous

X-RayX-Ray

• Advantages of x-rays:Advantages of x-rays:

--Inexpensive --Inexpensive

--Easy to obtain--Easy to obtain

--Past A-P or lateral images can be --Past A-P or lateral images can be

compared to present images.compared to present images.

--Gross bony morphology changes can--Gross bony morphology changes can

be detected quickly. be detected quickly.

X-RAYX-RAY

• Disadvantages of x-rays:Disadvantages of x-rays:

--Fracture must be collapsed to identify--Fracture must be collapsed to identify

VCF.VCF.

--Age of fracture indeterminate.--Age of fracture indeterminate.

--Osteopenia, scoliosis, and obesity will --Osteopenia, scoliosis, and obesity will

limit bony resolution.limit bony resolution.

--Difficult to detect middle column and--Difficult to detect middle column and

posterior column fractures.posterior column fractures.

CT SCAN CT SCAN

• CT ScanCT Scan--also known as CAT/TAC scan. --also known as CAT/TAC scan. Computed Axial Tomography. Uses a beam Computed Axial Tomography. Uses a beam of radiation which moves in an arc to create of radiation which moves in an arc to create an image.an image.

• Spiral CT ScanSpiral CT Scan--allows for quicker --allows for quicker assessment (20-30 sec.) of anatomic regions. assessment (20-30 sec.) of anatomic regions. Can obtain 3D images.Can obtain 3D images.

• Bone ScanBone Scan--Identifies metabolic bone activity.--Identifies metabolic bone activity.

CT/CAT SCANCT/CAT SCAN

• Advantages:Advantages:

----Used with Burst fractures to assess Used with Burst fractures to assess

bone fragments in the canal.bone fragments in the canal.

-- AP view allows you to see the fracture plane-- AP view allows you to see the fracture plane

-- Easy to obtain, almost always taken for -- Easy to obtain, almost always taken for traumatrauma

• Disadvantage:Disadvantage:

--Insensitive to edema--Insensitive to edema

--Age of fracture indeterminate--Age of fracture indeterminate

CT In traumaCT In trauma

CT In trauma same pt.CT In trauma same pt.

CT In trauma same pt.CT In trauma same pt.

CT In trauma same pt.CT In trauma same pt.

CT In trauma same pt.CT In trauma same pt.

Is this a case for Kyphoplasty?

Is this a case for Kyphoplasty?

What questions would you ask the doctor?

What questions would you ask the doctor?

MRIMRI

• AdvantagesAdvantages– High resolution, sensitivity and specificityHigh resolution, sensitivity and specificity– Can be useful for identifying micro-Can be useful for identifying micro-

fractures.fractures.– Better for assessing tissue damage, Better for assessing tissue damage,

tumors and infectiontumors and infection

MRIMRI

• Disadvantages:Disadvantages:

--Very costly--Very costly

--Time consuming--Time consuming

--Patient claustrophobia--Patient claustrophobia

--Difficult to differentiate posterior--Difficult to differentiate posterior

element fractureselement fractures

MRIMRI

• T1 - oedema is dark T1 - oedema is dark • T2 - oedema is bright but not always T2 - oedema is bright but not always

visible (can be obscured by fat.)visible (can be obscured by fat.)• STIR – Short Tau eliminates all fat to only STIR – Short Tau eliminates all fat to only

show fluidsshow fluids

• STIR is always the best image to use for STIR is always the best image to use for determining if the fracture is freshdetermining if the fracture is fresh

MRIMRI

T1 STIR

S.T.I.R. = Short Tau Inversion Recovery

T2

What is at T7?What is at T7?

MRI AND X-RAY

Candidate for Kyphoplasty????Candidate for Kyphoplasty????

Lateral FX.Lateral FX.

Enostosis or bone island or bone stoneEnostosis or bone island or bone stoneWhat is your diagnosis?What is your diagnosis?What is your diagnosis?What is your diagnosis?

No need kyphoplastyNo need kyphoplastyNo need kyphoplastyNo need kyphoplasty

500 Traumatic Patients 500 Traumatic Patients

147 Fractures147 Fractures

2 Cases of Spinal puncture or Dural tear 2 Cases of Spinal puncture or Dural tear

Common fractures are anterior wedging Common fractures are anterior wedging and upper end plate depressionand upper end plate depression

Fractures: Single ,2-3 ,5 Fractures: Single ,2-3 ,5

Gold standard: MRI WITH STIRGold standard: MRI WITH STIR

CT is better for V.Body processesCT is better for V.Body processes

Thank YouThank You