ESSENTIALS OF PLAIN

FILM INTERPRETATION:

SPINE

DR ASIF SAIFUDDIN Consultant Musculoskeletal Radiologist

Royal National Orthopaedic Hospital Stanmore,UK.

RCR 2012: SPINAL

RADIOGRAPHY 2

INTRODUCTION

RCR 2012: SPINAL

RADIOGRAPHY 3

INTRODUCTION

RCR 2012: SPINAL

RADIOGRAPHY 4

INTRODUCTION

Spinal alignment

Vertebral morphology

Bone density

Vertebral end-plates/enthesis

Vertebral cortex

Disc space

Neural arch

Para-spinal soft tissues

RCR 2012: SPINAL

RADIOGRAPHY 5

SPINAL ALIGNMENT

NORMAL

Cervical lordosis

C1-T2 30-400

Thoracic kyphosis

T2-T12 20-400

Lumbar lordosis

L1-L5 20-400

RCR 2012: SPINAL

RADIOGRAPHY 6

SPINAL MALALIGNMENT

Sagittal plane

Spondylolisthesis

Retrolisthesis

Kyphosis

Coronal plane

Scoliosis

Axial

Translation

Rotation

RCR 2012: SPINAL

RADIOGRAPHY 7

SPONDYLOLISTHESIS

Anterior slip of one

vertebra on vertebra

below

Assess

Aetiology (lumbar)

Types 1-6

Degree

Grades 1-3 or 1-4

spondyloptosis Grade 1 L3/L4 Grade 2 L5/S1

Degenerative Lytic

RCR 2012: SPINAL

RADIOGRAPHY 8

RETROLISTHESIS

Posterior slip of one

vertebra on vertebra

below

Usually mild

Aetiology

Almost always

degenerative

Pathological

Traumatic

RCR 2012: SPINAL

RADIOGRAPHY 9

KYPHOSIS

Increased curvature of

thoracic spine

Generalised

Young- Scheuermann’s

Old- osteoporosis

Focal

Congenital

Acquired

Pathological collapse

Trauma

RCR 2012: SPINAL

RADIOGRAPHY 10

KYPHOSIS

Osteoporosis TB Post-traumatic

RCR 2012: SPINAL

RADIOGRAPHY 11

SCOLIOSIS

Lateral curvature of spine in

coronal plane

Cobb angle >100

Side described by convexity

Aetiology (paediatric)

Idiopathic

Osteogenic

Neuromuscular

Syndromic/developmental

Reactive

RCR 2012: SPINAL

RADIOGRAPHY 12

SCOLIOSIS

Osteogenic

Look for vertebral

anomalies

Failure of fusion

Failure of

segmentation

Complex

Hemivertebra Bony bar

RCR 2012: SPINAL

RADIOGRAPHY 13

SCOLIOSIS

Degenerative

Lumbar

Commonly

associated with

lateral vertebral

subluxation at

apex of curve

RCR 2012: SPINAL

RADIOGRAPHY 14

AXIAL MALALIGNMENT

LATERAL

TRANSLATION

Uncommon

Degenerative

spondylolisthesis

Traumatic

RCR 2012: SPINAL

RADIOGRAPHY 15

AXIAL MALALIGNMENT

ROTATION

Idiopathic scoliosis

Traumatic

Unilateral facet

dislocation

RCR 2012: SPINAL

RADIOGRAPHY 16

VERTEBRAL MORPHOLOGY

Vertebral collapse

Flattened vertebrae (platyspondyly)

Vertebra plana

Vertebral enlargement

Abnormalities of shape Bullet -Hurlers/Morquio’s/achondroplasia

Tower -SSD

Reduced AP dimension -JRA

RCR 2012: SPINAL

RADIOGRAPHY 17

VERTEBRAL COLLAPSE

OP collapse

Trauma

WC fracture

Burst fracture

Look at PVBL

Wedge fracture Burst fracture

RCR 2012: SPINAL

RADIOGRAPHY 18

VERTEBRAL COLLAPSE

Pathological

Tumour

Infection

Myeloma TB

RCR 2012: SPINAL

RADIOGRAPHY 19

VERTEBRA PLANA

Severe vertebral

body collapse

LCH

RCR 2012: SPINAL

RADIOGRAPHY 20

PLATYSPONDYLY

Multilevel

flattening of the

vertebral bodies

Many causes

Idiopathic

osteoporosis

RCR 2012: SPINAL

RADIOGRAPHY 21

VERTEBRAL ENLARGEMENT

Paget’s disease

Associated

Involvement of neural

arch

Medullary sclerosis

Trabecular thickening

RCR 2012: SPINAL

RADIOGRAPHY 22

BONE DENSITY

Reduced

Osteopenia

Increased

Sclerosis

Either can be focal or diffuse

RCR 2012: SPINAL

RADIOGRAPHY 23

FOCAL OSTEOPENIA

Any cause of focal

vertebral body

destruction

Tumour

Infection

ABC Early osteomyelitis

RCR 2012: SPINAL

RADIOGRAPHY 24

DIFFUSE OSTEOPENIA

Osteoporosis

Metabolic bone

diseases

Neoplastic

Myeloma

Acute leukaemia

Picture frame Vertical striations

RCR 2012: SPINAL

RADIOGRAPHY 25

FOCAL SCLEROSIS

Within vertebral body

Tumours Osteoma

Osteoblastic metastasis

Multiple

Osteopoikilosis

Osteoma Prostate metastasis

RCR 2012: SPINAL

RADIOGRAPHY 26

FOCAL SCLEROSIS

Sub-Chondral

Degenerative

DHVS

20 Hyperparathyroidism

Multilevel T + L regions

‘rugger-jersey’ spine

RCR 2012: SPINAL

RADIOGRAPHY 27

DIFFUSE SCLEROSIS

Ivory Vertebra

Paget’s disease

Reactive

OO/OB

Schmorl’s node

Neoplastic

Osteoblastic

metastasis

Lymphoma

OB Ca bronchus met

RCR 2012: SPINAL

RADIOGRAPHY 28

VERTEBRAL END-PLATES

Abnormal morphology

Focal defect

Irregularity

Scheuermann’s

Degenerative disc disease

Erosion

Bi-concave

OP compression fractures

RCR 2012: SPINAL

RADIOGRAPHY 29

FOCAL DEFECTS

Multilevel T/L spine

Normal variant

Degenerative

Schmorl’s nodes

Traumatic

WC or burst fracture

Neoplastic

plasmacytoma

‘Pincer-type’ burst#

RCR 2012: SPINAL

RADIOGRAPHY 30

FOCAL DEFECTS

Anterior limbus lesion

T/L junction

Physically active

adolescents

RCR 2012: SPINAL

RADIOGRAPHY 31

END-PLATE EROSION

Spondylodiscitis

Usually combined

with loss of disc

height

RCR 2012: SPINAL

RADIOGRAPHY 32

VERTEBRAL ENTHESIS

Insertion of Sharpey’s

fibres of disc annulus

into end-plate

Erosion

Ossification

Avulsion

RCR 2012: SPINAL

RADIOGRAPHY 33

VERTEBRAL ENTHESIS

Erosion

Manifestation of

spondyloarthropathy

‘Shiny corner’

Associated with

‘squaring’ of vertebral

body

Ankylosing spondylitis

RCR 2012: SPINAL

RADIOGRAPHY 34

VERTEBRAL ENTHESIS

Ossification of

annulus

Bamboo

Spine

RCR 2012: SPINAL

RADIOGRAPHY 35

VERTEBRAL ENTHESIS

Disc marginal

osteophytes

DDD

DISH

RCR 2012: SPINAL

RADIOGRAPHY 36

VERTEBRAL CORTEX

Displaced

PVBL

Differentiates WC

from burst fracture

Scalloped

Eroded

Wedge fracture Burst fracture

RCR 2012: SPINAL

RADIOGRAPHY 37

SCALLOPED CORTEX

Multilevel

NF

Marfan’s

Single level

Neural tumour

Nerve sheath cyst

RCR 2012: SPINAL

RADIOGRAPHY 38

ERODED CORTEX

Anterior

Pre-vertebral tumour

lymphoma

Pre-vertebral infection

TB

Sub-ligamentous

spread

RCR 2012: SPINAL

RADIOGRAPHY 39

DISC SPACE

Normal

Reduced height

Increased height

OP collapse

Calcified

Thoracic DDD

Vacuum

RCR 2012: SPINAL

RADIOGRAPHY 40

REDUCED DISC HEIGHT

Generalised

End-plate intact

DDD

End-plate eroded

discitis

Vacuum phenomenon

RCR 2012: SPINAL

RADIOGRAPHY 41

REDUCED DISC HEIGHT

Generalised

End-plate intact

LSTV

RCR 2012: SPINAL

RADIOGRAPHY 42

REDUCED DISC HEIGHT

Focal Anterior

Anterior limbus lesion

Do not mistake for

infection

NEURAL ARCH

Pedicle

Lamina

SAP

IAP

Transverse process

Pars interarticularis

Spinous process

Absent

Enlarged

Sclerotic

Interpediculate

distance

Interspinous distance

RCR 2012: SPINAL

RADIOGRAPHY 44

ABSENT PEDICLE

Congenital

Acquired

Tumour

infection

Metastasis TB

RCR 2012: SPINAL

RADIOGRAPHY 45

ENLARGED PEDICLE

Tumour

OB

RCR 2012: SPINAL

RADIOGRAPHY 46

ENLARGED PEDICLE

Trauma

Bony Chance

fracture

Increased height

of pedicle

RCR 2012: SPINAL

RADIOGRAPHY 47

SCLEROTIC PEDICLE

Reactive due to

underlying

Tumour

Pars stress

fracture

L3 OO

Lt L5 stress fracture

RCR 2012: SPINAL

RADIOGRAPHY 48

INTERPEDICULATE DISTANCE

Normal

Increases

distally

Reduced

Congential

canal stenosis

Short pedicles

on lateral

radiograph

RCR 2012: SPINAL

RADIOGRAPHY 49

INTERPEDICULATE DISTANCE

Increased

Burst fracture

RCR 2012: SPINAL

RADIOGRAPHY 50

INTERPSPINOUS DISTANCE

Increased

flexion-

distraction

injuries

RCR 2012: SPINAL

RADIOGRAPHY 51

PARASPINAL SOFT TISSUES

Swelling

Tumour

Infection

Trauma

Calcification

TB

spondyloarthropathy

Gas

Infection

Post-operative

RCR 2012: SPINAL

RADIOGRAPHY 52

CONCLUSIONS

There is potentially a lot in a spinal radiograph

Systematic approach to assessment will reduce

misses

Normal radiography excludes NOTHING!