radiological assessment – part 1
TRANSCRIPT
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Image interpretation: spine
Dr David Lisle Brisbane Private Imaging
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Image interpretation
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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Image interpretation
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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Image interpretation
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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Development of CT
• 70’s • Each slice 60secs • 20-30 mins/ head scan
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• 70’s – 80’s • 5-10 secs/ slice • 5 mins/ head scan • Longer for body and spine: up to 20 mins
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1974 1988
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Spiral (helical) CT
• 90’s • Speed
– Patient acceptance – Different phases of contrast
enhancement
• Volumetric data set – Multiplanar and 3D
reconstructions
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Multidetector (multislice) CT
• Late 90’s to present • 0.175 - few seconds scan
time • Overlapping =
reconstructions • Contiguous = speed • Original: 4 slice • 2nd generation: 16, 64 • New: 256; 320
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Workstation reporting
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MRI: T1
– Fat bright • Bone marrow
– Bone cortex black – Anatomy
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MRI: T2
– Bone cortex black – Anatomy – Fluid bright – Fat bright
• Bone marrow – Oedema bright
• Difficult to differentiate
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MRI: STIR or T2FS
– Fat ‘saturated out’ • Bone marrow black
– Fluid bright – Differentiate oedema
from marrow
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T1 T2 STIR
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MRI: T1FS-Gd
– Fat ‘saturated out’ • Bone marrow and other
fat black – Non-fat T1 bright • Haemorrhage • Movement • Enhancement
Ø Pathology Ø Veins Ø Nerve root ganglia
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T1
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T1
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Image interpretation
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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NOMENCLATURE
• Consistent • Reflect common usage where appropriate • Surgically relevant • ‘Able to visualize over the phone’ • 2 morphological characteristics:
– Nature of disc pathology – Location
• Able to add further descriptors – Neural structures – Clinical context
• www.asnr.org/spine_nomenclature/reporting
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Disc bulge
• Generalised extension of disc tissue beyond intervertebral disc space
• ‘Generalised’ = >50% circumference (>1800) • Relatively short distance, <3mm
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Herniated disc • Localised displacement of disc material beyond
intervertebral disc space (ie bony margins excluding osteophytes) OR break in vertebral end plate (Schmorl’s node)
• ‘Localised’ = <50% circumference (<1800) – ‘Broad based’ = 25 - 50% circumference (>900) – ‘Focal’ = <25% circumference (<900)
• ‘HNP’ not accurate – Herniation may include NP, cartilage, annulus, bone
• ‘Rupture’ tends to refer to trauma/ acute event • ‘Prolapse’ and ‘bulging disc’ outdated • ‘Localised disc bulge’ = oxymoron
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Extruded disc
• Greatest distance in any plane between edges > base
T1
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Sequestered disc
• Extruded disc material that has no continuity with the disc of origin
• = free fragment • Migrated disc:
– Disc material displaced away from site of extrusion
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T2 T2
T1
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Location of herniation
• Anatomic system that correlates with surgery • Landmarks, transverse plane:
– Sagittal and coronal planes at centre of disc – Medial edge of articular facet – Medial, lateral borders of pedicles
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Location of herniation • Locations, transverse plane:
– ‘Central’ = midline – ‘Right central’ & ‘left central’ =
paracentral/ posterolateral – ‘Subarticular’ = lateral recess – ‘Foraminal’ – ‘Extraforaminal’ = far lateral
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Location of herniation • Locations, transverse plane:
– ‘Central’ = midline – ‘Right central’ & ‘left central’ =
paracentral/ posterolateral – ‘Subarticular’ = lateral recess – ‘Foraminal’ – ‘Extraforaminal’ = far lateral
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Location of herniation • Locations, transverse plane:
– ‘Central’ = midline – ‘Right central’ & ‘left central’ =
paracentral/ posterolateral – ‘Subarticular’ = lateral recess – ‘Foraminal’ – ‘Extraforaminal’ = far lateral
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Location of herniation • Locations, transverse plane:
– ‘Central’ = midline – ‘Right central’ & ‘left central’ =
paracentral/ posterolateral – ‘Subarticular’ = lateral recess – ‘Foraminal’ – ‘Extraforaminal’ = far lateral
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Location of herniation • Locations, transverse plane:
– ‘Central’ = midline – ‘Right central’ & ‘left central’ =
paracentral/ posterolateral – ‘Subarticular’ = lateral recess – ‘Foraminal’ – ‘Extraforaminal’ = far lateral
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Volume: degree of canal compromise
• X-sectional area at site of maximal narrowing • ‘Mild’: <1/3 • ‘Moderate’: 1/3 – 2/3 • ‘Severe’: > 2/3 • Same grading for foraminal narrowing as seen in
sagittal plane • Other descriptors such as compression of
specific neural structures
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Mild Moderate Severe
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Image interpretation
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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• 85 year old female • Severe acute on chronic mechanical back pain
– Can’t sleep – Limited walking to only a few steps
• Spontaneous onset • No known trauma
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What is the most likely diagnosis?
1. Acute disc herniation 2. Facet joint degeneration 3. Crush fracture secondary to osteoporosis 4. Metastatic cancer
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What is the most appropriate imaging modality?
1. Plain film 2. CT 3. Scintigraphy (bone scan) 4. MRI
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24/3/2012
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24/3/2012 16/12/2011
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MRI: pre-vertebroplasty
STIR
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2
3
2
3
T1 STIR
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• 68M • Sudden onset bilateral leg pain and weakness • Urinary retention
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What is the most likely diagnosis?
1. Guillain Barre syndrome 2. Cauda equina syndrome 3. Crush fracture secondary to osteoporosis 4. Discitis/ osteomyelitis
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What is the most appropriate imaging modality?
1. Plain film 2. CT 3. Scintigraphy (bone scan) 4. MRI
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• Dx: Cauda equina syndrome • Cause: massive sequestration • Other causes:
– Tumour • Primary of lower cord: ependymoma • Primary of nerve: BPNST • Primary of dura: meningioma • Primary of vertebral body: chordoma, giant cell
tumour • Secondary
– Trauma