ESSENTIALS OF PLAIN FILM INTERPRETATION: SPINE DR ASIF SAIFUDDIN

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1 ESSENTIALS OF PLAIN FILM INTERPRETATION: SPINE DR ASIF SAIFUDDIN Consultant Musculoskeletal Radiologist Royal National Orthopaedic Hospital Stanmore,UK.

2 INTRODUCTION 2

3 INTRODUCTION 3

4 INTRODUCTION Spinal alignment Vertebral morphology Bone density Vertebral end-plates/enthesis Vertebral cortex Disc space Neural arch Para-spinal soft tissues 4

5 SPINAL ALIGNMENT NORMAL Cervical lordosis C1-T Thoracic kyphosis T2-T Lumbar lordosis L1-L

6 SPINAL MALALIGNMENT Sagittal plane Spondylolisthesis Retrolisthesis Kyphosis Coronal plane Scoliosis Axial Translation Rotation 6

7 SPONDYLOLISTHESIS 7 Grade 1 L3/L4 Degenerative Grade 2 L5/S1 Lytic Anterior slip of one vertebra on vertebra below Assess Aetiology (lumbar) Types 1-6 Degree Grades 1-3 or 1-4 spondyloptosis

8 RETROLISTHESIS Posterior slip of one vertebra on vertebra below Usually mild Aetiology Almost always degenerative Pathological Traumatic 8

9 KYPHOSIS Increased curvature of thoracic spine Generalised Young- Scheuermann s Old- osteoporosis Focal Congenital Acquired Pathological collapse Trauma 9

10 KYPHOSIS Osteoporosis TB Post-traumatic 10

11 SCOLIOSIS Lateral curvature of spine in coronal plane Cobb angle >10 0 Side described by convexity Aetiology (paediatric) Idiopathic Osteogenic Neuromuscular Syndromic/developmental Reactive 11

12 SCOLIOSIS Osteogenic Look for vertebral anomalies Failure of fusion Failure of segmentation Complex Hemivertebra Bony bar 12

13 SCOLIOSIS Degenerative Lumbar Commonly associated with lateral vertebral subluxation at apex of curve 13

14 AXIAL MALALIGNMENT LATERAL TRANSLATION Uncommon Degenerative spondylolisthesis Traumatic 14

15 AXIAL MALALIGNMENT ROTATION Idiopathic scoliosis Traumatic Unilateral facet dislocation 15

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 16

17 VERTEBRAL COLLAPSE OP collapse Trauma WC fracture Burst fracture Look at PVBL Wedge fracture Burst fracture 17

18 VERTEBRAL COLLAPSE Pathological Tumour Infection Myeloma TB 18

19 VERTEBRA PLANA Severe vertebral body collapse LCH 19

20 PLATYSPONDYLY Multilevel flattening of the vertebral bodies Many causes 20 Idiopathic osteoporosis

21 VERTEBRAL ENLARGEMENT Paget s disease Associated Involvement of neural arch Medullary sclerosis Trabecular thickening 21

22 BONE DENSITY Reduced Osteopenia Increased Sclerosis Either can be focal or diffuse 22

23 FOCAL OSTEOPENIA Any cause of focal vertebral body destruction Tumour Infection ABC Early osteomyelitis 23

24 DIFFUSE OSTEOPENIA Osteoporosis Metabolic bone diseases Neoplastic Myeloma Acute leukaemia Picture frame Vertical striations 24

25 FOCAL SCLEROSIS Within vertebral body Tumours Osteoma Osteoblastic metastasis Multiple Osteopoikilosis Osteoma Prostate metastasis 25

26 FOCAL SCLEROSIS Sub-Chondral Degenerative DHVS 2 0 Hyperparathyroidism Multilevel T + L regions rugger-jersey spine 26

27 DIFFUSE SCLEROSIS Ivory Vertebra Paget s disease OB Ca bronchus met Reactive OO/OB Schmorl s node Neoplastic Osteoblastic metastasis Lymphoma 27

28 VERTEBRAL END-PLATES Abnormal morphology Focal defect Irregularity Scheuermann s Degenerative disc disease Erosion Bi-concave OP compression fractures 28

29 FOCAL DEFECTS Multilevel T/L spine Normal variant Degenerative Schmorl s nodes Traumatic WC or burst fracture Neoplastic plasmacytoma 29 Pincer-type burst#

30 FOCAL DEFECTS Anterior limbus lesion T/L junction Physically active adolescents 30

31 END-PLATE EROSION Spondylodiscitis Usually combined with loss of disc height 31

32 VERTEBRAL ENTHESIS Insertion of Sharpey s fibres of disc annulus into end-plate Erosion Ossification Avulsion 32

33 VERTEBRAL ENTHESIS Erosion Manifestation of spondyloarthropathy Shiny corner Associated with squaring of vertebral body Ankylosing spondylitis 33

34 VERTEBRAL ENTHESIS Bamboo Spine Ossification of annulus 34

35 VERTEBRAL ENTHESIS Disc marginal osteophytes DDD DISH 35

36 VERTEBRAL CORTEX Displaced PVBL Differentiates WC from burst fracture Scalloped Eroded Wedge fracture Burst fracture 36

37 SCALLOPED CORTEX Multilevel NF Marfan s Single level Neural tumour Nerve sheath cyst 37

38 ERODED CORTEX Anterior Pre-vertebral tumour lymphoma Pre-vertebral infection TB Sub-ligamentous spread 38

39 DISC SPACE Normal Reduced height Increased height OP collapse Calcified Thoracic DDD Vacuum 39

40 REDUCED DISC HEIGHT Generalised End-plate intact DDD End-plate eroded discitis Vacuum phenomenon 40

41 REDUCED DISC HEIGHT Generalised End-plate intact LSTV 41

42 REDUCED DISC HEIGHT Focal Anterior Anterior limbus lesion Do not mistake for infection 42

43 NEURAL ARCH Pedicle Lamina SAP IAP Transverse process Pars interarticularis Spinous process Absent Enlarged Sclerotic Interpediculate distance Interspinous distance

44 ABSENT PEDICLE Congenital Acquired Tumour infection Metastasis TB 44

45 ENLARGED PEDICLE Tumour OB 45

46 ENLARGED PEDICLE Trauma Bony Chance fracture Increased height of pedicle 46

47 SCLEROTIC PEDICLE Reactive due to underlying Tumour Pars stress fracture L3 OO 47 Lt L5 stress fracture

48 INTERPEDICULATE DISTANCE Normal Increases distally Reduced Congential canal stenosis Short pedicles on lateral radiograph 48

49 INTERPEDICULATE DISTANCE Increased Burst fracture 49

50 INTERPSPINOUS DISTANCE Increased flexiondistraction injuries 50

51 PARASPINAL SOFT TISSUES Swelling Tumour Infection Trauma Calcification TB spondyloarthropathy Gas Infection Post-operative 51

52 CONCLUSIONS There is potentially a lot in a spinal radiograph Systematic approach to assessment will reduce misses Normal radiography excludes NOTHING! 52

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