Lumbar Disc Classification
Lumbar Disc Classification
Steven J. Gould, D.C., D.A.C.B.R.
Central Plains Radiologic Services, P.A.
P.O. Box 190 / 126 N. Main Cheney, KS. 67025 316-542-3400
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Bulging?
Herniated? Protrusion? Extruded? Sequestered?
How would you describe these disc configurations?
Ruptured? Prolapsed?
Free fragment?
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Controversies;
Lack of pathologic or morphologic definitions limits comparison of research study results.
Use of terms like "ruptured" disc may be alarming to patients where surgical intervention may not be the best option.
Legal settlements have been based on defined morphology of disc derangements.
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Classification of Lumbar Disc Pathology
Dicussion: Importance of using reliable terms for defining normal and pathologic changes of lumbar discs. Terms that can be interpreted accurately, consistently, and with precision for communicating impressions from imaging for clinical diagnostic and therapeutic decision making.
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Principles guiding standardization
Definitions should be based upon anatomy and pathology.
Definitions of diagnoses... ...should not be dependent upon or imply value of specific tests. ... should not define or imply external etiologic events such as trauma. ... should not imply relationship to symptoms. ...should not define or imply need for specific treatment.
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Nomenclature and Classification of Lumbar Disc Pathology Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology David F. Fardon, MD, Chairperson, Clinical Task Force Pierre C. Milette, MD, Chairperson, Imaging Task Force
Clinical Task Force Members Tom Faciszewski, MD David F. Fardon, MD Steven R. Garfin, MD Scott Haldeman, MD, PhD Neil Kahanovitz, MD Volker K.H. Sonntag, MD
Imaging Task Force Members Brigitte Appel, MD Jean-Fran?ois Bonneville, MD Marco Leonardi, MD Pierre C. Milette, MD Jeffrey S. Ross, MD Alan L. Williams, MD Jan T. Wilmink, MD, PhD
FEBRUARY 2003 UPDATE
Since its initial publication, in March 2001, the terminology proposed in this work has been endorsed by other societies. It is now officially supported, recommended or web-linked by the following American and European professional organizations and scientific societies:
American Academy of Orthopaedic Surgeons (AAOS) American Academy of Physical Medicine and Rehabilitation (AAPM&R)
American College of Radiology (ACR) American Society of Neuroradiology (ASNR) American Society of Spine Radiology (ASSR) Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons (AANS) and Congress of
Neurological Surgeons (CNS) European Society of Neuroradiology (ESNR)
North American Spine Society (NASS) Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR)
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Lumbar disc nomenclature: version 2.0
David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD, F. Reed Murtagh, MD, Stephen L. Gabriel Rothman, MD, Gordon K. Sze, MD
The Spine Journal Volume 14, Issue 11, Pages 2525-2545 (November 2014)
DOI: 10.1016/j.spinee.2014.04.022
Copyright ? 2014 The North American Spine Society, The American Society of Spine Radiology and The American Society of Neuroradiology Terms and Conditions
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Fig. 1
The Spine Journal 2014 14, 2525-2545DOI: (10.1016/j.spinee.2014.04.022) Copyright ? 2014 The North American Spine Society, The American Society of Spine Radiology and The American Society of Neuroradiology Terms and Conditions
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Axial T2
Sagittal T2
Anatomy Review
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Annulus Fibrosus: Multilaminated ligament surrounding the periphery of each disc space, attaching craniad and caudad to the end-plate cartilage and ring apophyseal bone and blending centrally with the nucleus pulposus.
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Definitions; The Intervertebral disc
Nucleus Pulposus: Collagen and hydrophilic proteoglycans. Demarcation of the nucleus and annular fibers becomes more indistinct with age.
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Peridural Membrane: A delicate, translucent membrane that attaches to the undersuface of the deep layer of the PLL, and extends laterally and posteriorly, encircling the bony spinal canal outside the dura. The veins of Batson's plexus lie on the dorsal surface of the peridural membrane and pierce it ventrally. AKA lateral membrane, epidural membrane.
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Definitions related to disc configuration Bulge Herniation Protrusion Extrusion Sequestration Annular tear/ fissure High Intensity Zone (HIZ) 16
For classification purposes, the intervertebral disc is considered as a two dimensional round or oval structure having four 90 quadrants. By convention, a herniation is a "localized" process involving less than 50% (180) of the disc circumference
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Normal L3/L4 disc
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Definitions related to disc configuration
Bulge
Disc bulge; 1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal plane, beyond the edges of the disc space. Involves more than 50% of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophyses.
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Symmetrical presence (or apparent presence) of disc tissue "circumferentially" (50-100%) beyond the edges of the ring apophyses may be described as a "bulging disc" or "bulging appearance", and is not considered a form of herniation. Furthermore, "bulging" is a descriptive term for the shape of the disc contour and not a diagnostic category.
Fig. 3
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The Spine Journal 2014 14, 2525-2545DOI: (10.1016/j.spinee.2014.04.022) Copyright ? 2014 The North American Spine Society, The American Society of Spine Radiology and The American Society of Neuroradiology Terms and Conditions
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L2/L3 disc -- symmetrical bulge
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Asymmetrical bulging of the disc margin (50%-100%), such as is found in severe scoliosis, is also not considered a form of herniation.
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Asymmetric Bulge
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