Story of Lumbar Spine: page 1 of 13 2) When Things Fall Apart
Story of Lumbar Spine: page 1 of 13 2) When Things Fall Apart
Story of the Lumbar Spine:2
Goal
DDD
Radiograph Understand
MRI
appropriate
HNP
use of
Stenosis imaging in the
Rx
management
Post-Op of Low Back
Fx Patterns Comp/Burst
Pain
Chance/Dis
AS/DISH
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
When Things Break Down
Objectives
1)Imaging Chronic Low Back Pain
DDD Radiographs MRI: Gold Standard
2)Imaging Acute Low Back Pain
Fractures Patterns CT: Gold Standard
1 of 75
Story of the Lumbar Spine:2
When Things Break Down
How I Look at L-Spine Radiographs
DDD
AP & Lateral side-
Radiograph MRI HNP
1.
by-side
Label the
on PACS
vertebrae!
Stenosis 2. Vertebral body height
Rx
3. Alignment
Post-Op 4. Disc Spaces
Fx Patterns Wider @ Lower Levels
Comp/Burst L5-S1 variable
Chance/Dis AS/DISH
Rigidity Fxs
L4-L5 widest DDD starts L4-L5
? 2014 Ken L Schreibman, PhD/MD
AP
T12 L1 L2 L3 L4 L5 S1
J,D 20yoM
Lateral
T12 L1 L2 L3 L4 L5
S1
2 of 75
Story of the Lumbar Spine:2
When Things Break Down
DDD: My Grading System
DDD
If I have to
Lateral$ PATC12S
AP
Radiograph MRI HNP
convince the resident the disc is narrow
=MILDLY
Measurements
L1
L2-3 > L1-2 L2
T12 L1 L2
Stenosis
NARROWED
Rx
If we agree it's L3-4 < L2-3L3
L3
Post-Op narrow
M?ild
Fx Patterns Comp/Burst Chance/Dis
=MODERATELY NARROWED
Vacuum phenomenon
AS/DISH
=SEVERLY
Rigidity Fxs NARROWED
L4-5 < L3-4L4
L5
L5-S1 >>
S1
L4
L5
S1
Can't assess disc width on AP
? 2014 Ken L Schreibman, PhD/MD
W,L 48yoF
3 of 75
Story of the Lumbar Spine:2
When Things Break Down
DDD: Common & Progressive
DDD
AP
Radiograph
MRI HNP
Hypoplastic Ribs T12
Stenosis
L1
Rx
L2
Post-Op
Fx Patterns
L3
Comp/Burst
L4
Chance/Dis
AS/DISH
L5
Rigidity Fxs
S1
F,D 34yoF
? 2014 Ken L Schreibman, PhD/MD
Lateral T12 L1 L2 L3 L4 L5 S1
3 years later...
L1 L2 L3 L4
L5 S1
4 of 75
Story of the Lumbar Spine:2
When Things Break Down
"Vacuum Phenomenon"
DDD
Cannot be a vacuum in your body
Radiograph MRI
"horror
vacui"
Aristotle (384?322 BCE)? Parmenides (540 BCE)?
HNP Nature Abhors a Vacuum
Stenosis Nature requires every space to be
Rx
filled with something
Post-Op Fx Patterns
Comp/Burst Chance/Dis AS/DISH
What's in these black lines?
91% Nitrogen!
1977: Gilula et.al. aspirated one! Room Air: 78% Nitrogen, 21% O2
Rigidity Fxs Lack of disk material fills with N
Wikipedia AJR, 1977, 128: 1056-1057
? 2014 Ken L Schreibman, PhD/MD
L1 L2
L3 L4 L5
S1
N,B 79yoM 5 of 75
Story of the Lumbar Spine:2
When Things Break Down
DDD: Osteophytes
DDD
Just as osteophytes are a
Radiograph key feature of DJD,
MRI
osteophytes are a
HNP
key feature of DDD.
Stenosis Usually Unimportant
Rx
Clinically unimportant
Post-Op Anterior osteophytes
Fx Patterns don't impinge anything
Comp/Burst Imaging unimportant
Chance/Dis Don't correlate with
AS/DISH
degree of narrowing
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
T12
L1
L2
L3
L4
L5
S1
Osteophytes
D,R 66yoM
T12
L1
L2
L3
L4 L5
S1
F,D 34yoF
6 of 75
?Ken L Schreibman, PhD/MD 9/1/14
Story of Lumbar Spine: page 2 of 13 2) When Things Fall Apart
Story of the Lumbar Spine:2
When Things Break Down
How I Look at L-Spine Radiographs
DDD
AP & Lateral side-
Radiograph MRI HNP
1.
by-side on PACS
Label the vertebrae!
Stenosis 2. Vertebral body height
Rx
3. Alignment
Post-Op 4. Disc space narrowing
Fx Patterns Comp/Burst Chance/Dis
AS/DISH
Like joint space narrowing
------------------------------Compare with MRI
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
AP
T12 L1 L2 L3 L4 L5 S1
J,D 20yoM
Lateral
T12 L1 L2 L3 L4 L5
S1
7 of 75
Story of the Lumbar Spine:2
When Things Break Down
Spine Imaging: Radiographs vs MRI
DDD
Vertebrae Radiographs MRI
Radiograph MRI HNP
Numbering Alignment
(no ribs)
Standing, Big picture (small picture)
Stenosis Rx
Fractures N.F.
Wedging, Kyphosis
Occult!
Post-Op Canal
? MRI is
Fx Patterns Comp/Burst Chance/Dis
Non-Bones
Spinal Cord
?
AS/DISH Nerves ?
the Gold Standard
Rigidity Fxs Discs
?
? 2014 Ken L Schreibman, PhD/MD
8 of 75
Story of the Lumbar Spine:2
When Things Break Down
MRI: Imaging Planes
DDD
Coronal Plane (scout)
Radiograph
S
MRI
P
HNP
I
Stenosis
N
Rx Post-Op
E
Kidneys
Fx Patterns
Comp/Burst
Chance/Dis
AS/DISH
Rigidity Fxs Like AP view
K,H 15yoF
? 2014 Ken L Schreibman, PhD/MD
Sagittal Plane Axial Plane (to Discs) (Big Picture)
Kidneys
Like Lat view
Canal
NF{
}NF
Nerves
9 of 75
Story of the Lumbar Spine:2
When Things Break Down
MRI: T2-weighted Images
DDD
Fluid is Bright Sagittal
FxRMHSRPCtoPoNxaResmdaPnItit-ooptOegs/BriprnsausprshtCCHeBySredaSS(FbBtrrhppaareiilanntsSeiaan/pdsll)inuCNaDroelroFirrsdvulucenidssds
Disc CSFDisc
Chance/Dis
AS/DISH
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
Axial CSF
10 of 75
Story of the Lumbar Spine:2
When Things Break Down
Intervertebral Disc: 2 Components
DDD
1. Outside
Radiograph MRI HNP Stenosis Rx
Annulus Fibrosus
Fibrous collagen ring
2. Inside
Nucleus Pulposus
Post-Op Jelly-like substance
Fx Patterns Comp/Burst Chance/Dis
AS/DISH Rigidity Fxs
Sandwiched between vertebral body endplates
Allows for flexible motion between vertebral bodies
Wikipedia ?vi2s0u1a4llKyemneLdSiccharle.cibomman, PhD/MD
Disc
11 of 75
Story of the Lumbar Spine:2
When Things Break Down
Intervertebral Disc: Jelly Donut Model
DDD
Sagittal
Radiograph T2+FS
MRI
HNP
Stenosis
Rx
Post-Op Fx Patterns
Comp/Burst
Disc Disc
Chance/Dis
AS/DISH
Rigidity Fxs
K,H 15yoF
? 2014 Ken L Schreibman, PhD/MD
Fresh Donut:
Jelly is moist
Bounces back when squished
Just like hydrated disc
Disc
12 of 75
?Ken L Schreibman, PhD/MD 9/1/14
Story of Lumbar Spine: page 3 of 13 2) When Things Fall Apart
Story of the Lumbar Spine:2
When Things Break Down
Intervertebral Disc: Jelly Donut Model
SDaDgiDttal
Sagittal
T2+RFaSdiograph
T2+FS T12
MRI
HNT1P2
L1
Stenosis RLx1
L2
PL2ost-Op
L3
Fx PaDtetseicrncasted L4 LC3 omp/Burst
CL4hance/Dis L5
AS/DISH
S1
RigiLd5itySF1 xs
wwwS., E,D 56yoF
? 2014 Ken L Schreibman, PhD/MD
Old Donut:
Jelly dries out
Desiccated
Becomes less squishy
DDD:
1st: Disc Desiccation
2nd: Disc Narrowing
13 of 75
Story of the Lumbar Spine:2
When Things Break Down
Progression of DDD
DDD
Sagittal
Radiograph T2+FS
MRI
L1
HNP
Stenosis
L2
Rx
L3
Post-Op
Fx Patterns L4
Comp/Burst
Chance/Dis L5
AS/DISH
S1
Rigidity Fxs
V,E 38yoF
? 2014 Ken L Schreibman, PhD/MD
L5 S1
1.Disc desiccation 2.Disc narrowing 3.Small tear in
annular fibrosis
"Annular tear" "High Intensity
Zone (HIZ)" Usually posterior Like jelly just starting to squeeze out of donut
14 of 75
Story of the Lumbar Spine:2
When Things Break Down
Progression of DDD
DDD
Sagittal
L2
Radiograph T2+FSL1
MRI
HNP
L2
L3
Stenosis
Desiccated & Narrow
Rx
L3
Post-Op
L4
Fx Patterns DesiccLa4ted
Comp/Burst & Narrower Chance/Dis L5
L5
AS/DISH
S1
Rigidity Fxs
S1
H,K 29yoF
? 2014 Ken L Schreibman, PhD/MD
1.Disc desiccation
2.Disc narrowing
3.Annular tear
4.HNP
Herniated Nucleus Pulposus
Large Disc Jelly leaks out
Extrusion
Small Disc Protrusion
15 of 75
Story of the Lumbar Spine:2
When Things Break Down
HNP Terminology: Bulge
DDD
Broad-Based Disc Bulge (BBB)
Radiograph MRI
Extends
from
one
NF
to
the
other
HNP
Axial T2
(same)
Stenosis Rx Post-Op
Body Exiting
NF
Nerves
NF
Disc
Potentially contacting/ impinging
Exiting
Fx Patterns Comp/Burst
Lamina
Lamina
Nerves in NF
Chance/Dis AS/DISH
Rigidity Fxs
Spinous Process
Traversing Nerves in Canal
? 2014 Ken L Schreibman, PhD/MD
16 of 75
Story of the Lumbar Spine:2
When Things Break Down
HNP Terminology: Protrusion
DDD
More focal than a Broad-Base Bulge
Radiograph MRI HNP Stenosis Rx Post-Op Fx Patterns
Wider RL
Axial T2
Disc
than
AP
(same)
1 disc can
L4-L5
Disc
cause Exiting symptoms
L4 at >1 level
Lateral Recess
Traversing L5
Comp/Burst Chance/Dis
Central Disc Protrusion Not touching any nerves
Lateral Recess Protrusion Can touch exiting nerve in NF
AS/DISH CSF around nerves in canal Can touch traversing nerve canal
Rigidity Fxs Fat around nerves in NF
? 2014 Ken L Schreibman, PhD/MD
17 of 75
Story of the Lumbar Spine:2
When Things Break Down
HNP Terminology: Extrusion
DDD
Tend to be larger than protrusions
Radiograph MRI HNP
Wider AP Mushroom
than RL shaped
Sagittal
L3
T2
Stenosis Axial T2
Extrusions can hang down behind
Rx
L4
vertebral
Post-Op
bodies
Fx Patterns Comp/Burst
L5
If this HNP were to
become detached,
Chance/Dis AS/DISH
S1
it would be a "Sequestered"
disc
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
M,K 27yoF
18 of 75
?Ken L Schreibman, PhD/MD 9/1/14
Story of Lumbar Spine: page 4 of 13 2) When Things Fall Apart
Story of the Lumbar Spine:2
When Things Break Down
HNP Stenosis
DDD
[Gr] "Narrowing in a tubular structure"
Radiograph MRI
Stenosis
can
effect
canal
and/or
NF
HNP Pinched nerves radiculopathy
Stenosis Rx
"Dysfunction of one or more spinal nerve"
Post-Op Subjective Stenosis Grading (Axial T2):
Fx Patterns If CSF surrounds nerves: Not Stenotic
Comp/Burst No surrounding CSF: Mild Stenosis
Chance/Dis AS/DISH
Rigidity Fxs
Nerves/cord flattened: Moderate Stenosis Can't get any worse: Severe Stenosis
? 2014 Ken L Schreibman, PhD/MD
19 of 75
Story of the Lumbar Spine:2
When Things Break Down
HNP Stenosis Canal best seen: Axial T2
DDD
Sagittal T2+FS
Radiograph
MRI
HNP
L3
Normal Concavity
Large Left-Sided Disc Extrusion
Stenosis
Canal Widely Patent Causing Severe
Rx
Post-Op
L4
Fx Patterns
Comp/Burst L5 Chance/Dis
L2-L3
Ext Slight Convexity
Canal Stenosis
L4-L5
Small Central Disc Protrusion...
AS/DISH Rigidity Fxs
S1 Pro
H,K 29yoF
? 2014 Ken L Schreibman, PhD/MD
Canal Widely Patent
L3-L4
...Not Causing Canal Stenosis
L5-S1
20 of 75
Story of the Lumbar Spine:2
When Things Break Down
Spinal Stenosis: Causes
DDD
HNP
Radiograph MRI HNP
Osteophytes
Not so much from
vertebral
bodies Anterior
Stenosis From Facets Neural Foramen
Rx
Posterior element hypertrophy
Post-Op Facets, Lamina, Ligamentum Flavum
Fx Patterns Comp/Burst Chance/Dis
Congenitally short pedicles
"Congenital Spinal Stenosis"
AS/DISH Rigidity
Fxs
Even small
Epidural
HNPs in patients with short
Lipomatosis
pedicles
can
cause
stenosis
? 2014 Ken L Schreibman, PhD/MD
21 of 75
Story of the Lumbar Spine:2
When Things Break Down
Redundant Nerves = Severe Stenosis
DDD
Sagittal T1 Sagittal T2+FS
Radiograph
T12
MRI
HNP
L1
Stenosis
L2
Rx
Post-Op
L3
Fx Patterns Comp/Burst L4
HNP PEH
Chance/Dis L5
AS/DISH Rigidity Fxs
S1
Q,R 65yoM
? 2014 Ken L Schreibman, PhD/MD
Caused by combination of To me looks like small HNP + marked PEH spaghetti
(Posterior Element Hypertrophy)
22 of 75
Story of the Lumbar Spine:2
When Things Break Down
Congenital Spinal Stenosis = Short Pedicles
DDD
Sagittal T1
Radiograph T12
MRI
L1
HNP
Stenosis
L2
Rx Post-Op
L3
Fx Patterns L4
Sagittal T2+FS
T12
Redundant Nerves
= Severe Stenosis
L1
L2 Very
L2
L3
Tight L3 CSF
L4 space L4
Sagittal T2+FS
T12
L1
L2
L3
Lamin-
ectomy
L4
Comp/Burst L5
L5
Chance/Dis AS/DISH
S1
L5 S1
L5 S1
Rigidity Fxs
A,T 51yoM
? 2014 Ken L Schreibman, PhD/MD
Intra-Op
Post-Op
23 of 75
Story of the Lumbar Spine:2
When Things Break Down
Epidural Lipomatosis
DDD Radiograph
*EpTiodourMaluFchat
MRI
HNP
L1
Stenosis Rx Post-Op Fx Patterns Comp/Burst
L2
L3
* *
* L4 L5
Chance/Dis
S1
AS/DISH Sagittal T1
Rigidity Fxs Fat is Bright
S,B 64yoF
? 2014 Ken L Schreibman, PhD/MD
Axial T2 Canal widely patent
* Very Tight
CSF surrounds Spinal cord/nerves
CSF Axial T2
** space *Too Much Epidural Fat
Sagittal T2+FS Fluid is Bright
* * * Compresses thecal sac
* to star shape 24 of 75
?Ken L Schreibman, PhD/MD 9/1/14
Story of Lumbar Spine: page 5 of 13 2) When Things Fall Apart
Story of the Lumbar Spine:2
When Things Break Down
DDD: Treatment Options
DDD
Conservative treatment
Radiograph MRI HNP Stenosis Rx
Good first option
Much LBP resolves within 6 weeks ACR Guidelines: Image LBP after
Pain Medication as needed
6
weeks
Post-Op Physical Therapy always good idea
Fx Patterns HNPs can resolve spontaneously!
Comp/Burst It helps if you're young...
Chance/Dis
AS/DISH
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
25 of 75
Story of the Lumbar Spine:2
When Things Break Down
HNP can resolve with time & PT
DDD
Sagittal T2
Axial T2
Sagittal T2+FS
Radiograph MRI
L1
HNP
L2
Stenosis
Rx
L3
Post-Op Fx Patterns
L4
L1 L2
L3
Axial T2
L4
Comp/Burst L5
L5
Chance/Dis
AS/DISH
S1
S1
Rigidity Fxs
D,D 32yoM
? 2014 Ken L Schreibman, PhD/MD
15 months later 26 of 75
Story of the Lumbar Spine:2
When Things Break Down
DDD: Treatment Options
DDD
Image Guided Pain Injections
Radiograph MRI HNP Stenosis Rx
Performed in MSK Fluoroscopy suite @ Requires no sedations, IV's, ...
Patients don't even get undressed
We do use local anesthetic, generously
CSC
Post-Op
We are the painless pain service!
Fx Patterns Administer steroids (Triamcinolone) + Lidocaine
Comp/Burst Patients NEED to bring a driver
Chance/Dis Occasionally patient's leg is numb for a few hours
AS/DISH Patients NEED to stop Coumadin for 3 days
Rigidity Fxs radiology.wisc.edu/sections/msk/forReferring.php
? 2014 Ken L Schreibman, PhD/MD
27 of 75
Story of the Lumbar Spine:2
When Things Break Down
DDD: Treatment Options
DDD
Image Guided Pain Injections
Radiograph MRI HNP
Epidural Steroid Injections (This is what most PCPs should
order)
Stenosis Midline: For multi-level, bilateral, radiculopathy
Rx Post-Op
Transforaminal: Single level/sided radiculopathy
Nerve Root Block
Fx Patterns (This is what some Surgeons order)
Comp/Burst Targeted injection to one specific nerve
Chance/Dis AS/DISH
Ordered mostly for
Facet Injection
surgical
planning
Rigidity Fxs For facet pain (Infrequently ordered)
? 2014 Ken L Schreibman, PhD/MD
28 of 75
Story of the Lumbar Spine:2
When Things Break Down
Parts of Vertebra: Neural Foramen
DDD
Side View
Top (Axial) View
Radiograph MRI HNP Stenosis Rx Post-Op Fx Patterns Comp/Burst Chance/Dis
Neural Foramen:
Keyhole-shaped opening Under pedicle Front of facet
Lumbar Nerves:
Travel thru canal Exit at NF
under pedicles
Behind Disc NF
Disc
Posterior
Canal
Epidural Fat
Posterior
Epidural
Fat
AS/DISH
Rigidity Fxs
? 2014 Ken L Schreibman, PhD/MD
29 of 75
Story of the Lumbar Spine:2
When Things Break Down
Midline Epidural Steroid Injection
DDD
Side View
Radiograph
MRI
HNP
Stenosis Rx Post-Op
NF Disc
Fx Patterns
Comp/Burst
Chance/Dis Good for treating several levels,
AS/DISH as steroids tend to flow bilaterally,
Rigidity Fxs up/down several levels
? 2014 Ken L Schreibman, PhD/MD
Top (Axial) View
Canal 30 of 75
?Ken L Schreibman, PhD/MD 9/1/14
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- diagnosis and treatment of lumbar spinal canal stenosis
- minimally invasive surgical treatment for severe
- stable developmental lumbar canal stenosis rethink needed
- unilateral laminotomy with bilateral spinal canal
- degenerative spondylolisthesis of the lumbar spine
- lumbar canal stenosis start with nonsurgical therapy ccjm
- story of lumbar spine page 1 of 13 2 when things fall apart
- stenosis a technical note spinal canal decompression for
- spinal stenosis nhs tims
- in the united states district court for the western
Related searches
- back lumbar spine surgery
- lumbar spine surgery types
- lumbar spine surgery
- abnormal lumbar spine mri images
- understanding lumbar spine mri results
- mri lumbar spine interpretation
- synovial cyst lumbar spine icd 10
- lumbar spine cyst icd 10
- lumbar spine strain icd 10
- 1 13 2 hacks
- best 1 13 2 mods
- minecraft version 1 13 2 download