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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Story of the Lumbar Spine:2

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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

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Story of the Lumbar Spine:2

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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

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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

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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

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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

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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)

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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

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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

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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

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