nomenclature in spine mri
TRANSCRIPT
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Imaging Degeneration of the Lumbar Spine:
THE 1ST LESSONS
Hieder A`ala601
MUST
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Course Outline
• Introduction, Nomenclature, Evidence for Imaging
• Natural History and Prognosis
• New Techniques
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Spine Nomenclature and Evidence for Imaging
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Talk Objectives
• “Background”
• Nomenclature for disc findings
• Who should be imaged- evidence basis?
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15th Century Turkish Treatment- Cauterization
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21st Century American Treatment
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What sounds straightforward isn’t always
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Frequency of Back Pain Types
1% tumor, infection,
inflammatory arthritis
2% visceral
97%
“mechanical”
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“Mechanical” Causes of Low Back Pain
• Lumbar strain, sprain (70%)
• Degen (disc and facets) (10%)
• Herniated disc (4%)
• Spinal stenosis (3%)
• Osteoporotic comp fracture (4%)
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The Least We Can Do: Speak the Same Language
Nomenclature for disc findings
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Consensus Nomenclature
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Question???
• What is the ASNR/NASS nomenclature for describing lumbar discs?
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Consensus Nomenclature
• normal• degeneration• anular tears• herniation
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Consensus Nomenclature
• normal–well hydrated disc–central dark band= central
fibrosus
age-related changes=NOT normal
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Intranuclear Cleft
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Normal
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Consensus Nomenclature
• normal• degeneration
–desiccation–narrowing–bulging–endplate changes–osteophytes
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Glossary of disc pathology terms
• Herniation: nonspecific term subject to misinterpretation. – Not recommended.
• Bulge: diffuse enlargement of disc area– Very common– Usually not clinically important– May contribute to spinal stenosis
• Protrusion: nucleus pulposis pushes focally through fibers of annulus fibrosis– Base wider than apex– May focally impinge on nerve or thecal sac
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Glossary of disc pathology terms
• Extrusion: nucleus material pushes out beyond posterior longitudinal ligament but remains in contact with disc space– Apex wider than base– Likely to impinge on nerve roots
• Sequestration: Disc fragment isolated from parent disc
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Glossary of disc pathology terms
• Localizing terms:–Central
–Paracentral
–Foraminal
–Lateral
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Desiccation Narrowing
Disc Degeneration
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Disc Degeneration: Findings?
Narrowing
Endplate sclerosis
Osteophytosis
Vacuum Disc
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Bulging
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Consensus Nomenclature
• normal• degeneration• anular tear=anular fissure (high
intensity zones=HIZ)• herniation
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Degeneration and Tears
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Degeneration and Tears
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Degeneration and Tears
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Consensus Nomenclature
• Herniation– localized displacement of disc
>50% (180o) = bulge
<50% = herniation
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Consensus Nomenclature
• normal• degeneration• anular tears• herniation
–protrusion–extrusion
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Disc Classification
Protrusion Extrusion
Canal
Disc
Bony Endplate
Normal Bulge
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Disc Classification
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Protrusion
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Protrusion
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Extrusion
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Extrusion
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Extrusion
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Extrusion
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Classification of Nerve Root Condition
• Normal
• Contacted
• Displaced
• Compressed
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Normal Nerve Roots
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Contacted Nerve Root
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Contacted Nerve Root
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Displaced Nerve Root
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Compressed Nerve Root
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Displaced and Compressed Nerve Root
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Displaced and Compressed Nerve Root
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Talk Objectives
• “Background”
• Nomenclature for disc findings
• Who should be imaged- evidence basis?
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6%
32%
64%
0%
20%
40%
60%
80%
100%
bulge protrusion extrusion
Prevalence of Disc Findings in Subjects without LBP
Bulge Protrusion Extrusion
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Disc Degeneration
• Signal loss on T2-weighted images
• Height loss
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Disc Degeneration
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Disc Degeneration
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Anular Tear
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Take Home Points Regarding Prevalence
• many imaging findings are common in asx’s
• certain findings are related to prior low back pain and more likely to be clinically important–extrusions, root comp, stenosis
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Rationale for Imaging
• r/o low prob red flag condition
• rule-in treatable conditions–stenosis–herniated disc–spondyloarthropathy–instability ?
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Early Imaging Red Flags
• ? Fx–h/o major trauma
–minor trauma in older or osteoporotic pt
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Red Flags
• age>50 or <20
• h/o malignancy
• constitutional sx
• ↑ infection risk (IVDA, HIV, etc)
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Red Flags
• possible cauda equina syndrome–saddle anesthesia
–urinary retention
–severe/progressive neurologic deficit in lower extremity