rah med 4 ortho - spinal imaging
TRANSCRIPT
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Spinal imaging
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Topics for today
Overview:– Imaging choices– Anatomy• Mostly cervical spine
– Trauma
Case examples/quiz
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Imaging choices
Traditional approach:– Xray at presentation (clinical criteria can
exclude need for imaging)– CT scan if needed– MRI for specific indications (cord, ligaments etc)
Recent changes:– International guidelines support the use of CT
as first line imaging in suspected cervical spine injury, this will become common.
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Cervical spine anatomyLateral film:Bones• Vertebral bodies• “Posterior elements”
Soft tissues• Prevertebral• Intervertebral discs
Joints• Intervertebral• Uncovertebral• Facet
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Cervical spine anatomy
C2
C3
C4
C5
C6
C7
T1
Lateral film :Bones• Vertebral bodies
Roughly the same height and width (except C2)
C1 has an anterior arch (in green) but no “body”
To exclude fractures, you must see the top of T1.
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1
Cervical spine anatomyLateral film :Bones• Vertebral bodies• “Posterior elements”
Spinal canal
Lamina
Pedicle
Body
Spinous process
Transverse process
Facet
2
3
4
5
6
7
PedicleFacet
Spinous process
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Cervical spine anatomyLateral film :Soft tissues• Prevertebral (orange)• Intervertebral discs
(green)
Intervertebral discs are quite small in the cervical spine.
The prevertebral tissues should be less than half a vertebral body above C5, and less than one vertebral body below C5.
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Cervical spine anatomyLateral film :Joints
• Intervertebral
• Uncovertebral
• Facet1
2
3
3
2
1
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Cervical spine anatomyLateral film:Alignment:
• Anterior vertebral line (orange)
• Posterior vertebral line (purple)
• Spinolaminar line (blue)
These lines are usually smooth lordotic curves. In this case, they are nearly straight. Why?
Spinal collar forces a straight/slightly kyphotic position
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Cervical spine anatomyFrontal film:Structures that commonly demonstrate pathology and should be routinely assessed
• Vertebral bodies• Pedicles• Spinous processes• Transverse processes
Vertebral body
Pedicles
Spinous processTransverse processes
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Cervical spine anatomyFrontal film:Alignment:
• Spinous processes (orange)
• Pedicles (green)• Lateral borders (purple)
The lines are curved because of the tilted head position, but should always be smooth curves. Sudden shifts or steps are concerning.
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Thoracolumbar spine anatomyThe anatomy and principles are almost identical:
• Check alignment
• Check the anterior and posterior elements.
• No prevertebral soft tissues in thoracic or lumbar spine.
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Assessing spinal trauma
General approach
Alignment:– Spinal lines, abrupt steps can suggest fracture or dislocation
(intervertebral or facet joints).– Joint spaces. Widening can suggest ligament injury.
Bones:– See a fracture (cortical step etc.)– Absent normal anatomy (ie can’t see pedicles)– Vertebral body height loss.
Soft tissues:– Prevertebral soft tissue swelling.
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Assessing spinal trauma
Factors that influence management Stability:
– 3 major ligament “bundles” between:• Anterior vertebral bodies• Posterior vertebral bodies• Posterior elements
– Damage to 2 or more is “unstable”Cord injury:
– Vertebral body fragment displaced into the canal (retropulsion)
– Significant displacement between vertebral bodies (anterolisthesis / posterolisthesis)