Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Anterior Compression Fracture
KEY FACTS
TERMINOLOGY
Trauma
• Vertebral body fracture compressing anterior cortex,
sparing middle/posterior columns
IMAGING
• Vertebral body shorter anteriorly than posteriorly
○ < 40-50% loss of height in patients with normal bone
density
• ± vertebral body endplate abnormality
• ± anterior cortical irregularity
• Normal middle and posterior vertebral columns
• Most common in middle and lower thoracic spine
TOP DIFFERENTIAL DIAGNOSES
• Burst fracture
• Compression-distraction injury (Chance fracture)
• Pathologic fracture due to tumor
• Schmorl node
• Scheuermann kyphosis
(Left) Sagittal graphic shows 2
types of compression
fractures. The most common
type is compression of the
superior endplate ſt. Isolated
compression of the inferior
endplate st is rare. Note that
in these cases, there is angular
deformity of the anterior
cortex without focal endplate
angulation. (Right) Sagittal
graphic shows 2 additional
types of compression
fractures. The fracture
involving both endplates is
common, while the coronally
oriented fracture through the
vertebral body with wedge
deformity ſt is rare.
• Physiologic vertebral wedging
• Limbus vertebra
CLINICAL ISSUES
• Most common type of thoracic spine fracture due to blunt
trauma
○ Young patient (due to significant fall)
○ Osteoporotic patients: Insufficiency fracture
• American Academy of Orthopaedic Surgeons (AAOS)
practice guidelines (2011)
○ Against vertebroplasty for osteoporotic spinal
compression fracture in patients who are neurologically
intact (kyphoplasty is option)
• AAOS guidelines recommend calcitonin for 4 weeks
○ Ibandronate and strontium ranelate are options to
prevent additional symptomatic fractures
DIAGNOSTIC CHECKLIST
• Patients often have additional compression, burst, Chance,
or shear fractures at other spinal levels
180
(Left) Sagittal bone CT shows
a compression fracture
causing angular deformity of
the vertebral endplate st and
cortical step-off ſt anteriorly.
The normal vascular groove
posteriorly should not be
confused with a fracture.
(Right) Sagittal bone CT shows
multilevel injuries. The T12
compression fracture ſt has a
coronal split. T10 and T11
fractures are not compression
fractures but burst fractures,
since there is retropulsion of
the posterior vertebral body
cortex st.
Sacral Insufficiency Fracture
KEY FACTS
Trauma
TERMINOLOGY
• Sacral fracture resulting from normal physiological stress
on weakened (e.g., osteoporotic) bone
IMAGING
• Vertical fracture(s) through sacral alae
○ Either unilateral or bilateral
○ Located lateral to sacral foramina (zone I), roughly
parallel to sacroiliac joint
• ± transverse fracture of sacral body
• Subtle ventral cortical disruption of sacral alae
• Sclerotic bands or irregular zones in sacral alae during
healing phase
• Sacral marrow edema on MR
○ Hypointense on T1, hyperintense on T2
○ Greatest conspicuity on STIR or T2WI FS
○ May be overlooked on MR of lumbar spine obtained for
generalized back pain
• Variable presence of classic H-shaped pattern of radiotracer
uptake on bone scan: 19-62%
• Frequency of extrasacral tracer uptake 70% in 1 series
○ Multiple sites of tracer uptake may falsely raise concern
for metastatic disease
PATHOLOGY
• Associated abnormalities
○ Vertebral compression fractures
○ Other pelvic insufficiency fractures (pubic rami, iliac
wing)
○ Intertrochanteric femur fracture
CLINICAL ISSUES
• In 1 series, only 43% with unilateral fractures and 0% with
bilateral fractures regained preinjury levels of mobility
• CT-guided percutaneous sacroplasty is effective procedure
to treat painful sacral insufficiency fractures
(Left) Sagittal graphic depicts
bilateral vertical sacral alar
fractures ſt located lateral to
the sacral foramina and a
transverse fracture st
through the sacral body
resulting in the classic Hshaped insufficiency fracture.
(Right) Posterior bone scan
shows increased sacral uptake
in the classic "H" distribution
due to insufficiency
fracture. There is also uptake
in a T12 compression fracture
and in a pair of lower left
rib fractures .
(Left) Coronal reformatted CT
shows diffuse osteopenia and
bilateral sacral alae cortical
defects ſt due to sacral
insufficiency fracture. The
right-sided fracture extends
into the right S1 neural
foramen st. There is also a
transverse fracture of the
sacral body. (Right) Sagittal
T1WI MR shows a small focus
of low marrow signal involving
the S3 body in the midline ſt
in this patient with
insufficiency fracture. This
location is important to
evaluate in every lumbar spine
MR.
181
Posttraumatic Syrinx
KEY FACTS
IMAGING
Trauma
• Fusiform intramedullary hyperintensity tracking CSF signal
○ Myelomalacia precedes overt syrinx formation =
presyrinx state
• Cystic expansile cord lesion
○ May appear to be expansile lesion, relative finding in
presence of cord atrophy
• Consider cine PC CSF flow study if suspected obstruction to
CSF flow (e.g., arachnoid adhesions)
TOP DIFFERENTIAL DIAGNOSES
• Gibbs artifact
• Nontraumatic syrinx
• Myelitis
• Myelomalacia
(Left) Sagittal images show
extension of the syrinx over
time into regions of presyrinx
edema. This initial T2 MR after
C3-C4 fusion and prior flexion
injury at C5-C6 shows the welldefined syrinx cavity at the C5C6 level with cord expansion
ſt. T2 hyperintense signal
within the cord extends
cephalad from the syrinx to
the C2 level due to cord
edema . (Right) Sagittal CT
myelogram following
placement of a
syringoperitoneal shunt shows
the shunt catheter ſt within
the syrinx cavity, which has
decreased in size .
PATHOLOGY
• Current treatment assumes syrinx is related to
posttraumatic arachnoid scarring and CSF flow obstruction
at trauma level
CLINICAL ISSUES
• Symptoms include spasticity, hyperhidrosis, pain, sensory
loss, automotive hyperreflexia
• Classic presentation: Severe pain unrelieved by analgesics;
ascending disassociated sensory loss
• Surgery reserved from patients with progressive
neurological symptoms
○ 1st-line treatment has moved away from shunting of
syrinx to restoring normal CSF flow patterns at traumatic
site
– Untethering of cord
– Duraplasty
– Spine realignment or fusion may be added if
angulation or stability is problematic
182
(Left) Follow-up sagittal T2
MR 3 months later shows
extension of the syrinx to the
C3 level ſt with slight edema
cephalad to this site. Note
the presence of a shunt
catheter st, which has not
stopped the syrinx
progression. (Right) Sagittal
T2 MR 6 months later shows
expansion of the syrinx at the
C3 level ſt and marked,
increased presyrinx edema
extending cephalad to the
medulla with a small focus
of syringobulbia st.
Presyrinx Edema
KEY FACTS
Trauma
TERMINOLOGY
• Potentially reversible state of spinal cord edema caused by
obstruction or alteration of normal CSF flow pathways
IMAGING
• Increased T2 signal within central aspect of cord with
slightly decreased and ill-defined T1 signal and cord
expansion in setting of pathology that alters CSF flow
dynamics
TOP DIFFERENTIAL DIAGNOSES
• Posttraumatic syringomyelia
• Nontraumatic syringomyelia
○ Chiari 1 malformation
○ Tumor associated (ependymoma, astrocytoma,
hemangioblastoma)
○ Idiopathic
• Myelitis
○ Demyelinating disease
○ Viral infection
○ Vasculitis (SLE)
• Infarction
• Myelomalacia
• Type I dural arteriovenous fistula
• Radiation myelopathy/necrosis
CLINICAL ISSUES
• Surgical removal of CSF flow obstruction will quickly
eliminate cord edema
• Extensive arachnoid scarring gives poor prognosis with high
incidence of recurrence
DIAGNOSTIC CHECKLIST
• Presyrinx edema likely represents point on continuum to
development of syringomyelia
• May be misinterpreted as syringomyelia on MR studies
• May be related to progressive posttraumatic myelomalacic
myelopathy
(Left) Sagittal T1WI C+ MR of
the brain shows severe
hydrocephalus from diffuse
coccidioidomycosis basilar
meningitis with diffuse
leptomeningeal enhancement
ſt. (Right) Axial FLAIR MR
through the posterior fossa in
this case of coccidioidomycosis
meningitis shows
transependymal edema
surrounding the markedly
dilated 4th ventricle ſt.
(Left) Sagittal T2 MR shows
extensive cervical cord
presyrinx edema st that is due
to coccidioidomycosis
meningitis causing marked
hydrocephalus ſt. The cervical
subarachnoid space and 4th
ventricular outflow
obstruction causes abnormal
fluid shift into the cord. (Right)
For extensive cervical cord
edema (presyrinx) resolution
following ventricular shunting,
a follow-up MR study 7 days
after lateral ventricular shunt
placement shows resolved
cervical cord edema st and
diminished 4th ventricular size
ſt.
183
Spinal Cord Contusion-Hematoma
KEY FACTS
TERMINOLOGY
Trauma
• Spinal cord injury (SCI)
• Traumatic axonal injury, cord edema, &/or hemorrhage
IMAGING
• Abnormal cord signal on MR in setting of trauma
• Most common level of adult SCI is C4-C6
• Commonly associated fracture or subluxation in younger
adults (16-45 years)
• Underlying degenerative change (canal stenosis)
predisposes to cord injury in older population
• SCI without radiographic abnormality is common in
pediatric population (< 8 years)
• Cord injury typically occult on CT
PATHOLOGY
• Overall incidence of SCI in trauma estimated at 3.7%
• High-velocity mechanisms more common in youth and
young adults
(Left) Sagittal T2 MR of a
patient days after a motor
vehicle accident with upper >
lower extremity weakness
shows congenital narrowing of
the canal with multiple disc
bulges & levels of canal
stenosis, worst at C4-C5 ſt.
Caudally, mild, patchy T2
hyperintensity shows
nonhemorrhagic cord
contusion st. (Right) Sagittal
T2 MR in a child shows diffuse
contusion st in the cord from
C1 through the upper thoracic
cord. This patient presented
with 4 extremity neurologic
deficits after fall. Plain films
would be normal (SCIWORA).
• If > 45 years, more likely due to fall; short falls (< 1 m) may
result in significant injury in elderly
CLINICAL ISSUES
• Edema without hemorrhage: Good prognosis for recovery
• Hematoma: Poor prognosis, often without recovery
○ Extent of intramedullary hemorrhage and cord swelling
are key predictors of neurologic recovery after traumatic
cervical cord injury
• 30-60 new cases per million per year in USA
DIAGNOSTIC CHECKLIST
• Sagittal STIR is key sequence
○ Sensitive to cord edema
○ Ligamentous/muscular injury
○ Marrow edema
• Sagittal and axial gradient-echo images for cord
hemorrhage
184
(Left) Sagittal T2 MR in a
trauma patient shows low
signal intensity cord
hemorrhage at C4 ſt with
surrounding edema in the
setting of severe cervical canal
stenosis. Prevertebral edema
is present . (Right) Sagittal
T2WI MR shows a midthoracic
burst fracture ſt and
disruption of ligamentum
flavum st. There is complete
transection of the spinal cord
, demonstrated by a CSFfilled cleft with adjacent
edema.
Idiopathic Spinal Cord Herniation
KEY FACTS
Trauma
TERMINOLOGY
• Ventral cord herniation
• Herniation of spinal cord through defect in dura of ventral
canal
IMAGING
• Best diagnostic clue: Focal anterior displacement of cord
with expansion of dorsal subarachnoid space
• Location: Typically in midthoracic spine
○ T2-T8 level
• Focal cord deformity
• Cord displaced anteriorly against posterior edge of
vertebral body
• Increased dorsal subarachnoid sac
• May see secondary collection of contrast in extradural sac
• Best imaging tool: CT postmyelography
TOP DIFFERENTIAL DIAGNOSES
• Arachnoid cyst
• Epidermoid cyst
○ Restricted diffusion
• Adhesions
• Cystic schwannoma
○ Peripheral or nodular enhancement
• Epidural hematoma
• Epidural empyema
PATHOLOGY
• Defect or diverticulum in ventral dural sheet into which
cord herniates
• Several proposed mechanisms
○ Congenital weakening of ventral dural fibers
○ Damage to ventral dura by disc herniation or other
mechanism
○ Abnormal adhesion of cord to anterior dural sleeve
progressively wears down dura, leading to herniation
(Left) Sagittal graphic shows a
focal dural defect in the
thoracic spine allowing cord
herniation. Note the
distinctive and focal cord kink.
(Right) Axial CECT myelogram
(L) and sagittal T2WI MR (R)
show ventral cord distortion
and anterior displacement into
the extradural cavity ſt with
focal enlargement of dorsal
CSF . Note the extradural
CSF collection with slightly
less density from delayed
leakage of contrast st.
(Left) Axial heavily T2weighted CISS MR shows the
site of cord herniation through
the dura ſt as well as an
adjacent extradural fluid
collection along the ventral
thecal sac . Note the
associated disc herniation st.
(Right) Sagittal CECT
(postmyelography) shows a
focal kink of the thoracic cord
ſt and anterior adhesion to
the back of the vertebral body.
The expanded dorsal thecal
sac mimics an arachnoid cyst
.
185
Traumatic Epidural Hematoma
KEY FACTS
TERMINOLOGY
Trauma
• Spinal epidural hematoma
• Posttraumatic accumulation of blood into spinal epidural
space
IMAGING
• May be located at any spinal level
○ Typically extends over multiple levels
○ Fusiform, oval, or tubular
• Extends more freely in dorsal epidural space; ventral spread
limited by dural attachment to posterior longitudinal
ligament, anulus
• "Capping" of hematoma by epidural fat on sagittal imaging
○ Confirms epidural (rather than subdural) location
• MR signal intensity depends on age of hematoma
TOP DIFFERENTIAL DIAGNOSES
• Epidural abscess (or phlegmon)
• Epidural lipomatosis
(Left) Sagittal STIR MR shows
disruption of the anterior
longitudinal ligament at C5-C6
and a small ventral
epidural hematoma st. There
is contusion of the cervical
cord ſt. Injury to the
paraspinous musculature is
shown by hyperintense signal
. (Right) Sagittal STIR MR
shows a small dorsal epidural
hemorrhage st in this patient
with a L2 Chance fracture.
This image shows a portion of
the fracture extending
through the posterior
vertebral body ſt and
disruption of the interspinous
ligaments at L1-L2 .
• Epidural tumor
• Extramedullary hematopoiesis
• Ossification of posterior longitudinal ligament
• Sequestered disc fragment
PATHOLOGY
• Clot characteristics depend on compartment, age of
collection
• Venous source more common than arterial
CLINICAL ISSUES
• May be associated with significant compression of spinal
cord or cauda equina
• Surgical evacuation/decompression may be necessary to
alleviate compression of spinal cord, cauda equina
DIAGNOSTIC CHECKLIST
• IV gadolinium-based contrast and fat saturation for
complete characterization
• CT may help identify hemorrhage when MR confusing
186
(Left) Sagittal STIR MR shows
a compression deformity of T1
st and dorsal epidural
hematoma spanning C7 to T2T3 ſt, which effaces the
thecal sac and compresses the
cervicothoracic cord. Note
how STIR MR shows the
complex signal of the
hematoma distinct from the
homogeneous CSF and the fatsuppressed epidural fat.
(Right) Sagittal T2WI MR
shows disruption of the
anterior longitudinal ligament
and posttraumatic
herniation at C6-C7 ſt. There
is dorsal epidural hematoma
st with cord compression.
Traumatic Subdural Hematoma
KEY FACTS
Trauma
TERMINOLOGY
• Accumulation of blood between dura and arachnoid layers
of spine
IMAGING
• Lobulated subdural mass with smooth margins
○ May be located at any level of spine
○ Tends to have biconvex or lentiform appearance on both
sagittal and axial imaging
• MR signal depends on age of hematoma
○ MR most useful to assess size/extent and to evaluate
impact on neurologic structures
• Variable degree of compression of spinal cord or nerve
roots
TOP DIFFERENTIAL DIAGNOSES
• Epidural hematoma, traumatic
• Abscess, subdural
• Arachnoid cyst
• Meningioma
CLINICAL ISSUES
• Overall incidence of traumatic subdural hematoma is rare,
as subdural space is relatively avascular
○ tSSDH is particularly rare
○ Nontraumatic etiologies are more common
– Coagulopathy, arteriovenous malformation, or
vascular tumor
• May be associated with significant compression of spinal
cord or cauda equina
○ Surgical decompression or percutaneous drainage may
be performed to alleviate compression of spinal cord or
cauda equina
○ Conservative management may be considered
– Usually resorbs within weeks or several months,
depending on size
• Retroclival subdural hematoma requires evaluation for
possible atlantooccipital dislocation
(Left) Sagittal T1WI MR shows
a typical case of early
subacute clival and subdural
hematoma ſt demonstrating
the typical lobulated margin
of the arachnoid effacing the
ventral thecal sac. (Right)
Axial T1WI MR through the
lower cervical spine shows
early subacute subdural
hematoma ſt demonstrating
the typical lobulated margin
of the arachnoid effacing the
ventral thecal sac and
impinging on the anterolateral
cervical cord.
(Left) Sagittal CECT
myelogram shows extensive
posttraumatic spinal subdural
hematoma with contiguous
intracranial extension .
Note the larger ventral ſt and
smaller dorsal components of
the hematoma st. (Right)
Axial NECT shows
posttraumatic spinal subdural
hematoma with a small,
circumferential subdural
hematoma at the level of the
midcervical spine .
187
This page intentionally left blank
SECTION 6
Degenerative Diseases and Arthritides
Degenerative Disease
Nomenclature of Degenerative Disc Disease 190
Degenerative Disc Disease
Degenerative Endplate Changes
Disc Bulge
Anular Fissure, Intervertebral Disc
Cervical Intervertebral Disc Herniation 202
Thoracic Intervertebral Disc Herniation
Lumbar Intervertebral Disc Herniation
Intervertebral Disc Extrusion, Foraminal
Cervical Facet Arthropathy
Lumbar Facet Arthropathy 207
Facet Joint Synovial Cyst
Baastrup Disease
Bertolotti Syndrome
Schmorl Node
Scheuermann Disease 212
Acquired Lumbar Central Stenosis
Congenital Spinal Stenosis
Cervical Spondylosis
DISH
OPLL 217
Ossication Ligamentum Flavum
Periodontoid Pseudotumor
Spondylolysis
194
198
200
201
203
204
205
206
208
209
210
211
213
214
215
216
218
219
220
Inammatory, Crystalline, and Miscellaneous Arthritides
Adult Rheumatoid Arthritis 222
Juvenile Idiopathic Arthritis
Neurogenic (Charcot) Arthropathy
Hemodialysis Spondyloarthropathy
Ankylosing Spondylitis
CPPD 234
Gout
226
227
228
230
235