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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Disc Bulge
KEY FACTS
TERMINOLOGY
• Anular bulge
• Generalized extension of disc beyond edges of vertebral
ring apophyses
IMAGING
• Circumferential disc "expansion" beyond confines of
vertebral endplates
○ Short radius of extension: ≤ 3 mm
○ > 25% of disc circumference
○ If morphologic abnormality is < 25% of disc
circumference, then it is herniation and not bulge
• Smooth ventral extradural defect in contrast column, with
Degenerative Diseases and Arthritides
indentation on anterior thecal sac
○ Central canal and subarticular recesses usually not
compromised unless associated with ligamentous
hypertrophy
• T1WI and T2WI MR with sagittal and axial planes
• Discography may help identify symptomatic disc
(Left) Axial T2WI FS MR
demonstrates the broad-based
appearance of the bulging disc
ſt with predominately low
signal intensity. Associated
anular fissure would show
focal high signal. (Right)
Sagittal T2WI MR through the
lumbar spine shows L4-L5 disc
degeneration with loss of
signal and a bulging disc
touching the ventral thecal sac
without significant deformity.
An associated hyperintense
annular fissure is present ſt.
TOP DIFFERENTIAL DIAGNOSES
• Disc protrusion (< 25% of disc circumference)
• Ossification of posterior longitudinal ligament
○ Most common in cervical spine (70%)
• Vertebral endplate bony spur
○ Continuous with vertebral endplate
PATHOLOGY
• Bulge less important as separate entity but associated with
disc degeneration and anular fissures → "discogenic" pain
CLINICAL ISSUES
• Low back pain
• Up to 39% of asymptomatic adults have bulging discs
• > 80-90% success rate with conservative treatment
200
(Left) Axial NECT after
discography shows multiple
circumferential annular tears
ſt. These coalesce into a large
dorsal annular defect,
allowing contrast extending
beyond annulus . Note the
generalized extension of the
posterior disc margin into the
epidural space. (Right) Sagittal
T2WI MR shows grade II
spondylolisthesis at L5-S1 with
type I degenerative endplate
changes . There is extensive
"uncovering" of L4 and L5
discs, which should not be
confused with annular bulge
ſt. Note the annular fissures
at L2-L3 and L3-L4 st.
Anular Fissure, Intervertebral Disc
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Anular defect; high-intensity zone (HIZ) in posterior anulus
• Disruption of concentric collagenous fibers comprising
anulus fibrosus
• Term "tear" is nonstandard and may inaccurately imply
acute traumatic etiology
IMAGING
• Focal HIZ in anulus on T2WI with low signal of parent disc
• Contrast enhancement on T1WI
• Focally enhancing nidus in posterior disc margin
• Discography is more provocative test (symptom simulation)
rather than diagnostic imaging modality
TOP DIFFERENTIAL DIAGNOSES
• Disc space infection
• Focal disc protrusion
• Focal fat or ossification of disc with fatty marrow
CLINICAL ISSUES
• Most anular tears are asymptomatic
○ Autopsy demonstrates high prevalence of fissures
○ MR shows anular fissures in majority of asymptomatic
individuals
• Utility of discography remains controversial
• Direct association with disc degeneration
○ Recurrent meningeal nerve and ventral ramus of somatic
spinal nerve are sources of innervation
○ Anular disruption may allow inflammatory substances to
leak from nucleus
DIAGNOSTIC CHECKLIST
• Consider other sources of low back pain or disc pathology
(e.g., disc infection)
• Incidental HIZ of otherwise normal disc is essentially normal
finding
(Left) Sagittal PD FSE MR
demonstrates linear
hyperintensity within the
posterior aspect of the anulus
fibrosus at L5-S1, reflecting
the anular disruption of an
anular fissure. There is mild
bulging of the anulus at this
level as well. (Right) Sagittal
T1WI C+ MR shows focal
enhancement within posterior
anulus . This is a typical
pattern for focal enhancement
within anular fissure. There is
also enhancement within the
posterior anulus at L2-L3 and
severe degenerative disc
disease at L5-S1.
(Left) Lateral radiograph
during discography shows
leakage of intradiscal contrast
at L4-L5 and fissured and
degenerated L4-L5 and L5-S1
discs. Symptoms were
reproduced with injection of
L5-S1 disc, not at L4-L5.
(Right) Axial bone CT in the
same patient following the
discogram shows the leakage
of contrast into the ventral
epidural space at L4-L5,
verifying the presence of the
anular defect.
201
Cervical Intervertebral Disc Herniation
KEY FACTS
TERMINOLOGY
• Protruded disc, extruded disc, free fragment, sequestered
disc
• Localized (< 50% of disc circumference) displacement of
disc material beyond edges of vertebral ring apophyses
IMAGING
• Small mass in ventral spinal canal, contiguous with
intervertebral disc
• Protrusion is herniated disc with broad base at parent disc
• Extrusion is herniated disc with narrow or no base at parent
disc
• Sequestered or free fragment: Extruded disc without
Degenerative Diseases and Arthritides
contiguity to parent disc
• Migrated: Disc material displaced away from site of
herniation, regardless of continuity to parent disc
TOP DIFFERENTIAL DIAGNOSES
• OPLL
(Left) Sagittal graphic shows
disc extrusion ſt with the
base of the herniation smaller
than the epidural component,
effacing the thecal sac and
causing cord compression.
(Right) Sagittal T2WI MR
shows C5-C6 disc extrusion
with the base of herniation
smaller than the component
extending into the epidural
space.
• Osteophyte
• Tumor
• Hemorrhage
• Abscess
CLINICAL ISSUES
• 10% of people under age 40 have cervical herniation
• Acute radiculopathy usually self-limited disorder with full
recovery expected
○ Neck pain (90%)
○ Radicular pain (65%)
○ Paresthesia (89%)
• Treatment
○ Conservative treatment
○ Multiple surgical approaches without clear consensus
DIAGNOSTIC CHECKLIST
• Use fast STIR for cord disease
• Axial GRE, T2* GRE for disc definition
202
(Left) Sagittal T1WI C+ MR
shows C4-C5 extrusion ſt
impinging upon the cord.
Smaller C5-C6 protrusion also
compresses the ventral cord
st. Peripheral enhancement
is related to epidural
plexus and granulation tissue.
(Right) Axial T2* GRE MR
shows left-sided extrusion ſt
effacing the left side of the
thecal sac and compressing
the cord, extending toward
the left neural foramen.
Thoracic Intervertebral Disc Herniation
KEY FACTS
Degenerative Diseases and Arthritides
IMAGING
• Small mass in spinal canal contiguous with intervertebral
disc
○ Ventral epidural
○ Rare in upper thoracic spine (T1-T3)
• May enhance peripherally after intravenous contrast
material due to granulation tissue or dilated epidural plexus
○ Peripheral enhancement may give "lifted band" or "tent"
configuration
TOP DIFFERENTIAL DIAGNOSES
• Osteophyte
○ Sharp margins not arising directly from intervertebral
disc level
• Tumor
○ Homogeneous enhancement
• Hemorrhage
○ Elongated within epidural space, tends to be posterior
• Abscess
○ May mimic large herniation with peripheral
enhancement
CLINICAL ISSUES
• 5th decade
• Uncommon entity
• Thoracic disc surgery uncommon, represents 1-2% of all
disc surgery
• History of Scheuermann
DIAGNOSTIC CHECKLIST
• Calcification (65%)
• Multiple herniation (14%)
• T2WI critical since herniation may not be visible on T1WI
due to calcification
• Check and recheck herniation level, counting from C2
and L5 levels
Preoperative placement of gold fiducial markers
○
overlying posterior elements can aid intraoperative level
localization
(Left) Sagittal T1WI MR with
contrast shows a large low
signal intensity mass
contiguous with disc space
reflecting a large calcified disc
extrusion ſt. Prominent
distended epidural veins "tent"
around herniation . (Right)
Axial T1WI MR demonstrates
the large left-sided extrusion
ſt severely compressing the
left side of the cord .
(Left) Sagittal T2WI MR shows
multiple large lower thoracic
disc herniations, which
severely compress the cord ſt
at multiple levels. Thoracic
herniations are most common
from T7-T12. (Right) Sagittal
T1WI C+ MR shows
pronounced peripheral
enhancement surrounding the
nonenhancing large
herniations ſt. The
enhancement relates to
"tented" and distended
epidural plexus and
herniation-associated
granulation tissue.
203
Lumbar Intervertebral Disc Herniation
KEY FACTS
TERMINOLOGY
• Localized (< 25% of disc circumference) displacement of
disc material beyond confines of disc space
• Protrusion
○ Herniated disc with broad base at parent disc
• Extrusion
○ Herniated disc with narrow or no base at parent disc
• Sequestered: Free fragment
• Migrated: Disc material displaced away from site of
herniation
IMAGING
• Anterior extradural mass contiguous with disc space
Degenerative Diseases and Arthritides
extending into spinal canal
• Axial: Central, subarticular (lateral recess), foraminal, or
extraforaminal (far lateral)
• Sagittal: Disc level, infrapedicle, pedicle, suprapedicle
(Left) Graphic of large
recurrent disc herniation
shows displacement of the
nuclear material ſt through a
large defect in the posterior
annular fibers with
effacement of the ventral
thecal sac and displacement of
the intrathecal nerve roots.
(Right) Sagittal T2 TSE shows
a large extrusion of the
intervertebral disc at the L5S1 level with a sequestered
component (free fragment) ſt
that is migrated superiorly.
There is severe thecal sac
compression.
TOP DIFFERENTIAL DIAGNOSES
• Peridural fibrosis
• Epidural abscess
• Epidural metastasis
• Nerve sheath tumor
CLINICAL ISSUES
• Low back pain
• Radiculopathy: Posterolateral radiating pain down lower
extremity
○ Positive straight-leg raising test (Lasègue sign)
○ Cauda equina syndrome
• Back pain ± radiculopathy resolves within 6-8 weeks
• Treatments
○ Conservative
○ Minimally invasive techniques (many variations)
○ Standard open techniques, such as
laminotomy/discectomy
– ≥ 90% success rate
204
(Left) Axial T2WI MR shows a
large central and left
extrusion of the intervertebral
disc ſt with severe
effacement of the thecal sac
st. The herniation extends
into the left neural foramen
. (Right) Sagittal T2WI MR
shows a large disc extrusion
ſt with relatively low signal
intensity that is migrated
inferiorly . There is severe
effacement of the ventral
thecal sac by the herniation.
Intervertebral Disc Extrusion, Foraminal
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Extruded disc material within neural foramen
• Far lateral is disc material lateral to neural foramen
IMAGING
• Obliterated perineural fat in neural foramen on sagittal
images
• Soft tissue mass contiguous with parent disc
• T1WI isointense to parent disc
• T2WI iso-, hypo-, or hyperintense to parent disc
• May enhance peripherally
• Often missed on myelography
TOP DIFFERENTIAL DIAGNOSES
• Schwannoma
• Spinal nerve root diverticulum
• Large facet osteophyte
CLINICAL ISSUES
• May stabilize or resolve spontaneously
• Severe radicular pain
• Mass effect on exiting nerve root in narrow confines of
neural foramen
• 5-10% of all disc herniations
• Surgery
○ Failed conservative therapy after 6-8 weeks; progressive
deficits
○ Interlaminal approach with partial medial facetectomy
○ Endoscopic lateral approaches more commonly used but
no change in outcome relative to open procedures
(Left) Axial T1WI MR shows
large right lateral and
intraforaminal disc herniation
at L4-L5 ſt. The disc
herniation involves the lateral
aspect of the neural foramen
and extends to the root
ganglion level. (Right) Axial
T2WI MR shows the large right
lateral and intraforaminal disc
herniation ſt at L4-L5 as near
isointense signal to adjacent
paravertebral soft tissue.
There is slight lateral
displacement of the psoas
muscle.
(Left) Axial T1WI MR shows a
left L4-L5 foraminal disc
extrusion ſt, contacting the
exiting left L4 nerve root
at the level of the nerve root
ganglion. (Right) Sagittal T1WI
MR shows L5-S1 foraminal disc
extrusion displacing the
exiting L5 nerve root ſt
superiorly within the foramen.
205
Cervical Facet Arthropathy
KEY FACTS
TERMINOLOGY
• Facet arthrosis, degenerative facet disease, degenerative
joint disease
IMAGING
• Osseous facet overgrowth impinging on neural foramina in
conjunction with articular joint space narrowing
• Facet joint osteophytes producing foraminal narrowing
• Mushroom cap facet appearance
• Joint space narrowing with sclerosis and bone eburnation
• Intraarticular gas (vacuum phenomenon)
• Enhancing inflammatory soft tissue changes surrounding
facet joint are common
Degenerative Diseases and Arthritides
• Joint space narrowing, thinning of articular cartilage
• Facet effusions as linear hyperintensity
TOP DIFFERENTIAL DIAGNOSES
• Septic facet
• Healing facet fracture
(Left) Lateral radiograph
shows severe facet
hypertrophic degenerative
arthropathy at C2-C3 ſt with
marked hypertrophy of the
facets. (Right) Axial NECT
shows severe, exuberant right
facet degenerative
arthropathy.
• Inflammatory arthritides
• Paget disease
• Myositis ossificans
• Metastasis
CLINICAL ISSUES
• Clinical pain aggravated by rest and alleviated by
movement
• Poor correlation between duration/severity of pain and
extent of facet degeneration
DIAGNOSTIC CHECKLIST
• Best detail with thin-section CT
• T2* images overemphasize degree of foraminal or central
narrowing
206
(Left) Sagittal NECT shows
multilevel hypertrophic facet
degenerative arthropathy with
vacuum phenomenon ſt, bony
eburnation, and osteophyte
formation. (Right) Axial T2*
GRE MR shows severe right
uncovertebral hypertrophic
degenerative arthropathy with
severe foraminal stenosis ſt
with a facet degenerative
change.
Lumbar Facet Arthropathy
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Facet arthrosis, degenerative facet disease, degenerative
joint disease, facet hypertrophy
• Osteoarthritis of synovially lined lumbar apophyseal joints
IMAGING
• Osseous overgrowth impinging on foramina in conjunction
with articular joint space narrowing
○ Mushroom cap facet appearance
○ Joint space narrowing with sclerosis/bone eburnation,
ligamentum flavum hypertrophy
○ Intraarticular gas, effusion
○ Spondylolisthesis not uncommon
• CT more sensitive than plain films for detecting presence
and degree of arthrosis
○ Facet hypertrophic degenerative arthropathy,
particularly superior articular facet
• MR best demonstrates degenerative facet compression of
thecal sac and fat-filled neural foramina
○ Enhancing inflammatory soft tissue changes surrounding
facet joint not uncommon
• Consider CT myelography if MR contraindications or MR
does not demonstrate facet relationship to neural foramina
TOP DIFFERENTIAL DIAGNOSES
• Septic facet
• Inflammatory arthritides
• Paget disease
• Tumor
○ Metastasis
○ Lymphoma
CLINICAL ISSUES
• Symptoms aggravated by rest and alleviated by movement
• Poor correlation between duration and severity of pain and
extent of degeneration
DIAGNOSTIC CHECKLIST
• Look for associated synovial cysts
(Left) Axial T1WI MR shows
marked facet hypertrophic
degenerative arthropathy with
enlarged facets ſt producing
moderately severe foraminal
stenosis . (Right) Axial T2WI
MR shows bilateral facet
hypertrophy and small
bilateral facet effusions ſt.
There is mild deformity of the
posterior margin of the thecal
sac but no significant central
stenosis.
(Left) Sagittal T1WI MR shows
L4-L5, L5-S1 facet
degenerative arthropathy with
bony hypertrophy and low
signal involving the facets
from bony sclerosis. There is
narrowing of the L5-S1
foramen primarily by the
hypertrophied superior
articular facet of S1 ſt.
(Right) Sagittal T1WI C+ MR
shows enhancement of the L4L5 and L5-S1 facets ſt due to
degenerative arthropathy.
207
Facet Joint Synovial Cyst
KEY FACTS
TERMINOLOGY
• Juxtaarticular cyst
• Facet joint ganglion cyst
• Synovial cyst formed from degenerative facet joint
IMAGING
• Posterolateral extradural cystic mass communicating with
facet joint
• Posterolateral to thecal sac
• Adjacent to facet joint
• Lumbar spine: 90%
○ Cervical and thoracic spine uncommon
TOP DIFFERENTIAL DIAGNOSES
Degenerative Diseases and Arthritides
• Extruded disc fragment
• Nerve sheath tumor
• Septic facet arthritis/epidural abscess
• Asymmetric ligamentum flavum hypertrophy
(Left) Axial graphic depicts a
right facet joint synovial cyst.
Fluid expands the right facet
joint, extending into a
subarticular recess in a
loculated collection. There is
mass effect on the thecal sac.
(Right) Axial T2WI MR shows
bilateral subarticular
hyperintense masses at L4L5, consistent with bilateral
facet synovial cysts. There is
bilateral facet degeneration
with facet effusions.
PATHOLOGY
• Facet osteoarthropathy
• Facet instability and hypermobility
• Greatest mobility at L4-L5
• Degenerative spondylolisthesis
CLINICAL ISSUES
• Chronic low back pain, radicular symptoms
• May spontaneously regress
• High postsurgical success rate in symptomatic patients
• Myelopathy if cervical or thoracic location
• Treatment
○ Conservative
○ Laminectomy with cyst excision
○ Percutaneous cyst aspiration/steroid injection
• High surgical success rate in symptomatic patients
208
(Left) Sagittal T2WI MR shows
peripheral low signal and
central heterogeneous
hyperintensity within a
dorsal extradural mass at C7T1 due to a juxtaarticular cyst.
(Right) Axial bone CT after
myelography with coronal
reformation shows an
extradural mass abutting the
right L4-L5 facet joint,
severely distorting the thecal
sac.
Baastrup Disease
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Close approximation and contact of adjacent spinous
processes with enlargement, flattening, and sclerosis of
apposing interspinous surfaces
• Putative source of back pain exacerbated by extension,
relieved with flexion
IMAGING
• Plain films/CT: Contact of adjacent spinous processes with
sclerosis ("kissing" spinous processes)
• T1WI: Apposing surfaces of spinous processes may show
low signal with bony sclerosis or marrow edema
• T2WI: Increased signal from interspinous ligament cystic
degeneration and bursa formation
TOP DIFFERENTIAL DIAGNOSES
• Ligamentum flavum hypertrophy
• Osteomyelitis, pyogenic
• Metastases, lytic osseous
• Juxtaarticular cyst
• Tumoral calcinosis
CLINICAL ISSUES
• Interspinous bursitis appearance seen in 8% of subjects
undergoing MR of lumbar spine for back or leg pain
• Associations with Baastrup
○ Increasing age
○ Central canal stenosis
○ Anterolisthesis
○ Facet degenerative change with facet effusions
• Treatment
○ Conservative therapy with NSAIDs
○ Direct steroid injection into bursa
○ X-Stop or other interspinous spacing device for
treatment of canal stenosis (less common)
○ Resection of offending spinous processes
(Left) Sagittal graphic shows
degeneration of the L4-L5
interspinous ligament ſt with
spinous process flattening and
sclerosis of apposing
interspinous surfaces. There is
associated ligamentum flavum
hypertrophy and
spondylolisthesis st. (Right)
Sagittal STIR MR shows
Baastrup disease as irregular
hyperintensity at the L2-L3
interspinous ligament level ſt.
There is an associated protein
containing a synovial
(juxtaarticular) cyst with
central low signal within the
dorsal epidural space causing
severe canal stenosis .
(Left) Sagittal STIR MR shows
bursa formation of the
interspinous ligament at the
L4-L5 level ſt seen as linear
hyperintensity. No adjacent
marrow signal abnormality is
seen. Note the grade II
spondylolisthesis at L4-L5.
(Right) Sagittal STIR MR shows
irregularity of apposed
margins of L4-L5 spinous
processes with ligamentum
flavum and interspinous
process hypertrophy ſt. Cystic
degeneration is shown as focal
high signal.
209