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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Bertolotti Syndrome
KEY FACTS
TERMINOLOGY
• Back pain related to unilateral or bilateral enlargement of
transverse process of most caudal lumbar vertebra, which
may articulate or fuse with sacrum or ilium
IMAGING
• Partial sacralization of caudal segment of lumbar body on
plain films, CT, or MR
TOP DIFFERENTIAL DIAGNOSES
• Normal variant
• Osteochondroma
• Posttraumatic ossification
• Sacroiliac joint degenerative change
Degenerative Diseases and Arthritides
• Facet joint arthropathy
PATHOLOGY
• 4-6% of normal patients show transitional segment
○ Hypothesized mechanism is reduced and asymmetrical
motion at lumbosacral junction
(Left) Axial NECT shows large
bridging pseudoarticulation
ſt of the caudal lumbar
segment with the sacrum and
ilium st on the left,
contrasted with the normal
right-sided anatomy. (Right)
Coronal NECT shows the large
neoarticulation of the caudal
lumbar body with the sacrum
with articular irregularity and
vacuum phenomenon ſt.
• Type I: Unilateral (Ia) or bilateral (Ib) dysplastic transverse
process measuring at least 19 mm craniocaudal
• Type II: Unilateral (IIa) or bilateral (IIb)
lumbarization/sacralization with enlarged transverse
process with diarthrodial joint with sacrum
• Type III: Unilateral (IIIa) or bilateral (IIIb)
lumbarization/sacralization with complete osseous fusion
of transverse process to sacrum
• Type IV: Unilateral type II transition withtype III on
contralateral side
CLINICAL ISSUES
• Causal relationship to low back pain controversial
• Conservative treatment with NSAIDs, physical therapy
• Steroid and local anesthetic infiltration into anomalous
lumbosacral articulation
• Resection of accessory joint
• Posterolateral fusion of transitional segment
210
(Left) Axial T2WI MR shows
the transitional anatomy at
the caudal lumbar segment
with partial sacralization on
the left ſt. (Right) Coronal CT
reconstruction shows the
anomalous pseudoarticulation
ſt at the caudal lumbar level
on the left between the body,
sacrum, and ilium.
Schmorl Node
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Definition: Node within vertebral body due to vertical disc
extension (intravertebral disc herniation) through vertebral
endplate
IMAGING
• Focal invagination of endplate by disc material surrounded
by sclerotic (old) or edematous (acute) bone
• Plain films
○ Contour defect within endplate, extending from disc
space into vertebral body spongiosa with well-corticated
margins
• CT
○ Island of low density surrounded by condensed bone on
axial slice through vertebral body
• MR
○ Focal defect in endplate filled by disc ± adjacent marrow
edema, fatty marrow conversion
TOP DIFFERENTIAL DIAGNOSES
• Acute compression fracture
• Degenerative endplate change
• Discitis
○ Both endplates show defect
• Limbus vertebrae
○ Seen at vertebral body corners
• Bone island
○ Sclerotic nodule
• Focal metastasis
○ No contiguity with parent disc
CLINICAL ISSUES
• Seen in up to 75% of all normal spines
• Conservative management
DIAGNOSTIC CHECKLIST
• Schmorl node is always contiguous with parent disc
(Left) Sagittal T1WI MR shows
a well-defined focus of low
signal involving the
superior endplate of S1 due to
endplate herniation. There is a
thin rind of fatty marrow
conversion adjacent to the
Schmorl node ſt. (Right)
Sagittal T2WI MR in the same
patient demonstrates the
typical pattern of fatty
marrow ſt outlining low
signal intensity chronic
endplate herniation .
(Left) Axial T2WI MR in the
same patient shows a welldefined focus of low signal
in the superior S1 endplate
representing a Schmorl node.
There is a thin concentric rind
of fatty marrow conversion ſt
surrounding the Schmorl node.
(Right) Lateral fluoroscopy
image in a different patient
during discography reveals a
superior endplate Schmorl
node . Contrast injected
into the contiguous
intervertebral disc fills the
herniated disc within the
vertebral defect.
211
Scheuermann Disease
KEY FACTS
TERMINOLOGY
• Juvenile kyphosis, Scheuermann kyphosis
• Kyphosis secondary to multiple Schmorl nodes → vertebral
body wedging
IMAGING
• Wedged-shaped thoracic vertebrae with irregular
endplates
○ ≥ 3 contiguous vertebrae, each showing ≥ 5° of kyphosis
○ Undulation of endplates secondary to extensive disc
invaginations
○ Disc spaces narrowed with greatest narrowing anteriorly
○ Well-defined Schmorl nodes
Degenerative Diseases and Arthritides
TOP DIFFERENTIAL DIAGNOSES
• Postural kyphosis
• Wedge compression fractures
• Congenital kyphosis
• Tuberculosis
(Left) Sagittal graphic
demonstrates anterior
vertebral wedging and
herniation of disc material
through the vertebral
endplates, creating focal
subcortical bone defects in
conjunction with thoracic
kyphotic deformity.
Undulation of endplates
reflects sequelae of the
osseous reparative process.
(Right) Lateral radiography
reveals anterior wedging
deformity and undulation of
vertebral endplates with
multiple Schmorl nodes at
each level .
• Osteogenesis imperfecta
• Neuromuscular disease
PATHOLOGY
• Disc extrusions through weakened regions of vertebral
endplates
• Weightlifting, gymnastics, and other spine-loading sports
may contribute
CLINICAL ISSUES
• Thoracic spine pain worsened by activity
• Kyphosis develops in adolescence, may present later in life
• Peak incidence: 13-17 years
• Initial treatment includes observation, bracing
• Surgical treatment for> 75° kyphosis in skeletally immature
person
DIAGNOSTIC CHECKLIST
• Schmorl nodes without anterior wedging are not indicative
of Scheuermann disease
212
(Left) Sagittal bone CT shows
loss of anterior vertebral
height and endplate
irregularity involving multiple
thoracic discs. There are
multiple (> 3) contiguous
levels of endplate
irregularities (Schmorl node)
and increased thoracic
kyphosis. (Right) Sagittal T2WI
MR (same patient) confirms
loss of disc height and signal
intensity at multiple thoracic
levels. The thoracic spinal cord
is normal and there are no
associated thoracic disc
herniations into the spinal
canal.
Acquired Lumbar Central Stenosis
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Spinal canal narrowing secondary to multifactorial
degenerative changes; is progressive and dynamic process
IMAGING
• Trefoil appearance of lumbar spinal canal on axial imaging
• Sagittal diameter of bony lumbar canal < 12 mm relative
stenosis
• Sagittal diameter of bony lumbar canal < 10 mm absolute
stenosis
• Hourglass appearance of central canal on sagittal T2WI
TOP DIFFERENTIAL DIAGNOSES
• Disc herniation
• Metastatic disease
• Paget disease
• Epidural hemorrhage
CLINICAL ISSUES
• Chronic low back pain
• Neurogenic claudication
○ Leg pain (80%)
○ Bilateral lower extremity pain, paresthesia, and
weakness
○ Relief of pain by squatting or sitting (flexion) in 80%
• Bladder dysfunction and sexual difficulty (10%)
• Radicular pain (10%)
• Operative treatment includes surgical decompression
(common) or X-Stop interspinous implant-like devices (less
common)
• Natural history: Majority of symptomatic patients stable
over months to years (40-70%)
○ 1/3 improve with nonoperative treatment
○ 1/3 deteriorate
DIAGNOSTIC CHECKLIST
• Axial T2WI mandatory for stenosis identification
(Left) Axial T1WI MR shows
severe central canal stenosis
due to a diffusely bulging
anulus ſt anteriorly and
posterior facet hypertrophic
degenerative arthropathy,
which combine to compress
the thecal sac. (Right) Axial
T2WI MR demonstrates severe
central canal stenosis with
marked facet degenerative
arthropathy. The thecal sac
has assumed a trefoil
appearance.
(Left) Sagittal T2WI MR shows
severe central stenosis at L4L5 due to marked posterior
ligamentum flavum thickening
ſt. Hyperintensity within the
interspinous ligament denotes
degeneration , which is also
called Baastrup disease or
interspinous bursitis. (Right)
Sagittal T2WI MR shows canal
stenosis at L3-L4 with a
bulging disc and ligamentous
thickening ſt. Note
serpentine areas of low signal
within the cephalad thecal sac
due to redundant nerve roots
.
213
Congenital Spinal Stenosis
KEY FACTS
TERMINOLOGY
• Reduced AP canal diameter secondary to short, squat
pedicles and laterally directed laminae
IMAGING
• Central canal diameter is smaller than normal
○ Cervical spine: Absolute AP diameter < 14 mm
○ Spinal stenosis present if AP canal diameter at L1 < 20
mm, L2 < 19 mm, L3 < 19 mm, L4 < 17 mm, L5 < 16 mm,
S1 < 16 mm
– Lumbar spine: Critical stenosis at L4 < 14 mm, L5 < 14
mm, S1 < 12 mm
• Short, thick pedicles
Degenerative Diseases and Arthritides
• Trefoil-shaped lateral recesses
• Laterally directed laminae
TOP DIFFERENTIAL DIAGNOSES
• Acquired spinal stenosis
• Inherited spinal stenosis
(Left) Sagittal graphic shows
marked congenital
anteroposterior narrowing of
the central spinal canal.
(Right) Sagittal T2WI MR
reveals moderate congenital
AP canal narrowing
exacerbated by C4-C5 disc
herniation. The protrusion
produces spinal cord T2
hyperintensity
corresponding to clinical
myelopathy.
○ Achondroplasia
○ Mucopolysaccharidoses
PATHOLOGY
• Torg ratio (AP canal diameter/AP vertebral body diameter)
< 0.8
• Idiopathic
CLINICAL ISSUES
• Symptomatic cervical or lumbar stenosis symptoms at
younger age than typical of degenerative stenosis
○ These patients typically lack complicating medical
problems (diabetes or vascular insufficiency)
• Athletes present with temporary neurological deficit
following physical contact that subsequently resolves
• Lumbar: Decompressive laminectomy, posterior
foraminotomy at involved levels
• Cervical: Posterior cervical laminectomy or laminoplasty
214
(Left) Sagittal T1 C+ MR shows
diffuse congenital central
canal stenosis with
superimposed acquired
stenosis at L4-L5 and L5-S1
levels with disc bulges.
Note the root enhancement at
L3-L4 secondary to the
stenosis ſt. (Right) Axial GRE
study at C3-C4 shows diffuse
high signal throughout the
substance of the cord ſt,
which is a typical pattern for
chronic traumatic
myelomalacia related to disc
disease. Note the small AP
diameter of the bony canal
due to congenital stenosis .
Cervical Spondylosis
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Spinal canal and neural foraminal narrowing in cervical
spine 2° to multifactorial degenerative changes
IMAGING
• Cervical spine, ventral epidural, centered at disc levels
• Sagittal diameter of cervical canal < 13 mm
• Disc osteophyte complex protruding into canal and
compressing thecal sac and cord
• Completely effaced subarachnoid space at disc levels in
cervical spine → "washboard spine"
• Variable degrees of cord compression
TOP DIFFERENTIAL DIAGNOSES
• Ossification of posterior longitudinal ligament
• DDx of abnormal cord signal
○ Cord tumor
○ Syrinx
○ Multiple sclerosis
○ Motor neuron disease
PATHOLOGY
• Multilevel disc degeneration with decreased disc hydration
and fissures
• Disc herniation, bulge with associated broad osteophytes
• Uncovertebral joint osteoarthritic change with foraminal
stenosis
CLINICAL ISSUES
• Acquired cervical spinal canal stenosis has no pathognomic
symptoms or signs
○ Spastic paraparesis commonly seen
○ Upper extremity numbness, weakness ("myelopathic
hand")
• Natural history of insidious onset, periods of static disability,
and episodic worsening
• Most common cause of spinal cord dysfunction worldwide
(Left) Sagittal T2WI MR shows
multilevel degenerative disc
disease and disc osteophyte
complexes with canal stenosis
spanning C3-C4 through C6C7. T2 hyperintensity present
within the cord centered at
C3-C4 ſt reflects
myelomalacia. (Right) Sagittal
T1WI C+ FS MR shows
horizontal linear enhancement
within the cervical cord ſt at
C3-C4 due to chronic
myelomalacia. There is also
enhancement of type I
degenerative endplate
changes at C6-C7 .
(Left) Axial CT angiogram
shows severe central canal
stenosis from ventral discosteophyte complex with
marked cord compression.
There is severe right foraminal
stenosis st with
uncovertebral joint
hypertrophy. (Right) Axial GRE
MR shows severe central canal
stenosis from ventral discosteophyte complex with
underlying congenital central
stenosis.
215
DISH
KEY FACTS
TERMINOLOGY
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Forestier disease, senile ankylosing hyperostosis,
asymmetrical skeletal hyperostosis
IMAGING
• Flowing anterior vertebral ossification with minimal
degenerative disc disease, facet arthropathy, absent facet
ankylosis
• Thoracic spine (100%) > cervical (65-80%), lumbar spine (6890%); R > L
• Lateral radiography inexpensive, reliable
• Reserve MR to evaluate for coexistent OPLL or spondylosis-
Degenerative Diseases and Arthritides
related cord compression
TOP DIFFERENTIAL DIAGNOSES
• Spondylosis
• Ankylosing spondylitis
• Psoriatic or reactive (Reiter) arthritis
(Left) Lateral radiograph
shows a large anterior ossified
mass that is discontinuous at
several disc spaces, a variation
implying some degree of
continued cervical spine
mobility. (Right) Sagittal NECT
shows large flowing ventral
osteophytes from C2 through
the upper thoracic spine ſt.
There is no bony fusion at C2C3, allowing limited motion at
this segment. Note the
blunted odontoid with a
hypertrophic anterior C1 arch
st and os odontoideum
articulating with the basion
.
PATHOLOGY
• Exact cause for exaggerated new bone formation stimuli
unknown
○ Exuberant entheseal reaction at tendon, ligament, and
joint capsule insertions
○ Associated with OPLL
○ Dysphagia related to DISH multifactorial
• Primary diagnostic criteria for DISH
○ Flowing anterior ossification extending over at least 4
contiguous vertebral bodies
○ No apophyseal or sacroiliac joint ankylosis
○ Mild degenerative disc changes, no facet ankylosis
CLINICAL ISSUES
• Majority of cases incidental
• Osteophyte resection if severe symptoms
• Increased risk of extension-type fractures with high
morbidity
216
(Left) Sagittal T1WI MR shows
bulky anterior flowing
ossification ſt consistent with
diffuse idiopathic skeletal
hyperostosis (DISH). Fatty
marrow is responsible for high
T1 signal intensity within the
anterior ossification. (Right)
Sagittal T1WI MR right
parasagittal slice shows bulky
flowing anterior longitudinal
ligament ossification ſt
spanning more than 4
vertebral levels but minimal
disc abnormality that is typical
of DISH.
OPLL
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Ossification of posterior longitudinal ligament (OPLL)
IMAGING
• Flowing multilevel ossification posterior to vertebral bodies
with relatively minimal degenerative disc disease, absent
facet ankylosis
○ Midcervical (C3-C5) > midthoracic (T4-T7)
○ PLL ossification narrows AP spinal canal dimension →
spinal stenosis, cord compression
• Characteristic "upside-down T" or "bowtie" PLL
configuration on axial images
○ CT with sagittal reformats to confirm MR diagnosis,
clarify extent of ossification for surgical planning
○ Sagittal T1WI, T2WI to evaluate spinal cord compression,
extent of ligamentous ossification
TOP DIFFERENTIAL DIAGNOSES
• Spondylosis
• Calcified herniated disc
• Meningioma
PATHOLOGY
• Continuous → ossified mass over several vertebral
segments
• Segmental → fragmented ossified lesions behind each
vertebral body
• Mixed → combination of continuous and segmental
• Other → ossification confined to disc level
• Diffuse idiopathic skeletal hyperostosi seen in 25% of
patients with OPLL
• OPLL present in 16-20% of cases of ossification of
ligamentum flavum
CLINICAL ISSUES
• Spastic paresis → paralysis (17-22%)
• ↑ risk for developing progressive myelopathy if > 60%
canal stenosis, ↑ cervical range of motion
(Left) Sagittal graphic shows
flowing multilevel ossification
of the posterior longitudinal
ligament (OPLL), producing
canal narrowing and cord
compression. (Right) Sagittal
STIR MR shows the typical
pattern of continuous-type
OPLL seen as low signal
ventral to the cord ſt with
severe cord compression. Note
the associated diffuse
idiopathic skeletal
hyperostosis with multilevel
fusion .
(Left) Axial GRE MR shows a
rectangular focus of markedly
low signal ventral to the cord,
consistent with OPLL ſt.
There is severe cord
compression . (Right)
Sagittal T1 C+ MR shows a
slightly heterogeneous mass
ventral to the cervical cord
with severe cord compression.
OPLL may show low or
heterogeneous increased
signal on T1WI due to marrow
content with fat elements.
217
Ossification Ligamentum Flavum
KEY FACTS
TERMINOLOGY
• Ossification of ligamentum flavum, ossification of vertebral
arch ligaments, ligamentum flavum "pseudogout"
• Calcification/ossification of ligamentum flavum
IMAGING
• Linear thickening of ligamentum flavum with imaging
characteristics similar to adjacent vertebral marrow
ossification
• Curvilinear hyperdense thickening of ligamentum flavum
• Hypointense linear "mass" within ligamentum flavum ±
cord myelomalacia, ↑ signal intensity 2° to compression
• CT imaging best modality for primary diagnosis, "lesion
Degenerative Diseases and Arthritides
conspicuity"
TOP DIFFERENTIAL DIAGNOSES
• Facet arthrosis
• Meningioma
(Left) Sagittal NECT shows
that, at essentially every
thoracic level, there are
various patterns of
ligamentum flavum
ossification ſt. These areas of
ossification merge with the
facets along their ventral
margins. (Right) Axial NECT
shows typical thoracic
ligamentum flavum
ossification as clumped and
linear calcifications ventral
and medial to the facets ſt.
They may have variable mass
effect upon the thecal sac but
can be a source of thoracic
myelopathy.
PATHOLOGY
• Ectopic bone formation within ligamentum flavum
• In majority of patients (idiopathic presentation) mechanism
is unclear
○ Some cases clearly associated with metabolic or
endocrine disease
• Variably coexists with DISH, OPLL
CLINICAL ISSUES
• Often incidental observation on imaging study ordered for
other reasons
• May be associated with cord compression and chronic
thoracic myelopathy
○ Ambulation difficulty, weakness, back pain, and lower
extremity paresthesias
○ 4th → 6th decade
○ Symptomatic presentation more common in Japanese,
North African descent > > Caucasian > African American
218
(Left) Sagittal T2WI MR shows
ossified ligamentum flava as
low signal st at every thoracic
level, merging with the low
signal of the cortex of the
facet joints. (Right) Axial T2*
GRE MR demonstrates the
ossified ligaments as low
signal st with compression of
the dorsal thecal sac
producing central canal
stenosis. This should be
distinguished from congenital
stenosis with shortened
pedicles.
Periodontoid Pseudotumor
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Calcium pyrophosphate dihydrate deposition disease
(CPPD); articular chondrocalcinosis
• Crowned dens syndrome: Fever with cervicooccipital
junction pain, stiffness with associated calcification of
transverse ligament and nonenhancing retroodontoid soft
tissue; associated with CPPD or hydroxyapatite deposition
• Pseudogout: Arthritis caused by CPPD crystal inflammation
with symptoms like gout
IMAGING
• Calcification of transverse ligament on CT
• T1WI: Iso- to low-signal mass posterior to odontoid
• T2WI: Low-signal mass posterior to odontoid
• T1WI C+: May show peripheral enhancement
TOP DIFFERENTIAL DIAGNOSES
• Rheumatoid arthritis
• Osteoarthritis
• OPLL
• Osteomyelitis
• Meningioma
• Metastatic disease
• Longus colli calcific tendinitis
PATHOLOGY
• Nodular deposits of birefringent, rhomboid crystals
CLINICAL ISSUES
• Age 60 or older, prevalence of CPPD deposition = 34%
• Crowned dens: Inflammatory indicators + (fever, CRP,
elevated WBC count)
• Conservative treatment including NSAIDs, steroids, or both;
physical therapy
DIAGNOSTIC CHECKLIST
• Calcification of transverse ligament common in elderly but
symptomatic CPPD very uncommon
(Left) Axial NECT shows
amorphous calcification within
the transverse ligament at the
C1-C2 junction ſt. There is
also osteoarthritic
degenerative change at the
anterior C1-C2 joint with
vacuum phenomenon. (Right)
Sagittal T2WI MR shows a
low-signal pseudotumor
posterior to the odontoid
process ſt with moderate
mass effect upon the cervical
cord. A low-signal mass
extends over the superior
margin of the odontoid. Note
the associated calcification of
ligamentum flavum st.
(Left) Sagittal T1WI MR shows
prominent soft tissue
surrounding the odontoid
process ſt with mass effect
upon ventral thecal sac and
cord at C1 level. There is
severe multilevel disc
degeneration and canal
stenosis. (Right) Sagittal T1WI
C+ MR shows mild peripheral
enhancement of the calcium
pyrophosphate dihydrate
deposition pseudotumor
involving the periodontal soft
tissues ſt. Low T2 signal and
peripheral enhancement are
typical of this soft tissue.
219