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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Thoracic Spine
http://pdf-radiology.com
TERMINOLOGY
Abbreviations
• Costovertebral (CV)
Synonyms
• Costal facet = demifacet
GROSS ANATOMY
Overview
• Consists of 12 vertebrae (T1-12)
• Thoracic kyphosis
Normal Anatomy and Techniques
○ 1 of 2 primary spinal curves (thoracic & sacral) present at
birth, maintained throughout life
○ Cervical & lumbar lordoses are secondary curves, more
flexible than thoracic, & result of development
– Considerable variability in amount of kyphosis (20-45°)
– Each body contributes 3.8° of kyphosis via wedge-
shaped angulation
– Apex at T7
– Increases with age
– M < F
• Thoracolumbar junction
○ Transition from rigid thoracic spine to more mobile
lumbar spine
○ T11, T12 ribs provide less rigidity compared to rest of
thoracic spine
○ No connection to sternum (free floating)
○ Only single rib articulation on vertebral bodies
• Unique features of thoracic spine
○ Articulation with rib cage
○ Coronal facet orientation
○ Small spinal canal relative to posterior element size
Components
• Bones
○ Thoracic vertebrae increase in size from T1 → T12
○ Body
– Typical body contains 2 costal demifacets laterally
– T1 has complete facet superiorly and demifacet
inferiorly; T10 has superior demifacet only; T11 and 12
have complete facet
○ Arch
– Pedicle: Projects directly posterior
– Transverse process: T1 transverse process projects
superolaterally; T1-10 transverse process costal facet
articulates with costal tubercle
– Articular processes: Superior & inferior articular
process with coronally oriented facet joint
– Lamina
– Spinous process: T1-T9 project inferiorly; T10-T12
project more horizontally
• Intervertebral foramen
○ Oriented laterally below pedicle
• Joints
○ Intervertebral disc
○ Facet (zygapophyseal) joints
– Facets oriented near vertical in coronal plane
– Limit flexion & extension
○ Rib articulations
– Costovertebral joint: Rib head articulates with 2
costal demifacets; superior costal facet of same
number vertebra as rib & inferior costal facet of next
vertebral body
– Costotransverse joint: Transverse process of
vertebral body T1-T10
• Muscles
○ Superficial muscles include trapezius, rhomboid,
latissimus dorsi, & serratus inferior & superior
○ Deep muscles include erector spinae (sacrospinalis),
iliocostalis, longissimus, spinalis & semispinalis thoracis,
multifidus, rotatores, & interspinalis
• Ligaments
○ Anterior & posterior longitudinal, interspinous,
supraspinous ligaments & ligamentum flavum
○ Costovertebral ligaments
– Radiate ligament connects head of rib & adjacent
vertebral bodies
– Costotransverse ligaments (lateral & superior) connect
neck of rib with transverse process
• Biomechanics
○ Intact rib cage increases axial load resistance 4x
○ Rib cage & facets limit rotation
IMAGING ANATOMY
Radiography
• Short C7 transverse process projects inferolaterally; long T1
transverse process projects superolaterally
MR
• Body: Signal intensity of marrow varies with age
○ Hemopoietic ("red") marrow is hypointense on T1WI,
becomes hyperintense with conversion from red →
yellow (age 8-12 years)
○ Endplate, reactive marrow changes normally with aging
(can be fibrovascular, fatty, or sclerotic)
• Intervertebral disc: Signal intensity varies with age
○ Hyperintense on T2WI in children, young adults;
progressive ↓ water → hypointense on T2WI
○ Disc degeneration, desiccation, shape change (bulge)
normal after 2nd decade
• Ligaments: Hypointense on both T1 & T2WI
ANATOMY IMAGING ISSUES
Questions
• Thoracic spinal cord is protected & shielded from injury by
paraspinal muscles & rib cage
• Narrow spinal canal of thoracic spine allows for easy cord
compression with malalignment or trauma
• Normal kyphotic posture increases risk of fracture
• Thoracolumbar junction at more traumatic risk due to lack
of rib cage stabilization
Imaging Pitfalls
• Cervicothoracic junction
○ Cervical ribs arising from C7 found in 0.5% population
○ Short C7 transverse process projects inferolaterally
○ Long T1 transverse process projects superolaterally
30
Thoracic Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
3D VRT NECT
Lamina
Medial portion of rib
Transverse process with costotransverse
joint
Inferior demifacet of costovertebral joint
Superior demifacet of costovertebral
joint
Medial portion of rib
Lateral cortical margin of vertebral body
Neural foramen
Spinous process
Spinal canal
Anterior cortical margin of vertebral
body
Intervertebral disc
Costovertebral joint
Transverse process
Pedicle
Facet (zygapophyseal) joint
Inferior demifacet of costovertebral joint
Intervertebral disc
Medial portion of rib
Neural foramen
Inferior demifacet of costovertebral joint
Intervertebral disc
Superior demifacet of costovertebral
joint
(Top) Oblique anterior 3D VRT examination shows the thoracic spine. The complex costovertebral and costotransverse joints are
highlighted in the projection. The superior and inferior demifacets are identified with the joint proper crossing the intervertebral disc
space. (Middle) Lateral oblique 3D VRT examination shows the thoracic spine. The relationship of the neural foramen and the posterior
elements and costal joints is visualized in this projection. The foramen is bounded posteriorly by the facet joint, superiorly by the
pedicle, and ventrally by the posterior margin of the vertebral body. (Bottom) Lateral 3D VRT examination shows the thoracic spine.
The neural foramina are oriented laterally, therefore viewed en face in this projection and bound by the vertebral body anteriorly,
pedicle superiorly, and facet joint posteriorly.
Superior demifacet of costovertebral
joint
Spinous process
Transverse process with costotransverse
joint
Pedicle
31
3D VRT NECT
http://pdf-radiology.com
Medial portion of rib
Neural foramen
Normal Anatomy and Techniques
Intervertebral disc
Left rib
Thoracic Spine
Costotransverse joint
Spinous process
Lamina
Facet joint
Right transverse process
Left transverse process
Neural foramen
Medial portion of rib
Spinous process
Left transverse process with
costotransverse joint
Left rib
Lateral cortical margin of vertebral body
Medial portion of rib
Neural foramen
Right rib
Right transverse process
Spinous process
Costovertebral joint
Transverse process
Lamina
Right rib
Right transverse process with
costotransverse joint
Spinal canal
Costovertebral joint
Pedicle
Facet joint
Left rib
Left transverse process with
costotransverse joint
Lamina
32
(Top) Oblique anterior 3D VRT examination shows the thoracic spine. The facet joints are partially seen in this projection, primarily
obscured by the posterior surface of the inferior articular facet, which overlaps the dorsal surface of the superior articular facet from
the next caudal vertebra. The thoracic spinous processes are long and directed inferiorly, overlapping the next vertebral body level.
(Middle) Posterior 3D VRT examination shows the thoracic spine. The posterior bony projections of the thoracic spine are highlighted in
this projection, including the spinous processes, transverse processes, and the costotransverse articulations. (Bottom) Axial 3D VRT
examination shows the thoracic spine. The 2 costal articulations are viewed in this projection. The neural foramen is immediately
adjacent to the costovertebral articulations.
Thoracic Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
AXIAL BONE CT
Aorta
Vertebral endplate
Thoracic intervertebral disc
Neural foramen
Superior articular facet
Inferior articular facet
Spinal canal
Costovertebral joint
Superior articular facet
Inferior articular facet
Spinal canal
Facet (zygapophyseal) joint
Lamina
Spinous process
Aorta
Vertebral body
Pedicle
Facet joint
Lamina
Spinous process
(Top) The 1st of 6 axial bone CT images presented from superior to inferior at the intervertebral disc level is shown. Neural foramina are
directed laterally and bound anteriorly by the posterior vertebral body margin and dorsally by the facet joint (superior articular facet).
The facet joints are oriented in a coronal plane and strongly resist rotation combined with the costovertebral joints. (Middle) In this
image through the pedicle level of the thoracic spine, the coronal orientation of the facet joints is well identified. The pedicles are
relatively thin and gracile with the adjacent rib articulations. (Bottom) In this image through vertebral body level, the posterior bony
projections are highlighted, including the spinous process, transverse processes, and medial ribs.
Spinal canal
Superior articular facet
Medial rib
Transverse process
Aorta
Vertebral body
Pedicle
Costotransverse joint
Spinous process
33
SAGITTAL T2 MR
http://pdf-radiology.com
Vertebral body
Superior endplate
Inferior endplate
Anterior cortical margin
Normal Anatomy and Techniques
Intervertebral disc
Thoracic Spine
Spinal canal with spinal cord
Ligamentum flavum
Posterior dural margin
Epidural fat
Spinous process
Anterior longitudinal ligament
Basivertebral vein
Pedicle
Neural foramen
Vertebral body
Anterior cortical margin
Intervertebral disc
Interspinous ligament
Supraspinous ligament
Conus medullaris
Facet joint
Inferior articular facet
Superior articular facet
Lamina
Epidural fat
34
Costovertebral joint
Intervertebral disc
Vertebral body
(Top) The 1st of 3 sagittal T2 MR images of the thoracic spine presented from medial to lateral is shown. The square thoracic vertebral
bodies with the small intervening intervertebral discs are identified in this midline view. The spinous processes are large and dominate
the dorsal soft tissues. The thoracic cord is seen in its entirety with its smoothly tapering conus medullaris. (Middle) The facet joints are
identified on this sagittal image with the coronally oriented joints seen in lateral view. The superior and inferior articular processes and
neural foramen are easily viewed in this plane. (Bottom) The more lateral margin of the neural foramen is identified on this section as
well as the costovertebral joints at the disc levels.
Neural foramen
Erector spinae muscle
Superior articular facet
Inferior articular facet
Pedicle
Thoracic Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
AXIAL T2 MR
Aorta
Spinal canal
Costovertebral joint
Transverse process
Rib
Spinal canal
Neural foramen
Superior articular facet
Inferior articular facet
Vertebral body
Spinal cord
Pedicle
Costotransverse joint
Ligamentum flavum
Spinous process
Aorta
Vertebral body (endplate)
Spinal cord
Lamina
Spinous process
(Top) The 1st of 3 axial T2 MR images of the thoracic spine is shown. The relationship of the medial rib forming the strong
costotransverse and costovertebral joints is highlighted. The transverse processes extend dorsally and laterally to articulate with the
medial ribs. The spinous process is large and directed caudally. (Middle) In this image through the foraminal level of the thoracic spine,
the neural foramina are directed laterally with their posterior margin formed by the facet joints and anterior margin by the vertebral
body and disc. (Bottom) In this image through the disc level, the coronal orientation of the facet joints is identified, forming the
posterior boundary of the neural foramen. The components of the intervertebral disc are also shown in this section with well-defined
nucleus pulposus and annulus fibrosus.
Annulus fibrosus
Spinal canal
Neural foramen
Superior articular facet
Inferior articular facet
Supraspinous ligament
Aorta
Intervertebral disc (nucleus pulposus)
Facet joint
Lamina
Spinous process
35
Lumbar Spine
http://pdf-radiology.com
TERMINOLOGY
Abbreviations
• Anterior longitudinal ligament (ALL)
• Posterior longitudinal ligament (PLL)
Synonyms
• Articular processes = facets = zygapophyses
GROSS ANATOMY
Overview
• 5 discovertebral units (L1-L5)
Normal Anatomy and Techniques
Components
• Bones
○ Body
– Large oval cancellous ventral mass
– Larger in transverse width than AP diameter
○ Endplates
– Formed by superior & inferior surfaces of vertebral
bodies
– Consist of concave surfaces of 1-mm-thick cortical
bone & hyaline cartilage plates
– Endplates are transitional between fibrocartilage disc
& vertebral body
– Nutrients to disc diffuse via endplates
○ Arch
– Pedicle: Project directly posteriorly
– Transverse process: Extend out laterally, long and flat
on L1-L4, small at L5
– Articular process: Superior and inferior articular
processes with pars interarticularis between; facet
joints oriented obliquely
– Lamina: Broad, thick, overlap minimally
– Spinous process
• Intervertebral foramen
○ Aperture giving exit to segmental spinal nerves and
entrance to vessels
○ Oriented laterally below pedicle
○ Boundaries
– Superior & inferior pedicles of adjacent vertebrae
– Ventral boundary is dorsal aspect vertebral body
above and intervertebral disc below
– Dorsal boundary is joint capsule of facets and
ligamentum flavum
○ Vertical elliptical shape in lumbar region
– Vertical diameter 12-19 mm
– Transverse diameter from disc to ligamentum flavum
~ 7 mm; thus, little room for pathologic narrowing
• Joints
○ Intervertebral disc
– Outer annulus fibrosus (alternating layers of collagen
fibers)
– Inner annulus fibrosus (fibrocartilaginous component)
– Transitional region
– Central nucleus pulposus (elastic mucoprotein gel
with high water content)
○ Facet (zygapophyseal) joints
– Facet joints oriented obliquely
– Superior facet: Concave, faces dorsomedially to meet
inferior facet from above
– Inferior facet: Faces ventrolaterally to meet superior
facet from body below
• Ligaments
○ ALL and PLL, interspinous and supraspinous ligaments
○ Ligamentum flavum
– Thick in lumbar region
– Connects adjacent lamina
– Extends from capsule of facet joint to junction of
lamina with spinous process, discontinuous in midline
• Muscles
○ Erector spinae: Poorly differentiated muscle mass
composed of iliocostalis, longissimus, spinalis
○ Multifidi (best developed in lumbar spine)
○ Deep muscles: Interspinalis, intertransversarius
○ Quadratus lumborum & psoas muscles
• Biomechanics
○ Lumbar articulations permit ventral flexion, lateral
flexion, extension
○ Facets prevent rotation
○ Lumbosacral junction motion checked by strong
iliolumbar ligaments
IMAGING ANATOMY
Radiography
• "Scotty dog" demonstrated on oblique view
○ Nose = transverse process, eye = pedicle, ear = superior
articular process, neck = pars interarticularis, front leg =
inferior articular process
Cross-Sectional Imaging
• Facet joint orientation
○ Facet joint angle is measured relative to coronal plane
○ Normal facet joint angle ~ 40°
○ More sagittally oriented facet joints (> 45°) at L4 & L5
levels ↑ incidence of disc herniation & degenerative
spondylolisthesis
ANATOMY IMAGING ISSUES
Imaging Pitfalls
• Lumbosacral junction
○ Transitional lumbosacral vertebrae
– Congenital malformation of vertebrae, usually last
lumbar or 1st sacral vertebra
– Bony characteristics of both lumbar vertebrae and
sacrum
○ Vertebral facet asymmetry (tropism)
– Asymmetry between left & right vertebral facet
(zygapophyseal) joint angles
– Tropism defined as mild (6-10°), moderate (10-16°), or
severe (> 16°)
– Variable relationship between facet joint tropism &
disc herniation at L4 and L5 level
36
Lumbar Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
RADIOGRAPHY
Pedicle
Facet joint
Intervertebral disc space
Transverse process
Spinous process
Lamina
Sacroiliac joint
Inferior endplate L2
Superior endplate L3
Intervertebral disc space
L5 body
L5-S1 intervertebral disc space
T12 ribs
L1 body
L2 body
L3 body
L4 body
L5 body
Sacral ala
Sacral foramen
T12 ribs
Neural foramen L1-L2
Pedicle
Inferior articular process L3
Superior articular process L4
Facet joint
Pars interarticularis L5
S1 body
"Scotty dog"
Superior articular process (ear)
Transverse process (nose)
Pedicle (eye)
Pars interarticularis (neck)
Pars interarticularis L5
(Top) AP view shows the lumbar spine. The lumbar bodies are large and rectangular in shape with relatively thick intervertebral disc
spaces. The pedicles are viewed en face with the adjacent facet joints incompletely visualized due to their obliquity. The large
horizontal transverse processes are easily identified at the pedicle levels. (Middle) Lateral view shows the lumbar spine. The large,
strong lumbar bodies join with the stout lumbar pedicles and posterior elements. The neural foramina are large and directed laterally.
The boundary of the neural foramen includes the posterior vertebral body, inferior and superior pedicle cortex, and superior articular
process. (Bottom) Oblique view shows the lumbar spine. The typical Scotty dog appearance of the posterior elements is visible. The neck
of the dog is the pars interarticularis.
Transverse process
Inferior articular process (front leg)
37
3D VRT NECT
http://pdf-radiology.com
Inferior endplate
Intervertebral disc space
Normal Anatomy and Techniques
Superior endplate
Vertebral body
Lumbar Spine
Superior articular process
Transverse process
Neural foramen
Inferior articular process
Superior articular process
Pedicle
Transverse process
Vertebral body
Inferior endplate
Intervertebral disc space
Superior endplate
Pedicle
Transverse process
Pars interarticularis
Superior articular process
Neural foramen
Spinous process
Inferior articular process
Superior articular process
Pars interarticularis
Lamina
Spinous process
Inferior articular process
Facet joint
38
(Top) Left anterior oblique 3D VRT NECT examination shows the lumbar spine. The broad, stout pedicle/vertebral body junction is
highlighted in this projection with the superior facet arising as the dorsal extension. (Middle) Left lateral 3D VRT NECT examination of
the lumbar spine shows the neural foramen seen en face as it projects laterally. (Bottom) Left posterior oblique 3D VRT NECT
examination shows the lumbar spine. This view shows the surface anatomy inherent in the "Scotty dog." The transverse process (nose),
superior articular process (ear), inferior articular process (front leg), and intervening pars interarticularis (neck) are well defined. The
pedicle that forms the "eye" on oblique radiographs is obscured. The oblique sagittal orientation of the facet joints is evident in this
view, restricting lumbar rotation and allowing flexion/extension.
Lumbar Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
AXIAL BONE CT
Psoas muscle
Facet joint
Lamina
Pedicle
Facet joint
Ligamentum flavum
Intervertebral disc
Neural foramen
Spinous process
Vertebral body
Superior articular process & facet
Inferior articular process & facet
Spinous process
(Top) The 1st of 6 axial bone CT images through the lumbar spine is presented from superior to inferior. This image is at intervertebral
disc and lower neural foraminal level. The posterior intervertebral disc forms the lower anterior border of the neural foramen, which
contains primarily fat. Exiting nerves are in the upper neural foramen. (Middle) This image through the facet joint demonstrates the
typical lumbar morphology with the superior facet showing a concave posterior surface and inferior facet showing the complementary
convex anterior surface. Facet joints are oriented ~ 40° from the coronal plane. An angle of > 45° from the coronal plane increases
incidence of disc herniation and degenerative spondylolisthesis at L4 and L5 levels. (Bottom) This image shows the triangular central
vertebral canal and posteriorly oriented pedicles. Basivertebral veins enter the vertebral body through the posterior cortex.
Vertebral body
Vertebral canal
Basivertebral vein
Pedicle
Transverse process
Lamina
39