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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
AXIAL BONE CT
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Vertebral body
Basivertebral vein
Vertebral canal
Normal Anatomy and Techniques
Lumbar Spine
Pedicle
Transverse process
Lamina
Spinous process
Vertebral body endplate
Neural foramen
Vertebral canal
Psoas muscle
Neural foramen
Facet joint
Lamina
Psoas muscle
Posterior longitudinal ligament
Ligamentum flavum
Lamina
Spinous process
Intervertebral disc
Superior articular process
Inferior articular process
Ligamentum flavum
40
Spinous process
(Top) This image at the midvertebral body level shows a thick cortical vertebral body margin and midline posterior basivertebral veins.
The pedicles are strong, thick, and directed posteriorly. Large transverse processes project from the lateral margins. (Middle) In this
image at the endplate level, the neural foramen is identified, opening laterally. The posterior elements have a T pattern with the large
posteriorly directed spinous process. (Bottom) This image through the intervertebral disc level again demonstrates the lower neural
foramen bound anteriorly by intervertebral disc and posteriorly by the superior articular process and facet joint. Oblique coronal
orientation of the facet joints is again appreciated. Asymmetry between the left and right vertebral facet joint angles with 1 joint
having a more sagittal orientation than the other is termed tropism.
Lumbar Spine
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Normal Anatomy and Techniques
SAGITTAL T1 MR
Conus medullaris
Basivertebral vein
Anterior longitudinal ligament
Inferior endplate L4
Intervertebral disc
Superior endplate L5
L5 body
Anterior longitudinal ligament
Inferior endplate L4
Intervertebral disc
Superior endplate L5
L5 body
Spinous process
Supraspinous ligament
Interspinous ligament
Epidural fat
Dorsal dural margin
Lumbar cerebrospinal fluid
S1 body
L1 vertebral body
Epidural fat
Facet joint
Inferior articular process L4
Ligamentum flavum
S1 body
(Top) The 1st of 3 sagittal T1 MR images of the lumbar spine is presented from medial to lateral. The normal marrow signal on T1
images is of increased signal compared to the adjacent intervertebral discs in the adult due to fatty marrow content. The basivertebral
veins are seen as signal voids in the midline of the posterior vertebral bodies, often with surrounding high signal fatty marrow. The
intervertebral disc morphology is poorly identified on this sequence with little differentiation of annulus or nucleus. (Middle) In this
image, the lateral vertebral bodies are evident with the pronounced oblong-shaped inferior articular facets dominating the posterior
aspect. (Bottom) In this image, the anterior boundaries of the neural foramina are evident, as is the relationship of the disc to the
exiting nerve.
L1 vertebral body
L3 nerve root
Inferior endplate L4
Intervertebral disc
Superior endplate L5
L5 body
Neural foramen
Superior articular process L4
Facet joint
Pedicle L5
Nerve root L5
S1 nerve root
41
AXIAL T2 MR
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Lumbar Spine
Inferior vena cava
Psoas muscle
Thecal sac with cauda equina
Neural foramen
Normal Anatomy and Techniques
Multifidus muscle
Inferior vena cava
Ligamentum flavum
Lamina
Epidural fat
Thecal sac
Aorta
Intervertebral disc L3-L4
L4 transiting nerve
L3 nerve
L3-L4 facet joint
Ligamentum flavum
Spinous process
Aortic bifurcation
L4 vertebral body
L4 pedicle
L4 nerve
Spinous process
Inferior vena cava
Psoas muscle
Neural foramen
Lamina
Supraspinous ligament
(Top) The 1st of 6 axial T2 MR images of lumbar spine is presented from superior to inferior. This view through the intervertebral disc
shows increased disc signal within the central nucleus pulposus due to its high water content and low signal within the peripheral
annulus fibrosus. The margin with the thecal sac is sharp with the cauda equina seen as punctate nerves within the high signal
cerebrospinal fluid. The L3 nerve is extraforaminal in location; the L4 nerve is transiting in lateral recess. (Middle) This image just below
the L4 pedicle shows the exiting L4 nerve passing just below the pedicle within the upper neural foramen. (Bottom) This image shows
the L4 nerve ganglion and surrounding fat within the midneural foramen. The posterior margin of the neural foramen at this level is the
facet joint complex, and the anterior margin is the posterior vertebral body.
Left common iliac artery
L4 nerve ganglion
Spinous process
Interspinous ligament
42
Psoas muscle
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L4 nerve (ventral branch)
L4 nerve (dorsal branch)
Lamina
Lumbar Spine
Normal Anatomy and Techniques
Intervertebral disc L4-L5
Transiting L5 nerve
Superior articular process of L5
Inferior articular process of L4
Ligamentum flavum
Psoas muscle
Thecal sac with cauda equina
Pedicle
L5 nerve
S1 nerve within thecal sac
Thecal sac with cauda equina
Neural foramen
Facet joint
Lamina
Vertebral body
Spinous process
Intervertebral disc L5-S1
Superior articular process of S1
Inferior articular process of L5
Ligamentum flavum
(Top) This image through the lower neural foramen is bordered anteriorly by the posterior margin of the intervertebral disc and
posteriorly by the facet joint. The L4 nerve has divided into anterior and posterior branches. (Middle) This image through the upper L5
neural foramina shows the exiting L5 nerves just below the pedicles. (Bottom) In this image through the L5-S1 intervertebral disc, the
typical facet morphology is again identified. The superior articular facet is seen as a convex anterior bony mass with low signal cortical
margin. The joint space is seen as a linear focus of high signal due to joint fluid and cartilage. The inferior articular facet is typically
convex anteriorly, although it can be seen as a more straight margin or even slightly concave (as is seen on the left). The facet joints are
oriented ~ 40° from the coronal plane.
43
Measurement Techniques
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Terminology
Radiographic measurement techniques, skull base
craniometry, skull base lines
Pathology-based Imaging Issues
This chapter provides a broad summary of the varied
measurement techniques used to evaluate the spine. The
main focus for the reader should be the tables and the
multiple schematics that define the variously named lines and
angles. These summarize the classic measurement techniques
for the skull base and rheumatoid disease as well as some of
the most commonly used measurements for trauma
assessment. The rest of the measurements defined below are
Normal Anatomy and Techniques
a mixture of miscellaneous measurements and those that do
not translate well into a table (i.e., equations).
Torg-Pavlov Ratio
• Diameter of canal to width of vertebral body (initially
defined on plain radiographs of subaxial spine)
• Utility is controversial; < 0.80 as seen on lateral view
considered to be cervical stenosis, such small canal
potentially increases risk for cord injury
Maximum Canal Compromise (%)
• = 1-(Di/[(Da+Db)/2]) x 100%
• AP canal diameter at normal levels (immediately above
and below level of injury) and at level of maximum
compromise are defined; measurement of normal levels
is taken at the midvertebral body level: Di is
anteroposterior canal diameter at level of maximum
injury, Da is AP canal diameter at nearest normal level
above level of injury, and Db is AP canal diameter at
nearest normal level below level of injury
• In spinal cord injury patients, midline T1 and T2 images
provide objective, quantifiable, and reliable assessment
of cord compression that cannot be defined by CT alone
Maximum Cord Compression (%)
• = 1-(di/[(da+db)/2]) x 100%
• AP cord diameter at normal levels immediately above
and below level of injury and at level of maximum cord
compression are defined: di is anteroposterior cord
diameter at level of maximum injury, da is AP cord
diameter at nearest normal level above level of injury,
and db is AP cord diameter at nearest normal level below
level of injury (if cord edema is present, then
measurements are made at midvertebral body level just
above or below extent of edema where cord appears
normal)
Cobb Measurement of Kyphosis
• Lines are drawn to mark superior endplate of superior
next unaffected vertebral body and inferior endplate of
inferior next unaffected vertebral body, which are then
extended anterior to bony canal; perpendicular lines are
then extended, and angle between 2 perpendicular lines
is measured
Tangent Method for Kyphosis
• Lines are drawn along posterior vertebral body margin
on lateral view of affected body and next most superior
body that is unaffected; angle between these 2 vertically
oriented lines is measured
Centroid, or the geometric center of the vertebral body, is
defined by drawing diagonal lines between opposite corners
of the body, with the centroid at the intersection.
Apical Vertebral Translation (AVT)
• Lateral displacement of apex of coronal curve is relative
to center sacral vertical line (CSVL) on AP plain film; AVT
is horizontal distance between centroid of apical body
and CSVL
Sagittal Balance
• Sagittal alignment is defined on lateral view using C7
plumb line; distal reference point is posterior superior
aspect of sacrum (positive number if C7 plumb line falls
anterior to reference point, negative number if it falls
posterior to reference)
Selected References
1. Radcliff KE et al: Comprehensive computed tomography assessment of the
upper cervical anatomy: what is normal? Spine J. 10(3):219-29, 2010
2. Rojas CA et al: Evaluation of the C1-C2 articulation on MDCT in healthy
children and young adults. AJR Am J Roentgenol. 193(5):1388-92, 2009
3. Angevine PD et al: Radiographic measurement techniques. Neurosurgery.
63(3 Suppl):40-5, 2008
4. Bono CM et al: Measurement techniques for upper cervical spine injuries:
consensus statement of the Spine Trauma Study Group. Spine (Phila Pa
1976). 32(5):593-600, 2007
5. Furlan JC et al: A quantitative and reproducible method to assess cord
compression and canal stenosis after cervical spine trauma: a study of
interrater and intrarater reliability. Spine (Phila Pa 1976). 32(19):2083-91,
2007
6. Pang D et al: Atlanto-occipital dislocation--part 2: The clinical use of (occipital)
condyle-C1 interval, comparison with other diagnostic methods, and the
manifestation, management, and outcome of atlanto-occipital dislocation in
children. Neurosurgery. 61(5):995-1015; discussion 1015, 2007
7. Pang D et al: Atlanto-occipital dislocation: part 1--normal occipital condyle-C1
interval in 89 children. Neurosurgery. 61(3):514-21; discussion 521, 2007
8. Bono CM et al: Measurement techniques for lower cervical spine injuries:
consensus statement of the Spine Trauma Study Group. Spine (Phila Pa
1976). 31(5):603-9, 2006
9. Fehlings MG et al: The optimal radiologic method for assessing spinal canal
compromise and cord compression in patients with cervical spinal cord
injury. Part II: results of a multicenter study. Spine (Phila Pa 1976). 24(6):60513, 1999
10. Rao SC et al: The optimal radiologic method for assessing spinal canal
compromise and cord compression in patients with cervical spinal cord
injury. Part I: an evidence-based analysis of the published literature. Spine
(Phila Pa 1976). 24(6):598-604, 1999
11. Harris JH Jr et al: Radiologic diagnosis of traumatic occipitovertebral
dissociation: 1. Normal occipitovertebral relationships on lateral radiographs
of supine subjects. AJR Am J Roentgenol. 162(4):881-6, 1994
12. Harris JH Jr et al: Radiologic diagnosis of traumatic occipitovertebral
dissociation: 2. Comparison of three methods of detecting occipitovertebral
relationships on lateral radiographs of supine subjects. AJR Am J
Roentgenol. 162(4):887-92, 1994
13. Powers B et al: Traumatic anterior atlanto-occipital dislocation.
Neurosurgery. 4(1):12-7, 1979
44
Measurement Techniques
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Common CV Junction Measurements
Measurement Definition Normal Abnormal
Chamberlain
(palatooccipital) line
McGregor (basal) line Posterior hard palate to lowest point of
McRae line Basion to opisthion Entire dens below line < 19 mm
Wackenheim clival line Dorsum sellae to tip of clivus Entire dens ventral to line Dens bisects line
Fischgold digastric line Connects 2 digastric fossae Entire dens below line Dens bisects line
Fischgold bimastoid line Connects tips of mastoid processes Tip of dens 3 mm below to 10 mm
Anterior atlantodental
interval
Atlantooccipital joint
space
Summed condylar
distance
Atlantoaxial joint space Line defining midpoint of C1-C2 joint on
Posterior hard palate to opisthion < 2.5 mm of dens above line Dens > 2.5 mm above line
Tip of dens < 4.5 mm above line Tip of dens > 4.5 mm above line
occipital bone
Tip of dens > 10 mm above line
above line
Posterior aspect of anterior C1 arch to
anterior margin odontoid process
Line from midpoint of occipital condyle to
C1 condylar fossa
Sum of bilateral distances between
midpoint of occipital condyle and C1
condylar fossa
coronal view
Plain films in children: < 4-5 mm;
plain film in adults: Men < 3.0 mm,
women < 2.5 mm; sagittal CT
reformats in children: < 2.6 mm;
sagittal CT in adults: Both men and
women < 2.0 mm
Plain films in children: < 5 mm; CT in
children: < 2.5 mm
CT in adults: < 4.2 mm
CT in adults: < 3.4 mm; CT in
children: < 3.9 mm
Plain films in children: > 4-5 mm;
plain film in adults: Men > 3.0 mm,
women > 2.5 mm; sagittal CT
reformats in children: > 2.6 mm;
sagittal CT in adults: Both men and
women > 2.0 mm
Plain films in children: > 5 mm; CT in
children: > 2.5 mm
CT in adults: > 3.4 mm; CT in
children: > 3.9 mm
Normal Anatomy and Techniques
Rheumatoid Arthritis Measurements
Measurement Definition Normal Abnormal
Ranawat Distance between center of C2 pedicle and transverse
axis of atlas measured along axis of odontoid process
Redlund-Johnell line Distance between McGregor line and
midpoint of caudal margin C2
Clark stations Dividing odontoid process into 3 parts in sagittal plane Anterior ring of atlas is level
Posterior
atlantodental interval
Space available for
cord (SAC)
Spinal canal diameter Horizontal measurement from posterior vertebral
Horizontal distance from posterior dens to anterior
aspect of C1 lamina or ring
AP diameter on sagittal MR study between dorsal and
ventral dura
body to spinolaminar line
< 15 mm in men, < 13 mm in
women
< 34 mm in men, < 29 mm in
women
with 1st station
> 13 mm SAC < 13 mm then decompression
≥ 15 mm in men, ≥ 13 mm in
women
≥ 34 mm in men, ≥ 29 mm in
women
Anterior ring of atlas is level with
middle 1/3 (2nd station) or caudal
1/3 (3rd station)
Smaller is worse and relates to
potential neurologic deficit
in RA patients considered
On plain films < 14 mm, canal
stenosis warrants MR for further
evaluation
CV Junction Trauma Measurements
Measurement Definition Normal Abnormal
Basion dental
interval
Basion axial
interval
Powers ratio Ratio of distance between basion and C1
Basion to superior aspect of odontoid
process
Distance between basion and line drawn
along posterior cortical margin of C2
posterior arch divided by distance between
opisthion and midpoint of posterior aspect
of anterior C1 arch (BC/OA)
< 12-12.5 mm in children on plain
films, < 10.5 mm in children by sagittal
CT, < 8.5 mm in adults
0-12 mm on plain films Highly variable and not recommended as
< 1.0 > 1.0 (anterior dislocation only)
> 12 mm (Harris measurement)
primary diagnostic method
posterior dissociation or vertical
distraction could be missed with normal
value
45
(Left) Sagittal graphic of the
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craniocervical junction shows
a Wackenheim clival line (red)
extending tangent to the
normal odontoid position. The
line is drawn from the dorsum
sellae to the tip of the clivus.
(Right) Sagittal graphic of the
craniocervical junction shows
a Chamberlain line (red),
drawn from the posterior hard
palate to the opisthion, and
Normal Anatomy and Techniques
McGregor line (yellow), drawn
from the posterior hard palate
to the lowest point of the
occipital bone.
(Left) Sagittal graphic of the
craniocervical junction shows
lines comprising the Powers
ratio (BC/OA), where normal is
< 1: BC = basion to C1
posterior arch; OA = opisthion
& midpoint of the posterior
aspect of the anterior C1 arch.
(Right) Sagittal graphic of the
craniocervical junction shows
lines comprising the Lee
method. BC2SL & C2O should
just intersect tangentially with
the posterosuperior aspect of
the dens and the highest point
on the atlas spinolaminar line,
respectively, in a normal state.
Measurement Techniques
(Left) Sagittal graphic shows
the basion dental interval
(BDI) in red, which should be <
12.0-12.5 mm in children on
plain films and < 8.5 mm in
adults on CT. Black lines
define the basion axial interval
(BAI) ſt extending from the
basion to the line extended
along the posterior margin of
C2, which should be < 12 mm
on plain films. The C1-C2
spinolaminar line is shown in
purple (< 8 mm in adults).
(Right) Sagittal graphic shows
the atlantodental interval
(green) and spinal canal
diameter (red).
46
Measurement Techniques
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Normal Anatomy and Techniques
(Left) Sagittal CT
reconstruction in
atlantooccipital dislocation
(AOD) shows widening ſt of
the BDI > 8.5 mm in this adult.
Note the normal Wackenheim
line relationship. (Right)
Sagittal CT reconstruction in
AOD shows widening of the
C0-C1 junction ſt with
anterior subluxation of the
condyle. A condylar fragment
is present in the joint space
st. Note the normal C1-C2
relationship .
(Left) Sagittal STIR MR in AOD
shows widening of the BDI
with ↑ T2 signal ſt from alar
and apical ligament rupture.
Note also prevertebral edema
st & posterior interspinous
ligament disruption .
Posterior epidural hemorrhage
contributes to
subarachnoid space
narrowing. (Right) Coronal CT
reconstruction in AOD shows
marked widening of the C0-C1
joint space , which should
be ~ 2 mm. Bilateral
symmetric avulsion fractures
off of the condyles are present
st.
(Left) Sagittal graphic shows
maximum canal compromise.
The Di is anteroposterior canal
diameter at the level of
maximum injury; Da is the AP
canal diameter at the nearest
normal level above the level of
injury. The Db is AP canal
diameter at the nearest
normal level below the level of
injury. (Right) Sagittal graphic
shows maximum cord
compression. The di is AP cord
diameter at the level of
maximum injury. The da is the
AP cord diameter at nearest
normal level above injury. db is
AP cord diameter at nearest
normal level below injury.
47
(Left) Sagittal graphic shows a
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Redlund-Johnell line (red),
which is defined as distance
between the McGregor line
(yellow) and midpoint of
caudal margin of C2 body.
(Right) Sagittal graphic shows
a Ranawat measurement as
the distance between the
center of the C2 pedicle
(purple) and transverse axis
(yellow) of the atlas measured
Normal Anatomy and Techniques
along axis of the odontoid
process.
(Left) Sagittal graphic shows
the 3 Clark stations. If the
anterior ring of C1 is level with
the 2nd or 3rd station, then
basilar invagination is present.
(Right) Sagittal graphic shows
2 different measurements:
McRae line (yellow) is defined
from the basion to opisthion,
and the dens should be below
this line. Length of McRae
should be > 19 mm. Lower
measurement shows
components of Torg-Pavlov
ratio, which is diameter of
canal (red) to width of
vertebral body (black). Normal
is > 0.8.
Measurement Techniques
(Left) Coronal CT shows a
Fischgold digastric line
(yellow) connecting the 2
digastric fossae (normal when
dens below the line) and
Fischgold bimastoid line (red)
connecting the mastoid
processes (abnormal if tip of
dens > 10 mm above line).
(Right) Sagittal CT study
shows upward translocation
of odontoid with a
Wackenheim clival line &
Chamberlain line grossly
abnormal. The odontoid is
eroded with a thinned pencil
tip appearance. Note the
markedly increased
atlantodental interval.
48
Measurement Techniques
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Normal Anatomy and Techniques
(Left) Sagittal view shows a
Cobb angle method for
assessing the cervical
kyphosis. Lines are drawn
along the superior endplate of
the cephalad unaffected body
and inferior endplate of
caudal unaffected body
(yellow). The angle of the
perpendiculars (red) from
these lines is considered Cobb
angle (white). (Right) Sagittal
view shows posterior vertebral
body tangent method. Lines
extend from posterior body at
fractured level and superior
unaffected level. Distance can
be measured (red) or angle of
lines determined.
(Left) AP view shows a Cobb
measurement. Lines are drawn
(yellow) along end vertebrae,
which are upper & lower limits
of curve tilting most severely
toward concavity.
Perpendiculars are drawn
from the endplate lines (red),
with angle measurement
(white). (Right)
Anteroposterior radiograph
shows a measurement of the
overall coronal plane balance
by the distance (yellow) from
the C7 plumb line (white) to
the central sacral vertical line
(CSVL) (black). Positive
displacement is to the right,
negative to the left.
(Left) AP radiograph shows a
measurement of apical
vertebral translation (AVT).
The distance (line with arrows)
from the centroid of the apex
of the curve (yellow) is
measured relative to the
center sacral vertical line
(CSVL) (black). (Right) Lateral
radiograph shows
measurement of the sagittal
balance in which horizontal
displacement is measured
from the plumb line extended
from the centroid of C7 (black)
to posterior superior margin of
the sacrum (yellow). Positive
balance is identified when line
is anterior to reference point.
49