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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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3 Radiographic Anatomy
III. Sp in al ste n o sis.
A. Na r ro w in g o f t h e sp in a l ca n al o r n eu ro fo r a m e n ca n ca u se n e u ro logic a l
symptoms (Fig. 3.15, Fig. 3.16, and Fig . 3 .1 7 ).
B. Na r row i n g o f t h e sp in a l ca n a l m o r e o ft e n o ccu r s i n e ld e r ly p at ie n t s (> 6 0 ye a r s)
due to degenerative changes (Fig. 3.18):
1. Disk prolapse.
2. Hypertrophic facet joints or ligamentum avum.
3. Degenerative spondylolisthesis.
C. M RI is t h e m o da lit y o f ch oice fo r a s se ss in g s iz e a n d s h a p e o f t h e s p in a l c a n a l.
Fi g . 3 . 1 5 Ma gn e t ic re so na nce
imaging axial cut at C5–C6 disk
space: severe spinal stenosis.
1, central spinal stenosis (note
the absence of high-signal cerebrospinal uid surrounding the
spinal cord).
Fi g . 3 . 1 6 Ma gn et ic re so nance imaging axial cut at
L4 – L5 d i s k s p a c e . 1 , s e v e r e
lum ba r sp inal st e nosis; 2 ,
facet joint hype rtrop hy.
3 Radiographic Anatomy 65
Fi g . 3 . 1 7 Ma gn e t ic re so na nce
im a g in g (MRI) sagit t a l cut t hro ugh
the spinous process. 1, end of spinal
cord (conus medullaris); 2, L3–L4 disk
prolapse; 3, L4–L5 disk prolapse. MRI
sagit tal cut through right pedicles. 4,
L1 p e d i c l e ; 5 , n o r m a l L2 e x i t i n g n e r v e
root; 6, stenosed L4 nerve root.
Fi g . 3 . 1 8 Mag n et ic re so na nce
im a g in g sa g it ta l cu t t h roug h
the left-side pedicles. 1, normal
nerve root (high-intensity fat
surrounding low-intensit y nerve
root); 2, L3 pedicle; 3, L4 spinous
process; 4, L5 foraminal stenosis.
IV. Spo n dylolist h esis.
A. Re fe rs t o t he fo r w a r d s lip o f a ve r t eb r a l b o d y o n t h e o n e b elo w (Fig. 3.19).
B. Mo r e o ft e n o ccu r s a s a r es u lt o f a d efe ct in t h e p ar s in t e r a r t ic u la r is b u t ca n a l s o
occur as a result of degenerative disk disease.
C. Pla in lm r ad io g ra p h s a re u s e d t o d et er m in e t h e d eg re e o f t h e li s t h e sis (Fig. 3.20).
D. MRI allow s visu alization of n e u ral st ruct u res.
1. Spinal cord.
2. Spinal nerve roots.
a. Foraminal stenosis.
E. CT im a g in g is t h e m os t s e n sit ive fo r d et e ct in g a p a r s d efe ct .
1. It can also be used for preoperative planning.
66
3 Radiographic Anatomy
Fi g . 3 . 1 9 Ma gn e tic re so n an ce
im ag in g a xia l cu t L5 – S1 d isk. 1, le ft
foram in a l st e nosis; 2, fa ce t join t
arthropathy; SP, spinous process.
Fi g . 3 . 2 0 La t e r a l p l a i n l m r a d i o graph ( exion). 1, L2 spinous process;
2, L2 inferior articular process; 3, L3
superior articular process; 4, L4–L5 slip
(anterolisthesis); arrow, pars defect.
Sugg este d Reading
Bo g d u k N. Clin ic al An a t o m y o f t h e Lu m b ar Sp in e a n d Sa cr u m . Ph i l a d el p h ia , PA: Els e v ie r;
2005
Del Gran d e F, Maus TP, Ca r r in o JA. Im agin g th e in t e r ve r t ebral d isk: age-related changes,
herniat ion s, an d radicu lar p ain . Radiol Clin North Am 2 012;50(4):6 29– 649
Ka r a n t a n a s AH . W h a t ’s n e w in t h e u s e o f M RI i n t h e o r t h o p a e d i c t r a u m a p at i e n t ? In ju r y
2014;45(6):923–933
Va c c a r o AR , Ri z z o l o SJ, Ba l d e r s t o n R A, e t a l . P l a c e m e n t o f p e d i c l e s c r e w s i n t h e t h o r a c -
ic spine. Part II: An an atom ical an d radiographic assessm ent. J Bon e Joint Surg Am
1995;77(8):1200–1206
4 Spinal Imaging and Diagnostic Tests
4.1 Imaging Modalities
I. Ge n e r a l con sid e r at ion s.
A. Sp in a l im a gin g m od a lit ie s (Table 4.1):
1. Plain radiographs.
2. Computed tomography.
3. Magnetic resonance imaging (MRI).
4. Bone scintigraphy.
5. Myelography.
6. Angiography.
7. Diskography.
B. A t h or ou gh h ist or y a n d p h ys ica l e xa m in a t io n s h o u ld le a d t o a p r elim in a r y
clinical diagnosis th at should predicate both the selection and the tim ing of
im aging test s.
1. Diagnostic tests should be used to con rm information ascertained during
the history and physical examination.
C. Se le ct io n o f im a g in g t es t s s h o u ld b e b as e d o n t h e a p p re cia t io n o f t h e s e n s it ivit y,
speci city, and accuracy of various im aging m odalities in conjunction with
di erent disease processes.
1. Acute neck or back pain and radiculopathy:
a. The natural history is that of improvement with conservative treatment.
b. Diagnostic imaging should be delayed until 4 to 6 weeks after the onset of
symptoms.
(1) There are exceptions to an earlier im aging evaluation:
(a) Trauma.
(b) Progressive neurological de cit.
(c) Suspected neoplasm or infection.
2. Imaging evaluation alone without clinical correlation is associated with an
extremely high false-positive rate.
a. Plain radiographs show aging and degenerative processes in virtually all
individuals after the age of 40 years (Fig. 4.1).
b. MRI ndings of the cervical spine dem onstrate the following:
(1) Fourteen percent of asym ptom atic individuals < 40 years old and 28%
> 4 0 years old h ad evide n ce of a h er n iate d d isk .
(2) Degenerative disk disease is more comm on in asym ptom atic
individuals, w ith an inciden ce of 25% for < 40 years old an d 56% for
> 4 0 years old .
c. MRI ndings of the lum bar spine dem onstrate the following:
(1) In asym ptom atic individuals, a herniated disk was noted in 21% of
patients between 20 and 39 years of age and 36% of individuals > 60
years of age.
67
70
4 Spinal Imaging and Diagnostic Tests
a
Fi g . 4 . 1 ( a ) Lateral radiograph of the lumbar
spine dem onst rating a vacuum disk sign at L4–
L5. This is suggestive of disk space collapse and
disk degeneration. (b) Lateral radiograph of
the cervical spine demonstrating disk degeneration. (Reproduced from Bohndorf K, Imhof
H, Pop e TH Jr. Musculoske let al Im a ging : A Concise Multimodality Approach. Stut tgart, Germany: Georg Thieme Verlag; 2001: Figs. 9.61
and 9.62, with permission.)
b
(2) Spinal stenosis is found in 21% of those > 60 years of age, and bulging
disks are found in > 50% of patients in all age groups.
II. MRI (Fig. 4.2).
A. Co n t r a in dic a t io n s:
1. Ferrous metal implants in the brain.
2. Metal debris in the eye.
3. Inner ear implants.
4. Pacemakers.
4 Spinal Imaging and Diagnostic Tests 71
Fig . 4 . 2 Mag n et ic re so n an ce im ag ing (T2 sa g it tal im a g e ) of t he lu m bar
spine with decreased signal intensity
at the L4–L5 and L5–S1 interspace
with minimal loss of disk height .
B. Im ag i n g a ro u n d m et a l im p la n t s i s p o o r u n le ss sp e cia l t ech n iq u es a r e u se d a n d if
the metal is titanium instead of stainless steel.
C. T1 - ve rs u s T2 -w e igh t e d im a ge s t a ke a d va n t a ge o f i n t r in s ic t is s u e p ro p e r t ie s
(Fig. 4.3) (Table 4.2).
1. Repetition time (TR): time between radiofrequency (RF) pulses.
2. Echo time (TE): time between RF and recording.
3. T1-weighted image: short TR (400–600 ms), short TE (5–30 ms).
4. T2-weighted image: long TR (1,500–3,000 ms), long TE (50–120 ms).
D. Special in dicat ions:
1. Postoperative scar versus recurrent disk herniation.
a. Use of gadolinium contrast.
b. The scar is vascular and enhances with gadolinium. The disk does not
enhance with contrast agents. This is observed on T1-weighted sequence.
2. Infection versus tumor.
a. In spinal osteomyelitis, there is abnormal tissue with decreased signal
intensity on T1-weighted im ages and increased signal inten sity on T2weighted images at the disk margin.
b. In tumors, the intervertebral disk is spared, and similar changes are noted
involving the en tire vertebral body.
3. Compression fractures versus pathological fractures.
a. More di cult to di erentiate.
b. In pathological fractures.
(1) Entire vertebral body involvem ent.
(2) Frequent involvem ent of the pedicle.
(3) Presence of soft tissue masses.
(4) Canal comprom ise.
72
4 Spinal Imaging and Diagnostic Tests
ab
c
Fi g . 4 . 3 ( a , b ) T1 -w e ig h t e d m ag ne t ic r e so na nc e im a g in g ( a xia l a n d sa git t a l) o f t h e lu m b a r sp in e.
(c,d) T2-we ighted MRI im aging (axial and sagitt al) of t he lumbar spine.
d
Ta b l e 4 . 2 Mag ne t ic re so na n ce im ag in g n d in g s o f h u m a n t issu e
Ti s s u e t y p e T1 s i g n a l T2 s i g n a l
Co rt ica l b on e Lo w Lo w
Te n d o n / l i g a m e n t Lo w Lo w
Hyaline cart ilage Inte rm ediat e Interm ediate
Fr e e w a t e r Lo w Hi g h
Ad i p o s e H ig h Lo w
Ab s ce s s In t e r m e d ia t e Hig h
c. In osteoporotic compression fractures.
(1) No involvem ent of the pedicle.
(2) Partial involvem ent of the vertebral body.
4. Spinal cord injury.
a. Distinguishes spinal cord edema versus hemorrhage.
(1) Edem a is bright on T2- and decreased on T1-weighted images (Fig. 4.4).
4 Spinal Imaging and Diagnostic Tests 73
Fi g . 4 . 4 T2 -w e ig ht e d m a g ne t ic re so n a nce im a g in g d e m o n strating increased signal intensity suggestive of spinal cord
edema. (Reproduced from Uhlenbrock D. MR Imaging of the
Spine a nd Sp in a l Cord. St u t tga r t , Ge rm a n y: Ge o rg Thie m e
Ve r l a g ; 2 0 0 4 : F i g . 7 . 6 , w i t h p e r m i s s i o n . )
(2) Hemorrhage is bright on T1- and decreased on T2-weighted images
(Fig. 4.5).
E. Disk d e ge n er a t io n (Fig. 4.6 and Fig. 4.7):
1. A radial tear of the annulus brosus is outlined as a ssure extending from
the nucleus to the periphery.
a. A high-intensity zone in the posterior annulus suggests a radial tear that
may be clinically signi cant.
2. Modic end plate changes:
a. Type 1 (Fig. 4.8).
(1) Low intensity on T1-weighted image and high intensity on T2-weighted
im age.
(2) Associated with segm ental spine instability and pain.
b. Type 2 (Fig. 4.9).
(1) High intensity on T1-weighted image and norm al on T2-weighted image
(2) Fatt y marrow changes around the end plates.
(3) Less likely to be sym ptom atic.
c. Type 3 (Fig. 4.10).
(1) Hypointense on T1- and T2-weighted im ages.
(2) Sclerotic advanced degenerative changes with less segm ental motion.
74
4 Spinal Imaging and Diagnostic Tests
a
Fi g . 4 . 5 ( a , b ) T1 -we ig h t e d m ag ne t ic re so n an ce im a g in g de m o n st ra tin g in cre a se d sig na l in t e nsit y
suggestive of hem orrhage. (Reproduced from Uhlenbrock D. MR Imaging of the Spine and Spinal Cord.
St ut t ga rt , Ge rm an y: Ge o rg Th ie m e Verla g ; 2 0 04 : Fig . 8 .2 a ,b , w it h p e rm issio n.)
b
4 Spinal Imaging and Diagnostic Tests 75
Fi g . 4 . 6 Axia l c u t ( co m p u t e d t o m o g r a p h ic s c a n ) a t L4 t h a t d e m o n s t r a t e s t h e p e d ic le s a n d b o n y a n a t omy. Note: the thecal sac can be visualized as well.
ab
Fi g . 4 . 7 ( a ) Lateral diskogram demonstrating extravasation of dye at the L5–S1 level suggestive of
an annular tear. (b) Com put e d to m og ra p h y p o st d isko g ra p h y (sag it tal) de m on st ra t in g e xtra vasat ion o f
dye posteriorly at L4–L5.
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