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X-ray spine

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X-ray spine including Cervical spine fractures, Lumbosacral spine fractures and other pathological conditions.

Publicada em: Saúde e medicina

X-ray spine

  1. 1. X-RAY SPINE Dr.R.G.Unnikrishnan MD(Ay) Associate Professor & HOD, V.P.S.V.Ayurveda College Kottakkal 1
  2. 2. W.C. Roentgen discovered X-rays in 1895 •Nobel Prize in physics in 1901 2
  3. 3. • Nature of the rays was uncertain:– X-strahlung •`Skiagraph'(from Greek for a shadow) • Later `Radiograph' • Now `X-ray' or`Radiograph' WHY X-RAY ? 3
  4. 4. Conventional angiography Nuclear medicine Ultrasonography (USG) Computed tomography (CT) Magnetic resonance imaging (MRI) Interventional radiology Positron emission tomography (PET) 4
  5. 5. 5 X-Ray Most appropriate screening technique if a fracture is suspected and in low risk patients. ADVANTAGES •Can quickly identify if a fracture or other suspected bony pathology is present or not. DISADVANTAGES • A fracture might not be evident on one view and often several different projections are necessary. • A fracture may be occult.
  6. 6. 6 Computed Tomography (CT) To further evaluate numerous musculoskeletal disorders including neoplasms and simple or complex fracture. ADVANTAGES • Fast and efficient technique • Good for bony and articular details • Both intravenous peripheral contrast and intra- articular contrast may be given. DISADVANTAGES • More radiation than an x-ray. • Metal implants cause significant metal artifact.
  7. 7. 7 X-Ray CT
  8. 8. 8 Magnetic Resonance Imaging (MRI) •To evaluate ligament or tendon injury •To evaluate soft tissue masses •To evaluate stress fractures and osteomyelitis ADVANTAGES  Improved ability than CT to visualize the spinal cord and other contents of the spinal canal. Excellent for looking at soft tissue, marrow, ligaments, and marrow edema.  Both intra-articular and IV contrast may be used to better delineate anatomy/pathology.
  9. 9. 9 Herniated cervical disc MRI
  10. 10. 10 DISADVANTAGES • Many contraindications including cardiac pacemakers, metallic foreign bodies, cerebral aneurysm clips, electronic devices. • Metallic implants cause artifacts that limit image quality. • Some patients may be claustrophobic. • Sedation may be required.
  11. 11. 2 Branches •Diagnostic radiology •Radiation oncology (therapy) 11
  12. 12. Plastic sheet coated with a thin emulsion (silver bromide and a small amount of silver iodide) Film is exposed to ionizing radiation Chemical changes resulting in the deposition of metallic silver, which is black Amount of blackening on the film is proportional to the amount of x-ray exposure X-ray Film 12
  13. 13. 13 Five basic densities • Arranged from least to most dense. AIR < FAT < SOFTTISSUE/FLUID < CALCIUM < METAL (Black to White)
  14. 14. 14 PRINCIPLE • Denser an object is, the more x-rays it absorbs, and the whiter it appears on X-rays. • Less dense an object is, the fewer x-rays it absorbs, and the blacker it will appear on X- rays.
  15. 15. 15 1. Air - Appears the blackest. 2. Fat - Lighter shade of grey than air. 3. Soft tissue or Fluid – Less black than Fat. 4. Calcium - Usually contained within bones. 5. Metal – Whitest. (Objects of metal density are not normally present in the body.)
  16. 16. X-RAY FILM QUALITY Based on : • Contrast of image • Sharpness of image 16
  17. 17. Underexposed film Too white lacking contrast 17
  18. 18. Over exposed film Too black with poor contrast 18
  19. 19. 19 Spine
  20. 20. CERVICAL SPINE 20
  21. 21. C1 – C7 21
  22. 22. CERVICAL SPINE ANATOMY 22 Two anatomically distinct regions  Cervicocranium (C1 and C2)  Lower cervical spine (C3 to C7)
  23. 23. C1 VERTEBRA - ATLAS 23 • Named after the Greek mythological Atlas who supported the world on his shoulders.
  24. 24. 24 •Ring of bone with anterior and posterior arches and large lateral masses. •Lacks a body & spinous process. •Superior articular facets articulate with the occipital condyles (Atlanto-occipital joint) (“yes” movement). •Inferior articular facets articulate with C2 vertebra (Axis). (Sup.) (Inf.)
  25. 25. C2 VERTEBRA - AXIS 25 •Has a body. •Peg like process called the dens or odontoid process projects superiorly through the anterior portion of the vertebral foramen of the atlas (“no” movement). •Articulation between the anterior arch of the atlas and dens of the axis, and between their articular facets, is called the atlanto-axial joint.
  26. 26. C3 - C6 26 •Structural pattern of the typical cervical vertebra. •Spinous processes of C2 through C6 are often bifid.
  27. 27. C7 VERTEBRA • Vertebra prominens, has single large spinous process (seen and felt at the base of the neck). 27
  28. 28. 28 LIGAMENTS OF SPINE Transverse ligament of dens
  29. 29. 29
  30. 30. 30 CERVICAL SPINE X-RAY VIEWS & RADIOLOGICAL ANATOMY
  31. 31. 1. National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria • C-spine imaging is recommended for patients with trauma unless they meet all of the following criteria:- • No midline cervical tenderness • No focal neuro deficits • Normal alertness • No intoxication • No painful distracting injury 31 2. Canadian Cervical-Spine Rule
  32. 32. Mneumonic :- NSAID 1. Neuro deficit 2.Spinal midline tenderness in C-spine 3. Alertness 4. Intoxication 5. Distracting injury 32
  33. 33. • Views CERVICAL SPINE X-RAY • Antero Posterior view • Lateral view • Open mouth (odontoid) view • Oblique view 33
  34. 34. ANTERO POSTERIOR VIEW 34
  35. 35. 35 RADIOLOGICAL ANATOMY – AP VIEW
  36. 36. LATERAL VIEW • Important radiographic examination of the acutely injured cervical spine. 36
  37. 37. 37 RADIOLOGICAL ANATOMY – LATERAL VIEW
  38. 38. Visualize • All 7 cervical vertebrae • C7-T1 junction (Cervicothoracic junction is a common place for traumatic injury) 38
  39. 39. LIMITATION OF C7-T1 VIEW •By the amount of soft tissue - in the shoulder region. (shoulder soft tissue shadow) 39
  40. 40. ENHANCEMENT OF C7-T1 VIEW • Traction on arms if no arm injury is present. • Swimmer's view (taken with one arm extended over the head.) 40
  41. 41. Swimmer’s view 41
  42. 42. Flexion view FLEXION & EXTENSION VIEWS 42
  43. 43. Extension view 43
  44. 44. FLEXION & EXTENSION VIEWS CONDITIONS • If no fracture is seen on initial films and pain is present. • If a pure soft tissue injury is suspected • To demonstrate ligament instability and subsequent vertebral mobility. 44
  45. 45. CONDITIONS • Patient should perform the flexion and extension voluntarily. • Absolutely contraindicated in documented unstable injuries. 45
  46. 46. OPEN MOUTH (ODONTOID) VIEW 46
  47. 47. 47 RADIOLOGICAL ANATOMY OPEN MOUTH VIEW Body of C2, Atlantoaxial joints, Odontoid process, Lateral spaces between the odontoid process and the articular pillars of C1.
  48. 48. 48 OBLIQUE VIEW
  49. 49. OBLIQUE VIEW 49 Important in patients with pain and/or altered sensation in their upper limbs. Caused by nerve compression at the intervertebral foramina, which can be viewed in oblique view.  CT is better
  50. 50. AABCDS • A = Adequacy • A = Alignment • B = Bone • C = Cartilage • D = Disc • S = Soft tissue APPROACH TO C-SPINE X-RAY 50
  51. 51. ADEQUATE (LATERAL VIEW) • Film should include - all 7 vertebrae. • C7-T1 junction. • Have correct density • Show the soft tissue - and bony structures well. C1 C2 C3 C4 C5 C6 C7 T1 51
  52. 52. ALIGNMENT (AP VIEW) • Evaluated using the edges of the vertebral bodies and articular pillars. • Height of the cervical vertebral bodies should be approximately equal. 52
  53. 53. • Height of each joint space should be roughly equal at all levels. • Spinous process should be in midline and in good alignment. 53
  54. 54. • Pre-vertebral soft tissues • C2: < 7 mm from vertebral body • C6: < 22 mm from vertebral body • Normal contour of soft tissues. • Anterior vertebral line • Posterior vertebral line • Spinolaminar line • Spinous process line 54 Evaluate 5 parallel lines for discontinuity
  55. 55. 55 Evaluate the orientation of the epiglottis, hyoid bone, tracheal shadow and check for any foreign bodies.
  56. 56. 56 Check the Atlantodens interval or Predental space is < 3 mm in adults or < 5 mm in children.
  57. 57. CERVICAL SPINE X-RAYS DISLOCATIONS & FRACTURES 57
  58. 58. Dislocations 58
  59. 59. • Dislocation at the junction between the Atlas vertebra and the skull. • May result in death. • Anterior dislocation is much more frequent and much easier to see on X-ray. • Mechanism: Hyperflexion or hyperextension. 1. Atlanto occipital dislocation (unstable) 59
  60. 60. 60 •Anterior displacement of one vertebral body on another. •Best seen on the lateral view as a step deformity. •Step deformity of >3mm is always abnormal & the spine is unstable. •Occurs secondarily to hyperflexion of the C.spine. 2. Facet joint dislocations (unstable)
  61. 61. •3 types of bilateral facet dislocations, all are unstable. •In order of increasing severity • Subluxed facets • Perched facets • Locked facets 61
  62. 62. a) Subluxed facet joint •Mildest form, in which the ligamentous injury leads to partial uncovering of facet joint. • Results in mild anterior displacement of one vertebral body on another . 62
  63. 63. b) Perched facet joint • Inferior articular process appears to sit 'perched' on the ipsilateral superior articular process of the vertebra below. • Any further anterior subluxation will result in dislocation. • Unilateral perched facet results from flexion-rotation force • Complications  Spinal cord or Vertebral artery injury. 63
  64. 64. Spinal cord injury 64
  65. 65. c) Locked facet joint • Results from jumping of the inferior articular process over the superior articular process of the vertebra below and becomes locked in the position. 65
  66. 66. Fractures 66
  67. 67. 67 1. Unstable a.Flexion Teardrop fracture • Secondary to a flexion injury. • Results in disruption of all ligaments as well as the intervertebral disc at the level of injury. • A small fragment of the anteroinferior portion is broken off of a vertebral body with posterior displacement of the vertebral body itself. • Results in anterior spinal cord compression. • Most severe C-spine injury. • Presents as quadriplegia, loss of anterior column senses etc.
  68. 68. 68
  69. 69. b) Hangman's fracture • Secondary to an extension injury, which commonly occurs in motor vehicle accidents or in hangings. 69
  70. 70. • Bilateral C2 pars fracture, with anterior displacement of C2 vertebral body. 70
  71. 71. c) Hyperextension Fracture-dislocation • Secondary to a severe circular hyper extending force (e.g. impact on forehead). • Results in a slight anterior vertebral subluxation, with a complex fracture near the articular surfaces. 71
  72. 72. d) Burst fracture • Results from an axial injury. • Compression of the vertebral body and results in loss of both anterior and posterior vertebral body height. • Bony fragments may push on the spinal cord. • Occur most commonly in the mid-cervical spine. 72
  73. 73. 73
  74. 74. e. Jefferson's fracture •Secondary to an axial injury. (heavy object fall on one's head or diving into an empty pool). 74
  75. 75. •Consists of unilateral or bilateral fractures of both the anterior and posterior arches of C1. 75
  76. 76. f. Odontoid fracture • Secondary to a multidirectional injury. 76 Type I: fracture in the upper part of the odontoid. Type II: fracture at base of the odontoid Type III: fracture through base of odontoid into body of axis.
  77. 77. • Secondary to a powerful hyperflexion injury. • Avulsion of a piece of the spinous process and most frequently occurs in the lower C-spine. 77 2. Stable a) Clay-Shoveler's fracture
  78. 78. b) Wedge fracture • Due to flexion injury. • Compression of the anterior part of the vertebral body. 78
  79. 79. c) Extension Teardrop • Due to hyperextension injury. • Avulsion of a piece of the anteroinferior portion C2. 79
  80. 80. THORACIC & LUMBOSACRAL SPINE 80
  81. 81. 81
  82. 82. •Body •2 transverse processes •Pedicles •Pars interarticularis •Laminae •One spinous process •Vertebral foramen TYPICAL VERTEBRA 82
  83. 83. THORACIC SPINE 83
  84. 84. LUMBAR SPINE 84
  85. 85. SACRUM 85
  86. 86. RADIOLOGICAL ANATOMY OF THORACOLUMBAR SPINE -AP VIEW- 86
  87. 87. 87 RADIOLOGICAL ANATOMY OF THORACOLUMBAR SPINE -LATERAL VIEW-
  88. 88. Thoracic and Lumbar Fractures • Thoracic spine is an unusual site for fractures. • Most fractures occur at thoracolumbar junction (90% at T11-L4). • All patients should have CT except for patients with:-  Stable compression fractures  Isolated spinous or transverse process fractures  Spondylolysis 88
  89. 89. 1. Unstable injury a) Chance fractures (lap seatbelt fracture, usually at L2 or L3) • Distraction from anterior hyperflexion across a restraining lap seatbelt. • Horizontal splitting of vertebra • Rupture of ligaments 89
  90. 90. 90
  91. 91. b) Burst fracture •Results in collapse of an entire vertebral body. •Mechanism of injury is fall from a height. •On a lateral view, the height of the vertebral body is reduced. •Fragments extending into the spinal canal. •On AP view, the interpedicular distance is increased. 91
  92. 92. Burst fracture 92
  93. 93. 2. Stable injury a. Wedge fracture • Due to hyperflexion injury. • Results in the collapse of the anterior vertebral body. • On the lateral view, there is decreased height of the anterior wall of the vertebral body. • Posterior wall of the vertebral body is intact. • Spinal canal is not involved. 93
  94. 94. b. Spinous process fracture • Fracture line in the spinous process. • Spinal canal and the stability of the spine are unaffected. 94
  95. 95. c. Transverse process fracture X-ray 95
  96. 96. d) Spondylolysis 96 AP view Oblique view Appearance of a Scottie dog
  97. 97. 97
  98. 98. • A defect in the pars interarticularis. • Best seen on oblique view where it appears as a collar on a Scottie dog. • Chronic stress fracture with nonunion. • Typically in adolescents involved in sports. • Most often seen at the L4 or L5 level. 98
  99. 99. e) Spondylolisthesis • 95% of spondylolistheses occur at L4-L5 and L5-S1. • Occurs when there are bilateral pars interarticularis defects (bilateral spondylolysis). • Vertebral body of the affected level is only held against the rest of the vertebra by ligaments and intervertebral disc. • Later superior vertebral body slips forward on the inferior one. 99
  100. 100. 100
  101. 101. • Subluxation is classified into four grades, which indicates the percentage of displacement. 101
  102. 102. 102
  103. 103. Infections of the Spine 103
  104. 104. Pyogenic spinal infection • Destruction of the vertebral endplates and disc space narrowing (C3/C4 level). • Usually Bacterial infections from genitourinary tract. • Spreading of the infection causes increasing destruction of the vertebral bodies and development of a paravertebral soft tissue mass (e.g. psoas abscess) 104
  105. 105. Tuberculous spondylitis (Pott disease) 105 3 patterns of vertebral involvement. a. Discovertebral destruction • Similar to pyogenic infection • Large paravertebral abscess with later calcification. • Later develop a severe angular spinal deformity (kyphotic gibbus), as the vertebrae collapse.
  106. 106. b. Subligamentous • Infection begins anteriorly under the periosteum and spreads under the anterior longitudinal ligament. • Erosions of the anterior aspects of one or more vertebral bodies. 106
  107. 107. 107 c. Central • Infection develops within the vertebral body without involvement of the disc space. • Infected vertebra often collapses.
  108. 108. Discitis •Refers to infection of the intervertebral disc. • Staphylococcal infection,TB 108
  109. 109. 109 •Vertebral osteomyelitis and disc space infection at L2-L3. •Bony destruction with partial collapse of L3.
  110. 110. X-RAYS OF VARIOUS CONDITIONS 110
  111. 111. Osteophyte of degenerative arthritis 111
  112. 112. •Loss of cortical bone (picture frame vertebra) • Compression fractures and vertebra plana (Reduced entire height anteriorly and posteriorly) Osteoporosis 112
  113. 113. LUMBAR SPONDYLOSIS 113
  114. 114. •“Rugger jersey spine” :- striped appearance from the alternating areas of osteosclerosis along the disc plates with central osteoporosis. •In chronic renal failure, secondary hyperparathyroidism. 114
  115. 115. * Most serious complication of cervical rheumatoid arthritis is atlantoaxial subluxation. * Widening of the predental space. * Malalignment of the spinolaminar lines of C1 and C2 115
  116. 116. Spina bifida occulta • Failure of fusion of the laminae of L5, producing a cleft. • Normal variant with no associated neurologic or clinical findings. 116
  117. 117. Severe spina bifida • Congenital absence of the laminae of L3, L4, and L5. • Usually associated with neurologic abnormalities including hydrocephalus. 117
  118. 118. Mild cervical spondylosis •Narrowing of the C5 disc space. •Posterior spurs impinge on the vertebral canal. 118
  119. 119. Severe cervical spondylosis • Spurs encroaching the neural foramina at multiple levels. 119
  120. 120. Ankylosing spondylitis “Bamboo spine” appearance of vertebral column 120
  121. 121. Diffuse idiopathic skeletal hyperostosis (DISH) •Results in a rigid spine, similar to ankylosing spondylitis •Ossification of the posterior longitudinal ligament may produce spinal stenosis. •Syndesmophytes are coarse and usually symmetric. 121
  122. 122. Appearance after laminectomy • Absence of the laminae and spinous processes of L3 and L4. • Lucency represents the surgical margins 122
  123. 123. Osteoarthritis of the cervical spine • Disc space narrowing & Osteophytes at multiple levels. 123
  124. 124. Osteoarthritis of the lumbar spine •Narrowing of the intervertebral disc space between L5 and S1. • Sclerosis of the facet joints at L4/5 (F) with degenerative spondylolisthesis. 124
  125. 125. Vertebral metastasis •C/o Sudden onset back pain and leg weakness,H/o breast cancer. •X-Ray:- Reduced height of the T6 vertebral body & loss of visualization of the left pedicle due to bone destruction. •MRI:- Destruction and partial collapse of T6 & Neoplastic tissue is invading the spinal canal and compressing the spinal cord. 125
  126. 126. IVDP 126 •MRI is the choice. •Posterior herniation of the L4/5 disc. •Transverse image:- Herniation into the right side of the spinal canal. •Right L5 nerve root is compressed.
  127. 127. Prevertebral soft tissue swelling 127
  128. 128. Type-II Odontoid fracture 128
  129. 129. L1 compression fracture 129
  130. 130. T8 compression fracture 130
  131. 131. Facet fracture of C7 131
  132. 132. Scoliosis 132
  133. 133. Lordosis 133
  134. 134. Kyphosis 134
  135. 135. Gibbus 135
  136. 136. SACRALIZATION 136
  137. 137. 137 Lumbarization of S1 Spina Bifida
  138. 138. Vertebral artery calcification 138
  139. 139. CERVICAL SPONDYLITIS 139
  140. 140. Ankylosing spondylitis 140
  141. 141. Prevertebral mass 141
  142. 142. CERVICAL RIB 142
  143. 143. Thank you 143

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