ESSENTIALS OF PLAIN FILM INTERPRETATION:...
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ESSENTIALS OF PLAIN
FILM INTERPRETATION:
SPINE
DR ASIF SAIFUDDIN Consultant Musculoskeletal Radiologist
Royal National Orthopaedic Hospital Stanmore,UK.
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RCR 2012: SPINAL
RADIOGRAPHY 2
INTRODUCTION
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RCR 2012: SPINAL
RADIOGRAPHY 3
INTRODUCTION
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RCR 2012: SPINAL
RADIOGRAPHY 4
INTRODUCTION
Spinal alignment
Vertebral morphology
Bone density
Vertebral end-plates/enthesis
Vertebral cortex
Disc space
Neural arch
Para-spinal soft tissues
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RCR 2012: SPINAL
RADIOGRAPHY 5
SPINAL ALIGNMENT
NORMAL
Cervical lordosis
C1-T2 30-400
Thoracic kyphosis
T2-T12 20-400
Lumbar lordosis
L1-L5 20-400
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RCR 2012: SPINAL
RADIOGRAPHY 6
SPINAL MALALIGNMENT
Sagittal plane
Spondylolisthesis
Retrolisthesis
Kyphosis
Coronal plane
Scoliosis
Axial
Translation
Rotation
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RCR 2012: SPINAL
RADIOGRAPHY 7
SPONDYLOLISTHESIS
Anterior slip of one
vertebra on vertebra
below
Assess
Aetiology (lumbar)
Types 1-6
Degree
Grades 1-3 or 1-4
spondyloptosis Grade 1 L3/L4 Grade 2 L5/S1
Degenerative Lytic
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RCR 2012: SPINAL
RADIOGRAPHY 8
RETROLISTHESIS
Posterior slip of one
vertebra on vertebra
below
Usually mild
Aetiology
Almost always
degenerative
Pathological
Traumatic
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RCR 2012: SPINAL
RADIOGRAPHY 9
KYPHOSIS
Increased curvature of
thoracic spine
Generalised
Young- Scheuermann’s
Old- osteoporosis
Focal
Congenital
Acquired
Pathological collapse
Trauma
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RCR 2012: SPINAL
RADIOGRAPHY 10
KYPHOSIS
Osteoporosis TB Post-traumatic
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RCR 2012: SPINAL
RADIOGRAPHY 11
SCOLIOSIS
Lateral curvature of spine in
coronal plane
Cobb angle >100
Side described by convexity
Aetiology (paediatric)
Idiopathic
Osteogenic
Neuromuscular
Syndromic/developmental
Reactive
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RCR 2012: SPINAL
RADIOGRAPHY 12
SCOLIOSIS
Osteogenic
Look for vertebral
anomalies
Failure of fusion
Failure of
segmentation
Complex
Hemivertebra Bony bar
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RCR 2012: SPINAL
RADIOGRAPHY 13
SCOLIOSIS
Degenerative
Lumbar
Commonly
associated with
lateral vertebral
subluxation at
apex of curve
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RCR 2012: SPINAL
RADIOGRAPHY 14
AXIAL MALALIGNMENT
LATERAL
TRANSLATION
Uncommon
Degenerative
spondylolisthesis
Traumatic
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RCR 2012: SPINAL
RADIOGRAPHY 15
AXIAL MALALIGNMENT
ROTATION
Idiopathic scoliosis
Traumatic
Unilateral facet
dislocation
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RCR 2012: SPINAL
RADIOGRAPHY 16
VERTEBRAL MORPHOLOGY
Vertebral collapse
Flattened vertebrae (platyspondyly)
Vertebra plana
Vertebral enlargement
Abnormalities of shape Bullet -Hurlers/Morquio’s/achondroplasia
Tower -SSD
Reduced AP dimension -JRA
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RCR 2012: SPINAL
RADIOGRAPHY 17
VERTEBRAL COLLAPSE
OP collapse
Trauma
WC fracture
Burst fracture
Look at PVBL
Wedge fracture Burst fracture
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RCR 2012: SPINAL
RADIOGRAPHY 18
VERTEBRAL COLLAPSE
Pathological
Tumour
Infection
Myeloma TB
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RCR 2012: SPINAL
RADIOGRAPHY 19
VERTEBRA PLANA
Severe vertebral
body collapse
LCH
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RCR 2012: SPINAL
RADIOGRAPHY 20
PLATYSPONDYLY
Multilevel
flattening of the
vertebral bodies
Many causes
Idiopathic
osteoporosis
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RCR 2012: SPINAL
RADIOGRAPHY 21
VERTEBRAL ENLARGEMENT
Paget’s disease
Associated
Involvement of neural
arch
Medullary sclerosis
Trabecular thickening
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RCR 2012: SPINAL
RADIOGRAPHY 22
BONE DENSITY
Reduced
Osteopenia
Increased
Sclerosis
Either can be focal or diffuse
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RCR 2012: SPINAL
RADIOGRAPHY 23
FOCAL OSTEOPENIA
Any cause of focal
vertebral body
destruction
Tumour
Infection
ABC Early osteomyelitis
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RCR 2012: SPINAL
RADIOGRAPHY 24
DIFFUSE OSTEOPENIA
Osteoporosis
Metabolic bone
diseases
Neoplastic
Myeloma
Acute leukaemia
Picture frame Vertical striations
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RCR 2012: SPINAL
RADIOGRAPHY 25
FOCAL SCLEROSIS
Within vertebral body
Tumours Osteoma
Osteoblastic metastasis
Multiple
Osteopoikilosis
Osteoma Prostate metastasis
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RCR 2012: SPINAL
RADIOGRAPHY 26
FOCAL SCLEROSIS
Sub-Chondral
Degenerative
DHVS
20 Hyperparathyroidism
Multilevel T + L regions
‘rugger-jersey’ spine
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RCR 2012: SPINAL
RADIOGRAPHY 27
DIFFUSE SCLEROSIS
Ivory Vertebra
Paget’s disease
Reactive
OO/OB
Schmorl’s node
Neoplastic
Osteoblastic
metastasis
Lymphoma
OB Ca bronchus met
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RCR 2012: SPINAL
RADIOGRAPHY 28
VERTEBRAL END-PLATES
Abnormal morphology
Focal defect
Irregularity
Scheuermann’s
Degenerative disc disease
Erosion
Bi-concave
OP compression fractures
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RCR 2012: SPINAL
RADIOGRAPHY 29
FOCAL DEFECTS
Multilevel T/L spine
Normal variant
Degenerative
Schmorl’s nodes
Traumatic
WC or burst fracture
Neoplastic
plasmacytoma
‘Pincer-type’ burst#
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RCR 2012: SPINAL
RADIOGRAPHY 30
FOCAL DEFECTS
Anterior limbus lesion
T/L junction
Physically active
adolescents
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RCR 2012: SPINAL
RADIOGRAPHY 31
END-PLATE EROSION
Spondylodiscitis
Usually combined
with loss of disc
height
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RCR 2012: SPINAL
RADIOGRAPHY 32
VERTEBRAL ENTHESIS
Insertion of Sharpey’s
fibres of disc annulus
into end-plate
Erosion
Ossification
Avulsion
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RCR 2012: SPINAL
RADIOGRAPHY 33
VERTEBRAL ENTHESIS
Erosion
Manifestation of
spondyloarthropathy
‘Shiny corner’
Associated with
‘squaring’ of vertebral
body
Ankylosing spondylitis
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RCR 2012: SPINAL
RADIOGRAPHY 34
VERTEBRAL ENTHESIS
Ossification of
annulus
Bamboo
Spine
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RCR 2012: SPINAL
RADIOGRAPHY 35
VERTEBRAL ENTHESIS
Disc marginal
osteophytes
DDD
DISH
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RCR 2012: SPINAL
RADIOGRAPHY 36
VERTEBRAL CORTEX
Displaced
PVBL
Differentiates WC
from burst fracture
Scalloped
Eroded
Wedge fracture Burst fracture
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RCR 2012: SPINAL
RADIOGRAPHY 37
SCALLOPED CORTEX
Multilevel
NF
Marfan’s
Single level
Neural tumour
Nerve sheath cyst
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RCR 2012: SPINAL
RADIOGRAPHY 38
ERODED CORTEX
Anterior
Pre-vertebral tumour
lymphoma
Pre-vertebral infection
TB
Sub-ligamentous
spread
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RCR 2012: SPINAL
RADIOGRAPHY 39
DISC SPACE
Normal
Reduced height
Increased height
OP collapse
Calcified
Thoracic DDD
Vacuum
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RCR 2012: SPINAL
RADIOGRAPHY 40
REDUCED DISC HEIGHT
Generalised
End-plate intact
DDD
End-plate eroded
discitis
Vacuum phenomenon
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RCR 2012: SPINAL
RADIOGRAPHY 41
REDUCED DISC HEIGHT
Generalised
End-plate intact
LSTV
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RCR 2012: SPINAL
RADIOGRAPHY 42
REDUCED DISC HEIGHT
Focal Anterior
Anterior limbus lesion
Do not mistake for
infection
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NEURAL ARCH
Pedicle
Lamina
SAP
IAP
Transverse process
Pars interarticularis
Spinous process
Absent
Enlarged
Sclerotic
Interpediculate
distance
Interspinous distance
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RCR 2012: SPINAL
RADIOGRAPHY 44
ABSENT PEDICLE
Congenital
Acquired
Tumour
infection
Metastasis TB
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RCR 2012: SPINAL
RADIOGRAPHY 45
ENLARGED PEDICLE
Tumour
OB
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RCR 2012: SPINAL
RADIOGRAPHY 46
ENLARGED PEDICLE
Trauma
Bony Chance
fracture
Increased height
of pedicle
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RCR 2012: SPINAL
RADIOGRAPHY 47
SCLEROTIC PEDICLE
Reactive due to
underlying
Tumour
Pars stress
fracture
L3 OO
Lt L5 stress fracture
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RCR 2012: SPINAL
RADIOGRAPHY 48
INTERPEDICULATE DISTANCE
Normal
Increases
distally
Reduced
Congential
canal stenosis
Short pedicles
on lateral
radiograph
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RCR 2012: SPINAL
RADIOGRAPHY 49
INTERPEDICULATE DISTANCE
Increased
Burst fracture
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RCR 2012: SPINAL
RADIOGRAPHY 50
INTERPSPINOUS DISTANCE
Increased
flexion-
distraction
injuries
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RCR 2012: SPINAL
RADIOGRAPHY 51
PARASPINAL SOFT TISSUES
Swelling
Tumour
Infection
Trauma
Calcification
TB
spondyloarthropathy
Gas
Infection
Post-operative
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RCR 2012: SPINAL
RADIOGRAPHY 52
CONCLUSIONS
There is potentially a lot in a spinal radiograph
Systematic approach to assessment will reduce
misses
Normal radiography excludes NOTHING!