Exam 2: [Intro, Herniations & Fissures] Flashcards
MC Cause of work disability among U.S. adults
Articular Disease
Cost of Articular Disease in 2013 Annually & % of Adults with Doctor-Diagnosed Articular Disease
> $14 Billion
22.7% of Adults (1 in 7 people)
Articular Disease: % of Population Affected (18-44 years old)
7.3%
Articular Disease: % of Population Affected (45-64 years old)
30.3%
Articular Disease: % of Population Affected
(> 65 years old)
49.7%
Articular Disease: % of Population Affected (Males)
48.3%
Articular Disease: % of Population Affected (Females)
51.7%
4 things to look at while making Diff Dx’s for Articular Disease
1) Anatomy of Involved Joints
2) Pathophysiology
3) Clinical Features
4) Key X-Ray Findings
Arthropathies managed “Daily” in Practice
DJD (osteoarthritis)
Arthropathies managed “Monthly” in Practice
- Ankylosing Spondylitis
- CPPD crystal deposition (pseudo-gout)
- Osteitis Condensans Ilii
- Psoriatic Arthritis
- Rheumatoid Arthritis
- Synoviochondrometaplasia
Arthropathies managed “Yearly” in Practice
- Gout
- Infection
- Lupus
- Reiter’s Syndrome
- Scleroderma
Examples of Fibrous Joints
- Cranial Sutures
- Syndesmoses (tib/fib) & (radius/ulna)
Examples of Cartilaginous Joints
- Symphysis Pubis
- IVD’s
- Manubriosternal
Examples of Synovial Joints
- Facet Joints
- SI Joints
- Hips
- Knees
- Shoulders
- Fingers & Toes
Why is there a lack of periosteal response in synovial joints?
Generally, there is no periosteum found around the intracellular cortices
ABCDE’S Acronym for Arthropathies
Alignment
Bone
Cartilage
Distribution
Erosions
Soft Tissues
Imaging Considerations for Arthritis: Alignment
- Occurs secondary to ligament laxity
- With or Without Erosions
Non-Uniform Cartilage Wearing:
- Swan Neck
- Boutonnière
- Pencil in Cup
- Valgus/Varus
Imaging Considerations for Arthritis: Bone (Inflammatory Arthritides)
Osteopenia secondary to Inflammation & Hyperemia (osteoclast activity)
Imaging Considerations for Arthritis: Bone (osteoarthritis)
- Reactive Bone formation
Imaging Considerations for Arthritis: Bone (General)
Enthesophytic Changes
Imaging Considerations for Arthritis: Cartilage (Inflammatory)
Pannus Promoting Proteolytic Destruction of Cartilage in UNIFORM PATTERN
Imaging Considerations for Arthritis: Cartilage (osteoarthritis)
NON-UNIFORM Cartilage Loss along lines of stress
Imaging Considerations for Arthritis: Distribution
- Mono, Oligo, or Polyarticular
- Symmetry
- Specific Joint Involvement
Imaging Considerations for Arthritis: Erosions (Inflammatory)
- Focal subcortical bone loss
- Marginal (bare areas)
- Subchondral bone loss
Imaging Considerations for Arthritis: Erosions (Crystal Deposition Disease)
Non-marginal bone loss with overhanging margin
Imaging Considerations for Arthritis: Erosions (Non-Inflammatory)
Subchondral Bone Loss
Imaging Considerations for Arthritis: Soft Tissues (Rheumatoid Arthritis)
- Fusiform swelling
- Sometimes ST calcifications
Imaging Considerations for Arthritis: Soft Tissues (Psoriatic arthritis)
- Diffuse Swelling (sausage digit)
- Sometimes ST calcifications
Imaging Considerations for Arthritis: Soft Tissues (Gout)
- Asymmetric “lump-bumpy” swelling
- Sometimes ST calcifications
Non-Inflammatory Arthropathy Diseases
1) DJD (degenerative joint disease)
2) DDD (degenerative disc disease)
Inflammatory Arthropathies
1) Ankylosing Spondylitis (seronegative)
2) Psoriatic Arthiritis (seronegative)
3) Reactive Arthritis (seropositive)
Metabolic/Depositional Arthropathies
1) Gout
2) Calcium Pyrophosphate
3) Hydroxyapatite
Degenerative Arthropathies
1) DJD
2) DDD
3) DISH
4) OPLL
5) Neuropathic Osteoarthropathy
6) SOC/SCM
7) Erosive Osteoarthritis (EOA)
Key Radiographic features of Degenerative Arthropathies
- Asymmetrical
- NON-UNIFORM loss of joint space
- Osteophytes
- Subchondral sclerosis & cysts
- intra-articular loose bodies
- Joint deformity & subluxation
Inflammatory Arthropathies
1) RA & JIA
2) Ankylosing Spondylitis
3) Enteropathic Arthropathy
4) Psoriatic arthritis
5) Reactive arthritis
6) Scleroderma/PSS
7) Lupus (SLE)
Key Radiographic Features of Inflammatory Arthropathies
- ST Swelling (1st sign)
- Symmetric
- UNIFORM loss of joint space
- Marginal bone erosion
- juxta-articular osteopenia
- Periostitis (occasionally)
Metabolic (Depositional) Arthropathies
1) Gout
2) CPPD
3) HADD
Key radiographic features of Metabolic Arthropathies
- ST swelling adjacent to joints
- +/- well-marginated bone lesions
- non-marginal location of lesions
- preservation of joint spaces
T1 Weighted MR Imaging features
- fat sensitive (hyper intense)
- fluid (hypointense)
- muscle (intermediate intensity)
T2 Weighted MR Imaging features
- Fluid sensitive (hyper intense)
- fat (hyper intense)
- Muscle (intermediate intensity)
PD Weighted MR Imaging features
- Fluid & Fat (hyper intense)
- Muscle & Hyalin Cartilage (intermediate intensity)
- Fibrocartilage (hypointense)
STIR Weighted MR Imaging features
- Fluid sensitive (hyper intense)
- Fat suppressed (hypointense)
Degenerative Joint Disease: General Info
- most frequent articular affliction
- progressive & non-inflammatory
- Unknown cause
Precipitating factors of secondary DJD
1) Trauma/altered biomechanics
2) Congenital
3) Inflammatory & Metabolic Arthritis
Onset of DJD
[Insidious]
- Aching
- Pain
- Stiffness
- Swelling
Populations affected in DJD
Males over 45
Clinical Features of DJD
- Crepitus
- Decreased ROM
- Palpable Excrescences
- Adjacent Muscle Atrophy
Clinical Features of Spinal DJD
Signs of Stenosis & Nerve Entrapment
Common Joint Locations of DJD
1) Zygapophyseal
2) Uncovertebral
3) Discovertebral
4) Costovertebral/Costotransverse
5) Extremity Joints
What exists among the extent of radiologic changes & clinical signs of DJD?
Poor Correlation between the two.
What are the Synovial Joints of the Spine?
1) Facets
2) Uncovertebral
3) Atlantodental Interval
Degeneration of the Facets, Uncovertebral Joints, & the Atlantodental Interval is what?
Osteoarthrosis
What type of joints are the IVD’s?
Fibrocartilaginous
Degeneration at the IVD’s is called…
Discogenic Spondylosis
Spondylosis Deformans Radiologic Features
- Annular degeneration
- minimal disc space loss
- prominent Osteophytes
- annular vacuum clefts
Intervertebral Osteochondrosis (IVOC) radiologic features
- Nuclear degeneration
- prominent disc space loss
- minimal Osteophytes
- nuclear vacuum phenomenon
1st detectable sign of degenerative changes to the IVD nucleus
Loss of Water/Loss of Proteoglycan substance
MC Cervical Joints to undergo Degeneration
Facet, Uncovertebral & Intervertebral of
C5/C6 & C6/C7
Atlantoaxial Joint Arthrosis is best seen on what modality?
CT
Atlantoaxial Joint Arthrosis: Symptoms & Radiographic Features
[Often Asymptomatic}
- Loss of joint space
- Osteophytes
- Subchondral Sclerosis
Facet Arthrosis: Radiographic features
- Loss of joint space
- Subchondral sclerosis
- osteophyte formation
Facet arthrosis can lead to…
Degenerative Spondylolisthesis
Uncovertebral Arthrosis: Common where?
Lower cervical spine
Uncovertebral Arthrosis: Radiographic Features
- Osteophyte can cause “pseudo-fx” appearance on Cervical Lateral view
- Sharpening Uncinate Processes
- Lateral projection of Uncinates
Why do we Image Uncovertebral Arthrosis?
[Uncinate = Ant. Border of the IVF]
It can curl into IVF > neuro symptoms
Spondylosis: MC where? & What is it?
- MC: C5/C6
- IVD Degeneration
Spondylosis: Radiographic Features
- Disc height loss
- Osteophyte
- Endplate Sclerosis
- Vacuum Phenomenon
At what measurement of the Sagittal canal do you refer? And what do you refer for?
< 12mm
MRI Referral
Posterior Osteophytes may…
Project into the spinal canal causing central canal stenosis -> myelopathy
What are Intercalary Bones
Calcification within the annular fibers
What are Intercalary bones Indicative of?
DDD
Thoracic Spine Degeneration: Radiographic features
- involves typically 3 articulations
- IVD’s: spondylophytes, narrowing, endplate sclerosis
- Facet Joints: uncommon location
- Costovertebral/Costotransverse lower segments
What joints in the Lumbar spine undergo Degenerative changes?
1) Facets
2) IVD’s
What Lumbar Disc Space is typically the largest?
L4/L5
Hemispheric Spondylosclerosis: Characteristic Sign & What is it?
- Peripheral Convex Border
- Localized sclerotic focus adjacent to endplate
Degenerative Osteophytes: Traction
Typically non-marginal & horizontal
Degenerative Osteophytes: Claw
Non-marginal & horizontal BUT curve Sup/Inf and taper
Degenerative Spondylolisthesis: MC Sites
MC = L4
MC in C Spine= C7
Translation & Angulation Measurements Associated with Cervical Spine Instability
Translation: > 3.5mm
Angulation > 11 degree change
Translation Measurements Associated with Thoracic Spine Instability
Translation: > 2.5mm
Translation & Angulation Measurements Associated with Lumbar Spine Instability
Translation: > 4.5mm
Angulation: > 15 degree change
L4-L5: >20 degree change
L5-S1: >25 degree change
Synovial Cysts: WHat is it? & MC Site
Synovial fluid-filled cysts continuous w/ facets
MC: L4-L5
Synovial Cysts can lead to…
Spinal canal or neural foramen stenosis
Synovial Cysts: Modality & What do they mimic?
Only visible on MRI
Can Mimic Disc herniation SSx
Baastrup Syndrome: a.k.a & what is it?
“Kissing Spine” Syndrome
- Hypertrophy, approximation & sclerosis of the spinous process
Baastrup Syndrome: Best Modality
MR (may demonstrate interspinous friction bursa)
Progression of Disc Disease Order
1) Less nuclear matrix (proteoglycans)
2) less nuclear water
3) less pressure holding endplate apart
4) Less disc space
5) less annular fiber tension -> laxity + more motion
6) Osteophytes, endplate sclerosis
7) further Nucleus Degradation
(Start back @ 1)
What stage of Disc Disease does MR start to show changes?
1) Less nuclear matrix (proteoglycans) &
2) Less nuclear water
What stage of Disc Disease does X-Ray start to show changes?
4) Less disc space
What type of Modic change is seen on X-Ray?
Type 3 (sclerosis)
What is Type 1 Modic Change?
Para-Endplate Bone Marrow Edema & Inflammation
What is Type 2 Modic Change?
Para-Endplate Fatty degeneration of Marrow
What is Type 3 Modic Change?
Para-Endplate Bony Sclerosis
Modic Type 1 Effect on T1 & T2 Weighted Images
Decreased T1 & Increased T2
Modic Type 2 Effect on T1 & T2 Weighted Images
Increased T1 & Neutral T2
Modic Type 3 Effect on T1 & T2 Weighted Images
Decreased T1 & T2
Herniation Definition
Displacement of disc material beyond the normal disc margins by 2mm or more
Who standardized the nomenclature for disc herniation?
ASNR
Classification of disc herniation requires…
Viewing BOTH axial & Sagittal images
Disc Bulge: Associated with? & What is it?
- Associated w/ degeneration
- Asymmetric or Symmetric disc extension beyond margin less than 3mm
How much of the circumference does a disc bulge effect?
Greater than 25% of the circumference
What is a Disc Protrusion?
Focal extension of disc beyond the vertebral body margin posteriorly
Disc Protrusion: Features
- Base is greater than depth in both Sagittal & Axial dimensions
- Does not extend above or below adjacent end plates
Disc Protrusion: Symptoms & % of Population affected
- Often Asymptomatic
- 1/3-2/3 of people
Disc Extrusion: Features
- Nuclear material not contained by annulus
- maintains continuity of the parent disc
- base is narrower than the depth in both Sagittal & Axial planes
Disc extrusion can look like…
A protrusion in one plane and an extrusion in the other
(If one view looks like an extrusion it is NOT a protrusion)
Acute Extrusion may show ___________ on ____ and ____-_________ _________due to _____________
High Intensity
T2
Post-contrast enhancement
Surrounding Granulation Tissue
What % of Disc Extrusions w/ radiculopathy are managed w/o surgery?
90% with aggressive conservative management
Pain is most likely caused by what in a disc extrusion?
A Chemical Cause rather than mechanical compression
Sequestered Fragment: What is it?
- Uncontained disc material NOT connected to the parent disc
Sequestered Fragment: Where can it migrate?
[In the Spinal Canal]
- usually about 5mm
- but can be 2-3 levels
- can affect multiple nerve roots
Acute Sequestration on MRI Appearance
May have surrounding high T2 & post-contrast enhancement due to vascular granulation tissue
Sequestered Fragment: Treatment
Generally requires an Open Procedure
Disc Herniation Locations
92% are Central or Subarticular
4% foraminal
4% extraforaminal
Disc Herniation MC Locations in Lumbar Spine
L4/L5 & L5/S1
Disc Herniation MC Locations in Cervical Spine
C5/C6 & C6/C7
What location of Cervical Disc Herniations affect the exiting roots?
- Central
- Subarticular
- Foraminal
What location of Lumbar Disc Herniations affect the TRANSITING nerve roots?
[In the Lateral Recess]
- Central
- Subarticular
What location of Lumbar Disc Herniations affect the EXITING nerve roots?
Foraminal
3 Examples of what nerve roots are affected by herniations:
1) C5/C6 Subarticular hits C6 root
2) L4/L5 Subarticular hits L5 root
3) L4/L5 Foraminal hits L4 root
Management of Disc Herniations
- 90% managed w/ conservative care
- spontaneous reduction
Lumbar Disc herniation commonly lead to…
Radiculopathies
Pain in Disc Herniations
Frequently more related to inflammation rather than nerve compression
Annular Fissures: What shows on MRI?
- DOES NOT necessarily represent traumatic etiology
- Focal high signal on T2/STIR in the Annular Fibers
Annular Fissures: a.k.a.’s & MC Location
“Annular Tears” & “High intensity zones”
MC in Posterior Disc
Transverse Annular Fissure: What is it?
Separation of disc’s peripheral annulus (Sharpey’s) fibers at the Endplate
(No clinical significance)
Transverse Annular Fissure: Seen on what modalities?
- Seen as vacuum cleft on plain film
- Rarely seen on MRI
Concentric Annular Fissures: What is it & Symptoms
- Vertical oriented separation between annular layers
- no evidence of symptoms
Radial Annular Fissures: What is it?
Longitudinal fissuring from nucleus through multiple annular layers
Radial Annular Fissures can allow for…
Significant Nuclear Migration
Radial Annular Fissures: Symptoms
-Associated w/ symptoms of Discogenic Pain
1) growth of vascularized granulation tissue
2)chemical & mechanical irritation of outer annulus
