L2 Spine Flashcards
When to order lumbar films
- plain x-rays are not for routine eval of acute LBP within the 1st month of s/s unless certain red flags are present
- chronic conditions persisting beyond 4-6 weeks of conservative intervention can use imaging, specifically a/p or lateral
Red flags for Acute LBP
- recent significant trauma at any age
- recent mild trauma > 50 yo
- > 70 yo
- hx of prolonged steroid use or osteoporosis
Oblique images should be ordered when
there is medical hx, physical exam, or other images suggest spondylolisthesis or spondylolysis
they do cause increased radiation risk
L-spine positioning
A/P = supine
Lateral = sidelying
L5-S1 = sidelying
Oblique = twisted in sidelying
Columns of TL spine
Anterior = stable
Middle = possibly unstable
Posterior = unstable
Most common fractures of lumbar spine are
- wedge compression fx
- compression burst fx with fragments
- pars interarticularis or vertebral body
Wedge Compression Fracture
occurs in anterior column
Compression Burst Fracture
entire vertebra is crushed in all directions
Chance Fracture
- Known as seat belt injury
- flexion and distraction injury, usually in L1-L2
- CTs are best vs X-ray
- up to 50% will have associated blunt trauma injuries to organs
Spondylolysis and Spondylolisthesis
lolysis = breakdown or fracture of pars interarticularis
listhesis = slipping forward of vertebral bone
Degenerative changes in lumbar spine
often shows loss of disk space, osteophystes, disc calcification, herniated discs
MRI is best for detecting this
Spinal Infections
- occur in diabetic or post op patients
- destructive process that involves or crosses disc space
- MRI is best
Spinal Neoplasms
- most common is mets from cancer
- lesions can have altered bone density
- increased/sclerotic: prostate/breast cancer
- decreased/lytic: lung, renal, breast cancer
Sign of neoplasm
winking owl or pedicle erosion
Mets occur arise most commonly in
red marrow –> skull, ribs, spine, pelvis, humerus, femur
it is best to use body scan to detect them
Indications for bone scan
- initial staging of lung, breast, or prostate cancer
- bone pain
- elevated alkaline phosphatate
- to evaluate the response to chemotherapy
Ankylosing Spondylitis
- occurs in young adult males
- often associated with ulcerative colitis
- bamboo appearing spine caused by calcifications bridging over disc spaces
Osteoporosis
- primary = age related, estrogen deficiency
- secondary = results from other diseases
Indications for DEXA scan
- osteopenia on plain films
- nontraumatic fracture in postmenopausal female
- suspected osteopenia due to metabolic disorder
- loss of height >2.5 in
- chronic disease
DEXA
helps to detect osteoporosis/osteopenia. measures bone density
anything greater than 2.5 std deviations below mean is considered osteoporosis
Thoracic Spine positioning for imaging
A/P = supine
Lateral = sidelying
Common thoracic spine conditions
- compression fx
- schmorl’s nodes
- osteoporosis
- osteophytes
- pedicle irregularity
- scheuermann’s disease
scheuermann’s disease
AVN or steroid use
involves both inferior and superior end plates
Trauma in thoracic spine
- usually result of MVA or osteoporosis
- AP shows alignment, lateral for subluxation
Hyperflexion of thoracic spine
can result in compression burst fractures with bony fragments projecting into spinal canal
Compression fx of middle/lower thoracic are due to
osteoporosis
Vertebral compression fx occur in
25% of women over 65 yo
40% of women over 85 yo
Predictors of osteoporotic compression fracture
- age > 52
- BMI <22
- female
- absence of LE pain
- lack of regular exercise
2 or fewer signs = can rule out
4 or more = can rule in
Most common degenerative changes in thoracic spine
- spurs
- calcification of anterior spinal ligament
- calcification of intervertebral disc (usually what causes issues/pain)
Osteophyte spurs
- seen at T10 to L1
- common throughout spine
- not usually clinically significant
Diffuse idiopathic skeletal hyperostosis (DISH)
due to excessive bone formation at skeletal sites subject to normal or abnormal stresses, generally where tendons and ligaments attach to bone
Disc Calcification
usually due to trauma, however if present in more than one disc may be due to hypercalcemia or other pathology
High risk factors in Canadian c-spine rule
- age > 65 yo
- paresthesias in extremities
- dangerous MOI such as MVA, bike collision, fall from height
Low risk factors allowing assessment of cervical spine
- able to sit in ER
- ambulatory at any time
- onset of neck pain not immediate
- absence of midline tenderness in c-spine
- patient can rotate neck 45°
- MVA that does not involve push into traffic, hit by bus, rollover, high speed vehicle
High risk of c-spine injury (modified rules)
- posterior midline cervical tenderness
- evidence of intoxication
- reduced level of consciousness
- focal neuro deficits
- painful distracting injuries
C-spine views
- lateral = alignment
- A/P = oblique fx
- Odontoid = C1-C2
- Oblique = foraminal narrowing
- Swimmer’s view = C7-T1
Alantodental Interval
- > 3.5 mm = instability
- 7mm = disruption of transverse ligament
- > 9-10 risk of neuro injury, requires injury
normal is 8 mm in adults
Causes of increased ADI
- trauma
- down syndrome
- RA
- arthritis
George Line
- lateral view, connects posterior vertebral bodies
- should be a smooth curve
- can show instability, dislocation, ligamentous laxity
Cervical Gravity Line
- vertical line drawn from apex of dens
- line should pass through 7th cervical body
- allows for gross assessment of gravitational stresses
Soft tissues in cervical
- C2-C5 = 7 mm or less
- C5-C7 = 20 mm or less
Cervical Spinal Fractures
- most common sites are C1-C2, C5-C7
- trauma are usually the cause, most likely MVA
- Jefferson, Hangman, Clay-shoveler’s, Odontoid are common
Jefferson Fracture
- burst of the ring of C1
- due to axial loading of the head being compressed onto the spine
Odontoid Fracture
fracture of the odontoid process of C2
usually hyperextension of the cervical spine
Hangman’s fracture
- fracture of posterior aspects of C2
- hyperextension injury
- through pars interarticularis or pedicles
- spinal cord compromise
- subluxation of C2 over C3
Clay-shoveler’s fracture
- fracture of posterior spinous process
- occurs at c6-t2
- hyperflexion injury
C-Spine Degenerative Changes
- C4-C7 common areas, appear by age 30-40
- shows up as decreased disc space, sclerosis, spurring of margins of vertebral bodies
- oblique pain will show narrowing of foramina
- MRI is good for herniated dic or neurological deficit
Metastatic Lesion in C spine
- presents as rapidly worsening weakness of arms and legs
- causes compression of the cord
Lines of Life
- four lines, should be roughly parallel and spatial relationship should remain constant
- anterior borders of vertebral bodies
- posterior borders of vertebral bodies
- spinolaminar lines
- posterior spinous process of C2-C7
