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Radiology > Test 2: CT of the Spine > Flashcards

Test 2: CT of the Spine Flashcards

1
Q

Indications for CT of the spine

A
  • MRI contraindicated
  • before and after spinal surgery (bony anatomy, alignment of hardware)
  • visualize fractures, including pars defects
  • characterize osseous lesions: neoplasm/metastases, hemangioma, bone cyst, osteoid osteoma
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2
Q

Spine CT: contrast or non contrast?

A

NON

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3
Q

Best imaging modality to view spinal cord?

A

MRI

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4
Q

If a patient is contraindicated to get an MRI, but needs imaging of an IV disc, what type of imaging will be used?

A

CT, soft tissue window

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5
Q

What imaging findings might come with a pars defect? What imaging modality is a pars defect best seen, and why?

A

anterolisthesis, elongated, flute shaped spinal canal, horizontal lucency at pars interarticularis in sagittal and axial CT views
-CT best: too much overlap on XR

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6
Q

Burst fracture: characteristics on CT

A
  • break in cortical continuity (areas of lucency)
  • narrowed spinal canal
  • loss of height of vertebral body
  • vertebral body misshapen
  • may see fragments displaced posteriorly into spinal canal
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7
Q

Vertebral augmentation: define the concept and list 2 procedures

A
  • procedures used for palliation of pain related to vertebral compression fractures
  • 2 types: percutaneous vertebroplasty (PV) and balloon-assisted kyphoplasty
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8
Q

management of compression fractures

A
  • initially: conservative management is the gold standard
  • medical management with or without methods of immobilization
  • medication
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9
Q

complications of medication for treatment of pain in compression fractures:

A

NSAIDS: gastrointestinal hemorrhage, ulcers
Narcotics: addiction, constipation, nausea, somnolence

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10
Q

osteoporotic fractures: talk about pain, medication, and what happens over time

A

most patients have a spontaneous resolution of pain within 4-6 weeks of onset, even without medication

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11
Q

extra credit: causes of vertebral compression fractures

A
  1. osteoporosis (most common)
  2. direct trauma
  3. neoplasm/metastatic disease
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12
Q

indications for vertebral augmentation

A
  • conservative treatment failed
  • pain refractory to oral medications for 6-12 weeks
  • contraindications to medication
  • hospitalization with IV narcotics administered
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13
Q

Define percutaneous vertebroplasty

A

Injection of low viscosity PMMA cement into vertebral body using a unipedicule or bipedicule needle

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14
Q

Success rate for pain relief? who benefits most?

A

89-93% success rate; women and people <75 years old benefit most

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15
Q

Percutaneous Vertebroplasty: Clinical History/Physical exam criteria for indication/contraindication of PV procedure:

A
  1. focal pain at spinal process level corresponding to level of fracture
  2. 6-12 weeks after onset of pain: time frame for treatment (first 6-12 conservative)
    Patients treated EARLIER if:
    -they required hospitalization and IV narcotics for pain
    -they have a history of a successful prior PV
    DISQUALIFICATION for PV:
    -radicular pain involving LEs or LBP radiating to hips (pt may need a different intervention)
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16
Q

PV: complications; acute and delayed

A

ACUTE: 1-3.9%
-cement leak: symptomatic or asymptomatic
-cement pulmonary embolism: symptomatic or asymptomatic
-bleeding
-infection
-neurological deficit
DELAYED:
-risk for new fractures at other levels: cement decreases compliance
-clustering of fxs as a natural history of OP?

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17
Q

Balloon kyphopasty: explain the procedure

A

insertion of a unipedicle or bipedicle needle, inflation of intravertebral balloon to create a void in which high-viscosity bone cement is injected
-more recently developed (than PV?)

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18
Q

Between Balloon kyphoplasty and PV:

  • which has better outcomes?
  • which has fewer complications?
  • which has better height restoration?
  • which is better for burst fxs?
  • which is more expensive?
A
  • no difference in outcomes
  • no difference in complications
  • “some believe” kyphoplasty offers better height restoration
  • kyphoplasty may be better for burst fxs; can offer more controlled angular and fracture correction
  • kyphoplasty more costly
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19
Q

is cement bright or dark on CT?

A

bright

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20
Q

osseous metastasis: appearance on XR, CT

A

heterogenous, patchy appearance within bone

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21
Q

Indications for CT myelogram:

A
  • pt has a need for visualization of soft tissue within spinal canal:
  • pt cannot get an MRI
  • pt has hardware that obscures spinal canal on CT or MR
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22
Q

CT myeologram: technique

A
  • injection of contrast by lumbar puncture (into thecal sac) under fluoroscopic XR guidance
  • subsequent imaging of spine
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23
Q

CT myelogram: contraindications

A

-elevated INR or bleeding disorders

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24
Q

MRI indications: 6 main categories

A
  1. degenerative disease
  2. osseous/extraosseous infection
  3. neoplasm
  4. demyelinating/inflammatory disease
  5. trauma
  6. postop spine imaging
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25
Q

MRI: absolute and relative contraindications

A 
ABSOLUTE:
-pacemaker
-ferromagnetic aneurysm clip
-cochlear implant
-IVC filter
-orbital metallic foreign body
RELATIVE
-metal fragments, depending on location
-1st trimester pregnancy (risk v. benefits)
-transcutaneous nerve stimulators
-claustrophobia
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26
Q

Contrast enhanced MRI: indications

A
  • postop spine recurrent back pain evaluation: to view granulation tissue from recurrent or new disc herniation
  • metastatic bone disease (bone and spinal cord)
  • primary SC lesions (tumor, demyelination)
  • spinal infection (discitis, osteomyelitis, epidural abscess)
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27
Q

Noncontrast MRI: indications

A
  • degenerative disease
  • low back pain
  • preoperative planning
  • radiculopathy
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28
Q

Contraindication for MRI contrast

A

Pt with EGFR <30

  • measure of kidney function
  • risk of nephrogenic system fibrosis (NSF)
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29
Q

Non Contrast MRI for Cervical Spine: what sequences are used for the cervical spine, and which views for each sequence?

A

Cervical spine:

  • T1 and T2: sagittal and axial views
  • STIR: sagittal view
  • Gradient Echo: axial view
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30
Q

Non Contrast MRI for Thoracic and Lumbar Spine: sequences used and views

A

Thoracic/Lumbar Spine:

  • T1 & T2: sagittal and axial
  • STIR: sagittal
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31
Q

why might an MRI be better than an XR or CT in the case of viewing a fracture?

A

the age of the fracture can better be determined by the presence or absence of fluid/edema in the bone and surrounding area. newer fracture=edema in bone

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32
Q 
MRI Basics: T1 weighted image
hyperintense (bright) or hypointense (dark)?
-water:
-fat:
-normal bone:
-sclerotic bone:
A
  • water: hypointense
  • fat: hyperintense
  • normal bone: hypointense
  • sclerotic bone: markedly hypointense
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33
Q 
MRI Basics: T2 weighted image
hypo/hyperintense?
-water:
-fat:
-normal bone:
-sclerotic bone:
A
  • water: hyperintense
  • fat: hyperintense
  • normal bone: hypointense
  • sclerotic bone: markedly hyperintense
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34
Q 
MRI Basics: STIR
hypo/hyperintense?
-water:
-fat:
-normal bone:
-sclerotic bone:
A
  • water: hyperintense
  • fat: hypointense
  • normal bone: hypointense
  • sclerotic bone: markedly hyperintense
35
Q

What are water-rich structures that will show up on MRI?

A
  • CSF
  • normal disc space
  • bone/soft tissue edema
  • fluid collections: cysts, abscesses, postop seroma
36
Q

How does aging affect normal bone appearance on MRI?

A

Yellow (fatty) bone marrow increases with normal aging; so a younger bone will appear darker on MRI than an older bone

37
Q

Calcified ligament or disc: hypointense or hyperintense on MRI?

A

Hypointense (sclerosis)

38
Q

C-spine exiting nerve root numbering

A

Exiting nerve root named for the lower vertebra
Ex) at C5-C6, exiting nerve roots are C6
C7-T1: C8 nerve roots

39
Q

T-spine exiting nerve root numbering

A

Exiting nerve roots from the level above

ex) at T1-T2, exiting nerve roots are T1

40
Q

zygapophyseal joints: anatomy and function

A

facet joints
-articulation point of 2 vertebrae
-composed of inferior and superior articular processes
-put your hands up like you’re going give somebody a high 10: your hands are oriented like superior facets
-point your hands down, keeping your palms facing your body: your hands are oriented like inferior facets
function:
-carry axial load of body
-limit spine ROM
-form posterior border of intervertebral foramen

41
Q

intervertebral neural foramina

A
  • foramen through which spinal nerves exit the spinal canal
  • within foramen, motor and sensory nerve roots become mixed spinal nerves (“exiting nerve”)
  • facet joints make up the back of this foramen
  • more or less directly inferior/superior to vertebral pedicles of vertebrae above and below
42
Q

where does the spinal cord terminate? what happens then?

A

terminates at L1-L2 (conus medullaris) then becomes cauda equina

43
Q

contents: cauda equina

A

pia-wrapped 3-5 lumbar nerves, 5 sacral nerves, 1 coccygeal nerve
-cuada equina is still within the thecal sac

44
Q

sciatic nerve

A

Contains fibers from the anterior and posterior branches of the lumbosacral plexus
L4-S3
-sensory: skin of whole leg
-motor: hamstrings, lower leg, ankle/foot

45
Q

cervical spine XR: list views

A
  • AP
  • AP open mouth (odontoid)
  • Lateral (must include T1, need to see prevertebral soft tissues)
  • bilateral oblique
  • flexion
  • extension
46
Q

cervical spine XR AP open mouth view: what are we looking for?

A
  • alignment of odontoid process
  • C1/C2 alignment
  • lateral masses
47
Q

cervical XR AP view: what are we looking for?

A

-alignment: single row, top to bottom. including:
uncovertebral joint alignment
TP, SP alignment

48
Q

cervical lateral XR view: what to look for

A
  • IV disc spaces
  • prevertebral soft tissue
  • SPs
  • facet joints
49
Q

cervical XR lateral view: maneuvers to enhance views of lower C-spine

A
  • swimmer’s view: elevate arm nearest cassette
  • cervical spine CT
  • pull down on arms during cross table lateral (pt supine, shoulders depressed)
50
Q

cervical XR lateral view: what bony landmarks to use to analyze alignment

A
  • anterior column of vertebrae: vertebral bodies
  • posterior column: SPs
  • middle column: facets
  • Sps: middle of anterior spinous process lines up C1-C3 (WHAT DOES THIS MEAN?)
51
Q

pseudosubluxation of C2 and C3: cervical XR

A

normal in children due to joint laxity; may be seen in up to 20% of children under age 8

52
Q

predental space: cervical XR; define and give norm values

A

distance from dens to C1 body

  • adult: 3mm
  • child: 5mm
53
Q

cervical spine: oblique XR view; what is best viewed?

A

head turned to best expose neural foramina

  • foraminal stenosis
  • facet joints
  • pedicles
54
Q

cervical spine flexion and extension XR views: 2 main reasons

A
  • helps detect ligamentous injury (instability) not apparent on neutral view
  • assessment of RA at C1-C2 and any associated instability
55
Q

Cervical spine XR, flexion view-Vertebral body angulation/translation patterns of instability

A

Criteria for instability at C-spine

  1. 3.5 mm translation
    * **“vertebral body subluxation should be no greater than 1mm as compared to extension view”
  2. 1.7mm or greater disc space widening
  3. angulation between 2 adjacent vertebra of 11 degree or more
56
Q

ADI measurements: what is it, norms for adults, children

A
  • atlantodens interval: distance between the anterior aspect of the dens and the posterior aspect of the anterior ring of the atlas.
  • adults: ADI <3.5mm
57
Q

Type I dens fx

A

<5%

-(usually unstable) fracture through tip of dens at attachment for alar ligament

58
Q

Type II dens fx

A

> 60% (most common type)

  • fracture through the base of the dens
  • no alar involvement-relatively stable (in my notes, but later type II fx is listed as an unstable fx)
59
Q

Type III dens fx

A

30%

  • subdentate (does not involve dens)
  • through the body of C2
  • unstable-atlas and occiput can move together as a unit
60
Q

what type of injury most commonly results in cervical spine fracture?

A

hyperflexion injury

61
Q

c-spine flexion injuries: list 7 types

A
  1. anterior subluxation: anterolisthesis
  2. simple wedge fx: stable, fx of vertebral body
  3. unstable wedge fx: interspinous ligaments involved
  4. unilateral interfacet dislocation: “jumped facet”
  5. bilateral interfacet dislocation: “jumped facet”
  6. flexion teardrop fx
  7. anterior atlantoaxial dislocation
62
Q

jumped facet: define

A

top vertebrae “jumps forward”: inferior facet of top vertebra lies anterior to superior facet of inferior vertebra

  • can be unilateral or bilateral
  • unilateral: 50% anterolisthesis
63
Q

jumped facet: imaging characteristics

A
  • anterolisthesis
  • widening of interspinous distance
  • widening of facet jt
64
Q

3 types of extension injuries in the c-spine

A
  1. hangman’s fx
  2. extension teardrop fx: avulsion at anterior vertebral body
  3. hyperextension with pre-existing spondylosis (disc degeneration)
65
Q

hangman fx: bony areas affected, injury type, what is seen in imaging

A
  • fx involving both par interarticularis of C2
  • secondary to hyperextension and distraction
  • imaging: shows fractures at bilateral lamina and pedicles and usually anterolisthesis at C2-C3
66
Q

Jefferson fx: bony areas affected, how it happens, imaging characteristics

A
  • burst fx of C1 (UNSTABLE)
  • axial loading (diving into shallow water)
  • open mouth anterior view: bilateral, lateral offset of C1 on C2
  • lateral view: widening of ADI if transverse ligament affected
67
Q

list 3 cervical flexion injuries that are UNSTABLE

A
  1. bilateral interfacetal dislocation
  2. flexion teardrop fx
  3. wedge fx with posterior ligamentous rupture
68
Q

list 3 cervical extension injuries that are UNSTABLE

A
  1. odontoid fx type II
  2. Hangman’s fx
  3. extension teardrop fx
69
Q

what views are taken for lumbar spine X rays?

A

lateral, oblique

70
Q

Lateral lumbar XR: what is visualized

A
  • IV disc spaces
  • SPs
  • pedicles
  • alignment
  • vertebral body height
71
Q

what is viewed on the lumbar oblique XR view?

A

Scotty dog!

  • Nose: TP
  • Eye: pedicle
  • Front leg: inferior articular facet
  • Neck of dog: pars interarticularis
72
Q

common site for pars defects

A

L4/L5

73
Q

common site for anterolisthesis-lumbar

A

L5/S1

74
Q

spondylolisthesis: lumbosacral spine; 2 major types

A

Lumbo Sacral Spine L5-S1

  • anterolisthesis: forward slippage
  • retrolisthesis: backward slippage
75
Q

spondylolisthesis: 5 major types/causes

A
  1. dysplastic: caused by defect in formation of part of vertebra
    2* Isthmic: pars defect
    3* Degenerative: caused by arthritic changes
  2. Traumatic: usually pedicle, lamina, or facet jt fx
  3. Pathologic: caused by abnormal bone (e.g. tumor)
    *most common!
76
Q

spondylolisthesis: Grades

A 
Grade I: 0-25%
Grade II: 25-50%
Grade III: 50-75%
Grade IV: 75-100%
Grade V: >100% (spondyloptosis)
77
Q

spondylolysis

A
  • defect of lumbar vertebrae at pars interarticularis
  • pars located anterior to lamina and posterior to pedicle
  • typically secondary to stress fx from repetitive injury
78
Q

spondylolisthesis in C-spine: example

A

hangman’s fx

79
Q

Thoracic Lumbar spine fxs: flexion fractures

A
  1. compression fx: anterior parts of vertebral body breaks, loses height; posterior part intact (usually stable)
  2. axial burst fx: vertebra loses height both anteriorly and posteriorly
  3. chance fx: seatbelt injury
80
Q

thoracic/lumbar spine fxs: rotation fxs

A
  1. transvers process fx: uncommon, rotation or extreme lateral bending
  2. fracture dislocation: involves bone and soft tissue, vertebra may move off an adjacent vertebra; unstable
81
Q

Wedge fx: thoracic

A

compression fx secondary to hyperflexion and compression

  • buckled anterior cortex with loss of height of anterior vertebral body
  • anterosuperior fx of vertebral body
  • most common in thoracic spine
  • considered serious if: fx involves adjacent vertebrae, anterior wedge >50%, severe hyperkyphosis, bone fragments suspected within spinal canal
82
Q

chance fracture: describe, most common location?

A

T12-L2: thoracolumbar junction

  • flexion fracture primarily (also extension, but it’s classically thought of as a flexion injury)
  • seatbelt injury: compression injury to anterior vertebral body; transverse fx through posterior vertebral body and posterior elements
83
Q

Schmorl’s node: describe

A
  • vertical disc herniation through cartilaginous vertebral body endplates
  • may or may not be symptomatic
  • common with increasing age
  • strong heritability >70%
84
Q

Sacrum: views, features

A

AP view: SI joints, sacral ALA, coccyx

Lateral view: sacral coccygeal angle, cortical integrity, pre-sacral soft tissue (tumor involvement)

Radiology (5 decks)

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