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Differential Diagnosis/Imaging > Thoracolumbar and Chest Imaging > Flashcards

Thoracolumbar and Chest Imaging Flashcards

1
Q

Thoracic spine pathology

A
  • Osteoporosis/anterior compression fractures
  • Scoliosis
  • Scheuermann’s Disease
  • Spinal tuberculosis (Pott’s Disease)
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2
Q

Lumbar spine pathology

A
  • Spondylosis
  • Spondylolisthesis
  • Stenosis
  • Intervertebral disk herniation: anterior, intravertebrally, posterior/posterolaterally
  • Degenerative disc disease
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3
Q

Thoracic spine imaging choices

A
  • Radiograph: initial study unless high risk trauma
  • CT: initial study for high risk trauma; one scan = head CT, thoracic abdominal pelvic (TAP) for viscera, & all imaging of the spine can be derived from this initial data set
  • MRI: spinal cord, ligaments, soft tissues, neurological deficits not explained by CT
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4
Q

Thoracic spine imaging indications

A
  • Trauma
  • Pain radiating along chest wall (suspect rib fracture)
  • Decreased ROM
  • Compression fractures
  • Scoliosis evaluation
  • Instability
  • AP and lateral views are standard
  • ACR appropriateness criteria (4 clinical conditions) and diagnostic imaging pathway (thoracolumbar spine trauma)
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5
Q

Appropriate imaging for identification of low bone density & Fx risk in asymptomatic patient

A
  • DXA PA spine
  • DXA proximal femur and femoral neck & total hip
  • QCT spine
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6
Q

Appropriate imaging for follow-up patients demonstrated to have risk for Fx or low density

A
  • DXA PA spine
  • DXA proximal femur, femoral neck, and total hip
  • QCT spine
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7
Q

Appropriate imaging for identify low BMD

A
  • DXA PA spine
  • DXA proximal femur, femoral neck, and total hip
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8
Q

Appropriate imaging for follow up to low BMD

A
  • DXA PA spine
  • DXA proximal femur, femoral neck, and total hi
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9
Q

Appropriate imaging for diagnosis in patients with advanced degenerative changes of the spine with or w/o scoliosis

A
  • DXA proximal femur, femoral neck, and total hip
  • QCT spine
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10
Q

Appropriate imaging for suspected Fx, incident or prevalent of a vertebral body based on clinical Hx, height loss, or patient treated with corticosteroids

A
  • DXA VFA
  • X-ray thoracic & lumbar spine
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11
Q

How to rotation identified in a standard AP thoracic spine view

A
  • Identified by the rotation of a pedicle toward the midline or by the spinous process away from midline
  • Mild rotation is not abnormal
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12
Q

What is the normal interpedicular distance in the thoracic spine

A
  • 20 mm in the thoracic spine & is the transverse diameter of the spinal canal
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13
Q

Describe a thoracic spine swimmers lateral view imaging

A
  • patients arm is placed overhead to remove superimposition of the arm
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14
Q

Describe the T-spine 3 column stability concept

A
  • Spinal columns assist in determining stability of fractures
  • 1 column disrupted = stable spine
  • 2 columns disrupted = potentially unstable spine
  • 3 columns disrupted = instability
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15
Q

When is the thoracic spine most injured

A
  • Most injured with flexion forces
  • Most common fracture location is T12/L1
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16
Q

Describe the anterior, middle, and posterior column of the T-spine

A
  • Anterior column: anterior longitutidinal ligament, anterior annulus, and anterior 2/3 vertebral body
  • Middle column: Posterior 1/3 of vertebral body, posterior annulus, posterior longitudinal ligament
  • Posterior column: pedicle, facets, lamina, spinous process, and posterior ligaments
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17
Q

What are the big 3 signs of a compression fracture

A
  • Step defect
  • Wedge deformity
  • Linear zone of impaction
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18
Q

What fracture comprise the majority of all vertebral fractures over the age of 60 years old

A
  • Anterior compression fractures
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19
Q

Why are anterior compression fractures the most common

A
  • Bone density make-up
  • Anatomy: thoracic kyphosis
  • Forces: axial loading results in flexion moment
  • Fetal position for protection
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20
Q

How long does it take anterior compression fractures to heal

A
  • ~3-6 months
  • Wedge sign may persist after healing
  • Younger patients will have bracing for 4-6 wks
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21
Q

Describe a seat belt/Chance fracture

A
  • Fracture involves hyperflexion-distraction injury with compression of the anterior vertebral body & posterior ligament complex disruption
  • MOI: spine is forcibly flexed over a horizontal restraint as is commonly seen in MVAs where seatbelts have been used
  • Imaging: Radiographs will identify the Fx; CT will be used 1st to screen for significant injury via a TAP (thoracic-abdominal-pelvic) scan
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22
Q

What are the 4 common curve patterns seen in scoliosis

A
  • Right thoracic
  • Right thoracolumbar
  • Left lumbar
  • Double major right thoracic left lumbar
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23
Q

Radiography is critical in the management of scoliosis to determine etiology, demonstrate structural versus nonstructural curves, assess skeletal maturity, and monitor the effects treatment (True/False)

A
  • True
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24
Q

Describe nonstructural scoliosis

A
  • Not fixed and possibly amendable to bracing & physiotherapy
  • Retains flexibility & will reverse or straighten on lateral flexion toward the convex side
  • Can result form postural adaptations, nerve root irritation, inflammation, or leg length inequality
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25
Q

Describe Cobb angle

A
  • Widely accepted radiographic measurement of scoliotic curves
  • (1) Identify the uppermost involved vertebra of the curve
  • (2) Identify the lowermost involved vertebra of the curve
  • (3) Draw perpendicular lines through those 2 lines & measure the resulting intersecting angle
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26
Q

Scoliosis treatment

A
  • <20º: no active treatment but close observation for month/years
  • 20-40º: spinal bracing + exercise for several months/years until skeletal maturity
  • > 50º: surgical fixation
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27
Q

MRI indications for thoracic spine imaging

A
  • Degenerative disc disease (DDD)
  • Extradural soft tissue/bony neoplasms
  • Intramural masses
  • Intramedullary tumors
  • Treatment field for radiation
  • Intrinsic spinal cord pathology (demyelinating, inflammatory, vascular)
  • Syringohydromyelia
  • Post-op intraspinal fluid/post-op changes
  • Meningeal abnormalities
  • Spinal infections
  • Vertebroplasty; kyphoplasty
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28
Q

MRI interpretation (ABCDS)

A
  • Alignment: sagittal slices best for assessing normal spinal alignment/deviations in alignment that signal Fx, dislocation, destruction of bone
  • Bone signal: look for erosions signifying disease/infection, look for bone bruises on T2 weighted MRI
  • Canal space/CNS: spinal canal space, look for effacement
  • Disk integrity: disk height & hydration of NP, view posterior margins on sagittal view
  • Soft tissues: paravertebral soft tissues, inspect integrity of ligaments & SC (spinal cord)
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29
Q

CT indications for thoracic spine imaging

A
  • Trauma
  • Degenerative conditions like OA
  • Bone graft, instrumentation fusion, post operative
  • Infectious processes of the spine
  • Neoplastic conditions
  • Inflammatory lesions
  • Congenital/developmental spine abnormalities
  • Spinal cord syringes, intrathecal masses
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30
Q

CT interpretation (ABCDS)

A
  • Alignment: coronal reformats = AP view, sagittal reformats = lateral view
  • Bone density: cortical bone most dense (post vertebral structures); cancellous bone less dense (vertebral bodies)
  • Canal space: axial views for patency
  • Disk integrity: posterior & psosterolateral margins on axial view for contour & intact borders
  • Soft tissues
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31
Q

Describe Scheuermann’s Disease

A
  • Occurs when the front portions of the upper part of spine does not develop as much as the back part of the spine giving the vertebra a wedge shape
  • Adolescent boys/girls
  • Backache, thoracic kyphosis
  • Schmorl’s nodes
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32
Q

Describe Tuberculous osteomyelitis aka Pott’s Disease

A
  • Occurs secondary to tuberculous
  • Thoracic back pain
  • Kyphosis
  • Weight loss, fever, fatigue
  • Infection progresses to several vertebra
33
Q

Describe rib fractures

A
  • Chest wall injury can range ins severity from minor bruising to an isolated rib fracture
  • MOI: blunt trauma, in frail patients severe coughing can cause Fx, in infants/young children most rib Fx are suspicious of abuse
  • Imaging: PA chest radiograph is the primary study
34
Q

Lumbar spine imaging diagnostic approach

A
  • Strong for: pts with LBP recommend HX and physical exam, that should include identifying & evaluating neurologic deficits, red flag sx, and phychosocial
  • Weak for: pts with LBO suggest performing a mental health screening as part of the LBP evaluation & taking results into consideration during selection of tx
  • Strong for: pts with LBP recommend diagnostic imaging & appropriate laboratory testing
  • Strong against: pts with acute axial LBP recommend against routinely obtaining imaging studies or invasive diagnostic tests
  • N/A: pts with LBP greater than 1 mo who have not improved or responded to initial Tx
35
Q

Routine radiographic evaluation for lumbar spine

A
  • 2-5 different projections
  • AP = all 5 vertebra
  • Lateral = alignment, disc spaces
  • Lateral L5-S1 = lumbosacral junction view
  • R and L obliques to observe facet joint articulations
36
Q

Describe a normal AP view of the lumbar spine

A
  • Facet joints are vertically orientated
  • Spinous processes in midline
  • Intervertebral spaces equal
  • Pedicles are spaced equal distance from the spinous process
  • Intervals between spinous processes are equal
37
Q

Normal interpedicular distance in lumbar spine

A
  • 25 mm in L1-L3
  • 30 mm in L4-L5
  • Misalignment in the relationship of these structures may indicate a fracture-dislocation
  • Distance between pedicles represents the transverse diameter of the spinal canal
38
Q

Describe the alignment of lumbar vertebrae in a lateral view

A
  • Follows the same 3 column stability rule
  • Disruption in these parallel lines may indicate fracture, dislocation, or spondylolisthesis
39
Q

What does a standard lumbar oblique view show

A
  • Shows facet joints and “scottie dog”
40
Q

Radiologic findings of DDD

A
  • Decreased disk space height
  • Osteophytes at vertebral endplates
  • Schmorl’s nodes
  • Vacuum phenomenon
41
Q

Radiologic findings of degenerative joint disease (DJD)

A
  • Decreased zygapophyseal joint space
  • Sclerosis
  • Osteophytes at joint margins
42
Q

Radiologic findings of Spondylosis

A
  • Osteophytes visible as radio dense irregularities at vertebral joint margins
43
Q

Radiologic findings of Spondylosis deformities

A
  • Claw like spurs cupping toward intervertebral disk: present at more than one level but distinguished from DISH
44
Q

Radiologic findings of Diffuse idiopathic skeletal hyperostosis (DISH)

A
  • Flowing ossification of at least 4 contiguous vertebrae
  • Preservation of disk height & absence of DDD findings
  • Absence of sacroillitis or zygapophyseal joint DJD
45
Q

Describe spondylosis scotty dog sign

A
  • Spondylosis is diagnosed on the oblique radiograph as a radiolucent streak across the pars interarticularis (scotty dog)
  • MOI: heavy mechanical loading in spinal extension; most often sports like weightlifting, trunk rotation sports like tennis
  • Presentation: presents as non radiating unilateral LBP, pain reproduced with loading, 3-6 mod to heal, must stop loading the area
  • Nonunion is common and can result in spondylolisthesis
46
Q

What is a spot film

A
  • A spot film may be used to focus on a segment(s) versus all 5 lumbar vertebrae
47
Q

Grades of spondylolisthesis seen in a lateral view

A
  • Grade 1: 25%
  • Grade 2: 50%
  • Grade 3: 75%
  • Grade 4: 100%
48
Q

Signs of degenerative changes in the lumbar spine

A
  • Loss of disc space
  • Hypertrophic spurs
  • Disk calcification
  • Herniated/protruding disks
49
Q

Describe spinal stenosis

A
  • Spinal stenosis is a narrowing of the spinal canal caused by degenerative joint & disk changes
  • Classified into 3 anatomic regions: Stenosis of the central canal; Stenosis of the intervertebral foramen; and Stenosis of the lateral or subarticular recesses
  • More than one region may be involved at the same intervertebral level
50
Q

Features of neurogenic claudication

A
  • Cramping pain
  • LBP
  • Sensory symptoms
  • Muscle weakness
  • Reflex changes
  • Normal arterial pulses
  • Aggravating factors: erect posture, ambulation, extension of spine
  • Relieving factors: sitting, bending forward, squatting
  • Walking uphill produce symptoms later
  • Walking downhill produce symptoms earlier
  • No symptoms in bicycle test unless erect
51
Q

Features of vascular claudication

A
  • Burning, cramping pain
  • Decreased or absent arterial pulses
    -Arterial bruits
  • Skin/dystrophic changes (eg cyanosis, hair loss)
    -Aggravating factors: any leg exercise
  • Relieving factors: rest
  • Walking uphill produce symptoms earlier
  • Walking downhill produce symptoms later
  • Bicycle test provokes smyptoms
52
Q

Describe disk herniations

A
  • Protrusion of nuclear disk material through the annulus fibrosus
  • Spndylosos deformans: anterior disc herniation that disrupts all creating osteophyte formation at the anterior & lateral joint margins
  • Schmorl’s nodes are caused by intervertebral herniation
  • Infraspinal herniation = compressed neural elements
53
Q

What imaging is least valuable and which is the most appropriate for evaluating disk herniations

A
  • Conventional radiographs are of little value in the demonstration of intervertebral disk herniations
  • MRI is most appropriate for evaluating disk herniations if a patient is a surgical candidate
  • No imaging for 4-6 wks is appropriate for the clinical condition of low back and radicular pain with the exception of signs of cauda equina
54
Q

Slide 55

A

Image

55
Q

Most common to rare locations for disc herniation

A
  • Commonest: subarticular
  • Common: foramina or extraforaminal
  • Rare: central
56
Q

Describe degenerative disc disease (DDD)

A
  • Decreased disk space height
  • Spondylosis deformans
  • Vacuum disc phenomenon
  • Osteophyte formation
  • Potential signs of instability
57
Q

Describe ankylosing spondylitis

A
  • Chronic, progressive, inflammatory arthritis characterized by joint sclerosis & ligamentous ossification
  • Occurs in young adult males: about 20 yrs
  • Often associated with ulcerative colitis
  • Bamboo appearing spine caused by calcifications bridging over the disk spaces
58
Q

Signs of spinal infection

A
  • Destructive process that involved or crosses disk space
  • Tumor will typically not involve the dis space
  • MRI > CT scan
  • Indicated: localized pain, elevated ESR and WBCs, fever, + blood culture
59
Q

Signs of spinal neoplasms

A
  • Commonly from metastatic disease from cancer elsewhere in the body
  • Lytic lesions: lung, renal, breast cancer, multiple myeloma
  • Sclerotic lesions: prostate and breast cancer
60
Q

Indications for a bone scan (best option) for spinal neoplasms

A
  • Initial staging of lung, breast, or prostate cancer
  • Bone pain
  • Elevated alkaline phosphate
  • To elevate the response to chemotherapy
61
Q

Describe the winking owl sign

A
  • Indicates a destroyed pedicle due to spinal metastases, intraspinal malignancies, tuberculosis or other infection, congenital absence, neurofibromatosis, poor visualization or radiation therapy
62
Q

Describe Schmorl’s nodes (seen on CT)

A
  • Common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through an endplate defect
  • Commonly seen in the upper lumbar spine & are often discovered incidentally on imaging studies
63
Q

Most common fractures of the lumbar spine (seen on CT)

A
  • Wedge compression
  • Compression burst fracture
  • Spondylolysis
64
Q

Indications for MRI of the spine

A
  • DDD
  • Soft tissue neoplasm/masses
  • Meningeal anomalies
  • Intrinsic spinal cord pathology
  • Spinal vascular malformations
  • Spinal infections
  • Pre-operative assessment for vertebroplasty
65
Q

Purpose of chest radiograph & cardiopulmonary imaging

A
  • 1st imaging in cardiopulmonary assessment
  • Separates cardiac from pulmonary disease
  • Defines many conditions to initiate treatment
  • Narrows the differential diagnoses to direct further imaging
66
Q

Describe a routine chest radiograph & cardiopulmonary imaging

A
  • 2 projections
  • Posteroanterior (PA) view: lung fields, mediastinum (trachea, heart, great vessels, esophagus), and bony thorax
  • Lateral: left side to demo the heart, left lung, retrosternal space, anterior/posterior mediastinum, and thoracic spine
67
Q

ABC checklist for the chest radiograph (A-J)

A
  • Airways
  • Bones
  • Cardiac contours
  • Diaphragm
  • Effusion
  • Fields of the lungs
  • Gastric bubble
  • Hilum
  • Inspiration
  • Jazz, all that
68
Q

ACR appropriateness criteria for rib fractures

A
  • Adult <65 yrs: X-ray of the chest is usually appropriate (PA view)
  • Adult >65 yrs: X-ray of the chest is usually appropriate (PA view)
69
Q

Describe cardiothoracic ratio

A
  • Estimate of heart size on the PA radiograph
  • In adults the width of the heart should be less than half the width of the chest
70
Q

Describe Silhouette sign

A
  • Localize water based lesions to a specific lobe of the lung
  • Refers to a loss of the normal heart or diaphragm border when a lesion is in a lobe adjacent to it
71
Q

Describe the diaphragms location

A
  • 10th pair of posterior ribs
  • Can be elevated or flattened due to pathology
  • R side is higher due to underlying liver, L side overlies the stomach
72
Q

Classic characteristics of patients with chronic obstructive pulmonary disease (COPD) on a PA chest radiograph

A
  • Abnormally flattened diaphragm
  • Narrowed mediastinum
  • Elongated lung fields
  • Heart that appears to “swing” suspended over the diaphragm
73
Q

Pathologies that can show up on chest radiographs/cardiopulmonary imaging

A
  • Lung fields abnormally white = pneumonia, atelectasis, pleural effusion
  • Lung fields abnormally black = pneumothorax, chronic obstructive pulmonary disease
  • Mediastinum abnormally wide = aortic dissection, lymphadenopathy
  • Heart abnormally shaped = congestive heart failure (CHF), mitral valve stenosis
74
Q

Describe echocardiography

A

-Ultrasound study of the heart
- Assesses blood flow, cardiac output, ejection fraction, valve function, heart wall motion, pericardium

75
Q

Describe ventilation/perfusion scans (V/Q)

A
  • Use radioisotopes to evaluate flow of air and blood to all segments of the lungs
  • “mismatch” of ventilation and perfusion = PE (pulmonary embolism)
76
Q

Describe nuclear perfusion studies

A
  • Use of a radioisotope to define perfusion of blood in the myocardium at rest & under stress
  • Detects presence/severity of coronary artery disease
77
Q

Describe multicoated acquisition scan (MUGA)

A
  • Radioisotope to evaluate heart ventricles
  • Evaluates ejection fraction
78
Q

Describe angiography

A
  • Study of blood flow in blood vessels

Differential Diagnosis/Imaging (20 decks)

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