Imaging Degeneration of the      Lumbar Spine:    THE 1 LESSONS          ST          Hieder A`ala              601        ...
Course Outline• Introduction, Nomenclature, Evidence for Imaging• Natural History and Prognosis• New Techniques
Spine Nomenclature and Evidence for Imaging
Talk Objectives• “Background”• Nomenclature for disc findings• Who should be imaged-  evidence basis?
15 Century Turkish    thTreatment- Cauterization
21st Century American      Treatment
Frequency of Back Pain Types      2% visceral        1% tumor,                         infection,                       in...
“Mechanical” Causes of       Low Back Pain• Lumbar strain, sprain (70%)• Degen (disc and facets) (10%)• Herniated disc (4%...
The Least We Can Do:Speak the Same LanguageNomenclature for disc findings
Consensus Nomenclature
Question???• What is the ASNR/NASS  nomenclature for describing  lumbar discs?
Consensus Nomenclature• normal• degeneration• anular tears• herniation
Consensus Nomenclature• normal  –well hydrated disc  –central dark band= central   fibrosusage-related changes=NOT normal
Intranuclear Cleft
Normal
Consensus Nomenclature• normal• degeneration  –desiccation  –narrowing  –bulging  –endplate changes  –osteophytes
Glossary of disc         pathology terms• Herniation: nonspecific term subject to misinterpretation.   – Not recommended.•...
Glossary of disc        pathology terms• Extrusion: nucleus material pushes out beyond  posterior longitudinal ligament bu...
Glossary of disc    pathology terms• Localizing terms: –Central –Paracentral –Foraminal –Lateral
Disc DegenerationDesiccation   Narrowing
Disc Degeneration:         Findings?      Narrowing Osteophytosis Vacuum DiscEndplate sclerosis
Bulging
Consensus Nomenclature• normal• degeneration• anular tear=anular fissure (high  intensity zones=HIZ)• herniation
Degeneration and Tears
Degeneration and Tears
Degeneration and Tears
Consensus Nomenclature• Herniation – localized displacement of disc               o   >50% (180 ) = bulge   <50% = herniat...
Consensus Nomenclature• normal• degeneration• anular tears• herniation  –protrusion  –extrusion
Disc           Normal            BulgeBonyEndplate             Canal        Protrusion           Extrusion
Disc Classification
Protrusion
Protrusion
Extrusion
Extrusion
Extrusion
Extrusion
Classification of Nerve    Root Condition• Normal• Contacted• Displaced• Compressed
Normal Nerve Roots
Contacted Nerve Root
Contacted Nerve Root
Displaced Nerve Root
Compressed Nerve Root
Displaced andCompressed Nerve Root
Displaced andCompressed Nerve Root
Talk Objectives• “Background”• Nomenclature for disc findings• Who should be imaged-  evidence basis?
Prevalence of Disc Findings in Subjects without LBP100%80%         64%60%40%                        32%20%                ...
Disc Degeneration• Signal loss on T2-weighted  images• Height loss
Disc Degeneration
Disc Degeneration
Anular Tear
Take Home Points    Regarding Prevalence• many imaging findings are  common in asx’s• certain findings are related to  pri...
Rationale for Imaging• r/o low prob red flag condition• rule-in treatable conditions –stenosis –herniated disc –spondyloar...
Early Imaging Red           Flags• ? Fx –h/o major trauma –minor trauma in older or  osteoporotic pt
Red Flags• age>50 or <20• h/o malignancy• constitutional sx• ↑ infection risk (IVDA, HIV, etc)
Red Flags• possible cauda equina syndrome –saddle anesthesia –urinary retention –severe/progressive neurologic  deficit in...
Nomenclature in spine mri
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Nomenclature in spine mri

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Nomenclature in spine mri

  1. 1. Imaging Degeneration of the Lumbar Spine: THE 1 LESSONS ST Hieder A`ala 601 MUST
  2. 2. Course Outline• Introduction, Nomenclature, Evidence for Imaging• Natural History and Prognosis• New Techniques
  3. 3. Spine Nomenclature and Evidence for Imaging
  4. 4. Talk Objectives• “Background”• Nomenclature for disc findings• Who should be imaged- evidence basis?
  5. 5. 15 Century Turkish thTreatment- Cauterization
  6. 6. 21st Century American Treatment
  7. 7. Frequency of Back Pain Types 2% visceral 1% tumor, infection, inflammatory arthritis 97% “mechanical”
  8. 8. “Mechanical” Causes of Low Back Pain• Lumbar strain, sprain (70%)• Degen (disc and facets) (10%)• Herniated disc (4%)• Spinal stenosis (3%)• Osteoporotic comp fracture (4%)
  9. 9. The Least We Can Do:Speak the Same LanguageNomenclature for disc findings
  10. 10. Consensus Nomenclature
  11. 11. Question???• What is the ASNR/NASS nomenclature for describing lumbar discs?
  12. 12. Consensus Nomenclature• normal• degeneration• anular tears• herniation
  13. 13. Consensus Nomenclature• normal –well hydrated disc –central dark band= central fibrosusage-related changes=NOT normal
  14. 14. Intranuclear Cleft
  15. 15. Normal
  16. 16. Consensus Nomenclature• normal• degeneration –desiccation –narrowing –bulging –endplate changes –osteophytes
  17. 17. Glossary of disc pathology terms• Herniation: nonspecific term subject to misinterpretation. – Not recommended.• Bulge: diffuse enlargement of disc area – Very common – Usually not clinically important – May contribute to spinal stenosis• Protrusion: nucleus pulposis pushes focally through fibers of annulus fibrosis – Base wider than apex – May focally impinge on nerve or thecal sac
  18. 18. Glossary of disc pathology terms• Extrusion: nucleus material pushes out beyond posterior longitudinal ligament but remains in contact with disc space – Apex wider than base – Likely to impinge on nerve roots• Sequestration: Disc fragment isolated from parent disc
  19. 19. Glossary of disc pathology terms• Localizing terms: –Central –Paracentral –Foraminal –Lateral
  20. 20. Disc DegenerationDesiccation Narrowing
  21. 21. Disc Degeneration: Findings? Narrowing Osteophytosis Vacuum DiscEndplate sclerosis
  22. 22. Bulging
  23. 23. Consensus Nomenclature• normal• degeneration• anular tear=anular fissure (high intensity zones=HIZ)• herniation
  24. 24. Degeneration and Tears
  25. 25. Degeneration and Tears
  26. 26. Degeneration and Tears
  27. 27. Consensus Nomenclature• Herniation – localized displacement of disc o >50% (180 ) = bulge <50% = herniation
  28. 28. Consensus Nomenclature• normal• degeneration• anular tears• herniation –protrusion –extrusion
  29. 29. Disc Normal BulgeBonyEndplate Canal Protrusion Extrusion
  30. 30. Disc Classification
  31. 31. Protrusion
  32. 32. Protrusion
  33. 33. Extrusion
  34. 34. Extrusion
  35. 35. Extrusion
  36. 36. Extrusion
  37. 37. Classification of Nerve Root Condition• Normal• Contacted• Displaced• Compressed
  38. 38. Normal Nerve Roots
  39. 39. Contacted Nerve Root
  40. 40. Contacted Nerve Root
  41. 41. Displaced Nerve Root
  42. 42. Compressed Nerve Root
  43. 43. Displaced andCompressed Nerve Root
  44. 44. Displaced andCompressed Nerve Root
  45. 45. Talk Objectives• “Background”• Nomenclature for disc findings• Who should be imaged- evidence basis?
  46. 46. Prevalence of Disc Findings in Subjects without LBP100%80% 64%60%40% 32%20% 6% 0% Bulge bulge Protrusion protrusion Extrusion extrusion
  47. 47. Disc Degeneration• Signal loss on T2-weighted images• Height loss
  48. 48. Disc Degeneration
  49. 49. Disc Degeneration
  50. 50. Anular Tear
  51. 51. Take Home Points Regarding Prevalence• many imaging findings are common in asx’s• certain findings are related to prior low back pain and more likely to be clinically important –extrusions, root comp, stenosis
  52. 52. Rationale for Imaging• r/o low prob red flag condition• rule-in treatable conditions –stenosis –herniated disc –spondyloarthropathy ? –instability
  53. 53. Early Imaging Red Flags• ? Fx –h/o major trauma –minor trauma in older or osteoporotic pt
  54. 54. Red Flags• age>50 or <20• h/o malignancy• constitutional sx• ↑ infection risk (IVDA, HIV, etc)
  55. 55. Red Flags• possible cauda equina syndrome –saddle anesthesia –urinary retention –severe/progressive neurologic deficit in lower extremity
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