interpretation of the spine xrays, brief anatomy of the back, followed by approach in the interpretation of xray of the cervical spine, then thoracolumbar spine, with common pathologies and their radiological manifestations on xrays.

1. Interpretation of Xray's of the
spine
Dr TSAMO NDOMO V. MD, MPH
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2. Outline
• Introduction
• Overview of anatomy of the spine
• Interpretation of the cervical spine x-rays
• Interpretation of the thoracolumbar spine x-rays
• conclusion
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3. Introduction
• The back is mostly made up of bones and muscles, but the most
important structure in the back remains the spinal cord, enclosed
within the vertebrae, through which exits nerves.
• Various pathologies of the back will affect the spinal cord and its
nerves either directly or indirectly.
• Conventional radiograph of the spine provides a good and relatively
fast and low cost diagnostic guide in the diagnosis and follow-up of
pathologies of the spine.
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4. Overview of the Anatomy of the spine
• The spine is composed of 33 bones, called vertebrae, divided into five
sections:
• Cervical spine
• The cervical spine is made up of 7 bones from C1 to C7, connected to the base
of the skull.
• The top two vertebrae are also know as the atlas and axis,
• Thoracic spine
• located at chest level, between the cervical and lumbar vertebrae.
• They are labeled T1 to T12 and serve as attachments for the rib cage.
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5. Overview of the Anatomy of the spine
• lumbar spine
• The five lumbar vertebrae, labeled L1 to L5
• They are the main weight-bearing section of the spinal column.
• The sacrum
• It does not have discs separating the vertebrae, because its five levels, S1 to
S5, are fused together.
• coccyx bones.
• Located at the very base of the spinal column and is made of four vertebrae
that are fused together
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6. Overview of the Anatomy of the spine
• Spinal Curvature
• The neck and lumbar sections of the spine have a lordotic curve,
which means that they curve inward.
• The thoracic spine has a kyphotic curve, which means that it
curves outward.
• Parts of the spine
• Spinal Cord: has nerve pathways that carry signals, to the brain.
• Nerve roots: transmit information between the spinal cord and
the other parts of the body, such as arms, legs and organs.
• Vertebral Body: The cylinder-shaped vertebral body is the weight-
bearing structure of the vertebrae.
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7. Overview of the Anatomy of the spine
• Lamina: The flat plates of the lamina create the outer wall of the
vertebral canal and help protect the spinal cord.
• Vertebral Canal: The spinal cord sits in this channel formed by the
lamina and the vertebral body.
• Pedicles: Pedicles connect the lamina to the vertebral body
• Discs: Discs separate the vertebrae and made up of tough, elastic
material (annulus fibrosus and nucleus pulposus) that allows the
spine to bend and twist naturally.
• Articular Facet: The articular facets are where two neighboring
vertebrae attach.
• Spinous Process and transverse process: Muscles and ligaments that
move and stabilize the vertebrae attach to the spinous processes.
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8. Interpretation of cervical
spine x-ray
Dr TSAMO NDOMO V. MD, MPH
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9. Introduction
• Begin by:
• confirming you have the correct patient and the correct radiograph by
identification of the patient, compare it with the identification of the
radiograph, review previous films if available.
• Use the ABC’S approach of interpretation:
• A: adequacy
• A: alignment
• B: bone
• C: cartilage
• S: soft tissue
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10. Adequacy
• Make sure you have the right view.
• Check the radiograph’s adequacy to ensure you are able to clearly see
all relevant structures (you should be able to see from C1 down to the
C7/T1 junction).
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11. Alignment
• There are multiple lines you need to assess
across each of the three radiograph views
which should run uninterrupted in healthy
individuals.
• Lateral view
• The anterior longitudinal line runs along the
anterior surface of the vertebral bodies.
• The posterior longitudinal line runs along the
posterior surface of the vertebral bodies.
• The spinolaminar line runs along the anterior
edge of the spinous processes (at the junction of
the spinous process and the laminae).
• Tips of Spinous Processes
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12. Alignment
• Antero-posterior (AP) view
• The two lateral lines of the AP view
run down either side of the
vertebral bodies.
• The spinous process line runs
down through each spinous
process from C1 to C7.
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13. Alignment
• Anterolisthesis
• The term anterolisthesis refers to anterior
displacement (forward slip) of a vertebral body relative
to the one below, as opposed to posterolisthesis which
can be seen in osteoarthritis.
• Its severity can be graded by the Meyerding
classification which divides the superior endplate of the
vertebra below into 4 quarters.
• The grade depends on the location of the
posteroinferior corner of the vertebra above
• grade I: 0-25%
• grade II: 26-50%
• grade III: 51-75%
• grade IV: 76-100%
• grade V (spondyloptosis): >100%
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14. Bones
• Inspect the shape of each vertebra
• Size
• Density of the bone
• Detailed analysis of the different parts.
• In all the views available, carefully inspect the cortex (outer white
edge).
• The interpretation include the whole film, beware to stop the
interpretation after finding one abnormality.
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15. Bones
• Calcium pyrophosphate deposition
disease (CPPD) and crowned dens
syndrome
• Inflammatory condition resulting
from crystal deposition in the
cartilage and ligaments surrounding
the dens
• Best seen at CT but occasionally seen
on open-mouth radiographs.
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16. Bones
• Facet osteoarthritis
• Degenerative facet arthrosis
distorts the smooth curvilinear
lateral margin of the articular pillar
column, proportional to the
severity of osteophytic
hypertrophy.
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17. Cartilage
• For each cartilage, examine
• The shape
• Structure
• Size
• Include analysis of the facet joint and the unco-
vertebral joint (joint of Luschka).
• Intervertebral discs should be roughly similar in
height throughout the cervical spine, with no
obvious loss of height at any point in the disc.
• However, if you suspect disc pathology, this often
wouldn’t be clearly seen on a cervical spine X-ray
and would be better investigated with an MRI scan.
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18. Cartillage
• Spondylosis deformans (spondylosis): Characterized by osteophytes,
but normal disk height.
• Degenerative disk disease (DDD): Characterized by disk height loss.
• Intervertebral osteochondrosis (IVOC): Typically seen in the context of
severe DDD, characterized by central fissures within the disk (nucleus
and annular fibers), and resultant “vacuum cleft phenomeon” (gas in
the disk)
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19. Osteophytes proliferation with maintained disk height Severe degenerative disk disease with loss of height
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20. Cartillage
• Ankylosing spondylitis presents as in the cervical
spine:
• Loss of lordosis, anterior head carriage
• Anterior views quaring, syndesmophytes,
osteoporosis
• Facet erosion, syndesmophytes,sclerosis ankylosis
• C1/C2 involvement less common & usually less severe
than RA but may see instability in some patients
• Isolated regions of persistent motion may show
degenerative instability.
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21. Cartillage
• Infections
• Infectious spondylodiscitis is
least common in the cervical
spine.
• Presents with:
• Early loss of disk height, endplate
destruction, vertebral body
collapse.
• With treatment, healing may result
in ankylosis.
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22. Soft tissue
• Pre-vertebral (area directly anterior to the vertebral bodies) soft
tissue is best assessed using a lateral view.
• Soft tissue appears as a light grey opacity on cervical spine X-rays,
located between the vertebral bodies and the darker-grey area that
represents the trachea.
• Any widening of this space may represent a pre-vertebral haematoma
and should significantly raise suspicion of a cervical fracture.
• It should be noted that this area naturally gets wider around the level
of C4 so two different acceptable widths are used.
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23. Interpretation of Thoraco-
Lumbar spine x-ray
Dr TSAMO NDOMO V. MD, MPH
23

24. Introduction
• Lumbar spine X-rays are one of the most commonly requested
radiographic investigations of the spine especially in rheumatology
due to their weight carrying function unlike, thoracic spine which’s is
less requested.
• Interpretation begins by identifying the patient and the radiograph,
then acquire all the view and previous films.
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25. Alignment
• In the lateral view, the entire lumbar spine should be visible from T12-S1.
• On the lateral view
• check the alignment of the vertebral bodies.
• Each vertebra should be examined looking for a loss of height which could indicate a
compression fracture commonly associated with osteoporosis.
• Compression fractures are often seen in the upper lumbar or lower thoracic
vertebrae.
• On the AP view,
• The spinous processes should be central and there should be equal distance between
transverse processes.
• check that the vertebral bodies and spinous processes are aligned.
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26. Approach in the interpretation
• Step 1
• Inspect for loss of vertebral height:
• The height of vertebral bodies should be equal in healthy individuals
• Loss of vertebral height is suggestive of a fracture
• Step 2
• Inspect the vertebral spaces:
• In healthy individuals, the disc height should gradually increase from superior
to inferior
• Note: the L5/S1 space is normally slightly narrower than L4/L5
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27. Approach in the interpretation
• Step 3
• Inspect the vertebral endplates: the continuity of superior and inferior
endplates should remain uninterrupted.
• Step 4
• Trace the posterior elements including:
• Pedicles
• Laminae
• Spinous processes
• Ensure the vertebral and spinous processes are intact.
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28. Findings in an abnormal radiograph
• Spondylosis
• Spondylosis involves degeneration of the interverbal disc leading to disc
space narrowing, endplate sclerosis and osteophyte formation.
• In some cases, osteophytes can cause neural impingement.
• Spondylolysis
• Spondylolysis occurs when a fracture (acute or chronic) extends from the
inferior facet across the pars interarticularis (area of the lamina that lies
within the facets), to the superior facet.
• This defect can in some cases be bilateral and lead to spondylolisthesis.
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29. Findings in an abnormal radiograph
• Spondylolysis is often best identified on an
oblique radiograph, appearing (with the eye
of faith) to represent a “Scotty dog”:
• Nose: transverse process
• Eye: pedicle
• Ear: superior facet
• Front leg: inferior facet
• Neck: pars interarticularis
• Collar across the neck: fracture
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30. Findings in an abnormal radiograph
• Spondylolisthesis
• Spondylolisthesis occurs when one
vertebra is displaced forward upon
another.
• This can occur secondary to trauma or
as a result of degenerative disease such
as osteoarthritis.
• If severe it may lead to foraminal
stenosis, causing nerve root
impingement.
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31. Findings in an abnormal radiograph
• Vertebral bone lesions
• Vertebral bone lesions can often be asymptomatic in patients and
thus are often identified incidentally.
• These lesions typically become symptomatic when they present as a
pathological fracture with or without neurological deficits secondary
to extension into the spinal canal.
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32. Findings in an abnormal radiograph
• Sclerotic or osteoblastic bone metastases are
distant tumour deposits of a primary tumour
within bone characterised by new bone
deposition or new bone formation.
• Commonly caused by:
• Prostate carcinoma (most common)
• Breast carcinoma (may be mixed)
• Transitional cell carcinoma
• Medulloblastoma
• Neuroblastoma
• Mucinous adenocarcinoma of the GIT
• Lymphoma
• Small cell lung cancer
• Pulmonary adenocarcinoma
• Medullary thyroid carcinoma
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33. Findings in an abnormal radiograph
• Lytic bone (osteolytic) lesions are
characterised by a loss of bone with
the destruction of the bone matrix.
• The main etiologies include:
• Prostate cancer metastases
• Breast cancer metastases
• Thyroid cancer metastases
• Renal cell carcinoma metastases
• Lung cancer metastases
• Multiple myeloma
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34. Findings in an abnormal radiograph
• Ochronosis, or alkaptonuria
(AKU), is a rare multisystem
autosomal recessive metabolic
disorder.
• On imaging, the most particular
presentation is on the spine, with
osteoporotic bones and dense disc
calcifications.
34
Case courtesy of Mohammad Taghi Niknejad,
Radiopaedia.org, rID: 61667

35. Findings in an abnormal radiograph
• Diffuse idiopathic skeletal hyperostosis (DISH), also
known as Forestier disease, is a common condition
characterised by bony proliferation at sites of
tendinous and ligamentous insertion of the spine
affecting elderly individuals.
• On imaging, it is typically characterised by the
flowing ossification of the anterior longitudinal
ligament involving the thoracic spine and
enthesopathy.
• DISH is defined as flowing bridging anterior
osteophytes spanning at least four vertebral levels,
with normal disk spaces and sacroiliac joints
35
Case courtesy of Arvind Aggarwal,
Radiopaedia.org, rID: 28365

36. Findings in an abnormal radiograph
• Bamboo spine is a pathognomonic radiographic
feature seen in ankylosing spondylitis that occurs as a
result of vertebral body fusion by marginal
syndesmophytes.
• It is often accompanied by fusion of the posterior
vertebral elements as well.
• radiographic appearance, is that of thin, curved,
radiopaque spicules that completely bridge adjoining
vertebral bodies.
• with associated reactive sclerosis of the vertebral
body margins (shiny corner sign).
• Together these give the impression of undulating
continuous lateral spinal borders on AP spinal
radiographs and resemble a bamboo stem;
36
Case courtesy of Mohammad Taghi
Niknejad, Radiopaedia.org, rID: 21781

37. Findings in an abnormal radiograph
• Spondylodiscitis, also referred to as discitis-osteomyelitis, is
characterised by infection involving the intervertebral disc and
adjacent vertebrae.
• A disc space narrowing and irregularity or ill definition of the
vertebral endplates can be seen.
• In untreated cases, bony sclerosis may begin to appear in 10-12
weeks.
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38. In Fine
• Radiography of the spine remains an important diagnostic guide for
pathologies of the spine, especially in rheumatology.
• Interpretation of radiograph of the spine provides requires a good
knowledge of the anatomy of the spine.
• Remember to always use the ABCS approach for the interpretation.
• The thoracic and lumbar spine have almost the same pathologies.
• Always use the 4 steps methods to identify the common pathologies
present on thoracolumbar spine.
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39. you for your kind At
Meh Shakleh!!!