Vertebral column associated pathology and radiographic appearance

1. VERTEBRAL
COLUMN
ASSOCIATED
PATHOLOGY AND
RADIOGRAPHIC
APPEARANCE
Swapnil Shetty. Msc.MIT. MCHP. MAHE. Manipal

2. CONTENT
Basic Anatomy
Vertebral Pathologies
Radiographic Appearances

3. BASIC
ANATOMY

4. BASIC ANATOMY
• The vertebral column, also known as the spinal column, is the
central axis of the skeleton in all vertebrates.
• The vertebral column provides attachments to muscles, supports
the trunk, protects the spinal cord and nerve roots and serves as a
site for hemopoiesis.
• The human vertebral column consists of five morphologically
differentiated groups of vertebrae: cervical, thoracic, lumbar, sacral
and coccygeal (caudal)

5. BASIC ANATOMY
• the vertebral column usually consists of 33 vertebrae,
placed in series and connected by ligaments and
intervertebral discs.
• There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4
caudal (coccygeal) vertebrae.
• In humans, the length of the vertebral column is 71 cm in
males and 61 cm in females.

6. VERTEBRAL
COLUMN

7. VERTEBRAE
• Vertebrae, apart from those that are atypical, have a similar
basic structure which can be described as an anterior
vertebral body and a posterior neural (or vertebral) arch.
• These basic characteristics vary depending on the function
of each individual vertebra.
• The vertebral body is the large anterior cylindrical portion
that is predominantly responsible for bearing the weight of
the spine and body above it.
• Each vertebra articulates with the vertebrae above and
below it via an intervertebral disc.

9. ATLAS
AXIS

22. VERTEBRAL
PATHOLOGIES

23. PATHOLOGI
ES
• Ankylosing Spondylitis
• Fracture: Clay Shoveler’s, Compression,
Hangman’s & Jefferson
• Herniated Nucleus Pulposus (HNP)
• Kyphosis
• Lordosis
• Metastases
• Osteoarthritis or Degenerative - Joint
Disease

24. PATHOLOGI
ES
• Osteopetrosis
• Osteoporosis
• Paget's Disease
• Scheuermann's Disease or Adolescent
Kyphosis
• Scoliosis
• Spina Bifida
• Spondylolisthesis
• Spondylolysis
• Subluxation
• Tumor - Multiple Myeloma

25. ANKYLOSING
SPONDYLITIS
• Rheumatoid arthritis variant involving the SI Joints and
spine.
• The axial skeleton is predominantly affected, although in
~20% of cases the peripheral joints are also involved.
• MRI/CT may show early sacroiliitis, erosions, and enthesitis
that are not apparent on standard radiographs.
• These investigations are not routinely done though.
• MRI and a CT scan may be useful in the diagnosis of a
spinal fracture in patients with late-stage spinal disease.

28. FRACTURE
Spinal fractures are usually the result of significant trauma to a normally formed skeleton, or
the result of trauma to a weakened spinal column. Examples include:
• Jefferson fracture: ring fracture of C1
• Hangman fracture: Bilateral pedicle or pars fracture of C2
• Clay-shoveler fractures: Fractures of the spinous process of a lower cervical vertebra.
• Compression fracture also known as Wedge fracture
• Odontoid process fracture: Also known as a peg or dens fracture, fracture through the
odontoid process of C2.
• Chalk stick: Also known as carrot stick fractures

29. • Jefferson fracture

30. • Hangman fracture

31. • Clay-shoveler
fractures

32. • Compression Fracture/Wedge Fracture

33. • Odontoid process
fracture

34. • Odontoid process
fracture

35. • Chalk stick

36. HERNIATED NUCLEUS PULPOSUS
• The nucleus pulposus (plural: nuclei pulposi) is the central part of each intervertebral disc.
• Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the
surrounding annulus fibrosus. The tear causes pain because of the nerves in the disk, and
when the disk impinges on an adjacent nerve root, a segmental radiculopathy with
paresthesias and weakness in the distribution of the affected root results. Diagnosis is
usually by MRI or CT.
• Disc herniation refers to the displacement of intervertebral disc material beyond the normal
confines of the disc but involving less than 25% of the circumference (to distinguish it from
a disc bulge).

38. KYPHOSIS
• Kyphosis (plural: kyphoses), much less
commonly kyphus, is a term used to describe the
sagittal curvature of the thoracic spine.
• An increased kyphotic angle is seen in the
following conditions: Scheuermann disease,
spondyloarthropathies, osteoporosis and
vertebral body fracture.

40. LORDOSIS
• Lordosis (plural: lordoses) is the term used to refer to the normal anterior curvature of the
cervical and lumbar spines when viewed from the side (concavity at the posterior aspect of
the spine (cf kyphosis).
• However lordosis (also known as hyperlordosis) is also used to refer to abnormal inward
curvature of the spine, i.e. excessive lordosis.

42. METASTASIS
• Spinal metastases is a vague term which can be variably taken to refer to metastatic
disease to any of the following: vertebral metastases (94%)- may have epidural extension,
intradural extramedullary metastases (5%) & intramedullary metastases (1%).
• Spread of malignant cells to the region is variable and includes: haematogenic, direct
invasion, lymphatic and subarachnoid.

43. A solitary, centrally located
intramedullary lesion at
the C5/6 level with
perifocal oedema that
extends 2 segments
above and below. After IV
gadolinium, the lesion
enhances homogeneously.

46. OSTEOARTHRITIS
• Osteoarthritis of the vertebral column, also known as spondylosis deformans, is common
and usually merely referred to as spinal "degenerative change". Complications such as
spinal stenosis are important to recognize.
• The hallmark of osteoarthritis in the spine, as is the case elsewhere, is the presence of
osteophytes. Traction osteophytes project obliquely or horizontally from the endplates,
which is helpful in distinguishing them from syndesmophytes of ankylosing spondylitis.

48. OSTEOPOROSIS
• Osteoporosis is a metabolic skeletal disease defined as a reduction of bone mineral density
below a defined lower limit of normal.
• Osteoporosis per se is asymptomatic and is most often diagnosed when individuals are
evaluated on the basis of risk factors or following presentation with fragility fracture.
• Decreased bone density can be appreciated by decreased cortical thickness and loss of
bony trabeculae in the early stages in radiography.

49. Vertebral osteoporosis manifests as:
• Pencilling of vertebrae
• Loss of cortical bone and trabecular bone (ghost
vertebra)
• Compression fractures and vertebra plans
(Genant classification of vertebral fractures)
• Prominent vertical (primary trabeculae) with
thinning of horizontal/secondary trabeculae in
vertebral bodies

51. OSTEOPETROSIS
• Osteopetrosis, also known as Albers-
Schönberg disease or marble bone
disease, is an uncommon hereditary
disorder that results from defective
osteoclasts. Bones become sclerotic
and thick, but their abnormal structure
actually causes them to be weak and
brittle.

53. PAGET’S DISEASE
• Paget disease of the bone is a common,
chronic bone disorder characterized by
excessive abnormal bone remodeling.
The classically described radiological
appearances are expanded bone with a
coarsened trabecular pattern. The pelvis,
spine, skull, and proximal long bones are
most frequently affected.

54. SCHEUERMANN DISEASE
• Scheuermann disease, also known as juvenile kyphosis, juvenile discogenic disease 11, or
vertebral epiphysitis, is a common condition which results in kyphosis of the thoracic or
thoracolumbar spine. The diagnosis is usually made on plain film.
• Occurs in the thoracic spine in up to 75% of cases, followed by the thoracolumbar spine
combined and occasionally lumbar and rarely cervical spine.

56. SCOLIOSIS
• Scoliosis is defined as an abnormal lateral curvature of the spine. It is quite common in young
individuals and is often idiopathic and asymptomatic. In some cases, however, it is the result of
underlying structural or neurological abnormalities.
• By definition, scoliosis is any lateral spinal curvature with a Cobb angle >10° with terms
including:
• Levoscoliosis: curvature towards the left
• Dextroscoliosis: curvature towards the right
• Assessment and monitoring of scoliosis is primarily achieved with long-spine plain films in the
PA and lateral projections. CT and MRI have roles to play in assessing for underlying
abnormalities as well as, in certain situations, preoperative planning.

58. SPINA BIFIDA
• Spina bifida is a type of neural tube defect/spinal dysraphism which can occur to varying
degrees of severity. It is often considered the most common congenital CNS malformation.
• Common symptoms include:
• back pain
• bladder or bowel incontinence
• paraplegia
• spinal or lower limb deformities including neuropathic (Charcot) arthropathy
• Spina bifida is failure of the normal development of the neural tube.

60. SPONDYLOLISTHESIS
• Spondylolisthesis denotes the slippage of one
vertebra relative to the one below. Spondylolisthesis
can occur anywhere but is most frequent,
particularly when due to spondylolysis, at L5/S1 and
to a lesser degree L4/L5.

61. Grade 1 Grade 2 Grade 3

62. Grade 4 Grade 5

63. SPONDYLOLYSIS
• Spondylolysis is a defect in the pars interarticularis of the neural arch, the portion of the
neural arch that connects the superior and inferior articular facets. It is commonly known as
pars interarticularis defect or more simply as pars defect.
• Spondylolysis is commonly asymptomatic. Symptomatic patients often have pain with
extension and/or rotation of the lumbar spine.

65. SUBLUXATION
• Subluxation is the partial (<100%) loss of articular congruity, i.e. some part of the articular
surfaces of the bones contributing to the joint are touching each other
• Vertebral subluxation occurs when the joints of the spine fail to move properly and/or the
spinal bones become misaligned causing interference with the nerve messages from the
brain to the body and/or from the body to the brain. This can affect movement patterns,
muscle balance and even the function of organs and the chemicals and hormones they
produce. Most subluxations do not cause pain (as the majority of nerves are not nociceptive
or pain-sensing).

67. TUMOR - MULTIPLE MYELOMA
• Multiple myeloma is a monoclonal gammopathy and is the most common primary malignant
bone neoplasm in adults. It arises from red marrow due to the monoclonal proliferation of
plasma cells and manifests in a wide range of radiographic abnormalities. Multiple
myeloma remains incurable.
• Clinical presentation of patients with multiple myeloma is varied, and includes: bone pain,
initially intermittent, but becomes constant, worse with activity/weight-bearing, and thus is
worse during the day, anemia, typically normochromic/normocytic, renal failure, proteinuria
& hypercalcemia.

69. THANK YOU
Any questions?
References:
https://www.getbodysmart.com/skeletal-system
https://radiopaedia.org/?lang=us
Marrill’s textbook on positioning (Vol 1)