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NYCC Adv Img Warshel
addendum to Kelly Brown's study stack for same class on this site
| Question | Answer |
|---|---|
| Pattern of annulus fibrosis | herring bone outer annulus suffers more torsion Central pattern can break down and pt have no sx until reaches outer annulus! |
| Why does the nucleus pulposis lose it's ability to absorb shock? | Loss of PROTEOGLYCANS |
| Does anyone know why aging discs change exactly? | No, but it is well-documented from a histochemical perspective. Reversible? controversial. |
| What replaces chondroitin sulfate in aging discs? | keratin sulfate - not hydrophilic like chondroitin s. |
| What kinds of gas signs are there? **** | *Vacuum cleft (intervertebral osteochondrosis **Vacuum clefts adjacent to endplate (trauma) ***Intravertebral gas (AVN) |
| As the disc begins to lose height, what does it do? | BULGE outward |
| Can you have a vacuum sign in an infected disc? | NO |
| Describe changes brought on by stress to endplates | WOLFF'S law: more bone and get sclerotic so don't diffuse nutrients and waste through disc (wash disc). |
| As the disc loses hydration and height, the hyaline cartilage endplates develop __________ | fissures |
| As the disc loses hydration and height, the _________and __________ thicken. | subchondral bone & trabeculae thicken |
| As the disc loses hydration and height, these changes diminish the _________ of the bone adjacent to the disc. | vascularity |
| As the disc loses hydration and height, the sclerosis causes lowered ___________ diffusion. | nutrient |
| Additionally,as the disc loses height, there can be _________ /tearing of the _____ | fissuring/tearing of the annulus |
| POSTERIOR disc tends to have _________ tears. The ANTERIOR & LATERAL disc tends to have __________ tears, and form osteophytes (_________ _________) | RADIAL The anterior lateral tends to have peripheral tears and osteophytes (SPONDYLOSIS DEFORMANS). |
| The POSTERIOR disc tends to have ________ tears. | RADIAL |
| How good is x-ray for determining amount of disc derangement? | limited *need and MR to really see what's going on |
| X-ray shows later stages of disc disease: (4 indicators) | Loss of height Vacuum cleft (inside disc) Endplate sclerosis Osteophyte formation |
| Besides the need for later stages of disc disease to be present for visual on x-ray, what else can't you see? | INTERNAL structures like nucleus p. and annulus, or biochemistry of nucleus There are no sensitive or specific findings on plain film. |
| Discogram | not recommended anymore because thought to accelerate disc degeneration |
| There are no specific or sensitive plain film findings, but what can you see on xray for disc degeneration? | ABDOMINAL ILEUS ANTALGIA LOSS OF LORDOSIS |
| Imaging needed for assessment of disc pathology | MR or CT |
| C disc shape | oval |
| T & L disc shapes? | kidney beans |
| Normal, Congenital/Developmental variation, Degenerative/Traumatic, Infectious/Inflammatory, Neoplastic, Morphologic variant of uncertain significance | Classification of disc PATHOLOGY |
| NORMAL disc description | Morphologically normal No degenerative or adaptive changes Disc does NOT extend past bone margins Annulus not beyond vertebral body, nor above or below endplate Horizontal cleft is small dark line in center of nucleus (normal) |
| What is the dark line going through the center of a disc at the nucleus level on an MR? | HORIZONTAL CLEFT Normal: can be a sign of degeneration |
| Discs that are ALTERED as an ADAPTATION to structural variants | Congenital/Developmental disc variants |
| conditions of congenital.developmental disc variation (altered structure as an adaptation) | SCOLIOSIS TRANSITIONAL SEGMENTS SPONDYLOLISTHESIS HEMIVERTEBRAE BUTTERFLY VERTS |
| A morphologic change to a vertebral body results in a change to the ____ | disc. |
| Shape of disc in SCOLIOSIS | WEDGING on concave side |
| An L/S transitional segment with a unilateral articulation would cause a __________ disc. Where would the disc derangement occur? | HYPOPLASTIC Derangement at level ABOVE transitional segment |
| Two types of hemivertebrae seen in notes? | Lateral Dorsal |
| BUTTERFLY vertebrae: where does disc material go? | superior and inferior |
| What 3 things describe Degenerative/Traumatic disc pathology? | Degeneration Annular Tears Herniation |
| mULTIfACTORAL causes of Degenerative Disc Disease (DDD) | Aging and proteoglycan loss Trauma - whiplash accelerates DDD Overuse and wear Genetics |
| DDD xray findings | 1. Decreased T2 signal 2. Loss of disc height 3. Diffuse disc bulging 4. Osteophytes (xray more than MR) 5. Dessication |
| MODIC change is a change in _________ in response to degenerative changes | MARROW MODIC |
| Typical spinal marrow is | cellular red marrow MODIC is marrow change that results from degeneration and dehydration |
| One way to d/dx disc degeneration from infection | recognize the 3 types of MODIC (marrow) changes: I fibrovascular, II fatty, III bony sclerosis |
| Change associated with symptoms | MODIC type I (fibrovascular acute edema) Acute |
| Modic change associated with NO symptoms | Type II - fatty replacement of red marrow Chronic High TT1, either way on T2 |
| Modic change that has a signal near that of cortical bone on MR | Modic Type III - replacement of marrow by bony sclerosis Low T1, Low T2 |
| What is the term for type III modic change | HEMISPHERIC SPONDYLOSCLEROSIS |
| 3 terms for annular tears | Annular FISSURES Annular TEARS HIGH INTENSITY ZONE (HIZ) |
| Does a tear represent a TRAUMA origin? | NO, not necessarily |
| Where is an ANNULAR tear most common? | POSTERIOR disc |
| 3 types of annular tears | CONCENTRIC TRANSVERSE RADIAL - only radial are important! |
| Only important type of annular tear? | RADIAL because associated with DISCOGENIC PAIN and allows NUCLEAR MIGRATION |
| What does an HIZ look like on MR? | High Intensity Zone = ANNULAR tear High T2 inside annulus |
| Tear does NOT necessarily mean | trauma. |
| CONCENTRIC annular tears are ____ on sagittal and _______ on axial. | vertical horizontal, following contour of disc |
| Delamination tears that split layers of the annulus | CONCENTRIC: NOT painful because stay in INNER layers (no migration) |
| Represent separation of SHARPEY'S FIBERS from cartilaginous endplate | TRANSVERSE tears of annulus Seen as a VACUUM CLEFT (lifting of Sharpey's away from endplate) on plain film. Not clinically significant usually. |
| Type of tear associated with discogenic pain | RADIAL |
| How does discogenic pain from radial annular tear cause pain? | Grow vascular granulation tissue in tear...chem and mech irritation to outer (innervated) annulus |
| Radial tear that causes discogenic pain is a _______ tear | LONGITUDINAL = radial annular tear discogenic pain |
| On a sagittal image, describe radial tear | -----horizontal------ |
| On an axial image, describe a radial tear | I perpendicular to fibers I I I I I |
| Herniation is a ________ term. It just means something is wrong with the disc. | general, meaning displacement of disc material beyond normal confines/margins |
| What thinktank standardized the nomeclature for IVD herniations? | ASNR |
| 4 questions to ask yourself when hunting disc herniations to categorize | Extent...Morphology...Location...Neurologic involvement EMLN |
| EXTENT | Focal vs. Broad based |
| To what 2 categories of disc herniation does EXTENT apply? | Protrusion and Extrusion (because a bugle is diffuse/can't be measured and a sequestration cannot be measured) |
| P.E. Teachers can be focal or broad | Protrusion and Extrusion is for focal or broad based lesions only |
| How is the disc divided for herniation classification? | into fourths (25% x 4) |
| When does a woman begin to become 'broad based?' | Between the ages of 25-50 (broad based lesions involve 25-50%) of disc circumference |
| B.P oil, Exxon, and Shell | Bulge, Protrusion, Extrusion, Sequestration |
| In order to classify BP Exxon or Shell, you need _____ and _____ views. | AXIAL and SAGITTAL images – only one will not do. |
| Two caveats to call it a BULGE | Greater than 2 mm extension past margin. Involves more than 50% of circumference. |
| Two types of disc BULGE | Symmetric & Asymmetric (seen in pts. W/ little scoliotic change) |
| If a protrusion goes above or below either endplate, it is now called an? | EXTRUSION |
| A Focal or Broad based lesion, either, does/does not extend beyond the endplates? | Does not. |
| How to read a disc: | View?T2 Sag. How much? Focal [<25%], Broad based [25-50%], Bulge [>50%]. Where? Central, Paracentral, Foraminal, Extra-foraminal. Endplates? Protrusion-contained. Extrusion-uncontained. Bulge around. Sequestration is piece. |
| Often asymptomatic; 1/3 of population has these... | Protrusion – contained. Treat the patient, not the MRI |
| Disc material is not contained by outer annular fibers | EXTRUSION |
| Does an extrusion maintain continuity with parent disc? (is it attached?) | YES |
| Appearance of extrusion on MR | High T2 (water) and High T1 POST-CON due to surrounding granulation tissue (fatty tissue) |
| C-spine herniation affects __________ level. T & L spine herniation affects ____________ level | C-same T&L - one level down C4-5 affects root 4 L4-5 affects root 5 |
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hecutler
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